Elder Mistreatment among Chinese and Korean Immigrants: The Roles of Sociocultural Contexts on Perceptions and Help-Seeking Behaviors

Abstract

The purpose of this study was to identify dimensions of elder mistreatment in Chinese and Korean immigrant communities and to increase sociocultural understanding of such mistreatment by elucidating the complexities of abuse embedded in unique social and cultural contexts. In-depth interviews were conducted with 20 local professionals working primarily in Asian elderly advocacy, and six focus group discussions were conducted involving 60 community members in the San Francisco Bay area. Five dimensions of elder mistreatment were identified: psychological abuse, neglect by a trusted person, financial exploitation, physical abuse, and sexual abuse. In general, fewer Korean community member participants reported having observed physical or financial abuse than Chinese groups, but they reported greater knowledge of situations involving psychological abuse, neglect by a trusted person, and sexual abuse. The contexts of cultural influences and immigration and acculturation were salient themes that shaped participants’ subjective perceptions and beliefs about elder abuse and hence help-seeking behaviors.

Elder mistreatment (EM) has emerged as a public health problem profoundly affecting the welfare of elderly persons (National Research Council, 2003). In the United States, an estimated 2 million adults aged 65 or older suffer from some form of abuse every year; however, this might be an underestimate given only one in five cases are reported (Branch, 2001). Older adults who are abused physically, sexually, or psychologically exhibit serious negative physical and mental health consequences, including depression, fear, stress, early nursing home placement, and increased mortality (Dong et al., 2009; Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998).

Despite the remarkable growth of Asian populations in the United States, very little information is available regarding EM in these ethnic communities. Studies show Asian immigrants are less likely than other groups to report incidents of abuse and least likely to receive preventive care and treatment services due largely to linguistic, cultural, social, and institutional barriers (Bhaumik, 1988). Although sociocultural contexts influence perceptions and definitions of mistreatment, little is known about the perceptions and understanding of EM within Asian communities. This lack of information has limited the development of culturally sensitive protocols for the detection of mistreatment and the implementation of appropriate interventions.

To address this gap, a qualitative pilot study of definitions and perceptions of EM was conducted in two large Asian national origin groups—Chinese and Korean immigrants (U.S. Census Bureau, 2000). The goals of this study were to (a) identify dimensions of mistreatment among Chinese and Korean immigrants as perceived by the community at large, community professionals, and research experts with backgrounds in immigrant advocacy and direct services; (b) increase the understanding of sociocultural and situational contexts of EM that might exacerbate or ameliorate circumstances of elder abuse in these communities; and (c) identify beliefs and attitudes about EM affecting help-seeking and service utilization behaviors in Chinese and Korean immigrants.¹ Examining these issues is a critical first step toward selecting or developing a culturally appropriate measure of EM for these populations.

BACKGROUND AND RELATED LITERATURE

Older Asians are one of the fastest growing racial and ethnic groups among the U.S. elderly population, with nearly 40% living in California (U.S. Administration on Aging, 2010). California has the largest Asian population (5 million) in the United States. Chinese are the largest Asian national origin group, accounting for more than 24% (3.8 million) of the Asian population in the United States in 2009 (U.S. Census Bureau, 2009), and the Korean population has increased by 200% since 1990, constituting over 10% of Asians (1.59 million).

The National Elder Abuse Incidence Study reported that in 1996, approximately 450,000 persons aged 60 and over experienced abuse, neglect, or both in domestic settings (National Center on Elder Abuse, 1998). According to this report, 84% of those who experienced EM or neglect were Whites, followed by African Americans (8.3%), Latinos (5.1%), Asian or Pacific Islanders (2.1%), and American Indians or Alaskan Natives (0.4%). It is unclear whether the low rates of mistreatment among non-White groups reflect the actual incidence of or the procedural and instrumental limitations in reporting abuse and neglect in these communities. An upward trend in the number of suspected elder abuse reports among immigrant populations suggests that severity and prevalence might be higher among immigrants than previously suspected (Los Angeles County Community and Senior Services, Adult Protective Services, 2004 [as cited in Lee, 2006]).

There is an emerging consensus that researchers should consider the manifestations and perceptions of EM within the unique sociocultural contexts in which it occurs, and that the experiences of survivors should be taken into account when defining EM and in assessing its severity (Moon, 2000; see also Lee & Lightfoot, this issue). In assessing the risk of EM, most studies fail to consider sociocultural factors particularly relevant to Asian immigrants, such as the prioritization of family harmony over individual needs, immigration experiences, level of acculturation, and the view of endurance and suffering as cultural virtues. Derived largely from working with older Whites, existing measures of EM have failed to capture varying cultural contexts or to explore the breadth of its socially embedded manifestations. For example, silence is commonly employed as an extreme form of psychological humiliation or punishment in many Asian cultures (Anetzberger, Korbin, & Tomita, 1996; Tomita, 1994). Yet, current standardized measures of mistreatment would fail to detect abuse of this nature. This study attempts to fill these gaps.

Rationale: Study of Chinese and Korean Immigrants

One of the greatest challenges in EM research is the dearth of knowledge about abuse within racial and ethnic minority groups, and among Asian immigrant elders in particular. This study focuses on Chinese and Koreans because of their shared traditional Confucian values (e.g., collectivist orientation, interdependence), which pervasively impact human relations and social structures in all areas of life and mandate cultural allegiance to filial piety and family harmony. Shaped by this belief system, the cultural prohibition against the public disclosure of family problems not only might increase an Asian elder’s vulnerability to EM, but could also create notable gaps in the understanding of both how elder abuse occurs and what constitute effective prevention and intervention strategies. Culturally sensitive research is urgently needed to provide accurate information on elder abuse in these communities.

