key: cord-309997-iwueedmm authors: Chan, C.H.; Tiwari, A.; Fong, D.Y.T.; Ho, P.C. title: Post-traumatic stress disorder among Chinese women survivors of intimate partner violence: A review of the literature date: 2010-03-19 journal: Int J Nurs Stud DOI: 10.1016/j.ijnurstu.2010.01.003 sha: doc_id: 309997 cord_uid: iwueedmm BACKGROUND: Post-traumatic stress disorder is one of the most prevalent mental health sequelae of intimate partner violence, and as a result, it has been extensively documented in Western literature. However, whether abused women from non-Western cultures experience similar post-traumatic responses to intimate partner violence is less documented. OBJECTIVES: The objectives of this paper were (1) to review the literature for information about post-traumatic stress disorder among Chinese women survivors of intimate partner violence; (2) to provide a synthesis of the literature on post-traumatic stress disorder among abused Chinese women; and (3) to identify implications for practice and to suggest directions for research relating to post-traumatic stress disorder among abused Chinese women. DESIGN: A systematic review of the literature. DATA SOURCES: Following a systematic search for relevant literature in computerized databases and manual searches of English and Chinese language publications, five papers reporting on four studies conducted in China, Taiwan, Malaysia, and the United States were included in the review. REVIEW METHODS: Abstracts meeting the inclusion criteria were reviewed independently by two of the authors and any discrepancies were resolved by discussion. Full papers for selected abstracts were then retrieved and assessed independently by the same reviewers. RESULTS: The present literature review revealed a paucity of information relating to post-traumatic stress disorder symptoms or diagnoses in abused Chinese women. Nevertheless, a link between post-traumatic stress disorder and intimate partner violence was demonstrated by the reviewed papers. CONCLUSIONS: Caution should be exercised when making comparison of the findings across the four studies because of the inherent methodological differences. Also, as the assessment tools have not been validated for culture-bound interpretation of trauma and symptom manifestation, comparisons of findings for Chinese women to women in Western literature should be undertaken with due consideration. Implications for practice and recommendations for future research are discussed. A universal post-traumatic reaction to intimate partner violence cannot be assumed. Cultural beliefs may influence abused women's interpretation of trauma and their expression of posttraumatic stress disorder symptoms. There is a paucity of information relating to posttraumatic stress disorder symptoms or diagnoses in abused Chinese women. This review highlights the need for ethno-cultural and qualitative research in order to facilitate culture-bound interpretations of trauma, symptom expression, and coping in abused Chinese women. The review identifies suggestions for providing culturesensitive care in relation to intimate partner violence and post-traumatic stress disorder in the Chinese context. Intimate partner violence (IPV), also known as domestic violence, is one of the most common forms of violence against women. IPV consists of any one, or combination of, the following acts: physical violence, psychological abuse, sexual assault, controlling behaviors such as limiting resources or social contacts, intimidation, or creation of emotional dependence where the perpetrator is a current or former intimate partner (Saltzman et al., 1999) . IPV is a global problem. The World Report on Violence and Health found that between 10% and 69% of women had been physically assaulted by an intimate partner at some time in their lives in 48 population-based surveys world-wide (Krug et al., 2002) . IPV occurs across social, economic, religious and cultural boundaries. Even in cultures that emphasise social harmony, such as the Chinese culture, IPV against women is pervasive. For example, prior year prevalence of IPV victimization was reported to range from 16% to 26% in China (Chan et al., 2008) . Not only is IPV pervasive, it is also a major public health problem, with negative physical and mental health consequences (Campbell, 2002) . Specifically, PTSD has been recognized as one of the most prevalent mental health sequelae of IPV (Silva et al., 1997; Coid et al., 2003) . PTSD, an anxiety disorder which develops after traumatic exposure, is characterized by distressing memories or emotions about the trauma, avoidance of trauma reminders and elevated arousal (Green and Kimerling, 2004) . Golding (1999) , in a meta-analysis of the prevalence of mental health problems among women with a history of IPV, reported a pooled prevalence of 63.8% in 11 studies of