Survival after Sexual Violence and Genocide: Trauma and Healing for Yazidi Women in Northern Iraq

Introduction: In August 2014, the Yazidi community of Sinjar, in the Nineveh Governorate of Northern Iraq, was brutally targeted by the so-called Islamic State of Iraq and Syria (ISIS) for annihilation through murder, torture, and the systematic and premeditated use of rape and sexual slavery of Yazidi women. In 2016, the United Nations High Commissioner for Human Rights concluded that ISIS was committing genocide, crimes against humanity, and war crimes against Yazidis. Methods: Using current international literature, which includes reviews, qualitative interviews of survivors, and reports from medical and humanitarian actors, this paper explores the short and potentially long-term physical and mental health consequences of the extreme physical and sexual violence and atrocities perpetrated against Yazidi women. Results: Yazidi women survivors of kidnapping, sex slavery, and rape experienced significant levels of physical ailments, chronic pain, and mental health conditions. All women reported feelings of guilt, stress, insomnia, and severe flashbacks. The incidence of post-traumatic stress disorder (PTSD) ranged from 42% to 90%. Sixty-seven percent suffered from a somatoform disorder, 53% had depression, 39% experienced anxiety, and 28% suffered from dissociation. Conclusions: Sexual violence against women is a common tool systematically employed during wars and genocide. In recent ISIS attacks, intentional perpetration of mass rapes of women and execution of men was a strategy to destroy an entire population. PTSD and depression are How to cite this paper: Goodman, A., Bergbower, H., Perrotte, V. and Chaudhary, A. (2020) Survival after Sexual Violence and Genocide: Trauma and Healing for Yazidi Women in Northern Iraq. Health, 12, 612-628. https://doi.org/10.4236/health.2020.126046 Received: May 20, 2019 Accepted: June 15, 2020 Published: June 18, 2020 Copyright © 2020 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/


Introduction
In August 2014, the Yazidi community of Sinjar, in the Nineveh Governorate of Northern Iraq, was brutally targeted by the so-called Islamic State of Iraq and Syria (ISIS) for annihilation through murder, torture, and the systematic and premeditated use of rape and sexual slavery of Yazidi women [1] [2]. ISIS seized one-third of Iraq's territory causing massive displacement of its citizens, with more than 830,000 people being forced from their homes [3]. At least twenty historic sites of worship were destroyed [4]. The vast majority of Yazidis escaped to the Kurdistan region of North Iraq by late August 2014, but thousands of Yazidis were killed or kidnapped. In 2016, the United Nations High Commissioner for Human Rights concluded that ISIS was committing genocide, crimes against humanity, and war crimes against Yazidis [5].
This paper reviews the background, history, and religion of the Yazidi community who were targeted as a religious minority, and what is known about the actions of ISIS in the destruction and genocide of the Yazidi community, including an understanding of the number of Yazidi casualties of men, women, and children. The background and impact of ISIS, as terrorist actors, are summarized.
Using current international literature, which includes reviews, qualitative interviews of survivors, and reports from medical and humanitarian actors, this paper explores the short and potentially long-term physical and mental health consequences of the extreme physical and sexual violence and atrocities perpetrated against Yazidi women. Additionally, this report reviews the challenges these women face reintegrating into their surviving communities as part of the overall public health consequences of the ISIS reign of terror. database, followed by a PubMed search to identify more recent papers not currently indexed was used. The year 1990 was used as a beginning point, which was when the Balkan Wars led to the use of mass rape as a weapon of war [6]. In this time period, mass rape and sexual torture were internationally acknowledged as instruments of genocide for the first time [7]. References for included papers were crosschecked to ensure that all relevant literature was identified and included. A combination of terms describing Rape, Sexual Violence, Sexual slavery, trauma, rape as a weapon of war, post-traumatic stress, kidnapping, ISIS, ISIL, DAESH, and Yazidi was used in the search. An Internet search was done to identify pertinent news stories and reports documenting the events of the ISIS invasion of Northern Iraq from international humanitarian aid groups such as United Nations Refugee Agency, World Health Organization, Amnesty International, Human Rights Watch.
For inclusion, papers must have focused on sexual assault in the setting of war, conflict, and terror attacks. Articles on survivors of sexual assault, outcomes and therapeutic interventions were included. Papers were excluded if not available in English. Any study design was eligible for review. A final 75 references of papers and websites were included in this review. Figure 1 shows the PRISMA flowchart.

