Which of the following is found by anthropologists to be a common reason for body decoration?

Tattoos and Body Piercing

Body modification via tattooing and piercing has been an increasingly popular means of expression in today's society. With constant visual reminders from professional athletes to celebrities on television, the practice is certainly more mainstream and not relegated to any particular ethnic group, gender, or age demographic.

Mayers and colleagues42 performed a survey study on undergraduates at an American university that used a questionnaire on a voluntary and anonymous basis to inquire about age, sex, body piercing and tattooing at various body sites, and any complications associated with these practices (women were specifically asked not to include pierced earlobes). There were 454 completed questionnaires from 218 men and 236 women, accounting for approximately 15% of the total undergraduate population, and the average age of the respondents was 21 years. Body piercing was found to be present in 42% of men and 60% of women undergraduates, with 315 piercings in 229 students, with a maximum of five piercings. In men, 31% had pierced ears, with tongue, eyebrow, nipple, genitals, and navel in 2% or fewer for each. Additionally, 7% of students had ear piercings removed, and tongue, nipple, and navel piercings had been removed in 2% or fewer. By comparison, 29% of women had pierced navels, 27% had pierced ears (excluding pierced earlobes), 12% had a pierced tongue, and 5% had a pierced nipple, with genitals, nose, or lip in 2% or fewer. Additionally, 4% of those surveyed had tongue piercings removed, 3% had navel piercings removed, and ear, eyebrow, nose, lip, nipple, and genital piercings had been removed in 2% or fewer.

Complications were reported in 17% of piercings, the most common being bacterial infections, bleeding, and local trauma. No cases of viral infection (e.g., hepatitis B or C, human immunodeficiency virus [HIV] infection) were reported. Tongue piercing was associated with subsequent oral or dental injury in 10% of students surveyed. Tattoos were found to be present in 22% of men and 26% of women undergraduates, with one to three sites per individual. Common sites of tattooing for men were hand or arm, back, and shoulder, and the back was the predominant site for women. No complications from tattooing were reported in this study.

In 2006, a dermatology group from the University of Chicago performed a national survey to obtain demographic data on the practice of tattooing and body piercing in the United States.43 In reviewing the 500 interviews completed, the researchers were able to obtain a fairly representative sample of a cross-section of the US population. In this study, 24% of the 500 surveyed had at least one tattoo and 14% had at least one body piercing, with 8% having both. Tattoos were fairly equally distributed among men and women, but body piercings were statistically more common in females versus males. The proportion of respondents who either had received or had considered getting a tattoo and/or body piercing increased as the demographic became younger.

A study by Armstrong44 conducted at a Midwestern military installation surveyed 1835 recruits with a questionnaire regarding tattooing experiences. Almost half (48%) of the soldiers were either serious or very serious about getting a tattoo, with 31% stating that there were “no reasons” to keep them from getting one. More than one third (36%) already had a tattoo, and 22% possess three or more. Many soldiers (64%) entered the military already having tattoos. Limited use (15%) of alcohol or illicit drugs before tattooing was reported. Overall, the study findings included a high incidence of tattooing, a strong determination to obtain tattoos, the possession of tattoos for self-identity reasons, and the supportive role of friends.

Tattoos and body piercing are not without risks. Tattooing has been implicated in the transmission of hepatitis B, hepatitis C, and syphilis45–47; the literature is less definitive on HIV transmission via tattooing. However, situations of increased risk can be defined. For example, tattooing in prisons is often performed with nonsterile equipment48 in a setting where the presence of confirmed acquired immunodeficiency syndrome is 3.5 times higher in comparison with the general population.49

Body piercings can lead to a variety of complications depending on the site that is pierced. As piercings become more common, many persons have recommended that healthcare providers become familiar with health risks so that they can better counsel their patients. Some complications are present regardless of site, including allergic reaction (especially to nickel, often used in jewelry), local infection, swelling, pain, hematoma formation, trauma from accidental pulling of the jewelry, and keloid formation.50 More specifically, oral piercings can lead to trauma to the teeth (e.g., chipping and fracturing) and damage to the gingival tissue.51 Naval piercing can lead to scarring of the skin. Genital piercings can lead to significant infection, paraphimosis in men, or failure of barrier contraceptives.50

