AMA Journal of Ethics^®

Abstract

Because multiple Asian American and Pacific Islander (AAPI) communities in the United States have experienced historical trauma (HT), it is important to understand HT’s impact on the well-being of members of subsequent generations. This article addresses intergenerational trauma transmission, focusing primarily on Japanese American and Southeast Asian American communities. Research on these groups illuminates strategies for future empirical investigations of intergenerational trauma in other AAPI populations and suggests implications for care.

Historical Trauma and Health

Historical trauma (HT) is characterized as a traumatic event shared by a group of people that contributes to an increased prevalence of negative physical health outcomes, impaired parenting, distrust, and mental illness in subsequent generations.¹ HT research has utilized both qualitative and quantitative methodology and began with a focus on the offspring of Nazi Holocaust survivors. Several of these earlier studies relied on clinical samples of survivors’ children, leading to the impression that their mental and behavioral health problems (eg, depression, anxiety, and disruptive behavior) stemmed from their parents’ Holocaust trauma.^2,3,4 However, additional studies that utilized nonclinical samples and compared offspring whose parents did and did not experience the Holocaust failed to find increased pathology in survivors’ offspring.^5,6,7 Investigators have also noted the importance of studying general resilience and specific vulnerabilities in families of Holocaust descendants.⁸ Although there is limited research on HT in Asian American and Pacific Islander (AAPI) communities, this paper highlights findings on this topic related to Japanese Americans and Southeast Asian Americans, the AAPI groups for which there is the most published research on this topic. Because there is a dearth of research examining the physical ramifications of HT in both these groups, we focus here on the psychological impacts. Our review elucidates subtle factors related to HT that can influence the well-being of AAPI patients and suggests that ethical treatment of patient needs can benefit from assessing possible factors related to HT beyond general family background. Although not discussed in this article, recent pandemic-related instances of anti-Asian harassment, discrimination, and violence have negatively targeted AAPI individuals. The increased sense of vulnerability and race-related stress associated with these events have the potential to retraumatize the AAPI community and can be included among these factors as well.

Japanese Americans

Soon after the Japanese military attacked Pearl Harbor, Hawaii, in 1941, the United States ordered all persons of Japanese ancestry from Western portions of the country to live in internment camps in remote areas.⁹ Falsely portrayed as potentially disloyal, men, women, and children—two-thirds of whom were US citizens—were interned for up to 4 years.⁹ Four decades later, the US government admitted this policy was based on false pretenses of national security and racial prejudice⁹ and paid reparations of $20 000 to surviving internees.¹⁰

These actions, however, did not address the impacts of HT on postwar third-generation Japanese American (Sansei) internee offspring. Lost businesses, land, and livelihoods during internment left few economic resources for Sansei to inherit.¹¹ Some were deprived of a healthy parent. Survey data indicated that “former internees had a 2.1 greater risk of cardiovascular disease” than their noninternee counterparts,¹² and a study of Sansei found that twice as many formerly interned fathers as noninterned fathers died before the age of 60.¹³ Large-scale surveys and in-depth interviews with Sansei also reveal the impacts of HT on family dynamics and parenting.¹³ Despite the trauma associated with internment, several researchers have observed that most Japanese American families were silent about what happened.¹³ In one study, many Sansei reported having had approximately 10 brief conversations in their lifetime with their parents about the “camps.”¹³ Parents avoided the topic altogether or spoke of it in curt or evasive ways. Some only discussed the internment to help their child do a school project.¹³ Attempting to protect their Sansei children from further targeting, former internees minimized or omitted the teaching of Japanese language and culture and urged their children to blend into mainstream American culture and achieve scholastically.¹³ In turn, Sansei experienced a loss of identity, family history, and a self-consciousness about their ethnicity.^{11,13,14,15,16} This struggle was exacerbated by insufficient coverage of the trauma in the broader society. For example, 2 analyses of history books published between 1988 and 1992 and between 2002 and 2003 that were used in public high school curricula found that the internment was justified solely in terms of national security with no mention of racism or discrimination,¹⁷ and, in the media in the 1960s, Japanese Americans were portrayed as a “model minority” that overcame the wartime experience.¹⁸

Over time, most Sansei learned on their own about the trauma through books, ethnic studies courses, and films.^13,15 While the information helped close the gap in information that Sansei experienced growing up, survey data indicate that increased knowledge about the hardships suffered by their own parents and grandparents is associated with greater levels of sadness and anger.^13,14 Knowledge about the internment also engenders distrust of the government: those who have a parent who had been interned are less confident about their rights in the United States than those for whom neither parent had been interned.^13,14 Sansei are also, however, positively inspired by viewing their parents as role models of resilience. Some have been motivated to fulfill their parents’ lost dreams by pursuing the degree or career a parent had missed or by entering a legal career or community activism to prevent future injustices.^12,13,14

Southeast Asian Americans

The severe traumas experienced by Southeast Asian (SEA) groups are also linked to HT transmission. Starting in 1975, the Pol Pot regime implemented the Cambodian genocide, which resulted in the deaths of 1.5 million individuals and over 100 000 US refugees.¹⁹ Life under the regime included starvation, forced labor, executions, destruction of property, and separation of families.¹⁹ In the same year, North Vietnam’s capture of Saigon signaled the end of the Vietnam war and the first surge of the Vietnamese refugee exodus to the United States.²⁰ The ending of war was not the end of trauma for Vietnamese families, however; political repression, economic hardships, and warfare with other countries continued.²⁰ By 1996, over 700 000 refugees had escaped to the United States.²⁰ SEA refugees’ experiences in refugee camps prior to arriving in the United States also became a source of trauma.^19,20

Despite internment trauma, several researchers observed that most Japanese American families were silent about what happened.

