Women,Catastrophe and Mental Health

Abstract

This paper examines the concept of catastrophic experience, its relationship to the range of acute and prolonged stressors to which women may be exposed and the broad impacts on their mental health and well-being. It identifies catastrophe in terms of multiple accumulated stresses including death, loss, victimization, demoralization, shame, stigmatization, helplessness and identity. Catastrophic experiences include personal violence in domestic circumstances of intimate partner abuse, sexual assault and child physical and sexual abuse. Women's experiences of loss through the violent deaths of children and loved ones may also have such enduring impacts. Terrorism victimizes men and women in this way, with the enduring impacts for women in terms of threat of ongoing attacks as well as acute effects and their aftermath. The catastrophes of war, conflict, genocide, sexual exploitation and refugee status differentially affect large numbers of women, directly and through their concerns for the care of their children and loved ones. Ultimate catastrophes such as Hiroshima and the Holocaust are discussed but with recognition of the very large numbers of women currently experiencing catastrophe in ongoing ways that may be silent and unrecognized. This is significant for clinical care and population impacts, and in the losses for women across such contexts.

Meaning of catastrophe

Catastrophe is experienced at a personal level: the death of a child, a partner, a loved one; the experience of devastating injury or illness; horrendous life-threatening circumstances, for instance, the ongoing, unremitting experience of violence as in domestic circumstances or in times of war. The word ‘catastrophe’ implies a disaster or incident that is intense, powerful and damaging, adverse and extreme. Mass catastrophe is also experienced at a personal level, but with impacts affecting population masses, as in the case of major natural disasters such as the South-East Asian tsunami, Hurricane Katrina and many other mass events. There are the huge levels of damage and destruction that occur with man-made disasters, incidents such as the 1984 Bhopal chemical disaster in India. There are also impacts from terrorism, wars violent conflicts, which lead to mass death and destruction, and other human tragedies. The HIV/AIDS pandemic has reached catastrophic levels in many countries.

This paper attempts to address the experience of catastrophe as the most severe form of adversity: adversity so profound that it changes life course and world view; adversity that challenges one's existence as a human being. Catastrophe may occur through a single, terrible incident and its aftermath. It may be reflected in repeated inescapable threat and damage; but also in pervasive chronic and unending circumstances of loss, social disruption, conflict and the like. Catastrophe brings fear, but it may also bring courage. In this paper we are considering women's experience of catastrophe, how they may perceive and respond, and how they endure.

The word ‘catastrophe’ is sometimes used lightly about incidents that are brief, shocking and disruptive, but do not damage or destroy. Such use reflects the assumptions of secure and privileged world views. There is also recognition of the tendency to catastrophize in one's thinking styles, expecting, interpreting the worst outcomes in threat. That may occur for many reasons, including the sensitivities related to prior experience or to personality traits such as those of pessimism. A catastrophe implies a high level of exposure to multiple stressors through incidents, attacks, disasters, and so forth with profound and usually ongoing implications.

In examining this field, we hypothesize that a range of variables may define the experience of catastrophe. These include (i) multiple, concurrent, cumulative stressor exposures; (ii) loss, which is inherent, be it the loss of loved ones, community, place, way of life, livelihood, the loss of attachments; (iii) loss of the assumptions of a safe world because of what has happened, or continues to happen; (iv) death imprint, death encounter or even death immersion, either through the close personal experience of the threat of death or through the mass, gruesome, untimely, uncontrollable deaths of others, and the nature of survival in such circumstances; (v) ‘mental death’, the death of self, as described with those surviving profound trauma associated with torture, or becoming a refugee [1]; (vi) experiences that are the result of malevolent human intent as with homicide, war, terrorism, torture, perpetrated violence, with great impact on mental health [2]; (vii) enduring consequences of the incident or traumatic experience leading to horror, stigma and discrimination, anger, guilt, and frequently shame; (viii) societal and personal damage through impacts on the fabric of the social world, the experience of the self, and the loss of resources that sustain and mitigate impacts [3], [4]; (ix) impacts on the identity of the person, the community, or the nation (even when damage is repaired, injury healed, and communities rebuilt, this identity stays – e.g. a ‘Holocaust survivor’, a ‘Bali victim’, an ‘adult survivor of child abuse’; (x) a sense of unending experience that replaces some aspects, in memory, in world view, in life as it is lived, are unending, either through ongoing external changes, or through internalized, ‘living with’ what has happened; (xi) challenges to one's faith in the world, perhaps in one's god, creating a need to make meaning of what has happened; (xii) resilience, courage, and endurance as the norm but with their own costs; and (xiii) Lack of absolute validation of those affected in terms of their experience, suffering and needs, as well as their courage and resilience is frequently lacking.