In addition to counseling for negative health consequences, healthcare providers should also observe for risk-taking behaviors associated with tattoos or body piercings. One survey of adolescents between the ages of 12–22 years showed that those with a tattoo and/or body piercing were significantly more likely to engage in drug abuse, sexual activity, disordered eating behavior, or suicide.52 However, the literature is not consistent regarding this association. Another study tried to correlate healthy behavior with fewer tattoos and/or body piercings but could not find such a correlation. More significantly, a larger than expected portion of respondents in this study had not considered health risks, and those who were aware of health risks cited only localized infection as the major adverse effect, without consideration for transfusion-transmitted viral diseases associated with tattoos and body piercing.53

With the increasing popularity of tattoos and body piercing, some researchers have advocated the regulation of facilities that perform these services. Currently, there is little uniformity for regulation across the United States. A 1998 survey of all 50 state health departments plus that in the District of Columbia showed that the vast majority of states perform only cursory regulation at a local level. Only 13 states have regulated tattoo facilities, and only four states have regulated body piercing facilities.48 The task of developing and enforcing a consistent and uniform policy and agreeing on the literature is challenging. For example, in the Morbidity and Mortality Weekly Report from 199854 focusing on recommendations for prevention and control of the hepatitis C virus, the CDC stated that insufficient data existed in the United States to link tattooing and body piercing to an increased risk of hepatitis C infection. A subsequent investigation argued that this report did not have the benefit of tests developed to detect subclinical hepatitis C infections at that time. With the advent of more sensitive and specific testing methodologies, a strong link between tattoos and hepatitis C seropositivity was noted, leading the authors to advocate more strict regulation and inspection of facilities and practices.55

Although it is not possible at the present time to predict how many persons will contract a serious viral infection from body piercing or tattooing, we do know that there may be an increased risk depending on the procedure used and the setting. In the meantime, although some fear that a significant public health problem may be surfacing, persons considering tattooing and/or body piercing should be aware that there may be risks. Both on the federal and state levels, it is believed that this industry should be carefully regulated, single-use sterile devices should be mandatory, and hepatitis B vaccination for those performing the procedures should be standard policy.

Abstract

Circumcision may be undertaken as a body modification of the genitals to change the look of the penis to appeal more to certain aesthetics, but sometimes it may leave a permanent change of the natal characteristics of a body part, which will ever be subject to dispute, particularly from the cosmetic point of view. Many complications may result after nonaesthetic preputial cutting or the unhealthy healing of the circumcision wound. These complications usually manifest late, weeks or months after the procedure, and result in early family dissatisfaction and later on have a psychic impact on a man's satisfaction with his penis and may lead to loss of self-esteem.

Intraoral and Perioral Piercings

A growing interest among adolescents is body modification through intraoral and perioral piercings. This mode of self-expression carries risks and complications not typically experienced with more traditional types of body piercings. The increase in complications is related to the fact that these piercings involve violations of bacteria-rich mucosa that is more sensitive to disruption than would be dermal tissue. Complications can be categorized as immediate or delayed, as well as localized or systemic. Immediate complications occurring at the time of piercing include pain, excessive bleeding, and nerve damage causing immediate paresthesia. It is also possible that infectious diseases, such as hepatitis B and C, and microorganisms responsible for the development of cellulitis and bacterial endocarditis could be introduced at the time of piercing through improper aseptic techniques. Delayed complications include the formation of tissue defects both at the site of the piercing and on tissue adjacent to the jewelry. Ninety-seven percent of patients reported some form of delayed complication.31 Fractured teeth, allergic reactions to metals, ingestion and aspiration of jewelry parts, dysphasia, masticatory problems, and hypersalivation are additional complications that have been attributed to intraoral and perioral piercings.32

Although numerous case reports are available on the subject of complications associated with intraoral piercings, relatively few large studies have investigated the subject. What studies are available reveal a strong correlation between piercings and specific types of dental injuries and pathologic conditions. The most commonly reported dental conditions include fractured teeth and the development of mucogingival defects. Loss of tooth structure due to attrition or fracture has been reported to be as high as 80% in individuals with pierced tongues (Fig. 39.5).33 Similarly, studies have reported that 19% of individuals with pierced tongues experienced some type of gingival recession.34

Because of the high incidence of complications associated with perioral and intraoral piercings, dental professionals should react proactively to those adolescents contemplating piercings. Increasing social acceptance is making it hard to identify those adolescents at risk. Therefore dental professionals should include a discussion of the complications of perioral and intraoral piercings as part of their routine prevention program aimed at all adolescents. Those adolescents who present with existing piercings should be counseled as to their risks and possible complications. Because of the rapid development and progression of tissue defects related to piercings, it may be best to keep individuals with existing piercings on shorter recall schedules than what might otherwise be dictated from their caries risk assessments.