Despite cultural similarities, research also suggests interethnic differences in attitudes toward family violence among Asian subpopulations. For example, one study found that Korean immigrants were less likely to endorse marital violence than their Chinese, Vietnamese, and Cambodian counterparts (Yoshioka, DiNoia, & Ullah, 2001). These differences could reflect distinctions in immigration patterns, socioeconomic conditions in their countries of origin, and differing perceptions of violence (Yick & Agbayani-Siewert, 1997; see Lee, Yoon, et al., this issue). By incorporating two similar, yet distinct, Asian national origin groups into the research design, this study also seeks to provide valuable insights into the complex interplay of factors that contribute to intercultural differences in this area.

This qualitative study includes participants of varying ages and backgrounds: older Chinese and Korean individuals who deny personal experiences of abuse; middle-aged caregivers (formal or informal); college students; and community practitioners and researchers who have worked with the Chinese and Korean communities. Incorporating these multiple perspectives is critical to understanding culturally related constructs and establishing precise definitions of elder abuse relevant to the experiences of marginalized communities (Hudson, 1994; Hudson & Carlson, 1998).

METHODS

This study was conducted in the greater San Francisco metropolitan area, including the counties of Alameda, Marin, Contra Costa, San Mateo, Santa Clara, and San Francisco, between September 2008 and April 2010. Qualitative methods were used to identify the prominent meanings, values, normative expectancies, and contexts that characterize EM according to Chinese and Korean immigrant populations. Data were collected through two phases: (a) in-depth interviews with local professionals and service providers who work predominantly with older Chinese and Korean immigrants, and (b) focus groups with the general public, including college students, from these two ethnic groups.

Sample

Phase 1: In-depth interviews with local professionals and service providers

In-depth interviews were conducted with 20 local professionals and interdisciplinary experts and researchers with backgrounds in Asian elderly advocacy and abuse prevention, mandated reporters of EM (physicians, nurses, psychologists, social workers, and police officers), and adult protective service workers. The purpose of these interviews was to obtain firsthand information about how elder abuse occurs and is detected, reported, and investigated. Based on a purposive sample, service providers who work in the area of EM were interviewed at a place of their choosing (e.g., their office, researcher’s private office, etc.).

Phase 2: Focus groups with the general public

Six focus groups were conducted with members of Chinese and Korean ethnic groups (N = 60), including three focus groups with community-dwelling Chinese and Korean elders aged 60 and over who did not identify as having experienced mistreatment themselves (two Chinese, one Korean); two additional focus groups with middle-aged Chinese caregivers (formal or informal), who were aged between 30 and 59; and one with Korean college students aged between 20 and 29. Each focus group was homogenous with respect to race and ethnicity (Chinese or Korean) and age. The participants were recruited from social service organizations, senior centers, and religious institutions through announcements at events and flyers and by word of mouth.

Procedures

Interview and focus group questions and probes were developed based on a literature review of cross-cultural EM studies of Asians, consultation with two service providers, and the author’s past work with Asian immigrants (Lee, 2007; Lee & Hadeed, 2009). Each interview lasted approximately 90 to 120 minutes and each focus group lasted about 2 hours. The interviews and focus groups with Korean participants were conducted by the first author and the Chinese groups were conducted by two bilingual (English and Cantonese/Mandarin), bicultural research assistants who were trained in qualitative methods and had extensive experience working with Chinese populations. All procedures were approved by the Institutional Review Boards of San Francisco State University and the University of California, San Francisco.

Data Analysis

Qualitative analysis was conducted using grounded theory (Strauss, 1987). Both sets of interviews and all focus group sessions were audiotaped, transcribed, and translated into English as necessary, and the transcripts were then reviewed and subjected to content analysis. Open coding was used to broadly conceptualize what the data appeared to mean, and then, the data were categorized by developing specific units of analysis. Emerging themes and insights were recorded to formulate tentative thoughts about theoretical frameworks. The primary investigator (PI) and two research assistants read and simultaneously listened to the audiotapes. After several readings, a summary was made of each transcript and a list of themes was developed from these summaries. Using Atlas 6 software, commonly used words, phrases, sentences, expressions, and clusters of similar concepts and themes were identified and arranged into categories. Afterward, investigators developed a coding nomenclature based on the focus groups or in-depth interviews. Frequencies of major coded responses were computed and major themes were identified. To minimize misinterpretation and inconsistencies in analyses, two methods were used: random quality assurance, where random checks on several segments of audiotapes were compared to their respective transcripts, and investigator triangulation, where multiple investigators reviewed transcripts and discussed and resolved inconsistencies in coding. In addition, semiquantitative methods were conducted to examine differences in perceptions of EM among participants differing by national origin and age. We then examined the frequency with which various participant responses corresponded to the coded themes that emerged in the interviews and focus group sessions.

RESULTS

Sample Characteristics

This study included a total of 80 participants. Interviews were conducted with 20 multidisciplinary research experts and local professionals and 60 community members participated in the focus groups (40 Chinese and 20 Korean). Sixty-five percent of the local professionals and experts provided social services, violence prevention, and victim advocacy; 15% offered health or mental health services; 15% worked in the criminal and civil justice system; and 5% were religious leaders. They had worked with the Chinese and Korean communities for an average of 13 years (SD = 10.2 years). The majority were women (65%), and 45% self-identified as Korean, 40% as Chinese, 10% as Japanese, and 5% as another ethnicity. Approximately 65% of the local professionals had a graduate education or higher and 35% had a college education. Demographic characteristics of the community member sample (n = 60) are shown in Table 1. Korean respondents were substantially more educated, had higher monthly incomes, and were more likely to be proficient in English. The groups were similar in the number of years in the United States, age at immigration, and receipt of government assistance.

TABLE 1.