With regard to stressors that women experience as severe and potentially traumatic, rape, childhood abuse both physical and sexual, as well as other experiences of violence predominate. Women exposed to psychologically traumatic experience, are more likely to develop post-traumatic stress disorder (PTSD). Norris et al. have researched and reviewed questions around the sex difference in PTSD through disaster and other studies [5]. They highlight the complexities involved in differentiating biological sex and sociocultural gender influences over the lifecycle. On the basis that one of the core domains that reflected dominant value systems in culture is via the degree to which masculinity (the fostering of traditional gender differences) is prominent, they sought to explain how this might link to increased rates of PTSD for women (i.e. in cultures where women were seen as passive and subservient to the needs of men). Their findings supported the view that traditional cultures showed greater differences in the PTSD rate in women than did more egalitarian cultures, when both genders experienced similar disaster stressors. The Norris group's review of the research examined such questions in relation to the difference between men's and women's experience of stressors and stress, and noted the different theoretical models considered: biological; feminist/psychodynamic; social–cognitive perspectives. While they acknowledge that biological factors may contribute, they note that in their studies, the arousal symptom cluster (the most biological aspect) did not show such patterns. They report, too, the extra stresses faced by women in providing care to their children, families and communities at times of need. Following Hurricane Katrina, it is reported 2 years on, that 68% of female caregivers and 44% of children suffered new mental health problems [6].

Terr identified type I and type II trauma, the former reflecting specific acute, severely threatening incidents, the second chronic repeated exposure, as for instance with chronic child abuse, or domestic violence [7]. This distinction is useful, although those who are most severely traumatized may experience both types of trauma exposure. Herman has identified this more complex form of trauma impact on mental health with particular emphasis on how such trauma is damaging to personality development, with alterations in consciousness such as dissociation, self-perceptions involving helplessness, stigma, shame, guilt and self-blame; alterations in relations with others; alterations of systems of meaning with loss of faith and trust, and feelings of hopelessness, alterations in emotional regulation [8]. The mechanism for this may well be secondary to the neurobiological changes known to be shaped by patterns of attachment and in reaction to traumatic experience. Another model addressing the consequences of such profound damage and the adaptations to it is that proposed by Silove, building on his work with refugees in developing countries and in cross-cultural settings [9]. A person's trauma experience may impact on his or her perception of environmental (emotional/psychological/relational) danger, leading to an increased interpretation of threat and to choices made in states of heightened arousal and reduced executive functioning [10].

Women's different experiences of catastrophe

In the first chapter, ‘(En)gendering genocides’, of her edited book of essays Gender and catastrophe, Lentin calls for the definitions of catastrophe to be gendered so that the different impacts on men and women can be noted [11]. She notes that women are at least ‘half of the casualties of what is termed ‘catastrophe’ by organizations such as the International Federation of the Red Cross or Red Crescent Societies’ (p. 4). Lentin goes on to point out that women and (their) children are particularly vulnerable to food deprivation and suffer disproportionately from diseases secondary to malnutrition and lack of sanitation and water, as well as from violence, often in settings where they seek refuge. Lentin notes that although some social scientists consider the need to examine for gender effects only in catastrophes that are man-made rather than in natural disasters, all catastrophes have differing impacts for the genders.

The ways in which women's experience of catastrophe differs to men's result from a number of intertwining factors. These are biological, social and genetic. Women's different social roles play a large part. They are frequently separated from husbands, fathers, brothers or other male support in times of political conflict or war. Men are more likely to be called upon to provide manpower in communities that have experienced a natural disaster. Women usually have/assume the responsibility for care of children and the elderly, which at times of crisis may limit their capacity to react spontaneously, and increases the need for resources at times of scarcity. In some societies, women have lower status and lesser autonomy, so that their needs may be perceived as lower priority even, or especially, at times of calamity.

