Military Sexual Trauma: Issues in Caring for Veterans
Amy Street, Ph.D. and Jane Stafford, Ph.D.
What is Military Sexual Trauma?
Military sexual trauma refers to both sexual harassment and sexual assault that occurs in
military settings. Both men and women can experience military
sexual trauma and the perpetrator can be of the same or of the
opposite gender. A general definition of sexual harassment is
unwelcome verbal or physical conduct of a sexual nature that occurs
in the workplace or an academic or training setting. Sexual
harassment includes gender harassment (e.g., put you down because
of your gender), unwanted sexual attention (e.g., made offensive
remarks about your sexual activities or your body) and sexual
coercion (e.g., implied special treatment if you were sexually
cooperative). Sexual assault is any sort of sexual activity between
at least two people in which one of the people is involved against
his or her will. Physical force may or may not be used. The sexual
activity involved can include many different experiences including
unwanted touching, grabbing, oral sex, anal sex, sexual penetration
with an object, and/or sexual intercourse.
People tend to think that only women experience sexual trauma,
however, this is not the case. In 1995 the Department of Defense
conducted a large study of sexual victimization among active duty
populations and found rates of sexual harassment to be 78% among
women and 38% among men over a one-year period. Rates of attempted
or completed sexual assault were 6% for women and 1% for men. Rates
of military sexual trauma among veteran users of VA healthcare
appear to be even higher than in general military populations. In
one study, 23% of female users of VA healthcare reported
experiencing at least one sexual assault while in the
military.
Does Military Sexual Trauma Occur during
Wartime?
Sexual trauma in the military does not occur only during
training or peacetime and in fact, the stress of war may be
associated with increases in rates of sexual harassment and
assault.Research with Persian Gulf War military personnel conducted
by Jessica Wolfe and her colleagues found that rates of sexual
assault (7%), physical sexual harassment (33%) and verbal sexual
harassment (66%) were higher than those typically found in
peacetime military samples.
Are There Unique Aspects of Sexual Trauma Associated with
Military Service?
While there is almost no empirical data comparing experiences of
military sexual trauma with experiences of sexual harassment and
assault that occur outside of military service, there is some
anecdotal evidence that these experiences are unique and may be
associated with qualitatively or quantitatively different
psychological outcomes.
Sexual trauma that is associated with military service most
often occurs in a setting where the victim lives and works.In most
cases, this means that victims must continue to live and work
closely with their perpetrators, often leading to an increased
sense of feeling helpless, powerless, and at risk for additional
victimization. In addition, sexual victimization that occurs
in this setting often means that victims are relying on their
perpetrators (or associates of the perpetrator) to provide for
basic needs including medical and psychological care.
Similarly, because military sexual trauma occurs within the
workplace, this form of victimization disrupts the career goals of
many of its victims. Perpetrators are frequently peers or
supervisors responsible for making decisions about work-related
evaluations and promotions. In addition, victims are often
forced to choose between continuing military careers during which
they are forced to have frequent contact with their perpetrators or
sacrificing their career goals in order to protect themselves from
future victimization.
Most military groups are characterized by high unit cohesion,
particularly during combat. While this level of solidarity
typically reflects a positive aspect of military service, the
dynamics of cohesion may play a role in the negative psychological
effects associated with sexual harassment and assault that
occurs. Because organizational cohesion is so highly valued
within the military environment, divulging any negative information
about a fellow soldier is considered taboo. Accordingly, many
victims are reluctant to report sexual trauma and many victims say
that there were no available methods for reporting their
experiences to those in authority. Many indicate that if they
did report the harassment they were not believed or encouraged to
keep silent about the experience. They may have had their reports
ignored, or even worse, have been themselves blamed for the
experience. Having this type of invalidating experience
following a sexual trauma is likely to have a significant negative
impact on the victim’s post-trauma adjustment.
What Type of Psychological Responses are Associated with
Military Sexual Trauma Victimization?
Given the range of sexual victimization experiences that
veterans report (ranging from inappropriate sexual jokes or
flirtation, to pressure for sexual favors, to completed forcible
rape) there are a wide range of emotional reactions reported by
veterans in response to these events. Even in the aftermath
of severe forms of victimization, there is no one way that victims
will respond. Instead, the intensity, duration, and
trajectory of psychological responses will all vary based on
factors like the veterans’ previous trauma history, their
appraisal of the traumatic event, and the quality of their support
systems following the trauma. In addition, the victim’s
gender may play a role in the intensity of the post-trauma
reactions. While the types of psychological reactions
experienced by men and women are often similar, the experience of
sexual victimization may be even more stigmatizing for men than it
is for women because these victimization experiences fall so far
outside of the proscribed male gender role. Accordingly, men
may experience more severe symptomatology than women, may be more
likely to feel shame about their victimization, and may be less
likely to seek professional help.
Among both men and women in the active duty military, sexual
harassment is associated with poorer psychological well-being, more
physical problems and lower satisfaction with health and
work. Female veterans who use VA healthcare and report a
history of sexual trauma while in the military also report a range
of negative outcomes, including poorer psychological and physical
health, more readjustment problems following discharge (i.e.,
difficulties finding work, alcohol and drug problems), and a
greater incidence of not working due to mental health
problems. Studies of sexual assault among civilian
populations identify posttraumatic stress disorder (PTSD) as a
frequent outcome. Sexual assault victimization is associated
with high lifetime rates of PTSD in both men (65%) and women
(45.9%). Interestingly, these rates are higher than the rate
reported by men following combat exposure (38.8%). Major
depressive disorder (MDD) is another common reaction following
sexual assault, with research suggesting that almost a third of
sexual assault victims have at least one period of MDD during their
lives. Victims of sexual assault may also report increased
substance use, perhaps as a means of managing other psychological
symptoms. One large-scale study found that compared to
non-victims, rape survivors were 3.4 times more likely to use
marijuana, 6 times more likely to use cocaine, and 10 times more
likely to use other major drugs. In addition to these psychological
conditions, victims of sexual trauma may continue to struggle with
a range of other symptoms that interfere with their quality of
life. Common emotional reactions include anger and shame,
guilt or self-blame. Victims of sexual trauma may report
problems in their interpersonal relationships, including
difficulties with trust, difficulties engaging in social activities
or sexual dysfunction. Male victims of sexual trauma may also
express concern about their sexuality or their masculinity.
