The Dynamics of Post-traumatic Stress Disorder among Sexual

Violence Victims

Hera Wahyuni

1 2

, Hamidah

, and Nurul Hartini

Faculty of Psychology, Universita Trunojoyo, Madura, East Java, Indonesia

Faculty of Psychology, Universitas Airlangga, Surabaya, East Java, Indonesia

Keywords: Negative appraisal, strong emotion, social isolation.

Abstract: This study aims to show the dynamics of post-traumatic stress disorder (PTSD) in child sexual abuse

victims. This study applied qualitative methods with a case study approach through four participants (11–16

years old) diagnosed with PTSD. The data were collected using interviews, observation, and documentation

techniques, followed by data analysis using categorical aggregation and direct interpretation. Our findings

reveal that the dynamic of PTSD can be illustrated through five stages: 1) Traumatic Exposure, showing the

severity of traumatic exposure experienced by the participants; 2) Excessive Negative Appraisal –

participants assume that the sexual abuse experience has ruined their lives and they have no future; 3)

Personality – the individuals' vulnerability contributes in creating the next phase; 4) Strong Emotion, such

as feelings of guilt, shame, and sadness, 5). Social Isolation – participants feel isolated and tend to avoid

their community because they become victims of bullying.

1 INTRODUCTION

The number of child sexual abuse cases in Indonesia

has increased every year. Moreover, the National

Commission for Child Protection [Komisi Nasional

Perlindungan Anak] has launched "A Movement to

Fight Child Sexual Abuse, declaring that Indonesia

is in a state of emergency for child sexual abuse."

An increased in child sexual abuse cases can be seen

in the 2014 report of the KPAI Information and

Complaint Center (January 2011– August 2014).

The data shows that there is an increase in child

sexual abuse cases each year. In 2014, there were

621 child sexual abuse reports out of 1,236 reports

on child abuse cases. The data suggest that child

sexual abuse is the most common case, and requires

more attention from both the government and

society (Davit, 2017).

The phenomenon of child sexual abuse needs

immediate action due to the increasing number of

cases each year, causing Indonesia to launch an

emergency program for child victims of sexual

abuse, which inhibits their growth.

Child sexual abuse can cause long-term

psychological disorders, as revealed by the

following studies: Devirshi (2015) states that all

forms of child sexual abuse can cause post-traumatic

stress disorder (PTSD) as a reaction to their sadness

and psychological symptoms; Sagatun (2015)

proved that incest may cause prolonged PTSD in

children; Widom (2000) found that child sexual

abuse causes PTSD; and Zoladz (2013) points out

that people experiencing interpersonal trauma (e.g.,

rape and/or child sexual abuse) are more likely to

develop PTSD compared to people experiencing

non-violent trauma (e.g., accidents or natural

disasters).

These studies reveal that PSTD is a consequence

of child sexual abuse. Therefore, it should be given

more research attention. PTSD is a psychological

disorder that may develop after a person is exposed

to traumatic events (e.g., sexual abuse, war, a traffic

accident, life-threatening events).

The initial research on PTSD focused on the

veterans of the Vietnam War, and later developed to

include various other settings, such as natural

disasters, accidents, and abuse. During the last

decade, studies on PTSD have shown improvement.

Horowitz (1976) states that PTSD is caused by past

experiences that unconsciously ignites trauma and

anxiety. There are unconscious conflicts that could

affect our way of processing thoughts, images, and

emotions associated to the trauma. Lang (1979)

Wahyuni, H., Hamidah, . and Hartini, N.

The Dynamics of Post-traumatic Stress Disorder among Sexual Violence Victims.

DOI: 10.5220/0008588302830289

In Proceedings of the 3rd International Conference on Psychology in Health, Educational, Social, and Organizational Settings (ICP-HESOS 2018) - Improving Mental Health and Harmony in

Global Community, pages 283-289

ISBN: 978-989-758-435-0

283

found that the etiology of PTSD can be explained

using a behavioral approach, particularly through

conditioning. Classical conditioning dictates that

traumatic experience serves as an unconditional

stimulus, which is paired with neutral stimuli such as

something seen, heard or smelled associated with the

traumatic event. Ehlers and Clark (2000) reveal that

PTSD is a common reaction of traumatic events.

These threats occur as the consequences of the

following factors: excessive negative thoughts and

memory disruption towards memories of past

traumatic exposure.

