Childhood Cancer and Posttraumatic Stress Disorder

“Your child has cancer.” These are words no parent ever wants to hear.

“You have cancer,” is often a meaningless sentence to a child, but the fear and horror the child sees in his parents’ faces and hears in their voices is unmistakable.

For parent and child, a cancer diagnosis is a mental shock. And the physical shocks that follow that diagnosis—invasive treatments, surgeries, radiation and chemotherapy are also difficult to bear, also potentially traumatizing.

Cancer is a life threatening disease. And the threat to life—including the treatments to save life—can be traumatizing to those who witness their child or sibling going through cancer treatment. Death of course makes it even harder. Treatment is also potentially traumatizing to the child with cancer, potentially leaving psychic scars lasting well after a hopeful recovery.

Facing a series of repeated life threatening events puts each of this group (parents, siblings, and the childhood cancer patient as well) at risk for developing posttraumatic stress disorder (PTSD). PTSD is a disorder that is commonly associated with exposure to combat, natural disasters, or bodily assault.

PTSD in those who experience cancer, usually presents in response to feeling one’s life or one’s child/or sibling’s life is under serious and/or repeated threat.

The symptoms of PTSD include:

  • Reexperiencing the cancer treatment in nightmares, intrusive thoughts or flashbacks—scenes that are often reported to be much like full sensory movies playing unbidden in one’s mind.
  • Avoiding places, people and reminders of the cancer experience including shutting down sharing with others what one has been through.
  • Negative changes in beliefs and feelings including feelings of guilt, fear, shame or losing interest in previously enjoyed activities and feeling alienated from others.
  • Bodily hyper-arousal experienced as agitation, inability to fall or stay asleep, being easily startled, irritable, having difficulty concentrating and so on.

To qualify for a diagnosis of PTSD these symptoms must last for longer than a month and must significantly interfere with life functioning in relationships, work, education or other important areas of life.

In some cases delayed responses occur and in others only some of the features of PTSD occur. Or other related disorders arise such as anxiety disorder or panic, phobias or depression. Those who are suffer from PTSD are also at increased risk for substance abuse—as alcohol or drug abuse arises out of attempts to self medicate flashbacks and nightmares away.

Children who have PTSD often manifest their symptoms in ways that are unique to their developmental stage. For instance traumatized children may revert to wanting to sleep with their parents or go backwards on skills they previously mastered. They also often display a need to play and replay the cancer experience in attempts to master it. Or hyper-arousal may come across as aggression or misbehavior, especially in boys. Girls often go dissociative following a traumatic event—meaning their minds compartmentalize the event. They may say “everything is fine” and show no emotion but if someone where to measure their pulse when cancer is being discussed, they would see that their bodies are showing agitation. More loving touch, sleeping near to parents, and loving interactions with pets can help both adults and children to self soothe in the face of hyperarousal and posttraumatic re-experiencing.

When it comes to trauma children also often take their cues from their protectors. Parents who stay calm and who modulate their emotions well model to their children about how to cry over sad news, stay strong in the face of fear and self comfort, as well as seek comfort for overwhelming emotions. Parents who get hysterical or who shut down emotionally provide little support for children who have to navigate their own emotions and need help doing so.

The risk factors for developing PTSD in response to cancer include longer hospital stays, recurring cancers, invasive procedures such as bone marrow transplants, greater experiences of pain, previous traumas, previous psychological problems or high levels of stress in general. The protective factors against developing PTSD include a strong support network; help regulating emotions, and a good relationship with the medical staff.

PTSD following cancer should be treated sensitively. A child who is for instance triggered into fear states by the smell of a hospital or medical setting, or white lab coats needs help working through their present day anxiety while separating it from the pain or distress that went before. Children and parents may need help reframing present day thoughts that lead to anxieties and slow exposure to triggers to understand they are different (and safe) now, and help learning to calm.

The child patient as well as his or her siblings may develop more behavior problems than before the cancer treatment, become clingy or need help expressing anger versus acting it out. They may also want to avoid reminders of anything to do with cancer and even the medical system. In some case avoidance works to a certain point, but too much avoidance creates a cycle of trying to shut down only to have the painful re-experiencing start up again with another exposure to triggering reminders.

Families are strained when cancer is part of the picture. And each family member has their own way of responding to traumas—withdrawing, acting out, etc. adding an even heavier stress load on the marriage and family system. It can be hard for parents to meet the needs of everyone equally. Often the sick child gets all the attention and the siblings suffer and learn to withdraw or meet their needs outside the family creating complications later on.

Marriages are also at risk when one partner develops PTSD. For instance Stacey, a mother deeply traumatized by her young son’s cancer diagnosis and treatment found that after a hopeful resolution of his cancer she could no longer sleep well and was plagued with nightmares, flashbacks of hospital procedures and flash-forwards of imagining a dire future—including the return of cancer and death of her son.

To cope with her psychological agitation Stacey started avoiding activities she previously enjoyed. She stopped going to her son’s school or sports activities, didn’t want to have sex with her husband or go out to dinner with their friends—responses that Jim, her husband found inexplicably painful. And when Jim became angry over not understanding that posttraumatic triggers were causing Stacey to “shut down” they would have painful arguments that resolved nothing.

