SII 20Guidance 201 20Ethical 20Discussions 20of 20Trauma

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					                                                                   Ethical and effective discussions of trauma



… some responses from the community, such as “there is no violence against women… in
fact they are protected,” were taken at face value.

… the most problematic tool was the questionnaire for the survey, which included sensitive
questions related to violence.

“If I speak out, won’t I get a beating from my husband?”

       The first two comments above are from CARE staff investigating gender-based
violence in India; the third quote comes from a woman participating in the project (1, pp.
25,26,46)1. The statements reflect the challenges of researching violence against women
and other forms of trauma2. Researchers are often presented with comments denying the
presence of trauma in the community. The tools they employ may be inappropriate to elicit
disclosure of trauma. For participants, a range of barriers and fears prevent full disclosure
of trauma and other painful experiences.

        This report provides recommendations for how to elicit conversations of traumatic
and painful experiences among women by overcoming barriers to disclosure. The
recommendations address a range of reasons for nondisclosure of trauma: fear of reprisal
by perpetrators of the trauma, social mores against discussion of sensitive subjects,
feelings of shame and self-blame, and psychological distress caused by the trauma (2). For
the research staff, the recommendations help to alleviate some of the difficulty and
increase the skills involved in discussions of trauma.

        The recommendations presented in this report encourage disclosure of trauma and
are designed to promote autonomy3 and dignity of women through an action research
framework (3). Research with traumatized women can be extractive and further reinforce a
woman‟s lack of power (4, p.79). To counter this, every effort should be made to empower
women in the research process. Though it is impossible to fully balance power between
staff and participants based on the inherent qualities of research, the researcher should be
aware of power differentials and help maximize the autonomy of the participant. Action
research facilitates autonomy through development of direct applications for participants
and the community (5-8).

  All parenthetical numbers refer to literature sources included in the bibliography.
  Throughout this report the term „research‟ will refer to any actions by the Impact Measurement and
Learning Team. „Researcher‟ is used to refer to any individual involved ranging from planners to those
persons eliciting discussions of trauma. Additionally, although the examples presented in this report focus on
trauma among women, these recommendations can be applied to research among men.
  Autonomy refers to the participant having control in the research setting. “Respecting others as autonomous
individuals involves recognizing them as essentially self-governing agents, capable of exercising competent
self-determination in the selection of choices and actions. Autonomy implies that these choices are not
coerced or constrained by other people and rests on an assumption of individual competence,”(3).

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         These recommendations are drawn from discussions with CARE staff and a
literature review. Though most existing literature on women and trauma focuses only on
domestic violence, recommendations from the literature can be applied to a range of
traumatic experiences, including but not limited to sexual and other physical violence
outside the domestic sphere perpetrated by individuals in power such as employers, police,
soldiers, community leaders, refugee leaders, religious leaders, politicians, physicians, or
humanitarian workers; conflict-based violence; political-based torture; stigmatization or
social exclusion for commercial sex workers; denial of basic human rights, e.g. access to
education, political participation; and chronic trauma, e.g. inability to feed or provide
healthcare for children.4

        Barriers to discussing the traumatic experiences are discussed below, followed by
the recommendations for overcoming them. Safety issues that must be addressed during
trauma research are compiled in a second report, “Recommendations Regarding Psychological
and Physical Safety.”



        The quote from a CARE participant at beginning of this report illustrates the
attitude of many women toward participation in activities outside the domestic sphere.
Participants fail to disclose their experiences because they fear that their discussion is not
confidential and will result in reprisal by the original perpetrator of the trauma. An
individual‟s perception of safety has been cited by some as the most important predictor of
disclosure (9). Additionally, women fear for the safety of their children and the researcher
if the perpetrator were to discover the disclosure (10). In communities where independent
action of women is restricted without supervision of male relatives, they may fear for their
safety by simply participating in the research study.


        Despite attempts to assure confidentiality and safety, a participant may not disclose
her experiences because she feels that the events are too personal and evoke shame (9).
Shame results when “abuse symbolizes the victim‟s public failure in achieving intimate,
romantic, and familial ideals and dreams,” (11). Shame is associated with rationalizing
violent experiences, staying in abusive relationships, maintaining the secret of being
abused, failing to seek formal help, and nondisclosure in the research setting (11-13). Any
behavior that appears judgmental by the researcher can reinforce feelings of shame and
impair disclosure.

Psychological distress/ mental health (14)

         Trauma evokes reactions ranging from moderate stress to clinical psychiatric
illness. Understanding the various reactions to trauma is crucial for identifying and

    Definitions for specific forms of traumatic experiences are compiled in Appendix A.

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working with survivors of trauma because psychological distress can be a barrier to
disclosure. Participants with post-traumatic stress disorder (PTSD) fail to disclose because
of impaired memory or agitation and anxiety upon discussing the event. Depressed
participants will not easily disclose experiences because of augmented guilt and feelings of
low self-worth that increase shame and reduce willingness for disclose. Another
psychological reaction to trauma is „somatization‟; somatization occurs when individuals
do not discuss or address their traumatic experience but instead fixate on bodily complaints
such as headaches, stomachaches, and fatigue.

