Showing posts with label psychology. Show all posts
Showing posts with label psychology. Show all posts

Monday, October 12, 2015

An Ugly Reality: A Study of Developmental Behavior Of Children Born From Sexual Violence


By: Lydia Furman, MD,  Assistant Editor

      In a recently released study in Pediatrics, Dr. Rouhani et al. (doi: 10.1542/peds.2014-3373) presented us with a must read article about the burdens and experiences of women who are raising children conceived through sexual violence in the Democratic Republic of Congo (DRC) (ref here).  My first thought on reading this incredible article was that one does not need to go to the Democratic Republic of Congo (DRC) to meet women who are raising children conceived through sexual violence. Their conclusions are logical and intuitive, yet ground breaking, and I believe I can apply their “lessons” in my own practice. These authors interviewed over 700 women who are raising a child conceived through sexual assault. They used a specific method of locating hard-to-reach populations, called respondent driven sampling, in which ten initial identified women each recruited three other women, who then recruited three other women, and so on until the full population was identified.
      Please read the article to immerse yourself in the study, because likely you will find other parts of the work more meaningful than what captured me. What impressed me most was the extraordinary resilience of the women and of the maternal-child relationship.  Over one third of women reported that their community stigmatized their child, and over one third reported that their community stigmatized them personally. “Perceived acceptance of the child” by spouse, community and family seemed surprisingly low to me, given that the entire community was exposed to known, ongoing and multiple sexual assaults. Yet, despite all of this, 80.5% of women had “positive regard” (questions drawn from the Parental Stress Scale) for their child and 73.0% had “high attunement” (defined as “…awareness of, sensitivity to, and responsiveness to the child’s needs…”). So in the face of incomprehensible stress and challenge, including seeing their assailant and recalling the assault when looking at their child, the great majority of women are raising their children with engagement and kindness, as best one can understand. The authors’ multivariate analysis examines this question quantitatively and expands understanding further.
      While the upheaval in The DRC is notorious for the horror of widespread sexual violence, utilized as a weapon of war, the problems that women must face in raising a child who is the product of a rape respect no geographic boundaries. An issue that clinicians practicing in the US may have to recognize among women raising a child conceived through sexual violence is the complex racism of skin tone, which rears its ugly head when mother and child have obviously different skin colors or eye colors, prompting family or non-family members to ask about paternity. In the United States (US) it may be more possible for women to avoid stigma by non-acknowledgement of the sexual violence (e.g. by asking for non-inclusion of the information in the child’s medical record), but this does not permit future providers to treat the mother optimally (since she may have depression, anxiety, or other sequelae that are then not recognized), and this also makes support of any discussion she may want or need to have about conceiving in the setting of sexual violence   almost impossible.
       While Dr. Rouhani and colleagues studied a population in whom approximately 40% of women experienced sexual violence, it is sobering to realize that the Centers for Disease Control and Prevention (CDC) reports that “nearly one in five (18.3%) of women (in the US) … reported experiencing rape at some time in their lives” (http://www.cdc.gov/ViolencePrevention/pdf/SV-DataSheet-a.pdf ). While a continent and world away for some, this is a reality we cannot ignore. Ultimately prevention is the best cure, but in the meantime, removing stigma is critical.  Work is underway to support de-stigmatization of sexual violence in the DRC, for example through the Harvard Humanitarian Initiative (http://hhi.harvard.edu/sites/default/files/publications/women-in-war-stigmatization.pdf), and a brief search reveals relatively limited initiatives in the US, most primarily focused on domestic violence (for example, Triumph, a network for survivors of domestic violence, http://www.seethetriumph.org/). We have work to do, and the superb research of Dr. Rouhani and colleagues in the DRC is a wakeup call to all of us.

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Friday, July 17, 2015

A Farewell To Arms: The Concerns of Working with War Affected Youth In Sierra Leone

By: Joann Schulte  DO, MPH; Editorial Board Member  

       Familiarity with Sierra Leone has become commonplace over the past year, sadly due to the I Ebola epidemic in West Africa.   The cases are slowing to a trickle now with 25 new cases in Sierra Leone in the week ending July 8.  The cumulative total is 13,155 cases and 3,940 deaths in this
Country1.
      Even before Ebola arrived, Sierra Leone was a troubled country, fighting an 11-year civil war that killed an estimated 50,000 people.  That war was infamous for the use of child soldiers and sexual abuse of women and girls.  The civil war ended in 2002, and a new study published this month in Pediatrics by Betancourt et al.  (doi: 10.1542/peds.2014-1521) tracks  the outcomes of 529 war-affected youth who were ages 10 to 17 years when the war ended. About a fourth of the participants were girls. The investigators’  goals were to track outcomes  in these individuals and also identify areas where targeted interventions might do the most good.
     The study’s authors at Harvard University focused on internalizing and externalizing behaviors and the outcomes of participants as of  2008.  Internalizing behavior focus negative and inward; depression and anxiety are examples.  Externalizing behaviors focus on the outside world; hostility and aggression are examples.
      The researchers interviewed participants in 2002, just as the civil war was ending, and in 2004 and 2008. They did modeling to determine whether internal or external behaviors might be associated with better outcomes in 2008.  They found a significant association between internalization behaviors in 2004 and outcomes in 2008, such as post-traumatic stress and social attitudes and behavior.
     The authors suggested that working with war-affected youth by implementing programs to reduce anxiety and depression in survivors is an opportunity to improve their future lives and help them deal with the challenging environment in Sierra Leone.  They suggested that low-cost, group therapy that deals with trauma experienced in war might be a way forward.
     The study was done in a resource poor country, but the message about how internalization behaviors like depression and anxiety can shape future behavior is important.  In the United States, we see the impact of war on returning veterans from the Middle East with high rates of suicide.
      Maybe the Civil War Union General William T. Sherman said it best.  His 1880 speech in Ohio included the phrase “War is hell.” 2 And for survivors, the aftermath can be hell too.   Work like that done by these Harvard researchers is important in helping war-torn survivors live better lives.

1.  World Health Organization.  Ebola Situation Report - 8 July 2015.   http://apps.who.int/ebola/current-situation/ebola-situation-report-8-july-2015

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