Reading Analyses

VIOLENCE AGAINST WOMEN ‘J/ July 2002Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE An Empirical Inv\bstigati\non of th\b Psychological S\bqu\bla\b \nof Childhood S\bxual Abus\b in an Adult Lat\nina Population JOSIE VEGA HINSON Full\br Th\bological S\bmi\nnary CATHERINE KOVEROLA \fniv\brsity of Maryla\nnd, Baltimor\b MARY MORAHAN Los Ang\bl\bs County and\n \fniv\brsity of South\n\brn California Viol\bnc\b Int\brv\bntion Program This study \bxamin\bd th\b \bff\bcts of childhood s\bxual abus\b on p\brc\biv\bd social support among Latino wom\bn using th\b S\blf-In-R\blation th\bor\btical ori\bntation and th\b Compr\b- h\bnsiv\b Mod\bl of Trauma Impact to \bxamin\b th\b impact of child s\bxual abus\b. Partici- pants includ\bd 54 Latina survivors of child s\bxual abus\b s\b\bking m\bntal h\balth s\brvic\bs.

Th\b r\blationship b\btw\b\bn aff\bctiv\b distr\bss, int\brp\brsonal s\bnsitivity, and p\brc\biv\bd social support was inv\bstigat\bd. Findings r\bv\bal\bd d\bpr\bssion was a statistically signifi- cant pr\bdictor of int\brp\brsonal s\bnsitivity, sr(3, 49) = .45, p< .005) and of p\brc\biv\bd social support for both Important P\brson, r(47) = –.34, p< .05, and P\bopl\b in P\brsonal Lif\b, r(47) = –.38, p< .01. Clinical implications ar\b discuss\bd from a Latino cultural p\brsp\bctiv\b.

Th\b long-t\brm n\bgativ\b impact of child sexual abuse on the survivor has been extensively documented (Briere & Runtz‘b 1988; Bryer‘b Nelson‘b Miller‘b & Krol‘b 198‘f; Finkelhor & Browne‘b 1985; Landecker‘b 1992; Murphy et al.‘b 1988; Roesler & McKenzie‘b 1994; Rowan‘b Foy‘b Rodriguez‘b & Ryan‘b 1994; Wolfe & Wekerle‘b 1994). To date‘b the child sexual abuse research has focused predominantly on the majority Caucasian population with only limited research with minority populations (Arroyo‘b Simpson‘b & Aragon‘b 199‘f). Given the explosion of growth among minority populations in the United States‘b particularly among Latinos‘b there is an increasing need to understand how child sexual abuse affects minority populations.

816 VIOLENCE AGAINST WOMEN‘b‘J Vol. 8 No. ‘f‘b July 200 2816-84 4 © 2002 Sage Publicat‘Jions In this study, the Comprehensive Model of Trauma Impact and Self-In-Relation theoretical orientation are used to provide a con - ceptual framework from which to empirically investigate the impact of child sexual abuse among Latina survivors. The study focusedspecifically on the relationship of affective symptomatology and interpersonal support.

COMPREHENSIVE MODEL OF TRAUMA IMPACT The trauma of sexual abuse and its negative impact is not a lin - ear pathway but involves many interactive variables. Childhood sexual abuse does not occur in a vacuum. It happens to a unique individual who lives in a particular context, which includes imme - diate family, extended family, community, culture, and society. To conceptualize the impact of child sexual abuse and to consider the numerous issues involved in assessing child sexual abuse, Koverola and colleagues (Koverola, 1992) developed the Comprehensive Model of Trauma Impact (CMTI) (see Figure 1). This model pro- vides a framework for examining child sexual abuse and how it affects an individual’s areas of functioning, the nature of the trauma, and the particular systemic context in which the abuse occurred. The CMTI identifies a number of areas of functioning that can be affected by child sexual abuse, including cognitive, affective, moral, interpersonal, sexual, and physical. Further- more, the model considers the systemic context in which the indi- vidual exists that is understandably also affected by child sexual abuse, including family, community, and society.

The nature of the trauma is another important variable consid- ered by the CMTI. For example, child sexual abuse often co-occurs with other forms of victimization. Survivors may have been con- currently exposed to domestic violence, community violence, psychological abuse, physical abuse, or neglect. This is an impor- tant component of this model because clinicians and researchers have come to realize that many child sexual abuse victims have suffered multiple forms of victimization (Koverola & Friedrich, 2000).

Finally, the model recognizes that the effects of the trauma may not occur immediately. Delayed effects, such as anxiety related to sexual intimacy or body image, may not occur until adolescence Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 817 or young adulthood, and parenting issues, due to their own intrafamilial abuse, are not likely to appear until they have their own family. Because individuals are in a constant state of devel- opment, it is important to recognize that events occur on a contin- uum (i.e., pretrauma, trauma, and posttrauma), and the effects of trauma must be examined with this factor in mind.

The CMTI is a model and, as such, provides a framework to consider the interplay between the numerous factors believed to be important when conducting research or clinical interventions with child sexual abuse survivors. The model does not provide a theoretical basis to hypothesize the mechanism or process by which these variables are related. For a theoretical perspective to facilitate the understanding of how child sexual abuse has an 818 VIOLENCE AGAINST WOMEN / July 2002 INDIVIDUAL FAMILY COMMUNITY SOCIETY TRAUMA AREAS OF FUNCTIONING PHYSICALCOGNITIVE SEXUALAFFECTIVE INTERPERSONALMORAL PRETRAUMATRAUMAPOSTTRAUMA Figure 1: Comprehensive Model of Trauma Impact SOURCE: Koverola (1992). impact on survivors, we turn to the Self-In-Relation theoretical orientation (Jordan, 1997).

SELF-IN-RELATION THEORETICAL ORIENTATION The Self-In-Relation theoretical orientation, developed at the Stone Center for Developmental Service and Studies at Wellesley College, provides a particularly useful theoretical framework for investigating the impact of trauma on areas of an individual’s functioning within a particular context (Surrey, 1991). It is also inherently appropriate for use in research with a minority popula - tion, including Latinas, because it explicitly addresses cross- cultural issues (Jordan, 1997).

