Factors associated with women's risk of rape in the military environment

The Impact of the COVID-19 Pandemic on the Military Health System's Care of Military Sexual Assault

BACKGROUND

Sexual assault remains a high priority challenge for leaders in the U.S. military. The COVID-19 pandemic further complicated the issue by disrupting work and lifestyles, potentially affecting reporting and care-seeking by victims. To date, there are no studies addressing the impact of changes in access to health services and reporting of sexual assault by active duty service members to inform medical and public health interventions in a post-COVID-19 era and during future public health emergencies.

METHODS

Using the Military Health System Data Repository (MDR), we identified a retrospective open cohort of active duty servicemembers receiving care in the Military Health System (MHS) from fiscal years 2018 to 2021. Through the use of ICD-10 diagnostic codes, all corresponding sexual assault care was identified for the cohort before (October 1, 2017-February 28, 2020; pre-pandemic period) and after (March 1, 2020-September 30, 2021; pandemic period) the institution of COVID-19 pandemic protective measures. Pre-pandemic and pandemic period rates of sexual assault associated encounters per 10,000 total health encounters were calculated by geographic location and compared using Wilcoxon's sign rank test. Multivariate log binomial regression models were performed to estimate associated risk of sexual assault among active duty servicemembers and compared across both periods.

RESULTS

The study identified 47,067,073 encounters for servicemembers in the pre-pandemic period, of which 7,813 (0.016%) were associated with sexual assault. During the pandemic period, 4,377 (0.015%) of 28,926,480 encounters were associated with sexual assault, indicating a 44% reduction in total encounters and a 9% reduction in the proportion of encounters associated with sexual assault. Eighteen installations within the MHS had statistically significant increases in rates of encounters. Most sexual assault encounters occurred in the 20-24 year age, Female, White, Junior Enlisted, Army, and Unmarried categories. During both time-frames, younger age and being female were associated with an increased risk of sexual assault encounters. Race, service branch, and marital status were also associated with the risk of encounters.

CONCLUSION

Contrary to reports indicating a modest increase in the number of sexual assaults reported within the DoD, we found a reduction in the frequency of healthcare encounters associated with sexual assault during the pandemic which may be related to reduced access to care. Men comprised approximately 22% of sexual assault encounters delivered through the MHS although the racial distribution of encounters approximates the estimates of the DoD-published demographic statistics. This study illustrates that COVID-19 measures appear to have reduced access to care for sexual assault within the MHS but did not demonstrably alter the demographics of servicemembers seeking care. These findings suggest that the MHS may require contingency plans for future disruptions to care and public health emergencies.

Alcohol-involved sexual assault in the US military: a scoping review

Background: Sexual assault and alcohol use are significant public health concerns, including for the United States (US) military. Although alcohol is a risk factor for military sexual assault (MSA), research on the extent of alcohol-involvement in MSAs has not been synthesised.Objective: Accordingly, this scoping review is a preliminary step in evaluating the existing literature on alcohol-involved MSAs among US service members and veterans, with the goals of quantifying the prevalence of alcohol-involved MSA, examining differences in victim versus perpetrator alcohol consumption, and identifying additional knowledge gaps.Method: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for Scoping Reviews, articles in this review were written in English, published in 1996 or later, reported statistics regarding alcohol-involved MSA, and included samples of US service members or veterans who experienced MSA during military service.Results: A total of 34 of 2436 articles identified met inclusion criteria. Studies often measured alcohol and drug use together. Rates of reported MSAs that involved the use of alcohol or alcohol/drugs ranged from 14% to 66.1% (M = 36.94%; Mdn = 37%) among servicemen and from 0% to 83% (M = 40.27%; Mdn = 41%) among servicewomen. Alcohol use was frequently reported in MSAs, and there is a dearth of information on critical event-level characteristics of alcohol-involved MSA. Additionally, studies used different definitions and measures of MSA and alcohol use, complicating comparisons across studies.Conclusion: The lack of event-level data, and inconsistencies in definitions, measures, and sexual assault timeframes across articles demonstrates that future research and data collection efforts require more event-level detail and consistent methodology to better understand the intersection of alcohol and MSA, which will ultimately inform MSA prevention and intervention efforts.

Caring for Service Members Who Have Been Sexually Assaulted: The Military Health System

INTRODUCTION

Reports of sexual assault (SA) in the U.S. Military have increased in recent years. Given the deleterious effects of military SA, there remains a need for large-scale studies to assess SA-related health care utilization among active duty service members (ADSMs). The present study, therefore, utilized Military Health System (MHS) data to determine the prevalence of SA-related care, sociodemographic characteristics of ADSMs receiving said care, and the type of provider seen during the initial SA-related health encounter.