Demographic Characteristics of the Public Sample by Ethnicity

	Chinesea		Koreanb		Total samplec
Characteristics	n	%	n	%	n	%
Gender***
Male	3	7.5	9	47.4	12	20.3
Female	37	92.5	10	52.6	47	79.7
Age*
20–29	1	2.6	7	36.8	8	13.8
30–39	0	0.0	2	10.5	2	3.4
40–49	2	5.1	0	0.0	2	3.4
50–59	8	20.5	0	0.0	8	13.8
60–69	16	41.0	2	10.5	18	31.0
70 or older	12	30.8	8	42.1	20	34.5
Median age	65.00		62.00		64.00
Education***
12 years or less	27	67.5	5	27.8	32	55.2
13–15 years	7	17.5	1	5.6	8	13.8
16 years or greater	6	15.0	12	66.7	18	31.0
Household income (Month)*
$1,000 or less	33	89.2	11	78.6	44	86.3
$1,001–2,000	4	10.8	0	0.0	4	7.8
$2,001–3,000	0	0.0	1	7.1	1	2.0
$3,001 or greater	0	0.0	2	14.3	2	3.9
Median income	$700.00		$950.00		$700.00
Nativity status***
U.S.-born	0	0.0	0	0.0	0	0.0
Foreign-born	40	100.0	19	100.0	100	100.0
China	37	92.5	0	0.0	37	62.7
Hong Kong	2	5.0	0	0.0	2	3.4
Korea	0	0.0	19	100.0	19	32.2
Other	1	2.5	0	0.0	1	1.7
Years in the United States
Less than 5 years	2	5.0	3	15.8	5	8.5
5–10 years	10	25.0	3	15.8	13	22.0
11–20 years	11	27.5	7	36.8	18	30.5
21 years or greater	17	42.5	6	31.6	23	39.0
Age at immigration
Less than 12 years	0	0.0	0	0.0	0	0.0
13–17 years	1	2.6	3	15.8	4	6.9
18–34 years	9	23.1	6	31.6	15	25.9
35+ years	29	74.4	10	52.6	39	67.2
English proficiency*
Not at all	10	25.0	0	0.0	10	16.9
Poor/Fair	29	72.5	15	78.9	44	74.6
Good/Excellent	1	2.5	4	21.0	5	8.5
Generational status***
First immigrants	33	86.8	15	83.3	48	85.8
1.5 generation	5	13.2	0	0.0	5	8.9
F-1 visa status(students)	0	0.0	3	16.7	3	5.4
Government assistance
Welfare recipients	12	30.0	5	26.3	17	28.8
Nonwelfare recipients	28	70.0	14	73.7	42	71.2

Note. Missing data: (n = 1) gender, ethnicity, nativity status, years of immigration, English proficiency, and government assistance; (n = 2) age, years of education, and age at immigration; (n = 4) generation status; and (n = 9) monthly income.

^an = 40.

^bn = 20.

^cN = 60

^*p < .05.

** p < .01.

^***p ≤ .001.

Of the community member sample, approximately 36 (60%) reported that they had heard or read about EM before the focus group discussions. Nearly 41 (68.3%) reported that they knew someone who had experienced EM. Only one participant reported having mistreated an older person in the past. Although the older Chinese and Korean focus group participants were limited to those who did not identify as having experienced mistreatment themselves, the analysis showed that, of the Chinese and Korean elderly participants, nine (30%) reported having been mistreated previously (60% of Koreans and 15% of Chinese).

Dimensions of Elder Mistreatment

Five major dimensions of EM were identified through analysis: psychological or emotional abuse, neglect by a trusted person, financial exploitation, physical abuse, and sexual abuse (Table 2). All dimensions, with the exception of sexual abuse, emerged noticeably in all of the individual interviews and the six focus groups (Table 3).

TABLE 2.

Dimensions of Elder Mistreatment According to Chinese and Korean Interview and Focus Group Participants

Psychological or  emotional abuse	Mistreatment involving verbal or nonverbal acts inflicting mental or  emotional anguish or distress on an elder person through use of  control, intimidation, or domination. Categories of psychological  abuse include lack of love or affection; disrespect; silent treatment;  controlling what elders can or cannot do; threat (e.g., threat of  deportation); alienation/isolation from decision making, families and  friends, or significant events (e.g., wedding or family gathering);  restriction of freedom; or belittling, degrading, or hostile acts or  remarks toward an elderly person.
Neglect by a  trusted person	Mistreatment involving lack of sincere intention to care, or failure to  provide adequate care for an older adult by a trusted person. This  includes both tangible care (e.g., food, clothing, shelter, medical care,  or safety) and emotional support (psychological support and care).  This dimension also includes willful deprivation; for example,  throwing medication away or turning off gas, electronics, or water.
Abandonment	Mistreatment involving the complete desertion of an older person by  anyone who has assumed the responsibility for care or custody of  that person.
Half-day  abandonment	Mistreatment involving the partial desertion of an older adult person by  anyone who has assumed the responsibility for care or custody of  that person, forcing him or her to stay out of the home during the  day without proper food or appropriate care.
Financial  exploitation	Mistreatment involving control over an elder’s money or economic  resources; finance-related coercion or manipulation; illegal taking or  misuse (or unauthorized use); or concealment of funds, property, or  assets of an elder. It also includes failure to provide regular  allowances to the elderly parents to help in maintaining a minimum  standard of living; financial fraud; withholding money at will; and  expecting the older person to work without pay.
Physical abuse	Mistreatment involving intentional use of force, objects, or threats to  inflict physical pain, bodily harm, injury, or to cause feelings of  intimidation or fear to an older adult. This dimension includes  bruises, hitting, beating, pushing, shoving, slapping, pinching,  kicking, biting, spitting, throwing objects, stabbing, threatening to  harm or kill, restraining, or confinement. This physical abuse factor  also includes indirect forms of physical aggression; for example,  forcing a victim to eat nonfood items (e.g., urine) against his or her  will resulting in physical suffering, or depriving an elderly victim of  sleep or other necessities to inflict physical harm.
Sexual abuse	Mistreatment involving behavioral or verbal acts that force or coerce  unwanted sexual activity against an older adult’s will (e.g., touching,  fondling, rape/marital rape, intercourse, etc.).

