#### *3.2. Multivariable Analysis*

#### 3.2.1. Afghan Sample

Within the block analysis, socio-demographic characteristics such as being female and older were positively associated with professional help-seeking, while those living in regional Australia were less likely to receive help. Refugees reporting poorer physical and mental health were more likely to have received professional help. In contrast, refugees facing fewer structural barriers were less likely to receive professional help. Specifically, having fewer financial hardships, not requiring interpreting assistance, having a driver's licence, and knowing how to find out about available government services were all associated with a lower likelihood of seeking help. Measures of acculturation, including not having any friends in Australia and finding the process of getting used to life in Australia stressful, were both associated with increased likelihood of receiving professional help. In the full model, only older age and higher psychological distress were positively associated with help-seeking. Refugees who lived in regional Australia did not require interpreting assistance and who were able to find out about available government services were less likely to receive help (Table 2).

**Table 2.** Multivariate analysis by country of birth, including the predictors in blocks (demographics, health, trauma exposure, structural barriers, acculturation, trust and discrimination and the criterion professional help-seeking) and the full model.

OR = odds ratio; 95% CI = 95% confidence interval; *N* = number of observations. Ref. = reference category. *p* < 0.05 \*, *p* < 0.01 \*\*, *p* < 0.001 \*\*\*.

#### 3.2.2. Iraqi Sample

Within the Iraqi block analysis, older refugees were more likely to receive professional help while those with good English-speaking proficiency were less likely to receive help. Having a long-term disability or illness was also associated with increased likelihood of receiving professional help. Structural barriers such as having fewer financial hardships resulted in reduced professional help-seeking, while refugees that were able to receive an interpreter were more likely to seek professional help. Within the full model, poorer physical and mental health, alongside being able to find available government services, increased the likelihood of receiving help. In contrast, participants with fewer financial hardships were less likely to receive help (Table 2).

#### *3.3. PTSD Sample*

Amongst those with probable PTSD, having a disability or long-term illness was significantly associated with increased professional help-seeking, whereas having fewer financial hardships and living in regional Australia resulted in reduced help-seeking (Table 3).

**Table 3.** Full model displaying predictors of professional help-seeking within the PTSD sample.

OR = odds ratio; 95% CI = 95% confidence interval; *N* = number of observations. Ref. = reference category. *p* < 0.05 \*, *p* < 0.01 \*\*.

#### **4. Discussion**

This study sought to understand the factors associated with professional help-seeking for mental health problems within Iraqi and Afghan refugee populations in Australia, five years post-settlement. Factors of interest included socio-demographic characteristics, health, trauma exposure, structural barriers, acculturation, trust in government services, and experiences of discrimination, in line with Anderson's health care utilisation model [18]. The findings partially support the hypotheses, with differences noted between the two ethnic groups. Understanding these factors is crucial to developing suitable services tailored to the needs of refugees and enhancing their ability and willingness to access and engage with these services. Additionally, considering the increased rates of trauma-related mental illness amongst refugee populations, understanding the factors that promote professional help-seeking is critical in reducing the burden of mental health disorders on Australian communities [12,26].

Significant socio-demographic factors in the full model included age and living in regional Australia, albeit only in the Afghan sample. No associations were found between professional help-seeking and education level or being married. In the block analysis within the Afghan group, consistent with prior studies, older age and female gender were positively associated with professional help-seeking, while living in regional Australia held a negative association with help-seeking [15,25,50]. Similarly, amongst Iraqi refugees, being older was positively related to help-seeking; however, having good English-speaking proficiency resulted in a lower likelihood of seeking help. This finding contradicts previous research, which has suggested that refugees with poor English-speaking proficiency were less likely to receive professional help and have greater difficulties accessing services [28,51]. These results suggest that extra efforts are needed to promote mental health services amongst younger refugees and males, and additional mental health services targeting refugees in remote areas of Australia are needed. Further research in understanding why those with good English-speaking proficiency were not receiving professional help would be beneficial.

Amongst health and trauma related factors as hypothesised, within the full model, poorer self-rated health, greater psychological distress, and presence of a disability all increased the probability of seeking professional help while meeting criteria for PTSD held no association with help-seeking. Trauma exposure was significant at the block analysis level but only for the Iraqi sub-sample. Again, differences were noted between the two ethnic groups. Specifically, only psychological distress was consistently associated with professional help-seeking across both the Afghan and Iraqi refugee groups. Disability or presence of a long-term illness held no association with professional help-seeking amongst the Afghan sub-sample but was positively associated in the Iraqi group. These findings are aligned with Anderson's model (1995), which identified need as an important predictor of health care utilisation [18]. Interestingly, previous research on Afghan refugees found that higher rates of disability and better self-recognition of mental health symptoms were correlated with increased help-seeking from mental health professionals [16]. The association between physical health and professional help-seeking may be explained by the higher rates of somatic symptoms reported within refugee groups. These individuals may be seeking help for physical complaints and consequently receiving help for mental health problems [52]. The contrasting findings regarding disability in the Afghan sample could possibly be influenced by better overall health and lower rates of disability reported by Afghan participants compared to Iraqi participants. Finally, differences between ethnic groups in their help-seeking behaviours are consistent with previous research and highlight the importance of targeted mental health promotions that are culturally attuned to the characteristics of specific refugee groups [16]. Other clinical implications of these findings are that general practitioners may need specifically targeted training in recognising symptoms of poor mental health within this population and referral options to mental health specialists tailored to the needs of refugee groups.

The hypotheses related to structural barriers were also partly supported, and again, differences noted between the two groups. Specifically, amongst the Iraqi sub-sample in the full model, having fewer financial hardships was related to a decreased likelihood of receiving professional help, while, as hypothesised, knowing how to find out about available government services was associated with a greater likelihood of receiving professional help. In contrast, amongst the Afghan sub-sample, knowing fairly well how to find out about government services and not needing interpreting assistance was related to a lower likelihood of seeking professional help. Findings from the block analysis also suggested Afghan refugees with an Australian driver's license were less likely to receive professional help. No associations were found between knowing how to use public transport and professional help-seeking. These findings are contrary to previous research, which found financial hardship to be a significant barrier to help-seeking for most refugees as they were unable to pay for treatment or travel costs and often prioritised financial security over receiving help for mental health disorders [20]. A systematic review by Byrow et al. (2020) also found limited access to interpreters and understanding how to access available services was related to reduced help-seeking and longer durations of mental health disorders being left untreated [20]. A possible explanation for our contrasting results could be that refugees who were experiencing financial difficulties, language barriers, and difficulties navigating the new social systems were receiving support from other social services. It is possible that they were identified as needing psychological help in the context of other support services and had been linked with mental health professionals [53]. These findings imply that additional efforts are required to promote mental health services amongst refugees who are not in contact with other social services. They also again highlight the importance of targeted mental health promotion and services that focus on refugee groups separately based on cultural background.

When acculturative factors were taken into account in the full model, no factors were significantly associated with professional help-seeking. However, within the block model, contrary to predictions, those who found the acculturation process stressful and had no friends were more likely to seek professional help, albeit only in the Afghan sub-sample. No significant associations were found between time spent in Australia, receiving support from either one's own ethnic community or other communities and professional help-seeking. These findings are inconsistent with previous research, which has found that refugees who were more acculturated to the host culture were more likely to endorse seeking professional support for mental health problems [29]. However, previous studies have found that less acculturated refugees who experienced greater acculturative stress where more likely to have poorer mental health [53,54]. Therefore, it may be plausible in our study that those refugees who were less acculturated were experiencing poorer mental health and, thus, as suggested in Anderson's health care utilisation model, had a greater need for professional help [18]. These findings insinuate the need for additional services for refugees during the settlement period even five years post arrival to assist with adjusting to the host country and fostering social support. It is also important to mention that, given the study's design, time spent in Australia amongst our sample was highly homogenous. Future research incorporating a longer time span with greater sample variability is required to further examine the role of time in the host country as a predictor of help-seeking.

Both trusting that government services would keep information private and experiencing discrimination, were not significantly associated with receiving professional help. However, previous research on adolescent refugees in Australia found that lower trust in health professionals was related to fears that information would be disclosed to other community members, resulting in lower rates of professional help-seeking. Similarly, research has suggested that experiencing discrimination in the host country was associated with both poorer mental health and a reluctance to seek professional help [55,56]. Within our study, a very small number of participants reported experiencing discrimination; thus, this association may require further exploration with a larger sample size. Future studies could

include open ended questions in order to develop a deeper understanding of refugees' experiences of discrimination and its influence on help-seeking.

Finally, amongst the sub-sample who met criteria for PTSD, only having a long termdisability or illness was positively related to receiving professional help. However, refugees with PTSD who had fewer financial hardships and lived in remote parts of Australia were less likely to receive professional help. These findings again highlight the possibility that refugees are being identified as needing help when they access other social services and health professionals and are then referred onto mental health professionals. The implications of these results are that more integrated and culturally informed services are required for this population. Additionally, it may be beneficial to promote mental health services amongst refugees who are performing well in other social and health domains apart from mental health. Help-seeking was lower among refugees with likely PTSD in regional areas, highlighting the need to improve availability and access to mental health services outside of major cities.

This study has a number of limitations. Firstly, as self-report measures were utilised, results may have been impacted by social desirability and recall bias [57]. Responses may have also been affected by issues around translation of surveys and transcultural bias [58]. A limitation of our quantitative design is that it is not clear whether participants fully understand subjective concepts, such as discrimination. Additionally, variables such as community support may have been influenced by perceptions of need for support rather than acculturation. Despite some limitations, the large sample size representative of the leading groups of refugees in Australia is a major strength of this study, as these results can be utilised to improve the resettlement outcomes of a large proportion of refugees in Australia. Future research may wish to extend these findings by utilising a more extensive measure of professional help-seeking. Future research including open-ended questions, or a mixed-method design would be beneficial. This would provide the opportunity to ask follow-up questions and, therefore, gain a better in-depth understanding of the reasons for selecting certain options. Additionally, incorporating qualitative methodologies would contribute to our understanding of the underlaying cultural characteristics that my influence help-seeking behaviors amongst these two populations.

#### **5. Conclusions**

This study was amongst the first to explore professional help-seeking for mental health problems five years post-settlement amongst two of the largest resettled groups of refugees in Australia. The findings showed significant differences between the two ethnic groups and suggested socio-demographic variables, poorer overall health and structural barriers all predicted professional help-seeking, albeit differently within the two refugee groups. These findings have significant implications for policy makers and service providers who aim to support this group during the resettlement period.

**Author Contributions:** Conceptualization, A.-M.T., S.S.-Y., R.N. and P.R.; formal analysis, A.-M.T. and P.R.; methodology, A.-M.T. and P.R.; supervision, S.S.-Y. and R.N.; writing—original draft, A.- M.T.; writing—review and editing, S.S.-Y., R.N. and P.R. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the BNLA study.

**Data Availability Statement:** Data used in this study are publicly available to approved researchers. Access is managed by the National Centre for Longitudinal Data on National Centre for Longitudinal Data Dataverse.

**Acknowledgments:** This paper uses unit record data from Building a New Life in Australia: the Longitudinal Study of Humanitarian Migrants (BNLA) conducted by the Australian Government Department of Social Services (DSS). The findings and views reported in this paper, however, are those of the authors and should not be attributed to the Australian Government, DSS, or any of DSS' contractors or partners. DOI: 10.26193/0AF6TZ.

