Moral injury, not only an injury of war – feminist pastoral approach

Literature about and research on moral injury most often links moral injury with war. Moral injury is usually defined as an act of transgression against moral beliefs in wartime among military personnel. This article explores moral injury as not only an injury of war but also an injury caused by the gender-biased war in our society and homes. Moral injury occurs early in life with the teaching of the gender binary as “masculine” and “feminine”. This essay will focus on patriarchy as a deeper root of the trauma of moral injury. The article will also focus on how moral injury can cause gender-based violence. A feminist pastoral approach will aim to bring awareness to the cultural attitudes and practices that create the contexts where a moral injury occurs and explore ways to transform the patriarchal gender-biased dominant narrative to facilitate freedom and healing from the internal gender identity conflict.


Introduction
All over the world, different countries are at war with each other.We read about it in the media.Violence is not only part of our reality when we witness what happens to others, but also of the daily reality in South Africa.Statistics indicate that the South African society has one of the highest rates of gender-based violence against women worldwide (see Nduna & Thona 2021:347).Gender-based violence can be defined as "violations perpetrated against women in defence of patriarchal traditional values, gendered hierarchy and sex role expectations that uphold society's control over feminine and gender-nonconforming persons (Nduna & Tona 2021:347)."Klaasen (2018:1) describes gender-based violence as "an assertion of physical dominance between a man and woman and is characterised by physical, oppressive power that causes physical, psychological, or sexual harm".These definitions can be expanded on by the following definition of Dlamini (2021:583): Gender-based violence (GBV) … includes acts that inflict emotional, physical, mental, or sexual harm or suffering, threats of such acts, coercion, and other deprivations of liberty.It is psychological, physical, and/or sexual violence perpetrated or condoned within the family, the general community, or by the state and its institutions.
A more intimate form of gender-based violence is domestic abuse.The following definition by Inverson et al. (2009:242) on domestic violence can be used to indicate how GBV and domestic abuse are linked: "Domestic abuse against women is widespread and refers to physical, sexual, psychological, and/or verbal abuse in the context of an intimate partner relationship."This illustrates that the perpetrators of gender-based violence against women are often not strangers but those closest to them. 1n her book Trauma + Grace: Theology in a ruptured world, Serene Jones (2019: vii) provides the following important perspective on violence: "Violence must be understood not simply as the physical brutality meant to harm the bodies of people but also as systems of thought that objectify or negate the humanity of another."One of these systems of thought that objectify and negate women and will be indicated as the root cause of gender-based violence in this article is patriarchy.Patriarchy is a social system of male dominance.According to Gilligan & Snider (2018:6), patriarchy can be described as a "set of rules and values, codes and scripts that specify how men and women should act in the world."According to Christ (2016:214), patriarchy is "a system of male dominance rooted in the ethos of war, which legitimates violence, sanctified by religious symbols, in which men dominate women through the control of female sexuality."Christ (2016:214-215) further indicates how this system of male dominance teaches men through war how to kill other men and that raping women is permitted.These acts of violence that are carried out not only cause physical injury to the victims but also psychological injuries and psychological trauma.
I agree with Christ (2016:216) that it is not in the "nature of men" to dominate through violence.In this article, I propose that it is the patriarchal system that is integrated into society and enforces male dominance through violence that normalises gender-based violence and that this system of dominance causes psychological trauma in men and women.
In the following section, I will discuss moral injury as psychological trauma caused by acts of violence and indicate how the patriarchal system can be linked to violence and trauma.

Moral injury in the context of war and violence
The concept of moral injury (MI) was first used by the military psychiatrist Jonathan Shay (1994).As a military psychiatrist, Shay worked with Vietnam Veterans with severe post-traumatic stress syndrome (PTSS).In combat situations, soldiers often reported their experiences.Some of the experiences recorded by Shay (1991:562) were as follows: A leader's betrayal of "what's right", blunted responsiveness to any emotional, social, or ethical claims outside a tiny circle of combatproven comrades, grief, and guilt for death(s) in this circle, lust for revenge, renunciation of ever returning home, seeing one's self as already dead, berserking, dishonouring the enemy, and loss of humanity.
