Abstract
Sexual violence (SV) survivors face negative social reactions, which can affect their recovery. Based on the socio-interpersonal model of trauma, understanding how societal circumstances impact SV survivors’ mental health is important. This study examined conditional indirect effects of interpersonal shame and social acknowledgment on the relationship between perceived SV event severity and complex post-traumatic stress disorder (CPTSD) symptoms. Cross-sectional data from 157 community-based adults who had previously experienced SV were collected from an online panel. Exploratory factor analysis of the Social Acknowledgment Questionnaire was conducted, followed by conditional indirect analyses using Models 1, 4, and 7 of PROCESS macro. First, results showed that a two-factor model of social acknowledgment consisting of “social disapproval” and “social recognition” was more suitable for this study than a three-factor model predominantly used by Western societies. Second, interpersonal shame partially mediated the relationship between perceived SV event severity and CPTSD symptoms. Third, the conditional indirect effect of social disapproval on the mediating effect of interpersonal shame was significant when the social disapproval level was high. This indicates that the indirect effect of interpersonal shame on CPTSD increases when the social disapproval level is high. This study supported the socio-interpersonal perspective of trauma and suggested that increasing social acknowledgment beyond personal-level intervention would be a critical step for recovery of SV survivors to decrease their interpersonal shame and CPTSD.
Keywords
Sexual violence (SV) is defined as “any act that applies physical or psychological pressure through physical and social threats that violate the rights of sexual autonomy” (Koh et al., 2004). A survey in 2022 from the Ministry of Gender Equality and Family (MOGEF) in South Korea revealed that the lifetime victimization rate of sexual assault was 3.9%, which was 7.0% among women respondents and 0.9% among men respondents (MOGEF, 2023). It is important to note that the official incidence rate of SV in South Korea could be underestimated due to stigma and social pressure around SV victims (Shim, 1990).
SV is a critical traumatic event (American Psychiatric Association, 2013) strongly associated with mental health consequences such as post-traumatic stress disorder (PTSD) (Dworkin et al., 2017) and complex PTSD (CPTSD) (Frost et al., 2022). CPTSD is diagnosed when disturbances in self-organization (DSO) symptoms such as affective dysregulation (heightened or decreased emotional reactivity), negative self-concept (persistent feelings of failure or worthlessness), and disturbances in relationships (feeling distant or withdrawal from relationships) are present in addition to a PTSD diagnosis consisting of re-experience, avoidance, and heightened sense of threat (Maercker et al., 2013; World Health Organization, 2018). While prolonged and repetitive sexual trauma such as childhood sexual abuse have been identified as risk factors of CPTSD (McLean & Gallop, 2003; Villalta et al., 2020), a single SV event may also lead to CPTSD (Cloitre, Garvert, et al., 2013; Elklit et al., 2014). A survivor’s own subjective perception of experiences surrounding SV might negatively hinder the integration of traumatic experiences in their lives (Lauricella & Jones, 2021).
Numerous studies have recognized and emphasized the importance of social and interpersonal contexts after trauma, ranging from micro context to macro context (Charuvastra & Cloitre, 2008; Maercker & Horn, 2013; Maercker & Hecker, 2016; Woodhouse et al., 2018). The current study is based on the socio-interpersonal model of trauma suggested by Maercker and Horn (2013). This model shares the perspective with ecological models of community psychology (e.g., Bronfenbrenner, 1979). According to Maercker and Horn (2013), three levels of contextual and interactive relationships can impact post-traumatic responses of an individual affected by trauma. The first level is the individual level, which involves survivor’s social affect, such as shame, guilt, anger, and social cognition. The second level includes trauma-relevant processes such as disclosure and support that can occur during interpersonal relationships. Finally, the third level is the distant social level that can be explained by factors reflecting sociocultural influences.
