Child Sexual Abuse of Asians Compared with Other Populations KAVITHA RAO, M.D., RALPH J. DICLEMENTE, PH.D., AND LYNN E. PONTON, M.D. Abstract. This retrospective chart review study of a child sexual abuse clinic compared a consecutive sample of substantiated sexual abuse cases of Asian victims with random samples of black, white, and Hispanic victims. The findings suggest that there are clinically relevant differences between Asians and the other three populations. Asian victims showed a distinct demographic profile, suffered less physically invasive forms of abuse, were more likely to express suicidality, less likely to display anger and sexual acting out, and had less supportive primary caretakers than non-Asians. Awareness of such ethnic differences will help clinicians better evaluate and treat minority victims. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31,5:880-886. Key Words: sexual abuse, race, ethnicity.

The sexual abuse of children is a serious mental health problem in the United States. Sexually abused children suffer from a number of psychiatric signs and symptoms during their youth (Adams-Tucker, 1982; Brown and Finkelhor, 1986; Finkelhor, 1987; Gelinas, 1983; Massie and Johnson, 1989; Sauzier, 1989). Psychic distress can occur both when the child keeps the sexual abuse a secret and as a result of negative social reactions when he or she discloses the abuse (Sauzier, 1989). In particular, negative parental reactions toward the child after the disclosure of sexual abuse have been found to adversely affect the child's subsequent adjustment (Browne and Finkelhor, 1986). Childhood sexual abuse is also a significant risk factor for a variety of longterm psychiatric sequelae (Brown and Finkelhor, 1986; Finkelhor, 1987; Gelinas, 1983; Stone, 1989). Although sexual abuse of children and adolescents has been extensively reviewed in the literature, little attention has been paid to the role of ethnicity or race. A small number of studies have examined childhood sexual abuse among blacks and/or Hispanics, comparing them with whites (DeJong et aI., 1982; Finkelhor and Baron, 1986; Lindholm and Willey, 1986; Pierce and Pierce, 1984; Siegel et aI., 1987; Wyatt, 1985). Interviews with community-based populations and retrospective chart reviews of sexually abused children indicate differences in the characteristics of sexual abuse across ethnic/racial groups. For example, Dejong and colleagues (1982), in a chart review, found that black female

Accepted May28, 1992. Dr. Rao just completed the child and adolescent psychiatry fellowship at the Neuropsychiatric Institute at the University of California, Los Angeles. Dr. DiClemente is a Research Psychologist at the Center for AIDS Prevention Studies at the University of California, San Francisco. Dr. Ponton is an Associate Adjunct Professor at the Longley Porter Psychiatric Institute at the University of California, San Francisco. The authors wish to thank Catherine Kennedy, M.D., CASARC Psychiatric Consultant, and Frances Tauber, Director of CASARC, who facilitated this study at CASARC. This project was supported in whole by BRSG Grant S07-RR05755 awarded by the Biomedical Research Support Grant Program, Division of Research Resources, National Institutes of Health. Reprint requests to Dr. Ponton, 205 Edgewood St., San Francisco, CA 94143. 0890-8567/92/31 05-880$03.00/0© 1992 by the American Academy of Child and Adolescent Psychiatry.

880

victims were evaluated for sexual abuse at a younger age than Caucasian or Hispanic female victims. Pierce and Pierce (1984) report similar findings and also noted that black victims and their families were less likely to be referred for counseling after the sexual abuse report. Such studies suggest that each ethnic group may have unique risk factors that contribute to differences in the characteristics of sexual abuse. As child rearing practices are culturally influenced, familial attitudes toward sexually abused children may vary across ethnic/racial groups. In addition, a child's response to having been sexually abused and then having to deal with reactions from social support systems may be influenced by ethnic factors. It is particularly noteworthy that there are no studies of childhood sexual abuse among Asian populations in the United States. The present study of multiracial child victims in San Francisco was designed to investigate ethnic/ racial differences in sexual abuse with respect to demographic characteristics and victims' and familial reactions to the sexual abuse. More specifically, the authors were interested in the distinguishing features of sexual abuse among Asian populations. Method

The Child and Adolescent Sexual Abuse Resource Center (CASARC) at San Francisco General Hospital is the sole county-directed sexual abuse referral center in San Francisco for the initial evaluation of sexually abused children and adolescents. Approximately 600 new cases are evaluated each year; these include black, white, Hispanic, Asian, and racially mixed children under the age of 18. During a child or adolescent's initial visit, a brief history is taken from the person bringing the victim in and, as appropriate, a physical examination, cultures and serological tests for sexually transmitted diseases, and evidence collection are done. The child and family are then referred to a CASARC counselor who takes an extensive history of 'the assault and of the child's background from the primary caretaker and any present household members. The counselor assesses the need for treatment and, if appropriate, whether the family and victim would best be treated at another facility or at CASARC where short-term individual therapy and group therapies are available. If longer treatment is indicated at J.Am. Acad. Child Adolesc. Psychiatry, 31: 5, September 1992

