Rape, torture, and traumatization of Bosnian and Croatian women: psychological sequelae

Reported Methods, Distributions, and Frequencies of Torture Globally: A Systematic Review and Meta-Analysis

Importance

Despite its prohibition by the United Nations Convention against Torture and other international treaties, torture has been perpetrated against countless individuals worldwide, and health care practitioners globally are increasingly encountering refugee torture survivors in their clinical practices. The methods, geographic distribution, and frequency of torture globally are not well described, which limits health care practitioners' ability to adequately diagnose and treat the sequelae of torture.

Objective

To rank the commonness of torture methods and identify the regions of the world with which they are associated.

Data Sources

For this systematic review and meta-analysis, Ovid MEDLINE, Ovid Embase, Web of Science, and The Cochrane Library were searched from inception to July 2021.

Study Selection

Included studies were peer-reviewed articles in English, contained an independent sample population of individuals who experienced torture, and outlined the type(s) of torture experienced. Excluded studies were not peer reviewed, lacked an independent sample population, or did not specify torture methods. Articles were chosen for inclusion by 2 independent and blinded reviewers, and a third, independent reviewer resolved discrepancies. Overall, 266 articles-15.3% of the 1739 studies initially identified for full review-met the inclusion criteria.

Data Extraction and Synthesis

Data abstraction and quality assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were extracted by 2 independent and blinded reviewers into predefined templates, and a third, independent reviewer resolved discrepancies. The risk of bias was evaluated using the Downs and Black Checklist.

Main Outcomes and Measures

Torture methods were ranked by their average frequencies, numbers of reporting studies, and numbers of countries wherein the methods occurred.

Results

A total of 9937 titles and abstracts were screened, and 266 studies encompassing 103 604 individuals (13 350 men, 5610 women, and 84 644 unspecified) were analyzed. Torture was reported for 105 countries; 21 methods accounted for 84% of all reported methods and 10 methods accounted for 78% of all physical tortures. The top 3 methods were beating or blunt-force trauma (reported in 208 studies and 59 countries; average frequency, 62.4%; 95% CI, 57.7%-67.1%), electrical torture (reported in 114 studies and 28 countries; average frequency, 17.2%; 95% CI, 15.0%-19.4%), and starvation or dehydration (reported in 65 studies in 26 countries; average frequency, 12.7%; 95% CI, 10.2%-15.2%). According to the Downs and Black appraisal tool, 50 studies were rated as good or excellent and 216 as fair or poor.

Conclusions and Relevance

The findings of this study suggest that torture remains widespread. Although innumerable torture methods exist, a limited number account for the vast majority of reported tortures. So that targeted therapies may be developed, additional investigation is needed to better elucidate the sequelae associated with the most common torture methods, described here.

Antifragility of healthcare systems in Croatia and Bosnia and Herzegovina: Learning from man-made and natural crises

Acute crises, such as a war or a pandemic, are the ultimate tests for health care systems' resilience (temporary response to stress with change and adaptation) and antifragility (permanent benefit from change in response to stress). In this Health Policy paper, we analyse and discuss how the healthcare systems of two European countries - Bosnia and Herzegovina and Croatia - adapted to war as a man-made disaster, and how they adapted to COVID-19 pandemic twenty-five years later. These countries experienced full scale wars in recent history, which significantly changed their political and healthcare systems. This experience prepared the countries for the response to the pandemic, which coincided with two earthquakes in Croatia. We argue that healthcare systems in Croatia and Bosnia and Herzegovina are not only resilient but antifragile, and that they benefited from stressors they were exposed to. The antifragility of the two systems were primarily based on human effort - the strength, adaptability and resilience of health care professionals. We will look at lessons from the wars that were applied to the pandemic and discuss newly recognized opportunities and improvements.

