Korean J Women Health Nurs KJWHN Korean Journal of Women Health Nursing 2287-1640 2093-7695 Korean Society of Women Health Nursing 10.4069/kjwhn.2019.25.1.46 Original Article Association of Traumatic Events, Post Traumatic Stress Disorder and Sexual Autonomy among Female University Students of North Korean Defectors https://orcid.org/0000-0003-2471-0325 Lee Young Jin 1 https://orcid.org/0000-0002-6730-1575 Kim Hae Won 2 3 Graduate Student, College of Nursing, Seoul National University, Seoul, Korea. Professor, College of Nursing, Seoul National University, Seoul, Korea. Researcher, The Research Institute of Nursing Science, Seoul National University, Seoul, Korea. Corresponding author: Young Jin Lee. College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Tel: +82-2-740-8465, Fax: +82-2-740-8465, hygiene2@snu.ac.kr 03 2019 25 02 2019 25 1 46 59 19 11 2018 27 12 2018 31 12 2018 © 2019 Korean Society of Women Health Nursing 2019 Korean Society of Women Health Nursing This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose

To determine associations of traumatic events and post-traumatic stress disorder (PTSD) with sexual autonomy and identify factors influencing sexual autonomy among female university students of North Korean defectors.

 Methods

A cross-sectional, descriptive study was performed with a total of 103 female students who completed a structured online self-report survey from January 7 to March 31, 2018. This study was conducted using questionnaires on interpersonal trauma scale, the Traumatic Scale for North Korean Refugees (TSNKR), and sexual autonomy measurement for college students. Data were analyzed using descriptive statistics, t-test, one-way ANOVA, Pearson's correlation coefficients, and multiple linear regression with SPSS WIN 23.0 program.

 Results

Traumatic events, PTSD, and sexual autonomy scores were 3.96±3.07, 31.47±10.75, and 52.66±6.89, respectively. PTSD was positively correlated with traumatic events (r=.22, p=.030). Sexual autonomy was inversely correlated with PTSD (r=−.25, p=.010). Contraceptive use, PTSD, and voluntary sexual debut explained 26% of sexual autonomy of participants.

 Conclusion

To improve sexual autonomy of young women from North Korea, reproductive intervention programs including contraception, sexual assertiveness training, and psychoeducation to reduce PTSD need to be developed and implemented.

 Personal autonomy Post-traumatic stress disorders Refugees, Sexual health

The authors declared no conflict of interest.

Conceptualization: Kim HW, Lee YJ.

Data curation: Lee YJ.

Formal analysis: Lee YJ.

Investigation: Lee YJ.

Methodology: Kim HW, Lee YJ.

Supervision: Kim HW.

Validation: Kim HW.

Visualization: Lee YJ.

Writing - original draft: Lee YJ.

Writing - review & editing: Kim HW, Lee YJ.

Summary Statement

• What is already known about this topic?

Most female North Korean defectors are known to have post-traumatic stress disorder (PTSD) which is positively correlated with traumatic experience. Previous studies have shown that women with PTSD have negative sex-related behaviors.

• What this paper adds?

This is the first study to investigate sexual autonomy and PTSD among young female North Korean defectors. Results showed that the greater the severity of PTSD, the lower the sexual autonomy. In addition, this study revealed that PTSD was an influential factor of sexual autonomy. Our findings confirmed that the use of contraception, PTSD, and voluntary sexual debut were influential factors of sexual autonomy.

• Implications for practice, education, and/or policy

When providing reproductive health education for female North Korean defectors, it is necessary to develop educational programs that include discussion of contraception, sexual assertiveness training, and psychological intervention therapies.