Children and adults with PTSD do best to work slowly with help if needed, through their traumas by facing it in small steps and creating a narrative of sorts that works for them. One of the most painful parts of PTSD is dealing with a trauma that makes no sense and for which one has no cognitive frame—“You have cancer,” is often too horrific a statement to accept. Or the suffering of a child in treatment is also too horrific to accept—at first. But over time, cognitive frames must be created in which one finds peace and accepts into one’s life story that indeed this trauma occurred and now needs to be accepted as real.

Running away from it and living with the painfulness of cycling through flashbacks, avoidance and hyperarousal is no way to live. Medications in serious cases may be useful, and relaxation training is also helpful. Simply understanding what one has been through and that posttraumatic responses—even to cancer—are normal can help to work through it.

Most PTSD sufferers feel a sense of foreshortened future—that their lives will not be as long as previously expected or as fully lived. In some case that is the sad reality, but in others it is simply fear that needs, like the cancer, to be excised from the mind.

In the end, both the trauma and the cancer need to be accommodated and the sufferer must find peace in mind and soul with both—no matter the outcome.

Anne Speckhard, Ph.D. is Adjunct Associate Professor of Psychiatry at Georgetown University Medical School and author of several books. Her latest children’s book is Timothy Tottle’s Terrific Dream.

Sochi’s grim reapers – What to know about the terrorist threat hanging over the Olympic Games

Doku Umarov

Doku Umarov

The Olympic Games in Sochi are underway, and, at least so far, the world’s worst security fears have not come true.

But the threat will lurk for the duration of the Games. This part of Russia has a well-earned reputation for being one of the planet’s most dangerous regions, because it is a uniquely poisonous cauldron of violent militant jihadi ideology, separatist guerrilla warfare and personal grudges driven by Russia’s brutal war against the Chechens.

In a series of studies conducted from 2003 to 2005 constructing psychological autopsies of 65 Chechen suicide bombers, Khapta Ahmedova, a Chechen colleague, and I found all of them to have lost a family member to a violent death at the hands of the Russians. All acted out of trauma and revenge after having been inculcated with the fanatical militant jihadi ideology that preaches Islamic “martyrdom” as a way to exit one’s life heroically while striking a lethal blow at one’s enemies.

In addition, in strong contrast to the profile of Al Qaeda terrorists that has grown familiar to Americans, many of those who pose the most serious threat to Sochi are women.

Twenty-two-year-old Ruzanna Ibragimova a Dagestani woman, pictured in wanted posters, is dressed in a modest pink hijab with a scar across her face that she is said to have gained at the hands of the Russians. Last February, Ruzanna sat alongside her rebel husband in a car when the Russians killed him. Ruzanna escaped to live. Now, trained as a suicide terrorist, she is hell-bent on death — ready to use her body as a vehicle to avenge her husband’s death.

Oksana Aslanova, also from Dagestan, is also a widow. After the Russians killed her husband, the leader of the Jamaat Sharia in Dagestan, she volunteered to go as a “martyr.” She was trained and ready to explode herself at the Day of Russia last June, according to Russian news reports, but had to be held back for another event.

She is now believed to be lurking about Sochi fully armed and ready to take on the rewards of “martyrdom” – immediate entry to paradise where she will reunite with her husband and the promise that 70 of her remaining relatives will also gain entry to paradise upon their deaths as a result of her sacrifice.

Zaira Allieva and Dzannet Tshakhaeva, also from Dagestan, are also on the loose. They were close friends with Naida Asilova, who exploded herself on a bus in Volgograd last October. The two girls fled Dagestan a week later and are now thought to be also in the Sochi region — poised to activate as suicide bombers if given the opportunity.

The organization sponsoring these four women is an outgrowth of the Chechen separatist movement begun in 1992 with the breakup of the former Soviet Union. As then-Russian President Boris Yeltsin told the former republics to “Take all the freedom you can,” Ukraine, Belarus, Uzbekistan, Kazakhstan and Kyrgyzstan did just that.

But when the Chechens, conquered so many years ago by the Russians, also tried to break free, the Russians were unwilling for those inside their own federation to let them.

Part of the reason: Chechnya has oil. So two bloody wars ensued, with Vladimir Putin carpet-bombing the capital of Grozny in the second war, causing more than half the Chechen population to flee, many becoming refugees who resettled around the world.

Then-rebel leader Shamil Basaev, seeing that the West was not coming to his aid, became convinced by a middle easterner – Ibn al-Khattab – that the only way to win was to transition the rebel movement to a terrorist campaign that explicitly embraced martyrdom and suicide terrorism.

In 2000, Basaev began a campaign of suicide attacks. Distinguishing Chechnya from many other rebellions, from the beginning, women took part in over 30 acts of terror. These included blowing up two domestic flights, exploding subways, buses, trains; it also included mass-hostage takings – one in Moscow where over 800 theatergoers were held and another in Beslan where 1,300 school teachers, mothers and children were held. In this group women have taken part in suicide acts from the start. It was women who exploded themselves on planes, and women were involved in both hostage-takings as well.