The Self-In-Relation theoretical orientation conceptualizes iden- tity development as forming in the context of relationships. This orientation emphasizes the centrality of relational development rather than focusing on the development of autonomy and self- sufficiency. Self-differentiation, therefore, takes place in the con- text of relationships without the usual losses associated with per- sonal development. Women continually add to their primary rela- tionships to support their age-appropriate development. People grow because they are in relationships. Positive growth is thus measured by a person’s ability to participate in meaningful rela- tionships that positively affect one another. It is an “ongoing pro- cess of intersubjective relationship” that allows the self to grow in depth and vitality (Surrey, 1991).

The Self-In-Relation does not label cultural differences as devi- ant, deficient, or pathological (Surrey, 1991; Turner 1997). It empha- sizes the importance of interconnection, the evolutionary concept of the “relational self,” in women’s development—an important value for Latina culture, especially the relational context of the family (Turner, 1997). Moreover, rather than valuing autonomy and separation, the Self-In-Relation model allows for more tradi- tional values that are dominant in Latina culture. It can serve to validate and legitimize a significant part of the Latina woman’s maturation process, that is, her growth in community and espe- cially within ongoing significant relationships. Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 819 CHILD SEXUAL ABUSE AS AN INTERPERSONAL TRAUMA Child sexual abuse occurs in relationships and causes personal and interpersonal harm. It follows, then, that the affective difficul - ties and the interpersonal nature of child sexual abuse can affect a survivor ’s current and subsequent interpersonal relationships.

When child sexual abuse occurs, the sense of self is harmed within an interpersonal context. Therefore, the mechanism to rebuild the self or repair the psychological damage requires being in connec - tion with others (Ducharme, Koverola, & Battle, 1997; Herman, 1992). Healthy adult relationships depend on a secure sense of one’s self in relation to another, the ability to trust another, the capability to regulate one’s emotions, and the judgment to know when one can or cannot rely on another (Cole & Putnam, 1992).

Child sexual abuse can impair one’s perception of others. By the time the child sexual abuse survivor reaches adulthood, the cumulative effect of impairments to self and social functioning are likely to influence development and the transitions made into adulthood (Herman, 1992). The documented interpersonal diffi- culties that occur in child sexual abuse survivors include poor social adjustment, difficulty trusting others, social isolation, diffi- culty forming or maintaining relationships, feelings of alienation, isolation, and insecurity, parenting difficulties, physical abuse, and sexual revictimization (Barnett, Miller-Perrin, & Perrin, 1997; Herman, 1992).

Studies also indicate that the relationship with the perpetrator affects the long-term adjustment to child sexual abuse (Briere & Runtz, 1988; Browne & Finkelhor, 1986; Huston, Parra, Prihoda, & Foulds, 1995). These researchers found greater impairment in psychological adjustment when the perpetrator was someone in the family, particularly if the perpetrator was the father, a father figure, or someone with whom the individual had a close emo- tional relationship (Barnett et al., 1997; Beitchman et al., 1992; Briere & Runtz, 1988; Browne & Finkelhor, 1986; Huston et al., 1995). In a comparative study that examined the impact of child sexual abuse on survivors who experienced intrafamilial versus extrafamilial sexual abuse, Gregory-Bills and Rhodeback (1995) found that the trauma experienced is likely to be aggravated when the perpetrator was a family member. However, one study 820 VIOLENCE AGAINST WOMEN / July 2002 on depression and child sexual abuse in Latinos reported the woman’s relationship to the perpetrator did not influence her scores on depression when compared to child sexual abuse by a stranger (Roosa, Reinholtz, & Angelini, 1999). Yet, these research - ers cited several methodological problems and stated their results should be interpreted with caution. In sum, these studies not only indicate the prevalence of child sexual abuse within the family, but they also underscore the harmful and long-lasting effects that result from intrafamilial child sexual abuse.

FACTORS INFLUENCING THE OUTCOME OF ABUSE An investigation of social support and long-term psychological adjustment after child sexual abuse found that a negative response from others might aggravate the traumatic symptoms (J. Edwards & Alexander, 1992; Herman, 1992). For example, the child sexual abuse victim’s perception of the childhood family environment was found to be a predictor of anxiety and depression in adult women (Yama, Tovey, & Fogas, 1993). Other research indicates that when child sexual abuse occurs, an important mediating variable related to subsequent adult psychological distress is the family environment as perceived by the victim (Alexander, 1992; Nash, Hulsey, Sexton, Harralson, & Lambert, 1993). When child sexual abuse occurs, the family is also affected, whether the abuse occurred within or outside the family. How the family responds can affect the outcome of child sexual abuse. For example, in a study done by Gold (1986), the woman’s perception of her mother ’s response to the child sexual abuse significantly related to her adult functioning. However, it is not only how the family responds but also the response of other sources of support, including teach- ers, other adults, and institutions, that can mitigate or even play a protective role in the outcome of child sexual abuse (Gomes- Schwartz, Horowitz, & Cardarelli, 1990; Herman, 1992).

Because the response of others can affect the impact of child sexual abuse, this suggests that social support can serve as a means of helping the survivor cope with and heal from interper- sonal trauma. The influence of the family is also an important fac- tor in the long-term effects of child sexual abuse. Specifically, Mar- tinez (1988) found that Mexican-Americans’ use of the family as a Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 821 supportive network has served as a means to help them tolerate stress and dysfunction better. Finally, the importance of social support in general has been documented to have a positive impact on the treatment and recovery from child sexual abuse (Liese, 1999).

CROSS-CULTURAL ISSUES IN CLINICAL RESEARCH Researchers have recognized that there are cultural differences in values and behaviors that affect the outcome of events and do not necessarily point to pathological or deviant problems. For example, because of the differences found in a study comparing child sexual abuse and depression among four ethnic groups, researchers concluded that it is important to examine the effects of child sexual abuse separately for various ethnic groups (Roosa et al., 1999). Sue (1991) pointed out that “in ethnic minority issues, we need to recognize that some standards or criteria assumed to be universal (etics) are actually specific (emics) to mainstream American society” (p. 74). Sue argues that cross-culturally compe- tent researchers need to use an emic-based conceptual framework— namely, a framework designed from the perspective of the partic- ular culture under investigation. This avoids misinterpretations of ethnic minority behaviors. Therefore, unraveling the psycho- logical sequelae of child sexual abuse requires an examination of the values and attitudes that are in effect for the survivor ’s family system, including their particular cultural milieu.

