Abstract
BACKGROUND: Women who have been forcibly displaced in complex humanitarian settings suffer from poor sexual health, though the association with violence and war trauma is poorly characterised. We investigated sexual health outcomes and their relationship to violence and trauma among women living in a protracted forced displacement setting. METHODS: This cross-sectional study was conducted in an urban refugee camp in Beirut, Lebanon. Participants were Syrian women who are refugees aged 18-49 years. Community health workers conducted door-to-door recruitment and administered a survey to assess violence and trauma. Capillary blood and vaginal swabs were collected for sexually transmitted infection (STI) testing. Sexual health outcomes included gynaecologic symptoms, self-reported lifetime STI history and current STIs. The relationship of sexual health outcomes with violence, trauma and other factors was assessed using Bayesian Gaussian copula models. RESULTS: Recruitment and data collection were conducted from February to September 2023. Of 305 eligible participants, 250 (82.0%) consented for study participation. The mean age was 30.3 (SD±6.9) years. Over 80% of women disclosed experiencing gender-based violence. Participants experienced a median of 12 (IQR 7) traumatic war events; 197 (78.8%) met criteria for post-traumatic stress disorder (PTSD) and 125 (50.0%) had severe food insecurity. Among a subset (n=216), current gynaecologic symptoms (80.1%) and lifetime STI history (63.4%) were common. We detected one case of Trichomonas vaginalis. By graphical models, gynaecologic symptoms and STI history were significantly associated with sexual violence, which clustered with physical and emotional violence, war trauma, PTSD and severe food insecurity (posterior edge inclusion probability >0.5). CONCLUSION: In Lebanon, the sexual health of Syrian women who are refugees is closely linked to a syndemic of violence, war trauma, poor mental health and food insecurity. A syndemics-informed approach is urgently needed to address the needs of forcibly displaced women.