**Conflicts of Interest:** S.S.-Y. is a guest editor of the Special Issue on Mental Health Promotion for Refugees and Other Culturally and/or Linguistically Diverse Migrant Populations. The authors declare no other conflicts of interest.

#### **References**

## *Brief Report* **Screening for Posttraumatic Stress Symptoms in Young Refugees: Comparison of Questionnaire Data with and without Involvement of an Interpreter**

**Lauritz Rudolf Floribert Müller \*,†, Johanna Unterhitzenberger † , Svenja Wintersohl, Rita Rosner and Julia König**

> Department of Psychology, Catholic University Eichstätt-Ingolstadt, Ostenstraße 25, 85072 Eichstätt, Germany<EMAIL_ADDRESS>(J.U<EMAIL_ADDRESS>(S.W<EMAIL_ADDRESS>(R.R<EMAIL_ADDRESS>(J.K.)

**\*** Correspondence<EMAIL_ADDRESS>Tel.: +49-842-193-21265

† Joint first authors.

**Abstract: Background**: The substantial number of young refugees who have arrived in Europe since 2015 requires rapid screening to identify those in need of treatment. However, translated versions of screening measures are not always available, necessitating the support of interpreters. The Child and Adolescent Trauma Screen (CATS) is a validated questionnaire for posttraumatic stress symptoms. Here, we report on the psychometric properties of the CATS in a sample of young refugees as a function of interpreter involvement. **Methods:** A total of *N* = 145 (*M*age = 16.8, *SD* = 1.54; 93% male) were assessed with the CATS, with half of the screenings conducted with and half without interpreters. Post hoc analyses included calculating internal consistency using Cronbach's *α*. We used confirmative factor analysis to investigate the factor structure. **Results:** The CATS total scale showed good reliability (α = 0.84). Differences in psychometric properties between the interpreter vs. the no interpreter group were minor and tended to be in favor of the interpreter group. Results of a confirmatory factor analysis were acceptable after the exclusion of items with low item-scale correlations. **Conclusions:** The sample and the administration of the assessment represent the situation of young refugees in Germany, where resources are low and translated versions not always available. The CATS may be a helpful screening tool for clinicians working with young refugees, even when administered with an interpreter. Limitations include the post hoc design of the analysis without randomization of participants and the lack of a third comparison group using translated questionnaire versions.

**Keywords:** refugee; adolescent; assessment; screening; PTSD; interpreter

#### **1. Introduction**

Asylum-seeking youth, and especially unaccompanied asylum-seeking youth, have a high risk for posttraumatic stress disorder (PTSD; [1,2]). A brief and valid screening should constitute the first step of recently proposed stepped-care models to meet the psychological needs of young refugees, which are currently being tested in this group [3]. To this end, measures must be validated for culturally diverse samples. The Child and Adolescent Trauma Screen (CATS; [4]) is a short self-report questionnaire with items corresponding to PTSD criteria in the Diagnostic and Statistical Manual for Mental Disorders, 5th edition (DSM-5; [5]). It has been validated in an international (Western) sample with good reliability and validity and has since been used repeatedly with refugee youth [1,6,7].

However, self-report screening measures, including the CATS, are not available for all languages of interest in the refugee context, and, moreover, many asylum-seeking youth are illiterate and cannot use translated versions even when they exist [8]. Accordingly, in reallife care settings, screenings are often conducted with non-native language versions even

**Citation:** Müller, L.R.F.;

Unterhitzenberger, J.; Wintersohl, S.; Rosner, R.; König, J. Screening for Posttraumatic Stress Symptoms in Young Refugees: Comparison of Questionnaire Data with and without Involvement of an Interpreter. *Int. J. Environ. Res. Public Health* **2021**, *18*, 6803. https://doi.org/10.3390/ ijerph18136803

Academic Editor: Paul B. Tchounwou

Received: 30 April 2021 Accepted: 23 June 2021 Published: 24 June 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

when the respondents' language proficiency is low or must be supported by interpreters. In this context, untrained lay interpreters, who might be unfamiliar with mental health services, are often employed [9]. In principle, it is conceivable that the involvement of (lay) interpreters could change both screening results and therapeutic processes for a variety of reasons, including omission of cultural taboos in the translation process, role difficulties that might lead interpreters to take a directive rather than a neutral role, and lack of professional understanding regarding mental health services [10]. In terms of therapy effectiveness, the few existing post hoc findings on interpreter involvement present a mixed picture [11,12], whereby the latest study found that the group with interpreters involved showed poorer results than the comparison group without interpreters [12]. However, there are very few quantitative findings on the effects of employing an interpreter in mental health settings in general and, to our knowledge, no studies on the effects on screening or diagnostic results in particular.

Accordingly, this post hoc study aims (1) to investigate the internal consistency of the CATS in a sample of young refugees resettled to Germany using German language versions with vs. without the involvement of an interpreter; (2) to compare symptom severity, item values and item-scale correlations between the two groups; and (3) to examine the factor structure of the CATS in the total sample.

#### **2. Materials and Methods**

#### *2.1. Procedure and Participants*

Data from two studies were used with a total of *N* = 145. Study 1 assessed the mental health of *n* = 98 minor refugees resettled in southern Germany in an interview-like setting [1]. Study 2 was a pilot study [6] examining trauma-focused cognitive behavioral therapy [13] with *n* = 47 unaccompanied refugee minors. Overall, participants were, on average, *M* = 16.73 years of age (*SD* = 1.54). Most participants were unaccompanied (*n* = 115, 78.8%) and boys (*n* = 135, 93.1%), reflecting the population structure in Germany, where most unaccompanied refugee minors are male (for further sociodemographic information, see Supplementary Material Table S1).

Both studies were approved by the IRB of the Catholic University Eichstätt-Ingolstadt (2016/23 and 2015/02/16) and participants gave their written informed consent to participate in the respective study.

#### *2.2. Measure*

The Child and Adolescent Trauma Screen (CATS) assesses posttraumatic stress symptoms (PTSS) according to DSM-5 in youngsters aged 7 to 17 years [4]. Participants indicate whether they have experienced 15 potentially traumatic events (yes/no) and specify the currently most distressing event. Then, they rate 20 items on PTSS on a 4-point Likert scale (0—*never* to 3—*almost always*). The sum score is between 0 and 60, with scores ≥21 indicating clinically relevant PTSS. The four subscales—intrusion, avoidance, negative alterations in cognition and mood (NACM), and hyperarousal—can be formed, which refer to the PTSD diagnostic criteria in the DSM-5. The CATS has been validated in English, German, and Norwegian language versions. We used the German version. In half of the sample, *n* = 72 (50%), interpreters supported diagnostics (for one Study 1 participant, information on interpreter involvement was missing).

#### **3. Data Analysis**

We used SPSS version 25 (IBM, Armonk, USA) for all analyses. We examined descriptive statistics and internal consistency (Cronbach's *α*) for the CATS total score and symptom subscales, and for cases with and without involvement of an interpreter. We computed *χ 2* -statistics to examine differences in internal consistency between the two subgroups using cocron [14]. A confirmative factor analysis was applied to investigate the previously confirmed DSM-5 factor structure using AMOS for SPSS version 25. For RM- SEA, values ≤ 0.06 (marginal: 0.07–0.08) [15] and for CFI and TLI, values ≥ 0.95 (marginal: 0.90–0.94) indicate a good fit [16].

#### **4. Results**

#### *4.1. Internal Consistency*

The CATS showed a good internal consistency with Cronbach's *α* = 0.84 in the total sample. Internal consistency was slightly, but not significantly, higher when assessed with an interpreter (*n* = 72; *α* = 0.85) than without one (*n* = 72; *α* = 0.82; *χ 2* (1) = 0.684, *p* = 0.408). The four symptom clusters differed in their internal consistency and showed rather poor results (see Table 1). Internal consistencies of the four subscales were consistently, but not significantly, lower in the group without an interpreter, with avoidance even having a negative value in this group.

**Table 1.** Internal consistencies (Cronbach's α) of the four subscales in the full sample and the two subsamples.

Note. CATS = Child and Adolescent Trauma Screen. NACM = Negative alterations in cognition and mood. <sup>a</sup> As it was not possible to compute the comparison with a negative value of α, α = 0 was substituted in the group without interpreter.

#### *4.2. Symptom Scores and Item Analyses*

Participants from Study 1 had lower average CATS scores, *M* = 22.40, *SD* = 9.35, than participants from Study 2, *M* = 26.87, SD = 10.35, *F* (143) = 2.61, *p* = 0.010. CATS scores did not vary with interpreter involvement in either subsample. In Study 1, cases without interpreters had a mean CATS score of *M* = 21.56, *SD* = 9.07, and cases with interpreters of *M* = 23.91, *SD* = 9.78, *T* (96) = -1.200, *p* = 0.233, and in Study 2, cases without interpreters had a mean CATS score of *M* = 29.33, *SD* = 7.14 and with interpreters *M* = 26.51, *SD* = 11.03, *T* (44) = 0.727, *p* = 0.471.

Means and standard deviations, as well as corrected item-scale correlations of the 20 CATS items, are given in Table 2. Five items in the sample without interpreters, and three items in the sample with interpreters had item-scale correlations ≤ 0.30, resulting in five items (8, 10, 12, 16, and 17) in the overall sample with item-scale correlations ≤ 0.30.

#### *4.3. Factorial Validity*

The four-factor CFA model proposed by the DSM-5 and found by Sachser et al. (2017) did not show a very good fit. While RMSEA was good, at 0.06 (90% CI 0.04–0.07), the CFI was, at 0.86, below the acceptable range. Removing five items with item-scale correlations at or below *r* = 0.30 resulted in a slightly worse, but still acceptable, RMSEA of 0.07 (90% CI 0.05–0.09), and improved CFI to 0.89 (see Table 2).

deviation; ISC = item-scale correlations. ISCs ≤ 0.30 are in bold print. a

significant difference between means, *T* (138.8) = −2.364, *p* = 0.019.

c

significant difference between means, *T* (139.1) = −2.251, *p* = 0.026. b

significant difference between means, *T* (138.1) = −2.915, *p* = 0.004.

#### **5. Discussion**

We reported on the post hoc psychometric evaluation of the CATS as a function of interpreter involvement in a sample of severely traumatized refugee youngsters from 17 countries. The CATS previously showed good psychometric properties with translated versions and samples from Germany, Norway, and the US [4]. In our sample, the overall internal reliability was lower, but still good and did not differ between the subgroup that involved an interpreter and the one that did not. In our sample, however, avoidance, hyperarousal, and NACM showed questionable to very poor alphas, with a negative α for avoidance in the group without an interpreter. It must be kept in mind, however, that this subscale has only two items dealing with different forms of avoidance and is, therefore, not ideal to begin with from a factor analytic point of view [17]. Although the internal consistencies of the subscales tended to be consistently better in the group with interpreters, some of them were still outside the acceptable range. On the one hand, this could indicate that the young refugees were unfamiliar with psychological test formats [18], that language difficulties might have occurred, or that culturally divergent concepts were captured by the questionnaires. On the other hand, the sometimes low reliability even in the interpreter group may also stem from the difficulty of translating almost simultaneously in the screening situation and the resulting quality of translation for culturally disputable constructs. Accordingly, translated questionnaire versions, in which the translation process is more elaborate due to iterative improvements, could contribute to increasing the reliability in the recording of the subscales [19].