There are many studies on PTSD in both

developing and developed countries. However,

existing theoretical assumptions of PTSD do not

consider cultural factors in reformulating the

theories. Thus, it cannot be generalized to a

particular culture. This argument is explained in the

following studies: Scott et al. (2014) state that the

findings of PTSD studies cannot be used to

generalize other populations; Jobson and O’Karney

(2008) emphasize that cultural differences are key to

the development of trauma impact on one's identity,

hence the process of reforming PTSD theory

requires cultural factors; Darleen Susanne Haj

(2015) explains that cultural background is

important during the process of identifying,

diagnosing, and treating PTSD cases; and Taku et al.

(2009) reveal the need for the sample’s ethnic

background specification to help researchers to find

out how socio-cultural factors can aggravate or

protect victims of sexual violence from negative

occurrences.

Studies focusing on PTSD are fairly well-

developed in Indonesia, although it does not

compare to the number of studies carried out in

Western countries. PTSD studies in Indonesia

mostly focus on trauma that emerges after natural

disasters, e.g., tsunamis and volcano eruptions.

Several examples include, “Tsunami and Post-

Trauma Stress in Children” by Hartini (2009), a

study conducted by Agustini et al. (2011) which

measured demographic factors, such as gender and

parental support in adolescents experience of PTSD

in Aceh after the tsunami; and “Social Support and

PTSD in Adolescent Survivors of Mount Merapi” by

Tentama (2014). The results of those studies

demonstrate that there is a significant negative

relationship between social support and PTSD. This

indicates that lower social support reflects higher

PTSD disturbances in adolescents.

PTSD studies conducted in Indonesia do not

provide an understanding about the dynamics of

PTSD within Indonesian culture, including the risk

factors that cause PTSD in victims of child sexual

abuse. In this regard, the lack of research conducted

in Indonesia has an impact on limited psychological-

oriented preventive efforts. By analyzing the risk

factors of PTSD on child sexual abuse victims, this

study is expected to provide benefits in modeling the

prevention of PTSD in the victims.

A developed PTSD concept in Western countries

cannot be applied in Indonesia due to cultural

differences. Jobson and O'Karney (2008) pointed out

that cultural factors contribute to individual trauma,

particularly on memory, information management,

and self-concept traumas. The findings indicate that

the current PTSD model and theoretical assumptions

should consider cultural factors in the process of

theory reformulation. Looking at this issue, we are

interested in conducting PTSD research on child

sexual abuse victims in Indonesia.

This study examines the process of change in

sexual abuse victims until PTSD is developed.

Dynamics is a form of change, which can be small

or large and can happen sooner or later, and is real

and related to a condition or state of the person

(Chaplin, 2006). The arising question was, “What

are the dynamics of PTSD development in children

who are victims of sexual violence?” The answer

cannot simply be explained using existing PSTD

theories because the context is different. Current

theories by experts from developed countries are

largely related to victims of war and natural

disasters. However, very few PTSD studies has been

conducted within the context of child sexual abuse,

especially in Indonesia.

2 METHOD

This research used a qualitative method using an

instrumental case study. Instrumental case studies

(Stake, 2005) aim to provide an in-depth

understanding or re-explanation about the process of

generalization. This approach examines an issue

using a case-study as an instrument to provide a

detailed description. The case-study approach allows

victims of sexual abuse to describe their condition

before and after the traumatic event. This method

can highlight changes in more detail compared to

quantitative methods (Sagatun, 2015).

The subject of this research were children and

adolescents who have experienced sexual violence

and are showing an indication of PTSD. The

inclusion criteria are as follows:

1) Children between the age of 11 to 16 years old.

This is the stage of formal operations.

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

284

2) Experience of sexual violation during the last

year to avoid biased information (Derivois, et al.,

2014; Usami, et al., 2014).

3) Experience of PTSD. The diagnosis of PTSD

was performed on the basis of preliminary

assessment through interviews, observations, and

Child PTSD Scale Symptoms for DSM V (CPSS

V scale).

4) Willingness to be involved in this research and

share their experience as victims of sexual

violence with PTSD.

This research used interviews as the main

method with observation and documentation as

supporting methods.

Creswell (2007) stated that there are four stages

in data analysis along with its interpretation in case

study research. The stages of data analysis

conducted with categorical aggregation and direct

interpretation, through the process of validity is data

triangulation. According to Stake (1995),

triangulation pattern should be used in case studies,

for two essential reasons: 1) Case studies are

oriented towards the disclosure of the "peculiarities"

and "complexity" of a social event or phenomenon.

