Fallout: How rape has affected the women I study, and my life

Karestan Koenen

I. My rape
I was sexually abused at the age of 6. I did not know this experience was merely an initiation into sexualized violence that seems, too often, throughout the world to be as inescapable a part of becoming a woman as menstruation. My coming of age in New Jersey in the late 1980s was marked by sexual harassment in school ranging from male students using sexual comments to dismiss my intelligence to more direct physical threats such as grabbing my breasts. Such behavior was overlooked or encouraged by teachers. In young adulthood, sexual coercion in dating seemed almost normative. My experience of sexualized violence culminated in being brutally raped while serving as a Peace Corps volunteer in Niger, West Africa.

As a result of my rape, I developed full-blown posttraumatic stress disorder (PTSD). I was plagued with unwanted memories, I felt numb, could not eat or sleep, and was constantly on guard. I was hopeless about the future and often wished he had killed me because living with the shame of the rape seemed unbearable. I also found out my attacker was likely HIV positive and, due to the lack of prophylactic medication for HIV in 1991and inconclusive testing, feared for almost a year that I had also contracted the disease.

However, I was lucky. Unlike the women in conflict situations from Darfur to the Holocaust, I could escape back to the United States, where I slowly rebuilt my life and created meaning from my experience by pursuing a career aimed at understanding the causes and consequences of trauma and PTSD.

II. The consequences, compounded by conflict
Sexualized violence—which includes everything from forced penetration to sexual slavery—has wide-ranging mental and physical health consequences for victims and their children across all cultures and societies. PTSD is the most common and most well-studied mental disorder following sexualized violence. Population-based studies in the Archives of General Psychiatry and the American Journal of Psychiatry have repeatedly shown that people who report sexualized violence are at higher risk of PTSD than those who report other types of traumatic events such as exposure to disasters, sudden unexpected death of a loved one, or even combat. The high prevalence of PTSD, as well as other mental health problems such as depression, anxiety, and suicidal behavior among survivors of sexualized violence has been documented throughout the world—including in Liberia, Rwanda, Bosnia and Croatia, Bangladesh, and the Democratic Republic of Congo.

The adverse consequences of sexualized violence go well beyond mental health. This kind of violence and its subsequent mental health problems increase women’s risk of developing cardiovascular disease and diabetes. Rape is used as a tool of genocide via the spread of HIV, as it was in Rwanda, where women “were taunted by their genocidal rapists, who promised to infect them with HIV,” according to a 2006 briefing paper from the United Nations Population Fund. Traumatic genital injury from sexualized violence impairs women’s ability to produce offspring, compounding the shame of rape with infertility in societies where a woman’s value is placed largely on having children, such as Congo.

Studies carried out in Bangladesh and Saudi Arabia among other places has shown that sexualized violence alters life trajectories by increasing risk of women’s poor school performance, poverty, marital instability, and teen pregnancy. By affecting her ability to care for her children, the consequences of sexualized violence extend from the victim herself to the next generation. Moreover, children of women who experienced sexualized violence are at greater risk of being victims themselves.

Food insecurity and lack of access to quality medical care are common in conflict-ridden countries and further compound the intergenerational impact of sexualized violence. Research published in the Proceedings of the National Academy of Sciences and Nature suggests traumatic events such as sexualized violence may produce chemical changes to our genes that may be passed to our offspring. Children of mothers with PTSD who survived the Holocaust are more reactive to stress whether or not they have PTSD themselves, according to research published in the American Journal of Psychiatry.

III. Adapting to terror
The human brain evolved to maximize physical survival. When threatened, the brain activates the body’s “fight or flight” system in an attempt to thwart or escape the threat. When the threat is overwhelming (cannot be fought) and inescapable (cannot be fled)—as is so often the case in sexual assault—the brain tells the body to shut down or freeze.

Many victims of sexual assault describe this process in vivid detail: “I was struggling to get him off me by pushing against his chest but he was very forceful and much stronger than me. I tried harder and harder to push him off and started kicking. But he used his knees and right hand to hold me down. I remember thinking, ‘Oh my God he is going to rape me.’ Suddenly I felt nothing. I was floating outside my body.”

This is taken from my journal entries written shortly after the rape.

