Literature Reivew

Journal of Traumatic Stress December 2015, 28, 531–538

Posttraumatic Stress among Victimized Latino Women: Evaluating the Role of Cultural Factors

Carlos A. Cuevas,1 Chiara Sabina,2 and Emilie H. Picard3

1School of Criminology and Criminal Justice, Northeastern University, Boston, Massachusetts, USA 2School of Behavioral Sciences and Education, Penn State Harrisburg, Middletown, Pennsylvania, USA

3Department of Psychology, Fordham University, Bronx, New York, USA

Research examining victimization and posttraumatic symptomatology among Latinos is lacking in the extant literature. This analysis used the victimized subsample (N = 752) of the Sexual Assault Among Latinas Study. The aim was to evaluate victimization prevalence and test the following hypotheses: (a) that victimization would be associated with higher levels of posttraumatic symptoms, (b) that cultural factors that move away from traditional Latino culture would be associated with higher levels of posttraumatic symptomatology, and (c) that cultural factors associated with traditional Latino culture would be related to lower posttraumatic symptomatology. Average age of the sample was 44.57 years, with three fourths having a high school education or higher, and two thirds having a household income below $30,000. Of exposure types, adulthood threats were most likely to result in Criterion A traumatic events (23.4%). Using the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) based PTSD Checklist, between 8.8% and 45.5% of individuals met presumed PTSD diagnosis based on various PCL cut scores or algorithm criteria. Regression analyses indicated that the combined different types of adult and childhood victimizations, masculine gender role, and negative religious coping were associated with increased symptoms (βs ranging from .16 to .27). The results suggested a role of culture in posttraumatic symptoms for Latinas.

The Latino population is the largest and one of the fastest growing minority groups in the United States. They comprise 16.3% of the current population and experienced 43% growth since 2000 (Humes, Jones, & Ramirez, 2011). This group, how- ever, is underrepresented in the trauma literature with many studies ignoring culturally salient components that may play a role in the manifestation of posttraumatic symptoms among Latinos.

Although they do not necessarily endure more traumatic ex- periences, research has indicated that Latino women are more likely to develop stress related symptoms after a traumatic event than non-Latinos and they manifest these symptoms for longer periods (Pole, Best, Metzler, & Marmar, 2005; Rosenheck & Fontana, 1994; Sanders-Phillips, Moisan, Wadlington, Morgan,

This project was supported by Grant No. 2007-WG-BX-0051 awarded by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. Points of view in this document are those of the author and do not necessarily represent theofficial position or policies of the U.S. Department of Justice.

Correspondence concerning this article should be addressed to Carlos A. Cuevas, School of Criminology and Criminal Justice, Northeastern Univer- sity, 204 Churchill Hall/360 Huntington Avenue, Boston, MA 02115. E-mail: [email protected]

Copyright C© 2015 International Society for Traumatic Stress Studies. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.22060

& English, 1995). Some research found that Latino women are more likely to show excess of normal functions related to trauma such as hypervigilance or intrusive thoughts rather than deficits of normal functions like emotional detachment or restricted affect (Marshall, Schell, & Miles, 2009). Recent research has indicated that dissociation and anxiety may be more prominent for Latino women relative to other symptoms (Cuevas, Sabina, & Picard, 2010; Greenwell & Cosden, 2009). Latino women were also more likely to report other trauma-related symptoms such as suicidal ideation, physical symptoms, comorbid psy- chiatric disorders, substance abuse disorders, eating disorders, or depression in comparison to non-Latino Caucasians (Kr- ishnan, Hilbert, & VanLeeuwen, 2001; Lown & Vega, 2001; Newcomb & Carmona, 2004; Newcomb, Munoz, & Carmona, 2009). Some have argued that these symptomatic discrepancies may be attributed to emotional expression rather than emotional experience or innate conditioning (e.g., an inherent predispo- sition and acclimation for greater emotional arousal; Marshall et al., 2009; Ortega & Rosenheck, 2000). In contrast, there is empirical support showing no differences in how traumatic stress presents between cultures (Mennen, 1995). Further, oth- ers have found Latinos are actually less likely to develop trau- matic stress symptoms than non-Latinos (Andrés-Hyman, Cott, & Gold, 2004; Axelrod, Myers, Durvasula, Wyatt, & Cheng, 1999), with associated symptoms such as dissociation being

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the least commonly experienced in the Latino population as compared to non-Latinos (Newcomb et al., 2009).

