Journal of Affective Disorders 173 (2015) 232–238

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Preliminary communication

Symptoms of PTSD in a sample of female victims of sexual violence in post-earthquake Haiti Guitele J. Rahill a,n, Manisha Joshi a, Celia Lescano b, Dezeray Holbert a a b

School of Social Work, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL, United States Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL, United States

art ic l e i nf o

a b s t r a c t

Article history: Received 30 September 2014 Received in revised form 15 October 2014 Accepted 28 October 2014 Available online 11 November 2014

Background: Globally, sexual violence (SV) impacts 25–33% of women, is often perpetrated by intimate partners and occurs even post-disasters. The 2010 Haiti earthquake occasioned a SV epidemic in Cité Soleil, where over 50% of females are reportedly victims of SV via non-intimate partners/strangers (NPSV). Little is known about the psychological effects of SV perpetrated by NPSV; even less in known about the biopsychosocial consequences of NPSV on women in Haiti. Yet, the World Health Organization recently called for research on NPSV, particularly in poor and disaster-affected countries. Methods: As a first step in categorizing the consequences of NPSV on female victims in Haiti, we conducted 2 focus groups of 16 female residents of Cité Soleil who survived the earthquake and its aftershocks, along with ensuing hurricanes and cholera. Results: Participants reported rapes by strangers who intentionally “crush the uterus.” All endorsed criteria for PTSD, including enduring physiological, neurological and psychological symptoms: significant intrusive, avoidance, arousal, cognitive, mood changes, as well as significant distress/impairment in various areas of functioning; and all but one became pregnant from the experience. All denied substance use and other illness that is not associated with the sexual violence. Limitations: Our study was exploratory, targeting a small sample of women in one specific neighborhood and cannot be generalized to all SV victims in Haiti. Conclusions: Following earthquakes, there should be vigilance by public health officials and rescue teams for prevention of SV against women. Women who survive SV in Haiti should be provided access to trauma-informed care that addresses biological consequences of the SV, as well as biological, neurological and psychological sequelae. & 2014 Elsevier B.V. All rights reserved.

Keywords: Haiti earthquake Haiti sexual violence Cité Soleil Haitian PTSD Haitian women Haitian victims

1. Introduction Sexual violence (SV) is an issue of global public health significance impacting between 25 and 33% of women around the world, depending on the age group (World Health Organization, 2002). Sexual violence is “any sexual act, attempt to obtain a sexual act … directed against a person’s sexuality using coercion … by any person regardless of their relationship to the victim, in any setting … includes rape, defined as physically forced or otherwise coerced penetration … of the vulva or anus, using a penis, other body parts or an object.” (World Health Organization, 2002, p. 149). Women in post-disaster settings are particularly vulnerable to domestic and sexual violence (SV) perpetrated by intimate n Correspondence to: School of Social Work, University of South Florida, 13301 Bruce B. Downs Blvd., Tampa, FL 33612, United States. Tel.: þ 1 813 974 7385; fax: þ1 813 974 4675. E-mail address: [email protected] (G.J. Rahill).

http://dx.doi.org/10.1016/j.jad.2014.10.067 0165-0327/& 2014 Elsevier B.V. All rights reserved.

partners (United Nations Population Fund, 2012). The psychosocial consequences of violence perpetrated by intimate partners are well documented, revealing that it often occasions trauma and stress-related disorders in victims/survivors. Little is known about the psychological effects of SV perpetrated by non-intimate partners, as indicated by a recent call from the World Health Organization for research on non-partner sexual violence, particularly in poor and disaster-affected countries (World Health Organization (WHO), 2013). Haiti’s geographical position in the Caribbean has rendered it susceptible to natural disasters in the form of recurrent annual assault from hurricanes/cyclones, flooding, and loss of life. However, the 2010 earthquake that measured 7.0 on the Richter scale was an unprecedented assault on the island nation that resulted in the death of approximately 300,000 people and to a tremendous loss of property and infrastructure (Chemaly, 2013; Rahill, 2012; Rahill et al., 2014a). Compounding the trauma of the earthquake, an epidemic of non-partner SV against women followed the 2010 earthquake (Center for Human rights and Global Justice, 2010;

