At the end of 2024, approximately 123.2 million people worldwide were forcibly displaced or stateless due to armed conflicts, violence, and human rights violations. Germany was the third largest recipient of new individual applications worldwide (1). The largest group consisted of Ukrainian nationals, followed by individuals from Syria, Afghanistan, Iraq and Turkey. These five nationalities accounted for nearly three-quarters of all protection seekers residing in Germany (2). Approximately 50% of the refugees worldwide are estimated to be girls and women (1); however, the majority of refugees arriving in Europe –with exemption of Ukrainians- are male (2). Two potential reasons for the gender gap are: high smuggling costs prevent families from fleeing together, and many choose to protect women and children from the dangerous journey. Also, women are not allowed to travel alone and families often sent one man ahead, hoping to reunite later through legal family reunification. Men leave the country to evade compulsory military conscription or as a consequence of having deserted military service (3, 4).

While these figures highlight especially the scale of female refugee displacement, there are gender specific implications. Besides common war and conflict related stressors like lack of shelter, food or hygiene facilities there is a wide range of traumatic events and trauma types that in particular, women frequently experience: Severe war-related trauma such as torture, imprisonment, and life risk (5) as well as sexual or gender-based violence (6). Twice as many women reported exposure to family violence and sexual abuse compared to men (7). Female refugees also face social repercussions, including rejection or isolation, discrimination (e.g. for wearing a veil), divorce, abuse, “honor” crimes, and ostracism (8). Without a partner, they often lack protection and social support (9–11). A person’s vulnerability to developing mental disorders is increased by exposure to traumatic events (10).

Traumatic experiences have profound implications for mental health outcomes. Refugees suffer more often from mental health disorders as compared to the general population. In post-conflict settings, more than one in five people show signs of mental health problems (12). In response to pre-, peri- and postmigration trauma and acculturative stress, they can develop a wide range of emotional, cognitive, physical, behavioral, and social problems and have high prevalence for mental disorders (8, 13–17). As we previously reported (18), cumulative exposure to potentially traumatic events strongly associated with depression (13, 19, 20), somatization (21) and Posttraumatic stress disorder (PTSD) (22). The risk to develop the latter is influenced by the type of trauma, for example interpersonal violence or self-experienced traumatic events (15, 23). However, prevalence estimates vary greatly (24), possibly due to methodological differences and refugee characteristics (25).

These mental health challenges are frequently expressed through somatic complaints highlighting the complex interplay between mind and body in refugee populations. Somatization describes the expression of physical symptoms that a medical examination cannot explain (26). While PTSD, depression, and anxiety are well studied, there is little research on somatic symptoms, although somatic stress disorder is also related to trauma exposure (26–28), emotional distress and problems in functioning. Somatization is very common among refugees and often drives their increased utilization of health services, to address apparently physical complaints (29). For example, Syrian participants reported various somatic symptoms, like cardiovascular and pulmonary symptoms, severe pain in different body parts, hair loss, or even unfulfilled desire to have children (30). Yazidi women who escaped from the Islamic State (IS) reported feelings of suffocation, movement disorders, back pain, headaches, internal pain, heavy movement, heavy legs, kidney and eye problems, hair loss and anger (31).

The challenge of distinguishing somatization from other mental illnesses highlights the complexity of mental health evaluations in refugee populations. Symptoms of PTSD, anxiety, depression, and somatic symptoms can cluster, making differentiation between the different entities difficult (29, 32, 33). The frequent co-occurrence of psychological distress and pain is driven by complex mechanisms that are likely bidirectional and influenced by both genetic and environmental factors (34). Somatization is often associated with trauma, but the causal direction of the correlation between PTSD and somatization is unclear and there is uncertainty about the presence of a potential third mediator variable. One hypothesis is that psychological stress caused by PTSD increases the vulnerability to develop somatic symptoms (35). Somatization might also be the preferred suffering expression mode in certain populations (36). Another hypothesis is that past traumatic bodily experiences are stored in memory and influence the development of somatic symptoms (37).

Traumatization may lead to mental health challenges including somatization, consecutively impacting the quality of life for refugees. Increased mental health disorders and somatic complaints could be a reason why refugees experience lower quality of life compared to international population norms. For example, high somatization of mental disorders or current physical pain due to past torture experiences might explain lower scores in the physical health domain of quality of life (38, 39). Furthermore, the relationship between trauma and quality of life was mediated by somatic complaints among Tunisians during the Arab Spring and among Ivorian Refugees (40).

Being a woman is a significant and common sociodemographic risk factor among refugees (29). Female refugees and asylum seekers report more frequent and severe somatic, depressive, and anxiety symptoms compared to males (33, 41, 42). Female refugees are a vulnerable group and Vallejo-Martín et al. (23) propose several reasons why addressing their mental health in studies must be done sensitively and with care: The risk of traumatization, concentration problems, language barriers, discrimination, social rejection, or addressing taboo topics like rape and sexual assaults (23). Research on women remains underreprensented. This underscores the importance of focusing research and interventions on female refugees, whose unique experiences and mental health needs often differ significantly from those of their male counterparts.

