American Journal of Orthopsychiatry 2014, Vol. 84, No. 3, 284 –294

© 2014 American Orthopsychiatric Association DOI: 10.1037/ort0000001

Examining Cumulative Victimization, Community Violence Exposure, and Stigma as Contributors to PTSD Symptoms Among High-Risk Young Women Angie C. Kennedy and Deborah Bybee

Megan R. Greeson

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Michigan State University

DePaul University

This study examines patterns of lifetime victimization within the family, community violence exposure, and stigma as contributors to posttraumatic stress disorder (PTSD) symptoms within a sample of 198 high-risk young women who are pregnant or parenting. We used cluster analysis to identify 5 profiles of cumulative victimization, based on participants’ levels of witnessing intimate partner violence (IPV), physical abuse by an adult caregiver, and sexual victimization, all beginning by age 12. Hierarchical regression was used to examine these 5 clusters (ranging from a High All Victimization cluster characterized by high levels of all 3 forms of violence, to a Low All Victimization cluster characterized by low levels of all 3 forms), along with community violence exposure and stigma, as predictors of PTSD symptoms. We found that 3 of the cumulative victimization clusters, in comparison with Low All Victimization, were significant predictors of PTSD symptoms, as was stigma, while community violence exposure was not a significant predictor.

PTSD symptoms within a diverse community sample of poor young women who are pregnant or parenting. Cumulative disadvantage theory suggests that early adversities will tend to compound over time, with one form of disadvantage associated with heightened vulnerability to other forms in a process that has been referred to as stress proliferation or stress sensitization (Nurius et al., 2013; Pearlin, Schieman, Fazio, & Meersman, 2005; Thoits, 2010). In particular, researchers have highlighted the importance of allostatic load, understood as the strain imposed on an individual’s physiological systems when adjustment is repeatedly demanded by early exposure to adversity and stress; a dysregulated stress response system can result, which in turn has been linked to PTSD (Evans & Kim, 2007; Nurius et al., 2013). Thus, early exposure to adversities during childhood such as poverty and victimization appears to work in tandem with other potentially traumatic events (PTEs) in influencing rates of PTSD for adolescents and young adults (Lloyd & Turner, 2003; Milan, Zona, Acker, & Turcios-Cotto, 2013). Among those who have experienced PTEs, there is evidence that girls and young women are at higher risk of developing PTSD than males (Cisler et al., 2012; Kilpatrick, Ruggiero, Acierno, Saunders, Resnick, & Best, 2003; Koenen & Widom, 2009; Lloyd & Turner, 2003), while Black youths may be at reduced risk in comparison with their peers (Milan et al., 2013; Thoits, 2010). For many young people, particularly those who are low-income and living in urban communities, exposure to violence within their families and communities is oftentimes co-occurring and chronic, and plays a key role in their experience of adversity and stress (Zinzow et al., 2009; Zona & Milan, 2011). Although female and male adolescents report similar rates of witnessing intimate partner violence (IPV) and physical abuse by a caregiver, young men tend

Young women who become pregnant during adolescence are disproportionately likely to be poor (Child Trends, 2013). Researchers have found that living in poverty as a child or adolescent is positively associated with multiple stressors, including family turmoil (Evans & Kim, 2007). Indeed, low socioeconomic status (SES) is linked to higher rates of exposure to individual forms of violence among adolescents including witnessing violence and experiencing victimization, both at home and in the community (Crouch, Hanson, Saunders, Kilpatrick, & Resnick, 2000; Mrug, Loosier, & Windle, 2008), as well as cumulative victimization across multiple types and contexts (Finkelhor, Ormrod, & Turner, 2007). In addition, adolescent mothers may face stigma for being poor, non-White, unmarried and parenting, homeless, and/or a sexual assault survivor (Broussard, Joseph, & Thompson, 2012; Gibson & Leitenberg, 2001; Gray & Montgomery, 2012; Prettyman, 2005; Rayburn & Guittar, 2013). As experiences with poverty, cumulative violence exposure, and stigma accumulate, they can lead to both physical and mental health issues, such as posttraumatic stress disorder (PTSD; Lloyd & Turner, 2003; Nurius, Uehara, & Zatzick, 2013; Thoits, 2010). The focus of the current study is to examine how patterns of lifetime family victimization, along with community violence exposure and stigma, contribute to

Angie C. Kennedy, Michigan State University, School of Social Work; Deborah Bybee, Department of Psychology, Michigan State University; Megan R. Greeson, Department of Psychology, DePaul University. Correspondence concerning this article should be addressed to Angie C. Kennedy, Michigan State University, School of Social Work, Baker Hall, 655 Auditorium Road, East Lansing, MI 48824. E-mail: kenne258@ msu.edu 284

