The term “comfort women” refers to approximately 200,000 women who were forced into sexual slavery by the Imperial Japanese Army during World War II [1]. Young women and girls, mostly between the ages of 11 and 20, were abducted from their homes in countries under Imperial Japanese rule, mostly from Korea, and the rest from China, Philippines, Malaysia, Taiwan, Indonesia, the Netherlands etc [2]. They were detained in comfort stations and were forced to serve as sex slaves for the Japanese soldiers, being raped 10 to 50 times a day for years [3]. They also suffered immeasurable pain from sexually transmitted diseases, aggressive treatment of these disease, forced abortion and sterilization, starvation, physical abuse, torture, threats of death, and approximately 75 percent are estimated to have died during the ordeal [4].

When the war ended, the survived victims had to go on with their lives enduring the incurable physical and psychological wounds, as well as the social stigma. The “comfort women” issue was tabooed in the post-war decades and hidden by most of the survivors. In 1991, a Korean former “comfort woman” broke the silence and came forward publicly for the first time, seeking a formal apology and reparation from the Japanese government [3]. Her action led hundreds of other women in Korea to come forward, and 239 women officially registered with the South Korean government as former “comfort women.” Testimonies of many survivors revealed vivid details of their unbelievably cruel experience and the atrocities committed by the Japanese military. Since then, much research has been done investigating the concealed truth.

Nevertheless, studies on the survivors’ mental health problems or psychosocial sequelae is scarce. Most literature on the “comfort women” have been focused on the historical facts and the political issues. Majority of the publication regarding “comfort women” are the testimonies of the survivors which reveal the extreme nature of the sexual violence and exploitation suffered by the survivors, but lack an analytical perspective. As former “comfort women” are a hard-to-reach population, studies that do have an analytical perspective or a theoretical discussion on the psychological impact of the trauma are mostly analyses based on the published testimonies of the survivors.

This article reviews all the studies which conducted a direct evaluation on the survivors of the Japanese military sexual slavery in order to investigate the psychiatric or psychosocial sequelae of the trauma. Most importantly, a recent study which conducted a psychiatric evaluation on the former “comfort women” currently alive in South Korea is introduced.

Currently available literature on “comfort women” were searched using the PubMed and the Korean databases such as the KoreaMed and Research Information Sharing Service (RISS). The terms “comfort women” and “Japanese military sexual slavery” were used. All abstracts of publications through the three databases were screened for the search of the studies that investigated the long-term effects of the traumatic event on the survivors’ mental health and social functioning. Studies that conducted a direct evaluation on a relatively large sample of the survivors were included. Analyses of the published testimonies of the survivors and case reports were excluded. Only the articles published in Korean or English were included.

Six studies had investigated the psychiatric or psychosocial sequelae of the survivors of the Japanese military sexual slavery (Table 1). Four studies conducted a psychiatric evaluation on the survivors and 2 studies conducted an in-depth qualitative interview with the survivors. Five studies are briefly reviewed, and the most recent study is thoroughly introduced in the next section, as the results of the study most accurately reflects the current status of the survivors.

In 1999, Shim conducted in-depth qualitative interviews with 6 survivors in order to examine the lives of the survivors after the return from the comfort stations [5]. She found that after the war, the survivors were cut-off from their hometowns and their families. The study showed that survivors had difficulty making intimate relationships with friends and family and had poor living conditions. They couldn’t live an ordinary life as a woman and had confusion in their identity. The factors that made them remain in silence for such a long time were their poor living conditions, broken family ties, and cultural factors that valued chastity. This study was among the first attempts to focus on the lives of the survivors after the trauma than the trauma itself. Since there were 199 registered survivors alive at the time, the small sample size is a limitation in generalizing the results of the study.

In 2003, Min et al. conducted a psychiatric evaluation on 26 former “comfort women” and compared them with a control group [6,7]. Psychiatrists and a clinical psychologist used the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to diagnose posttraumatic stress disorder in the participants. The SCID-I is a standardized diagnostic interview widely used to assess psychiatric disorders and the Korean version has been validated [8]. Self-reports consisting of Geriatric Depression Scale (GDS), paranoid state scale from Minesota Multiphasic Personality Inventory (MMPI), State and Trait Anger Expression Inventory (STAXI) were also used. All 26 participants had suffered from symptoms of posttraumatic stress disorder at least once in their lives, and 30.8% were diagnosed with posttraumatic stress disorder at the time. PTSD symptom profiles of former “comfort women” were characterized by avoidance, recollection, and anger. Former “comfort women” had impairments in anger control and were more depressed than the control group. In Rorschach test, former “comfort women” showed higher scores on responses that reflect impulse emotions, anxiety, aggressive movement content than the control group. Also, former “comfort women” recorded significantly higher mean scores than the control group on sex response, morbid response, and trauma content index. This study shed light on the psychiatric sequelae of the former “comfort women.” The limitation of the study was that convenience sampling was used and 26 participants were chosen among the 151 registered survivors alive at the time. Also, other psychiatric disorders other than posttraumatic stress disorder were not evaluated.