LATINA CULTURE DEMOGRAPHICS The termLatinacomprises a very diverse group of people in whom there are distinct differences from others and from other Latinas. Within the Latino population are various groups: the Mexican-origin population constituting 60% (or two thirds); Cen- tral Americans, South Americans, and other Latinos, comprising 22%; Puerto Ricans, 12%; and Cubans, 5%. These various groups 822 VIOLENCE AGAINST WOMEN / July 2002 are concentrated in different parts of the country but are highly urbanized (67%) (Vasquez, 1994).

FAMILY AND VALUES For Latinas, family and familial responsibilities are integral aspects of life. “The family” includes concepts of extended family, loyalty/respect for family, and family unity. Cooperation rather than competition and the value of maintaining interpersonal rela - tionships within the family in contrast to the importance of indi - viduality are central components of the Latina family (Comas- Díaz, 1995; Sue & Sue, 1990). Family members, including the extended family, are expected to be a source of emotional support for one another, and familial obligations or responsibility to the family are viewed as a priority above other obligations. There is a high paternal or male dominance with different cultural expecta- tions for men and women within the family. There are varying degrees of acculturation within the family that, particularly among Mexican Americans, usually result in parents who are first- generation U.S. residents being more traditional in their roles, whereas their children adopt a more “modern” approach or become bicultural (Martinez, 1988). Negy and Woods’s (1992) review of the Latino acculturation literature found that some studies indicate that increases in the level of acculturation changes the role of the family for the individual but to varying degrees.

Gaines (1997) reported that studies have shown that “familism is more pronounced as a cultural value among Latinas/os than among Anglos,” (p. 43), also suggesting that the family is an important source of social support in Latino culture. Within the Latino family, there are culturally based patterns of childrearing and parental expectations that differ from the dominant Cauca- sian culture in America. These include the expectation of silence among children, the expectation that children should be able to control their emotions, respect for adults within the family, and taboos against discussing sexual issues (Sanders-Phillips, Moisan, Wadlington, Morgan, & English, 1995). This orientation to the family and its values produces the following consequences: (a) the family is valued higher than the individual; (b) depending on the level of acculturation, conflicts in values are likely to occur Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 823 between parents, grandparents, and children; and (c) if marital conflicts occur, divorce is seen as a less acceptable option than working things out for the good of the family (Sue & Sue, 1990).

LATINO VALUES MAY AFFECT CHILD SEXUAL ABUSE Latino families, with their high level of interpersonal closeness and involvement, can be a strong source of social support or stress for child sexual abuse survivors. Vasquez (1994) cites the cultural characteristics of support from the family, family obligations, and family as referents (relatives as attitudinal and behavioral models of identity) as the core characteristics of Latino culture. The sup - portive family has been found to provide a buffer, or ameliorative effect, to stress for Mexican Americans (Martinez, 1988). How - ever, it is just as likely that additional stressors, because of the demanding cultural expectations placed on Latinas, may make it more difficult to resolve issues of abuse. For example, Sanders- Phillips et al. (1995) cite a scenario where an abused Latino child may remain silent after the abuse because of cultural constraints or because of placing the family above one’s own needs or wishes.

Comas-Díaz (1995) argues that the cultural value of respect (respeto) may actually place children at increased risk for sexual abuse and in the position of maintaining silence. Comas-Díaz points out that the child who is abused by someone deserving of respect will fear breaking the silence due to respect for the abuser and fear of the consequences. In addition, given these cultural values, the Latina’s ability to seek support outside the familial context when she has been sexually abused can be compromised. That is, the cultural value of keeping one’s personal problems within the family can function as a barrier to obtaining social support. In sum, the Latino family’s values may contribute to the impact of child sex- ual abuse either positively or negatively (Comas-Díaz, 1995). MULTIPLE FORMS OF VICTIMIZATION AND CHILD SEXUAL ABUSE There are other issues that are likely to affect the psychological adjustment of Latinas to child sexual abuse. Research indicates that child sexual abuse survivors often suffer multiple forms of victimization due to living in the inner city, in substandard housing, 824 VIOLENCE AGAINST WOMEN / July 2002 and being unaware of resources that can be of help (Koverola, Proulx, Battle, & Hanna, 1996; Nadon, Koverola, & Schluderman, 1998). Examples include exposure to violence and crime, natural disasters, institutional racism, and discrimination (Wyatt, 1990).

Stigmatization has been identified as a traumagenic dynamic due to child sexual abuse (Finkelhor & Browne, 1985). Racism can make people feel angry, helpless, or betrayed, and may parallel the dynamics of child sexual abuse, adding to the stigmatization experienced when one is sexually abused (Wyatt, 1990). Minor - ities in general are likely to confront neglect, hostility, and preju - dice, and this heightens the effects of a crisis, such as child sexual abuse (Norris, 1992). Comas-Díaz (1995) points out that among some Latinas, there is evidence of a cultural fatalism in response to sexual abuse:Eso tenia que pasar(“It had to happen”). She argues that this must be examined within the context of colonialism. In response to historical domination and political control, cultural fatalism may have developed as a realistic adaptation to the limi- tations imposed by external realities. The cumulative effects of multiple forms of victimization are often, unfortunately, an all too common part of the Latina’s life experience and must not be overlooked.

RATIONALE The long-term negative impact of child sexual abuse on the sur- vivor has already been substantially documented in the literature.