Therefore, it takes various categories of information

or data that cannot be collected by only one method;

and 2) The credibility of case studies will reach a

high level if the data collection process combines a

number of methods that complement each other or

cover each other's weaknesses.

3 RESULTS

Most children who have experienced sexual violence

have traits of a psychological disorder called PTSD.

Symptoms include intense fear, increased anxiety,

and quietness after a traumatic event. Based on the

cognitive point of view, PTSD is associated with the

tendency to pay more attention to negative stimuli,

to interpret ambiguous information as a threat, and

fear of such events reoccurring in the future. Our

findings reveal that the dynamics of PTSD occur in

five stages: 1) Traumatic Exposure; 2) Excessive

Negative Appraisal; 3) Personality; 4) Strong

Emotion; and 5) Social Isolation.

3.1 Traumatic Event

Zoladz (2013) states that a person experiencing

interpersonal trauma, such as sexual violence, would

be more likely to develop PTSD compared to people

exposed to non-traumatized events (e.g., accidents

and natural disasters). Kessler (2017) agrees with

this statement and states that 70.4% of respondents

have experienced lifelong trauma. Traumas caused

by interpersonal violence with the highest risk are

rape (13.1%), other sexual violence (15.1%),

stalking on the street (9.8%), and the unexpected

death of loved ones (11.6%). We examined

symptoms shown by 13 victims of sexual violence.

Participants were assessed using observation,

research interviews and the Children’s Post-

Traumatic Stress Disorder Symptom Scale (CPSS

V). Four out of 13 participants suffered from severe

PTSD: severe CD PTSD (P1); severe EF PTSD

(P2); OP (P3); ST (P4). These participants

experienced sexual violation with threat. Here are

the results of the interview:

“Mr. N sodomized me. At first I didn’t want to do it, but he

forced me. He groped my body when I was sleeping after

reading Quran after Isha prayer. He said that if I scream,

I will embarrass myself, so I kept quiet.” (P1.2003.008/18-

24)

“I didn’t know either of them. The first person was an

angkot driver. He said that he would drive me home. I said

yes, but he ended up bringing me to a rice field and raped

me.” (P2.1704.009/16-22)

“Yes, and the second person was someone riding a

bicycle. I didn’t know him, but he wore transparent

helmet. He urged me to go to a rice field and raped me

there.” (P2.1704.010/23-30)

“In the night, Mr. N. groped and grabbed my butt. I was

shocked and tried to resist, but he was stronger than me.

He also intimidated me.” (P3.2103.006/19-29)

“I was raped on a table when no one was around. I didn’t

want to do it anymore, but he forced me (crying).”

(P4.2404.013/21-23)

The interview results of the four participants

revealed that they had received threats when they

were victims of sexual violence. The first participant

(P1) was sodomized more than three years ago when

he was in elementary school. The second participant

(P2) was raped twice: 1) When she was at seventh

grade, the perpetrator was a public transportation

driver; and 2) A year after the first assault, she was

raped by a man who wore a helmet. Both assaults

were carried out by strangers in a rice field. The

third participant (P3) was sodomized by a Qur’an

teacher. P3 was invited to stay over in a mushola

[small mosque]. However, the teacher assaulted him

in the middle of the night. P3 tried to fight back but

Mr. N was more powerful than him. The fourth

participant (P4) was assaulted and threatened. The

perpetrator was her Quran teacher whom she has

known since she was five years old. The traumatic

exposure continues because of the threats she

receives from the family.

The Dynamics of Post-traumatic Stress Disorder among Sexual Violence Victims

285

3.2 Negative Appraisal

Ehlers and Clark (2000) stated that PTSD is a

normal reaction from traumatic events. The

development process of PTSD is influenced by

external factors (e.g., dangerous environment),

causing victims to experience excessive negative

thoughts and anxiety. It was perceived by the

participants as follows:

“All of my brothers and sisters hate and blame me. I’m the

one who made my mother die. This is all my fault. I’m sad,

ma’am (P1 hung his head down in embarrassment)”

(P1.2003.022/68-76)

“Yes, I’m already ruined. I have no future. I did not go to

school and has nothing to do, so there is no future for me.

(P21704.071/223-226).