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CUMULATIVE VICTIMIZATION, CV, STIGMA, AND PTSD

to report higher rates of community violence exposure, with sexual victimization rates higher among young women (Kennedy, 2008; Mrug, Loosier, & Windle, 2008; Turner, Finkelhor, & Ormrod, 2006). Particularly within high-risk groups such as adolescent mothers, who are disproportionately likely to be poor, Black or Latina, and to have experienced homelessness (Child Trends, 2013; Kennedy, 2007), violence exposure appears to be quite high. Roughly 9 out of 10 report community violence exposure, 8 out of 10 have witnessed IPV, between one half and two thirds have been physically abused by a caregiver, and just under one half have experienced sexual victimization (Kennedy & Bennett, 2006; Lindhorst, Beadnell, Jackson, Fieland, & Lee, 2009; Noll, Shenk, & Putnam, 2009); given these high individual rates, cumulative exposure to multiple forms of victimization is the norm. Among all of the different types of adversity and PTEs, cumulative violence exposure—particularly involving physical victimization within the family as well as sexual victimization—is an especially strong predictor of adolescent women’s PTSD symptoms (Cisler et al., 2012; Copeland, Keeler, Angold, & Costello, 2007; Koenen & Widom, 2009; Milan et al., 2013; Walsh, Danielson, McCauley, Saunders, Kilpatrick, & Resnick, 2012). If cumulative physical and sexual victimization is particularly important in influencing PTSD among young women, what is the role of community violence exposure? Fowler and colleagues (2009) conducted a meta-analysis of the effects of youths’ hearing about, witnessing, and being victimized by community violence on their mental health symptoms, including PTSD. Key findings included significant, moderate effect sizes for all of the mental health outcomes, with the strongest effect for PTSD, particularly for the nonhigh-risk samples compared with the high-risk ones, and no significant differences in effects on PTSD across type of community violence exposure (e.g., witnessing vs. victimization). These findings suggest that community violence exposure is an important contributor to adolescents’ PTSD symptoms. However, the studies used in the meta-analysis did not appear to control for the effects of other forms of violence exposure and victimization: Because community violence exposure is likely to co-occur with family violence, particularly within high-risk samples (Kennedy, 2008; Zinzow et al., 2009), it is important to examine cumulative exposure to disentangle the effects of different types on mental health outcomes. Researchers doing just that have obtained mixed results: In two studies reporting on findings from nationally representative samples, community violence exposure was found to be a significant predictor of girls’ PTSD symptoms, after controlling for family violence and sexual victimization in one study, and witnessing IPV in the second (McCart, Smith, Saunders, Kilpatrick, Resnick, & Ruggiero, 2007; Zinzow et al., 2009). On the other hand, two studies conducted with high-risk samples found that community violence exposure played a less important role in comparison with family violence and/or sexual victimization: Mrug and colleagues (2008), in their study of urban, predominately Black adolescents, reported that violence exposure at home was positively linked to the broadest range of mental health and behavioral outcomes, whereas neighborhood violence exposure was directly associated only with aggressive fantasies. Lipschitz and colleagues (2000) examined rates of PTSD among a sample of adolescent women (17% of whom were pregnant) attending an urban health clinic; they found that participants with PTSD had significantly higher

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rates of physical, sexual, and emotional abuse compared with participants without PTSD, with no significant differences in community violence exposure and/or victimization across PTSD status. Perhaps, in keeping with findings from Fowler and colleagues’ (2009) meta-analysis, exposure to community violence plays a less critical role in influencing mental health outcomes such as PTSD among members of high-risk groups—particularly young women—who are more likely to experience high rates of family violence and sexual victimization along with other forms of adversity. Stigma, first identified by Goffman (1963) and currently conceptualized as the co-occurrence of labeling, discrimination, stereotyping, separation, and status loss (Link & Phelan, 2001), can be understood as a chronic stressor and key contributor to cumulative adversity for those who are stigmatized by other, more powerful members of society. Experiencing stigma can be very demanding, as one attempts to cope with a devalued social identity and its attendant negative effects such as discrimination (Miller & Kaiser, 2001). These demands may engender shame as well as constant vigilance, as the environment is continually assessed for threats (Major & O’Brien, 2005; Scambler, 2009). As such, stigma is associated with poor mental health outcomes (Thoits, 2010), with discrimination based on race, ethnicity, and gender widely studied as a key factor. Pascoe and Richman, in their (Pascoe & Richman, 2009) meta-analysis, found that perceived discrimination and mental health outcomes were significantly associated, after controlling for multiple covariates. For adolescents or young adults who have experienced victimization, stigma, or perceived discrimination has been found to predict PTSD symptoms, after controlling for victimization (Ellis, MacDonald, Lincoln, & Cabral, 2008; Seng, Lopez, Sperlich, Hamama, & Meldrum, 2012), and to exacerbate the effects of childhood maltreatment on PTSD symptoms (Gray & Montgomery, 2012). Guided by cumulative disadvantage and stress sensitization theory, which emphasize the importance of examining early exposure to violence and other forms of adversity as the key to understanding mental health problems (Nurius et al., 2013; Pearlin et al., 2005; Thoits, 2010), the current study seeks to add to the empirical literature on cumulative victimization and mental health by examining patterns of physical and sexual victimization that began in childhood, community violence exposure, stigma, and PTSD symptoms within a community sample of poor young women who are pregnant or parenting. The predominant approach to research on cumulative victimization among youths is an additive one, in which types of violence exposure are dichotomized and added together, with a higher summed score associated with poorer outcomes (e.g., Cisler et al., 2012; Finkelhor et al., 2007; Mrug et al., 2008; Seng et al., 2012). Although this approach has been useful in demonstrating a link between the accumulation of victimization experiences and poor outcomes, it cannot tell us anything about which individual types, or which patterns of cumulative exposure, are particularly important. To address these issues, we used cluster analysis to identify patterns of lifetime victimization that began in childhood (i.e., by age 12), including witnessing IPV, physical abuse by a caregiver, and sexual victimization. We examined these clusters, in conjunction with community violence exposure and stigma, as predictors of PTSD symptoms. We chose to restrict the clustering variables to family violence and sexual victimization because these forms of victimization have been found to be particularly important in predicting PTSD within

