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Community Mental Health Journal, Vol. 43, No. 1, February 2007 (Ó 2006) DOI: 10.1007/s10597-006-9060-9

Psychological Symptomatology among Palestinian Male and Female Adolescents Living under Political Violence 2004–2005 Rachel Lev-Wiesel, Ph.D. Alean Al-Krenawi, Ph.D. Mahmud A. Sehwail, M.D., Ph.D.

ABSTRACT: The aim of the study was to investigate gender differences in relation to exposure to domestic violence, political violence, family relations and psychological symptomatology in Palestinian adolescents. The sample consisted of 1766 adolescents, males (54.1%) and females (45.9%), residents of West Bank cities subjected to violent political conflict. Participants completed a self-report questionnaire consisting of the following measures: demographic variables, domestic violence, political violence events, the McMaster Family Assessment Device, and the Brief Symptom Inventory (BSI) psychological symptomatology. Results indicated that whereas there was no significant difference in the level of exposure to political violence between boys and girls, female adolescents exhibited higher levels of psychological symptoms compared to their male counterparts. Girls also reported higher levels of exposure to domestic violence and lower levels of family function than boys. KEY WORDS: psychological symptomatology; political violence; adolescents; gender; Palestinians.

Alean Al-Krenawi is affiliated with the Spitzer Department of Social Work, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Rachel Lev-Wiesel is affiliated with the School of Social Work, Haifa University, Haifa, Israel. Mahmud A. Sehwail is affiliated with the Center for Victims of Torture, Ramallah, Palestine. Address correspondence to Alean Al-Krenawi, Ph.D., Spitzer Department of Social Work, BenGurion University of the Negev, P.O. Box 653, Beer-Sheva, 84105, Israel; e-mail: 49

Ó 2006 Springer Science+Business Media, Inc.


Community Mental Health Journal

TodayÕs Palestinian adolescents have lived with political violence most of their lives. Born during the first Intifada (Palestinian Uprising 1987–1993), and exposed to ongoing military activities such as geographic mobility restrictions, house searching or street battles, these children witnessed or actively participated in the second Intifada 2000–2005. As a result of the Israeli–Palestinian violent engagement, civil services such as education and health could no longer supply their services; schools and universities were closed and re-opened according to the army order, and the ill were sometimes prevented from receiving essential medical treatment. In addition, the economic situation deteriorated and many parents lost their jobs; the unemployment rate has increased from 23 to 45% and poverty rates have increased from 25 to 60% (World Bank, 2003). Previous research indicates that the Palestinian population was psychologically and socially affected by the ongoing political violence (Giacaman, Husseini, Gordon, & Awartani, 2004). Al-Ashhab (2005) for example, reported that about two-thirds of Palestinians feel insecure, a feeling reinforced by the growing occurrences of domestic violence. In relation to childrenÕs responses, he reported that 67% of children between the ages of 9–18 suffer from posttraumatic stress reactions. In a study conducted among Palestinian children exposed to war trauma by Thabet and Vostanis (1999), 72.8% reported posttraumatic stress disorder (PTSD) symptoms of at least mild intensity, and 4% reported moderate/severe PTSD reactions. Palestinian children living in war zones are also at high risk of suffering from depressive disorders (Thabet, Abed, & Vostanis, 2004). Recently, Al-Krenawi, Lev-Wiesel, & Sehwail (in press) studied the psychological well-being of Palestinian adolescents and found that the actual exposure to political violence contributed to the severity of the psychological symptomatology. Based on the fact that womenÕs status in the Arab world in general and in the Palestinian society in particular is lower than menÕs status, and on the fact that women as well as children of both sexes often took an active part in the Intifada (e.g., threwstones or at soldiers, became suicidal bombers, or assisted other fighters in any way needed), the current study attempts to investigate the impact of living under political violence in relation to gender. More specifically, the study examines gender differences in relation to exposure to domestic violence, political violence, family function and psychological symptomatology among Palestinian adolescents.

Rachel Lev-Wiesel, Ph.D., et al.


