|Home | About | Journals | Submit | Contact Us | Français|
Hyeouk Chris Hahm, is Assistant Professor at Boston University, School of Social Work. Her fields of special interest include HIV/STDs risk factors, substance use/abuse, acculturation, and health disparities among ethnic minority adolescents and young adults.
Eric Kolaczyk, Ph.D., M.S.
Professor Kolaczyk is the Director of the Program in Statistics in the Department of Mathematics and Statistics at Boston University. He is a leading research expert in statistical analysis of network-indexed data and works to develop new methodology and inter-disciplinary studies.
Yookyong Lee, Ph.D.
Yookyong Lee is Assistant Professor in the School of Social Work, College of Health Professions and Social Work at Temple University. Her research focuses on adolescent parenthood, child abuse and neglect, father involvement, and child and family policy.
Jisun Jang, M.A.
Jisun Jang completed her M.A. in Biostatistics at Boston University School of Public Health and has a B.S. in both Statistics and Economics from the University of Wisconsin-Madison. She now works at Children’s Hospital Boston as a statistical programmer.
Lisa Ng, B.A.
Lisa Ng is a NYC Teaching Fellow, certified in secondary level Special Education and mathematics. She graduated from Boston University with a B.A. in Cultural Anthropology and International Relations. Her research interests include analyses of socioeconomic inequalities, race/ethnic relations, and gender disparities.
This study is the first to systematically investigate whether multiple child maltreatment is associated with HIV risk behaviors and adverse mental health outcomes among Asian-American women.
We conducted a cross-sectional study of unmarried Chinese, Korean, and Vietnamese women (n = 400), aged 18 to 35, who are identified as children of immigrants, using Computer-Assisted Survey Interviews (CASI).
Approximately seven in ten women reported having been maltreated as a child and 6.8% reported any type of sexual abuse. Only 15% of our sample reported having sex at age 16 or before, yet almost 60% had ever engaged with risky sexual partners. Contrary to the findings from previous studies of White and Black women, sexual abuse plus other maltreatment was not associated with HIV risk behaviors among Asian-American women. However,it was associated with a marked increase in depression, lifetime suicidal ideation and suicide attempts. A higher education was associated with increased odds of HIV risk behaviors including ever having anal sex and ever having potentially risky sexual partners.
There was no evidence indicating that multiple child maltreatment was linked to HIV risk behaviors, but it exhibited a robust association with poor mental health outcomes. These empirical patterns of internalizing trauma, suffering alone, and stayingsilent are in accord with Asian-cultural norms of saving face and maintaining family harmony. The prevention of multiple child maltreatment may reduce high levels of depression and suicidal behaviors among this population. It is urgently needed to identify victims of multiple child maltreatment and provide culturally appropriate interventions.
Accumulating evidence demonstrates that a significant prevalence of child maltreatment consists of combinations of multiple types of maltreatment (Dong et al., 2004; Scher, Forde, McQuaid, & Stein, 2004). Moreover, these multiple combinations of child maltreatment have also been associated with HIV risk behaviors and poor mental health outcomes, particularly among women (Bensley, Van Eenwyk, & Simmons, 2000; Edwards, Holden, Felitti, & Anda, 2003; Mullen, Martin, Anderson, Romans, & Herbison, 1996).
However, little systematic investigation in examining the role of multiple child maltreatment on both HIV risk behaviors and mental health outcomes among Asian-American women has been done. Is multiple child maltreatment (e.g. sexual abuse plus other maltreatment) associated with HIV risk behaviors and adverse mental health among Asian-American women? Does multiple child maltreatment have similar or distinct sequalae for HIV risk behaviors and mental health outcomes among Asian-American women? Answers to these questions are critical for developing culturally appropriate HIV prevention as well as mental health interventions for this population.
