J Immigrant Minority Health DOI 10.1007/s10903-015-0227-8
ORIGINAL PAPER
Family Violence and Child Sexual Abuse Among South Asians in the US Hillary A. Robertson1 • Nitasha Chaudhary Nagaraj2 • Amita N. Vyas2
Ó Springer Science+Business Media New York 2015
Abstract Family violence, including child sexual abuse (CSA), is a significant public health problem in the United States. It is particularly difficult to assess family violence and CSA among South Asians because it is often hidden due to cultural and familial stigma. A web-based survey was administered to a convenience sample (n = 368) of South Asian adults in the US. One-fourth (25.2 %) of the sample reported CSA; 13.8 % reported abuse involving exposure; 21.5 % reported abuse involving touching; 4.5 % reported attempted sexual intercourse; and 3.5 % reported forced sexual intercourse. Adjusted odds ratios found that participants who reported any relationship violence were significantly more likely to have experienced CSA (OR 2.28; 95 % CI 1.26–4.13); and suicide attempt was significantly associated with CSA (OR 3.96; 95 % CI 1.27–12.3). The findings presented in this formative study will assist in guiding future studies and interventions for South Asians in the United States. Keywords Child sexual abuse Family violence South Asian health Mental health
& Hillary A. Robertson [email protected] 1
College of Social Work, The Ohio State University, 1947 College Road, 325Q Stillman Hall, Columbus, OH 43210, USA
2
Department of Prevention and Community Health, The George Washington University, Washington, DC, USA
Introduction Family violence in South Asian countries has received increased media attention in the last few years [1, 2]. There are many reasons why family violence in particular merits focus. In contrast to other forms of violence (i.e. gang violence, violent crime, or war), family violence, which includes child maltreatment, domestic violence, and elder abuse, [3] presupposes a relationship between those involved [4]. There is much controversy in defining family violence and whether it should include physical and sexual violence, and while an exact definition of family violence is controversial, understanding the major components are central to understanding and quantifying the degree to which family violence occurs [4]. The present study focuses on several types of family violence including relationship violence, witnessing parental violence, and child sexual abuse (CSA), which may be experienced outside the family context. As more research is underway to better understand the complex factors surrounding family violence and CSA in South Asia, it is important to explore the extent to which violence extends beyond geographic boundaries and afflicts South Asian children and families living in the United States. First, the exposure to violence and CSA in one’s family of origin is alleged to increase the risk of perpetuating violence and CSA, and therefore immigrant families from high-prevalence countries may be at increased risk [5, 6]. Second, family violence and child abuse are of significant public health concern in the US. In 2013, the Administration on Children, Youth and Families reported that an estimated 679,000 children in the United States were victims of child maltreatment [7]. There are over 3.4 million South Asians living in the US, comprising of individuals with family origins from
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Afghanistan, Bangladesh, Bhutan, India, the Maldives, Pakistan and Sri Lanka [8]. Although the South Asian population in the US has increased significantly in the last several decades, there has been limited data and research on family violence in these immigrant communities and no published quantitative studies on CSA specifically. Several challenges to this type of research exist including the ‘‘healthy and wealthy/model minority stereotype’’ for this minority group [9]. The model minority stereotype posits that persons from South Asian countries are most often perceived to achieve higher degrees of income and education, and lower levels of crime rates and family instability. This ‘‘myth’’ has been a driving force behind the paucity of health-focused studies of South Asians in the US [9, 10]. Family violence and CSA are highly stigmatized issues and are often left undetected or unaddressed within families and communities [5, 6]. Therefore, it is more than plausible that family violence and CSA found within South Asian countries exists globally within South Asian families. Child abuse, both physical and sexual, has been linked to many psychological conditions [11]. The devastating effects of these experiences are typically seen well into adulthood. A study conducted by McCauley et al. [12] found that many of the associations between child abuse and physical symptoms, psychological problems, and substance abuse issues were as strong as the associations for patients experiencing current abuse. Further, in a study conducted by Sugaya et al. [13], other childhood adversities and psychiatric comorbidities, including suicide ideation and suicide attempt, were all independently and significantly associated with CSA. Dube et al. [14] found that witnessing maternal violence during childhood increased the likelihood of early initiation of illicit drug use by 1.6-fold. Adolescent exposure to parental intimate partner violence was found to be associated with anxiety, depression, and substance abuse [15]. Furthermore, family of origin violence, including CSA, has been found to predict both marital and dating violence [5, 6, 11, 16]. The consequences of family violence and CSA are devastating and there is clearly a need for increased efforts to prevent and mitigate these experiences among children living in the United States. Researchers have suggested that it is particularly difficult to determine the prevalence of family violence and CSA among South Asian communities due to pervasive cultural norms including patriarchal ideology and traditional family and gender norms [5, 6, 11, 16, 17]. Family violence is highly stigmatized amongst the South Asian population living in-country and abroad. The South Asian culture is a patriarchal social system that places girls and women in subordinate positions relative to men [5, 18]. Particular to sexuality, gendered roles in the South Asian