Alternative Perspectives on DSH: Cross-Cultural and Historical Examples

Skin cutting, excoriation, and other forms of dramatic body modification have long and varied cultural histories. Practices such as head deformation, scarification, foot binding, tooth filing, lip plates, nose rings, tattoos, subincision, and genital cutting have roots reaching back as far as 30 000 years. Cutting, burning, piercing, stretching, scarring, and tattooing of the skin are central in many cultures as parts of rites of passage, marking the transition from childhood to adulthood. Often, physical pain and the shedding of blood enfold powerful symbolic significance, linking the initiate to generations upon generations who have undergone such rituals. In his classic work on rites of passage, anthropologist Victor Turner argued that these rituals – especially when tied to puberty – crystallize and communicate key cultural meanings about proper selves, and work to move the initiate from one socially recognized state to another.

Cutting and excoriation are also often linked to practices of health and healing. ‘Bleeding’ patients was a common medical practice in Europe and the United States well into the 1900s, and the use of leeches, cupping, and other skin-abrading techniques are still used throughout much of the world today. The idea of purging or cleansing the body through the shedding of blood or other bodily fluids is deeply ingrained in the human cultural repertoire and imagination.

Similarly, the practice of shedding blood to expiate guilt, relieve sorrow, or attain spiritual advancement is found cross-culturally and cross-historically, and is not generally considered to be indicative of pathology. In fact, it is often revered. For example, during puberty rituals in New Guinea, young men traditionally pierce the foreskin of the penis to symbolize shedding the blood of their mothers’ wombs. Moroccan Hamadsha excoriate their skin with whips or knives during ecstatic dance in order to become closer to the gods. Medieval Christian monastics regularly drew blood during penitential devotions for their own sins and those of humankind. The Plains Indians endured hooks through the flesh (with ropes attached to a pole) as testament to purity of heart. Thomas Jefferson bled himself nightly by cutting his forearms with a knife in a practice of mourning and grief. In each of these cases (and in hundreds of others in the human cultural record), we find common elements of pain, blood, atonement, ideas about change or transformation, and a marking of the body as a stand-in for nonmaterial realities. And in each case, harming the body is not merely about destroying the physical body (although that is certainly relevant in different ways in different contexts); rather, it is also about creating a new mode of being in relation to powers outside the self. This creative potential of harming the body is discussed in detail below.

From a cultural relativist perspective, then, body modification or self-harming behavior is not necessarily pathological as long as it is socially normative and articulates to socially recognized categories of being. But ‘self-harm’ in the contemporary clinical sense is decidedly nonnormative for the general public. This has led to its characterization as an individual dysfunction rather than social practice, and has kept the social and cultural dimensions of the practice largely unexamined.

Body Modification

Self and body do not align themselves in every society in the way assumed by European jurisprudence and psychology. Yet, this does not mean that body size and shape are inconsequential in other regions. Early European explorers were impressed, and sometimes repelled, by the bizarre (to them) appearance of non-Westerners, which became a potent sign of savagery, animality, or simply otherness. Anthropologists and others have since documented a remarkable range of body modification practices. In fact, the prevalence and antiquity of body modification suggests that it is a near universal.

Body modification, however, has often had a special, morally contentious position in the Judeo-Christian tradition, which can subtly influence interpretations of non-Western practices. In Jewish law, the body belongs to the Creator and is only on loan to the person, who becomes its guardian. Many kinds of interference with the body, dead or alive, are prohibited or restricted, such as mutilation, tattooing, shaving, and cremating the dead. Christian ethics often views bodily display and decoration with suspicion. And later Renaissance and Humanistic thought and art privileged bodily integrity and idealized the unadorned form.