“Now I’m afraid to know men because most of them are

bad people.” (P2.1704.030/81-85)

“I feel miserable because of that incident. I have no future

and many people hate me.” (P3.2103.020/66-68)

“My future has been ruined. I also put shame on my

family. It is very shameful. I am also uncomfortable of

going to school, I have no purpose.” (P4.2404.040/108-

111)

“That incident destroyed my hopes. I don’t have anyone to

rely on. If I am a glass, I’ve been broken to pieces.”

(P4.2404.032/82-84)

The interview results of the four participants

reveal that traumatic exposure results in an excessive

negative judgment, especially for their future. Four

participants thought that their future had been

destroyed. They no longer had a purpose in life and

felt unable to live their future life after the sexual

violence they experienced.

3.3 Personality

Schiraldi (2000) concludes that personality could be

considered as a trigger factor of PTSD. Personality

traits, such as pessimism, being closed-off, self-

blame, and denial are vulnerable traits of people who

experience PTSD. The following interview excerpts

support this argument:

“I once wanted to tell someone, but I was afraid of being

scolded. I also didn’t know the previous stories. People

told me that I am quiet. I was just afraid that they would

interrogate me. This is all my fault. This happened

because I’m such a fool.” (P1.2003.004/6-12).

“I am a disgrace, if it’s already out then there is nothing

to do.” (P2.1704.044/146-147).

“That’s right, I am already a bad woman, and people said

I am a bad liar. That’s how I am.” (P3.2103.041/153-

155).

“I want to talk to someone, but… I am afraid I can’t be

open to people, even my siblings don’t understand. I am

ashamed, moreover if I tell this story.” (P4.2404.047/130-

132).

The interview results indicate that all participants

considered themselves having a closed and shy

personality, preventing them to find the courage to

express their thoughts and feelings after being

abused. Self-disclosure is important for sexual abuse

victims. This statement is in line with a study

conducted by Purves (2004) who stated that self-

disclosure has an important emotional role in

managing traumatic experience. Self-disclosure is

alleged to release feelings of guilt and anxiety in

individuals experiencing traumatic exposure

(Calhoun and Acocella, 1990).

In addition to personality vulnerabilities (e.g.,

pessimism and shyness), intelligence factors also

affect the development of PTSD. This is supported

by Macklin et al. (1998) who reveal that high-

intelligence acts as a protective factor. It is

associated with better coping skills. The following

interview excerpts support this argument:

“That’s right, my grades have failed two or three times, so

I grew up by myself. I decided to go to a boarding school.

(P3.2103.027/103-106).

“That’s okay, Miss. People don’t believe that I was forced.

They assume that I’m a bad and stupid person. I have bad

grades because I often skipped school with my friends.

They persuaded me.” (P3.2103.004/5-16)

3.4 Strong Emotion

In addition to external factors, Ehlers and Clark

(2000) state that victims of traumatic exposure

consider themselves to have no ability. It could be

observed through strong emotion such as shyness,

inferiority, and isolation. This argument is consistent

with the results of data collection as follows:

“My siblings don’t like me, but I don’t really know. All of

my siblings blame me. I was the one who made my mother

die… She was sick because she thought about my problem.

My siblings said I was the cause…everything is my

mistake, I am sad. (P1 looking down in shame)”

(P1.2003.022/68-76).

“I’ve put my family to shame. My father didn’t know. If he

knew, I would be expelled from home. (P2.1704.032/105-

106).

“Yes… I stole a printer in my elementary school. My

friend, A, persuaded me but it was still my mistake. Most

people think I have no future. Sometimes I recall that

incident when I’m alone.” (P3.2103.035/133-139)

I usually hang out with my friends, drinking, or smoking. I

also have difficulty sleeping.” (P3.2103.037/143-145).

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

286

The four participants thought that the incident

was their mistake, particularly that they have put

shame on their families. In fact, P4 was intent on

committing suicide out of embarrassment, like in the

results of the following observations:

“He/she sent a message to his/her aunt, ‘I miss father; I

also want to meet mother K (his/her biological mother). I

also want to meet them, to go together and loved by them’.

Since a child, I was never loved by father. Mother, I don’t

want to live in this world anymore.” (P4).