Based on the evaluation of existing empirical evidence, a number of theories have been put forth in an effort to understand the potential impact of cultural factors as the mech- anism that may help explain the discrepant results regarding victimization and psychological distress among Latinos. Dis- crimination is one factor that may make Latinos more suscep- tible to developing pathology (Araújo & Borrell, 2006; Ortega, Rosenheck, Alegria, & Desai, 2000). Another explanation is that the stress of immigration and acculturation could make Latinos more susceptible to traumatic events and victimization (Sabina, Cuevas, & Schally, 2013). One theory associates higher rates of symptoms with male dominance in the Latino culture, leaving women to endure trauma without seeking help or iden- tifying it as a traumatic event (Abreu, Goodyear, Campos, & Newcomb, 2000). The research suggests that the disruption of traditional gendered scripts may be associated with increased victimization, and potentially increased trauma-related symp- tomatology (Comas-Diaz & Fontes, 1995; Perilla, Bakerman, & Norris, 1994; Vasquez, 1998). Overall, it appears that moving away from one’s culture of origin is associated with increased levels of psychological distress and symptomatology, includ- ing posttraumatic stress disorder (PTSD). This is consistent with the immigrant paradox, which is the tendency for immi- grants to show similar or better mental health outcomes than U.S. born Latinos (Burnam, Hough, Karno, & Escobar, 1987; Cuevas, Sabina, & Bell, 2012; Kaplan & Marks, 1990; Ortega et al., 2000).

Religion and religious coping are also a particularly salient aspect of Latino culture that has received limited research at- tention. Although religion and spirituality are associated with positive mental health outcomes (Hill & Pargament, 2003), some research has found the opposite for Latinos, where it has played a negative role in coping with sexual victimization (Comas-Diaz & Fontes, 1995). It is suggested that for Lati- nos the concept of fatalism (being under God’s control and not personal control) might lead victims to avoid the problem and endure suffering.

A recent analysis of the Sexual Assault Among Latinas (SALAS) Study data indicated that the connection between cul- tural factors and distress was more complex than expected. It was found that Anglo orientation had both a direct and moderat- ing effect in the victimization—distress link (Cuevas, Sabina, & Bell, 2012). Specifically, the connection between victimization and anger, depression, and anxiety was weaker at higher levels of Anglo orientation. As a result, both direct and moderating effects should be examined for cultural factors. Unlike other conceptualizations of cultural adaptation that examine degree of integration and biculturalism (Cuéllar, Arnold, & Maldon- ado, 1995), we chose to use the continuous scales of Anglo and Latino orientation which reflect a more fluid conceptual- ization of acculturation/enculturation rather than a categorical approach which we do not believe is in line with the process of cultural adaptation.

The current study aimed to fill gaps in the research on post- traumatic stress and how it relates to Latino women. First, we present descriptive data on PTSD Criterion A among this victimized sample of Latinas, as well as estimates for current prevalence of PTSD based on the PTSD criteria according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000). Given the prior research, we tested the following hypotheses: (a) victimization would be associated with higher levels of posttraumatic symptoms; (b) being an immigrant, hav- ing higher levels of Latino orientation, positive religious coping, and feminine sex role would be associated with lower levels of posttraumatic symptoms; and (c) Anglo orientation, negative religious coping, and masculine sex role would be associated with higher levels of posttraumatic symptomatology. Using the SALAS data overcomes the methodological limitations found in using community-based and/or geographically limited sam- ples (Clemmons, DiLillo, Martinez, DeGue, & Jeffcot, 2003; Kataoka et al., 2009; Marshall & Orlando, 2002; Marshall et al., 2009; Sanders-Phillips et al., 1995), which restricts the gener- alizability of the results and overlooks the diversity within the Latino population.