As it has metastasized over the years, the Chechen suicide terror campaign has involved more than 115 suicide bombers – half of them women. The spillover from it has spread well beyond Chechnya into neighboring Dagestan, Ingushetia and beyond.

The present terrorist leader, Doku Umarov, declared the region in 2007 as the Caucasus Emirate. In 2013, he declared that he would not allow the Russians to hold the Olympics in Sochi over the dead bones of his Muslim compatriots, the Circassians. Following the Crimean war, where, in 1859, the Russians killed and deported Circassians from the region en masse, with an estimated 625,000 deaths in what historian Walter Richmond has labeled Europe’s first genocide.

Umarov now leads an organization that has since 2000 shown itself to be capable to standing up a significant militant and terrorist campaign against Putin’s formidable authority.

Importantly for those considering the possibility of terrorist acts at the Games, the rebel forces have frequently succeeded in penetrating Russian security forces through bribes and corruption.

Ruzanna Ibragimova

NATALYA VASILYEVA/AP

Ruzanna Ibragimova

In 2004, the Chechens embarrassed Putin by placing explosives under the review stand of then-Chechen President Akhmad Kadyrov, who was blown to smithereens while viewing a parade of Russian military force.

Similarly, the Beslan hostage takers bragged to their hostages that they had “bought” them at a small price referencing that they had bribed their way from Chechnya into North Ossetia to take over the school. The terrorists there had also managed to have a cache of weapons placed under the floorboards of the school before their arrival.

Are Umarov’s cadres capable of placing explosives under the Russian review stand at Sochi? That’s unlikely, given that the Russians would be ready for it this time. And not only are the Russians scrutinizing the Olympic venue, but multinational forces are also working alongside them on the ground. While the Russians may take bribes to turn a blind eye, the FBI and other forces won’t.

Could he and his compatriots spirit in a cache of weapons and stage a Munich-style attack on the athletes themselves? Also unlikely, given Umarov’s stated ambivalence about attacking civilians and suicide attacks after the Beslan school hostage.

After the Beslan debacle, there was a worldwide backlash to Basaev’s decision to take women and children in a school hostage. In response, Umarov declared that his group would no longer attack civilians or use suicide terrorism. Their fight, he insisted, was with the Russian forces and their desire to gain independence from Putin’s rule. He reversed that position however when the Olympics were announced, urging his followers to “do their utmost to derail” them. He’s warned foreigners to avoid the Games.

That said, Umarov knows that gunning down the athletes themselves would likely result in a similar backlash. Expect him to avoid that tactic.

But it would be worse than naïve to expect Chechen terrorists to sit out the Games entirely. When the Sochi Olympics were announced, Umarov could not resist the worldwide stage and press opportunities presented. He was no doubt additionally irritated that Putin believed he could stage the Winter Olympics with impunity in this previously Muslim-dominated area, on-as he stated, “the bones of our ancestors.” That’s why he vowed to stop the Olympics.

Now he has a worldwide stage on which to play out his desires. And, as one of the only organized resistance movements to Putin’s dismantling of democratic freedoms, he may think he can win over adherents by flexing his militant muscles in the face of a frantic Russian security apparatus.

But can’t Putin, among the world’s most powerful strongmen, detect and snuff out whatever a rebel army might be planning – especially given the unprecedented surveillance infrastructure that’s in operation at Sochi?

While more than 40,000 Russian security forces have been dispatched to guard the Olympics, those that have been shipped in from other parts of Russia lack local knowledge and contacts. They have not yet won the trust of the local population.

Umarov’s cadres, by comparison, have tight-knit cells reliant on familial and religious bonds and they have demonstrated their capability to construct explosives, train and motivate operatives and pass security checkpoints.

Their cadres do not fear death. Their motto is “Victory or paradise!” They are ready to die for their cause.

They could also receive unexpected help from abroad. As half the population of Chechnya fled the second war’s carpet bombing, many now live abroad and have European, American, Canadian and Australian passports.

They could pass into Russia on clean passports, unsuspected. Tamerlan Tsarvaev, the Boston bomber, was after all originally from Chechnya and eluded U.S. and Russian surveillance when he traveled to and from Dagestan before attacking Boston.

Whatever “special package” the terrorists have planned for the 2014 Sochi Winter Olympics, spectators can take some comfort in the fact that their security is reliant on multinational cooperation among forces that are not all subject to legendary Russian corruption. The Olympic venue itself is likely to be secure. That said, transportation hubs and places where crowds gather in Sochi itself may be vulnerable to attack.

And, in at least one small way, the terrorists have already managed to disrupt Olympic plans. Most official delegations have decreased their size, some teams are leaving their family members home and ticket sales are down. As for further disruptions, let’s hope that while our athletes go for the gold, the terrorists are unable to do anything further to upstage them.