Women's biological differences may also contribute to their different experiences. In situations where there are few resources, women's greater need for nutrition during pregnancy and lactation (and with menstruation) may lead many to be more nutritionally depleted than their male partners, and so more physically vulnerable to ongoing stressors. There will also be the added distress of being pregnant or giving birth during times of adversity, when resources are limited and the chance of mother/infant survival is lowered.

In some catastrophes women's reproductive capacity has been used as a tool for genocide with systematic rape/impregnation and forced abortions. Exploitation and abuse of women sexually is abhorrent, but ‘women as spoils of war’ has a long tradition through humanity's history of wars and conflicts. The impact of sexual degradation is not only experienced at the time, but also later, because it affects women's views of themselves, and society's frequent rejection of them as in some way ‘damaged goods’.

Women have a different vulnerability to the negative mental health effects of trauma. A number of studies show that women have higher rates of PTSD, anxiety and depression after large-scale disaster or terror events, than men who have also been similarly exposed. Furthermore, there may be differential disaster effects by gender and age as suggested by Amaratunga and O'Sullivan [12], who see disasters as ‘profoundly discriminatory’ with greater risk of death, potential losses related to gender roles as family caregivers, and their selective deprivation and vulnerability in the aftermath.

In the paper by Pirkola et al. from the Finnish Health 2000 Study, the authors note that the effect of reported childhood adversities was stronger among women than men [13]. It is well acknowledged that women experience greater rates of depression, 2–3-fold that for men. The genetic research indicates a number of genes associated with depression, including evidence that there are sex-linked loci [14], [15]. Given the gene–environment interaction needed for phenotyping, it is possible that female subjects may be more vulnerable to environmental effects.

In a recent article by Clark et al. reporting from the 1958 British Birth Cohort, the authors describe a number of ways that environmental effects can be associated with greater mental health problems in women [16]. They suggest that onset of mental health problems in adulthood may be partly determined by continuity of childhood problems, but it is also very strongly influenced by life events and chronic stressors to which women may be more exposed in adulthood, as well as the biological and social role differences.

The World Health Organization in its 2002 report on gender inequities in mental health, highlights the gender specific risk factors for common mental disorders; the higher rates of social violence to which women are exposed; the longer term cumulative psychosocial adversity; the economic and social policies impacting on access to basic resources, social capital, and the associated patterns of morbidity [17].

Domestic violence is associated with high rates of depression and comorbid psychopathology, including PTSD, dissociative disorders, phobias and substance use and suicidality [18]. These researchers conclude that being subjected to ‘coercive control’ through such violence affects self-esteem and leads to a sense of demoralization, and is one of the variables affecting these differential problems.

Shame

Sexual abuse and domestic violence lead many victims to feel ashamed. Shame causes a sense of irreversible failure and worthlessness. They may reject themselves and so experience rejection by others, ‘leading to a sense of weakness, helplessness, defeat, inferiority, vulnerability, loss of control, and paralysis’ [19]. Shame may relate to the inability to provide for one's children and family, or the inability to fight back.

Shame is associated with many states of victimhood, degradation, abuse and humiliation for women and for men.

In shame, the bad object is experienced as self. As a result the shamed individual feels worthless and powerless, and open to criticism. There is a sense of wanting to hide this defective self. Tangney et al. examined the links between shame and guilt and psychopathology in their paper [20]. They found that proneness to shame was strongly related to psychological maladjustment in general, and that shame accounted for substantial variance in depression, above and beyond attributional style.

Women's experience of violence as catastrophe

Violence against women is recognized as a violation of their human rights and as having significant impact on their mental health and well-being. Severe and ongoing domestic violence is seemingly unending, associated with helplessness, terror, loss and lowered sense of worth and self-efficacy. It has all the implications of personal catastrophe. Sexual abuse and social assault are other forms of personal violence with significant and ongoing adverse consequences.

