Develop a 500-750 word paper addressing the current interventions and treatment of MST.

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Develop a 500-750 word paper addressing the current interventions and treatment of MST. Identify current gaps in MST intervention and treatment.

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RESEARCH AND PRACTICE Military-Related Sexual Trauma Among Veterans Health Administration Patients Returning From Afghanistan and Iraq Rachel Kimerling, PhD, Amy E. Street, PhD, Joanne Pavao, MPH, Mark W. Smith, PhD, Ruth C. Cronkite, PhD, Tyson H. Holmes, PhD, and Susan M. Frayne, MD, MPH We examined military-related sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans. Of 125 729 veterans who received Veterans Health Administration primary care or mental health services, 15.1% of the women and 0.7% of the men reported military sexual trauma when screened. Military sexual trauma was associated with increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders. Sexual trauma is an important postdeployment mental health issue in this population. (Am J Public Health. 2010;100:1409–1412. doi:10.2105/ AJPH.2009.171793) Emerging research with US veterans of Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq suggests that the mental health effects of these deployments are significant. An estimated 19% to 42% of this population have mental health conditions.1–4 One of the potential contributors to this burden of mental illness is exposure to sexual assault or harassment during service, referred to within the Veterans Health Administration as military sexual trauma.5 Considerable data attest to the negative mental health consequences of such experiences in both military and civilian populations,5–13 yet no data investigating military sexual trauma in the context of postdeployment mental health among the Operation Enduring Freedom and Operation Iraqi Freedom cohort are currently available. Operation Enduring Freedom and Operation Iraqi Freedom veterans are eligible for 5 years of free care through the Veterans Health Administration for conditions related to their military service. This cohort is turning to the Veterans Health Administration for health care in record numbers, with nearly 40% enrolled to date.14 The Veterans Health Administration has recently invested significant resources in the detection and treatment of military sexual trauma, implementing universal military sexual trauma screening in 2002 and providing free care for all related conditions.5 Although military sexual trauma had been documented in veterans of previous war eras,15,16 Operation Enduring Freedom and Operation Iraqi Freedom veterans are the first generation of Veterans Health Administration users to return from a large-scale deployment to these comprehensive screening and treatment services. For our study, we completed, to our knowledge, the first national, population-based assessment of the mental health profile associated with a history of military sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans who used Veterans Health Administration services. We describe the prevalence of military sexual trauma and characterized the postdeployment mental health conditions among patients who reported a history of military sexual trauma. METHODS We included all veterans deployed in service of Operation Enduring Freedom and Operation Iraqi Freedom and separated from military service by September 30, 2006, who used Veterans Health Administration mental health or primary care services between October 1, 2001, and September 30, 2007. This cohort had 21834 women and 142 769 men. Data were extracted from centralized electronic medical records and coded for military sexual trauma screen status and International Classification of Diseases, Ninth Revision,17 diagnoses for mental health conditions with methods identical to those used in a previous study.5 The Veterans Health Administration Operation Enduring Freedom and Operation Iraqi Freedom roster was used to identify our cohort and to August 2010, Vol 100, No. 8 | American Journal of Public Health provide demographic and military service characteristics.4 We used the c2 analysis to determine demographic characteristics, use of Veterans Health Administration mental health or primary care services, and military service characteristics that were associated with military sexual trauma status in veterans by gender. For each mental health condition, we modeled the odds of the diagnosis as a function of military sexual trauma and adjusted for all demographic characteristics, health care services use, and military service characteristics that were significant (P 50% 27.6 13.7 < .001 27.6 16.6 < .001 7.3 5.8 .002 9.2 5.5 < .001 87.2 .04 84.3 85.4 .41 53.3 46.0 46.7 54.0 94.7 94.1 5.3 5.9 Veterans Health Administration services use before Operation Enduring Freedom and Operation Iraqi Freedom Time in Veterans Health Administration care > 12 mo 88.7 Military service characteristics Component Active duty National Guard/Reserve < .001 54.9 47.0 45.1 53.0 Rank < .001 .92 Enlisted 93.3 93.3 Officer 6.7 6.7 Branch .53 .002 < .001 US Air Force 12.7 13.0 9.7 7.7 US Army US Navy/Coast Guard 69.1 14.4 71.7 12.2 66.4 14.6 70.3 9.1 3.8 3.1 9.3 12.9 Multiple deployments Marines 32.2 35.3 .002 35.8 37.1 .46 Most recent deployment > 6 mo duration 50.9 53.2 .03 51.9 58.3 .001 1410 | Research and Practice | Peer Reviewed | Kimerling et al. American Journal of Public Health | August 2010, Vol 100, No. 8 RESEARCH AND PRACTICE TABLE 2—Military Sexual Trauma Screen Results and Mental Health Conditions of Operation Enduring Freedom and Operation Iraqi Freedom Veterans Health Administration Outpatients: October 1, 2001, to September 30, 2007 Women Mental Health Condition Screened Positive Screened Negative for Military Sexual for Military Sexual Trauma, % Trauma, % Men OR (95% CI) AOR (95% CI)a Screened Positive Screened Negative for Military Sexual for Military Sexual Trauma, % Trauma, % OR (95% CI) AOR (95% CI)a Any mental health condition 75.7 46.6 3.57 (3.25, 3.92) 3.28 (2.97, 3.62) 76.5 51.5 Depressive disorders 56.2 30.3 2.96 (2.72, 3.22) 2.64 (2.41, 2.88) 46.6 25.9 3.07 (2.58, 3.64) 3.08 (2.57, 3.67) 2.49 (2.15, 2.88) 2.32 (1.99, 2.70) Posttraumatic stress disorder 51.1 21.5 3.82 (3.51, 4.16) 3.83 (3.49, 4.21) 52.5 31.8 2.37 (2.05, 2.74) 2.53 (2.16, 2.97) Other anxiety disorders 29.1 16.6 2.05 (1.87, 2.26) 1.80 (1.64, 1.99) 28.3 16.1 2.06 (1.75, 2.42) 1.98 (1.68, 2.34) Alcohol and substance 13.9 5.2 2.89 (2.53, 3.29) 2.51 (2.19, 2.87) 22.0 12.7 1.93 (1.62, 2.30) 1.84 (1.53, 2.20) 20.6 13.4 1.68 (1.51, 1.86) 1.68 (1.50, 1.87) 20.9 13.4 1.71 (1.43, 2.04) 1.72 (1.44, 2.06) use disorders Adjustment disorders Note. AOR = adjusted odds ratio; CI = confidence interval; OR = odds ratio. a The AOR compares likelihood of the specified mental health condition in military sexual trauma positive versus military sexual trauma negative patients, adjusting for age, race/ethnicity, marital status, health insurance, service connection greater than 50%, Veterans Health Administration services use before Operation Enduring Freedom or Operation Iraqi Freedom, time in Veterans Health Administration care greater than 12 months, component, branch, multiple deployment, and recent deployment of more than 6 months’ duration. posttraumatic stress disorder (PTSD), other anxiety disorders, depression, and substance use disorders. These results are consistent with data suggesting that patients who experience military sexual trauma frequently present with substantial mental health treatment needs.15,22,23 Effect sizes for the relation of military sexual trauma to PTSD were substantially stronger among women compared with men, suggesting that military sexual trauma may be a particularly relevant gender-specific clinical issue in PTSD treatment settings. The results of this study bear several caveats. The rate of military sexual trauma and the rate of mental illness reported in this study likely represent conservative estimates because both tend to be underreported.24–27 Although significant proportions of Operation Enduring Freedom and Operation Iraqi Freedom veterans use Veterans Health Administration services, these data do not necessarily generalize to other health care settings. Our analyses were crosssectional, so the exact timing of military sexual trauma, deployment, and the onset of mental health conditions cannot be determined. Thus, no conclusion can be drawn about causal relations between military sexual trauma and mental health. Finally, although frequency and length of deployment (measured in this study) may serve as proxies for combat exposure, research accounting for a broader range of service-related stressors, including both military sexual trauma and combat exposure, is needed. Studies of mental health care for military sexual trauma among veterans of previous service eras have focused on experiences that were detected at times considerably more distal from military service. The Veterans Health Administration’s ability to detect military sexual trauma in this recently returned cohort will help focus early interventions for this population. However, survivors of sexual trauma often delay disclosure and treatment of their experiences,28 and Operation Enduring Freedom and Operation Iraqi Freedom Veterans report stigma associated with help-seeking.29 Thus, the population of Operation Enduring Freedom and Operation Iraqi Freedom veterans seeking Veterans Health Administration care for military sexual trauma may increase with time. These data highlight the need to ensure adequate access to and capacity of mental health care for military sexual trauma and associated postdeployment mental health conditions. j University School of Medicine, Stanford, CA. Ruth C. Cronkite is with the Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, and the Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford. Tyson H. Holmes is with Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford. Susan M. Frayne is with the Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, and the Division of General Internal Medicine at Stanford University School of Medicine, Stanford. Correspondence should be sent to Rachel Kimerling, PhD, VA Palo Alto Health Care System, National Center for PTSD, 795 Willow Rd (334-PTSD), Menlo Park, CA 94025 (e-mail: rachel.kimerling@va.gov). Reprints can be ordered at http://www.ajph.org by clicking on the ‘‘Reprints/Eprints’’ link. This brief was accepted November 9, 2009. Contributors R. Kimerling conceptualized the study. R. Kimerling