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context put girls and women at a much larger risk for violence and sexually-related diseases [19]. Specifically looking at CSA, a study conducted in Great Britain found that disclosure of CSA among South Asian women was often impeded by lack of basic knowledge of CSA; lack of awareness surrounding the existence of the CSA services; fear of public exposure due to disclosure of CSA; fear of culturally insensitive responses from professionals; and other cultural factors such as izzat [honor/respect], haya [modesty], and sharam [shame/embarrassment]) [19, 20]. Furthermore, previous research has found that the upbringing and personality of Asian Indians are partly shaped by the influence of extended adult family members, and they are expected to depend on their parents, grandparents, other siblings, and aunts and uncles throughout their lifespan [21]. This familial norm is often a significant barrier for disclosure of family violence and CSA within families [5, 6]. A history of CSA places an individual at increased risk of suicide in childhood, adolescence, and adulthood [22]. When compared with never-abused patients, childhoodonly abused patients were nearly four times more likely to report attempted suicide [12]. Although research linking CSA and subsequent suicide has not focused specifically on South Asians, studies have revealed high rates of attempted and successful suicide among South Asians across the world [23, 24]. A study conducted in the United Kingdom (UK) found that the rate of attempted suicide among South Asian women ages 18–24 was three times higher than the rate of attempted suicide among their white counterparts [25]. Intimate partner violence has been found to be associated with increased sexual health concerns, poor physical health, depression, anxiety, and suicidal ideation among South Asian women living in the US [26, 27]. Furthermore, a history of CSA is associated with an increased risk of intimate partner violence and adult sexual re-victimization [28, 29]. Raj et al. found a high prevalence of IPV (40.8 %) among immigrant South Asian women living in the US. Fergusson et al. found that adults who have experienced CSA have greater sexual vulnerability during adolescence and higher rates of sexual victimization after the age of 16 [26]. One landmark quantitative national study examined the prevalence of child abuse in India and found that about half of India’s children reported experiencing some form of CSA, and the majority never reported the abuse [30]. This 2007 study was conducted by India’s Ministry of Women and Child Development and also noted that CSA in India begins as early as 5 years and can include a myriad of sexual crimes. Twenty-two percent of respondents indicated severe (defined as sexual assault, fondling, exposure, or child pornography) sexual abuse and 69 % of all Indian
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children were found to be victims of physical, mental, or emotional abuse. Of the 12,447 children interviewed oneon-one, the study found that it was usually family members (89 %) who perpetrate such crimes [30]. Despite what is known in South Asian countries, there is virtually no research on this highly stigmatized, public health issue among the growing population of South Asians in the US. To that extent, a quantitative survey of South Asian adults living in the US was conducted to better understand the relationships between family violence, mental health, and CSA. The study was reviewed and approved by The George Washington University Institutional Review Board (IRB # 080920).
Methods Sample and Procedures This study recruited a convenience sample of 425 South Asians living in the United States. Eligibility criteria included English-proficient male and female adults 18 years of age and older who self-identify their origin as South Asian regardless of where they were born. Study participants were not remunerated for participation. The project team collaborated with 58 local and national South Asian organizations with social media and/or listserv capabilities. These organizations spanned a variety of domains including religious, cultural, professional associations, and non-profits. Between June and July 2013, organizations disseminated a web-based survey electronically to its members via email listservs and social media sites and did not provide the research team contact information for their individual members. Given the universe of email lists and databases, including overlap of individuals on multiple lists, a valid response rate could not be calculated. People of Indian decent represent the largest percent of the US. South Asian population, and therefore, the majority of organizations and listservs (approximately 80 %) focused on this subgroup [8]. Significant efforts were made to reach out to all non-Indian focused South Asian organizations for data collection. Instruments and Measures Data were collected via an 82-item quantitative survey. Questions were adapted from the Centers for Disease Control and Prevention (CDC) Adverse Childhood Experiences (ACE) Study [31] and additional questions were adapted from the Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on
Drug Use and Health [32], the Revised Conflict Tactics Scale [33], the Woman Abuse Screening Scale [34] and the CDC’s Behavioral Risk Factor Surveillance System [35]. The survey took approximately 10–15 min to complete and collected information on socio-demographics, suicide ideation and attempt, number of lifetime sexual partners, relationship violence and childhood experiences, including sexual abuse and violence. Responses were downloaded into IBM SPSS 20.0 and didn’t require manual data entry and coding. Demographic characteristics included gender, country of origin, marital status, parity, education level, annual household income, and parents’ education level. Immigration status was captured with US born and citizenship status. Suicide ideation/attempt has been documented as a consequence of child abuse, and therefore the survey included two questions. Number of sexual partners was measured by asking an open-ended question; any type of relationship violence was captured by adapting the Revised Conflict Tactics Scale [33] and the Woman Abuse Screening Scale [34]; witnessing parental violence was measured using questions adapted from the CDC ACE Study [31]. Questions on CSA were adapted from the CDC ACE Study [31]. Participants were asked: ‘‘during your first 18 years of life, did an adult or older relative, family friend, or stranger ever (1) expose themselves to you or force you to expose yourself to them, (2) touch or fondle your body in a sexual way, (3) have you touch their body in a sexual way, (4) attempt to have sexual intercourse (oral, anal, or vaginal) with you, (5) actually have sexual intercourse (oral, anal, or vaginal) with you?’’ A ‘‘yes’’ response to any of these five questions classified the respondent as having experienced sexual abuse during childhood. We created an ‘‘any sexual abuse’’ variable from a summation of these items and dichotomized as ‘‘yes/no.’’