The burden of domestic violence has been studied in Australia, showing that intimate partner violence is estimated to cause more ill health and premature death among women of reproductive age than any other risk factor, including hypertension, obesity and smoking [21]. These researchers highlight the extent of such violence in their WHO multicentre study of women aged 15–49 from 15 sites in 10 countries. Domestic violence is extensive and estimated to affect one in three women globally, with some form of victimization in childhood, adolescence or adulthood. Their study showed that in 13 of the 15 sites studied, between one-third and three-quarters of women had experienced physical or sexual assault since the age of 15. Most of this violence was severe, and much undisclosed and ongoing, highlighting the shame and fear associated with such abuse. Physical injury, physical health complaints, emotional distress, attempted suicide and PTSD and depression were among the consequences. Sadly, the belief that such violence is normal, or deserved, was frequent, as part of social or cultural norms in some settings, but also reflected women's interpretations in relation to their helplessness and lack of sense of self-worth. Other studies support the finding of a strong relationship between domestic violence and poor mental health, for instance in India [22]. A report also describes findings in Arabic and Islamic countries, with surveys in Egypt, Palestine, Israel and Tunisia showing that at least one in three women were affected, and this again was frequently perceive as ‘justified’ [23]. A cross-cultural review highlights the ‘profound physical and psychological sequelae of endemic intimate partner violence’ [24]. These writers identify the culture-specific rationale for such violence, ranging from honour murders to disproportional exposure to HIV/AIDS. Such violence has significant, ongoing impacts on mental health and well-being, and in its extent and impact, in its reflection of human rights abuse, is catastrophic for the well-being of women.

All forms of sexual violence represent a form of catastrophic experience. Girls are more likely to be sexually abused as children, than boys, and by someone within their families, so there is the additional implication of betrayal when a parent, sibling or other male relative is the perpetrator.

Australian studies report that 29% of women had experienced physical or sexual violence before the age of 16 years, and that the lifetime experience of sexual violence to the level of forced intercourse or attempted intercourse was 20%: that is, one in five women [25]. Indigenous women were more likely to experience such violence [26]. Child sexual abuse is an established risk factor for child and adult mental health problems and is experienced by 12% of women and 4.5% of men in the population [27]. Living with the psychological damage to the sense of self, with the threat, loss and impact for identity as a woman, demonstrates the potentially catastrophic nature of such experience.

Loss: violent death of a loved one

Loss and grief are inevitable parts of human experience. Although the bereaved are likely to experience high levels of distress when death is unexpected or untimely, the majority of people come to terms with such losses and, over time, move on in life. Resilience is the norm. There is significant evidence that women's patterns of grief are more intense and more prolonged, although not necessarily problematic [28]. Men and women have been shown to demonstrate a range of different coping styles. However, some losses are perceived as catastrophic in their significance, in the intensity of the grief and in their implications. The death of a child brings the most intense grief [29]. The violent death of a child is not only untimely, but unexpected, filled with trauma and horror of a special kind, with consequences that may seem never-ending. Murphy reports on her prospective studies of parental reactions to the violent death of a child (12–28 years) [30]. Deaths were by accident, suicide and homicide, and parents were followed up from 4 months to 5 years. The mothers’ symptom scores on mental distress (Brief Symptom Inventory) were higher than the fathers’ at all times and the mothers had much more difficulty in accommodating their loss. While both mothers and fathers showed health impairment, mothers’ health impairment was strongly associated with increased emotional distress, and they were more likely to report taking antidepressants and anti-anxiety medication. Nevertheless, most parents reported (at 4 months) some health-protective behaviours such as exercise, healthy diet, not smoking. At 4 months, PTSD symptoms were found in 60% of mothers and 40% of fathers whose child was murdered. These had decreased by the 5 year follow up, but were still high with many impacts that would hold parents, especially mothers, to their experience with hyperarousal, re-experiencing and avoidance symptoms. A particularly telling aspect was that of parents’ struggle to make meaning of what had happened, with a sense of unfairness, or search for reasons, and questioning about their responsibilities in terms of the death. Parents came to some level of acceptance by 5 years on, although 43% had still not found any meaning they could encompass, and frequently spoke of their continuing pain. There were also ongoing impacts for self-efficacy, coping and self-esteem. Murphy concluded that mothers used more destructive forms of coping such as denial and disengagement, and that those who did not find meaning were more likely to report intense symptoms of mental distress. Mothers fared worse, as has been shown in many studies of this kind. Such ongoing grief and distress are likely to be catastrophic for those most severely affected.