At the individual level, shame is one of the devastating emotional responses to trauma (Andrews et al., 2000; Maercker & Horn, 2013). Shame is a painful emotion of experiencing oneself as essentially bad and defective with a feeling as if one is not accepted (Lewis, 1971). Vidal and Petrak (2007) have reported that about 75% of adult women SV survivors experience shame, revealing shame as a major emotional response of SV survivors. It has also been reported that 50.4% of SV survivors in South Korea experience shame after victimization (MOGEF, 2023). Studies have focused on the mediating role of shame in maintaining posttraumatic symptoms. Studies examining differential effects of shame and guilt on PTSD symptoms have demonstrated that shame can predict PTSD better than guilt (Badour et al., 2020; Leskela et al., 2002; Street & Arias, 2001). It has been shown that shame can impede emotional processing, which in turn can maintain PTSD symptoms (Leonard et al., 2020). Because shame exacerbates avoidance reactions (Street et al., 2005; Van Vliet, 2010), increased risk of social withdrawal and isolation (Maercker & Horn, 2013) can also worsen disturbances in relationships.
Meanwhile, it is important to know that Korean culture shows a strong vertical collectivism stemming from a Confucian background (Sivadas et al., 2008). Confucian culture values courtesy, humility, and belonging in groups, which is likely to act as a moral norm. Therefore, self-concept is interdependent on the group to which a person belongs (Singelis, 1994). This explains why “interpersonal shame” is prevalent in South Korean culture (Choi & Shin, 2016). Interpersonal shame was first conceptualized by Wong et al. (2014), which involves relational aspects of shame, including two sub-concepts: “external shame” and “family shame.” Wong and colleagues have explicated that external shame is associated with receiving negative evaluations from others and that family shame is being shameful by bringing damage to the family or perceiving responsibility to not bring shame to one’s family. For SV survivors, as relationships with others, including one’s family may function as important resources for support and safety according to the socio-interpersonal model of trauma, experiencing interpersonal shame in relation to familial and social belongings may impact post-traumatic responses.
At the interpersonal and social level, the effect of interpersonal shame on post-traumatic psychopathology may depend on survivors’ perception of their acceptance by others regarding their experiences. In line with their socio-interpersonal model of trauma, Maercker and Müller (2004) have introduced the concept of “social acknowledgment” reflecting the sociocultural context of the survivor, which involves recognizing and experiencing positive responses from the society regarding ones’ unique state and difficulties as a trauma survivor. In other words, perceiving social acknowledgment is the recognition of social reactions, accepting them positively rather than ignoring, rejecting, criticizing, or disapproving them. The term “social” not only includes survivors’ closest social networks, such as family and friends, but also significant persons, such as local authorities, collective entities such as workplace and citizens, and impersonal expression of views (e.g., media) about their experiences (Maercker & Müller, 2004).
There are three sub-factors in social acknowledgment: The social recognition factor refers to acknowledgment or validation of thoughts, feelings, and behaviors related to the traumatic event experienced by the survivor. The general disapproval factor and the family disapproval factor each refer to the rejection, ignorance, or invalidation of survivors’ traumatic experiences by the social environment or the family, such as no longer feeling like a member of society or no longer feeling close to the family (Sommer et al., 2017).
“Rape myth” is one example of the social phenomenon representing the importance of social acknowledgment. “Rape myth” defined as “prejudicial, stereotypical, or false beliefs about SV, victims of SV, and victims, that create a hostile environment for rape victims (Burt, 1980)” is prevalent in South Korea. In a survey conducted in a South Korean general population, 52% of respondents responded that “SV is caused by unproper clothing of the victim” (MOGEF, 2023). Such negative societal response is also known as “secondary victimization,” which is experienced as an additional violation of a survivor’s legitimate rights or entitlements (Montada, 1994). Secondary victimization of South Korean SV survivors after they spoke out on the “me too” movement has been a critical issue with extensive societal and political ramifications (Chung, 2019). As one of the few social acknowledgement studies related to SV, Kuwert et al. (2014) have pointed out that survivors who have experienced sexual trauma during wartime experience less social acknowledgement than survivors who have experienced non-sexual trauma during wartime.
Social acknowledgment is critical because invalidating an individual’s personal experience can lead to self-concealment, emotional suppression, and avoidant behaviors. For example, “rape myth” precludes survivors to inform others about their harm or report the crime (Newins et al., 2018). An experimental study has shown that perceptions of invalidation can affect disclosure behavior of sexual victimization (Catton et al., 2023). Previous studies of social acknowledgment have revealed negative effects of general disapproval (Schumm et al., 2014; Sommer et al., 2017) and consistently reported that negative social responses from others upon trauma disclosure are related to more serious PTSD symptoms (Littleton, 2010; Ullman et al., 2007). Forstmeier et al. (2009) have also discussed that the degree of social recognition provided to survivors might be important for cultivating the will to incorporate new perspectives on their traumatic events. However, positive social reactions, such as social recognition, have been reported to have inconsistent effects on psychopathology compared to negative social responses, such as social disapproval (Charuvastra & Cloitre, 2008; Orchowski & Gidycz, 2015; Ullman & Peter-Hagene, 2016).