Method

Participants

Participants were part of the SALAS Study (Cuevas & Sabina, 2010), which examined victimization experiences, help-seeking responses, and associated reactions among Latino women. Trained professionals conducted computer-assisted telephone interviews (CATI) in English or Spanish with 2,000 Latino women randomly sampled in the United States, the ma- jority of whom (90%) were living in high-density Latino areas (defined as 80% or higher density using 2000 Census figures) (U.S. Census Bureau, 2000). The data collection period was from May 2008 to September 2008. See the study final report for response rates and further procedural details (Cuevas & Sabina, 2010).

The criteria for participation included being a woman, 18 years of age or older, self-identifying as Latino, and a pri- mary language of either English or Spanish. The survey was conducted in the participant’s preferred language, with 71.4% completing the interview in Spanish. All instruments without an established Spanish version were translated by experienced translators and then reviewed by bilingual experts on survey interviewing. The victimized subsample consisted of anyone who experienced at least one form of direct victimization.

The 752 women in the victimized subsample used in this anal- ysis had an average age of 44.52 (SD = 14.44) years with almost half being married (49.5%). Almost three quarters had a high- school education or higher (73.4%), with a third (34.2%) being employed fulltime, and almost two-thirds (62.0%) having an an- nual household income < $30,000. Most women (69.0%) were U.S.-born or naturalized citizens. Detailed sample descriptives

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Posttraumatic Stress Among Latino Women 533

for the victimized and full sample, including demographic com- parisons have been previously presented with key differences being that victimized women were younger, more likely to be single, and reported higher socioeconomic levels based on ed- ucation, employment, and income than non-victimized women (Cuevas, Sabina, & Milloshi, 2012; Cuevas et al., 2010).

Measures

Participants were asked background information including age, relationship status, sexual orientation, country of origin, immi- gration status, preferred language, educational level, employ- ment status, and household income.

A shortened version of the Lifetime Trauma and Victim- ization History (LTVH; Widom, Dutton, Czaja, & DuMont, 2005) was used to evaluate interpersonal victimization. Par- ticipants were asked if they had experienced any incidents of stalking, physical assaults, weapon assaults, childhood phys- ical assaults, threats, threats with weapons, sexual assaults, attempted sexual assaults, sexual fondling, kidnapping, and witnessed victimization. Follow-up questions included age of occurrence, duration, perpetrator, and injury, including ques- tions about whether the individual felt in danger of death or se- rious injury (DSM-IV-TR PTSD Criterion A1) and if they expe- rienced fear/helplessness/horror (DSM-IV-TR PTSD Criterion A2). The questions regarding victimizations were consolidated into five categories to align with key forms of victimization that are studied in the literature: physical assaults, sexual assaults, stalking, threat of victimization, and witnessed violence. For the purpose of this analysis, the total count of victimizations was the number of different forms of victimization that occurred in either childhood or adulthood (possible range of 1 to 13 in the victimized subsample). Prior research, including analyses with these data, showed that multiple forms of victimization are the best predictors of psychosocial outcomes (Cuevas et al., 2010). The LTVH was also found to have adequate predictive, criterion, and convergent validity (Widom et al., 2005).

The PTSD Checklist–Civilian Version (PCL-C) is an instru- ment that assesses the severity of PTSD symptoms (Weathers, Litz, Herman, Huska, & Keane, 1993). It is a 17-item scale that maps onto the three symptom clusters of the DSM-IV-TR criteria for PTSD. The PCL-C has shown excellent reliability, with coefficients above .90 for both the English and Spanish ver- sions (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Buckley, Blanchard, & Hickling, 1996; Cuevas et al., 2006; Marshall, 2004; Weathers et al., 1993). Reliability coefficients for the SALAS victimized subsample were .93 for the full scale, .86 for reexperiencing, .82 for avoidance, .84 for numbing, and .81 for hyperarousal. The PCL-C has also demonstrated strong diagnostic utility using varying cut scores (Andrykowski & Cordova, 1998; Blanchard et al., 1996; Bollinger, Cuevas, Viel- hauer, Morgan, & Keane, 2008; Manne, Du Hamel, Gallelli, Sorgen, & Redd, 1998) and the empirically derived algorithm developed by Blanchard and colleagues (1996).