This moral and aesthetic tradition departs markedly from what is found in many non-Western societies. The work of the anthropologist Mary Douglas has influenced many interpretations of body symbolism. She argues that the body is a microcosm of society. Rituals that decorate, mark, or protect the body reflect social meanings and conflicts. An Australian indigenous practice of splitting the penis in half lengthwise symbolizes the two moieties of the group, she argues (and not castration anxiety, as a psychoanalyst had suggested). Many forms of body modification convey messages about individual or group identity. Often, they are performed at life cycle events. Among the Sudanese Nuba, scarification is divided into stages that signal a woman’s passage through puberty and motherhood. In initiations for girls and boys, the ability to undergo intense pain can signal a capacity to take on the adult roles of mother or warrior. Decorations can also symbolize individual accomplishments, such as the number of enemies killed.

While anthropological studies often emphasize the function and social symbolism of body modification, they may minimize its undeniably erotic and aesthetic significance. The European corset was – among other things – an instrument of erotic body sculpting. The garment thrust the breasts up and accentuated waist to hip contrasts. Similar kinds of body swelling are found in other societies too. Some groups in Guyana tightly bind the legs of young girls below the knee to create an attractive shape. Male corsets or belts have been used in West Africa and the Pacific to emphasize the contrast between a slender waist and prominent buttocks or shoulders. The Chinese bound foot – with its hoofed, animal-like appearance – was an erotic fetish.

Thus while body modification often has multiple meanings, its primary aim is sometimes aesthetic and erotic enhancement. The Tiv of Nigeria chip their teeth and create elaborate patterns of scars on their bodies. They deny that these are tribal marks and instead say their purpose is simply to make themselves more attractive. Scars enhance an individual’s best traits. A man with ‘good legs’ (full calves and prominent heels) will have scars applied to draw attention to them. Often rubbed with oil and red dye until they ‘glow’, scars have a strongly erotic attraction. Areas of skin that have been scarred are sensitive and erogenous, and a woman with scars on her belly is said to be both more fertile and sexually demanding.

In the West, body modification and decoration are often viewed as primarily a female and feminized activity. In the nineteenth century, as men adopted the somber suit, aesthetic expression and cosmetics were often seen as the domain of women. But in some non-Western societies, beauty is equally a male concern. The courtship dances of the Papuan North Mekeo center more on male than female erotic allure, for example. And the West African Woodabe practice a ritual courtship dance that functions in effect as a male beauty contest. Young men apply yellow powder to lighten the skin and black kohl to highlight the whiteness of eyes and teeth. Hair removal emphasizes a high forehead, a desired trait. These transformations function much like Western cosmetic practices; rather than decorate the skin, they enhance desirable traits. The men’s beauty and dancing are then judged by young women.

Non-Western body modification and theories of the body have been in flux due to colonialism, religious conversions, and other forces of globalization. Under the influence of Christian missionaries, some groups have given up practices they now regard as primitive or savage. National governments have repressed some harmful practices, such as foot binding and cranial shaping. Other kinds of body modification, however, have experienced a revival. Tattooing is now flourishing in the Pacific. Europeans too have long borrowed body modification practices from colonized peoples. In the eighteenth century, sailors brought Polynesian tattoos to Europe. In recent decades, ‘modern primitive’ subcultures seek inspiration from tribal body piercing, tattooing, and scarification.

Contemporary Blood Rituals

Across cultures and throughout history the one practice common to all religions is sacrifice and the most potent form of sacrifice is achieved through blood rituals. Whether animal or human, blood historically is the mandatory substance for religious ritual and sacrifice is the ultimate religious experience. Historically people attributed sacred and magical qualities to blood, and blood rituals entailed everything from drinking, pouring on the body, and a variety of uses in ceremonies. In some cultures it was believed that drinking the blood of a victim would endow you with his/her strength; similarly, in drinking the blood of an animal you would acquire its qualities. Today there is a revival of magical ideologies that entail a variety of individual and group blood rituals. The most familiar examples are evident in the current popularity of tattooing, piercing, branding, and body modifications. These and other forms of self-mutilation comprise the basic prerequisites for entry into the contemporary subcultures of modern primitives, the body modification movement, vampire culture, and the fetish scene. The modern primitive movement is a term that is used in the avant-garde art world to refer to visual artists who distort, manipulate, mutilate, and mark their bodies as a form of ritual performance. The modern primitive movement blends tribal traditions with technology to combine magic and science. The body modification movement includes people who are involved in piercing, tattooing, branding, implants, and extreme body modification but do not have a unifying ideology. They differ from modern primitives who claim their performances are a spiritual experience of transformation. Vampire culture is the fastest-growing manifestation of the occult and entails the practice of what is referred to as “blood sports” – the exchange of blood for both ritual and sexual purposes. Finally the fetish scene entails nightclubs where members of all of the previously described movements come together to engage in all manner of sadomasochism, sexual bondage, and blood rituals. Acts of self-mutilation include everything from cutting the body with razors, burning the flesh, having nails hammered through limbs, being suspended from the ceiling with hooks attached through the skin, being pierced with heavy weights, having objects implanted under the skin, and self-amputation. Every kind of body modification imaginable is being performed, sometimes resulting in death.

