International Journal of Gynecology and Obstetrics 113 (2011) 58–62

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International Journal of Gynecology and Obstetrics

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

Posttraumatic stress disorder, depression, and hopelessness in women who

are victims of sexual violence
Carolina L. Machado a, Renata C.S. de Azevedo b, Claudia O. Facuri b,
Maria-José N. Vieira a, Arlete-Maria S. Fernandes a,⁎
a
Gynecological Division, Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
b
Department of Medical Psychology and Psychiatry, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To evaluate posttraumatic stress disorder (PTSD), depression, and hopelessness in women 1 and
Received 1 August 2010 6 months after they experienced sexual violence. Methods: This prospective study, in which the clinician-
Received in revised form 20 October 2010 administered PTSD scale, the Beck depression inventory, and the Beck hopelessness scale were used, included
Accepted 15 December 2010 67 women at 1 month and 52 women at 6 months after they experienced sexual violence. Results: Overall,
77.6% of the women were ≤24 years of age, and 52% were adolescents; 15% had a history of drug abuse, and
Keywords:
13.5% had a history of previous sexual violence. The aggressor was unknown in 76% of cases, and there was
Clinician-administered posttraumatic
stress disorder scale
more than 1 aggressor in 9% of cases. In the first month, 43% of the women had moderate or very severe PTSD;
Depression 52.2% had moderate or severe depression; and 22.4% had moderate or severe hopelessness, which decreased
Hopelessness to 21%, 20% and 10%, respectively, at 6 months. In the first month, severity of PTSD was associated with
Posttraumatic stress disorder moderate or severe depression, and at 6 months severity of PTSD was associated with multiple aggressors and
Sexual violence previous psychiatric disorders. All scores decreased in the sixth month. Conclusion: Severe mental health
disorders were still present 6 months after women had experienced sexual violence.
© 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction The Gynecological Division of the University of Campinas is a

referral center for women who are victims of urban sexual violence,
Posttraumatic stress disorder (PTSD) is a syndrome with charac- which covers a catchment area of 20 cities within the state of São
teristic symptoms that result from exposure to extreme trauma; Paulo, southeast Brazil, with a population of almost 2.5 million
symptoms include persistent re-experiencing of the traumatic event, inhabitants. The service is focused on emergency care within the
avoidance of situations associated with the trauma, numbing of gen- first 72 hours after the incidence of sexual violence at which time
eral responsiveness, and symptoms of increased arousal; symptoms a protocol is implemented that includes prophylaxis for sexually
must have been present for at least a month [1]. PTSD is the most transmitted diseases and emergency contraception. Women are
common complication of sexual violence; the reason for its higher referred for outpatient follow-up by 6 months in which a multidis-
prevalence among women is unknown [2–4]. Female victims of sexual ciplinary approach is used with psychiatric assessment, and psycho-
violence usually have an intense fear of a new episode of sexual logical, medical, and social care.
violence, nightmares, insomnia, difficulty in being alone, decreased The aims of this study were to evaluate PTSD scores, depression
interest in usual activities, feelings of strangeness, and recurrent and scores, and symptoms of hopelessness in a population of women in the
intrusive recollections. first and sixth months after an incidence of sexual violence and to
The observation that some psychiatric disorders triggered by identify the variables that are associated with more severe cases of PTSD.
trauma are more likely to occur in patients with PTSD [5] suggests that
diagnosis of PTSD may identify a subgroup of patients who are 2. Materials and methods
considered to be at risk of major depression, anxiety disorder, and
drug abuse [4–7] and may be a strong predictor of suicidal ideation The study was conducted at the Gynecological Division of the
measured by the presence of intense feelings of hopelessness about Department of Obstetrics and Gynecology, School of Medical Sciences,
life and future plans [8]. University of Campinas (UNICAMP), Campinas, Brazil. The project was
approved by the Institutional Review Board of the university.
The sample size was based on a prospective study in which scales
⁎ Corresponding author. Caixa Postal 6181, 13084-971, Campinas, SP, Brazil.
were used to assess PTSD in women who experienced sexual violence
Tel.: + 55 19328 92856; fax: + 55 19328 92440. [9] and was calculated at 52 women. The significance level was
E-mail address: arlete@fcm.unicamp.br (A.-M.S. Fernandes). defined as 5%, and the power of the test was 80% [10]. Women who