Five items had low corrected item-scale correlations of 0.30 or below, and this problem was more pronounced in the group not supported by an interpreter. The four-factor model showed an acceptable fit only after removing items with bad item characteristics and even then, fit indices were worse than those reported in the original study [4]. Given the heterogeneity of our sample including refugee youth from 17 countries, this deviation from the original study, which examined more homogeneous national samples, may not, however, be too surprising.

#### *5.1. Limitations*

A key limitation of this analysis is its retrospective nature and the fact that the variable of interest is difficult to manipulate experimentally. Study clinicians decided whether to employ an interpreter for screening according to their perception of participants' German language skills and preferences. However, most studies on the impact of interpreters on mental health services share this limitation. While sample 1 offered voluntary participation in a screening study, sample 2 was a service use sample, which might have resulted in selection biases affecting this analysis. Furthermore, a third group using translated versions was lacking and the subsamples were too small so as to conduct CFAs for both groups separately.

#### *5.2. Implications*

Overall, the psychometric differences between the two groups were small and tended to favor the assistance of interpreters (internal consistency, item-scale correlations). Considering the multilingual population of young refugees in Germany, where translated versions of screening measures are often lacking, the common practice to employ lay interpreters does not seem to be disadvantageous, at least in terms of reliability.

#### **6. Conclusions**

The CATS is a reliable screening instrument for PTSS in culturally diverse refugee youth samples, including its use with the involvement of interpreters, making it a feasible screening tool for professionals working in this field (available at https://ulmeronlineklinik.de/course/view.php?id=1701, accessed on 24 June 2021). Assessments should be followed by a (semi-)structured interview to ascertain clinically relevant symptoms or diagnostic status. From a scientific point of view, these findings should be verified

by means of a validation of the CATS with a gold standard clinical interview. Given the paucity of quantitative research findings on the influence of interpreters on processes in mental health services, which has been emphasized by a variety of research groups [10,20], this study can be understood as a starting point for further rigorous studies, despite the limitations due to the post hoc design.

**Supplementary Materials:** The following are available online at https://www.mdpi.com/article/10 .3390/ijerph18136803/s1, Table S1: Characteristics of study sample.

**Author Contributions:** L.R.F.M. undertook the data collection in Study 1 and was responsible for drafting the manuscript. J.U. was principal investigator in both studies and was responsible for drafting the manuscript and analyzing the data. S.W. undertook the data collection in Study 2 and was responsible for the integration of datasets. R.R. supervised both studies and revised the manuscript. J.K. was involved in all issues with regard to data analysis and manuscript drafting. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was supported by the funding program proFor+ of the Catholic University Eichstätt-Ingolstadt (ID: 2316). Publication of this work was supported by the German Research Foundation (DFG) within the funding programme Open Access Publishing.

**Institutional Review Board Statement:** This is an additional analysis of two pre-studies. The studies were conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of the Catholic University Eichstätt-Ingolstadt (protocol code 2016/23 and 2015/02/16).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from all participants to publish this paper.

**Data availability statement:** The datasets generated and analyzed during this study are not publicly available due to sensitive and potentially identifying participant information but are available from the corresponding author on reasonable request.

**Acknowledgments:** We would like to thank Margret Lang and Karl Büter and all participants.

**Conflicts of Interest:** The authors declare no conflict of interest. The sponsors had no role in the design, execution, interpretation, or writing of the study.

#### **Abbreviations**

#### **References**

## *Article* **Trauma, Post-Traumatic Stress Disorder, and Mental Health Care of Asylum Seekers**

**Rafael Youngmann 1,\* , Rachel Bachner-Melman 1,2 , Lilac Lev-Ari <sup>1</sup> , Hadar Tzur <sup>1</sup> , Ravit Hileli <sup>3</sup> and Ido Lurie 4,5**

**Abstract:** Asylum seekers in Israel from East Africa frequently experienced traumatic events along their journey, particularly in the Sinai Peninsula, where they were subjected to trafficking and torture. Exposure to trauma has implications for rights that are contingent on refugee status. This retrospective chart review aimed to characterize the types of traumas experienced by 219 asylum seekers (149 men) from Eritrea and Sudan who sought treatment at a specialized mental health clinic in Israel, and to compare the mental health of trauma victims (*n* = 168) with that of non-trauma victims (*n* = 53). About 76.7% of the asylum seekers had experienced at least one traumatic event, of whom 56.5% were diagnosed with post-traumatic stress disorder (PTSD). Most reported traumas were experienced en route in the Sinai, rather than in the country of origin or Israel. Few clinical differences were observed between trauma victims and non-trauma victims, or between trauma victims with and without a PTSD diagnosis. Our findings emphasize the importance of accessibility to mental and other health services for asylum seekers. Governmental policies and international conventions on the definition of human trafficking may need to be revised, as well as asylum seekers' rights and access to health services related to visa status.

**Keywords:** asylum seekers; Eritrea; Sudan; PTSD; trauma; mental health care

#### **1. Introduction**

The number of international migrants worldwide is growing, and currently exceeds 244 million [1]. Refugees and asylum seekers constitute one of the largest migratory movements, driven by violence, insecurity, and armed conflict [2]. Refugees are people who left their country of origin to avoid life-threatening circumstances or persecution for political, religious, or other reasons, and are recognized under the 1951 Convention on the Status of Refugees [3]. Asylum seekers have applied for but have not yet been granted refugee status. In 2020, there were 82.4 million refugees and 4.1 million asylum seekers worldwide [4].

As part of the global trend of migration, and in the wake of war and genocide in Darfur, and the political situation in Eritrea, the number of asylum seekers arriving in Israel from East Africa has increased significantly since 2006 [5,6]. Between 2006 and 2016, approximately 64,318 asylum seekers entered Israel, of whom 40,274 still resided there in 2016 [7]; 72% (29,014) from Eritrea, 20% (8002) from Sudan, 0.3% (121) from Ethiopia, 5.8% (2349) from other African countries and 2% (556) from elsewhere [7]. Based on the principle of non-refoulement, 91% of asylum seekers from Sudan and Eritrea have been

**Citation:** Youngmann, R.; Bachner-Melman, R.; Lev-Ari, L.; Tzur, H.; Hileli, R.; Lurie, I. Trauma, Post-Traumatic Stress Disorder, and Mental Health Care of Asylum Seekers. *Int. J. Environ. Res. Public Health* **2021**, *18*, 10661. https:// doi.org/10.3390/ijerph182010661

Academic Editor: Paul B. Tchounwou

Received: 16 August 2021 Accepted: 6 October 2021 Published: 12 October 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

granted group protection, including the right to remain in Israel until their home countries are deemed safe. The Israeli government has, however, adopted restrictive policies towards them, excluding them from full participation in Israel's social, political and health systems, with financial and psychological implications [6,8].

An estimated 7000 of the 52,961 asylum seekers who arrived in Israel between 2009 and 2013 [9] were exposed to kidnapping, torture, and human trafficking during their journey through the Sinai desert [6]. An estimated 4000 did not survive the journey [10]. Asylum seekers exploited in this way are defined by the UN conventions as "Smuggling Victims", "Torture Victims", or "Human Trafficking Victims" [11]. Only those recognized as "Trafficking Victims" or "Victims of Holding in Conditions of Slavery" by the State of Israel are legally entitled to shelter and rehabilitation services, including health insurance and a valid work permit, for one year [12], regardless of their physical and mental health status [13]. According to the UN Convention on the rights of refugees to health care [3], ratified by Israel in 1958 [14], asylum seekers who were victims of torture or human trafficking are entitled to recognition as refugees with rights to medical care and other services.

Asylum seekers living in Israel have very slim chances of receiving refugee status. In 2016, only 500 of the 37,016 asylum seekers from Sudan and Eritrea were officially recognized as "Trafficking Victims" or "Victims of Holding in Conditions of Slavery" [15]. These asylum seekers included 5000–7000 victims of torture, human trafficking and kidnapping in Sinai or their country of origin. No asylum seekers, however, were officially recognized as victims of human torture [15]. Of 13,764 asylum requests submitted by people from Sudan and Eritrea by July 2017, only ten had refugee status in 2018 [16], and therefore access to medical services. Others were granted access to health services in medical or psychiatric emergencies only [17]. Identifying victims of trafficking remains a major challenge due to the ambiguity of the international definition of exploitation [18], difficulties in defining types of victims in the Sinai desert [19,20], victims' lack of awareness of their rights [13], and restrictions imposed by the Israeli government on asylum seekers seeking recognition as trafficking victims [21].

The process of migration involves significant socio-psychological pressures that affect migrants' mental state. Asylum seekers and trafficking victims are particularly vulnerable to trauma-related disorders including post-traumatic stress disorder (PTSD), depression, somatic disorders, eating disorders, substance abuse (such as self-medication), self-injurious behavior, suicidality, and psychotic disorders [22–31]. As elsewhere, asylum seekers in Israel have high rates of emotional distress and psychiatric disorders [32,33]. Victims of torture experienced trauma directly or vicariously [6]. In addition, as a visible minority, African asylum seekers in Israel are vulnerable to racism and rejection by the local population [34,35]. Asylum seekers undoubtedly need social support, employment, and medical treatment to cope with post-migration challenges [36,37].

Most asylum seekers in Israel are not eligible for national health insurance, which provides psychiatric treatment [36,38]. One of their main options for psychiatric care is *Gesher* ("Bridge" in Hebrew), an adult (>18 years) psychiatric clinic established by the Ministry of Health in 2014 in Tel Aviv-Jaffa, for asylum seekers and other undocumented migrants [39]. The goal of the clinic is to deliver culturally competent and trauma-sensitive mental health treatment that includes the work of cultural brokers. A description of the clinic and its activities can be found elsewhere [40].

This study aimed to characterize asylum seekers mainly from Eritrea and Sudan who arrived in Israel through the Sinai Peninsula, between 2007 and 2013, including the types of traumas they experienced and the mental health care they received. These aims are of particular importance in Israel, where asylum seekers, referred to by the Ministry of the Interior as "infiltrators", have almost no access to mental health services.

We hypothesized that compared to asylum seekers who were not trauma victims, trauma victims would:

These outcomes have important implications for promoting the initiative to allow asylum seekers in Israel and elsewhere to benefit from health insurance and health services.

#### **2. Materials and Methods**

#### *2.1. Measures*

Demographic data were taken from patients' files: country of origin, age, gender, years of education, marital status, partner in Israel (yes/no/missing), full or partial employment, and religion (Muslim/Christian/other).

Categories of victims were defined as follows, based on international definitions [41] and the law in the State of Israel [8]:

Place of trauma: country of origin; en route to Israel (Sinai); Israel.

PTSD was diagnosed by a mental health professional according to ICD-10 criteria (F43.1.) [43]. Number of consultations was the number of appointments with a mental health professional at the *Gesher* Clinic.

Additional variables: Psychiatric medications (yes/no); current drug abuse (yes/no); current alcohol use (yes/no); suicidal ideation (yes/no); and one or more psychiatric inpatient admissions in Israel (yes/no).

#### *2.2. Procedure*

The study was approved by the Internal Review Boards of the Abarbanel Mental Health Center and the Ruppin Academic Center [TASHAZ 26]. The data was collected and coded from the files by H.T. and R.H. Anonymity was strictly respected. Inter-rater reliability for variable coding between the coders for a random sample of 10 files, evaluated by H.T and I.L was 100%.