When analyzing ritualistic forensic evidence it is important to distinguish mutilations that are the result of willing participation in the many new subculture trends of self-mutilating the body or unwilling victims of group religious rituals and individual occult crimes. This can be accomplished by distinguishing between the types of crime scenes, victimology, and trauma associated with particular occult traditions. There are distinct and discernible forensic differences in the blood rituals, animal and human sacrifices perpetrated by practitioners of Vampirism, Santería, Voodoo, Palo Mayombe, Satanism, serial killers, and natural animal predators.

Contemporary Blood Rituals

Across cultures and throughout history the one practice common to all religions is sacrifice and the most potent form of sacrifice is achieved through blood rituals. Whether animal or human, blood historically is the mandatory substance for religious ritual and sacrifice is the ultimate religious experience. Historically people attributed sacred and magical qualities to blood, and blood rituals entailed everything from drinking, pouring on the body, and a variety of uses in ceremonies. In some cultures it was believed that drinking the blood of a victim would endow you with his/her strength; similarly, in drinking the blood of an animal you would acquire its qualities. Today there is a revival of magical ideologies that entail a variety of individual and group blood rituals. The most familiar examples are evident in the current popularity of tattooing, piercing, branding, and body modifications. These and other forms of self-mutilation comprise the basic prerequisites for entry into the contemporary subcultures of modern primitives, the body modification movement, vampire culture, and the fetish scene. The modern primitive movement is a term that is used in the avant-garde art world to refer to visual artists who distort, manipulate, mutilate, and mark their bodies as a form of ritual performance. The modern primitive movement blends tribal traditions with technology to combine magic and science. The body modification movement includes people who are involved in piercing, tattooing, branding, implants, and extreme body modification but do not have a unifying ideology. They differ from modern primitives who claim their performances are a spiritual experience of transformation. Vampire culture is the fastest-growing manifestation of the occult and entails the practice of what is referred to as ‘blood sports’ – the exchange of blood for both ritual and sexual purposes. Finally the fetish scene entails nightclubs where members of all of the previously described movements come together to engage in all manner of sadomasochism, sexual bondage, and blood rituals. Acts of self-mutilation include everything from cutting the body with razors, burning the flesh, having nails hammered through limbs, being suspended from the ceiling with hooks attached through the skin, being pierced with heavy weights, having objects implanted under the skin, and self-amputation. Every kind of body modification imaginable is being performed, sometimes resulting in death.

When analyzing ritualistic forensic evidence it is important to distinguish mutilations that are the result of willing participation in the many new subculture trends of self-mutilating the body or unwilling victims of group religious rituals and individual occult crimes. This can be accomplished by distinguishing between the types of crime scenes, victimology, and trauma associated with particular occult traditions. There are distinct and discernible forensic differences in the blood rituals, animal and human sacrifices perpetrated by practitioners of Vampirism, Santería, Voodoo, Palo Mayombe, Satanism, serial killers, and natural animal predators.

Gender Transition Health Care, Including Hormonal Supplementation, Should Be Reassessed Across the Life Span

During the gender-transition process, the focus of the patient and his helping professionals often narrows to the immediate medical and social exigencies of the transition itself. (Is adequate physical transition being safely achieved? Is it time to inform the patient's employer of the change in identity, and is the patient emotionally prepared to do this?) However, once body modification has been accomplished, the focus of both medical care and social development must shift to a more long-term perspective.

Patients should be advised early in treatment that health maintenance is a lifelong process. Transsexual men have the same need for preventive care as their non-transsexual peers. In addition, decisions regarding use of hormones will need to be periodically revisited during mid life and older age. Testosterone production declines by approximately 50% between the ages of 30 and 80 years among natal males,124 and the appropriateness of routine androgen supplementation for older men is currently a matter of debate.117,124 Gradually reducing testosterone dosage as the transsexual man ages has intuitive appeal, but evidence regarding best practices in this regard is currently lacking. Physicians and their transsexual male patients will need to reassess the practical aspects of hormonal care in the years ahead, as the current cohort of transsexual men ages and as better evidence-based practices are defined.

