Comparison of Trauma Symptoms Among Nonpartner Sexual Violence Victims and Nonvictims in Urban Haiti’s Cité Soleil Neighborhood

Abstract

Women in resource-constrained, postdisaster, urban enclaves, such as Haiti’s Cité Soleil, are at risk for nonpartner sexual violence (NPSV) by multiple perpetrators, and subsequently, psychological trauma and sexually transmitted infections (STIs), including HIV/AIDS. These biopsychosocial risks suggest that NPSV victims may benefit from an adapted evidence-based intervention for sexually transmitted infection (EBI-STI) that includes a trauma component. Yet there is a dearth of knowledge on trauma symptoms experienced by victims in Haiti. We administered a Haitian Kreyòl version of Trauma Symptom Checklist (TSC-40), including its subscales (depression, dissociation, anxiety, sexual problems, sleep disturbance, sexual abuse trauma) to women in Cité Soleil, comparing victims’ scores (n = 54) with those of nonvictims (n = 179). After controlling for child sexual abuse, arrest, transactional sex, and sociodemographics, being a victim was associated with higher scores on the full TSC-40, and subscales of anxiety and sexual abuse trauma index. These increased scores of victims underscore the need to incorporate trauma in adaptation of EBI-STI for Haitian NPSV victims like our sample.

Keywords

nonpartner sexual violence Haitian women Trauma Symptom Checklist (TSC-40)trauma-informed care

Over a third of women around the globe have experienced intimate partner violence (IPV) and/or sexual violence in the form of coercive sex (World Health Organization [WHO], 2017). Roughly 15 million teens between the ages of 15 and 19 years have experienced forced sex (United Nations [UN] Women, 2019). It is difficult to determine the proportion of girls who experience child and adolescent sexual abuse (CASA) globally because CASA is difficult to disentangle from issues of trafficking of girls and issues of child marriages (UN Women, 2019). Efforts are underway to clarify the proportion of women who are victims¹ specifically of nonpartner sexual violence (NPSV) apart from IPV, but the emerging research places that figure at approximately 5% to 7% (WHO, 2017).

Biological and social sequelae of NPSV include unwanted pregnancies, sexually transmitted infections, including the human immunodeficiency virus (HIV), sexual promiscuity, and social stigma (Aniekwu & Atsenuwa, 2007); psychological effects of NPSV include depression and related sleep disruptions, suicidality, anxiety), psychological trauma (including intrusive thoughts and memories of the NPSV experience, and posttraumatic stress disorder (PTSD; Brezing et al., 2015; Dworkin et al., 2017; Jina & Thomas, 2013; Watt et al., 2017). These outcomes of NPSV are complicated when victims have also experienced CASA.

Relationships Among CASA, Trauma, and NPSV

Women who have a history of CASA prior to experiencing NPSV as adults are at increased risk of using substances to cope with trauma-related negative cognitions and moods (e.g., difficulty problem solving and hopelessness), and, to mitigate symptoms of hyperarousal (e.g., hypervigilance, anxiety, insomnia; Jina & Thomas, 2013; Rahill et al., 2015). CASA survivors’ use of substances, in turn, can affect their decisions to engage in high-risk sexual behaviors such as having multiple sex partners or engaging in unprotected sex (Jina et al., 2016). Thus, CASA, substance use, NPSV, trauma, and sleep disruption together heighten health risks for women, including risks of acquiring sexually transmitted infections (STIs) as well as risks of experiencing NPSV as adults (Jina & Thomas, 2013; Klanecky et al., 2016; Sciolla et al., 2011).

Studies conducted in Haiti indicated that among NPSV victims, psychological trauma and related behavioral expressions coincided with age at first sexual assault, with the severity of the assault, and with the number of times NPSV is experienced (Jina & Thomas, 2013; Loeb et al., 2011). Indeed, the more severe the initial and subsequent sexual assault experiences, the higher the risks of depression, suicidal ideation, anxiety, trauma, and sleep disorders (Sciolla et al., 2011). Additionally, reproductive injuries and genital lacerations from NPSV experiences enable greater access for STIs to enter the body (Aniekwu & Atsenuwa, 2007; Masters et al., 2015; Rahill et al., 2015; WHO, 2017). For example, women who acquired HIV as a result of sexual assault, avoidance (a trauma and stress–related symptom of trying to avoid people, activities, places that remind them of the sexual assault) may reduce the likelihood that they will seek postassault care (Watt et al., 2017).

Transactional Sex and NPSV in Haiti

Traditional cultural norms in Haiti reflect gender inequities that typically devalue women, hinder their access to education, employment, and economic self-sufficiency foster their economic dependence on men as a culturally mandated quid pro quo; in such cases, they are compelled to acquiesce to transactional sex (Daniel & Logie, 2017). Economic reliance on men and transactional sex elevate women’s vulnerability to NPSV and exposure to STIs as transactional sex places women in a position of reduced power and control of their sexual choices, reduces the likelihood that they will successfully negotiate for condom use, and involves sex with multiple partners (Cyrus et al., 2016; Daniel & Logie, 2017). Transactional sex and reduced sexual autonomy were particularly evident in the aftermath of the 2010 Haiti earthquake.

In the aftermath of the earthquake, unsafe temporary shelters, inadequate lighting, and poor security in displacement camps, and women’s loss of family and primary heads of households, reportedly, occasioned epidemic proportions of NPSV against girls and women; victims ranged in age from early childhood to late adulthood (D’Adesky & PotoFanm+Fi, 2012; Jina & Thomas, 2013; Koenig et al., 2010). Girls and women in the poorest communities were even more likely to be NPSV victims and to retain the biopsychosocial and neurological symptoms even 5 years after the earthquake (Rahill et al., 2015; Revol, 2015).

Study Setting: Cité Soleil

Sociodemographic Characteristics of Cité Soleil Residents

Cité Soleil, a seaside shantytown in Haiti’s capital of Port-au-Prince, is less than eight and a half square miles, with roughly 350,000 residents subsisting in “the zone,” as residents routinely call the area (Leve, n.d.). The majority of Cité Soleil residents are law-abiding, hardworking, bright, capable, respectable people, who strive to improve opportunities for their children and for their community, even within their limited financial means (Kolbe, 2015; Rahill et al., 2014; Torgan, 2019; World Bank, 2020). However, residents of Cité Soleil have a per capita income of less than 1.25 U.S. dollars per day; that is, they live in extreme poverty (World Bank, 2020).

Cité Soleil’s population is young. The majority of its residents are between 15 and 35 years, in part because of food insecurity, preventable infectious diseases, and violation of human rights; consequently, most Cité Soleil residents do not live past age 30 (AIDS Healthcare Foundation, 2017; Beer, 2008; United States Department of State, 2015). In fact, the life expectancy in Cité Soleil is 50, 2 years less than Haiti’s national average, and few reach it (Marcelin et al., n.d.).

