Research roundup: Military sexual trauma

Behavioral health outcomes associated with military sexual trauma and implications for clinical intervention.

Military sexual trauma (MST) is defined as any sexual assault, sexual battery or repeated and threatening sexual harassment experienced during military service. A Veterans Health Administration Directive (VHA Directive 2010-033) from July 2010 mandated that screening for MST be routinely conducted with all veterans who use Department of Veterans Affairs (VA) health services. MST is associated with poorer post deployment readjustment in multiple areas, including an increased likelihood of receiving multiple mental health diagnoses, specifically PTSD and substance abuse. Among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, the rates of MST range from 1-13 percent for men and 14-42 percent for women. 

The following studies examine the psychological correlates of MST in both male and female veterans. The first study examines the prevalence of insomnia in veterans with MST. The second study focuses on correlates of more severe MST experiences in male veterans. Finally, the third study investigates the relationship between MST, PTSD symptoms and subsequent alcohol problems.

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.

Jenkins, M.M., Colvonen, P.J., Norman, S.B., Afari, N., Allard, C.B., & Drummond, S.A. (2015). Prevalence and mental health correlates of insomnia in first-encounter veterans with and without military sexual trauma. Sleep: Journal of Sleep and Sleep Disorders Research, 38(10), 1547-1554.

Insomnia is one of the most common reasons for health referrals in active-duty military personnel and recently deployed veterans. Military personnel also face increased risk of trauma, which is related to sleep disturbance. However, empirical information about the prevalence of insomnia among veterans is limited primarily to older male veterans. This study sought to examine the prevalence of insomnia in a large, relatively young, diverse sample of veterans. In addition, the researchers examined rates of insomnia among veterans with MST, and reported clinical correlates of insomnia for veterans with and without MST.

Data from 917 veterans were collected from a larger study to screen newly enrolled Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn veterans. Participants completed the Insomnia Severity Index (ISI), which assesses the severity of insomnia, with a score of 10 or higher indicating insomnia in community samples. Participants also completed the VA Military Sexual Trauma Screen, which is a two-item screening instrument that assesses uninvited or unwanted sexual attention or sexual contact. Veterans completed several other clinical measures, including the PTSD Checklist-Civilian Version, the Alcohol Use Disorders Identification Test-Consumption and the Veteran Traumatic Brain Injury Screening Tool.

The study found that insomnia was more prevalent than depression, hypomania, PTSD and substance misuse. Notably, 53 percent of veterans without MST and 61 percent of veterans with MST had clinically significant insomnia symptoms. For veterans with MST, employment status, pain and depression were significantly associated with more severe insomnia. Veterans with MST also reported lower resilience than veterans without MST. Furthermore, insomnia was more prevalent and more severe in veterans with MST. The researchers concluded that given the large population of veterans with significant insomnia symptoms, routine empirically validated insomnia assessments and referrals to behavioral interventions, such as Cognitive Behavioral Therapy for Insomnia (CBT-I) are crucial.

Schry, A.R., Hibberd, R., Wagner, H.R., Turchik, J.A., Kimbrel, N.A., Wong, M., & ... Brancu, M. (2015). Functional correlates of military sexual assault in male veterans. Psychological Services, 12(4), 384-393.

Although MST affects all veterans, research examining MST specifically in male veterans is limited. The present study sought to examine the correlates of MST among male veterans. More specifically, the study focused on correlates on sexual assault among Iraq and Afghanistan-era veterans who served in the military since Sept. 11, 2001. This research examined a more severe form of MST, the experience of sexual assault during military service (MSA). Individuals with a history of MSA were compared to those without MSA on a variety of clinical measures, including PTSD, depression, substance use, suicidality, violent behavior, incarceration and use of mental health treatment.

Data was collected from 2,042 male Iraq/Afghanistan-era U.S. military veterans, active duty personnel, and reserve members. Approximately 2 percent (n = 39) of participants reported experiencing MSA. Participants with MSA history were compared to all veterans without MSA, and in a second set of analyses, matched with a subsample of participants without MSA based on age, race, marital status, reports of pre-enlistment sexual assault or incidents of childhood sexual and/or physical abuse, and traumatic events reported prior to enlistment. Participants completed a structured diagnostic interview and several self-report measures measuring function, substance abuse, mental health status and use of services.

