CMPH Journal

Introduction

By the end of 2023, over 117.3 million people globally were forcibly displaced due to persecution, armed conflict, violence, human rights violations, and severe disruptions to public order. Operational data from the UNHCR indicates that this upward trend continued into 2024, with estimates suggesting the number exceeded 120 million by the end of April [1]. Long-term mental health impact of the events leading to displacement has been described as a key challenge for any mental health strategy and has been demonstrated also to continue in those host countries providing exile and asylum. Recent events in Syria and the long-term impact on survivors of torture, genocide survivors and in minorities exposed to violence, that cannot be sufficiently addressed by existing resources, can be also considered in this context, especially when considering the situation of vulnerable groups. Elderly persons are such an often-neglected vulnerable group, besides children and women who are covered by a larger number of research projects. In the few studies focusing on elderly population, authors reported on the increased burden of memories and related posttraumatic stress spectrum symptoms, such as an increase in flash-backs and intrusive memories of traumatic of events long past. This might also interact with more recent stressful events, such as the present COVID crises or might be triggered by triggers remindful of earlier psychological trauma.

We intend to fill this gap with a first study using qualitative interviews with elderly survivors, belonging to a minority exposed to multiple genocides in Iraq.

In 2014, the populations of Iraq and Syria faced immense stressors due to the rise of the so-called "Islamic State" (ISIS), which overran vast territories in both countries [2]. ISIS employed extreme brutality, particularly targeting longstanding ethnic groups and religious minorities such as the Yazidis. Large numbers of Yazidi men were executed, while thousands of women and children were abducted and subjected to systematic sexual violence [3]. These atrocities precipitated massive refugee movements.

The Duhok region of Iraq, bordering Turkey to the north and Syria to the southwest, hosted the majority of Internally Displaced Persons (IDPs). By 2015, the region’s population of approximately 1.5 million swelled significantly. As of 2019, the Duhok region housed 350,231 IDPs across 21 refugee camps, while Iraq as a whole accommodated 2,045,718 IDPs [4,5].

Experiences of violence and torture have been shown to markedly increase the risk of mental health disorders, particularly affective disorders and Post-Traumatic Stress Disorder (PTSD) [6,7]. Refugees' lives are often characterized by intense competition for employment, poor living conditions in camps, social rejection, experiences of sexual and physical violence, and cultural dislocation. These factors frequently lead to conflicts in social environments, alongside feelings of helplessness, worry, insecurity, and hopelessness [7-9].

A number of studies have investigated the prevalence of psychological disorders among refugees and IDPs consisting of a wider range of age groups across 21 countries [10]. These studies report varying prevalence rates of mental disorders. A systematic review identified PTSD (3-88%), depression (5-80%), and various anxiety disorders (1-81%) as the most common conditions. However, only 12 studies explored other psychological disorders. Findings emphasize that trauma caused by human actions, such as torture and sexual violence, often precedes the development of PTSD [10,11] and comorbid depression [3]. These studies also suggest that demographic and socio-economic factors, including the experience of internal displacement, gender and age significantly influence psychological well-being.

Research has shown that direct personal experience of traumatic events is not a prerequisite for psychological impact [9]. Secondary traumatization, commonly observed in individuals exposed to war zones and conflict areas, can arise from indirect exposure to trauma through observing or hearing about traumatic events affecting others, a factor receiving also increasing importance through the widespread availability and use of social media and television [12,13]. This form of psychological stress is particularly prevalent among older individuals, especially those from communities with a history of collective trauma [14,15]. Consequently, it could be argued, that newly arising symptoms of distress reflect also a reactivation of “hidden” psychological trauma sequels leading to increased vulnerability.

The Yazidi community is a poignant example, having endured at least 74 massacres or genocides over the past 1,400 years, perpetrated by radical Islamist groups and states targeting them solely for their Yazidi identity [16]. Elderly Yazidis, particularly those over the age of 70 and now living in Germany, have reported through various media outlets that the genocide of 2014 not only recalls their personal experiences but also revives the collective suffering of their ancestors [17,18]. As members of this community, they are often exposed in an indirect but meaningful way to traumatic events through family discussions, interactions with friends, and media coverage of terror, displacement, and genocide [19]. This repeated exposure to their people's traumatic history can transfer trauma symptoms such as hyperarousal, avoidance, and intrusive memories to elderly Yazidis, even those living abroad [9]. The possible protective role of living in a non-violent environment could be expected to be insufficient in offering sufficient protection against indirect or transmitted trauma in elderly populations, and especially in those who had to abandon their homme country, roots, and traditional networks.

These narratives underscore the intergenerational transmission of trauma and the enduring psychological scars borne by marginalized and persecuted populations [19,20].