Characteristics and Outcomes of NPSV in Cité Soleil

Little is known about the biological or psychological impact of NPSV on girls and women in Cité Soleil. But it is estimated that over 50% of Cité Soleil’s girls and women, sometimes even prepubertal (indicating CASA), have experienced NPSV that is intentionally misogynistic and designed to destroy their reproductive organs (Chemaly, 2013; Joshi et al., 2014; Revol, 2015). These acts typically include multiple assailants who insert sharp objects, such as broken toothbrushes, into the victims’ vaginas in the course of raping them, resulting in long-term consequences for the victims (e.g., unplanned and unwanted pregnancies, STIs, social stigma, neurological problems, such as tinnitus, and psychological complications, including suicidality and PTSD (Joshi et al., 2014; Rahill et al., 2015). In previous studies of Cité Soleil NPSV victims, participants reported that victims of NPSV in Cité Soleil reported drinking bleach or rat poison in suicide attempts when they had exhausted their ability to cope with the shame, stigma, hopelessness, and constant reminder that the fetus in their wombs came from NPSV (Rahill et al., 2015; 2020). In addition, recent anecdotal evidence from physicians working at an HIV-testing and treatment center in Cité Soleil indicated that the zone’s HIV rate was 3.6% compared with Haiti’s national prevalence of 2.3% (P. Phycien, personal communication, March 4, 2020; Joint United Nations Programme on HIV/AIDS [UNAIDS], 2019). This information underscores that NPSV and its adverse health outcomes are particularly salient issues of public health significance for women in Haiti’s Cité Soleil shantytown.

What little is known about psychological outcomes of NPSV against victims of NPSV in Cité Soleil indicates that trauma symptoms rise to arousal symptoms of PTSD, such as hypervigilance and insomnia, as they lie awake anticipating that the unknown perpetrators may return (Rahill et al., 2015). However, given that nonvictims in Cité Soleil also witness and are subjected to gang violence, IPV, social stigma related to their extreme poverty, and sociopolitical violence (Willman & Marcelin, 2010), there was a need to further investigate trauma symptoms among victims relative to nonvictims.

Purpose of the Study

Our first goal was to describe and highlight differences in the sociodemographic characteristics of NPSV victims and nonvictims in a sample of female residents of Haiti’s Cité Soleil shantytown. These characteristics included participants’ age, education levels, employment status, and partnership status, as well as history of CASA, substance use, arrest, and transactional sex. Our second goal was to explore specific characteristics of victims’ sexual violence experiences to elaborate on findings from previous studies of heightened STI risks from NPSV in Cité Soleil (e.g., number of NPSV experiences, number of perpetrators in each NPSV experience, whether or not injury provoking objects were inserted in the vagina during NPSV). Because NPSV victims and nonvictims share the same neighborhood, health risks, and political contexts and also survived the 2010 Haiti earthquake, our third goal was to measure and compare the trauma symptoms reported by victims in our sample with trauma symptoms reported by women in our sample who reported not having experienced NPSV; these included sleep disturbances.

Our hypotheses are related to our stated goals. Because neighborhood violence, disease epidemics, and poverty are experiences for all residents of Cité Soleil, we first hypothesized that the majority of women residents of Cité Soleil in our sample would endorse trauma symptoms, such as nightmares, flashbacks, and sleep disturbance, regardless of their status as NPSV victim. However, due to the unusually brutal aspects of NPSV in Cité Soleil, which often includes insertion of foreign sharp objects in the vagina in the course of forced sex by several assailants (Joshi et al., 2014), we further hypothesized that trauma symptoms reported by NPSV victims would be higher than those reported by nonvictims. Finally, we hypothesized that the experience of CASA would help predict part of the difference between trauma symptoms reported in victims as well as nonvictims of NPSV.

Theoretical Framework

Social justice dictates

full and equal participation of all groups in a society that is mutually shaped to meet their needs . . . in which the distribution of resources is equitable, and all members are physically and psychologically safe and secure. . . . (Bell, 2007, p. 2)

For several reasons, social justice (Bell, 2007) is a useful lens to investigate Cité Soleil women’s exposure to various forms of violence and the biopsychosocial sequelae of such experiences. First, women in Cité Soleil are underrepresented in research; they are also underserved in that health prevention/intervention resources often do not reach them because Cité Soleil is often avoided by health workers due to its violence (Willman & Marcelin, 2010). Second, it is a moral and ethical obligation to elucidate the factors that are addressed in this study in order to arrive at just and sustainable solutions for Cité Soleil NPSV victims, irrespective of where they live or how much they earn (Patel & Farmer, 2020). Third, sex and gender-based inequities heighten NPSV risk for women in Cité Soleil and globally (Joshi et al., 2014; UNAIDS, 2019).

Applied to this study, social justice means that women who reside in Haiti’s Cité Soleil deserve to be protected from NPSV and the bodily harm it causes and to have their bodily integrity and autonomy respected and preserved by not being coerced into nonconsensual sex; social justice also mandates that when victims of NPSV in Cité Soleil sustain injuries stemming from NPSV, they should have access to legal recourse, affordable health care, and, psychological safety as they endeavor to navigate the traumatic sequelae of NPSV (Bell, 2007). Social justice also stipulates that all societal groups should have the opportunity to participate in decisions that affect their well-being (Bell, 2007); therefore, we were careful to empower victims as participants and contributors in this study, detailed in the study method below. In previous studies, NPSV victims had indicated that being included in studies about NPSV was both helpful to them psychologically and essential for any interventions because the NPSV in Cité Soleil is their problem (Joshi et al., 2014).

Method

Participants

The sample comprised 233 Haitian women aged 18 years or older (M = 27.46 years; SD = 8.39; age range: 18-60 years) who self-identified as residents of Cité Soleil or its adjacent neighborhoods (see Table 1). Our resources did not permit inclusion of women younger than 18 years. Approximately 23% (n = 54) women who participated in the study reported experiencing NPSV. Most victims as well as nonvictims (90.74% vs. 91.62%) were currently living in Cité Soleil and were in the 18- to 35-year age range (77.78% vs. 69.38%). Almost half of the victims (50%) were born in Cité Soleil as compared with one-third of nonvictims (34.08%). Most (49.36%) participants had completed the third fundamental cycle (roughly equal to middle school/7th-10th grade in the United States). Few (4.72%) participants had completed the secondary level or had gone to a university (4.72%) or technical school (1.72%). More than half of victims (53.70%) as well as nonvictims (57.54%) were unemployed. Almost two thirds of victims (66.67%) and nonvictims (61.45%) reported having a boyfriend. However, only 5.56% of victims and 7.26% of nonvictims reported that they had lived with a significant other/spouse in the past 2 weeks. About a quarter of victims (22.2%) reported living alone as compared with 10.61% nonvictims. A smaller percentage of victims reported that they lived with an adult relative as compared with nonvictims (27.28% vs. 48.60%).

Table 1.

Sociodemographic Characteristics of Participants in Cite Soleil Study (%), Chi-Square Tests.