In light of these reports of the veterans, Shay (2014:183) describes the psychological trauma (injury) experienced by the veterans as moral injury.Shay's definition of moral injury is "a betrayal of what is right, by someone who holds legitimate authority (e.g., in the military -a leader), in a high stakes situation" (Shay 2014:183).To comprehend the perspective of war Veterans regarding their understanding of what is right, we must consider that their understanding of morality is tied to what is deemed as standard expectations, conventions, moral principles, appropriateness, ethics, and commonly accepted social values.(Shay 1991:563).Moral injury occurs when soldiers experience an officer doing something against what they hold as "what is right".Out of the reports of the Veterans, Shay (1991:564-565) shares the following experience of one of the Veterans as an example of this: M. came over with a newly activated division.The first deaths in his platoon were caused by "friendly fire" from adjoining sectors of the defensive perimeter; the officer had neglected to inform them that he was sending men out on the berm.
During one long patrol in the dry season, his squad ran out of water and was not resupplied.They walked for a day and a half in search of water in Viet Cong-controlled territory.When men started to collapse from dehydration in the heat, an officer's plea for emergency resupply was needed: a helicopter flew over and "bombed" the squad with a case of Tab, seriously injuring one of the men.The Major who dropped the Tab was recalled evacuating the casualty.There was no enemy activity.M subsequently read in the division newspaper that the Major had put himself in for and had received the Bronze Star.
According to Shay (2014:185), this type of leadership malpractice inflicts moral injury that leaves lasting psychological imprints.The betrayal experienced on this level by war Veterans destroys their capacity to trust.Shay (2014:186) observed that war veterans who experience betrayal by leadership multiple times replace lost social trust with a sense of "expectancy of harm, exploitation, and humiliation from others."A second form of moral injury is described by clinical researchers Brett Litz, Nathan Stein, Eileen Delaney, Leslie Lebowitz, William Nash, Caroline Silva, and Shira Magauen (2009), in their article titled: Moral injury and moral repair in war veterans: A preliminary modal and intervention strategy.The concept of moral injury described by Litz et al. (2009) differs from the one described by Shay (1991;2014) regarding the violator's identity.While Shay (2014) identifies the power holder as the violator, Litz et al. (2009) identify the self as the violator.Litz et al. (2009:696) describe moral injury as a psychological injury that arises when the service members does something that transgresses their own moral beliefs or witness others behaving unethically with regard to their moral beliefs (see Shay 2014:184).
At the beginning of this section, it is mentioned that the veterans who reported their experience to Jonathan Shay were suffering from PTSS.It would therefore be fair to ask: how is MI different from PTSS?Although MI is viewed as a separate syndrome from PTSS, there is some definitional overlap.According to the DSM-5 diagnostic criteria for PTSS (American Psychological Association 2013), PTSS is diagnosed when: A severe traumatic stressor is present (Criterion A; exposure to death, threatened death, actual or threatened serious injury, actual or threatened sexual violence) along with four major fear and trauma-based symptom clusters that adversely affect functioning in daily life: intrusive nightmares and flashbacks (Criterion B), avoidance (Criterion C), emotional negativity and numbing (Criterion D), and hyperarousal and irritability (Criterion E).
According to Koenig & Al Zaben (2021:2994), moral injury develops when offences against moral beliefs or values are committed, observed, or heard about.The consequences of this experience, as mentioned by Koenig & Al Zaben (2021:2995), are: Feelings of guilt, shame, feelings of betrayal, moral concerns, difficulty forgiving, loss of meaning, loss of trust, selfcondemnation, spiritual struggles, and loss of religious faith as a result of those moral transgressions.For some, transgressing moral beliefs or values in high stake situations may be severely distressing affecting the ability to function in daily life, whereas, for others, these events may be disturbing yet do not disrupt functioning.
The predominant painful emotions for a person suffering from PTSS are fear, horror, and helplessness.In contrast, the dominant painful emotions of a person suffering from moral injury (MI) are guilt, shame, anger, and betrayal (Shay 2014:185; see Koenig & Zaben 2021:2994).Some consequences of suffering from MI are depression, anxiety, and suicide.
According to Koenig & Zaben (2021:2996), it is not only those inside the military who experience MI.Healthcare professionals and other first responders like paramedics, firefighters and police officers exposed to severe trauma also experience moral injury.In high-stress situations, moral injury can occur in healthcare professionals and first responders when decisions that may lead to loss of life must be made.There is an increased risk of MI for first responders because of repeated exposure to violence and trauma.After responding to traumatic events, the first responders and other healthcare professionals might become fixated on what they might have done differently to have a different outcome (prevent loss of life or more injury).They may struggle with guilt or shame when they feel that they have betrayed the moral codes of their profession through their actions.This signifies moral injury.
Moral injury is not limited to those in the military, healthcare professionals and first responders.Individuals who experience severe physical/emotional trauma, like rape, abortion, car accidents, and other accidents, also have a high risk of MI.