However, there is a paucity of research investigating the impact among minorities (Arroyo et al., 1997; Vasquez, 1994). The little research that has been done on Latinas has been done with chil- dren or adolescents, comparing them to members of other ethnici- ties who have experienced childhood sexual abuse (Arellano, Kuhn, & Chavez, 1997; Huston et al., 1995; Kellogg & Hoffman, 1995; Lindholm & Willey, 1986; Mennen, 1994, 1995; Sanders- Phillips et al., 1995). All except one of these studies (Arellano et al., 1997) found racial/ethnic differences between groups. These stud- ies reported elevated symptoms of depression, higher anxiety, differences in type of sexual abuse, and a greater frequency of feel- ing self-blame and ambivalence about their sexual abuse in minor- ity populations. There is a need for further research, with specific consideration given to cultural context. Awareness of the particular Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 825 issues Latina survivors may experience in light of their culture may be helpful in understanding the impact of child sexual abuse.

The influence of cultural values, attitudes, and beliefs may have a damaging or, in contrast, an ameliorating effect on the impact of child sexual abuse.

Research that does not impose a majority culture ethnocentric bias must, at its core, utilize a theoretical premise that considers cross-cultural issues. Research comparing one cultural group to another, for example, does not address the issues inherent within one specific cultural group. This study, therefore, will examine one specific minority group, Latinas who have experienced child - hood sexual abuse. Furthermore, this research will be guided by a theoretical orientation that places cultural issues at the center of the investigative process. Of particular interest in this study is the premise that the Latino culture is highly relational in nature, that is, strong in its familial and social ties. As such, child sexual abuse is posited to disrupt relational ties within the context of the family, affecting the survivor ’s ability to seek social support.

This study proposes that when the child sexual abuse victim suffers from depression, anxiety, or hostility, her perception of others is impaired or damaged, resulting in a heightened negative interpersonal sensitivity. The negative interpersonal sensitivity results in her being unable to accept or benefit from the social sup- port of others. These findings will have important clinical impli- cations. It is only as these clinical symptoms are addressed in ther- apy and only as the survivor is able to be in relationship with others that the survivor can recover adequately from the interper- sonal damage done by sexual abuse in childhood.

Using the CMTI’s delineation of critical variables involved in mediating the impact of child sexual abuse and utilizing the self-in-relation theoretical perspective as a guiding premise, this study investigated the affective functioning of a sample of Latinas who have been multiply victimized and are survivors of child sex- ual abuse. The study provides descriptive demographic and psy- chological adjustment information about this significantly under- studied population of minority women. Research has shown the negative psychological sequelae child sexual abuse has had on adults (i.e., depression, anxiety, and hostility). There is a need to understand how this affective damage affects the survivors’ social relationships. Social support is an especially important variable 826 VIOLENCE AGAINST WOMEN / July 2002 among Latinas and has been found to have a positive impact on treatment and recovery from child sexual abuse. Thus, the rela - tionship between affective symptoms and interpersonal sensitiv - ity as well as between these variables and perceived social sup - port was investigated. It was hypothesized that these affective sequelae of child sexual abuse interact with interpersonal sensi - tivity, which will in turn affect perceived social support.

HYPOTHESES This study included the following specific hypotheses:

1. The affective variables of depression, anxiety, and hostility will all have a significant and positive correlation with interpersonal sensitivity.

2. The variable of global distress, depression, anxiety, and hostility will have an inverse correlation with social support.

3. Interpersonal sensitivity will have a significant negative correla- tion with social support. METHOD PARTICIPANTS The participants in this study were drawn from a specialty clinic in an inner-city public hospital in Southern California pro- viding services to victims of child abuse, sexual assault, and domestic violence. The participants included 54 clients of Latin descent, aged 18 to 52, who were seeking mental health services and presenting with a history of sexual abuse. Country of origin data were not specifically obtained from participants in the study.

However, the Latina population served by the clinic is known to be predominantly Mexican American and Mexican, with a small minority being immigrants from Central American countries. MEASURES All measurement packages were available in English and Span- ish. The published Spanish version of the Symptom Checklist 90-Revised (SCL90-R) was used. All measures, except the SCL90-R were translated into Spanish. A back translation was completed Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 827 for verification. Spanish translation was completed by individuals of Mexican descent residing in Southern California and familiar with the language used within the specific community in which most participants resided. Background Demographic Questionnaire Background demographic information was obtained from an intake questionnaire. The information gathered included age, gender, ethnicity (differentiating only among Caucasian, African American, Latina, Asian, and other), language spoken at home, education, socioeconomic status, history of substance abuse,physi - cal abuse, and child sexual abuse. These data were gathered for descriptive purposes.

History of Unwanted Sexual Contact A self-report measure developed by Koverola and colleagues (1996) was used to obtain the history of sexual abuse. Child sexual abuse was defined as any unwanted physical sexual contact that occurred prior to age 18 by someone at least 5 years older than the victim. Peer sexual abuse was defined as any unwanted physical sexual contact that occurred prior to age 18 by someone less than 5 years older. Adult sexual assault is defined as any unwanted physical sexual contact having occurred after the age of 18. For the purposes of this study only child sexual abuse and peer sexual abuse forms were examined because the first incident of sexual abuse would have occurred prior to age 18. The questionnaire documents the following: type of abuse (sexual kissing; fondling of the buttocks, thighs, breasts, and/or genitals; insertion of fin- gers or objects into the vagina or anus; oral sex; attempted or com- pleted vaginal intercourse; and anal intercourse), the age of onset of the abuse, the frequency of abuse, the participant’s relationship to the perpetrator, and threatening behaviors or forms of coercion used.

SCL-90-R The Symptom Check List-90-Revised (SCL-90-R) was used to measure the global distress and symptoms of depression, anxiety, hostility, and interpersonal sensitivity (Derogatis & Cleary, 1977). 828 VIOLENCE AGAINST WOMEN / July 2002 The SCL-90-R has been used in previous research to assess the long-term effect of child sexual abuse and to measure current level of distress on child sexual abuse survivors (Greenwald, Leitenberg, Cado, & Tarran, 1990; Murphy et al., 1988; Surrey, Swett, Michaels, & Levin, 1990). The SCL-90-R is designed to assess global distress as well as provide subsections for measur - ing more specific symptomatology, such as depression, somatization, anxiety, and anger (hostility). The participant indicates which symptoms have caused her distress on a scale of 0 to 4.