Characteristics	Total (N = 233)	Victim (n = 54)	Nonvictim (n = 179)	χ²	df	p	Cramer’s V
Age, years, mean (standard deviation)	27.46 (8.39)	27.96 (8.30)	27.32 (8.44)	—		—
				3.83	5	.280	.14
18-25	45.92	37.04	48.60
26-35	35.62	46.30	32.40
≥36	18.03	16.67	18.44
Missing	0.43	0.00	0.56
Place of birth				6.58	3	.086	.17
Cite Soleil	37.77	50.00	34.08
Bel Air/Carrefour/La Saline	12.02	14.81	11.17
Other	48.50	33.33	53.07
Missing	1.72	1.85	1.68
Place of residence				0.41	2	.814	.04
Cite Soleil	91.42	90.74	91.62
Bel Air/Carrefour/La Saline	8.15	9.26	7.82
Missing	0.43	0.00	0.56
Educational status^a				4.64	9	.864	.14
None/preschool	6.87	9.26	6.16
First fundamental cycle	15.45	12.96	16.20
Second fundamental cycle	12.45	14.81	11.73
Third fundamental cycle	49.36	53.71	48.04
Secondary	4.72	1.85	5.59
University	4.72	1.85	5.59
Other	1.72	1.85	1.68
Missing	4.72	3.70	5.03
Paid for work				0.98	2	.612	.06
Yes	39.91	44.44	38.55
No	56.65	53.70	57.54
Missing	3.43	1.85	3.91
Have a boyfriend
Yes	62.66	66.67	61.45	1.01	3	.799	.07
No	32.19	27.78	33.52
I do not want to answer	4.72	5.56	4.47
Missing	0.43	0.00	0.56
Who lived with in past 2 weeks^b
Alone	13.30	22.22	10.61	5.58	2	.061	.15
Roommate/friend	6.01	9.26	5.03	2.17	2	.338	.10
Mother/father	24.46	35.19	21.23	5.05	2	.080	.15
Children	22.32	14.81	24.58	3.38	2	.184	.12
Relatives	43.78	27.78	48.60	8.83	2	.012	.19
Significant other/spouse	6.87	5.56	7.26	1.13	2	.568	.07
Other	3.43	1.85	3.91	1.79	3	.615	.09
Have children
Yes	52.79	64.81	49.16	4.28	2	.117	.14
No	43.35	33.33	46.37
Missing	3.86	1.85	4.47
Ever indulged in transactional sex				8.08	3	.040	.19
Yes	23.61	37.04	19.55
No	65.67	57.41	68.16
I do not want to answer	2.15	1.85	2.23
Missing	8.58	3.70	10.06
Ever arrested				30.49	2	.000	.36
Yes	9.01	27.78	3.35
No	85.84	66.67	91.62
Missing	5.15	5.56	5.03
Sexually abused as a child				16.24	2	.000	.26
Yes	42.92	66.67	35.75
No	42.92	24.07	48.60
I do not want to answer	14.16	9.26	15.64
Had street drugs in past 4 weeks				12.52	2	.002	.23
Yes	3.43	11.11	1.12
No	55.36	51.85	56.42
Missing	41.20	37.04	42.46
Had alcohol in past 4 weeks
Yes	11.16	18.52	8.94	4.10	2	.129	.13
No	57.51	50.00	59.78
Missing	31.33	31.48	31.28

Note: Percentages do not always total 100 due to rounding error. df = degrees of freedom.

More details on the education system can be made available on request. ^bQuestion asked respondents to check all that apply therefore the percentages do not total to 100.

Procedures

Our university’s institutional review board approved this study. Our collaborators were administrators and staff at OREZON Cité Soleil (French acronym for Organization for the Renovation of the Cité Soleil Zone), a community-based social service organization that serves Cité Soleil and its adjacent neighborhoods. OREZON colleagues received training in human subjects’ protection, and contributed to the different stages of this study, that is, to the development, translation, and back-translation of the survey, and to recruitment and data collection.

We presented consented participants with a Haitian Kreyòl community survey that assessed their health knowledge, health status, and health behaviors. The consent form and the survey were translated into Haitian Kreyòl and were back translated into English by two translators at MEXSAF (French Acronym for Maison des House of Languages without Borders), a branch of OREZON. One of the authors is a native Haitian who is fluent in both English and in Haitian Kreyòl. She reviewed all translations and back translations of the consent form and survey. OREZON administrators read the consent form aloud to participants who could not read and witnessed their “mark,” and, clarified concerns for participants who were literate. The study site was OREZON’s field office in Cité Soleil.

We collected the data between March 2015 and June 2016, recruiting participants in two phases. In Phase 1, we recruited from hundreds of women who attended an International Women’s Day event (n = 147). In Phase 2, volunteers, who had heard about the survey via word-of-mouth, were consented by OREZON (n = 90). The measures in the survey were presented in the same order to all participants. It took participants anywhere between 60 to 90 minutes to complete the survey; OREZON administrators were available in case participants had questions about any item in the survey instrument. We were not in a position to provide financial incentives but provided clean drinking water and a shady work area. We excluded from analysis four surveys of women who did not answer the question on experience of NPSV. The final sample, described in the participant section, was 233.

Measures

The Trauma Symptom Checklist–40 (TSC-40)

The TSC-40 (Briere & Runtz, 1998) assesses dissociation (6 items), anxiety (9 items), depression (9 items), sleep disturbance (6 items), sexual problems (8 items), and sexual abuse trauma index (SATI; 7 items). The TSC-40 is brief and its concepts were easy to translate. The outcome variables in this study were the total TSC-40 score and the subscale scores. Women were asked to rate how often they experienced each of the 40 symptoms in the past 2 months on a 0 to 3 scale: 0 = never to 3 = often. These responses were summed across all 40 items for a total TSC-40 score (maximum of 120), and, across the subscale items for subscale scores. Higher scores indicate increased symptomatology of the particular problem (Elliott & Briere, 1992).

Multiple studies have provided support for reliability and validity of the TSC-40 scores in assessing symptoms among sexual abuse survivors; subscale alphas typically have ranged from .66 to .77, with alphas for the full scale averaging between .89 and .91 (Briere & Runtz, 1998; Elliott & Briere, 1992; Higgins & McCabe, 1994; Neal & Nagle, 2013). In a study by Zlotnick et al. (1996), the convergent and discriminant validity of the TSC-40 was examined among 130 women psychiatric inpatients. In other studies, significant positive associations were found between the following: (a) the TSC-40’s Dissociation subscale and the Dissociative Experiences Scale (Bernstein & Putnam, 1986) (r = .78), (b) the TSC-40’s Anxiety subscale and the Symptom Checklist 90-R subscale of Anxiety (Derogatis, 1977) (r = .60), (c) the TSC-40’s Depression subscale and the Symptom Checklist 90-R subscale of Depression (Derogatis, 1977; r = .64; and (d) the SATI subscale of TSC-40 and a subscale of frequency of PTSD symptoms (Davidson, 1995; r = .56). Small correlations (e.g., r = .30) were found between scores on a social support measure and the TSC-40 and its subscales, indicating discriminant validity. Furthermore, TSC-40 has indicated predictive validity with reference to child sexual abuse in clinical and nonclinical samples (Neal & Nagle, 2013). Furthermore, a recent examination of the factor structure of TSC-40 found a strong invariance across groups with or without histories of abuse and trauma, providing support for its factor structure (Rizeq et al., 2018).