Longitudinal study of posttraumatic stress disorder, depression, and changes in traumatic memories over time in Bosnian refugees

This longitudinal study examined traumatic memory consistency over a 3-year period among a sample of highly traumatized Bosnian refugees, focusing on demographic factors, types of trauma, and posttraumatic stress disorder (PTSD) and depression. In 1996 and 1999, 376 Bosnian refugees were interviewed about 54 wartime trauma and torture events, and symptoms of PTSD and depression. Reports were compared for both time periods, and changed responses were analyzed for significance. Overall, there was consistency in reporting over time; when change occurred it was in the direction of decreased reports at follow-up. This downward trend was not associated with any particular diagnosis. However, PTSD alone, without comorbid symptoms of depression, was uniquely associated with the group that exhibited an upward trend. This implies that increased reporting is related specifically to the presence of PTSD symptoms, and that PTSD may be distinctly associated with the failed extinction of traumatic memories.

Female victims of torture

Torture is common today and is practised in over 100 countries according to Amnesty International. A substantial number of refugees coming to Europe have been tortured including females. Documentation of physical injuries due to torture is done by forensic pathologists often in collaboration with psychiatrists. In Sweden, the majority of torture documentations is done by an organization (KTC) which have specialized in documenting torture, and in short-term therapy of refugees and other crime victims suffering from post-traumatic stress. From the KTC archives of 500 documented alleged torture victims, the records of 63 females were studied separately. Age, nationality, asylum motive, social situation, torture methods, number of injuries, and sequels to torture were among the variables studied. Female torture victims differed from their male counterparts studied previously in the following: (i) The most common reason for seeking asylum was persecution because of the political activity of their husbands or some other close relative. (ii) Rape often both anal and vaginal, several times, and by different persons, was reported by 76% of the women. Physical abuse by use of blunt force was alleged by 95% but (iii) other types of force and specific torture methods was reported infrequently. (iv) A high frequency of PTSD -- 87% was diagnosed.

The childbearing health and related service needs of newcomers (CHARSNN) study protocol

BACKGROUND

Refugee and asylum-seeking women in Canada may have significant harmful childbearing health outcomes and unmet health and social care needs. The most vulnerable of these women are: those who have left their countries by force (e.g., war, rape or abuse histories), are separated from their families, have limited knowledge of the host country languages, and are visible minorities. Asylum-seekers face additional stresses related to their unknown future status and are marginalized with regards to access to provincial health care systems. The prevalence and severity of health issues in this population is not known nor is the extent of response from social service and health care systems (including variation in provincial service delivery). Understanding the magnitude of health and social concerns of newcomers requires data from a representative sample of childbearing refugee and asylum-seeking women resettling in Canada to permit comparisons to be made with non-refugee immigrant and Canadian-born women. Our research questions are: (1) Do refugee or asylum-seeking women and their infants, experience a greater number or a different distribution of harmful health events during pregnancy, at birth, and during the postpartum period than non-refugee immigrant or Canadian-born women? (2) Are the harmful health events experienced postpartum by asylum-seeking women and their infants, addressed less often (compared to refugees, non-refugee immigrants, and Canadian-born women) by the Canadian health care system as delivered in each of the three major receiving cities for newcomers?

METHODS/DESIGN

This is a four-year multi-site prospective cohort study (pregnancy to 4 months postpartum). We will seek to recruit 2400 women [200 in each of 4 groups (refugees, asylum-seekers, non-refugee immigrants, and Canadian-born) from 1 of 12 postpartum hospital units across the 3 largest receiving cities for newcomers to Canada - Montreal, Toronto, and Vancouver].

DISCUSSION

Knowledge of the extent of harmful health events occurring to asylum-seeking, refugee, immigrant, and Canadian-born women, and the response of the health care system to those events and group differences, if they exist, will inform immigration and health policy makers as well as providers of services.

Traumatic memories of war veterans: not so special after all

Several authors have argued that traumatic experiences are processed and remembered in a qualitatively different way from neutral events. To investigate this issue, we interviewed 121 Croatian war veterans diagnosed with posttraumatic stress disorder (PTSD) about amnesia, intrusions (i.e., flashbacks and nightmares), and the sensory qualities of their most horrific war memories. Additionally, they completed a self-report scale measuring dissociative experiences. In contrast to what one would expect on the basis of theories emphasizing the special status of traumatic memories, amnesia, and high frequency intrusions were not particularly typical for our sample of traumatized individuals. Moreover, traumatic memories were not qualitatively different from neutral memories with respect to their stability and sensory qualities. The severity of PTSD symptoms was not significantly correlated with dissociative experiences. Our findings do not support the existence of special memory mechanisms that are unique to experiencing traumatic events.

