Contextualizing the Trauma Experience of Women Immigrants From Central America, South America, and Mexico

Abstract

Trauma has been understudied among Latina immigrants from Central and South America. This study examined the types and context of trauma exposure experienced by immigrant women from Central America, South America, and Mexico living in the United States. Twenty-eight women seeking care in primary care or social service settings completed life history interviews. The majority of the women reported some type of trauma exposure in their countries of origin, during immigration, and/or in the United States. In the interviews, we identified types of trauma important to the experience of these immigrants that are not queried by trauma assessments typically used in the United States. We also identified factors that are likely to amplify the impact of trauma exposure. The study highlights the importance of utilizing a contextualized approach when assessing trauma exposure among immigrant women.

Most mental health research has been conducted in high-income, developed countries (Patel, 2007), but researchers recognize the need to determine and document whether trauma exposure and the prevalence of associated mental health disorders differ across cultures and subpopulations (Norris & Slone, 2007). One important population that has received little research attention is Latina immigrants. The trauma-related experiences and mental health needs of immigrants from Central America, South America, and Mexico have been understudied despite the fact that many immigrants from these regions havebeen exposed to war-related trauma and political violence in addition to other forms of trauma and violence. Atrocities in Central and South America included massacres of women, children, and the elderly, assassinations of civilians by death squads, and executions of prisoners. More recently, violence along drug-trafficking routes in Central America and Mexico has resulted in historically high murder rates and social instability (Central America: The Tormented Isthmus, 2011). In the context of war and civil upheaval, other types of trauma, including interpersonal violence, also tend to increase (e.g., Usta, Farver, & Zein, 2008). Immigrants from these areas bring the emotional and physical legacy of their traumatic experiences with them to the United States and may also be at risk for additional types of trauma during the immigration process and in their adopted country.

Central American immigrants living in the United States have been shown to have a high prevalence of trauma and posttraumatic stress disorder (PTSD; e.g., Eisenman, Gelberg, Liu, & Shapiro, 2003; Michultka, Blanchard, & Kalous, 1998). There is almost no specific research focused on the impact of trauma exposure among South American immigrants living in the United States despite significant periods of political violence and instability in many countries including Argentina, Chile, Colombia, and Peru during the 1970s–1990s (Gleditsch, Wallensteen, Eriksson, Sollenberg, & Strand, 2002). Because of the strong link between trauma exposure and mental disorders (e.g., Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; O’Donnell, Creamer, & Pattison, 2004), it is important to understand the extent of trauma exposure and how trauma is experienced by this growing group of immigrants.

One concern is whether standard measures used in the United States to assess trauma histories capture the full extent of trauma exposure experienced by immigrants from Central America, South America, and Mexico. For example, in a sample of immigrants entering a clinical trial of depression treatment, 25% endorsed experiencing an extremely frightening situation and 10% endorsed exposure to a dangerous situation that were not included on the questionnaire that assessed trauma exposure (Kaltman, Green, Mete, Shara, & Miranda, 2010). This suggests a need to understand the specificities of trauma exposure among the Mexican, Central American, and South American immigrant community to improve trauma exposure assessments when working with this group.

The purpose of the current study was to explore the trauma experiences of Latina immigrants from Central America, South America, and Mexico to better understand the range of traumatic experiences among these women as well as important contextual details. In semistructured life history interviews, 28 women immigrants were asked to describe their life and experiences in their country of origin, during immigration, and in the United States. Qualitative analyses focused on the diversity of trauma exposure types, where the exposure occurred, and factors that might amplify the impact of the trauma exposure.

METHOD

Participants and Procedures

Twenty-eight participants were recruited from primary care clinics (n = 26) and social service settings (n = 2) in the Washington, DC metropolitan area that serve low-income Latino immigrants. Posted flyers invited women to participate in an interview about their history, and experiences with trauma and loss. Participants had to be female, 18-70 years old, born in a Central or South American country or Mexico, and able to provide informed consent.