Note. These five dimensions of elder mistreatment identified by study participants reflect what is perceived as elder abuse in the Chinese and Korean communities. It does not necessarily mean that all acts are seen as abusive in the courts or considered legally abusive. For example, “lack of love or affection” is not seen as legally abusive, although it is considered psychologically abusive in these two communities.

TABLE 3.

Frequency of Thematic Codes on Five Dimensions of Elder Mistreatment by Type of Participant Response

Interviews	Focus groups
Experts and professionals (27–67 years old)a	Chinese seniors (≥ 60 years old)a	Korean seniors (≥ 60 years old)b	Chinese caregivers (30–59 years old)a	Korean college students (20–29 years old)b	All participantsc
Psychological or emotional abuse
223	37	22	24	19	325
Neglect by a trusted person
129	41	18	17	22	227
Financial exploitation
122	20	3	6	5	156
Physical abuse
80	6	1	4	3	94
Sexual abuse
10	0	0	0	2	12

Note. In analyzing interview and focus group transcripts, investigators viewed each passage of participant speech as a separate unit of analysis. They assigned thematic codes to each passage based on their interpretation of content. A unit could have more than one code. Hierarchical codes (one included within another) were also used. The total number of times that each thematic code appeared in an interview or focus group discussion was computed. Thematic codes were broadly categorized into five dimensions of elder mistreatment: psychological or emotional abuse, neglect by a trusted person, financial exploitation, physical abuse, and sexual abuse.

^an = 20.

^bn = 10.

^cN = 80.

Psychological or emotional abuse

The most frequently described dimension of EM was psychological or emotional abuse. Two subdomains, verbal and nonverbal aggressive acts, were included under the domain of psychological abuse. Verbal aggression was represented by episodes of yelling, name-calling, belittling, verbal threats, or hostile remarks; and nonverbal aggression by exclusion, isolation, intimidation, control, domination, or restriction of freedom. Overall, interview and focus group results were consistent with the findings in the general population.

Although not reported by the general population, six forms of psychological abuse were commonly identified by both the Chinese and Korean focus groups: disrespect, silent treatment, lack of love and affection, intense level of child care, isolation of elderly grandparents from grandchildren, and adult children’s blaming of elderly parents for their mental illness caused by acculturative stress. Two forms emerged specifically among the Chinese participants: forcing elderly parents to leave when grandchildren grew up and emotional abuse of an elderly parent using immigration status and fear of deportation. In the Korean groups only, three forms were prominent: passing elderly parents from one child to another to avoid caregiving responsibility, spreading gossip and rumors to blackmail an elderly person to inflict mental anguish, and male spouse’s psychological domination and control of his female partner.

Focus group discussions expanded our definition of psychological abuse to include the concept of disrespect. Traditionally, Asian communities placed great value on the veneration of all elders, who were given great authority and power in all spheres of family matters and important decision making. Thus, many Chinese and Korean elderly participants perceived being disrespected, ignored, or excluded particularly distressing and psychologically abusive. As one elderly Korean man stated:

Elder abuse is, first, alienating us because we are old. For example, kids tell us, “You mom and dad can’t speak English, so don’t speak anything. Keep your mouth shut.” It hurts a lot. It results in complete alienation. When I’d like to go to some places, especially party places or family gathering, kids say, “No, you can’t go.” But they all go there and we are told not to join and stay home.

Most of the Chinese and Korean professionals and the community member participants endorsed verbal aggression as a form of psychological abuse. Notably, verbal aggression was highly prevalent among the two communities but overlooked by community members in many cases. The local professionals strongly agreed that yelling or degrading remarks, such as “Go die,” and “You’re useless,” were psychologically violent and intentionally hurtful to elders. Others commented that yelling, although not desirable, would be understandable in certain situations or contexts (i.e., unintended yelling out of extreme frustration). The information gleaned from professionals and community members underlined the significance of taking contextual and situational factors (e.g., frequency, severity, harmful outcomes) into account when determining EM.

A unique form of psychological abuse to the Chinese and Korean communities was the silent treatment, an identified nonverbal aggressive act. Consistent with previous studies (Anetzberger et al., 1996; Tomita, 1994), silence was commonly perceived as an extreme form of psychological humiliation or punishment in the Chinese and Korean communities and had even more impact due to cultural expectations. To illustrate, a Chinese participant made the following comment:

When worse come to worse, seniors have to suffer all the verbal abuse. Sometimes, it’s just like silent treatment. For example, at a dining table, no one greets or talks to them, or all family members just leave a dining table while elders are still eating.

Another form specific to the Chinese and Korean communities was the isolation of grandparents from their grandchildren. Although this relational isolation, which is also observed in the general population, is not typically recognized as a form of abuse, it was viewed as being abusive in both of the Chinese and Korean focus group discussions. Such alienation from families was found to be difficult for many Asian immigrant older adults, who are already isolated due to language, cultural, and social barriers. Among Chinese and Korean immigrant older adults, unpaid child care and housework by grandparents are two major stressors that restrict their independence and social life. It is common for Asian elders to take care of their grandchildren and perform housework while their adult children work during the day. Both professionals and senior participants, however, commented that the intense level of these tasks were abusive and exploitive in some cases. Adult children’s forced eviction of an elderly parent from their house, despite having initially invited their parent to the United States, once their grandchildren grew up was a form of psychological abuse specifically identified in the Chinese focus groups. A Chinese elderly woman stated:

Some adult children ask their old parents to come to the U.S. to take care of the grandchildren. So the elders move to America, while they sell their house and bring their money to the U.S. They may put their money to support the adult children to buy a house, such as down payment. Once the grandchildren grow up, then the elders’ task is completed. Some children want to abandon their elderly parents. They will say all kinds of bad things. “How come you don’t move out? We need more room.” They just have a lot of verbal and mental abusive things going on in a family.