#### *2.3. Data Analysis*

Group comparisons were reported by the percentages within each group. Chi Square tests were conducted to compare between types of victimization in country of origin, en route in Sinai and in Israel with demographic variables. Chi Square tests were also conducted to assess if trauma victims would be at greater risk for PTSD than non-trauma victims. *t*-test analyses were conducted to assess the differences between trauma victims and non-trauma victims for the means of clinical consultations. Multiple *t*-test analyses were conducted, separately for trauma en route to Israel (Sinai), in Israel and in country of origin, and separately for types of trauma when warranted. Chi square analyses were also conducted to assess the frequencies of trauma victims' medication, hospitalization, and suicide ideation. Pearson correlations were used to assess relationships between variables. All statistical analyses were deemed significant at a *p* < 0.05 level. We built an index summing the locations where traumatic events were experienced. This Trauma Index ranged between 0 (no trauma) to 3 (trauma en route, trauma in Israel and trauma in country of origin).

SPSS version 23 (IBM, Amonk, NY, USA) was used for all analyses.

#### **3. Results**

#### *3.1. Participants*

This study is based on a retrospective chart review, based on medical records of 271 patients who were asylum seekers living in Israel and sought treatment at the *Gesher* Clinic from 2014–2016. The 52 patients who did not report whether they had been victims of trauma were excluded, so 219 asylum seekers (149 men, 68%) were included in the study. Their ages ranged from 20–61 (M = 32.7, SD = 7.65). Most (*n* = 134, 61.2%) were from Eritrea, 56 (25.6%) were from Sudan, 3 were from Ethiopia and 26 did not report their country of origin. Over half (*n* = 126, 57.5%) were unemployed. Of the 78 employed patients, 46 (21.0%) reported working full time. Most asylum seekers (*n* = 141, 64.4%) were Christian, 47 (21.5%) were Muslim and 31 (14.1%) did not report their religion. Participants reported receiving 0–20 years of education (M = 8.83, SD = 3.71) and had 0–9 children (M = 1.09, SD = 1.63), of whom 0–4 (M = 0.49, SD = 0.83) were born in Israel. Most (*n* = 125, 57.1%) were single, 78 (35.6%) were married, 11 divorced, and 3 widowed. Two of the single patients, 32 of those married, and one of those divorced had partners in Israel.

#### *3.2. Traumatic Events in Country of Origin*

Almost half (42.9%, *n* = 94) the asylum seekers reported having experienced traumatic events in their country of origin. Political persecution was reported by 38 (17.4%), physical or sexual violence by 24 (11.0%), military trauma by seven (3.2%), and civil trauma by 17 (7.8%). Table 1 shows demographic variables across different types of traumatic events in country of origin.

Significant differences were found for gender and country of origin. More men than women had suffered political persecution, military trauma and civil trauma. Asylum seekers from Eritrea suffered more traumatic events than those from Sudan, except for civil war.

#### *3.3. Traumatic Events en Route to Israel*

There were significant differences for gender and country of origin across asylum seekers who experienced different types of trauma en route to Israel (in the Sinai Peninsula). Only about one quarter of the non-victims were women, and almost two-thirds from Eritrea. Most smuggling, torture and trafficking victims were men, whereas most sexual violence and torture victims were women. Approximately three-quarters of the torture victims and the trafficking and torture victims, and over 80% of the sexual violence victims were from Eritrea. There were no significant between-group differences for family status, religion, employment or partner in Israel (see Table 2).

**Table 1.** Demographic variables across different types of traumatic events in country of origin.

**Table 2.** Demographic variables of asylum seekers who experienced different types of trauma in the Sinai Peninsula, and non-trauma victims.

\* Only 84 non-victims reported their country of origin. \*\* Included in the table are only participants for whom we had data concerning country of origin and type of victimization.

#### *3.4. Traumatic Events in Israel*

Only 23 (10.5%) of the asylum seekers reported experiencing traumatic events in Israel. Eleven (~48%) were from Eritrea and 13 (~57%) were Christian. Nine (4.1%) reported having experienced sexual or physical violence in Israel. Fourteen (6.4%) of the asylum seekers reported having experienced civil trauma in Israel. Ten (71.4%) were male, 12 (85.7%) had no partner in Israel, half were married, and 7 (58.3%) were from Eritrea. Half were Muslim and most (*n* = 10, 71.4%) were unemployed.

#### **Hypothesis 1 (H1)**. *Trauma victims would be at greater risk for PTSD than non-trauma victims.*

To assess differences between trauma victims and non-trauma victims for PTSD diagnosis, multiple chi square analyses were conducted, separately for trauma en route to Israel (Sinai), in Israel, and in country of origin, and then separately for types of trauma in each location.

A PTSD diagnosis was given to 96 (43.8%) of the asylum seekers. Trauma was experienced by 114 (52.1%) asylum seekers in Sinai, 23 (10.5%) in Israel and 94 (42.9%) in their country of origin. Asylum seekers who experienced trauma in Sinai were more likely to be diagnosed with PTSD than those who did not, and asylum seekers who experienced trauma in their country of origin were more likely to be diagnosed with PTSD than those in each location.

who did not (see Figure 1). The number of asylum seekers who reported traumatic events in Israel was insufficient for statistical analysis (e.g., 4.1% [9] were victims of physical/sexual violence, and 6.4% [14] were victims of civil trauma). It was not possible to perform statistical analyses between groups, because the expected cells in chi square were in some cases less than 5. in Israel was insufficient for statistical analysis (e.g., 4.1% [9] were victims of physical/sexual violence, and 6.4% [14] were victims of civil trauma). It was not possible to perform statistical analyses between groups, because the expected cells in chi square were in some cases less than 5.

To assess differences between trauma victims and non-trauma victims for PTSD diagnosis, multiple chi square analyses were conducted, separately for trauma en route to Israel (Sinai), in Israel, and in country of origin, and then separately for types of trauma

A PTSD diagnosis was given to 96 (43.8%) of the asylum seekers. Trauma was experienced by 114 (52.1%) asylum seekers in Sinai, 23 (10.5%) in Israel and 94 (42.9%) in their

trauma in their country of origin were more likely to be diagnosed with PTSD than those who did not (see Figure 1). The number of asylum seekers who reported traumatic events

*Int. J. Environ. Res. Public Health* **2021**, *18*, x 7 of 17

**Figure 1.** Percentage of asylum seekers with PTSD across place of trauma. \*\*\* Significant at *p* < 0.001, \* Significant at *p* < 0.05. PTSD = Post-traumatic stress disorder. **Figure 1.** Percentage of asylum seekers with PTSD across place of trauma. \*\*\* Significant at *p* < 0.001, \* Significant at *p* < 0.05. PTSD = Post-traumatic stress disorder.

Fifty-one (23.3%) asylum seekers reported no trauma, one of whom received a PTSD diagnosis. Approximately half (111, 50.7%) experienced trauma at one location, 51 (23.3%) at two locations and 6 (2.7%) at all three places of trauma. The Trauma Index of asylum seekers with a PTSD diagnosis (M = 1.33, SD = 0.54) was significantly higher than that of Fifty-one (23.3%) asylum seekers reported no trauma, one of whom received a PTSD diagnosis. Approximately half (111, 50.7%) experienced trauma at one location, 51 (23.3%) at two locations and 6 (2.7%) at all three places of trauma. The Trauma Index of asylum seekers with a PTSD diagnosis (M = 1.33, SD = 0.54) was significantly higher than that of those without a PTSD diagnosis (M = 0.84, SD = 0.83; *t*(217) = −5.07, *p* < 0.001).

those without a PTSD diagnosis (M = 0.84, SD = 0.83; *t*(217) = −5.07, *p* < 0.001). Victims of any kind of torture en route to Israel (torture, trafficking and torture/sexual violence and torture) were more likely to receive a diagnosis of PTSD than those who Victims of any kind of torture en route to Israel (torture, trafficking and torture/sexual violence and torture) were more likely to receive a diagnosis of PTSD than those who did not experience torture en route to Israel (*X 2* (5) = 57.89, *p* < 0.001; see Figure 2). The vast majority of smuggling victims had no PTSD diagnosis.

did not experience torture en route to Israel (*X2*(5) = 57.89, *p* < 0.001; see Figure 2). The vast majority of smuggling victims had no PTSD diagnosis. No significant differences were observed in the frequency of PTSD diagnoses across different types of trauma in Israel. Victims of political persecution or physical/sexual trauma in their country of origin were significantly more likely to receive a PTSD diagnosis than non-victims of political persecution or physical/sexual trauma (*X 2* (4) = 15.07, *p* = 0.005; see Figure 3).

The number of clinical consultations ranged from 1–45 (M = 9.29, SD = 9.21). To assess differences between trauma victims and non-trauma victims for clinical consultations, multiple t-test analyses were conducted, separately for trauma en route to Israel (Sinai), in Israel and in country of origin, and separately for types of trauma when warranted.

*Int. J. Environ. Res. Public Health* **2021**, *18*, x 8 of 17

trauma in their country of origin were significantly more likely to receive a PTSD diagno-

**Figure 2.** Percentage of asylum seekers who experienced trauma en route to Israel, with and without PTSD as a function type of trauma. PTSD = Post-traumatic stress disorder. **Figure 2.** Percentage of asylum seekers who experienced trauma en route to Israel, with and without PTSD as a function type of trauma. PTSD = Post-traumatic stress disorder. sis than non-victims of political persecution or physical/sexual trauma (*X2*(4) = 15.07, *p* = 0.005; see Figure 3).

**Figure 3.** Percentage of asylum seekers with and without PTSD across different types of trauma in country of origin. PTSD = Post-traumatic stress disorder. **Figure 3.** Percentage of asylum seekers with and without PTSD across different types of trauma in country of origin. PTSD = Post-traumatic stress disorder.

#### **Hypothesis 2 (H2).** *Trauma victims would have more clinical consultations than non-trauma*  **Hypothesis 2 (H2).** *Trauma victims would have more clinical consultations than non-trauma victims.*

**Figure 3.** Percentage of asylum seekers with and without PTSD across different types of trauma in country of origin. PTSD = Post-traumatic stress disorder. **Hypothesis 2 (H2).** *Trauma victims would have more clinical consultations than non-trauma victims*. The number of clinical consultations ranged from 1–45 (M = 9.29, SD = 9.21). To assess differences between trauma victims and non-trauma victims for clinical consultations, *victims*. The number of clinical consultations ranged from 1–45 (M = 9.29, SD = 9.21). To assess differences between trauma victims and non-trauma victims for clinical consultations, multiple t-test analyses were conducted, separately for trauma en route to Israel (Sinai), in Israel and in country of origin, and separately for types of trauma when warranted. There was no significant difference in the number of clinical consultations between asylum seekers who experienced trauma en route to Israel and those who did not, or between those who experienced trauma in Israel and those who did not. However, the 94 asylum seekers who experienced trauma in their country of origin had significantly more clinical consultations (M = 11.82, SD = 10.27) than the 125 who did not (M = 0.49, SD = 0.73, There was no significant difference in the number of clinical consultations between asylum seekers who experienced trauma en route to Israel and those who did not, or between those who experienced trauma in Israel and those who did not. However, the 94 asylum seekers who experienced trauma in their country of origin had significantly more clinical consultations (M = 11.82, SD = 10.27) than the 125 who did not (M = 0.49, SD = 0.73, *p* < 0.001). Asylum seekers who suffered civil trauma in their country of origin had the highest number of consultations (M = 13.27, SD = 12.53), followed by victims of physical/sexual trauma (M = 11.29, SD = 8.96), political persecution (M = 11.00, SD = 10.15), military trauma (M = 9.14, SD = 8.21), and non-trauma victims (M = 7.49, SD = 7.95; F (4193) = 2.52, *p* = 0.04). There was a positive, significant association between the Trauma Index and number of clinical consultations (r = 0.25, *p* < 0.001).

multiple t-test analyses were conducted, separately for trauma en route to Israel (Sinai), in Israel and in country of origin, and separately for types of trauma when warranted.

asylum seekers who experienced trauma in their country of origin had significantly more clinical consultations (M = 11.82, SD = 10.27) than the 125 who did not (M = 0.49, SD = 0.73,

There was no significant difference in the number of clinical consultations between asylum seekers who experienced trauma en route to Israel and those who did not, or be*trauma victims*.

