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Symptoms of PTSD in a sample of female

victims of sexual violence in post-earthquake
Haiti

Article in Journal of Affective Disorders November 2014

DOI: 10.1016/j.jad.2014.10.067 Source: PubMed

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

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
School of Social Work, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL, United States
b
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: Background: Globally, sexual violence (SV) impacts 2533% of women, is often perpetrated by intimate
Received 30 September 2014 partners and occurs even post-disasters. The 2010 Haiti earthquake occasioned a SV epidemic in Cit
Received in revised form Soleil, where over 50% of females are reportedly victims of SV via non-intimate partners/strangers
15 October 2014
(NPSV). Little is known about the psychological effects of SV perpetrated by NPSV; even less in known
Accepted 28 October 2014
about the biopsychosocial consequences of NPSV on women in Haiti. Yet, the World Health Organization
Available online 11 November 2014
recently called for research on NPSV, particularly in poor and disaster-affected countries.
Keywords: Methods: As a rst step in categorizing the consequences of NPSV on female victims in Haiti, we
Haiti earthquake conducted 2 focus groups of 16 female residents of Cit Soleil who survived the earthquake and its
Haiti sexual violence
aftershocks, along with ensuing hurricanes and cholera.
Cit Soleil
Results: Participants reported rapes by strangers who intentionally crush the uterus. All endorsed
Haitian PTSD
Haitian women criteria for PTSD, including enduring physiological, neurological and psychological symptoms: signicant
Haitian victims intrusive, avoidance, arousal, cognitive, mood changes, as well as signicant 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 specic neighborhood
and cannot be generalized to all SV victims in Haiti.
Conclusions: Following earthquakes, there should be vigilance by public health ofcials 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.

1. Introduction partners (United Nations Population Fund, 2012). The psychosocial

Sexual violence (SV) is an issue of global public health sig-
nicance 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 persons sexuality using coercion
by any person regardless of their relationship to the victim, in
any setting includes rape, dened 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.: 1 813 974 7385;
fax: 1 813 974 4675.
E-mail address: gjrahill@usf.edu (G.J. Rahill).
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, parti-
cularly in poor and disaster-affected countries (World Health
Organization (WHO), 2013).
Haitis geographical position in the Caribbean has rendered it
susceptible to natural disasters in the form of recurrent annual
assault from hurricanes/cyclones, ooding, and loss of life. How-
ever, 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;