The Brief Acculturation Rating Scale of Mexican- Americans-II (Brief ARSMA-II) examines the cultural iden- tity of both minority and majority populations (Bauman, 2005; Cuéllar et al., 1995). This scale is commonly used among Lati- nos and does not specifically mention Mexican culture. As such, we refer to the scales as Anglo Orientation and Latino Orientation. The Brief ARSMA consists of 12 items where par- ticipants report the degree to which each statement accurately describes them on a scale of 1 = not at all to 5 = almost always. Scores for Anglo Orientation and Latino Orientation are cal- culated by averaging the response scores for the six questions that make up each scale. Scores can range from 1 to 5 for both the Anglo and Latino Orientation Scales. The Brief ARSMA-II has been found to have high internal consistency (Cuéllar et al., 1995). For these data, the Anglo Orientation Scale had an inter- nal consistency coefficient α of .79 and the Latino Orientation Scale had an α of .88.

The Short Bem Sex Role Inventory (BSRI-Short Form; Bem, 1981) is made of 30 items that describe personality character- istics, 10 masculine, 10 feminine, and 10 neutral. Participants are then asked to report to what degree each adjective describes them on a scale from 1 = never or almost never true to 5 = always or almost always true, which was adjusted from the original 7-point scale (with the same anchors) for better phone administration (Beere, 1990; Bem, 1981). The adjectives re- flect characteristics typically associated with masculine (e.g., “aggressive”) or feminine (e.g., “warm”) qualities. Responses are averaged (possible range from 1 to 5) to find the degree to which someone conforms to the culturally defined behavior for the gender role (Bem, 1981). The BSRI is a commonly tool used in gender research and has been used with minority groups (Beere, 1990). Coefficient α for the Masculinity and Femininity Scales were .80 and .87, respectively, for the sample.

The Brief Multidimensional Measure of Religious- ness/Spirituality (BMMRS) is a 33-item measure that examines religiousness and spirituality. The questions cover topics such as religious affiliation, personal religious/spiritual history, reli- gious practices, and religious coping. This analysis only used the six questions from the positive and negative religious cop- ing scales with response choices being from 1 = not at all to 4 = a great deal, with the possible averaged score ranging from 1 to 4 (Pargament, Koenig, & Perez, 2000), with higher scores indicating a greater amount or use of religious coping. Positive religious coping refers to seeing God as a source of support and guidance, whereas negative religious coping refers to seeing God as a punishing force. The pertinent indices have α ranging from .54 to .86 (Idler et al., 2003). In our data, the coefficient αs were .77 for Positive Religious Coping, and .50 for Negative Religious Coping.

Procedure

The archival data extracted from the parent study, used an expe- rienced survey firm trained on the SALAS instruments, using a CATI system, random digit dialed prospective participants in

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

534 Cuevas, Sabina, & Picard

high-density Latino areas in the United States based on the 2000 U.S. Census (U.S. Census Bureau, 2000). Telephone interviews were found to have comparable validity and reliability as in- person interviews (Bermack, 1989; Czaja, 1987). Only female interviewers were used as studies showed potential respondents to be more likely to participate with female interviewers NVAW (e.g., National Violence Against Women Survey; Tjaden & Thoennes, 2000). If more than one age-eligible Latina was in the household the “most recent/next birthday” method was used to select the participant (Salmon & Nichols, 1983).

Once respondents provided informed consent, they were ad- ministered the various study instruments. Participants who en- dorsed feeling distressed at the end of the survey were called back and provided support information (1% of participants re- quired follow-up). Interviews lasted an average of 28 minutes. Participants were paid $10 upon completion. The Northeast- ern University Institutional Review Board approved the study procedures.

Data Analysis

First, DSM-IV-TR PTSD Criterion A prevalence (using both A1 and A2 from the LTVH) for each victimization category in childhood and adulthood were computed. Using the PCL, presumed current DSM-IV-TR PTSD diagnosis prevalence was calculated using empirically guided cut scores and Blanchard and colleague’s (1996) algorithm. The cut scores used were 30 (Lang, Laffaye, Satz, Dresselhaus, & Stein, 2003; Walker, Newman, Dobie, Ciechanowski, & Katon, 2002), 44 (Blanchard et al., 1996; Ruggiero, Del Ben, Scotti, & Rabalais, 2003), and 50 (Andrykowski, Cordova, Studts, & Miller, 1998; Forbes, Creamer, & Biddle, 2001; Manne et al., 1998). The algorithm identified a symptom as present if the individual endorsed either a 3 (for 11 of the items) or 4 (for 6 of the items), and then tallying the number of symptoms corresponding to the DSM- IV-TR diagnostic criteria. This algorithm was used in addition to cut scores based on its mapping onto the diagnostic criteria and its empirical support from its validation with the Clinician Administered PTSD Scale (CAPS; Blanchard et al., 1996).