GENDER DIFFERENCE IN WAR ZONES The effect of conflict, specifically its impact on women, has been discussed in a wide variety of contexts, including South Africa, Yugoslavia, Lebanon, Palestine, Yemen, Malaysia, and Northern Ireland (e.g., Peteet, 1997; Shehadeh, 1999). Studies show that women in conflict areas are more prone than men to depression, posttraumatic stress disorder (PTSD) and other psychopathologies (Karam, 1999). Palestinian women have been involved in political activities seeking Palestinian independence (Haj, 1992). Nassar (1989) for example, pointed out that in 1988, the first year of the first Intifada, more than 3,000 Palestinian women were imprisoned by Israeli authorities for protesting against the occupation. Empirical studies in Palestine (e.g., Baker & Shalhoub-Kevorkian, 1995) reveal the extreme trauma that Palestinian mothers suffer, especially when they lose a child as a result of military or political acts (AbdelHamid et al., 2002). The effects of the violent political situation are compounded by the burden women carry in their traditional roles of providing marital and domestic stability and child rearing (ShalhoubKevorkian, 1998, 2001, 2003; Farhood, 1999; Karam, 1999). From a social-cultural perspective, it has also been found that to a certain extent, political conflicts can provide a catalyst for the emancipation of women and their eventual empowerment. Cook (1998) for example, who studied womenÕs literary responses to the Lebanese war, described how these women went through a transformation in consciousness in which they became aware that they remained in conflict areas out of a sense of responsibility for others and that they survived these experiences. However, the empowerment of women as political actors in conflict zones is still questionable. Peteet (1997) who investigated practices of mothering among Palestinian women, both in the refugee camps of Lebanon during the civil war (1975–1990) and during the first Palestinian Intifada (1987–1993) in the Palestinian Occupied Territories, argues that the emergence of a transformed ‘‘female practice and emotion’’ (Peteet, 1997, p. 104) challenged theconstruct of women as icons of the nation. While political conflict empowered women, the conflicted space simultaneously became a source of further gender oppression and subordination. Thus, the consequences of such socio-political pressures and psychological disorders are devastating to the women and their families (Shalhoub-Kevorkian, 1998, 2001, 2003; Farhood, 1999; Karam, 1999). Gad (1990) posits that womenÕs political involvement has not increased womenÕs status at


Community Mental Health Journal

home, nor altered family roles. Khamis (1998) studied the extent to which differences in the presence of trauma, political and normative stressors, family resources and hardiness could account for variation in Palestinian womenÕs psychological distress and well-being. She found that normative stressors were more predictive of psychological distress and well-being than was the presence of trauma or political stressors. Taking into account that female adolescents have been living all their lives under the shadow of political violence, we sought to investigate gender differences in relation to the level of exposure to political and domestic violence, family function and the severity of psychological symptomatology.

METHOD Participants A random sample of 2,328 adolescents, ranging in age from 12 to 18.5 (M = 15.56, SD = 1.22) and residents of the major cities in the West Bank, were administered selfreport questionnaires. The sample was originally based on major cities, refugee camps and several villages that were randomly selected from the Palestinian Central Bureau of Statistics lists by using special computer software. Each city had the same probability of being included in the sample, dependant upon the number of adolescents in the 12–18 age range and the high schools in the area. The final sample used in the current study consisted of 1,766 adolescents (only residents of cities subjected to violent political conflict were included in the sample) divided into two groups: males (54.1%) and females (45.9%). The groups did not differ in demographic variables. Most of the teenagers live with both their parents (88.7%) while 6.6% were orphaned of their fathers, and 1.2% of their mothers. The average number of children at home was 6.92 (SD = 3.11). The research team trained male and female social work and psychology students from universities in the West Bank who interviewed the youth. During the administration of the questionnaires, the interviewers were present to offer assistance in completing the survey, as required.