In this study there are five subscales of interest: (a) Global Severity Index (GSI), (b) Depression (DEP), (c) Anxiety (ANX), (d) Hostility (HOS), and (e) Interpersonal Sensitivity (I-S). According to the SCL-90-R, the GSI is an indicator of the current depth or level of the disorder. It combines information about the number of symptoms endorsed with the intensity of perceived distress. It is a single summary measure. The DEP dimension reflects a range of symptoms as manifested in clinical depression. Symptoms of dysphoric mood and affect are common, as are signs of with- drawal of interest, loss of vital energy, and lack of motivation.

Other cognitive and somatic symptoms may occur, such as thoughts of suicide and feelings of hopelessness. The ANX dimension reflects general signs of anxiety, such as tension, trembling, rest- lessness, and nervousness. It also includes the symptoms of panic attacks, such as apprehension and feelings of terror and dread.

The HOS dimension reflects feelings, thoughts, and actions that are characteristic of the negative affect state of anger. Rage, irrita- bility, aggression, and resentment are common modes of expres- sion that are measured. Finally, the I-S index focuses on feelings of inferiority and inadequacy, especially in comparison with others.

Self-doubt, self-deprecation, and marked discomfort or acute self-consciousness during interpersonal encounters, are charac- teristic manifestations of those with a high I-S score. They also express a tendency to have negative expectations regarding inter- personal behavior with others and others’ perceptions of them. Social Relationships Questionnaire Perceived social support was measured by the Social Relation- ships Questionnaire (Abbey, Abramis, & Caplan, 1985). This self- report instrument documents the survivor ’s perception of support Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 829 in relationships. It is divided into three sections with 15 questions in each, with 6 of these questions addressing her social relation - ship with (a) an important individual in her personal life, (b) peo - ple in the participant’s personal life in general, and (c) a spouse or partner.

PROCEDURE All clients receiving services at the clinic have an initial intake interview and complete several screening measures. The mea - sures used in this study represent a subset of the data gathered as part of routine intake procedures in the clinic. Data from intakes conducted over a 12-month period were included in this study.

Participants were included if they disclosed a history of child sex - ual abuse and indicated that they were Latina. DATA ANALYSIS The data were analyzed using the Statistical Program for Social Sciences (SPSS).

RESULTS DEMOGRAPHIC CHARACTERISTICS The sample included 54 Latinas, ranging in age from 18 to 52.

The women were predominantly Spanish speaking, 50% being monolingual Spanish, 20.4% bilingual, and 25.9% English speak- ing only. The majority of the women had less than nine grades of schooling, with 9.3% having none to third grade, 16.7% having fourth to sixth grade, 20.4% having seventh to ninth grade, 33.3% having 10th through 12th grade, 11.1% having some college, and 1.9 reporting having a bachelor ’s or above. The sample was of low SES, with 65% having a household income of less than $15,000 per year. The average household included four people. Of the sample, 39% were U.S. natives, 46% reported having resided in the United States more than 5 years, with the remainder (15%) having resided in the United States fewer than 5 years. A total of 39% of the sam- ple never married, 33% were separated, 22% were married or cohabitating and 4% were divorced. 830 VIOLENCE AGAINST WOMEN / July 2002 ABUSE CHARACTERISTICS Age when abuse first occurred ranged from 3 years to 17 years; 15% were abused when they were 5 years old or younger, 39% were abused during ages 6 through 11, and 49% were abused when they were between the ages of 12 and 17. The most common type of perpetrator was someone that the survivor knew, with 69% being familial and consisting of 21.3% parent/stepparent/ guardian, 11.1% a sibling, 36.2% an extended family member, and 51.1% being an unrelated acquaintance. The remainder (25.5%) were abused by a stranger. With respect to the types of manipula - tion used by the perpetrator, 54.5% reported being coerced, 33.3% were threatened, 55.6% were physically forced, and 24.4% were physically hurt.

Within the sample, the types of sexual abuse reported included sexual kissing, fondling, insertion of fingers and objects, oral cop- ulation, attempted vaginal intercourse, completed vaginal inter- course, and anal intercourse. Frequencies are reported in Table 1. DEPENDENT MEASURES The mean scores for the distress scales on the SCL-90-R were as follows: I-S, 66.62 (SD= 9.50); DEP, 66.85 (SD= 8.04); ANX, 63.91 (SD= 9.89); HOS, 62.15 (SD= 11.20); and Global Distress, 67.35 (SD= 8.61).

The mean score for social support on the Social Relationships Questionnaire for “Important Person” was 3.28 (SD= 1.16), and “People in Personal Life” was 2.96 (SD= 1.06). Reliability analysis of the subscale for social support for “Important Person” was .90 and for “People in Personal Life” .87, using a Cronbach’s alpha. RELATIONSHIP OF AFFECTIVE FUNCTIONING AND INTERPERSONAL SENSITIVITY A Pearson correlation was used to test whether the affective variables of depression, anxiety, and hostility were significantly correlated with interpersonal sensitivity. The relative contribu- tion of these variables was determined using partial correlational analysis. As hypothesized, each of the affective scales on the SCL-90-R was found to correlate significantly with I-S; with DEP, r(51) = .67,p< .0005; with ANX,r(51) = .56,p< .0005; and with Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 831 HOS,r(51) = .53,p< .0005. Post hoc analysis using partial correla- tions and a Bonferroni test with the alpha set at .02 revealed that when controlling for anxiety and hostility, only depression remained significant,sr(3, 49) = .45,p< .001. These findings are reported in Table 2.