The relationships between trauma, mental health problems and quality of life in female refugees is not well understood. This study aims to explore the influence of sociodemographic variables and cumulative traumatic experiences on the severity of mental distress, somatization, and life quality. Furthermore, we examine the link between experienced traumatic events, somatization, psychological distress, and quality of life. Though similar relationships have been explored in the literature, this research seeks to shed new light on the complex interplay between these variables, offering an original angle by examining sequential mediation effects. We hypothesized that traumatic experiences, somatic symptoms, and psychological distress would be associated with a lower quality of life. We also predict that somatization and psychological distress have mediating roles in the relationship between trauma and quality of life.

This study investigates the relationships between traumatic events, somatization, psychological distress, and quality of life of female refugees residing in Germany. We demonstrated that somatization and psychological distress have an influence on the relationship between trauma and quality of life. In this context, it’s important to highlight the observation established through serial mediation suggesting that cumulative trauma may impact quality of life sequentially by first influencing somatization, which then appears to influence psychological distress. A further result is that cumulative trauma emerges as the key predictor of increased somatization, psychological distress and reduced quality of life.

The finding that somatization and psychological distress independently mediated the relationship between trauma and quality of life, aligns with our initial research question and supports existing results by other researchers (36, 40, 71, 72), showing that a higher number of traumatic events is associated with somatization as well as psychological distress and further leads to lower quality of life. But beyond that, our study reveals that cumulative trauma affects somatization, which in turn influences psychological distress and finally contributed to a lower quality of life. This result suggests that it is important for clinicians to take into account the centrality of somatization for mental health, particularly since somatic symptoms often manifests as the initial presentation to clinicians. (29). Healthcare providers need to expand their understanding of the co-occurrence and potential interplay between psychological and somatic symptoms, especially when treating traumatized refugee patients. This may help to reduce misdiagnoses or failed treatment attempts due to unclear somatic symptoms. Clinical assessments should be broadened to incorporate integrated screening for both somatic and psychological distress (34).

The number of medically unexplained physical symptoms among refugees from non-Western countries is generally higher than among the general population (26). It is well-documented that PTSD coexists with somatic symptoms within the population of refugees. The association between PTSD and somatization is complex and not fully understood. It is possible that injuries suffered in traumatic events, such as torture or violence, explains this relationship, at least in part (73). Our previous study found that in addition to the overall level of trauma exposure, family violence experienced by refugee women played the most significant role in contributing to various symptoms, highlighting the critical impact of interpersonal trauma and insecurity (74). Within the current study, we did not differentiate between types of trauma and therefore can´t assess specific effects of family violence and other traumatic events.

Pain and distress are expressed in culturally specific ways, influenced by local beliefs, stigma, and accepted norms of suffering. In Syrian idioms of distress, for instance, the body and soul are seen as deeply interconnected, with physical symptoms often serving as valid expressions of emotional or psychological pain (34). Similarly, Hinton and Bui (75) show that experiencing of trauma differs radically across cultural groups, shaped by both universal and culturally specific dimensions of psychopathology. Their cross-cultural model, based on Cambodian populations emphasizes the importance of somatic symptoms, cultural syndromes, catastrophic cognitions, and culturally patterned worry and implies that trauma experience and recovery varies locally (75). Refugees may explain symptoms in ways that western professionals interpret as somatization (76) or nonspecific symptoms of PTSD. And, similar to torture survivors, pain from violence may be under-assessed (77).Our sample did not undergo a medical physical assessment. It is possible that participants in our sample still suffered from physical pain due to injuries experienced in their country or in flight, which was evaluated as somatic pain in our study.

This finding has implications for the diagnosis and treatment of refugees. Diagnosing and treating this population with the necessary sensitivity requires a deep and comprehensive understanding of women’s experiences of war and flight, as well as knowledge of partner and family violence. For the health assessment, the support of interpreters and written evaluation instruments in the native language is necessary. In the case of acute and chronic pain, a physician should give a clear assessment. The multifaceted aspects of chronic pain, pain physiology, mechanisms for chronification, and biopsychological model should be understood by the clinicians. Furthermore, the consequences of trauma and violence on mental health should be addressed and communicated in an understandable way to female refugees. This means that treatment options should be provided, and pain rehabilitation should be an option (76).

A recent meta-analysis by Sambucini et al. (78) on 52 studies spanning 24 years assessed the effectiveness of psychological treatments, for depression anxiety and somatization in migrants, including refugees. Cognitive-behavioral therapy emerged as the most effective. Notably, the number of studies addressing somatization were limited and underscore the necessity for additional research to evaluate the efficacy of psychological treatments for somatization in refugees (78). This is supported by a systematic review and network meta-analysis of 103 studies on psychosocial interventions for migrants which reported promising effects on PTSD, depression, and anxiety. However, due to generally low confidence in the evidence, no clear conclusions could be drawn (79).