A salient form of psychological abuse noted only in the Korean groups included the avoidance of caregiving responsibilities by adult children who recanted caring for their elderly parents by forcing them to move around from one child’s house to another’s. Although unrecognized by the general population, the majority of Korean participants viewed such incidents as being abusive, reflecting traditional values of filial responsibility.

Neglect by a trusted person

All study participants perceived neglect by a trusted person, which frequently occurred in the Chinese and Korean communities, as a serious form of EM. Study results supported constructs recognized in the general population, such as neglect by a formal or informal caregiver to provide adequate care. Any neglectful acts resulting in negative consequences (i.e., neglect leading to falls or injury) to an elder were also viewed as abuse. A Chinese professional described:

Another form of EM is neglect, usually by many formal or informal caregivers. Caregivers are not doing their job, such as not taking the senior to the doctor. So, elders get infected from not changing diapers, elders eat the leftover food, or get skin disease.

More important, commentaries from the interviews and focus groups broadened our definition of neglect to include two added dimensions: lack of sincere intention to care for an older adult and refusal or failure to provide emotional care. Several professionals agreed that sincere intention alone does not always lead to proper care as evidenced by a family caregiver with good intentions but lacking sufficient knowledge and training to care for an older adult. However, immigration conditions must be examined when probing for the vulnerability of elder neglect, especially as professional interviewees believed unintended neglect (i.e., missed medical appointments, missing medication dosages) by adult children, who might be forced to work more than 12 hours a day, might be more common and even exacerbated in Chinese and Korean immigrant communities than in non-Asian ethnic groups.

Culturally specific types of neglect common to the Chinese and Korean groups emerged, including the unwillingness of an adult son and his wife to live with his elderly parents, sending an elderly parent to a nursing home, infrequent visits or irregular contact with adult children, and interference with medical treatment (e.g., medical decision or dietary regulation) leading to inadequate care and harm by family members. Additionally, willful deprivation, such as throwing medication away, a symbol of an elderly person’s life and safety, was identified as a salient form of neglect by the Chinese group.

On the basis of traditional filial piety and caregiving responsibilities, many elderly Chinese and Korean participants expected to live with their adult children, particularly with the oldest son and his wife. Adult children who lived separately from their elderly parents were expected to achieve their caregiving duties through frequent calls or regular visits. Failure to provide such living arrangements was viewed as neglect by a disproportionate number of both Chinese and Korean participants.

Sending an elderly parent to a nursing home was considered abusive across all of the sampled racial and ethnic and age groups because of cultural beliefs in filial piety and family-based elder care. Furthermore, the sociocultural isolation and language barriers older Chinese and Korean immigrants might experience in a nursing home were cited as another major problem.

Inadequate elderly care by a family member providing in-home supportive services (IHSS) was an especially salient concern to both groups because Chinese and Korean immigrant elders seemed more likely than other elders to prefer family member caregivers due to shared language, values, and food choices and distrust for strangers. Interestingly, many Chinese and Korean community member participants tended to regard negligent acts by a family IHSS home caregiver as acceptable, whereas neglect by a paid formal caregiver was clearly regarded as abusive. A Korean professional illustrated how neglect by a paid family caregiver occurred:

IHSS home caregivers receive compensation from government, which is about $10–12 an hour. If they work 25 hours a month, they can get health insurance. So, if an elder’s adult children do not have a job, then the IHSS work becomes a financial means for their living. In some cases, adult children do not complete their minimum work hours but still receive money.

Abandonment and half-day abandonment. In both the Chinese and Korean focus group discussions, an extreme form of neglect focused on abandonment. A Chinese elderly participant commented:

There is an elderly woman. She sometimes has little problems and illness. The daughter-in-law needs to go to work and busy. Once conflicts came up, she left the mother-in law in Oakland alone. The elderly woman was unable to speak English. Luckily, she knew one word, “Chinese.” Then the policeman called many places where Chinese people live, and finally found that her son lived in San Francisco.

Korean elderly participants also cited similar cases of abandonment that happened in an affluent family, suggesting that socioeconomic factors were not determinants of abandonment. A form of neglect particular to the Chinese groups was “half-day abandonment,” where older adults were forced by their adult children to stay out of the home during the day without proper food or appropriate care on a daily basis. A Chinese older adult described:

I saw a daughter who lives with her mother. When the son-in law goes to work, he leaves his mother-in law to Portsmouth Square every day, even in a rainy day. She wanders around the Portsmouth Square and there is nothing to eat. So, she goes to the cafeteria to eat, but that is only one meal. Then, she goes back to the Square to sit. It is so bad that she pushes her mother out.

Abandonment and half-day abandonment were often considered culturally unacceptable despite the general consensus that making caregiving arrangements was difficult.

Financial exploitation

Respondents from all racial and ethnic and age groups highlighted significant problems pertaining to financial exploitation. Several forms emerged across the Chinese and Korean groups that were similar to the financial abuse reported in the general population: the transference of property from an elderly parent to adult children (e.g., unauthorized transfer of or coercion to transfer legal title of property); forcing an elderly parent to move out of the house he or she fully or partially paid for; using an elderly person’s money or economic resources (e.g., supplementary security income [SSI], Social Security benefits, or pensions); restricting an elderly parent’s financial freedom despite his or her ability to make sound decisions; forcing elderly parents to pay back loans or debts; and financial fraud by a stranger.

