The mediating role of stigmatization in the mental health of adolescent victims of sexual violence in Eastern Congo

Abstract

This study aims to explore the factors that explain the mental sequelae of war-related sexual violence and focuses in particular on the role of stigmatization. Drawing on a large-scale quantitative survey undertaken in the war-affected region of eastern Democratic Republic of the Congo, we analyze how stigmatization mediates the mental health impact of sexual violence on adolescent girls who were victims of rape. Twenty-two secondary schools were randomly selected out of a stratified sample in Bunia, Eastern Congo. In a cross-sectional, population-based survey, 1,305 school-going adolescent girls aged 11–23 completed self-report measures assessing war-related traumatic events, experiences of sexual violence, stigmatization, and mental health symptoms. Of the 1,305 participants, 38.2% (n = 499) reported experiences of sexual violence. Victims of sexual violence reported more war-related traumatic events and more stigmatization experiences. Several hierarchical regression analyses examined the mediating impact of stigmatization on the relationship between sexual violence and mental health outcomes, thereby controlling for sociodemographics (age, parental availability, and socioeconomic status) and war-related traumatic exposure. Our findings show that this stigmatization largely explains the mental health impact of sexual violence, in particular, on adolescent girls’ reported symptoms of depression (full mediation) and posttraumatic stress (avoidance and total PTSD: full mediation; hyperarousal: partial (40%) mediation). No evidence of mediation by stigmatization was found for symptoms of anxiety and intrusion. Stigmatization plays thus an important role in shaping the mental sequelae of sexual violence, a finding with major consequences for clinical practice.

Introduction

For decades, the eastern regions of the Democratic Republic of the Congo (DRC) have been affected by war, costing the lives of over five million people (International Rescue Committee Survey, 2008), and marked by massive human rights abuses against civilians (Johnson et al., 2010). These war tactics, using civilians as targets of violence, show how organized violence often aims primarily to affect families, kinship, and community bonds and, as a result, pervasively disrupts those core social ties (Derluyn, Vindevogel, & De Haene, 2013).

In the context of the DRC, one of these weapons of war that disrupts social bonds is the excessive use of sexual violence (Bartels et al., 2010, Duroch et al., 2011, Maedl, 2011, Peterman et al., 2011, Wakabi, 2008), with overall estimates of between 1.69 and 1.80 million Eastern Congolese women aged 15–49 years having reported histories of being raped (Peterman et al., 2011). Despite formal peace agreements, sexual violence is still highly prevalent (Maedl, 2011), with increasing reports of rape by civilian perpetrators (Bartels et al., 2010, Duroch et al., 2011), in particular against minors (Kalisya et al., 2011). Through targeting women in communities in which female members’ social position is intricately linked to their sexual trajectories, sexual violence operates as a powerful weapon for destroying social connectedness (Derluyn et al., 2013). Indeed, the social exclusion of victims of sexual violence is highly prevalent in war-affected communities in the DRC and is documented as being associated with the pervasive stigmatization of violated girls and women (e.g., Kelly et al., 2012). Here, victims are labeled, perceived according to negative stereotypes (e.g., contaminated, defiled, of less value, and worthless), and are discriminated against within their own families and communities (Dolan, 2010, Kelly et al., 2012).

This disruption of community ties through stigmatization also leads to the question of how pervasive stigmatization in the aftermath of sexual violence may shape mental health sequelae in victims. Previous studies have documented the impact of war-related sexual violence on victims’ mental health (Bartels et al., 2010, Johnson et al., 2008, Johnson et al., 2010), showing a robust association between sexual violence and posttraumatic and depressive symptomatology. Furthermore, studies have equally shown how, in the aftermath of sexual violence, victims are confronted with negative social consequences invoked by sexual violence, such as negative social reactions, stigmatization, abandonment, rejection, and loss of social support networks (Campbell et al., 2001, Filipas and Ullman, 2001). However, studies evaluating to what extent these social disruptions mediate (i.e., explain) posttraumatic and depressive mental health outcomes in victims of sexual violence in contexts of organized violence are very scarce: Only one study documented how social stigmatization explained depressive functioning in Sierra Leonean former child soldiers who were victims of rape (Betancourt, Agnew-Blais, Gilman, Williams, & Ellis, 2010). This study therefore aims at furthering an understanding of the intricate interactions between mental health outcomes and social disruption resulting from sexual violence in war-affected communities, and analyses the mediating role of stigmatization in shaping the mental health sequelae of sexual violence. Specifically, considering the paucity of research on this population, we study the extent to which stigmatization explains (i.e., mediates) the relationship between sexual violence and mental health outcomes in Eastern Congolese adolescent girls, given continuing reports of the high prevalence of sexual assaults on adolescent girls and their particularly vulnerable position in the DRC (Kalisya et al., 2011, Kelly et al., 2010).