In this literature review, we found a fairly homogeneous use of terms concerning the somatic expression of distress; the most frequent were “somatic symptoms,” “somatic complaints,” and “somatization.” The DSM-IV term “somatoform disorder” is found in only a few articles (17–21), while the DSM-5 term “somatic symptoms and related disorders” was not used at all. These terms are mainly related to the specific definition and term used in the assessment scales the authors chose, e.g., the Symptom Checklist 90 (SCL-90), the Brief Symptom Inventory (BSI), which is a short version of the SCL-90, the Somatic Symptoms Scale (SSS-8), and the Youth Self Report (YSR), which includes a subscale labeled “somatic complaints.” The precise meaning or implications of the terms used in reference to somatic symptoms was generally difficult to determine, because of both the frequent overlap with anxiety and depression and the highly variable clinical presentation.

There was one major commonality between the different migrant populations referred to in this review: they all face the issue of acculturation. According to Berry, acculturative stress refers to the trade-offs that migrants face as a result of differences between their home and host cultures [cited by (36)]. This stress results from several factors, including the need to learn new and sometimes confusing cultural rules and expectations, experiencing prejudice and discrimination, and managing the conflict between maintaining elements of the old culture while incorporating those of the new, according to Berry and Suàrez-Orozco (36). Rumbaut and Mahalingam observed that acculturative stress also stems from negative stereotypes and attitudes that the host culture may hold toward migrants [cited by (36)].

Discrimination was the phenomenon most often discussed in the articles we reviewed. A 4-year longitudinal study found an association between perceived discrimination and the expression of somatic symptoms in young students of immigrant origin in the USA (67). Another study, conducted in Israel with migrant adolescents (from the former Soviet Union and Ethiopia) investigated the relations between the experience of discrimination and externalized behaviors (aggression and substance abuse). It found that discrimination reduced the young migrants' sense of identity as part of the host country and led to increases in “psychosomatic symptoms,” aggression, and substance abuse. The authors found that psychosomatic symptoms mediate the link between discrimination and externalized behaviors and that this mediating role differs by origin: it was partial for the adolescents from the former USSR and total for the Ethiopian youth (68).

Another study examined how ethnic composition in US schools, as measured by the percentage of non-Hispanic White students in a school, affects depressive and somatic symptoms in a representative sample of 18,419 US adolescents, and whether the association differs by ethnicity. After controlling for individual and school characteristics, the analysis indicated that the likelihood of black students experiencing somatic symptoms increased with the percentage of white students in their school. This interaction between somatic symptoms, Black ethnicity and the school's ethnic composition was no longer significant, however, after controlling for the effects of feeling discriminated against and school attachment (69).

In New York, Ong and his team found that 78% of Asian Americans experienced daily racial microaggressions and that somatic symptoms increased with their number (70). The same was true among Chinese-American families in California, where adolescents' experiences of discrimination were linked to an increase in somatization. It is important to note that in these families, higher conflict exacerbated the negative effects of discrimination, while greater family cohesion mitigated its negative effects (71). The same authors reported similar findings with a larger sample in 2012 and pointed out that the acculturation process gives rise to conflicts between parents and adolescents over everyday issues and deeper cultural values (72). In contrast to everyday conflicts, however, the levels of acculturation-based conflicts are not similar across ethnic groups. Lee and Liu have found that Asian Americans report higher levels of acculturation-based conflict than Latinos or European Americans [cited by (72)].

Discrimination and associated acculturative stress are prominent in this review of somatization. Everyday challenges for young people of migrant origin raise the issue of ethnic identity in families. They are a source of intrafamily conflicts between young people and their parents that are often expressed through somatic complaints.

Many improvements remain to be made in patient care for young people with somatic symptoms. The initiation of their treatment is sometimes delayed, and the provision of care is more limited for some patients. An Austrian study looked at the medical records of young people with a history of trauma of various kinds (“trauma-related disorder”) and compared the data between patients of Turkish origin in Austria and native Austrians. The natives received psychiatric and psychotherapeutic treatment more often (32.7%), whereas Turkish-speaking patients mainly received only psychiatric treatment (59). The delay in diagnosing psychological distress has often been pointed out.

