Our findings suggest that benefits of post-rape psychological support, integrated in a global care, are present and lasting in this conflict context. In more than 2/3 of the patients, the GAF showed a clear improvement of psychological state between the first and the last psychological support during the initial management. These benefits were apparent with few interviews (median 3), and persisted afterward, supporting the fact that short psychological intervention therapies, conceivable in such settings, have an impact on the long-term resilience. The TSQ was not used at admission as a pre-test questionnaire, so the impact of psychological care in terms of PTSD cannot be adequately assessed by its domains evolution. We can however notice that 24.2% of the women presented an acute stress disorder or a PTSD when admitted in the post-rape programme, whereas it is much lower one to two years after rape (3.1% of the women who undergone the TSQ met a PTSD diagnosis criteria). Nevertheless, this improvement cannot be certainly attributed to the psychological care, as the spontaneous evolution could not be assessed by a control group.
Psychological reactions after sexual violence vary greatly, but overall people who experienced rape are more likely to develop PTSD than victims of any other crime [22, 23]. However, TSQ results showed a low prevalence of PTSD of approximately 3%, confirming the low findings of a first evaluation of this program . Considering that six women could not complete the TSQ because of a too severe psychological state, PTSD prevalence could have been underestimated. Nevertheless, even if we consider the extreme situation, that is all of them presenting a PTSD, the prevalence would be 11.4% (8/70). These results are very different from European or North American studies where post-rape PTSD prevalence was much higher, between 60 and 80% [24–27]. Some authors underline that PTSD, as defined in DSM-IV, cannot constitute or gather all the consequences of psychological trauma . Moreover, DSM-IV has been developed for western-occidental psychiatry, and may not have the same validity in conflict contexts in Africa. There has been a tendency in Western psychiatric research to focus exclusively on PTSD when describing the psychological consequences of violence. Understanding human responses to extreme experiences solely in terms of PTSD has serious shortcomings. Nevertheless, PTSD prevalence in traumatized population was found very high in conflict contexts in Africa. Different studies conducted with war-affected Ugandans showed 40% to 54% of PTSD prevalence [28, 29]. Others conducted with Internally Displaced People (IDP) in Kenya or with Sudanese refugees found respectively 80.2% and 40.1% of PTSD prevalence in the highly traumatized population [30, 31]. There is ample evidence in support of the fact that Western conceptualizations of PTSD have validity in Africans, and that Africans can and do show symptoms of PTSD [32–34]. The low PTSD prevalence in our study is therefore interesting. African populations living in war contexts seem to develop PTSD as defined by DSM. This suggests that the low prevalence of PTSD in our study could be partly due to the initial psychological support. This hypothesis requires further evaluation, given that the aforementioned studies on PTSD in African population did not focus on victims of rape. At the contrary, the frequency of sexual dysfunction (1/3) is consistent with the results of European or American studies that report such disorders in 25% to 60% of sexual violence victims [27, 35].
Several limitations require comment. Out of the 178 women meeting the inclusion criteria, 108 were lost to follow up, because they had an initial incomplete address or they had moved. Their characteristics when entering the program were similar to those participating in the study in terms of age, number of assailants, delay between rape and admission in the program and post-rape physical injuries. Nevertheless, it is not possible to extrapolate our findings to all the women that were admitted in the program. Notably, among the 70 women that could be evaluated, the proportion of unwanted pregnancy due to rape was higher than for those lost to follow up. This may be due to an increased need of socio-medical and psychological support in post-rape pregnant women. It is troublesome that more than half of the selected women could not be found because of the context (conflict and population displacement that did not allow to later locate the patients), and this leads to concerns regarding the generalizability of these findings. Nevertheless, this study, based on the interviews of 70 women admitted in a program which was not designed for long-term follow-up, provides the first long-term evaluation in this context.
The implementation of this study raised questions about the cultural appropriateness of the diagnosis process. The likelihood of cultural response bias to the questionnaires cannot be excluded. Moreover, there was no evidence of the cultural validity of our scales in this context. To reduce this cross-cultural bias, we tried to improve the semantic validity of the questionnaires using a mixed French and Congolese team for translation and back-translation, which was validated by two senior psychiatrists, and adjusted after being field-tested. Internal consistency of our scales, using Cronbach's alpha, appeared to be acceptable for the TSQ, and high for the EUMP which revealed information about avoidance symptoms, psycho-somatic and sexual disorders prevalence that are not developed within TSQ or GAF. The GAF as the sole pre and post test is problematic as there is a subjective component, and its nature of looking at global functioning does not well characterize some of the long term impacts of violence exposures that we attempted to address with the other tests. GAF internal consistency could not be measured with our data. However, we found a correlation between GAF score, which was the criterion we used to assess long-term impact, and the different initial diagnosis. This suggests that it is an appropriate instrument to measure mental distress and functionality in this context.
Our study is based on the assumption, that DSM-IV disorders have diagnostic validity across cultures. PTSD and other trauma stress disorders seem to be a cross-cultural way of post-traumatic suffering; nevertheless we cannot dismiss the eventuality of cultural different responses to trauma, particularly late complications that were not assessed in our study. Moreover, this type of impact study cannot lead to causal links as conducting a randomized placebo controlled trial would not be conceivable or ethical. The spontaneous evolution of psychological state improvement without any psychological intervention could not therefore be assessed. Evidence concerning the evolution of PTSD over time in similar contexts is mixed. Some evidence from Mozambique in a conflict context suggests that PTSD rates go down spontaneously over time; other studies suggest otherwise [36–38]. These studies evaluated war traumatized population, and did not focus on woman victims of sexual violence. Finally, it is difficult to distinguish the specific impact of psychological support as the women in a large majority benefited of integrated medico-socio-psychological care (only four refused psychological support when entering the program, which does not allow comparative analysis).