Ministry of Unification 2018 North Korean defectors policy [Internet] Seoul Ministry of Unification 2018 cited 2018 Sep 1 Available from: https://www.unikorea.go.kr/unikorea/business/statistics/ Lee SK A study on the identity composition of North Korean 1.5th generation migrant women [master's thesis] Seoul Ewha Womans University 2009 117 Kim SH Hyun IA Cho YJ A study on the improvement of North Korean defectors' adaptability to university life in the Republic of Korea Seoul Korea Hana Foundation 2016 192 Han IY Ku HJ Oh SK A study on sex knowledge among North Korean female Korean Journal of Woman Psychology 2010 15 1 87 102 Chang SB Lee MK Sexual autonomy in college students Journal of Korean Academy of Nursing 2003 33 3 339 346 Chang SB Development of sexual autonomy measurement for college students Korean Journal of Women Health Nursing 2002 8 1 106 115 Cho GY Kim YH Factors affecting sexual autonomy among female university students Journal of the Korea Academia-Industrial Cooperation Society 2014 15 11 6710 6718 Do ES Seo YS Factors influencing sexual autonomy in college students Journal of Korean Academy of Fundamentals of Nursing 2013 20 2 129 136 Park S Song W The effects of rape myth and tolerance towards violence on dating to the sexual assertiveness in college women Korean Journal of Woman Psychology 2012 17 2 265 280 Jouriles EN Choi HJ Rancher C Temple JR Teen dating violence victimization, trauma symptoms, and revictimization in early adulthood Journal of Adolescent Health 2017 61 1 115 119 Kolts RL Robinson AM Tracy JJ The relationship of sociotropy and autonomy to posttraumatic cognitions and PTSD symptomatology in trauma survivors Journal of Clinical Psychology 2004 60 1 53 63 Goldstein B Bradley B Ressler KJ Powers A Associations between posttraumatic stress disorder, emotion dysregulation, and alcohol dependence symptoms among inner city females Journal of Clinical Psychology 2017 73 3 319 330 Overstreet NM Willie TC Hellmuth JC Sullivan TP Psychological intimate partner violence and sexual risk behavior: examining the role of distinct posttraumatic stress disorder symptoms in the partner violence-sexual risk link Women's Health Issues 2015 25 1 73 78 Son YH Lee JS Park MC Lee SY Influence of posttraumatic stress on the mental health among adolescents of North Korean refugees Anxiety and Mood 2010 6 1 37 44 Kim MJ A study on North Korean female defectors' traumatic experience Korean Journal of Clinical Social Work 2010 7 1 1 18 Jeon W Hong C Lee C Kim DK Han M Min S Correlation between traumatic events and posttraumatic stress disorder among North Korean defectors in South Korea Journal of Traumatic Stress 2005 18 2 147 154 Yoon YS Kim HA Han SY Validation and development of a post-traumatic stress symptom scale for dislocated North Koreans in South Korea The Korean Journal of Counseling and Psychotherapy 2007 19 3 693 718 Faul F Erdfelder E Buchner A Lang AG Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses Behavior Research Methods 2009 41 4 1149 1160 Won JH A study of relations between complex PTSD, experiential avoidance and repetitive interpersonal trauma, among North Korean refugees [master's thesis] Seoul Kwangwoon University 2014 72 Kang S Development of Trauma Scale for North Korean refugee [master's thesis] Seoul Yonsei University 2001 82 Kim MO Ha JY A study on sexual autonomy, attitude towards homosexuality, and reproductive health promoting behavior among undergraduate students Asia-Pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology 2018 8 3 723 732 Yee NH Jung JS Song HS Influencing factors on female university students' sexual experience and sexual assertiveness Journal of the Korea Academia-Industrial Cooperation Society 2016 17 3 414 422 Kim HA Meta-analytic review on the mental health among the North Korean refugees in South Korea (depression and post-traumatic stress disorder) Crisisonomy 2016 12 1 105 124 Lowry R Robin L Kann L Effect of forced sexual intercourse on associations between early sexual debut and other health risk behaviors among US high school students Journal of School Health 2017 87 6 435 447 Wiles M Agustin S Narasimhan S Gipson JD Reproductive consequences of unwanted sexual debut among young adult women from Metro Cebu, Philippines Health Care for Women International 2018 39 8 888 905 Lee RLT Yuen Loke A Hung TTM Sobel H A systematic review on identifying risk factors associated with early sexual debut and coerced sex among adolescents and young people in communities Journal of Clinical Nursing 2018 27 3-4 478 501 Park HS A study on the effects of North Korean women defectors' gender equality consciousness: focused on gender sensitivity, sexual harassment and sexual violence recognition Asia-Pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology 2018 8 2 647 655 Kim YH Son HM Affecting factors on reproductive health behavior of female college students Journal of the Korean Data Analysis Society 2010 12 4 1935 1950 Im H Jettner JF Warsame AH Isse MM Khoury D Ross AI Trauma-informed psychoeducation for Somali refugee youth in urban Kenya: effects on PTSD and psychosocial outcomes Journal of Child & Adolescent Trauma 2018 11 4 431 441 Widman L Golin CE Kamke K Burnette JL Prinstein MJ Sexual assertiveness skills and sexual decision-making in adolescent girls: randomized controlled trial of an online program American Journal of Public Health 2018 108 1 96 102 General and Sex-related Characteristics of Subjects (<italic>N</italic>=103)
Characteristics Categories n(%) M±SD Range
General characteristics
Age (year) ≤25 54 (52.4) 25.89±2.98 20–36
≥26 49 (47.6)
Grade Freshman 34 (33.0)
Sophomore 20 (19.4)
Junior 15 (14.6)
Senior 26 (25.2)
Leave of absence 8 (7.8)
Major Health-related 33 (32.0)
Health-unrelated 70 (68.2)
Religion Yes 86 (83.5)
No 17 (16.5)
Living with Alone 42 (40.8)
With family 44 (42.7)
With friends/others 17 (16.5)
Length of stay in South Korea (month) ≤60 62 (60.2) 60.95±45.29 2–240
≥61 41 (39.8)
Length of stay in China or other nation (month) ≤24 78 (75.7) 24.94±40.24 0–264
≥25 25 (24.3)
Sex-related characteristics
Sex education Yes 80 (77.7)
No 23 (22.3)
Experience of sexual intercourse Yes 70 (68.0)
No 33 (32.0)
Age of sexual debut† (year) ≤21 39 (55.7) 21.23±2.56 15–30
≥22 31 (44.3)
Voluntary sexual debut† Yes 50 (71.4)
No 20 (28.6)
Contraceptive use† Never 13 (18.6)
Sometimes 12 (17.1)
Always 45 (64.3)
Experience of pregnancy† Yes 15 (21.4)
No 55 (78.6)
Experience of birth† Yes 9 (12.9)
No 61 (87.1)
Experience of abortion† Yes 10 (14.3)
No 60 (85.7)