3.5 Social Isolation

Martine, Hebert, et al. (2016) reveal that over half of

sexually abused children were reportedly bullied by

their friends (60%), and 51% had verbal disorders

and experienced physical abuse from their

colleagues at school (35%). This allows the victim to

experience up to three-times the clinical level of

dissociation and PTSD symptoms. This argument is

also expressed by McFarlane et al. (2001), who state

that PTSD symptoms greatly disrupt attachment and

intimate behavior, leading to widespread negative

effects on interpersonal relationships and a decline

in social functioning. These arguments are reflected

in the following interview excerpts:

“It’s different. The way they look at me was different.

Hate, friends who used to be close to me no longer wants

to meet me. It’s different.” (P1.2003.030/98-101).

“They stayed away... my siblings also stayed away from

me.”(P2.1704.041/128).

“Don’t hang out with P3, he/she will rape you,” they see

me as a trash. No one wants to talk to me. It’s the reason I

don’t want to go to school.” (P3.2103.026/96-102).

“My teacher used to say harsh words to me. I am so sad.

All of my friends stay away, they know about that

incident.” (P4.2404.012/18-20).

The examination results reveal that all

participants were often bullied by their friends at

home and school. They tried avoiding other people

and went as far as to drop out of school and isolate

themselves at home. Victims of sexual abuse also

received minimal support from their families and

teachers. They tended to be asked questions that

cornered them, causing them to feel blamed for

the

incident.

The interview excerpts above describe how

traumatic events experienced by the victims

influence the way they value themselves, their lives,

and future. The more severe and the longer that

victims experience traumatic events, the more

negative they value themselves, their lives and their

future. The assessment is influenced by their

personality or personal tendencies. Children with

low intelligence tend to be less effective in choosing

coping strategies, preferring to escape from

problems or becoming addicted to alcohol.

Furthermore, pessimistic and closed personalities

will create strong emotions such as extreme guilt,

excessive embarrassment, and sadness.

These emotions affect children’s social lives,

because they tend to distance themselves from

communities due to being verbally or physically

bullied by some community members. The stages

above are dynamics of PTSD, which can be seen

from several symptoms, such as re-experiencing,

arousal, avoidance, negative mood, and cognition.

4 CONCLUSION

Our findings reveal that PTSD dynamics in child

sexual abuse victims consists of five processes,

namely: 1) Traumatic exposure: the severity of

sexual violence exposure experienced by

participants; 2) Excessive negative judgments:

participants assume that the sexual abuse has

destroyed their lives, leaving them with no future; 3)

Personality: individuals’ susceptibility contributes to

the formation of the next phase; 4) Strong emotions,

such as feelings of guilt, shame, and sadness; and 5)

Social isolation: participants experience alienation

and tend to avoid the community due to bullying.

The results are consistent with a study conducted

by William (2006) who found that PTSD dynamic is

cognitively described through individual

personalities and environments in the social context.

PTSD cognitive dynamic can be illustrated through

the participants’ assessment of their sexual abuse

experiences, which is influenced by personality,

emotional state, and coping strategies. Furthermore,

Ehlers and Clark (2000) revealed that PTSD is a

common reaction to traumatic events. As a

consequence, these factors appear: excessive

negative judgment and memory disruption to

traumatic exposure and past historical memories.

Furthermore, this study is expected to contribute

in explaining the dynamics of PTSD among sexual

abuse victims. Therefore, the theoretical concept of

PTSD can be applied in children or adolescents who

have experienced sexual abuse, particularly in

Indonesia. It is also expected to provide discourse,

allowing child sexual abuse victims to build positive

coping strategies against PTSD. In addition, it can

instill awareness about the importance of being open

and alert to avoid traumatic experiences.

The Dynamics of Post-traumatic Stress Disorder among Sexual Violence Victims

287

The results of this study can provide an overview

or discourse for the families of the victims about the

importance of family support, providing information

on the behavioral changes experienced by sexual

abuse victims. This is particularly valuable to

preventive efforts against the risk factors of PTSD. It

also provides knowledge about the importance of

community and school support around the victims

after such a traumatic experience in preventing

prolonged trauma or PTSD.

In the future, this research is expected to be

utilized as a basis to develop a wider and deeper

assessment of the PTSD concept, particularly among

child sexual abuse victims.

ACKNOWLEDGMENTS

This research was supported by Direktorat Riset and

Pengabdian Masyarakat, Kementerian Riset,

Tekhnologi and Pendidikan Tinggi. We thank our

colleagues from the Program Study of Psychology at

Trunojoyo University and the Psychology Faculty of

Airlangga University, which provided insight and

expertise that greatly assisted this research.

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