To address these challenges, we conducted a study involving qualitative and quantitative data collection to examine the psychological resources and stresses of elderly Yazidis who have lived in Germany for over 30 years and were not directly affected by the 2014 genocide in Iraq. Additionally, we explored how and what these older Yazidis remember a decade after the genocide. Through this research, we aim to identify strategies to support elderly individuals who have experienced individual, collective, and historical trauma.

Methods

Based on the lack of comparable earlier research data on this group, we used a mixed-method approach, integrating qualitative interviews and a parallel assessment using standardized questionnaires. Both components will be described in more detail below.

In the beginning we used our earlier research data to define inclusion and exclusion criteria in a more precisely defined approach. Inclusion criteria were: being born in what is at present Kurdistan Region, living in Germany for over 30 years, not having been directly exposed to the genocidal actions in that region. We considered further as a criterion that the person included had to be at least 70 years of age and had an important stressful experience themselves or directly witnessed it about 50 years ago in Kurdistan – meaning structural violence by armed forces, big Muslim landowners or other groups who for different reasons used violence against Yazidis. The exclusion criteria was: the absence of self- reported illness such as psychosis that might interfere with communication quality, or lack of informed consent. The participants were contacted through different peer associations and the first author who is working with the Yazidi for more than 20 years and a trusted gatekeeper for research in the Yazidi communities.

We were able to identify 92 participants fulfilling inclusion criteria. All participants accepted the interviews and gave written consent, that was freely given by all persons contacted. A semi-open interview guideline interview was developed and then discussed with the interviewers, corrected and then accepted in the final version. The interviews for the qualitative part of the survey were recorded, transcribed and rendered anonymous by four trained psychologists.

Every interviewer in turn gave informed consent to conduct the interview. The participants were visited in their home by four trained psychologist interviewers, and conducted the interviews face to face, and recorded the interview as described further on in more detail. All records were anonymized and stored in a safe location compliant with German (GDPR) guidelines.

In the next step, the 92 persons recruited as described above were interviewed asked about their recollections of life (using the interview guideline described before). Among the 92 Yazidi interviewees, 80 categories were identified. We analyzed the data from 24 individuals who showed 20 percent or more similarities during the interviews. All participants were Yazidis.

Social Background and Age of Participants

The interviews were recorded on a digital audio and then pseudonymized, transcribed and analyzed on a PC. The evaluation was done according to the qualitative content analysis after Mayring [21]. The evaluation was supported by Atlas.ti 5.2.12 (Scientific Software Development GmbH). Categories were developed inductively from the material in an interplay with the theory (research questions). We have analyzed the interviews based on a code system with the following steps: selection of units for analysis, definitions of the dimensions for structuring, definition of the characteristics and development of the code system, description of definitions, examples and rules for coding, coding, extraction of the codes, revision of the code system and further coding and interpretation and preparation of results. In order to meet the quality criteria of qualitative research, in particular that of intersubjective comprehensibility [21], two academic staff from the Institute for Transcultural Health Science developed main categories and sub-categories from the participants responses inductively, independently of each other. Subsequently, the classifications were compared and discussed in the sense of a consensual coding. This procedure together with a well-tested research platform ensure both inter-subjectivity and comprehensibility of the results. During consensus meetings, major categories and subcategories were discussed with the two-academic staff until mutual agreement was reached. The author (JIK) recoded the material according to the final categories.

As part of the quantitative research component, validated quantitative psychometric survey instruments as well as self-developed quantitative questionnaire-items were used. They included:

Sociodemographic Aspects

Sociodemographic data and context characteristics regarding the work and personal trauma or flight experiences were assessed using the general sociodemographic part of the qualitative interview schedule.

Questionnaire for Secondary Traumatization (QST)

The Questionnaire of Secondary Traumatization (FST; [22,23]) was used to assess the severity of secondary traumatization. The FST consisted of five secondary traumatization subscales: ‘intrusion’, ‘avoidance’, ‘hyperarousal’, ‘parapsychotic sense of threat’ and ‘PTSD-comorbidities’. Participants were prompted to rate how often these symptoms occurred during the first week of the time period in question with the highest level of distress in the professional context (here: psychotherapy with traumatized survivors of ISIS Terror). The FST showed a high internal consistency with α = .94 [23].

Statistical Analysis

As regards the sample description, we used means, percentages and distributions. For the analysis of differences in means, Mann-Whitney-U-tests for independent samples were applied, since the data were not normally distributed. To test correlations of determinants with the respective outcome (FST-scores), the Spearman rho test was applied as a nonparametric measure. Multiple linear regression analyses were performed to assess whether the determinants were associated with FST-scores and to identify potential risk and resilience factors. The level of significance for all analyses was set at α=.05. All statistical analyses were performed using IBM SPSS Statistics version 24.

