2012. Vol.3, No.4, 352-363
Published Online April 2012 in SciRes (
Copyright © 2012 SciRes.
Gender Inequality and Its Effects in Females Torture Survivors
Ibrahim Kira1, Jeffery Ashby2, Linda Lewandowski3, Iris Smith4, Lydia Odenat4
1Center for Cumulative Trauma Studies, Stone Mountain, USA
2Georgia State University, Atlanta, USA
3Wayne State University, Detroit, USA
4Emory University, Atlanta, USA
Received January 31st, 2012; revised February 23rd, 2012; accepted March 27th, 2012
The study explores the effects of gender discrimination GD as type III trauma in 359, (160 females and
199 males) torture survivors. Data includes measures of GD and other traumas, PTSD and cumulative
trauma disorders CTD. GD found to decrease PTSD symptoms in males favoring mental health status of
males, and increase CTD symptoms in females. GD mediated the effects of personal identity traumas on
PTSD and CTD symptoms of psychosis/dissociation; executive function deficits, and suicidality. The re-
sults highlight GD as type III trauma that contributes to the mental health differences between males and
Keywords: Gender Discrimination; Torture Survivors; PTSD; Cumulative Trauma Disorders; Type III
Torture and Gender Inequality: A Feminist
The adverse effects of gender discrimination on the mental
health outcomes of women have been a well-documented phe-
nomenon in the research milieu. Gender discrimination (GD),
defined as the assignment of values to real or imagined differ-
ences between genders, remains a ubiquitous part of the female
experience and a major mental health concern for women
worldwide. GD has been attributed to a number of poor mental
health outcomes, including psychological distress (Dambrun, e.
Defined as the intentional infliction of psych2007), low self-
esteem (Schmitt, Branscombe, & Postmes, 2003), anger (Swim,
Hyers, Cohen, & Ferguson, 2001), low self-efficacy, and de-
pression and anxiety symptoms (Landrine, Klonoff, Gibbs,
Manning, & Lund, 1995). Despite the abundance of research on
the etiology and consequences of GD, there remains a dearth of
literature on the impact of this societal ill on the psychological
well-being of female refugee torture survivors.
Research on GD has provided some insight into its deleteri-
ous effects on economic, political, and educational institutions
in global communities. According to a qualitative focus group
study of African female refugee torture survivors (conducted by
the authors), GD, as well as the promotion of extreme male
dominance and asymmetrical patriarchal world views, was
perceived to be instrumental in the development of condi-
tions/cultural environments that foster torture and other human
rights abuses. Study participants argued that gender inequality
gave way to the emergence of dominant male dictators, military
junta, tribalism, and political, military and intelligence institu-
tions that promote torture, oppression, discrimination and hu-
man rights violations against men and women alik ological,
physical, or emotional pain or deprivation, torture is a practice
commonly used in an astonishing array of societies for pur-
poses of punishment, intimidation, and coercion (Pope, 2001).
Research on the experiences of torture survivors has found it to
be significantly predictive of post-traumatic stress, depression,
anxiety, and somatic complaints (Punamaki, Qouta, & Sarraj,
2010). The primary aim of the present investigation is to ex-
plore how GD affects the mental health of female refugee tor-
ture survivors.
Gender Discrimination GD as Type III Identity
Traumatology developmental theorists have identified GD as
a unique form of trauma that can have profound and negative
mental health effects on clients (Kira, 2001; Kira et al., 2008).
As such, a trauma taxonomy has been proposed to classify
various forms of trauma based on their severity and complexity.
According to this classification system, Type I trauma consists
of a singular and potentially traumatic event (e.g. car accident),
while Type II trauma is the complex and potentially repeated
trauma that is discontinued (e.g., sexual or physical abuse).
Type III represents ongoing social structural violence that
represents mostly inter-group traumas that are without a fore-
seeable end (e.g., poverty, racism, discrimination, including
GD), and Type IV are the multiple concurrent or sequential
traumas occurring across the lifespan that have potential cumu-
lative effects. Among the four types, traumatologists have iden-
tified Type III traumas as potentially the most serious kind, in
terms of their impending adverse effects on the individual (Kira
et al., 2008). It is important to note that the accumulative kin-
dling dynamics are present in both Type III and IV traumas. It
is argued that Type III trauma, due to its ongoing nature, may
mediate or moderate the effects of other trauma types. Addi-
tionally, Type III is potentially the most serious kind, in terms
of its negative effects on the individual due to its duration and
lasting impact (Kira et al., 2008). Research has also demon-
strated that Type III trauma tends to be internalized by those
who employ this defense mechanism to cope with continuous
exposure to painful micro- and macro-aggressions. Such ac-
ceptance of discrimination and stereotypes can harm self con-
cept and efficacy and sense of control which are keys to health
and mental health. However, some others resist the discrimina-
tion at different levels (e.g., mild, moderate, or tough resis-
The aforementioned trauma types have been found to directly
and indirectly impair emotional processing and cognitive func-
tioning. The accumulation, kindling, and amplification dynam-
ics makes cumulative trauma effects significantly different
from a single Type I or Type II complex trauma, in that the
effects of one trauma cannot be isolated from the other several
traumas that the same individual has endured before or after its
occurrence. The additive effects of multiple traumas amplify
the severity of trauma related mental health symptoms and may
be significantly related to executive function deficits and life
achievements. Cumulative dynamics of GD’s related micro-
and macro-traumatic stressors across life span of women can be
at play. The effects of cumulative dynamics of GD events can
be severe beyond the PTSD syndrome. Cumulative trauma and
poly-victimization across the life span have been found to con-
tribute to significant unique variance in mental health out-
comes beyond that accounted for by the combination of all
aggregate trauma and victimization types (Kira, et al., 2008a;
Richmond et al., 2009).
Dimensions and Dynamics of Gender Discrimination
Patriarchal systems have been identified as the foundation of
women’s subordination and positioning as second-class citizens
in most of the contemporary cultures (Hunnicutt, 2009; Walby,
1990; Yllo, 1993). Childhood socialization, by family and so-
cial institutions, is one of the primary methods through which
patriarchal values and gender expectations shape core dimen-
sions of the self/gender identity. The core concept of patriar-
chy—systems of male domination and female subordination—
evokes images of gender hierarchies, dominance, and some-
times power struggle (e.g., Brownmiller, 1975; Walby, 1990;
Yllo, 1993; Hunnicutt, 2009). Patriarchy and institutionalized
gender stratification shapes power structures, in turn creating
GD that determines differential access to economic and social
resources, as well as the perception of personal and collective
GD may include micro and macro, implicit and explicit gen-
der related discriminative aggressive events that may include
bullying, coercive control and violence against girls and women
over a lifetime. Such aggressions often begin in childhood,
occur concurrently, sequentially, or over the course of lifetime,
and come from individuals, families and institutions. Internali-
zation of comparative degraded status does not cancel the nega-
tive effect of such life term gender focused cumulative aggres-
sions and degradations.
Gender-based violence (GBV) serves to maintain an unequal
balance of power between men and women. GBV is a risk fac-
tor for injury and disability; executive function deficits, e.g.,
inattention, mental health disorders; chronic pain syndromes,
somatic complaints; and other negative health behaviors (smok-
ing, alcohol and drug abuse, physical inactivity, overeating) for
women (Watts & Zimmerman, 2002; Zimmerman et al., 2003).
In domestic violence, women are usually the victims of the
attack and the perpetrator may well be motivated directly by the
desire to demonstrate his own dominance to enforce male
power and control over women (Heise, 1998).
