The extent to which people who self-harm actually wish to die must always be evaluated carefully and should not be assumed to be absent in cases where there is also a component of anxiety relief or the self-harm is frequently repeated. Active suicidal ideation can fluctuate widely, and clinicians should ensure that they respond considerately and sensitively to any expressions of suicidal ideation and acts of self-harm. An Asian woman trafficked for sexual exploitation Mai has a long history of self-harm. She says she would feel much better, calmer, when she saw her own blood. She feels no pain when she self-harms but is calmer afterwards. She is afraid of her own anger. Mai expresses feelings of intense rage and is not sure why. Generally this rage gets turned inwards and she self-harms. This behaviour indicates a very high level of psychological distress and disturbance. It raises significant concerns in terms of further self-harming and risk taking behaviours. An Eastern European woman trafficked for sexual exploitation “I felt like rubbish. Dirty. Like the last person in the world. Sometimes I cut myself to feel real pain rather than just pain inside.” A West African woman held in domestic servitude from the age of 12 and then trafficked to the UK Amanda has engaged in controlled vomiting since age 14. She has self-harm scars: a burn mark on one arm and a knife cut on the other. Previously she has heated a utensil on the stove and held it against her skin. 5.9 Suicidal Ideation People who suffer suicidal ideation have repeated thoughts about deliberately ending their lives. Suicidal ideation is often a symptom of depression and may be expressed as a current intention of an act of suicide, or in preparatory plans made for suicide, which in some cases may be carried out. Suicidal ideation and intent are frequently experienced by victims of trafficking. This reflects the destruction of their self-worth due to the shame and humiliation of degrading treatment and being made to feel worthless by traffickers’ complete control of them. In some cases victims attempt suicide while trapped in a trafficking situation and may have their life forcibly preserved by traffickers who punish them for having made the attempt and prevent them from trying it again. In HBF’s experience, suicide attempts by trafficking victims can happen at any time after escape. They can occur in cases where a trafficking victim is considered to be “out of danger” and is therefore perceived as having “recovered” from their experiences. A young woman who was raised in forced prostitution in her Asian country of origin and trafficked to the UK for sexual exploitation. During a police raid she ran into heavy traffic, and when her asylum case was refused she took an overdose of tablets. “It takes so much courage to live.” A South East Asian woman trafficked for sexual exploitation. She previously drank large amounts of alcohol and bleach in an attempt at suicide. She was hospitalized and advised to seek counseling. “I don’t know why I have to live. Since the trafficking I just think about dying.” A South Asian man who was trafficked for domestic servitude who suffered rape and sexual abuse. He tried to kill himself by walking out onto a motorway. “I felt so despairing that several times I tried to kill myself.” 82