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International Journal of Adolescent Medicine and Health

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Military sexual trauma as a determinant in the development of mental and physical illness in male and female veterans

1Mount Sinai School of Medicine, Department of Psychiatry, Box 1230, One Gustave L. Levy Place, New York, NY 10029, USA

2Mount Sinai School of Medicine and James J Peters Veterans’ Administration Medical Center, New York, NY, USA

Corresponding author: Betsy S. O’Brien, MD, Mount Sinai School of Medicine, Department of Psychiatry, Box 1230, One Gustave L. Levy Place, New York, NY 10029, USA

Citation Information: International Journal of Adolescent Medicine and Health. Volume 25, Issue 3, Pages 269–274, ISSN (Online) 2191-0278, ISSN (Print) 0334-0139, DOI: 10.1515/ijamh-2013-0061, September 2013

Publication History

Received:
2012-08-25
Accepted:
2012-10-04
Published Online:
2013-09-04

Abstract

Background: Military Sexual Trauma (MST) is defined as sexual harassment and or sexual assault experienced by a military service member. It is much more widespread and common than reported. It is associated with pre-combat traumatic experiences and pathologic sequelae including mental and medical illness.

Methods: An electronic search of the major behavioral science databases was conducted to retrieve studies detailing the social, epidemiological and clinical characteristics of MST and its relationship to psychiatric and medical illness.

Results: Studies indicate that military sexual trauma is related to an increase in psychiatric pathology, including posttraumatic stress disorder (PTSD), substance abuse and dependence, depression, anxiety, eating disorders and suicidal behavior. MST is also related to an increase in medical illness, primarily pain-related symptoms involving multiple organ systems, including gastrointestinal, neurological, genitourinary and musculoskeletal.

Conclusion: MST is associated with an increased prevalence of mental and physical illness. Although there are some gender differences in the reported rates of MST and there may be some variables, such as prior traumatic experiences, that may make an individual more vulnerable to the psychiatric and medical sequela of MST, it is clear that MST is a major healthcare issue that affects both sexes and warrants further attention and an increase in clinical resources devoted to it. Some preventive measures for decreasing the prevalence of MST may include increasing education and legal prosecution of perpetrators in the military, and increasing access to mental health services for individuals who have suffered from MST.

Keywords: childhood trauma; depression; female veterans; male veterans; medical illness; military sexual trauma; posttraumatic stress disorder; veterans

Introduction

The Department of Veterans Affairs has defined military sexual trauma (MST) as sexual harassment and or sexual assault experienced by a military service member without regard to the location of service, gender of the victim or relationship of the victim to the perpetrator (1). In 1992, there was a congressional mandate for the Department of Veterans Affairs to treat veterans for symptoms related to MST (2). The data on the prevalence of MST contains some variability, depending on whether the studies include only actual or threatened sexual assault or more broadly include offensive sexual behavior or unwanted sexual attention. For example, Allard et al. (2) cited a prevalence estimate of 22%–45% based on prevalence studies that primarily included actual or threatened sexual assault. In 2006, the Department of Defense (DOD) conducted a study that also estimated prevalence of MST and sited prevalence numbers for different types of MST. Specifically, the DOD estimated that 52% of women and 29% of men reported offensive sexual behavior, 31% of women and 7% of men reported receiving unwanted sexual attention, 9% of women and 3% of men reported sexually coercive behavior and 6.8% of women and 1.8% of men reported being sexually assaulted (1). Data from OEF/OIF (Operation Iraqi Freedom, OIF and Operation Enduring Freedom, OEF, Afghanistan) veterans suggests that 15.1% of women and 0.7% of men reported MST when screened (3).

Individuals that are most vulnerable for MST are most likely to be women between the ages of 30 and 49 years who are white, highly educated, have served in the reserves more than 5 years and more likely to have a service-related disability (4). Alcohol abuse is another risk factor that increases instances of MST, and an estimated 50% of sexual assaults in the military feature alcohol involvement (5). As women become an increasing part of the total veteran population, with the prevalence of female veterans estimated at 15% when including the wars in Iraq (OIF) and Afghanistan (OEF) (3), MST becomes a larger health issue affecting the military as well as the veteran population.