Analysis Quantitative data analysis was conducted on 368 participants. A total of 425 people participated in the survey, but only 395 met the eligibility criteria, and 27 participants did not complete more than 15 % of the survey and were dropped from the dataset. Univariate and bivariate analyses were conducted to describe the study population and to explore relationships between sociodemographic characteristics, suicide ideation/attempts, and violence-related variables. A logistic multivariate regression model for any CSA examined relationship violence, family violence, suicide ideation and attempt, and adjusted for gender and US born.
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J Immigrant Minority Health Table 1 Demographic, health, and violence related characteristics of study participants (N = 368) Variables
Total % (n)
Mean current age (years)
32.99 (332)
Gender Female
77.7 (286)
Male
22.3 (82)
Country of origin India
74.2 (271)
Other US citizen
25.8 (94) 90.8 (334)
Born in the US
55.9 (205)
Marital status Single
44.7 (164)
Married
48.8 (179)
Other Mean total children
6.5 (24) 1.88 (111)
Education level Less than a 4-year degree
3.6 (13)
4-year college degree
24.9 (91)
More than a 4-year degree
71.6 (262)
Total household income $100,000 or less
41.5 (151)
$101,000–$200,000
27.2 (99)
Over $200,000 Suicide ideation Yes
31.3 (114) 21.9 (75)
Suicide attempt Yes Mean number of sexual partners
5.3 (18) 8.01 (293)
Relationship violence Yes
24.0 (80)
Witness parental violence Yes
41.2 (135)
Any childhood sexual abuse Yes
25.2 (79)
Exposure Yes
13.8 (44)
Touching Yes Attempted penetration (oral, anal, or vaginal) Yes
21.5 (68) 4.5 (14)
Penetration (oral, anal, or vaginal) Yes
3.5 (11)
Results Table 1 presents demographic, health, and violence related characteristics of study participants. As shown, the mean age of study participants is 32.9 years and participants are
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predominantly female (77.7 %). The majority of participants are of Indian origin (74.2 %); are US citizens (90.8 %); have more than a 4-year degree (71.6 %), and 58.5 % reported an annual income over $100,000. As shown, 21.9 % of participants reported suicide ideation and 5.3 % attempted suicide. Twenty-four percent reported experiencing relationship violence, and 41.2 % reported witnessing parental violence. The average number of sexual partners in our study sample was eight. With respect to CSA, 25.2 % of the population reported experiencing some form of childhood sexual abuse (exposure, touching, attempted penetration, penetration). Further, 13.8 % reported that during the first 18 years of their life an adult had exposed themselves to them or had forced the participant to expose themselves; 21.5 % reported sexual abuse involving touching; 4.5 % reported experiencing attempted sexual intercourse; and 3.5 % reported experiencing actual sexual intercourse. Table 2 presents adjusted odds ratios from three multivariate logistic models for (1) witnessing parental violence, (2) relationship violence, and (3) suicide ideation/attempt on ‘any childhood sexual abuse’, adjusting for age, gender, and US born as they were significant covariates in the bivariate analyses. Model 1 did not yield significant findings. Model 2 found that participants reporting any relationship violence are significantly more likely to report any CSA (OR 2.28; 95 % CI 1.26–4.13). Model 3 found that participants reporting suicide attempts are significantly more likely to report CSA (OR 3.96; 95 % CI 1.27–12.3).
Discussion Approximately one-fourth of our sample reported any childhood sexual abuse; 41.2 % reported witnessing parental violence; and 24 % reported relationship violence. Together, these data provide preliminary evidence of substantial prevalence of family violence and CSA among South Asians in the US. The present analysis is consistent with previous studies whereby subsequent consequences such as relationship violence (marital and dating) and suicide attempts were found related to CSA [36–38]. Further, as found in other studies, violence and CSA cuts across social class and is prevalent among high income, high education subgroups [36], such as the current study sample. The dynamics between family violence, suicide, and CSA are certainly far more complex than what has been explored in this study. However, the present study’s findings are important as multivariate analyses found significant relationships between CSA and relationship violence and suicide attempt. Certainly, growing up in a household that considers violence to be an acceptable
J Immigrant Minority Health Table 2 Multivariate logistic analysis for any childhood sexual abuse
Adjusted odds ratio (95 % CI) Model 1
Model 2
Model 3
1.00 (0.97–1.04)
1.0 (0.96–1.03)
1.00 (0.97–1.04)
Female
2.01 (0.97–4.17)
1.92 (0.92–4.0)
2.17 (1.03–4.56)*
Male
Ref
Ref
Ref
Age Gender
US born 1.76 (1.0–3.11)*
1.75 (0.99–3.11)
1.82 (1.03–3.23)*
Witnessed parental violence
Yes
1.63 (0.95–2.83)
–
–
Relationship violence
–
2.28 (1.26–4.13)**
–
Suicide ideation
–
–
1.02 (0.47–1.88)
Suicide attempt
–
–
3.96 (1.27–12.3)**
* p \ 0.05; ** p \ 0.01; *** p \ 0.001
behavior may help to normalize this type of behavior in a child’s mind and further the cycle of violence. The findings presented here must guide future research, policy, and practice. Community-based organizations (CBOs), public health professionals, educators, and clinicians should be aware that CSA is not limited to one socioeconomic, cultural, or ethnic group. These stakeholders must collaborate to appropriately prevent and identify family violence and CSA to ameliorate long-term consequences. Studies such as this one ought to (1) guide increased awareness and sensitivity among pediatricians and providers; (2) prompt public health professionals to create CSA and violence prevention interventions that are uniquely tailored to South Asians in the US; and (3) direct researchers to undertake an extensive study to fully understand the nuances associated with family violence and CSA in these communities.