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D’Adesky, 2012; Theodore, et al., 2011). In Cité Soleil, an urban shantytown of Haiti’s capital, estimates of women who experienced SV in the aftermath of the earthquake range between 50 and 72% (Kay Fanm, 2012; Willman and Marcelin, 2010). Theodore and colleagues studied 326 female survivors of sexual violence who were seen at the GHESKIO clinic during 2010. They reported shame and stigma as experienced by their clients (Theodore et al., 2011). Lacking from their report is more detailed descriptions and categorizations of their symptoms in their own words. We document trauma and stress-related disorders reported in a sample of female residents of Cité Soleil, who survived both the earthquake and subsequent sexual violence. We use the terms survivors and victims interchangeably because the women in our study self-identified as victims. Cité Soleil is an ideal context for investigating trauma and stress-related disorders such as PTSD because of structural and neighborhood factors that interact to increase risk of SV and of trauma, particularly for its female residents. These include it being the poorest, most violent zone in Haiti, and the most dangerous zone in the capital (Faedi, 2008). For its female residents, as with women in other resource-poor settings, poverty, hunger, discrimination, gender inequity, low education, have contributed to the risk of sexual violence (D’Adesky and PotoFanm þ Fi, 2012; Willman and Marcelin, 2010); Cité Soleil and its adjacent zones have been identified by D’Adesky and colleague as among the most impacted by gender-based violence, particularly sexual violence against women, asserting, “much of the violence … has been confined to [Haiti’s] urban shantytowns …” (p. 114). We contribute to extant knowledge on non-intimate partner sexual violence against women by reporting findings from a study of female residents of Cité Soleil who live in the embattled neighborhood, survived the earthquake and the ensuing hurricane and cholera epidemic and subsequent sexual violence. We use the American Psychiatric Association’s (APA’s) criteria for PTSD to categorize their reported symptoms, and conclude by offering suggestions for effective prevention interventions to address physical and psychological trauma for them and women like them in post-disaster settings around the world. Sexual violence in post-disaster Haiti is a substantive research area for several reasons: First, to the authors’ knowledge, this is among the few studies that document specific psychological consequences of compounded trauma such as experience of an earthquake followed by an experience of sexual violence in Haiti. Moreover, after the earthquake there was a devastating hurricane followed by an epidemic of cholera in Haiti. Indeed, many Haitians expressed fear that this confluence of traumatic events heralded the end of the world (Rahill et al., 2014b). Second, Haitians are historically underrepresented in health and health disaster research. Third, as mentioned above, the WHO recently heralded research on non-partner sexual violence, particularly in poor and disaster-affected countries. Fourth, Bass and colleagues reported that women who survive sexual violence are prone to a host of mental health problems, including mood and anxiety disorders, most typically post-traumatic stress disorder (PTSD) (Bass et al., 2013). It follows that the psychological/affective consequences of SV for women who survived the earthquake only to fall victim to sexual violence would ostensibly be more severe, given that they will have experienced compounded trauma stemming from the earthquake, the loss of homes, loved ones and then the sexual violence. 1.1. Trauma- and stress-related disorders and PTSD Trauma- and stress-related disorders comprise disorders in which a necessary condition for being diagnosed with the disorder