**Hypothesis 3 (H3).** *Trauma victims would be prescribed more psychiatric medication than nontrauma victims.* higher number of clinic consultations (M = 9.82, SD = 9.19) than those who did not (M = 6.52, SD = 9.11, *t*(200) = −1.68, *p* = 0.045).

*p* < 0.001). Asylum seekers who suffered civil trauma in their country of origin had the highest number of consultations (M = 13.27, SD = 12.53), followed by victims of physical/sexual trauma (M = 11.29, SD = 8.96), political persecution (M = 11.00, SD = 10.15), military trauma (M = 9.14, SD = 8.21), and non-trauma victims (M = 7.49, SD = 7.95; F (4193) = 2.52, *p* = 0.04). There was a positive, significant association between the Trauma Index and

**Hypothesis 3 (H3).** *Trauma victims would be prescribed more psychiatric medication than non-*

ducted. No significant between-group differences emerged for different locations or types of traumas. However, participants who were prescribed psychiatric medication had a

Most participants (*n* = 190, 86.8%) were prescribed psychiatric medication. To com-

*Int. J. Environ. Res. Public Health* **2021**, *18*, x 9 of 17

number of clinical consultations (r = 0.25, *p* < 0.001).

Most participants (*n* = 190, 86.8%) were prescribed psychiatric medication. To compare trauma victims with non-trauma victims, multiple chi square analyses were conducted. No significant between-group differences emerged for different locations or types of traumas. However, participants who were prescribed psychiatric medication had a higher number of clinic consultations (M = 9.82, SD = 9.19) than those who did not (M = 6.52, SD = 9.11, *t*(200) = −1.68, *p* = 0.045). **Hypothesis 4 (H4).** *Trauma victims would report more drug and alcohol use than non-trauma victims.* Only 18 (8.2%) of the asylum seekers reported using alcohol and 10 (4.6%) reported using drugs. To assess differences between trauma victims and non-trauma victims for

#### **Hypothesis 4 (H4).** *Trauma victims would report more drug and alcohol use than non-trauma victims*. alcohol and drug use, multiple chi square analyses were conducted. No between-group

Only 18 (8.2%) of the asylum seekers reported using alcohol and 10 (4.6%) reported using drugs. To assess differences between trauma victims and non-trauma victims for alcohol and drug use, multiple chi square analyses were conducted. No between-group differences for alcohol or drug use were observed for type or place of trauma or for the Trauma Index. differences for alcohol or drug use were observed for type or place of trauma or for the Trauma Index. **Hypothesis 5 (H5).** *Trauma victims would report more suicide ideation than non-trauma victims.*

#### **Hypothesis 5 (H5).** *Trauma victims would report more suicide ideation than non-trauma victims.* Only 15 (6.8%) of the asylum seekers reported suicidal ideation. To assess differences between trauma victims and non-trauma victims for suicidal ideation, multiple chi square

Only 15 (6.8%) of the asylum seekers reported suicidal ideation. To assess differences between trauma victims and non-trauma victims for suicidal ideation, multiple chi square analyses were conducted, for place of trauma and then for types of trauma. No significant between-group differences were found for trauma en route to Israel or in country of origin, and no significant association was found between suicide ideation and the Trauma Index. However, significantly more asylum seekers who suffered trauma in Israel experienced suicidal ideation (*n* = 7, 33.3%) than those who did not (*n* = 8, 4.7%; *X 2* (1) = 21.48, *p* < 0.001). As can be seen in Figure 4, fully 75% of asylum seekers who suffered physical or sexual violence in Israel reported suicidal ideation. analyses were conducted, for place of trauma and then for types of trauma. No significant between-group differences were found for trauma en route to Israel or in country of origin, and no significant association was found between suicide ideation and the Trauma Index. However, significantly more asylum seekers who suffered trauma in Israel experienced suicidal ideation (*n* = 7, 33.3%) than those who did not (*n* = 8, 4.7%; *X2*(1) = 21.48, *p* < 0.001). As can be seen in Figure 4, fully 75% of asylum seekers who suffered physical or sexual violence in Israel reported suicidal ideation.

**Hypothesis 6 (H6).** *Trauma victims would have more psychiatric hospitalizations than nontrauma victims.*

Twenty-seven (12.3%) of the asylum seekers had been hospitalized in psychiatric units in Israel. To assess differences between trauma victims and non-trauma victims

for psychiatric hospitalization, multiple chi square analyses were conducted, separately for place of trauma and then for type of trauma. No significant difference was found for trauma in Israel or in country of origin. However, significantly fewer asylum seekers who had suffered trauma en route to Israel (*n* = 6, 5.5%) reported a history of psychiatric hospitalizations than those who had not (*n* = 21, 21.4%; *X 2* (1) = 11.54, *p* < 0.001). This finding was in the opposite direction to our hypothesis.

**Hypothesis 7 (H7).** *Emotional support (i.e., having a partner in Israel or being employed) would be associated with fewer PTSD diagnoses, clinic consultations, psychiatric medication prescriptions, drug and alcohol use, suicidal ideation, and psychiatric hospitalizations.*

Chi-square analyses were conducted to assess whether having a partner in Israel (yes/no) and/or being employed (yes/no) were related to PTSD diagnoses, number of consultations, psychiatric medication, drug and alcohol use, suicidal ideation and/or psychiatric hospitalizations. No significant differences were found between having a partner in Israel and the other variables. A significant association was observed between employment status and alcohol use. More currently employed participants (*n* = 11, 14.7%) abused alcohol than currently unemployed participants (*n* = 7, 5.7%; *X 2* (1) = 4.52, *p* = 0.03). This finding was in the opposite direction to our hypothesis.

#### **4. Discussion**

This study aimed to examine the psychiatric status and mental health care of asylum seekers in Israel, mostly from Eritrea and Sudan, who received psychiatric treatment at the *Gesher* Clinic in Israel between 2014 and 2016. We compared the profiles of those who had experienced traumatic events with those who had not, since this distinction has policy implications in Israel.

Only asylum seekers whom the State of Israel recognizes as victims of trafficking and slavery are entitled to medical care and rehabilitation services, yet even these are limited in duration [21] The most surprising finding was, perhaps, that in contrast to our hypotheses, there were few significant differences in the psychiatric characteristics that differentiated between trauma victims and non-trauma victims, and between asylum seekers with and without PTSD. Those with PTSD were no more likely than those without PTSD to take psychiatric medications, use psychoactive drugs and alcohol, have suicide ideation, and report a history of psychiatric hospitalizations. All asylum seekers included in this study were in mental distress, whether or not they reported having experienced a traumatic event or were diagnosed with PTSD. All had turned to a psychiatric clinic for help, and it, therefore, seems arbitrary to restrict access to psychiatric care to the few whom the State of Israel has recognized as refugees, or victims of human trafficking or slavery.

The high prevalence of PTSD among trauma victims is in line with previous studies highlighting the vulnerability of asylum seekers and refugees to cumulative trauma [25,31,44,45]. Traumatic experiences occur in asylum seekers' countries of origin, along migratory routes, and in their post-migratory environment.

Among asylum seekers who were victim of trauma, the highest prevalence of PTSD was observed among those who experienced trauma in the Sinai Peninsula en route to Israel. This supports previous findings that asylum seekers who crossed the Sinai desert were victims of a wide range of traumas [6]. They were found to be at high risk for mental health problems [46], and prolonged exposure to traumatic events greatly increased their risk of developing PTSD [47]. Similar risk was found in asylum seekers from various countries in Switzerland, who had experienced or witnessed torture [48]. The low rate of PTSD observed among victims of smuggling may stem from the complicated relationship between smuggling and trafficking—some incidents of smuggling turn into trafficking and some incidents of trafficking turn into smuggling [10]. It may be that being smuggled may scar the souls of asylum seekers less than previous or subsequent traumatic experiences.

Political persecution and physical/sexual trauma in the asylum seekers' country of origin were risk factors for PTSD. Cumulative documentation from victims of political persecution and physical or sexual violence in Eritrea and Sudan corroborates the depth of their vulnerability from these forms of trauma [49–51]. Asylum seekers who had experienced trauma in their country of origin also had more clinical consultations than those who did not, underscoring the heavy residue of trauma in their country of origin.

No specific trauma in the host country, Israel, was found to be associated with PTSD. This may be due to the small number of asylum seekers who reported experiencing trauma in Israel. In addition, many asylum seekers may experience high distress due to postmigration difficulties, whether or not they experienced traumatic events on their migratory path [6,37,52]. Such post-migration difficulties include socioeconomic, social, and interpersonal factors, asylum-related bureaucracy, immigration policy [53], and perceived threat of detention and deportation [54]. Future research should examine the relative impact of specific postmigration stressors on PTSD and mental health.

Asylum seekers who were victims of trauma and diagnosed with PTSD had experienced traumas in more places than those without PTSD. Traumatic events were most experienced in the Sinai Peninsula, followed by country of origin. This supports previous findings that experiencing trauma in more than one location increases risk for PTSD and other disorders among asylum seekers [55,56]. Experiencing a traumatic event in the Sinai desert conferred risk for PTSD, underscoring the severe and prolonged injuries suffered by the asylum seekers in Sinai [6,47]. However, experiencing an additional traumatic event elsewhere along the asylum seekers' journey did not increase this risk further. This suggests that the asylum seekers' overall subjective experience of having been traumatized, regardless of the number of their traumatic experiences, confers risk for developing PTSD [57].

Whereas both men and women commonly experience torture, trafficking and sexual violence during their migratory journeys, particularly in Africa [19,58], certain traumas appear to be gender-based. Most torture, trafficking and smuggling victims in our study were men, whereas most sexual violence and torture victims were women. Similar findings were reported in other studies on this population [6,59], and asylum seekers in other Western countries [60–62].

Fully 43 (8%) of the trauma victims in our study received a PTSD diagnosis, underscoring the devastating effects of trauma such as torture, trafficking, and physical and sexual violence [6,28]. However, 37% did not. Whereas resilience is a possible explanation, it is important to keep in mind that all participants were in treatment for mental problems at the *Gesher* Clinic. One non-trauma victim was diagnosed with PTSD. She may have omitted to report a traumatic event or been misdiagnosed, possibly due to cross-cultural variation in the presentation of posttraumatic symptoms [63]. Similarly, at least some of the non-trauma victims may not have reported traumatic events they experienced.

In contrast to our hypothesis, a similar percentage of trauma and non-trauma victims were prescribed psychiatric medications. This was no doubt because they were prescribed to the vast majority of asylum seekers. Medications may have been needed, available, convenient, and over-prescribed. We unfortunately had no access to reliable information on the patients referred to individual or group psychotherapy; however, these may be under-used and regarded with mistrust because of differences in cultural attitudes [36,64].

