North Korean women defectors have suffered from anxiety, depression, and somatization after defection. Also they have had many menstrual problems like amenorrhea. This study was done to identify the correlations of anxiety, depression, and somatization to menstrual problems among North Korean woman defectors in South Korea.
The participants in this study were 126 women from 5 government resettlement centers throughout South Korea. Questionnaires which included State-Trait Anxiety Inventory (STAI), Center for Epidemiological studies-Depression Scale (CED-S), and Symptom Checklist-90-Revised (SCL-90-R) were used to identify anxiety and somatization. Data were collected between June and September, 2012.
The women reported the following problems; amenorrhea (9.5%), hypomenorrhea (13.6%), menorrhagia (19.8%), polymenorrhea (13.5%), oligomenorrhea (4.8%), changes in amount of menstrual discharge (4.0%), and changes in amount of blood clot (9.5%). Anxiety (r=0.20, p=0.002), depression (r=0.25, p=0.005), and Somatization (r=0.35, p<0.001) were correlated with number of menstrual problems.
The results of this study indicate that mental health services need to be taken into account in interventions for North Korean woman defectors to improve their reproductive health including addressing menstrual problems.
For political and economic reasons, North Korean defectors started to come to South Korea via third nations in the 1990s. After 2,000, 1,000–2,700 people came to South Korea every year. The total number of defectors from North Korean is now over 20,000. The rate of women among North Korean defectors rapidly increased from 12% in 1998 to 76% of the total annual number in 2013. Over 95% of women defectors were of reproductive age between 20 to 49 years old.
North Korean Women Defectors (NKWD) usually suffered from life threatening during their escape. They were exposed to starvation, cold, gun shots, torture, detention, and arrest. Because they were women their risks included unintended marriage with men of the third nations, abortion, sexual abuse, and human trafficking.
Painful experiences during escape caused anxiety and somatization as mental problems.
Over 70% of women who experienced the Sichuan earthquake in China had menstrual abnormalities like amenorrhea.
NKWD have roles of childbearing and care in the process of their adaptation to the new environment in South Korea. Their reproductive health rights should be supported not only for their wellness but also for the next generation's health. South Korea is responsible to ensure their reproductive health rights as fundamental human rights. Therefore the aim of this study was to identify the menstrual problems of these women as an index of reproductive health, and anxiety and somatization as indicators of psychological health status, and the relationship between menstrual problems and psychological health. The results of this study will provide basic data for interventions to alleviate menstrual problems in NKDW that result from psychological health problems.
The purpose of this study was to identify correlations between anxiety and somatization with menstrual problems among NKWD in South Korea. The goals were identifying 1) general characteristics and menstrual problems, 2) anxiety, depression, and somatization, and 3) correlations of anxiety, depression, and somatization with menstrual problems.
This study was a cross sectional research investigation of correlations of anxiety, depression, and somatization with menstrual problems. A convenience sampling was used in 5 Hana centers throughout South Korea. Data were collected from June 1 to September 30, 2012. The research participants were 132 NKWD in South Korea living at 5 Hana centers (government resettlement centers). The calculated sample size was 109 using G*power 3.0.10 program (power=0.90, effect size medium=0.30, correlation with two tailed test).
The Institutional Review Board at a university hospital approved this study (No: 13-005). Trained assistant researchers who passed the proof of education in research ethics collected the data. They explained the purpose of the study, method, time required, confidentiality, a description of the investigator's qualifications and that rejecting participation or withdrawing at any time carried no penalty. After consent to participate was received, the questionnaires were given to the women. An assistant researcher read the questionnaire for women who had problems with vision or fatigue. Time required to complete the questionnaire was 15–20 minutes. Money was given to the women as thanks for participation.
Anxiety is the subjective emotional response, that ambiguous unpleasant feeling occurring due to unmet psychological need in a risky environment.
Depression was measured using Korean version of the Center for Epidemiological studies-Depression Scale (CED-S),
Somatization describes a complex symptom disorder in which various and consistent physical symptoms appear but a clear cause is not apparent.
Menstrual problems according to International Federation of Gynecology and Obstetrics (FIGO) were classified into period, duration, regularity, and amount of discharge.
The data were analyzed using the SPSS/WIN 21.0 (IBM Corp., Armonk, NY, USA). Means, standard deviations, and ranges were used to analyze general and menstrual characteristics, anxiety, depression, and somatization level. Pearson correlation coefficients were used to analyze correlations between anxiety, depression, somatization, and total number of menstrual problems.