were less likely to report CSA indicating that the prevalence of CSA among non-English speakers may in fact be higher than English speakers, and our results may be an underestimate. Certainly, South Asians originating from countries other than India and low-income South Asians are underrepresented in the sample, and therefore this sample is biased. In addition, women who have experienced CSA may be more likely to report other negative experiences, which may explain and overestimate the findings related to relationship violence and suicide attempt. And finally, many previous studies disaggregate findings by sex as there are often differential factors that influence CSA among males and females. However, the present analysis did not stratify by sex due to the small sample size among males (n = 82). Despite these limitations, this study recruited a significant sample size and provides valuable insights for future methodologicallysound research efforts.
Limitations of the Study It is important to note that there are several methodological limitations to this study. First, this was a convenience sample and geographic location in the country was not assessed, and therefore generalizability to a national sample of South Asians is limited. This was a cross-sectional sample prohibiting causal inferences and therefore the findings are primarily descriptive in nature. Additionally, survey methodology relied on participants’ recall and selfreport, leaving the study vulnerable to memory and willingness to report on sensitive experiences. It is likely that the reported prevalence of CSA is an underestimate due to underreporting. The survey was developed in English only and therefore non-English speakers were excluded and it is unknown whether non-English speakers’ CSA experiences are similar or different. US born South Asians in this study
Conclusion It is without question that the prevention of family violence and CSA is of great concern to communities worldwide. In totality, this study found substantial levels and forms of violence, including (1) CSA; (2) relationship violence; (3) witnessing parental violence; and (4) self-inflicted injury i.e. suicide ideation and attempt. Further significant relationships were found between CSA and relationship violence, and CSA and suicide attempts. To date, this is the first study to assess CSA and its relationship with other forms of violence among South Asians in the United States. Although the analysis was simple due to the study methodology, this study presents compelling evidence that family violence and CSA, and its consequences should not
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be overlooked as a public health issue and must be added to the public health agenda focused on South Asians living in the US. In recent years, more research on South Asians in the US has been conducted and yet, these studies overwhelmingly focus on chronic disease prevention and treatment [9, 10]. The present study’s findings suggest that family violence and CSA are important public health issues for South Asians in the US and warrant further attention. It is essential that interdisciplinary research occurs and culturally salient primary and secondary prevention programs are implemented.
References 1. Human Rights Watch. News. India: rape of 6-year-old highlights sexual abuse. http://www.hrw.org/news/2014/07/24/india-rape-6year-old-highlights-sexual-abuse. Accessed 17 Dec 2014. 2. Special feature: the 28th CMAAO general assembly and 49th council meeting. New Delhi, India. Japan Medical Association. 2013;56(5):282–284. 3. Chalk C, King PA. Violence in families: assessing prevention and treatment programs. Washington, DC: The National Academies of Press; 1998. 4. Tolan P, Gorman-Smith D, Henry D. Family violence. Annu Rev Psychol. 2006;57:557–83. 5. Purkayastha B. Liminal lives: South Asian youth and domestic violence. J Soc Distress Homeless. 2000;9(3):201–19. 6. Ahmad F, Steward DE. Patriarchal beliefs and perceptions of abuse among South Asian immigrant women. Violence Against Women. 2004;10:262–82. 7. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau: Child Maltreatment 2013. 2015. https://www.acf.hhs.gov/sites/default/files/cb/cm2013.pdf#page= 15. 8. U.S. Census Bureau. Asian population. http://www.census.gov/ population/race/data/asian.html. Accessed 11 Sept 2013. 9. Upadhyay UD, Vyas AN, Ghosh A, Akram SA. Brown paper: the health of South Asians in the United States. The South Asian Public Health Association (SAPHA), October 2002. 10. Vyas AN, Chaudhary N, Ramiah K, Landry M. Addressing a growing communities health needs: project SAHNA (south Asian health needs assessment). J Immigr Minor Health. 2012;15(3): 577–83. 11. Molnar BE, Buka SL, Kessler R. Child sexual abuse and subsequent psychopathology: results from the national comorbidity survey. Am J Public Health. 2001;91(5):753–60. 12. McCauley J, Kern DE, Kolodner K, Dill L, Schroeder AF, DeChant HK, Ryden J, Derogatis LR, Bass EB. Clinical characteristics of women with a history of childhood abuse: unhealed wounds. J Am Med Assoc. 1997;277(17):1362–8. 13. Sugaya L, Hasin DS, Olfson M, Lin KH, Grant BF, Blanco C. Child physical abuse and adult mental health: a national study. J Trauma Stress. 2012;25:384–92. 14. Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003;111(3):564–72.