832 VIOLENCE AGAINST WOMEN / July 2002 TABLE 1 Sexual Abuse Types and Frequency Type of Sexual Abuse Frequency Sexual kissing Never 19 Once or twice 14 3 to 10 times 6 11 to 20 times 3 More than 20 times 11 Fondling of the buttocks, thighs, breasts, genitals Never 10 Once or twice 19 3 to 10 times 7 11 to 20 times 1 More than 20 times 16 Insertion of fingers or objects into vagina/anus Never 12 Once or twice 18 3 to 10 times 7 11 to 20 times 1 More than 20 times 15 Oral sex Never 13 Once or twice 17 3 to 10 times 7 11 to 20 times 1 More than 20 times 15 Attempted vaginal intercourse Never 31 Once or twice 12 3 to 10 times 4 11 to 20 times 2 More than 20 times 3 Completed vaginal intercourse Never 40 Once or twice 6 3 to 10 times 2 11 to 20 times 2 More than 20 times 2 RELATIONSHIPS OF GLOBAL DISTRESS AND PERCEIVED SOCIAL SUPPORT It was predicted that global distress would be inversely corre- lated with perceived social support. In particular, it was hypothe- sized that depression, anxiety, and hostility would correlate with perceived social support. A zero-order correlation revealed that Global Distress was significantly correlated with perceived social support in the negative direction when the client is considering “People in Personal Life,”sr(47) = –.34,p< .05. Global Distress was not significantly correlated with “Important Person.” Zero-order correlations found depression was significant for both aspects of social support; the finding for “Important Person” wassr(47) = –34,p< .018, and for “People in Personal Life”,sr(47) = –38,p< .007, whereas anxiety and hostility were not significant. The alpha level for each Bonferroni test was adjusted to .02. These findings are reported in Table 3. RELATIONSHIP OF INTERPERSONAL SENSITIVITY AND PERCEIVED SOCIAL SUPPORT A Pearson correlation was computed to determine whether interpersonal sensitivity was negatively correlated with perceived social support. It was found that interpersonal sensitivity was inversely correlated with perceived social support only when the client was considering an “Important Person,”r(48) = –.30,p< .05, and not significant with “People in Personal Life.” These findings are reported in Table 4. In addition, post hoc analysis using a Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 833 TABLE 2 Correlation Matrix: Intercorrelations Between Interpersonal Sensitivity and Affective Variables in Child Sexual Abuse Survivors Variable IS Dep Anx Hos IS — .67*** .56*** .53*** Dep — .72*** .54*** Anx — .64*** Hos— NOTE: IS = interpersonal sensitivity; Dep = depression; Anx = anxiety; Hos = hostility.

n= 51.

***p< .0005. protected-F test revealed that both forms ofsocial support were highly correlated with depression; “Important Person” wassr(48) = –.30,p< .05, and “People in Personal Life” wassr(48) = –.33,p< .05. Although “Important Person” and “People inPersonal Life” were correlated with each other,sr(48) = .38,p< .01, when depres- sion was controlled for, neither “Important Person” nor “People in Personal Life” was found to be significantly correlated.

DISCUSSION It was predicted that in child sexual abuse survivors, the symp- toms of depression, anxiety, and hostility would be significantly correlated with interpersonal sensitivity. That is, as depression, anxiety, or hostility increased, so would interpersonal sensitivity.

As predicted, when depression, anxiety, or hostility was reported as part of the client’s affective symptomatology, interpersonal sensitivity also was a significant symptom. These findings corrob- orate results in the literature that find these affective symptoms to often be the sequelae of child sexual abuse (Briere & Runtz, 1988; Browne & Finkelhor, 1986; Murphy et al., 1988; Surrey et al., 1990).

Further examination of the data using post hoc analysis revealed that when each of the affective variables was held constant, depression was the only variable found to be significantly corre- lated with interpersonal sensitivity. This finding provides stron- ger support for previous studies that found that depression is one 834 VIOLENCE AGAINST WOMEN / July 2002 TABLE 3 Correlation Matrix: Intercorrelations Between Global Distress, Affective Variables, and Social Support in Child Sexual Abuse Survivors Variable SSIP SSPPL Global Dep Anx Hos SSIP — .37** –.25 –.34* –.18 –.26 SSPPL — –.34* –.38** –.27 –.19 Global———— Dep — — — Anx — — Hos— NOTE: SSIP = social support by an important person; SSPPL = social support by people in personal life; Dep = depression; Anx = anxiety; Hos = hostility.n= 51.

*p< .05. **p< .01. of the most salient long-term negative sequelae of child sexual abuse (Beitchman et al., 1992; Greenwald et al., 1990; Jumper, 1995; Roesler & McKenzie, 1994). Of particular interest to this study is that this result is also consistent with the findings of a study that examined child sexual abuse and depression in four ethnic groups. The results found depression to be a significant symptom among the Mexican American women (n= 472) who reported a history of child sexual abuse (Roosa et al., 1999). There- fore, although interpersonal sensitivity has components of anxi- ety and hostility, it is depression alone that significantly accounts for the interpersonal sensitivity of child sexual abuse survivors.

These findings highlight that depression needs to be closely assessed in child sexual abuse survivors, even when they may present with other distress symptomatology. Clinical assessment of child sexual abuse survivors should include a careful differenti- ation of the broad range of distress symptomatology.

It was hypothesized that depression, anxiety, and hostility would correlate with perceived social support. This part of the study extends previous research that found global distress and the affective symptoms of depression, anxiety, or hostility to be significant consequences of child sexual abuse (Briere & Runtz, 1988; Browne & Finkelhor, 1986; Greenwald et al., 1990; Murphy et al., 1988; Surrey et al., 1990). Initial analysis revealed that global distress was significantly correlated with perceived social sup- port, but only when participants were considering an important person in their lives (such as a spouse, relative, or close friend) rather than people they viewed as important, such as family or any group. However, when depression was controlled for, there Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 835 TABLE 4 Correlation Matrix: Intercorrelations Between Interpersonal Sensitivity and Social Support in Child Sexual Abuse Survivors Variable IS SSIP SSPPL IS — –.30* –.13 SSIP — .38** SSPPL — NOTE: IS = interpersonal sensitivity; SSIP = social support by an important person; SSPPL = social support by people in personal life.n= 51.

*p< .05. **p< .01. was not a significant correlation between global distress and any kind of perceived social support (i.e., neither important person nor important people was significant). Results suggest that depres - sion is the main factor that must be considered in relationship to perceived social support.

Social support consists of the positive interpersonal relation - ships a person has with several people. Having healthy relation - ships is an important part of self-formation and personal growth.