Table 1 presents the demographic characteristics of the study sample. On average, participants were 43 years old (SD = 11.72). They were 31.07 years old when they arrived in the United States (SD = 10.87) and had lived in the United States for 11.39 years (SD = 7.10). Of the 28 participants, 18 women were from Central America, 5 were from South America, and 5 were from Mexico. The most frequently represented countries of origin were El Salvador (32.1%), Mexico (17.9%), Honduras (17.9%), and Guatemala (14.3%). Other participants were from Bolivia, Peru, Chile, and Colombia.

Table 1.

Demographic Characteristics of the Sample

Variable	n	%
Years of education
0–6	9	32.1
7–12	8	28.6
> 12	11	39.3
Marital status
Married, cohabitating	11	39.3
Never married	9	32.1
Divorced, separated, widowed	8	28.6
Gross income for the prior year
≤$20,000	20	71.4
≥$20,000	8	28.6
Employment (n = 26)
Employed	14	53.8
Unemployed	12	46.2

Note. N = 28.

The interviews took place in the clinic, social service setting, or a nearby public library and were conducted in Spanish by bilingual, bicultural research assistants from Latin America with advanced training in psychology. Following the verbal informed consent procedures, the interviewer asked each woman to describe her life in her country of origin, immigration process, experience in the United States upon arrival, and more recent experience in the United States. At each point in their story, we asked women if they had been exposed to any stressful and violent experiences and if so, to describe them. Prompts used included, “What type of stressful experiences did you have? What type of violent experiences did you have?” Interviews were audiotaped and lasted 1-2.5 hours. Participants received a $30 gift card for their time and a list of local mental health resources. Georgetown University’s Institutional Review Board approved the research procedures.

Coding Procedures

The coding system for traumatic experiences used both predetermined and emerging coding criteria (Creswell, 2009). Trauma categories that emerged from the interviews were only included in the analysis if they were consistent with the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychological Association, 1994) Criterion A1, which defines the types of traumatic events that are linked with PTSD (i.e., “the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” p. 427). This procedure allowed us to maintain the tension between expanding current conceptualizations of trauma and adhering to criteria used by mental health professionals, which have been shown to be linked with PTSD and other posttrauma mental disorders (Green, 1990).

A bilingual, bicultural member of the research team transcribed the interviews. The coding procedures were conducted in Spanish. The coding team (SK, AH, FG, AS) read three interviews and developed a preliminary codebook of content categories and their respective definitions. Then, the team independently coded two interviews and met to compare the coding and achieve consensus on the coding criteria. Categories were refined in an iterative process. Next, each of the remaining interviews was assigned to two members of the research team (including at least one native Spanish speaker) for independent coding. Analysis proceeded using Consensual Qualitative Research (CQR; Hill et al., 2005; Hill, Thompson, & Williams, 1997) guidelines such that consensus was used to form judgments about the meaning of data and an auditor reviewed and discussed the work of the team.

Each experience of trauma was categorized by type of trauma (e.g., political violence, domestic violence) and location (country of origin, during the immigration process, in the United States). The final consensus was entered in a qualitative software package (NVIVO 8) to facilitate content analysis. The team selected the quotes that best represented each category of violence, and the two native Spanish speakers (AH, AS) translated and back-translated the quotes to ensure accuracy. The goal of the translation process was to convey the meaning accurately while also staying as close as possible to the women’s actual words. For space purposes, some quotes were shortened with excluded text indicated by (…).

RESULTS

The following types of trauma were coded in the interviews: childhood interpersonal violence, domestic violence, political violence, violent loss, community violence, immigration-related violence, adult interpersonal abuse perpetrated by a nonpartner, witnessed violence, and other types of violence. Of the 28 participants, 25 (89%) described one or more types of violence. Types of trauma exposure were organized by location of occurrence (country of origin, during immigration, in the United States). Because women were 31 years old on average when they arrived in the United States, the childhood trauma exposures were confined to the country of origin. Each type of trauma is described below with exemplary quotes. Although we attempted to be comprehensive in our discussion of the trauma types, emphasis was placed on types of trauma and violence that are specific to their home countries or were in some way related to the immigration experience.

Trauma Exposure in the Country of Origin

Women reported experiencing and witnessing different types of childhood interpersonal violence in their country of origin, including physical, sexual, and emotional violence.