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15. Schiff M, Plotnikova M, Dingle K, Williams GM, Najman J, Clavarino A. Does adolescent’s exposure to parental intimate partner conflict and violence predict psychological distress and substance use in young adulthood? A longitudinal study. Child Abuse Negl. 2014;38(12):1945–54. 16. Fergusson DM, McLeod GF, Horwood LJ. Childhood sexual abuse and adult developmental outcomes: findings from a 30-year longitudinal study in New Zealand. Child Abuse Negl. 2013;37:664–74. 17. Malley-Morrison K, Hines DA. Family violence in a cultural perspective: defining, understanding, and combating abuse. Thousand Oaks, CA: SAGE Publications, Inc; 2004. 18. Fikree FF, Pasha O. Role of gender in health disparity: the south Asian context. Br Med J. 2004;328:823–6. 19. Hollen CV. HIV/AIDS and the gendering stigma in Tamil Nadu, South India. Cult Med Psychiatry. 2004;34(4):633–57. 20. Gilligan P, Akhtar S. Cultural barriers to the disclosure of child sexual abuse in Asian communities: listening to what women say. Br J Soc Work. 2006;36(8):1361–77. 21. Khairulla DHZ, Khairulla ZY. Second generation Asian-Indian reactions to Asian-Indian and American magazine advertisements. Int Bus Econ Res J. 2005;4(9):37–44. 22. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the lifespan: findings from the adverse childhood experiences study. J Am Med Assoc. 2001;286:3089–96. 23. Ahmed K, Mohan RA, Bhugra D. Self-harm in south Asian women: a literature review informed approach to assessment and formulation. Am J Psychother. 2007;61(1):71–81. 24. Raleigh VS, Bulusu L, Balarajan R. Suicides among immigrants from the Indian subcontinent. Br J Psychiatry. 1990;156:46–50. 25. Bhugra D. Suicidal behavior in South Asians in the UK. Crisis J Crisis Interv Suicide Prev. 2002;23(3):108–13. 26. Raj A, Liu R, McCleary-Sills J, Silverman JG. South Asian victims of intimate partner violence more likely than non-victims to report sexual health concerns. J Immigr Health. 2005;7(2): 85–91. 27. Himelfarb-Hurwitz EJ, Gupta J, Liu R, Silverman JG, Raj A. Intimate partner violence associated with poor health outcomes in U.S. South Asian women. J Immigr Minor Health. 2006;8(3): 251–61. 28. Daigneault I, Hebert M, McDuff P. Men’s and women’s childhood sexual abuse and victimization in adult partner relationships: a study of risk factors. Child Abuse Negl. 2009;33:638–47. 29. Filipas HH, Ulman SE. Child sexual abuse, coping responses, self-blame, posttraumatic stress disorder, and adult sexual revictimization. J Interpers Violence. 2006;21(5):652–72. 30. Kacker L, Varadan S, Kumar P. Study on child abuse: India 2007. New Delhi: Ministry of Women and Child Development, Government of India; 2007. 31. Centers for Disease Control and Prevention (CDC). Family Health History Questionnaire. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 1995. 32. Substance Abuse and Mental Health Services Administration (SAMHSA). National survey of drug use and health (NSDUH). Rockville, MD: U.S. Department of Health and Human Services, SAMHSA; 2010. 33. Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised Conflict Tactics Scales (CTS-2): development and preliminary psychometric data. J Family Issues. 1996;17:283–316. 34. MacMillan HL, Wathen CN, Jamieson E, Boyle MH, Shannon HS, Ford-Gilboe M, Worster A, Lent B, Coben JH, Campbell JC, McNutt LA. Screening for intimate partner violence in health
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ORIGINAL PAPER
Family Violence and Child Sexual Abuse Among South Asians in the US Hillary A. Robertson1 • Nitasha Chaudhary Nagaraj2 • Amita N. Vyas2
Ó Springer Science+Business Media New York 2015
Abstract Family violence, including child sexual abuse (CSA), is a significant public health problem in the United States. It is particularly difficult to assess family violence and CSA among South Asians because it is often hidden due to cultural and familial stigma. A web-based survey was administered to a convenience sample (n = 368) of South Asian adults in the US. One-fourth (25.2 %) of the sample reported CSA; 13.8 % reported abuse involving exposure; 21.5 % reported abuse involving touching; 4.5 % reported attempted sexual intercourse; and 3.5 % reported forced sexual intercourse. Adjusted odds ratios found that participants who reported any relationship violence were significantly more likely to have experienced CSA (OR 2.28; 95 % CI 1.26–4.13); and suicide attempt was significantly associated with CSA (OR 3.96; 95 % CI 1.27–12.3). The findings presented in this formative study will assist in guiding future studies and interventions for South Asians in the United States. Keywords Child sexual abuse Family violence South Asian health Mental health
& Hillary A. Robertson [email protected] 1
College of Social Work, The Ohio State University, 1947 College Road, 325Q Stillman Hall, Columbus, OH 43210, USA
2
Department of Prevention and Community Health, The George Washington University, Washington, DC, USA
Introduction Family violence in South Asian countries has received increased media attention in the last few years [1, 2]. There are many reasons why family violence in particular merits focus. In contrast to other forms of violence (i.e. gang violence, violent crime, or war), family violence, which includes child maltreatment, domestic violence, and elder abuse, [3] presupposes a relationship between those involved [4]. There is much controversy in defining family violence and whether it should include physical and sexual violence, and while an exact definition of family violence is controversial, understanding the major components are central to understanding and quantifying the degree to which family violence occurs [4]. The present study focuses on several types of family violence including relationship violence, witnessing parental violence, and child sexual abuse (CSA), which may be experienced outside the family context. As more research is underway to better understand the complex factors surrounding family violence and CSA in South Asia, it is important to explore the extent to which violence extends beyond geographic boundaries and afflicts South Asian children and families living in the United States. First, the exposure to violence and CSA in one’s family of origin is alleged to increase the risk of perpetuating violence and CSA, and therefore immigrant families from high-prevalence countries may be at increased risk [5, 6]. Second, family violence and child abuse are of significant public health concern in the US. In 2013, the Administration on Children, Youth and Families reported that an estimated 679,000 children in the United States were victims of child maltreatment [7]. There are over 3.4 million South Asians living in the US, comprising of individuals with family origins from