Appearance as Indicative of Group Membership

Cultural anthropologists have extensively studied how appearance may signal group membership or identity. Group membership may be voluntary or involuntary. In multiple groups in West Africa such as the Mende of Sierra Leone, youth experience scarification to mark their full adult belonging to certain tribes. This change in appearance is highly valued and desirable as it commands a different set of social relations and status. In a related example of youth-driven rather than adult-sanctioned body modification, youth identifying with particular subcultures in industrialized nations as diverse as England and Korea have been found to initiate piercings or tattoos to index membership. Body adornment and grooming are also strong signals of group membership around the world in addition to body modification.

Some signs of identity signaled by appearance are involuntary. This may be due to structural inequalities, disease, or other issues. One of the most obvious examples of this is racial categorization by skin color and bodily features. Historically, in the United States, the ‘one-drop’ rule was used. That is, one drop of ‘Black’ blood categorized someone as ‘Black’ regardless of a multicultural heritage or how they might categorize themselves. Even among historically African American fraternities, the ‘brown paper bag test’ was used to categorize people. If a partygoer had skin lighter than the paper bag, he could attend the party; if it was darker, he would be excluded. Anthropologists and other social scientists have studied how people who are part of minority groups have used appearance modification – through skin bleaching, plastic surgery, hair straightening, and other technologies – to cope with discrimination and attempt appearance modification around the world. Many of these practices are dangerous, and all speak to how appearance is related to cultural norms, practices, and institutions.

Historically and cross-culturally, appearance has also signaled disease status, particularly in the face of pandemics. A vivid example is in urban South Africa where rates of HIV and AIDS remain extremely high – up to one-third of young women are infected in some communities. Here, a thin body may signal illness as opposed to an aesthetic ideal, but also a particular body fat distribution with reduced fat in the limbs and face and increased central adiposity is a common effect of antiretroviral therapies and therefore also signals disease status. New body ideals are emerging for women in this context that are slim but muscular in the hope of distancing oneself from disease stigma. Historians have identified similar powerful patterns of appearance signaling disease in the case of TB and other pandemics.

Whether pursued from physical or cultural perspectives, anthropologists are interested in understanding the empirical variation of human appearance worldwide, the meanings of appearance, and the varied relationships among appearance, individual experience and behavior, and group- and institutional-level practices and meanings. Anthropologists tend to combine emic and etic approaches to get at this sort of multilevel analysis.

Examination of a Headache Patient

A general physical examination is important, especially to determine headaches related to systemic illness. Measure vital signs, height, and weight. Postural blood pressure measurements are helpful if the patient has complained of lightheadedness, for the possible use of medications that could cause drops in blood pressure. Listen to the lungs for wheezing, the heart for arrhythmia, and observe the general habitus and posture. Note grooming and behaviors during the examination, pain provoked by moving onto the examination table, and any peculiarities about clothing, piercings, and other body modification art.

A careful neurological examination is important to document any abnormalities, which may alter your diagnosis of a primary headache disorder. It will be useful for comparison if the patient should later develop neurological symptoms. Examine carefully the cranial nerves, motor, sensory, coordination, and gait functions, as well as the patient’s affect, speech, and appropriateness.

The eyes should be examined25 for extraocular movement abnormalities and the presence of nystagmus. Attention should be paid to pupillary symmetry and reactivity. The fundoscopic examination is important to observe for papilledema. Confrontation visual field testing is valuable; test each eye independently. Visual acuity testing is also important.

It is important to auscultate the carotid arteries for bruits (at any age) and to palpate the superficial temporal arteries for induration, reduced pulsations, and tenderness. Examine the temporalis muscles for tenderness or asymmetry.

Examination of the head and neck includes observation of cervical range of motion to rotation, flexion, and extension. The cervical muscles and trapezius muscles should be palpated for tenderness and trigger points (hard, tender areas). The posterior cranium should be palpated for tenderness, especially over the upper cervical muscles and over the greater occipital nerves. Observe the patient’s posture and symmetry of shoulder height. If the patient describes a specific location of pain on the head or face, gently palpate it. This is particularly true when pain is located in specific nerve territories such as the greater occipital or supraorbital nerves.