0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2010.10.016
 C.L. Machado et al. / International Journal of Gynecology and Obstetrics 113 (2011) 58–62 59

attended the hospital between October 2008 and April 2009 were Table 1
invited to participate and were enrolled in the study after they had Characteristics of participants according to classification of posttraumatic stress
disorder in the first month after the incidence of sexual violence.a
signed an informed consent form. Women with cognitive difficulties
who were unable to answer the evaluation questions were excluded Characteristics Posttraumatic stress disorderb
from the study. Absent/mild Moderate/very severe
Scales were used to evaluate PTSD, depression, and hopelessness, (n = 38) (n = 29)
and 2 structured interviews were conducted during the first and Age, y
the sixth month evaluation by the same psychologist. Data on b14 4 (10.5) 2 (6.9)
sociodemographic variables [11], the woman's gynecological history, 14–19 18 (47.4) 11 (37.9)
illicit drug use, psychiatric history, and use of medication were 20–24 9 (23.7) 8 (27.6)
N24 7 (18.4) 8 (27.6)
recorded. The variables that typified the violence were: aggressor was Schooling, y
known or not, the number of aggressors, whether the woman was b8 17 (44.7) 7 (24.1)
conscious and whether her life was threatened during the violence. ≥8 21 (55.3) 22 (75.9)
The woman's attitudes after the event measured by disclosure of Marital status
Living with partner 6 (15.8) 6 (20.7)
violence (telling someone about the violence), support received,
Not living with partner 14 (36.8) 9 (31.0)
resumption of routine activities, and their perceptions regarding their No partner 18 (47.4) 14 (48.3)
recovery were noted. Sexual activity
The Beck depression inventory (BDI) [12], which consists of 21 Sexual activity not yet initiated 11 (28.9) 7 (24.1)
items that evaluate symptoms and attitudes, was completed for each Initiated before aggression 27 (71.1) 22 (75.9)
Psychiatric history
woman. The intensity measurements range from 0 to 3, and the total Yes 4 (10.5) 8 (27.6)
score was used to classify depression as: severe (36–63), moderate No 34 (89.5) 21 (72.4)
(20–35), mild (12–19), minimal (b11), or absent (0). The Beck hope- Known aggressor
lessness scale (BHS) [13] for screening for suicide risk, which is based No 27 (71.1) 24 (82.8)
Number of aggressors
on the symptoms of hopelessness, and has been used in adolescents
1 36 (94.8) 24 (82.8)
[14,15], was used to classify the symptoms of hopelessness as: severe N1 1 (2.6) 5 (17.2)
(14–20), moderate (9–13), mild (5–8), minimal (b4), or absent (0). Unknown 1 (2.6) –
The clinician-administered posttraumatic stress disorder scale Conscious during the aggression
(CAPS) [16], which is composed of 30 items that measure the Yes 23 (60.5) 20 (69.0)
Depression
frequency and intensity of PTSD symptoms, was completed for each
Minimal/mild 28 (73.7) 4 (13.8)
woman. More restrictive criteria (frequency of symptoms N1 and Moderate/severe 10 (26.3) 25 (86.2)
intensity ≥2) were used to score PTSD [17]. The total score was Hopelessness
used to classify PTSD as: very severe (N80), severe (60–79), moderate Absent 4 (10.5) –
Minimal/mild 31 (81.6) 17 (58.6)
(40–59), mild (20–39) or absent (b20).
Moderate/severe 3 (7.9) 12 (41.4)
Bivariate analysis was performed, and crude odds ratios were
a
calculated with a 95% confidence interval. Next, multiple logistic Values are given as number (percentage).
b
Clinician-administered posttraumatic stress disorder scale (CAPS), diagnostic