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Afghanistan, Bangladesh, Bhutan, India, the Maldives, Pakistan and Sri Lanka [8]. Although the South Asian population in the US has increased significantly in the last several decades, there has been limited data and research on family violence in these immigrant communities and no published quantitative studies on CSA specifically. Several challenges to this type of research exist including the ‘‘healthy and wealthy/model minority stereotype’’ for this minority group [9]. The model minority stereotype posits that persons from South Asian countries are most often perceived to achieve higher degrees of income and education, and lower levels of crime rates and family instability. This ‘‘myth’’ has been a driving force behind the paucity of health-focused studies of South Asians in the US [9, 10]. Family violence and CSA are highly stigmatized issues and are often left undetected or unaddressed within families and communities [5, 6]. Therefore, it is more than plausible that family violence and CSA found within South Asian countries exists globally within South Asian families. Child abuse, both physical and sexual, has been linked to many psychological conditions [11]. The devastating effects of these experiences are typically seen well into adulthood. A study conducted by McCauley et al. [12] found that many of the associations between child abuse and physical symptoms, psychological problems, and substance abuse issues were as strong as the associations for patients experiencing current abuse. Further, in a study conducted by Sugaya et al. [13], other childhood adversities and psychiatric comorbidities, including suicide ideation and suicide attempt, were all independently and significantly associated with CSA. Dube et al. [14] found that witnessing maternal violence during childhood increased the likelihood of early initiation of illicit drug use by 1.6-fold. Adolescent exposure to parental intimate partner violence was found to be associated with anxiety, depression, and substance abuse [15]. Furthermore, family of origin violence, including CSA, has been found to predict both marital and dating violence [5, 6, 11, 16]. The consequences of family violence and CSA are devastating and there is clearly a need for increased efforts to prevent and mitigate these experiences among children living in the United States. Researchers have suggested that it is particularly difficult to determine the prevalence of family violence and CSA among South Asian communities due to pervasive cultural norms including patriarchal ideology and traditional family and gender norms [5, 6, 11, 16, 17]. Family violence is highly stigmatized amongst the South Asian population living in-country and abroad. The South Asian culture is a patriarchal social system that places girls and women in subordinate positions relative to men [5, 18]. Particular to sexuality, gendered roles in the South Asian
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context put girls and women at a much larger risk for violence and sexually-related diseases [19]. Specifically looking at CSA, a study conducted in Great Britain found that disclosure of CSA among South Asian women was often impeded by lack of basic knowledge of CSA; lack of awareness surrounding the existence of the CSA services; fear of public exposure due to disclosure of CSA; fear of culturally insensitive responses from professionals; and other cultural factors such as izzat [honor/respect], haya [modesty], and sharam [shame/embarrassment]) [19, 20]. Furthermore, previous research has found that the upbringing and personality of Asian Indians are partly shaped by the influence of extended adult family members, and they are expected to depend on their parents, grandparents, other siblings, and aunts and uncles throughout their lifespan [21]. This familial norm is often a significant barrier for disclosure of family violence and CSA within families [5, 6]. A history of CSA places an individual at increased risk of suicide in childhood, adolescence, and adulthood [22]. When compared with never-abused patients, childhoodonly abused patients were nearly four times more likely to report attempted suicide [12]. Although research linking CSA and subsequent suicide has not focused specifically on South Asians, studies have revealed high rates of attempted and successful suicide among South Asians across the world [23, 24]. A study conducted in the United Kingdom (UK) found that the rate of attempted suicide among South Asian women ages 18–24 was three times higher than the rate of attempted suicide among their white counterparts [25]. Intimate partner violence has been found to be associated with increased sexual health concerns, poor physical health, depression, anxiety, and suicidal ideation among South Asian women living in the US [26, 27]. Furthermore, a history of CSA is associated with an increased risk of intimate partner violence and adult sexual re-victimization [28, 29]. Raj et al. found a high prevalence of IPV (40.8 %) among immigrant South Asian women living in the US. Fergusson et al. found that adults who have experienced CSA have greater sexual vulnerability during adolescence and higher rates of sexual victimization after the age of 16 [26]. One landmark quantitative national study examined the prevalence of child abuse in India and found that about half of India’s children reported experiencing some form of CSA, and the majority never reported the abuse [30]. This 2007 study was conducted by India’s Ministry of Women and Child Development and also noted that CSA in India begins as early as 5 years and can include a myriad of sexual crimes. Twenty-two percent of respondents indicated severe (defined as sexual assault, fondling, exposure, or child pornography) sexual abuse and 69 % of all Indian
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children were found to be victims of physical, mental, or emotional abuse. Of the 12,447 children interviewed oneon-one, the study found that it was usually family members (89 %) who perpetrate such crimes [30]. Despite what is known in South Asian countries, there is virtually no research on this highly stigmatized, public health issue among the growing population of South Asians in the US. To that extent, a quantitative survey of South Asian adults living in the US was conducted to better understand the relationships between family violence, mental health, and CSA. The study was reviewed and approved by The George Washington University Institutional Review Board (IRB # 080920).