Findings are mixed regarding whether refugee parents’ exposure to trauma or symptoms of posttraumatic stress directly affect their children’s mental health and behavioral functioning.^21,22,23 However, parents’ experience does seem to exert an indirect effect on their children’s health through various components of family dynamics, including parenting style, family functioning, parent-child engagement, and intergenerational communication.^21,22,23 One study, for example, noted that observed patterns of severe anger episodes among Cambodian Americans receiving psychiatric treatment at a clinic were frequently directed toward children and associated with intergenerational conflicts that had elicited parents’ somatic trauma recall.²⁴ As with Sansei, intergenerational communication about families’ trauma is a critical component of SEA youths’ experience of HT. Findings among young adults in Cambodian refugee families indicate that communication patterns vary widely—from complete silence, to partial avoidance, to open communication.^25,26 These patterns could both positively and negatively affect (1) connectedness between offspring and parents and (2) offspring’s emotions. For example, open communication could either engender positive emotions in children in response to learning more about family history or emotionally overwhelm them.^25,26 Like Sansei’s parents, sometimes SEA parents have only been willing to talk about their trauma with their children if it was needed for a school project.^25,26 Also similar to the Sansei, SEA children face societal silence about their group’s HT, although they have had increased access to information via the internet.^20,25,26

Similar to Japanese Americans, an emphasis on academic achievement and professional success as a means to security has been one impact of HT in SEA refugee families.^20,27 However, both the Sansei offspring of internees and their internee parents were US-born, whereas immigrant SEA parents encountered posttrauma challenges of adjusting to the United States due to limited English facility and job opportunities, which contributed to low income, living in disadvantaged neighborhoods, and hardships in navigating American life.^20,28,29,30 Unsurprisingly, then, their offspring have lower rates of educational attainment compared to other Asian groups and the general US population.^27,31 Such findings caution against perceiving Asian American youth as a model minority generally and in the context of HT.

Future Research and Care

This brief review suggests the benefits of considering the impacts of HT in order to provide ethical assessment of and care for AAPI individuals and to promote future research. An understanding of the trauma that patients’ families and communities have experienced can help contextualize patients’ health problems and inform efforts to improve their health. Both clinicians and researchers are urged to:

• Investigate patients’ unique histories and characteristics related to HT when assessing the impacts of HT on well-being by adopting a historical perspective that considers when and where the group trauma occurred; the potential existence of multiple and varying types of trauma linked to historical events; the amount of time since the group trauma took place; and the developmental and social context of subsequent generations. Such a perspective can give researchers a more complete picture of the context of and factors contributing to HT.
• Assess the role of acculturation and cultural gaps in HT transmission, especially among children of immigrants. Such gaps have contributed to maladaptive mental and behavioral outcomes for children and poorer parent-child relationship quality,^24,32,33 suggesting that they warrant consideration as potential mechanisms of HT.
• Consider the effect of mainstream society’s lack of awareness of AAPI traumas on patients’ ability to process their HT. Intrafamilial silence, combined with societal silence, may increase hesitancy to share concerns related to HT with health care professionals and may inhibit service utilization and treatment.
• Assess potential protective factors associated with HT, including the degree to which patients view the trauma and parents’ or ancestors’ resilience as a source of positive inspiration. Community-level factors might also facilitate resilience. For example, part of some Sansei’s resilience is attributable to being actively involved in the reparations movement, a form of collective activism comprising multiple generations and organizations.¹³

Researchers can also take the following steps:

• Take a developmental approach—particularly by including younger children, since studies including this group are lacking—to prospectively examine variation in HT effects across developmental stages.
• Investigate potential biological mechanisms of HT transmission in light of emerging findings on the role of epigenetic transmission of stress in Holocaust survivor families.³⁴ Although previous studies have found that those who directly experienced the trauma (such as parents of Sansei,^13,14 SEA refugee parents²⁸) suffered physiological consequences, there is a dearth of literature examining the physical ramifications of HT on subsequent generations.
• Emphasize qualitative methodology. Prior AAPI studies have included quantitative measures (eg, the Harvard Trauma Questionnaire), but the research discussed in this review on Sansei and Southeast Asians indicates that qualitative methodology—specifically, in-depth interviews and open-ended questions—are beneficial in discerning nuanced impacts of HT not revealed by quantitative measures.
• Expand research on other AAPI groups’ experiences of HT. Preliminary research among Native Hawaiians and Sikh Americans exists,^35,36 but more studies on these and other under-researched AAPI groups is needed.

Conclusion

Research on Japanese Americans and Southeast Asians has assessed potential impacts of HT on well-being and care considerations. Future investigations on this topic are needed to expand the depth and breadth of this work. These efforts should be undertaken bearing in mind the unique nature of trauma faced by different AAPI groups.