Moral injury as a wound of gender-based violence
In this section, I will use the insights gained from the research by Carol Gilligan, published in her article, titled Moral injury and the ethic of care: Reframing the conversation about differences (2014).
In her exploration of moral injury, Gilligan (2014) draws on her previous research on early childhood development (1993 [2003]) and the work of Shay (1994;as cited in Shay, 1991).Her analysis offers a unique perspective on moral injury.In Gilligan's (2014:90) discussion of moral injury, she describes it as "the shattering of trust that compromises our ability to love."Her slant on moral injury MI comes from one of the remarks that one of Shay's Veterans made, namely that he "knew in his heart it was wrong" (Gilligan 2014:93).This remark confirms her finding that our understanding of what's right and wrong, what is praiseworthy and blameworthy, "is rooted not only in culture but also in our humanity" (Gilligan 2014:93).Her research on development illuminated that we carry inside us an inner moral compass that alerts us when we are doing something that we know in our hearts is wrong.This inner compass becomes distorted by culture and what she calls our initiation into the patriarchal gender binary of masculinity and femininity.This patriarchal discourse also determines what Gilligan (2014:98) describes as the "Love Laws -the laws that establish who can be loved, and how, and how much."Gilligan (2014:95) describes what happens in this initiation process as follows: By splitting human qualities into "masculine" or "feminine," the gender binary forces dissociation, and the hierarchy undermines trust.Thus, the initiation entails a betrayal of what's right by shattering the ability to live with integrity in connection with others.The stakes are high -identity and inclusion are on the line -and the betrayal is enforced by shaming and rewarded with the equivalent of medals of honour … This initiation teaches girls to betray what they know about their selfworth to be accepted in the patriarchal culture and to avoid the violence of shaming.This initiation teaches boys to betray their emotions of care and vulnerability in relationships.The patriarchal gender binary that is enforced teaches them that being a man means being "emotionally stoic and independent", and being a man means not being a woman or like a woman, being on top" (Gilligan 2014:94).This dissociation the gender binary causes teach girls it is impossible to have a voice and have relationships, it teaches boys that they are not supposed to care.To be accepted in this patriarchal culture, girls must betray what they know, and boys must betray that they care, but "research shows that girls do know, and boys do care, although they may need not to know or to show this" (Gilligan 2014:95).
An example of this betrayal of the self is the story that Donald Moss (2012) talks about his experience in the first grade.In class, the children learned a new song each week.They were told that at the end of the year, they would each have the opportunity to lead the class in singing their favourite song.When it was his turn, he wanted to sing the lullaby "When at night I go to sleep [Fourteen angels watch do keep]".The song had special meaning to Moss as he sang the song at night to himself as he fell asleep.In his experience, the angels saved him from his night terrors.Moss (2012:140) recalls his experience of what happened when he started to tell the teacher what song he wanted to sing as follows: I began to tell her: "it's the lullaby …" But immediately, out of the corner of my eye, I saw the reaction of the boys in the front row.Their faces were lighting up in shock … I knew, knew in a way that was immediate, clear, and certain, that what I was about to do, the song I was about to choose, the declaration that I was about to make, represented an enormous, irrevocable error … what the boys were teaching me was that I was to know now, and to always have known, that … a lullaby had no place here, that something else was called for.
Moss chose to sing a different song and felt in doing so, he betrayed the angels.This illustrates the moral injury that occurs with the initiation into the patriarchal gender binary.With this said, we need to be reminded that the response to moral injury, as indicated by Shay (see 1991:184-185), is anger, guilt, shame, and withdrawal.For Gillian (2014:102), the moral injury patriarchy inflicts leads to memory loss.We forget what we know.Patriarchy is an order of domination, giving some men power over other men and giving men power over women.This moral injury that patriarchy inflicts can lead to violence against women.This is connected to how human beings are valued.According to Jean Hampton (2007:115-150), moral injury is also caused by a particular conception of human worth.Conceptions of human worth like those posed by patriarchy, according to which human beings are awarded unequal value depending on their sex, race, intelligence, and accomplishments, cause moral injury.
