Abstract

Subjects and methods

The study was conducted within the Program for Long-term Psychosocial Help for women victims of war at the Zagreb Medical Center for Human Rights from April 1992 to December 1995. Study subjects were 68 women who lived in small towns and villages in three Croatian war zones, the eastern Slavonia (n = 8), Banovina (n = 5), and villages around Zadar (n = 2); and the northwestern (n = 19) and eastern (n = 34) parts of Bosnia and Herzegovina. The inclusion criteria were female sex and the experience of the war-time rape. The women entered the study on average (± standard deviation) 11.9 ± 2.4 months after being raped or released from captivity during which they had been raped. Most women were contacted and recruited by Center workers offering professional help to war victims through lectures and individual contacts at Croatian refugee camps in the eastern Slavonia and Zagreb.

Fifty-eight victims were recruited at the camps, 7 came to the Center in Zagreb on their own initiative, and 3 came after being persuaded by other women treated by the psychiatrist at the Center (Table 1). The women were aged between 14 and 83 years, but most were in their reproductive age (32 ± 6.4 years). More than half were housewives, married, with children, and had lower level of education. Many spent more than 30 days in captivity, during which majority was repeatedly raped and tortured by various perpetrators. Initially, there were 100 raped women recruited for the study, but 32 emigrated from Croatia and Bosnia and Herzegovina during the course of the study, which reduced the size of the study sample.

Table 1

Demographic characteristics of 68 women victims of war rape, at the time of study

Results

Rape characteristics

Most women were raped more than once and by different rapists (Table 2). Many were raped every day during their captivity. Almost a third of participants were forced to witness the rapes of other women. Two-thirds of women did not know their rapists personally; in other cases, they were their neighbors. Victims and their assailants were always of different nationalities. The rapists were Serbian soldiers or civilians, or Muslim (Bosniak) soldiers (Table 2). Women reported their rapists being drunk in almost half of the cases. The site of rape was a woman’s home or some other house, Serbian war camp, or brothel camp. Sixty-six women were civilians and two were in military service. According to their testimonies, rapes occurred continually during Serbian occupation of Croatia and Bosnia and Herzegovina from 1991 to 1994. During that time, the non-Serbian population on the occupied territories decreased as the number of killings, tortures, and deportations increased. In 32 cases rapes occurred during the first 10 days of the Serbian occupation of the town or village. Most rapes were accompanied by verbal threats of death, physical injury, or injury to the family members and physical torture, which consisted of beating and slapping on the face, cutting, stabbing, strangling, and burning of the skin. The nature of the rape was vaginal penetration and a combination of touching and vaginal penetration in 37 women. Sexual torture included insertion of foreign objects in vagina and other body openings, and forcing to perform various obscene acts.

Table 2

Characteristics of rapes and rapists as reported by 68 women victims of war rape

Psychological symptoms immediately after rapes

Immediately after the trauma, victims suffered a number of physical symptoms including nausea, vomiting, headache, sweating, palpitations, and muscle pain, while the most frequent psychological consequences were depressiveness, avoidance of thoughts, feelings, or conversations associated with the trauma, negation of the trauma, and intense feelings of self-accusation (Table 3). Furthermore, 25 victims had suicidal ideas and impulses. Younger age was a weak predictor for suicidal thoughts and attempts (OR, 0.95; 95% CI, 0.9-1.0), whereas strong predictors were physical injuries suffered during the rape (OR, 7.2; 95% CI, 1.4-36.7), not knowing the rapist (OR, 8.18; 95% CI, 1.7-39.1), and vomiting after the rape (OR, 5.2; 95% CI, 1.3-21.4). This set of predictors explained 33% of variance (Nagelkerke R² = 0.327). Avoidance of thoughts, feelings, or conversations associated with the trauma was less present among women with residency in Bosnia and Herzegovina (OR, 0.1; 95% CI, 0.01-0.56; Nagelkerke R² = 0.498). Women who experienced physical torture during the rape were more likely to have intense feelings of self-accusation (OR, 7.8; 95% CI, 1.7-35.5; Nagelkerke R² = 0.440).