PTSD, compared to estimates of lifetime prevalence of 1.3% to 12.3% in general populations of women (Resnick et al., 1993; Kessler et al., 1995) . A dose-response relationship was also suggested, as severity or duration of IPV was associated with the prevalence or severity of PTSD (Golding, 1999) . In recent studies conducted in North America, PTSD was found to mediate the association between intimate partner aggression and physical health symptoms (Taft et al., 2007; Wuest et al., 2009) while PTSD avoidance symptoms predicted physical health problems in women abused by an intimate partner (Woods et al., 2008) . The current body of knowledge related to trauma and PTSD is mainly based on research conducted in Western nations (Bedard et al., 2004) . It is not so clear whether people from non-Western societies have similar reactions compared to those of their Western counterparts (Tang, 2007) . There is even an argument that PTSD is a Euro-American culture-bound syndrome that does not apply to those in traditional cultures (Summerfield, 2004) . Although these views are expressed about reactions to trauma in general, the same considerations could also apply to women's reactions to IPV, long recognized as a traumatic event (Houskamp and Foy, 1991) . It is important, therefore, not to assume a universal post-traumatic reaction to IPV. Instead, there is a need to understand IPV and PTSD in culturally sensitive ways so that appropriate interventions can be developed for IPV survivors in culturally diverse populations. This paper aims to contribute to the development of increased awareness by presenting a comprehensive review of the literature on PTSD among Chinese women survivors of IPV. For the purpose of this review, PTSD includes the diagnosis of PTSD and PTSD symptoms. The objectives of this paper are as follows: 1. To review the literature for information about PTSD among Chinese women survivors of IPV (hereafter known as abused Chinese women). 2. To provide a synthesis of the literature on PTSD among abused Chinese women. 3. To identify implications for practice and to suggest directions for research relating to PTSD among abused Chinese women. The authors conducted a systematic search for relevant English language publications in computerized databases (Pubmed, Medline, PsychINFO, CINAHL, EMBASE and Google Scholar) using the keywords intimate partner violence, domestic violence, partner violence, sexual abuse, physical violence, abused women, battered women, posttraumatic stress disorder, PTSD, PTSD symptoms, trauma, traumatic stress, post-traumatic responses, mental disorder, and Chinese or Asian, with date restrictions from 1900 to June 2009. An electronic search of websites of government departments, and women's health or domestic violence organizations in Mainland China, Hong Kong, and Taiwan, was undertaken for relevant materials or citations. Manual searches of reference lists of relevant articles found in the primary search were also performed. In addition, a search for Chinese-language papers in the China Journals Full-text Database was conducted using the above Keywords. The authors contacted the corresponding authors of relevant research studies in order to obtain more information or check for possible omissions. Papers were included for full review if the main focus of the study was on PTSD (diagnoses and/or symptoms) among Chinese women abused by an intimate partner. The authors also included articles in the review if abused Chinese women were part of a diverse cultural group of participants. Abstracts of articles found were reviewed in accordance with the inclusion criteria, that is, reports on PTSD diagnoses and/or symptoms related to Chinese women with a history of abuse by an intimate partner. The abstracts were reviewed independently by two of the authors (CHC and AT). Discrepancies between the review authors were resolved by discussion. Consensus was achieved after two meetings. Full papers for selected abstracts were retrieved. Each of the articles was assessed independently by the same review authors against the inclusion criteria. There were no disagreements between the reviewers about the appropriateness of a paper for inclusion in this review. A flow chart of studies from search to inclusion is shown in Fig. 1 . Of the 74 potentially relevant abstracts retrieved, 5 papers were eventually included in this review. Two of the five included papers reported on different aspects of the same study (Hou et al., 2003 (Hou et al., , 2005 . The reason for the large number of studies being excluded was that many of them addressed either PTSD or IPV but not both IPV and PTSD. The five papers are summarized as follows. 