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European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2026 Sep 21;17(1):2715186. doi: 10.1080/20008066.2026.2715186

The burden of shame: PTSD symptoms and social support in Arabic-speaking women survivors of sexual violence

El peso de la vergüenza: síntomas del TEPT y soporte social en mujeres de habla árabe sobrevivientes a violencia sexual

Freya Specht a,b,*,CONTACT, Johanna Stenz a,*, Yuriy Nesterko a,b,c, Nadine Stammel a, Birgit Wagner d, Christine Knaevelsrud a, Maya Böhm b,#, Maria Böttche a,#
PMCID: PMC13600302  PMID: 42766479

ABSTRACT

Background:

Research has consistently linked symptoms of posttraumatic stress disorder (PTSD) to diminished social support. Key factors that may explain this relationship are trauma-related shame, guilt, and self-blame, which are common among survivors of sexual violence.

Objective:

This study investigates the mediating role of trauma-related shame, guilt cognitions, and self-blame in the association between PTSD symptoms and perceived social support among Arabic-speaking women with a history of sexual violence exposure.

Methods:

Participants included N  = 3,419 Arabic-speaking, treatment-seeking women with a history of sexual violence exposure who registered for an online intervention. First, correlational analyses examined the association between PTSD symptoms, trauma-related shame, guilt cognitions, and self-blame. Second, a parallel mediation tested whether these three constructs mediated the association between PTSD symptoms and perceived social support. All variables were assessed using standardized self-report questionnaires.

Results:

Trauma-related shame, guilt cognitions, and self-blame were positively correlated with PTSD symptoms (r = .54, r = .28, and r = .45, respectively). Higher PTSD symptoms were associated with lower perceived social support (β = −0.21). In the mediation model, trauma-related shame emerged as the most explanatory mediator, partially accounting for the association between higher PTSD symptoms and lower perceived social support. By contrast, guilt cognitions showed a small indirect effect in the opposite direction, whereas self-blame showed no significant indirect effect.

Conclusion:

These findings suggest that trauma-related shame may play a role in the relationship between PTSD symptoms and perceived social support among women with a history of sexual violence exposure, and should therefore be considered in diagnostic processes and psychotherapeutic interventions.

KEYWORDS: Sexual violence, posttraumatic stress, shame, guilt, self-blame, social support, Arabic-speaking women

HIGHLIGHTS

  • Trauma-related shame, guilt cognitions and self-blame were positively associated with PTSD symptoms in Arabic-speaking women with a history of sexual violence exposure.

  • Higher PTSD symptoms were associated with lower perceived social support.

  • Trauma-related shame emerged as the strongest mediator between PTSD symptoms and perceived social support, underscoring its relevance in this population.

1. Introduction

Sexual violence against women is a global crisis with devastating psychological and social consequences (Serrano-Rodríguez et al., 2025; World Health Organization, 2024). Nearly one-third of women worldwide experience physical and/or sexual violence, placing them at a heightened risk of developing posttraumatic stress disorder (PTSD) and other mental health symptoms (Creamer et al., 2001; García-Moreno et al., 2021). However, prevalence studies are predominantly conducted in Western countries, with limited data available from women living in Arabic-speaking countries (Alhalal et al., 2021; Dworkin et al., 2021; Haj-Yahia & Clark, 2013). Prevalence rates of intimate partner violence (IPV) in Arabic-speaking countries vary widely, with the highest rates reported in Lebanon (33% of ever-married women aged 20–65) and Iraq (21.1% of ever-married women aged 16–65; Al-Atrushi et al., 2013; Awwad et al., 2014). Lower lifetime prevalence rates of forced sexual acts were found in Arabic-speaking women in African countries (Yaya & Bishwajit, 2018). However, underreporting due to stigma and social pressure remains a significant concern (Zolezzi et al., 2018).

Sexual violence has wide-ranging consequences, affecting survivors’ physical and mental health, social well-being, and economic circumstances. Women survivors of sexual violence often suffer from poor general health, impaired reproductive health (e.g. unwanted pregnancies, stillbirths), chronic pain, and sexually transmitted diseases (Akyüz et al., 2012; García-Moreno et al., 2005; Grose et al., 2021). The economic burden of sexual violence against women is substantial, including healthcare costs, reduced productivity, and social services (e.g. counseling, costs of legal advice, refugee services; Duvvury et al., 2004, 2016; Morrison & Biehl, 1999). Mental health is often severely impacted, with women survivors facing an increased risk of developing PTSD, depression, substance abuse, as well as experiencing feelings of guilt, shame, anger, betrayal, anxiety, and suicidal ideation (women: Abrahams et al., 2013; Campbell et al., 2009; García-Moreno et al., 2005; general: Hassanpour et al., 2025; Aakvaag et al., 2016; Kessler et al., 2017).

Focusing on PTSD as the most prevalent mental disorder after experiencing a traumatic event, research shows strong empirical support for the assumed influence of posttraumatic cognitions and emotions on PTSD etiology (Gómez de La Cuesta et al., 2019). Beyond their role in the development of PTSD symptoms, posttraumatic cognitions and emotions (e.g. shame, guilt, anger, self-blame) have also been conceptualized as maintaining factors that contribute to the persistence of symptoms over time by shaping ongoing appraisal processes and coping responses such as avoidance behavior and withdrawal (Ehlers & Clark, 2000).

The relationship between trauma, PTSD symptoms, and posttraumatic cognitions and emotions may be mutually reinforcing: Traumatic events can trigger posttraumatic cognitions and emotions, including distorted appraisals about the self, others, and the world, as well as feelings of loss of control, trust, and self-esteem (Foa et al., 1999; Hosny et al., 2023; Kubany et al., 1996). In turn, these trauma-related responses are thought to worsen PTSD symptoms, influencing their onset, severity, and persistence (Andrews et al., 2000; Beck et al., 2011; Ehlers & Clark, 2000).