Violent deaths associated with terrorism are also likely to be profound in their impacts. First, it is likely that those bereaved will experience very high levels of distress, because terrorism is deliberate and malevolent in intent, as is homicide. Additional factors include the mass nature of the deaths, their unexpected, untimely, and violent occurrence and the fact that the remains of the deceased may be difficult to identify or may not be found, as occurred with September 11 (9/11). Those bereaved in such ways are acutely distressed, may lack the opportunity to say their goodbyes to the deceased, and may themselves have also experienced and survived the terrorist incident. Experience with Australian women after the Bali bombings of 2002 showed the complex and intense grieving such losses may bring [31]. The complexity of their experience was due to the ways their children and loved ones died, and the fact that the remains of their loved ones may not have been whole, or showed signs of the horror of their deaths. Their distress was ongoing, even with skilled support for the disaster victim identification (DVI) process, and was added to by their own experience of trauma when they had survived the incident themselves, and perhaps also to the experience of searching in the horror of the aftermath, for their loved ones. Like 9/11, such losses bring grief for those lost, for the loss of innocence and of the sense of personal and national invulnerability, and ongoing impacts of reminders, such as the search for, and trials of, the perpetrators. A further element that may affect the grieving process is the public nature of such incidents and the expectations surrounding them. Mass outreach and support was provided as indicated by the Neria et al. review of response and research of these issues after 9/11, but many people need to seek support in their own time, and in their own way [32]. While mutual support is frequently of value, as are shared rituals and memorialization, there is also the powerful identification of victimhood and survival linked to the specific incident: Bali, 9/11 and so forth. Women endure, as do men, but the suffering and damage may seem unending.

Pivar and Prigerson have reviewed the experiences of loss of a loved one through terrorism and noted the high levels of complicated and traumatic grief, and the particular vulnerabilities of women bereaved in such circumstances, linked to many of the issues identified here [33]. More recently Neria et al. have reported that 2.5–3.5 years after 9/11 43% of those bereaved had prolonged and complicated grief, and this was more likely for women, and for those who have lost a child, or a loved one in the World Trade Centre itself [32]. Viewing of these events live on television added to such risk.

Mass violent death may also occur in other mass man-made incidents such as plane crashes, without human intent, and in mass disasters such as the South-East Asian tsunami. While the aspect of malevolent intent does not occur, the gruesome nature of such deaths, the fact that the bodies of the deceased may never be able to be found or identified, mass burials, the inability to fulfil religious requirements, may all mean that the catastrophic nature of the loss is increased. Whole communities as well as families may be lost in such circumstances. Women are more vulnerable to dying in such circumstances, to losing their children, because both may not have the physical strength to survive. And when they do live, they may face ongoing and severe challenges with the prolonged impact of the destruction on their capacity to provide shelter, food, resources, the capacity to earn a living, for themselves and their surviving family members. The impact of demoralization, depression and despair, as well as profound grief, may be overwhelming.

Bonanno et al. looked at resilience among those who had lost a friend or loved one, after 9/11 [34]. They found that while the bereaved's distress was higher than those who had not experienced such loss, especially for those who had directly witnessed the attack, many were still resilient, even though not to the same degree as the broader population of those exposed. This study showed differential effects for women: that they were less resilient than men.

Another report on resilience of families after violent loss suggested a number of attributes that would promote resilience, including hopeful expectations or belief systems, nurturing behaviours, communications of mutual respect and problem-solving strategies [35]. Although no gender differences are noted, some of these strategies, such as nurturing behaviours may be more inherent to women's coping behaviours and contribute to resilience. Nevertheless, the evidence suggests that women's grief is more intense, devastating and prolonged – seemingly unending.

Women left alone through violent loss, or loss more broadly, may face stigma and discrimination, may lack access to social resources, or indeed access to the resources to maintain the lives of themselves and their children. It may be more difficult for them to have a sense of their own value as widows, compared to that as wives, and this may be made explicit in social and cultural perceptions of their worth and entitlements in society. Safety may be a challenge, and even survival, but nevertheless these women endure, frequently for the sake of their children. They face their ongoing struggle with courage in the face of continuing adversity.

Women's experiences of terrorism

The catastrophic personal and community experience of recent terrorist attacks has been documented most extensively with findings from the September 11 attacks in New York and the ongoing experience of terrorism in Israel. Much of this research has focused on patterns of PTSD, depressive and psychiatric morbidity in affected populations. For instance, findings from population studies after September 11 showed that women reported more post-traumatic symptomatology than men [36].