Yazidi Culture
Yazidis (also spelled Yezidi and Êzîdî) are a small ethnic-religious minority who speak the Northern Kurdish language, Kurmanji, and were historically spread over several Middle Eastern countries (Iraq, Syria, Turkey, Armenia). Their total population worldwide is estimated at 800,000 to 1,000,000 [8]. The largest Yazidi community of approximately 400,000 people lived in the area of Mount Sinjar in Northern Iraq [9]. The Yazidi religious monotheistic tradition has roots in pre-Islamic ancient Persian origin, with influences from Sufi mysticism, and contains elements of Zoroastrianism, Judaism, Christianity, and Islam. In Yazidi mythology, they are the people created by God who passed on commands to seven angels. The Peacock Angel, Melek Taus, is the chief angel. The religion is closed to outsiders and conversion is not allowed [10]. Yazidis who marry outside of the community are ostracized [8].
Religious rituals are inseparable from the cycle of nature. Several times a day, Yazidis worship God by facing towards the sun, heavens, and moon. They worship light, which is why they face the sun when they pray [11]. There are festivals of New Year (in the month of April), summer, and winter and an annual summer pilgrimage to Lalish, a temple in mountain valley in the Kurdistan region of Iraq, a mystical place and the holiest temple in their religion.
There are three hereditary Yazidi castes: Two clergy castes, Sheiks and Pirs, and the laymen Murid caste [12]. There are three general socioreligious principles for all Yazidis: Sheriet, marriage is permitted only to other Yazidis; Teriquet,  marriage is permitted only to members of your own caste; and Derba Kherqe Shekhadi, respect religious authority [13] [14].
It is common and highly desirable to marry a cousin [13]. The code of honor makes a bride's virginity extremely important. Women are not required to cover their heads. White is the color of spiritual purity. The Yazidis have a male-dominated and community-oriented culture [15]. Compliance with the rules of the community is considered necessary to enter paradise [16].
Historically, there has been a long history of persecution and suffering against Yazidis. They have been attacked by Muslim Kurds, the Iranian government, the Ottoman Sultans, and most recently prior to ISIS, the Sunni extremists [17]. The story of Yazidi survival in the history of its people includes the stories of the "72 persecutions" known as Fermans over the past 800 years to force Yazidis to renounce their religion [18]. In 2007, two Yazidi villages were destroyed in a large Islamist terror attack; this is known as the 73th Ferman. Their persecutors have denigrated Yazidis as "Ibadat al-Shaytan": "those who worship the Lord of Hell". ISIS called them "devil-worshippers" [19]. Their exceptionalism, minority status, and rejection of Islam made them a significant target for the ISIS terror group and led to the 74 th Ferman.