Shame refers to a negative, self-conscious emotion which is accompanied by negative appraisals of the self, often influenced by social exposure or expected judgment by others (Lewis, 1971). Unlike guilt, which stems from a negative evaluation of specific behavior, shame reflects a negative evaluation of the global self (Lewis, 1971; Niedenthal et al., 1994). Shame shows a robust positive association with PTSD symptoms (Beck et al., 2011; Street & Arias, 2001), as it undermines a person’s sense of belonging, self-worth, and attachment security (López-Castro et al., 2019; Wilson et al., 2006). Amstadter and Vernon (2008) demonstrate that shame tends to be more pronounced following sexual violence compared to other trauma types. Furthermore, preliminary treatment evidence suggests that as PTSD symptoms improve, shame decreases (Saraiya & Lopez-Castro, 2016).

Guilt, and trauma-related guilt in particular, describes an unpleasant emotional arousal involving beliefs ‘that one should have thought, felt, or acted differently’ during a traumatic event, because these (in)actions are perceived as inconsistent with a person’s value system (Kubany & Watson, 2003, p. 53; Niedenthal et al., 1994). Trauma-related guilt appears to be more chronic and severe than non-trauma-related guilt (Kubany & Watson, 2003). The relationship between guilt and PTSD symptoms seems less stable (Beck et al., 2011; Street & Arias, 2001). Guilt tends to increase across different types of trauma (Amstadter & Vernon, 2008) but especially after experiencing severe interpersonal violence (Aakvaag et al., 2016).

As multidimensional constructs, shame and guilt encompass affective, behavioral, and cognitive dimensions, with self-blame representing one key cognitive aspect embedded within these broader constructs (Kubany & Watson, 2003; Ullman et al., 2014). Therefore, self-blame is a cognitive attribution style where survivors hold themselves responsible for their victimization, often as a maladaptive way to regain a sense of control (Janoff-Bulman, 1979; Ullman et al., 2014). Shame and self-blame are consistently linked to PTSD symptoms across diverse populations and are often tied to cultural perceptions of nonconformity and failure to meet societal expectations (Hosny et al., 2023; Saraiya & Lopez-Castro, 2016).

An important contextual factor that interacts with posttraumatic cognitions and emotions in PTSD is perceived social support. It is defined as the internal belief that reliable and adequate help is available when needed (Wang et al., 2021). Research suggests a reciprocal relationship between PTSD symptoms and social support: increasing PTSD symptoms impair individuals’ perception of social resources, and in turn, reduced perceived or actual social support may maintain PTSD symptom severity, while, conversely, higher levels of social support seem to buffer PTSD symptoms (Wang et al., 2021). However, existing evidence does not clearly indicate that one direction of this association is stronger than the other, with both pathways showing effects of comparable magnitude (Wang et al., 2021).

A study by Dodson and Beck (2017) found that trauma-related shame in a sample of women survivors of IPV in the United States fully mediated the relationship between PTSD symptoms and negative expectations of social support. Specifically, PTSD symptoms predicted elevated shame cognitions, which in turn predicted negative network orientation (Dodson & Beck, 2017). These findings suggest that trauma-related shame may undermine expected social support following interpersonal trauma. More broadly, posttraumatic emotional and cognitive responses, including shame, and possibly also guilt and self-blame, may influence survivors’ expectations of social support. A potential downward spiral is set in motion: Posttraumatic cognitions and emotions reinforce negative expectations of social support, leading to diminished perceived or actual support, which in turn worsens PTSD symptoms anew (Clapp & Beck, 2009; Dodson & Beck, 2017; Wang et al., 2021).

Although previous findings suggest that trauma-related shame, guilt, and self-blame are important for the psychological adjustment of women with a history of sexual violence exposure (Aakvaag et al., 2016; Dunmore et al., 1999; Hassanpour et al., 2025; Saraiya & Lopez-Castro, 2016), questions regarding the concrete interplay between these posttraumatic cognitive and emotional responses, perceived social support, and PTSD symptom severity remain unanswered, particularly in underrepresented populations such as Arabic-speaking women with a history of sexual violence exposure.

The present study aimed to investigate whether previous findings on the mediating role of trauma-related shame, guilt cognitions, and self-blame in the association between PTSD symptoms and perceived social support can be replicated and extended in an Arabic-speaking sample of treatment-seeking women with a history of sexual violence exposure. Specifically, we expected that higher levels of trauma-related shame, guilt cognitions, and self-blame would be significantly correlated with higher PTSD symptom severity. Based on prior research, we further assumed that trauma-related shame would show a stronger association with PTSD symptoms than guilt cognitions. Although self-blame was included as a relevant posttraumatic cognition, we did not formulate a directional contrast hypothesis for self-blame relative to trauma-related shame or guilt cognitions, because prior evidence did not provide a sufficiently consistent basis for such a comparison.

In addition, this study examined the associations between PTSD symptoms, perceived social support, and trauma-related shame, guilt cognitions, and self-blame as explanatory mediators. We proposed that PTSD symptoms would serve as a significant predictor of perceived social support, with increasing PTSD symptom severity corresponding to a lower subjective perception of social support among adult women with a history of sexual violence exposure. Moreover, we posited that the relationship between PTSD symptoms and perceived social support would be mediated by trauma-related shame, guilt cognitions, and self-blame. Finally, we compared the three paths to determine which trauma-related cognition or emotion best explains the association between PTSD symptoms and perceived social support. We expected that all mediators would differ significantly in their relevance, with trauma-related shame showing the strongest indirect effect.