M±SD=mean±standard deviation.

†Participants with experience of sexual intercourse (n=70).

 The Degree of Traumatic Events, PTSD and Sexual Autonomy (<italic>N</italic>=103)
Characteristics Categories n(%) M±SD Range
Traumatic events† Total 3.96±3.07 0–10
Separation from family† 84 (81.6)
Witness death of family or close person† 54 (52.4)
Witness death† (except family or close person) 43 (41.7)
Family violence† 31 (30.1)
Physical assault† (except family violence) 24 (23.3)
Sexual assault† 28 (27.2)
Verbal violence† 56 (54.4)
Interrogation and torture† 26 (25.2)
Forced confinement† 27 (26.2)
Identity threat† 36 (35.0)
PTSD Total score 31.47±10.75 16–62
Item score 1.97±0.67 1–4
Sexual Total score 52.66±6.89 36–65
Autonomy Item score 4.05±0.53 1–5

M±SD=mean±standard deviation; PTSD=post-traumatic stress disorder.

†Multiple responses.

 Differences in Sexual Autonomy by General and Sex-related Characteristics (<italic>N</italic>=103)
Characteristics Categories Sexual autonomy
M±SD t or F p
General characteristics
Age ≤25 52.85±7.75 0.30 .769
≥26 52.45±5.88
Grade Freshman 50.74±5.69 1.10 .362
Sophomore 53.55±6.51
Junior 54.53±7.03
Senior 53.38±7.98
Leave of absence 52.75±8.31
Major Health-related 53.76±7.32 1.11 .269
Health-unrelated 52.14±6.68
Religion Yes 52.44±6.95 0.72 .472
No 53.76±6.69
Living with Alone 53.26±7.01 0.60 .550
With family 51.80±6.73
With friends/others 53.41±7.19
Length of stay in South Korea (month) ≤60 51.23±6.15 2.67 .009
≥61 54.83±7.45
Length of stay in China or other nation (month) ≤24 53.01±6.62 0.73 .470
≥25 51.97±7.45
Sex-related characteristics
Sex education Yes 53.01±6.95 0.97 .336
No 51.43±6.69
Experience of sexual intercourse Yes 53.07±6.34 0.88 .381
No 51.79±7.99
Age of sexual debut† (year) ≤21 52.36±6.70 1.06 .295
≥22 53.97±5.83
Voluntary sexual debut† Yes 54.50±6.09 3.17 .002
No 49.50±5.61
Contraceptive use†,‡ Nevera 50.23±4.69 6.39 .003
Sometimesb 49.17±3.64
Alwaysc 54.93±6.60
Experience of pregnancy† Yes 50.20±5.94 2.02 .047
No 53.85±6.26
Experience of birth† Yes 49.00±6.89 2.12 .038
No 53.67±6.08
Experience of abortion† Yes 49.30±4.00 2.90 .009
No 53.70±6.46

M±SD=mean±standard deviation.

†Participants with experience of sexual intercourse (n=70); ‡Scheffé post hoc test (a,b<c).

 Correlations of Traumatic Events, PTSD and Sexual Autonomy (<italic>N</italic>=103)
Variables Traumatic events PTSD
r (p) r (p)
PTSD .22 (.030) -
Sexual autonomy −.02 (.855) −.25 (.010)

PTSD=post-traumatic stress disorder.

 Influencing Factors on Sexual Autonomy (<italic>N</italic>=70)
Variables B SE β t p
(Constant) 52.74 2.91 - 18.12 <.001
Contraceptive use† (1=always) 4.06 1.40 .31 2.90 .005
PTSD −0.15 0.07 −.24 −2.15 .035
Voluntary sexual debut† (1=yes) 3.27 1.52 .24 2.15 .035
Adj. R2=.26, F=9.03, p<.001

SE=standard error; PTSD=post-traumatic stress disorder; Adj. R2=adjusted coefficient of determination R2.

†Dummy variable: contraceptive use (1=always,0=never,0=sometimes), voluntary sexual debut (1=yes,0=no).