The majority of research on child maltreatment among Asian-Americans has focused on either prevalence of single types of maltreatment among children (Chang, Rhee, & Weaver, 2006; Ima & Hohm, 1991; Rhee, Chang, Weaver, & Wong, 2008) or predictors of child maltreatment among parents (Ima & Hohm, 1991; AS Lau, Takeuchi, & Alegría, 2006; Park, 2001). Although these studies are critical to understanding the nature of child maltreatment among Asian-American families, the scope of investigation of child maltreatment needs to be expanded for a deeper understanding of the role of multiple child maltreatment in health and behavior outcomes of Asian-Americans during young adulthood. This article investigates whether exposure to multiple types of child maltreatment is associated with two emerging public health problems among Asian-American women: HIV risk behaviors and poor mental health functioning.
Various sexual risk behaviors are associated with the prevalence and incidence of STIs and HIV (Centers for Disease Control and Prevention [CDC], 2010; MacDonald et al., 1990). While decreases in gonorrhea were seen in Blacks, Hispanics, and Whites in 2008, the incidence of gonorrhea increased in Asian-American Pacific Islanders (AAPIs) by 8.1% (CDC, 2008). The prevalence of chlamydia and syphilis has also been increasing among young Asian-American women (CDC, 2008). Studies have found that although Asian-Americans have a later sexual debut than other racial groups, those who are sexually experienced consistently report rates of HIV risk behaviors at least as high as those among other groups (Schuster, Bell, Nakajima, & Kanouse, 1998). Collectively, these findings underscore the importance of recognizing Asian-American women as a group potentially at high risk for HIV and other STIs.
The comparatively poor mental health status of Asian-American women is also alarming (Lin-Fu, 1988; Takeuchi et al., 2007). Two studies have shown that the mean depression score of Korean Americans, using the Centers for Epidemiology of Depression Scale (CES-D), was substantially higher (ranges from 16-19.7) (Cho, Nam, & Suh, 1998; Shin, 1994) than the general U.S. population, which ranged from 7.9 to 9.2 (Radloff, 1991). Furthermore, in 2006, the suicide mortality rate of young Asian-American women, 4.25 per 100,000 individuals, surpassed the suicide mortality rate of all major racial and ethnic groups, except for Native Americans (CDC, 2006). Therefore, understanding the factors associated with HIV risk behaviors and poor mental health among this population is critical.
The majority of existing studies categorize child maltreatment based on single types of maltreatment (e.g. no maltreatment, sexual abuse, physical abuse, or neglect) (Anda et al., 2006; Walsh, MacMillan, & Jamieson, 2003). However, accumulating evidence shows that victims of multiple types of maltreatment have reported higher levels of distress, self-blame, and dysfunctional sexual behaviors (Banyard, Williams, & Siegel, 2002; Davis, Petretic-Jackson, & Ting, 2001; Edwards et al., 2003; Mullen et al., 1996). Therefore, investigating a single type of maltreatment may underestimate the potential impact that multiple types of maltreatment have on the health and health behaviors of individuals.
According to Lau et al.’s (2005) Expanded Hierarchical Type (EHT) system, certain maltreatment types (e.g., sexual abuse) are more harmful than others and are associated with worse behavioral or disease outcomes. EHT defines a hierarchy of maltreatment types to differentiate between single types and certain combinations of maltreatment types. Each maltreatment type is considered to weigh differently. Finkelhor & Browne (1985)’s traumagenic dynamics model provides explanations on why child sexual abuse is assumed to be more influential on negative outcomes than physical abuse, neglect, and emotional abuse. The model posits that the negative effects of sexual abuse can be examined in terms of four trauma-causing factors or traumagenic dynamics: traumatic sexualization, betrayal, powerlessness, and stigmatization. Traumatic sexualization, for instance, suggests that children who have been sexually abused may develop maladaptive and dysfunctional expectations for sexual behaviors. Empirical studies have documented that sexually abused young women (74% White sample) were two or three times more likely to have had an earlier sexual debut and multiple sex partners than those without such a history (Raj, Silverman, & Amaro, 2000). Furthermore, childhood sexual abuse has been associated with poor mental health outcomes, such as depression and suicide attempts (Brown, Cohen, Johnson, & Smailes, 1999).