2. Methods

2.1. Procedure and participants

This cross-sectional study forms part of a larger open-label dissemination trial examining the efficacy of internet-based interventions for Arabic-speaking adults experiencing posttraumatic stress symptoms or depression. Comprehensive details about the treatment program are available (El-Haj-Mohamad et al., 2025a; Stein et al., 2023). Recruitment for this study took place between February 2021 and May 2024 via multiple online platforms, including social media, collaborations with local organizations, word-of-mouth recommendations, and the program’s website. The website provided information about PTSD, depression, treatment availability, and study objectives. All participants were informed that their participation was voluntary and that their data would be handled with strict confidentiality and security protocols. Participants did not receive financial compensation; however, eligible participants were offered access to the online intervention.

Participants in this study needed to be literate in Arabic, be 18 years or older, and have internet access. To reduce cultural heterogeneity, we restricted the sample to women born in 18 countries that fall within both the World Bank’s Arab World category and its broader Middle East and North African regional grouping (World Bank, 2026a, 2026b). After providing written informed consent, they completed a baseline assessment, which was used both to screen eligibility for the intervention and for the purposes of this study. Eligibility for this secondary analysis was determined retrospectively based on responses in the baseline assessment: participants reported being ‘female’ on the baseline sex/gender item and endorsed at least one sexual traumatic event. These two items assessed sexual assault by a family member or acquaintance and sexual assault by a stranger. Consistent with the broader trauma checklist and DSM-5 Criterion A, endorsement could refer to direct or indirect exposure. Ethical approval was granted by the ethics committee at Freie Universität Berlin (107/2016; 126/2016; 185/2018; 010/2023).

2.2. Measures

All measures were administered online via a secure web platform. With the exception of perceived social support (for which we used an established Arabic version), a structured translation process was implemented for instruments not previously available in standard Arabic at the time of study planning. First, a native Arabic speaker translated the instrument into Arabic. Second, an independent translator who was blind to the original version back-translated the Arabic version into English. A team of clinical/research professionals involved in the broader program reviewed both versions, discussed wording nuances, and finalized each measure by consensus. When necessary, instruction texts were adapted to align with the online administration format.

2.2.1. Sociodemographic characteristics

The study included the following sociodemographic characteristics: age, education, country of origin, country of residence, employment and two binary questions inquiring whether participants had to flee from their home country as a consequence of an armed conflict or fear of persecution, and whether they had ever received therapeutic treatment for their current mental health problem.

2.2.2. Traumatic experiences

Exposure to traumatic events was measured using a checklist that combined items from the Harvard Trauma Questionnaire (HTQ; Mollica et al., 1992), the Posttraumatic Diagnostic Scale (PDS; Foa et al., 1997), and the Life Events Checklist for DSM-5 (LEC-5; Weathers et al., 2013). The resulting list included 23 items (yes/no) capturing a range of potentially traumatic experiences, and participants could endorse multiple event types. The number of different traumatic event types was the sum of endorsed items across the 23-item checklist (range: 0–23). Two items specifically assessed sexual traumatic events and were adapted from the PDS (Foa et al., 1997): (1) sexual assault by a family member or acquaintance and (2) sexual assault by a stranger. In line with the DSM-5 Criterion A, exposure was defined as participants reporting having directly experienced the event, witnessed it, learned about it happening to a close family member or friend, or were exposed to it through their professional roles. At the end, participants identified the event that currently distressed them most, which served as the index trauma for subsequent trauma-referenced measures.

2.2.3. Posttraumatic stress symptoms

Posttraumatic stress symptoms over the past month were assessed using the PTSD Checklist for DSM-5 (PCL-5; Blevins et al., 2015; Weathers et al., 2013), a 20-item self-report questionnaire aligned with DSM-5 diagnostic criteria for PTSD (American Psychiatric Association, 2022). Participants rated each item on a 5-point Likert scale from not at all (0) to extremely (4), with higher scores indicating greater symptom severity, which were used in all primary analyses. To descriptively characterize the sample, a provisional PTSD diagnosis was derived according to Blevins et al. (2015) by dichotomizing item responses (0/1 = symptom absent; 2–4 = symptom present) and applying DSM-5 cluster criteria (≥1 B, ≥1 C, ≥2 D, ≥2 E). The PCL-5 has been validated as a screening tool for Arabic-speaking individuals (Ibrahim et al., 2018). Internal consistency in this study was α = .89.

2.2.4. Trauma-related shame and self-blame

The Trauma Appraisal Questionnaire (TAQ; DePrince et al., 2010) assesses what participants have felt, experienced, and thought during the past month when reflecting on their index trauma. No specific assumption was made regarding when the event had occurred. The TAQ is a 54-item self-report scale comprising six distinct subscales (betrayal, self-blame, fear, alienation, anger, and shame). The present study used the self-blame (10 items; e.g. ‘I deserved what happened to me’, ‘The event happened because I wasn’t careful enough’) and the shame (7 items; e.g. ‘I feel ashamed’, ‘I feel embarrassed’) subscales. The Arabic translation of the shame subscale included items capturing both internal, self-focused experiences of shame (e.g. feelings of humiliation and inner ‘dirtiness’) as well as more socially situated forms of shame related to honor and social evaluation (e.g. ‘ār [‘shame’] and ḥaraj [‘embarrassment’]). Responses are assessed using a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Higher scores on these TAQ subscales indicated greater perceived trauma-related shame or self-blame. The TAQ has shown satisfactory reliability and validity (DePrince et al., 2010). Internal consistency for trauma-related shame and self-blame subscales in the current sample was α = .83 and α = .86, respectively.