Healthy relationships, by definition, require give and take from all parties involved. Therefore, the ability to give as well as the ability to receive are necessary parts of the process of being in a healthy relationship. When one is depressed, it understandably becomes more difficult not only to initiate the giving process, but also to receive from others. It has been well documented in the depression literature that when one is depressed, one often feels unworthy, has low self-esteem, and may feel misunderstood or alienated from others. In addition, Latinas have cultural issues that may affect how they manage their depression, such as feel- ings of shame or fear of criticism that may occur for being depressed.

These feelings, together with cognitive distortions and the low energy that often accompanies depression, can make sustaining relationships difficult.

How the client perceives social support has important clinical implications because it has the potential of negatively or posi- tively affecting treatment and help-seeking behavior. Previous research has shown that social support can influence the impact of child sexual abuse (Liese, 1999). That is, positive social support can reduce the negative symptomatology due to child sexual abuse. The current study extends the findings of the literature and assesses factors that may interfere with a client’s seeking or accepting social support. Because depression was determined to be a significant factor negatively associated with social support, the need to initially assess for depression before proceeding with treatment planning appears to be critical. The issues surrounding depression need to be addressed before the client will be ready to seek or fully benefit from social support.

In addition, one source of social support, namely the family, has been found to help child sexual abuse survivors tolerate stress better (Gomes-Schwartz et al., 1990; Herman, 1992). Familialsupport 836 VIOLENCE AGAINST WOMEN / July 2002 has also been identified as an important mediating factor with research investigating Mexican Americans (Martinez, 1988).

Therefore, family therapy may also be a beneficial component of treatment recommendations when working with Latinas. Family therapy can facilitate the client’s reconnection with significant family members and provide support. Thus, these findings sug - gest that a part of the treatment goal would be to directly address the need to develop significant relationships despite the client’s negative feelings and perceptions about these relationships. An empathic and supportive relationship in therapy along with devel - oping decision-making skills may help the client ascertain who is trustworthy within the family and who is not, and thus empower and remind them of the choices they still have to make changes in their lives.

It was predicted that among child sexual abuse survivors, there is an inverse relationship between interpersonal sensitivity and perceived social support. The results of the study extend previous research that found interpersonal sensitivity to be significantly related to the outcome of child sexual abuse (Greenwald et al., 1990; Murphy et al., 1988; Surrey et al., 1990). Results indicated that there was a statistically significant inverse relationship between interpersonal sensitivity and perceived social support when considering an important person but not for important peo- ple in their lives. However, once again, when depression was held constant, neither variable for perceived social support (important person nor important people) was significantly related to inter- personal sensitivity. This suggests that only depression was a fac- tor affecting perception of social support for these participants.

The implication of this finding underscores the importance of assessing for depression and, if present, determining how the individual’s perception of others may have been affected by their depression. An item analysis of the interpersonal sensitivity subscale on the SCL-90-R revealed that the primary constructs on this subscale are the cognitive components or inaccurate perceptions that occur in a relational context, which are often related to depression. For example, some of the questions include the fol- lowing: “feeling critical of others,” “feeling others do not under- stand you or areunsympathetic,” “feeling that people are unfriendly or dislike you,” “feeling uneasy when people are watching you or Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 837 talking about you,” and “feeling very self-conscious with others.” Interpersonally sensitive individuals feel inadequate and inferior when they compare themselves with others. Similarly, depressed individuals feel self-conscious and inadequate around others.

Issues of trust and difficulty with intimacy are likely negative con - sequences of child sexual abuse that may have an impact on rela - tionships. Therefore, these findings highlight the importance of directly working with clients on their capacity for healthy social relationships. Focusing on these issues in therapy will help the cli - ent to accept and benefit from the support of others, which is a crucial component in healing from child sexual abuse.

In sum, the results of this study revealed that depression is a significant predictor of interpersonal sensitivity. Further, it is depression, not interpersonal sensitivity, which also predicts per - ceived social support.

CULTURAL IMPLICATIONS Although these results have implications for non-Latinas, there are a number of considerations specific to the Latino culture that bear mentioning. Fontes (1993) has argued strongly that there are many pressures within a Latino child’s family that will hinder dis- closure of abuse. She notes that the cultural dynamics within the Latino family may often intensify the struggle. A child may remain silent because he or she has been taught from an early age that the needs of the family supersede the needs of the individual— the family always comes first (Falicov, 1982; Gaines, 1997). In a male-dominated culture and one in which “children are to be seen and not heard,” it seems likely that if child sexual abuse occurs and the perpetrator is a male inside the family, it would be exceed- ingly difficult for the child to report it to someone. For example, if a girl told her mother that her father molested her, it would create a crisis situation that might be difficult for the mother to manage.

In many cases the father is the sole provider, the head of the fam- ily, and the one who makes the rules (Sue & Sue, 1990). Speaking out may mean losing provision for the family, which can be exceedingly difficult, especially if there are other children to con- sider. These factors need to be considered when treating an adult Latina child sexual abuse survivor. For example, because she may have felt the need to keep her child sexual abuse a secret, the 838 VIOLENCE AGAINST WOMEN / July 2002 survivor may be revealing it to the therapist for the very first time.

The cultural value of keeping one’s problems within the family may also make it difficult for the Latina to speak about her child sexual abuse (Falicov, 1982; Sanders-Phillips et al., 1995). In addition, there are taboos within the family regarding talking about sexual issues (Espin, 1986). Furthermore, the Latino child must make sense of the pressure to “respect” the person who may have abused him or her by keeping silent (Comas-Díaz, 1995). The ther - apist needs to find a sensitive way to give the Latina adult survi - vor safety and permission to speak about the unspeakable thing that was done to her.

Given Latinas’ strong family ethic, if child sexual abuse occurs within the family and it is discovered, even years later, the shame and betrayal by the family in not keeping her safe are likely issues that need to be addressed. The rippling effect, even if it occurs with a stranger or acquaintance, can cause devastating harm within the family. That is, in a close-knit family, such a harmful and shameful event is likely to cause a crisis within the family.