GD, as manifested in most cultures, tends to validate, favor,
empower and strengthen male’s feelings of control and position
as a dominant agent in the family and society. In turn, it sup-
presses female’s personal identity, increases stereotype and
injustice against them by the family and by social institutions,
and gives way to relative feelings of powerlessness, loss of
perceived control, decreased collective (gender) and personal
self-esteem, self-efficacy, and agency, which eventually lead to
diminished mental health potential (Swim, Hyers, Cohen, &
Ferguson, 2001).
GD against girls by parents during childhood initiates, rein-
forces, and cross-generationally perpetuates the practice of un-
equal treatment of females over the lifetime. Such types of
traumas, because they are entrenched in the structure within the
family and society, tend to be internalized and accepted by the
victim as the normal course of life (Heise, 1998); however,
internalizing the ongoing traumas does not necessarily cancel
their negative effects on identity development, the concept of
self and on physical and mental health of the victim. Suppress-
ing or reframing thoughts and emotions through internalization,
accepting culturally endorsed rationalization and submission to
a second class status may even create violated self and induce
degraded self-worth.
GD, that subjugates females, can arouse, sensitize, and bias
females to be more prone to over respond to Type I and Type II
stressors, as well as mediate or moderate their effects. Women
may experience fewer other traumas than men, however GD, as
previous and ongoing trauma, continue to sensitize them to
stress, yielding more internalizing and more severe symptoms,
in general, compared to men who do not suffer such GD (Em-
slie et al., 2002; Goldberg & Williams, 1988; Macintyre, Ford,
& Hunt, 1999, Astbury, 2006; Dambrun, 2007; Rosenfield,
1999; WHO, 2006). On the other hand, GD that favors male
dominant actors, does not only make them less vulnerable, but
also empowers them to act aggressively and display more ex-
ternalizing symptoms (e.g., Mejia, 2005, Scott, 1998; Hawton et
al., 2002; Parker & Roy, 2001; Linzer et al., 1996). Overall, GD
may be lead to losses for both genders when mental health in-
ternalizing/externalizing outcomes are taken into consideration.
Further, GD overlaps, for females, with the other Type III
traumas (e.g., racism, stigma, poverty, discriminations and
other forms of social structural violence), producing different
cumulative traumagenic dynamics that predispose the affected
individual to respond differently to subsequent stressors. GD
intersects with other discriminations enforced by social struc-
tural violence against women and minorities, (e.g., race, minor-
ity status) adding to the negative effects of its cumulative dy-
namics (Pittaway, 1999; Pittaway & Bartolomei, 2001).
While GD perpetuates micro and macro aggressions against
females, women may engage in systemic violence, for example
prostitution, as a way of resisting and negatively responding to
the social structural violence of gender victimization (Wesley,
2006). Research indicates that GD is negatively correlated with
distributive and procedural justice, and positively linked to
work conflict (Foley et al., 2005; Gutek, Cohen, & Tsui, 1996).
It also showed a negative correlation with job satisfaction and
organizational commitment and a positive correlation with
intentions to leave (Foley et al., 2005). Perceived procedural
injustice has been positively linked to retaliation against the
organization (Skarlicki & Folger, 1997); perceived distributive
Copyright © 2012 SciRes. 353
injustice has been positively linked to employee theft (Green-
berg, 1990);
Some studies seem to suggest that GD contributes to the
documented differences in mental health between males and
females. Klonoff, Landrine, & Campbell (2000) found that
women who experienced frequent sexism had significantly
more depressive, anxious, and somatic symptoms than men,
whereas women who experienced little sexism did not differ
from men on any symptom measure. They found that negative
sex stereotyping, isolation, and sexual objectification was asso-
ciated with mental heath symptoms such as depression, anxiety,
somatization and low self esteem (Klonoff, Landrine, & Camp-
bell, 2000). Findings suggest that gender discrimination may
account for such gender differences in psychiatric symptoms
(Landrine et al., 1995). Most studies found a significant rela-
tionship between gender and different mental health variables
explaining between 5% and 15% of the observed variance.
According to Dambrun (2007), perceived personal gender dis-
crimination mediates the relationship between gender differ-
ences in mental health. Berg (2006) found that the most predict-
tive variable for females’ trauma was recent sexist degradation,
accounting for 20% of the variance in PTSD scores.
The purpose of the present study is to examine the potential
role of GD in the development of cumulative trauma disorders
(CTD) and symptoms of PTSD among female refugee torture
Hypothesis 1: GD for females by parents (GD-P) and by so-
ciety (GD-S) has significant negative effects on their mental
health and executive functions.
Hypothesis 2: GD is protective factor for males that lead to
decreased PTSD symptoms for them, while it is a risk factor for
females that lead to increased symptoms for them.
Hypothesis 3: GD, as ongoing life-long term type III trauma
sensitizes females to other life time type I and type II traumas,
and mediates and/or moderates the effects of such traumas (e.g.,
personal identity, collective identity, survival and secondary
traumas) on CTD and PTSD.
Participants are 359 primary and secondary torture survivors
(a primary torture survivor is the person that had been subjected
directly to torture, while a secondary torture survivor is one of
his/her close family members). The sample for this study con-
sisted of all the clients in the CTTS data base that were seen
and screened in the Center between April 2008 and the end of
September 2009. There were 160 females and 199 males seen
during this time period. The ages of participants ranged from 12
to 79 years. The participants include 215 primary torture survi-
vors and 143 secondary torture survivors (family members).
For the females that most of our analysis will focus on, there
are 53 primary torture survivors and 107 secondary torture
survivors (affected family members). The participants came
from 32 countries with the majority from Iraq (n = 99, Female
= 48, Male = 51), Burma (n = 93, Female = 31, Male = 62),
Bhutan (n = 77, Female = 42, Male = 35), Somalia (n = 31,
Female = 21, Male = 10), and others (Female = 21, Male = 38).
Others include refugees’ torture survivors from, Afghanistan,
Chad, Congo, Cuba, Eritrea, India, Iran, Liberia, Nigeria, Rus-
sia, Rwanda, Zimbabwe, China and others. Female participants’
employment, in their own countries, included: farmer = 39,
teacher = 16, house wife = 15, student = 12, business women =
9, lab technician and medical assistant = 4, seller = 7, engineer
= 1, other occupations = 57. Fourteen percent (14%) of females
were 12 - 19, 36% 20 - 35, 43% 36 - 55, and 7% were 56 - 79
years old. The majority (55.8%) were married, 1.3% living with
partners, 19.9% single and never married, 3.8% divorced,
12.8% are widows, 6.4% had either a missing spouse or a
spouse that still resided in their home country. Average num-
bers of children for those who are or were married are 5.6. Most
of them are new arrivals within 2 - 6 month of entry (95%), few
(less than 5%) have been in US more than a year. GD is most
profoundly observed in low-income economies of most of re-
fugee cultures. (e.g., World Health Organization, 1988., Chri-
stiana & Okojie 1994, Glick & Fiske, 1996, Heise, Pitanguy, &
Germain, 1998).
PTSD Measure-(CAPS-2) (18 items): This measure was de-
veloped by Blake et al. (1990) and is widely used to assess
post-traumatic stress disorder (PTSD). It is a structured clinical
interview that assesses 17 symptoms rated on frequency and
severity on a 5-point scale. CAPS demonstrated high reliability
with a range from 0.92 - 0.99 and showed good convergent and
discriminant validity (Weathers, Keane, & Davidson, 2001).