Measures The self-report questionnaire consisted of the following measures: demographic variables such as the socio-economic status of the adolescentÕs family, domestic violence, political violence events (these two latter measures were prepared by the research teams based on focus groups adapted to cultural norms and specific situations), the McMaster Family Assessment Device that measures the family function, and the Brief Symptom Inventory (BSI) that measures psychiatric symptomatology (Derogatis & Melisavados, 1983; Derogatis & Spencer, 1982). Domestic Violence developed by the authors, measures two-dimensional verbal and physical violence within the family: violence between parents and children or among siblings (9 items) and spousal violent relationships (4 items). Respondents were asked to rate the level of occurrence ranging from ‘‘All the Time’’ (5) to ‘‘Never’’ (1). CronbachÕs alpha reliability coefficient was found to be .87 (.85, .92, respectively).

Rachel Lev-Wiesel, Ph.D., et al.


Political Violence Events developed by the authors, measures the level of subjective severity of experiencing different political events activated by the Israeli army. Respondents were asked first to indicate (Yes or No) whether they experienced any of the following events: physical or verbal abuse at a military checkpoint; the arrest of themselves or a family member; being subject to long curfew periods, injury caused by soldiers, conflict-related death of a relative, property damage or loss during military house searching. If the answer was yes, they were asked to rate the level of severity ranged from ‘‘no impact’’ (1) to ‘‘serious impact’’ (5). CronbachÕs + alpha reliability coefficient was found to be .92. Family function- The McMaster Family Assessment Device (FAD) was developed by Epstein and colleagues (Epstein, Baldwin, & Bishop, 1983; Miller, Epstein, Bishop, & Keitner, 1985). This questionnaire includes 60 items on seven dimensions of family function: problem solving, communication, roles in the family, emotional involvement, behavior control, emotional responses and general function. We used only the 12 scale items that assess the general function dimensions. A study conducted by Ridenour, Daley, and Reich (1999) found that these 12 items give a satisfactory picture of the familyÕs general function, and as a result, there is no need to use all 60 questions. All sub-scales range from 1–4, with higher scores indicating more problems in a familyÕs function. Cut-off points discriminating between ‘‘clinical’’ and ‘‘normal’’ families in American populations are available. The scale has satisfactory reliability (CronbachÕs alpha = .72–.92), good test–retest reliability (r = 0.66) and high validity, as indicated by comparing the scaleÕs scores to other measures of the same matters (Epstein et al., 1983; Miller et al., 1985). The Brief Symptom Inventory (BSI) is a shortened version of the Hopkins Symptom Checklist (H-SCL-90) (Derogatis, Lipman, Rickels, Uhlenhuth & Covi, 1974). It includes 53 items that elicit perception of symptoms during the last month. The nine dimensions of the BSI are: somatization, interpersonal sensitivity, obsession–compulsion, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychotic symptoms. In addition, the scale provides a General Severity Index (GSI), a Positive Symptom Index (PSDI) and a Positive Symptoms Total (PST). The scale has been used to assess mental health of Soviet, American and Israeli adolescents in several studies (Canetti, Shalev, & Kaplan-De Nour, 1994; Slonim-Nevo & Sheraga, 1997). The internal consistency of the nine sub-scales is adequate (CronbachÕs alpha = .71–.81) and an adequate level of reliability has been found to exist by test-retest analysis (r = .60–.90).

RESULTS To examine group differences in the above measures, three types of analyses were conducted: (a) Analysis of correlations between the study variables, (b) Analyses of variance (MANOVA) comparing the two groups in terms of the severity of psychological symptomatology resulting from: exposure to political violence, exposure to domestic violence, and family function assessment. (c) A regression analysis in which the dependent variable was the psychological symptomatology and the independent variables were: demographic variables, exposure to political and domestic violence, and the family function. In order to examine the association between the psychological symptomatology and the other variables, we correlated the mean BSI


Community Mental Health Journal


Brief Symptom Inventory (BSI), Political Violence, Family Assessment Device (FAD), and Domestic Violence Measures: Comparing Male vs. Female Adolescents scores Male