Deeply affected by collectivism and family preservation over individual rights, most Chinese and Korean immigrants believed in group responsibility and sharing their financial resources with family members. Although rapid modernization and acculturation have weakened the cultural norms, a sense of these traditions is embedded in the culture and remains an integral part of these communities. In addition, traditional emphasis on educational achievement as a dominant path toward upward mobility for the family is still widespread. Many Chinese and Korean elderly parents expended all of their economic resources to support their children’s education or business, sacrificing their personal needs for their children.

It is common for both Chinese and Korean adult children to live with their elderly parents until marriage without contributing to the household. However, Korean participants reported a growing trend during the recent economic recession, where adult children and their families moved back into their elderly parent’s home and shared their resources without contributing to the rent or living expenses. Some reported extreme financial and emotional distress, and others described frustration but considered it something they had to endure. Many participants illustrated how cultural norms of collectivism and family harmony might contribute to Chinese and Korean elders’ vulnerability to their adult children’s financial dependency and exploitation. A Chinese elder reported:

A woman received SSI and saved some money. Once she went on vacation, she worried [about] her money. She gave a key to her children and told them the money she saved. When she came back, she found her children took all her money to buy a house.

Socioculturally unique forms of financial abuse emerging only within the Korean groups entailed (a) immigration-related financial abuse, where a Korean elderly husband with U.S. citizenship refused to file immigration papers for his noncitizen elderly wife while using her financial assets to his advantage and exploiting her for intense caregiving labor for himself; and (b) adult children who failed to provide a regular monthly or weekly allowance to their elderly parent(s). The Korean culture dictates that grownup children provide their frail elderly parent with a regular allowance to tend to their financial needs. Failure to perform this filial duty leads to a sense of disappointment, is considered “bad treatment,” and equates to financial mistreatment.

Sociocultural barriers and adjustment difficulties in the United States were viewed as significant obstacles, restricting the ability of most Chinese and Korean elders to manage their personal finances and other related business matters. Due to language barriers, cultural differences, and an unfamiliarity with mainstream socioeconomic systems, many immigrant elders relied on their children for things like managing bank accounts, using ATM cards, or receiving SSI or Social Security benefits. Such dependence might aggravate the elders’ vulnerability to exploitation. Although all participants unequivocally considered the unauthorized use of an elderly person’s money by a nonfamily member to be exploitive and reportable, elderly victims were less likely to report financial exploitation committed by a family member.

Like the general older adult populations, Chinese and Korean elders frequently reported being victimized by multiple forms of financial fraud: lottery (asking an elderly person to deposit $500–$1,000 to secure their lottery winnings), telephone marketing (obtaining personal information, such as a Social Security or bank account number), investment (coercing to invest money in a ghost company), and fake money (selling them a cluster of fake money) scams.

Physical abuse

Physical abuse was the most blatant form of EM identified. Many forms of physical violence found in the general population were validated over the course of the interviews and focus groups, including biting, hitting, slapping, spitting, pushing, grabbing, kicking, punching, stabbing, threatening with a knife, destroying an object, restraining, or confinement. More unique forms to both samples included pinching the skin as a disciplinary method for stopping or punishing certain behaviors, forcing a victim to eat nonfood items (e.g., urine) against his or her will resulting in physical suffering (an act typically interpreted as extreme contempt or scorn), and depriving an elderly victim of sleep or other necessities to inflict physical harm.

Some participants reported that physical assault against an older adult was uncommon in the Chinese and Korean communities, but others indicated that physical abuse was not rare. Assailants most frequently quoted were men and included the spouse or son, although women were occasionally involved. A Korean professional described the onset, severity, and manifestations of physical abuse against an elderly mother and how the victim dealt with the abusive incidents:

An elderly Korean woman, who does not speak of a word of English, lived with her first son. He was drinking and behaving so badly. He cannot hold any work. He threatened his mother for money every day. He destroyed everything around the house, yelled, and threatened if she didn’t give money. If she ran away to a room and locked a door and then he kicked and broke the door. The difficulty is none of these women look for help or contact criminal justice systems to stop their child from hurting them. One day, his violence was so severe, she ran out of the house to avoid his beating her up. She ran out with her bare feet, some people in a bar saw she was bare foot and distressed, so they called the police.

Although this quote described a scenario not uncommon in the general population, the cultural value of filial piety makes this incident even more egregious in the Korean population. Frequency and degree of abusive behaviors were regarded differently between professionals and Chinese and Korean community members. Whereas the experts unanimously defined both “severe violent behaviors” and “minor physical assaults” as physical elder abuse, the community member focus groups agreed only “severe violent behaviors” warranted the label of EM. Indeed, both Chinese and Korean participants addressed the “cultural tolerance of violence.” In particular, Korean focus group participants expressed acceptance for spousal elder abuse based on traditional patriarchal ideologies and male dominance, providing a foundation for the “cultural tolerance” of wife battering in the Korean culture.

Premigration trauma and traumatic experiences associated with war and life difficulties were viewed as risk factors for the greater tolerance of and increased vulnerability to physical violence by Korean immigrants. A Korean professional commented:

A lot of elderly populations I’ve worked with went through the Korean War and a lot of personal trauma and difficulty in their lives. So, this period of time living in the U.S. and getting support from the government is relatively easy, even though they struggle with depression and health conditions. Since physical assault doesn’t seem as tragic or difficult as what they had to go through before, they don’t think of it as something as severe or as abusive. And then couples are used to not getting along and fighting physically, so they don’t really think of the actions that they take as abusive because they’ve endured it for a long while and they are used to it.

Consistent with findings from the general population (National Research Council, 2003), instances of elder physical assault associated with the childhood trauma of witnessing parental violence as children were described only in the Korean groups. This study also revealed that physical abuse was commonly preceded by psychological and verbal abuse in both communities.