Stigmatizing labels (15-19)

        Participants fear that by disclosing sensitive experiences and accompanying
psychological distress, they are susceptible to receiving a stigmatizing label by the
researcher or community. They assume that enrollment in these studies would lead the
community to label them as victims of rape and incest then treat them in a further
marginalized fashion. Additionally, participants do not disclose the psychological distress
associated with their trauma for fear of being labeled as „mad‟. Because of this, many
cultural groups advance attitudes of stoicism in the face of trauma.

Community acceptance and promotion of women’s traumatic experiences

        Social and cultural norms can perpetuate the gendered distribution of trauma. Often
communities view violence and discrimination against women as normal or acceptable (1).
Or, as evidenced by the quote above, they deny its existence. Furthermore, the individuals
charged with protection may be the perpetrators. For example, although police are
theoretically sources of protection for women, police often allow if not perpetrate violence
against women. Health care workers also should be advocates for women who come to
health settings as survivors of violence; however, physicians can be complicit with
perpetrators of political violence and they often blame or judge survivors of violence (20).
Women themselves can propagate beliefs of a woman‟s culpability in trauma,
discrimination, and violence.

Lack of understanding

        As with any research, the lack of disclosure may be the result of not understanding
details of the research project (9). For example, unless a dialogue about „women‟s rights,‟
„human rights,‟ „food security,‟ and „gender equity‟ has begun in a community, it may be
difficult to initiate discussion about violations of these rights. Language can also impact
understanding. Participants may only associate terms such as „rape‟ to forced intercourse
with a stranger but not use the word with reference to marriage or incest. This is an
opportunity for CARE to conduct action research by raising consciousness about these
issues while simultaneously researching them.

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        The following are recommendations for how CARE research staff can overcome
barriers to communication and to elicit conversations about trauma among women while
promoting their autonomy and dignity:

1. Preparation for research should include formation of partnerships with local
organizations whose mission is to advance women’s rights, safety, and health. CARE
should endeavor to increase capacity in these areas in communities without existing

The United Nations and other groups have advocated for the establishment of the
following alliances before ethical trauma research can begin (2, 21):

      Trusted security personnel and legal advocates to address fear of reprisal by
       perpetrators of abuse;
      Counselors, traditional healers, and other individual trained in psychological needs
       of traumatized persons to help alleviate psychological distress;
      Women‟s rights groups to provide information about existing resistance within the
       community and strategies to surmount barriers to community support for ending
       trauma against women;
      Local leaders and community-based organizations to help with research planning,
       e.g., the identification of local language appropriate for sensitive topics as well as
       highlighting stigmatizing labels that should be avoided (2, p.51); and
      Women‟s groups, health care workers, and traditional healers to identify potential
       participants willing to disclose personal experiences (20, 22)

Realistically, it is not always possible to have local partners in all these arenas; it is
especially difficult in many of the resource-poor communities where CARE is active.
However, CARE is fortunate to be able to facilitate the development of women‟s groups,
legal aid, human rights groups, and health programs. Through CARE resources, local
individuals and groups with interest in women‟s rights can gain capacity to serve the
community. Furthermore, through action research CARE can foster the development of
skills in health, rights, and community development. Ultimately, it is recommended that
any project with trauma incorporate strategies for development of the above resources if
they do not already exist.

2. Research staff should receive specific and intensive training highlighting gender-
sensitivity issues and the specific needs of trauma survivors.

         A review of trauma literature highlights the need to address program staff‟s own
experiences and perceptions of trauma, be based on a human rights framework, and
promote investment all program staff, not just interviewers (23, p. iv). Furthermore, ideally
all staff should undergo direct training from specialists in trauma; a review of programs
finds that training of trainers‟ programs are not as effective for skill development (23,
p.33). The length of staff training is associated with the amount of disclosure of trauma by

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participants (9). Specifically, individuals trained for at least one week in gender issues and
trauma were more successful in eliciting disclosure as compared with staff trained for only
one or three days. Researchers should be educated about the research focus and particularly
about the referral system for security, legal, and health needs so that participants can fully
utilize these resources. Researchers involved in gender-based violence often express
distress at not being able to help participants in dangerous and painful situations (9). By
having staff fully educated about resources, they will feel more equipped to help women
they interview. (See Appendix B: Training for trauma research and Checklist of training

3. Recruitment strategies should maximize autonomy and disclosure.

        Traditional sampling protocols (household- and clinic-based) have been criticized
because they do not give women adequate control to decline participation in a study,
especially within cultural groups where women are expected to respond affirmatively to
requests of them (10). To circumvent this, feminist researchers have advocated voluntary
presentation and recruitment strategies (24). Woman can be informed about the project at a
group meeting or at community health center, and then told whom to contact if they wish
to take part. Individuals are not forced to partake in the study through this approach.
Regardless of strategy chosen, only one woman per household should be sampled to
enhance confidentiality (9).