How Has the VA Responded to the Problem of Military
Sexual Trauma?
Given the alarming prevalence rates of sexual harassment and
sexual assault among military veterans, it has been necessary for
the VA to respond actively to the healthcare needs of veterans
impacted by these experiences. In July 1992, a series of
hearings on women veterans’ issues by the Senate Veterans
Affairs Committee first brought the problem of military sexual
trauma to policy makers’ attention. Congress responded
to these hearings by passing Public Law 102-585, which was signed
into law in November of 1992. Among other things, Public Law
102-805 authorized health care and counseling to women veterans to
overcome psychological trauma resulting from experiences of sexual
assault or sexual harassment during their military service.
Later laws expanded this benefit to male veterans as well as female
veterans, repealed limitations on the required duration of service,
and extended the provision of these benefits until the year
2005. Following the passage of these public laws, a series of
VA directives mandated universal screening of all veterans for a
history of military sexual trauma and mandated that each facility
identify a Military Sexual Trauma Coordinator to oversee the
screening and treatment referral process.
Are There Screening, Assessment or Treatment Issues That
Are Unique to Sexual Assault and Harassment?
Screening
It is
important to screen all veterans for a history of sexual
harassment and assault. Not only is universal screening
mandated by VA, it also represents good clinical practice given
the high prevalence rates of military sexual trauma among male
and female veterans and the reluctance of many sexual trauma
survivors to volunteer information about their trauma
histories. Screening for all forms of trauma exposure
should be approached with compassion and sensitivity, but
screening for a history of sexual trauma requires particular care
because of the stigma associated with this type of
victimization. For accurate screening, good rapport with
the veteran is essential, as is close attention to issues of
confidentiality (e.g., not screening in the presence of other
providers or family members). Regardless of the care taken
by the interviewer, the victims’ shame and self-blame may
prevent or delay disclosure, particularly for male victims or for
victims who have experienced punishment or disbelief following
previous disclosures.
When screening for a history of sexual trauma it is important to
avoid words like “rape” and “sexual
harassment.” Asking the question, “While you were
in the military, were you ever raped?” assumes that the
victimized person knows how rape is defined and perceives what
happened to them as a rape. Additionally, these words are
“loaded terms” for many people and a victim may respond
negatively in order to avoid the social stigma that goes along with
being a rape victim. A method of screening that is likely to
yield fairly accurate results without being perceived by the
veteran as too intrusive involves two general questions that use
descriptive, non-judgmental wording (i.e., While you were in the
military did you ever experience any unwanted sexual attention,
like verbal remarks, touching, or pressure for sexual favors?; Did
anyone ever use force or the threat of force to have sex with you
against your will?).
Assessment
At this
time, there are no published measures specifically designed to
assess sexual trauma that occurs as part of military service.
While most checklist measures that assess for trauma exposure
include at least one question about sexual assault, generally
these measures do not assess sexual harassment. However, there
are a number of existing self-report measures and structured
interviews specifically designed to assess sexual harassment
and/or sexual assault. The Sexual Experience Questionnaire
by Louise Fitzgerald is the most widely used measure of sexual
harassment. One of the most widely used measures of sexual
assault, the Sexual Experiences Survey by Mary Koss and her
colleagues, is a self-report measure that assesses a variety of
unwanted sexual experiences including those associated with
substance use. An example of an interview developed for the
purpose of assessing sexual assault is The National Women’s
Study interview developed by Heidi Resnick and her
colleagues. It includes a series of behaviorally specific
questions that ask about a variety of unwanted sexual
experiences.
Treatment
While the consequences of sexual
harassment and assault can be severe and complex, there are
treatments available that can significantly reduce psychological
symptoms and improve a victim’s quality of life. There is
very little empirically-based information on the treatment of
sexual harassment or on the treatment of any sexual trauma
associated with military service. However, there is a wealth of
information available on the treatment of sexual assault in
civilian populations that can be used to inform treatment of
veteran populations.
Interventions for sexual trauma often involve addressing
immediate health and safety concerns (particularly in the case of
an acute trauma), normalizing post-trauma reactions by providing
education about trauma and psychological reactions to traumatic
events, providing the victim with validation, supporting existing
adaptive coping strategies and facilitating the development of new
coping skills, like muscle relaxation or deep breathing.
Treatment interventions may also include exploring affective and
cognitive reactions including fear, self-blame, anger and
disillusionment, some form of exposure therapy and/or some form of
cognitive restructuring. Clinicians looking for more in depth
information on the treatment of sexual trauma are referred to Foa
and Rothbaum
1 and Resick and Schnicke.
2
References
1.
Foa, E. B.,
& Rothbaum, B. O. (1998).
Treating the trauma of rape: Cognitive-behavioral therapy for
PTSD. New York: Guilford.
2.
Resick,
P. S., & Schnicke, M. K. (2002).
Cognitive processing therapy for rape victims: A treatment
manual. Newbury Park, CA: Sage.