Sexual abuse

This study revealed that Korean and Chinese older adults are not immune to sexual assault. This dimension emerged only in key informant interviews with professionals and a focus group with Korean college students; it was not mentioned in other focus group discussions. Several Korean and Chinese professionals shared stories about older women who were subjected to unwanted sexual activity but unable to understand the nature of the acts due to illness. Another expert also described nonconsensual attempted or completed sexual acts in intimate relationships. Unlike other studies (Ramsey-Klawsnik, 2003), participants in our study did not report any incidents of incestuous sexual abuse committed by adult offspring or relatives. In both of the Chinese and Korean groups, sexual abuse mostly affected women, and the perpetrators were usually known and trusted, such as an intimate partner (a husband or a boyfriend), a healthcare provider, or a security guard.

Information gathered from interviews and focus group discussions revealed that Asian elderly victims of sexual assault were at a particular risk of physical injury and negative mental health outcomes, such as posttraumatic stress disorder, depression, anxiety disorders, and even suicidal ideations. A Chinese professional stated:

There was an elderly woman in her 80s who was sexually assaulted. She was pulled in and got raped by a stranger. Her vagina was torn and bleeding, and her back was twisted. She was very shamed and described herself as “I am polluted and dirty” and “I must have been punished by God.”

Another professional working with Korean immigrants reported:

An elderly woman close to 75 was touched, fondled, and almost raped by her healthcare provider but managed to escape. She was very fearful of retaliation by the perpetrator who was working in her neighborhood. He was trusted and loved by many elderly women, she was afraid of being blamed and stigmatized as a slut. Whenever she ran into the perpetrator, he gave her a threatening look, like “If you say anything, I will destroy you.” It’s torturing. This poor elderly woman became very sick, physically and mentally, but did not know what to do, so she tried to move out from her residence.

These quotes illustrate how social stigmatization, gender stereotypes, victim blaming, and shame make it extremely difficult for a female elderly victim to disclose the abuse and seek instrumental and emotional support. Moreover, more than half of the key informants identified cultural beliefs in male superiority and control of women’s behaviors as important factors to account for in the examination of sexual abuse against elderly women. Such staunch patriarchal cultural beliefs could serve to exacerbate victimization and discourage help-seeking behaviors. Several Chinese and Korean experts commented that identifying elder sexual abuse is especially challenging due to the prohibition of disclosure of such a culturally taboo subject.

Attitudes, Responses, and Barriers to Service Utilization

Attitudes about EM were similar across groups and included shame and stigma, tolerance, protection of abusive children or spouse, preservation of family harmony and privacy, self-blame, and karma. Social stigma made it more difficult for people to come to terms with elder abuse and seek services. Participants expressed that EM was especially challenging to report when the perpetrator was their own child.

Corroborating previous studies (Lee, 2006), in both Chinese and Korean participants, a strong reluctance to reveal EM was associated with cultural norms against the public disclosure of family issues and obtaining outside help. In response to EM, most of the public indicated substantial differences in perception and reporting behaviors between general populations and Asian immigrant communities. A Chinese participant explained:

One thing is very purely cultural. There are Asian sayings that you keep your problems within your own family. They don’t believe somebody else outside of their family can help their problems. So, Chinese and Korean thinking are different from Western thinking. They don’t want to talk about it, they don’t want to expose it, and the only time when elder abuse surfaces is when it reaches a crisis.

The help-seeking behaviors of abused victims are often thwarted by barriers, such as shame and stigma, fear of retaliation, physical and functional limitations, and isolation from support systems. This study also found that abused Chinese and Korean immigrant elders faced additional impediments, such as immigrant-specific obstacles (e.g., language barriers), lack of knowledge on EM, fear of deportation, lack of linguistically appropriate services, fear of involvement with public authorities, and perceived discrimination and racism.

Sociocultural barriers faced by the immigrants were particularly salient across both the Chinese and the Korean immigrant groups. Many Chinese and Korean senior participants reported experiencing discrimination or racism due to a lack of English proficiency or stereotypes about Asians. Indeed, several participants indicated that their social isolation was exacerbated by institutional discrimination as evidenced by inadequate health care and social services for immigrant elders, the exclusion of some minority populations from certain government programs, negative media portrayal of older adults in general, and the absence of multicultural social events for the immigrant elderly.

DISCUSSION AND IMPLICATIONS

This study sought to identify dimensions of elder mistreatment in Chinese and Korean immigrant communities and enhance sociocultural understandings of such mistreatment by describing the complexities of abuse embedded in a unique sociocultural context. The information generated from interviews and focus groups provided corroboration for key constructs and categories of EM typically accepted in the general population: psychological or emotional abuse, neglect by a trusted person, financial exploitation, physical abuse, and sexual abuse (National Research Council, 2003). We also identified additional constructs and culturally based manifestations of EM previously unrecognized in the general population, such as immigration-related abuse or half-day abandonment.

The qualitative results of this study highlight the importance of factoring in cultural values and beliefs when conceptualizing EM. Although some abusive behaviors are strikingly similar to those in the general population, certain types of elder abuse were culturally rooted or were uniquely considered elder abuse only in the study samples. For example, the dimensions of psychological, physical, and sexual abuse are somewhat similar to those found in EM measures, such as the Revised Conflict Tactics Scale (Straus, Hamby, Boney-McCoy, & Sugarman, 1996), an interpersonal violence measure widely tested and used with different populations. Nevertheless, Chinese and Korean samples differ in the definition of elder abuse compared to other populations. For example, psychological abuse particular to the Chinese and Korean immigrants included constant threat of deportation, silent treatment, disrespect, and lack of love or affection. Although these constructs might not be recognized in other populations or considered legally abusive, clearly they were perceived as hurtful as physical inflictions in the Chinese and Korean communities. Discussions of physical abuse also highlighted culturally specific forms of aggressive and, at times, malicious behaviors (e.g., pinching the skin, forced consumption of nonfood items, or sleep deprivation).