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is exposure to a traumatic or stressful event is (American Psychiatric Association (APA), 2013). Examples of trauma and stress-related disorders are social anxiety disorder in which anxiety occurs in response to social situations, generalized anxiety disorder which denotes experiences of fear with no specific eliciting factor, panic disorder in which panic attacks are the hallmarks of anxiety, and obsessive-compulsive disorder in which anxiety provoking thoughts result in compulsive actions designed to neutralize the thoughts. Within this classification of mental disorders, PTSD is recognized as expressions of clinical distress following exposure to traumatic events vary greatly and can include dissociative, anxiety and other symptoms (American Psychiatric Association (APA), 2013). Criteria for a PTSD diagnosis include direct or vicarious exposure to life-threatening or life-ending events, serious injury, or sexual violence along with intrusive symptoms. Intrusive symptoms include distressing memories and dreams pertaining to the catastrophic event, re-experiencing the event through flashbacks, and severe/enduring physiological and psychological suffering when faced with memories or environmental cues reminiscent of the event. In addition to intrusive symptoms, PTSD symptoms include intentional efforts to avoid memories, feelings, thoughts and external contexts that remind survivors of the traumatogenic experience (American Psychiatric Association (APA), 2013). Other symptoms include: … Negative alterations in cognitions and moods associated with the traumatic event [including] fear, guilt, sadness, shame, confusion …. Hypervigilance … Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world … Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) … Feelings of detachment or estrangement from others … [and] Sleep disturbance .… (American Psychiatric Association (APA), 2013, p. 271) 1.2. Trauma- and stress-related disorders among survivors of earthquakes in developing countries The short-term psychological consequences of disasters on survivors in developing countries have been well documented. For example, Bunney (2003) documented that stress and trauma are “psychological sequelae” of disasters among those who experienced the disaster directly and even for those who experienced it vicariously through media reports or from significant others who survived the disaster. He describes psychological trauma as, “overwhelming, unanticipated danger” (p. 2) with no means of escape and no means of managing emotions associated with the trauma. He adds that psychological trauma also includes “complex neurophysiological dysregulation … somatic and mental symptoms including a feeling that one’s heart is about to burst … feelings of terror and … autonomic reflexes or freezing and feelings of helplessness or being out of control …” (p. 3). Gigantesco et al. (2013) examined long term effects of natural disasters for various stakeholders and found PTSD and major depression as psychological consequences. They indicated that being female, having been directly exposed to the earthquake, loss of a loved one in the earthquake, being unemployed and having economic problems result in a double likelihood that survivors of natural disasters such as earthquakes, will experience a major depressive episode and PTSD. Similarly, others have found enduring symptoms of PTSD (41.3% prevalence) among exposed individuals two and a half years after exposure to the traumatic event, confirming chronicity both in the symptoms and in the course of PTSD. Being female, single, poor before and after the earthquake and low education were all PTSD risk factors for survivors in some studies (Ali et al., 2012; Naeem et al., 2011). Naeem and colleagues

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added that poverty and severity of exposure were all relevant in predicting PTSD. They emphasized that “disruptions in life and social network” (p. 269) (e.g., the SV and disruption of family life experienced by women in our study) were particularly relevant to symptomatology. In all these studies, social connection to others appeared to serve as protective factors. Still others summarized that survivors of disasters such as earthquakes commonly report symptoms anxiety (50%), depression (52%), PTSD, somatization disorders and high comorbidity of PTSD and depression ( Sezgin and Punamaki, 2012; Xu and Liao, 2011). Sezgin and Punamaki also confirmed vulnerability of female survivors of disasters to PTSD and that the severity and the directness of exposure to an earthquake as well as the number of traumatic events experienced predicted especially high levels (over 60%) of PTSD and an increase in the number of symptoms in their study sample. This is particularly salient since within a week and a half of the original 7.0 shock, earthquake survivors in Haiti endured 52 aftershocks measuring 4.5 or greater (United States Geological Survey, 2014). Cenat and Derivois (2014) exploring the consequences of the Haiti earthquake among adult survivors two and half years after the event corroborated that gender, lack of employment/poverty and low education all predicted enduring symptoms of PTSD. He added that low literacy levels and emotional distress after the traumatic event was most predictive of PTSD. This is particularly relevant to women in our study who also experienced sexual violence after the earthquake. Cerda et al. (2012) documented risks of PTSD and major depression in survivors of the Haiti earthquake and that found that nearly quarter of the studied population endorses PTSD symptoms and over 28% endorse major depressive symptoms. A notable contribution is that a history of violent trauma was a risk factor for both mental disorders. Although they document “periearthquake factors” such as personal injuries incurred during the earthquake, they did not address post—disaster violent trauma such as sexual violence in their study, or the emotional distress that female victims experience in relation to developing PTSD and other stress-related disorders.

2. Methods This study was approved by the University of South Florida (USF) Institutional Review Board. Support for this study was provided by the USF School of Social Work. There is no conflict of interest to declare. We employed purposive sampling and a semi-structured questionnaire to collect focus group data from 16 women who selfidentified as “victims” of sexual violence and residents of Cité Soleil to answer the following research questions, how can we categorize the symptoms reported by victims of sexual violence in our sample who survived the 2010 earthquake and its subsequent aftershocks, as well as ensuing hurricanes and a cholera epidemic?