Recognition of MST

The diagnosis of PTSD, included in the DSMIII and in the PTSD manual, was seen as the result of certain gender-specific stressors, mainly combat for men and rape and sexual trauma for women (6). Sources have suggested that seeing certain stressors as gender-specific, such as rape for women and combat for men, has perhaps led to a decrease in reporting MST and thus artificially lowered the MST prevalence rates in male veterans (6). Initially, in the first decade of DoD research on MST in servicemen, the reported rates were <1% (6). Then, during the 1990s, there was an increase in reported rates of MST in men to 2%–9% (6). Now, reported rates of MST in men vary widely across studies in the DoD, from 0.02% to 12% (6). Sources have also looked at nonresponse rates, which ranged from 3% to 92%, and have extrapolated that 66% of men’s sexual assault incidents are not formally reported and that only 10% of sexual assaults on men at the service academies are thought to be reported (6).

The question arises as to what causes this under-recognition of MST, especially in the male veteran population. Some studies have suggested that those who do not report want to avoid thinking or talking about an assault and do not want to disclose the event, whereas other sources have suggested that the military and government have created certain administrative barriers to reporting MST, including the length of questionnaires, the substantial number of surveys to fill out and the fostering of a perception that the surveys will not change policy (6). The military philosophy as well, with its emphasis upon the need for cohesion, discipline, loyalty and collectivism, may create an environment that discourages the reporting of sexual assault and the feeling that the victims will be attacked verbally and even physically for reporting (5, 6). Studies quote common reasons for not reporting MST to be that victim feels embarrassed, is fearful of reprisal through evaluations, believes that the incident was not important enough to warrant reporting and fears nothing will be done (6). An element of guilt may also play a role in not reporting the crime, as male victims of MST may interpret reporting to be a threat to their manhood (6). Studies have also shown that MST affects military careers, as a substantial portion transfer or leave the services as a result of their experiences (7), which may decrease the likelihood of reporting the incident.

Civilian traumatic experiences and MST

Military personnel in general report higher rates of trauma before, during and after their military involvement than the civilian population (2). Allard and colleagues (2) suggested that the prevalence of rape among female veterans (49%) was significantly higher than among civilians (22%). Kelly and colleagues (8) reported that of the 135 female participants that indicated MST in their study, 95.4% also reported at least one trauma in addition to the MST, the most common being sexual abuse as adult civilians (77%) and then sexual abuse as children (53%) (8).

Being in the military does not make women less vulnerable to intimate partner violence. Studies have shown that, in a sample of females enlisted in the army married to civilian spouses, the sample of women were almost four times more likely to be victims of unilateral violence from their nonmilitary spouses than perpetrators of unilateral violence (4). The women were also three times more likely to be victims of severe violence from their partners, which is similar to nonmilitary studies of intimate partner violence (4).

Methods

An electronic search of the major behavioral science databases (PUBMED, PSYCINFO, MEDLINE) between the years 1990 and 2012 was conducted to retrieve studies detailing the social, epidemiological and clinical characteristics of military sexual trauma and its relationship to psychiatric and medical illness. Search items included “military sexual trauma,” “childhood trauma,” “veterans,” “posttraumatic stress disorder,” “depression,” “female veterans,” “male veterans,” and “medical illness.” Additional references were incorporated from the bibliographies of the retrieved articles.

Results

Sources have shown that since returning from Iraq, 15% of service members meet criteria for major depression, generalized anxiety disorder or PTSD, and 11% of those returning from Afghanistan meet those criteria (3). The mental health consequences of MST include PTSD, alcohol abuse, depression, somatization disorders, suicidality and impulsive behavior (3, 4, 7, 9–12). MST has also been correlated with difficulty with psychosocial readjustment to civilian live, particularly in areas involving intimacy (13).

Studies have also associated MST with suicidality in both genders (4, 12). Interpersonal trauma and sexual assault during military service was associated with suicide attempts in both military men and women (4).

MST and psychiatric illness in females

The most prevalent trauma-related mental health problem is PTSD, with the lifetime prevalence of PTSD among female veterans attending VA primary care clinics being 27% (7). Women veterans who suffered from MST are nine times more likely to develop PTSD than women without a history of sexual assault (4). Studies have also identified that MST specifically, more than other trauma, is a stronger predictor of PTSD (14–16). In one study, 60% of women veterans who suffered from MST were diagnosed with PTSD using the DSM-IV criteria vs. 40% of women veterans who suffered from other traumas both pre-service, during service and post-service, including sexual and physical assault, witnessing violence, combat trauma, illness, accidents, traumatic deaths and natural disasters (14). Suris and colleagues (16) also showed that MST specifically is a stronger predictor of PTSD than other sexual trauma. They found that female veterans were nine times more likely to have PTSD if they had a history of military sexual trauma versus seven times more likely if they had a history of child sexual abuse versus five times more likely if they had civilian sexual assault histories in comparison with female veterans who did not report a history of sexual assault (16).