MATERIALS AND METHODS

Utilizing the MHS Data Repository and Defense Enrollment Eligibility Reporting System, all ADSMs from the Air Force, Army, Navy, and Marine Corps during fiscal years (FY) 2016-2018 were identified. Those with an International Classification of Diseases diagnostic code related to SA during the study period were isolated. Descriptive statistics and multivariable logistic regression analyses were conducted. The study was exempt from human subjects review.

RESULTS

A total of 1,728,433 ADSMs during FY 2016-2018 were identified, of whom 4,113 (0.24%) had an SA-related health encounter. Rates of SA-related health care encounters decreased each FY. Women (odds ratio [OR] = 12.02, P < .0001), those in the Army (reference group), and enlisted personnel (OR = 2.65, P < .0001) were most likely to receive SA-related health care, whereas ADSMs aged 18-25 years had lower odds (OR = 0.70, P < .0001). In addition, higher odds of SA-related care were observed among those identifying as American Indian/Alaskan Native (OR = 1.37, P = .02) and "Other" race (e.g., multiracial) (OR = 4.60, P < .0001). Initial SA-related health encounters were most likely to occur with behavioral health providers (41.4%).

CONCLUSIONS

The current study is the first large-scale examination of health care usage by ADSMs in the MHS who have experienced SA. Results indicated that rates of SA-related care decreased throughout the study period, despite the increasing rates of SA documented by the DoD. Inconsistent with previous research and DoD reports indicating that younger ADSMs are at the highest risk for SA, our study observed lower rates of SA-related care among those aged 18-25 years; additional research is warranted to determine if there are barriers preventing younger ADSMs from seeking SA-related health care. Behavioral health providers were most frequently seen for the initial SA-related encounter, suggesting that they may be in a unique position to provide care and/or relevant referrals to ADSMs who have experienced SA. The present study provides key insights about the prevalence of SA-related care within the MHS, not yet reported in previous literature, which could help inform MHS screening practices. The strengths of the study are the inclusion of the entire active duty population without the need for research recruitment given the utilization of de-identified TRICARE claims data. The study is limited by its use of health care claims data, general SA International Classification of Diseases codes as a proxy indicator for military SA, and lack of data on ethnicity. Future research utilizing MHS data should examine mental health outcomes following the documentation of SA and disruptions in SA-related care due to SARS-CoV-2.

Mortality of Women Vietnam War-Era Veterans

PURPOSE

Our objectives were to 1) understand the scope of the current mortality literature on U.S. women Vietnam War-era veterans and 2) identify major themes and knowledge gaps that might guide future research.

METHODS

A systematic scoping review was conducted. Electronic bibliographic databases were searched for studies published on women Vietnam War-era veterans' mortality between 1973 and 2020. Inclusion and exclusion criteria were applied, study information was charted using pre-established design parameters, and studies deemed eligible were retained for a more in-depth review.

FINDINGS

One hundred nineteen studies were initially identified. Of these, six were ultimately retained for critical review. External cause, all-cause, cancer, and cardiovascular mortality were prominent outcomes across studies. Although both methodology and outcomes varied by study, unifying themes emerged. Prominent themes included a) historic barriers to accurately identifying and classifying this veteran cohort, b) historic barriers to comprehensive assessment of their health and mortality risk, and c) the healthy soldier effect and its limitations. Research gaps identified in this review reflect a need to pay more attention to sex differences in mortality risk and military occupational and sex-specific health risk confounders in mortality models.

CONCLUSIONS

The research literature examining mortality among women Vietnam War-era veterans is circumscribed in size and scope. Questions about the roles of salient military occupational exposures and health risk factors on mortality risks and trends in this cohort remain unaddressed. These questions should be areas of focus in next steps research.

The Effects of Adverse Childhood Experiences and Warfare Exposure on Military Sexual Trauma Among Veterans

Military sexual trauma (MST) is a pervasive problem; this study examined the relationship of the precursory traumas of adverse childhood experiences (ACEs) and warfare exposure with MST. Post-9/11 veterans were surveyed at 3 months and at 24 to 30 months post-military separation. Female veterans who experienced at least 1 ACE but no warfare exposure were significantly more likely to receive unwanted sexual attention. Veterans (males and females) experiencing three or more ACEs but no warfare exposure were significantly more likely to receive unwanted sexual attention and contact. Experiencing only warfare exposure was not related to unwanted sexual attention or contact for females; however, a significant interaction was found between combined warfare exposure, ACEs, and MST for males and females. Veterans who reported warfare exposure and one to two or three or more ACEs were more likely to report unwanted sexual attention and/or contact. Exploration of individual ACEs revealed a significant relationship between childhood sexual abuse and unwanted sexual contact. For females, witnessing domestic violence predicted unwanted sexual contact. There was also a significant interaction between childhood sexual abuse and warfare exposure. Females who experienced both childhood sexual abuse and warfare exposure were significantly more likely to receive unwanted sexual attention and unwanted sexual contact. Albeit a small sample, males who experienced both were also significantly more likely to receive unwanted sexual attention. The findings reveal that precursory traumatic experiences in childhood and the interaction of ACEs and warfare exposure during military service can increase the likelihood of unwanted sexual attention and contact. This research further substantiates the need for screening efforts. It also demonstrates the importance of practitioners engaging in trauma-informed care principles and practices to address the residual effects of previous experiences during sexual trauma or mental health treatment efforts.