university’s Institutional Review Board. Our primary author, a female of Haitian-descent who spoke English and Kreyòl fluently and who is a licensed clinical social worker facilitated the focus groups. We were alert to signs of distress which participants might exhibit when recounting their experiences and had planned for those who might require crisis intervention, referrals or follow-up to be connected with local mental health service providers in Haiti. Following consent, we collected brief demographic information such as age, education level and employment status. We audiorecorded focus group discussions with the informed consent of the participants, transcribed the Kreyòl recordings to English, and used ATLAS.tis 6.2, a computer-assisted software package, to analyze the content of the transcriptions. ATLAS.tis provided a hermeneutic or interpretive framework for reading, comparing and coding the textual transcriptions and enabled us to store, manage, and compare meaningful segments of text for constant comparative analysis. 2.2. Data analysis We read the transcripts one line at a time and marked key points pertaining to affective/emotional consequences of sexual violence in our sample were marked with a series of codes, which we applied to segments of the text. We grouped the codes into similar concepts; and from these concepts, we formed categories which were the basis for developing open codes. Open codes comprised lower level labels and categories related to the focus of our research, emotional/affective consequences of sexual violence for women who had also endured the shocks and loss of the earthquake. During open coding, a core category, “Psychological Trauma,” emerged as we read participants’ descriptions of the psychological impact of the sexual violence. We linked this category to segments of text and quotations from our participants that reflected experiences of psychological trauma. The “code manager” feature supported axial coding, in which we explored relationships between the category “Psychological Trauma” and other segments of text from the transcription. The “Code Families” feature of ATLAS.Tis enabled us to link “Psychological trauma” to other categories such as “Avoidance Reactions,” and “Impairment in Social Functioning.” The “Super Families” feature of Atlas.tis enabled us to conceptualize how the codes may relate to each other and to what became evident were terminology from the DSM-5, e.g., hypervigilance, insomnia, anxiety. During axial and selective coding, we obtained network views that illustrated graphical images of relationships among categories and modified those relationships when needed, based on the transcripts and memos written during data collection and on comments noted during data analysis. We analyzed the demographic information using SPSS 21s. Table 1 provides a sample of the process of coding and provides examples of concepts, categories, and codes that led to our understanding of PTSD as characteristic of our sample.

2.1. Data collection We collected data in March 2013, over three years after the 2010 Haiti earthquake, expecting that any reported symptoms would be fewer if not less severe, but expecting some reports of trauma. We did not anticipate PTSD, nor did we anticipate that all the women would respond with “echoes” of “Yes” and with moans as others recounted their symptoms. We asked out loud for confirmation, dissent or clarification when these loud verbal consents occurred. We conducted two separate focus groups in Haitian Kreyòl following provision of informed consent that was approved by our

3. Results 3.1. Demographic characteristics The focus group participants were between 19 and 52 years of age, and 5 (62%) were 25 years old or younger. Four had completed 0–5 years of formal education. Fifteen had more than five years but less than 12 years of formal education, and one had completed 12 years of school. None of the victims were employed. Seven of the eight victims had children, and all reported that at least one of

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Table 1 Examples of analytic process from open through selective coding employing ATLAS.Tis code manager. Open coding/ concepts/ quotations

Core categories

Psychological Hearing of trauma kadejak on radio causes heart to kase or sote

Never pass by the same location

Avoidance reactions

Axial coding/code families from ATLAS.Tis

Selective coding/super families from ATLAS.Tis

Illustrative quote

Because sometimes you turn on the radio, you hear them say “There, they have done kadejak on such and such a person”, you who had already undergone, your heart breaks … and then, now suddenly you’re not the same-you’re not a person … and little by little, the thing becomes more difficult To this day that I am speaking to you … I have Criterion C: persistent avoidance Criterion C1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about drawn a cross on that … I have not ever yet of stimuli associated with the or closely associated with the traumatic event(s) dated/had a boyfriend in my life! traumatic event Where he works, I never pass by there anymore; Criterion C2. Avoidance of or efforts to avoid external reminders that arouse distressing even-the zone where—the event had happened thoughts, or feelings about or closely associated to me with the traumatic event … Criterion B: presence of one or more intrusion symptoms; intense and psychological and physiological distress

Criterion B1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s); Criterion B5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event …