However, most studies mentioned here examined White (Davis et al., 2001; Edwards et al., 2003; Raj et al., 2000) or Black women (Banyard et al., 2002). A recent study conducted by Hahm, Lee, Ozonoff, & Van Wert (2010) showed that women who reported childhood sexual abuse plus other maltreatment had the poorest outcomes in sexual risk behaviors and suicidality. However, they used a nationally representative sample of young women from diverse racial groups. The relationship between child maltreatment and mental and behavioral outcomes among Asian-American women still remains understudied. To our knowledge, only one study has examined the relationship between sexual abuse and sexual acting out in addition to suicidality among Asian-Americans. Based on a retrospective review of hospital charts, Rao, DiClemente, and Ponton (1992) found that Asian sexual abuse victims have unusually distinctive patterns, which set them apart from other racial groups. Compared to White, Black, and Hispanic children of sexual abuse victims, Asian sexual abuse victims were least likely to display inappropriate sexual behaviors (e.g., sexual acting out or masturbation), anger, or hostility; however, they were more likely to report suicidal ideation and suicide attempts. Asian victims may bear more Asian cultural pressure to be less sexually active and instead, to internalize severe conflicts within themselves (Rao et al., 1992). This study also helps establish the hypothesis that the mechanisms for HIV risk behaviors and mental health functioning among Asian-Americans might be different. However, due to study limitations of Rao et al. (1992) (e.g., small samples, lacking multivariate analysis tests, and employing only single type of abuse), our understanding of the role of sexual abuse plus other maltreatment in health and behaviors is limited among Asian-Americans.
Using the data from the Asian-American Women’s Sexual Health Initiative Project (AWSHIP), this study aims to: (1) Describe the prevalence of single and multiple types of child maltreatment among unmarried Asian-American women; and (2) Investigate whether multiple child maltreatment is associated with the two domains of outcomes (HIV risk behaviors and poor mental health outcomes). Building on Rao et al.’s (1992) study, we hypothesize that the patterns of associations between multiple types of child maltreatment and two domains of outcomes (HIV risk behaviors and poor mental health outcomes) will be different among Asian-American women. We hypothesize that after controlling for demographic characteristics, Asian-American women with a history of child sexual abuse plus other maltreatment will be associated with a greater risk of poor mental health functioning, but that its association with HIV risk behaviors will be weaker.
AWSHIP was designed to investigate prevalence of HIV risk behaviors and mental health functioning among Chinese, Korean, and Vietnamese women who are children of immigrants. We chose to solely focus on these ethnic groups because they are greatly influenced by Confucianism, which highlights female sexual modesty and reticence (Zhang, Li, Li, & Beck, 1999), and also they are among the five most prevalent Asian ethnic populations in Massachusetts (MA), where the study was conducted. Among Asian-Americans in MA, 35.4% are Chinese, 14.3% are Vietnamese, and 7.3% are Korean (U.S. Census Bureau, 2000). Finally, Asian Indian women were excluded even though they are the second largest Asian population in MA because the majority practices Islam and Hinduism, which promote extreme levels of female modesty and inhibition. This may play as a significant obstacle to accurate data collection concerning sexual practices (Nussbaum, 2001).
To be eligible for the study, participants had to be: (1) an unmarried woman; (2) between the ages of 18 and 35; (3) identify as Vietnamese, Chinese, Korean, or a mix of these ethnicities; (4) be a child of immigrants (either 1.5 or 2nd generation); and (5) reside in the greater Boston area. A special effort was made to incorporate diversity among socioeconomic strata as well as to include both 1.5 and 2nd generation immigrants. AWSHIP utilized existing ties and established new relationships with eight universities and twenty community resources, various health and community agencies, and ethnic supermarkets that helped recruit participants and provide locations for interviews. To maintain cultural and linguistic sensitivity, outreach workers consisted of trained, bilingual, and bicultural Chinese, Korean, and Vietnamese women.