The measure utilized in adult and adolescents samples. In this
study, we used the frequency sub-scale of CAPS-2 that is cur-
rently widely used in psychiatric literature. It has, in this mixed
sample, Cronbach alpha reliability coefficient of .94 for all
participants, which indicates a good reliability. The scale has
four sub-scales: re-experiencing, avoidance, arousal and emo-
tional numbness/dissociation. Reliability of the four sub-scales
in our sample are adequate to high (alphas are .96, .92, .89
and .85 respectively). Further the alpha coefficients were high
across all national origin groups (Bhutanese = .92, Burmese =
91, Iraqi = .85, Somali = .96, others = .97. The measure reli-
abilities were high in each national origin female groups as well
(Bhutanese = .89, Burmese = .93, Iraqi = 84, Somali = .96, and
all others = .96).
Cumulative Trauma Disorders Measure CTD (15 items). The
measure has been developed on five community and clinic
samples of adults and adolescent Iraqi refugees, Arab Ameri-
cans, and African Americans. It is an index measure that covers
13 different symptoms: depression, anxiety, somatization, dis-
sociation, auditory and visual hallucinations, avoidance of be-
ing with people, paranoid ideations, concentration and memory
deficits, loss of self control, feeling too harsh with family and
with people in general, feeling suicidal, and feeling like hurting
self. Exploratory factor analysis found four factors: Executive
function deficits, suicidality, psychosis/dissociation, and de-
pression/anxiety interface. Confirmatory factor analysis con-
firmed this structure. It has good reliability (ranged from .85
and .98). Test-retest reliability in a 6 week-interval is .76. The
measure has good predictive validity. Different kinds of trau-
mas, and cumulative trauma in general accounted for signify-
cant variance as predictors of CTD symptoms (Kira, 2004; Kira,
Clifford, Wiencek, & Al-haider, 2001, Kira, Clifford, & Al-
Haider, 2002, 2003; see also Kira et al., 2006, 2007). The
measure was found to be highly correlated with PTSD, DASS-
Copyright © 2012 SciRes.
A anxiety and CES-D depression measures in a clinic sample (n
= 399) which substantiate its convergent validity. It was found
to be highly negatively correlated with futuristic orientation,
socio-cultural adjustment and post-traumatic growth which ade-
quately substantiate its divergent validity. It has, in this mixed
sample Cronbach alpha reliability coefficient of .98, which
indicates a good reliability. Reliability of the four subscales in
the current study was found to be high (.95, .97, .98, and .96
respectively). Further the alpha coefficients were high across all
national origin groups (Bhutanese = .93, Burmese = .94, Iraqi
= .94, Somali = .89, others = .94. The measure reliabilities were
high in each national origin female groups as well (Bhutanese
= .92, Burmese = .95, Iraqi = 93, Somali = .92, and all others
= .87).
CTS Cumulative Trauma Scale (33 items) short form: CTS
screens for the occurrence and frequency of trauma across life
time. The measure is short form of a longer version that utilized
taxonomy of traumas that are based on child and adult devel-
opmental theories. It was validated previously in Iraqi refugees
and found to have good reliability, construct, divergent, con-
vergent, and predicative validity (Kira et al., 2008a, 2008b;
Kira et al., 2011). The measure originally has six main cate-
gorical sub-scales (attachment, for example abandonment by
mother, personal identity, for example sexual abuse or rape,
collective identity, for example oppression, and family, second-
dary, and survival traumas). Different sub-categories were fur-
ther added, e.g., gender discrimination, and torture. The total
score represents the cumulative trauma load that the individual
endured across life span. For the purpose of this study we fo-
cused on cumulative trauma occurrence for the total scale and
for other six trauma types. The six trauma types include: per-
sonal identity traumas, e.g. sexual abuse, physical abuse, rape,
robed or mugged, collective identity traumas, e.g., oppression,
discrimination, survival traumas, e.g., shot at or stabbed, sec-
ondary trauma, e.g., witnessing or hearing about others traumas,
torture trauma, and gender discrimination trauma. The measure
has, in this mixed sample an adequate Cronbach alpha reliabili-
ty coefficient of .81. Alpha reliabilities for the sub-scales in the
present data are as follows: Torture = .89 (2 items scale), gen-
der discrimination, GD (2 items scale) = .62, survival trauma (3
items scale) = .60, secondary traumas (3 items scale) = .66,
personal identity traumas (15 items scale) = .62, and collective
identity traumas (6 items scale) = .68, gender discrimination
GD in Iraqi females was .80, and .65 for the others. Such reli-
ability coefficients are acceptable for short scales with binary
response questions. GD sub-scale consists of two items one
asks about the occurrence of gender discrimination by parents
and the second asks about the gender discrimination by other
society members and institutions. Because we used each item as
a separate measure one for GD by parents (GD-P) and the other
for GD by society (GD-S), in our analysis, we calculated the
reliability of each. Following the Wanous and Hudy (2001)
method of estimating single-item reliability, we conducted fac-
tor analysis of the CT measure, the reliability of GD-P single
item scale ranged between .69 (communality of the item)
and .76 (factor loading). The reliability of GD-S scale ranged
between .67 (communality of the item) and .72 (factor loading).
Further the alpha coefficients for CTS (the total scale) were
adequate across all national origin groups (Bhutanese = .86,
Iraqi = .80, Somali = .70, others = .80), except for Burmese
(.50), which is considered relatively low. The measure reliabil-
ities were adequate in each national origin female groups as
well (Bhutanese = .69, Iraqis = 79, Somalis = .75, and all others
= .79).
Study investigators utilized an existing data set from a clini-
cal database developed by a Center for Torture and Trauma
Survivors (CTTS) that includes mental health data collected for
all its clients. The data include a comprehensive intake con-
ducted by qualified staff and mental health screening that in-
cluded measures for PTSD- Clinician-Administered Posttrau-
matic Stress Scale CAPS-2, CTD and different trauma occur-
rence including gender discrimination by parents and society.
The procedures in the clinic meet all HIPPA regulations con-
cerning clients’ protection. The assessments were conducted
through face to face interviews in the clinic. Participants were
referred to clinic by resettlement agencies and health screening
authorities as a torture victims.
Data Analysis
Study investigators explored the trauma profiles for each
gender using two-ways cluster analysis, and the mental health
differences based on the two trauma profiles. Correlational
analysis was conducted between GD sub-scale, its two items,
and PTSD and CTD and their sub-scales in the females sub-
sample (N = 160). Multiple regression analysis was conducted
with PTSD and CTD as dependent variables and other traumas
including GD as independent variables. Different plausible path
models were tested for direct, indirect effects, using structural
equation model SEM (AMOS 7 software), (Arbuckle, 2006).
Model fit indices were selected in accordance with several
recommendations and included the normed test statistic
( /df), the root mean square error of approximation (RMSEA)
and the comparative fit index (CFI). /df values < 5.0 are
considered acceptable; RMSEA values .05 indicate close fit,
values .05 to .08 indicate reasonable fit, and values > .10 indi-
cate poor fit. CFI values > .95 indicate good fit (e.g., Kline,
2005; Hu & Bentler, 1999). Bootstrap (N = 200) with bias-
corrected confidence intervals was used to test the significance
of the direct and indirect effects of each variable in the model.
Bootstrapping is a computer-intensive re-sampling technique.