With respect to our sample, we analyzed the psychometric properties and found that the scores of TSC-40 and its subscales had acceptable internal consistency reliability (TSC-40: α = .94; Disassociation: α = .75; Anxiety: α = .80; Depression: α = .81; Sexual Abuse Trauma: α = .70; Sleep Disturbance: α = .78; Sexual Problems: α = .77). For convergent validity, we found a significant moderate positive association between the five-item Negative Affect subscale of the Bradburn Scale of Psychological Well-being, included in the survey instrument (Bradburn, 1969) and TSC-40 (r = .34). Furthermore, a significant but mild to moderate positive association was found between the Negative Affect subscale and each of the TSC-40 subscales (Disassociation: r = .25; Anxiety: r = .38; Depression: r = .35; Sexual Abuse Trauma: r = .27; Sleep Disturbance: r = .33; Sexual Problems: r = .21). For discriminant validity, we found a significant moderate negative association between the five-item Positive Affect subscale of the Bradburn Scale of Psychological Well-being and TSC-40 (r = −.48). In addition, a significant moderate negative association was found between the Positive Affect subscale and each of the TSC-40 subscales (Disassociation: r = −.37; Anxiety: r = −.47; Depression: r = −.42; Sexual Abuse Trauma: r = −.49; Sleep Disturbance: r = −.41; Sexual Problems: r = −.39).

Experience of NPSV

To assess the main predictor variable, NPSV experience, we first sorted the surveys based on participants’ answers to the NPSV question, if they had ever been a NPSV victim, contextually called “kadejak” (Joshi et al., 2014). If they answered “Yes,” we categorized these surveys in the victim class. We initially sorted 10 surveys into the “maybe” category because participants indicated, “I don’t know,” or “Don’t want to answer.” These were later classified as “Yes” because participants completed sections that detailed the number of times they had experienced NPSV and their health-seeking activities post-NPSV. We classified in the “No” category, surveys on which respondents answered “No” to experiencing NPSV, and also omitted sections containing specific questions related to post-NPSV health-seeking behaviors.

Potential covariates

The covariates used in the analyses were age, education, employment status, and other characteristics, such as experience of CASA, alcohol and substance use, transactional sex, and arrest history. As noted in the introduction section, these covariates have previously been found to be useful in understanding trauma symptoms in relation to experience of violence (e.g., Daniel & Logie, 2017; Ghee et al., 2010; Lutnick et al., 2015). Participants provided their specific age; thus, age was treated as a continuous variable. To measure CASA, we asked women if before they turned 18, someone older had done any of the following: (a) touched them inappropriately in their private parts, (b) persuaded them to perform a sexual act, or (c) forced them to perform a sexual act. If they answered “Yes” to any of these questions, they were classified as having experienced CASA. Thus, we combined responses into a single variable called “experience of CASA” (coded as 1 = yes, 0 = no). To measure substance use, the participants were asked if they had used alcohol in the past 4 weeks. If they said, “yes,” the follow-up question was, “On how many days have you had any alcohol to drink over the past 4 weeks?” If participants said yes to the first question, then they were categorized as “yes” (1), otherwise “no (0).” In some cases, although the initial response to the screening question was “no,” the participants’ then answered the follow-up questions related to amount of alcohol use. In such cases, the responses were then coded as a “yes” for substance use. The participants were also asked to indicate if in the previous 4 weeks they had used any street drugs (e.g., cocaine, marijuana, heroin, speed, LSD [lysergic acid diethylamide]) and the variable was coded as yes (1) and no (0). To assess “transactional sex,” participants were asked if they had ever engaged in any type of sexual activity for money (coded as yes [1] and no [0]. Participants were also asked if they had ever been arrested (coded as yes [1] and no [0]).

Data Analysis

Our first aim was to describe the sociodemographic characteristics of NPSV victims and nonvictims in our sample of women residents of Haiti’s Cité Soleil and highlight important differences. Thus, we calculated descriptive statistics (i.e., frequencies, percentages), correlations, chi-square statistic (χ²), and effect size using Cramer’s V. The second aim was to describe specific characteristics of NPSV victims’ sexual violence experiences; thus, we used simple percentages to explore sexual assault-related characteristics reported by victims (e.g., when assaulted, number of perpetrators, foreign objects inserted during assault, and if victims obtained medical care after any assault).

Finally, we conducted hierarchical regression analyses to investigate the effect of sociodemographic characteristics on the relationship between victim status and trauma symptomatology (TSC-40 total and each subscale). Theoretically grounded variables that were potentially related to trauma were identified via literature review (e.g., Daniel & Logie, 2017; Elliott & Briere, 1992; Ghee et al., 2010; Lutnick et al., 2015; Zlotnick et al., 1996). These covariates, noted above, were entered in the regression models. All the covariates, except age, were categorical and thus dummy variables were created. Reference groups were chosen based on their significance to the research question, theoretical relevance, and importance for practice, and, on whether they had previously been used in studies, and are specified above. The Stata pcorr command was used to estimate sr² (i.e., an estimate of how much of the variance of y not explained by the other xs is explained by x₁) as the measure of effect size in regression analyses.

Results

Preliminary Analyses

The TSC-40 data were examined for missing data; not more than 10% of the values were missing for the responses. Therefore, we used individual mean imputation to address the missing data on TSC-40, an acceptable method when the missing data are less than 10% (Bono et al., 2007). The imputed value was the calculated mean of any given participant’s complete responses to other TSC-40 questions/items. There were high percentages of missing data on the substance use questions (31% to 41%); thus, we did not include these variables in the regression models.

Before undertaking regression analyses, standard diagnostic statistics (e.g., tests for multicollinearity between predictor variables, residual analysis) were calculated; no observations were found to deviate markedly from other observations. To ensure that regression coefficients were uniquely defined and were stable, the variance inflation factor (VIF) was calculated. A conservative cutoff is a VIF of 2.5 or lower for each predictor variable as acceptable (Allison, 1999). Diagnostics indicated that the VIF ranged from 1.05 to 1.47 for individual predictor variables; and the average VIF was 1.23. Given that the values were below the conservative cutoff, multicollinearity was deemed not to be a problem in the regression models. Our data also met the assumptions of homoscedasticity and normality of scores.

Descriptive Statistics for Sociodemographic Features

Our first goal was to describe and highlight differences in the sociodemographic characteristics of NPSV victims and nonvictims in our sample. The sociodemographic characteristics of the participants are presented in Table 1. A series of chi-square analyses were conducted on some of these sociodemographic characteristics based on victim status. Multiple tests of significance were conducted: hence, the alpha level was set at .001. There was a significant association between victim status and transactional sex. Almost twice the percentage of victims versus nonvictims (37.04% vs. 19.55%), χ²(3, N = 233) = 8.08, p = .04 (V = .19) reported having engaged in transactional sex.² As much as 27.78% of victims indicated a history of arrest compared with less than 4% of nonvictims, χ²(2, N = 233) = 30.49, p < .001 (V = .36). Over two thirds of victims also reported experiencing CASA (66.67% vs. 35.75% of nonvictims), χ²(2, N = 233) = 16.24, p < .001 (V = .26). Higher percentages of victims (vs. nonvictims) reported use of street drugs (11.11% vs. 1.12%; V = .23) and alcohol (18.52% vs. 8.94%; V = .13) in the previous 4 weeks; however, missing data for these two variables were substantial (i.e., 31% to 41%). Furthermore, there were high percentages of participants who checked “I do not want to answer” or omitted questions related to transactional sex (8.58%) and CASA (14.16%), perhaps due to the sensitive nature of these questions.

Characteristics of NPSV

Our second goal was to explore specific characteristics of victims’ sexual violence experiences to elaborate on past findings from previous studies of heightened STI risks stemming from NPSV in Cité Soleil. With regard to victims of NPSV, participants reported that more than one-third of assaults (35.19%) had occurred 6 months to 2 years before data collection (see Table 2). Nearly 10% of the assaults had occurred in the immediate aftermath of the 2010 earthquake. About one-fifth (20%) of the victims had endured insertion of foreign objects in their vaginas. A significant minority (24.07%) reported that four or more men had attacked them in the first assault. About a quarter (24.07%) reported four or more perpetrators for any assault.