Value or worth awarded to someone generates certain entitlements.The moral injury caused by patriarchy and gender-based violence is the loss of value (self-worth).Regarding gender-based violence, it is also about the worth awarded to men or rather the worth that men think they are entitled to, against the worth awarded to women.Acts of gender-based violence like rape and domestic abuse diminish the value of women and their self-worth, causing them moral injury.The moral injury caused by actions influenced by conceptions of human worth and self-worth is described by Hampton (2007:126)

as follows:
A person behaves wrongfully in a way that effects a moral injury to another when [he]she treats that person in a way that is precluded by that person's value, and/or by representing [her]him as worth far less than [her] his actual value; or, in other words, when the meaning of [his] her action is such that [he] she diminishes [her] him, and by doing so, represents herself [himself] as elevated with respect to him [her], thereby according herself [himself] a value that she [he] does not have.
In light of this, it is my opinion that patriarchy causes moral injury to men in so far as patriarchy allows for a perception that they are worth more than women and are entitled to treat them in a degrading manner.
Value-denying acts, like gender-based violence, "can encourage the action of similar injuries by people who find appealing the apparent diminishment of the victim …" (Hampton 2007:127).Gender-based violence is not limited to violent actions but includes words, pictures, books, and jokes that denigrate women and influence others to inflict harm on them.In light of this, it is not only people's actions but also the dominant discourses within a society that can be morally injurious (see Hampton 2007:128;Miller 2009:510).
In an article with the title, Moral Injury and Relational Harm: Analysing Rape in Darfur, Sarah Clark Miller (2009:505-523) states that sexual violence, and in this specific instance, rape, causes moral injury because it affects the human dignity of the victim.It is indicated that the predominant painful emotions of a person suffering from MI, guilt, shame, betrayal, and withdrawal from society, are part of the psychological injuries and psychological trauma experienced by women who were raped.The experience of shame grows from how the victims feel about themselves and their beliefs on how others might think of them and the violation they experienced.There is a connection between the victim's experience of shame and the value that the culture and society in which they live assign to such an act (Miller 2009: 511).Part of the moral injury that the rape victim experience is the feeling of guilt, guilt because they could not resist the attacker(s), fight them off and also a feeling of self-betrayal because they were powerless to resist, and the perceptions that their body has somehow betrayed them (see Miller 2009:513).
The consequences of the psychological trauma of women suffering from domestic abuse, such as anxiety, shame, guilt, and betrayal (see Inverson et al. 2009:243), resemble the dominant emotions of persons suffering from moral injury.The consequences of suffering from MI are depression, anxiety, anger, distrust of self and others, hopelessness, interpersonal difficulties, and isolation.

A feminist pastoral approach
Being aware that gender-based violence causes moral injury, and that in some instances moral injury is the cause of gender-based violence, and that there is a connection between moral injury and self-worth, human worth, the need arises to address the conceptions and cultural attitudes and practices that create the contexts where moral injury occurs.The aim is to find ways to transform the patriarchal gender-biased dominant narrative to facilitate freedom and healing for perpetrators and victims from the "gender-based violence war" and the moral injury it brings.
One of the ways to transform the patriarchal dominant narrative is to recognise that the Christian tradition has a morally injurious legacy tainted by patriarchy.Christians operate within an institution (the Church) and tradition (patriarchy) that often betrays its moral values (unconditional love and equality) (see Guth 2018:167-186).Through the recognition that the Christian tradition is tainted by patriarchy, the possibility arises to view moral injury as a psychological injury caused by gender-based violence, with patriarchy as its root, as collective trauma.Collective trauma gets passed down from generation to generation in communities.Trauma lives in our bodies, unconscious minds, and actions (see Jones 2019: xii).Individual and collective trauma affects a person's capacity to know, remember, act and love.The effect of this is described by Jones (2019: xxi) as follows: It becomes difficult for victims to experience the healing power of God's grace because their internal capacities (where one knows and feels) have been broken.It is hard to know God when your knowing faculties have been disabled.It is hard to feel Devine love when your capacity to feel anything at all has been shut down.
This illustrates how far-reaching the moral injury caused by the patriarchal gender binary, with its gender-based violence, is.Therefore, a critical theology of Christian practice is needed (see Graham 2002:3).Feminist theologies that criticise patriarchal ideologies and views regarding human nature, the self, knowledge, action, and value can help reform the patriarchal ideologies that are harmful to both women and men (Graham 2002:4).According to Ruether (1996:18), "the critical principle of feminist theology is the promotion of the full humanity of women."The critical feminist theology of liberation proposed by Schüssler Fiorenza (1995:12-13) provides the perspective that demonstrates that the patriarchal tradition falls short because it offers women and men nothing more than the stereotypical limited image of themselves.The aim of a critical theology of liberation is described by Schüssler Fiorenza (1995:12) as follows: In consequence, a critical feminist theology of liberation does not simply seek to analyse and explain the socioreligious structures of domination that marginalise and exploit women and other nonpersons … Instead, it aims to change entirely structures of alienation, exploitation, and exclusion.Its goal is to transform theoretical and theological-religious knowledges and socio-political systems of domination and subordination.