         Respondent driven sampling, a derivative of snowball sampling, is a form of
voluntary recruitment (25). A participant is asked to inform others about the study. The
participant explains to others about the study and how to enroll. Researchers do not
directly confront potential participants, rather the recruitment is done through peers. Thus
respondent driven sampling promotes autonomy, and the individuals who do enroll are
more prepared for disclosure. Respondent driven sampling with a large enough sample is
as statistically significant as other random sampling procedures for prevalence studies (26).
Because of its statistical accuracy and ability to recruit difficult populations the Center for
Disease Control and Prevention has been employing respondent driven sampling
worldwide (27). (See Appendix C: Respondent Driven Sampling.)

4. Research staff should disclose research purpose to potential participants and local
partners. Disclosure of research purpose should be broad enough that it does not
exclusively require personal disclosure of trauma.

        Disclosure of the research purpose fosters autonomy by enabling participants to
make more informed decisions about participating and how their information will be used.
Typically, survivors of trauma become more invested in research through understanding
that their disclosure may help others in similar positions (24). Disclosure of research
purpose should also occur at the community level to foster trust among community leaders.
Studies that disclosed research purpose to the community and gained trust from respected
community leaders, religious figures, health professionals and traditional healers
encouraged more effective and widespread participation (2, p.17, 22).

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        Disclosure of the research purpose, however, should be broad enough that a
participant feels that she may have information to offer that could be of use without
specifically describing personally-experienced violence. For example, disclosure of
research purpose could include obtaining information regarding gender-differences in
negotiating styles, community roles, emotions, behaviors, and body perception. These
more general topics allow for discussion that does not require individual disclosure.
Autonomy should also be promoted during disclosure of the research by asking the
participant about her reasons for being involved with the study and what she hopes to
obtain from the experience (24, 28).

5. Safety and confidentiality should be explained to participants.5

         After describing the purpose of the study, it is important to emphasize that safety
has been considered during the design period. The participant should be aware that every
effort is made to keep specific information confidential from the community and
perpetrators of violence. After discussing the purpose of the research, the researcher can
explain that based on the research goals only certain information from the interview will be
used publicly. Furthermore, identifying information will not be included unless explicitly
approved by the participant. Studies without adequate safety do not produce accurate
results since disclosure is greatly impaired when participants do not feel safe. Ultimately,
the World Health Organization and other groups have come to the conclusion that research
on gender-based trauma should only be conducted when basic safety precautions can be
addressed (9).

6. Gender-matched and/or psychologically trained personnel should be employed.

        Many effective research techniques for discussion of trauma are related to comfort.
Researchers that are able to create an atmosphere of comfort are more likely to have
participants disclose trauma (9). Different interview protocols and styles may help
encourage disclosure later in the interview for participants who are initially reluctant.
Researchers recommend that gender-matching of participant and interviewer be employed
whenever possible (9). Work with female survivors of torture, however, has shown that the
level of training and expertise of the researcher can outweigh gender differences in
influencing disclosure (14). For example, survivors of rape have been known not to say
anything to women without clinical training but to disclose to a physician, even if male.
Similarly, men trained in counseling for gender-based violence may be successful
researchers if they demonstrate empathy. Studies of gender differences in attitudes toward
gender-based violence have found that although male-female differences were present at
lower training levels with less educated men more likely to blame women for gender-based
violence, attitudes were not different at higher levels of education, training, and experience
(29). Thus, although gender-matching should be employed whenever possible for female
participants, a man trained in gender-sensitivity and trauma research should be employed if
no woman of equal training and experience is available.

  The pragmatics of arranging safety and confidentiality during research is discussed in the accompanying
report, “Recommendations for Psychological and Physical Safety.”

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7. Prior to discussing personal trauma or stigmatized topics, research staff should
begin dialogues with more general, less personal inquiries and activities.

        Participants are unlikely to feel immediately comfortable discussing personal
trauma at the outset. A rapport including sense of trust and lack of judgment can be
established by first discussing less sensitive issues (See Appendix D: Initiation of discussion
for trauma experienced by women). General issues relating to family and community
dynamics are an effective starting point. Discussions could include access to financial and
material resources, participation in household or community decision-making, negotiation
styles, general security in the community or refugee/displaced-persons camp, physical
health, and child care (9).

        Another approach is to ask about trauma in other communities. The Center for
Disease Control and Prevention has used this approach effectively in Afghanistan by
asking women about gender-based violence in and outside their community, rather than
inquiring about personal experiences (30). One can also ask about services and resources
available in the community to persons who have experienced trauma (2).

