If We Don't Ask, They Won't Tell

This was the man's third visit to my family medicine clinic. He was a middle-aged Latino man, a construction worker. I was a second-year resident and I just couldn't figure out what was going on with this man: daily headaches, near constant abdominal pain, some depression symptoms. His physical exam was always completely normal, save for some scars on his back and thighs, surely from his construction job. Basic lab tests showed nothing abnormal. I just couldn't put it together. What was I missing? I was close to ordering an expensive abdominal CT scan in the hopes it would help me figure out how to help this man. I knew he couldn't afford it, so I did the only thing I could at that point. I sat down and talked to him.

I learned he came from El Salvador. When? In the early '90s. That rang a distant bell. In my former life as a TV producer I did some reporting about a particularly brutal civil war in El Salvador. "Were you or any family members affected by the civil war?" I asked. The quivering lip and downcast eye told me I hit the jackpot. And the scars... ? Indeed. The scars were not the result of some construction work mishap as I assumed, they were -- to the uninitiated and possibly ignorant -- the not-so-tell-tale signs of torture.

Torture victims and survivors live among us. Often silently. They are a construction worker from El Salvador; a journalist from Pakistan; an economist from the Sudan; an academic from Somalia; a teacher from Egypt; a domestic aid from Nepal; a young woman from the Ukraine who won't disclose what her job is. They live in DC and in Utah, in New York and in Texas, in Minnesota and in Maine.

According to torture victim advocacy organizations quoting U.S. Office of Refugee Resettlement figures, there are an estimated 500,000 survivors of torture and war-related trauma now living in the United States. That's as many Americans living in the U.S. with Parkinson's disease.

Today is United Nations International Day in Support of Victims of Torture. It is a day that commemorates the millions of people around the world who suffered rape, blows to the soles of the feet, suffocation in water, burns, electric shocks, sleep deprivation, shaking and beating, in an effort to break them down physically and psychologically. Break them down because they belonged to the 'wrong' tribe, practiced the 'wrong' religion, made the 'wrong' comment, advocated for the 'wrong' candidate, voted for the 'wrong' party, resisted the 'wrong' cultural norm, dared to voice the 'wrong' opinion. It is not a list that is comfortable to read, nor are these action that are easy to imagine. More often than not, these are awkward topics to bring up with patients -- and as a profession, we, doctors, do a terrible job asking about these experiences.

An article in the Western Medical Journal from 2000 surveying torture survivors in a primary care setting noted that "none of the survivors of torture had been identified as such by their primary care physician."

Evidently we don't ask. And when we fail to probe, we fail to connect the dots.

Sure, some victims have very noticeable scars. But more often than not, by the time they come to see us their scars have healed, their sense of horror has subsided. They are here, in the U.S., after all, rebuilding their lives. They want to put it all in the past. But their bodies have not necessarily forgotten what the mind wanted to erase. Few doctors, when faced with symptoms such as muscle and joint pain, low back pain, headache, fatigue, palpitations, irritable bower or insomnia, would ascribe them to torture. We are trained to identify heart disease, and diabetes, and anemia, muscle strain and migraines. But these are what we call "somatic" symptoms: non-specific symptoms that could be caused by almost anything. Just as I did as a resident, many of us spend months and waste a lot of money trying to come up with a medical diagnosis, when, in reality, these 'unexplained' symptoms, in many cases, are directly related to a history of psychological and physical abuse and torture.

Once identified, there are resources out there that can make things better for victims. Many organizations around the country offer medical, psychological, educational and vocational services to victims of torture. But in order to connect the services with the people, we must first help identify who might need them.

The lesson I learned from that man has stayed with me for years -- and it is one I try to impart to the medical students and residents I work with: read the newspapers, brush up on world history, learn about conflict zones. Inquire where your patients are from. Don't be afraid to ask uncomfortable questions. Then, the next time you see a woman from the Sudan who is vehemently insisting she doesn't need a pelvic exam, or a young woman from Eastern Europe who is not divulging much information about how she came here and what she does for a living, or a man from Cameroon whose missing a part of his ear, or a middle-aged construction worker from El Salvador, you won't just assume it's nothing and you'll know what needs to be asked.

And when you ask, you'll hear about the rape, the sex trafficking, the brutal beating at the police station, and the kidnapping, confinement and whipping in the countryside. The story-telling itself may be therapeutic, and it may be the beginning of a healing process that every torture victim deserves.