Trauma exposure and post-traumatic stress disorder in the general population

OBJECTIVE

To examine the lifetime prevalence of trauma experiences and post-traumatic stress disorder (PTSD).

METHOD

Questionnaire-assessed PTSD, the type of traumatic event experienced, perceived trauma impact, and trauma frequency in 1824 randomly selected men and women.

RESULTS

PTSD lifetime prevalence was estimated at 5.6% with a 1 : 2 male-to-female ratio, in spite of men reporting greater trauma exposure. The highest PTSD risk was associated with sexual and physical assault, robbery and multiple trauma experiences. Controlling for trauma type did not account for gender differences, while controlling for experienced distress did.

CONCLUSION

The conditional probability for PTSD varied as a function of trauma type, frequency and impact of the event, with increased rates associated with prevalent trauma exposure and higher perceived distress. The latter accounted for the gender effect, suggesting that gender differences in PTSD in part represent a generally greater vulnerability to stress in women.

Belonging and adapting: mental health of Bosnian refugees living in the United States

The purpose of this study was to elucidate the experience of Bosnian refugees currently living in the United States. Using a phenomenological method, seven adult female Bosnian refugees each participated in an audio-recorded interview lasting from one to two hours. Two major themes emerged from the analyses of the text: belonging and adapting. Belonging included concepts of cultural memory, identity and difference, empathy and reciprocity, and perfection of speech. Adapting focused on coping with transitions, coping with memories of past and attendant losses, coping with accepting a new culture while trying to fit into the new culture, and learning the new language perfectly. Implicit in the refugees' experiences were states of culture shock, loneliness, psychic numbness, grief, nostalgia, and feelings of dejection, humiliation, inferiority, and feeling as if they belonged nowhere. Simultaneously, the refugees reported feelings of relief and safety after leaving behind the threat of death in their old homes, feelings of gratefulness for their new freedom to hope for a better life, and their restored ability to notice beauty, as well as a sense of normalcy in their new lives. Recommendations for nursing research include the need to identify additional factors promoting successful belonging and adapting in refugees. Recommendations for nursing practice include the importance of adopting a perspective that is respectful of the uniqueness of each refugee and the necessity for recognizing the normal processes of refugee adaptation.

The psychiatric sequelae of human rights violations: a challenge for primary health care

High rates of psychiatric morbidity have been documented in survivors of gross human rights abuses. Nevertheless, there has been relatively little focus on such patients in the context of primary care medicine. A sample of 134 survivors of gross human rights violations was assessed using a structured interview to determine exposure to violations and psychiatric status. In addition, psychiatric treatment history was probed with an open-ended interview. The study found that of the 95 of 134 (72%) participants who were assessed and found to have a current psychiatric diagnosis, only three were receiving treatment for such a disorder. Many subjects had presented to primary care clinics with somatic symptoms and had been prescribed benzodiazepines. Reasons for not reporting trauma or not seeking treatment included issues revolving around fear and mistrust, privacy and confidentiality, re-experiencing the trauma, and lack of awareness. Misdiagnosis and ineffective treatment of survivors of human rights abuses are likely to pose a significant drain on primary care resources. Accurate diagnosis and appropriate treatment are important challenges in primary care settings.

Post-traumatic stress disorder among family physicians in Bosnia and Herzegovina

BACKGROUND

The traumatic events experienced by thousands of people in Bosnia and Herzegovina during the 1992-1995 conflict may have a lasting effect on the mental health of the country, characterized by high rates of post-traumatic stress disorder (PTSD). A diagnosis of PTSD among family physicians could affect their ability to diagnose and treat patients for depression, anxiety and PTSD.

OBJECTIVE

The aim of the present study was to determine the prevalence of PTSD among family medicine physicians in Bosnia and Herzegovina.