3.1. Post-traumatic responses to domestic violence in Taiwan (Hou et al., 2003 (Hou et al., , 2005 Hou, Wang, and Chung assessed the post-traumatic responses of 109 Chinese women to domestic violence in a cross-sectional survey. The women were recruited from the Kaohsiung area of Taiwan and were included if they had suffered physical, psychological, and/or sexual abuse from their husband, ex-husband, or former or current intimate heterosexual partner within the last year. A 15item Post-Traumatic Response Scale (PTRS), a Chinese version translated from Horowitz et al.'s (1979) Impact of Event Scale (IES), was used to measure the subjective impact of marital violence on abused women within the past week. In their 2003 paper, Hou et al. reported that most (93.6%) of the participants had scores of 19 indicating a high level of post-traumatic response. They also found that the standardized mean score of the intrusion subscale of the PTRS was higher than that of the avoidance subscale. The significance of the high intrusion score was compared to an earlier study by Houskamp and Foy (1991) in which PTSD was predicted by high intrusion reaction. Based on this observation, Hou and colleagues concluded that the women in their study had a higher rate of developing PTSD. In their 2005 paper, Hou et al. reported that most (89%) of the women faced life-threatening situations in their abusive intimate relationships. Also, the more dangerous the life-threatening situations faced by the women, the greater their overall post-traumatic response scores, a finding similar to those reported in Western literature (Houskamp and Foy, 1991) . (Huang et al., 2006) In a study of 471 Chinese female prisoners randomly selected from the Hunan female prison in China, Huang, Zhang, Momartin, Cao and Zhao used structured psychiatric interviews and a clinician-administered PTSD scale (CAPS) (Blake et al., 1997) to arrive at a diagnosis of PTSD as specified by the DSM-IV. A history of IPV was reported by 24.6% of the participants and was found to be one of the most predictive factors for PTSD. Specifically, survivors of IPV in the younger age group were nearly five times more likely to develop lifetime PTSD while those in the older age group were twice as likely to develop lifetime PTSD. Despite their high exposure to traumatic events, which included IPV, the lifetime and current rates of PTSD for this Chinese sample of female prisoners, at 15.9% and 10.6% (Chandra et al., 2009; Leahy et al., 2004; Yoshihama and Horrocks, 2003; Yoshihama and Horrocks, 2005) . respectively, were much lower than those found in Western literature (Cauffman et al., 1998; Ruchkin et al., 2002) . Differences between the Chinese and Western study subjects were suggested as a possible reason for the discrepancy in the prevalence of PTSD, although the researchers did not elaborate on the differences. Interestingly, not only were the rates of PTSD lower than those in Western literature, they were also lower than those reported in colleagues' (2003, 2005) study of women in a community in Taiwan. What may have accounted for the apparent difference in PTSD scores between female prisoners in Mainland China and community-dwelling women in Taiwan? Could this be due to differences in coping strategies or personality hardiness that may have insulated the female prisoners from developing PTSD? As Huang et al.'s study did not elaborate on the participants' coping strategies or personality hardiness, it was not possible to draw a conclusion. 3.3. Cross-cultural assessment of post-trauma reactions among abused women (Phillips et al., 2006) Chinese women seeking refuge in a domestic violence shelter in Malaysia were included in a study conducted by Phillips, Rosen, Zoellner, and Feeny, to examine posttraumatic reactions in abused women from non-Western cultures. Seventeen female residents at a domestic violence shelter, consisting of 10 Indian, 5 Malay and 2 Chinese, completed semi-structured interviews and standardized measures for the assessment of post-trauma psychological morbidity. The 17-item PTSD-SR symptom scale-self-report (PSS-SR, Foa et al., 1997) and the 15-item Revised Impact of Events Scale (RIES, Sundin and Horowitz, 2002) were administered. A majority (82.4%) of the women met the criteria for PTSD symptoms on the PSS-SR, and 76.5% of the women also met, or exceeded, a recommended cut-off score of 35 on the RIES. Additionally, the participants' reports of post-trauma reactions were comparable to those of a sample of women in the United States who experienced partner violence. In their discussion of the findings, Phillips and colleagues identified several limitations of the study including the small sample size, the use of the Western construct of PTSD in non-Western cultures and the omission of comorbidity. Specifically, they raised their concern about imposing Western PTSD symptomatic criteria on the participants in their study whose cultural experience of trauma might be different to trauma victims in the West. Also, although Phillips and colleagues did not elaborate on the issue of comorbidity, they nevertheless highlighted the importance of including comorbidity when assessing the psychological status of trauma victims. 