Methods Sample and Procedures This study recruited a convenience sample of 425 South Asians living in the United States. Eligibility criteria included English-proficient male and female adults 18 years of age and older who self-identify their origin as South Asian regardless of where they were born. Study participants were not remunerated for participation. The project team collaborated with 58 local and national South Asian organizations with social media and/or listserv capabilities. These organizations spanned a variety of domains including religious, cultural, professional associations, and non-profits. Between June and July 2013, organizations disseminated a web-based survey electronically to its members via email listservs and social media sites and did not provide the research team contact information for their individual members. Given the universe of email lists and databases, including overlap of individuals on multiple lists, a valid response rate could not be calculated. People of Indian decent represent the largest percent of the US. South Asian population, and therefore, the majority of organizations and listservs (approximately 80 %) focused on this subgroup [8]. Significant efforts were made to reach out to all non-Indian focused South Asian organizations for data collection. Instruments and Measures Data were collected via an 82-item quantitative survey. Questions were adapted from the Centers for Disease Control and Prevention (CDC) Adverse Childhood Experiences (ACE) Study [31] and additional questions were adapted from the Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on
Drug Use and Health [32], the Revised Conflict Tactics Scale [33], the Woman Abuse Screening Scale [34] and the CDC’s Behavioral Risk Factor Surveillance System [35]. The survey took approximately 10–15 min to complete and collected information on socio-demographics, suicide ideation and attempt, number of lifetime sexual partners, relationship violence and childhood experiences, including sexual abuse and violence. Responses were downloaded into IBM SPSS 20.0 and didn’t require manual data entry and coding. Demographic characteristics included gender, country of origin, marital status, parity, education level, annual household income, and parents’ education level. Immigration status was captured with US born and citizenship status. Suicide ideation/attempt has been documented as a consequence of child abuse, and therefore the survey included two questions. Number of sexual partners was measured by asking an open-ended question; any type of relationship violence was captured by adapting the Revised Conflict Tactics Scale [33] and the Woman Abuse Screening Scale [34]; witnessing parental violence was measured using questions adapted from the CDC ACE Study [31]. Questions on CSA were adapted from the CDC ACE Study [31]. Participants were asked: ‘‘during your first 18 years of life, did an adult or older relative, family friend, or stranger ever (1) expose themselves to you or force you to expose yourself to them, (2) touch or fondle your body in a sexual way, (3) have you touch their body in a sexual way, (4) attempt to have sexual intercourse (oral, anal, or vaginal) with you, (5) actually have sexual intercourse (oral, anal, or vaginal) with you?’’ A ‘‘yes’’ response to any of these five questions classified the respondent as having experienced sexual abuse during childhood. We created an ‘‘any sexual abuse’’ variable from a summation of these items and dichotomized as ‘‘yes/no.’’
Analysis Quantitative data analysis was conducted on 368 participants. A total of 425 people participated in the survey, but only 395 met the eligibility criteria, and 27 participants did not complete more than 15 % of the survey and were dropped from the dataset. Univariate and bivariate analyses were conducted to describe the study population and to explore relationships between sociodemographic characteristics, suicide ideation/attempts, and violence-related variables. A logistic multivariate regression model for any CSA examined relationship violence, family violence, suicide ideation and attempt, and adjusted for gender and US born.
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J Immigrant Minority Health Table 1 Demographic, health, and violence related characteristics of study participants (N = 368) Variables
Total % (n)
Mean current age (years)
32.99 (332)
Gender Female
77.7 (286)
Male
22.3 (82)
Country of origin India
74.2 (271)
Other US citizen
25.8 (94) 90.8 (334)
Born in the US
55.9 (205)
Marital status Single
44.7 (164)
Married
48.8 (179)
Other Mean total children
6.5 (24) 1.88 (111)
Education level Less than a 4-year degree
3.6 (13)
4-year college degree
24.9 (91)
More than a 4-year degree
71.6 (262)
Total household income $100,000 or less
41.5 (151)
$101,000–$200,000
27.2 (99)
Over $200,000 Suicide ideation Yes
31.3 (114) 21.9 (75)
Suicide attempt Yes Mean number of sexual partners
5.3 (18) 8.01 (293)
Relationship violence Yes
24.0 (80)
Witness parental violence Yes
41.2 (135)
Any childhood sexual abuse Yes
25.2 (79)
Exposure Yes
13.8 (44)
Touching Yes Attempted penetration (oral, anal, or vaginal) Yes
21.5 (68) 4.5 (14)
Penetration (oral, anal, or vaginal) Yes
3.5 (11)
Results Table 1 presents demographic, health, and violence related characteristics of study participants. As shown, the mean age of study participants is 32.9 years and participants are
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predominantly female (77.7 %). The majority of participants are of Indian origin (74.2 %); are US citizens (90.8 %); have more than a 4-year degree (71.6 %), and 58.5 % reported an annual income over $100,000. As shown, 21.9 % of participants reported suicide ideation and 5.3 % attempted suicide. Twenty-four percent reported experiencing relationship violence, and 41.2 % reported witnessing parental violence. The average number of sexual partners in our study sample was eight. With respect to CSA, 25.2 % of the population reported experiencing some form of childhood sexual abuse (exposure, touching, attempted penetration, penetration). Further, 13.8 % reported that during the first 18 years of their life an adult had exposed themselves to them or had forced the participant to expose themselves; 21.5 % reported sexual abuse involving touching; 4.5 % reported experiencing attempted sexual intercourse; and 3.5 % reported experiencing actual sexual intercourse. Table 2 presents adjusted odds ratios from three multivariate logistic models for (1) witnessing parental violence, (2) relationship violence, and (3) suicide ideation/attempt on ‘any childhood sexual abuse’, adjusting for age, gender, and US born as they were significant covariates in the bivariate analyses. Model 1 did not yield significant findings. Model 2 found that participants reporting any relationship violence are significantly more likely to report any CSA (OR 2.28; 95 % CI 1.26–4.13). Model 3 found that participants reporting suicide attempts are significantly more likely to report CSA (OR 3.96; 95 % CI 1.27–12.3).