Table 2.

Victims’ Reports on the Sexual Violence Experience (Kadejak; N = 54).

Characteristics	Victim (%)
When victim of kadejak
<1 year after the earthquake	7.41
Within past 6 months	9.26
>6 months, <1 year	11.11
12-24 months ago	14.82
>2 years ago	3.70
>5 years ago	7.41
I don’t remember/I don’t know/Don’t want to answer	29.63
Missing	16.67
Insertion of foreign object (not penis) in vagina, during kadejak
Yes	20.37
No	38.89
Do not want to answer/missing	40.74
Number of perpetrators in the first kadejak even if one time victim
1	24.07
2	7.41
3	5.56
4 or more	24.07
Do not want to answer/missing	38.89
If victim more than once, greatest number of perpetrators ever
1	12.96
2	7.41
3	7.41
4	7.41
Do not want to answer	48.15
Had opportunity to go to doctor after any of kadejak experiences
Yes	20.37
No	42.59
Do not want to answer/missing	37.03
Where victim went for help after most recent kadejak^a
Nowhere	29.63
Police	20.75
GHESKIO (Haitian Group for Study of Kaposis Sarcoma & Opportunistic Infections	7.41
KOFAVIV (Commission of Victims for Victims)
Family/relatives	5.56
Friends	1.85
Injectionists (Picuriste)^b	9.26
Pharmacy to pick up self-identified medication	25.93

Note: Percentages do not total 100 due to rounding error.

Check all that apply—therefore percentages do not total 100. ^bInjectionists (Picuriste) refers to traditional health workers with no formal medical training who provide injections, typically with nonsterile needles.

Nearly 43% of victims had not had the opportunity to obtain medical are after any assault. Furthermore, about a third (29.63%) did not ask anybody for help, 20% reached out to the police, over a quarter self-medicated with pharmaceutical substances easily procurable from street vendors, e.g., antibiotics in attempts to treat what they suspected were symptoms of STIs (25.73%), and close to 10% sought help from an injectionist/picuriste, a Haitian individual who administers injections without the benefit of medical training or knowledge of safe injection protocol (Rahill & Rice, 2010). Few participants endorsed seeking help from existing social/health-related organizations, such as GHESKIO (French acronym for Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (7.41%) or KOFAVIV (Haitian Kreyòl acronym for Commission of Women Victims for Women) (7.41%), and fewer sought succor or emotional support from family/relatives (5.56%) or friends (1.85%).

Sociodemographic Characteristics, Victim Status, and Trauma Symptomatology

Our third goal was to measure and compare the trauma symptoms (including sleep disturbances) reported by victims in our sample with trauma symptoms reported by nonvictims who live in Cité Soleil and both survived the 2010 Haiti earthquake and sociopolitical conditions in the zone. We conducted seven hierarchical regression analyses to examine the relationship between the predictor, victim status, while controlling for 9 sociodemographic characteristics (covariates) and the criterion, level of trauma (i.e., score on six TSC-40 subscales, and TSC-40 total). The results from the regression models are presented in Tables 3 through 5. Statistical significance was set at <.001. A recent meta-analysis noted that medium-effect sizes were associated with research on sexual assault survivors in terms of trauma symptomatology when compared with people who are nonvictims (Dworkin et al., 2017); therefore, the a priori effect size was set at .05 for sr².

Table 3.

Hierarchical Regression Analyses of Nonpartner Sexual Violence Status and Scores on Trauma Symptom Checklist–40 (TSC-40) Subscales of Dissociation, Anxiety, Depression.

	Dissociation					Anxiety					Depression
	Model 1		Model 2			Model 1		Model 2			Model 1		Model 2
	B	SE	B	SE	sr ²	B	SE	B	SE	sr ²	B	SE	B	SE	sr ²
Predictor variables (Reference category)
Age	0.05	0.04	0.06	0.04	<.01	0.07	0.06	0.08	0.05	<.01	0.03	0.06	0.03	0.06	<.01
Education (vs. First-third cycle)
None/preschool	0.94	1.28	0.75	1.27	<.01	1.30	1.64	0.81	1.55	<.01	2.31	1.68	1.98	1.66	<.01
Secondary/University/Other	–2.90	1.13	−2.90	1.13	.03	−3.38	1.45	−3.14	1.38	.02	−5.60*	1.50	−5.48*	1.48	.05*
Paid for work (vs. No)	−1.49	0.70	−1.51	0.71	.02	−1.67	0.91	−1.99	0.87	.02	−2.60	0.93	−2.79	0.93	.03
Boyfriend (vs. No boyfriend)
Yes	0.72	0.74	0.63	0.73	<.01	0.17	0.95	−0.07	0.89	<.01	1.49	0.97	1.30	0.96	<.01
Refused to answer	3.51	1.64	2.99	1.68	.01	2.91	2.10	1.52	2.06	<.01	4.57	2.16	3.72	2.20	<.01
Children (vs. No children)	0.16	0.78	−0.05	0.78	<.01	0.36	1.00	0.09	0.96	<.01	1.09	1.03	0.95	1.02	<.01
Place of birth (vs. Cite Soleil)
Bel Air, Carrefour, La Saline, Martissant	−2.91	1.15	−2.93	1.15	.03	−5.27*	1.48	−5.23*	1.41	.05*	−3.71	1.52	−3.70	1.51	.02
Other	−0.99	0.72	−0.81	0.72	<.01	−3.09	0.92	−2.49	0.88	.03	−1.89	0.95	−1.53	0.95	<.01
Ever arrested (vs. No)	2.09	1.17	1.67	1.24	<.01	2.61	1.51	1.17	1.52	<.01	0.44	1.54	−0.03	1.63	<.01
Indulged in transactional sex (vs. No)
Yes	0.32	0.87	0.15	0.86	<.01	0.98	1.11	0.80	1.06	<.01	1.04	1.14	0.84	1.13	<.01
I do not want to answer/don’t know	−0.75	1.19	−0.73	1.18	<.01	−1.47	1.53	−1.33	1.45	<.01	−2.28	1.57	−2.22	1.56	<.01
Sexually abused as a child (vs. No)
Yes	0.75	0.72	0.60	0.73	<.01	2.62	0.93	1.93	0.89	.02	2.78	0.95	2.46	0.96	.02
I do not want to answer	−0.83	1.10	−1.04	1.11	.01	1.06	1.41	0.84	1.36	<.01	0.99	1.45	0.81	1.46	<.01
NPSV victim (vs. Nonvictim)	—	—	1.73	0.86	.02	—	—	4.85*	1.05	.07*	—	—	2.63	1.13	.02
	Model details
	Mod 1		Mod 2			Mod 1		Mod 2			Mod 1		Mod 2
R ²	0.18		0.21			0.24		0.32			0.28		0.30
Adjusted R²	0.13		0.15			0.19		0.28			0.22		0.25
F for each model	3.35*		3.58*			4.76*		6.58*			5.69*		5.91*
F for change in R²				5.59					24.01*					6.36

Note: N = 219. Level of statistical significance = .001; sr² is a measure of effect size; Mod stands for model. NPSV = nonpartner sexual violence.