http://dx.doi.org/10.1016/j.jad.2014.10.067
0165-0327/& 2014 Elsevier B.V. All rights reserved.
 G.J. Rahill et al. / Journal of Affective Disorders 173 (2015) 232238
DAdesky, 2012; Theodore, et al., 2011). In Cit Soleil, an urban
shantytown of Haitis 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 Cit 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-identied as victims.
Cit 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, discrimi-
nation, gender inequity, low education, have contributed to the
risk of sexual violence (DAdesky and PotoFanm Fi, 2012;
Willman and Marcelin, 2010); Cit Soleil and its adjacent zones
have been identied by DAdesky and colleague as among the
most impacted by gender-based violence, particularly sexual
violence against women, asserting, much of the violence has
been conned to [Haitis] urban shantytowns (p. 114).
We contribute to extant knowledge on non-intimate partner
sexual violence against women by reporting ndings from a study
of female residents of Cit 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 Associations (APAs) 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 specic 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 conuence 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
233
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 specic
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 classication 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 expo-
sure to life-threatening or life-ending events, serious injury, or
sexual violence along with intrusive symptoms. Intrusive symp-
toms include distressing memories and dreams pertaining to the
catastrophic event, re-experiencing the event through ashbacks,
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 estrange-
ment 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 experi-
enced the disaster directly and even for those who experienced it
vicariously through media reports or from signicant others who
survived the disaster. He describes psychological trauma as, over-
whelming, 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 neuro-
physiological dysregulation somatic and mental symptoms
including a feeling that ones heart is about to burst feelings
of terror and autonomic reexes 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 endur-
ing symptoms of PTSD (41.3% prevalence) among exposed indivi-
duals two and a half years after exposure to the traumatic event,
conrming 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
234 G.J. Rahill et al. / Journal of Affective Disorders 173 (2015) 232238
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%), depres-
sion (52%), PTSD, somatization disorders and high comorbidity of
PTSD and depression ( Sezgin and Punamaki, 2012; Xu and Liao,
2011). Sezgin and Punamaki also conrmed 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 peri-
earthquake factors such as personal injuries incurred during the
earthquake, they did not address postdisaster 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 conict
of interest to declare.
We employed purposive sampling and a semi-structured ques-
tionnaire to collect focus group data from 16 women who self-
identied as victims of sexual violence and residents of Cit
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?
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
conrmation, dissent or clarication when these loud verbal
consents occurred.
We conducted two separate focus groups in Haitian Kreyl
following provision of informed consent that was approved by our
universitys Institutional Review Board. Our primary author, a
female of Haitian-descent who spoke English and Kreyl uently
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 audio-
recorded focus group discussions with the informed consent of the
participants, transcribed the Kreyl 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 descrip-
tions of the psychological impact of the sexual violence. We linked
this category to segments of text and quotations from our
participants that reected 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 Psycho-
logical 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 modied those relationships when needed, based on the
transcripts and memos written during data collection and on
comments noted during data analysis. We analyzed the demo-
graphic 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.
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
05 years of formal education. Fifteen had more than ve 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
 G.J. Rahill et al. / Journal of Affective Disorders 173 (2015) 232238
Table 1
Examples of analytic process from open through selective coding employing ATLAS.Tis code manager.
Open coding/ Core Axial coding/code families from
concepts/ categories ATLAS.Tis
quotations
Hearing of Psychological Criterion B: presence of one or
kadejak on trauma more intrusion symptoms;
radio causes intense and psychological and
heart to kase physiological distress
or sote
Never pass by Avoidance Criterion C: persistent avoidance Criterion C1. Avoidance of or efforts to avoid
the same reactions of stimuli associated with the
location traumatic event
their children was conceived as a result of sexual violence. The
pregnancies emphasized the increased risk for sexually trans-
mitted 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 dened sexual violence as non-
consensual 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 perpetra-
tors 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 WHOs
denition of sexual violence, but highlights purposeful injury.
Moreover, it was clear from several examples provided, that
cumulative trauma for some participants involved complex rela-
tionships 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
methe 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 xed their tents, but I didnt have the
means to x 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 x itoh! He began to ignore me
he heard that they had done kadejak on me, so he came to
ignore meMy child was bornof 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
dont take you for anythingThey dont 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, Naturenature)
235
Selective coding/super families from ATLAS.Tis Illustrative quote
Criterion B1. Recurrent, involuntary, and intrusive
Because sometimes you turn on the radio, you
distressing memories of the traumatic event(s); hear them say There, they have done kadejak
Criterion B5. Marked physiological reactions to on such and such a person, you who had
internal or external cues that symbolize or already undergone, your heart breaks and
resemble an aspect of the traumatic event then, now suddenly youre not the same-youre
not a person and little by little, the thing
becomes more difcult
To this day that I am speaking to you I have
distressing memories, thoughts, or feelings about drawn a cross on that I have not ever yet
or closely associated with the traumatic event(s) dated/had a boyfriend in my life!
Criterion C2. Avoidance of or efforts to avoid Where he works, I never pass by there anymore;
external reminders that arouse distressing even-the zone wherethe event had happened
thoughts, or feelings about or closely associated to me
with the traumatic event
[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, THATit had to happen; if it didnt 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 nd 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 didnt-you didnt
have that spirit/notion in your head. You have a vision; you
come from a poor class; you would like-for you to be some-
thing in your lifeand now the person comeshenot only
does he RUIN your objectivesyour visionsince he RUINS (her
emphasis) your female dignity! Because eh-eh-I heard my
mothermy 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 deathsexual violence, as they both experi-
enced 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 reac-
tions, intense and psychological and physiological distress at
exposure to cues that resemble the event:
I cant sleep, I feel scared, and I always feel that the rapist is
near me you are not in yourself, here (gestures to head)-
youre not in yourself here [participants emphasis]its when
afterbecause 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 difculty breathing, eating,
sleepingso traumatized that I can pdi tt (lose my head)
become crazy Maybe if you lived in a place where you
never see misery you never see where people arewhere
people are talking of misery where people are talking about
236 G.J. Rahill et al. / Journal of Affective Disorders 173 (2015) 232238
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 youre
not the same-youre not a person and little by little, the
thing becomes more difcult I can be walking- me, the
reason my heart breaks/jumps is because it was at night time
they hadespecially when there is a knock at the door to be
hearing the same noises I am always asking myself if he wont
return againit 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 asso-
ciated with the traumatic event beginning after the traumatic
event occurred as evidenced by efforts to avoid associated distres-
sing 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, lets
say someone who would woo mefor 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 dont
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 wherethe
event had happened to me, I dont let the child [of kadejak] go
in that zone-
Concerning 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:
Its as if life for me had ended completely, completely, com-
pletely! my parents had always told me, When a person is a
girl, heres how that (sex) is, heres 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 dont live
near my mother anymore THIS KADEJAK THING, I SAY THIS
AGAIN, MADAME, SO LONG AS YOU HAD ALREADY UNDER-
GONE IT ITS WHEN YOU ARE STRETCHED OUT IN DEATH
[Her emphasis]thatthat it is erased from your mind.
One woman stated, This is not my normal weight. Im not this
skinny, its 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 Cit 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 youre 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 its
that sort of thing that always gave me problems, and it
continues to there are some times when I cry-because when
I considerforyou-you are with a child in handshe doesnt
have a father to call on, and then she herself is always asking
you, Momma, where is my father! Yes yes, thats what
they say to you, yes. They use it as an insult; they use it to
criticize youto attack you.
Our participants reported all aspects of Criterion E and pro-
vided 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 pro-
blems. 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 footstepyou know my heart
skips . it can be midnight- one in the morning and I am laying
there listening to doors that are closingI 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, youre 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 youre not the sameyoure not a person and little
by little, the thing becomes more difcult Its 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 specically 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 fullled this criterion. A majority of women
experienced the sexually violent event(s), in the immediate after-
math 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
signicant 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
 G.J. Rahill et al. / Journal of Affective Disorders 173 (2015) 232238 237