ASIAN CHILD SEXUAL ABUSE

the end of the CAS ARC treatment phase, the family is referred to another facility. The present study consists of a retrospective review of closed charts of patients who were seen from January 1986 through December 1988. This time period was chosen to ensure that a sizable number of the cases would have completed their evaluation and treatment at CAS ARC and the charts would have been closed by the start of the present study. During this period, 2,007 cases were evaluated. The racial/ethnic distribution of the victims was: 37.6% black, 25.9% white, 21.9% Hispanic, 6.6% Asian, 6.7% racially mixed, and 0.5% other races. Cases in which sexual abuse was suspected but not substantiated by a report of a specific incident, nor by physical evidence of sexual abuse (such as semen detection or genital trauma) or by diagnosis of a sexually transmitted disease or pregnancy, were excluded from the analysis. Twenty-six percent of all examined charts were excluded from the analysis because of unsubstantiated reports of sexual abuse. To generate a sizable sample of Asians, the total number of available charts of Asian victims was selected for review (N = 98). Of these, 29.9% (N.::" 29) involved unsubstantiated sexual abuse and were excluded. For comparison, 80 charts each of black, white, and Hispanic children in which sexual abuse was substantiated were randomly selected and included in the analysis. A preliminary chart review was conducted to determine the type and quality of information available in CAS ARC charts. An evaluation instrument was devised to measure a number of variables related to the sexual abuse, including descriptions of the victim, the family, the assailant, the nature of the assault, the method of discovery, and the course of evaluation and treatment. It consisted of 40 multiple choice questions and three open-ended ones. The multiple choice questions focused on demographics and family responses to the disclosure of sexual abuse; the open-ended questions focused on psychiatric symptoms observed or reported in the victim, family stressors, and family attitudes towards the victim. Contingency table analyses (Fleiss, 1973) were conducted to evaluate differences in variables of interest between the four ethnic/racial groups. CAS ARC does not routinely obtain information about the family's income. Thus, the average household income for the zip code in which the victim's immediate family lived at the time of the abuse report (The Sourcebook of Demographics and Buying Power for Every ZIP Code in the U.S.A., 1989) was used as an estimate of the victim's socioeconomic status. To refine the research instrument, a pilot study was conducted on charts from each ethnic/racial group. A research assistant was trained to independently review the charts. Coding criteria were jointly developed. Interrater reliability was 94.8% in a test of 32 charts (eight randomly selected from four ethnic groups) comparing data obtained by the research assistant and principle investigator. Items that resulted in discordant coding were reevaluated to identify areas of confusion and the coding criteria modified. All of the variables in the chart were examined for availability of data. For 35 out of 40 variables, information was available in more than 75% of the charts, with the average chart availability for the 40 variables being 90%. The variJ. Am.Acad. Child Adolesc.Psychiatry, 31:5, September1992

1. Ethnic Differences in Demographic Characteristics Demographic Asians Hispanics Whites Blacks Variable Age (years) 11.5 10.5 9.0" 8.7b Immigrant victims, %' 2.5 71.0 66.7 o Immigrant mothers, %d o 78.9 80.5 o Immigrant fathers, %' 44.4 75.8 o o Parents living together, Ole! 54.0 27.0 23.9 12.7 "p < 0.003 for differences between Asians and whites. "p < 0.0005 for differences between Asians and blacks. 'p < 0.0001 for differences across all four groups. dp < 0.0004 for differences across all four groups. 'p < 0.0006 for differences across all four groups. fp < 0.0001 for differences across all four groups. TABLE

able with the lowest availability of data was parental immigration status.

Results The present report includes findings with respect to Asian, black, white, and Hispanic subgroups. The results are presented here under the categories of characteristics of the victim, of the family, of the assailant, and of the abusive incident(s).

Characteristics of the Victim Of the 69 Asian cases, 30.4% were Filipino; 15.9% were Vietnamese; 15.9% were Pacific Islander; 11.6% were Chinese; 5.8% were Fiji Indian; 5.8% were Cambodian; 1.4% were Laotian; 1.4% were Thai; 4.3% were multi-Asian; and 7.2% were other-Asian. The black, white, and Hispanic groups were not subdivided. The key differences found among racial/ethnic groups are described in Table 1. Asians and Hispanics on average were older than blacks and whites at the time of presentation to CASARC. This was independent of delays in the reporting of the abusive incidents, as there were no significant racial/ ethnic differences in the time interval between the occurrence of the abuse and presentation to CASARC. Asians and Hispanic victims were also much more likely to be immigrants to the United States. An examination of the living situation (Fig. 1) also revealed marked ethnic/racial differences. Asians were the group most likely to be living with both parents at the time of the evaluation, whereas blacks were the least likely group to be living with both parents. Whites and Hispanics were similar to each other (p < 0.009 for intergroup differences). Asians were less than half as likely as the other groups to be living in a single parent household (p < 0.0001 for intergroup differences). Asian victims were more likely than the other ethnic groups to be living in a shelter at the time of evaluation (18.2% versus 6.3%, 7.6% and 10.3% for Hispanics, blacks, and whites, respectively; p < 0.02), most often having been sent there by authorities to protect the victims' safety after the discovery of intrafamilial sexual abuse. Psychiatric/behavioral symptoms were obtained from a symptom check list (filled out by the CAS ARC counselor