Prior to conducting regression analyses, seven interaction terms were constructed for use in the regression models using standardized variables. This process of standardizing or center- ing variables prior to creating interaction terms helps prevent multicollinearity when including them in regression models (Aiken & West, 1991).

Correlations were calculated to evaluate the bivariate rela- tionships and screen the variables to be entered in the regres- sion models. Hierarchical (sequential) regressions were then conducted to evaluate the impact of victimization and cultural variables on the PCL scores. Given the extensive research sup- porting the existence of four symptom clusters (reexperiencing, avoidance, numbing, and hyperarousal; Asmundson, Wright, McCreary, & Pedlar, 2003; Cuevas et al., 2006; King, Leskin, King, & Weathers, 1998; Krause, Kaltman, Goodman, & Dut- ton, 2007; Marshall, 2004; Shelby, Golden-Kreutz, & Ander-

Table 1 Means, Standard Deviations, and Ranges for Core Variables

Variable n M SD Range

Total victimization count 749 2.43 1.50 1–8 Total PCL-C 732 32.76 15.09 15–83

Reexperiencing 732 9.56 5.10 5–25 Avoidance 732 4.20 2.59 2–10 Numbing 732 9.16 4.99 1–25 Hyperarousal 732 9.86 4.81 5–25

Anglo orientation 727 3.46 1.00 1–5 Latino orientation 740 3.96 1.07 1–5 Positive religious coping 727 3.11 0.78 1–4 Negative religious coping 714 1.48 0.60 1–4 Masculine sex role 747 3.57 0.75 1.1–5 Feminine sex role 747 4.33 0.64 1–5

Note. PCL-C = PTSD Checklist-Civilian Version.

sen, 2005; Simms, Watson, & Doebbelling, 2002) and the new DSM-5 diagnostic criteria (APA, 2013), the subsequent regres- sion models examined the four cluster scores separately. All regression analyses adjusted for participant age and socioe- conomic status (a standardized combination of education and household income). Furthermore, due to the large number of coefficients being calculated in each regression model, a false detection rate (FDR) correction procedure was applied using the Benjamini and Hochberg adjustment (Benjamini & Hochberg, 1995). FDR procedures are less conservative (more statistically powerful) than traditional familywise error rate corrections in adjusting for Type I error risk. The resultant values were q values, which are adjusted p values and can be interpreted as traditional p values (we will use p values for clarity and to be consistent with significance reporting conventions). Missing data existed for approximately 5% of the sample in the regres- sion models; therefore, no imputation techniques were applied and listwise deletion was used. In total, five sequential regres- sions were conducted, with the final step being presented in the Results section.

Results

The victimized sample of Latino women on average experi- enced 2.43 (SD = 1.50) victimizations. The average PCL-C total score was 32.76 (SD = 15.09), with scores of 9.56 (SD = 5.10), 4.20 (SD = 2.59), 9.16 (SD = 4.99), and 9.86 (SD = 4.81) for reexperiencing, avoidance, numbing, and hyper- arousal, respectively (Table 1).

Using the LTVH, victimization events were categorized as to whether they met PTSD Criterion A (both A1 and A2). Threat in adulthood was the form of victimization that most frequently met PTSD Criterion A (23.4%), followed by adulthood physi- cal assault (22.2%), childhood physical assault (13.8%), adult stalking (10.3), childhood sexual abuse (10.2%), adult sexual abuse (7.7%), childhood threats (7.3%), and childhood stalking

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Posttraumatic Stress Among Latino Women 535

Table 2 Multiple Regression Results of a Complete Model for Posttraumatic Stress Symptoms

PCL-C Total Reexperiencing Avoidance Numbing Hyperarousal

(R2 = .17***) (R2 = .13***) (R2 = .13***) (R2 = .17***) (R2 = .14***) Variable B SE β B SE β B SE β B SE β B SE β