MST is also correlated with other Axis I diagnoses, mental health symptoms and use of prescription medication for mental health symptoms (17). For women who reported military-related sexual assault, screening prevalence for current depression was three times higher and, for current alcohol abuse, three times higher than for women veterans not reporting MST (11). Furthermore, some studies have suggested that the majority of female veterans with PTSD will have comorbid psychiatric illness, with some research supporting a link between PTSD and substance abuse (7). With respect to eating disorders and impulsive behavior, sources have suggested a prevalence of eating disorders of about 25% in female veterans who have suffered from MST (10). Studies have shown that MST itself has been linked to eating disorders and substance use (9). Other studies have identified four major coping strategies for females with post-deployment stress, including coping with the aftermath of MST. These coping strategies include disordered eating behavior, substance abuse and impulsive behavior including binging and purging, compulsive spending, over-exercising and prescription drug abuse (3).

MST and psychiatric illness in males

Similar to female veterans, male veterans who experienced sexual harassment and assault have a greater incidence of PTSD, depression and somatization disorders than male veterans who had not experienced sexual harassment (4). Studies have suggested that, perhaps due to the increased stigma attached to MST in male veterans and a decrease in reporting of MST among male veterans, there may be greater levels of psychological sequela, including PTSD and other psychiatric symptoms as well as poorer physical health (2). Studies have reported that sexual harassment of men in the military has shown a stronger association with psychological problems, including more persistent sexual abuse trauma symptoms, more persistent sexual problems, more emotional problems and a larger decrease in work productivity than in women (6, 18). Some studies have shown that psychological problems also appear to be more persistent and resistant to treatment after MST in men than in women (6).

MST and medical illness

Associations between stress reaction and physical illness are seen throughout medical systems, including cardiovascular, respiratory, GI, cancer and chronic pain problems in both females and males. Studies have shown that war zone stressor-related trauma was associated with increased disordered functioning in arterial, gastrointestinal and musculoskeletal systems in female and male veterans (19). In female and male veterans, MST is associated with physical health problems, primarily pain-related and affecting multiple organ systems including genitourinary, musculoskeletal, neurological and gastrointestinal (4). Individual physical symptoms include back pain, headaches, GI symptoms and chronic fatigue (4). MST has also been associated with an increase in health risk factors, including obesity, smoking and sedentary lifestyles (4, 18), as well as with chronic medical comorbities, including liver disease and pulmonary disease (4). MST has also been associated with sexual dysfunction in both female and male veterans (2).

MST and medical illness in females

Many studies restricted the study population to female veterans as MST is more common in the female veteran population, as highlighted above. These studies found that MST in female veterans was correlated with an increase in chronic medical problems (17) as well as current symptoms across almost every organ system assessed, including reproductive/gynecological, urological, neurological/rheumatological, gastrointestinal, pulmonary, cardiovascular and other symptoms including chronic fatigue (20). Women veterans who reported sexual assault while in the military were more likely to report a heart attack within the previous 12 months than women who had not reported sexual assault while in the military (9). A reported history of MST was also associated with an increase in cardiac risk factors, including obesity, smoking, problems with alcohol use and a sedentary lifestyle (9). For female veterans, metabolic comorbidities, including hypothyroidismis, were also associated with MST (4). Women reported more frequent symptoms of pelvic pain, vaginal bleeding/discharge, painful intercourse, rectal bleeding, bladder infections and painful urination compared to those not sexually assaulted (4). Female veterans who were victims of MST also reported sexual dysfunction, including decreased sexual satisfaction as well as fear, disdain or avoidance of sexual intimacy and difficulty with arousal and desire (2). MST was associated with poorer reproductive outcomes in women, including infertility and lost pregnancies (20) as well as hysterectomies before the age 40 years (9).

Discussion

Sources have suggested that psychiatric sequela may mediate the relationship between MST and medical illness, especially PTSD (14). Sources have shown that posttraumatic stress symptomatology (PSS) mediates the relationship between violence and physical health symptoms (19). Some studies have suggested that there are gender differences in the relationship between MST and physical health symptoms and that PSS mediates the relationship between MST and perceived physical health in men but not in women (19).

Smith and colleagues (19) separated sexual harassment from sexual assault and found that sexual harassment was not a significant predictor of posttraumatic stress symptomatology when warfare stressors were not included, thus indicating that warfare stressors may actually be the mediator between sexual harassment and physical illness, including gastrointestinal and neurological symptoms, in male veterans who suffered from sexual harassment (19). However, sexual assault was a significant predictor of PSS, even when warfare stressors were controlled for (18). Furthermore, for veterans who suffered from sexual assault, PSS mediated the relationship between sexual assault and health symptoms, including gastrointestinal (primarily abdominal pain), genitourinary (primarily sexual discomfort or difficulties), musculoskeletal (primarily muscle or joint pain) and neurological (primarily headaches) (19).