The activation of the stress response system is adaptive. It mobilizes energy, increases vigilance and focus, and facilitates memory formation. If the body survives, the brain, having evolved over tens of thousands of years of evolution to maximize survival, will encode the memory with the goal of keeping the body alive in the future.

This process is referred to as “fear conditioning.” Sensory details present at the time of the event—the gas fumes, a scratchy beard, drums beating, a military uniform—become inextricably linked to the memory of the event. Previously innocuous, any one such detail will trigger the victim’s memory, reactivating the stress response and the memory of the assault. The memory may be so vivid she may even feel like she is reliving the assault over again.

To use my own experience as an illustration, about a month after my rape I was riding the D.C. metro to meet a friend for dinner. A man came in the car who smelled like my rapist. Suddenly, my heart was racing, I couldn’t breathe, and I was propelled back into the courtyard in Agadez, where the rape occurred. My flight response was fully activated; my only thought was to get away from the smell. I stumbled off the train at the next stop thinking I was going crazy. I was not. My brain had been alerted to danger by the smell of my attacker and, to protect me, told me in no uncertain terms to get away.

IV. Recovery, elusive in conflict
Over time, I had the opportunity through individual and group therapy with other rape survivors to experience reminders and memories of the event in safety. The physiological and emotional response to the event diminished, a process referred to as fear extinction. The memory was not erased, but my brain learned to modulate my body’s response to the memory. I was forever changed, but with time I was able to put the event in the past where it belongs and move on with my life. My HIV test came back negative and since I had received immediate prophylactic care for STDs, I experienced no long-term medical or physical adverse effects from the rape.

For women in conflict situations, however, the potential for recovery from sexual assault is much more difficult on multiple levels. Global and culture-specific attitudes of permissiveness around male violence against women and that blame the victim perpetuate sexualized violence in all its forms—and hinder recovery. On top of that, the chronic stress of food shortages such as in Darfur IDP camps or Liberian villages, inadequate shelter, and unpredictable living conditions make women more vulnerable to developing PTSD.

When all the members of a society are experiencing horrific events, such as during the Holocaust or the Rwandan genocide, women’s experiences of sexualized violence are often minimized. When I was working as a clinician, a Holocaust survivor who had been raped reported she had been told many times, “So what if you were raped? At least you are alive.”

Women in all societies have primary responsibility for protecting and caring for the next generation. Under threat, women may cope by caring for others and may, therefore, ignore their own suffering. Women who become pregnant as the result of rape, particularly in countries without prophylactic pregnancy prevention or Plan B, will be stigmatized either for having an abortion (which may even be illegal in cases of rape, as in El Salvador, Afghanistan, or Niger), or having a child from the rape. Cultural values around virginity (see our Egypt analysis on “virginity tests") and sexual relations outside of marriage may dictate that victims of sexual violence be punished for their experiences—becoming “unmarriageable” or considered “whores” by their families or peers.

Narratives from women who have experienced sexualized violence in conflict situations attest to their heroic resilience in the face of these challenges. Rwandan genocide-rape survivors have organized associations to address problems associated with genocide-rape including using informal networks to provide mental health care. Women in other countries have merely gone on with their lives, continuing to provide for their families and dealing with stigma from being rape survivors.

Sexualized violence is perpetuated by the shame of its victims, who are instructed by society to suffer privately. The only cure for sexualized violence is to make the personal political. Only then, via education and legal action can the hard work of cultural change begin. Until that occurs, women who are sexually assaulted need to be provided with the opportunity to revisit reminders and memories of the assault in safety in order to recover. For women in conflict situations—such as the Democratic Republic of Congo or Somalia, where the violence is ongoing—no such place exists.

Karestan C. Koenen, Ph.D., is an associate professor of epidemiology at the Mailman School of Public Health at Columbia University in New York, where she does research and teaches about psychological trauma and posttraumatic stress disorder. She served as a Peace Corps volunteer in Niger from 1991 through 1992. She testified about the rape she experienced while serving in Niger and the need for reform of the Peace Corps rape response protocols at House Foreign Affairs full committee hearings, and was the driving force behind a Polk Award-winning ABC News investigation. Koenen is a licensed clinical psychologist and epidemiologist and is currently president-elect of the International Society of Traumatic Stress Studies.