This procedure involves generating bootstrap samples based on
the original observations. Bootstrapping is often used to get a
better approximation of sampling distribution of a statistic than
its theoretical distribution provides, especially when assump-
tion of normality may be violated. Bootstrapping is more robust
modern statistics that are used to generate and to create a sam-
pling distribution, and bootstrapped distribution is used to com-
pute p values, test hypotheses and generate confidence intervals
for direct and indirect effects (e.g., Erceg-Hurn & Mirosevich,
Hypothesis 1 and 2: The Effects of GD, GD-P and
The differences in gender discrimination between the major
nationalities in the current sample were not statistically signifi-
cant. Correlational relationships were examined between gen-
der discrimination scale (total), gender discrimination by par-
ents, gender discrimination by society, PTSD and its four sub-
Copyright © 2012 SciRes. 355
scales, and CTD and its four sub-scales in females sub-sample.
GD (Total) was found to be significantly correlated with PTSD,
CTD and all their sub-scales with the highest correlation with
CTD-psychosis sub-scale (r = .42). GD-P was not significantly
correlated with PTSD; however it was significantly correlated
with PTSD-Arousal sub-scale and significantly correlated with
CTD, CTD-executive functions deficits, suicidality, psychosis/
dissociation sub-scales. PGD-S (GD by society) has the highest
significant correlations with PTSD, CTD and all their sub-
scales. Table 1 presents these results.
Separate multiple regression analyses was conducted for
males and females, with PTSD and CTD alternatively as de-
pendent variables and other trauma types including GD as in-
dependent variables. While other traumas generally predicted
increase in PTSD and CTD, GD predicted significant decrease
in PTSD in males but not in females, and significant increase in
CTD in females but not in males. Tables 2 and 3 present these
Table 1.
Pearson correlations: Associations of Gender Discrimination for fe-
males all ethnic backgrounds with PTSD and CTD and components. N
= 160.
GD-Total GD-P GD-S
PTSD .15* .07 .17*
PTSD-Experiencing .23** .15+ .23**
PTSD-Arousal .32** .20* .32**
PTSD-Avoidance .29** .19* .28**
PTSD-Numbness/Dissociation .16* .04 .21**
CTD .38** .26** .37**
CTD-Depression/Anxiety .20* .12 .21**
CTD-Psychotic/Dissociation .35** .23** .34**
CTD-Executive functions deficits .32** .22** .30**
CTD-Suicidality .34** .26** .30**
CTD-Neuroticism .27** .17* .27**
CTD-Psychoticism .42** .28** .41**
Note: GD-Total = Gender discrimination scale, GD-P = Gender discrimination by
parents, GD-S = Gender Discrimination by society. +Close to significant, (at .10
level). **Correlation is significant at the 0.01 level (2-tailed). *Correlation is
significant at the 0.05 level (2-tailed).
Table 2.
Multiple regression for the effects of traumas and GD on PTSD.
Males Females
Independent variables
B SE Beta B SEBeta
Secondary Traumas 4.71 1.22 .32** 4.57 1.28.29**
Discrimination –13.96 6.92 –.14* –1.38 5.03 –.02
Collective Identity
Traumas .92 .54 .11+ .54 .65.06
Identity Traumas 3.20 .704 .40** 3.81 .74.43**
Note: +
Close to significant, (at .10 level). **Correlation is significant at the .01
level (2-tailed). *Correlation is significant at the .05 level (2-tailed).
Table 3.
Multiple regression for the effects of traumas and GD on CTD.
Males Females
Independent variables
B SE Beta B SEBeta
Traumas 1.42.87 .15+ 3.00 .74.31**
Discrimination –4.585.07 –.07 9.67 2.62.27**
Identity Traumas .70 .38 .13+ –.22 .39–.04
Identity Traumas 1.70.52 .33** 1.49 .43.28**
Note: +Close to significant, (at .10 level). **Correlation is significant at the .01
level (2-tailed). *Correlation is significant at the .05 level (2-tailed).
Hypothesis 3 (Sensitizati on, Mediatio n a nd
Moderation Hypothesis)
Exploring the trauma profile for each gender using two way
cluster analysis, findings suggest that males, in this population,
are significantly higher in total trauma load as compared to
females (11.25 for males, and 9.68 for females). Females ap-
peared to suffer more from torture, personal identity traumas,
and survival traumas. There is no difference between them in
collective identity or secondary traumas. The only trauma type
that was significantly higher for females was gender discrimi-
nation. However, regardless of the higher trauma load in males,
there is no gender differences in the severity levels of PTSD, or
CTD (see Table 2). The only difference is that females have
significantly higher scores in PTSD-hyperarousal sub-scale
which may corroborate, to a degree, the sensitivity hypothesis.
Such sensitivity is assumed to be related to the continuous sub-
jection to gender discrimination that sensitizes them to differ-
ential arousal level in responding to other life stressors. Tables
4 and 5 present these findings.
To explore the GD mediation/moderation hypothesis, study
investigators utilized SEM AMOS 7 software to build a model
that reflects our theoretical assumptions and past research find-
ings. Different plausible models were tested and all the models
had adequate to excellent fit with the data. Among the two
models presented, the first has all trauma types as independent
variables, GD as mediating variable, and PTSD four factors
(reexperiencing, arousal, avoidance and dissociation/numbness)
as dependent variables. The model has good fit with the data
(Chi Square = 11.078, d.f. = 14, p = .680, CFI = 1.000, RMSEA
= .000). In this model, GD has direct effects on increased avoi-
dance and arousal and indirect effects on increased re-experi-
encing. Personal identity traumas (PIT) have direct effects on
increased perceived GD. GD mediated the PIT effects on in-
creased avoidance, arousal and reexperiencing. Collective iden-
tity traumas (CIT) have direct effects on increased GD (close to
significant). GD mediated CIT effects on increased avoidance.
Survival traumas on the other side have significant negative
effects on perceived GD. GD mediated the negative effects of
survival traumas on decreased avoidance and arousal.
The second model has all trauma types as independent vari-
ables, GD as mediating variable, and CTD four factors (depre-
sssion/anxiety interface, psychosis/dissociation, executive func-
tion deficits, and suicidality) as dependent variables. The model
has good fit with the data (Chi Square = 9.301, d.f. = 15,
Copyright © 2012 SciRes.
Copyright © 2012 SciRes. 357
Table 4.
Centroids that depict the trauma profiles for those that suffered perceived gender discrimination and those that do not in the sample N = 359.
GD trauma clusters Cumulative trauma load Torture Collective identity
traumas Personal identity traumasSurvival traumas Secondary trauma
Experienced GD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
1. No 7.97 2.70 .82 .95 3.55 1. 70 2.15 1.05 .68 .69 .72 .78
2. Yes 14.68 3.72 1.67 .65 3.83 2.04 5.26 1.67 2.14 .70 2.32 .77
Combined 10.55 4.52 1.14 .94 3.66 1.84 3.35 2.01 1.24 .99 1.34 1.10
Table 5.
The differences between genders in trauma types, PTSD, CTD and their sub-scales.