and A. E. Street wrote the brief. J. Pavao analyzed the data. T. H. Holmes provided statistical consultation. All authors collaborated on study conceptualization, interpreted the findings, and reviewed and edited drafts of the brief. Acknowledgments About the Authors Rachel Kimerling is with the National Center for Posttraumatic Stress Disorder and the Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, CA. Amy E. Street is with the National Center for Posttraumatic Stress Disorder, VA Boston Health Care System, Boston, MA, and the Department of Psychiatry, Boston University School of Medicine, Boston. Joanne Pavao is with the National Center for Posttraumatic Stress Disorder, VA Palo Alto Health Care System, Menlo Park. Mark W. Smith is with the Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, and the Center for Primary Care and Outcomes Research, Stanford August 2010, Vol 100, No. 8 | American Journal of Public Health Funding was provided by the Health Services Research and Development Service, US Department of Veterans Affairs (IAE 05-291 and SDR 07-331). Note. The views expressed in this brief are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. The funding source had no role in study design, data collection, analysis, interpretation, manuscript preparation, or decision to publish the manuscript. Human Participant Protection All research was approved by the human subjects research institutional review board at the Stanford University School of Medicine. Kimerling et al. | Peer Reviewed | Research and Practice | 1411 RESEARCH AND PRACTICE References 1. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295: 1023–1032. 2. Kang HK, Hyams KC. Mental health care needs among recent war veterans. N Engl J Med. 2005;352:1289. 3. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA. 2007;298:2141–2148. 4. Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar CR. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008. Am J Public Health. 2009;99:1651–1658. 5. Kimerling R, Gima K, Smith MW, Street A, Frayne S. The Veterans Health Administration and military sexual trauma. Am J Public Health. 2007;97:2160–2166. 6. Hankin CS, Skinner KM, Sullivan LM, Miller DR, Frayne S, Tripp TJ. Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military. J Trauma Stress. 1999;12:601–612. 7. Murdoch M, Nichol KL. Women veterans’ experiences with domestic violence and with sexual harassment while in the military. Arch Fam Med. 1995;4:411–418. 8. Magley VJ, Waldo CR, Drasgow F, Fitzgerald LF. The impact of sexual harassment on military personnel: is it the same for men and women? Mil Psychol. 1999;11: 283–302. 9. Ouimette PC, Kimerling R, Shaw J, Moos RH. Physical and sexual abuse among women and men with substance use disorders. Alcohol Treat Q. 2000;18(3):7–17. 10. Ullman SE, Brecklin LR. Sexual assault history and suicidal behavior in a national sample of women. Suicide Life Threat Behav. 2002;32:117–130. 11. Golding JM. Sexual assault history and limitations in physical functioning in two general population samples. Res Nurs Health. 1996;19:33–44. 12. Golding JM. Sexual-assault history and long-term physical health problems: evidence from clinical and population epidemiology. Curr Dir Psychol Sci. 1999;8: 191–194. 18. Corbett S. The women’s war. New York Times. March 18, 2007;sect 42. 19. Lee C. More sex assaults in military reported: new policy ensures victims’ privacy. Washington Post. 2006: A21. 20. Hansen C. Prepared statement of Christine Hansen, Executive Director, The Miles Foundation Personnel Subcommittee, Senate Armed Services Committee, February 25, 2004. 21. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167: 476–482. 22. Frayne SM. Clinical challenges in primary care of women with prior sexual trauma. Federal Practitioner. 1998;15(5S):3–5. 23. Surı̀s AM, Lind L, Kashner TM, Borman PD. Mental health quality of life, and health functioning in women veterans: differential outcomes associated with military and civilian sexual assault. J Interpers Violence. 2007;22: 179–197. 24. Pérez-Stable EJ, Miranda J, Muñoz RF, Ying YW. Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med. 1990;150: 1083–1088. 25. Leibowitz RQ, Jeffreys MD, Copeland LA, Noel PH. Veterans’ disclosure of trauma to healthcare providers. Gen Hosp Psychiatry. 2008;30:100–103. 26. Campbell R, Raja S. The sexual assault and secondary victimization of female veterans: help-seeking experiences with military and civilian social systems. Psychol Women Q. 2005;29:97–106. 27. Magruder KM, Yeager DE. Patient factors relating to detection of posttraumatic stress disorder in Department of Veterans Affairs primary care settings. J Rehabil Res Dev. 2008;45:371–382. 28. Ullman SE. Correlates and consequences of adult sexual assault disclosure. J Interpers Violence. 1996;11: 554–571. 29. Tanielian T, Jaycox LH, Schell TL, et al. Invisible Wounds of War: Summary and Recommendations for Addressing Psychological and Cognitive Injuries. Santa Monica, CA: RAND Center for Military Health Policy Research; 2008. 13. Schneider KT, Swan S, Fitzgerald LF. Job-related and psychological effects of sexual harassment in the workplace: empirical evidence from two organizations. J Appl Psychol. 1997;82:401–415. 14. Kang H. Analysis of Health Care Utilization Among US Global War on Terrorism Veterans. Washington, DC: Department of Veterans Affairs, Veterans Health Administration; 2007. 15. Skinner KM, Kressin N, Frayne S, et al. The prevalence of military sexual assault among female Veterans’ Administration outpatients. J Interpers Violence. 2000;15:291–310. 16. Wolfe J, Sharkansky EJ, Read JP, Dawson R, Martin JA, Ouimette PC. Sexual harassment and assault as predictors of PTSD symptomatology among U.S. female Persian Gulf War military personnel. J Interpers Violence. 1998;13:40–57. 17. International Classification of Diseases, Ninth Revision. Geneva, Switzerland: World Health Organization; 1980. In this cross-sectional, clinicbased study, we estimated 1-year prevalence of intimate partner violence among 986 patients who had elective abortions. We assessed physical, sexual, and battering intimate partner violence via selfadministered, computer-based questionnaires. Overall, physical and sexual intimate partner violence prevalence was 9.9% and 2.5%, respectively; 8.4% of those in a current relationship reported battering. Former partners perpetrated more physical and sexual assaults than did current partners. Violence severity increased with frequency. Abortion patients experience high intimate partner violence rates, indicating the need for targeted screening and community-based referral. (Am J Public Health. 2010;100:1412–1415. doi:10.2105/ AJPH.2009.178947) Intimate partner violence has far-reaching, adverse consequences for women, children, and families.1–5 In live birth populations, women with unintended pregnancies reported higher intimate partner violence rates than did those with planned conceptions.6–9 Women seeking abortion may be an important target population for intervention because a small but growing body of research suggests that intimate partner violence prevalence is higher among abortion patients than among women who continue their pregnancies.10–15 Most studies, however, have been limited by small sample sizes and failure to measure nonphysical abuse. METHODS Prevalence of Intimate Partner Violence Among an Abortion Clinic Population Audrey F. Saftlas, PhD, MPH, Anne B. Wallis, PhD, Tara Shochet, PhD, MPH, Karisa K. Harland, MPH, Penny Dickey, BS, and Corinne Peek-Asa, PhD 1412 | Research and Practice | Peer Reviewed | Saftlas et al. We conducted this cross-sectional study from November 1, 2007, through July 18, 2008, within a large family planning clinic that provides aspiration and medication abortion. Eligibility criteria included attendance for elective abortion, age 18 years or older, Iowa residency, and English or Spanish proficiency. Following clinic intake, education staff introduced the study to eligible patients in a private room. Participants who provided informed, voluntary consent completed a 10-minute American Journal of Public Health | August 2010, Vol 100, No. 8 Copyright of American Journal of Public Health is the property of American Public Health Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Military Sexual Trauma Services Offered in the VHA Regina Kakhnovets, PhD and Dana R. Holohan, PhD Since the early 1990s, VA medical centers have expanded their services for sexual trauma, but offerings continue to vary widely across different facilities. M ilitary sexual trauma (MST)—which includes sexual assault and harassment—is a serious problem, with prevalence rates reported to be as high as 41% for female veterans and 4.2% for male veterans.1–3 According to 2002 VA national MST surveillance data, 22% of female and 1% of male VA patients report experiencing MST.4 But because veterans overwhelmingly are male, more than half (54%) of all veterans who screen positive for MST within the VHA are male.4 The effects of sexual trauma on men and women are profound. Survivors of such trauma tend to struggle with marital and family problems, feelings of shame and anger, issues with trust and safety, and sexual difficulties.5 Other common problems include substance abuse and dependence, depression, anxiety disorders, and suicidal ideation. 6–12 Male victims also often report concern over their sexuality or masculinity.13 Both men and women who experience sexual trauma are likely to experience psychiatric symptoms after the trauma (41.2% of men and 11.3% of women) and a general history of psychiatric hospitalizations (51.7% of men and 17.9% of women).11 In particular, a diagnosis of posttraumatic stress disorder (PTSD) is quite common. Estimates Dr. Kakhnovets is an assistant professor in the department of psychology at Auburn University at Montgomery, Alabama. Dr. Holohan is director of the Center for Traumatic Stress at the Salem VA Medical Center, Salem, Virginia. 