regression with stepwise selection criteria was used to determine the criteria: frequency N1 and intensity ≥2; classification: very severe (N 80), severe
multiple odds ratio for the variables of PTSD in the first month (60–79), moderate (40–59), mild (20–39), and absent (b 20).
(absent/mild or moderate/very severe), PTSD in the sixth month
(present/absent), and discontinuation of outpatient follow-up after
the first month evaluation (yes/no). All the variables evaluated were 64% (data not shown); and multiple aggressors were involved in 9% of
taken into consideration in the analysis. The paired t test was used to cases (Table 1).
compare the BDI and BHS scores obtained at the two evaluation Of the 67 women evaluated in the first month, 64% were diagnosed
points, and the Wilcoxon test was used to compare CAPS scores. with PTSD, which was moderate in 30%, severe in 10%, and very severe
Fisher's exact test [10] was used to compare the perceptions and in 3%. Of the women with moderate to very severe PTSD, 28% had a
attitudes women who had PTSD with those that did not have PTSD. history of psychiatric disease, 86% had moderate or severe depression,
and 41% had moderate to severe symptoms of hopelessness (Table 1).
Fifteen women (22%) failed to return after the first month; 31% of
3. Results these women had moderate to very severe PTSD (data not shown).
Of the 52 women evaluated in the sixth month, 18 women (34.6%)
Sixty-seven women aged 12 to 49 years were admitted to the had diagnosis, alone or in association, of PTSD, moderate/severe
study. Table 1 shows the distribution of variables according to the depression, and symptoms of moderate/severe hopelessness; 6 of
severity of PTSD at the first month after the incidence of sexual the women had prior psychiatric disease: 3 women had depression,
violence. Most of the women were ≤24 years of age; slightly more 2 women had anxiety disorders, and 1 woman had attempted suicide
than half of the women were adolescents; and 64% had attended before the assault (data not shown). Eleven women (21.2%) had
school for at least 8 years. The majority of the women did not have or symptoms of PTSD (9 mild, 1 moderate, and 1 severe PTSD); 19.2% of
did not live with a partner, and 73% of the women had already the women still had moderate to severe depression, and 63.5% had
initiated sexual activity at the time of the event (Table 1). Most of the minimal or mild depression; 9.6% of the women had symptoms of
women (85%) belonged to the less privileged socioeconomic classes moderate or severe hopelessness, and 73% had minimal or mild
(data not shown). hopelessness. Overall, 22% of women had no symptoms of depression
In total, 15% of the women reported previous substance abuse or hopelessness (Table 2).
(10.4% marijuana, cocaine and/or heroin, and 4.5% cigarettes and/or There was an improvement in the scores of depression (BDI),
alcohol); 13% of the women reported that they had used psychiatric hopelessness (BHS), and PTSD (CAPS) between the first and the sixth
drugs, and 13.5% reported that they had experienced sexual violence months of the study (Fig. 1). Of the 52 women who continued in the
before 19 years of age; half of these incidences had occurred before study for 6 months after the incidence of sexual violence, 50% were
they were 14 years of age (data not shown). The aggressor was in paid employment and 59.6% were studying in high school. A
unknown in 76% of cases; the woman's life had been threatened in comparison was made between the women with and without PTSD at
60 C.L. Machado et al. / International Journal of Gynecology and Obstetrics 113 (2011) 58–62