        Asking about physical health can also facilitate disclosure of trauma (31).
Researchers should ask participants about quality of their health recently including a range
of health issues: general aches and pains especially pelvic pain, sleeping problems,
gynecologic health issues, physical injuries, and gastrointestinal health. If a participant
describes or reveals multiple physical injuries of different ages especially injuries such as
fingernail scratches, bite marks, cigarette burns, rope burns, forearm bruising, and forearm
fractures, this is strongly suggestive of ongoing physical violence.

        Although discussions of mental health are often a barrier to disclosure because of
fear of stigmatizing labels, discussion of idioms of distress can be used to segue to personal
trauma histories (32). Idioms of distress are local expressions that are often connected to
trauma but do not carry the stigmatization of a mental illness (33). The symptoms are
general complaints such as weakness, back pain, inability to work, difficulty concentrating,
poor appetite, headaches, and insomnia. Examples of these local expressions include dhat
in India, kesambet in Bali, nervios and susto in Latin America, yadargaa in Mongolia, and
hwa-byung in Korea (22, 34, 35).

        A final suggestion is to use activities such as community mapping, body mapping,
pile sorts, and games to soften barriers to disclosure. Work by CARE India has found that
body mapping is an effective transitional activity. In body mapping, participants describe
how different parts of the body lead to pleasurable versus painful experiences. Adolescent
girls provided unsolicited discussions of trauma when asked about painful experiences
with the body map. Although certain methods such as body mapping may be effective for
eliciting trauma narratives, they may also present a risk for the participant because of
community or family disapproval of the activity (See “Recommendations for
Psychological and Physical Safety”). Any alternative methods such as body mapping need
to be reviewed with local stakeholders to address the potential risk of harm.

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8. When transitioning to discussions of personal experiences, participants should be
reassured of confidentiality of the interview and questions should be phrased in a
manner that makes the participant aware that these are experiences that other
women also suffer.

        If participants do not disclose trauma histories when discussing the above topics,
the next step is to directly ask about experiences. These questions should be general and
open-ended as well as not stigmatizing. When asking about personal experiences, the
participant should be reminded of the confidential nature of the research as well as the
significance of disclosure for individual and community purposes. (See Appendix E:
Transition to personal experience with trauma.)

9. Research staff should ask specific questions about physical and sexual trauma.

        In the transition from the less morally charged subjects toward discussion of
gender-based violence, multiple studies have shown the need to ask specific questions
about actions that have occurred rather than simply asking, “Have you ever been abused?”
(9). Because terms such as „rape‟, „incest‟, and „wife-battering‟ carry social and moral
stigmatization, a participant may choose not to answer „yes‟ to these questions. Also, a
woman who is forced to have sex with her husband may not consider this „rape‟ despite the
use of physical force and threats. Thus a questions regarding “forced or unwanted sexual
intercourse with your husband,” has been shown to provide a more accurate picture of
marital relations than using broader terms such as „rape‟ and „abuse‟ (24). The same
applies with regard to asking about specific actions rather than inquiring about “verbal and
emotional abuse” (21, p.20).

        Regarding specific questions, project staff for CARE India found it difficult to ask
a long list of specific detailed questions about abuse as evidenced by the quote in the
introduction (1). Based on the findings of the CARE India project and other research with
surveys, the list of questions can be simplified to a few “gateway” questions. Gateways
questions assess more common forms of trauma. If individuals answer „yes‟ to any of these
questions, then additional specific questions can be asked. If they answer „no‟, then the
researcher can move on to other issues. The questions below are exemplar gateway
inquiries for their respective subject:

      Physical violence: Has someone ever hit you? Has some ever kicked you?
      Sexual violence: Has someone ever forced you to have sex?
      Emotional abuse: Has someone ever insulted you?
      Mobility: Has someone ever limited where you could go?
      Economic: Has someone ever spent money you earned against your wishes?

        Another caveat to asking about specific actions relates to use of general language
by the participant. If a participant reports that she was „abused‟ as a child or by a current
intimate partner, it is best to wait until experiences are described before pressing for details
of the specific type of „abuse‟. Do not interrupt the participant to acquire these specifics.
Rather when there is a period of silence later in the interview, the researcher can ask what

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kind of abuse occurred (24), for example, “Abuse takes many forms, would be comfortable
telling me what kind of abuse occurred during your relationship.” The research should not
interrupt a description to clarify if the abuse was verbal degradation versus physical or
sexual or asking specific details such as anal versus oral versus vaginal rape.

       Studies have also found that repeating inquiries about abuse in different manners
throughout an interview increases probability of disclosure (9). Women who clearly deny
any violence initially in an interview may likely disclose a long history of abuse as they
become more comfortable with the researcher.

10. Research staff should offer encouragement, acknowledge the participant’s
emotional state, avoid obstructive comments, redirect conversation only under special
circumstances, and adapt verbal and non-verbal communication techniques to the
local context (36, p. 663).