Veterans who experienced MSA reported higher levels of negative functional and psychiatric outcomes. They were more likely to report a service-connected disability, receive mental health treatment in the past three years, have higher levels of PTSD and depression symptoms, and higher levels of suicidality. However, veterans with and without MSA history did not differ on several outcomes, including violent behavior, social support and past-year substance use. Importantly, levels of PTSD, depression and suicidal ideation remained significantly higher among veterans reporting MSA even when controlling for variables such as prior trauma history. These results emphasize that MST is not a female-only issue and that screening for MST is important for all veterans. The researchers recommended that when a history of MST is present, careful screening and ongoing monitoring of mental health, symptom severity and suicidality is prudent.

Hahn, A., Tirabassi, C., Simons, R., & Simons, J. (2015). Military Sexual Trauma, Combat Exposure, and Negative Urgency as Independent Predictors of PTSD and Subsequent Alcohol Problems Among OEF/OIF Veterans. Psychological Services, 12(4), 378-383.

PTSD and alcohol use disorders are highly comorbid, with rates ranging from 41 percent to -79 percent. Combat exposure and MST are significant predictors of PTSD and alcohol-related problems, and personality factors may also increase the risk of PTSD and problematic alcohol use. One personality factor associated with higher rates of PTSD and alcohol-related problems is negative urgency, defined as the rash actions (including substance use) an individual may take in response to intense negative affect. Although both are significant traumatic experiences, MST and combat exposure may play independent roles in the development of PTSD and subsequent alcohol use. The present study examined MST, combat exposure and negative urgency as predictors of PTSD symptoms. The study also tested whether PTSD mediated the relationship between these variables and alcohol-related problems.

The sample consisted of 90 OIF/OEF veterans who reported consuming at least one drink per week (age ranging from 18-50 years; 65 percent male). Subscales of the Deployment Risk and Resilience Inventory (DRRI) were used to measure combat exposure and MST. Alcohol problems were assessed using measures of daily drinking and negative consequences associated with alcohol use, and negative urgency was assessed with a scale measuring impulsive behavior. More than 26 percent of the sample reported experiencing MST, and 97 percent reported some combat exposure.

For individuals who experienced MST and/or combat exposure, the development of PTSD symptoms partially accounted for the association between MST and alcohol-related problems. Veterans who experienced MST had a significant risk of experiencing PTSD symptoms and alcohol-related problems, regardless of their exposure to combat. Negative urgency also predicted alcohol problems directly as well as through the increased likelihood of PTSD symptoms. Overall, this study highlighted the complex relationship between traumatic experiences, emotion regulation, PTSD and alcohol-related problems. The results of this study suggest that clinical interventions aimed at treating posttraumatic stress symptomatology and reducing emotional dysregulation may improve alcohol-related problems among veterans.

Clinical implications

These studies suggest that Military Sexual Trauma is associated with higher levels of PTSD, depression and suicidality, as well as greater insomnia and alcohol abuse. The evidence indicates that MST affects all veterans, regardless of gender identity, and that the negative outcomes associated with MST remain when controlling for factors such as prior trauma history. Overall, these studies highlight the importance of addressing MST when working with veterans.

Screening, assessment and treatment planning with this population are especially important, particularly when other diagnoses are present. For example, while alcohol use disorders and PTSD have historically been treated separately, the findings of Hahn et al. (2015) suggest that successfully treating PTSD symptoms may subsequently decrease alcohol-related problems. Therefore, trauma-focused therapies may be the most effective treatment for comorbid substance use and PTSD. Similarly, Jenkins et al. (2015) suggests that screening for PTSD and MST is important when assessing insomnia, and that therapy (such as CBT-I) may be more effect than pharmacological treatment with this client population. Even when seeing clients for seemingly unrelated reasons, clinicians working with Veterans should routinely screen for MST, and if necessary, refer to appropriate treatment.

Given the rates and ramifications of MST, APA and the Practice Organization focus not only on the clinical indications but also policy implications. The Practice Organization advocates within the Department of Defense and both houses of Congress to find better ways to prevent military sexual assault.