Results

Sociodemographic background

The group composition is also given in table 1. In summary:

Table 1: In summary, all participants were farmhands or workers in their homeland, were married at the time of the interview, and were living as workers in Germany. All participants retired at the age of 65.

In the participants (n=92), the mean age was 89 years, with a percentage of 51% (47) men and 48% (45) women. All participants were at their homeland farmers and went to Germany, working as unskilled workers for more than 30 years.

Prevalence of Secondary Traumatization

Applying the QST diagnostic criteria, secondary traumatization was present in 33.4% of the women and with 23.4% of men showing severe secondary traumatization and 22.2% of the Yazidi women and 27.6 % of the men indicating a moderate secondary traumatization (Table 2). The mean secondary traumatization score was 34.74 (SD=10.62).

Table 2: Secondary traumatization of psychotherapists and personal trauma.

A personal trauma history was reported by 26.7% of by the women and by 23.4% of the Yazidi elderly men. A personal history of displacement and flight was reported by 25.0% of the complete sample.

Qualitative Results

In this part of the study, we did not find any observations on perceived gender differences. The interviews also explored memories from before the 2014 genocide, presenting the knowledge produced in these texts and situating it within the respective situational and historical frames of meaning. This approach aims to reveal complementary, antagonistic, and combinable discourse lines, as well as remnants of other narrative threads and results are summarized in the following subchapter.

Memories of the Past After the Genocide of 2014

The participants were specifically asked, in addition to questions about their general memories of the past, “What did you remember in the moment you learned about the start of the genocide?”

All women and men (100%) mentioned that they recalled the Ferman from the past. Ferman is an Ottoman term for “command” but is equated in Yazidi narratives with “genocide” or “massacre,” similar to Shoah among Jews or Aghet among Armenians.

“When I heard that ISIS was attacking the Yazidis, I remembered the past Fermans and fell silent for a long time. I was trapped in my past memories of violence and flight, and then I could do nothing but cry for a long time”. (T.N., 78 years old)

As seen in Table 3, both female and male participants recall personal experiences of discrimination (w=71%, m=79%), as well as the stories of their ancestors about massacres and discrimination (w=88.9%, m=85%). Violence by the military was more vividly recalled by men (72.3%), as they were more frequently targeted during military operations compared to women (31%).

“The Muslims attacked our villages, beat us, and insulted the women terribly. The soldiers watched everything and laughed at us. They did not help us. We tried to hide in the houses.” (A.F., 74 years old).

Similarly, “violence by Muslims” and “discrimination while shopping in the city” were more prominently reported by men. This is because the women predominantly lived in Yazidi villages, had little contact with Muslims, and men were often sent to procure essential supplies. Men also reported discrimination during military service (63.8%). Women did not serve in the military and thus did not experience such discrimination.

“When we went to the city to shop, Muslim children and adults would gather around us and insult us as unbelievers. They recognized us by our white clothing.” (H.K., 82 years old)

Women (94%) and men (82%) report strong emotional reactions, sleep disturbances, anxiety, and helplessness after learning about the brutal actions of ISIS.

General memories that participants still have after 10 years.

Table 3: Categories of Personal Memories After Participants Directly Experienced the ISIS Attack on Yazidis.

The memories triggered by the ISIS genocide against the Yazidis extend beyond personal events, encompassing other significant aspects of their lives. The analysis demonstrates how various discourses or narrative threads within the interview texts can be identified. These texts generate knowledge that is then situated within their respective situational and historical frames of meaning. In this process, multiple complementary, antagonistic, and combinable discourse lines—as well as certain relics of past narratives—are revealed. Overall, more than 80 categories were identified during the analysis. However, purely localized narratives, such as those focused on specific individuals or incidents, were excluded to maintain a broader scope.

A gender-specific distinction was not made here, as no significant differences were observed (Table 4).

Table 4: General memories from the past. The categories mentioned in more than 20 percent of the cases.

The analysis highlights a strong emphasis on recollections of violence and oppression in general (98%), particularly acts perpetrated by Muslim Kurdish compatriots (94%). Additionally, vivid memories of violence and coercion aimed at forced Islamization (84%) and by armed forces (54%) were also prominent. These instances of violence against the Yazidis were predominantly attributed to their religious identity.

“We were persecuted, beaten, and attacked by Kurdish Muslims. They said we were also Kurds, but because we were Yazidis, they felt entitled to act against us. They wanted to force all of us to become Muslims. Former Yazidis who had converted to Islam participated in the violence against us.” (M.Y., 80 years old)

Approximately half of the interviews yielded accounts of violence by Kurdish tribes against Yazidis, as well as reports of internal conflicts within the Yazidi community itself (51%). In contrast, positive aspects, such as development initiatives (e.g., the presence of nurses in villages, access to doctors, trade opportunities, paid employment, and schools), were rarely mentioned.