        Once an individual has begun to disclose personal trauma, it is important to
continue to facilitate discussion and provide empathy. Attention to supportive language
including encouragement, reassurance, and acknowledging emotions is especially
important. Certain communication techniques can help to facilitate trust that the researcher
is involved and concerned (See Appendix F: General conversation techniques.)

       Obstructive comments are those that disrupt communication and damage a trusting
and empathic relationship between participant and researcher. Obstructive interventions
impair disclosure for various reasons. Compound questions create confusion about the
focus of inquiry. Judgmental questions increase shame and impair disclosure. Why
questions can exacerbate shame and should generally be saved for sessions with trained
psychological personnel. Minimization and dismissal of participant‟s concerns imply that
the event was not traumatic. Premature advice creates an image that the participant‟s
problems are easily solvable and exacerbates low self-esteem

         Redirection of a conversation has both beneficial and negative impact on
discussions depending on timing and use. If a participant is describing physical complaints,
it is more empathic and attentive to ask about how the physical complaints are affecting
daily life rather than abruptly transitioning to psychological distress related to a traumatic
experience. However, a severely depressed or a „somatizing‟ individual may focus
exclusively on somatic complaints to avoid discussion of psychological distress or
traumatic experiences.

        Nonverbal communication such as leaning toward the participant and making eye
contact facilitates empathy. Nonverbal communication can also be disruptive. Extreme
verbal expression such as displaying shock distances the researcher and participant.

       Ultimately, both verbal and nonverbal communication techniques need to be
adapted to the local setting.

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11. Research staff should adopt an attitude of conscious partiality to encourage trust
and promote positive mental health.

        Research with traumatized populations, particularly survivors of GBV is unique
from many other forms of research. Most other research fields have an unstated preference
for detached, emotionally distant, so-called „objective‟ approaches. However, from both an
efficacy and ethics standpoint, this is not desirable for research in traumatized populations.
Rather a “conscious partiality,” an empathic and emotionally supporting approach by the
researcher, is needed (24). From an efficacy standpoint, studies of GBV conducted with
emotionally-unresponsive interviewers show significant underreporting of traumatic
experiences; conversely, emotionally supportive interviewers who are seen as allies are
more likely to soften barriers to disclosure and obtain accurate, but not overestimated,
results (9).

        Conscious partiality includes acknowledging that the discrimination and violence
experienced by the participant is wrong and that the participant is not to blame. For
example, women who suffer the chronic trauma of not being able to feed or educate their
children may attribute this to personal failure rather than resource allocation within her
community. Communities also highlight attitudes that blame the woman for rape. The
isolation and sense of personal weakness can be palliated through the researcher
empathizing or sympathizing with the participant and discouraging self-blame attitudes
toward the trauma (11). The combination of empathy expressed by research and alleviation
of blame and shame facilitates disclosure of experiences as well as psychological healing.

       Conscious partiality can also be demonstrated by expressing personal experience
(24). Researchers can relate that they are very familiar with the subject and interested in
addressing it. Researchers can also disclose some personal reasons for involvement in the
research during the interview. Personal disclosure cannot follow a stereotyped template.
Rather, each interaction between researcher and participant will require idiosyncratic
disclosure. If the researcher is from a different ethnic, cultural, or national background, it
may be useful to describe gender roles or GBV issues in one‟s own culture. This, however,
must be done with caution in a non-judgmental manner that does not imply blame or
prejudice toward the participant.

        Conscious partiality is an important area for the application of action research.
Conversations with CARE staff have revealed an attitude of fatalism among women
experiencing violence. By empathizing with the participant, a connection can be developed
to discuss healthy coping strategies for protection and prevention. An example of empathic
but action-oriented statements could include, “We have worked with many communities of
women and realize how difficult it is to address the way women are treated. However,
women have found strength and success in some approaches to change their situation.
Would you like to share some of the approaches that are used in your community?” then,
“Would you like me to mention some of the approaches used in other communities?” This
will hopefully initiate a conversation about improving the condition of the participant‟s life
and the lives of others in the community.

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12. Research staff should emphasize that psychological distress is a normal response
to trauma.

         Survivors of trauma are often embarrassed and frightened by the psychological
distress they feel in response to trauma. Survivors will attempt to mask the psychological
distress by not acknowledging or discussing the trauma itself. Researchers can address this
by emphasizing that psychological reactions to trauma are common and normal (33). By
„normalizing‟ the psychological trauma response, researchers can help a participant feel
less alienated and frightened. Participants are then more likely to discuss the distress and
feel emotionally safe. However, it is essential that while „normalizing‟ the psychological
response, researchers do not minimize the severity of distress of the traumatic event.


        Traumatic and painful life events are challenging but vital issues for research.
Participants are often reluctant to disclose their traumatic experiences within the context of
research studies. Participants will not disclose trauma when they feel that their safety, the
safety of their children, or even the safety of the researcher is jeopardized by reprisal of the
original perpetrator of the trauma. Shame and self-blame about the traumatic experiences
decreases willingness to openly admit that certain traumas have occurred. Psychological
distress resulting from the trauma can damage memory, concentration, and the motivation
to disclose traumatic experiences. The fear of being stigmatized by the community or by
the researcher exacerbates reluctance to reveal traumatic event. Community acceptance
and promotion of trauma and discrimination against women also decreases motivation to
openly discuss these issues. Lastly, a lack of understanding about rights, discrimination,
sexual issues, and purpose of the research does not facilitate disclosure.

