Alice in trauma-land

Warning: This article contains material of distressing nature related to sexual violence.

It was a cold English Christmas when I first met her in 2007. Her therapist was off and I was called in to deal with a crisis.

She was reliving a childhood sexual trauma on the 20th anniversary of being raped by her uncle. She was 30 and refusing to eat. She was at the Oxford Eating Disorders Unit, so refusing meals was not an option. My mission was to ground her by bringing her back to the here-and-now, so she could stop reliving the trauma and eat her Christmas lunch.

After half an hour of failed attempts, she finally stopped shaking and told me she really needed to starve herself in order to maintain her skinny tomboy look as a deterrent to assailants all around her. Another prolonged silence was broken as she looked at me, or rather through me, and shared the tormenting images and sensations of her assault.

She told me that, just like Alice in wonderland, she had long ago decided to drink the bottle that made her shrink so HE could never find her. Her illustrative words captured me and transported me to this fairytale I always enjoyed as a child, and I too could identify with Alice at that moment. I saw myself holding a biscuit that read “eat me.”

I ended up telling her that the reason why I chose to be a psychiatrist specializing in sexual abuse in the first place was also based on a decision I made a long time ago to eat Alice’s biscuit — to become a giant to step on HIM.

Unfortunately, some trauma survivors do not feel that healing is a choice they have.

The World Health Organization (WHO) defines healing as “not merely the absence of disease and infirmity, but a positive state of physical, emotional and social well-being.”

There are many obstacles to healing, starting with seeking help. Our culture stigmatizes mental health issues, and this is the biggest obstacle facing those who want to heal. The nature of trauma itself can also play a role in shaming the survivor, especially if trauma is of a sexual nature.

I first met him in August 2012, following the protests at the Syrian Embassy in Cairo. Military police had detained this 16-year-old boy, who I refer to here as MA. He was among other adolescents who were in detention for several days. After they were released, they told of some horrifying encounters with those who detained them. MA documented his alleged torture and rape with Al-Nadeem Center for the Rehabilitation of Victims of Violence and with Amnesty International.

When I saw him, he was in a state of terror and delirium as he relived the rape incident. His comrades had taken him to a hospital and contacted me to go see him there. They told me this was not the first episode of reliving.

Emergency doctors at the hospital would not examine him, and all they said was he needed admission to a mental health hospital and that they might need to call the police. I asked to examine him and suggested some medication to calm him down. Within half an hour, his body had started to relax and his mind started to come back to the here-and-now as he became mindfully aware of the moment.

I explained to him what had happened, and that he was suffering severe traumatic anxiety and was reliving this terrifying moment over and over again.

His shame was the strongest symptom of all, and it is one of the rigid beliefs mental health specialists need to target when dealing with traumas of a sexual nature. The international tribunal for the prosecution of humanitarian law violations committed in the territory of the Former Yugoslavia since 1991 observed how rape “strikes at the very core of human dignity and physical integrity.”

After rape, survivors of sexual violence may experience severe feelings of anxiety, stress or fear, known as post-traumatic stress disorder (PTSD). While it is natural to have some of these symptoms after a traumatic event, if they last more than a few weeks and become an ongoing problem, it is then diagnosed as PTSD. If left untreated, the symptoms of PTSD worsen and could last for months and years.

MA asked me to be his psychiatrist and therapist, and together we planned to tackle the fear behaviorally and cognitively. MA was clear, however, that he might not be able to stop protesting against the regime, especially after it became “personal.”

For most victims of PTSD, memories of their trauma strike without warning. Many of the same feelings and emotions experienced during the traumatic event accompany the flashbacks unpredictably — sometimes as extreme as feeling as though the actual trauma was occurring again.

Despite the medication and the early therapy sessions, I saw MA dissociate many times, and I even witnessed him act as his perpetrator. During one political public event, he dissociated and became the police officer who raped him. This of course caused social repercussions for him.

In addition to the elevated risk of suicide, research has shown that adult survivors of adolescent sexual violence, such as MA, are far more likely to experience acute and chronic mental health issues. In addition to PTSD, they could suffer from dissociative identity disorder, major depression and severe anxiety. More recent research indicates that traumatic stress caused by childhood sexual violence can even cause neurological damage and changes in brain function.

Rape and torture-land

The Committee Against Torture and international human rights laws have long understood rape and sexual violence to be forms of torture. It is an especially common form of organized violence during conflict and wartime. The rape of men, women and children has occurred during conflicts across the globe. During the Balkan wars of the 1990s, Rwanda in the early 1990s and the Congo from 2000 to 2006, more than 40,000 women and children were raped.