Based on the socio-interpersonal model of trauma, the current study focused on how interpersonal shame (Wong et al., 2014) of SV experienced at an individual level and social acknowledgment (Maercker & Müller, 2004) perceived at interpersonal and social levels could affect CPTSD symptoms of SV survivors. First, this study hypothesized that interpersonal shame could mediate the relationship between perceived severity of SV events and CPTSD symptoms. Second, general disapproval and family disapproval of social acknowledgment, but not social recognition, could interact with perceived severity of SV events to increase interpersonal shame, thus increasing CPTSD symptoms.
Methods
Participants and Procedures
This study was part of a large survey on childhood adversity, SV, and post-traumatic symptoms approved by the Institutional Review Board of the authors’ affiliated institution. Through a community sample online panel system of a research company, participants provided informed consent and completed an online survey. After completing the survey, all participants were given coupons presented by the research company, which could be transferred to cash for approximately $2. Inclusion criteria were those aged more than 19 years, those who could speak native Korean, and those who had at least one SV experience in their lifetime. To ensure validity of the data, only registered members of the panel were able to access the survey. From 504 respondents, data from a total of 157 participants were found to be eligible for this study. The number of participants was decided as sufficient when calculating the required sample size using G*Power 3.1.9.4 software package (Kiel University, Germany) with a significance level of 5%, a power of 95%, and an effect size of 0.15 (Faul et al., 2009).
Participants were predominantly women (96.8%). Their mean age was 39 years (SD = 8.72 years, range, 20–55 years). Most participants (n = 116, 73.9%) had a college or university-level education. Seventy-nine (50.3%) participants were married or living with a partner. Seventy-six (48.4%) participants were single and 2 (1.3%) participants were divorced.
Measures
Perceived SV Event Severity
Two self-reporting items were used to determine perceived severity of in-person SV events, each asking whether the perpetrator was a known person (an acquaintance and/or in a close relationship including partner and family member) or was a stranger (i.e., Have you ever experienced in-person SV by a stranger? How serious was this event to you?). The degree of perceived severity of the event was evaluated on a 5-point Likert scale (0 = totally not serious, 1 = generally not serious, 2 = normal, 3 = generally serious, and 4 = extremely serious). The average score of these two items was used as the perceived SV event severity score.
Social Acknowledgment
The Social Acknowledgment Questionnaire (SAQ) (Maercker & Müller, 2004) measures an individual’s perception of validation and acknowledgment as a survivor by the entire society and other close people such as family members. The original author of the SAQ permitted the use of this questionnaire. First, English items were translated into Korean by the first author. Another author blindly back-translated them into English, the accuracy of which was then confirmed by the original author of the SAQ. Participants rated their responses on a 6-point Likert scale from 0 indicating strongly disagree to 5 indicating strongly agree. The scale included three sub-factors: social recognition (e.g., “The people where I live respect me more since the incident”), general disapproval (e.g., “Most people cannot understand what I went through”), and family disapproval (e.g., “My experiences are underestimated by my family”). In a study by Maercker and Müller (2004), the Cronbach’s α of the SAQ was .79 for social approval, .82 for general disapproval, and .78 for family disapproval. According to factor analysis in this study, the Cronbach’s α of the scale was .81 for social recognition and .88 for social disapproval (see Table 1). Subfactor items were summed for further analyses.
Factor Loadings and Cronbach’s α for Each Item in the Social Acknowledgment Questionnaire.
Note. Item numbers are from the original questionnaire.
p < .01
Interpersonal Shame
The Interpersonal Shame Inventory developed by Wong et al. (2014) and validated into Korean by Choi and Shin (2016) (Korean Version of Interpersonal Shame Inventory, KISI) was used to evaluate interpersonal shame. This scale included two sub-factors: external shame (related to concerns about other people’s negative evaluations) and family shame (related to concerns and awareness that one made the family feel ashamed). Participants rated their responses to 10 items on a 6-point Likert scale (from 1 indicating strongly disagree to 6 indicating strongly agree). In both the study of Choi and Shin (2016) and the present study, the Cronbach’s α for total interpersonal shame was .95. Items were summed for further analyses.