Denotes significance at the .001 level.

Dissociation

For dissociation, the omnibus test for the nine covariates in Model 1 was statistically significant, F(14, 208) = 3.36, p < .001, R² = .18. None of the individual covariates were statistically or meaningfully significant in Model 1. The effect size for the individual variables ranged from less than 1% to 3%. Although the omnibus test was also statistically significant for Model 2, in which the victim status was included, F(15, 203) = 3.58,p < .001, R² = .21, ΔR² = .03, the F change for ΔR² was not significant, F(1, 203) = 5.59, p = .019. None of the individual covariates in Model 2 were statistically significant. The overall adjusted R² was .15 for all of the variables in the model.

Anxiety

With regard to anxiety, the omnibus test for the nine covariates in Model 1 was statistically significant, F(14, 208) = 4.76, p <.001, R² = .24. Being born in neighborhoods other than CitéSoleil was statistically significant for Model 1 (sr² = .05). The effect sizes for the other variables ranged from <.01 to .03. The omnibus test was also statistically significant for Model 2, with the addition of victim status, F(15, 203) = 6.58, p < .001, R² = .33, ΔR² = .09. Being a victim of NPSV versus not was associated with an increased level of anxiety (sr² = .07). Being born in neighborhoods other than Cité Soleil was also statistically significant for Model 2. The overall adjusted R² was .28. As indicated by the regression coefficient for victim status in Model 2, on average NPSV victims scored 4.85 points higher on the anxiety subscale of TSC-40 than the nonvictims.

Depression

With regards to depression, the omnibus test for Model 1 was statistically significant, F(14, 208) = 5.70, p < .001, R² = .28. Secondary or university-level education was the only covariate that was statistically significant for depression in Model 1. Women with higher education level on average scored 5.60 points less on depression than those with less education. The effect sizes for the other eight covariates ranged from <.01 to .03. The omnibus test was also statistically significant for Model 2, in which the victim status was included, F(15, 203) = 5.90, p < .001, R² = .30, ΔR² = .03; however, the F change for ΔR² was not significant, F(1, 203) = 6.37, p = .012. In Model 2, also, secondary or university-level education was the only individual covariate that was statistically significant. The overall adjusted R² was .26.

SATI

The SATI is a subscale comprising the following elements: sexual problems, flashbacks, nightmares, fear of men, memory problems, bad thoughts or feelings during sex, and feeling that things are unreal. As indicated in Table 4, the omnibus test for Model 1 was statistically significant, F(14, 208) = 4.63, p < .001, R² = .24. None of the individual covariates was statistically significant in Model 1. The individual effect sizes ranged from <.01 to .02. For Model 2 also, the omnibus test was statistically significant, F(15, 203) = 5.40, p < .001, R² = .29, ΔR² = .06. Including victim status in Model 2 explained an additional 6% of variation in SATI score and this change in R² was statistically significant, F(1, 203) = 12.22, p < .001. For victims of NPSV, the total score on SATI was on average 3.02 points higher than the scores for nonvictims. No other individual covariate was statistically significant for Model 2. The overall adjusted R² was .23.

Table 4.

Hierarchical Regression Analyses of Nonpartner Sexual Violence Status and Scores on Trauma Symptom Checklist–40 (TSC-40) Subscales Sexual Abuse Trauma Index (SATI), Sleep Disturbance, Sexual Problems.

	SATI					Sleep disturbances					Sexual problems
	Model 1		Model 2			Model 1		Model 2			Model 1		Model 2
	B	SE	B	SE	sr ²	B	SE	B	SE	sr ²	B	SE	B	SE	sr ²
Predictor variables (Reference category)
Age	0.06	0.04	0.07	0.04	<.01	0.01	0.04	0.01	0.04	<.01	0.07	0.05	0.08	0.05	<.01
Education (vs. First-Third cycle)
None/preschool	0.36	1.25	0.05	1.22	<.01	1.13	1.26	0.90	1.25	<.01	0.17	1.53	−0.04	1.51	<.01
Secondary/University/Other	−2.46	1.11	−2.36	1.08	.02	−2.68	1.12	−2.65	1.11	.02	−1.99	1.36	−1.80	1.34	<.01
Paid for work (vs. No)	−0.81	0.69	−1.02	0.68	<.01	−1.83	0.70	−1.98	0.69	.03	−0.61	0.85	−0.90	0.84	<.01
Boyfriend (vs. No boyfriend)
Yes	0.45	0.72	0.30	0.71	<.01	1.11	0.73	1.01	0.73	<.01	0.35	0.88	0.14	0.88	<.01
Refused to answer	2.95	1.60	2.06	1.61	<.01	2.90	1.62	2.33	1.66	<.01	4.23	1.96	3.23	2.01	<.01
Children (vs. No children)	0.98	0.76	0.85	0.75	<.01	1.81	0.77	1.78	0.77	.02	1.48	0.93	1.40	0.94	<.01
Place of birth (vs. Cite Soleil)
Bel Air, Carrefour, La Saline, Martissant	−2.51	1.13	−2.51	1.10	.02	−2.26	1.14	−2.30	1.14	.01	−2.93	1.39	−2.83	1.37	.02
Other	−1.78	0.70	−1.49	0.70	.02	−0.85	0.71	−0.70	0.71	<.01	−2.71	0.86	−2.43	0.87	.03
Ever arrested (vs. No)	2.76	1.15	2.25	1.20	.01	1.50	1.16	1.50	1.23	<.01	1.05	1.41	0.89	1.49	<.01
Indulged in transactional sex (vs. No)
Yes	0.81	0.85	0.63	0.83	<.01	−0.37	0.85	−0.56	0.85	<.01	1.72	1.04	1.67	1.03	<.01
I do not want to answer/don’t know	−1.28	1.17	−1.22	1.14	<.01	−2.58	1.17	−2.58	1.17	<.01	−1.03	1.43	−0.89	1.42	<.01
Sexually abused as a child (vs. No)
Yes	1.33	0.71	1.03	0.70	<.01	1.76	0.71	1.65	0.72	.02	3.25*	0.86	2.98*	0.87	.04*
I do not want to answer	−0.43	1.08	−0.55	1.07	<.01	−0.71	1.09	−0.72	1.10	.02	1.60	1.31	1.34	1.33	<.01
NPSV victim (vs. Nonvictim)	—	—	3.02*	0.88	.03*	—	—	1.23	0.85	<.01	—	—	1.74	1.03	.01
	Model details
	Mod 1		Mod 2			Mod 1		Mod 2			Mod 1		Mod 2
R ²	0.24		0.29			0.26		0.28			0.25		0.27
Adjusted R²	0.19		0.23			0.21		0.22			0.20		0.21
F for each model	4.63*		5.40*			5.09*		5.21*			5.05*		5.03*
F for change in R²				12.22*					5.47					2.82

Note: N = 219. Level of statistical significance = .001. sr² is a measure of effect size; Mod stands for model. NPSV = nonpartner sexual violence.

Denotes significance at the .001 level.