2.2.5. Guilt cognitions

The Trauma-Related Guilt Inventory (TRGI; Kubany et al., 1996) is a self-report measure assessing cognitive and emotional attributes of guilt related to the index trauma. It consists of three subscales: global guilt (four items), distress (six items), and guilt cognitions (22 items). The current study used the guilt cognitions subscale. Participants rated each item on a 5-point Likert scale ranging from not at all true (0) to extremely true (4). The guilt cognitions subscale has demonstrated high internal consistency and construct validity in a trauma sample (Kubany et al., 1996). In the present study, internal consistency of the TRGI guilt cognitions subscale was α = .90.

2.2.6. Perceived social support

The subjective experience of perceived social support by family, friends, and significant others was measured via the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet et al., 1988). It consists of 12 items on a 7-point Likert scale ranging from very strongly disagree (1) to very strongly agree (7). Higher scores indicated higher perceived social support. The translation of the MSPSS used in the present study has shown good psychometric properties in Arabic-speaking populations (Fekih-Romdhane et al., 2023; Merhi & Kazarian, 2012). Internal consistency in the present sample was α = .89.

2.3. Statistical analyses

All analyses were conducted in R (version 4.4.1; R Core Team, 2024). Only participants who completed all relevant screening measures were included, resulting in a complete dataset without missing values. First, descriptive statistics were calculated for sociodemographic and trauma-related characteristics. After testing for extreme values (Eid et al., 2015), Pearson correlations were calculated between PTSD symptom severity, trauma-related shame, guilt cognitions, self-blame, and perceived social support. In line with our hypotheses, a bias-corrected bootstrap test was used to compare the correlation between trauma-related shame and PTSD symptoms with the correlation between guilt cognitions and PTSD symptoms (Beasley et al., 2007), as this procedure leads to a more reliable estimation (Eid et al., 2015).

To test the direct relationship between PTSD symptoms and perceived social support, a linear regression analysis was performed. Assumptions of regression and mediation (e.g. normality, linearity, homoscedasticity) were examined with standard diagnostics and satisfied. Next, a parallel multiple mediation model as shown in Figure 1 was tested using the PROCESS macro for R Version 4.3.1 (Hayes, 2013, 2024), following current recommendations for mediation analysis and reporting (Lee et al., 2021). Trauma-related shame, guilt cognitions, and self-blame were entered simultaneously as mediators of the relationship between PTSD symptoms (predictor) and perceived social support (outcome), allowing estimation of the differential indirect effect of each mediator while controlling for the others (Preacher & Hayes, 2008). This parallel mediation model allowed us to examine whether self-blame explains unique variance beyond the shared cognitive components with trauma-related shame and guilt cognitions. Contrast analyses were conducted to compare the three indirect effects. A bootstrap procedure with 5,000 resamples and bias correction was used to compute 95% confidence intervals. For all analyses, an α-level below .05 was considered statistically significant.

Figure 1.

A diagram showing PTSD Symptoms predicting Perceived Social Support through parallel mediators Shame, Guilt, and Self Blame with paths a, b, c prime. The figure shows a conceptual diagram of a parallel mediation model. On the left, a rectangle labeled PTSD Symptoms ( X ) represents the predictor. On the right, a rectangle labeled Perceived Social Support ( Y ) represents the outcome. A horizontal arrow labeled c prime runs directly from PTSD Symptoms to Perceived Social Support. Between these 2 rectangles, 3 mediator rectangles are stacked vertically on the right side of the predictor and to the left of the outcome. From top to bottom, they are labeled Shame ( M1 ), Guilt ( M2 ), and Self Blame ( M3 ). Three diagonal arrows run from PTSD Symptoms to the mediators, labeled a1 to Shame, a2 to Guilt, and a3 to Self Blame. Three diagonal arrows run from the mediators to Perceived Social Support, labeled b1 from Shame, b2 from Guilt, and b3 from Self Blame. All arrows have single arrowheads indicating directional paths only. No numerical values are shown. All data are approximate.

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Hypothesized pathways in the mediation model of PTSD symptoms on perceived social support.

Notes: ai describes all paths between the predictor and the mediators M1, M2 and M3. bi describes all paths from the mediators to the criterion. The direct path from the predictor to the criterion is denoted with c’. Shame =   trauma-related shame. Guilt =   guilt cognitions.

3. Results

A total of 11,668 Arabic-speaking women from the 18 selected countries of origin within the Arabic-speaking world registered, provided informed consent, and completed the screening questionnaires. Of these, 580 were excluded due to incomplete data, and 52 were excluded because extreme values had the potential to influence the statistical analyses. Among the remaining participants, N = 3,419 women (31.0%) reported at least one sexual traumatic event and therefore constituted the final sample.

3.1. Sociodemographic characteristics

Table 1 provides an overview of the sample’s sociodemographic characteristics. The sample had an average age of 23.47 years (SD = 5.97, range = 18–56 years). A substantial proportion, 52.7% (n = 1,801) reported having attained a high school certificate. Corresponding to the relatively low average age of the sample, approximately half of the participants reported that they were currently studying or undergoing vocational training (n = 1,607, 47.0%). The majority stated that they did not have children (n = 2,993, 87.5%) and indicated being single (n = 2,225, 65.1%). Participants were from 58 different countries of residence, with the five most frequent being Egypt (n = 1,054, 31.1%), Saudi Arabia (n = 651, 19.0%), Jordan (n = 238, 7.0%), Morocco (n = 236, 7.0%), and Iraq (n = 235, 6.9%). Furthermore, 236 women (6.9%) reported having experienced forced displacement at some point in their lives. Figure A in the Supplementary Material presents the most common countries of origin and countries of residence.

Table 1.

Sociodemographic characteristics of participants.