CPTSD Symptoms
A validated Korean version (Choi et al., 2021) of the International Trauma Questionnaire (ITQ) (Cloitre et al., 2018) was used to determine CPTSD symptoms. The scale consisted of three sub-symptoms of each construct of PTSD and DSO. PTSD consists of re-experience, avoidance, and persistent sense of threat. DSO consists of affective dysregulation, negative self-concept, and disturbed relationships. Responses were rated on a 5-point Likert scale from 0 (strongly disagree) to 4 (extremely agree). In a study by Choi et al. (2021), the Cronbach’s α was .92 for PTSD and .91 for DSO. In this study, the Cronbach’s α was .92 for both PTSD and DSO. Items were summed for further analyses.
Data Analyses
Data analyses were conducted using the R program, SPSS 25, and PROCESS macro v3.4.1 (Hayes, 2013, 2018). First, we examined the facture structure of SAQ by conducting an exploratory factor analysis (EFA). EFA was performed because the original scale was first developed in Germany, where the culture might be different. Thus, the possibility of a different factor structure of social acknowledgment in Korea was considered. The cortest.bartlett and KMO functions of the psych package were used. For EFA, the factanal function of the stats package in the R program was used. The EFA analysis was performed using the maximum likelihood method and promax oblique rotation. Items with a factor load coefficient greater than .30 were selected. When an item was loaded with two or more factors, the difference in factor loading coefficient should be at least .10 (Floyd & Widaman, 1995). Items correlated with a total score of less than .3 and items that increased Cronbach’s α when removed were deleted (Kim, 2001). Kline (1994) has suggested that 100 subjects would be sufficient if the structure is clear in factor analysis. Cattell (1978) and Gorsuch (1983) have considered that 100–250 subjects are appropriate for EFA. In terms of the ratio of participants (N) to variables (P), the minimum sample size begins to stabilize when the ratio of N:P exceeds six regardless of the number of factors or the level of commonality (Mundfrom et al., 2005). The number of samples in this study was 157 and the number of factors was a maximum of three, which satisfied the sample size required for factor analysis.
Descriptive statistical analysis was performed to determine tendencies of variables and whether the assumption of normal distribution was satisfied. Pearson’s correlation was then conducted. According to Muller et al. (2005), testing whether social acknowledgment moderates the relationship between perceived SV event severity and CPTSD symptoms should be tested as a prerequisite for verification of a conditional indirect effect. This moderating effect was verified using Model 1 of PROCESS macro (Hayes, 2018). To facilitate interpretation of the moderating effect, all variables were mean-centered. The mediating effect was tested using Model 4 of PROCESS macro (Hayes, 2018) to determine whether interpersonal shame mediated the effect of perceived SV event severity on CPTSD symptoms. Finally, to examine the conditional indirect effect of social acknowledgment, conditional process analysis was performed using Model 7 of PROCESS macro (Hayes, 2018). The use of Model 7 allowed for comprehensive testing of the moderating effect of social acknowledgment on the relationship between perceived SV event severity and interpersonal shame. In the conditional process analysis, the perceived SV event severity score was assigned as an independent variable with interpersonal shame as a mediating variable (Figure 1). The conditional indirect effect of social acknowledgment on CPTSD through interpersonal shame was examined by testing a3 and b pathways (Figure 1). To confirm the statistical significance of the above mediating, moderating, and conditional indirect effects, bootstrapping was used with 5,000 times sampling replacements to obtain a 95% confidence interval of the indirect effect. The effect was judged to be significant when zero was not included in the confidence interval.
Statistical model of conditional indirect effect (unstandardized regression coefficient).