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samples of young women (Cisler et al., 2012; Copeland et al., 2007; Koenen & Widom, 2009; Milan et al., 2013; Walsh et al., 2012); age 12 was used as the cut-off because childhood is widely recognized as ending at approximately age 12, with the onset of adolescence (Huberman, 2002). The current study builds on earlier work in which we identified cluster profiles of cumulative victimization within samples of high-risk adolescent and young women (Kennedy, Bybee, & Greeson, in press; Kennedy, Bybee, Kulkarni, & Archer, 2012). In the first study, we examined cumulative victimization clusters as predictors of IPV victimization (i.e., dating violence) and sex trade exposure within a sample of 180 Black female high school students living in a poor urban community. We found that the cluster profile of high witnessing IPV, high physical abuse by a caregiver, and high sexual victimization was associated with the highest rate of IPV victimization and sex trade exposure (Kennedy et al., 2012). In the second study, we examined the relationships between lifetime victimization clusters and depression symptoms, mediated by IPV victimization and homelessness, within a sample of 206 pregnant and parenting young women. Using the same sample and cumulative victimization clusters as the current study, we found that a significant portion of the effect of cumulative childhood victimization on depression was explained by the mediators (Kennedy et al., in press). Our current focus on cumulative victimization, community violence exposure, and stigma as predictors of PTSD symptoms is the first study, to our knowledge, to examine these types of violence exposure in this way, and in combination with stigma. As such, the study makes a unique contribution to the empirical literatures on cumulative or co-occurring victimization, family violence, sexual victimization, community violence, and stigma as predictors of PTSD symptoms, and adds to the growing body of research that is grounded in cumulative adversity and stress sensitization theory. We addressed the following research questions: What is the relationship between patterns of lifetime cumulative victimization that began in childhood and PTSD symptoms within a sample of high-risk adolescent women? After controlling for these profiles of cumulative victimization, what role do community violence exposure and stigma play in explaining PTSD symptoms?

Method Research Design and Participants The study was a cross-sectional survey in which 198 participants completed a self-administered questionnaire on violence exposure and victimization within their family and community, perceived stigma, mental health symptoms, and demographic variables. We recruited participants who were between the ages of 16 and 21, and who were pregnant or had birthed a child, from three urban sites in Michigan: a county health department prenatal clinic that serves low-income women (70%), a hospital prenatal clinic that serves low-income women (17%), and a home-visiting program for adolescent mothers (13%). We chose to focus on young women who were pregnant and parenting, rather than both male and female participants, because young women are especially likely to experience a high rate of co-occurring victimization that includes sexual violence (Finkelhor et al., 2007), we wanted to build on our earlier cluster analysis with young women, and

because adolescent mothers are particularly vulnerable to exposure to cumulative violence exposure as well as stigma (Kennedy & Bennett, 2006; Prettyman, 2005). Flyers advertising the study were distributed at the first two sites, while the home visitors distributed the flyers at the third site. At both prenatal clinics, participants completed the consent process and questionnaire in private at the clinic; at the home-visiting program, participants completed the consent process and questionnaire in their homes. Participants were compensated $25 each; the university Institutional Review Board approved the study. Participants were just over 19 years old (M ⫽ 19.3 years, SD ⫽ 1.4) and poor: Approximately 9 out of 10 reported receiving some sort of means-tested public assistance (i.e., TANF, Medicaid, food stamps, or WIC) within the last year. Half (50%) of the participants were Black, with 29% White, 15% biracial or mixed ethnicity, and 6% Latina. Roughly three quarters were currently pregnant (72%), with over half of the sample (55%) reporting that they had at least one child (M age at first pregnancy ⫽ 17.4 years, SD ⫽ 1.7, range of 13 to 21 years old). Approximately 4 out of 10 (41%) reported a history of at least one night of homelessness in their lifetime, with 40% of the sample currently living with family members, 34% with a male partner, 22% living independently, and 5% currently homeless.

Measures Lifetime witnessing IPV that began by age 12. Lifetime witnessing physical violence between adults within the family, with onset by age 12, was assessed using the physical assault subscale of the Revised Conflict Tactics Scale (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996). There are 12 items in the subscale ranging from less severe (e.g., “I have seen or heard adults in my family getting pushed or shoved”) to more severe (e.g., “I have seen or heard adults in my family getting a gun or knife used on them”). Participants were asked if they had seen each of the 12 types of violence, with no coded 0, yes coded 1; a total score was created by summing the 12 items. If participants endorsed at least one type, they were asked how old they were when they first witnessed violence; only witnessing that began before age 13 was included. Retrospective reporting of experiences with violence and victimization has been demonstrated to be accurate; that is, positive reports are likely to be correct (Hardt & Rutter, 2004, p. 270). The CTS physical assault subscale has been widely used to assess youths’ witnessing IPV (e.g., Graham-Bermann, Gruber, Howell, & Girz, 2009; Hungerford, Ogle, & Clements, 2010). This variable was used in the cluster profiles; Cronbach’s ␣ ⫽ .93. Lifetime physical abuse by a caregiver that began by age 12. Lifetime experiencing physical abuse by a parent or adult caregiver, with onset by age 12, was assessed using the CTS2 physical assault subscale described above (Straus et al., 1996). Participants were asked if they had experienced each of the 12 types (e.g., “An adult whom I live with has beaten me up”), with no coded 0, yes coded 1; a total score was created by summing the 12 items. If participants endorsed at least one type of abuse, they were asked how old they were when it first occurred; only abuse by a caregiver that began by age 12 was included. The