Pre-military abuse as a predictor of PTSD and mediator between MST and mental and physical illness

Not all veterans who suffer from military trauma, whether it be MST or combat-related trauma, will go on to develop PTSD, but it does appear that veterans are more predisposed to PTSD symptomatology than the civilian population. As mentioned above, military personnel have a higher prevalence of trauma before, during and after their military involvement (2). Studies have shown that female veterans in Desert Storm who describe pre-service abuse reported greater PTSD symptomatology than those denying pre-combat abuse (21). In a study with 2392 male soldiers returning from Iraq, those that suffered from childhood trauma were more likely to have positive screenings for both PTSD and depression (22). The same trend was seen with Vietnam veterans in which Vietnam veterans with PTSD had higher rates of childhood physical abuse than Vietnam veterans without PTSD, and veterans with PTSD overall had higher total traumatic events before joining the military than patients without PTSD (23). It is possible that this may apply to MST and that those who suffer from pre-MST abuse may be more vulnerable to PTSD symptomatology than those who deny pre-MST abuse.

If PTSD is a mediator between trauma and the development of physical illness, and the presence of multiple traumas is a predictor of PTSD, we propose that veterans who suffer from multiple traumas, with MST being one of those traumas, are the veterans who are more vulnerable to developing physical illness in the aftermath of MST. Perhaps it is both the prevalence of multiple traumas and the development of PTSD that mediates the relationship between trauma and the development of both mental and physical illness. Previous studies have supported that multiple traumatic events increase vulnerability for medical illness. In the Adverse Child Experience Study (ACE Study 1998), children who suffered from multiple adverse childhood events (defined as experiencing four or more categories of childhood exposure to trauma) had a 4- to 12-fold increased prevalence of multiple poor mental and physical health outcomes, including alcoholism, drug abuse, depression, suicide attempt, smoking, sexual promiscuity and sexual transmitted diseases, obesity and physical inactivity as well as an increased risk for medical illness including ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease (24). We suggest that there may be a similar outcome in the veteran population, with those veterans who suffered from MST as well as multiple other adverse experiences pre-combat having an increased risk of mental and physical illnesses.

Prevention and treatment

Education of military personnel about MST to increase awareness and reporting is necessary. Awareness and discussion of MST is often avoided, especially if the perpetrator is a coworker or a superior officer, as it disrupts the focus of military experience, including closeness, dependence, cohesion and leadership, which in the military are often necessary for survival, especially in combat (2). The reporting system in the military also contributes to underreporting of MST as well as to decreased law enforcement against perpetrators of MST (5). The reporting system in the military is a two-tiered system (5). In the first tier of reporting, the victim anonymously files a restricted report of the assault and can receive medical care and counseling but does not prosecute the perpetrator (5). In the second tier of reporting, the victim also prosecutes the perpetrator and no longer remains anonymous (5). Although this two-tiered reporting system may increase the number of victims who seek treatment, it does not bring justice to the perpetrator and may do little to prevent the continuation or even escalation of MST in the military (5). Thus, to prevent the perpetuation of MST, it becomes important to not only educate military personnel but also to remove barriers to reporting and prosecuting perpetrators of MST.

In the aftermath of MST, treatment and access to treatment becomes essential. Increasing access to supports in the aftermath of trauma while veterans are still in active duty may be necessary to facilitate recovery, but may also be difficult in the military, where deployment means one is cut off from primary support systems (2). That being said, barriers to treatment continue to exist after deployment. Access to treatment is important. Some studies where women veterans were interviewed described that female veterans did not feel comfortable seeking VA services as they felt that WWII, Korean or Vietnam veterans should be entitled to VA services before them (3). For women who have suffered from MST, there is also a fear of utilizing services where they may encounter the same type of individuals who perpetrated the sexual trauma (3). Childcare may be a barrier for women seeking services (3). There needs to be increased availability of mental health treatment specific to sexual-assault-related psychopathology, including prolonged exposure (PE) and cognitive processing therapy (CPT) as well as some other less empirically supported modalities (stress inoculation training and eye movement desensitization and reprocessing) (1).

In conclusion, MST is a clinically significant issue that deserves recognition and discussion for both men and women. Although there are some gender differences in the reported rates of MST as well as physical and psychological sequela, it is clearly a major healthcare issue that affects both sexes and warrants further attention and an increase in clinical resources devoted to it.

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