Number of clinical appointments does not necessarily indicate a need for treatment or a level of distress [64]. Prescriptions for psychiatric medications require monitoring, which may explain the association between the number of clinical consultations and the prescription of psychiatric medications. In Israel, at the time of the study, the movement of asylum seekers was restricted and the renewal of medical prescriptions was a common pretext for freedom of movement [65].

Notably, no differences in alcohol or drug use were found between asylum seekers with and without PTSD, which can perhaps be attributed to low rates of report and selfdisclosure. Low rates of substance and alcohol abuse were also reported among Russian, Somali and Kurdish migrants in Finland [66], and refugees from former Yugoslavia and the Middle East in Sweden [67]. Although some studies have observed massive drug use in some ethnic minorities in the US [68], Muslim refugees may be protected against substance

use and misuse [29]. In this study, employed asylum seekers reported using more alcohol than the unemployed, possibly because they could pay for them.

Suicide ideation was not reported more frequently by asylum seekers who were victims of trauma and those who were non-trauma victims, whether in the country of origin or en route to Israel. Suicide ideation may have been underreported in our study, since there are high rates of suicidality among asylum seekers in Australia [23] and the U.S. [69], among moderate and severe levels of distress among Afghanistan and Syrian asylum seekers in Sweden [70], and detention can increase the risk for suicide ideation in asylum seekers [71]. Yet, most (75%) of victims of physical/sexual violence in Israel reported suicidal ideation. Post-resettlement violence was found to have a larger association with mental health symptoms than pre-resettlement exposure, among Somali refugees in the US and Canada [72]. Trauma-affected refugees in Germany who experienced an additional stressful life event during treatment had more severe symptoms of PTSD, anxiety, and depression than those without a renewed event [73]. Experiencing a new trauma, especially physical or sexual violence in the "land of refuge", a place that had offered hope for a better future, may lead to despair to the point of wanting to die. Whereas physical/sexual violence experienced in one's country of origin or en route is traumatic, it may still leave hope for a better future.

Asylum seekers with and without PTSD had similar numbers of psychiatric hospitalizations in Israel. Surprisingly, victims of trauma in Sinai with PTSD reported fewer hospitalizations than those without PTSD. This may suggest resilience, although factors such as socio-demographic and ecological variations in their post-migratory environment, possible alternatives to psychiatric admission, like the Open Clinic of Physicians for Human Rights [47], and traditional healers and religious leaders [36,74] may explain this finding.

Previous research found that emotional support from a partner [75,76] and employment [77,78] in the host country was protective against PTSD. However, we did not find having a partner in Israel or being employed to be associated with lower risk for PTSD, psychiatric medications, clinical consultations, alcohol abuse, suicide ideation, or psychiatric inpatient admissions. A study examining the association between perceived social support and posttraumatic symptoms among Eritrean and Sudanese male asylum seekers in Israel found a significant negative link between the two, but only for men who reported low exposure to traumatic events [36]. In our study, 76.7% of the asylum seekers reported experiencing at least one traumatic event at some point along their process of migration, which may explain why having a partner was not connected to lower distress levels. It is known that the levels of torture experience in the Sinai Desert by trauma victims from Eritrea and Sudan are extreme [10,59].

The lack of association between PTSD diagnosis and employment may be explained by the fact that over half the participants (57.5%) were unemployed and almost 80% of the employed worked part-time, presumably not out of choice. Economic opportunities such as the right to work and access to full employment have been found to have a linear relationship with mental health among refugees and asylum seekers [78]. However, earnings from part-time employment in Israel are not high and does not generally provide economic security in Israel. Part-time employment may even render asylum seekers in Israel vulnerable to trafficking and abuse. Employment may not have been protective of PTSD in this study because most asylum seekers were employed part-time. Moreover, a residence permit is a precondition for asylum seekers to obtain a work permit in Israel. Residence permits are temporary and must be periodically renewed at the Ministry of the Interior [21], which adds to the burden and stress of employed asylum seekers.

This study has several limitations. First, given the cross-sectional nature of the data, causality cannot be determined. Second, the findings are based on a clinical sample of asylum seekers who sought psychiatric help at a specific clinic. It is therefore unclear whether the findings can be generalized to a broader population of asylum seekers. Third, the asylum seekers were assessed by different mental health workers and the inter-judge reliability of diagnoses and other information recorded in the files was not assessed. Professionals based their assessments on patients' self-report so some information may have been biased or omitted.

#### **5. Conclusions**

Although this is a clinical sample, with a relatively small number of participants, the findings of this study add to our knowledge about the psychiatric status of asylum seekers seeking mental health care in Israel. The study examined differences between trauma victims and non-trauma victims, and between trauma victims with and without PTSD. Although trauma victims received more PTSD diagnoses than non-victims, no differences were observed between the psychiatric status and mental health care of victims versus non-victims of trauma among asylum seekers in Israel from East Africa. Asylum seekers are a vulnerable population, and it is vital to understand that the risks and hazards they face before, during, and after their migration journey increase the risk for physical and mental problems among trauma victims and non-trauma victims alike. It may be of value to integrate cultural and societal-structural approaches such as the Socio-Cultural Formulation [79] into the psychiatric assessment of asylum seekers. This could help make it clear that they are vulnerable and deserving of psychiatric treatment and psychological support. In any case, clinicians should examine the mental health status of asylum seekers and victims of human trafficking with thoroughness and dignity, and ensure that they receive the help warranted by their experiences and needs.

From a clinical perspective, the lack of difference between the psychiatric status and mental health care of victims versus non-victims in this study strongly support a recent initiative of the Israel Ministry of Health [80]. According to this initiative, the Israeli government would provide health insurance for asylum seekers [80] and abandon the narrow interpretation of the Refugee Convention [3] adopted to date in the field of health. The results of our study strengthen the case for establishing organized, coordinated, sustainable mental health services that serve the needs of the community of asylum seekers in Israel. It would seem to be appropriate for the Ministry of Health or a Health Maintenance Organization to extend tailored services to meet the needs of the community.

The few clinical differences we observed between asylum seekers who were victims of human trafficking, torture, and other atrocities and asylum seekers who were nontrauma victims challenges the narrow interpretation currently given by the State of Israel to the international conventions it ratified. The Refugee Convention [3] and the Palermo Protocol [41], for example, enable Israel to recognize only 0.06% of all asylum seekers' applications for refugee status [80]. This stance joins local and international voices calling for a review of the Palermo Protocol [41] and the definition of human trafficking [81–83], so as to " . . . protect and assist the victims of such trafficking, with full respect for their human rights" ([41]; Article 2(b)), and help asylum seekers gain access to appropriate services, regardless of their visa status.

**Author Contributions:** R.Y.—conceived the study (with I.L.), supervised H.T. in the fieldwork (along with R.B.-M.) and wrote most of the paper. R.B.-M. guided the fieldwork, contributed significantly to conceptualization, methodology, and writing the manuscript. L.L.-A. analyzed the data and wrote the Results section. H.T. conducted the fieldwork, collect the raw data, contributed significantly to the statistical analyses. R.H. collect the raw data. I.L. conceived the study, contributed significantly to ensure the reliability of the data, and commented on all sections of the manuscript. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of Abarbanel Mental Health Center, Israel. Protocol code 123; 1 March 2015.

**Informed Consent Statement:** Informed consent was waived since the study was a retrospective chart review. Anonymity was kept during all stages of data processing.

**Data Availability Statement:** The data is available on demand from the corresponding author.

**Acknowledgments:** The authors would like to thank Tehila Jouchovitzky and Era Ben Yehoyada for their support of the clinic's work and data collection.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

### *Review* **Refugee Women with a History of Trauma: Gender Vulnerability in Relation to Post-Traumatic Stress Disorder**

**Macarena Vallejo-Martín 1,\* , Ana Sánchez Sancha <sup>2</sup> and Jesús M. Canto <sup>1</sup>**

**Abstract:** Refugees represent a population whose living conditions have a strong impact on their mental health. High rates of post-traumatic stress disorder (PTSD), more than other mental disorders, have been found in this group, with women having the highest incidence. The objective of the present systematic review was to identify and examine studies from the last fifteen years on the relationship between the impact of traumatic experiences and PTSD psychopathology in refugee women. Twelve studies were included, from which the overall results approved this relation. In addition, six of these studies show that exposure to sexual trauma in refugee women is associated with the high odds of being at risk for PTSD. These findings suggest that gender-related traumatic experiences can explain the high rate of PTSD in refugee women and highlight the unmet need for psychosocial health care in this population.

**Keywords:** refugee women; post-traumatic stress disorder (PTSD); traumatic experiences; sexual violence; systematic review

#### **1. Introduction**

At present, we are in the midst of a humanitarian crisis that is causing millions of people to be displaced, for reasons of war, violence and the precarious situations in their countries of origin. Specifically, the UNHCR [1] estimates that 70.8 million people are forcefully displaced all over the world, resulting in 25.9 million refugees, half of whom are under the age of 18. The circumstances in which refugees often flee cause them to experience mental health problems and a significant deterioration in their psychological well-being [2,3]. Mental disorders and psychosocial problems are much more frequent in individuals that have had to confront these types of adversities, such as being exposed to a humanitarian crisis [4] or experiencing different types of discrimination [5]. In this sense, it was confirmed that refugees have a rate of mental disorders that is twice than that identified in migrant workers [6].

The traumatic events experienced before and during displacement cause refugees to suffer from psychological manifestations related to loss of persons or places with symptoms of grief, traumatic reactions and even dissociative symptoms or acute stress disorders [7]. Situations of uncertainty and problems of adaptation also arise, since refugees grapple with unpredictable and difficult changes [1]. As a consequence of this exposure to stressful and traumatizing factors, the majority of uprooted persons experience suffering and diverse emotional problems [8]. Among the different disorders and mental health problems that can affect refugees, post-traumatic stress disorder (PTSD) and depression are the most frequent [9–11].

**Citation:** Vallejo-Martín, M.; Sánchez Sancha, A.; Canto, J.M. Refugee Women with a History of Trauma: Gender Vulnerability in Relation to Post-Traumatic Stress Disorder. *Int. J. Environ. Res. Public Health* **2021**, *18*, 4806. https://doi.org/10.3390/ ijerph18094806

Academic Editors: Shameran Slewa-Younan and Greg Armstrong

Received: 30 March 2021 Accepted: 29 April 2021 Published: 30 April 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

#### *1.1. Post-Traumatic Stress Disorder in Refugees*

PTSD is considered to be the mental disorder most specific to refugees and it is associated with circumstances involving political and social repression, war and armed conflict, as well as violence and torture, to which they are subjected in their countries of origin [12]. Although post-traumatic stress symptoms can be different in diverse cultures, there is abundant historical and transcultural evidence indicating that exposure to extreme traumatic experiences can activate extreme psychological stress [13]. When individuals suffer from a traumatic experience and do not have the capacity to integrate it by themselves with their cognitive and emotional schemes, a dissociation mechanism may appear as a defense strategy, allowing them to continue living with their previous mental schemes while wiping out the painful part of the experience from their consciousness [14]. This disassociation mechanism can be understood as "a memory phobia" that prevents integration of traumatic events and disassociates these memories from the consciousness [15]. The continued use of disassociation as a way of coping with stress interferes with memory and psychological functioning, hindering the integration of associated memories and causing an inability to provide a coherent narrative of events [16,17]. Furthermore, sharing these negative experiences can cause shame, guilt and a high degree of distress, which very significantly impacts self-image and sense of personal worth, leading to a tendency to avoid and repress these issues [18].