The function of feminist theologies is to emphasise the inadequacy of the given tradition and contribute to a new vision (Graham 2009:10).Continuous reflection regarding gender is essential.People are socialised in a "gendered" culture and are agents of change and its reinterpretation.Gender is not ontological but constructed and reconstructed through social and cultural practices.The formation of gender is the product of socialisation and institutional structures (see Graham 2009: xii).Feminist theologies want to free all from the gender binary and hierarchy.The aim is to heal the wounds sustained when powerful institutions, traditions, and leaders violate their professed values (Guth 2018:174) This also poses a challenge to practical theology because it is part of the tasks of practical theology to reflect on the practice and traditions of society and faith communities (see Browning 1991:2-4).According to Browning (1991:36), practical theology should focus on "critical reflection on the church's dialogue with Christian sources and other communities of experience and interpretation with the aim of guiding its action toward social and individual transformation."Therefore, practical theology should listen to the experience of those injured by the patriarchal master narrative.This challenge extends to the concepts of gender because "patriarchy implants itself into the psyche by attaching itself to gender, so that becoming a man or a woman, a real man of a good woman, means internalising its binary and hierarchy" (Gilligan 2014:102).This calls for a program for changing values and assumptions based on Christian practice and tradition (see Graham 2002:44).

Addressing the cause of the moral wound
Pastoral care in practical theology is not only about the care of individuals but is also concerned with the intentional actions of faith communities.It is part of the tasks of practical theology to evaluate, interpret and reconstruct Christian practice and practices as the creators and bearers of the truth claims of Christian communities (see Graham 2009:160-161).Practical theology that investigates Christian practice should pay critical attention to all aspects of the Christian tradition, especially how patriarchy has tainted it (cf.Magezi & Manzanga 2019:5).For practical-theological practice to change, it is necessary to move away from patriarchal symbols and dogmas, including the gender binary.Transformative action is needed.The purpose of transformative action in practical theology is to hear everyone's voice and to heal wounds.
The transformation and healing of those morally injured by patriarchy and the violence it causes begins with awareness and active listening to the narratives of those who are victimised and silenced, morally injured.If we are serious about listening to everyone's voice, we need to encourage society's full range of voices.We need to be receptive to what it means to listen actively.Gilligan (2014:104) states that "active listening means asking, how might I call forth a voice that is held in silence" by the moral injury caused by the patriarchal gender binary?This is listening in such a way that it empowers those who find it hard to resist the identity assigned to them and encourages them to claim back the freedom to find their own identity in what they know in themselves to be true.Through the power of this reclaimed freedom, they can resist the labelling and stigmatisation.
They will be able to resist the notion presented by society that the current state of gender violence is a matter of course and acceptable while they know that this condition is harming their bodies and minds.One must remain constantly suspicious of the veiled power behind ideologies and the damage they cause.
Further exploration and research are needed on the effect of the patriarchal ideology in society and possible ways of resisting the current state of gender-based violence by exploring the question of why patriarchy persists.

Conclusion
As discussed in this article, moral injury is not only a moral wound sustained by soldiers during and in war situations.MI is also caused by the patriarchal gender binary of masculinity and femininity that we are initiated into from an early age.The gender binary teaches about self-worth.The conceptions of human worth posed by patriarchy give some men power over other men and give men power over women.This creates the assumption that men are entitled to exercise power over those considered to have less worth.This moral injury that patriarchy inflicts leads to violence against women.Gender-based violence against women causes MI in women because it lets them question their self-worth.The dominant emotions of persons suffering from MI are anxiety, shame, guilt, and betrayal.Healing from the moral injury inflicted by the patriarchal gender binary in our society will only start when there is a conscious movement to reset the gender-biased moral code of patriarchy to the moral codes of unconditional love and equality.Churches, faith communities, and other institutions that influence how people understand their roles and identities can contribute to this movement of change when they establish moral codes of unconditional love and equality.
After experiencing these types of trauma, individuals often become fixated on what they might have done differently to prevent the traumatic experience or have done differently to change the outcome of what happened.This obsessing about what happened can lead to the perceived transgression of moral values, guilt, shame, and self-betrayal (Dombe et al. 2013:201).At this point, I would like to shift the focus to moral injury as a wound of gender-based violence.