The data were collected from January 2010 to September 2010, and of the initial 547 women screened for eligibility, 3.3% were ineligible and 5.1% never followed through with the interview appointment after initial contact, resulting in 501 participants who received interviews. Of these 501 participants, 101 did not respond to all four child maltreatment questions. Non-response to any of the four questions was considered as missing; the final sample size of 400 was used for the data analyses. No difference was noted in socio-demographic variables including age, education, or ethnicity between study participants and non-study participants, except birth place. A higher proportion of the non-study participants were born in Asia, when compared to the study participants.
Trained interviewers administered the confidential Computer-Assisted Survey Interviews (CASI) in locations convenient for the participants. The interviewers distributed consent forms and CASI in five different languages (English, Traditional and Simplified Chinese, Korean, and Vietnamese) to accommodate potential language barriers. Additionally, 12 translators and back-translators (2 translators and 2 back translators for Chinese, Korean, and Vietnamese) completed the multilingual interview questions. However, the majority of participants chose to take English CASI; only 2% took multilingual CASI. It took approximately 45-60 minutes for the participants to complete the questions on CASI and they received $20 in compensation for their time. Boston University’s Institutional Review Board (IRB) approved all protocols and procedures.
Ever having anal sexwas ascertained by asking if participants have ever had anal sex and their responses were dichotomized as “yes” versus “no.” Ever having potentially risky sexual partners was measured by asking if participants had ever had vaginal or anal sex with risky partners, as far as they knew. In our study, potentially risky partners referred to 5 criteria: anyone who has worked as a prostitute; anyone who has HIV/AIDS; anyone who has injected drugs; anyone whose sexual history was not known very well; and has a risky partner who cannot be categorized as one of the previous criteria. When participants agreed with one of the conditions, responses were coded “yes” and otherwise, coded “no.” More than one sex partner in past 6 monthswas coded “yes” for having had more than one partner in the past 6 months and “no” for one or no partners. Sex at age 16 or before was coded “yes” if participants had first had vaginal intercourse at age of 16 or before and otherwise, coded “no.”
Three variables were used to measure mental health status, and these variables were also dichotomized. (1) Moderate to severe depression was examined by utilizing 20 questions from the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977). CES-D scores greater than or equal to 16 were coded “yes” and otherwise, coded “no.” (2) Lifetime suicidal ideation was measured by asking if participants had ever seriously thought about committing suicide. (3) Lifetime suicide attempt was coded “yes” if a participant had ever attempted to commit suicide.
Age at the time of the interview was divided into two groups: age 18 to 27 years versus age 28 to 35 years. Education was classified into three groups: (1) High school diploma or less; (2) In college or graduate from a college; and (3) Graduate school or professional school. Birth place was categorized as either born in Asia or born in U.S. Ethnicity was expressed in Korean, Chinese, Vietnamese or Other, which indicates a mix of one of these races.
Child maltreatment was determined by asking if the following experiences occurred by the time they started 6th grade. Neglect was evaluated using the following two questions, “How often had your parents or other adult caregivers left you home alone when an adult should have been with you?” and, “How often had your parents or other adult caregivers not taken care of your basic needs, such as keeping you clean or providing food and clothing?” A respondent was considered to have been neglected if she experienced either situation one or more times. Physical abuse was assessed by asking “How often had your parents or other adult caregivers slapped, hit or kicked you?” An answer of one or more times constituted the occurrence of physical abuse. Sexual abuse was determined by responses of “How often had one of your parents or other adult caregivers touched you in a sexual way, forced you to touch him or her in a sexual way or forced you to have sexual relations?” When a participant reported one or more times of the incidence, she was said to have experienced sexual abuse. These measures were drawn from the National Study of Adolescent Health (Wave 3) (National Longitudinal Study of Adolescent Health, 2001).