their children was conceived as a result of sexual violence. The pregnancies emphasized the increased risk for sexually transmitted disease from the assault, since pregnancy presumes that the vaginal environment was directly exposed to sperm. One woman had been assaulted twice. 3.2. Characteristics of sexual violence in our sample Our study participants defined sexual violence as nonconsensual sex, including but not limited to rape under conditions of coercion and force, involving penetration of the vagina, mouth or anus, with a penis and/or other body parts or objects. They also informed that sexual violence in their experience comprised particularly injurious rapes using broken marbles, rubber bands and other objects in addition to the male genitalia. They reported each of their experienced involved multiple, unknown perpetrators who used strangulation to subdue, intimidate and silence them and who intentionally aim to “crush the uterus” of their victims. Their description is consistent with that of the WHO’s definition of sexual violence, but highlights purposeful injury. Moreover, it was clear from several examples provided, that cumulative trauma for some participants involved complex relationships between the earthquake, the ensuing hurricane and the alienation experienced in social relationships with others and their opinions of themselves: A girl who was 14 years old used to sleep in the house with me—the tent where I slept after the earthquake was destroyed by the hurricane that passed; there were a lot of tents that fell; the majority of people fixed their tents, but I didn’t have the means to fix mine, so I was obliged to live in mine in the state that it was; each time the man [a married man who she was seeing] appeared for him to fix it—oh! He began to ignore me— he heard that they had done kadejak on me, so he came to ignore me—My child was born—of kadejak— because he heard they did kadejak on me, that means for him, I am NOT A WOMAN ANYMORE (her emphasis). [ALL TOGETHER YELLED OUT THE FOLLOWING DIFFERENT STATEMENTS]: Yes! They don’t take you for anything—They don’t give you worth. The following conversation occurred as the women in one focus group discussed the trauma of the earthquake in relation to that of the sexual assault which was facilitated by what they perceived as lack of security in the post-earthquake temporary shelters: The earthquake, everybody saw that it was a problem that came from nature (Other participants echo, ‘Nature—nature’)—

[the kadejak] happened because of lack of security. After the earthquake, the way the little shelter was stuck up next to a tarp covered shelter- everyone had time to put in their spirits, well, THAT—it had to happen; if it didn’t happen today, it would happen tomorrow. But before-before the earthquake, who would have imagined seeing yourself laying in your bed, sleeping, and the person would find a way and dismantle the door, to come in and pull you and -pull you and rape you! THAT is another thing. I myself underwent that thing. Another participant had continued, explaining that even with socioeconomic disadvantage, her self-worth had been linked to her virginity, and: For several to kouche (bed) you! Besides, you didn’t-you didn’t have that spirit/notion in your head. You have a vision; you come from a poor class; you would like-for you to be something in your life—and now the person comes—he—not only does he RUIN your objectives—your vision—since he RUINS (her emphasis) your female dignity! Because eh-eh-I heard my mother—my mother said she herself, she passed only one man; she would not like to pass two; but you, you might want to follow the path of your mother, you would not want to pass several men, but well 3.3. Symptoms of PTSD in our sample of victims of sexual violence All (100%) of our participants met Criterion A., “Exposure to actual or threatened death—sexual violence, as they both experienced and witnessed the earthquake and its consequences in addition to sexual violence. There was evidence of Criterion B, “Presence of one or more intrusion symptoms” in all (100%) of our participants, and within criterion B, there was evidence of all 5 symptoms, including involuntary, intrusive and distressing memories, dissociative reactions, intense and psychological and physiological distress at exposure to cues that resemble the event: I can’t sleep, I feel scared, and I always feel that the rapist is near me … you are not in yourself, here (gestures to head)you’re not in yourself here [participant’s emphasis]—it’s when after—because I was crying a lot … I was looking at myself in the mirror … how I had received blows … do not feel secure, even if the rapist is not around … difficulty breathing, eating, sleeping…so traumatized that I can pèdi tèt (lose my head) … become “crazy”… Maybe if you lived in a place … where you never see misery … you never see where people are—where people are talking of misery … where people are talking about