Solomon et al. have reviewed gender differences in terms of the reaction to terror events, with the question of why women might react more strongly to this and other adversity [37]. They note the common themes in this literature: the level of exposure to stresses and the different types of stresses; different coping styles (women tending to use more emotion-focused strategies and social interactions); that there may be different perceptions and reporting, with men perhaps understating stressful events; and that there may not only be differences in reactions but a greater willingness of women to report such reactions. For women, specific gender and social roles may determine their experience and their reactions, and they may also perceive and report themselves to be less effective in their response in terms of a set of social perceptions of their lower efficacy and subordinate social roles. These issues will be considered further here.

In their study using telephone interviewing of a representative sample of the Israeli population, Solomon et al. found that terror was not gender blind. Men were more likely to report that they had experienced exposures such as knowing someone hurt. Women reported higher levels of suffering from traumatic stress type symptoms/reactions. In terms of coping styles, women were more likely to check the whereabouts of family members and friends, then talk with others about the feelings that the terror events had produced. They also reported less self-sufficiency in the event of an attack. Women reported less optimism about the future than men, and reported themselves to be more afraid in terms of the future for themselves and for those close to them. Women tend to seek more support, yet are also more concerned for those close to them.

This research provides an overview of how women perceive and respond to the impact of ongoing and actual terrorist threat in a population. The specific effects of terrorist attacks on women have also been identified in accounts such as those of Danieli et al. [38]. The contributors to that volume demonstrate the acute and enduring effects and also report the voices of many women who have had such experiences.

In the context of a range of terrorist incidents, Pfefferbaum et al. identify the profound mental health effects for children, in terms of impacts on development and the prevalence of disorders, with girls in childhood and adolescence demonstrating higher rates [39]. As Pfefferbaum et al. suggest, the impacts of terrorism come from the emotional consequences that accompany ‘the altered environment in which we now live our lives’ (p. 940).

Terrorism produces ongoing impacts, particularly when there is anger, conflict and other deprivations. Somasundaram described the collective trauma that occurs in communities such as Sri Lanka, with demoralization, deterioration in social values, and sexual mores and increased rates of child abuse [40]. The personality of individuals frequently becomes brutalized. The vulnerabilities of women and children in such circumstances of collective and continuing trauma, and the short and longer term impact on their mental health and well-being are reflected in his studies.

Rubin et al. surveyed Londoners at 11–13 days after the bombings, and at 7 months [41]. They found that those who had initially feared that a family member or close friend might be killed, or who were from poorer households, were more likely to report persistent ‘substantial stress’. There were also other ongoing impacts: 61% reported that the bombings had altered their view of the world, 26% to feeling a different person; 19% altered travel and 28% other behaviours; 43% still believed their own life to be in danger from terrorism and 52% still felt that the lives of close family members may be in danger; and 90% considered another attack to be likely in London. There were enduring effects for women and men, changing their lives and world views.

Grief in circumstances of terrorism adds further to the impacts, due to the nature of such loss, and associated bereavements, their complex and unexpected nature, and the violent extent, thereby adding to the trauma [33]. Neria et al. have also demonstrated the enduring impacts of traumatic loss of a loved one through 9/11 [32].

The catastrophe of war

A recent paper by Jansen examined the effects of armed conflict on women's health and mental health [42]. She suggested that gender inequalities were magnified by war: the decisions to go to war are made by men, and women are increasingly involved not only as victims, but as combatants, and even at times as leaders. Issues identified included the further definition of men in their roles as the protectors, in patriarchal ways and as the decision makers of war, and of peace. More clearly, however, women are casualties. Rates of civilian casualties have risen from 15% in World War I to 90% in recent wars. These casualties in many instances have chiefly been women and children. The destructive force of recent wars has also been highlighted by patterns such as systematic rape with forced impregnation of women as part of ethnic cleansing, and in the kidnapping of girls and women to become sexual slaves for male combatants.

There is also much loss for women through warfare and conflict. Women lose their loved ones in wars through the deaths of their partners and similarly their sons in combat. Other family members are also likely to be casualties, among them their parents and children.

A specific report on the impact of war on women has drawn attention to the finding that ‘no matter which war or armed conflict fought’ from civil wars in South American nations, to the ethnic cleansing of the former Yugoslavia, to the Rwandan genocide, ‘the conditions and the effects of all these different wars, fought on different continents, for different reasons, are painfully similar for women’ [42]. This is reflected in issues such as the Japanese comfort women and other such abuses.