CUMULATIVE VICTIMIZATION, CV, STIGMA, AND PTSD

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CTS physical assault subscale has been widely used or adapted to assess youths’ abuse by a caregiver or parent (e.g., Dube et al., 2003; Kennedy & Bennett, 2006). This variable was used in the cluster profiles; ␣ ⫽ .92. Lifetime sexual victimization that began by age 12. Lifetime sexual victimization with onset by age 12 was assessed using an adapted version of Russell’s (1983) interview for child sexual abuse. The original interview consists of 20 yes or no questions that measure different forms of unwanted, contact sexual abuse before age 18; it has been widely used with adolescents, including youths of color (e.g., Auslander, McMillen, Elze, Thompson, Johnson-Reid, & Stiffman, 2002). For the current study, we used four items that assessed for contact sexual victimization, including two that asked about touching (e.g., “Someone has made me touch their breasts/chest or genitals, or touch mine, when I did not want to”), one that assessed for attempted rape (“Someone has attempted to have sex with me [includes oral sex] when I didn’t want to”), and one that asked about rape (“I have had sex with someone [includes oral sex] when I didn’t want to, or because I was forced to”). Participants were asked if they had experienced each item, with no coded 0, yes coded 1; if participants endorsed at least one form of sexual victimization, they were asked how old they were when it first occurred. Only sexual victimization that began by age 12 was included; ␣ ⫽ .85. To better capture the level of severity of sexual victimization experienced beginning by age 12, we created a most severe sexual victimization variable, with touching as most severe coded as 1 (experienced by 2.5% of the participants), attempted rape as most severe coded as 2 (experienced by 11.6%), and rape as most severe coded as 3 (experienced by 7.6%); this variable was used in the cluster profiles. Lifetime community violence exposure. Exposure to community violence, including witnessing and victimization, was assessed using a modified version of the Richters and Martinez (1990) Things I Have Seen and Heard scale. This scale includes 20 items that assess both community and family violence exposure; for the current study, we used eight of the items that measured community violence exposure. These items ranged from less severe witnessing (e.g., “In the neighborhoods where I have lived, I have seen somebody get beaten up”) to more severe victimization in the community (e.g., “In the neighborhoods where I have lived, I have been threatened by a gun”). We added four items that assessed witnessing or being robbed, and having a knife or gun used on oneself, all in the community. Participants were asked if they had experienced any of the 12 items within their lifetimes, with no coded 0, yes coded 1; a total score was created by summing all of the items. This scale has been widely used and adapted to assess for youths’ experiences with violence in their community (Thompson et al., 2007); for the current study, ␣ ⫽ .82. Stigma. Participants’ experiences with perceived stigma and discrimination were assessed using a modified version of Harvey’s (2001) Stigmatization Scale. The short form of the scale has 10 items: Six prostigma items (e.g., “I feel that society views me as inferior”) and four antistigma ones (e.g., “I feel that I am not deprived of opportunities that are generally available to the main-

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stream”). For the current study, we used the six prostigma items because the data indicated participants found the wording of the other four items confusing. Responses were dichotomized, with no coded 0, yes coded 1; we created a total score by summing the six items, with higher scores indicating higher perceived stigma. The scale has demonstrated good construct, convergent, and discriminant validity, with Black and Native American participants scoring significantly higher than White participants (Harvey, 2001); for the modified 6-item scale used in the current study, ␣ ⫽ .72. PTSD symptoms. Participants’ lifetime PTSD symptoms were assessed using Brewin and colleagues’ (2002) Trauma Screening Questionnaire (TSQ). The TSQ is a brief version of Foa’s PTSD Symptom Scale-Self Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993): It uses five re-experiencing (e.g., “At some point in my life, for at least 1 month at a time, I have experienced intrusive thoughts [thoughts that popped into my head when I didn’t want them to]”) and five hyperarousal items (e.g., “At some point in my life, for at least 1 month at a time, I have experienced difficulty concentrating”) from the PSS-SR, and offers dichotomized response options. Participants were asked if they had experienced any of the 10 items at some point in their lives, for at least 1 month at a time, with no coded 0, yes coded 1; a total score was created by summing all of the items. The TSQ has demonstrated high levels of sensitivity and specificity in diagnosing PTSD symptoms, in comparison with other PTSD screening instruments with complete coverage of all diagnostic categories of PTSD, and compared with a diagnostic PTSD interview. The authors recommend a clinical cut-off of endorsement of six or more items in any combination (Brewin, 2005; Brewin et al., 2002). Researchers examining lifetime cumulative physical and sexual victimization have likewise measured PTSD symptoms over time, rather than focusing on a discrete event followed by an acute time period during which PTSD symptoms are experienced (e.g., Cloitre et al., 2009; Walsh et al., 2012). Given that the current study examines lifetime cumulative victimization, violence exposure, and stigma, we took the same approach to measuring PTSD symptoms. The TSQ has been widely used with youths, including high-risk young women who have experienced victimization and homelessness (e.g., Charuvastra, Goldfarb, Petkova, & Cloitre, 2010; Saewyc & Edinburgh, 2010); in the current study, ␣ ⫽ .82. Race or ethnicity and homelessness. These variables were assessed as part of the demographic profile, and are used in the current study as controls in the regression model. Participants were asked to identify their racial or ethnic group membership (e.g., Black, White, biracial, or mixed ethnicity), with White participants coded 0, participants of color coded 1. Participants were asked if they had ever experienced or were currently experiencing homelessness, defined as spending the night sleeping or staying in a place that is not meant to be a home (e.g., an abandoned building or park or car) or staying with someone on their couch or floor, because they had nowhere else to go, with no coded 0, yes coded 1 for both past and current homelessness. Operationalizing homelessness this way reflects the definition used by Ringwalt and colleagues (1998) in their national study of adolescent homelessness. Because participants who were currently homeless (5% of the sample) reported similar levels of victimiza-

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tion, community violence exposure, stigma, and PTSD symptoms as those who had experienced homelessness in the past, the categories were combined into a history of homelessness variable for the analyses.

predictors (e.g., Gray & Montgomery, 2012; Mrug et al., 2008), we included interaction terms such as community violence exposure ⫻ cumulative victimization clusters; none of these interactions was significant, so they were dropped from the model.