Terrorism and Islamic State of Iraq and Syria (ISIS)
There are many definitions of terrorism. The United States Department of State defines Terrorism as premeditated, politically motivated violence perpetrated against non-combatant targets by sub-national groups or clandestine agents, usually intended to influence an audience [20]. Forest defines more broadly: "Terrorism is a combination of strategies and violent tactics in which the victims (e.g. ordinary citizens) are a sub-element of broader target (e.g. a government). These strategies and tactics are used by individuals or groups in pursuit of objectives, typically of a political, social, criminal, economic, and/or religious nature, and they perceive terrorism to be the most effective way to obtain the power needed to achieve those objectives" [21]. Individuals who carry out these attacks are consumed by hatred towards their victims and targets and display a willingness to kill without remorse. Genocide, defined as acts perpetrated with the intent of destroying a group based on its national, ethnic, racial, political, or religious roots, includes killing, serious mental or bodily harm, impairing the ability to procreate, expulsion, or creating impossible living conditions [22]. A final brutality of genocide is to politically silence the telling of the story so that the existence of the people annihilated disappears from the annals of history [18]. The incitement to terrorism and ultimately to genocide as accomplished by ISIS comes from inspiring individuals and groups to violent action through the "5 D's": dehumanization, demonization, delegitimization, disinformation, and denial of past atrocities [23]. Amnesty International (AI) interviewed witnesses and survivors who reported the mass killings of Yazidi men in multiple villages in August 2014, including the mass murder of 400 men shot to death in Kocho [1]. Executions by ISIS were in-discriminate and included the murder of children and adults. This information has been confirmed through the discovery of thirty-five mass graves around the city of Kocho [26].
Thousands of women and girls were systematically abducted and sold as sexual slaves [11] [13] [14] [27]. In 2014, AI reported that hundreds and possibly thousands of women and girls as young as eight years old were subjected to rape and sexual abuse and forced into labor to make rockets [1] [8]. Male children were beaten and forced to study Koran, build rockets, and become child soldiers [28]. ISIS called the women "Sabaya" (sex slaves). In another report, survivors described girls as young as nine to be "married" to militants [11]. ISIS developed an organized system of kidnapping, transportation, and accommodations of enslaved Yazidi women including a register and an online auction site [29]. While ISIS is not the first terrorist group to use kidnapping and sex slavery as a terrorist tool, the scale and extent at which slavery and sexual violence is incorporated into the social and financial fabric of the organization is unprecedented [30]. The International Centre for Counter-Terrorism developed a framework to describe ISIS's systematic processing of captives, the Division and Regulation Enslavement Framework. Women and girls were separated by marital and childbearing status, and virginity carried a high value on the slave market [30]. Table 1 summarizes the health disorders experienced by Yazidi women survivors. Both physical illness and profound mental health disorders have long-term and persistent consequences for these survivors of kidnapping, sex slavery, rape, and other physical and mental trauma. A recent population survey analyzed the relationship of thirty-one specific physical conditions with ten broad categories of mental illness among non-refugee population in peacetime, and noted that most mental illnesses are associated with an increased risk of subsequent medical conditions [31]. In another study of a forty-year follow-up of women war veterans, exposure to dealing with death, sexual discrimination, harassment and consequent PTSD was associated with lower health functioning and greater disability [32]. In the setting of extreme violence, direct and lasting health consequences are even more profound. Studies referencing outcomes of violence in multiple countries have demonstrated the significantly high rates of morbidity and mortality in survivors of human rights violations [33]. In Iraq, a survey of thirteen camps run by the Kurdish Board of Relief and Humanitarian Affairs, where displaced Yazidi communities now reside, over one third of households required healthcare interventions for both communicable and non-communicable disease and for mental health problems and physical injuries [34]. Twelve and a half percent of adult women had pathologic gynecologic problems and 15% had mental health problems, including post-traumatic stress disorder (PTSD) and major depression. Surveys report a high prevalence in sexual assault survivors of non-communicable disease such as hypertension (19.7%), musculoskeletal conditions (13.5%), and diabetes (9.7%) [35]. In another investigation of internally displaced persons (IDP) camps in Northern Iraq, 62% of survivors, all less than 45 years of age, self-reported poor overall health [36]. Survivors suffer from pain all the time, which can manifest through psychosomatic illnesses [8] [11]. In interviews of 116 ISIS-traumatized women survivors, the severity of trauma-related somatic symptoms was evaluated [37]. Pain was the major somatic complaint in 73% of the women. These survivors also commonly endorsed feelings of suffocation including shortness of breath, and movement disorders such as difficulties walking and with coordination of movements.

Public and Personal Health Consequences for Yazidi Women
Physical problems often develop from repeated sexual assault. Survivors of systematic rape experience significant genital injuries, and the often-resulting pregnancies are another source of shame and trauma [38]. Although there are few studies exploring the consequences of these pregnancies in the context of the Yazidi community, other work on survivors of war-related rape show that one in five women reported a sexual violence-related pregnancy (SVRP) [39]. In a mixed methods study in the Democratic Republic of Congo, psychological wellbeing of women with SVRPs was directly impacted and worsened by negative reactions from their peers and elders including stigmatization, abandonment by husbands, and social rejection [40]. In traditional Yazidi culture, the community prefers that women do not keep the children from rapes, resulting in reports of a high number of illegal abortions among surviving Yazidi women [41]. One survivor was quoted as saying, "Nobody wants to have the children of terrorists" [11]. It is known that 25% to 50% of maternal deaths are secondary to complications of illegal abortions [42]. In addition, in Iraq each civilian is required to have an identity card that includes religion as an identifier and is considered a priority factor. At birth, the child's religion is assigned based on the biological father's religion, which in these cases would make the child Muslim. Yazidi women are then forced to choose between abandoning their children born of rape to return to their Yazidi communities or staying with their children [30] [43].