METHODS

A self-administered questionnaire, including the PTSD Checklist-Civilian Version (PCL-C) which is a validated scale for PTSD screening, was distributed to family medicine residents and specialists in Bosnia and Herzegovina. The prevalence of PTSD was determined, and factors related to PTSD were considered.

RESULTS

One hundred and thirty-three (90.5%) of the 147 physicians who were available to be surveyed completed the questionnaire. Of the 88% who had a traumatic experience during the war, 18% met the criteria for PTSD. The likelihood of meeting the criteria for PTSD was not affected by age, sex or whether the physician had worked in a field hospital during the war. However, a positive response to the question "Do you think the traumatic event you experienced during the war still affects you today?" was highly associated with the diagnosis of PTSD (odds ratio 7.26, 95% confidence interval: 1.57-33.60). Also, this question was shown to have a high degree of sensitivity and negative predictive value, and may be of use as a screening tool for ruling out the presence of PTSD after a traumatic war experience.

The relation of appraisal, coping efforts, and acuteness of trauma to PTS symptoms among former political prisoners

We examined how trauma-specific appraisals and coping efforts mediate between traumatic experiences, acuteness of trauma, and length of imprisonment and posttraumatic stress symptoms (PTS) among 103 Palestinian former political prisoners. The findings provide support for both direct and mediated models of trauma. The acuteness of trauma (time since release), appraisal of prison experience as harmful and involving loss, and use of both emotion- and problem-focused coping efforts were associated with high levels of PTS symptoms. Torture and ill-treatment had a direct association with intrusion, and recent release from prison with avoidance symptoms. Acuteness of trauma turned out to be important in the coping and symptom association: emotion-focused coping was associated with a low level of PTS symptoms in the long run, whereas problem-focused coping was associated with a low level of PTS symptoms in the short run.

Children's trauma and adjustment reactions to violent and nonviolent war experiences

OBJECTIVE

According to most studies, more than half of children exposed to war meet criteria for posttraumatic stress disorder (PTSD). Although we know that children are adversely affected by atrocities of war, we do not know which specific war events are associated with children's stress reactions. For example, it is unclear whether differences exist in response to violent versus nonviolent war-trauma experiences. This study examined the relationship of violent and nonviolent war experiences to children's trauma reactions and adjustment in a group of children from Bosnia.

METHOD

During the 1994 siege in Sarajevo, 791 children aged 6 to 16 years participated in a study of trauma experience and response, in which assessment questionnaires (Impact of Event Scale, PTSD Reaction Index, Children's Depression Inventory, Child Behavior Checklist, and War Experience Questionnaire) were completed by children and their teachers.

RESULTS

In this sample 41% had clinically significant PTSD symptoms. Children were adversely affected by exposure to both violent and nonviolent war-traumas. An additive effect of trauma exposure on trauma reactions was also found. However, many war experiences were not associated with children's adjustment and trauma reactions.

CONCLUSIONS

Additive effects of violence and deprivations during war may overwhelm the coping skills of children and leave them vulnerable to externalizing and internalizing adjustment difficulties and symptoms of PTSD.

Shan women and girls and the sex industry in Southeast Asia; political causes and human rights implications

The human rights abuses which occur during civil conflicts pose special threats to the health and lives of women. These can include rape, sexual violence, increased vulnerability to trafficking into prostitution, and exposure to HIV infection. The long-standing civil conflict in the Shan States of Burma is investigated as a contributing cause to the trafficking of ethnic Shan women and girls into the Southeast Asian sex industry, and to the subsequent high rates of HIV infection found among these women. The context of chronic human rights abuses in the Shan states is explored, as well as the effects of recent forced population transfers on the part of the Burmese Military Regime. Rights abuses specific to trafficked women may further increase their vulnerability to HIV and other STD. The need for a political resolution to the crisis in Burma is discussed, as are approaches aimed at preventing trafficking, empowering women already in the sex industry, and reducing the risks of HIV and other STD among these women and girls.