War leads to the displacement of women and children, both internally and as refugees. It is reported that up to 80% of the world's refugees are women and children. In circumstances of displacement into camps, women frequently continue to live out the catastrophe of loss and violence with greater rates of infant mortality, vulnerability to rape, and concerns for the well-being and future of themselves and of their children.

A report on the health and mental health of internally displaced women in South Darfur in the Sudan highlights the impacts of such experience, where women head up to 84% of the internally displaced households [43]. Darfur exemplifies both the extent of inhumanity of such conflict circumstances, and the catastrophic effects on women's human rights and mental health. Such circumstances feel unending to those involved, and the authors describe them as worsening. The researchers surveyed women in six of nine registered Internally Dispersed Persons camps in the Nyala state of South Darfur. They perceived significant deficiencies in human rights, with lack of support for women's rights. The women surveyed supported the importance of access to education and legal protection but accepted lack of rights with respect to marriage, reproductive choice and issues relevant to their well-being (e.g. that a man had the right to beat a disobedient wife). The study found heightened rates of morbidity, inadequate access to basic resources such as adequate daily levels of water intake, inadequate access to food and rations, compounded by lack of access to local foods because of drought, and the heightened risk of violence. They also found very high rates of depression, with almost one-third meeting criteria for major depression. This was seen as comparable to the rates found in other complex emergencies. Because that study examined only depression and suicidal ideation, the authors suggested that it is likely that this is only a proportion of the mental health morbidity, with PTSD and other psychiatric disability likely to be heightened as has been found similarly in complex emergencies. They concluded that provision of basic needs, security, education and health care as well as counselling and psychosocial support were needed to address such circumstances. Of concern is the researchers’ comment that these findings may be better than such surveys might have found if they had gained access to other camps that they could not access. They also reported their concerns that security and the capacity to provide humanitarian aid were deteriorating.

A study of mental health symptoms following war and repression in Afghanistan found that symptom rates for depression, anxiety and PTSD were higher for women than men, and that these rates were similar to those found in population surveys, reflecting the long history of war in that country [44]. The higher rates of symptoms were associated with increased experience of trauma with women experiencing these at higher rates than men. These included for all the population, lack of access to food, water, shelter, medical care, experiencing the murder of a family member or friend, or the death of such a person through illness or lack of food, torture, interrogation, beatings, bombings, shelling, having to flee, losing property, living in a refugee camp and being close to death. Such stressors had been experienced by >70% of women. The numbers of these experiences, as well as their severity, were likely to be associated with poorer mental health. The enduring, life-threatening, unending nature of such catastrophe is clear, with the inherent threats to survival.

The complex interplay of human rights abuses and women's human rights in such conflict-affected settings, and the profound effects on women's mental health, have also been considered in studies in Southern Iraq [45]. The survey of households demonstrated high levels of abuse under the regime of Saddam Hussein. High rates of suicidal attempts were reported in the population and domestic violence, with impacts for community health and development. It should be noted, however, that while the survey showed some commitment to rights for women, both men and women agreed that a man had the right to beat his wife if she disagreed with him.

de Jong discussed the impacts of war, conflict and disaster and human rights violations in low-income countries and identified the huge numbers of refugees and internally displaced people affected by such traumatic experiences, with estimates of at least 33 000 000 [46]. He identified the extensive range of traumatic exposures that such populations are likely to have experienced, including the violence of conflict, deprivation of shelter, food, water, home, sense of safety and personal encounter with death, witnessing mass deaths, losing loved ones, and unremitting and unpredictable violence, rape, torture, and captivity. In refugee camps threats and deprivation may continue. It is likely that 70–80% of these people are mothers with children, and they are particularly vulnerable to the most profound impacts on mental health and well-being, including extremely high rates of PTSD, depression and anxiety disorders. Children's great vulnerability is reflected in impacts on their development, as well as mental health. A sense of safety is difficult to achieve, even with resettlement, and more so when there are ongoing traumas associated with continuing fear and uncertainty as for instance with further detention. Physical, social, emotional, cognitive and all aspects of health and development are likely to be affected, not so much by single trauma, but rather the unending and continuing experience of multiple traumas, including violence especially. Women are also affected by service in wartime, in roles as nurses, support workers and, increasingly, as soldiers [47], and deal with death, injury, disease, life threat, and the psychological wounds associated with killing others.