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Analytic Strategy

Results

Before cluster analysis, we standardized the variables we used to identify the clusters to minimize differential weighting because of different scales. We used a two-stage approach to group cases into clusters, using the 198 cases with complete data on the three cluster-defining variables (witnessing IPV, physical abuse by a caregiver, and sexual victimization, all beginning by age 12). We used Ward’s method of hierarchical agglomerative cluster analysis on squared euclidean distances; by inspecting the sequential changes in the fusion coefficients, we derived a five-cluster solution. Next, starting with the centroids from this initial cluster solution, we used K-means cluster analysis to assign cases to the nearest cluster, resulting in the smallest possible within-cluster variances. To examine the relationships between cumulative victimization clusters and PTSD symptoms, and determine to what extent community violence exposure and stigma contributed to those symptoms after controlling for the cumulative victimization clusters, we used hierarchical regression. We dummy coded the cumulative victimization clusters; the Low All Victimization cluster (low exposure to the three types of victimization beginning by age 12) was the reference category. Because history of homelessness was positively associated with each type of victimization, community violence exposure, stigma, and PTSD symptoms, it was controlled for in the regression model; likewise, race or ethnicity was associated with community violence exposure and stigma (i.e., participants of color reported higher rates of both) and was also entered as a control variable. To examine the extent of PTSD symptoms variance explained by each predictor or set of predictors, we entered the predictors in blocks and assessed for change in R2. In the first model, we entered history of homelessness and race or ethnicity as controls; in the second model, we added the four cumulative victimization cluster variables (other than Low All Victimization) as predictors; in the third, we added community violence exposure; finally, in the fourth model, we added stigma as a predictor. To examine possible moderation effects among the

Descriptives and Bivariate Correlations A majority of participants reported witnessing IPV (72.2%) and being physically abused by an adult caregiver (58.1%), with approximately one in five (21.7%) reporting sexual victimization, all beginning by age 12. Most participants (86.9%) had experienced community violence; two thirds of the participants reported stigma (66.8%). In terms of co-occurrence, over one half (⬃56%) of the sample reported at least two types of victimization beginning during childhood, with 16% of the sample reporting experiences with witnessing IPV, physical abuse by an adult caregiver, and sexual victimization, all with onset by age 12. When we include exposure to community violence, over three quarters of the sample (77.7%) reported exposure to three or more types of violence. The average level of lifetime PTSD symptoms was 4.13 (SD ⫽ 2.89), with just over one third of the participants (34.3%) endorsing six or more symptoms and thus, meeting the threshold for PTSD. The cumulative victimization variables were all positively associated with one another, with community violence exposure, and with PTSD symptoms (rs ranging from .20 to .59, all significant at p ⬍ .05). Stigma was positively associated with race or ethnicity (i.e., participants of color reported higher levels of stigma than White participants) as well as all of the other variables except physical abuse by a caregiver (rs ranging from .15 to .43, all significant at p ⬍ .05). See Table 1 for descriptives and bivariate correlations among the primary variables.

Cumulative Lifetime Victimization Clusters Twenty-three participants (11.6% of the total sample) made up the first cluster, characterized by high exposure to all three forms of victimization beginning by age 12 (high witnessing IPV, medium-high physical abuse by a caregiver, and high sexual

Table 1. Descriptives and Intercorrelations Among Primary Variables Variable

Mean

SD

HxHmlss

Raceth

WIPV

PAC

SxVict

CV

Stigma

HxHmlss Raceth WIPV PAC SxVict CV Stigma PTSD

.41 .71 5.10 2.95 .48 3.91 1.73 4.13

.49 .45 4.15 3.59 .96 2.75 1.72 2.89

1.00 .02 .18ⴱ .18ⴱ .27ⴱⴱⴱ .17ⴱ .15ⴱ .37ⴱⴱⴱ

1.00 .09 ⫺.01 .05 .14ⴱ .20ⴱⴱ ⫺.06

1.00 .59ⴱⴱⴱ .20ⴱⴱ .53ⴱⴱⴱ .21ⴱⴱ .33ⴱⴱⴱ

1.00 .26ⴱⴱⴱ .49ⴱⴱⴱ .13 .35ⴱⴱ

1.00 .21ⴱⴱ .17ⴱⴱ .32ⴱⴱⴱ

1.00 .21ⴱⴱ .27ⴱⴱⴱ

1.00 .43ⴱⴱⴱ

Note. HxHmlss ⫽ history of homelessness; Raceth ⫽ race/ethnicity, with participants of color (Black, biracial, Latina, Native American, Asian American) coded 1, White participants coded 0; WIPV ⫽ witnessing intimate partner violence; PAC ⫽ physical abuse by a caregiver; SxVict ⫽ sexual victimization; CV ⫽ community violence exposure. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

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CUMULATIVE VICTIMIZATION, CV, STIGMA, AND PTSD

victimization); this cluster was the High All Victimization cluster. The second cluster was comprised of 31 young women (15.7% of the sample) with high levels of both forms of family violence (witnessing IPV and physical abuse by a caregiver) and very low sexual victimization; this was the High Family Violence cluster. The third cluster was made up of 47 participants (23.7% of the sample) with high witnessing IPV, low physical abuse by a caregiver, and almost no sexual victimization; this was the High Witnessing IPV cluster. The fourth cluster was comprised of 15 participants (7.6% of the sample) with high sexual victimization, medium witnessing IPV, and low physical abuse by a caregiver; this was the High Sexual Victimization cluster. Eighty-two participants (41.4% of the sample) made up the fifth cluster, characterized by low levels of witnessing IPV and physical abuse by a caregiver, and no sexual victimization; this cluster was termed Low All Victimization.