Gender:NMean SD SEMean Difference t
Males 1991.50 .75 .05
Torture Traumas
Females 160.64 .88 .07
.85 9.97***
Males 1991.46 .89 .06
Survival Traumas
Females 160.96 .99 .08
.50 5.0***
Males 1991.40 1.07.08
Secondary Traumas
Females 1601.27 1.09.09
.14 1.22
Males 1993.67 1.78.13
Collective Identity Traumas
Females 1603.67 1.70.13
.01 .03
Males 1993.58 1.94.14
Personal Identity Traumas
Females 1603.11 2.01.164
.47 2.23**
Males 199.01 .16 .01
Perceived Gender Discrimination
Females 160.07 .29 .02
–.05 –1.98**
Males 19911.25 3.88.28
Cumulative Trauma Occurrence Scale
Females 1609.68 4.46.35
1.57 3.57***
Males 19914.70 15.651.11
Post-Traumatic Stress Disorder (PTSD)
Females 16015.94116.02 1.27
–1.24 –.739
Males 1997.66 7.84.57
PTSD-Re-experiencieng Sub-Scale
Females 1607.71 7.39.60
Males 1992.19 2.46.18
PTSD-Avoidance Sub-Scale
Females 1602.19 2.68.22
Males 1993.01 4.63.34
PTSD-Arousal Sub-Scale
Females 1604.70 5.93.48
Males 1991.93 3.50.25
Females 1602.03 3.51.28
–.10 –.263
Males 19911.73 10.63.75
Cumulative Trauma Disorders CTD
Females 16011.98 10.18.81
–.25 –.228
Males 1994.60 3.51.25
CTD-Depression/Anxiety Interface
Females 1605.11 3.61.29
–.51 –1.325
Males 1991.91 2.13.15
CTD-Executive Functions Deficits Sub-Scale
Females 1601.80 2.04.16
.11 .474
Males 1991.60 2.52.18
CTD-Psychoticism /Dissociation Sub-Scale
Females 1601.74 2.51.21
–.14 –.527
Males 199.75 1.44.10
CTD-Suicidality Sub-Scale
Females 160.71 1.28.10
.04 .278
ote: +p < .10 (close to significant) *p < .05, **p < .01, ***p < .001.
p = .861, CFI = 1.000, RMSEA = .000). In this model, GD has
direct significant effects on increased psychosis/dissociation
and indirect effects on increased deficits in executive function
and suicidality. PIT has direct effect on increased perceived GD.
GD mediated their effects on increased on psychosis/dissocia-
tion, deficits in executive functions and increased suicidality.
Collective identity traumas (CIT) have direct effects on in-
creased GD (close to significant). GD mediated CIT effects on
suicidality. Survival traumas on the other side have significant
negative effects on perceived GD. GD mediated the negative
effects of survival traumas on decreased psychosis/dissociation.
GD does not seem to mediate secondary trauma effects in either
model. Figures 1 and 2 present the direct paths for each model.
Tables 6 and 7 include the decomposition of standardized di-
rect, indirect, and total effects of the variables in each model.
While sex differences in pro-social behavior that appear in
research and match widely gender role beliefs, lie in the his-
torical division of labor and has its origins in physical attributes
and hormonal process of both genders (Wood & Eagley, 2002),
GD reflects another cultural dimension that exploits such dif-
ferences to proclaim domination and privileges of male gender
in patriarchal cultural and political systems (e.g., Walby, 1990).
Such exploitation is gender specific identity trauma type III
trauma that is ongoing and has accumulative effects and is po-
tentially more severe in most refugee cultures.
GD tends to buffer against or decrease PTSD symptoms in
males as the study findings indicated, favoring mental health
status of males over females. GD is a protective factor for
males and risk factor for females’ mental health. GD, embed-
ded in the culture, tends to validate, favor, empower and
strengthen male’s feelings of control and self esteem as a
Tr au mas)
Tra u m a s )
Tra u m a s )
Reexperi en cing
.67 .16
Chi Square = 11.078, d.f.= 14, p=.680
CFI = 1.000
RMSEA = .000
.21 .38
Figure 1.
Path model for the direct effects of different traumas on PTSD four
components mediated by GD.
Tr au mas)
Tr au mas)
Tr au mas)
Pers onal
.67 .16
Chi Squa re = 9.301, d.f .= 15, p = . 8 61
CFI = 1.000
RMSEA = .000
Figure 2.
Path model for the direct effects of different traumas on CTD four
components mediated by GD.
dominant agent in the family and society, giving them such
mental health advantage over females. On the other side, as the
current study findings indicated, GD is associated with increase
in the more complex symptoms of CTD in females and not
males. GD suppresses female’s personal gender identity, and
increases stereotype, injustice and coercive control and poten-
tial violence against them by the family and by social institu-
tions, creating relative feelings of powerlessness, loss of per-
ceived control, decreased collective (gender) and personal self-
esteem, self-efficacy, and agency (c.f., e.g., Swim, Hyers, Cohen,
& Ferguson, 2001).
The effects of gender discrimination by parents (GD-P) are
worth noting. GD-P is associated, in females, with executive
function deficits that include deficits in memory and of control
of own reactions. It is associated with increase of suicidality,
dissociation, psychotic reactions, avoidance and arousal. Neural
mechanisms studies utilizing fMRI technology found that gen-
der threat underlies women’s underperformance in math (Krendl,
Richeson, Kelley, & Heatherton, 2008, see also Richeson et al.,
2003). Other studies found no gender differences in genetic
etiology in higher math performance in males (Petrill et al.,
2009). Parenting style and family culture that favor males ex-
erts its toll on the girls’ executive functions, related potential
achievements. Family gender discrimination while has serious
effects, society’s discrimination, especially, seems to have the
most detrimental effects on all functioning of affected females.
This speaks to pervasive societal-wide GD, which appears to
account for most of the variance accounted for by family-spe-
cific GD.
The results of this study highlighted the serious effects of
GD, as a complex ongoing serious trauma on females’ mental
Copyright © 2012 SciRes.
Table 6.
Decomposition of standardized direct, indirect, and total effects of trauma variables on PTSD four components, and GD (a mediation model for gen-
der discrimination).
Endogenous Variables
Causal Variables
Dissociation/Numbness GD Avoidance Arousal Reexperiencing
Personal Identity trauma
Direct Effects .321** .60* .000 .000 .000
Indirect Effects .000 .000 .28** .30** .25**
Total Effects .32** .602* .28** .30** .25**
Collective Identity Traumas
Direct Effects .17* .11+ –.13* .000 .000
Indirect Effects .000 .000 .108* .07 .001
Total Effects .17* .11+ –.03 .07 .001
Secondary Traumas
Direct Effects .21* .000 .24** .000 .000
Indirect Effects .000 .000 .11* .21** .28**
Total Effects .21* .000 .36** .21** .28**
Survival Traumas
Direct Effects .000 –.31* .000 .22** .000
Indirect Effects .000 .000 –.06* –.06* .003
Total Effects .000 –.31* –.06* .15** .003
Dissociation/ Emotional Numbness
Direct Effects .000 .000 .53** .39** .000
Indirect Effects .000 .000 .000 .19** .48**
Total Effects .000 .000 .53** .57** .48**
Gender Discrimination
Direct Effects .000 .000 .18* .14* .000
Indirect Effects .000 .000 .000 .06* .17**
Total Effects .000 .000 .18* .20** .17**
Direct Effects .000 .000 .000 .35** .63*
Indirect Effects .000 .000 .000 .000 .09**
Total Effects .000 .000 .000 .35** .72**
Direct Effects .000 .000 .000 .000 .25**
Indirect Effects .000 .000 .000 .000 000
Total Effects .000 .000 .000 .000 .25**
Squared Multiple Correlations .27 .24 .49 .66 .68
Note: +p < .10 (close to significant), *p < .05, **p < .01, ***p < .001.
Copyright © 2012 SciRes. 359
Table 7.