Croatia and Bosnia: the imprints of war--I. Consequences

As Serbia and Kosovo emerge from yet another European war, their people's health and the region's health care, scientific research, and medical education have been seriously damaged and disrupted. There are lessons to be learned from recent Balkan wars, lessons that might help doctors, international relief organisations, and governments to do better than they have done elsewhere during the long reconstruction period that will follow this recent savage conflict. An analysis of the medical legacies of war may also raise issues for doctors worldwide to consider as part of their role in a larger public-health community. For a week in May, 1999, I travelled to Croatia and the Croat-Muslim Federation of Bosnia-Herzegovina to meet doctors working in peace but next to war. In the first part of this essay, I briefly survey some of the medical consequences of the Croatian and Bosnian conflicts. In the second part, to be published in the June 26 Issue, I consider plans for and limitations to restoration, and try to identify possible opportunities for prevention of the adverse health effects of war in a newly enlarged Europe.

The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework

Torture is a complex trauma that often occurs within the context of widespread persecution and human rights violations. In addition, the nature of modern warfare is such that whole populations are at risk of suffering extensive trauma, injustices, loss, and displacement. Refugees, in particular, experience sequential stresses that may compound each other over prolonged periods of time. The present overview examines whether contemporary notions of trauma, and especially a focus on the category of posttraumatic stress disorder (PTSD), are adequate in assessing the multiple effects of such experiences. Recent studies are reviewed to indicate the strengths and limitations of current research approaches. Rates of PTSD in such studies have varied with relatively low rates being found in recent epidemiologic studies undertaken on refugee populations. It is suggested that a focus on intervening psychosocial adaptive systems may assist in delineating more clearly the pathways that determine whether traumatized persons achieve psychosocial restitution or are at risk of ongoing psychiatric disability. A model is proposed which suggests that torture and related abuses may challenge five core adaptive systems subserving the functions of "safety," "attachment," "justice," "identity-role," and "existential-meaning." It is argued that a clearer delineation of such adaptive systems may provide a point of convergence that may link research endeavors more closely to the subjective experience of survivors and to the types of clinical interventions offered by trauma treatment services.

Travelling with "excess baggage": health problems of refugee women in Western Australia

Refugee women face problems during resettlement in host countries that are often worse than those faced by voluntary migrants. Although these problems are generally thought to be related to previous traumatic experiences, this may not always be the case; there are many refugee women who may not have personally experienced torture or trauma but who nonetheless express needs that suggest a perception of profound marginalisation from the mainstream society. This paper summarises the health problems identified in a needs assessment of refugee women from Latin America resident in Perth, Western Australia and discusses some of the issues that create "excess baggage" for refugee women.

Individual differences in posttraumatic distress: problems with the DSM-IV model

OBJECTIVE

To evaluate the evidence concerning the role of threatening life events in accounting for clinically significant posttraumatic stress responses.

METHOD

Research was examined to review the epidemiology, evidence of dose-response relations, and individual difference factors in accounting for variations in conditions, including posttraumatic stress disorder, after exposure to threatening events.

RESULTS

The evidence is significantly discrepant from the clinical Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) model. Greater distress arises from individual differences than from event characteristics. Important individual differences that interact with threat exposures include trait negative affectivity (neuroticism); beliefs about emotions, the self, the world, and the sources and consequences of danger; and prevent acts, disorders, and intelligence. Reasons for the discrepancies between the evidence and the current model of posttraumatic distress are proposed.

CONCLUSION

In accounting for responses to threatening life events, the relatively minor contribution of event qualities compared with individual differences has significant treatment implications. Treatment approaches assuming that toxic event exposure creates a posttraumatic disorder fail to consider individual differences that could improve treatment efficacy.

Gender differences in psychological distress among Southeast Asian refugees

The focus of this study was to examine gender differences in levels and predictors of psychological distress in a community sample of Southeast Asian refugees. Although previous studies with clinical samples of Southeast Asian refugees have found gender differences in the degree of psychological distress, the few community-based studies have been inconclusive. This community study found that there were gender differences in the predictors of distress and that refugee women reported significantly higher levels of psychological distress than their male counterparts. Implications of the findings are discussed.