        To address these barriers to disclosure of traumatic experience this report has
provided a number of recommendations compiled from a review of trauma literature as
well as conversations with CARE staff engaged in gender and trauma programs.

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1.    Preparation for research must include formation of local partnerships with
      organizations whose mission is to advance women‟s rights, safety, and health. CARE
      should endeavor to increase capacity in these areas in communities without existing

2.    Research staff should receive specific and intensive training highlighting gender-
      sensitivity issues and the specific needs of trauma survivors.

3.    Recruitment strategies should maximize autonomy and disclosure.

4.    Research staff should disclosure research purpose to potential participants and local
      partners. Disclosure of research purpose should be broad enough that it does not
      exclusively require personal disclosure of trauma.

5.    Safety and confidentiality measures should be explained to participants.

6.    Gender-matched and/or psychologically trained personnel should be employed.

7.    Prior to discussing personal trauma or stigmatized topics, research staff should begin
      dialogue with more general, less personal inquiries and activities.

8.    When transitioning to discussions of personal experiences, participants should be
      reassured of safety and confidentiality of the interview. Questions should be phrased
      in a manner that makes the participant aware that these are experiences that other
      women also suffer.

9.    Research staff should ask specific questions about physical and sexual traumas.

10. Research staff should offer encouragement, acknowledge the participant‟s emotional
    state, avoid obstructive comments, redirect conversation only under special
    circumstances, and adapt all verbal and non-verbal communication techniques to the
    local context.

11. Research staff should adopt an attitude of conscious partiality to encourage trust and
    promote positive mental health.

12.   Research staff should emphasize that psychological distress is a normal response to

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1.    RACHNA (2004) CARE India Gender Analysis Report, pp. 68 (India, CARE).
2.    Reproductive Health Response in Conflict Consortium (2004) Gender-based
      violence tools manual, pp. 207 (New York, Reproductive Health Response in
      Conflict Consortium).
3.    Sobocinski, M. R. (1990) Ethical principles in the counseling of gay and lesbian
      adolescents: Issues of autonomy, competence, and confidentiality, Professional
      Psychology: Research & Practice, 21, 240-247.
4.    Houskamp, B. (1994) Assessing and treating battered women: A clinical review of
      issues and approaches, in: Briere, J. (Ed.) Assessing and treating victims of
      violence, pp. 79-90 (San Francisco, Jossey-Bass).
5.    Greenfield, T. K., Zimmerman, R. & Center for Substance Abuse Prevention (U.S.)
      (1993) Experiences with community action projects new research in the prevention
      of alcohol and other drug problems (Rockville, MD, U.S. Dept. of Health and
      Human Services Public Health Service Substance Abuse and Mental Health
      Services Administration Center for Substance Abuse Prevention).
6.    McTaggart, R. & NetLibrary Inc. (1997) Participatory action research: international
      contexts and consequences (Albany, State University of New York Press).
7.    Radford, J., Friedberg, M. & Harne, L. (2000) Women, violence and strategies for
      action : feminist research, policy and practice (Buckingham [England] ;
      Philadelphia, PA, Open University Press).
8.    Holsti, K. J. & World Institute for Development Economics Research. (1997)
      Political sources of humanitarian emergencies (Helsinki, UNU/World Institute for
      Development Economics Research).
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Appendix A: Definitions for trauma research among women

To encourage effective research and disclosure it is important to develop a language
intelligible to participants, staff, and donor agencies. Definitions of trauma experienced by
women may differ significantly among donors, researchers, and participants. These
definitions should be discussed with local partners to develop and adjust language
effective for participants before effective research can be conducted.

        The RHRC (2, p.13-14) defines rape with reference to a non-consensual act of
“the invasion of any part of the body of the victim or of the perpetrator with a sexual organ,
or of the genital or anal opening of the victim with any part of the body by force, threat, or
coercion.” This can include rape of an adult female, rape of a minor, incest, gang rape
(multiple assailants), rape between husband and wife, and male rape/sodomy. Attempted
rape includes any of the above actions where penetration is attempted but not achieved.
The legal definition of sexual assault in the United States involves three criteria: carnal
knowledge, lack of consent, and compulsion or fear of harm (31).

Sexual abuse
       Sexual abuse includes “forced removal of clothing, forced kissing or forced
touching, or forcing someone to watch sexual acts,” (2, p.13-14).