Decomposition of standardized direct, indirect, and total effects of trauma variables on PTSD, CTD and GD (a mediation model for gender discrimi-
Endogenous Variables
Causal Variables
GD Depression/Anxiety Interface Psychosis/Dissociation Executive Function Deficits Suicidality
Personal Identity trauma
Direct Effects .60* .32** .20* .000 .000
Indirect Effects .000 .000 .19** .27** .26**
Total Effects .60* .32** .39** .27** .26**
Collective Identity Traumas
Direct Effects .11+ .000 .000 .15** .000
Indirect Effects .000 .000 .02+ .01+ .04*
Total Effects .11+ .000 .02+ .16** .04*
Secondary Traumas
Direct Effects .000 .31* .17* .000 .000
Indirect Effects .000 .000 .08** .19** .17**
Total Effects .000 .31* .25** .19** .17**
Survival Traumas
Direct Effects –.31* .000 .000 .13+ .000
Indirect Effects .000 .000 –.06* –.03+ –.01
Total Effects –.31* .000 –.06* .10 –.01
Gender Discrimination
Direct Effects .000 .000 .18** .000 .000
Indirect Effects .000 .000 .000 .10** .12**
Total Effects .000 .000 .18** .10** .12**
Depression/Anxiety Interface
Direct Effects .000 .000 .26** .16** .000
Indirect Effects .000 .000 .000 .15** .19**
Total Effects .000 .000 .26** .31** .19**
Direct Effects .000 .000 .000 .56** .54**
Indirect Effects .000 .000 .000 .000 .10+
Total Effects .000 .000 .000 .56** .64**
Executive Function Deficits
Direct Effects .000 .000 .000 .000 .168
Indirect Effects .000 .000 .000 .000 .000
Total Effects .000 .000 .000 .000 .168
Squared Multiple Correlations .24 .29 .34 .57 .45
ote: +p < .10 (close to significant), *p < .05, **p < .01, ***p < .001.
Copyright © 2012 SciRes.
Copyright © 2012 SciRes. 361
health. The study confirmed the hypothesis that GD, in females,
have direct effects on increased PTSD arousal, avoidance, and
reexperiencing symptoms, and increased CTD symptoms of
dissociation/psychosis, executive function deficits, and sui-
GD seems to mediate the effects of some, but not all trauma
types. GD mediated the specifically the effects of personal
identity traumas (PIT) on increased PTSD symptoms of avoid-
ance, arousal and reexperiencing and CTD symptoms of psy-
chosis/dissociation; executive function deficits, and suicidality.
GD mediated the effects of collective identity traumas (CIT) on
increased PTSD avoidance and CTD suicidality. While PIT and
to some extent CIT seems to accentuate perceived GD, survival
traumas seems to mobilize women on survival issues and
minimize their perceived GD. On the other hand, GD does not
seem to mediate, in the current study, the effects of secondary
traumas on PTSD or CTD symptoms.
The women in this sample reported experiencing signifi-
cantly fewer traumas (by trauma count) than the male partici-
pants; however, they also reported higher PTSD symptoms.
The only trauma in females’ trauma profile that may explain
such differences in their mental health is the high gender dis-
crimination trauma that is continuous and cumulative, and
mostly ignored as traumatic stressors for females. The ongoing
implicit and explicit , micro and macro aggression, and gen-
dered coercive control included in GD by family, by commu-
nity and society, appears to have an effect on the women’s re-
activity and sensitivity to some other non-gendered traumatic
events, especially those related to personal or collective iden-
tity. For women who have been tortured, the feelings of pow-
erlessness and helplessness triggered by restrictive gender dis-
crimination may lead to heightened negative responses to selec-
tive future traumatic events.
Various explanations have been proposed to explain gender
difference in mental health (e.g., Astbury, 1999; Bruchon-
Schweitzer, 2002; Jenkins, 1991), including biological, behave-
ioral, and social factors. In the present study, we examined the
role of gender discrimination; a type III trauma that has accu-
mulative effects, in great part, to the observed gender gap in
psychological distress. This is at least a plausible alternative
explanation of the differences between genders in mental health.
Gender discrimination, as ongoing internalized trauma, may
continuously traumatize and sensitize females, thus leading
them to have a heightened level of arousal and sensitivity in
response to other traumas compared to their counterpart males
that GD gave them advantage and relative protective buffer
against further shorter term adversities.
Adopting a paradigm shift about the nature of GD as type III
trauma that has been sometimes internalized, rationalized or
resisted, will entail revising our legal standards for violence
against women, as well as some of the assumptions and meth-
odologies of gendered social sciences. This perspective re-
frames our understanding of some forms of domestic violence
and gendered like crimes to be a liberty and human rights
crimes rather than a crimes of assault. Seeing severe part-
ner-perpetrated abuse, by a chauvinist male, as a human rights
violation requires paradigm shift. The mechanisms of coercive
control reveal political patterns in profoundly individual situa-
tions with the micro-regulation of everyday behaviors associ-
ated with stereotypic female roles (e.g., Stark, 2007). Our
analysis goes even further, to reconsider, such gendered crimes
of discrimination to be equal to other crimes of discrimination.
Some of such crimes can amount to be gender hate crimes and
should be legally handled as such. Such paradigm shift would
likely provide more effective state intervention into what were
once considered private relationships and reduce or eliminate
gender discrimination in society.
Another implication of our findings is the importance of re-
viewing our scientific perspective and research methods con-
cerning gender. One of the cultural by-products of GD is the
gendered science. Gendered science assumes that biological
differences between genders underlie social and economic gen-
der hegemony. Gendered science holds that genders are natu-
rally unequal and therefore must be ranked hierarchically. It
assumes that each gender has distinctive cultural behaviors and
assigned roles linked to their biology (e.g., Bleier, 1984). Some
psychologists contend that gender refers to biological charac-
teristics of individuals whereas others assert that gender is a
social construction that establishes and maintains a socio-po-
litical structural violence against women in societies and cul-
tures. In research, researchers agree to use factitious gender
categories as independent, predictor, or covariant variables in
their theories and research designs. GD is usually lumped under
one variable in analysis as gender variable. Gender category is
static and limited conception of chunk and reflect a reification
process, whereby dynamic and expansive processes are trans-
formed into things or objects. Consolidating the components of
Gender discrimination masks its traumatic and struggling dy-
namics and represents either inability to analyze and understand,
or ignoring such dynamics by gendered science. The use of
gender category as precise measure of some genuine psycho-
-logical theoretical construct accords scientific legitimacy to
what are essentially gender stereotypes that psychologists share
with the larger society (c.f., Bergvall, 1999). The methodology-
cal limitations of using gender category as independent variable
make its replacement necessary. Utilizing a measure for GD or
controlling for it, can be more scientifically helpful than just
categorizing gender in research.
Advocating for a culture of gender equality and for cultural
change toward this goal is important intervention to reduce or
eliminate such gender gap in mental health. Gender equality
may help reduce internalizing disorders in girls and women,
and possibly externalizing disorders in boys and men. Further,
if we accept feminist perspective on torture, discussed earlier,
eliminating gender inequality world wide may contribute to
reduction in torture incidents and in extreme conflicts.
In 2002, World Health Organization (WHO) passed its first
Gender Policy, acknowledging the gender issue as important on
its own. At about the same time, WHO began using the UN’s
Millennium Development Goals (MDGs), which go beyond the
Health for All frameworks’ focus on equity in general. They,
specify, more particularly, that gender equality and the empow-
erment of women are vital goal.