Anne Speckhard, Ph.D. is Adjunct Associate Professor of Psychiatry at Georgetown University in the Medical School and has interviewed over four hundred terrorists, their associates and close family members and their hostages in various countries around the world. She is author of the book “Talking to Terrorists.”  This piece was printed originally in the New York Daily News Opinion Section February 9, 2014  http://www.nydailynews.com/opinion/sochi-grim-reapers-article-1.1606377#ixzz2swHh4ASw

Too Young for Powerless—Cancer Through the Eyes of the Siblings

Comfort to sibs pix

“Scary”, “hard”, and “difficult” are words that youngsters frequently use to describe the feelings they have about cancer treatment of a sibling.  Watching a sibling lose weight, lose his hair, be hospitalized, etc. engenders fears of death that children left to their own devices are ill equipped to work through.  Siblings also often feel guilt, powerless, loneliness, anxiety, depression, anger, and jealousy.  Unable to understand what “cancer” even means—they know their sibling is sick, but they may not be able to understand why their brother or sister is getting so much extra attention, gifts, and invited to special events focused on them meanwhile their own feelings may be unintentionally discounted.

If these feelings are left unattended the sibling without cancer may end up with issues of their own.  They may stumble in their academic achievement or suddenly show misbehaviors.  Some siblings after the death of a sister or brother may suddenly also get “sick” often and need to stay home close to Mom or Dad—perhaps unconsciously wanting to be cared for and safe.  Siblings may also have trouble at school or in social settings when adults or other children express kind sympathies (adults) or awkward questions (children) that the sibling has no idea how to respond appropriately.

Sephora siblings week

During cancer treatment, or in a time of bereavement, a sibling may become super responsible and take on the role of caring for their distressed and often overwhelmed parent—a role that may be dearly appreciated during a crisis but shouldn’t be left in place for a long time afterward—as children need to be parented versus having this role reversed.

Mom and cancer kidChildren also want to believe that their parents are powerful versus powerless in the face of challenges and they may suddenly move into crisis finding their parents cannot prevent the suffering or death of their sibling.  These feelings of fear that a parent isn’t as strong as the child hoped may lead to inexplicable outbursts of anger or blame—words that a bereaved parent may not be equipped to hear in their time of grief.

Childhood cancer, treatment, and sometimes the death of a sister or brother, are extremely challenging events for a sibling to face.  When cancer strikes a child, a lot of things happen and fail to happen for the siblings at home—despite the best wishes of their parents who want all their children to thrive.

As parents support their sick child and literally engage in a life and death medical battle to save the child with cancer they may unintentionally overlook the emotional and even physical needs of their other children.  Healthy children may witness the physical and emotional pain of their loved one as well as the distress of their parents—often all without a good support system around them.

Good and loving parents may be too overwhelmed to explain things properly and children who are too young to understand concepts like “cancer” and “death” may find themselves floundering in a sea of anxiety for which there are not adequate supports in or outside of the family.  If the cancerous child is hospitalized out of town, parents may literally not be present to help the siblings work through their own adjustments to this very difficult challenge.

Children with cancer clearly suffer and may even die, but the overlooked siblings also suffer—from anxiety and sometimes even posttraumatic stress—with these issues displaying as nervousness, intrusive thoughts, nightmares, and avoidance which all need to be addressed—lovingly in the family or also with professional help depending on the need.

While the challenges of cancer, death, and bereavement, if the battle is lost are substantial, parents should recognize that their other children are also going to be deeply affected.  They can take steps to mitigate their other children’s suffering by turning to other family members, teachers, clergy, and even professionals to ask them to offer much needed support.  Siblings will need opportunities to sensitively talk with their parents and perhaps even with a grief counselor about what death means, if the cancerous child is likely to die, what the suffering is about and how to deal with a grieving and overwhelmed parents.  While it isn’t easy they will ultimately need to find healthy ways to grow through and beyond this difficult time in their lives.

Anne Speckhard, Ph.D. is Adjunct Associate Professor of Psychiatry at Georgetown University Medical School. This is the second in a series of blogs for Donna Speckhard’s initiative My Truth in 365 – A Virtual Journal Project on Pediatric Cancer.  Check out her site at and please donate to the cause….  http://mytruthin365.wix.com/mytruthin365#!Finding-Courage-Healing-in-Story-Telling/cke9/B75436BB-E716-4D13-BF7A-447C9F84E58B

Finding Courage & Healing in Storytelling

Journaling picture

The human mind likes to categorize events. When we have new experiences our brain searches for matches in order to help us formulate the proper response. Particularly when we have previously encountered danger the brain gives these events high priority and quickly activates if there is a match—to warn us to take caution if there might again be danger—to fight, flee or hide if necessary.

Our mind’s system of pattern matching also helps us to make sense of new experiences—placing the memory of new ones alongside others like it.

But what about if we encounter something completely new—a threat we never expected could strike us?

What if it’s childhood cancer and we have neither a match for that in our past experiences nor any expectation of cancer striking one of our young and beloved family members?  What then?

The mind, when confronted with any serious threat to life or limb, or witnessing of such a threat to others, goes immediately into high alert and tries to find a way to categorize it. But if there is no pattern match and the emotions are horrifying enough we either: freeze in numb dissociation, flee in attempts to get away from the bad news and events, or we put up a fight.

This project is about journaling via film and it’s an opportunity to address all three of these responses and help us to shift out of the ones that are no longer working for us.

Fighters will tell about how they are putting up the good fight and give courage to others who are also in the battle. But when the fight becomes overwhelming and loss looms too near they may also need to move through the painful stages of grieving: denial, anger, bargaining, depression and ultimately acceptance.