First, if a respondent did not identify any type of maltreatment, she was identified as never been maltreated (No maltreatment). “Pure” types are categorized: (1) Neglect only (Figure 1.a); (2) Physical abuse only (Figure 1.b); and (3) Sexual abuse only (Figure 1.c). “Multiple maltreatment type combinations” are identified as follows: (1) Physical abuse plus neglect (Figure 1.d; both physically abused and neglected, but not sexually abused); and (2) Sexual abuse plus other maltreatment (Figure 1.e, f and g; sexual abuse and any other type of maltreatment, neglect or physical abuse).
Pearson χ2 tests were performed to compare the proportions of HIV risk behavior and mental health outcomes among women who were exposed to child maltreatment (Table 3). We ran multiple logistic regression models of HIV risk behaviors and mental health outcomes, adjusting for participants’ age group, education level, birth place, and ethnicity. These regression analyses were performed to estimate the effect size of child maltreatment types on HIV risk behaviors and mental health outcomes. The threshold of 0.05 was used as the significance level to test the statistical hypotheses. In our exploratory analysis, we made sure that there was no multicollinearity in the models by obtaining the variance inflation factors (VIFs). The VIFs of predictor variables were about 1, which provides sufficient evidence that there was no concern for multicollinearity.
This study found that 73.3% women in our sample reported one or more types of child maltreatment. Among those who were victims of child maltreatment (n = 293), physical abuse was the most prevalent form of child maltreatment (58.4%). More than one third of the sample reported having experienced physical abuse plus neglect. Approximately 7% of the total sample reported sexual abuse in combination with other maltreatment. The most common form of sexual abuse was sexual abuse combined with both neglect and physical abuse (4.3%). The majority of sexual abuse victims reported co-occurring maltreatment; only one individual reported sexual abuse only.
Table 1 presents the number and percentage distributions of Asian-American women by demographic characteristics. Among the 400 study participants, Chinese is the most predominant ethnic group in this study, followed by Korean, Vietnamese and Other. The majority of our sample had a college degree or was in college, and more women were born in the U.S. than Asia.
Table 2 provides prevalence of HIV risk behaviors, depression, and suicidality. In regard to HIV risk behaviors, approximately 20% reported ever having anal sex, and almost 60% reported ever having potentially risky sexual partners, including those whose sexual histories were not known very well to them. In terms of mental health outcomes, 31% of participants reported moderate to severe depression score, about 16% had lifetime suicidal ideation, and 8% had lifetime suicide attempts.
Table 3 shows the proportion of HIV risk behaviors and mental health functioning by six different types of maltreatment. The proportion of women who had sex at age 16 or before was the highest among participants who experienced sexual abuse plus other maltreatment. However, this pattern was not consistent in the other three HIV risk behaviors. None of the child maltreatment types were significantly associated with HIV risk behaviors.
However, the association between sexual abuse plus other maltreatment and mental health outcomes was stronger than the association with HIV risk behaviors. Approximately 4 out of 10 women who experienced sexual abuse plus other maltreatment during childhood reported moderate to severe depression (p = 0.011), and two out of 10 who experienced sexual abuse plus other maltreatment reported ever having attempted suicide (p = 0.006).
Table 4 shows the adjusted odds ratios and 95% confidence intervals for multiple logistic regression models for HIV risk behaviors, adjusting for age, education, birth place, and ethnicity. Exposure to child maltreatment, including physical or sexual abuse, was not associated with HIV risk behaviors. However, age and higher education were significant explanatory variables for both ever having anal sex and ever having potentially risky sexual partners, and ethnicity was also a significant explanatory variable for ever having potentially risky sexual partners.