The majority of childhood physical violence was perpetrated by parents, but some of these exposures occurred as a consequence of the immigration of the parents of our participants to the United States. Some respondents who were left under the care of relatives in the home country were then abused by the caretaker or others who had access to the participants.

They hit us whenever they wanted. They said bad words to us. And they would not let me speak to my mother. Sometimes, I called her. My mother confronted them about what I had told her, and then it was worse for me.

Many women described the violence they experienced as typical, accepted forms of discipline. Some only began to see the violence as abuse after coming to the United States and learning about norms regarding physical discipline in their adopted country. Other women described how the abuser rationalized the violence as preparation for marriage or other adult experiences.

She made me iron for the very first time … “Mom, the trousers are ready, I finished ironing them.” And she looks at them, and she unfolds them … . She goes to the fire takes the iron and she comes and sticks it on me [points to a scar on her face]. And she told me, “You have to learn how to iron … because the day you get married your husband is going to ask you to iron for him. And what happens if you iron like that? He will tell you that it is my fault, because I did not teach you.”

Many women labeled their experiences of childhood sexual abuse as traumatic or abusive: “In my childhood home, there was violence. My eldest brother abused us. It was a very traumatic process.” With one exception, the perpetrators of the sexual violence were family members. In many cases, the women did not disclose their experiences to others and some revealed them for the first time as a part of the study.

Women described emotional abuse during childhood largely in the context of the disintegration of families due to divorce, death of a parent, or immigration. Sometimes caretakers forced them to work and did not provide for their basic physical and emotional needs. This was described as abusive and over and above what might be necessary for financial reasons.

They would send me to sell. They used to wake me up at 3:00 in the morning. Then, they would make me prepare the food. I used to arrive at school at 9:00 in the morning. It started at 7:30 … . They would take me out very early (from school) to go finish the housework, washing the dishes, and then I had to go sell.

One woman believed that her stepfather was her biological father until he revealed his identity during an argument. Another woman’s stepfather kidnapped her when she was a child, only returning her to her mother when the police found him.

Violence witnessed within the family was often between parents or was perpetrated by members of the extended family: “My mom and dad used to hit each other. My dad used to beat her; he used to leave her looking like a monster.” Eighty percent of the women who reported witnessing violence between family members as children also reported experiencing domestic violence as adults.

Women reported experiencing different types of domestic violence (physical, sexual, emotional) in their country of origin, and several reported these experiences in both their home country and in the United States.

Physical violence perpetrated by a partner in the country of origin was particularly brutal, often including weapons or knives and resulting in significant injury: “One time, he arrived drunk and hit me with a machete here in the forehead because I didn’t want to make him dinner in the middle of the night.” The women described violence that was often reciprocal and was frequently witnessed by children. A few of the women linked their experience of violence with their reason for leaving the country: “I found another partner. He was bad, very bad, the worst thing that has happened to me in my life. And this is why I came here.”

Sometimes the violence was seen as a normal part of the marital relationship by others who the women turned to for support or assistance. One woman went to a lawyer in response to the violence and was told that she should not divorce but rather learn karate to protect herself. Some family members encouraged the women to stay in the violent relationship or actively sided with the abusive partner.

Sexual violence in women’s intimate relationships was described less often. One woman agreed to marry a much older man but changed her mind at the last minute. However, her mother forced her to marry. A few days after the wedding, the husband picked her up from her house (following the traditional custom) and she tried to hide with no success. She went to live with him and described her first sexual experience:

When he tried, I didn’t want to … . Because he wanted to [have sex] by force. And so, I cried. I was far from where my mom and my dad lived. I lasted 10 days like that, until he got angry and he hit me. He ripped my clothes by force and what was going to happen, happened. What a horror!

Emotional violence frequently co-occurred with physical abuse in an intimate relationship. The women described examples of being humiliated and repeatedly put down by their partners. They also described being controlled by their partners, which was often facilitated by financial dependence. Even in the absence of financial dependence, the extent of the controlling behaviors could be extreme.