When death occurs there are again the painful stages of grieving and accepting loss.  Parents and siblings need to talk through how hard it is to face letting go of dear attachments and while still honoring and remembering, finding a path to slowing filling up the gapping hole that is left behind.

Life constantly requires us to let go but this is so hard when it’s letting go of one’s own child. Telling our stories can help to share the burden, to put words to this overwhelming grief and to find ways to rebuild when one just wants to withdraw and give up.

Those who have taken flight or who are numbly frozen in place—having fallen into depression, grief, avoidance, alienation or a numb dissociative state can find their way back into relationship by talking through their experiences and listening to others. By doing so they learn that they are not alone, that others understand, and that they can draw courage in community. They will find words for what they’ve been feeling and in doing so work through the confusion of being emotionally overwhelmed by a threat and potential or actual loss that seems too large to bear.

Traumatic news and traumatic bereavement often causes us to feel like we are experiencing life in little snippets of horrifying news and experiences. Narrating the journey can help us pull those snippets together into a coherent story that we can then search for answers to make sense of it, share with others, mull over and eventually come to peace with—no matter the outcome.

By telling our stories we will find our way through this experience, place it in the context of the human community and hopefully make friends, encourage each other and honor the ones who are in the battle and those who have moved beyond it.

Recently, a young person in the Washington, D.C. area succumbed to a type of childhood cancer. In the wake and aftermath of that person’s death the school’s counselor expressed concern that that there weren’t more parents of classmates seeking grief counseling for their children who were also deeply affected. Perhaps the parents felt a stigma, were overwhelmed with other priorities, or simply didn’t see the need.  But the truth is—when cancer strikes, whether a death occurs or not—it impacts more than just the family. It also causes a ripple effect of concern, confusion, sadness, and even horror through the ranks of classmates—close friends and acquaintances alike—who may be too young to make sense of this difficult experience.

Life continually challenges us. Journaling is one approach and outlet to advance healing within families and classmates as well. Telling our stories and finding community and coherence by doing helps us to stay centered and heal from the things that are so silently piercing our hearts.

Pick up your journals and i-pads and join us on a healing journey!

Anne Speckhard, Ph.D. is Adjunct Associate Professor of Psychiatry at Georgetown University Medical School. This is first in a series of blogsfor Donna Speckhard’s My Truth in 365 – A Virtual Journal Project on Pediatric Cancer http://mytruthin365.wix.com/mytruthin365#!Finding-Courage-Healing-in-Story-Telling/cke9/B75436BB-E716-4D13-BF7A-447C9F84E58B

“Sex Jihad”—A New Role for Extremist Women in Militant Jihadi Groups?

When Ayman Zawahiri’s wife, the al Qaeda successor to Osama bin Ladin, was asked in 2009 about the permissible roles of women in waging jihad she wrote a letter to her “Muslim sisters” encouraging them to leave the fighting to the men and to wage jihad through giving money, Internet support and by training up the next generation of young believers for jihad.  She reminded women of their duty: ‘to goad their brothers, husbands and sons to defend Muslims’ territories and properties … to assist the (male) jihadis with prayers and money.’ She also warned Muslim women not “to abandon [the modesty] of her appearance and covering herself, this is [necessarily] followed by a series of other [neglects] that push her away from her religion.’

While this was the central al Qaeda party line in 2009, it now appears that a new militant jihadi role has emerged for women—at least for Tunisian women who are reportedly going off to Syria to sexually “comfort” the rebels fighting there.

And it’s become enough of a problem that Tunisian Interior Minister Lotfi ben Jeddou announced Thursday to the National Constituent Assembly that an alarming number of Tunisian women have gone to aid rebel militants in Syria having “sexual relations with 20, 30, 100 militants” adding that “After the sexual liaisons they have there in the name of “jihad al-nikah’ [translated as sexual holy war] they come home pregnant.”

Following this statement, the Tunisia women’s ministry said on Saturday that they are drawing up plans to counter the growing number of women going to Syria to comfort militants. “The ministry intends to boost its cooperation with both government and non-government bodies on this issue to come up with appropriate ways to thwart the plans of those who encourage such practices,” a ministry statement announced.

While neither ministry gave any figures about the numbers of Tunisian women taking part in “jihad al-nikah” media reports have said hundreds of Tunisian women have gone to Syria for such purposes—some of them perhaps following the hundreds of men who have also been joining militants to battle the regime of Syrian dictator Bashar al-Assad. It appears that the practice of permitting extramarital sexual relations with multiple partners via temporary marriage contracts is viewed by militant jihadi groups affiliated with al Qaeda as a legitimate form of holy war.

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Over the past fifteen years thousands of Tunisians took part in militant jihadi battles in Afghanistan, Iraq and now Syria. Interior Minister ben Jeddou stated that in the past six months since he’d taken office he had instituted increased border controls that had thwarted six thousand young persons from traveling to Syria to join the rebels and that eighty individuals organizing travel to Syria had also been arrested.

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While I’ve been studying female terrorists for years now noting the number of roles they often play in militant jihadi groups—from translators of texts that glorify and justify terrorism, to couriers of messages and money, cooks and support roles in militant camps, trainers of the new generation of militants and for those willing to give up their lives for the cause—carriers of suicide bombs, this is completely new to me.