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kadejak (rape); because sometimes you turn on the radio, you hear them say “There, they have done kadejak on such and such a person,” you who had already undergone, your heart kase, sote (breaks, jumps) … and then, now suddenly you’re not the same-you’re not a person … and little by little, the thing becomes more difficult … I can be walking- me, the reason my heart breaks/jumps is because it was at night time they had—especially when there is a knock at the door— to be hearing the same noises I am always asking myself if he won’t return again—it can be midnight- one in the morning and I am laying there listening to doors that are closing-I really never slept at all! And during those times, the blood pours even faster from me … Regarding Criterion C, persistent avoidance of stimuli associated with the traumatic event beginning after the traumatic event occurred as evidenced by efforts to avoid associated distressing memories, thoughts, feelings or environments associated with the event, our participants endorsed avoidance of attention so as to not be targeted for revictimization. These efforts, along with efforts to avoid external reminders of the event are supported by the following: I have come to not be interested in going to doctors anymore … because the stress is always here with me when I think-I am asking myself WHO?!!! For a person who would meet me, let’s say someone who would woo me—for example, I have a judge who was speaking with me —as I was telling him about myself, he said “There are a lot of things I know of you … you don’t have to talk.” I became afraid! And then the problem he presented was that problem (the rape). Where he works, I never pass by there anymore— even-the zone where—the event had happened to me, I don’t let the child [of kadejak] go in that zoneConcerning Criterion D, negative alterations in cognitions and mood, we found evidence that our study participants were experiencing all of the 7 symptoms, except inability to remember an important aspect of the earthquake or the sexual violence. The conversation was replete with exaggerated beliefs/expectations about themselves and others as well as distorted cognitions about the consequences of the sexual violence, persistent negative emotional states, estrangement from members of their social network/loved ones, inability to feel good, happy or loss of interest in things that had been important to them. These are summarized below: It’s as if life for me had ended completely, completely, completely! … my parents had always told me, When a person is a girl, here’s how that (sex) is, here’s how this goes, and what happiness is! Now, when I came to look and saw something that I was conserving had been stolen without my consent— my parents could not help me, my mother could not rescue me, my father could not help me— so that the conditions of life, the way things were no longer the same, to see myself having undergone such an act, I asked who-what-where do I go? That has brought a lot of [negative] things in my life … I don’t live near my mother anymore … THIS KADEJAK THING, I SAY THIS AGAIN, MADAME, SO LONG AS YOU HAD ALREADY UNDERGONE IT … IT’S WHEN YOU ARE STRETCHED OUT IN DEATH [Her emphasis]—that—that it is erased from your mind. One woman stated, “This is not my normal weight. I’m not this skinny, it’s because of stress. My hair is falling; I have pimples in my scalp and face. Nothing the doctors prescribe works”. Anger, shame guilt and fear were also associated with the fact all of the participants had become pregnant from the sexual violence, and many had run away from the neighborhood where

they had experienced such hurt and where they continued to experience stigma and shame associated of being a victim of kadejak: The population/community of Cité Soleil came to know -I am a -umm-umm- ka-I am a woman that they raped … (VOICE SPEEDS UP). They did kadejak on me; I have a kadejak child— —whenever you’re going by, they always say, ‘Ha! There goes Mrs. kadejak walking by!” Yes, they say you are the wife of kadejak and they did kadejak on you— well, I can tell you it’s that sort of thing that always gave me problems, and it continues to —there are some times when I cry-because when I consider—for—you-you are with a child in hand—she doesn’t have a father to call on, and then she herself is always asking you, “Momma, where is my father!” … Yes … yes, that’s what they say to you, yes. They use it as an insult; they use it to criticize you—to attack you. Our participants reported all aspects of Criterion E and provided evidence of marked alterations in arousal and reactivity associated with the sexual violence event. They often spoke of experiences that indicated hypervigilance, exaggerated startle responses, problems with concentration, and sleep related problems. There was no direct evidence of reckless or self-destructive behavior although women did indicate having suicidal thoughts and shared stories of other victims who had attempted suicide. The following quotes substantiate the points further: “I am walking, and I am afraid.; I hear a noise, I am afraid … At night, I sometimes just hear a footstep—you know my heart skips …. it can be midnight- one in the morning and I am laying there listening to doors that are closing—I really never sleep at all! I do pray but when you hear footsteps at 1:00 AM, it can be stressful. After surviving an attack like that, you’re never comfortable. You can pray but sometimes, the prayer cannot ease the stress. If I hear footsteps at 1:00 AM, I can never go back to sleep … it [sexual assault] can make you kill yourself …. For example, some people endured this like a young lady who suffered it, and tried to drink Clorox to kill herself”. “… sometimes you turn on the radio, you hear them say “There, they have done kadejak on such and such a person”, you who had already undergone, your heart breaks … and then, now suddenly you’re not the same—you’re not a person … and little by little, the thing becomes more difficult” … “It’s every time I turn around, I am losing my temper! I have become someone who is easily enraged! There can be a moment when you are very cool; but the next moment, you cannot tolerate someone even speaking with you. Also, although we had not specifically asked women if they had become pregnant from being raped, they freely shared that they had and that the “child of kadejak” is a constant reminder of the event for them; indeed, only woman indicated that she gets irritated and “beats” her “son of kadejak” when he cries for food because she herself does not have food to eat. All of the others rebuked her and counseled her gently about not beating the child. Criterion F, regarding the presence of symptoms for more than a month, all women fulfilled this criterion. A majority of women experienced the sexually violent event(s), in the immediate aftermath of the 2010 earthquake; their shared narratives noted above illustrate the variety of traumatogenic symptoms they continue to endure months and years since the event(s). The PTSD Criterion G indicates the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Our participants that the sexual violence event had affected their ability to develop new or sustain old social relationships. For example one woman stated, “When I