20 • FEDERAL PRACTITIONER • JULY 2010 from community samples of women who were victims of rape found that between 32% and 57.1% experienced symptoms of PTSD at some time following the rape.14,15 PTSD symptoms include nightmares; exaggerated startle; irritability; avoidance of reminders of the traumatic experience; flashbacks or intrusive memories; sleep disturbances; feeling numb, detached, or disconnected; and trouble concentrating. Since the early 1990s, VA medical centers (VAMCs) have been responding to congressional mandates to provide screening and services to men and women who have experienced sexual trauma while in the military. In 1995, a survey revealed that while all VAMCs have responded to the mandates, the level of response has varied widely.16 The goals of the current study, therefore, are (1) to determine whether VA services have adapted or expanded since the 1995 survey, (2) to investigate the types of services currently provided to veterans who have experienced MST, (3) to identify any existing barriers to providing such services, and (4) to evaluate if there are any disparities in treatments offered to men and women. BACKGROUND During the last decade, Congress, the DoD, and the VA increasingly have recognized the problem of sexual trauma experienced by many veterans while in the service. The Veterans Health Care Act of 1992, P.L. 102585, provided the authority for treating MST in female veterans, and the Veterans Health Programs Extension Act of 1994, P.L. 103-452, extended this authority to all veterans. However, these acts “do not outline specific guidelines for clinical protocols, team make-up, administration, or treatment procedures.”16 Therefore, treatment may vary widely across different VAMCs. The initial 1995 survey of MST treatment in female veterans at VAMCs showed that approximately 5 patients were seen per week and newly referred patients were seen, on average, within a week.16 The number of facilities that offered treatment of MST in male veterans is unknown because the survey did not ask this question.17 About half of the VAMCs had established a sexual trauma treatment team. VAMCs without such a team tended to provide nonspecialized services to female veterans or provide community referrals. The survey did not examine the types of treatments offered.17 Treatments for MST Cognitive behavioral treatments— which address problematic thinking patterns—are the most studied interventions to address the psychological sequelae of sexual trauma. Several empirically supported, manualized treatments (treatments with a protocol of specific steps for clinicians to follow) have been developed, such as cognitive processing therapy (CPT). Other treatments include stress inoculation training and imaginal and in vivo exposure. 17–19 Treatments focus on improving anxiety manage- ment and coping skills, changing fear networks, decreasing avoidance, and modifying maladaptive or problematic beliefs. Stress inoculation training, for example, consists of a 3-phase program focused on helping patients change how they react to stress and “inoculate” them against future stressors. In the conceptualization phase, therapists working within this treatment model educate patients about the nature of the stress response and teach them how to evaluate situations in order to determine the appropriate coping strategy. In the skills acquisition and rehearsal phase, patients are taught coping skills. Finally, in the application and follow-through phase, therapists encourage patients to apply the newly learned skills to a variety of stressful situations.18 Treatments using imaginal and in vivo exposure rely on the process of habituation by presenting patients with an anxiety-producing stimulus with the goal of reducing the emotional impact of that stimulus. 19 When the exposure procedure is carried out in a real life situation, it is called in vivo exposure. When in vivo exposure is not possible, therapists instruct patients to imagine the stressproducing situation using imaginal exposure techniques. CPT was designed specifically for the treatment of rape victims.17 This treatment draws on cognitive information processing theory, which describes how trauma can create conflicts between pre-existing schemas and the rape experience, causing patients to either (1) assimilate new information into their current schemas: “Good things happen to good people and bad things happen to bad people. I was raped, thus, I must have deserved it;” or (2) to accommodate the trauma information in a maladaptive way: “I thought the world was a safe place, but this horrible thing happened to me. Therefore, the world is a completely dangerous place.” In this type of treatment, therapists educate patients about the effects of trauma and the information processing theory. They then instruct patients to write about the traumatic event and to read their accounts out loud during the treatment session, exposing them to the traumatic material. METHODS Each VAMC has an identified MST coordinator who is in charge of coordinating screening for MST. Many MST coordinators also organize treatment programs for MST-related conditions (for example, PTSD, depressive disorders, anxiety problems, or sexual dysfunctions), offer treatment for these conditions, and/or refer patients to appropriate providers. Using a national list, we contacted each VAMC’s MST coordinator through e-mail and invited him or her to participate in an online survey about the MST services available at his or her facility during the last 12 months. Our survey was based on the survey conducted in 1995, but we added questions to obtain additional information.16 Specifically, we asked participants about the sources of referrals for MST services, the number of patients referred to the program, the organization of their MST program, the types of mental health and medical services offered to MST patients, the barriers to providing services, the average waiting time for first appointment, the assessment used, and future plans for additional treatments. Most of the questions allowed participants to select 1 or several provided choices and to supply additional information not covered by the choices available. We conducted the survey using a Web-based survey service (www.surveymonkey.com). The site instructed participants to follow a link and complete the online questionnaire. (The survey was accessible only to study participants.) We initially contacted the MST coordinators in December 2005 to invite them to complete the survey. We sent a reminder e-mail after 1 month and concluded the study at the end of February 2006. The Salem VA Medical Center’s research and development committee approved the study under exempt protocol because we did not collect any personal information about the participants. No compensation was provided to participants. RESULTS We sent the survey to 145 MST coordinators at VAMCs across the country; of these, 89 participants (61%) completed the survey. Six coordinators indicated that they did not wish to participate for a variety of reasons, such as being too busy. The remainder of those we contacted did not respond to the requests to participate in the study. About half (49%) of respondents indicated that they work as part of an “organized treatment team” (n = 44). Approximately one-quarter of all respondents (n = 21) reported having a specific MST treatment team at their facility. Others who are part of an organized team work with a mental health outpatient team, a women’s stress disorder treatment program, a women’s health team, or a PTSD clinical team (PCT). The purpose and function of each organized team varied. Of those with a treatment team, roughly 70% (n = 29) hold staff meetings, which are used for administrative and interdisciplinary case management (86.2%), team support and education (86.2%), staffing of new patients (82.8%), and peer supervision (55.2%). In addition, a small pro- JULY 2010 • FEDERAL PRACTITIONER • 21 Military Sexual Trauma Table 1. Service differences between VAMCsa with and without a treatment team Male clients per week, mean (SD), no. VAMCs with VAMCs without treatment team treatment team 13.0 (13.6) 4.5 (4.6) t test t (51) = 3.073, p < .01 Female clients per week, mean (SD), no. 31.5 (32.2) 9.7 (8.1) t (54) = 3.482, p < .01 New male referrals per year, mean (SD), no. 22.3 (23.1) 8.9 (11.3) t (53) = 2.743, p < .01 New female referrals per year, mean (SD), no. 50.7 (49.2) 21.9 (24.0) t (55) = 2.765, p < .01 Waiting time for new referrals, mean (SD), days 16.7 (9.2) 15.8 (11.9) t (61) = 0.334, p = .740 VAMCs = VA medical centers. a portion of respondents with teams (10.3%) indicated that they use these meetings for other purposes, including program development, planning, and staffing for patients experiencing problems. On average, the teams hold about 25 meetings per year (SD = 19.77, with 1 outlier of 350 removed). Many teams also meet regularly with various health professionals, including staff of women’s health care clinics (38.6%) and psychiatric treatment providers (36.4%). For most VAMCs, the MST coordinator’s position falls under women’s services (24%) or general outpatient services (35%). Approximately onethird fall under another program, including a PCT (8%), or within behavioral health, nursing, social work, or psychology (22% total). We asked respondents how many patients they see each week (male and female), the number of new patient referrals (male and female), and the wait time for new patients (Table 1). Overall, an average of 54 new veterans are referred per year and 30 veterans are seen per week. Responses ranged widely, however, with some facilities reporting no referrals or seeing only 1 patient per week, while others have as many as 317 new cases per year and see 200 patients per week. The average wait time for an initial appointment is 16 days, with a range from 0 to 45 days. 22 • FEDERAL PRACTITIONER • JULY 2010 On average, VAMCs see fewer males (mean, 8.8) than females (mean, 20.6) per week. Similarly, more women are referred for MST services per year than men (mean, 36.3 vs 15.6, respectively). Independent samples t tests indicate that VAMCs with a treatment team see significantly more male and female patients each week (mean, 44.6) than VAMCs without a treatment team (mean, 14.2). Further, the number of both men and women referred for MST services is significantly higher at VAMCs with a treatment team than those without a treatment team (mean, 73 vs 30.8, respectively). Waiting times for newly referred patients did not differ significantly between VAMCs with or without a treatment team. According to independent samples t tests, fewer total patients (male and female) are seen at VAMCs where the MST coordinator is located in women’s services than in other VAMCs. More specifically, women’s services VAMCs, on average, see 2.4 male patients and 10.9 female patients per week compared with an average of 10 men and 23 women per week at other VAMCs. In addition, significantly fewer male referrals are made at these women’s services VAMCs (mean, 7.7) compared with other VAMCs (mean, 17.7). Interestingly, we found no significant difference be- tween the average number of