881

RAO ET AL. Percent of Cases

2. Percentage of Psychiatric and Behavioral Symptomatology

TABLE

6'..-r------=:---------,~-~

so.l-/-----

Percentage of Cases

".I-/----~ • \Hth both parents

3'

EIWith single

20

.. With other relative

parent

Elln a shelter

10

ASIAN

BLACK

WHITE

HISPANIC

RACE/ETHNICITY OF VICTIM

FIG. 1. Victim's living situation. The sample sizes for the Asian, black, white, and Hispanic groups were 66, 79, 78, and 79, respectively.

at the time of the evaluation) and the chart narrative. Most report~d symptoms were noted to appear after the abuse, but this was not always specifically stated. Symptoms were recorded in the chart if they were reported by adults involved in the victim's life, reported by the victim, or observed by the counselor during the evaluation or treatment. The most common symptoms in the four groups combined were, in descending order of frequency, anxiety (44.7%); depressed or sad mood (25.2%); anger (20.3%); sleep disturbance (21.6%); sexual acting out (17.5%); suicidal ideation or attempts (13.1%); somatic symptoms such as abdominal pain, chronic headaches, and encopresis (11.6%); school problems (11.3%); low self-esteem (10.0%); running away (9.8%); withdrawal (9.3%); urinary disturbance such as enuresis (8.7%); clinging behavior (7.2%); physical aggression toward others or homicidal ideation or attempts (4.1 %); and self-mutilation (0.5%). There were no racial/ethnic differences in the total number of psychiatric or behavioral symptoms reported for each victim. Racial/ethnic differences were found in four symptoms (Table 2). Examples of sexual acting out included compulsive or' public masturbation and compulsive attempts to engage 'Others in sexual behaviors. Asians were distinct from ~he other .groups because ~hey were least likely to display inappropriate sexual behaviors and anger, but most likely to express suicidal ideation or attempt suicide. Whites were distinct as the group most likely to exhibit urinary problems (such as enuresis).

Symptom

Asians

Sexual acting out (p < 0.0001) Anger (p < 0.08) Suicidal ideation/attempt (p < 0.14) Urinary symptoms (p < 0.02)

Blacks

Whites

Hispanics

1.4

15.0

17.5

13.8

8.7

21.3

22.5

20.0

21.7

11.3

15.0

10.0

2.9

10.0

17.5

6.3

pattern. There were no interethnic differences in the length of time since immigration by the parents (or the victims) to the U.S. At the time of the CASARC evaluation, 21.2% (7/33) of Asian and 48.1% (13/27) of Hispanic fathers were out of the country. Also, Asian parents were far more likely than the other groups to be living together at the time of the ~S'ARC evaluation. Primary Caretaker's Response to the Abuse

Asians, whites and Hispanics were just as likely to have their mothers as primary caretakers (73.9%, 71.3%, and 75.0%, respectively, of primary caretakers were the mothers of victims). Blacks, on the other hand, were less likely (60.0%) to have their mother as primary caretaker. Instead, blacks were more likely to be primarily cared for by another relative (27.6%, compared with 12.5%, 13.8%, and 17.4%, for whites, Hispanics, and Asians, respectively; p < 0.04). Asian primary caretakers, whether the mother or someone else, were half as likely, relative to caretakers of the other ethnic groups, to spontaneously report the abuse to authorities such as health care workers or police (Fig. 2). Among blacks, whites, and Hispanics, the primary caretakers were about equally likely to spontaneously report the abuse (67.1%,62.8%, and 60.0%, respectively; p < 0.0001). Similarly, despite the fact that Asian mothers were as lik~ly as whites and Hispanics to be the primary caretakers, ASIan mothers (whether the primary caretaker or not) were much less likely than the other groups to have brought the abuse to the attention of authorities (13.2% versus 31.2%,

Characteristics of the Family

Estimates of income were similar across racial/ethnic groups. There were no differences in the projected average household income for 1989 for the zip code region in which the victim's family lived. Immigration status varied across racial/ethnic groups (Table 1). Of those cases in which maternal immigration information was recorded, the vast majority of Asian and Hispanic mothers were immigrants to the United States. In addition, 17.1% (7/41) of Asian and 10.5% (4/38) of Hispanic mothers were out of the country at the time of the CASARC evaluation. In contrast, none of the black and ~hite m~thers appeared to be immigrants, although this information was not always specifically recorded in the charts. The fathers' immigration status followed a similar 882

6' so

BAslan

"

C3 Black

3'

IIIHispanic

20

C]Whlte

10

REPORTED ABUSE

DISBELIEVEO VICTIM

ATTENDED INTAKE

COMPLETED TREATMENT

RESFONSES OF PRIMARY CARETAKER

FI

Child sexual abuse of Asians compared with other populations.

This retrospective chart review study of a child sexual abuse clinic compared a consecutive sample of substantiated sexual abuse cases of Asian victim...
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