described as “cumulative” because it stems from original injuries which have been compounded. An Asian woman trafficked for domestic servitude and sexual exploitation Tai describes feeling pain all the time. She pointed to her heart, saying that her heart is always breaking. She says that she feels cold all over and has “no warmth” in her life, internal or external, nobody is there to care for her. She suffers from severe lower back pain, which she has experienced since she was seven years of age as a result of repeated violence at the hands of her relative. She was beaten almost daily with a stick. The pain has worsened over the past year and was exacerbated by injuries sustained while she was held in sexual exploitation. Psychosomatic pain “Somatisation” is very common in people who have suffered trafficking and other forms of interpersonal violence. This means that symptoms reported have no identifiable physical cause. The psychological effects of trauma may result in pain in an area of the body that is perceived by the victim to be particularly defiled or injured. For example, rape victims may experience subsequent pain in the pelvis, lower abdomen or anus, even in the absence of any clinically identifiable physical injury. If no specific physical cause of a victim’s pain is identified, clinicians can reassure them that serious physical illness is unlikely or has been ruled out. However, the pain symptoms experienced should not be dismissed for that reason. Pain is distressing and disabling, whatever its cause, and even reassurance about the apparent lack of a physical cause may be experienced as rejection or denial of the severity of the pain or distress experienced. At the initial stages of contact, it is important for clinicians to observe and/or document all pain and its potential causes, therefore permitting time for further clinical investigation. Early Documentation of Pain Sarah’s severe leg pain may have a physical cause, such as osteomalacia (the result of severe vitamin D deficiency for which she has risk factors because of her physical captivity) or direct physical trauma. It also may be a form of somatisation, where psychological distress converts into a physical symptom. Her headaches may be due to depression, to “somatisation”, physical causes, or a combination of these. Source: Clinical assessment of a European woman who was trafficked for sexual exploitation Typical psychosomatic complaints include back pain, musculoskeletal pain and headaches, often from head injuries. Headaches are very common among torture survivors and often lead to chronic post-traumatic headaches. They may also be caused or exacerbated by tension and stress.39 The Istanbul Protocol states that, “Somatic symptoms such as pain, headache or other physical complaints, with or without objective findings, are common problems among torture victims. Pain may be the only manifest complaint and may shift in location and vary in intensity. Somatic symptoms can be directly due to physical consequences of torture or be psychological in origin.” 40 It is essential to investigate all symptoms reported by victims to provide early treatment for any identifiable physical cause. For example, a person who suffers psychosomatic headaches might also be diagnosed with migraines which are treatable and pain experienced in the lower abdominal area could be the result of a urinary or genital infection. 63