Although Chinese and Korean older adults fall prey to the same types of financial abuse as the general population, our conceptualization of exploitation was refined to include illegal taking, misuse, fraud, and, most notably, failure of adult children to fulfill cultural expectations to provide financial support to their elderly parents. The latter category has not been documented in studies with the general population.

The dimension of neglect by a trusted person was largely consistent with findings from other ethnic groups. However, the definitions of neglect, such as “a lack of intention to care for an elderly” and “failure to provide emotional support,” have not been defined in the prior literature. As well, culturally specific forms of neglect were identified, including half-day abandonment, the placement of an elderly into a nursing home by their adult children, and the unwillingness of adult children to live with their frail elderly parents.

Immigration-related elder abuse is a dimension that could be relevant to any immigrant elderly persons. Prior research (Orloff, 2000) documents that noncitizen immigrant women are at greater risk for interpersonal violence because of their lack of legal rights; otherwise, little is known about the impact of immigration status on EM. More than two thirds of elderly Chinese and Korean immigrants gained entry as parents of U.S. citizens (Treas, 1995). Abusive adult children or spouses frequently use immigration status as a weapon to establish power and control over their elderly victims. Indeed, both Chinese and Korean participants revealed that immigrant elders confronted additional forms of psychological, financial, and sexual abuse. Abused Chinese and Korean elders often avoided reporting cases of EM to public agencies due to a fear of deportation and discrimination against immigrants (see Lee & Lightfoot, this issue). Given the increasing number of immigrant elders in the United States, future assessments of EM should consider including a scale to measure the types of immigration-related abuse. Moreover, intervention strategies should include educating immigrant elderly victims on legal protections, such as Title VIII of the Violence Against Women Act (VAWA) of 2005, which extends protections to elderly victims abused by their adult U.S. citizen children.²

This study demonstrated how cultural influences, immigration, and acculturation are prominent factors that shape a person’s subjective perceptions of and response to elder abuse among Chinese and Korean immigrants. The majority of Chinese and Korean older adults endorsed traditional values, especially cohabitation with their adult children in their house. Most defined a good later life as “living harmoniously with and being taken care of by their children,” demonstrating the centrality of their children in their lives. In contrast, younger participants exhibited shifts away from traditional beliefs regarding filial piety, extended family, and culturally based family roles. Adult children and grandchildren tend to acculturate rapidly to the mainstream culture, possibly widening generational gaps and moving away from traditional values. Moreover, adherence to traditional values might no longer be feasible for immigrant families with financial and time constraints. As conflicting values raise family stress, an older adult’s vulnerability to EM could increase. Our findings highlight the need for services entailing improved communication, understanding, and relationship building between aging parents and their adult children’s families.

Ethnic differences between Chinese and Korean immigrants were found in manifestations of EM and help-seeking behaviors. In general, fewer Korean participants reported observing or hearing about physical or financial abuse than the Chinese groups but reported greater knowledge of situations involving psychological abuse, neglect by a trusted person, and sexual abuse. These ethnic differences point to the need for clinicians and medical professionals to be sensitive to culturally specific forms of abuse, such as half-day abandonment and extreme levels of unpaid child care. Future research in this area should detail how sociocultural contexts influence the types of EM and physical and mental health consequences.

Findings from this study underscore the importance of strategizing interventions focused on increasing help-seeking behaviors through the alleviation of negative consequences (e.g., arrest of abusive family member, deportation), reduction of stigma, and promotion of education on reporting and advocacy. Enhanced reporting and service utilization by Chinese and Korean elders could be promoted through community education to reduce stigma and dissemination of information on reporting procedures, the benefits of intervention, community resources, and alternatives to abusive situations (Nerenberg, 1999).

This study has several limitations. First, because we purposefully recruited participants from the San Francisco Bay area, our findings might not represent the perceptions and beliefs of Chinese and Korean populations from other regions of the United States. Second, this study was not based on a population-based probability sample of the general public, which might limit the extent to which findings can be generalized to all Chinese and Korean populations in the area studied. The methods used to recruit a voluntary, nonrandom sample of study participants through community organizations or churches might be subject to self-selection biases and are likely to have attracted persons with prior knowledge of or interest in EM, which could give an impression of high frequency of abuse and neglect. In addition, the small sample size precluded more substantial comparisons in perspectives, cultural manifestations, and attitudes to elder abuse by ethnicity or other personal characteristics. Another potential limitation includes the restriction of our focus group discussions to older adults without cognitive impairment. Excluding those with significant impairments, who make up the most vulnerable populations, could limit our understanding of EM. Finally, due to the group setting, focus group participants might have been reluctant to reveal some information and possibly expressed viewpoints reflecting more socially desirable than truly honest opinions.

CONCLUSION

This study reveals that EM is a culturally laden construct, where key aspects of culture and traditional beliefs are central in shaping perceptions and constitutions of elder abuse in the Chinese and Korean immigrant communities. Acculturation status is also crucial because of its role in transforming values and norms associated with filial piety, marital and gender roles, and options available to the victims. Clinicians and service providers must engage in discussions with Chinese and Korean immigrants about their indigenous understanding of EM and interrelated constructs. Critical examination of the dimensions and definitions of elder abuse used in instruments must be clearly preceded before applying them to populations other than those from which the instrument was derived and tested. Identification and inclusion of relevant factors, such as immigration, and domains, such as immigration-related abuse, are vital to validly assessing and capturing the range and breadth of EM in immigrant communities. Further investigation is needed to examine how cultural values and acculturation influence the onset and types of EM and the health of older racial and ethnic minority groups. Research collecting more nuanced information about the nature and scope of elder abuse among Asian immigrants could help formulate culturally based interventions and guide policy responses.