the beating and provides an indication of its nature. Clinicians have observed that some victims of trafficking have used whitening cream or other products to fade their scars or burns, making them difficult to observe and document. 3.1.6 Infliction of “Invisible” Injuries Traffickers may avoid inflicting visible injuries which could attract unwanted attention to the situation of victims. In cases of sexual exploitation, traffickers may avoid inflicting visible injuries so as not to jeopardize the “sale” of victims’ bodies. An Asian victim of trafficking for sexual exploitation Yasmin explained that she was not beaten on her body because her traffickers did not want her to have visible bruises. Instead “they beat my head and stuck needles under my nails.” She enacted the process by which she was “punished” and grimaced with remembered pain as she described what her “owners” had done. 3.2 Head Injuries Head injuries are common amongst this client group, ranging from being pulled by the hair to being beaten severely enough to cause loss of consciousness. Common head injury symptoms of victims of trafficking observed at HBF include: – – – – – – – – – – – – Persistent headaches Dizziness Nausea Blurred vision Fatigue/lethargy Changes in sleep patterns Behavioural and mood changes Poor motor-coordination Memory and cognitive problems, for example difficulty with thinking, reasoning, concentration and attention Problems with higher executive functioning, for example becoming unable to read or write Post-traumatic epilepsy Episodes of “collapse”, suffering “blackout” or fainting. The precise clinical cause of this may be difficult to identify. whom suffer blows to the head. Although headaches are generally psychosomatic or due to tension, it is possible in some cases with a history of repeated blows to the head to feel areas of hyperaesthesia (…) and some thickening of the scalp from scar tissue” 33. A study of women who had been trafficked noted that symptoms relating to the central nervous system (e.g. headaches, memory difficulties and dizzy spells) were prevalent and persistent.34 Unlike other symptoms, women reported little relief from headaches over time, which were the most prevalent and severe symptoms. The report noted that although headaches were often stress-related, the fact that many of the women had suffered head or neck trauma should not be overlooked35. Consideration of pain is an important first step. Headaches are very distracting and can interfere with normal functioning. A person who is suffering from headaches may not be able to concentrate or respond adequately or fully to questions. There is a possibility that a head injury may have occurred even if headaches are not apparent. Injuries to the head which have resulted in loss of consciousness may cause post-traumatic epilepsy and/or organic brain dysfunction. This possibility should be properly investigated. The significance of episodes of loss of consciousness In her study, “Errors of Recall and Credibility”, Dr. Juliet Cohen states that “many victims of torture are not surprisingly unable to clearly estimate periods of unconsciousness… A detailed history should elicit rough estimates of severity and frequency of head injury, prolonged or brief loss of consciousness and symptoms noted afterwards attributable to head injury (post-concussion syndrome). Such symptoms include dizziness, drowsiness, double vision, headache and nausea in the short term and persisting headache, dizziness, poor concentration, poor memory, fatigue, irritability, anxiety, noise sensitivity and insomnia in the longer term” 36. This also applies to victims of trafficking. They should be specifically asked about any periods of unconsciousness experienced after suffering head injury and any subsequent periods of amnesia. In HBF’s experience, they may omit this information when recounting their experiences 33 Medical Investigation and Documentation of Torture: A Handbook for Health Professionals 34 Stolen smiles: a summary report on the physical and psychological health consequences of women and adolescents trafficked in Europe “Head trauma and persistent and recurrent headaches are well documented among victims of state torture, many of 61