In all of my interviews, with and about female terrorists involved in militant jihadi groups, I’ve always been impressed that despite the many roles they may take on—they rarely—if ever hold leadership roles or wield much power.  Indeed in the Nord Ost siege in Moscow where eight hundred hostages were held for three days the terrorist women took orders from the men.  And despite being rigged with suicide bombs strapped around their waists not one of the twenty women dared detonate before being overcome with gas while their men went out in the foyer to fight the onslaught of Russian Special Forces. In that case the women’s doubt to take initiative may have saved the hostages who survived the gassing that occurred by their own side.

While sexual relations do play a role in militant jihadi groups, often claims are made by opposing forces that militant jihadis coerce women into becoming suicide bombers by raping or compromising them sexually.  However for most of the women I’ve interviewed—or if they are an already dead suicide bomber I talked to their family members or close associates and sometimes also to their senders—most appear to have gone willingly.  They didn’t need to be compromised or coerced inside conflict zones but instead begged their senders to equip them to enact revenge for traumatic experiences they had undergone at the hands of their enemy.  Their own men had no need to use rape or sexual coercion to motivate them.

In non-conflict zones females get involved for more complicated reasons involving converts who may want to purify themselves—like Muriel Degauque in Belgium who appeared to want to cleanse herself from survival guilt and her past by becoming a “martyr”.  Likewise in the Netherlands a small group of girls seduced into a militant jihadi group signed last wills and testaments and offered themselves in informal marriages to young men who promised to become “martyrs” apparently seeing themselves exalted among their peers in the future by becoming widows of “martyrs”.

In the case of the Tunisian girls who are going to Syria it still remains unclear if they are following young men they love and then end up servicing the needs of many, or if they are voluntarily engaging in such acts, or somehow coerced. Despite the strict practice of Islam—one thing clear in Islamic culture is a healthy respect for the sex drives of both males and females.  Perhaps in this case some Tunisian females are finding a way to throw off all fetters and embrace their sexuality? And it is also not clear who takes responsibility for the babies born out of such sexual liaisons and if the girls are accepted back into society when they return home?  If the extremists group’s bonds are strong it may be that extremists at home protect them just as widows and children of “martyred” fighters in Palestine and Chechnya also receive support.

In April, the former mufti of Tunisia Sheikh Othman Battikh speaking about thirteen girls that had been sent to Syria for such purposes, said that Tunisian girls were being fooled into going to provide sexual services and he named these services prostitution—moral and educational corruption.

While their services are likely much appreciated by the rebels receiving them—it does seem it can hardly be good for the women involved.

New note:  Interestingly it appears there may be a campaign of disinformation regarding “sex jihad” having begun with RT who IS DEFINITELY reporting pro-Assad propaganda.  Yet even this article states, “So what then can we make of the Interior Minister’s statements? Dismissing them is not an option, yet questioning them certainly is as ultimately we don’t have enough details about the story from the source itself, Ben Jeddou, whose information more than likely came from within the intelligence service in his ministry and not (hopefully) from online gossip sites.” and “What we do know is that, according to the Tunisian government, at least thirteen Tunisian girls are missing, several hundred Tunisian men have allegedly gone to join Syrian rebels, several thousand have been stopped from going to Syria and we know that sex (especially in terms of sexual violence and exploitation) is an inseparable part of any conflict and war.” For me I would hope the Interior Minister of a country would be a reliable source regarding his own citizens…but perhaps that is hoping for too much…

9-26-2013 more information (via Berto Jongman – thank you Berto!) We have new claimed information in the continuing saga of the so called “sex jihad” reports of Arab reports of actual women who have taken part.  Are these credible sources? Honestly I don’t know, but either way — a propaganda campaign started by RT or for real? –It’s fascinating to follow and if real, very sad for the women involved…. For more on claims of interviews of actual women involved…http://frontpagemag.com/2013/dgreenfield/sex-jihadist-catches-aids-serving-servicing-free-syrian-army-holy-warriors/

Another interesting piece sent by Berto Jongman (thank you Berto!) http://www.humanevents.com/2013/09/25/sex-jihad-and-western-disbelief/

Psychological Health for All—Throwing off the Beauty Queen Routine

Beauty pageants have dominated the news this past week. The French Senate banned them for girls under 16, threatening a two-year prison sentence and stiff fines of thirty thousand Euros for organizers–or parents–who enter their children into illegally organized contests. The French bill referenced the spate of advertising already occurring in France with hypersexualized images of prepubescent girls showing up in advertising and the potential negative mental health effects to girls of sexualizing them at a young age by requiring them to wear heavy makeup and provocative attire.

Living Dolls

In the same week many in the U.S. were surprised to learn that we still hold the Miss America contest and that it was won by an American of Indian heritage. Derogatory comments on Twitter erupted about why an Arab and Muslim had won the American contest despite the fact the new Indian descent Miss America was neither Arab nor Muslim and we already had an Arab Miss America two years ago (Rima Fakih). It seems some forget the beauty of the American dream– in myth at least–is its ability to assimilate and offer opportunity to all. Even our beauty contests allow American contestants of any ethnicity or religion to potentially win–despite prejudices held by these few on Twitter.

