Background
The Yazidis (
Êzidî) are a Kurdish religious minority living in the north of Iraq, western Iran, eastern Turkey, and northern Syria [
1]. They are followers of Yazidism, a non-Abrahamic, orally transmitted religion [
2] that shares common characteristics with Christianity, Islam, and other monotheistic religions. Following the upheaval of the Arab Spring movement in the Middle East, an Islamic fundamentalist militant group, the so-called Islamic State of Iraq and Syria (ISIS), declared an Islamic Caliphate in Syria and Iraq. In June 2014, ISIS fighters captured the center of the Nineveh governorate in Iraq and announced a campaign to purify their Caliphate of non-Arab and non-Sunni Muslim communities, committing numerous atrocities against the civilian population. Due to their ethnicity and religion, Yazidis, as a Kurdish religious minority, were among the most severely affected communities [
3]. In August 2014, ISIS attacked the Yazidi’s ancestral homeland in northwestern Iraq, close to the Iraqi–Syrian border. During the attack, ISIS killed, kidnapped, and enslaved thousands of children, men, women, and girls, displacing the entire community to refugee camps in the process [
4]. Based on survey data, Cetorelli et al. [
5] estimated that 3100 Yazidis were killed and 6800 were kidnapped in this operation. The Independent International Commission of Inquiry on the Syrian Arab Republic by United Nations Human Rights Council investigated the violations committed against Yazidis and documented that the Yazidi people were subjected to mass killings, rape, sexual violence, enslavement, torture, and forcible transfer, leading the it to declare ISIS’s crimes against the Yazidis as a genocide [
6].
War and atrocities in the context of genocide have negative effects for the survivors at both the individual and collective levels. Multiple types of traumatic events during periods of genocide, including witnessing extreme violence, the disappearance and loss of family members, rape and sexual humiliation, torture, imprisonment, and kidnapping [
7,
8], can have psychological consequences [
9‐
11]. Research conducted in other conflict regions, including Rwanda [
12] and Bosnia [
13], has found that genocidal atrocities bring about long-lasting and severe effects for the survivors, with up to almost 70% of the survivors fulfilling criteria for trauma-related disorders. Studies among non-Yazidi Kurdish genocide survivors in the Middle East have shown that survivors still suffer from a wide range of mental health conditions years and even decades after the genocide campaigns [
14‐
17]. A few recent studies with small- to medium-sized samples of forcibly displaced Yazidis have documented high rates of mental ill-health. Based on clinical interviews, Tekin et al. [
18] found rates of 43% for PTSD and 40% for major depression among Yazidis displaced into Turkey. Similar levels were found for Yazidi children in Turkey [
19,
20].
Sexual violence against women has commonly been systematically used during wars and genocide, with the aim of traumatizing the civilian population and the elimination of the targeted group through the desecration of individual group members [
21]. Systematic rape and sexual violence have devastating effects on social, psychological, and physical health, including genital and non-genital injuries experienced by the survivors [
22,
23]. Such violence contributes to a range of psychological disorders. Clinically significant psychological disorders have been documented in 69.4% of survivors of war-related sexual violence in northern Uganda. Sexual violence may occur over extended periods of time after the abduction of girls and women. Such extreme adversity hardly goes without long-term harm for the survivors, with almost 85% of the sample of abducted rape survivors from Bosnia and Congo presenting with trauma-related disorders [
24]. A recent review of 20 studies of civilians who experienced war-related sexual violence from six countries across Africa and Europe concluded that the psychological sequelae of wartime sexual violence most often included extreme rates of PTSD, anxiety, and depression [
25]. More recently, Hoffman et al. [
26] assessed the prevalence of PTSD as well as complex PTSD among 108 female Yazidi former ISIS captives and found that 50.9% of them had probable complex PTSD, while 20% had probable PTSD.
The negative impacts of rape and wartime sexual violence extend into the survivors’ social lives. Victims of wartime sexual violence are commonly faced with rejection by their community and family members [
27,
28]. Sexual violence has been associated with perceived levels of stigma and poor community relations among girls who were abducted by a rebel army in northern Uganda [
29]. A recent study in the war region of eastern Congo [
30] documented stigmatization, rejection, and abandonment among survivors of sexual violence. More than half of survivors of sexual violence had been told they should leave their home because they had been raped, and the same proportion perceived that their status in the community had decreased. More than two-thirds of survivors avoided attending church due to fear of being stigmatized as a survivor of sexual violence.
It is likely that the psychological and social consequences of sexual violence are more than independent outcomes that occur on different socioecological levels. Across different conceptual and theoretical frameworks, the association between social factors and psychological trauma has been well documented. Social support from the immediate environment has been identified as one of the most consistent predictor of psychological adaptation following a wide range of traumatic event types [
31], including forced displacement [
32,
33], although causality of this relationship remains unclear [
34,
35]. Consistent with research on social support, the manner and extent to which people in the social community acknowledge the survivor’s experiences of violence are associated with the survivor’s well-being [
36‐
39]. Conversely, social rejection seems to promote and maintain the symptoms of psychological disorders. A significant association between family rejection, PTSD, and depression symptoms has been documented among conflict-affected adult women in the eastern Congo [
40]. A similar association between social discrimination and a range of mental health problems was also found in formerly abducted girls in northern Uganda [
41].