Sexual exploitation
        Sexual exploitation “includes sexual coercion and manipulation by a person in a
position of power who uses that power to engage in sexual acts with a person who does
not have power,” (2, p.13-14). Humanitarian workers requiring sex in exchange for goods
and services, educators exchanging admission or passing scores for sex, refugee leaders
demanding sex for camp privileges, and soldiers/security workers providing supervision or
safe passage for sex are all examples of sexual exploitation.

Domestic violence/ intimate partner violence (2, p.13-14)
         Domestic violence is the standard term referring to violence among family
members with intimate partner violence specifically referring to spouses or other regular
partners that need not necessarily involve a sexual relationship. Violent actions include
slapping, hitting, beating, kicking, and use of weapons. Emotional abuse such as public
and private humiliation and degradation are facets of domestic violence as well as threats
to life. Abuse may also take the form of control and deprivation of a partner‟s access to
food, water, shelter, clothing, health care, and fertility (forced pregnancies and/or
abortions). Mothers-in-law, in addition to male relatives, are common perpetrators of
domestic violence because of daughter-in-law‟s perceived subordinate status in the

Denial of human rights and other forms of gender-based violence
        Trauma experienced by women can also take the form of political violence
manifest as myriad forms of discrimination. The United Nations Convention on the
Elimination of all Forms of Discrimination Against Women contains thirty articles outlining
equal treatment and protection of women under national and international legislation (37).
Articles include provisions for understanding of maternity as a social function, right to vote
and formulate government policy, minimum conditions for career and educational

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guidance, minimum requirements for employment and remuneration, the right to
protection of reproductive health in the workplace, and right to equal treatment under law
for marriage including choice of spouse, access to property, and child protection. The
RHRC provides illustrations of gender based political violence such as lack of education
for daughters, forced marriage, and prohibitions against women moving freely in a
community unaccompanied by a male relative (2, p.13-14).

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Appendix B: Training for trauma research and checklist of training items

      The Reproductive Health Response in Conflict Consortium has developed a 207-
       page manual which reviews assessment tools, program design tools, and program
       monitoring and evaluation tools. The text is entitled Gender-based Violence Tools
       Manual: For Assessment & Program Design, Monitoring & Evaluation in Conflict-
       affected Settings. For more information, see

      The International Center for Research on Women (ICRW) has conducted research
       throughout the world and has been involved in multiple collaborations with CARE.
       ICRW provides monitoring and evaluation consultants for women‟s issues
       including reproductive health, gender-sensitivity, food security, and violence. For
       more information, see

      The International Planned Parenthood Federation (IPPF) provides consultants for
       conducting training on gender-based violence sensitization with a strong focus on
       the role of personal experiences. For more information, see

      Physicians for Human Rights provide trainings for health professionals working
       with survivors of torture. The trainings are free and review gender-based violence,
       sexual violence as a form of torture, and psychological torture of women. For more
       information see under the Asylum heading. Training manuals
       covering psychological and physical trauma are available in PDF format free of
       charge on the website.

      The Trauma Research. Education, and Training Institute, Inc. (TREATI), a project
       of the Traumatic Stress Institute conducts international projects with trauma
       survivors. TREATI provides a training curriculum that has been employed in
       Rwanda. For more information, see

          Checklist for training staff for research on gender-based trauma

    Development of language and communication skills for discussion of gender and
       trauma in locally appropriate but non-judgmental manner
    Training is use of referral list for services needed by study participants
    Awareness raising of common staff reactions and distress that occur during
       research into gender-based trauma
    Exploring personal prejudices and stereotypes regarding gender and trauma (e.g.
       issues of blame in discrimination and sexual exploitation)
    Development of empathy and „conscious partiality‟ skills when working with
       survivors of gender-based trauma
    Development of basic skills in trauma debriefing for psychological distress
    Awareness raising of risk factors for violence including threat to participant and

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Appendix C: Respondent Driven Sampling

        Respondent driven sampling (RDS) is a derivation of snowball sampling that
provides statistical accuracy for prevalence studies and promotes more autonomy for
participants than traditional recruitment techniques (25-27, 38). RDS has been employed
many difficult to access populations, such HIV-infected individuals and intravenous drug
users. These populations, like traumatized women, are concerned about confidentiality in
their participation, an issue which RDS addresses.

        A study of users of the drug „ecstasy‟ (MDMA) employed RDS (39). The
researchers identified a range of individuals initially who self-identified as ecstasy users.
Within the ecstasy study, these original individuals—termed „seeds‟—were then asked to
identify three and only three other individuals who were also ecstasy users. Each
individual who then presented was interviewed then became a seed for three more
participants. By only allowing three recruits per seed, researchers reduce the bias typical
in snowball or chain sampling. Furthermore, the potential participants all enroll in the study
without coercion from research recruiters; this helps to promote autonomy.

       Within the framework of a CARE project or research study this would be
comparable to identifying a few women who are survivors of trauma as the initial seeds.
These women would then inform three acquaintances about the study and how to become
involved if the choose to do so. All three may enroll but this is not required because the
other seeds could produce more participants. Ultimately, women are recruiting other
women instead of project staff doing the enrollment.