Next, a Marina High School in Huntington, CA elected sixteen-year-old Cassidy Campbell, a male to female transgender who is still in the process of transition, to be its homecoming queen.

Cassidy Campbell

It turns out that Campbell is not the first transgender girl to win the homecoming queen title. Jessee Vasold, a male to female transgender became homecoming queen in 2009 at William and Mary in Williamsburg, VA and a nineteen-year-old named Devon, also a male to female transgender student still undergoing transition was voted her school’s Junior Homecoming Princess. In the last case Devon was elected to the queen’s role without letting on about her status and prior to having sex reassignment surgery.

So what does all this news amount to? Are women of any background now able to break the sexist stereotypes of beauty pageants these days? Or, are the stereotypes still breaking the women and girls they crown? Is crowning any girl—a still transitioning or fully transitioned transgender woman, an Arab, a Muslim, or none of these categories—to become a high school or college homecoming queen, or beauty pageant winner a good thing? Is it healthy for any group of females to be submitting themselves to the organized judgment of others—to determine who is most worthy according to external standards?

The French are perhaps the first to officially recognize that it is not healthy for young girls organized by adults–to try to fit stereotyped gender roles and compete in popularity contest in large or whole part based on sexualized ideals of beauty that have nothing to do with innocence or childhood–and that these pageants are detrimental to the psychological health of all young girls.

Transgender individuals now entering into homecoming contests may perhaps begin to cause some of us to ask ourselves what is both gender and beauty anyway–and how much of it is culturally defined versus intrinsically known? And why would we want any developing young person under the age of eighteen–male or female, transgender or not, to submit themselves to the scrutiny of others to decide if they measure up? For a country that got rid of royalty on its road to independence it seems Americans could also now grasp the wisdom of doing away with the hierarchal idea of beauty queens. Can’t we recognize and bring out the beauty in everyone and celebrate real beauty without any king or queen being crowned among us?

Mental Health Issues and the Security Clearance Process—Questions Raised after the U.S. Navy Yard Active Shooter

The recent Navy Yard shooting in which active shooter Aaron Alexis entered the Washington, D.C. Navy facility with a gun that he used to kill twelve and injure many more–before being shot and killed himself, raises some important national security issues regarding the clearance process and granting of access to military facilities. 

Edward Snowden, Chelsea Manning (at the time Bradley Manning), Nidal Hassan, and Aaron Alexis all carried clearances.  Snowden and Manning betrayed their clearance by releasing classified documents into the hands of others.  Nidal Hassan, a military psychiatrist who had been treating wounded veterans returning from war and who was about to deploy into Afghanistan and Aaron Alexis were both active shooters.  They took weapons into a military facility and opened fire upon their colleagues ending in their own anticipated suicide. 

Today over five million U.S. security clearances are issued–one third of them to “contractors”–that is individuals who work for companies that hold government contracts.  Snowden and Alexis were both contractors.  Snowden, working for Booz Allen amazingly maneuvered himself into a position with access to innumerable classified and highly important government documents that he was able to surreptitiously remove from his workplace and then release to media contacts. 

How were these persons holding security clearances and with access to government facilities able to penetrate a system to do it terrible damage without the system having some idea of the impending danger?  Is our security clearance system broken? 

If one goes back over these cases it’s clear there were some warnings in nearly every case.  In the case of Nidal Hassan, he was becoming increasingly agitated over the wars in Afghanistan and Iraq and about being a Muslim serving in a military conflict against a Muslim country.  He expressed his concerns to his colleagues in a fashion that caused them to be disturbed–but nothing was done about it. He also asked the military not to send him to Afghanistan.

Likewise Hassan, a Palestinian by descent, would by anyone’s estimation likely have been aware of the campaign of suicide terrorism-glorified as “martyrdom” being carried out by Palestinians during the Second Intifida.  That campaign and its ideology may or may not have infected his own way of thinking about suicide rampages in behalf of what he might have felt was a good cause.  And if authorities had tracked his Internet and personal records they would have found him worshipping at the same Northern VA mosque in which Anwar al-Awlaki served and that Awlaki–then living in Yemen and highly radicalized–had become a mentor to Hassan discussing his concerns about serving as a Muslim in the U.S. military.  Before his active shooter campaign, Hassan packed up his belongings, settled his debts and bid goodbye to his landlady–although leaving her with the impression he was going off to war.  It was just a different type of war he was engaging in and no one picked up the warning signs.  

If Hassan had been subject to a more frequent security review process, if his colleagues had engaged more with him about his very real concerns, if the military had considered his expressed reservations about being sent as Muslim military member to Afghanistan, and if he had been subject to a data base review of his Internet contacts, he might have been flagged and successfully treated or discharged from the military before he went on his murderous rampage.  His acts depended upon his access to the base and trust that had been placed in him by a government that failed to realize how mentally unstable he had become. 

