3 Clinical Assessment of Physical and Psychological Injuries in Human Trafficking Cases Distinctions made between physical and psychological violations are artificial. The infliction of injuries and their psychological impact are in all cases intertwined. Interpersonal physical violence always includes a psychological component, for example physical injury which is specifically intended to degrade, humiliate or subjugate the victim results in psychological injury and distress. Psychological control (ranging from emotional manipulation to threats of violence or witnessing violence against others) may cause a victim to self-harm or attempt suicide, thereby resulting in physical injury. The Istanbul Protocol advises against a “checklist” approach to the assessment of symptoms: “A method-listing approach may be counter-productive, as the entire clinical picture produced by torture is much more than the simple sum of lesions produced by methods on a list.” 22 Some pain which is experienced in part, or all of the body may be “psychosomatic” (i.e. it is psychological in origin and cannot be explained in terms of physical pathology), and both physical and psychological forms of violence and control can exacerbate illness and conditions relating to mind and body. Effective clinical work requires an integrated, holistic approach that can take into account the multiple causes and influences connected to the experience of pain, ranging from direct physical damage to psychosomatic symptoms. to humiliate and degrade them into feeling that they have no choice but to cooperate with traffickers. Injuries may also be unintended in that they are not deliberately caused, but result from poor working conditions or from the fatigue and fearful actions of victims. HBF clinicians have noted burns from cooking or handling chemicals in unsafe working environments, muscular strains and injury from repetitive work, or from trips and falls when victims have tried to escape assault.23 A West African girl trafficked for domestic servitude and sexual exploitation Yemi was trafficked to the UK at age 13 and held in domestic servitude. She was sold to a woman whom she was told to call “Auntie”, who subjected her to physical and emotional abuse. She was expected to do all of the housework for the family, including cleaning and looking after the children. Her work was frequently criticised, and if there were any perceived shortcomings in her work she was physically assaulted, for example by being struck on the head, knocked to the floor or having her ears pulled. She was repeatedly insulted and told that she was “lazy”. Men who visited the house raped her and gagged her to stop her from screaming. “Auntie” did not help her and she remembers hearing her turning up the volume of the radio to drown out the noise. Later “Auntie” told her that when this happened, she “must try to relax”. To assist easy reference within this chapter, the clinical identification of physical injuries (i.e. those which affect the physical body) and those which relate to psychological conditions and injuries (i.e. those which affect the mind, daily functioning and emotional state) are broadly separated, while recognition of the considerable overlap between them is maintained throughout. 3.1 Physical Injuries Various forms of physical violence and injury may be suffered by victims of trafficking. Injuries are often deliberately inflicted in order to coerce, threaten or punish the victim or Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 57