A significant 94% of participants recalled experiences of religious oppression and segregation, which had a profound emotional impact on them. Overall, violence emerged as a central theme across most categories of their recollections.

“The only reason for this mistreatment was because we were Yazidis.” (I.A., 78 years old)

Discussion

This study investigated the stressors and resources of Yazidis aged 70 and older living abroad, ten years after the 2014 genocide against the Yazidis perpetrated by the so-called Islamic State. The findings reveal a significant mental health burden among elderly Yazidis, rooted not only in their direct experiences of earlier trauma and genocidal persecution but also by the secondary trauma induced by the suffering of their community in Iraq and Syria. For many, hearing about the genocide and its atrocities has reignited personal trauma, contributing to a collective psychological toll.

The prevalence rates observed in the study underscore this risk. Personal trauma histories were reported by 26.7% of the women and 23.4% of the men, with 25% of all participants indicating a history of forced migration. These rates highlight the enduring impact of past traumatic events, exacerbated by the collective trauma associated with the genocide.

The results align with existing research indicating that individuals with prior traumatic experiences—such as discrimination, violence, or forced displacement—are more vulnerable to reactivation of trauma when confronted with new stressors, especially those affecting their community [3]. This vulnerability to secondary traumatization is heightened in the context of collective and historical trauma, as seen in the Yazidi population [24,25]. Prior studies have shown that individuals with a history of collective trauma, even events occurring more than 30 years ago, are more likely to develop secondary trauma than those without such histories [26,27]. This suggests that both personal and collective trauma histories are significant risk factors for elderly individuals [28].

The findings also contribute to the understanding of transgenerational trauma, a phenomenon well-documented in research on Holocaust survivors and their descendants [29,30]. Like other communities affected by systemic oppression and genocide, the Yazidis have transmitted memories of violence, persecution, and loss across generations. Oral traditions, narratives, rituals, and cultural practices serve as conduits for these memories, ensuring that past atrocities remain part of the collective identity [31]. However, these same mechanisms also perpetuate the psychological scars of past trauma, creating a cycle that is difficult to break.

The qualitative component of this study highlights the enduring presence of violence, oppression, and displacement in the collective memory of the Yazidi community. While these memories serve as a testament to resilience and survival, they also reflect the persistent impact of historical and recent events. The reinterpretation of past individual and collective traumas within the framework of ongoing struggles suggests that the Yazidi community continues to grapple with a legacy of insecurity, injustice, and displacement [32,33], again contributing to a complex “genocidal” environment. For decades, the Yazidis have lived under the shadow of violence and aggression, with little opportunity to experience lasting safety or stability. The genocide of 2014 is only the most recent chapter in a history marked by systematic attempts to destroy their community. These experiences remain deeply embedded in the collective consciousness and are transmitted through cultural practices, oral histories, and community narratives [2]. The elderly can therefore be seen as an especially vulnerable group and as potential sources of trauma transmission through generations.

Addressing the psychological and social effects of these traumas will require a multifaceted approach. While psychological and psychiatric interventions are essential, they must be supported by broader social measures, including justice, reparations, and the restoration of security and dignity for the Yazidi people. Historical trauma cannot be resolved in isolation; it requires the acknowledgment and participation of multiple groups, including those responsible for past injustices, to create a framework for reconciliation and healing [34,35].

Breaking the cycle of trauma for future generations will be one of the greatest challenges for the Yazidi community. This will require efforts to process and understand both individual and collective trauma in the context of their historical experiences [19]. Initiatives that foster dialogue, cultural preservation, and community solidarity could provide pathways for healing. Furthermore, addressing the root causes of their ongoing marginalization and creating conditions for sustainable safety and dignity will be essential for restoring balance and rebuilding a sense of collective identity.

Conclusion

This study underscores the profound and lasting impact of the 2014 genocide on elderly Yazidis and highlights the broader implications of collective and historical trauma also in other persecuted populations. By addressing these challenges through psychological, social, and justice-oriented frameworks, there is hope for breaking the cycle of trauma and restoring dignity and resilience for the often-neglected elderly survivors and also future generations as vulnerable groups. Only by confronting and acknowledging the past can the Yazidi community, and also similar groups and those who support them, pave the way for a more hopeful and unified future.

Declarations

Ethics Approval and Consent to Participate

We confirm that all the research meets the ethical guidelines, including adherence to the legal requirements of the country in the study. All participants confirm their participation in the study in writing. This study was approved by the ethics committee of the University of Duhok, Kurdistan Region Iraq (IPP-4-2024/25).

Consent for Publication

All authors consented to publication of the article in the present form.

Availability of Data and Materials

The data and materials of study are available from the corresponding author on reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Authors' Contributions

JIK planned the study, analyzed all psychometric data in Germany and was main author of the manuscript, TW contributed to writing, methodological aspects and the literature review. The authors read and approved the final manuscript.

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