Mental Health
Survivors of torture and sexual violence are at high risk for both acute and long-term mental health disorders. Risk factors for significant disorders include older age, female gender or coming from a rural background [44]. Worldwide, the prevalence of depression and PTSD among refugees is 30% [45]. Experience of sexual violence and torture is a strong predictor of these disorders [46]. A review of twenty publications from six countries that reported on the long-term effects of war-related sexual violence identified that survivors experienced extreme rates of PTSD, depression, and anxiety [47]. In one report of Yazidi women survivors, forty-two percent experienced PTSD and another 35.9% suffered from major depression [48]. A separate study of 108 Yazidi women who had been subjected to captivity by ISIS reported a 50.9% rate of complex PTSD and another 20% with probable PTSD [49]. Interviews with another 416 surviving Yazidi women sheltered in IDP camps in the Kurdistan region of Iraq identified an exceptionally high PTSD rate of 90% [15]. These high rates were attributed to the insecurity of these particular camps and the isolation many women felt, deprived of their families and homeland. In another survey of 296 Yazidi women survivors living in Germany, 82% of the women had been physically tortured. Sixty-seven percent suffered from a somatoform disorder, 53% had depression, 39% experienced anxiety, and 28% suffered from dissociation [50].
Children, also, are deeply harmed by mass violence and terrorism. PTSD in children was proportional to level of exposure to violence, history of rape, and witnessing others being killed or tortured [51]. Surviving refugee children are resilient. Protective factors against long-term psychological distress include being accompanied by a parent, social support, and stable settlement. However, major depression and ongoing trauma symptoms have been reported among surviving Yazidi children in Turkish refugee camps [52].
In a case study of Yazidi survivors, all women reported feelings of guilt, stress, insomnia, and severe flashbacks, and experienced neurocognitive disorders and psychosis [53]. Other symptoms include nightmares, gastrointestinal complaints, and dizziness [54]. A specific enslavement trauma scale with 20-item events (e.g. forced conversion, being sold in ISIS sex slave markets, witnessing beheading, witnessing people being burnt to death) was developed to fully document the depth of trauma experienced by survivors [11]. Mental health symptoms directly correlated with the intensity of trauma exposure. Risk of suicide along with major depression continues to be a danger for rape survivors over their lifetime [55] [56] [57]. According to one Yazidi survivor, "Staying alive doesn't mean permanent survival. Anyway what is survival when the calamity survives along with you? To survive all alone is the worst kind of survival" [11].

Consequences to Yazidi Society
Yazidis have a strong connection to their place of origin where sanctuaries and holy shrines are localized and are extremely important for the existential meaning of their lives [8]. The displacement of Yazidis in and of itself and the complete destruction of some of their ancestral villages is an enormous rent in the fabric of the community.
Studies have well documented the social stigma and societal rejection of women after sexual slavery in other conflicts [58]. In contrast, social support and acceptance is the single most important predictor of healing from trauma [59].
In interviews with survivors of sexual slavery, perceived social rejection by their community was significantly associated with poor mental health among Yazidi women [15]. As one study explains, "very few women want to speak openly about it because they don't dare, because they are ashamed of what happened…" [24]. Violation of honor is an important negative concept in Yazidi culture and women carry the fear of exclusion from their community as a result of their trauma [8]. Some women have committed suicide because of their fear of being discriminated against by their own community [8] [36] [60] A recent study shows that six years after the start of the 2014 ISIS assault on Sinjar, the Yazidi community remains both physically and culturally fragmented, a continuing legacy of the ISIS-led genocide [61]. Refugee women in general and Yazidi women in camps are at risk for continued gender-based violence [36] [62].
The United Nations Security Council has recognized rape as a tactic of war, specifically used to "to humiliate, dominate, instill fear in, disperse and/or forcibly relocate civilian members of a community or ethnic group" [63]. What was once considered an inevitable consequence of soldier's absence of female companionship has now been redefined as an intentional terrorist method to weaken community social ties, or, as described by author Slavenka Drakulic, "a kind of slow murder" [63]. The use of sexual assault by ISIS fits the definition of a war tactic to destabilize the Yazidi community as a whole.
Yazidi Spiritual leader Baba Sheikh has worked to bring the community back together and accept rescued and escaped women. He issued a statement declaring that "Yazidi girls running away from Daesh were helpless, powerless yet brave when resisting terrorism and their honor cannot be impugned even if their hymens are damaged" [11]. In addition, he declared that Yazidis would accept children of ISIS rape into their community [64]. In 2019, the Yazidi Supreme Spiritual Council allowed the return of women residing in IDP camps who had refused to be separated from their children and has initiated searches of orphanages across Iraq for hundreds of Yazidi babies born of rape [65]. The Yazidi community has also established special rituals in its holy temple, Lalish, to rehabilitate abducted women [66].
Yazidi women affected by these acts of terrorism continue to display incredi-A. Goodman et al. ble strength [13] [14]. The Yazidi community has historically heavily relied on women, who are responsible for parenting and for the oral transmission of cultural heritage [18] [36]. A systematic review of 217 articles on the impact of terrorist events worldwide identified the strong role of resilience, fortitude, and courage amongst those affected, and stressed the importance of families in recovery [57].