BSI Political violence FAD Family violence






F value

30.35 4.98 2.81 .85

10.74 1.71 .52 .65

35.34 5.07 2.82 .94

9.87 1.90 .53 .72

98.38** 1.09 .11 6.76**

**p < 0.01. N = 933 males, 775 females.

scale score with the exposure to political and domestic violence, and the FAD scores. The FAD score was negatively correlated with the mean measure of BSI in both groups (r = ).24, p < .01; r = ) .23, p < .01, respectively), whereas the mean measure of BSI was positively correlated with the mean measures of exposure to political violence (r = .14, p < .01) and to domestic violence (r = .46, p < .01) in both groups. Table 1 presents the means, standard deviations and p values for each of the four measures. The results reveal significant differences regarding gender by BSI and domestic violence (Multivariate Wilks F (5, 1702) = 22.91, p < .01). Regression analysis revealed that 25.8% of the variance of psychological symptomatology can be explained by the following variables: evaluation of the socio-economic status (b = ).06, p < .001), sex (b = ).20, p < .001), exposure to political violence (b = .10, p < .001), exposure to domestic violence (b = .37, p < .001), and the family function (b = ).10, p < .001). DISCUSSION The study examined gender differences of psychological symptomatology among Palestinian adolescents, residents of the occupied territories who face ongoing political violence (female vs. male). Results indicated that whereas there was no significant difference in the level of exposure to political violence between boys and girls, the female

Rachel Lev-Wiesel, Ph.D., et al.


adolescents exhibited higher levels of psychological symptoms compared to the male adolescents. Girls were also found to report higher level of exposure to domestic violence and lower level of family function than boys. As in many parts of the Arab world, Palestinian women have faced oppressive patriarchal forces. The fact that boys and girls did not differ in the level of exposure to political violence, yet girls seem to suffer more from domestic violence in addition to having been exposed to political violence, is consistent with Shalhoub-KevorkianÕs (2004) findings that Palestinian women often bear a greater psychological burden than men because of patriarchal demands in addition to the violent political situation. It is also in line with KhamisÕs (1998) previous report that the internal strengths of a family were more predictive of psychological distress and well-being of Palestinian women, than the political situation per se. Furthermore, Khamis emphasizes the dual nature of race and gender for Palestinian women; a reality that posits a stressful experience for them. Future research should determine whether this experience influences young girls in the same manner. Moreover, the fact that exposure to domestic violence contributed the most to the severity of psychological symptomatology and that girls reported higher levels of exposure to domestic violence and lower levels of family function than boys, seems to indicate that while political conflict empowered women according to Peteet (1997), the conflicted space simultaneously become a source of further gender oppression and subordination. Thus, it seems that despite the fact that both sexes face political violence, pervasive gender inequalities seem to remain. From a practical perspective, the suffering of Palestinian girls who continuously face political violence as well as additional difficulties within their homes needs to be acknowledged and cared for by professionals and social leaders. It is a profound necessity to the Palestinian societyÕs well-being and equality.

REFERENCES Abdel-Hamid, A., Odd, S., Dalgard, S. O., Espen, B., Grunfeld, B., & Hauff, E. (2002). The prevalence and associated socio-demographic variables of post-traumatic stress disorder among patients attending primary health care centers in the Gazastrip. Journal of Refugee Studies, 15(3), 283–295. Al-Ashhab, B. (2005). An update on mental health services in the West Bank. Israel Journal of Psychiatry, 42(2), 81–83. Al-Krenawi, A., Lev-Wiesel, R., & Sehwail, M.A. (In press). Psychological symptomatology among Palestinian adolescents livingwith political violence. Child and Adolescent Mental Health.