3.4. Effects of social support and coping strategies on IPV and psychological outcomes in Asian and Caucasian women In this study, the potential mediating effects of social support and coping strategies on the relationship between IPV and psychological outcomes of PTSD symptoms and depression were investigated. A sample of 100 Caucasian women and 61 Asian women were recruited from nine domestic violence agencies located in Texas and California. The Asian women consisted of 25 Chinese, 22 Vietnamese and 14 Koreans. The PTSD Checklist-Civilian version (PCL-C; Weathers et al., 1993) , the Perceived Social Support scale (PSS; Norris and Kaniasty, 1996) , and the revised Ways of Coping Checklist (WCCL; Vitaliano et al., 1985) were used to measure PTSD symptoms, perceived social support, and coping efforts, respectively. Analysis of the combined Caucasian and Asian groups revealed that there was an indirect effect of the level of violence on psychological outcomes via the mediating variables of perceived social support and passive coping strategies. However, ethnic group comparisons indicated differences between Caucasian and Asian women. Specifically, in the Asian group, the effect of IPV on the women's psychological distress was entirely direct. Thus, the higher the levels of IPV experienced, the more severe the PTSD and depression symptoms. Neither social support nor coping mediated the impact of IPV on the Asian women's psychological health. Based on the findings, Lee et al. suggested that Asian women may be more vulnerable to adverse psychological outcomes following IPV. As the results were drawn from a diverse group of Asian participants, they should be interpreted with caution with regard to generalizability. The present review demonstrated a paucity of information on PTSD among abused Chinese women. This is consistent with the current state of PTSD research in Chinese societies that, to date, has mainly focused on the post-traumatic impact of natural disasters such as earthquakes and flooding (for example, Zhang and Zhang, 1991; Zhao et al., 2001; Liu et al., 2006) . However, relatively little is known about the post-traumatic impact of human-instigated disasters. Additionally, caution should be exercised when making comparisons across the reviewed studies because of the methodological differences. For example, the use of different assessment tools could account for the variability in the rates of PTSD across the studies. Specifically, the differences may be due to measuring PTSD diagnosis versus severity scores or the use of self-reports versus clinician-administered measures. For instance, the use of the clinician-administered PTSD scale (CAPS) in Huang et al.'s (2006) study to measure the diagnosis of PTSD could have led to lower rates of PTSD because the CAPS is not a self-report measure and the participant has to answer questions face-to-face. It is possible that some of the participants may be reluctant to admit psychological difficulty to another person, but would have more highly endorsed mental health problems on a self-report measure. Despite the variability, a link between PTSD and IPV was demonstrated in the reviewed studies. The studies included in this review used measurement instruments developed in the United States to assess abused Chinese women's PTSD (symptoms and/or diagnosis). Evaluation of the translated measurement instruments was described in one of the papers (Hou et al., 2003) , which focused only on surface validity and reliability. None of the papers provided adequate evidence regarding the scientific rigor with which the translated instruments were evaluated and revised in the Chinese context. Indeed, Phillips et al. (2006) expressed their concern about imposing the Western construct of PTSD in non-Western cultures. Such concern is consistent with that expressed by Tang (2007) about the widespread use of translated instruments from the West in an imposed-etic approach when measuring PTSD in Chinese trauma survivors. Also, by assuming that PTSD is a relevant and meaningful construct in Chinese culture, researchers conducting PTSD research in abused Chinese women could fail to recognise omissions of emic constructs that are central to Chinese ways of conceptualizing life adversity, expressing symptoms of post-trauma reactions, and coping with life's vicissitudes. Therefore, future research should adopt more rigorous validation procedures when translated instruments are used. For example, back-translation should be used to ensure that the underlying meaning of the original wording is preserved after translation. Further, the translated version of the instrument should be reviewed