The most widely known consequence of exposure to traumatic events is PTSD. PTSD was officially categorized as a mental disorder in the 1980 edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM) [19]. An individual is diagnosed as suffering from PTSD when the symptoms caused by the trauma are severe and prolonged and interfere with their social and/or occupational functioning [20]. In the DSM-5 [21], PTSD is characterized by the presence of multiple symptoms that can be grouped into four clusters: (1) intrusive symptoms (for example, nightmares), (2) persistent avoidance of stimuli associated with the trauma, (3) negative alterations in cognition and mood associated with the traumatic event (for example, difficulty concentrating, guilt, etc.), and (4) alterations in arousal and reactivation associated with the traumatic event (for example, difficulty sleeping).

According to Weinstein, Khabbaz and Legate [22] "becoming a refugee is a powerful risk factor for indicators of psychological disorders such as stress, generalized stress and posttraumatic stress disorder (PTSD)". Between 10 and 40% of refugees suffer from mental disorders after having experienced grave traumatic events in their countries of origin [9]. At the same time, different studies [11,23] have determined that among refugees, the rate of PTSD is higher than any other mental disorder. In addition, this group is ten times more likely to experience PTSD than the general population [24]. In the same vein, the study by Priebe, Giacco, and El-Nagib [25] points to a higher prevalence of PTSD and depression among refugees compared with the general population. Furthermore, refugees that have been submitted to torture and/or rape have the highest rates of PTSD [26]. For example, in a research on refugees from North Korea, significantly higher rates of suicidal thoughts and alcohol consumption after experiencing rape were found in comparison with refugees who had not undergone such types of traumatic experiences [27].

#### *1.2. Gender Differences and PTSD: Traumatic Experiences in Refugee Women*

According to Tolin and Foa [28], women are twice as likely as men to meet the criteria for PTSD, despite the fact that men usually experience greater overall exposure to traumatic events throughout their lifetimes. For Griffin, Resick and Mechanic [29], the dissociative response seems to be more common in individuals who have suffered sexual aggression. Along these lines, Norris [30] points out the survivors of rape are more prone to manifesting PTSD than victims of car accidents, robbery, physical assault, combat, fire, events involving deaths, and natural disasters. As such, it can be said that rape is the event most strongly linked to PTSD [31,32].

Wolfe and Kimerling [33] observed that the high incidence of sexual assault among women and the extremely high rates of PTSD in survivors of sexual assault contribute to the idea that being female is a risk factor for PTSD. According to different studies [30,31,34], throughout their lives, women contend with sexual assault and rape to a greater degree than men do.  This gender difference in the risk of sexual victimization has clear implications for PTSD [35]. As such, in any study analyzing differences between men and women and PTSD, a significant role should be given to sexual-based trauma, since it is strongly linked to gender [35].

  For that reason, this population group presents a profile that is especially harmed and vulnerable and that often display symptoms of complex trauma [38]. However, studies focusing on the mental health status of refugee women are scarce [39]. This fact could be due to different reasons. First, upon interviewing extremely traumatized women, there is a serious risk that the questions may act to trigger traumatic content, which could be destabilizing, causing retraumatization and hindering recovery [40]. On the other hand, highly traumatized individuals can have difficulties concentrating long enough so as to complete extensive questionnaires [41]. At the same time, the language barrier can represent another obstacle to communicating with these individuals [42]. Additionally, women who have been the object of sexual assault might be rejected by their community and family and on many occasions, they are not able to make any sort of revelations in their interviews for asylum [43].

The aforementioned factors may be some of the reasons why few studies have examined specific violence in refugee women (suffered both in the fleeing phases in their countries of origin and in the experiences in the country of asylum where violence may persist) [45] and the effects it has on their mental health. The objective of this study is to present a systematic review that analyzes the relation between the impact of traumatic experiences in refugee women and developing PTSD. We consider this comprehensive review of the available research to date is original, innovative, and essential to understanding trauma in refugee women. Moreover, it is important for several reasons. Firstly, because of the need for attention that the refugee and asylum-seeking population have with respect to their mental health, which in most cases is affected by the experiences they have undergone. Secondly, it is essential to carry out this analysis from a gender perspective, determining the role that certain specific factors or traumatic events suffered by women, such as sexual violence understood in a broad sense, have on the deterioration of their psychological well-being and in the triggering of different disorders. Thirdly, so that the conclusions drawn from this study can be incorporated into resettlement or community integration programs for refugees, especially women, giving mental health a special relevance for the reconstruction of their lives.

#### **2. Method**

#### *Literature Search and Study Selection*

A systematic review of published studies on the incidence of PTSD in refugee women was made. This search was carried out through four research platforms: PsycInfo, Pubmed, Science Direct and Scopus, being limited to articles published between April 2005 and December 2020. In order to obtain a specific search, result from the terms "post-traumatic stress" and "female refugees" or "refugee women" were used. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for our study search and selection [46,47].

With the purpose of establishing uniform selection standards, the following inclusion criteria were applied: (a) publications of studies and clinical trials; (b) type of study: cohort studies or case-control studies; (c) language: Spanish or English; (d) population group: refugee women with a history of trauma; (e) diagnosis: PTSD by means of internationally accepted assessments instruments, including interviews that apply criteria from the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) or the International Classification for Diseases (CIE); (f) published during the period 2005–2020; (g) journals with a high impact factor indexed in the Journal Citation Reports (JCR).

In addition, the following exclusion criteria were established: (a) narrative accounts, qualitative systematic reviews, and case studies; (b) subjects without a past history of trauma or PTSD diagnosis; (c) studies that used non-standardized tests; (d) studies whose data duplicates another study or that are not original; (e) articles in a language other than Spanish or English; (f) studies prior to 2005; (g) journals not having a high impact factor or not JCR-indexed.

The database search generated 82 results, which were classified in the Mendeley Desktop program. Two additional studies were identified, after reviewing articles from the bibliographic references of the research studies chosen. A total of 21 duplicated articles were excluded, so 63 articles were revised by title and abstract. Of these, 51 were excluded for not meeting the inclusion criteria, obtaining 12 articles that were read in their entirety and which were all chosen to be included in the results of our review. The search strategy results are summarized in Figure 1.

Unfortunately, a meta-analysis was not feasible given the diversity of the methodology used in the studies and the different co-variables dealt with in each one of them [48]. Accordingly, a narrative analysis was used, which enabled us to improve our understanding of PTSD in refugee women and help us to identify issues of importance to take into account in future paths for socio-healthcare intervention in this group.

**Figure 1.** Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram of each stage of the study selection. **Figure 1.** Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram of each stage of the study selection.

#### **3. Results 3. Results**

**ID-Article**

1.

2.

**Authors and**

Robertson C.L., Halcon L., Savik K., Johnson D., (2006) [49]

Reedwood-Campbell L., Thind H.,

A critical reading was performed and a synthesis made of the 12 selected articles. These articles provided original data on PTSD in refugee women. Table 1 shows the main results of the studies considered. A critical reading was performed and a synthesis made of the 12 selected articles. These articles provided original data on PTSD in refugee women. Table 1 shows the main results of the studies considered.

**Table 1.** Main results and characteristics of selected studies. **Year Sample Origin of Study Assessment Objective Instruments Results**  N = 458 (M = 200; F = 258) Somalia and South Central Ethiopia PTSD (Trauma and Torture) PCL-C High levels of PTSD symptoms were found in women with many children. In general, the chosen studies include participants from different countries, especially those who are in a situation of displacement (highlighting the Democratic Republic of the Congo and Somalia). The studies were carried out among adolescents and adults in different countries: The United States of America (1, 3), Canada (2), the Democratic Republic of the Congo (4, 5), the Republic of Uganda (6, 7), Germany (8, 11), Turkey (9), Australia (10), and the Republic of South Africa (12). Participants included both refugees and asylum seekers. The age of participants ranged between 13 and 85. The research was of a transversal nature, with the exception of study 3, for which a longitudinal follow-up took place at three and a half years of resettlement.

N = 85 F Kosovo PTSD HTQ A fourth of the population scored high

in PTSD.

**Table 1.** *Cont.*

All of the studies evaluated PTSD, except number 11, which based its research on factors associated with the history of trauma measured by a questionnaire designed by psychologists and psychiatrists. In addition, some of the studies assessed dissociative symptoms (5, 8), sexual violence (4), sexual and/or physical violence (7), the impact of gender on traumatic experiences (10) and trauma and torture (1).  PTSD and Other Mental Health Problems in Refugee Women*

Of the twelve selected articles, five of them based their sample solely on female refugees (2, 5, 7, 8, and 11) and four specifically reported data regarding the prevalence of PTSD in this population group. Three of them showed similar and significant results in relation to the presence of PTSD symptoms in refugee women, with the percentage ranging from 66% to 71% [50,55,56], only 25.9% of the women had a score that indicated the presence of PTSD. At the same time, study 11 [42] was the only one that did not assess PTSD itself, but rather psychological symptoms through scores given by healthcare professionals. The most noteworthy symptoms related to trauma were nightmares, followed by insomnia and depression. The subjects also suffered from somatic ailments such as aches and pains, dizziness, and gastrointestinal issues.

In different studies (4, 5, 7 and 8) PTSD in refugee women was linked with other mental health problems, such as dissociative symptoms and depression. In Study 5, disassociation was pointed out as a predictor of PTSD severity in women with traumatic experiences, since the female participants that suffered from greater disassociation had a higher PTSD score. At the same time, study 8 [56] revealed that women patients with a higher degree of PTSD displayed greater disassociation and this correlated with symptoms of depression. Specifically, in this study, it was shown that the severity of PTSD in refugee women was linked to disassociation and severity of depression, being very closely interrelated. Other research studies also pointed to the relationship between depression and PTSD. For example, in study 5 [53] and study 7 [55] there was a high prevalence of depression (almost 95%), and in study 4 [52] it was observed that 40.5% of the sample met the criteria of having a major depressive disorder.

Study 1 [49] carried out a comparative analysis among three groups of women: women without children, women who had between one and six children and women with more than six children. It was found that the female refugees who were mothers with more than six children had undergone a higher number of torture and traumatic events, for which they had much more significant scores in PTSD than women who had fewer than six children or none. They also had higher rates of illiteracy, limited knowledge of spoken English, were caring for the children on their own, and were less likely to be working. At

the same time, almost half of the women reported taking medication to calm themselves down, and nearly one in ten reported having seen a physician for their health problems. The majority used prayer to combat stress. The accounts involving greater exposure to trauma were highly correlated with more social, psychological and physical problems, and higher PTSD scores. Furthermore, 89% of women with large families reported having had to do things in order to survive that still bothered them, and almost two thirds (64%) of these women stated that they had been exposed to various types of torture, including rape.

#### *3.2. Differences in PTSD between Male and Female Refugees*

Seven of the studies carried out a differential analysis of the presence of PTSD symptoms among male and female refugees (1, 3, 4, 6, 9, 10, and 12). Similar results were obtained in all of them. In general, the women were more exposed to traumatic events and scored higher in psychological problems, including PTSD, than men. For example, study 6 [54] found that 75% of female refugees had PTSD compared with 25% of the men. Furthermore, women obtained higher scores than men in intrusive symptoms, evasion symptoms, hyper-activation symptoms and overall PTSD severity. Along these same lines are the results of study 9 [57], which pointed out that the likelihood of having PTSD is much higher in women than in men. On the other hand, studies 1 [49], 4 [52] and 10 [58] showed that, even although there were no differences in the presence of PTSD among men and women, the scores for the latter were higher. These higher scores in women for PTSD also seem to become exacerbated over time. According to study 3 [51], the scores for PTSD severity were higher in women than in men at the three moments of assessment (baseline, after one year, and after three and a half years) but the differences were only statistically significant at the three-and-a-half-year follow-up.