It is important to reframe our understanding of the potential
role of GD as a type III traumatic stresses and as a mediating
and moderating variable of the effects of other lesser variant
stressors in helping to assess and counsel females. Such para-
digm shift in understanding GD will help providing more gen-
der competent counseling for girls and women.
While explanations for the findings in this study warrant
further investigation, it is clear that refugee women who have
experienced significant traumatic events, particularly those who
have experienced gender discrimination, are in need of inter-
ventions and supports that are different than those developed
largely for military men suffering post-combat PTSD. Therapy
for women must include a focus on empowerment, self-efficacy,
and a sense of control in their new environments. The signifi-
cance of these results for assessing and treating females, and
especially female refugees who are either primary or secondary
torture survivors is important. Assessing GD in female clients,
their gender esteem, and the interaction of GD with the current
other traumas is important when working with female clients.
Assessment of trauma and intervention with women should
address gender discrimination in counseling and therapy to
re-empower victims and minimize the effects of such ongoing
trauma across cultures.
Cumulative trauma complex dynamics, in GD trauma with
refugees, may be better addressed effectively through parallels
of multi-systemic, multi-modal, multi-component intensive in-
terventions that match such complexity. Such multi-compo-
nent interventions, addressing different levels of cognitions and
affect regulation, can have synergetic effects beyond the simple
added effects of their components. A wide spectrum of holistic
multi-systemic, multi-modal, multi-component therapies (MSMCT),
that include community healing and cultural change, have been
proposed to better address such complex syndromes (e.g.,
Henggeler et al.,1998; Saxe, Ellis, & Kaplow, 2007; Kira, 2002,
2010; Kira et al., 2003, 2005; Courtois , Ford, Herman, & van
der Kolk, 2009). Community-based intervenetions which go
beyond home-based family sessions have shown evidence to
enhance generalizabilty and durability of treatment benefits
(Kazdin & Weisz, 1998).
Arbuckle, J. L. (2006). Amos 7.0 user’s guide. Chicago: SPSS.
Astbury J. (2006). Gender and m e n t a l he a l t h. Paper presented under the
Global Health Equity Initiative (GHEI) project on “Gender and
Health Equity” based at the Harvard Center for Population and
Development Studies. URL (last checked 27 August 2009).
Astbury, J. (1999). Gender and mental health. Working Paper Series No.
99. Cambridge, MA: Harvard Center for Population and Deve-
lopment Studies. 8.
Berg, S. (2006). Everyday sexism and posttraumatic stress disorder in
women: A correlational study. Violence Against Women, 12, 970-
988. doi:10.1177/1077801206293082
Bergvall, V. (1999). Toward a comprehensive theory of language and
gender. Language in so ci et y, 28, 273-293.
Blake, D. D., Weathers, F. W., Nagy, L. N., Kaloupek, D. G., Klau-
minser, G., Charney, D. S., & Keane, T. M. (1990). A clinician rating
scale for assessing current and lifetime PTSD: The CAPS-1.
Behavior Therapist, 18, 187-188.
Bleier, R (1984). Science and gender: A critique of biology and its
theories on women. Oxford: Pergamon.
Bruchon-Schweitzer, M. (2002). Health psychology. Paris: Edition
Brownmiller, S. (1975). Against our will: Men, women and rape. New
York: Fawcett Columbine.
Cassiman, S. A. (2005). Toward a more inclusive poverty knowledge:
Traumatological contributions to the poverty discourse. The Social
Policy Journal, 4, 93-106. doi:10.1300/J185v04n03_06
Christiana, E. & Okojie, E. (1994). Gender inequalities of health in the
third world. Social Sc i e n c e M e di c i n e , 3 9 , 1237-1247.
Courtois, C., Ford, J., Herman, J., van der Kolk, B. (2009). Treating
complex traumatic stress disorders: An evidence-based guide. New
York: Guilford Press.
Dambrun, M. (2007). Gender differences in mental health: The
mediating role of perceived personal discrimination. Journal of
Applied Social Psychology, 37, 1118-1129.
Erceg-Hurn, D., & Mirosevich, V. (2008). Modern robust statistical
methods: An easy way to maximize the accuracy and power of your
research. American P sy ch ol og is t, 63, 591-601.
Foley, S., Hang-Yue, N., & Wong, A. (2005). Perceptions of Dis-
crimination and justice: Are there Gender Differences in Outcomes?
Group Organization Management, 30, 421-450.
Glick, P., & Fiske, S. T. (1996). The ambivalent sexism inventory:
Differentiating hostile and benevolent sexism. Journal of Personality
and Social Psychology, 70, 491-512.
Goldberg, D., & Williams, P. (1988). A user’s guide to the General
Health Questionnaire. Windsor: NFER.
Greenberg, J. (1990). Organizational justice: Yesterday, today, and
tomorrow. Journal of Man agement, 16, 399-432.
Gutek, B. A., Cohen, A. G., & Tsui, A. (1996). Reactions to perceived
discrimination. Human Relations, 49, 791-813.
Hawton, K., Rodham, K., Evans, E., & Weatherall, R. (2002). Deli-
berate self harm in adolescents: Self report survey in schools in
England. British Medical Journal, 23, 1207-1211.
Heise, L. (1998). Violence against women: An integrated, ecological
framework. Violence Against Women, 4, 262-290.
Heise, L., Pitanguy, J., & Germain, A. (1998). Vi o lenc e ag ain st w omen :
The hidden health burden. Washington DC: World Bank.
Henggeler, S. W., Schoenwald, S., Borduin, C. Rowland, M., &
Cunningham, P. (1998). Multi-systemic treatment for antisocial be-
havior in children and adolescents. New York: Guilford.
Hu, L., Bentler, P. M. (1999). Cutoff criteria for fit indexes in
covariance structure analysis: Conventional versus new alternatives.
Structural Equation Modeling, 6, 1-55.
Hunnicutt, G. (2009). Varieties of patriarchy and violence against
women: Resurrecting “patriarchy” as a theoretical tool. Violence
Against Women,15, 553-573. doi:10.1177/1077801208331246
Jenkins, R. (1991). Demographic aspects of stress. In C. L. Cooper, & S.
V. Kasl (Series Eds.), C. L. Cooper, & R. Payne (Vol. Eds.),
Personality and stress: Individual differences in the stress process
(Vol. 14, pp. 107-132). Chichester: John Wiley & Sons.
Kazdin, A. E., & J. R. Weisz (1998). Identifying and developing
empirically supported child and adolescent treatments. Journal of
Counseling and Clinical Ps ycho logy , 66, 19-36.
Kira, I. (2010). Etiology and Treatments of post-cumulative traumatic
stress disorders in different cultures. Traumatology: An International
Journal, 16, 128-141.
Kira, I. (2004). Cumulative trauma disorder: A new scale for complex
PTSD. 28th International Congress of Psychology, Beijing, 8-13
August 2004.
Kira, I. (2002). Torture assessment and treatment: The wraparound
approach. Traumatology: An International Journal, 8, 23-51.
Kira, I. (2001). A taxonomy of trauma and trauma assessment. Trau-
matology: An International Journal, 2, 1-14.
Kira, I., Templin, T., Lewandowski, L., Ramaswamy, V., Bulent, O.,
Abu-Mediane, S., Mohanesh, J., & Alamia, H. (2011). Cumulative
tertiary appraisal of traumatic events across cultures: Two studies.
Journal of Loss and Trauma: International Perspectives on Stress &
Coping, 16, 43-66.