Results
Characteristics of SV Experiences
After examining SV experiences, 82 (52.2%) participants experienced SV committed by “known person only,” 42 (26.8%) participants experienced SV by “stranger only,” and 33 (21.0%) participants experienced SV by “both known person and stranger.” Mean perceived severity scores of SV events for those who experienced SV by “only known person,” “only stranger,” and by “both known person and strangers” were 1.88 (SD = 0.46, 95% CI [1.78, 1.99]), 1.73 (SD = 0.62, 95% CI [1.53, 1.92]), and 3.26 (SD = 1.15, 95% CI [2.85, 3.66]), respectively. ITQ values for probable diagnoses of PTSD and CPTSD were 8.54% and 48.78% for those who experienced SV by “known person only,” 2.38% and 59.52% for those who experienced SV by “stranger only,” and 0% and 78.79% for those who experienced SV by “both known person and strangers,” respectively.
Factor Analysis of Social Acknowledgment
An EFA was conducted to identify the structure of the SAQ. Bartlett’s sphericity test (χ2 = 1230.484, df = 120, p = .000) and Kaiser-Meyer-Olkin (KMO) test (KMO = .85) showed that data were appropriate for factor analysis. Three factors with eigenvalues above one (5.73, 2.88, and 1.37, respectively) were extracted, explaining 51.8% of the total variance. Factors 1 and 2 explained 23.4% and 19.0% of the total variance, respectively. Factor 3 explained 9.3% of the total variance. Factors 1 and 2 were found each to include all items of “social recognition” and the “general disapproval” subscales from the original scale constituting social acknowledgment. However, in Factor 3, only two items from the original “family disapproval” sub-factor were included. Remaining items of “family disapproval” were scattered in Factors 1 and 2. Therefore, these two items included in Factor 3 were deleted. Among items included in Factor 1, two items (“family approval” in the original questionnaire) were deleted because they decreased the Cronbach’s α value.
EFA was then re-conducted after setting the number of factors to two (Table 1). The two-factor construct explained 49.6% of the total variance. Factor 1, which consisted of items commonly describing socially unrecognized experiences, was named “social disapproval”. Eight items in Factor 1 explained 27.9% of the total variance. All items showed high factor loadings of .57 and above. The internal consistency was reliable (Cronbach’s α = .877). Factor 2 consisted of items from the social recognition sub-scale of the original scale, called “social recognition”. Six items from Factor 2 explained 21.7% of the total variance. They had high factor loadings of .57 and above with a reliable internal consistency (Cronbach’s α = .851).
Descriptive Statistics and Correlations
Mean and standard deviation of variables, skewness and kurtosis, and correlation between variables were calculated (Table 2). Perceived SV event severity had significant positive correlations with CPTSD symptoms (r = .321, p < .01), social disapproval (r = .273, p < .01), and total scores for interpersonal shame (r = .248, p < .01). CPTSD symptoms were highly correlated with social disapproval (r = .658, p < .01) and interpersonal shame (r = .687, p < .01). They were moderately correlated with social recognition (r = .387, p < .01). The variance inflation factor value was within 2, indicating no multicollinearity problem.
Pearson Correlation Coefficients and Descriptive Statistics of Variables.
Note. CPTSD = complex posttraumatic stress disorder.
p < .01.
Mediation Effect of Interpersonal Shame
We investigated whether interpersonal shame mediates the relationship between perceived SV severity and CPTSD. Perceived SV event severity had significant associations with CPTSD symptoms (B = 3.849, t = 4.223, p < .001) and interpersonal shame (B = 3.684, t = 3.190, p < .01). When perceived SV event severity and interpersonal shame were simultaneously added to the model, the association between interpersonal shame and CPTSD symptoms (B = .522, t = 10.950, p < .001) and the association between perceived SV event severity and CPTSD symptoms remained significant, suggesting that interpersonal shame partially mediated the relationship between perceived SV event severity and CPTSD symptoms (B = 1.925, t = 2.720, p < .01). To test the statistical significance of the indirect effect of interpersonal shame, the confidence interval was confirmed through bootstrapping. Results showed that the indirect effect was 1.92. Since zero was not included in the confidence interval (95% CI [0.52, 3.25]), the indirect effect was significant.