Chelsea Manning also gave clear signs of distress to colleagues and the medical system prior to her betrayal of U.S. secrets.  Her dilemma was quite different than Nidal Hassan’s but every bit as personally distressing.  As a serving transgender individual in the U.S. military which still does not accept and more disturbingly does not reassure it’s well serving transgender service members that they can continue to serve if they disclose their status or seek treatment along existing standards of care–she faced automatic discharge if her “secret” became known. 

As is often the case with many transgender service members, Manning had likely entered the service without having come to grips with her transgender issues.  At the time when she could no longer ignore it, she was already committed to her military career and caught in the don’t ask/don’t tell dilemma that continues to this day for transgender service members.  She was literally harboring a painful personal secret that was bursting to be addressed at the same time when she was becoming increasingly disturbed by U.S. military practices in Iraq.  Unable to disclose her secret or to get adequate treatment for it without losing her military career, she instead addressed her other concerns about U.S. military practices making a decision to become what she believed was a whistleblower–a decision that involved disclosing state secrets, betraying her country and her security clearance. 

Aaron Alexis also gave out serious warning signals.  Prior to being accepted into the Navy reserves he had been arrested, but not charged in 2004, when he shot out the tires of a car in what he explained to police afterward was an anger induced rage–a signal that he might have a serious dissociative tendency and anger management issues.  Then while in the military in 2008 he was thrown out of a bar after destroying furniture in it.  In that incident he was arrested and spent two nights in jail.  Then in 2010 he had intimidated a neighbor over his complaints about her being noisy, in an ongoing altercation that culminated in him “accidently” discharging his gun, shooting through her apartment’s floor.  The Navy was alerted of all three incidents.  

Likewise despite being discharged from the Navy and their knowing from his parents that they were also concerned about their son’s “anger management” issues, the Navy allowed him to continue to carry his security clearance that allowed him to be later hired by a contractor and gain access to multiple military facilities.  And in the past month Alexis had been seeking emergency treatment more than once at the VA for multiple nights of insomnia–another flag that he might have been deeply psychologically distressed.

Perhaps most disturbingly in his long record of signaling possible impairment to those who gave him his clearance and access to the bases, Alexis had also called the police in August of 2013 while in Rhode Island complaining that he was being microwaved and that there were persecuting voices in his head–potential signals of a schizophrenic episode.  The Rhode Island police alerted the Navy police who somehow failed to take action.  Clearly with all these signals of a troubled mind, the Navy had some obligation to re-review his security clearance and access privileges but it appears that given numerous warnings they failed to do so.  And now twelve people are dead and many more are wounded, bereaved and psychologically traumatized by his actions. 

The security clearance process in the U.S. does not require a person never to have sought mental health treatment or even not to have mental health issues and that is probably correct given that many people serve their country well despite psychological challenges and there are many treatments available to stabilize mental conditions. What the clearance process does require is an assessment of whether a psychological condition and its treatment would impair that person’s judgment and behavior in regard to classified materials and access.  This includes an assessment as to whether or not they are faithfully following their treatment.  So carrying a diagnosis and receiving treatment is not a definitive block to carrying a security clearance.

Despite this, I have personally been asked over the years many times to treat military and diplomatic personnel outside their medical system because they were seriously enough concerned over their security clearance status should they seek treatment for anxiety, addictions, PTSD, dissociative disorders, marriage stressors and even suicidal family members that they wished to do so paying cash rather than having any entry of their treatment logged into their medical system.  In each case that I was involved as a treating clinician, I was given no reasons to doubt the cleared individual’s ability to carry out their duty to their country.  And it seemed wise to me that they did seek treatment as the issues they were facing were serious ones that could impair their ability to perform without treatment.  But had they been compromised, I as an outside clinician would have also faced a dilemma–would this constitute an instance of duty to warn, or would I be obliged to not break their confidentiality? 

While we certainly don’t want to discourage those carrying clearances from seeking and receiving help for psychological challenges they may inevitably as members of the human family face, we also must consider some way of flagging those who should not for mental health reasons be carrying a clearance or having access to military or government facilities, personnel and data bases.  That is a difficult issue to maneuver as penalizing security clearance holders for needing and responsibly seeking treatment can also mean they simply won’t seek treatment–which can also have disastrous consequences.

More frequent review of clearances seems to be a likely solution.  When a military pilot project on security clearance reform was carried out looking only at social media traces of a group holding security clearances it revealed that twenty percent showed demonstrable reasons for review of their security clearance status–including threats to a president, history of arrest and charges, and suicidal intentions. Perhaps the most important things we can do immediately as a country is to enact some kind of security clearance reform that requires continuous evaluation of those who hold clearances without penalizing those who are legitimately addressing any mental health issues they may have.

We could also encourage more police reporting of those they arrest and interact with, who carry security clearances–to flag the appropriate agencies.  These days with big data applications we could easily track those who carry security clearances to be, at a minimum, alerted of their arrest histories.  While medical records likely should not be the subject of privacy invasions, it certainly could be possible to collect all arrest records and have them analyzed to spit out those like Aaron Alexis who we now see in hindsight, gave us many warnings of his psychic unraveling. 

 Sadly he was not flagged for a diagnostic workup and comprehensive treatment and continued on with a clearance and access status while falling apart, a failure of the system that allowed him to hurt not only himself but many others in the process.  Clearly we need to and can find a better way to address these issues.