There at his house, there are fruit trees … . If I went and grabbed a fruit without his permission, it was a fight of 2, 3 days. I wasn’t worthy to touch even a glass of water … To be able to have a cup of tea I had to ask for his permission to turn on the stove.

Additional examples included being locked in their houses, often with the help of other family members, and having their children kidnapped by their partners. Some women cited the emotional abuse as a trigger for migrating.

With regard to political violence, the women described both salient events as well as the experience of living in a generalized context of fear. Salient events included witnessing murders, seeing corpses in the streets, and having family members disappear who were presumably kidnapped and murdered.

When I was in El Salvador, we were eating pupusas (stuffed corn tortillas) with my dad on the street. Some armed people arrived; they were guerrilla soldiers. They came down and killed someone who was sitting next to us. They shot him in the head, and then they went to throw him into a truck. They were carrying many bodies. We were afraid that they would do the same to us and put us into that truck. They carried them off as if they were a pile of pancakes. They told us, “Okay, Okay, keep eating!” They left the blood bath there. Can you imagine?

The disappearances of family members were described as particularly distressing because of the uncertainty involved in never learning exactly what happened to the loved ones. The participants also described the atmosphere engendered by political upheaval. They described a context of fear in which danger could occur in any place (public or private) or at any moment. “There were orders to shoot whoever went outside. If they passed by in a helicopter they would shoot whoever they saw, even those who were inside their own yard.” The women also spoke about the experience of not knowing who might be dangerous and not being able to trust anyone because of uncertainty about which side of the conflict individuals were affiliated.

Violent loss was common in the country of origin, where murders accounted for most of the losses, and there was also one case of suicide. In each case, the decedent was a close, male family member or friend. “My uncle was found dead … they know (who murdered him), but they didn’t want to do anything because they were going to kill the family members. They remained silent.” Lost loved ones included three fathers (one of which was witnessed by our participant) and one husband. Murders of family members were often not resolved and the bereaved frequently had no recourse because pursuing answers might bring more violence upon the family.

With regard to community violence, many women experienced armed robbery in their country of origin. The women also described pervasive gang violence. Often the violence described was quite brutal, with the participant witnessing the violence itself or the result. “They were many, like 17 men. They raped the lady and she fainted. We were witnessing all this, and that frightened me a lot.” One woman reported threats of gang violence as her primary reason for coming to the United States, and several others mentioned concerns about the increasing levels of violence in their home countries. In one case, fear of gang violence was noted to be an impediment to returning to the country of origin.

With less frequency, the women described other typical types of trauma (e.g., natural disasters) as well as culturally specific experiences. For example, one participant described a culturally sanctioned experience called robo. The robo is a complex cultural practice that is practiced differently by different communities in various parts of the world, including Latina America. This act forms part of the marriage ritual in which men “kidnap” young women, sometimes with their consent, before the wedding (Fondo de Población de las Naciones Unidas/Family Care International Bolivia, 2008).

I was 15 years old when I met him (the father of her children) … Like they say, “he robbed me” and I left with him … . My parents were very angry … . They wanted me to get married and … I got married.

As the quote suggests, after the robo, which often involves sexual intercourse, the women’s parents typically want their daughters to get married to avoid being socially stigmatized. This participant described the process without providing insight into her feelings. Although this practice can be consensual, we categorized it as a trauma because recent studies suggest that sometimes women are kidnapped against their will and subjected to violence and rape (Instituto para el Desarrollo Humano, 2009), and there have been recent attempts to penalize this practice on behalf of women’s rights (Garcia, 2010).

Violence During Immigration

Women’s stories regarding their immigration journey differed sharply depending on their region of origin. Women from South America typically flew to the United States and had unremarkable trips, from a trauma perspective. In stark contrast, the women from Central America and Mexico had prolonged journeys on foot and in various forms of land transportation. The trips often lasted weeks to months and were marked by violence, deprivation, and fear. Six women described life-threatening situations during their journey, typically involving gangs, thieves, or coyotes. These events typically involved being threatened with a weapon.