Ultimate catastrophe

The concept of catastrophe is associated with many experiences for women and men, and there should be no competition for the most catastrophic of experiences. Nevertheless two incidents stand out in many historical reviews: both are linked to World War II, although there are many other circumstances of damage and loss that may have been more widespread. The Holocaust is one such event, with the deaths of women in camps, their use as sexual slaves, and prostitutes, and as experimental objects in terms of reproduction. Men, of course, also experienced this catastrophe in terrible and damaging ways. The ongoing impacts for their children and future generations have also been recognized.

Women's stories of the Holocaust have been a focus of some recent publications such as that of Ofer and Weitzman in the book on that topic, and Waxman's essay on the untold stories and testimonies [48], [49]. These authors describe the experience of women, not to suggest vast differences from men, but more the specific nature of women's experience. There is also the suggestion that much of this was not previously revealed, in part because of the gender roles of the time, where women were more often subordinate in speaking of their needs.

Women's experience in the bombing of Hiroshima is vividly depicted in their stories, in themes of death encounter, loss, struggle to nurture others and survival with ongoing psychological, physical and social damage [50]. These women, identified as hibakusha (atomic bomb survivors) describe such experience: ‘the three of us – a mother with two children – what should we do?’; ‘a feeling of helpless desperation’; ‘I didn't know what I could do about caring for my children, what would happen to us’; ‘I lost my self-confidence’; ‘the feeling of loneliness and fear’. Ongoing concern for survival reflected the fears of bodily disease from the atomic bomb, of infertility, of deformed children. Lifton identified the ‘enduring taint – a taint of death which attached itself to one's entire psychobiological organism and, beyond that, to one's posterity as well’ (p. 130). The burn scars or keloids were a perpetual psychological reminders of the impairment of one's body, one's status as a hibakusha was ‘there for everyone to see’. The ongoing mark of damage as a woman, and stigmatization as a victim continued.

Conclusion

It is interesting to note that a paper dealing with the economic costs and benefits of catastrophes and their aftermath fails to take into account the costs of mental health impacts, including those for women [51], recognized widely elsewhere, as critical to recovery and renewal of individuals and communities, and as contributing in major ways to the costs of catastrophes.

It is vitally important to acknowledge such catastrophes. Nevertheless the catastrophic experiences of women, men, children and humanity more broadly are frequently ongoing, often silent, and may seem to be beyond our ability to encompass. Women and men, and even more powerfully their children, are all affected, and women share their loved ones’ suffering as well as experiencing their own. Women in many settings of life are living with catastrophic experience from their past, in their present: from women in the terror of violent domestic circumstances, to the damaging and demoralizing settings many Aboriginal women experience in their lives and communities. Australia is not immune to catastrophe. As well, many who have come to this country carry the legacy of war, violation, torture, refugee status and the personal horrors any woman may experience with sexual or other malevolent violence and degradation.

The silencing of women, as with State-sponsored violence [52], through cultural prescriptions for women's roles and behaviours [48] or with ‘tears you never see’ [53] means that there is the need for atonement for their experiences – first with empathy beyond words.

It is important for clinicians and researchers to recognize and understand catastrophic experience, knowing that it is often silently endured, for the survival of children, family, self, or because of shame, the stigma of victimhood, ongoing helplessness, a loss of trust in people, instructions, safe worlds, or because there is no choice. It is more than PTSD, or DESNOS, or than any diagnostic category. Once recognized it calls forth the humanity in all of us, and the opportunity to acknowledge the courage, resilience and suffering that it involves, and to assist with the repertoire of our healing strategies in partnership with those who wish to deal with its consequences. The special nature of women's experience and its impact on mental health place it centrally in the areas of responsibility of psychiatrists, psychologists and all clinicians working with women, for the ongoing impact on their lives.

There are no easy therapeutic solutions to the mental health impacts of such catastrophic experience. Pharmacological, cognitive–behavioural or psychoanalytic techniques will not provide solutions, although facets from each may contribute. Central, as suggested by many writers in this field, is the recognition of these population impacts for women globally and individually and clinically, the establishment of safe and trusted personal and physical environments, provision for the narratives of their experiences or their testimony, and support for their strengths, identity, value and recognition as women.