At the same time, with regard to traumatic events, study 5 [53] analyzed the differences between a traumatic event experienced firsthand and one that was witnessed. The traumatic self-experienced event referred to whether the participant had been the victim of a traumatic event and witnessed ones, to whether the participant was the witness who observed the traumatic event involving another person. The results indicated that the number of traumatic self-experienced events significantly predicted the severity of PTSD. Furthermore, study 6 [54] revealed that the experienced traumatic load made up the most significant contributing factor to PTSD and that it was higher in refugee women.

Study 10 [58], on the other hand, assessed the effect of two types of trauma: interpersonal and non-interpersonal. The first type is conceived as a traumatic event that is perpetrated by another person with the intention of harming or threatening an individual; for example, rape or sexual abuse, torture, brainwashing, imprisonment, witnessing the murder of family members or friends, etc. Non-interpersonal trauma is not based on a relationship with others, and encompasses, for example, lack of food or water, being in poor health without access to medical care, lack of shelter, forced isolation, etc. The results of this study showed that in female refugees a link could be observed between PTSD symptoms and six of the eight traumatic interpersonal events: imprisonment, serious injuries, combat situations, brainwashing, rape or sexual abuse, and torture. On the contrary, for men, none of the subtypes of interpersonal trauma produced a significant effect in relation to PTSD symptoms. Three of the eight subtypes of non-interpersonal trauma did have an effect, however: lack of food or water, being near death and in poor health without access to medical care. In the case of women, none of the subtypes of non-interpersonal trauma produced significant effects in relation to PTSD symptoms.

#### *3.3. Traumatic Experiences in Refugee Women: The Importance of Rape and Sexual Abuse*

The importance of violence and sexual abuse in refugee women in relation to the presence of PTSD symptoms is reflected in six studies (4, 5, 6, 7, 10, and 12).  For example, in study 4 [52], the rate of sexual violence reported by women was 39.7%

compared to 23.6% in men, which significantly increased the presence of PTSD. In addition, according to study 5 [53], the firsthand traumatic event most often experienced among refugees is sexual assault (96.2% for this case). In study 7 [55], it was found that 87.2% of those surveyed reported having been subjected to some type of physical or sexual violence during their lives, of which 84.6% reported physical violence and 71.8% sexual violence.

In study 6 [54], significant correlations were found between sexual assault and other types of violence by a family member or an acquaintance and PTSD. Furthermore, a relation was established between having had sexual contact before the age of 18 with an individual five or more years older and PTSD, with PTSD significantly higher in women than in men.  PTSD over Time*

In the longitudinal study 3 [51], rates of PTSD were assessed in male as well as female refugees at three different moments: baseline, after one year and after three and a half years. At the beginning of the assessment, 76% met the diagnostic criteria of PTSD, 33% did so at one year, and at three and a half years, 24% of the subjects did. An inverse correlation was found between the global assessment of functioning (GAF) scores and PTSD severity scores. Although the severity of the PTSD symptoms diminished with time, the majority of the refugees continued having at least one or more symptoms related to traumas after three and a half years. In addition, the refugee women who did not speak the language of the host country seemed to be more vulnerable to the persistence of effects stemming from the trauma.

#### **4. Discussion**

Upon reviewing the existing literature to determine the relation between refugee women and PTSD, twelve studies dealing with this subject were identified. In these studies, important evidence was found for a high prevalence of PTSD in refugee women [55,56]. Furthermore, the presence of PTSD and its severity seems to be linked to other mental health problems, such as dissociative symptoms [56] and depression [52,53,55].

With respect to the differences between men and women, the majority of the studies pointed out that the incidence of PTSD is significantly higher in women than in men [54,57] Other studies reported that although there are no differences between the presence of PTSD in men and women, there are in fact differences with respect to its severity, as it is higher among the latter [49,52,58]. In addition, according to the study by Vojvoda et al. [51], these differences become sharper with time, finding a greater degree of severity in refugee women than in men three and half years after resettlement.

Likewise, women are more vulnerable to displaying PTSD symptoms from interpersonal-type traumatic experiences (for example, sexual abuse or torture), while men are more prone to suffering PTSD as a result of traumatic experiences of a noninterpersonal type (such as lack of food or lack of water) [58]. Additionally, refugees could suffer from PTSD if the violence incurred is carried out by a family member or an acquaintance, and in this sense, women experience it to a greater degree than men do [54]. At the same time, according to the study by Schalinski et al. [53], the severity of PTSD is determined depending on whether the traumatic event of the refugees is self-experienced or if, on the contrary, it is witnessed, with firsthand experience resulting in a greater degree of severity. For the authors, women are more likely to live through a traumatic experience firsthand than are men, for which the severity of PTSD is greater.

After a review of the different studies, it seems clear that the higher predominance and severity of PTSD in refugee women is related to gender-based traumatic experiences, such as rape, sexual assault and abuse, or genital mutilation, among others [52–55,58,59]. As stated by the World Health Organization (WHO), situations of conflict and displacement can exacerbate gender violence already existing in families and communities and bring about new forms of violence (for example, sexual slavery) against women and girls [60]. In this sense, the meta-analysis carried out by Tolin and Foa [28] on gender differences and the risk of suffering traumatic experiences and having PTSD, had observed that women are more likely than men to meet the criteria of PTSD, in spite of having a lower overall likelihood of having a traumatic experience. As such, in accordance with this review, men are more likely than women to experiences accidents, non-sexual assault, combat or war, fire or natural disaster, serious illness or non-specific injury.  Furthermore, according to the study by Schalinski et al. [53], the most common traumatic event experienced firsthand in refugees is sexual assault.

The results obtained from this review of the different studies are in line with the theory of situational vulnerability to trauma with respect to the symptoms of PTSD formulated by Pimlott-Kubiak and Cortina [34]. According to this theory, being a woman raises the risk of sexual victimization throughout an individual's lifetime and this victimization increases the risk of suffering from PTSD [35]. Thus, the source of the main risk resides not in the female gender itself, but in the adjacent situation. For Pimlott-Kubiak and Cortina [34], female vulnerability to PTSD is simply a product of exposure to gender-based trauma and not to any attributes that women have.

In today's world, the relation between gender-based traumatic experiences, the psychological difficulties of refugee women and possible intervention programs are an emerging topic of interest [61] and they are not reliable [62]. In fact, according to the UNHCR [63], sexual violence among female refugees is often unknown, due to different factors. On one hand, this is due to the social stigma and shame associated with rape that weighs upon the women, and on the other, due to fear of possible reprisals (rejection, blame, isolation, criminalization, increased gender inequality and punishment by other forms of violence, among others). Furthermore, as pointed out by Robbers and Morgan [61], it is likely that refugee women who are victims of sexual violence do not know how to act or where to go, are terrorized by their family members, and mistrust official procedures and authorities, since they might be immersed a circle of systematic violence. This leads to survivors often avoiding communication of their traumatic experiences, which makes us suppose that data on the presence of PTSD is not entirely accurate. This results in possible erroneous interpretations and unawareness of the psycho-socio healthcare needs of this population group [64]. This review sheds light on the relation between posttraumatic stress disorder and refugee women, especially if they have suffered a traumatic experience linked to sexual violence in any of its manifestations, which we hope will serve as a starting point for future work.

#### *Limitations and Future Research Lines*

The main obstacle encountered in this study is the scant literature and lack of research on PTSD and the mental health of refugee women. This represented a challenge in gathering the most information possible, while also highlighting the need to analyze results found until now, aimed at gathering coherent data to promote research, create awareness among the general population, and promote social and healthcare actions in this group with their pronounced need for multidisciplinary care and intervention, particularly with respect to sexual violence. In this sense, the review undertaken by Robbers and Morgan [61] points out that sexual violence against refugee women is a complex public health concern, which requires a multicomponent solution and cultural sensitivity.

On the other hand, as observed in the study by Redwood-Campbell et al. [50], in which slightly more than one-fourth of the refugee women obtained a score indicating the presence of PTSD, these women can unconsciously block or feel uncomfortable about revealing intimate and painful experiences of sexual nature, due to religious and cultural issues, or they may be facing other barriers such as language or illiteracy. Due to these

factors, the results of this study and other similar ones must be approached with caution, taking into account the numerous interferences that could arise in making a diagnosis of the mental health problems in refugees, particularly in women. In this sense, some of the studies included in this review [42,56] found numerous somatic ailments in women with histories of trauma. For socio-healthcare professionals, it is very important to take into account this expression of PTSD, because, in many instances, physical pain is more obvious and easier to detect than psychological issues. As various authors have pointed out [65–68], trauma, especially when it involves the body, stays in the body, and although possible associated emotions tend to be avoided, the body responds to the pain of the unconscious memory through somatization. For this reason, it is essential that the sociohealthcare teams who attend to this population group be aware of the involvement of PTSD or traumatic experiences in a patient's physical symptoms and ailments, with the aim of ensuring effective treatment.

It would also be favorable to target the research to better assess symptoms of disassociation in refugee women, since it is a reaction to trauma that cannot be concealed. Work by Schalinski et al. [53] revealed that the self-experienced traumatic event most frequently reported is sexual assault, which was related with higher scores for PTSD severity that at the same time was diagnosed by disassociation, and for which it could be concluded that the disassociated response seems most common in individuals who have been sexually assaulted [29]. This finding invites us to direct possible future research lines to examine the presence of dissociative symptoms in refugee women, aimed at studying its relation to traumatic experiences of a sexual nature.

#### **5. Conclusions**

As a final conclusion, we would like to underline that mental health disorders are to a large extent determined by social and cultural factors and they must be taken into consideration for their analysis and intervention in refugees. In this sense, with respect to the differences between men and women, as established by the WHO [60] (p. 3), "gender determines the power differential and control that men and woman have over socioeconomic determinants in their lives and their mental health, their position, social condition, the way that they are treated in society and their susceptibility and exposure to specific risks to their mental health". Accordingly, to understand the impact of traumatic experiences on mental health and deterioration of psychological wellbeing in refugee women, analysis from the perspective of gender is necessary, with attention paid to power relations between men and women, focusing on the significant emotional impact for women that these relations can entail, linked to having experienced traumatic events of sexual violence.

In a similar vein, this gender analysis has implications for intervention strategies aimed at survivors. Gender violence and sexual abuse must be a vital component in treatment programs and social reconstruction for refugees, particularly women. Thus, prevention and the response to sexual violence must include the active participation of refugee women in the design as well as in the implementation of prevention measures [61]. Prevention programs must hence be focused on increasing their empowerment, training and education in order to reduce sexual violence [69,70], involve the entire community [71] and transform gender norms, reinforcing community responsibility [72].

**Author Contributions:** Conceptualization, M.V.-M. and A.S.S.; methodology, M.V.-M. and A.S.S.; writing—original draft preparation, M.V.-M. and A.S.S.; writing—review and editing, M.V.-M.; supervision, J.M.C.; funding acquisition, J.M.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research has been funded by the University of Malaga research project "The role of stereotypes in intergroup relationships in the multicultural context of the province of Malaga" (Reference Number 18-B3-02).

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Conflicts of Interest:** The authors declare that there are no potential conflicts of interest with respect to the research, authorship and/or publication of the article.

#### **References**

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