A few women reported having sexual relations with men who were helping them travel to the United States. These experiences were described in a somewhat ambiguous manner, with the sexual acts seen as unpleasant but strategic instead of forced, increasing the likelihood of reaching the United States.

The other truck driver was a bad person. He told me, “We are going to stay here. You have to live with me.” (implying that she had to have sex with him). I had to do it because he was giving me a ride. The next day, he told me, “Get out! I am not driving you anymore. Get out! Look for other people to drive you.” After using me, he left me there.

Although not necessarily described as violence, the women described this as their only solution to their extreme vulnerability. The women used euphemisms to describe this sexual violence, which contrasted with how they discussed sexual violence under other circumstances. “I ended up (sexually) involved with him because he used to sleep next to me. God bless him, if he is still alive! This man did take care of me, even though I had to be his woman.”

Some women reported witnessing the physical assault or rape of others during the journey to the United States. They described their helplessness in being unable to prevent the violence due to a fear of being victimized themselves.

A young girl was hugging and kissing a man. We told her to come with us, and she ignored us. The young girl was taken out and all of the men who were there raped her. She screamed and everything, but we could not do anything. I told the other girls not to get involved because then they would take us as well.

Kidnapping was another type of trauma experienced during the immigration process. The kidnapping involved being kept in unfamiliar places for indeterminate amounts of time while being deprived of resources to meet basic needs. It was in these circumstances that the women also described witnessing violence against others.

Trauma Exposure in the United States

When describing abuse by partners in the United States and in contrast to descriptions in the country of origin, two women used the label “domestic violence”: “I married him. After 8 months, I had to get divorced because I suffered domestic violence … He always used to drink. One day he came home and almost killed me … . It is still traumatic … He broke my rib.”

Several women described physical violence perpetuated by a partner. Violence was more often linked with the partner’s use of alcohol in the United States: “He got drunk … He started to insult me. He grabbed a knife and he cut my fingers. I have pictures because I wanted to call the police. But I refrained out of fear.” Although the women demonstrated that they were conscious of differences in the norms regarding violence in the United States, they reported not following through on their threats to call the police, often due to fears related to immigration status. However, others were willing to take steps to get help for the women. One woman’s neighbor called the police after her husband had beaten her and broken her rib, and another woman’s daughter spoke to the social worker at her school about the violence her mother was experiencing. In both cases, an intervention by outside authorities stopped the violence.

Few women described sexual violence in an intimate relationship in the United States, which was again the least prevalent type of domestic violence. The women’s stories suggested that sexual violence in the context of an intimate relationship is not frequently discussed. One participant was repeatedly raped by her partner. In her description of these events, she likened her experience to rape rather than directly labeling it as rape, suggesting that she assumes that forced sex by an intimate is not the same as rape: “Sometimes I don’t want to be with him and he forces me. It is as if he is raping me.”

Many women reported emotional abuse in an intimate relationship in the United States. The women described partners who attempted to control them by socially isolating them or limiting financial resources. The women often linked the controlling behaviors to jealousy on the part of their partners. This may have been related to changes in the social context in the United States. For example, in many cases the women were working while their partners were not, contributing to shifts in gender roles from the country of origin.

Several women also reported adult interpersonal violence that was not perpetrated by a partner. The violence was often facilitated by the women’s vulnerability as recent immigrants due to limited financial resources, lack of English fluency, and no understanding of how to navigate their surroundings. Upon arrival in the United States, the women were often forced to rely on others, who then became abusive.

My friend’s husband frequently tried to force me to have sex with him … . But, because I wouldn’t ever let him, he beat me … He threatened me that if I said anything, he was going to report me to immigration and that I owed him. “You owe me money, and you’ll have to pay me,” he said.

Physical violence and emotional abuse often arose out of difficulties related to reunification within the family, with conflict developing between those already in the United States and those recently immigrated.

When I came to this country, my siblings treated me badly. They used to tell me: “You come from El Salvador, you are an Indian, you are an idiot” … I had been at my mom’s place for only one month. She treated me badly. She would say, “You are a freeloader, I wish you were dead.”

Employers were also perpetrators of abuse. Some women reported being forced to work constantly, with no time off and having money stolen by employers.