Age −0.00 0.04 −.00 −0.01 0.01 −.04 −0.01 0.01 −.08* 0.02 0.01 .06 0.00 0.01 .01 SES −1.62 0.53 −.12* −0.54 0.18 −.12 −0.26 0.09 −.11 −0.51 0.18 −.12 −0.31 0.17 −.07 VIC 2.54 0.41 .25*** 0.69 0.14 .20*** 0.47 0.07 .27*** 0.69 0.14 .21*** 0.70 0.13 .22*** IMM 0.60 1.92 .02 −0.20 0.66 −.02 −0.08 0.34 −.02 0.44 0.64 .04 0.45 0.62 .04 ANGOR 1.37 0.94 .09 0.18 0.33 .03 0.18 0.16 .07 0.41 0.31 .08 0.60 0.31 .12 LATOR 0.95 0.87 .08 0.36 0.30 .08 0.08 0.15 .03 0.41 0.29 .09 0.09 0.28 .02 PRELCP −0.28 1.05 −.01 −0.01 0.36 −.00 −0.10 0.19 −.03 −0.34 0.35 −.05 0.17 0.34 .03 NRELCP 4.09 1.30 .16* 1.14 0.45 .13 0.39 0.23 .09 1.37 0.43 .16* 1.18 0.42 .14 MASC 3.55 1.07 .18* 1.04 0.37 .15 0.33 0.19 .09 1.07 0.35 .16* 1.11 0.35 .17* FEM −1.59 1.22 −.07 −0.04 0.42 −.01 −0.11 0.21 −.03 −0.78 0.41 −.10 −0.66 0.40 −.09 IMM × VIC 0.21 0.57 .02 0.07 0.20 .02 0.05 0.10 .03 0.14 0.19 .05 −0.06 0.18 −.02 ANGOR × VIC −1.32 0.67 −.13 −0.37 0.23 −.11 −0.33 0.12 −.19 −0.39 0.22 −.11 −0.22 0.22 −.07 LATOR × VIC −0.73 0.52 −.09 −0.33 0.19 −.12 −0.08 0.09 −.06 −0.17 0.17 −.06 −0.15 0.17 −.06 PRELCP × VIC −0.25 0.53 −.03 −0.08 0.18 −.02 −0.03 0.09 −.02 0.01 0.18 .00 −0.14 0.17 −.05 NRELCP × VIC 0.90 0.50 .09 0.19 0.17 .06 0.05 0.09 .03 0.40 0.17 .12 0.25 0.16 .08 MASC × VIC −0.48 0.59 −.42 −0.11 0.20 −.03 0.03 0.10 .02 −0.17 0.19 −.05 −0.22 0.19 −.06 FEM × VIC 0.83 0.56 .08 0.33 0.19 .09 0.09 0.10 .05 0.23 0.19 .07 0.17 0.18 .05

Note. n = 711. Significance values are false discovery rate (FDR) corrected p values to adjust for the multiple coefficients being tested in each regression model. The exception are the omnibus R2 tests that are uncorrected p values. VIC = Total Victimization, IMM = Immigrant, ANGOR = Anglo Orientation, LATOR = Latino Orientation, PRELCP = Positive Religious Coping, NRELCP = Negative Religious Coping, MASC = Masculine Sex Role, FEM = Feminine Sex Role. *p < .05. **p < .01. ***p < .001.

(7.1%). Using empirically derived PCL-C cut scores of 30, 44, and 50, as well as Blanchard et al.’s (1996) algorithm, 45.5%, 22.7%, 15.0%, and 8.8%, respectively, were presumed to meet criteria for a PTSD diagnosis.

Bivariate correlations were calculated to review the vari- ables in the regression models, screen for multicollinearity, and evaluate potential suppressor effects. Linear regression model results are presented in Table 2. Regression models for total PCL scores show the full count of victimization experiences was significantly associated with posttraumatic symptoms (β = .25, p < .001) as was negative religious coping (β = .16, p = .030) and masculine sex role (β = .18, p = .017).