        Statistical analyses of RDS reveal that by the forth recruitment wave, the bias of
the technique is reduced to the level of other accepted random sampling approaches (26).
With three recruited participants per original participant, four waves would total 81

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Appendix D: Initiation of discussion for trauma experienced by women (2, p.26)

1. What is the age of consent to marriage? What are the conditions of consent to marry?
2. In your community what are women‟s rights concerning education, property rights,
   divorce, child custody, and child support?
3. Is emergency contraception legal? What cost, under what circumstance, done by
4. If a woman in your community were having conflict with her husband (her boyfriend,
   her mother-in-law, her employer, a co-worker, a community leader, a policeman, a
   refugee leader, a humanitarian worker) to whom would she go for help?
5. If someone in your community were sexually harassed, to whom would she tell this?
6. How likely are the following groups to be victims of violence: women in female-headed
   households, unaccompanied children, minority groups, physically handicapped,
   mentally handicapped?
7. Where are women most endanger of physical assault in your community? Of sexual

Appendix E: Transition to personal experience with trauma (9, 21, p.20, 24)

1. Now I am going to ask you some questions regarding different kinds of violence that
    many of us as women have experienced in some way or another. We know that these
    are difficult subjects to talk about; however, sometimes talking about them can be a
    first step for making changes in our lives…
2. Now I would like to ask you some questions regarding some aspects of relationships
    among couples. I know that these questions are very personal, but I would like you to
    answer sincerely. I would also like to reassure you that your responses are completely
    confidential. No one else will know what we are about to discuss. When two people
    marry or live together they usually share good and bad times…
3. No matter how well a couple gets along, there are times when they disagree, get
    annoyed with each other, want different things from each other, or just have spats or
    fights because they are in a bad mood, are tired or for some other reason. Couples
    also have many different ways of trying to settle their differences…
4. Sometimes men in positions of power such as employers, police, soldiers,
    community/refugee leaders, humanitarian workers, or physicians use that power to
    force relationships with women. These relationships may involve forcing a woman to
    have sex with the man…
5. Since abuse and violence are so common in women‟s lives today, we have begun
    asking these questions of all women…
6. Does your partner (employer, community leader, security personnel) have any
    problems with alcohol, drugs, or gambling? How does it affect his behavior with you?
7. Sometimes when hear about physical health problems like yours, it‟s because
    somebody hit (kicked, burned, etc.) them. Did that happen to you?
8. Do you generally feel that you are in control when you have sex? Are there times
    when your partner may force you unexpectedly?
9. Did you have any upsetting sexual experiences as a child?
10. What is/was sex with your husband like?

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Appendix F: General conversation techniques (21, p.20)

FORM OF           PREFERRED                                        DISCOURAGED
Encouragement     I understand it is difficult to tell all the     You are not explaining your history
                  details, but I think you are describing          very clearly.
                  your situation very well.
Acknowledge       Even now I can tell that the experience is       Not responding to emotional
emotion           painful and brings tears to your eyes.           changes
Conscious         - No one deserves to be discriminated                             X
partiality        against. - You are not to blame for what
                  has happened. - You are not responsible
                  for other‟s actions.
                  - No one deserves to suffer violence.
Sexual violence   Has anyone ever forced you to have               Have you ever been raped?
                  sex? (employ culturally-acceptable terms
                  for vaginal, oral, and anal sex)
Physical          Pushing, slapping, throwing objects,             Have you been physically abused?
violence          kicking, hitting, using a knife or a gun,
                  and burning
Psychological/    - What emotions do you feel when you             Have you ever felt harmed
emotional         think about your partner?                        emotionally or psychologically by
violence          - Have you ever felt humiliated or               your partner or another person
                  ashamed in public by your partner?               important to you?
                  - Has your partner ever threatened or
                  ridiculed you in front of your children?
Redirection       I understand that your health is causing         I wouldn‟t worry about your finances
                  you distress now, could you tell me about        right now; let‟s talk about the
                  some of the experiences you had when             refugee leader‟s behavior toward
                  your health began to deteriorate?                you.
Compound          - Have you been hit by your mother-in-           Have you experienced violence from
questions         law?                                             your mother-in-law and your
                  - Have you been hit by your husband?             husband?
Minimization      Tell me more about your financial                I wouldn‟t worry about your finances
                  concerns.                                        right now; let‟s talk about the
                                                                   refugee leader‟s behavior toward
Judgmental                             X                           How do you think your family felt
questions                                                          about the policeman having sex with
Why questions                          X                           Why do you feel anxious when you
                                                                   go outside?
Premature                              X                           Why not just live just avoid going to
advice                                                             the part of town with the drunken
Nonverbal         If culturally-appropriate, employ eye            Yawning, checking the time, lack of
                  contact, reassuring touch, leaning toward        facial reactions, extreme reactions-
                  participant                                      shock

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