and agreed by a committee of bilingual members who have not participated in the translation process. Validation efforts should also include testing the translated instrument with a sample made up of members of the target culture as well as submitting it to a full psychometric evaluation (Polit and Beck, 2008) . The expression of PTSD by the participants in the reviewed studies should be contextualized in the traditional Chinese health beliefs. This is because, unlike Western medicine, there is no clear distinction between physical disorders and mental disorders in Chinese medicine. As such, internal organs are viewed as centers for combined physiological and psychological functions and vital organs such as the heart, lungs and kidneys are often used by Chinese people for colloquial expression of feeling states (Lin, 1982) . It has been suggested that such beliefs, together with the stigma associated with mental illness in Chinese societies, may be responsible for Chinese patients presenting with somatic symptoms (e.g. headache, back pain) rather than expressing their mental health problems (e.g. depression) (Tang, 2007) . Interestingly, in Hou and colleagues' (2005) study, somatization was the fourth most common symptom expressed by the participants. In Huang et al.'s (2006) study, where the prevalence of PTSD in Chinese female prisoners was found to be lower than that in the Western studies of female prisoners, somatization was not assessed. To what extent was the apparent lower prevalence of PTSD an artifact of the Chinese women prisoners' health beliefs? In other words, could some of the participants have expressed their PTSD in the form of somatic symptoms? Such a question cannot be answered because the measures in Huang et al's study did not include somatization. This shows the need for future research to include the assessment of somatic symptoms when studying PTSD in abused Chinese women Previous studies on the psychological status of trauma survivors in Western populations have identified the need to consider the issue of comorbidity (Boudreaux et al., 1998; Stein and Kennedy, 2001) . Specifically, Stein and Kennedy have found major depressive and post-traumatic stress disorder comorbidity in female victims of IPV. Despite this, with the exception of Phillips et al. (2006) , none of the reviewed studies have identified the need to address comorbidity when assessing psychological responses of Chinese IPV survivors. Interestingly, studies on natural disasters in China and Taiwan have found comorbidity of PTSD and other mental health problems (mainly depression) among adult community survivors (Lai et al., 2004; Wu et al., 2006) , long-term survivors (Zhang and Zhang, 1991; Zhang et al., 2002) and rescue workers (Chang et al., 2003) . In addition, comorbidity of PTSD and depression, as a result of the Severe Acute Respiratory Syndrome (SARS) outbreak, was also found among patients in China (Yan et al., 2004) , health care workers in Taiwan (Chong et al., 2004) , and survivors of SARS in Hong Kong (Cheng et al., 2004) . In light of such findings, future research should also consider psychiatric comorbidity when investigating the psychological responses of abused Chinese women. Since IPV is still considered to be a private matter and victim-blaming attitudes are still prevalent in Asian communities (Yoshioka et al., 2000) , it is important to educate the community as a first step in the promotion of primary prevention of IPV. Nurses can, through public education programs, teach members of Chinese communities that IPV reflects the community's normative acceptance of violence against its members, which goes against the Confucian teachings of respect and harmony. Furthermore, the psychological damage caused by IPV, not only to the survivor but also to the family and the community as a whole, should be emphasized. By raising public awareness of the problem of IPV and by promoting community involvement in the prevention of IPV, nurses can help to ensure that abused Chinese women are not revictimized when they seek assistance from their informal social networks. As identified by Hou et al. (2005) , Chinese women survivors of IPV are at risk of developing PTSD if no support or intervention is provided. Thus, detection of IPV is an important step to prevent deterioration of these women's mental health. In view of the fact that IPV is considered to be a family shame in the Chinese culture and would not be disclosed to outsiders (Tang et al., 1999) , nurses should be sensitive to Chinese women's reluctance to discuss their abusive relationships, and their reluctance to accept help from formal services. Earlier studies have found that, in a safe and trusting environment, Chinese women were prepared to disclose their abuse experiences to nurses who had been trained to elicit such sensitive information (Tiwari et al., 2005 (Tiwari et al., , 2007 . It is, therefore, important that culture-sensitive training on screening for IPV be provided if nurses are to conduct assessment for IPV in Chinese women. In the cases of abused Chinese women with physical problems, their mental health should also be assessed because somatic symptoms may be reported instead of psychological symptoms (Tang, 2007) . Although none of the studies reviewed focused on the relationship between psychological abuse and PTSD in Chinese women, an earlier study of Japanese-American women found that those women who had experienced emotional, but not physical, violence reported increased post-traumatic stress symptoms relative to those with no history of partner violence (Yoshihama and Horrocks, 2002) . Previous studies of IPV among Chinese women have found a predominance of psychological abuse, in the absence of physical or sexual violence (Leung et al., 1999 (Leung et al., , 2002 Tiwari et al., 2005 Tiwari et al., , 2007 , but no assessment for PTSD was conducted in these cases. In light of Yoshihama and Horrocks' findings, consideration should be given to screening Chinese women, who have experienced psychological intimate partner abuse, for the possibility of PTSD as well. In their analysis of the apparent vulnerability of Asian women to adverse psychological outcomes (PTSD being one of them) after exposure to IPV, Lee et al. (2007) suggested that the existing social support systems, that were not consistent with Asian cultural beliefs, might not be helpful to Asian women. Reluctance to utilise formal services was not only confined to abused Chinese women, but it was also noted that Chinese survivors of natural disasters were also reluctant to seek outside help. For example, only 18-25% of those who reported PTSD symptoms after the Chi-Chi earthquake in Taiwan in 1999 used the available mental health services (Kuo et al., 2003) . When offering assistance to abused Chinese women, nurses should be aware that these women may be hesitant to accept help from individuals outside their families, especially if they perceive that such help would bring shame to their family reputation or threaten their family unity. Thus, reassurance should be given in a culturally appropriate manner. Also, as Chinese women are more likely to seek help from informal social networks, nurses may consider collaborating with such networks in providing abused Chinese women with social support. When deciding which of the interventions would be appropriate for abused Chinese women at risk for developing PTSD, nurses should ensure that the chosen intervention is evidence-based as well as culturally appropriate. A recent review of advocacy interventions for abused women provided comprehensive information about the effects of advocacy interventions in reducing post-traumatic stress (Ramsay et al., 2009) . If advocacy interventions are to be used for Chinese women, it is crucial for nurses to recognise that ''empowerment'' is a socially constructed term and may not be compatible with the traditional Chinese values of sacrificing one's needs for the greater good of the family (Yick, 2001) . Care should be taken not to encourage the women to end their abusive relationships. Instead, time and effort should be spent to assist them to resolve their self-blaming attitudes, and to acknowledge their dilemma of wishing to end the abuse, yet wanting to keep their family together (Yick et al., 2003) . Furthermore, nurses can empower abused Chinese women by affirming their coping behaviors and supporting them in developing their own resources. Research conducted in developed nations has shown that IPV is associated with PTSD in women survivors (Resnick et al., 1993; Kessler et al., 1995) . For Chinese women, as demonstrated in this review, relatively little is known about the post-traumatic impact of IPV. Even though trauma research has a relatively short history in Chinese societies and the research focus is mainly on natural disasters, there is already an accumulation of evidence of PTSD within Chinese survivors (Tang, 2007) . Future PTSD research should broaden the scope to include not only the mental health impact of IPV but also the possible differential relationship between types of IPV (e.g. psychological abuse, physical violence, or sexual assault) and PTSD symptoms or diagnoses. Additionally, the use of cross-sectional design precludes an examination of causality between IPV and PTSD in Chinese women. By adopting a longitudinal approach within the Chinese context, a more reliable conclusion can be drawn regarding the causal process (if any) from IPV to PTSD. The use of convenience samples in the studies reviewed has restricted the generalization of the results to other abused Chinese women. In order to enhance representativeness of the sample, stratified probability