Moderating Effect of Social Acknowledgment
Moderating effects of social disapproval (B = .055, t = .776, p = .44) and social recognition (B = −.027, t = −.237, p = .81) on the relationship between perceived SV event severity and CPTSD symptoms were insignificant, meeting the prerequisite for verification of the conditional indirect effect. Therefore, the moderating effect of social disapproval on the relationship between perceived SV event severity and interpersonal shame was tested. Results showed that the moderate effect of perceived SV event severity and social disapproval was significant (B = .208, t = 2.286, p < .05). The statistical significance of the moderate effect was tested through bootstrapping with 5,000 bootstrapping iterations and a confidence interval of 95%. The moderate effect of social disapproval at the +1 SD level was confirmed to be statistically significant (B = .11 [boot SE = .04], boot Lower Limit Confiednce Interval, LLCI = .03, and boot Upper Limit Confidence Interval, ULCI = .20) (Figure 2). When social recognition was set as a moderating variable, the main effect of social recognition on interpersonal shame remained significant (B = .522, t = 3.295, p < .01). However, no significant moderating effect was observed (B = .097, t = .665, p = .51). Therefore, social recognition was not analyzed further.
Moderate effect of social disapproval between perceived sexual violence (SV) event severity and interpersonal shame.
Conditional Indirect Effect of Social Disapproval
As shown in Figure 1, perceived SV event severity was not significantly associated with interpersonal shame (B = 1.045, t = 1.096, p = .27). Next, social disapproval and the interaction of perceived SV event severity and social disapproval were added to the model. Results showed that the direct effect of social disapproval on interpersonal shame was significant (B = .912, t = 9.456, p < .001). The moderate effect of perceived SV event severity and social disapproval on interpersonal shame was also significant (B = .208, t = 2.286, p < .05). Not only the direct effect of perceived SV event severity on CPTSD (B = 1.925, t = 2.720, p < .01), but also the effect of interpersonal shame on CPTSD were significant (B = .522, t = 10.950, p < .001). Social disapproval moderated indirect effects of perceived SV event severity on CPTSD symptoms through interpersonal shame.
In addition, the Johnson-Neyman technique was used to specifically explore whether the conditional indirect effect was significant (Hayes & Mattes, 2009; Johnson & Neyman, 1936). The conditional indirect effect of social disapproval was found to be insignificant at the average or low level of social disapproval. However, the indirect effect of SV on CPTSD through interpersonal shame was statistically significant in areas where social disapproval was higher than 25.13 (Figure 3).
Johnson-Neyman significance region of conditional indirect effect of social disapproval.
Discussion
This study aimed to examine the influence of interpersonal and societal contexts of sexual trauma on CPTSD symptoms based on the socio-interpersonal model of trauma. Focusing on the concept of social acknowledgment, this study analyzed the factor structure of the SAQ and discovered how it moderated the indirect effect of perceived SV event severity to CPTSD symptoms through interpersonal shame.
The EFA showed that the Korean SAQ was better explained by a two-factor model. Sub-constructs of general disapproval and social recognition were identified. However, items originally included in the family disapproval sub-factor were loaded under the general disapproval factor, inconsistent with studies conducted mostly in Western societies (e.g., Maercker & Müller, 2004; Schumm et al., 2014). This might be due to cultural differences in perceiving the importance of family. Yu and Yang (1994) have pointed out that Asian cultures are more influenced by external forces such as social contexts, relationships, and expectations of others than Western cultures. Furthermore, Asian cultures are inherently collectivist. They value family reputation by acting in accordance with family expectations (Triandis, 1995). Since Korea is also a highly interdependent society valuing family norms (Park & Kim, 2018), family disapproval might be perceived as disapproval from the greater society.
Perceived SV event severity had a direct effect on CPTSD symptoms. However, this effect was also mediated by interpersonal shame, in line with previous studies. Shame is known to predict PTSD (Alix et al., 2017; Andrews et al., 2000; Street & Arias, 2001). A previous study has reported that CPTSD is associated with trauma-related shame and negative self-evaluation (Hyland et al., 2017). Interpersonal shame after severe trauma can increase the belief that oneself is inappropriate, inferior, or weak (Lee et al., 2001), which is a part of negative self-concept symptoms of CPTSD. Interpersonal shame might also lead to decreased emotional processing and interpersonal regulation capacities, which are components of CPTSD, by affecting survivor disclosure and sense of belonging in interpersonal relationships (Bhuptani & Messman-Moore, 2019).