patients referred for MST services at these 2 types of VAMCs. We also asked participants about specific services that are offered to MST patients at their facilities (Table 2). The treatments offered most often are psychoeducation (82.4%), anxiety management or relaxation skills training (86.5%), cognitive behavioral therapy (CBT) (83.8%), and supportive therapy (91.9%). In addition, many facilities offer specialized treatments, such as CPT (66.2%), dialectical behavior therapy (DBT) (43.2%), eye movement desensitization and reprocessing (EMDR) therapy (32.4%), and exposure therapy (40.5%). About half of VAMCs use psychodynamic (44.6%) or interpersonal therapy (52.7%) approaches. Finally, many facilities have added treatments targeting specific symptoms and issues, such as a focus on nightmares and sleep (37.8%) or intimacy issues (52.7%). VAMCs with a treatment team offer significantly more services than those without a treatment team. Participants in the study also indicated the kinds of services they plan to offer in the future. Most often reported were group treatments for men, including groups for CBT (9%), psychoeducation (6.7%), psychodynamic therapy (6.7%), and interpersonal therapy (6.7%). No Military Sexual Trauma Table 2. MST a services offered at VAMCsb All VAMCs, % (n = 74)c VAMCs with treatment team, % (n = 36) VAMCs without treatment team, % (n = 38) EMDRd 32.4 38.9 26.3 DBT 43.2 52.8 34.2 Exposure therapy 40.5 55.6 26.3 CPT f 66.2 72.2 70.5 g CBT 83.8 88.9 78.9 Psychoeducation 82.4 88.9 76.3 Relaxation 86.5 86.1 86.8 Supportive therapy 91.9 97.2 86.8 Psychodynamic therapy 44.6 55.6 34.2 Interpersonal therapy 52.7 52.8 52.6 Sleep/nightmare reduction 37.8 47.2 28.9 Intimacy issues treatment 52.7 52.8 52.6 Other 14.9 16.7 13.2 Treatments e MST = military sexual trauma. bVAMCs = VA medical centers. c15 participants of the total 89 did not respond to the question about services offered. d EMDR = eye movement desensitization and reprocessing. eDBT = dialectical behavior therapy. fCPT = cognitive processing therapy. gCBT = cognitive behavioral therapy. a participants plan to offer either individual or group DBT or exposure therapy to men, and only a few plan to add these services for women (1% to 2%). We also investigated how many empirically supported treatments VAMCs offer for MST patients. For the purposes of this study, empirically supported treatments include EMDR therapy, DBT, exposure therapy, CPT, and CBT, offered either individually or in a group setting. The average number of empirically supported treatments offered was 6.4. An independent samples t test indicates that sites with a treatment team offer significantly more empirically supported treatments than those without a team (mean, 7.4 vs 5.4, respectively). The number of services offered to men and women also differ among facilities. Overall, VAMCs offer more services to women (mean, 10.3) than to men (mean, 8.0). The MST coordinators responding to this study also identified specific barriers to providing MST services at their facilities. About half of the respondents saw lack of time to design a program and lack of staff as significant barriers (53.9% and 51.7%, respectively). Other barriers included lack of staff training (37.1%), lack of administrative support (33.7%), and lack of screenings and referrals (18%), which result when medical providers do not consistently ask patients about experiencing MST (screening) or do not refer those with positive screens. When we examined responses about perceived barriers based on whether or not a facility has a treatment team, differences emerged between those that do have a team and those that do not (Table 3). Although the biggest barrier for facilities with a treatment team appears to be lack of staff (cited by 45.5% of VAMCs), this deficiency was cited by an even larger proportion (57.8%) of VAMCs without a treatment team. For VAMCs without a treatment team, the other most significant barriers included lack of time to design a program (68.9%), lack of staff training (46.7%), and lack of administrative support (44.4%). We also analyzed the total number of barriers identified by the participants. Respondents from VAMCs with a treatment team identified fewer barriers than those from VAMCs without a treatment team (mean, 1.7 vs 2.6, respectively). DISCUSSION Since the last survey of MST services, awareness of MST has grown, especially among male veterans. Indeed, Congress has extended MST benefits to include all veterans, not just women. The goals of this study were (1) to determine whether VA services have adapted or expanded since the initial survey in 1995, (2) JULY 2010 • FEDERAL PRACTITIONER • 23 Military Sexual Trauma Table 3. Barriers to providing MSTa services VAMCsb with treatment team, % VAMCs without treatment team, % Lack of staff 45.5 57.8 Lack of time to design program 38.6 68.9 Lack of staff training 27.3 46.7 Lack of administrative support 22.7 44.4 Lack of screenings and referrals 15.9 20.0 Other 13.6 20.0 Barrier MST = military sexual trauma. bVAMCs = VA medical centers. a to determine what kinds of services are currently being offered to veterans who have experienced MST, (3) to identify barriers that are interfering with the provision of MST services in VAMCs, and (4) to evaluate any disparities in treatments offered to men and women. Our findings indicate that at about half of the VAMCs represented in the sample, practitioners treating MST patients work as part of a treatment team. These results are comparable to those of the previous survey where 51% of the VAMCs represented worked as part of a treatment team.16 Overall, we found more MST patients currently are being served than were in the past. With regard to types of services offered to MST patients, VAMCs with a treatment team offer more empirically supported and other treatments. This is understandable because facilities without a treatment team are more likely to have a single provider, who would be unable to handle as large a workload as a team. It is also interesting to note that participants do not plan on much expansion of their treatment offerings in the future. This may be because of the perceived barriers to providing services to this population. This study’s findings suggest that VAMCs with treatment teams are able to see more patients and provide 24 • FEDERAL PRACTITIONER • JULY 2010 more services to veterans than those without treatment teams. While still reporting barriers to offering treatments, VAMCs with treatment teams seem better equipped to respond to the needs of the MST patient population, both male and female. Our results also demonstrate a significant disparity between services VAMCs offer to men and women. While VA surveillance data indicate that more than half of all veterans who screen positive for MST are men, more female patients are referred for services than male patients, according to our study. In fact, our data indicate that 2.4 times more female than male veterans are referred for MST services. The data also suggest that significantly more empirically supported treatments are offered to women than men who report experiencing MST. The reason for these disparities is unclear, though we can posit several plausible hypotheses. First, practitioners may not be aware of MST services for men, especially in those VAMCs where MST coordinators are housed in women’s services. In fact, our data suggest that at VAMCs where the MST coordinator is within women’s services, significantly fewer men are referred for services and are seen each week than at facilities where the MST coordinator is housed in another ser- vice line. Second, the MST movement originated with a need to serve female veterans. Coordinators may need to adapt their services, brochures, and educational materials to ensure that men who have experienced MST are referred for services and that specialized services are made available for these veterans. Third, just as women often do not feel comfortable attending treatments targeting men, men who have experienced MST may not feel comfortable attending treatments targeting primarily women. Facilities may need to offer gender specific treatments for men and women who have experienced MST. Fourth, men may be more likely to refuse referrals for MST-related services. Educating providers on how to speak with male veterans about sexual trauma may increase the likelihood that men will accept referrals. Study Limitations Some findings of this study should be interpreted with caution. Our collected data are based on self-report information provided by MST coordinators at different VAMCs and were not verified through any outside sources. The findings may, therefore, be subject to biases. In addition, the information presented represents only the facilities that responded and are not necessarily representative of Military Sexual Trauma all VAMCs. Also, we did not provide respondents with definitions of the various types of treatments, so different participants who indicated that a certain type of service is provided at their facility may not always have been referring to the same treatment. Future research should include clear definitions of treatments to ensure accurate conclusions. CONCLUSIONS Our study provides a snapshot of the VA’s MST programs for men and women as well as important directions for future funding, training, and research. Although the federal government and the VA now recognize that MST is an important problem that requires attention, our findings show that additional administrative, staffing, and training support are needed. Of note, the VA has recently begun a national rollout initiative of evidence-based practices to enhance training of VA mental health personnel regarding use of treatments for PTSD. In addition, the VA’s Office of Mental Health Services established an MST support team in 2007, which promotes best practices of care for MST.20 The support team offers training for MST coordinators and may help staffs who function without a team to receive some administrative guidance and to develop knowledge and expertise in best practices. The effects of the funding and establishment of this support team on the use of empirically supported treatments, the existing disparities in treat- ments, and the current barriers to MST treatment will be worthy of investigation. ● Acknowledgment The authors of this paper would like to thank the Salem Research Institute of Salem, Virginia for providing a small research grant to support this study. 5. 6. 7. 8. Author disclosures The authors report no actual or potential conflicts of interest with regard to this article. 9. Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Quadrant HealthCom Inc., the U.S. government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients. 11. REFERENCES 1. 2. 3. 4.  alente S, Wight C. Military sexual trauma: VioV lence and sexual abuse. Mil Med. 2007;172(3):259– 265. Coyle BS, Wolan DL, Van Horn AS. The prevalence of physical and sexual abuse in women veterans seeking care at a Veterans Affairs Medical Center. Mil Med. 1996;161(10):588–593. Murdoch M, Polusny MA, Hodges J, O’Brien N. Prevalence of in-service and post-service sexual assault among combat and noncombat veterans applying for Department of Veterans Affairs posttraumatic stress disorder disability benefits. Mil Med. 2004;169(5):392–395. U.S. Department of Veterans Affairs. Veterans Health Initiative: Military Sexual Trauma. Office of Public Health and Environmental Hazards Web site. 10. 12. 13. 14. 15. 16. 17. 18. 19. 20. http://www.publichealth.va.gov/vethealthinitiative /sexual_trauma.asp. Published January 2004. Accessed June 9, 2010. Foa EB, Rothbaum BO. Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. New York, NY: Guildford Press; 1998. Calderwood D. The male rape victim. Medical Aspects of Human Sexuality. 1987;21(5):181–189. Mezey GC. Treatment for male victims of rape. In: Mezey GC, King MB, eds. Male Victims of Sexual Assault. New York, NY: Oxford University Press; 1992:67–74. Mezey GC, King MB. The effects of sexual assault on men: A survey of 22 victims. Psychol Med. 1989;19(1):205–209. Rentoul L, Appleboom N. Understanding the psychological impact of rape and serious sexual assault of men: A literature review. J Psychiatr Ment Health Nurs. 1997;4(4):267–274. Elliott DM, Mok DS, Briere J. 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A survey of sexual trauma treatment provided by VA Medical Centers. Psychiatr Serv. 1998;49(3):382–384. Resick PA, Schnicke MK. Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Newbury Park, CA: Sage; 1993. Meichenbaum D. Stress inoculation training for coping with stressors. The Clinical Psychologist. 1996;49:4–7. Foa EB, Rothbaum BO, Riggs DS, Murdrock TB. Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol. 1991;59(5):715–723. Street AE, Galbreath N, Kimerling R. Sexual assault during military service: Preventing the trauma and mental health consequences. Panel presented at: International Society for Traumatic Stress Studies Annual Meeting; November 2007; Baltimore, MD. JULY 2010 • FEDERAL PRACTITIONER • 25 Research in Nursing & Health More Than Military Sexual Trauma: Interpersonal Violence, PTSD, and Mental Health in Women Veterans Ursula A. Kelly,1,2* Kelly Skelton,1,2** Meghna Patel,1y Bekh Bradley1,2z 1 Atlanta VA Medical Center, Decatur, GA Emory University, 1520 Clifton Rd., NE, Atlanta, GA 30322 Accepted 27 July 2011 2 Abstract: Military sexual trauma (MST) is reported by 20–40% of female veterans. The purpose of this study of female veterans referred for MST treatment was to examine the relationships between lifetime trauma (physical, sexual, and psychological) and posttraumatic stress disorder (PTSD), depression, physical health, and quality of life using retrospective cross-sectional data from medical records. Of the 135 participants, 95.4% reported at least one trauma in addition to MST, most notably sexual abuse as adult civilians (77.0%) and as children (52.6%). PTSD, depression, and sleep difficulty rates were clinically significant. Chronic pain (66.4%) was associated with childhood abuse, physical health, sleep difficulties, and coping. Integrating mental and physical health treatment is necessary to treat MST and PTSD in female veterans. ß 2011 Wiley Periodicals, Inc. Res Nurs Health Keywords: trauma; military sexual trauma; child sexual abuse; child physical abuse; child emotional abuse; intimate partner violence; physical abuse; cumulative trauma; female veterans; posttraumatic stress disorder; health Experiences of military sexual trauma (MST) are common among female veterans, who represent 8% of the total veteran population (Department of Veterans Affairs, 2007). There are currently 1.5 million female veterans; this number is expected to grow significantly over the next decade (Department of Veterans Affairs, 2007; National Center for Veterans Analysis and Statistics [NCVAS], 2011). MST is a veterans affairs (VA) term that refers to sexual assault and to repeated threatening sexual harassment during military service. Researchers have consistently reported prevalence rates of sexual assault of women during military service of 21–25% or higher and of sexual harassment of 24–60% (Skinner et al., 2000). In a national random sample of women seeking health care in a VA medical center, approximately one in every four women reported experiencing sexual trauma while on active duty (Skinner et al., 2000). In one study of posttraumatic stress disorder (PTSD) disability-seeking female veterans, 71% reported MST experiences (Murdoch, Polusny, Hodges, & O’Brien, 2004). Published reports indicate that women veterans who experienced MST also experienced other traumas and that MST is strongly associated with PTSD (Zinzow, Grubaugh, Monnier, Correspondence to Ursula A. Kelly *Nurse Scientist. **Medical Director, Trauma Recovery Program. y Psychologist, Trauma Recovery Program. z Program Director, Trauma Recovery Program. Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/nur.20453 ß 2011 Wiley Periodicals, Inc. 2 RESEARCH IN NURSING & HEALTH Suffoletta-Maierle, & Frueh, 2007). However, the relationships among specific childhood and adult trauma experiences and mental and physical health problems in these female veterans have not been adequately described. This study explored these relationships in a population of PTSD treatment-seeking female veterans who experienced MST. Many female survivors of MST go on to develop mental health problems, most frequently PTSD, which is strongly associated with sexual trauma (Kimerling et al., 2010; Street, Gradus, Stafford, & Kelly, 2007; Street, Stafford, Mahan, & Hendricks, 2008). Both MST and PTSD are associated with a variety of other mental and physical health disorders and symptoms, negative health behaviors (Brewin, Andrews, & Valentine, 2000; Sadler, Booth, Nielson, & Doebbeling, 2000; Zinzow et al., 2007), and impairments in social functioning and quality of life (QOL; Rheingold, Acierno, & Resnick, 2004; Surı́s & Lind, 2008). Comorbidity between PTSD and pain has been reported as high as 80% in veteran populations (Haskell, Papas, Heapy, Reid, & Kerns, 2008; Shipherd et al., 2007). In one study of sexually traumatized female veterans, PTSD was a strong correlate (r ¼ .80, p  .01) and significant predictor of chronic pain (Campbell, Greeson, Bybee, & Raja, 2008), consistent with other reports of the high correlation between MST, PTSD, and chronic pain in female veterans (Dobie et al., 2004; Sadler et al., 2000). Moreover, PTSD is a strong predictor of suicidal ideation and suicide attempts for both men and women (Cougle, Keough, Riccardi, & Sachs-Ericsson, 2009). Female Veterans and Trauma Exposure In addition to MST, women in the military are increasingly exposed to combat-related trauma, which includes both physical and psychological traumatic events (e.g., receiving hostile fire and observing or handling human remains). Reports of combat exposure by female veterans vary widely, likely due to variation in the types of combat experiences assessed. Estimates of combat exposure within female Gulf War era veterans range from 4% to 31% (Zinzow et al., 2007). In one study of non-treatment seeking veterans of Gulf War I, for females the mean number of combat experiences was 2.02 (SD ¼ 2.38) and aftermath of battle experiences (e.g., observing or handling human remains) Research in Nursing & Health was 5.41 (SD ¼ 4.18; Vogt, Pless, King, & King, 2005). In Iraq and Afghanistan more women are being exposed to combat-related trauma than in any prior war, largely due to their expanding roles in the conflicts and the lack of a discrete front line, both of which put them at higher risk for physical and psychological combat-related experiences (Street, Vogt, & Dutra, 2009). Female veterans also experience high rates of non-military service-related trauma; 81–93% report at least one lifetime trauma. These include 38–64% lifetime sexual assault, 27– 49% childhood sexual abuse, 24–49% adult sexual abuse, 46–51% adult physical assault, 35% childhood physical abuse, and 18–19% domestic violence (Zinzow et al., 2007). These estimates are higher than reported estimates among nationally representative samples. Research findings suggest that many women join the military in an effort to leave violent home environments. In one study of female veterans, more than half of the sample (n ¼ 520) reported pre-military physical or sexual violence; one in four had been raped prior to her entry into the military; one in five had experienced both childhood sexual abuse and rape as an adult (Sadler, Booth, Mengeling, & Doebbeling, 2004). Female Veterans and PTSD PTSD is a mental disorder that may develop after exposure to life-threatening or other traumatic events that are accompanied by intense fear, feelings of helplessness, and/or horror (American Psychiatric Association [APA], 2000). Female veterans experience PTSD at similar rates to male veterans (Kang, Dalager, Mahan, & Ishii, 2005; Vogt et al., 2005). Female veterans with histories of sexual assault are as much as five times more likely to develop PTSD compared to those without sexual assault histories (Surı̀s, Lind, Kashner, & Borman, 2007). As a specific assault type, MST was found to confer a ninefold risk for PTSD (Surı̀s et al., 2007). It is only recently that trauma-related mental health disorders other than PTSD have been investigated in female veterans. Findings from a few studies have shown that the other mental health disorders most strongly associated with sexual trauma among female veterans are major depressive disorder (MDD), anxiety, and substance abuse (Zinzow et al., 2007). In one MORE THAN MST/ KELLY ET AL. study of female veterans who screened positive for PTSD, 62.4% screened positive for MDD compared to 7.8% of those with negative PTSD screens; they were 18.9 times more likely to have MDD, consistent with findings of PTSD– MDD co-morbidity in civilian populations (Cascardi, O’Leary, & Schlee, 1999; Stein & Kennedy, 2001). Despite the relative lack of data linking specific psychiatric disorders to PTSD, it is very clear that female veterans with MST and PTSD have complex