sampling should be considered. As well, the ethnic makeup within the Asian participants in two of the reviewed studies (Phillips et al., 2006; Lee et al., 2007) may be too diverse, thus confounding the overall results. For example, in Lee et al.'s study, Chinese, Korean and Vietnamese women made up the Asian group. China has not seen warfare or combat for more than half a century, whereas Vietnam's experience of warfare is more recent. Therefore, it should not be assumed that traumatic life events for the Chinese and Vietnamese women are similar. Although it is often assumed that Korean, Vietnamese and Chinese people are influenced by Confucian beliefs, in fact, because of the different political, social and economic conditions in these countries, the actual Confucian influence may not be the same. Thus, future research should clearly delineate the post-traumatic impact of IPV on different ethnic groups. As discussed earlier, the studies in this review adopted an imposed-etic approach (Berry, 1980) by using translated assessment tools from the West. Cross-cultural differences in terms of psychometric properties or interpretation have not been considered. Thus, the assessment instruments may be appropriate for the culture where they were developed but may not be appropriate in a different culture where they may be applied. Indeed, Tang (2007) has argued for the need to obtain emic constructs that are appropriate for Chinese societies when conducting trauma research among Chinese people. Future research should consider using ethno-cultural or qualitative approaches in order to collect, interpret and compare perceptions of, and reactions to, the same traumatic life events from Chinese and non-Chinese survivors. It is hoped that using ethnocultural or qualitative approaches will facilitate culturebound interpretations of trauma, symptom expression, and coping, in the Chinese context. In recent Western studies, people who report PTSD symptoms, but who do not necessarily meet the diagnostic criteria, have been found to have impaired functioning (Grubaugh et al., 2005; Jeon et al., 2007) . In some cases, the reporting of PTSD symptoms has been shown to be a predictor of delayed onset PTSD (Carty et al., 2006) . There is a need to validate whether the findings of impaired functioning also apply to Chinese people and to assess how such information may inform the choice of interventions for abused Chinese women. Finally, there is a need to investigate the role played by PTSD in mediating the relationship between IPV and physical health problems among abused Chinese women. Despite an increased understanding about the relationships between IPV, physical health problems, and PTSD (Wuest et al., 2009; Woods et al., 2008) , the specific relevance for abused Chinese women remains unknown. This needs to be addressed so that appropriate preventive strategies for Chinese women can be instituted in a timely manner. A search of the existing literature has identified five papers reporting on PTSD symptoms or diagnoses in abused Chinese women. The studies were conducted in China, Taiwan, Malaysia and the United States, with Chinese women being the sole participants, or participants as part of a mixed Asian group. Interview schedules and/or rating scales utilized to assess the women for PTSD at diagnostic or symptomatic levels, were exclusively developed in Western countries. The present review has revealed a paucity of information about PTSD among abused Chinese women, and has also highlighted the methodological differences across the studies. Furthermore, the studies utilized assessment tools that have not been validated for culture-bound interpretation of trauma and symptom expression; therefore, comparing the findings with those in the Western literature should be undertaken with care. Implications for practice and suggestions for future research are discussed. None. International publication trends in the traumatic stress literature Introduction to methodology Clinician-administered PTSD Scale for DSM-IV, Current and Lifetime Version Criminal victimization, posttraumatic stress disorder, and comorbid psychopathology among a community sample of women Health consequences of intimate partner violence Delayed-onset PTSD: A prospective study of injury survivors Posttraumatic stress disorder among female juvenile offenders Understanding violence against Chinese women in Hong Kong: An analysis of risk factors with a special emphasis on the role of in-law conflict Women reporting intimate partner violence in India: Associations with PTSD and depressive symptoms Posttraumatic distress and coping strategies among rescue workers after an earthquake Psychological distress and negative appraisals in survivors of severe acute respiratory syndrome (SARS) Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital Abusive experiences