Characteristics Total sample
(N = 3,419)
Age, M (SD) 23.47 (5.97)
Family status, n (%)  
 Single 2,225 (65.1%)
 In a relationship 616 (18.0%)
 Married/partnership 417 (12.2%)
 Divorced 153 (4.5%)
 Widowed 8 (0.2%)
Education, n (%)  
 No school-leaving certificate 89 (2.6%)
 Middle school 320 (9.4%)
 High school 1,801 (52.7%)
 College or university degree 1,209 (35.4%)
Occupation, n (%)  
 Studying or in training 1,607 (47.0%)
 Housekeepers 287 (8.4%)
 Employed or self-employed 523 (15.3%)
 Unemployed 510 (14.9%)
 Pensioner 7 (0.2%)
 Other 485 (14.2%)
Past psychotherapeutic or psychiatric treatment, n (%) 641 (18.7%)
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3.2. Trauma exposure and PTSD

Sexual violence by a partner or family member was reported by 2,570 (75.2%), while 2,232 (65.3%) reported sexual violence by a stranger and 1,383 (40.5%) endorsed both categories. On average, participants reported 5.37 (SD = 3.62, range = 1–23) different traumatic event types. Besides sexual trauma, the three most frequently reported trauma types were being close to death (n = 1,371, 40.1%), poor health without access to medical care (n = 1,259, 36.8%), and violent attack by a family member or acquaintance (n = 1,067, 31.2%). Figure B in the Supplementary Material presents the frequencies of all different trauma categories within this sample. Based on the categorical assessment of the PCL-5, N = 3,419 women met the criteria for provisional PTSD. The sample displayed an average PCL-5 score of M = 53.32 (SD = 14.09, range = 0–80).

3.3. Correlation analyses

Bivariate correlations among PTSD symptoms, trauma-related shame, guilt cognitions, self-blame, and perceived social support are presented in Table 2. PTSD symptom severity was positively correlated with trauma-related shame, guilt cognitions, and self-blame, and negatively correlated with perceived social support. Observed imposed bootstrap analyses with bias correction confirmed that the correlation between trauma-related shame and PTSD symptoms (rBS = .54, 95% CI [.52, .57]) was significantly larger than that between guilt cognitions and PTSD symptoms (rBS = .28, 95% CI [.25, .31]).

Table 2.

Pearson correlation coefficients and descriptive statistics for all considered variables.

Variable M SD Range 1 2 3 4 5
1. Shame 25.33 6.96 7–35 –        
2. Guilt cognitions 1.95 0.86 0–4 .50*** –      
3. Self-blame 31.85 9.84 10–50 .66*** .68*** –    
4. PTSD symptoms 53.32 14.09 0–80 .54*** .28*** .45*** –  
5. Social support 3.07 1.37 1–7 −.19*** −.06*** −.13*** −.21*** –
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Notes: Means (M), standard deviations (SD), and possible score ranges for each variable are reported. ***p <   .001. Shame =   trauma-related shame.

3.4. Mediation analyses

PTSD symptoms were a significant predictor of perceived social support, R2 = .04, F(1, 3417) = 155, p < .001, indicating a small effect size. One-standard-deviation increase in PTSD symptoms corresponded to a 0.21 SD decrease in perceived social support (β = −0.21, 95% CI [−0.24, −0.18]). Subsequently, the mediation analysis and its different paths possibly explaining the effect of PTSD symptoms on perceived social support are illustrated in Figure 2.

Figure 2.

A path diagram showing PTSD Symptoms predicting Shame, Guilt, and Self Blame, which in turn predict Perceived Social Support with coefficients. The figure shows a mediation path diagram linking trauma related variables. On the left, a rectangle labeled Posttraumatic Stress Disorder Symptoms, X, points to three rectangles in the center labeled Shame, M1, Guilt, M2, and Self Blame, M3. Three diagonal arrows run from Posttraumatic Stress Disorder Symptoms to these mediators. The first arrow to Shame is labeled a1 equals 0.27 with 0.54 in parentheses followed by three asterisks. The second arrow to Guilt is labeled a2 equals 0.02 with 0.28 in parentheses followed by three asterisks. The third arrow to Self Blame is labeled a3 equals 0.31 with 0.45 in parentheses followed by three asterisks. On the right, a rectangle is labeled Perceived Social Support, Y. From the mediators to Perceived Social Support, three diagonal arrows point right. The arrow from Shame is labeled b1 equals negative 0.03 with negative 0.14 in parentheses followed by three asterisks. The arrow from Guilt is labeled b2 equals 0.09 with 0.06 in parentheses followed by one asterisk. The arrow from Self Blame is a dashed arrow labeled b3 equals negative 0.0012 with negative 0.0086 in parentheses. Along the bottom, a horizontal arrow leads directly from Posttraumatic Stress Disorder Symptoms to Perceived Social Support. This arrow is labeled c prime equals negative 0.01 with negative 0.15 in parentheses followed by three asterisks, and beneath it c equals negative 0.02 with negative 0.21 in parentheses followed by three asterisks. All data are approximate.

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Parallel mediation model of PTSD symptoms on perceived social support.

Notes: N = 3,419. Regression coefficients for each path are displayed in their unstandardized form. Standardized estimates are provided in parentheses. c’ refers to the direct path from PTSD symptoms to perceived social support, taking into account the three mediators, while c describes the total effect of PTSD symptoms on perceived social support without the influence of the mediators. Paths labeled with a dashed line are not significant at p > .05. *p < .05. ***p < .001. Shame = trauma-related shame. Guilt = guilt cognitions.

The direct effect from PTSD symptoms on perceived social support, controlling for all three mediators (c’), was significant, indicating partial mediation. PTSD symptoms were significantly associated with trauma-related shame (path a1), R2 = .29, F(1,3417) = 1,414.11, p < .001. For every one-point increase on the PCL-5, participants’ scores on the shame scale increased by 0.27 points. Trauma-related shame showed a significant negative association with perceived social support when controlling for guilt cognitions, self-blame, and PTSD symptoms (b1). Based on a 95% bootstrapped CI, the indirect effect through trauma-related shame, controlling for the other mediators, was significant (ab1 = −0.0072, 95% CI [−0.0099, −0.0048]). Detailed statistics, including confidence intervals for all coefficients, R² values, and significance tests, are presented in Table A of the Supplementary Material.