In 2013, Park et al. [9] conducted semi-structured qualitative interviews with 16 former “comfort women” in order to evaluate the impact of this early-life trauma on the lives of the survivors. The study provided understanding of the types and depth of the trauma, as well as the impact it had on the life course of the survivors. The study revealed that as the consequence of the trauma, the survivors had strained relationships with men, difficulties in having children, physical pain, and emotional suffering. Feelings of intense loneliness, sense of remorse, resentment and anger were the common emotional distress the survivors showed. The limitation of the study was that convenience and snowball sampling was used which may have resulted in response bias. There were 59 registered survivors alive at the time. Also, the data was translated from Korean to English prior to analysis which could have affected the analysis of the result.

In 2014, Korean Women’s Development Institute evaluated 12 survivors for posttraumatic stress disorder [10]. Modified PDS scales were used for the evaluation. There were 48 registered survivors alive at the time in South Korea. 3 (25%) survivors were found to have all 3 symptoms of reexperience, avoidance, and hyperarousal. Subjective well-being and satisfaction with life were also measured in a 5-point scale. Both scores of subjective well-being and satisfaction with life were both highest (3.6 and 3.4 respectively) before the abduction and lowest (1.6 and 0.8 respectively) during captivity. The scores rose after returning from the comfort stations but stayed lower than 2.5 throughout their lives. The generic health status measured by EQ-5D was 0.64 in the participants; while the mean EQ-5D index in the elderly population has been reported to be 0.82 in South Korea [11]. The limitation of the study was that the diagnosis of posttraumatic stress disorder was not made by diagnostic interviews with psychiatrists or clinical psychologists. Also, the lifetime prevalence of the posttraumatic stress disorder was not evaluated.

In 2015, as a substudy of “A Comprehensive Study to Resolve the Japanese Military ‘Comfort Women’ Issue (I)” by the Korean Women’s Development Institute, psychiatrists conducted a semi-structured psychiatric interview with 5 survivors, using Mini International Neuropsychiatric Interview (MINI) [12]. Several clinician-administered scales such as Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), Short PTSD Rating Interview (Sprint), Positive Resources Test (POREST), Mini Mental Status Examination (MMSE) were also used. All 5 survivors showed symptoms of posttraumatic stress disorder such as reexperience, avoidance, and hyperarousal, as well as chronic depression, anxiety, rage, humiliation, and insomnia. The sample size was too small and the investigators didn’t consider lifetime prevalence of the psychiatric disorders including the posttraumatic stress disorder.

As a substudy of “A Comprehensive Study to Resolve the Japanese Military ‘Comfort Women’ Issue (II)” by the Korean Women’s Development Institute, psychiatrists from the Special Committee for Gender-Equality and Family of Korean Neuropsychiatry Association conducted a psychiatric evaluation on the former “comfort women” currently alive in South Korea [13]. Gender-Equality and Family Department of the Korean government contacted all the registered survivors currently alive, which was 38 in July 2016, asking for their participation in the study. Seven survivors were excluded because they had a physical or mental illness which made it impossible to participate in the study. Eleven survivors refused to participate in the study; 5 had personal reasons, 4 had political differences from the government, and 2 had health problems. Finally, 20 survivors agreed to participate in the study.

Interviews took place at the homes of the participants between July and August 2016. A psychiatric interview was conducted to review the lives of the participants focusing on the psychosocial sequelae throughout their lives. The SCID-I was used to assess current (30 days) and lifetime diagnosis of psychiatric disorders including posttraumatic stress disorder [14]. Because the participants were in their 80’s or 90’s, recall bias and memory gaps were expected. To enhance the validity and reliability, a group of two, consisting of two psychiatrists or one psychiatrist and one clinical psychologist conducted the psychiatric interview. Two interviewers assessed separately during the interview, and made a consensus afterwards. A close family or a relative was also interviewed to attain objective information and enhance reliability.

Seven decades have passed since the end of the World War II. Majority of the former “comfort women” have passed away, currently leaving only 37 registered survivors in South Korea. This article summarizes the psychiatric and psychosocial sequelae of the survivors. It is evident that the trauma of the Japanese military sexual slavery has affected the mental health and social functioning of the survivors throughout their lives, and even to the present day. Thus, the trauma should not be considered a matter of the past, but of today. As most of the studies had been published in Korean, this article could enlighten many others who were not familiar with the issue. Further, this article could also provide insights into the consequences of trauma of victims of sexual trafficking, which is still happening around the world.