Furthermore, this study revealed that social disapproval moderated the relationship between perceived SV event severity and interpersonal shame, which in turn was associated with CPTSD. This supports how social acknowledgment can critically affect mental health consequences of SV survivors, consistent with the socio-interpersonal perspective of trauma (Maercker & Horn, 2013). We found that interpersonal shame was associated with CPTSD symptoms, and we identified social disapproval as a moderator, which may work as a distant social context. This was consistent with discussions of how stigma and social exclusion could have a devastating impact on survivors (Kennedy & Prock, 2018; Nietlisbach & Maercker, 2009). Social exclusion and social disapproval have been repeatedly found in Korean people who have experienced trauma (e.g., Choi & Cho, 2020; Choi et al., 2017; Kim et al., 2021). This strongly suggests that seeking awareness of sociocultural influences on an individual’s mental health consequences is critical for coping with the aftermath of trauma.
However, the moderating effect of social recognition was insignificant. As expected, the effect of positive social reactions showed inconsistent results, unlike negative social reactions (Charuvastra & Cloitre, 2008). Based on the expectancy violations theory (Dworkin et al., 2019), social recognition might be a response that individuals already expect, which adds little protective effect. On the other hand, social disapproval is contrary to beliefs and expectations of survivors, which may bring negative impacts. This may worsen disturbances in interpersonal relationship symptoms in CPTSD.
This study particularly focused on interpersonal shame, which had previously received less attention than internal shame. Distinguishing internal shame from interpersonal shame can play an important role in therapeutic interventions (Choi & Shin, 2016; Lee et al., 2001). In a collectivist culture such as Korea, where shame has interpersonal features as a result of negative social reactions, focusing on changing internal shame at an individual level may not yield therapeutic success. Therapeutic intervention could benefit from targeting interpersonal shame by helping survivors understand how the socio-interpersonal context surrounding oneself can affect CPTSD symptoms and address their environmental challenges based on survivor advocacy and community recognition (e.g., Herman, 2023). Symonds (2010) has described this rejection and lack of support from family, friends, and society as “secondary injury,” now known as “secondary victimization.” It should be stressed that this study confirmed how secondary victimization from society, a serious issue in the Korean context and others, might affect mental health consequences of SV survivors. Unlike other crimes, there is a strong myth that SV is caused by survivors (Kwon et al., 2016). In addition, SV survivors tend to be reluctant to disclose their experiences due to biased social perceptions (Lee & Choi, 2001). Enhancing social acknowledgment and discouraging victim blaming could help survivors disclose their trauma and seek support (Kazlauskas et al., 2017). Public campaigns on awareness of SV, such as targeting rape myths, noticing secondary victimization, providing education and support for families of survivors, and providing education to officials in the criminal justice service system, would be helpful. These experiences of being acknowledged by society can help survivors perceive safety and a sense of belonging, which is a critical first step in trauma treatment (e.g., Cloitre, Courtois, et al., 2012).
It should be noted that this study was based on a cross-sectional design, making it difficult to estimate the causal pathway relationship between variables. The relationship between social responses and CPTSD should be dynamic. A longitudinal design tracking societal reactions and trajectories of CPTSD would be fruitful. In addition, data collected were self-reported questionnaires from a community sample of online panels. Therefore, to generalize our understanding, additional measurements such as clinician rating scales and further studies with clinical populations are necessary. Perceived SV event severity was measured by averaging scores of two items inquiring whether the perpetrator was a known person or a stranger, which might not accurately represent how different aspects of violence had different impacts. Further research should use validated questionnaires to assess perceived severity, accurately measure different types of SV, and determine the age of occurrence and time since occurrence that could show different impacts. In terms of cross-cultural issues, comparison of the factor structure of the SAQ from different cultural backgrounds and seeking the effect size of social variables related to CPTSD among different cultures are interesting areas of future research. Equally, as the experience of social acknowledgment of SV may differ among various gender identities and socioeconomic status of individuals, it should be further addressed in future research.
The current study identified interpersonal shame and social disapproval as key experiences that affected CPTSD symptoms of South Korean SV survivors. We presented institutional and clinical implications for raising awareness and developing legal and institutional norms to prevent secondary victimization as crucial steps for recovery. Broadening perspectives of clinicians and evaluating the sociocultural context of SV could help us decide on appropriate therapeutic and systematic interventions for sexual trauma.
Footnotes
Data Availability Statement
Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: This study was supported by the Ministry of Gender Equality and Family of the Republic of Korea.