stand across a young man who is speaking with me, the person
can be well dressed, but I reject himbased on the idea that comes
into my spiritit 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 articu-
lated 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. Its like a ringing; thats
why I wear glasses. I thought it was my eye but its not. Like
right now, Im 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 cant see you, I
cant hear you. I dont know but I think once you endure
kadejak it never ends for you, unless youre in a cofn.
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 ndings.
engage in future intimate, consensual relationships must be
considered in intervention development and implementation.
We caution that our ndings 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
ofcials 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 Evidence-
Based interventions for HIV from the CDCs 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
Difficulty Insomnia/ Awaken
falling asleep during the night

4. Discussion
Fear Revenge/
Revictimization Feeling Unsafe
We found evidence that our study participants are likely to
suffer from PTSD based on their endorsement variable expressions
Single/ Living alone
of clinical distress following exposure to sexual violence in the
aftermath of the 2010 Haiti earthquake. Our ndings have clinical Anxiety Still hurt
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 post-
disaster contexts. Also, interventions should include STI/HIV test- Stress is always on
ing, due to intentionally injurious nature of rapes by multiple me

perpetrators. Further, since pre-earthquake conditions such as Fig. 2. Network view from ATLAS.tis denoting relationships among concepts and
neighborhood violence and poverty persisted after the experience category always waiting and listening for Noises at Night, which was eventually
of SV, risks of re-victimization, and capacity to contemplate and 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 signicant distress and impairment in social, occupational and
other important areas of functioning.
238 G.J. Rahill et al. / Journal of Affective Disorders 173 (2015) 232238
analysis or to the preparation of this manuscript, except insofar as it provided my
ofce and equipment. I am grateful to the School and its leadership.
Conict of interest
I certify that there is no conict 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 Clrism from the Centre de Recherche pour le Dvel-
oppement in Ption Ville, Haiti and Mr. John Wesley Placide as well as Mr. Paul
Phycien from the Organization for the Renovation and the Education of the Cit
Soleil Zone (OREZON Cit 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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