Table 3

Psychological symptoms of 68 women victims of rape immediately after the rape and at the time of the study

Psychological symptoms at the time of study

At the time of the study, ie, approximately a year after the trauma, most victims suffered from depression and social phobia, whereas PTSD and sexual dysfunctions were present in fewer women (Table 3). These disorders were often co-morbid, with social phobia with depression being most frequent (Table 3). Logistic regression analysis did not show age, nationality, marital status, education, and duration of captivity as predictive variables of the psychological disorders diagnosed in these women. However, the prevalence rates of these disorders showed a significantly different distribution (Table 4). Out of 21 women with PTSD, 17 said the rape was the most traumatic experience they had, while for the others it was witnessing killings of their family members. There was no significant difference in the prevalence rates of psychiatric disorders with respect to women’s age (Table 4). Psychogenic amnesia or inability to recall important aspect of the trauma was more prominent among married women (13/42 vs 1/21, χ²₁ = 5.56, P = 0.018) and those who were in captivity <30 days (11/34 vs 3/34, χ²₁ = 6.6, P = 0.01). Restricted range of affect, as a symptom of avoidance, was more noticeable among women with higher level of education (11/21 vs 13/47, χ²₁ = 5.05, P = 0.025). Impaired relationship with a partner was more pronounced among women who were in a relationships but not married (18/20 vs 26/42, χ²₁ = 10.14, P = 0.017) and among Muslim women (25/29 vs 19/36, χ²₁ = 7.63, P = 0.049). Single women had more pronounced sense of a foreshortened future (17/21 vs 19/42, χ²₁ = 4.58, P = 0.032) together with impaired social functioning due to changes in relationships with family members and friends (18/21 vs 24/42, χ²₁ = 8.9, P = 0.030). Impaired social functioning was also more pronounced among women with higher level of education (17/21 vs 25/47, χ²₁ = 8.6, P = 0.035). Sexual dysfunctions seemed to be more prominent among single women (11/21, vs 6/42, χ²₁ = 8.5, P = 0.004) and among those who were in captivity for shorter period (11/34 vs 6/34, χ²₁ = 3.91, P = 0.048).

Table 4

Long-term psychological consequences of rape found in 68 women at the time of study (11.9 ± 2.4 months after the rape)

Twenty-nine raped women (42.6%) got pregnant. Logistic regression analysis showed that significant predictors of pregnancy were younger age (OR, 0.92; 95% CI, 0.86-0.98) and being raped once (OR, 7.42; 95% CI, 1.81-30.34). These two variables explained 45% of variance (Nagelkerke R² = 0.450). Seventeen women had artificial abortion, while 12 gave birth to healthy children. Suicidal thoughts and impulses after the rape were significant predictor of artificial abortion (OR, 25.8; 95% CI, 2.5-263.2), explaining 48% of variance (Nagelkerke R² = 0.0488). Only one woman in our study kept the child after delivery, while all of the others (n = 11) gave their children for adoption.

Discussion

Our study showed that rape was a strong trauma, resulting in various psychiatric disorders in all women in the study, including long-term depression, social phobia, PTSD, and sexual dysfunctions. The studies into consequences of war-time rapes on civilians (18,19) or female veterans (20,21) often connected the trauma of rape with chronic PTSD, a disorder characterized by a continuous re-experience of the trauma, avoiding behavior, and symptoms of hyperarousal. The importance of studying PTSD relates to the occurrence of chronic PTSD, because of its severe psychopathology and not acute stress reactions, which are more likely to result in complete resolution of symptoms (5).

Rape, together with other superimposed war-related traumatic events, resulted in high long-term prevalence rates of depression and social phobia in women victims included in our study. It might be possible that the genesis of this phenomenon is partially related to the traditional background of the victims under study. According to their testimonies, the posttraumatic period was characterized by reduced subjective confidence, feelings of worthlessness, and disgrace they thought they had brought to their families. The women tended to avoid social situations because they were concerned about the feelings of their family members and friends who knew about the rape, and because of fear of blame. However, causal mechanisms could not be easily inferred from data we collected and the psychological responses to the trauma of rape were individually specific for each woman.