Table 2 the sixth month after the incidence of sexual violence in relation to
Perceptions and attitudes of participants according to the presence of posttraumatic the women's perceptions and attitudes (Table 2). In total, slightly
stress disorder in the sixth month after the incidence of sexual violence.a
more than half of the women considered that they had overcome the
Perceptions and attitudes Posttraumatic stress P valuec event, and 58% of the women classified the event as belonging to the
disorderb past. Women with PTSD had more negative perceptions with respect
Absent Present to having overcome the aggression and to the presence of the event in
(n = 41) (n = 11) their lives. Overall, 42% of the women perceived that their health was
Considers the event overcome b0.0001 very good/good, whereas 40% perceived it as average; however, 45%
Yes 28 (68.3) 1 (9.1) of the women with PTSD evaluated their health as bad/very bad.
No 13 (31.7) 10 (90.9) Moderate and severe depression was more prevalent in the women
How would she classify the event 0.04
Belongs to the past 27 (65.9) 3 (27.3)
with PTSD.
Belongs to the present 11 (26.8) 6 (54.5) There was no difference between the groups of women with and
Will be present for a long time 3 (7.3) 2 (18.2) without PTSD in the evaluation of the factors that had helped in their
Helped in recovery 0.31 recovery; 48% of the women referred to the support provided by their
Support of family/a specific person 18 (43.9) 7 (63.6)
family or by a specific person; 17% referred to medical care, and 11.5%
Medical follow-up 6 (14.6) 3 (27.3)
Psychotherapy 6 (14.6) 0 (0.0) to psychotherapy (Table 2). With respect to factors that may have
Religion 4 (9.8) 1 (9.1) been lacking in their recovery, 17% of the women referred to a lack of
Other 7 (17.1) 0 (0.0) support from their family or from a specific person; 7.7% of the
What was missing for recovery 0.13 women referred to a lack of medical follow-up, and less than 6%
Support of family/a specific person 8 (19.5) 1 (9.1)
Medical follow-up 3 (7.3) 1 (9.1)
referred to a lack of psychotherapy and medication. Most of the
Psychotherapy 0 (0.0) 2 (18.2) women reported that nothing had been lacking in their recovery. Of
Medication 1 (2.4) 0 (0.0) the 38 women who had an active sexual life at the time of the event,
Nothing was missing 29 (70.7) 7 (63.6) 23% had resumed sexual activity with their partners by the time of the
Sexual activity 0.31
sixth month evaluation.
Not recommenced 21 (51.2) 5 (45.5)
Recommenced 11 (26.8) 1 (9.1) After multiple logistic regression, moderate/severe PTSD in the first
Never had sexual activity 9 (22.0) 5 (45.5) month was associated with moderate/severe depression (OR = 19.6;
Currently employed N0.999 95% CI, 5.3–71.8), whereas PTSD in the sixth month was associated
Yes 22 (53.7) 4 (36.4) with more than 1 aggressor (OR = 14.5; 95% CI, 1.3–166.7) and a
Currently studying 0.50
history of psychiatric disease (OR = 5.5; 95% CI, 1.2–25.6) (Table 3).
Yes 23 (56.1) 8 (72.7)
Current health 0.02
Very good 10 (24.4) 0 (0.0)
Good 8 (19.5) 4 (36.4) 4. Discussion
Average 19 (46.3) 2 (18.2)
Bad/very bad 4 (9.8) 5 (45.5) The study population was predominantly young; half of the
Depression 0.02 women were still adolescents, and from the less privileged socioeco-
Absent 9 (22.0) –
Minimal/mild 27 (65.9) 6 (54.5)
nomic classes. These are characteristics of the general population that
Moderate/severe 5 (12.2) 5 (45.5) is most exposed to urban violence, because they live in the suburbs
Hopelessness 0.15 where public safety is precarious and they use public transport to
Absent 9 (22.0) – commute between work/school and their homes. Because this hospital
Minimal/mild 29 (70.7) 9 (81.8)
is a regional referral center, more affluent women are also attended
Moderate/severe 3 (7.3) 2 (18.2)
here; however, after receiving prophylactic treatment, these women
a
Values are given as number (percentage).
b
tend to decide to continue their medical and psychotherapeutic care at
Clinician-administered posttraumatic stress disorder scale (CAPS), criteria:
frequency N1 and intensity ≥2. Classification: very severe (N80), severe (60–79),
other healthcare services, either private institutions or those managed
moderate (40–59), mild (20–39), and absent (b20). by medical insurance companies. Therefore, the present results refer to
c
Fisher's exact test: significance level, P b 0.05. women from the less privileged socioeconomic classes.

