How the CDC-Kaiser ACE Study Will Make You Rethink the Lasting Impact of Trauma

Several years ago, I began writing about my experiences of being trafficked as a part of my healing.  My original goal had been to explore that initial point of exploitation and identify the key piece.  As I looked in detail at the day I had been officially “turned out,” I realized I couldn’t just start my story into trafficking on that day, I needed to explain the month of grooming that had happened prior to that.  But even trying to explain how my experience of going from being groomed to being turned out happened in less than 30 days, I had to yet again take a step back and look at how the five years of domestic violence in a marriage had set the stage for that chance encounter with my would-be trafficker.  Growing frustrated, I explained to a friend (who was a LCSW) this revelation that the deeper I dug into this specific incident, the more I felt like I needed to explain what set the stage for each of the event that led up to the next.  She chuckled, “Yep, what you’re actually seeing is that life happens in a cyclical process, not a linear one.”  Correctly reading my now utterly confused face, she continued, “Humans tell stories in a linear fashion; we summarize a timeline of events into major events, there’s many benefits of this, but it isn’t helpful as we process life experiences because it causes us to miss all the tiny threads leading up to or included in a major life event.” As she explained this, she drew two lines – one straight with equally-spaced dots, indicating linear thinking, and one that looked like a stretched out slinky, indicating the cyclical reality of human life.

As my friend explained these two ways of looking at life experiences, I was reminded of my EMDR therapist, who had explained when I first started the treatment that we would work on directly processing several highlighted memories, that I would also start to see connections being made to other experiences I had lived through at other points in time as well. She helped prepare me for the fact that as I processed and healed from those major trauma markers, I would also start to make connections between seemingly unrelated experiences as well.  Of course, she was right, and as I progressed through the treatment, I did have revelations about other events I hadn’t recalled previously or ones I had deemed relatively less traumatic.  But it wasn’t until I was independently processing through journaling several years later that I understood why that happened with my memories.

A person’s life is not a series of points on a timeline, but rather an interconnected flow of individual interactions and decisions.  Traumatic or not, it is only in hindsight that we began to summarize in a linear fashion, but it typically in processing our trauma that we delve into the tangled mess of threads in an attempt to make sense of those major event memories.  And it is in understanding and accepting the cyclical (and in cases of trauma, tangled) journey through life that we can not only better understand our own path, but the paths of others.

In the mid-90’s, Kaiser Permanente and the Center for Disease Control conducted a massive quantitative study of 17,000 people insured through Kaiser to examine the potential causes of chronic physical and mental health conditions.  What this study revealed was that adverse childhood experiences (ACEs) have a direct correlation to chronic health conditions later in life, and not only that but that the greater the number of ACEs, the exponentially greater the likelihood that these chronic health conditions would present.  The data from this study revealed findings that are only now even beginning to be talked about in many communities across the US, much less adopted into policies and procedures for existing programs and services.  The ACE questionnaire itself is a series of ten questions around forms of abuse and neglect a person may experience before the age of 18, with each question being scored with a 0 (not experienced) or a 1 (experienced).  The questions were then totaled to give each participant their ACE score.  Nearly 60% of the sample had an ACE score of 0-1, indicating that most people do experience a major negative event growing up.  An ACE score of 4 is where the exponential increase in chronic health conditions was observed to begin.

Prostitution or commercial sexual exploitation were not directly tracked in the ACE study.  However, in 2017 Free Our Girls conducted the largest qualitative study commercially sexually exploited women in US history, and while ACEs were not directly documented, they frequently shared their major life experiences leading up to, during, and following their exploitation.  In fact, the original ACE study indicates that 25% of their female sample population had an ACE score of one, while our research revealed that nearly three times as many (72%) females in our sample voluntarily disclosed at least one ACE. And likewise, while sexual abuse was indicated in 25% of the original ACE study female participants, nearly three times as many (70%) females in our sample of CSE survivors voluntarily disclosed childhood sexual abuse.  It is clear to see that early childhood trauma is a vulnerability indicator of potential commercial sexual exploitation later in life.  It is also important to understand that early childhood trauma, especially sexual abuse, normalizes these experiences, significantly diminishing the argument that the commercial sex trade primarily employs women who are freely consenting adults.

The CDC-Kaiser ACE Study states “as your ACE score increases, so does the risk of disease, social and emotional problems.  With an ACE score of four or more … the likelihood of … hepatitis [increases] 420 percent; depression 460 percent; suicide 1220 percent.”  It sadly comes as no surprise then when our CSE survivor sample indicated that their most common methods of successful exit were either intentional drug overdose or attempted suicide.  Additionally, when looking at chronic medical conditions of survivors of trafficking, a 2018 survey by United Against Slavery titled Lingering Medical Symptoms of Survivors After Being Freed from Enslavement revealed that the top ongoing issues we struggle with include neck, back and hip issues, dental deterioration, PTSD, and scar tissue.  The study also highlights the importance of access to ongoing, quality medical care, as most victims did not have access to routine healthcare during their time of exploitation.  While the symptoms and conditions varied, it is vital to note that when surveyed, no one survivor indicated having overall excellent health following their exploitation, which supports not only the statement that the commercial sex trade is not only exploitative but inherently damaging to those involved, but also that in lifelong journey of the impact of trauma, physical and mental health conditions are highly correlated to past lived experiences.