PTSD symptoms were also significantly associated with guilt cognitions (path a2), R2 = .08, F(1, 3417) = 298.17, p < .001. Guilt cognitions showed a significant positive association with perceived social support when controlling for trauma-related shame, self-blame, and PTSD symptoms (b2). Based on a 95% bootstrapped CI, the indirect effect through guilt cognitions, controlling for the other mediators, was positive and significant (ab2 = 0.0015, 95% CI [0.0003, 0.0028]). Contrary to expectations, higher guilt cognitions were associated with greater perceived social support.

Self-blame was significantly associated with PTSD symptoms (path a3), R2 = .20, F(1, 3417) = 845.06, p < .001. However, self-blame was not significantly related to perceived social support when controlling for trauma-related shame, guilt cognitions, and PTSD symptoms (b3). The bootstrapped 95% CI for the indirect effect of self-blame, controlling for the other mediators, was not significant (ab3 = −0.0004, 95% CI [−0.0026, 0.0019]).

The total indirect effect of all three mediators was −0.0060 (bootstrapped 95% CI [−0.0082, −0.0039]). The mediation model explained 5.5% of the variance in perceived social support, F(4, 3414) = 49.41, p <   .001. Trauma-related shame showed a significantly stronger effect than guilt cognitions (contrast C1 =   0.06, 95% CI [0.03, 0.09]) and self-blame (C2 =   0.07, 95% CI [0.04, 0.10]). Guilt cognitions and self-blame differed significantly (C3 =   0.01, 95% CI [0.002, 0.03]).

4. Discussion

This study examined the relationships among PTSD symptoms, trauma-related shame, guilt cognitions, self-blame, and perceived social support among treatment-seeking Arabic-speaking women with a history of sexual violence exposure. Consistent with our hypotheses, trauma-related shame, guilt cognitions, and self-blame were positively associated with PTSD symptoms, with trauma-related shame showing a significantly stronger association than guilt cognitions. Furthermore, higher PTSD symptom severity was significantly associated with lower perceived social support. This relationship was partially mediated by trauma-related shame and guilt cognitions. Specifically, higher trauma-related shame was associated with lower perceived support, while, unexpectedly, higher guilt cognitions were associated with greater perceived support. Self-blame showed no significant indirect effect when trauma-related shame and guilt cognitions were accounted for. Among these three, trauma-related shame showed a significantly stronger indirect effect than either guilt cognitions or self-blame in explaining the association between PTSD symptoms and reduced perceived social support. These findings extend previous evidence on trauma-related shame, guilt cognitions, and self-blame to an underrepresented sample of Arabic-speaking women with a history of sexual violence exposure.

Our findings support previous research showing a stronger association of trauma-related shame with PTSD symptoms than guilt cognitions across various trauma types and cultural contexts (Beck et al., 2011; Leskela et al., 2002; Street & Arias, 2001). Trauma-related shame appears to be more prevalent in the psychopathology of PTSD symptoms, either in the sense that PTSD symptoms induce more experiences of shame and/or, conversely, that greater shame causes more severe PTSD symptoms. As suggested by Beck et al. (2011), one possible explanation for the difference could potentially be that shame involves more global negative self-evaluations, unlike guilt, which is typically focused on specific behaviors. Shame might lead to avoidance behaviour and withdrawal, hindering processing of traumatic events and adding distress (Saraiya & Lopez-Castro, 2016). This might be amplified in cultural contexts where honor, modesty, and social reputation carry significant weight (Hosny et al., 2023).

Consistent with earlier findings (e.g. Dodson & Beck, 2017; Dworkin et al., 2018; Wang et al., 2021), we replicated the association between PTSD symptoms and reduced perceived social support. The moderate effect size aligns with meta-analytic evidence across 34 studies, primarily conducted in the USA (Wang et al., 2021). Moreover, longitudinal studies suggest a significant impact of PTSD symptoms on social support (King et al., 2006; Shallcross et al., 2016; Wang et al., 2021). It also seems plausible that the category of trauma experienced may influence both how the social environment responds and how survivors evaluate these responses. In our sample, such evaluations may be perceived as particularly salient or threatening, which in turn can reinforce avoidance of disclosure and limit access to support (Ahrens, 2006). However, PTSD symptoms accounted for only 4% of the variance in perceived social support, suggesting additional explanatory factors. Other factors may also shape perceived social support in this sample, including relationship status, migration and displacement experiences, age, country of residence, and broader socioeconomic conditions. These factors may influence both the availability of support and survivors’ expectations that support will be helpful or safe (El-Haj-Mohamad et al., 2025b).

The findings on the partial mediation via trauma-related shame extend earlier work by Dodson and Beck (2017) on survivors of IPV by suggesting that shame is an operative posttraumatic process that impacts mental health and reduces expectations about the availability and utility of social support. The authors reason that shame may contain a self-protective aspect to prevent anticipated judgment and rejections from others. However, such avoidance may inadvertently sustain trauma symptoms by restricting opportunities for social connection and by blocking adaptive emotional processes, thereby limiting survivors’ ability to process their experiences of sexual violence. Over time, shame may deepen isolation, ultimately reinforcing the well-established cycle between PTSD symptom severity and reduced social support.

Research suggests that shame may have context-dependent functions. While transient shame may motivate people to sustain social bonds or align with social norms (Schaumberg & Skowronek, 2022), our findings are more consistent with evidence that enduring, trauma-related shame is associated with more severe psychological burden in survivors of sexual violence, including PTSD symptoms and suicidal ideation (Alix et al., 2020; Hassanpour et al., 2025).