Kira, I., Smith, I., Lewandowski, L., & Templin, T. (2010). The effects
of perceived gender discrimination on refugee torture survivors: A
cross-cultural traumatology perspective. Journal of the American
Psychiatric Nurses As sociation, 16, 299-306.
Copyright © 2012 SciRes.
Copyright © 2012 SciRes. 363
Kira, I., Lewandowsk, L., Templin, T., Ramaswamy, V., Ozkan, B., &
Mohanesh, J. (2008a). Measuring cumulative trauma dose, types
and profiles using a development-based taxonomy of trauma,
Traumatology: An International Journal, 14, 62-87.
Kira, I., Lewandowski, L., Templin, T., Ramaswamy, V., Ozkan, B., &
Mohanesh, J. (2008b). Measuring Cumulative Trauma dose, types
and profiles using a development-based taxonomy of traumas: The
long version. American Psychological Association 116th Annual
Convention, Boston: APA PsycExtra Data base.
Kira, I., Hammad, A., Lewandowski, L., Templin, T., Ramswamy, V.,
Ozkan, B., & Mohanesh, J.(2007). The health and mental status of
Iraqi refugees and their etiology. Ethnicity & Disease, 17, 79-82.
Kira, I., Templin, T., Lewandowski, L., Clifford, D., Wiencek, E.,
Hammad, A., Al-Haidar, A., & Mohanesh, J. (2006). The effects of
torture: Two community studies. Peace and Conflict: Journal of
Peace Psychology, 12, 205-228. doi:10.1207/s15327949pac1203_1
Kira, I., El-gouhari, G., Bazzi, H., & Kazak, A. (2005). Treating
children victims of cumulative trauma: An Innovative model. 15th
National Conference on Child Abuse & Neglect, Boston, 18-23 April
Kira, I., Clifford, D., & Al-Haider, D. (2003). Assessing and treating
cumulative trauma disorders (CTD) in Iraqi refugees. American
Psychological Association Annual Convention, Toronto, 7-11 August
Kline, R. B. (2005). Principles and practice of structural equation
modeling (2nd ed.). New York: The Guilford Press.
Klonoff, E. A., Landrine, H., & Campbell, R. (2000). Sexist discri-
mination may account for well-known gender differences in psy-
chiatric symptoms. Psychology of Women Quarterly, 2 4 , 93-99.
Krendl, A., Richeson, J. A., Kelley, W., & Heatherton, T. F. (2008).
The negative consequence of threat: An fMRI investigation of the
neural mechanisms underlying women’s underperformance in math.
Psychological Science, 1 9 , 186-175.
Landrine, H., Klonoff, E. A., Gibbs, J., Manning, V., & Lund, M.
(1995). Physical and psychiatric correlates of gender discrimination:
An application of the Schedule of Sexist Events. Psychology of
Women Quarterly, 19, 473-492.
Linzer, M., Spitzer, R., Kroenke, K., et al. (1996). Gender, quality of
life, and mental disorders in primary care: results from the PRIME-
MD 1000 study. Amer ica n J our nal o f Medicine, 1, 526-533.
Macintyre, S., Ford, G., & Hunt, K. (1999). Do women “over-report”
morbidity? Men’s and women’s responses to structured prompting
on a standard question on longstanding illness. Social Science and
Medicine, 48, 89-98. doi:10.1016/S0277-9536(98)00292-5
Mejía, X. E., (2005). Gender matters: Working with adult male
survivors of trauma. Journal of Counseling & Development, 83,
29-40. doi:10.1002/j.1556-6678.2005.tb00577.x
Parker G, & Roy K. (2001) Adolescent depression: A review.
Australian and New Zealand Journal of Psychiatry, 35, 572-580.
Petrill, S., Kovas, Y., Hart, S., Thomson, L., & Plomin, R. (2009). The
genetic and environmental etiology of high math performance in
10-years old twins. Behavior Genetics, 39, 371-379.
Pittaway, E. (1999). Refugee women—The unsung heroes. In B.
Ferguson, & E. Pittaway (Eds.), Nobody wants to talk about it-
refugee women’s mental health (Chapter 1). Sydney: Transcultural
Mental Health Centre.
Pittaway, E., & Bartolomei, L. (2001). Refugees, race, and gender: The
multiple discrimination against refugee women. Refuge: Canada’s
Periodical on Refugees, 19, 21-32.
Richmond, J., Elliot, A., Pierce, T., Aspelmeier, J., & Alexander, A.
(2009). Polyvictimization, childhood victimization, and psycho-
logical distress in college women. Child Malt reatment, 14, 127.
Richeson, J. A., Baird, A. A., Gordon, H. L., Heatherton, T. F., Wyland,
C. L., Trawalter, S., & Shelton, J. N. (2003). An fMRI examination
of the impact of interracial contact on executive function. Nature
Neuroscience, 6, 1323-1328. doi:10.1038/nn1156
Rosenfield, S. (1999). Gender and mental health: Do women have more
psychopathology, men more, or both the same (and why). In A.
Horwitz, & T. Scheid (Eds.), Handbook for study of mental health.
Cambridge: Cambridge University Press.
Saxe, G., Ellis, B. H., & Kaplow, J. (2007). Collaborative treatment of
traumatized children and teens: The trauma systems therapy
approach. New York: Guilford Press.
Scott S. (1998). Aggressive behavior in childhood. British Medical
Journal, 316, 202-206. doi:10.1136/bmj.316.7126.202
Skarlicki, D. P., & Folger, R. (1997). Retaliation in the workplace: The
roles of distributive, procedural, and interactional justice. Journal of
Applied Psychology, 82, 434-443. doi:10.1037/0021-9010.82.3.434
Stark, E. (2007). Coercive control: How men entrap women in personal
life. New York: Oxford University Press.
Swim, J. K., Hyers, L. L., Cohen, L. L., & Ferguson, M. J. (2001).
Everyday sexism: Evidence for its incidence, nature, and psycho-
logical impact from three daily diary studies. Journal of Social Issues,
57, 31-53. doi:10.1111/0022-4537.00200
Walby, S. (1990). Theorizing patriarchy. Cambridge: Basil Blackwell.
Wanous, J., & Hudy, M. J. (2001). Single-item reliability: A replication
and extension. Organizational Research Methods, 4, 361-375.
Watts, C., & Zimmerman, C. (2002). Violence against women: Global
scope and magnitude. The Lanc et , 359, 1232-1237.
Weathers, F. W., Keane, T. M., & Davidson, J. R. (2001). Clinician-
administered PTSD scale: A review of the first ten years of research.
Depression and Anxiety, 1 3, 132-156. doi:10.1002/da.1029
Wesley, J. (2006). Considering the context of women’s violence gender,
lived experiences, and cumulative victimization. Feminist Crimi-
nology, 1, 303-328. doi:10.1177/1557085106293074
Wood, W., & Eagley, A. H. (2003). A cross-cultural analysis of the
behavior of women and men: Implications for the origins of sex
differences. Psychological Bulleti n, 128, 699-727.
World Health Organization (2009). Gender disparities in mental health.
URL (last checked 27 August 2009).
Yllo, K. A. (1993). Through a feminist lens: Gender, power and
violence. In R. J. Gelles & D. R. Loseke (Eds.), Current contro-
versies on family violence (pp. 47-62). Newbury Park, CA: Sage.
Zimmerman, C., Hossain, M., Yun, K., Roche, B., Morison, L., &
Watts, C. (2003). Stolen smiles: A summary report on the physical
and psychological health consequences of women and adolescents
trafficked in Europe. London: London School of Hygiene and
Tropical Medicine.