Sleep Disturbance

For sleep disturbance, the omnibus test for the nine covariates in Model 1 was statistically significant, F(14, 208) = 5.10, p < .001, R² = .26. None of the individual covariates was statistically significant in Model 1. Their effect sizes ranged from <.01 to .03. The omnibus test was also statistically significant for Model 2, in which the victim status was included, F(15, 203) = 5.21, p < .001, R² = .28, ΔR² = .02; however, the F change for ΔR² was not significant, F(1, 203) = 5.47, p = .020. None of the individual covariates in Model 2 was statistically significant. The overall adjusted R² was .22.

Sexual Problems

With regard to the Sexual Problems subscale, the omnibus test was statistically significant for Model 1, F(14, 208) = 5.05, p < .001, R² = .25. However, only one sociodemographic variable was statistically significant, being a victim of CASA (b = 3.25, p < .001). NPSV victims’ scores on the Sexual Problems subscale was 3.25 points higher on average than the average score obtained by women who had not experienced CASA. The effect sizes for the other variables ranged from <.01 to .03. The omnibus test was also statistically significant for Model 2, F(15, 203) = 5.03, p < .001, R² = .27, ΔR² = .01; however, the F change for ΔR² was not significant, F(1, 203) = 2.82, p = .095. In Model 2 also, being a victim of CASA was statistically significant, with NPSV victims’ scores on the Sexual Problems subscale being about 3 points higher on average than the average score of women who had not experienced CASA. The overall adjusted R² for Model 2 was .21.

TSC-40

As indicated in Table 5, the omnibus test for Model 1 was statistically significant, F(14, 208) = 6.20, p < .001, R² = .29. Three sociodemographic variables were statistically significant, secondary or university level education (b = −16.94, p < .001), being born outside Cité Soleil (b = −18.32, p < .001), and being a victim of CASA (b = 11.68, p < .001). The individual effect sizes for the other variables ranged from <.01 to .03. The omnibus test was also statistically significant for Model 2, F(15, 203) = 7.03, p < .001, R² = .34, ΔR² = .05. Including victim status in Model 2 explained an additional 5% of variation in TSC-40 score and this change in R² was statistically significant, F(1, 203) = 12.58, p < .001. In Model 2, being a victim of NPSV was the only variable that remained statistically significant (b = 13.47, p < .001). For victims of NPSV, the total score on TSC-40 was 13.47 points higher than the score for nonvictims. The overall adjusted R² for Model 2 was .29.

Table 5.

Hierarchical Regression Analyses of Nonpartner Sexual Violence Status and Scores on Trauma Symptom Checklist–40 (TSC-40).

	Full TSC-40
	Model 1		Model 2
	B	SE	B	SE	sr ²
Predictor variables (Reference category)
Age	0.22	0.22	0.28	0.21	<.01
Education (vs. First-Third cycle)
None/preschool	4.96	6.04	3.42	6.20	<.01
Secondary/university/other	−16.94*	5.68	−16.20	5.50	.03
Paid for work (vs. No)	−7.46	3.54	−8.56	3.46	.02
Boyfriend (vs. No boyfriend)
Yes	3.53	3.69	2.62	3.59	<.01
Refused to answer	20.13	8.21	15.34	8.21	<.01
Children (vs. No children)	4.60	3.90	3.80	3.83	<.01
Place of birth (vs. Cite Soleil)
Bel Air, Carrefour, La Saline, Martissant	−18.32*	5.80	−18.00	5.62	.03
Other	−9.91	3.60	−8.17	3.55	<.01
Ever arrested (vs. No)	8.55	5.88	5.66	6.10	<.01
Indulged in transactional sex (vs. No)
Yes	4.53	4.34	3.74	4.23	<.01
I do not want to answer/don’t know	−7.72	5.98	−7.30	5.80	<.01
Sexually abused as a child (vs. No)
Yes	11.68*	3.61	9.84	3.57	.03
I do not want to answer	2.21	5.50	1.22	5.45	<.01
NPSV victim (vs. Nonvictim)	—	—	13.46*	4.22	.04*
	Model details
	Model 1		Model 2
R ²	0.29		0.34
Adjusted R²	0.24		0.29
F for each model	6.19*		7.03*
F for change in R²				12.57^*

Note: N = 219. Level of statistical significance = .001; sr² is a measure of effect size. NPSV = nonpartner sexual violence.

Denotes significance at the .001 level.

Discussion

The purpose of this study was to describe and highlight differences in the sociodemographic characteristics of NPSV victims and nonvictims in a sample of women residents of Haiti’s Cité Soleil, to explore specific characteristics of victims’ sexual violence experiences, to measure and compare the trauma-related symptomatology among NPSV victims and nonvictims who share the same socioeconomic context and survived the 2010 Haiti earthquake, and, to assess the relative contribution of CASA on trauma symptoms of NPSV victims compared with nonvictims.

We had hypothesized that due to the recurrent violence in Cité Soleil, the majority of women in our sample would endorse trauma symptoms, such as nightmares, flashbacks, and sleep disturbance, regardless of their status as NPSV victim. However, due to the unusually brutal characteristics of NPSV in Cité Soleil (described above), we hypothesized that the level of trauma symptoms reported by NPSV victims would be higher than those reported by nonvictims.

Sociodemographic Features

Our first goal was to describe and highlight differences in the sociodemographic characteristics of NPSV victims and nonvictims in our sample of female residents of Haiti’s Cité Soleil. What we found seemed to align with findings from prior studies on victims of NPSV (Daniel & Logie, 2017). Specifically, our participants who were victims of NPSV reported having engaged in transactional sex, indicated history of arrest, and reported experiencing prior CASA.

Characteristics of NPSV in Our Sample

Our second goal was to explore specific characteristics of victims’ sexual violence experiences to compare with findings from previous studies of heightened STI risks from Cité Soleil NPSV (e.g., number of NPSV experiences, number of perpetrators per experience, insertion of objects during NPSV) (Joshi et al., 2014). More than a third of victims in our study reported that multiple perpetrators had assaulted them; about one fifth stated that perpetrators had inserted foreign objects into their vaginas. The particularly injurious and traumatic experiences and cumulative sexual trauma reported by victims certainly heighten STI risk as well as risk of long-term reproductive injuries. Nevertheless, victims in our sample rarely approached their families for support or felt comfortable to access available health resources in Port-au-Prince, citing shame, fear, and trauma. These findings are consistent with those reported previously (Joshi et al., 2014; Rahill et al., 2015).

Victim Status and Trauma Symptoms

Our third goal was to measure and compare the trauma-related symptomatology among NPSV victims and nonvictims who share the victims’ neighborhood and political contexts and survived the 2010 Haiti earthquake but did not experience NPSV. We had hypothesized that due to the unusually brutal aspects of NPSV in Cité Soleil, trauma symptoms reported by NPSV victims would be higher than those reported by nonvictims. Overall, the findings indicated that beyond the demographic variables, victims experienced increased burden of trauma symptomatology, in specific areas, as measured by TSC-40 and its subscales. Specifically, the victims compared with the nonvictims reported higher levels of anxiety and sexual abuse trauma/SATI, and, higher levels of trauma symptoms, in general. These findings are consistent with previous research which showed that sexual violence enhanced risks of a variety of mental health issues (Campbell et al., 2009). Our findings are also consistent with previous research that indicates when treating women for mental health disorders, practitioners may need to consider sexual violence history (O’Dwyer et al., 2019).