These findings underscore that trauma-related shame is deeply shaped by ‘the gaze of the other’. In their review of studies from Arabic-speaking countries, Hosny et al. (2023) summarize various studies in which ‘sexually abused women described their experience of fear of being shamed for: not protecting themselves, not taking action, breaking cultural codes of virginity, losing their honor, or ruining their family’s reputation’ (p. 16). Sexual violence is often embedded in social contexts in which survivors anticipate blame, disbelief, or moral judgment, which may contribute to internalized self-devaluation and experiences of shame (Finkelhor & Browne, 1985). While we did not assess disclosure or reactions to disclosure, perceived social support reflects a general belief that support is available and may be shaped by anticipated stigma and negative social evaluation in sexual violence contexts.

Consequently, the reverse direction of the mediation model also seems plausible, with lower perceived or expected social support reinforcing an internalized sense of ‘I am wrong,’ thereby intensifying PTSD symptoms. Supporting this, prior research suggests that shame may help explain why unsupportive social reactions to sexual violence disclosure (e.g. blame or disbelief) are linked to increased psychological distress (Bhuptani et al., 2019; DeCou et al., 2017). Notably, even women survivors of sexual violence who did not report feeling internal shame or beliefs that they should be blamed nevertheless feared being shamed in their communities (Hosny et al., 2023), illustrating the intersubjective nature of shame. Ultimately, this process shifts the burden onto survivors, rather than keeping responsibility with the perpetrators and structural dynamics that sustain stigma and silence.

The unexpected positive association between guilt cognitions and perceived support underscores its distinct nature. Unlike shame, which reflects a global negative self-evaluation, guilt typically concerns negative appraisals of specific actions and is often accompanied by regret and reparative intentions (Broucek, 1991; Tangney, 1995; Tilghman-Osborne et al., 2010). This action-focused quality of guilt may actually encourage survivors to reconnect and restore relationships, which could relate to greater perceived social support. At the same time, guilt cognitions were slightly negatively correlated with perceived social support at the bivariate level (r = −.06), but showed a small positive conditional indirect effect in the parallel mediation model. This discrepancy may reflect shared variance and possible statistical suppression due to overlap with trauma-related shame and self-blame. Therefore, the guilt cognition pathway should be interpreted cautiously.

The lack of a unique effect for self-blame may reflect its comparatively narrower cognitive focus, which does not encompass the broader affective or behavioral components involved in shame and guilt. At the same time, prior research suggests that self-blame is linked to PTSD and related distress, and that trauma-related shame may partly account for these associations in survivors of sexual violence (e.g. Robinson et al., 2024; Salim et al., 2023). Because the parallel mediation model simultaneously included trauma-related shame, guilt cognitions, and self-blame, the diminished role of self-blame may therefore reflect conceptual overlap and shared variance with shame and guilt.

When contrasting all three mediators, trauma-related shame remained the strongest explanatory variable. In addition, guilt cognitions and self-blame also differed significantly, indicating that guilt cognitions retained a distinct, but small and cautiously interpretable, indirect association with perceived social support. In contrast to Dodson and Beck (2017), the mediators in the present study explained only 5.5% of the variance in perceived social support. This might be due to different measures or to the limited number of three mediators included in the model. Furthermore, this sample consisted of treatment-seeking individuals, i.e. women who had already recognized their psychological symptoms and were seeking help, which may have reduced the variance in perceived support or shame-related responses. As noted by Hassanpour et al. (2025), the sample type may influence the magnitude of shame experienced and shame can act as both a barrier to and a motivator for help-seeking, depending on its intensity and context.

4.1. Limitations

Several limitations should be considered when interpreting these findings. First, the study's cross-sectional design precludes any inference of causality among PTSD symptoms, trauma-related shame, guilt cognitions, self-blame, and perceived social support, as all variables were measured simultaneously (Hayes, 2013; Maxwell et al., 2011). Although mediation models typically assume temporal precedence, the identified associations offer a meaningful foundation for future longitudinal research.

The sample's generalizability is limited by the recruitment approach, which may have introduced selection bias. Such bias is common in internet-based interventions across Arabic-speaking and other populations (Donkin et al., 2012; Kayrouz et al., 2018). Future studies should aim to recruit more diverse samples, including older individuals and those with lower educational attainment (Toscos et al., 2019).

Reliance on single self-labeling items to assess sexual trauma, as in the present study, may underestimate prevalence compared to behaviorally specific measures that do not require survivors to identify their experience as sexual violence (Cook et al., 2011; Wilson & Miller, 2016). In addition, trauma checklists may be understood differently across cultural contexts; therefore, endorsements may reflect both exposure and interpretation (e.g. Shoeb et al., 2007). Measures of trauma-related shame, guilt cognitions, and self-blame were assessed with reference to participants’ self-identified most distressing traumatic event. Although all participants reported at least one sexual assault, the index trauma selected for appraisal assessment was not restricted to the sexual trauma. Therefore, the observed associations cannot be interpreted as specific to sexual trauma-related PTSD symptoms but rather reflect associations within a sample of women with sexual violence histories. This is in line with Hassanpour et al. (2025), who note that while some studies examine sexual assault-related or abuse-related shame, many rely on measures of trauma-related shame. Lastly, relying on self-report screening measures may introduce biases such as socially desirable responding or underreporting (Brenner & DeLamater, 2016). As these questionnaires were originally developed in Western contexts, cultural and linguistic differences may shape how constructs such as shame, guilt, and self-blame are understood (de Groot et al., 2021), with studies documenting inconsistencies both within Arabic-speaking contexts (Hosny et al., 2023) and across broader cultural and racial/ethnic groups (Hassanpour et al., 2025), underscoring the need for culturally validated assessment tools.