mental health profiles. There is a paucity of theoretical models to help explain the interplay of mental and physical health symptoms and QOL among MST survivors. As noted previously, many women who join the military report pre-military trauma exposure (Sadler et al., 2004). A multitude of studies have demonstrated that adverse early life experiences can lead to the development of poor coping skills and difficulties with emotional regulation (Cloitre et al., 2010; Felitti et al., 1998; Kim & Cicchetti, 2010). However, some survivors of childhood and adult trauma do well and do not develop mental or physical health symptoms or impairments in functioning; these survivors are deemed resilient. Resilience has many definitions in the literature and has been considered variously as a character trait, a process, and an outcome (Reich, Zautra, & Hall, 2010). Resilience has been demonstrated to have a protective effect on individual’s risk for trauma-related mental and physical health disorders. A theoretical model that reflects the current state of knowledge is illustrated in Figure 1. Resilience moderates the development of PTSD symptoms in response to childhood, adult, and military trauma. Resilience also moderates the sequelae of trauma and PTSD symptoms, including mental health problems (depression, anxiety, and suicidality), physical symptoms (chronic pain and sleep disturbance), health status, and QOL. However, the mechanisms of the protective effect of resilience are not well-understood and are areas that continue to be studied by many scholars in the field of trauma. In the past decade the VA has implemented a national initiative to provide treatment to veterans who experienced MST. This included the development of a national MST Support Team and local MST Coordinators in each VA medical center. Individual VA medical centers have developed MST treatment programs; however, programs and treatment approaches vary widely and are segmented, with MST, PTSD, and primary care issues addressed separately. Nationally, there is a lack of a consistent and comprehensive model of care for this population. The MST/Women’s Trauma Program within the Trauma Recovery Program was developed in 2007 to respond to the distinct needs of traumatized female veterans who experienced MST. At that time, existing mental health treatment for PTSD was primarily developed for male veterans with combat-related trauma. Given the lack of a comprehensive treatment model that addressed the needs of female veterans with MST experiences and PTSD, the Trauma Recovery Program developed a gender-specific treatment program that was based on the complex trauma exposure and mental health treatment needs of this population. Program evaluation is used to assess the FIGURE 1. Trauma, resilience, and trauma-related outcomes. Research in Nursing & Health 3 4 RESEARCH IN NURSING & HEALTH relevance and effectiveness of specific components of this VA Trauma Recovery Program Women’s/MST treatment program. The purpose of this program evaluation study was to characterize the population of female veterans receiving care for PTSD within this program. Specific aims were to: (1) describe (a) lifetime trauma exposure, (b) mental health symptoms, (c) health status, and (d) QOL; and (2) describe the relationships between trauma exposure and the levels of (a) PTSD symptoms, (b) other mental health symptoms, (c) health status, and (d) QOL. Methods Design Overview This cross-sectional and retrospective study was part of a VA Medical Center MST-related PTSD treatment program evaluation study. Appropriate Institutional Review Board approval was obtained for this study. Sample Data were collected on female veterans (N ¼ 135) who experienced MST and sought mental health care in a southeastern VA medical center Trauma Recovery Program from August 2006 to June 2008. Compared to all women veterans (NCVAS, 2011), this sample was younger (mean age 40.3 years [SD ¼ 10.01] vs. 49.0 years), primarily African American (71.9% vs. 23.9%), with significantly fewer White, non-Hispanic women (17.1% vs. 69.6%). They were less likely to be married (26.6% vs. 47.4%). More women in the sample had never been married (26.6%) compared to all female veterans (16.6%). All women in the sample completed high school, with an average of 14.4 years of education (SD ¼ 2.17). Variables and Their Measurement The data used in this study were obtained using the Veterans Affairs Military Stress Treatment Assessment (VAMSTA), a psychometrically sound instrument that assesses veterans’ symptom severity, social functioning, QOL, and service use (Fontana, Ruzek, McFall, & Rosenheck, 2006). Additional data were Research in Nursing & Health extracted from electronic medical records. Study variables, their measurement, and primary sources are detailed in Table 1. Independent variables included trauma exposures: military (MST and combat) and non-military (childhood and adult). Outcome variables include PTSD, MDD, suicidal thoughts, health status, sleep, pain, coping, and QOL. MST was defined as including at least one of the following: (a) sexual assault, (b) threatened sexual assault, and (c) repeated threatening sexual harassment. Combat exposure was defined as receipt of friendly or hostile fire. In this study, combat exposure did not include other combat-related trauma exposure (e.g., seeing or handling dead bodies, encountering landmines or IEDs, or taking care of injured or dying people). Data Collection The program evaluation data measures were completed by patients over the course of treatment. These data were de-identified and kept in a locked filing cabinet and on a password protected VA network computer. Two sources of data were used: VAMSTA self-report questionnaires completed by women at the time of their Intake interview and clinician-obtained trauma histories during the Intake interview, both taken from the VA program evaluation data base. Data Analysis Data were analyzed using PAWS 18.0 for Windows. Descriptive statistics were computed for all variables. Pearson product–moment correlation coefficients were used to analyze the relationships between trauma types (childhood, military-service related, and adult non-military service related) and all outcome variables. Given the limited sample size relative to variables, regression analyses were not conducted. Results Trauma Exposure Military trauma. Nearly all of the women experienced MST (83.1%). Experiences of at least one lifetime trauma exposure in addition to MST were nearly universal (95.4%) and far Research in Nursing & Health Ability to cope with military stress reactions Overall life satisfaction; composite of satisfaction with 10 life domains Coping Quality of Life Interview (a ¼ .74) VAMSTA Pittsburgh Sleep Quality Index (a ¼ .83) Trauma Recovery Program Intake Interview SF-36 (a ¼ .78–.93) Total index based on 19 items (0: very good—3: very bad) Single item (1: none—4: very well) 11 selected items (overall plus 10 domains, 1: terrible—7: delighted) Lehman (1988) Buysse, Reynolds, Monk, Berman, and Kupfer (1989) Fontana et al. (2006) Ware et al. (2001) 7/36 items 9 items (1-36) 3/19 items 17 items (17–85) Single item Fontana et al. (2006) Single item/(1: none—6: very severe) Single items VAMSTA Fontana et al. (2006) VA Electronic Medical Record VA Electronic Medical Record Primary Sources/Refs. Fontana and Rosenheck (1994) Weathers, Litz, Huska, and Keane (1994) Kroenke et al. (2001) Beck, Kovacs, and Weissman (1979) Ware, Kosinski, Dewey, and Gandek (2001) Electronic Medical Record Single items 11 items (13–65) Single items Trauma Recovery Program Intake Interview VAMSTA Short Mississippi Scale (a ¼ .87) PTSD Checklist (PCL) (a ¼ .94) PHQ-9 (a ¼ .89) Scale for Suicide Ideation (a ¼ .89) SF-36 (a ¼ .78–.93) Single items Number of Items/ (Range) Trauma Recovery Program Intake Interview Instruments (Cronbach Alpha) VAMSTA, Veterans Affairs Military Stress Treatment Assessment; PHQ-9, Patient Health Questionnaire-9. Quality of life Sleep quality Bodily pain in previous month Sleep Pain Health status MDD: symptom severity Suicidal Thoughts: presence, frequency and severity Mental health, physical health, overall health Presence of pain/severity of pain in previous 4 weeks MST: sexual harassment, threats and sexual assault Combat: service in war zone, received friendly or hostile fire PTSD: symptom severity Trauma: military-related Mental health disorders and symptoms Adulthood: verbally or physically abusive relationship; physical abuse or beating; sexual abuse or assault; emotional abuse Childhood: physical, sexual, and emotional abuse Variables and Operationalization Trauma: nonmilitary related Constructs Table 1. Study Constructs, Variables, Instruments, and Sources MORE THAN MST/ KELLY ET AL. 5 6 RESEARCH IN NURSING & HEALTH Mental Health Symptoms FIGURE 2. Experiences of military sexual and combat trauma. exceeded rates reported in other female VA populations. Over half of the sample (53.1%) served in a war zone, with 41.0% reporting combat-related trauma (Fig. 2). Non-military adult trauma. Sexual abuse/ assault was the most common non-military adult trauma, reported by more than three-quarters of the women (77.0%). More than half of the women reported having been in an abusive relationship in the past (52.7%). As adults, 54.8% had been beaten or physically abused and 48.9% had been persistently emotionally abused. Only 14.4% reported no non-military adult trauma, while 36.7% reported experiencing all three types of abuse (physical, sexual, and emotional; Fig. 3). Childhood abuse. Abuse in childhood was more common than not. Nearly two-thirds (60.4%) reported at least one form of child abuse, more than one in four reported at least two forms of child abuse (26.7–30.6%), and nearly one in four women (23.1%) reported experiencing all three: physical, sexual, and emotional. Sexual abuse was the most common, and was reported by more than half of the sample (52.6%). PTSD. The recommended clinical cutoff score for the PTSD Checklist (PCL) is 30–50. The mean severity of PTSD symptoms in this sample was 65.15 (SD ¼ 14.05), a very clinically significant result. The mean of the Short Mississippi Scale was mid-range, 36.87 (SD ¼ 7.23). MDD. The mean score of the Patient Health Questionnaire-9 (PHQ-9) was 17.58 (SD ¼ 5.49). Clinical cutoff scores recommended in the literature are 10–12 (Kroenke, Spitzer, & Williams, 2001). Within the VA, a screening PHQ-9 score >9 necessitates a suicide assessment within 24 hours. The mean score for this sample falls within the clinical range for moderately severe depression (15–19). Suicidal thoughts. Suicidal thoughts in the previous month were endorsed by 43% of the sample; 6.7% had attempted suicide in the previous 4 months. Health Status and Symptoms of Distress Health status. Respondents rated their overall health and health-related impairments as moderate to severe. They reported personal and emotional problems as more strongly limiting their ability to perform usual physical activities than did their physical health (Table 2). Sleep, pain, coping, and QOL. All of the respondents endorsed some amount of sleep difficulty. Two-thirds (66.4%) endorsed the presence of chronic pain, with a mean severity of 4.14 (SD ¼ 1.20), a moderate to severe level. The mean score of ability to cope with stress reactions was mid-range, 2.31 (SD ¼ .82). QOL was measured as a single question, ‘‘How do you feel about your life as a whole, overall?’’ and as a composite of 10 QOL domains. The mean scores for these two QOL variables were nearly identical and mid-range: 3.19 (SD ¼ .82) for the single item and 31.88 (SD ¼ 9.09) for the mean of the 10 items in the composite score. Correlations Between Trauma and Health Outcomes FIGURE 3. Experiences of intimate partner violence and adult physical, sexual and emotional abuse. Research in Nursing & Health Total child abuse and emotional childhood abuse alone were strongly associated with chronic physical pain, which was also negatively associated with sleep quality and physical 7 MORE THAN MST/ KELLY ET AL. Table 2. Health Status in the Previous 4 Weeks Mean SD Median Overall health 4.03 1.03 4.00 Bothered by emotional problems, e.g., anxious, depressed, or irritable Energy level 4.06 .90 4.00 3.66 .73 4.00 Physical health limited usual physical activities Personal or emotional problems limited usual physical activities Physical health or emotional problems limited usual social activities with family and friends Physical health limited ability to do daily work 3.10 1.28 3.00 3.51 1.01 4.00 3.69 1.02 4.00 3.09 1.27 3.00 health (Table 3). Pain severity in the previous 4 weeks was strongly associated with physical health, mental health, sleep quality, and coping (Table 3). Additionally, childhood sexual abuse was associated with suicidal thoughts (r ¼ .216, p ¼ .017). As expected, combat-related trauma was associated with PTSD symptoms (PCL: r ¼ .217, p ¼ .012). Combat-related trauma also was associated with violence and anger (r ¼ .248, p ¼ .005). In turn, violence and anger were negatively associated with coping (r ¼ .300, p ¼ .001). Notably, the data did not suggest a significant association between MST and the identified outcome variables. Given the overall low variability in the MST Table 3. Correlations With Physical Pain Current Chronic Pain (Y/N) Child abuse Physical Sexual Emotional All three Distress symptoms Sleep quality Coping Physical health Mental health .193 .034 .239 .208 .239 .035 .403 .117  p  .05.  p  .01.  p  .001. Research in Nursing & Health Severity of Bodily Pain in Previous 4 Weeks .009 .070 .105 .074 .410 .329 .732 .255 Rating Scale 1 6 1 5 1 5 1 5 1 5 1 5 ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ Excellent Very poor Not at all Extremely Very much None Not at all Could not do activities Not at all Could not do activities Not at all Could not do activities 1 ¼ Not at all 5 ¼ Could not work variable, as well as the overall high levels of PTSD and MDD symptoms in this sample, there may be a ceiling effect with these data. Discussion This sample of treatment seeking female veterans was remarkable for high levels of lifetime trauma exposure and clinically significant levels of mental health symptoms, as well as co-morbid physical health symptoms and diagnoses. Combat exposure (41%), which was measured using one type only, far exceeded reported rates of combat exposure for women that include multiple types of exposure and often involve the aftermath of battle (e.g., handling human remains; 4–31%; Zinzow et al., 2007). Non-military trauma exposure also exceeded rates reported in other samples of female veterans typically obtained from health care registries and primary care patients; for example, childhood sexual abuse (52.6% vs. 27–49%) and domestic violence (52.7% vs. 18– 19%; Zinzow et al., 2007). The complex trauma exposures experienced by this sample are best illustrated by the high percentages of women who experienced all three types of child abuse (21.3%) and adult abuse (36.7%). These results indicate a lifelong pattern of trauma in families of origin, during military service, and as civilian adults. These complex trauma histories are matched by complex mental health profiles. On average, symptoms of PTSD and MDD in this sample far exceeded DSM-IV (APA, 2000) diagnostic 8 RESEARCH IN NURSING & HEALTH criteria, with PCL and PHQ-9 scores at or above clinical significance. The women reported high levels of sleep disturbances and chronic pain, which were strongly associated with each other, with childhood abuse, and with current physical health status. Pain severity was strongly associated with mental health status. These findings are consistent with data suggesting that patients with MST frequently present with substantial mental health treatment needs (Kimerling et al., 2010; Surı̀s et al., 2007). Further, these findings illustrate the interplay of mental health and physical health symptoms in trauma survivors. A number of investigators have established links between deployment-related trauma, both MST and combat-related, PTSD, and multiple adverse outcomes in female veterans (Surı́s & Lind, 2008; Zinzow et al., 2007). The findings of this study support those findings and characterize the full range of trauma exposure and severity of mental and physical health outcomes in a primarily African American sample of female veterans who experienced MST. These data are consistent with data from other samples indicating that exposure to early life adverse experiences contributes significantly to both physical and mental health problems and their co-morbidities across the lifespan (Felitti et al., 1998). Overall, the findings in this study are consistent with the current state of knowledge in the field, illustrated in the model in Figure 1. The complexity of the trauma histories and severity of mental and physical health symptoms in this sample suggest a dose-related relationship between trauma, PTSD, and associated negative sequelae. Limitations We used a cross-sectional, single-site, retrospective design to obtain data from a self-selected population of women seeking treatment for MST/PTSD. This treatment seeking sample is not likely to be representative of the overall population of female veterans seeking care in the VA who may have experienced MST but either were not appropriately screened and referred for treatment or did not follow through with referrals made to the Trauma Recovery Program. Additionally, the relatively small sample size and the sample characteristics (i.e., primarily African American and on average younger than most women veterans) limit the generalizability of the results to a national Research in Nursing & Health sample. Also, the low MST variability and the high levels of PTSD and MDD symptoms may be associated with ceiling effects which limit analyses of the strength of the relationships between trauma and mental health symptoms. Trauma history variables were based on clinical records; future researchers should instead use well-validated instruments. Given the design, we are not able to determine causal relationships between trauma experiences and outcome variables. Longitudinal research would address this limitation. However, characterizing the trauma and health outcomes in a treatment seeking sample can help guide the development of programs designed to address the range and depth of trauma and health problems in this population. Implications for Treatment The steadily rising rate of female veterans is matched with an increased demand within the VA for services for women trauma patients, particularly those with MST. The significant associations between childhood abuse and health outcomes in women exposed to MST suggests the necessity of assessment for pre-military trauma as part of routine mental health evaluations of women presenting with PTSD or other psychological distress. The development of specialized treatment teams within VA PTSD Treatment Programs can facilitate access to appropriate and effective trauma-focused care for female veterans. Given the emergence in this study of pain and sleep difficulty as predominant problematic health effects of trauma, integrated clinical assessments, and interventions are indicated. Pain and sleep difficulty are two common treatment refractory disorders seen in many clinical settings and are examples of symptoms that would be best treated with close coordination between mental health and physical health care providers. Pain and sleep were, in turn, significantly associated with QOL and overall functioning. As such, they illustrate the intertwined and nuanced effects of interpersonal trauma on the health and wellness of female veterans. Further, detailed assessment of patients with chronic pain and sleep disorders can help identify trauma and its mental health sequelae, particularly PTSD and MDD. Treatment programs for traumatized female veterans that integrate services from mental health, primary care, nursing, and pain 9 MORE THAN MST/ KELLY ET AL. management and rehabilitation clinicians will be well-suited to address the complex mental and physical health problems of female veterans who have experienced MST and other lifetime trauma. By definition, MST occurs while victims are serving in the military. Therefore, those serving in the military on active duty are also at risk for developing PTSD, MDD, and associated mental and physical health disorders and symptoms, prior to becoming veterans. This suggests the need to screen for pre-military trauma at enlistment as well as during active duty. Treatment for MST-related PTSD in this population has not been studied adequately; theoretically, given soldiers’ need to function at high levels in stressful situations, standard PTSD treatment, particularly prolonged exposure, might not be indicated. Further research in this area is warranted. Implications for Research Areas for future research include assessing whether specific characteristics of MST, such as the victim’s relationship to the perpetrator, the deployment status of the survivor, and active duty versus reserves duty at the time of the MST, are associated with subsequent mental and physical health outcomes. An additional variable that needs to be evaluated is how length of service among MST survivors correlates with mental, physical, and social functioning. More broadly, there is an important gap in our knowledge in this field of study in that we have little understanding of the specific factors influencing vulnerability to PTSD and its negative health and functional effects in traumatized female veterans. Particular attention needs to be paid to understanding why some female veterans with pre-military service trauma histories function fairly well (i.e., are resilient, and do not require intervention) whereas others display a range of mental and physical health problems in addition to poor QOL. Such future research on the mechanisms whereby risk and resilience factors affect the development of PTSD and associated mental and physical health and functional outcomes related to MST, combat-related, and lifetime trauma in female veterans could be vital for developing effective treatment interventions. Particular consideration also should be given to the interplay between trauma-related mental health and physical health Research in Nursing & Health outcomes. A more thorough understanding of the vulnerability and protective factors for PTSD and other negative health outcomes of MST and cumulative trauma on female veterans will enable us to better plan for and provide effective health care to this important population. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th, Text Revision ed.). Washington, DC: American Psychiatric Association. Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748–766. DOI: 10.10371/0022-006X.68.5.748. Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: The Scale for Suicide Ideation. Journal of Consulting and Clinical Psychology, 47, 343–352. DOI: 10.1037/ 0022-006X.47.2.343. Buysse, D. J., Reynolds, C. F., III, Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193–213. DOI: 10.1016/01651781(89)90047-4. Campbell, R., Greeson, M. R., Bybee, D., & Raja, S. (2008). The co-occurrence of childhood sexual abuse, adult sexual assault, intimate partner violence, and sexual harassment: A mediational model of posttraumatic stress disorder and physical health outcomes. Journal of Consulting and Clinical Psychology, 76, 194–207. DOI: 10.1037/ 0022-006x.76.2.194. Cascardi, M., O’Leary, K. D., & Schlee, K. A. (1999). Co-occurrence and correlates of posttraumatic stress disorder and major depression in physically abused women. Journal of Family Violence, 14, 227–249. DOI: 10.1023/ A:1022827915757. Cloitre, M., Stovall-McClough, K., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L. . . . Petkova, E., (2010). Treatment for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry, 167, 915–924. DOI: 10.1176/appi.ajp.2010.09081247. Cougle, J. R., Keough, M. E., Riccardi, C. J., & Sachs-Ericsson, N. (2009). Anxiety disorders and suicidality in the National Comorbidity Survey-Replication. Journal of Psychiatric Research, 43, 825–829. DOI: 10.1016/j.jpsychires. 2008.12.004. Department of Veterans Affairs. (2007). Women veterans: Past, present and future: Office of policy 10 RESEARCH IN NURSING & HEALTH and planning. Washington, DC: Government Printing Office. Dobie, D. J., Kivlahan, D. R., Maynard, C., Bush, K. R., Davis, T. M., & Bradley, K. A. (2004). Posttraumatic stress disorder in female veterans: Association with self-reported health problems and functional impairment. Archives of Internal Medicine, 164, 394–400. DOI: 10.1001/archinte. 164.4.394. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V. . . . Marks, J. S., (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245–258. DOI: 10.1016/S0749-3797(98)00017-8p. Fontana, A., & Rosenheck, R. (1994). A short form of the Mississippi Scale for measuring change in combat-related PTSD. Journal of Traumatic Stress, 7, 407–414. Fontana, A. F., Ruzek, J. I., McFall, M., & Rosenheck, R. (2006). The Veterans Affairs Military Stress Treatment Assessment (VAMSTA): A descriptive and monitoring instrument for the treatment of PTSD and comorbid disorders. Washington, DC: Government Printing Office. Haskell, S. G., Papas, R. K., Heapy, A., Reid, M. C., & Kerns, R. D. (2008). The association of sexual trauma with persistent pain in a sample of women veterans receiving primary care. Pain Medicine, 9, 710–717. DOI: 10.1111/j.15264637.2008. 00460.x. Kang, H., Dalager, N., Mahan, C., & Ishii, E. (2005). The role of sexual assault on the risk of PTSD among Gulf War veterans. Annals of Epidemiology, 15, 191–195. DOI: 10.1016/j.annepidem. 2004.05.009. Kim, J., & Cicchetti, D. (2010). Longitudinal pathways linking child maltreatment, emotion regulation, peer relations, and psychopathology. Journal of Child Psychology and Psychiatry, 51, 706–716. DOI: 10.1111/j.1469-7610.2009.02202.x. Kimerling, R., Street, A., Pavao, J., Smith, M. W., Cronkite, R. C., Holmes, T. H., & Frayne, S. (2010). Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq. American Journal of Public Health, 100, 1409–1412. DOI: 10.2105/ ajph.2009.171793. Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606–613. Lehman, A. F. (1988). A quality of life interview for the chronically mentally ill. Evaluation and Program Planning, 11, 51–62. DOI: 10.1016/01497189(88)90033-X. Murdoch, M., Polusny, M. A., Hodges, J., & O’Brien, N. (2004). Prevalence of in-service and postservice sexual assault among combat and Research in Nursing & Health noncombat veterans applying for Department of Veterans Affairs posttraumatic stress disorder disability benefits. Military Medicine, 169, 392–395. National Center for Veterans Analysis and Statistics, (2011). Profile of veterans: 2009 Data from the American Community Survey. Retrieved from http:// www.va.gov/vetdata/docs/SpecialReports/Profile_ of_Veterans_2009_FINAL.pdf. Reich, J. W. Zautra, A. J. & Hall J. S. (Eds.), (2010). Handbook of adult resilience. New York, NY: Guilford Press. Rheingold, A. A., Acierno, R., & Resnick, H., (2004) Trauma, post-traumatic stress disorder, and health risk behaviors. In P. P. Schnurr & B. L. Green (Eds.) Trauma and health: Physical health consequences of exposure to extreme stress (pp. 217– 243). Washington, DC: American Psychological Association. Sadler A. G. Booth, B. M., Mengeling, M. A., & Doebbeling, B. N. (2004). Life span and repeated violence against women during military service: Effects on health status and outpatient utilization. Journal of Women’s Health, 13, 799–811. Sadler, A. G., Booth, B. M., Nielson, D., & Doebbeling, B. N. (2000). Health-related consequences of physical and sexual violence: Women in the military. Obstetrics & Gynecology, 96, 473–480. Shipherd, J. C., Keyes, M., Jovanovic, T., Ready, D. J., Baltzell, D., Worley, V., & Duncan, E. (2007). Veterans seeking treatment for posttraumatic stress disorder: What about comorbid chronic pain? Journal of Rehabilitation Research and Development, 44, 153–165. DOI: 10.1682/jrrd. 2006.06.0065. Skinner, K. M., Kressin, N., Frayne, S., Tripp, T. J., Hankin, C. S., Miller, D. R., & Sullivan, L. M. (2000). The prevalence of military sexual assault among female Veterans’ Administration outpatients. Journal of Interpersonal Violence, 15, 291– 310. DOI: 10.1177/088626000015003005. Stein, M. B., & Kennedy, C. (2001). Major depressive and post-traumatic stress disorder comorbidity in female victims of intimate partner violence. Journal of Affective Disorders, 66, 133–138. DOI: 10.1016/S0165-0327(00)00301-3. Street, A. E., Gradus, J. L., Stafford, J., & Kelly, K. (2007). Gender differences in experiences of sexual harassment: Data from a male-dominated environment. Journal of Consulting & Clinical Psychology, 75, 464–474. DOI: 10.1037/0022006X.75.3.464. Street, A. E., Stafford, J., Mahan, C. M., & Hendricks, A. (2008). Sexual harassment and assault experienced by reservists during military service: Prevalence and health correlates. Journal of Rehabilitation Research & Development, 45, 409–419. DOI: 10.1682/JRRD.2007.06.0088. Street, A. E., Vogt, D., & Dutra, L. (2009). A new generation of women veterans: Stressors faced by women deployed to Iraq and Afghanistan. Clinical MORE THAN MST/ KELLY ET AL. Psychology Review, 29, 685–694. DOI: 10.1016/ j.cpr.2009.08.007. Surı́s, A., & Lind, L. (2008). Military sexual trauma: A review of prevalence and associated health consequences in veterans. Trauma, Violence & Abuse, 9, 250–269. DOI: 10.1177/1524838008324419. Surı̀s, A., Lind, L., Kaashner, T. M., & Borman, P. D. (2007). Mental health, quality of life, and health functioning in women veterans: Differential outcomes associated with military and civilian sexual assault. Journal of Interpersonal Violence, 22, 179–197. DOI: 10.1177/ 0886260506295347. Vogt, D. S., Pless, A. P., King, L. A., & King, D. W. (2005). Deployment stressors, gender, and mental health outcomes among Gulf War I veterans. Research in Nursing & Health 11 Journal of Traumatic Stress, 18, 115–127. DOI: 10.1002/jts.20018. Ware, J. E., Kosinski, M., Dewey, J. E., & Gandek, B. (2001). How to score and interpret single-item health measures: A manual for users of the SF-8 Health Survey. Lincoln, RI: Quality Metric Incorporated. Weathers, F. W., Litz, B. T., Huska, J. A., & Keane, T. M. (1994). PTSD checklist—Civilian version. Boston, MA: National Center for PTSD, Behavioral Science Division. Zinzow, H. M., Grubaugh, A. L., Monnier, J., Suffoletta-Maierle, S., & Frueh, B. C. (2007). Trauma among female veterans: A critical review. Trauma, Violence, & Abuse, 8, 384–400. DOI: 10.1177/1524838007307295.
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Running head: INTERVENTIONS AND TREATMENT OF MST

Interventions and treatment of MST
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INTERVENTIONS AND TREATMENT OF MST

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Military sexual trauma
Military Sexual Trauma is inclusive of sexual harassment and assault that veterans
experience during deployment or in the courses of service (Kimerling et al, 2010). It poses a
serious predicament as the prevalence is noted to continuously rise to 41% for female veterans
whilst for men it has been reported to rise to 4.2 %. In spite of the rising numbers of patients in
this regard, however, the effects of the trauma on both sexes regardless is profound and in most
cases victims of the sexual trauma may find it hard to cope with the family or maintain their
marital status as feelings of anger shame, seep into their lives thereby causing trust issues and
sexual difficulties. Addi...


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