PTSD Symptoms on Cumulative Victimization Clusters, Community Violence Exposure, and Stigma, Controlling for History of Homelessness and Race or Ethnicity In Model 1, history of homelessness is a significant predictor, with participants with any lifetime experience of homelessness reporting PTSD symptoms that are 2.09 points higher than those participants with no prior experiences with homelessness (see Table 2). This block explains 13% of the variance in PTSD symptoms: F(2, 186) ⫽ 13.70, p ⫽ .000. In Model 2, after controlling for history of homelessness and race or ethnicity, each of the cumulative victimization clusters is a significant predictor, in comparison with the Low All Victimization cluster: The High All Victimization cluster is associated with a 2.89 increase in PTSD symptoms (␤ ⫽ .32, p ⫽ .000), the High

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Family Violence cluster with a 2.43 increase (␤ ⫽ .32, p ⫽ .000), the High Sexual Victimization cluster with a 2.91 increase (␤ ⫽ .28, p ⫽ .000), and the High Witnessing IPV cluster a 1.20 increase in symptoms (␤ ⫽ .18, p ⫽ .011). This block explains an additional 15% of the variance in PTSD symptoms: F(6, 186) ⫽ 11.87, p ⫽ .000. In Model 3, after controlling for history of homelessness, race or ethnicity, and the cumulative victimization clusters, community violence exposure is not a significant predictor of PTSD symptoms, nor does it explain any additional variance in PTSD symptoms (⌬ in R2 ⫽ .00; R2 ⫽ .28). History of homelessness remains a significant predictor, as do each of the cumulative victimization clusters, in comparison with the Low All Victimization cluster: F(7, 186) ⫽ 10.13, p ⫽ .000. The final model explains an additional 10% of the variance in PTSD symptoms (⌬ in R2 ⫽ .10; R2 ⫽ .38), with the addition of stigma: F(8, 186) ⫽ 13.71, p ⫽ .000. Those participants with a history of homelessness report symptoms that are 1.30 points higher than those with no history (␤ ⫽ .22, p ⫽ .000), and three of the cumulative victimization clusters are significant predictors, compared with the Low All Victimization cluster: The High All Victimization cluster is associated with a 2.26 increase in PTSD symptoms (␤ ⫽ .25, p ⫽ .001), the High Family Violence cluster a 1.98 increase (␤ ⫽ .26, p ⫽ .001), and the High Sexual Victimization cluster is associated with a 2.29 increase (␤ ⫽ .22, p ⫽ .001). The High Witnessing IPV cluster is no longer a significant predictor of PTSD symptoms in comparison with Low All Victimization (␤ ⫽ .13, p ⫽ .064), nor is community violence exposure associated with symptoms (␤ ⫽ ⫺.00, p ⫽ .978). Stigma is a significant predictor, with each increase in stigma associated with a .55 increase in PTSD symptoms (␤ ⫽ .33, p ⫽ .000). With the effects of stigma taken into account in the model, race or ethnicity is now a significant predictor: Participants of color report rates of

Table 2. PTSD Symptoms on Cumulative Victimization Clusters, Community Violence, and Stigma, Controlling for History of Homelessness and Race/Ethnicity Model 1 Variable HxHmlss Raceth HiAlla HiFVa HiSVa HiWIPVa CV Stigma R2 ⌬ in R2 F(df, N) Sig. of ⌬ in F Constant

B (SE) ⴱⴱⴱ

2.09 (.40) ⫺.33 (.44)

.13 .13 13.70ⴱⴱⴱ (2, 186) .000 3.60

Model 2 ␤ .36 ⫺.05

B (SE) ⴱⴱⴱ

1.42 (.39) ⫺.48 (.40) 2.89ⴱⴱⴱ (.63) 2.43ⴱⴱⴱ (.54) 2.91ⴱⴱⴱ (.71) 1.20ⴱ (.47)

.28 .15 11.87ⴱⴱⴱ (6, 186) .000 2.71

Model 3 ␤ .24 ⫺.08 .32 .32 .28 .18

B (SE) ⴱⴱⴱ

1.41 (.39) ⫺.49 (.41) 2.81ⴱⴱⴱ (.70) 2.36ⴱⴱⴱ (.61) 2.90ⴱⴱⴱ (.72) 1.15ⴱ (.50) .02 (.08) .28 .00 10.13ⴱⴱⴱ (7, 186) .797 2.68

Model 4 ␤ .24 ⫺.08 .31 .31 .28 .17 .02

B (SE) ⴱⴱⴱ

1.30 (.36) ⫺.86ⴱ (.38) 2.26ⴱⴱ (.66) 1.98ⴱⴱ (.57) 2.29ⴱⴱ (.68) .88 (.47) ⫺.00 (.08) .55ⴱⴱⴱ (.10) .38 .10 13.71ⴱⴱⴱ (8, 186) .000 2.36

␤ .22 ⫺.14 .25 .26 .22 .13 ⫺.00 .33

Note. HxHmlss ⫽ history of homelessness; Raceth ⫽ race/ethnicity, with participants of color (Black, Biracial/mixed ethnicity, Latina, Native American, Asian American) coded 1, White participants coded 0; HiAll ⫽ cluster with high all forms of victimization; HiFV ⫽ cluster with high witnessing IPV and physical abuse by a caregiver; HiSV ⫽ cluster with high sexual victimization; HiWIPV ⫽ cluster with high witnessing IPV; CV ⫽ community violence exposure. a LoAll cluster is the reference category. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

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PTSD symptoms that are .86 points lower than White participants (␤ ⫽ ⫺.14, p ⫽ .027).

