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
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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
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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
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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
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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
•
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•
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.
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Suris AM, Davis LL, Kashner TM, Gillaspy JA,
Petty F. A survey of sexual trauma treatment
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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
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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.
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