Such a trauma may bring the family in for therapy to address issues concerning the sexually abused child. The therapist needs to have respect for their culturally specific family system or they could lose the opportunity to help these clients (Falicov, 1982). As mentioned, consideration for the family’s and individual’s cul- tural background is the only effective and ethical way to do cross-cultural therapy.

The literature has shown that survivors are likely to be multiply victimized because of many variables such as poverty, violence in the neighborhood, living in substandard housing, and being unaware of resources (Koverola et al., 1996). Wyatt (1990) adds that minor- ity children are likely to experience multiple forms of victimiza- tion that include, in addition to the aforementioned factors, insti- tutional racism. The participants in this study similarly were from a low SES, living in substandard housing, in violent neighbor- hoods, and reporting violence in their homes. These additional stressors combined with child sexual abuse create a special set of circumstances that need to be assessed carefully and treated accordingly and responsibly. A therapist must be careful not to revictimize the survivor by failing to evaluate the impact of these additional stressors. Hinson et al. / LATINA CHILDHOOD SEXUAL ABUSE 839 DIRECTIONS FOR FUTURE RESEARCH AND LIMITATIONS One of the limitations of this study is the generalizability of the results. The literature clearly establishes the heterogeneity evident among ethnic minority populations and, thus, these findings may not be generalizable to other Latino groups nor to other ethnic groups. The population included for this study was Latinas who reported a history of child sexual abuse. It is, however, important to consider the issue of acculturation. Our sample included pre - dominantly Latinas who were U.S. born or who had lived in the United States for more than 5 years. It is interesting to note that the majority were Spanish-speaking or bilingual, continuing to embrace their mother tongue. If language is viewed as a proxy for accultur - ation, this would suggest that the majority of our participants were not highly acculturated. The findings of our study, therefore, may be most applicable to Latinas who, although American born, or who have lived in the United States for a significant period of time, nonetheless identify themselves as Latina and may prefer their native tongue, customs and cultural values. Although anec- dotal, it bears noting that the vast majority of Latinas served in this particular clinic were of Mexican or Mexican American back- ground, so the findings may apply more directly to this subgroup within the larger group of Latinas.

A second limitation of this study is the fact that most of the par- ticipants had a history of multiple victimization. The focus of the discussion has been on the sequalae of child sexual abuse, and it is not possible to tease out the differential effects of the different types of victimization experienced. Another limitation is the small sample size. A larger sample may be able to provide stronger rela- tionships between the variables and the possibility of examining issues such as the unique contributions of different types of vic- timization experiences. Future research that would replicate the findings of this study with a larger sample size could prove beneficial.

The design of this study as retrospective and self-report has inherent limitations. The limitations of self-reporting have been widely documented and critiqued. The findings have been inter- preted as the participants’ perceptions of their reality. In view of this being a Latina population, pressures or loyalty to the family may have led to a bias in underreporting severity and minimization 840 VIOLENCE AGAINST WOMEN / July 2002 of symptoms. However, in spite of these limitations, the robust - ness of the findings give a relatively high degree of confidence as to the voracity of the findings. The findings suggest a strong likeli - hood that depression is a major factor in child sexual abuse among Latinas and that is related to perceived social support.

Further studies are needed that focus on the specific issues sur - rounding the psychological sequelae of child sexual abuse, partic - ularly among those from a minority culture who are multiply vic - timized. There are many complex issues and circumstances involved that affect our understanding of child sexual abuse and the multi - ple interactions and powerful effects that result from different types of trauma that may occur. Given the complexity and multi - plicity of issues for Latinas, future research endeavors need to continue to focus on such underresearched populations in our society.

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Yama, M. F., Tovey, S. L., & Fogas, B. S. (1993). Childhood family environment and sexual abuse as predictors of anxiety and depression in adult women.Journal of Orthopsychiatry, 63, 136-141. Josie Vega Hinson recently received her Doctor of Psychology degree from Fuller Theological Seminary’s clinical psychology program. She is currently seeking licensure as a psychologist in New Jersey. Her clinical practice consists of her training experiences, which she tailored toward an emphasis in trauma, particu - larly working with Latino women and children who are sexual abuse survivors as well as their nonoffending parents. She also has a strong interest in psychological testing for Latinos. In December 2001, Dr. Vega Hinson joined the Child Protection Center at Saint Peter’s University Hospital in New Brunswick, New Jersey, where she conducts psychological assessments with children and adolescents who have been physically or sexually abused, neglected, or have witnessed domestic violence. She also works with their parents or caregivers of whom many are Latinos.

Catherine Koverola is a researcher and clinician with expertise in the areas of child maltreatment, sexual abuse, domestic violence and cross-cultural service delivery.

Her clinical practice also includes the intersection of forensic psychology within the domain of child maltreatment and domestic violence. The emphasis of her research has been on the psychological impact of trauma exposure. Dr. Koverola’s clinical and research experience includes more than 10 years of working with indigenous peoples in isolated communities throughout Canada and Alaska. She also has extensive experience in the inner city with African American families as well as new immigrant and refugee families from Mexico and Central America who have experienced multiple forms of violence and trauma. Dr. Koverola is cur- rently on the faculty at the Center for Families, University of Maryland as Direc- tor of Research. In this capacity, her role is to develop and expand ongoing research efforts that build knowledge concerning the prevention, assessment, and treat- ment of child abuse and neglect.

Mary Morahan, M.S.W., L.C.S.W., is director of clinical training at the Violence Intervention Program at the Los Angeles County and University of Southern Cal- ifornia Medical Center in Los Angeles, California. She has more than 20 years experience as a clinical social worker and therapist, with expertise in the areas of domestic violence and child maltreatment, and with an emphasis on services to underserved and marginalized populations. Her clinical work has spanned the range of child welfare, school-based prevention, health care, and outpatient mental health services. As an educator, she has taught social work students at both the undergraduate and graduate levels. She serves on the Executive Board of the Los Angeles County Domestic Violence Council as chair of the Health Issues Committee. 844 VIOLENCE AGAINST WOMEN / July 2002