Interventions
Trauma-specific interventions, including short-term psychological first aid and longer-term psychiatric treatment, were part of the care given to Yazidi refugees [67] [68]. Germany accepted 1000 very physically ill and mentally traumatized Yazidi women and children for integrated care as part of a special quota project to support 2500 women and children who had been held hostage by ISIS [53].
These integrated care interventions aim to heal the trauma of humiliation and bodily invasion by giving women platforms and allowing them to tell their stories [69]. The stories of past persecutions, called "Fermans" (equivalent to the Holocaust), are part of the collective Yazidi memory. Acknowledging this shared experience in the context of recent trauma can be a mechanism to strengthen resilience in survivors [8] [18]. Of note, secondary traumatization was present in 22% of the caregivers, interpreters, physicians, psychotherapist, and social workers working with surviving Yazidi women and children [70].
Another phase of healing requires bringing justice and retribution against terrorists [71]. Identifying the actions of ISIS as war crimes and crimes against humanity is the first step in accomplishing that goal [

Discussion
Currently, the United Nations High Commissioner for Refugees (UNHCR) has identified 70.8 million forcibly displaced people, of whom 25.9 million are refugees [74]. Sexual violence against women is a common tool systematically perpetrated during wars and genocide. The purpose of mass sexual violation is to eliminate a particular group through desecration of the central core of a community, its women, mothers, and families [75] [76]. In recent ISIS attacks and in previous documented wars and conflicts in Rwanda, Democratic Republic of Congo, and Bosnia, intentional perpetration of mass rapes of women is a strategy to destroy a population [77]. In addition, the tactic of enslavement contributes to the military, financial and political growth and empowerment of ISIS [30]. The genocidal assault against the Yazidi population was gender-specific; men were executed and women were sexually violated [36] [78]. Women are at especially high risk for PTSD and depression after traumatic stress [48]. Survivors of torture and sexual slavery also struggle with deep existential issues sur-rounding their legitimacy and place in their community as women, mothers, and wives.
From a public health perspective and using social ecological models of health, there are several key areas that those involved in emergency preparedness response must understand and plan for: the health challenges of survivors, the concurrent and future health challenges of the next generation, and the functionality of the community at large after such devastating collective trauma. Additionally, humanitarian aid workers, public health experts, and medical providers must also ask questions specific to the particular culture and population that has been victimized, including: What are the risk factors for post-traumatic stress disorder, suicide, and potential vulnerability to domestic violence after abduction and sexual exploitation and abuse? How can we support and foster resilience and healing for women and their communities after such events?
The Sendai framework of emergency preparedness includes mitigation, preparedness, response, and recovery and focuses on habitat safety, structural safety of buildings, and physical health [79]. Training and education to understand, try to prevent, and plan for interventions when gender-based violence and sexual exploitation occur must become a mandatory part of emergency preparedness. The tactics of ISIS and the financial success of its sex slave business should teach us that future large-scale terrorist attacks may include this atrocity again and are ultimately a threat to public health and social stability.

Conclusion
Sexual violence against women is a common tool systematically employed during wars and genocide. In recent ISIS attacks, intentional perpetration of mass rapes of women and execution of men was a strategy to destroy an entire population. Yazidi women survivors of kidnapping, sex slavery, and rape and other physical and mental trauma experienced significant levels of physical ailments, chronic pain, and mental health conditions. All women reported feelings of guilt, stress, insomnia, and severe flashbacks. The incidence of post-traumatic stress disorder (PTSD) ranged from 42% to 90%. Both physical illness and profound mental health disorders have long-term and persistent consequences for these survivors.