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Discussion The participants in the current study— overwhelmingly poor and predominately young women of color living in urban settings— have experienced much higher rates of physical and sexual victimization, and community violence exposure, than those reported in the two National Surveys of Adolescents (NSA and NSA-R). These high rates of co-occurring exposure to individual forms of violence within the current study sample necessarily translate into high rates of cumulative exposure: Over one half of the sample reports at least two types of victimization beginning during childhood, with 16% of the sample reporting experiences with witnessing IPV, physical abuse by an adult caregiver, and sexual victimization, all beginning by the age of 12. Certainly, their low SES is significant in influencing these very high rates of cumulative violence exposure (Finkelhor, Ormrod, & Turner, 2007); together, poverty, victimization, and violence exposure contribute greatly to the adversity they have experienced, and may play a role in heightening their vulnerability to later stressors as they enter young adulthood, as stress sensitization models would suggest (Nurius et al., 2013; Pearlin et al., 2005). In our current study, we were interested in going beyond simply counting up multiple forms of victimization, instead utilizing a cluster analysis approach. By identifying five cluster profiles of cumulative victimization that began during childhood, we were able to examine patterns of different levels of victimization, and how these patterns influence PTSD symptoms. We found heterogeneity within the sample in terms of cumulative lifetime victimization beginning by age 12, with some participants, for example, reporting very high rates of exposure to all three forms (the High All Victimization cluster, roughly 12% of the sample), some reporting high levels of witnessing IPV, very high levels of physical abuse by a caregiver, and almost no sexual victimization (the High Family Violence cluster, ⬃16% of the sample), and the largest group (roughly 41% of the sample) reporting very low levels of both witnessing IPV and physical abuse by a caregiver, coupled with no sexual victimization (the Low All Victimization cluster, which was used as the reference category in the regression analysis). These patterns parallel the clusters we identified in our earlier study with Black female high school students (Kennedy et al., 2012), which included a High All Victimization cluster (14% of participants), a High Family Violence cluster characterized by high family violence but low sexual victimization (22%), and a Low All Victimization cluster (41%). The patterns we found in the current study reflect, in part, the high rates of individual forms of physical victimization. For example, three out of the five clusters are characterized by high levels of witnessing IPV. In a sample with a much lower overall rate of witnessing IPV, we would not expect to find this. Instead, we might identify two clusters: one characterized by victimization experiences, and one by no exposure. By examining these different patterns and their relation to PTSD symptoms, we can begin to gain an understanding about which types of victimization in which combinations and at what levels are especially important in influencing mental health outcomes among high-risk young people. Given the extent of the cumulative victimization and low SES within the current sample, it is not surprising that just over one third (34.3%) scored in the clinical range for lifetime PTSD. This

seems somewhat high compared with the 4 –13% current PTSD rate found within two samples of high-risk urban adolescent girls (Lipschitz et al., 2000; Milan et al., 2013), but more in keeping with the 42– 45% lifetime PTSD rate within a sample of adult women who had experienced substantiated maltreatment as children as well as cumulative traumas as adults, as reported by Koenen and Widom (2009). Overall, the young women in our study report a high rate of PTSD symptoms, with these linked to specific patterns of cumulative victimization beginning by age 12: We found that the High All Victimization, High Family Violence, and High Sexual Victimization (high rates of sexual victimization, medium levels of witnessing IPV, and low physical abuse by a caregiver) clusters were similarly important as individual predictors of PTSD symptoms in the final regression model, in comparison with the Low All Victimization cluster. More specifically, PTSD symptoms were best explained by the three cluster profiles that were characterized by either high levels of cumulative physical and sexual victimization, or high levels of either form of victimization in combination with moderate to high levels of witnessing IPV, lending support to theories of cumulative disadvantage and stress proliferation that emphasize the role of cumulative victimization early in life as a key factor in mental health outcomes. As other researchers have found, experiencing high levels of co-occurring forms of victimization is associated with an elevated risk of developing serious mental health problems such as PTSD, especially among young women (Copeland et al., 2007; Koenen & Widom, 2009; Walsh et al., 2012). Cumulative victimization experiences within the family that begin during childhood, in the context of poverty, may be particularly pernicious because of the physiological effects on the developing nervous system via stress dysregulation and sensitization, which have both been associated with long-term negative effects on physical and mental health over the life course (Evans & Kim, 2007; Nurius et al., 2013). In contrast to the three cluster profiles just discussed, the High Witnessing IPV cluster (roughly 24% of the sample, characterized by high levels of witnessing IPV, low physical abuse by a caregiver, and very low sexual victimization) did not significantly differ from the Low All Victimization cluster in explaining variance in PTSD symptoms. In this very high-risk, all-female sample, high levels of witnessing IPV, without concomitant high levels of either physical or sexual victimization, do not appear to be associated with heightened vulnerability to PTSD. Witnessing IPV has been associated with significant negative effects on youths’ internalizing symptoms and PTSD, particularly when youths reported being afraid they would be injured (Wolfe, Crooks, Lee, McIntyre-Smith, & Jaffe, 2003; Zinzow et al., 2009), but these studies did not examine girls’ effects separately while controlling for victimization— especially sexual victimization, which has been shown to be particularly salient to girls and young women in influencing their PTSD symptoms (Hanson et al., 2008; Koenen & Widom, 2009; Walsh et al., 2012). In the current study, perhaps high levels of physical and sexual victimization in tandem, as well as high victimization in combination with witnessing IPV, were subjectively experienced by participants as particularly threatening and harmful and, thus, tied to the PTSD symptoms of re-experiencing and hyperarousal assessed in the current study, whereas witnessing IPV alone was not (McGee, Wolfe, & Wilson, 1997). In a similar vein, participants’ community violence exposure contributed nothing to their PTSD symptoms, after controlling for