and psychiatric morbidity in women primary care attenders The validation of a selfreport measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale Intimate partner violence as a risk factor for mental disorders: A meta-analysis Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress Subthreshold PTSD in primary care: prevalence, psychiatric disorders, healthcare use, and functional status Impact of event scale: a measure of subjective stress Post-traumatic responses of abused women to marital violence Domestic violence against women in Taiwan: their life-threatening situations, post-traumatic responses, and psycho-physiological symptoms: an interview study The assessment of posttraumatic stress disorder in battered women Prevalence and characteristics of trauma and posttraumatic stress disorder in female prisoners in China Partial versus full PTSD in the Korean community: prevalence, duration, correlates, comorbidity, and dysfunctions Posttraumatic stress disorder in the National Comorbidity Survey World Report on Violence and Health. World Health Organization Prevalence of psychiatric disorders among bereaved survivors of a disastrous earthquake in Taiwan Full and partial PTSD among earthquake survivors in rural Taiwan Perpetrator methodology as a predictor of traumatic symptomatology in adult survivors of childhood sexual abuse Intimate partner violence and psychological health in a sample of Asian and Caucasian women: The roles of social support and coping Domestic violence and postnatal depression in a Chinese community The prevalence of domestic violence against pregnant women in a Chinese community An epidemiologic study of posttraumatic stress disorder in flood victims in Hunan China Traditional Chinese medical beliefs and their relevance for mental illness and psychiatry Received and perceived social support in times of stress: a test of the social support deterioration deterrence model A cross-cultural assessment of posttrauma reactions among Malaysian and US women reporting partner abuse Nursing Research: Generating and Assessing Evidence for Nursing Practice Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. Cochrane database of systematic reviews Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women Violence exposure, posttraumatic stress, and personality in juvenile delinquents Intimate Partner Violence Surveillance: Uniform definitions and recommended data elements, Version Symptoms of post-traumatic stress disorder in abused women in a primary care setting Cross-cultural perspectives on the medicalisation of human suffering Impact of event scale: psychometric properties Major depressive and post-traumatic stress disorder comorbidity in female victims of intimate partner violence Posttraumatic stress disorder and physical health symptoms among women seeking help for relationship aggression Assessment of PTSD and psychiatric comorbidity in contemporary Chinese Societies Breaking the silence: Violence against women in Asia Identifying intimate partner violence: comparing the Chinese abuse assessment screen with the Chinese revised conflict tactics scales A randomised controlled trial of empowerment training for Chinese abused pregnant women in Hong Kong The ways of coping checklist: revision and psychometric properties The PTSD checklist (PCL): reliability, validity, and diagnostic utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies Physical health and posttraumatic stress disorder symptoms in women experiencing intimate partner violence Survey of quality of life and related risk factors for a Taiwanese village population 3 years post-earthquake Abuse-related injury and symptoms of posttraumatic stress disorder as mechanisms of chronic pain in survivors of intimate partner violence Survey on mental status of subjects recovered from SARS Feminist theory and status inconsistency theory: Application to domestic violence in chinese immigrant familes Partner violence, depression, and practice implications with families of Chinese descent Posttraumatic stress symptoms and victimization among Japanese American women The relationship between intimate partner violence and PTSD: an application of Cox regression with time-varying covariates Relationship between emotional numbing and arousal symptoms in American women of Japanese descent who experienced interpersonal victimization Asian family violence report: A study of the Cambodian, Chinese, Korean, South Asian and Vietnamese communities in Massachusetts. Asian Task Force Against Domestic Violence Long-term effects of Tangshan earthquake on psychosomatic health of paraplegic sufferers Psychological consequences of earthquake disaster survivors Prevalence and correlated factors of PTSD in adolescents 17 months after earthquake This review was supported by a Small Project Funding (#200807176148) from the University of Hong Kong.