4.2. Implications

In general, among the screened Arabic-speaking women from the selected countries of origin, nearly one in three (31.0%) reported at least one sexual traumatic experience. This underscores the importance of assessing experiences of sexual violence within broader sociopolitical and structural realities.

Specifically regarding the findings of the study, clinicians and support services should pay particular attention to shame-related appraisals, anticipated stigma, and survivors’ social support systems. This requires a shame-sensitive and nonjudgmental approach that acknowledges the particular vulnerability associated with sexual violence and trauma-related shame (Hassanpour et al., 2025; Saraiya & Lopez-Castro, 2016). In psychotherapeutic settings, clinicians should monitor shame-related responses during sessions and create conditions in which patients can approach trauma-related appraisals without experiencing further self-devaluation, judgment, or social disconnection.

Shame may prevent people suffering from PTSD symptoms from utilizing both formal services and informal sources of support, although the latter have been described as particularly important and often preferred in Arabic-speaking populations (Khatib et al., 2023). In many Arabic-speaking countries, mental health services are lacking, and access is further constrained by barriers such as stigma, mental health literacy, and logistical difficulties (Khatib et al., 2023; Okasha et al., 2012). Public mental health campaigns, work with social networks, and collaboration with community actors and policy-makers may help address the topic of trauma-related shame in society and strengthen supportive environments over time. In addition, online interventions can offer anonymity, and may therefore be especially useful in contexts where trauma-related shame poses barriers to disclosure and help-seeking (El-Haj-Mohamad et al., 2025a; Stein et al., 2023; Vöhringer et al., 2025).

Future research should build on these findings by examining additional mechanisms that may shape the link between PTSD symptoms and perceived social support, including social acknowledgment, barriers to disclosure, and structural conditions such as socioeconomic disadvantage, rural versus urban living, and sociocultural conditions, including gender norms, women’s rights and public awareness of sexual violence. Accounting for such factors is crucial to distinguish between individual and structural determinants and can inform multi-systemic and culturally sensitive interventions that also address policy gaps and community-level silence (Hosny et al., 2023).

To better understand both gender-specific and common consequences of individuals with a history of sexual violence, future research should include survivors of all genders (women, men, and gender-diverse individuals), who may experience distinct dynamics (e.g. Byers & Glenn, 2012).

5. Conclusions

To our knowledge, this is the first study to examine how trauma-related shame, guilt cognitions, and self-blame relate to perceived social support in a unique sample of Arabic-speaking women with a history of sexual violence exposure. It advances current understanding of cognitive and emotional responses to trauma by identifying trauma-related shame, more so than guilt cognitions or self-blame, as a mediator linking PTSD symptoms and perceived social support.

These findings underscore the importance of addressing trauma-related shame and its social causes, including stigma and norms in psychosocial contexts. Reducing trauma-related shame may not only alleviate individual psychological distress but also improve survivors’ agency and access to social and therapeutic support systems. For women with a history of sexual violence exposure, this can be a vital step toward reconnection and recovery.

Supplementary Material

260614_Burden of Shame_Supplementary Material.docx
ZEPT_A_2715186_SM5169.docx (209.3KB, docx)

Acknowledgements

The authors gratefully acknowledge the financial support provided by Misereor e.V. as well as the contributions and expertise of all members of the Ilajnafsy team.

Funding Statement

This work was supported by Misereor e.V. under Grant 800-900-1033 ZG. The funders had no role in the study design, data collection, analysis, interpretation, or in the decision to submit the article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics approval and consent to participate

The studies involving human participants were reviewed and approved by the ethics committee at Freie Universität Berlin (107/2016; 126/2016; 185/2018; 010/2023). The participants provided written informed consent to participate in this study.

Data availability statement

The dataset contains highly sensitive information that (1) could be misused for political purposes, (2) describes individuals who may be experiencing political persecution, and are therefore at risk, (3) describes individuals who have experienced sexual violence within the family or within the community and live in regions where such exposure may lead to serious harm (e.g. prison sentences, punishment by family, exclusion from society), and (4) describes clinical data with potential patients for treatment of posttraumatic stress and depression. Researchers who meet the criteria for accessing confidential data may submit a formal request to the research department of Center ÜBERLEBEN Berlin (contact wissenschaft@ueberleben.org) for consideration under appropriate data sharing agreements.

Consent for publication

Informed consent was obtained from all subjects involved in the study.

Abbreviations

DSM-5

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

HTQ

Harvard Trauma Questionnaire

IPV

Intimate partner violence

LEC-5

Life Events Checklist for DSM-5

MSPSS

Multidimensional Scale of Perceived Social Support

PCL-5

PTSD Checklist for DSM-5

PDS

Posttraumatic Diagnostic Scale

PTSD

Posttraumatic stress disorder

TAQ

Trauma Appraisal Questionnaire

TRGI

Trauma-Related Guilt Inventory

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2026.2715186.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

260614_Burden of Shame_Supplementary Material.docx
ZEPT_A_2715186_SM5169.docx (209.3KB, docx)

Data Availability Statement

The dataset contains highly sensitive information that (1) could be misused for political purposes, (2) describes individuals who may be experiencing political persecution, and are therefore at risk, (3) describes individuals who have experienced sexual violence within the family or within the community and live in regions where such exposure may lead to serious harm (e.g. prison sentences, punishment by family, exclusion from society), and (4) describes clinical data with potential patients for treatment of posttraumatic stress and depression. Researchers who meet the criteria for accessing confidential data may submit a formal request to the research department of Center ÜBERLEBEN Berlin (contact wissenschaft@ueberleben.org) for consideration under appropriate data sharing agreements.

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