Fig. 1. Boxplot comparison of the Beck depression inventory (BDI) a, Beck hopelessness scale (BHS) a, and the clinician-administered posttraumatic stress disorder scale (CAPS) b
scales (T0, first month; T6, sixth month). Fifty-two women were evaluated. Each box is within the 25th and 75th percentiles; the solid line in the middle of each box indicates the
median, and the whiskers represent the minimum/maximum value measured. a Paired t test; b Wilcoxon signed rank test.
 C.L. Machado et al. / International Journal of Gynecology and Obstetrics 113 (2011) 58–62 61

Table 3 frequency of severe depression in this group. We believe that the

Variables associated with the presence of posttraumatic stress disorder after multiple more restricted scoring system used for diagnosis confirmed that this
logistic regression.
manner of applying the scales permits identification of the women
Associated variables OR (95% CI) P valuea who need more prolonged mental health treatment.
Evaluation in the first monthb In the study sample, the majority of women told someone about
Moderate to very severe PTSD the violence they had experienced (data not shown), and few women
Moderate/severe depression 19.6 (5.3–71.8) b0.01 reported lack of support from the family or from a specific person after
Lost to follow-up
the event. These 2 factors are known to be positive markers in the
No associated variable
Evaluation in the sixth monthc recovery process of victims of violence [21,22]. However, these may
Diagnosis of PTSD be the very factors that contributed towards encouraging women to
No. of aggressors N 1 14.5 (1.3–166.7) b0.01 seek institutional support after the event, because it is possible that
History of psychiatric disorder 5.5 (1.2–25.6) b0.01 for the majority of the women who experience sexual violence and fail
Abbreviations: OR, odds ratio; CI, confidence intervals; PTSD posttraumatic stress disorder. to attend the service, this support may not have been present.
a
Sixty-seven women evaluated. It is estimated that fewer than 20% of cases of sexual violence are
b
Fifty-two women who completed the 6 months of follow-up were evaluated.
c reported to the authorities [23,24]. Although urban sexual violence is
Multiple logistic regression with stepwise selection criteria. Variables studied: age,
schooling, family income, marital status, initiation of sexual activity, pregnancies, living more often reported and institutional support sought, the percentage
children, previous sexual violence, age at previous violence, use of drugs, psychiatric of women who attend emergency services is still small. The possible
problems, use of psychiatric medication, known aggressor, number of aggressors, complications expected for very young victims of sexual abuse
conscious during aggression, threat of death by aggressor, reported aggression, social emphasize the importance of multidisciplinary care after this type
support, recommencement of sexual activity, employment/study status, self-evaluation
of general health, depression score, and hopelessness score.
of violence and the fact that victims should be encouraged by the
community, the media, and institutions to seek treatment.
The principal limitation of this study was the short duration of the
follow-up period, in which the women's sentiments were measured
The present study found that 21% of the women evaluated still had using assessment scales, with no qualitative component. It cannot
symptoms of PTSD and 3.8% had moderate or severe PTSD at 6 months be stated that the improvement in the scores was due to the
after the event, which suggests that recovery takes much longer for multidisciplinary follow-up, although this probably contributed
some women and that other women may be expected to recover over towards the recovery of the majority of the women. Nevertheless, at
a longer period of time and with further treatment. The highest PTSD the end of the 6-month follow-up period, the prevalence of severe
scores were associated with moderate and severe depression in the mental health conditions was high: PTSD was diagnosed in 21% of the
first month, which is expected because the aggression was recent; this women, and moderate to severe depression was diagnosed in 20%,
result is compatible with the findings of previous studies [3,7,9]. whereas scores N9 for symptoms of hopelessness were found in 10%
The association of PTSD in the sixth month after the incidence of of the women. These results should be used to define follow-up
sexual violence with violence perpetrated by multiple aggressors and measures that extend beyond 6 months and to implement new
a history of psychiatric disease was also to be expected. The severity of interventions for women who experience sexual violence.
the violence is a factor that should be considered a risk factor in the
immediate aftermath of the event [3]. Individual vulnerability to Conflict of interest
trauma is a characteristic that will require multidisciplinary support
and more time for recovery. The authors have no conflicts of interest.
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