While the negative psychosocial consequences of war-related mass sexual violence seem obvious given the background of current knowledge about trauma, there is a dearth of systematic research on individuals who experienced extreme levels of adversities during war, including enslavement. Herein, we compared two samples of Yazidi survivors of the ISIS atrocities in the Middle East, one with a history of enslavement and one without experiences of such. In this context, we aimed to determine predictors for poor mental health, specifically seeking to investigate whether enslavement has a unique contribution to PTSD and depression symptoms above and beyond other traumatic, war-related events. In addition, given the observation that some of the formerly abducted survivors reported rejection from their own communities, we aimed to test whether perceived social rejection contributed to the maintenance of poor mental health.
Discussion
The current study demonstrated the psychosocial consequences of genocide and enslavement among Yazidi women and girls living in IDP camps in KRI. Findings suggest that high rates of mental health symptoms were mainly predicted by the intensity of trauma exposure. Enslavement predicted a worse outcome over and above the effect of traumatic event types. At the same time, our findings indicate that perceived social rejection plays a mediating role in the relationship between trauma and mental health.
Yazidi women who survived war atrocities represent a highly traumatized population. Rates of trauma exposure documented in our study are in line with numerous reports by international organizations about sexual and gender-based crimes against Yazidi women and girls [
3,
6,
48]. It is also consistent with studies among female survivors of other genocides and armed conflicts [
49‐
51]. The high exposure to adversities in this population is associated with very high rates of mental ill-health, which confirms previous reports of excessive rates of mental disorders in extremely traumatized war populations [
52‐
54]. Yazidi women and girls who survived enslavement reported even more severe PTSD and depression symptoms. This effect remained stable after controlling for traumatic event types experienced by the survivors. While we are not aware of research on comparable populations reporting enslavement, studies with survivors of abduction, including victims of sex trafficking [
55], child soldiers [
56,
57], and formerly abducted people [
58,
59], have confirmed the extraordinarily harmful effects of abduction. Even when considering the severity of trauma load reported by the population, the prevalence rate of DSM-5 PTSD of approximately 90% found in this study is exceptionally high, especially when considering that a validated instrument was utilized. Such high prevalence of mental health disorders can be potentially attributed to the fact that all participants were females. Studies among genocide-affected populations showed that the prevalence rates of PTSD and depression are more than two times higher in women than in men [
60,
61]. Moreover, subjects still lived in dependence and insecurity in refugee camps and less than one-quarter of the participants reported any type of professional psychosocial support. Furthermore, given that the Yazidis have a male-dominated and community-oriented culture, any intimate relationship outside of their social community is prohibited. Therefore, Yazidi women and girls who have a history of enslavement, rape, and sexual violence may find themselves isolated in the aftermath of enslavement, and this may contribute to severe mental health symptoms. Together, all these factors could be a potential explanation for the high prevalence rates of mental health disorders in this study’s sample.
Formerly enslaved women and girls perceived diverse levels of social rejection by their family and community members. The same phenomenon has been found among formerly abducted girls [
62] and female victims of war-related sexual violence [
27], who were likely to face or perceive stigma, discrimination, and social rejection. In line with research from Africa [
41,
63], we found a significant relationship between mental health disorders and post-enslavement social stressors such as perceived stigma and social rejection. This finding is also consistent with results from meta-analytic studies that showed that, in general, perceived discrimination has negative outcomes on individual well-being [
64,
65]. Furthermore, our findings indicate that the relationship between enslavement events and depression are partially mediated by perceived social rejection, while the mediation effect for PTSD did not reach significance. The nature of depression, associated with social conditions and life events, in contrast to PTSD, which may be conceptualized as a disorder of memory, could explain part of this finding.
This study has implications for the development of psychosocial and mental health programs. The high rates of mental health symptoms present should serve as a call to local and international organizations for urgent psychological intervention for Yazidi women and girls. Moreover, organizations could consider designing some social activity programs using the context of education for reintegrating formally enslaved females into their social community.
While our study is, to our knowledge, one of the first comprehensive studies to evaluate the mental health of Yazidi women and girls in the aftermath of genocide, several limitations should be noted. First, although we were careful to obtain an unbiased sample, it is impossible to evaluate to what extent the sample is representative of all female Yazidi survivors. Our sample consists only of those Yazidi women and girls who live in IDP camps in KRI, while some of the Yazidi survivors, especially those who were without male protection, live outside the camps. Further, although the majority of formally enslaved Yazidis were children and adolescents, we only interviewed those who were above the age of 17. Third, the results were also limited by the cross-sectional design, which prevents us from drawing temporal or even causal relationships in the interplay between traumatic events, social factors, and mental health outcomes. For example, it could be that PTSD and/or depressive symptoms mediate the effect on trauma exposure and perceived social rejection. Further longitudinal research could provide clarity to the links between these variables. Fourth, social rejection has been evaluated according to participants’ perception and, given that the majority of them are suffering from severe PTSD and depression symptoms, this may have an impact on the manner in which they perceive social reactions. Fifth, while participants had experienced repeated and multiple traumatic events, the current study only addressed PTSD, which is usually caused by a single traumatic event limited in duration. Complex PTSD, on the other hand, is a psychological syndrome following prolonged and multiple trauma.
Acknowledgements
We are grateful to all study participants for their trust and generous involvement. We thank Ms. Bahar Munzir Osman, the general director of People’s Development Organization, for her continued support. We are grateful to all mental health professionals from Rawshan community center, Arbat camp hospital, and other local and international NGOs who took care of our participants. Special thanks go to our local research team for their dedication and effort in this research project. We also thank camp managers, administration, and security staff for their facilitation.