None of the individual covariates were statistically significantly related to the Sleep Disturbance and Dissociation subscales. Given the context in which women in our sample live (i.e., extreme poverty, violent and noisy neighborhoods), disturbance of sleep can be widespread irrespective of victim status. These findings are one of the first to report on sleep disturbance and dissociation symptoms experienced by women in urban Haiti’s Cité Soleil Neighborhood.

Sociodemographic Variables and Trauma Symptoms in Our Sample

Several sociodemographic variables emerged as predictors of trauma symptoms prior to the inclusion of victim status. Those born outside of Cité Soleil reported less anxiety and less overall trauma symptomatology (as indicated by full TSC-40) than those born in Cité Soleil, an observation made in prior literature (Marcelin, 2015). As reported in extant literature (e.g., McFarland & Wagner, 2015), we also found that those with a higher level of education (i.e., secondary education) reported less depression and overall trauma symptomatology (i.e., full TSC-40 score) than those who had less education.

The experience of CASA rather than victim status emerged as a significant factor on the Sexual Problems subscale. This finding indicates that the history of CASA might be as strong a factor in predicting high scores on sexual problems as is experiencing NPSV in adulthood. The findings that the history of CASA might be as strong a factor in predicting high scores on sexual problems and in experiencing NPSV in adulthood may be useful for researchers/practitioners who are interested in mental health effects of NPSV and in the sexual health of adult survivors of CASA. Moreover, given that some studies report that mental health problems, which affect sexual violence victims before the assault (e.g., problems related to child sexual abuse) are strongly related to the severity and range of post-assault trauma symptomatology (Campbell et al., 2009; Ozer et al., 2003), focus in treatment of adult survivors of CASA who also experience NPSV as adults should be comprehensive, including experiences across the life cycle. In considering the sociodemographic as well as the various aspects of trauma symptoms in such women, medical and mental health professionals could strengthen capacity to prevent or decrease the experience of sexual and psychological problems in adult survivors of NPSV who also experienced CASA.

Finally, our findings indicate that covariates in this study were rarely statistically significant (Tables 3 -5). Nevertheless, their inclusion in the models resulted in an overall high effect size (15% to 21%); thus, indicating the potential cumulative effect of these covariates’ (i.e., sociodemographic characteristics) on the mental health (i.e., anxiety, depression, dissociation, sexual abuse trauma, sleep disturbances, sexual problems) of all participants. This underscores the role of these characteristics/covariates as likely risk factors on the mental health of all participants in addition to the mental health concerns of victims who experience these issues as well.

Strengths and Limitations

This study has several strengths and limitations. First, to our knowledge, this study is among the first to use the TSC-40 to investigate the experience of trauma symptoms among NPSV victims in Haiti (as measured by scores obtained on TSC-40 and each of its six subscales); it is also the first to compare trauma symptoms of NPSV victims with the trauma symptoms of nonvictims. Another strength of this study was the employment of community-based participatory research (CBPR) as part of our research methodology. CBPR involves collaborating with key gatekeepers and stakeholders as equal partners in all phases of research geared at achieving change in vulnerable communities (Holkup et al., 2004). We intentionally partnered with OREZON staff and administration (gatekeepers) and with victims (key stakeholders) in research for change. CBPR is consistent with our social justice framework and with the ethical principles that guide our work with women in Cité Soleil. CBPR is also crucial to efforts we have been making for over a decade to alleviate victims’ experiences of injustice and to increase opportunities to avail them with needed services (American Psychological Association, 2017; Pratt & Loff, 2015). CBPR in collaboration with Cité Soleil victims and community leaders maximized our capacity to take into account historical, national, socioeconomic, and structural factors in our research and can improve human rights, social justice, and health outcomes for NPSV victims in the long term (Belone et al., 2016).

Nevertheless, this study has several limitations. One, we used self-report data, which are subject to recall and social desirability bias. Two, we used a cross-sectional survey, so we cannot claim causality from the statistical associations observed in our results. Three, we used a nonprobability sampling approach, which resulted in nonvictims comprising 75% of our sample, a disproportionate sample size, which could mask statistical significance; the sampling approach also means that we cannot generalize findings to other victims and nonvictims of NPSP who live in Cité Soleil. Four, a high percentage of women declined to answer or skipped questions on CASA, substance abuse, and transactional sex. Five, the questions were presented to all the participants in the same order. For future studies, and to mitigate order effects, we need to randomly rotate questions and response items. Finally, time, financial constraints, and recurrent political strife in Haiti did not permit collection of data concerning experiences of male NPSV victims.

Implications

Our findings provide points of comparison for TSC-40 scores for trauma research in Haiti and suggest that further studies should be conducted with female NPSV victims who previously experienced CASA, disasters, and neighborhood violence. For victims in this study, the confluence of low educational level, experience of injurious and sometimes recurrent NPSV (a significant risk factor for STIs). When considered in the context of Haiti’s 2.2$ HIV prevalence (UNAIDS, 2019), we suggest that victims of NPSV in Cité Soleil may benefit from primary and secondary interventions for STIs, including HIV. This is especially important because Haitian women of reproductive age (15 years and older) comprise most of Haiti’s people living with HIV/AIDS, and STIs are associated with HIV (UNAIDS, 2019).

In Cité Soleil, and in similar contexts, successful adaptation, delivery, and uptake of a trauma-informed evidence-based intervention for STIs is a crucial need of women who like the victim participants in our study experience intentionally injurious NPSV and who have reported PTSD symptoms. Elliot et al. (2005) state, “Trauma-informed care embraces a perspective that highlights adaptation over symptoms and resilience over pathology” (p. 467). De Arellano et al. (2008) observe,

There is no one treatment intervention appropriate for all [individuals] who have experienced trauma. However, . . . evidence-supported treatments and promising practices . . . share core principles of culturally competent trauma-informed therapy . . . that are appropriate for [individuals] from diverse cultural groups. (p. 8)

Planned strategies are needed to intentionally enable such care in an environment that victims perceive and experience as safe. OREZON, our community partner, is a familiar and trusted context for Trauma-informed care in Cité Soleil.

As part of trauma-informed care, and in keeping with the social justice framework, we will need to engage the community (including survivors of NPSV) and staff of organizations that work with NPSV victims in providing a greater sense of safety as a foundation for mitigating more serious consequences (Fallot & Harris, 2006). In the present case, a prerequisite to providing trauma-informed care to NPSV victims is training of the staff and administrators of OREZON. Also, given that NPSV victims had higher scores in Anxiety subscale as compared to nonvictims, we may need to consider the following: (a) ensure confidentiality and privacy as essential to trusting OREZON female staff; (b) identify female social peers; (c) include trust building exercises with peers and OREZON staff; (c) identify healthy boundaries with men; and (d) identify trustworthy community females and males (e.g., relatives).

Finally, our results indicate that those victims of NPSV who had higher level of schooling/education (i.e., secondary or higher) and who were not born in Cité Soleil, experienced less depression and anxiety. Opportunities to improve educational/skill levels and facilitate gainful employment for women and policies that promote safer environments warrant attention. In our study, as high as 30% of the victims did not reach out for medical or other help after the sexual assault. In addition, we have previously reported that lack of money for transportation and decent clothes were among reasons why women did not go to doctors after experiencing NPSV (Joshi et al., 2014). A social justice framework calls for creation of such conditions that women are able to live lives that are free of violence, to secure access to resources including those for their psychological health, and are able to participate in decisions that affect their health and safety.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

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