One of the single most important pieces of information gained from the CDC-Kaiser ACE Study was the shift in perception by service providers to trauma-informed and client-centered policies and programs.  In the journal article Adverse Childhood Experiences and the Lifelong Consequences of Trauma by the American Academy of Pediatrics, this shift was explained in the simple rephrasing as “questions for patients have focused on ‘what’s wrong with you?’ rather than ‘what happened to you?’”  A better understanding of a person’s series of life experiences can lead to markedly better physical and mental care.  Additionally, Dr. Anda, author of The Adverse Childhood Experiences Study: Child Abuse and Public Health, published by Prevent Child Abuse America, explains that “people can also find their ACE Scores and talk about their ‘Score’ without revealing the details and personal nature of the adverse experiences,” all the while helping their care providers better understand the culmination of life events leading up to present time.  And finally, the study revealed the importance of the “life course perspective,” wherein professionals step away from viewing life as disconnected stages and singular events, but as a flow of decisions and experiences that have layered over time.  It is only in understanding the complexities of individual stories that professionals are best able to serve their patients and clients, as they begin to see the oftentimes generational patterns those in their care are working to overcome.

I have always been a “why?” person, meaning I am annoyingly persistent sometimes.  However, when I read chapter five of the book The While Umbrella: Walking with Survivors of Sex Trafficking byMary Frances Bowley, I finally had a laymen’s terms explanation of what had happened to my brain, and the brains of my survivor sisters, and Free Our Girls’ ladies.  In fact, I have repeatedly had the women we walk with read this chapter to better understand their experiences and why seemingly simple things like impulse control, staying present, and emotion regulation are so hard for so many of us now as adults.  The author explains:

Like a series of building blocks, each portion of the brain that develops provides a foundation for further development, so the brain’s higher functioning abilities depend entirely on those early, basic “building blocks” of development.  What this means is that a traumatic event can interrupt the brain’s development at any time, and shake it so powerfully that it changes the way the rest of the brain continues to grow.  This trauma literally provides the foundation for a child’s further understanding of the world.

The information in this powerful chapter goes on to explain that “environmental cues can also change the course in the developing brain by redefining what is considered ‘normal,’” and that “when abuse happens, every part of the brain is accessed all at once because it is responding to a threat … [and] serious damage can be done to all parts of the brain, which in turn has lasting consequences for the person’s ability to function and process information in all aspects of life.  The CDC-Kaiser study echoes these findings, stating that “toxic stress physically damages a child’s developing brain,” and that “when children are overloaded with stress hormones, they’re in flight, fright, or freeze mode.”  To put this another way, using an analogy that a mental health professional shared at a trauma-informed care training for case managers, childhood trauma is often like living with a grizzly bear in your home – a person is constantly on high alert to survive.  A child living with a grizzly bear is not thinking about helping prepare dinner with their parent, or the spelling test on Friday, they are not sleeping well, and they are not spending time reading books before bedtime – they are in a constant state of survival.

While these findings can seem discouraging or hopeless for those of us who have survived childhood trauma, they do not have to be.  At a macro level, knowledge of the cyclical course of life and the long-term impact of trauma means that we as service providers are better able to walk alongside our clients, and design programs to better serve them where they are at.  It also provides a foundation for improving intake and interview processes and fixing the justice system to address root causes of behavior as opposed to layering on additional traumas on into adulthood.  As a childhood trauma and CSE survivor, it helps me to better understand the series of events that created and exacerbated my vulnerabilities to exploitation, and what I need to be conscious of now that I have access to quality mental and physical health care.  Knowing my ACE score, and my subsequent journey to freedom helps me understand the protective factors that made that journey possible, and better identify what my survivor sisters and brothers need as they exit and rebuild.  The ACE Study notes that protective factors are present in trauma survivors’ lives who have defied statistical predictions for chronic health conditions later in life, but also states that “a secure early childhood is helpful, but not necessary,” meaning that despite the odds, we can all be outliers and overcomers when we have access to community support and trauma-informed, client-centered services.

Megan Lundstrom, Founder and director of national non-profit, Free Our Girls, Megan Lundstrom brings her experiences, education, and personal exposure to the issue of domestic sex trafficking to the forefront of the movement using groundbreaking research and practices to serve those in the process of finding their freedom. A survivor consultant for the Department of Homeland Security’s Blue Campaign, and Case Coordinator for Larimer County’s CSEC High-Risk Intervention Team, Megan has dedicated her life’s work to preventing and responding to commercial sexual exploitation, and challenging the culture that fuels it.