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Baker, A. M., & Shalhoub-Kevorkian, N. (1995). Differential effects of trauma on spouses of traumatized households. Journal of Traumatic Stress, 8(1), 61–74. Canetti, L., Shalev, A., & Kaplan-De-Nour, A. (1994). Israeli adolescentsÕ norms of the Brief Symptom Inventory (BSI). Israel Journal of Psychiatry, 31(1), 13–18. Cook, M. (1998). WarÕs other voices: Women writers on the Lebanese civil war, London: Cambridge University Press. Derogatis, L. R., & Melisaratos, N. (1983). The brief symptom inventory: An introductory report. Psychological Medicine, 13(3), 595–605. Derogatis, L., & Spencer, P. (1982). The Brief Symptom Inventory (BSI): Administration, scoring and procedures, Manual I, Baltimore, MD: Johns Hopkins University School of Medicine, Clinical Psychometrics Research Unit. Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral-Science, 19 (1), 1–15. Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983). The McMaster family assessment device. Journal of Marital and Family Therapy, 9(2), 171–180. Farhood, L. (1999). War, trauma, and women: Predisposition and vulnerability to adverse psychological health outcomes. In L. R. Shehadeh (Ed.), Women and war in Lebanon (pp. 259– 271). Gainesville, FL: University Press of Florida. Gad, I. (1990). From salon ladies to popular committees: Women in the uprising. In I. Gad (Ed.), Readings in contemporary Palestinian society. (pp. 75–103). Birzeit, Palestine: Birzeit University. Giacaman, R., Husseini, A., Gordon, N., & Awartani, F. (2004). Imprints on the consciousness: The impact on Palestinians civilians of the Israeli army invasion of West Bank towns. European Journal of Public Health, 14(3), 286–290. Haj, S. (1992). Palestinian women and patriarchal relations. Signs, 17(4), 761–778. Karam, E. G. (1999). Women and the Lebanon wars: Depression and post-traumatic stress disorder. In L. R. Shehadeh (Ed.), Women and war in Lebanon. (pp. 272–281). Gainesville, FL: University Press of Florida. Khamis, V. (1998). Psychological distress and well-being among traumatized Palestinian women during the Intifada. Social Science and Medicine, 46(8), 1033–1041. Miller, I. W., Epstein, N. B., Bishop, D. S., & Keitner, G. I. (1985). The McMaster family assessment device: Reliability and validity. Journal of Marital and Family Therapy, 11(4), 345–356. Nassar, J. R. (1989). The nature of the Palestinian Intifada. Journal of Arab Affairs, 8(1), 10–27. Peteet, J. (1997). Icons and militants: Mothering in the danger zone. Signs: Journal of Women in Culture and Society, 23(1), 103–129. Ridenour, T. A., Daley, J. G., & Reich, W. (1999). Factor analyses of the family assessment device. Family Process, 38(4), 497–510. Shalhoub-Kevorkian, N. (1998). Crime of war, culture, and childrenÕs rights: The case study of female Palestinian detainees under Israeli military occupation. In G. Douglas, & L. Sebba (Ed.), ChildrenÕs rights and traditional values (pp. 228–248). Ashgate/Dartmouth, Brookfield, MA. Shalhoub-Kevorkian, N. (2001). Using the dialogue tent to breakmental chains: Listening and being heard. Social Service Review, 75((1), 135–50. Shalhoub-Kevorkian, N. (2003). Liberating voices: The political implications of Palestinian mothers narrating their loss. WomenÕs Studies International Forum, 26(5), 391–407. Shalhoub-Kevorkian, N. (2004). The hidden casualties of war: Palestinian women and the second Intifada. Indigenous PeoplesÕ Journal of Law, Culture and Resistance, 1(I), 67–82. Shehadeh, L. R. (1999). Women and war in Lebanon, Gainesville: University Press of Florida. Slonim-Nevo, V., & Sheraga, Y. (1997). Social and psychological adjustment of Soviet-born and Israeli-born adolescents: The effect of the family. Israel Journal of Psychiatry and Related Sciences, 34(2), 128–138. Thabet, A. B. M., & Vostanis, P. (1999). Post-traumatic stress reactions in children of war. Psychiatric Bulletin, 23(5), 385–391. Thabet, A. A. M, Abed, Y., & Vostanis, P. (2004). Comorbidity of PTSD and depression among refugee children during war conflict. Journal of Child Psychology and Psychiatry, 45(3), 533–542. World Bank. (2003). Two years of Intifada, economic closures, and Palestinian economic crisis. World Wide Web publication. WBGsummary-ENG/$File/WBGsummary-ENG.pdf#search=%22two%20years%20of%20intifada%22.

Psychosocial symptomology