With the exceptions of domestic and interpersonal violence, other types of violence exposure were reported much less frequently in the United States. In contrast to their experiences in their home country where having someone close murdered was a pretty common experience, only one participant reported a murder in the United States. Descriptions of the community violence experienced in the United States tended to be less violent and occurred in impoverished neighborhoods. Few women reported witnessing violence within the family in the United States related to disturbances caused by the reintegration of recently immigrated family members.

DISCUSSION

This qualitative study examined the full range of trauma and violence experiences of Latina immigrants from Central America, South America, and Mexico through an analysis of semistructured interviews with women seeking services in primary care and social service settings. We found very high levels of trauma and violence exposure in this sample, which is consistent with other studies (Eisenman et al., 2003; Holman, Silver, & Waitzkin, 2000) that found a high prevalence of exposure among Latino populations. Most commonly reported types of trauma exposure included domestic violence, community violence, and witnessing violence.

The women described types of trauma exposure that were specific to life in their country of origin and the immigration experience. This included specific exposures associated with political violence, including having family members kidnapped or disappeared, or exposure to the grotesque. They also described living in the context of ongoing fear engendered by political violence. Participants described communities in their countries of origin that were rife with violence related to gang activity. Although community violence certainly exists in the United States, the descriptions of the gang activity in Latin America were noteworthy in terms of its pervasiveness and brutality. Finally, stressors associated with immigration such as extreme deprivation of basic resources were also described. These types of trauma exposures will be important to consider when working clinically or doing research with immigrants from Central America, South America, and Mexico. These events, however, are not typically surveyed on trauma history measures used in the United States (e.g., Green, Chung, Daroowalla, Kaltman, & DeBenedictis, 2006; Resnick, Falsetti, Kilpatrick, & Freedy, 1996; Wolfe & Kimerling, 1997). Therefore, modifications should be considered when working with this group to ensure that trauma assessments capture the full range of potential trauma exposures.

In addition to identifying trauma types that are particularly relevant for this population, we observed a number of contextual factors across types of trauma exposure that are likely to amplify the impact of the trauma. For example, the level of brutality in the trauma and violence exposure occurring in the country of origin (e.g., types of weapons used, level of injuries to victims, exposure to dismembered bodies) seemed much greater than what occurred in the United States. This may have implications for an increased mental health impact given the consistent findings relating the degree of exposure to worse mental health outcomes (Green, 1990). As such, additional queries regarding the level of brutality involved in the violence will be important when working with this population both clinically and in research settings.

Further, in the domain of domestic violence, the women’s attempts to extract themselves from violent situations were often met with resistance from those in their environment. Instead of supporting the woman to achieve her stated goal of leaving her abusive husband, some family members stressed the importance of her role as a wife or the importance of her children having a father in their lives over her safety and well-being. These experiences contributed to a social norm of domestic violence; at times, violence towards women and children was accepted. This norm was supported at an institutional level as well, with few legal or social services available to assist the women. Knowing that their requests for help leaving a violent relationship would go unanswered, or having had this happen, could potentially exacerbate the mental health impact of the violence by including a component of betrayal by important members of the support network (Freyd, 1996). Views on violence appeared to shift somewhat in the United States, with women using terms such as “trauma” and “domestic violence” to label their experiences. Despite the fact that institutions in the United States are available to offer support and some women described their value and importance, the services were not uniformly accessed. This is likely due to the myriad of barriers experienced by this vulnerable group including concerns about legal status, extreme economic dependence on partners, fears of retaliation, and role conflicts (Bauer, Rodriguez, Quiroga, & Flores-Ortiz, 2000; Kelly, 2006).

The study findings have significant implications for the understanding of the extent and important contextual details regarding trauma exposure among Latina immigrants from Central America, South America, and Mexico. Because our sample was a volunteer sample, and the proportion of women from South America was relatively small, their experiences and perspectives should not be considered representative of Latina immigrants in general or even Latina immigrants seeking care in these settings. Despite this limitation, the study highlights the importance of considering context when assessing trauma exposure among Latina immigrants, an underserved and rapidly growing population, in both clinical and research settings.