We postulate that there is a bidirectional relationship between somatization and depression. In our mediation models, increased psychological distress is associated with increased risk for somatization and vice versa. This is in accordance with research showing that somatization and depression are often comorbid, but the causal direction is not clear (26, 29, 32–34).

As we found that cumulative trauma affected somatization, which in turn influenced psychological distress and finally contributed to a lower quality of life. Interestingly, the reverse prediction that cumulative trauma would influence quality of life via psychological distress and somatization was not supported. This sequence, where somatization comes before psychological distress, appears most compelling and may reflect a key pathway for early detection and intervention, with important implications for both research and clinical practice. A reason for this might be that somatic symptom disorder is characterized by enduring physical symptoms, which are not always attributed to a recognized medical condition (73). The inability to attribute pain to a physical cause and thus remain unexplained could trigger excessive thoughts, anxiety, and/or behaviors that lead to considerable distress.

We further found that the number of traumatic events was the most important predictor across all dependent variables. Also, the result that cumulative trauma is a predictor of somatization is consistent with previous findings (21). We confirmed that an increase in the number of traumatic events led to a higher overall psychological distress (10, 14) as we already reported in a previous study (18), which supports the dose-effect relationship hypothesis of cumulative trauma on psychiatric symptoms (9, 80). The quality of life decreased with an increasing number of traumatic experiences, which is consistent with a previous study (72) and has been confirmed in the serial mediation analysis.

Counterintuively, lower quality of life was also linked to higher education. Atrooz et al. (81) identified higher education as a key protective factor against psychological distress among Syrian female refugees, suggesting that it could serve as a buffer against mental health challenges (81). One possible explanation for our contrasting result is that highly educated female refugees face distinct disadvantages and systemic barriers in the labor markets such as job downgrading and economic penalties (82). In addition, they are more vulnerable to negative effects of discriminatory social attitudes, which can further diminish their overall quality of life (83).

The results of our study need to be interpreted with consideration of several limitations. First, we used cross-sectional data. The participants in our study represent women living in German facilities with a high probability of being granted a successful decision on their asylum applications. Further, this study focused exclusively on females, and the findings cannot be generalized to males — who represent the majority of refugees in Germany — as gender differences in mental disorders have been documented both in the general population and specifically among asylum seekers and refugees in prior research (84). The generalizability of the findings into groups living under other conditions, e.g. with less certainty in regard to their future, is therefore also limited.

The participants of our study had to fill out questionnaires. Participants from these countries who did not speak one of the target languages (e.g. Pashto or Kurdish speakers) were excluded based on the language inclusion criteria. Although questionnaires were translated and back-translated, there are still language differences due to various dialects or language comprehension. Illiterate women completed the questionnaires with the help of interpreters. Even though they were trained, the face-to-face situation is often intense, which might have influenced the interpreters, potentially affecting their objectivity and ability to maintain scientific detachment. Furthermore, the instruments used in our study are developed by western standards. There might be other culture-bound symptoms which can be seen as somatization symptoms or symptoms of distress that were not considered in our study. Therefore, instruments that are validated for different ethnic, cultural and language backgrounds are needed.

The countries of origin of the study participants are predominantly Islamic (85, 86). Therefore, the results cannot be readily generalized to female refugees from non-Muslim countries, such as Ukraine, where Christianity is the predominant religion (87). Our approach assessed questionnaire-based symptoms, appropriate to an overall epidemiological picture, but not for precise individual diagnosis. For a deeper understanding, an additional diagnosis of PTSD could provide more information, as participants reported traumatic events, which could also result in PTSD. It is also important to know whether the traumatic experiences occurred recently or much earlier in the participants’ lives. However, even after arriving in the host country, refugees face numerous challenges that affect their mental health, resilience, and quality of life such as the asylum process, language barriers, forced family separation, financial hardship, housing difficulties, cultural dissonance, discrimination, and everyday racism (88–90). These post-migration stressors should be systematically considered in future research.

Future research should focus on predictor variables investigating the relationship between trauma type and somatization symptoms and psychological distress. There is especially a need for more longitudinal high-quality research and further evaluation across diverse settings and populations. This study especially sheds more light on the psychological well-being of female refugees and highlights the need to include the gender perspective in diagnosis and intervention strategies.

Our research sheds light on the internal process through which traumatic events affect quality of life in female refugees. Inparticular, the impact of traumatic experiences on somatization and psychological distress leading to a reduced quality of life and worse mental health.

The finding is of high clinical relevance and highlights mechanisms of impaired quality of life in refugees. Therefore, when asylum seekers and refugees disclose trauma-related experiences, clinical assessments should be expanded to include integrated culturally sensitive tools screening for both somatic and psychological distress. Clinicians must be aware that the experience and expression of trauma can vary significantly across cultural groups and gender. They should also be particularly attentive when physical or somatic symptoms are reported, as these may indicate underlying traumatic experiences. Further studies should investigate more details of the interplay of somatization and distress. In particular, they should include more groups of refugees, as we only examined a selected number of countries of origin, and incorporate futher assessment of traumatic experience, for example including partner or domestic violence.