Discussion Approximately one-fourth of our sample reported any childhood sexual abuse; 41.2 % reported witnessing parental violence; and 24 % reported relationship violence. Together, these data provide preliminary evidence of substantial prevalence of family violence and CSA among South Asians in the US. The present analysis is consistent with previous studies whereby subsequent consequences such as relationship violence (marital and dating) and suicide attempts were found related to CSA [36–38]. Further, as found in other studies, violence and CSA cuts across social class and is prevalent among high income, high education subgroups [36], such as the current study sample. The dynamics between family violence, suicide, and CSA are certainly far more complex than what has been explored in this study. However, the present study’s findings are important as multivariate analyses found significant relationships between CSA and relationship violence and suicide attempt. Certainly, growing up in a household that considers violence to be an acceptable
J Immigrant Minority Health Table 2 Multivariate logistic analysis for any childhood sexual abuse
Adjusted odds ratio (95 % CI) Model 1
Model 2
Model 3
1.00 (0.97–1.04)
1.0 (0.96–1.03)
1.00 (0.97–1.04)
Female
2.01 (0.97–4.17)
1.92 (0.92–4.0)
2.17 (1.03–4.56)*
Male
Ref
Ref
Ref
Age Gender
US born 1.76 (1.0–3.11)*
1.75 (0.99–3.11)
1.82 (1.03–3.23)*
Witnessed parental violence
Yes
1.63 (0.95–2.83)
–
–
Relationship violence
–
2.28 (1.26–4.13)**
–
Suicide ideation
–
–
1.02 (0.47–1.88)
Suicide attempt
–
–
3.96 (1.27–12.3)**
* p \ 0.05; ** p \ 0.01; *** p \ 0.001
behavior may help to normalize this type of behavior in a child’s mind and further the cycle of violence. The findings presented here must guide future research, policy, and practice. Community-based organizations (CBOs), public health professionals, educators, and clinicians should be aware that CSA is not limited to one socioeconomic, cultural, or ethnic group. These stakeholders must collaborate to appropriately prevent and identify family violence and CSA to ameliorate long-term consequences. Studies such as this one ought to (1) guide increased awareness and sensitivity among pediatricians and providers; (2) prompt public health professionals to create CSA and violence prevention interventions that are uniquely tailored to South Asians in the US; and (3) direct researchers to undertake an extensive study to fully understand the nuances associated with family violence and CSA in these communities.
were less likely to report CSA indicating that the prevalence of CSA among non-English speakers may in fact be higher than English speakers, and our results may be an underestimate. Certainly, South Asians originating from countries other than India and low-income South Asians are underrepresented in the sample, and therefore this sample is biased. In addition, women who have experienced CSA may be more likely to report other negative experiences, which may explain and overestimate the findings related to relationship violence and suicide attempt. And finally, many previous studies disaggregate findings by sex as there are often differential factors that influence CSA among males and females. However, the present analysis did not stratify by sex due to the small sample size among males (n = 82). Despite these limitations, this study recruited a significant sample size and provides valuable insights for future methodologicallysound research efforts.
Limitations of the Study It is important to note that there are several methodological limitations to this study. First, this was a convenience sample and geographic location in the country was not assessed, and therefore generalizability to a national sample of South Asians is limited. This was a cross-sectional sample prohibiting causal inferences and therefore the findings are primarily descriptive in nature. Additionally, survey methodology relied on participants’ recall and selfreport, leaving the study vulnerable to memory and willingness to report on sensitive experiences. It is likely that the reported prevalence of CSA is an underestimate due to underreporting. The survey was developed in English only and therefore non-English speakers were excluded and it is unknown whether non-English speakers’ CSA experiences are similar or different. US born South Asians in this study
Conclusion It is without question that the prevention of family violence and CSA is of great concern to communities worldwide. In totality, this study found substantial levels and forms of violence, including (1) CSA; (2) relationship violence; (3) witnessing parental violence; and (4) self-inflicted injury i.e. suicide ideation and attempt. Further significant relationships were found between CSA and relationship violence, and CSA and suicide attempts. To date, this is the first study to assess CSA and its relationship with other forms of violence among South Asians in the United States. Although the analysis was simple due to the study methodology, this study presents compelling evidence that family violence and CSA, and its consequences should not
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be overlooked as a public health issue and must be added to the public health agenda focused on South Asians living in the US. In recent years, more research on South Asians in the US has been conducted and yet, these studies overwhelmingly focus on chronic disease prevention and treatment [9, 10]. The present study’s findings suggest that family violence and CSA are important public health issues for South Asians in the US and warrant further attention. It is essential that interdisciplinary research occurs and culturally salient primary and secondary prevention programs are implemented.
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