Rita Chi-Ying Chung, PhD

It is well-documented that for the general U.S. population, women are more likely to experience depression than men (Kessler, 1995; Leaf et al., 1986). Among the specialized refugee population in the United States, there is little research on the gender differences in psychological distress, which is considerable.

Since 1975, more than 1.5 million Southeast Asian refugees have come to the United States. Studies have found that many refugees suffer from major psychiatric disorders, such as posttraumatic stress disorder (PTSD), as a result of trauma experienced during the Vietnam War (Kinzie et al., 1990). These traumatic experiences included torture, threat of mass genocide, family loss, persecution, rape, starvation, death, hazardous escape from their home country and hardships in resettlement camps. 

Southeast Asian refugee women have been identified as an at-risk group for developing serious psychiatric disorders primarily due to their premigration experiences. Many in this population suffered sexual abuse and multiple rapes and beatings, as well as death and separation from family members, poor nutrition and health, and extreme hardships in caring for their children (Mollica and Jalbert, 1989). In response to the severity of their premigration trauma, some older Cambodian women have developed nonorganic or psychosomatic blindness: They literally can no longer stand to "see" the painful memories of their distress (Rozee and Van Boemel, 1989).

A recent study by Chung et al. (1998), using a community sample of 2,180 Southeast Asian refugees, found that Vietnamese, Cambodian and Lao refugee women reported significantly higher levels of psychological distress than did their male counterparts. Gender differences in distress for this population have been previously attributed to variations in premigration traumatic experiences. However, the study found that multiple traumatic events were a significant predictor of distress for both refugee men and women. Therefore, gender differences in psychological distress may not be solely attributed to premigration traumatic experiences, but to other factors such as coping skills, social support and postmigration adjustment.

For Southeast Asian refugees, their own ethnic community is the primary social support system as it not only provides a sense of identity and belonging, but also acts as a buffer to stressful events, and has a beneficial effect on mental health. The family is another supportive resource, with people in intact marriages at lower risk for psychological distress compared to those who are single, widowed or divorced (Beiser et al., 1989; Lin et al., 1982). 

Refugee women who reported the death or loss of a spouse may not receive the same family and emotional support as do refugee men. This is best illustrated in the Cambodian community where it has been reported that women who are widowed are often seen as a threat in their community, and are avoided by married Cambodian women who fear losing their husbands (Mollica et al., 1985). 

Furthermore, refugee women who reported loss of their spouses and/or close family members must not only cope with the bereavement over the loss of their spouse or family member, but also with the added stress of assuming a new role as head of the household. This may be particularly difficult given the context of a new and unknown culture, lack of familiar social support networks such as family, and lack of knowledge in accessing resources for economic self-sufficiency. It is not surprising to find also that significantly more women are welfare dependent than men. This puts refugee women at higher risk for cultural isolation and alienation, which leads to higher distress levels. 

A major first step in refugees' adjustment to living in an unfamiliar country such as the United States is to learn English and secure employment. One study reported that individuals who are literate in their native language achieve literacy in English much faster (Raccine, 1984). Refugee women reported having less education and a lower degree of literacy in their native language compared to the men. This fact increased distress for women. 

Not surprisingly these women reported significantly lower ESL (English as a second language) class attendance in their new country than men. This may be due to their lack of education and having little or no experience as students, which in turn may cause high levels of anxiety about the anticipated classroom experience. Without the context of formal education, women may find themselves not only having to learn new content areas such as English, but simultaneously "learning how to learn." 

There may also be a relationship between refugees' past traumatic experiences and difficulty in learning English. Many refugees were tortured during the Vietnam war. The most common form of torture for Southeast Asian refugees was beatings to the head, oftentimes resulting in head injury, and impaired memory and concentration (Allden, 1997). Such beatings may interfere with educational potential as well as other facets of adaptation such as socialization skills, daily routine functioning, general intelligence and/or problem-solving abilities.

The pressure to learn English is great, because in traditional Southeast Asian cultures there are prescribed gender roles, with husbands functioning as providers and wives staying at home to care for the family. It is necessary for men to master the host language of a country in order to increase their chances of securing a job. Vietnamese refugee men have reported that the decision they made to leave their country was distressing, which suggests that men may feel guilty for subjecting their families to hardship and for being unable to provide or protect the family from economic and related psychological problems. 

Unemployment or underemployment of refugee men has commonly forced refugee women to work in order to support their families. Ironically, whereas many men have experienced downward mobility, many women have experienced upward mobility due to increased occupational opportunities in the United States as compared to Southeast Asia. The resulting changes in gender roles have created conflicts between the values of the Southeastern Asian culture and those of the resettlement country. In turn, these shifts have placed severe pressure on traditional marriage and family relationships (Ito et al., 1997). 

The Chung et al. study (1998) strongly suggests that it is not only premigration trauma that contributes to gender differences in psychological distress among refugees but also a complex interaction of both pre- and postmigration factors. Given the large extent of family loss and degree of trauma, additional research focusing on coping strategies, resiliency and social support would be beneficial in treating the refugee population. In addition, investigations regarding traditional cultural healing methods and individual, group and family resiliency would expand the theoretical knowledge regarding effective and culturally responsive community and mental health programs. 

The research previously discussed also has important implications for mental health practitioners working with refugee populations. For example, issues such as the role reversals of men and women may be critical to address in conjunction with premigration trauma. Furthermore, it is also important that mental health professionals be aware of gender differences in degrees of psychological distress. Nolen-Hoeksema (1990) has argued that the higher incidence of depression among women may be related to childhood habits of dwelling on depressive memories. Knowledge about gender role socialization within the cultural and historical context is essential for mental health practitioners to provide effective treatment. 

Group psychotherapy may be important for Southeast Asian refugees. Studies have shown that women exhibit greater distress than men only when the stressors they experience affect their social relationships (Kessler, 1984). Thus social support networks of similar ethnic groups, especially for women, should be developed through group sessions that facilitate an exploration of deeper psychological issues regarding pre- and postmigration concerns. The concept of universality, a curative factor identified by Yalom (1995), would be important in fostering these crucial networks.

Changing U.S. policy regarding refugee assimilation raises serious mental health concerns for both men and women. The lack of continued welfare support while learn-ing English and prevocational skills as well as U.S. customs and culture may place refugees at risk for developing serious psychological problems. Shifts in traditional women's roles as family caregivers and men's roles as providers will further contribute to problems in adjusting to life in the United States. 

Sufficient support provided to refugees would ensure adequate mastery of the English language, which in turn will lead to their economic self-sufficiency and a more successful adjustment.

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Articles

Among the specialized refugee population in the United States, there is little research on the gender differences in psychological distress, which is considerable. Southeast Asian refugee women have been identified as an at-risk group for developing serious psychiatric disorders primarily due to their premigration experiences.

Rita Chi-Ying Chung, PhD

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Southeast Asian Refugees: Gender Difference in Levels and Predictors of Psychological Distress