It is difficult to name the bodily expression of psychological distress in medical diagnostic terms. This is not only true in the transcultural context. A systematic review of the literature on the subject revealed a great heterogeneity of names and very little use of the DSM-5 terminology: “disorder with somatic symptoms” (8). Similarly, the borderlines of this diagnosis, in psychopathological terms, are unclear. In particular, it is very strongly entangled with anxiety and depressive symptoms (85–89). The actual content of a diagnostic term to embody medically the somatic expressions of distress remains unclear.

Contact with the transcultural field makes these terms appear even more impoverished. In particular, no study in this review mentions the DSM-5 diagnosis, while only 10 referred to it in a review of this topic outside the transcultural field (8). In non-Western and migrant populations, it is only a question of “somatic complaints/symptoms” and “somatization.” Could the additional difficulty in naming come from a loss of our diagnostic reference points in a transcultural context? Might issues of discrimination, highly present in this review, have something to do with this additional difficulty in naming?

This review points to significant delays in diagnosing psychological distress, and vague and impractical approaches to treatment. The therapist's countertransference must then be questioned, particularly in relation to the patient's culture. This specific countertransference is defined as “the set of reactions of a person to the encounter with another person from another culture who enters into a relationship with him/her” (90). It is essential to be aware of “cultural coding,” i.e., the divergence of clinical manifestations and symptoms from one culture to another, and of the necessary “decentering,” that is, “to not interpret the unknown in terms of the known” (91). This countertransference is especially important to analyze, because there are necessarily traumatic elements (92).

A qualitative study of the experiences of health professionals would be useful to understand how they perceive the expression of somatic symptoms in the clinical populations they treat, specifically adolescents and young adults, according to the patient's cultural history. In a more cognitivist reading, it might be considered a question of analyzing these professionals' “implicit biases,” particularly in a transcultural context. That is, a doctor might systematically—illogically and irrationally—determine the importance of symptoms of the same nature according to characteristics, often cultural, of the person presenting them. Accordingly, a systematic review of 15 studies investigated the implicit racial and ethnic biases among health professionals (93) thought to be responsible for the inequalities in access to care, quality of care received, and health outcomes that people of color face in the USA. Although some associations between implicit attitudes and medical outcomes were not significant, the results showed that some of these attitudes were significantly related to patient-prescriber interactions, treatment decisions, treatment adherence, and medical prognosis. Are we dealing with racial prejudice (which can be explored through cultural countertransference or implicit bias) or with racialization/racization of patients? Racialization or racization in health care can take the form of “prejudice, clinical uncertainty, beliefs, stereotypes of care” on the part of health professionals (94). In addition, “communication problems between patient and provider” can contribute to health disparities (94).

Furthermore, we know that it is important to use the patient's mother tongue to access emotional subtleties as well as representations and body expressions. Thus, the use of interpreters is essential for diagnosis (95). But we also need to adapt our modalities of symptomatic assessment to the patient's culture—and do so without ignoring the transcultural principle of psychic universality. The Temas (Tell-Me-A-Story) developed in 1988 in New York by the Italian psychologist Giuseppe Costantino et al. (96) is an illustration of this: this projective and narrative test was invented in response to the observation that conventional tests did not always allow minorities living in the United States to verbalize their intrapsychic conflicts, as it was sometimes difficult for them to identify with the characters represented. Similarly, Fanon, a psychiatrist from Martinique who directed the psychiatric department of the Blida hospital in Algeria, sought to reconstruct personality tests or thematic perception tests that represented scenes that were incomprehensible to the local populations because of the inadequacy of the cultural references of the images presented (97). When questioning the symptoms coming from the body, it is necessary to know the representations of the body in the patient's culture.

The mediating role of somatic expressions between immigrant discrimination and externalized symptoms appears to be a particularly interesting theme observed in this review. One important theme of Fanon's work was precisely the link between alienation and violence. He contributed to the understanding of the psychology of oppression (98), in both his psychiatric and political reflections on the relations between White and Black individuals in the colonialist context of the time. He considered assimilation (which he had experienced in his natal Martinique and had fled) a form of alienation (99). According to Fanon, colonization freezes, blocks, and compartmentalizes the colonized; and for him any compartmentalization, in either the body or in thought, produces alienation. He thus analogized the impact of confinement in an asylum on psychiatric alienation and the impact of colonialism on historical alienation. This parallel is carried forward in an article dealing with migration in Italy (100), highlighting the impact of nationalist and xenophobic language on migrants and in particular on the violent radicalization of second- and third-generation immigrants. Compartmentalization in thought would thus produce physical and psychological effects of uneasiness.