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stand across a young man who is speaking with me, the person can be well dressed, but I reject him—based on the idea that comes into my spirit—it traumatizes me … makes me think a lot!” With respect to Criterion H, “The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition”, participants clearly articulated a link between the sexually violent incident(s) and the variety of traumatogenic symptoms and negative physical and neurological health effects they were experiencing: I have a headache that never leaves me. It’s like a ringing; that’s why I wear glasses. I thought it was my eye but it’s not. Like right now, I’m not good at all. The headache is very strong. It starts from my skull down; no medicine would work … I black out; you can be talking to me right now and I can’t see you, I can’t hear you. I don’t know but I think once you endure “kadejak” it never ends for you, unless you’re in a coffin. However, none of them indicated a history of substance use or presence of a medical condition as the cause for the symptoms they are experiencing. Among limitations of this study was the small sample size, that experiences of women outside the targeted neighborhood are not included, and that a trauma-scale would have yielded individual level data to support our findings.

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engage in future intimate, consensual relationships must be considered in intervention development and implementation. We caution that our findings are not generalizable to all female victims of SV in post-earthquake Haiti; but, we emphasize that following earthquakes, there should be vigilance by public health officials and rescue teams for prevention of SV against women. Women who survive SV in Haiti should be provided access to trauma-informed care that addresses consequences of the SV, including biological, neurological and psychological sequelae. One direction is to assess the feasibility of adapting EvidenceBased interventions for HIV from the CDC’s Compendium of Evidence-Based Interventions for use in Haiti with victims of SV Figs. 1 and 2.

Role of funding source The funding source for this study was the University of South Florida School of Social Work. The School provided funds for travel, lodging, and food during our trip to recruit participants and collect data. The School did not contribute to the data

Always waiting and listening for noises at night

Insomnia/ Awaken during the night

Difficulty falling asleep

4. Discussion We found evidence that our study participants are likely to suffer from PTSD based on their endorsement variable expressions of clinical distress following exposure to sexual violence in the aftermath of the 2010 Haiti earthquake. Our findings have clinical relevance for efforts to work with victims of SV in similar contexts. For example, co-occurring epidemics of neighborhood violence, hunger, lack of access to psychological screening and care, coital injuries incurred during the SV and risks associated with sexually transmitted disease, should all be considered when developing interventions for women who survive SV, particularly in postdisaster contexts. Also, interventions should include STI/HIV testing, due to intentionally injurious nature of rapes by multiple perpetrators. Further, since pre-earthquake conditions such as neighborhood violence and poverty persisted after the experience of SV, risks of re-victimization, and capacity to contemplate and

Fear Revenge/ Revictimization

Feeling Unsafe

Single/ Living alone Anxiety

Still hurt

Stress is always on me

Fig. 2. Network view from ATLAS.tis denoting relationships among concepts and category “always waiting and listening for Noises at Night, which was eventually Coded as “Hypervigilance”, part of PTSD Criterion E.

Fig. 1. PTSD_ Criterion G_ Initial concepts and categories that led to selective coding of Criterion G., clinically significant distress and impairment in social, occupational and other important areas of functioning.

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analysis or to the preparation of this manuscript, except insofar as it provided my office and equipment. I am grateful to the School and its leadership.

Conflict of interest I certify that there is no conflict of interest to declare with respect to the research, writing, or submission of this work entitled, “Symptoms of PTSD in a sample of Female Victims of Sexual Violence in post-earthquake Haiti”.

Acknowledgements We thank Professor Clérismé from the Centre de Recherche pour le Développement in Pétion Ville, Haiti and Mr. John Wesley Placide as well as Mr. Paul Phycien from the Organization for the Renovation and the Education of the Cité Soleil Zone (OREZON Cité Soleil) for their contribution to recruiting study participants. We also extend a special note of thanks to the self-described “victims” who participated in our focus groups and who shared their life experiences with us and with each other.

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