Table 5 presents the results of multiple logistic regression models for mental health outcomes. These models indicate that having experienced sexual abuse plus other maltreatment during childhood was significantly associated with a greater likelihood of reporting both having experienced depression, suicidal ideation (model p = 0.06) and attempted suicide, controlling for demographic and background characteristics. Sexual abuse plus other maltreatment increased the risk of having moderate to severe depression by 3 times, having suicidal thoughts in one’s lifetime by almost 4 times and having attempted suicide in one’s lifetime by almost 12 times. None of the covariates were associated with any of the mental health outcomes.
Our study found that 73% of Asian-American women reported some type of child maltreatment. This overall maltreatment prevalence (73%) is substantially higher than a report from a community sample of adult women as well as a nationally representative sample of young women in the U.S., which were estimated at approximately 30-50% (Scher et al., 2004; Hahm et al., 2010). The high prevalence of maltreatment within our sample is similar to self-reported data from Asian college students that found substantially higher levels of physical abuse, emotional abuse, and neglect, compared to their White counterparts (Meston, Heiman, Trapnell, & Carlin, 1999). Our findings corroborate that child maltreatment appears to be more common among Asian-American immigrant families.
Our study also found that among those who were maltreated, any physical abuse (58%) was the most common form of abuse in this study, similar to other studies of Asian-American immigrant families (Chang et al., 2006; Rhee et al., 2008). Furthermore, among those who were maltreated, the prevalence of any physical abuse in our study (58%) was higher than the prevalence found in studies which examined predominantly White and Black women (44%-54%) (Hahm et al., 2010; Scher et al., 2004).A possible explanation for this phenomenon may be found in Asian culture, where corporal punishment is a common childrearing practice (Hahm et al., 2001; Park, 2001; Zhai & Gao, 2009).It is suggested that physical child abuse may be a byproduct of excessive physical discipline and corporal punishment (Whipple & Richey, 1997), as there is a fine line between corporal punishment (e.g., spanking) and physical child abuse. Therefore, the combination of cultural practices (i.e., corporal punishment) and excessive physical disciplinemay put Asian parents at high risk for engaging in physical abuse (Whipple & Richey, 1997).
We found striking contrasts in the associations between multiple maltreatment and HIV risk behaviors and mental health outcomes. Exposure to multiple child maltreatment (physical abuse plus neglect, sexual abuse plus other maltreatment) linked to substantial increases in risks of poor mental health functioning. In particular, sexual abuse plus other maltreatment was the only significant variable which increased odds of all three mental health outcomes (depression, lifetime suicidal ideation, and lifetime suicide attempts). In contrast, multiple maltreatment did not have any association with any HIV risk behaviors despite the fact that the prevalence of HIV risk behaviors was relatively higher than mental health outcomes. Asian-American victims may perceive that manifesting their trauma through externalizations, including engaging in risky sexual behaviors, brings greater chance of shame and loss of face to themselves and their families. Hence, Asian-American women who have been sexually abused may choose to internalize their trauma and suffer alone in order to maintain family harmony, one of the most important values among Asian families (Futa, Hsu, & Hansen, 2001). Our findings challenge the conventional belief that experiencing child sexual abuse leads to sexual risk behaviors, including promiscuity, due to a failure to form long-term attachments in adulthood (Anda et al., 2006). Rather, our findings raise the possibility that Asian cultural dynamics play an important role in how Asian-American women exhibit symptoms of early childhood trauma. This pattern of internalization of trauma is particularly compelling since 66.7% of the sample was born, raised, and received education in the U.S., yet still reacted to maltreatment in an “Asian way.” In Asian cultural contexts, family violence, particularly sexual abuse, burdens the entire family and community with a deep sense of shame, loss of face, and stigma, which goes beyond the individual level (Futa et al., 2001). Consequently, family violence tends to be concealed by the individual to avoid social ostracism. Rao et al. (1992) found Asian-American children to be the least likely to disclose their sexual abuse history to their mothers, compared to White, Black, and Hispanic victims.