Mean age was 34.31 (SD=8.33) and married women accounted for 33.3%. Mean residence in South Korea was 2.27 years (SD=1.94). The majority of the women were unemployed (42.1%) or students (24.6%). Economic status was low, and women reporting no income accounted for 57.9%. The mean number returned to North Korea was 0.26 (SD=0.57) (
The means for menarche and first pregnancy were 16.51 (SD=2.51) and 24.88 (SD=3.35) respectively, for gravity and parity, 2.42 (SD=1.40) and 1.26 (SD=0.44) and for spontaneous and artificial abortion, 1.24 (SD=0.73) and 1.58 (SD=1.08). The rate for amenorrhea was 9.5%, for polymenorrhea and oligomenorrhea, 13.5% and 4.8%, and for hypomenorrhea and menorrhagia, 13.6% and 19.8%. The rate for irregular menstruation was 34.2% and the rates for change in amount of menstrual discharge and blood clots were 4.0% and 9.5%. The total mean number and range of menstrual problems were 1.61 (SD=1.36) and 0–5 (
The mean and range for anxiety were 44.56 (SD=11.91) and 20–79. The positive rate of anxiety was 31.0%. The mean and range for depression were 19.94 (SD=12.41) and 1–53. The positive rate of depression was 40.0%. The mean and range for somatization were 24.93 (SD=10.24) and 0–48. The positive rate of somatization was 66.7% (
Somatization was correlated with anxiety (r=0.79, p<0.001). Depression was correlated with anxiety (r=0.48, p<0.001) and Somatization (r=0.60, p<0.001). The number of menstrual problems was correlated significantly with anxiety (r=0.20, p= 0.002), depression (r=0.25, p=0.005), and somatization (r=0.35, p<0.001) (
The results of this study contribute to investigations of anxiety, depression, somatization, and menstrual problems of NKWD. They study show that the number of menstrual problem correlated with anxiety, depression, and somatization among NKWD in South Korea. The women's general characteristics showed that their socioeconomic status was similar to the population of 18,000 NKWD.
In this study, the mean number of those returned to North Korea was 0.26 times. They escaped from North Korea and went to third nations like China, Mongolia, Vietnam, and Cambodia, as illegal immigrants.
Reproductive health of the women was not good. Their mean menarche was at 16.51 years of age. There have been consistent reports of the late of menarche of North Korean women compared to that of South Korean women at 11–13 years of age.
Amenorrhea was reported as 9.5% of the women. This result is lower than that of another study which reported 30.5% of NKWD at 3.08 months after escape.
Irregular menstrual cycle was reported by 34.2% of the women which is a lower proportion compared to 43.3% found in Yuk et al.
Psychological health problems of the women were dangerously high. Anxiety level was high. The anxiety positive group whose STAI cut off was over 52 accounted for 31.0% in this study. Kim et al.
The China women who experienced the Sichuan earthquake reported a much higher somatization level than that of other studies (75.4%), possibly because the result found just a short time 9 month after the earthquake. The subjects with menstrual problems in this study was 71.4% and 76.6% of Sichuan women have abnormal menstruation. Higher phobic anxiety and somatization Sichuan women have more abnormal menstruation.
Chronic PTSD can occur 3 years after traumatic event.
Psychological problem of somatization was correlated with menstrual problems in this study (r=0.25). Blood bradykinin is related anxiety and it causes somatization.
Psychological stress affects other physiologic symptoms, but in NKWD it was easy to overlook their somatic symptoms, because the neurobiological mechanism was not clear. They would not see a psychiatrist because they didn't know the cause of the physical symptoms.
In this study, a cross sectional research design was used to identify the correlations of anxiety, depression, and somatization with menstrual problems. The results of this study revealed that psychological and reproductive health conditions of NKWD in South Korea were associated with somatization, depression, and menstrual problems. Because of the low status of these women they are in urgent need of help from health professionals. The level of anxiety, somatization, depression, and menstrual problems was high. The results of this study indicate aspects of health circumstances that provide help for NKWD who have overcome painful experiences. Health professionals should understand and endeavor to promote their health status and that of the next generation because these women are of reproductive age. This study was performed with 126 subjects at 5 adaptation centers. Therefore, the present study had a limitation about generalization problems of expansion and interpretation into total NKWD. We suggest that health intervention programs should be developed to promote the psychological and reproductive health of NKWD.
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STAI: State Trait Anxiety Inventory, CES-D: Center for Epidemiological studies-Depression Scale, SCL-SOM: Symptom Checklist Somatic
*p<0.05, **p<0.01, ***p<0.001