Almost a half of women in our study got pregnant as a result of rape. Women who were raped once, compared with those repeatedly raped, had seven times higher risk of pregnancy. This finding suggests an association between prolonged exposure to stress and conception, but the mechanisms of this interaction are still unclear and require further investigation. Most women said that the unwanted pregnancy made their mental recovery more difficult. Women who had experienced suicidal thoughts after the rape were more likely to have artificial abortion, which may indicate that they suffered particularly humiliating trauma. According to the results of a US study, rape-related pregnancy rate is 5.0% per rape among victims of reproductive age, ie, those aged 12-45 years (22). However, this rate can change in war circumstances, especially when women are systematically raped. About 5000 children were born as a result of mass rapes during the genocide in Rwanda in 1994, sometimes called “children of bad memories” (23).

Female sexual dysfunctions include hypoactive sexual desire, sexual arousal disorder, orgasmic disorder, and postcoital dysphoria (16). In our study, it was not possible to identify the type of sexual dysfunction on the basis of information collected via clinical interview. We showed that single women or those in relationships but not married had more difficulties in posttraumatic period due to more prominent sexual dysfunctions. This result is consistent with previous findings showing that these symptoms persisted for years after the assault (24). It also suggests that marriage itself provides a certain level of protection and support. Also, we found that more Bosniak (Muslim) than Croat women thought the relationship with their partner worsened after the trauma. This could be explained by the fact that Bosniak women come from a more traditional culture. The social environment and personal upbringing influence the victim's reaction to rape. In societies with patriarchal social structure, victims refuse to talk about the trauma and do not want the event to be documented even in medical files. Victims often refuse any kind of psychiatric treatment and professional help (25,26). To overcome these problems in dealing with victims of rape, we used the testimony method developed by the Chilean psychologists Cienfuegos and Monelli to obtain information about the repressive Pinochet regime, but it proved to have therapeutic effect on the victims of torture (14,15,27). The testimony method was used in almost all participants. While giving the testimony, the victim has a chance to perceive the trauma from another perspective. A raped woman moves from the role of victim to the role of witness, which is an important psychotherapeutic step. After that, the victims are much more inclined to accept psychiatric help. Gradually, they become ready to talk openly about the event, allow the therapist to have an insight into their condition, and go through a diagnostic procedure. It might be an advantage to have therapists of the same cultural and social environment as the victims, because it may foster better personal contact and understanding between them. Also, there is no need for a translator as a third party person.

Most women in our study did not know their rapists before the traumatic event, which suggests that the rapes were committed not only by paramilitary soldiers from the country, but also by the members of military and paramilitary units from other parts of former Yugoslavia. Rapes in these cases might have been more violent and humiliating, and women were more likely to have suicidal thoughts and impulsions after the rape. Bassiouni reported that the number of committed rapes decreased with the increase of media attention for war events in this region (28), which indicates that war commanders may have been able to control the perpetrators. Almost two-thirds of women were raped repeatedly. Besides, some women were forced to witness rapes of other women, usually their mothers, daughters, and neighbors, which were extremely humiliating and painful events.

Limitations of our study are related to the nature of the problem that we explored. It was not possible to reach the victims immediately after the rape, so we gathered the data on immediate reactions on trauma retrospectively, based on the victim’s memory and testimony. Therefore, change of women’s impressions and interpretations over time might have influenced the magnitude of the observed associations. Although the assessments were performed by an experienced psychiatrist trained to work with the war victims, especially victims of sexual assaults, two independent assessments could have increased both reliability and validity of the data. However, the study was performed during the war and early post-war period when the applied study design was the only one possible to carry through successfully. Also, building a therapeutic alliance with the victims was a long-lasting and extremely delicate process and bringing another person to witness women’s testimonies might have been counterproductive..

In conclusion, war-time rapes left deep and lasting consequences on the mental health of the victims and their families. Many suffered from depression and social phobia, which were often comorbid. As causal relations between the trauma and its consequences could not be completely revealed from the data we collected, future studies are needed to establish to what extent the psychological consequences depend on a multi-dimensional nature of trauma in situations of war.

References