The regression models examining reexperiencing and avoid- ance symptoms had similar results with only the full count of victimization being significantly associated with reexperienc- ing and avoidance scores (β = .20 and β = .27, respectively, ps < .001). For numbing symptoms the main effects for victimiza- tion, negative religious coping, and masculine sex role (β = .21, p < .001, β = .16, p = .03, and β = .16, p = .048, respectively) were significant. Regression results for hyperarousal mirrored those of numbing with significant effects for victimization (β = .22, p < .001) and masculine sex role (β = .17, p = .02). Across all models none of the interaction terms was significant.

Discussion

The more conservative DSM-IV-TR PTSD criteria figure of 9% is likely to be the more accurate estimate of current diagnostic

prevalence for the victimized women, as it is consistent with prior rates for victimized samples (see Keane & Barlow, 2002, for a review). With the exception of sexual violence, adulthood victimizations were more likely to fulfill PTSD Criterion A. Al- though this suggested that adults were more likely to recognize threats of death or harm and react with fearfulness or horror, it may also have been indicative of a recency effect, where those reactions were more easily recalled than those that took place in childhood.

As has been the case with previous research on polyvic- timization (Sabina & Straus, 2008; Turner, Finkelhor, & Orm- rod, 2010) and in previous analyses with this sample (Cuevas et al., 2010), overall victimization was consistently the strongest correlate of posttraumatic stress symptoms. As we have ar- gued before, this indicated that the evaluation of the full spectrum of victimization experiences is crucial in adequately determining the impact of victimization on posttraumatic symptomatology.

Negative religious coping and masculine gender role ideol- ogy were consistent in their connection to posttraumatic symp- toms. Specifically, both of these cultural variables were asso- ciated with an increase in overall PCL-C scores. This religious coping style may have increased feelings of guilt and self- blame, which are already common among victims of abuse and part of the DSM-5 PTSD diagnosis. This informs prior results showing the conflicting impact of spirituality and religion on the outcomes of violence (Comas-Diaz & Fontes, 1995; Hill & Pargament, 2003), suggesting the need to consider the role

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536 Cuevas, Sabina, & Picard

of spirituality for Latina victims of violence in their trauma sequelae.

Although our hypothesis surrounding Anglo Orientation was not supported, masculine gender role was associated with wors- ening of posttraumatic symptoms. This fit with the notion that moving away from cultural norms and expectations may result in negative psychosocial outcomes (Kaplan & Marks, 1990; Ortega et al., 2000). In prior analyses that could not use all of the cultural factors (some instruments were only asked of vic- timized women in SALAS), this was manifested in Anglo ori- entation being associated with worsening symptoms (Cuevas, Sabina, & Bell, 2012). Those results supported the idea that countering traditional gender and cultural expectations was a risk factor for worsening mental health for Latinas. Alterna- tively, and as we have noted before (Sabina et al., 2013), this move away from traditional roles may have contributed to an increased willingness to disclose victimization and/or endorse symptoms among Latinas.

Clinically, the results showed that evaluating these cultural components and using them to understand how they can con- tribute to posttraumatic symptomatology may be valuable when working with Latina victims. For example, helping Latinas re- frame religious beliefs and exploring adaptation to the Anglo culture with them could be helpful in managing the sequelae of victimization.

The key limitations of these analyses were the reliance on retrospective reports of victimization, which were susceptible to memory deterioration and recall distortion, and the cross- sectional design that prevented making causal inferences. Re- latedly, these analyses focused solely on interpersonal violence; as a result, how these concepts would function with other types of traumatic events is unknown. Also, the telephone method- ology targeted landlines and could have systematically missed younger participants and groups that may have been at increased risk of victimization and psychopathology (e.g., homeless or transient populations).

It should be noted that due to the time at which the SALAS data were collected, all instrumentation was based on the DSM- IV-TR PTSD diagnosis. The diagnosis of PTSD has undergone notable changes in the DSM-5, including a revised Criterion A and changes/additions to the symptoms across the four cri- teria. Although our analyses touched upon diagnostic issues, the primary focus centered around the role of culture on post- traumatic symptomatology. The results provided a significant contribution to the field of posttraumatic stress as it pertains to Latinos, highlighting the complex interplay of victimization, culture, and trauma symptoms. Future research should aim to replicate these findings with instrumentation based on DSM-5.

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