Fanon presents himself as a man who has experienced how some people in a colonized society look at a man they call a “man of color” (101). Elaborating a phenomenology of colonized consciousness, describing the path of this consciousness that passes “from the desire for assimilation to negritude” [chapter 5 “The Fact of Blackness” (99)].

He speaks of a “corporeal schema, assailed at various points” and which “crumbled, its place taken by a racial epidermal schema.” He describes a day, when he had “to meet the white man's eyes…completely dislocated, unable to be abroad with the other, the white man, who unmercifully imprisoned me, I took myself far off from my own presence, far indeed, and made myself an object.” And further on he adds “My body was given back to me sprawled out, distorted.” (102). Violence is thus thought of as a reaction to a situation of confinement. We then witness an embodiment of the colonial gaze, internalized by the colonized, in the form of “muscular and mental rigidity” and at a certain point, a “motor crisis of dissolution” appears: this is when violence occurs (103). Through the incessant parallels that Fanon, the militant, draws to colonialist alienation, Fanon the psychiatrist illuminates his clinical observations: similar psychic and bodily effects on the human subjected to compartmentalization. And discrimination can indeed be considered to compartmentalize the person subjected to it.

The Subaltern Studies Group was a group of South Asian scholars interested in the postcolonial and post-imperial societies, under the leadership of Guha (104). Its work also sheds light on this topic of somatic expression of distress. The Indian philosopher Gayatri Chakravorty Spivak defined subalterns as “those who in official history are never allowed to speak” (105). The subalternist project was inflected in the late 1980s by several cross-influences; the first was Foucault's work (106), together with the epistemological relativism it engages, and the broad theme of the “power-knowledge” complex it proposes. Another influence was the work of Said et al. (107), whose influence spread rapidly in Indian historiography, taking, in particular, Subaltern Studies as its anchor. He inaugurated what was to become the postcolonial movement and demonstrated how Orientalism is a Western style of domination, restructuring, and authority. Thus, for Said, Orientalism is a scholarly but clichéd study of the East; it is also another way of dividing the world into two parts, one of which is dominant, as well as a modern way of manipulating the East for colonialist purposes.

The question of the unheard word, which makes subalterns people without identity and excludes them from discourses and representations, seems to us an important notion to discuss here, to help us understand the place that the body can take and the need to hear what it expresses. In her work “Can subalterns speak?,” a question that Spivak answers in the negative, she ends the essay with a narrative example: a situation where an Indian women (Bhuvaneswari Bhaduri) 16 or 17 years old, has tried with all her might to speak, to the point of making her suicide a message whose reach will be prevented (including by her own family which presented it as the consequence of an illegitimate love) and which will only be transmitted thanks to the philosopher's analysis of the fact that she had killed herself while menstruating. Indeed, almost 10 years after her suicide, it was discovered that “she was a member of one of the many groups involved in the armed struggle for Indian independence. She had finally been assigned a political assassination. Unable to confront the task [of assassination that had been entrusted to her] and yet aware of the practical need for trust, she killed herself” (105).

Spivak hypothesizes a rewriting of the social text of sati-suicide in an interventionist way: “she generalized the sanctioned motive for female suicide by taking immense trouble to displace (not merely deny), in the physiological inscription of her body its imprisonment within legitimate passion by a single male... The displacing gesture-waiting for menstruation-is at first a reversal of the interdict against a menstruating widow's right to immolate herself; the unclean widow must wait, publicly, until the cleansing bath of the fourth day, when she is no longer menstruating, in order to claim her dubious privilege” (105). Spivak tells her critics that some mechanisms of discrimination do not refer to subalternity, especially if they can be resolved through speech, within a hegemonic discourse. As she makes clear, “when we say ‘cannot speak', it means that, if ‘speaking' implies speaking and being heard, this possibility of a response, responsibility, does not exist in the sphere of the subaltern” (105). Thus, in the subject that interests us and inspired by this work on subalternity, we hypothesize a somatic translation occurs because verbal expressions of the experience of discrimination is impossible and cannot be heard.