The robust links between multiple child maltreatment and mental health outcomes suggest that mental health treatment services should incorporate a family violence component when treating Asian-American women. Therefore, in order to prevent severe depression and suicidality among Asian American women, mental health clinicians should screen for a history of child maltreatment and specifically look for experience of sexual abuse plus other maltreatment. The direct and indirect impact of stigma on the mental health functioning of these women should be captured and measured during assessment. During treatment, the issues of shame and stigma should be explored, and both children and parents should have opportunities to understand and process the specific impact of multiple child maltreatment on their mental health functioning. Treatment should also include monitoring suicidal behaviors of those who were exposed to sexual abuse plus other maltreatment and ascertaining strategies to follow up with these women in case of premature drop out from treatments. In addition, for community interventions, Asian-American student and community organizations should promote awareness about the linkages between multiple child maltreatment and depression, suicidal ideation, and suicide attempts in Asian-American communities. Finally, Asian-American organizations should advocate for child maltreatment prevention programs and support campaigns that address the harm that may be produced by a face-saving culture deeply permeating from the individual and family level to the community.
Being in college or graduate school was associated with increased odds of HIV risk behaviors, including ever having anal sex and ever having potentially risky sexual partners. The prevalence of HIV risk behaviors among our sample also supports previous literatures (Hahm, Lee, Ozonoff, & Amodeo, 2007; Hahm, Lee, Rough, &Strathdee, 2011) indicating that although Asian-Americans have a later sexual debut, those who are sexually active have similar risk behavior profiles to other racial groups. Only 15% of our sample reported having sex at age 16 or before, yet almost 60% had ever had potentially risky sexual partners. The college environment may offer an “escape zone” where Asian-American women can experience their sexuality and become involved in risky sexual behaviors, especially for those who were raised with an emphasis on sexual conservatism. Thus, HIV preventive programs should target Asian-American women who may be engaging in HIV risk behaviors beginning in the college setting.
The present study has several limitations. First, only 7% of our sample reported some type of sexual abuse. This proportion is markedly lower than that of other racial groups of women in the U.S. which ranges from 10-27% (Feldman et al., 1991; Putnam, 2003). Our sample might have underreported due to the limitation of how sexual abuse was measured. Finkelhor (1994) found that retrospective self-report studies which asked two or more questions on sexual abuse generated higher prevalence than asking one question. Considering this crude measure of sexual abuse, the lack of a relationship between multiple maltreatment and HIV risk behaviors requires verification in future research where a more sophisticated child maltreatment measure is employed. We note, however, the same child maltreatment measure used in our study has been extensively employed in other studies predicting substance use, mental health, and HIV risk behaviors (Currie & Tekin, 2006; Kim, 2009; Ouyang, Fang, Mercy, Perou, & Grosse, 2008; Slade & Wissow, 2007).
Second, we indicated that the non-study participants, who did not complete the maltreatment questions, were more likely to be born in Asia compared to the study participants who provided complete child maltreatment information. It is possible that those who skipped the child maltreatment questions are more likely to adhere to Asian norms of face-saving and stigma related to child maltreatment; thus, the actual child maltreatment prevalence may be potentially higher. Lastly, our sample is skewed toward higher educational groups; therefore, our findings cannot be generalized to Asian-American women with lower socioeconomic status. Despite these limitations, this is the first systematic and comprehensive study that shows that HIV risk behaviors and mental health outcomes among Asian-American women have varying predictors; further, it uncovers distinct mechanisms of multiple maltreatment on HIV risk behaviors and mental health outcomes among Asian-American women.
This study was funded by a Mentored Research Scientist Development Grant (K01), National Institute of Mental Health (Primary Investigator: H.C.H., 1K01 MH086366-01A1). Dr. Eric Kolaczyk and Jisun Jang are supported by Office of Naval Research Award N000140910654. Authors would like to acknowledge Dr. Donald Cox for his valuable comments and suggestions for this paper.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.