Rape as a systematic method of torture by states is politically motived when state agents such as the army, police and security forces or other groups perpetrate such abuse. States have a duty to prevent, investigate and prosecute cases of torture, but if those who are supposed to do so are themselves the torturers, then there is no official protection.

A huge obstacle we faced as we tried to heal MA’s trauma was this notion of never getting retribution, as the state that was supposed to protect him and prosecute those who raped him was in fact the direct violator of his body and soul.

Both men and women may suffer sexual assault. However, the documented rape cases of men tend to be lower, as men may be more reluctant to report such episodes. MA, for instance, felt his manhood was “murdered,” and he could not face his sisters and mother for a long time.

Mariane Kastrup of the International Rehabilitation and Research Center on Torture Victims in Copenhagen argues that “systematic torture is designed to break the spirit of an individual, but in many countries the intention is also to intimidate a minority or dissident group or even an entire population.”

MA suffers from a congenital joint problem that prevents him from running properly. But we could not stop him from joining protests, and he was captured and detained again. I was told that all the detained were asked by police officers to strip naked and were examined anally for razor blades. I visited the station and explained MA’s past trauma to the station’s head. Of course, he assured me that no such practice would take place in his police station.

However, we were told it did happen.

This meant an escalation of MA’s sexual trauma, and no therapy would be possible as trauma was ongoing. Egypt, it seemed, was breeding traumatized youths and creating a violent future that could kill any dream of a transitional justice one day.

In 2004, Al-Nadeem published an article that outlined 43 documented cases of different forms of torture committed between 2000 and 2004. According to Basma Abdel Aziz, a psychiatrist with Al-Nadeem, 43 men and women were subjected to sexual violence and rape. Among them, seven women were stripped naked and abused by words and touch, seven were threatened with rape, one woman was actually raped and one man was exposed to violent squeezing of his scrotum.

This does not account for undocumented cases. The article suggested that the fear of police threats and repeated acts of torture or rape was the reason why many couldn’t dare to come forward to give their testimonies.

These practices continued after former President Hosni Mubarak’s ouster, into former President Mohamed Morsi’s era and still exist under the current regime.

On July 1, Amnesty International issued a report saying that there has been a surge in arbitrary arrests and torture in the past year. It included graphic testimonies from male detainees who allege that they were raped in police detention. A 23-year-old student arrested in February, 2014 gave a horrifying account of how he was sexually assaulted and raped. He is one of many who had to endure this state violation of his body and soul.

Sexual violence is a very powerful weapon against individuals, families, and communities. For both men and women, the dominant subsequent emotion is usually deep shame; community and family, especially, are more likely to shun women after they have been sexually abused.

Ayat Hamada, a student who was sexually assaulted, told the BBC that the assault was a means to breaking her spirit. She mentioned how it was culturally very difficult for her to come forward, and that she could not disclose all the details of the attack. Mada Masr recently published the testimony of a secular female activist who was raped by state security forces, but could not go public for fear of facing a smearing campaign amid the many threats she is still facing.

MA was recently arrested and detained again. This is his fourth arrest, and a possible continuation of his story with trauma.

Has he developed coping skills to deal with recurrent violations, or is he just caught in this vicious cycle of violence?

Either way, it is our role, as a society, to ensure they have this choice to begin with.

Due to the interconnectedness and complexity of the various effects of a traumatic event, the healing process is difficult and lengthy. Too often, treatment for individuals affected by trauma — if it’s even available — focuses on the immediate and obvious symptoms of the trauma, but ignores the possibly detrimental healing methods used by the society itself.

What is necessary, according to Brandon Hamber, the director of the International Conflict Research Institute, is “not just dealing with the causes of the distress and the symptoms … what needs to be ‘healed’ is the multitude of individual, political, social and cultural responses to a traumatic situation and its aftermath.”

Many times, the problems associated with individual trauma survivors are, in actuality, social problems that have not been fully resolved. Although the methods for PTSD treatment are continuously being examined and perfected, ultimately the individual’s right to heal is only possible when the entire population is working towards incorporating methods for positive cultural healing into the treatment plan.

The consequences of abuse and torture can be grave for the victim. But why are some sufferers condemned to Alice’s “bottle,” while others have found the “biscuit” and conquered the fear, humiliation, guilt and injustice they have endured? While this battle is primarily theirs, it is our role, as a society, to ensure they have the right to heal to begin with. It is our collective duty to create the environment of healing, of tolerating and respecting mental illness, where everyone has access to adequate mental health services.

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