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CUMULATIVE VICTIMIZATION, CV, STIGMA, AND PTSD

the cumulative victimization clusters. While Fowler and colleagues’ (2009) meta-analysis of the effects of community violence on mental health outcomes found significant, moderate effects on PTSD for youths’ hearing about, witnessing, and being victimized by community violence, they also found that the effects on PTSD were weakest within high-risk samples versus low-risk ones. The current study sample is certainly high-risk: It is plausible that, much like the diminished role for witnessing IPV alone in comparison with high levels of combined victimization along with witnessing, described earlier, community violence exposure is experienced as less explicitly threatening or fear-inducing. Researchers have discussed the effects of violence exposure in terms of proximity, conceptualized as related to severity level (e.g., victimization vs. hearing about), time (e.g., 10 years ago vs. last month), and level of intimacy and emotional engagement (e.g., witnessing a stranger get beaten up on the street vs. witnessing your mother get beaten up in your living room; Lynch & Cicchetti, 1998; Zinzow et al., 2009; Zona & Milan, 2011). Perhaps participants in the current study did not experience community violence as a proximal threat, given their much more intimate experiences with cumulative victimization within their families. These familybased maltreatment experiences may prompt feelings of constant threat, deprive youths of any sort of safe haven, and irreparably harm critical intimate relationships—and thus, contribute to mental health issues such as PTSD—in ways that community violence exposure do not, at least within this sample of high-risk young women (Mrug et al., 2008; Wekerle, Wolfe, Hawkins, Pittman, Glickman, & Lovald, 2001). While neither high levels of witnessing IPV alone nor community violence exposure were important predictors, stigma was significantly, positively associated with participants’ PTSD symptoms. Further, once the effects of stigma were accounted for in the model, participants of color had significantly lower levels of PTSD symptoms in comparison with White participants. To experience stigma means to be labeled, marginalized, and discriminated against by other, more powerful members of society (Link & Phelan, 2001); as such, it can be understood as a chronic stressor and key contributor to cumulative adversity among those who are stigmatized. The young women in the current study face stigma in relation to multiple social identities, including being poor, nonWhite, adolescent mothers, homeless (or previously homeless), and/or survivors of sexual victimization (Broussard, Joseph, & Thompson, 2012; Gibson & Leitenberg, 2001; Gray & Montgomery, 2012; Prettyman, 2005; Rayburn & Guittar, 2013). How might stigma in the context of poverty and cumulative victimization negatively influence youths’ mental health? Experiencing societal discrimination and prejudice based on race, for example, may add to the feelings of worthlessness and shame fostered by an abusive family context, and thus, predict PTSD symptoms (Bernard, 2002; Gray & Montgomery, 2012). Other researchers have emphasized how chronic stressors such as discrimination and marginalization can act as triggers or traumatic reminders for those who have experienced cumulative traumas as children; this repeated triggering is conceptualized as an impediment to their development of a cohesive sense of self and a key contributor to PTSD symptoms (Ellis et al., 2008). Additionally, the constant vigilance associated with being stigmatized, as the environment is continually assessed for threats (Major & O’Brien, 2005), may play a key role, given

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the prominence of the hyperarousal component of PTSD (Schell, Marshall, & Jaycox, 2004). Before turning to the research and practice implications of the current study, its limitations must be acknowledged. Because we used a nonprobability sample, the extent to which we can generalize the findings is unknown. Additionally, the cross-sectional design limits our ability to know with certainty how the primary variables are causally related: Although we assessed for the time of onset of the cumulative victimization variables used in the cluster profiles, we did not examine the timing of stigma, for example, and we used a lifetime measure of PTSD symptoms. Next, our study relied exclusively on participants’ self-report for all of the measures. A self-report approach has been shown to yield reliable, valid data (Caskey & Rosenthal, 2005; Durant & Carey, 2000), but the methods could have been strengthened by including other sources of data. In addition, we relied on participants’ memory of their experiences with victimization beginning during childhood; while a recent analysis of retrospective reporting of victimization indicated that positive reports of abuse are usually correct, retrospective reports are likely to be underestimates (i.e., false negatives occur; Hardt & Rutter, 2004). Our study is also limited by its exclusive focus on young women, given that young men typically experience similarly high rates of family violence, and higher rates of community violence exposure (Kennedy, 2008). Finally, several authors have argued persuasively that PTSD alone cannot possibly capture the complexity of the sequelae associated with youths’ experiences with cumulative trauma. Future studies should examine multiple developmentally appropriate outcomes, including PTSD as well as other issues that have been found to co-occur, such as affective dysregulation, poor executive functioning, and interpersonal problems (Cloitre et al., 2009; D’Andrea, Stolbach, Ford, Spinazzola, & van der Kolk, 2012). Despite these limitations, our study has several implications for research and practice. In terms of research, our findings highlight the merits of a cluster analysis approach to studying cumulative victimization versus one that relies on counting: By examining cluster profiles, we can begin to better understand patterns of multiple forms of victimization, uncover heterogeneity in terms of exposure within high-risk samples, and isolate which types of victimization at what levels appear to be especially important in predicting poor mental health outcomes. Future research with low-income girls and young women living in urban areas should focus on both assessing for multiple forms of victimization and disentangling the effects of various forms of victimization and violence exposure (e.g., high levels of co-occurring family-based victimization vs. community violence exposure) on outcomes. Finally, the role of perceived stigma and discrimination must be examined as a potential key contributor to poor mental health among poor adolescents of color, young women who are pregnant or parenting, and those who have experienced homelessness or sexual victimization. For practitioners working with adolescents and young adults, the role of cumulative victimization—particularly in concert with chronic sources of adversity such as poverty—in shaping PTSD symptoms cannot be underestimated. Practitioners should assess for multiple forms of victimization and violence exposure, as well as other forms of adversity including poverty and stigma, and be prepared to provide care such as trauma-focused cognitive– behavioral therapy (TF-CBT) or prolonged exposure, both of

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which have demonstrated effectiveness with adolescents and adults (Cohen, Mannarino, Berliner, & Deblinger, 2000; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010; Seidler & Wagner, 2006). For young women experiencing stigma and discrimination, an empowerment approach may be effective, as it facilitates selfefficacy, critical consciousness, and group solidarity, which in turn may help to buffer the effects of marginalization and promote collective activism (Gutiérrez & Lewis, 1999). It is crucial that cumulative victimization receives the attention it deserves from researchers and practitioners, so that we can begin to address it and reduce its pernicious effects on young people. Keywords: cumulative victimization; family violence; sexual abuse; community violence; stigma

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