Complex PTSD and its correlates amongst female Yazidi victims of sexual slavery living in post‐ISIS camps
Authors: Yaakov S.G. Hoffman, Ephraim S. Grossman, Amit Shrira, Mordechai Kedar, Menachem Ben‐Ezra, Mirza Dinnayi, Lee Koren, Rassul Bayan, Yuval Palgi, Ari Z. Zivotofsky
Journal: World Psychiatry (2018)

The atrocities committed by the Islamic State of Iraq and Syria (ISIS) are having vast psychological effects around the world1, 2. The Yazidis, a Kurdish religious minority, have suffered the most at the hand of ISIS3. Many men have been executed, while many women have been captured and subjected to sexual slavery, experiencing repeated abuse and rape. Detrimental effects of torture and sexual abuse have been repeatedly documented in the literature4, 5, but the Yazidi genocide includes both elements, and has not been hitherto addressed. This preliminary study assessed post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD) among female Yazidi former captives residing in post-ISIS camps. Following traumatic exposure, both PTSD and CPTSD may ensue. PTSD typically follows a single traumatic event, while CPTSD is associated with prolonged trauma where one's destiny is under another's control and escape is unfeasible6. According to the ICD-11 draft6, PTSD comprises three symptoms: re-experiencing, avoidance and arousal. CPTSD includes three more symptoms pertaining to disturbances in self-organization, i.e., affective dysregulation, negative self-concept, and disturbed relationships. Previous data from refugees experiencing torture showed that while 19% had PTSD, 32% fulfilled CPTSD criteria4. It is important to estimate both PTSD and CPTSD, as these conditions may correlate with different variables and require distinct interventions7, 8. Resettled female Yazidi captives (N=108, mean age 24.4 ± 5.7 years; mean education 2.8 ± 4.0 years; 45.4% married; mean duration of captivity 7.7 ± 2.7 months; mean times sold 4.3 ± 5.7; mean number of fellow captives 32.3 ± 80.0) were sampled from four post-ISIS camps in Northern Iraq/Kurdistan region during February-March 2017. Dichotomous (yes/no) exposure items (witnessing mass killings, people being killed; experiencing injury, torture, shelling, shooting, sexual abuse, rape, physical abuse; family members injured or killed) were aggregated to produce an exposure score. We administered the ICD-11 PTSD questionnaire, including six items which addressed the three proposed ICD-11 criteria6 (alpha=0.71), and the ICD-11 CPTSD questionnaire, including six additional items, addressing the three proposed ICD-11 criteria6 (alpha=0.71). Factor structure for two related yet distinctive constructs (PTSD vs. CPTSD) was slightly better than for a single construct. We also assessed stress in the post-ISIS camp, including experiencing violence, physical abuse, sexual abuse and hunger. These four items were responded on a 5-point Likert scale (from 1=not at all to 5=very much so, alpha=0.79). Items that were not already available in Arabic were translated and back translated into English, reviewed, analyzed and corrected. Two pilot studies (N=20) were conducted, and two items (referring to feeling worthless and guilt) were re-worded to ensure comprehension. Maintenance of the original meaning was evaluated by five assessors. Questionnaires in Arabic were read by female interviewers (trained by research team). Fifty-five (50.9%) women had probable CPTSD, while 23 (20.0%) had probable PTSD. Dividing the sample into those with no PTSD, only PTSD and CPTSD revealed no significant group differences in age or marital status, but a marginally significant difference in mean years of education: no PTSD=1.58, only PTSD=2.08, CPTSD=3.92; F(2,92)=2.98, p=0.055. The groups did not differ significantly in captivity duration, number of fellow captives, number of times sold, or exposure score. The groups differed significantly in stress endured in post-ISIS camps as evaluated on the Likert scale: no PTSD=2.45, PTSD=2.77, CPTSD=3.78; F(2,93)=53.37, p<0.0001. Post-hoc Bonferroni tests revealed that, while the no PTSD and PTSD groups were statistically comparable, the CPTSD group reported significantly higher post-ISIS stress than the other two groups. The CPTSD prevalence we found was higher than CPTSD estimates in samples experiencing captivity/torture alone4 or sexual abuse alone9, which reflects the unique type of endured trauma combining captivity with sexual slavery. Given the high CPTSD prevalence, Kurdish training/intervention centers in formation should focus on preparing suitable CPTSD interventions. For example, CPTSD requires a phase-based treatment8 where safety is a central initial goal; such victims benefit less from traditional PTSD treatments typically focusing on fear reduction. Indeed, safety seems most relevant to our population, as the very same camp conditions may be less safe for CPTSD women who feel socially cut-off, worthless and guilty. Another possibility aligns with the "straw that broke the camel's back" model, whereby the emergence of CPTSD may be triggered by post-ISIS camp stress, which is less severe than the focal trauma. The above possibilities may be relevant to different women, as CPTSD may both be a catalyst for increasing risk of experiencing future stress, as well as increasing one's vulnerability to such exposure. These various options can be assessed in a future longitudinal study addressing PTSD/CPTSD immediately after captivity release and at different time points in the post-ISIS camps. In any case, fortifying such traumatized women with a safe environment along with psychoeducation targeting their increased sensitivity may be very helpful until suitable interventions are available. Limitations of the current study include a cross-sectional cohort and a relatively small sample. Although alpha values exceeded the reliability benchmark, they were lower than in previous studies1, 2, perhaps due to cultural/educational factors, which markedly differed in our sample from usual ones. Yet the findings illuminate the psychological aftermath of perhaps the most extreme atrocity occurring in recent years. Results also indicate the need for greater awareness of post-captivity conditions. Future large-scale studies are required to continue the assessment of Yazidi captives. This should be informative with regard to theoretical issues concerning CPTSD, its distinction from PTSD, as well as aiding the development of feasible, culturally relevant and effective interventions to help these survivors. Yaakov S.G. Hoffman1, Ephraim S. Grossman2, Amit Shrira1, Mordechai Kedar3,4, Menachem Ben-Ezra5, Mirza Dinnayi6, Lee Koren7, Rassul Bayan8,9, Yuval Palgi10, Ari Z. Zivotofsky11 1Interdisciplinary Department of Social Sciences, Bar-Ilan University, Ramat-Gan, Israel; 2School of Communication, Bar-Ilan University, Ramat-Gan, Israel; 3Department of Arabic, Bar-Ilan University, Ramat-Gan, Israel; 4Begin-Sadat Center for Strategic Studies, Bar-Ilan University, Ramat-Gan, Israel; 5School of Social Work, Ariel University, Ariel, Israel; 6Luftbrücke Irak, Osnabrück, Germany; 7Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat-Gan, Israel; 8Erbil Psychiatric Hospital, Erbil, Kurdistan; 9Emma Organization for Human Development, Erbil, Kurdistan; 10Department of Gerontology, University of Haifa, Haifa, Israel; 11Gonda Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat-Gan, Israel This research was funded by a grant awarded to Y.S.G. Hoffman and A.Z. Zivotofsky by the Research Center for the Middle East and Islam (under formation), Bar-Ilan University, Ramat-Gan, Israel. The authors thank J. Neurink and E. Wisman for their assistance.