Psychosocial Outcomes Among Veteran and Non-Veteran Survivors of Sexual Assault

Although it is well-established that sexual assault results in variable and long-lasting negative impacts on emotional well-being, perceptions of physical health, and relationship functioning, these "psychosocial" outcomes may vary based on the type(s) of sexual trauma experienced. To identify the differential impact of sexual trauma type(s) on psychosocial outcomes among veterans and non-veterans, we conducted a secondary analysis of data from the Comparative Health Assessment Interview Research Study, a large, national survey study sponsored by the Department of Veterans Affairs. Participants included veterans (n = 3588) and non-veterans (n = 935) who endorsed experiencing childhood sexual assault (CSA), adult sexual assault (ASA, outside of military service for veteran participants), and/or military sexual assault (MSA). Eight measures were used to assess psychosocial outcomes: Well-Being Inventory (WBI) health satisfaction and physical health functioning items, Posttraumatic Stress Disorder Checklist, Patient Health Questionnaire (depression symptoms), Generalized Anxiety Disorder Questionnaire, WBI social satisfaction items, WBI social functioning items, and the Multidimensional Scale of Perceived Social Support (social). A profile analysis was used to determine how sexual trauma type(s) influenced the pattern of responding to the eight psychosocial outcome measures. Veteran sexual assault survivors reported poorer psychological outcomes compared to non-veteran sexual assault survivors. Non-veteran sexual assault survivors reported poorer outcomes on the majority of social variables compared to veteran sexual assault survivors. Survivors of MSA-only reported poorer psychosocial outcomes compared to veteran and non-veteran survivors of CSA-only and ASA-only on most of the variables assessed. Survivors of ASA-only reported similar or modestly worse psychosocial outcomes when compared to survivors of CSA-only on the majority of variables assessed. Survivors of different types of sexual trauma reported distinct psychosocial outcomes, suggesting that assessment and treatment needs may differ by trauma type.

Examining the Use of Mobile Technology to Deliver Tailored Sexual Assault Prevention in a Classroom Environment in the Military: Development and Usability Study

BACKGROUND

Advances in mobile technology over the last 10 years have expanded its use in scientific research. However, there are challenges in creating a reliable system for intervention content delivery and data collection in an environment with limited internet connectivity and limited staffing capacity. The Sexual Communication and Consent (SCC) study used tablets to provide individualized Sexual Assault Prevention and Response training in a classroom environment that was both technologically and support staff limited.

OBJECTIVE

We developed the SCC Basic Military Training app and a separate Sexual Assault Response Coordinator app to support individualized training within the new SCC program. This paper presents the functionality, protocols, challenges, and feasibility of deploying mobile technology in an educational environment in the military with limited resources.

METHODS

We developed both mobile apps targeting the Apple iOS ecosystem. The Basic Military Training app provided a screening instrument that routed the trainee into 1 of 5 specific intervention programs. Over 2 days of basic military training set 2 weeks apart, trainees received a combined 6 hours of program-specific tablet training, combined with universal, interactive classroom training, led by qualified instructors. The Sexual Assault Response Coordinator app, used to deliver supplemental content to a subgroup of trainees, was made available for voluntary and private use at the Sexual Assault Response Coordinator's office on base. All anonymous data were manually transferred onto laptops, where the data were aggregated into files and securely transferred to the project staff for analysis. The study was conducted at the Lackland Air Force Base, Joint Base San Antonio, with 9196 trainees providing the data.

RESULTS

A total of 7742 trainees completed both the sessions of the SCC program and a series of evaluative assessments. Some trainees did not receive day 2 training, and only received day 1 training because the COVID-19 pandemic shortened the study period. Of the 190 SCC classes taught, only one class was unable to complete tablet training because of Apple licensing-related technology failure. The 360 study tablets were distributed across 3 classrooms (120 per classroom) and were handled at least 16,938 times with no reports of breakage or requiring replacement. Wi-Fi access limitations exacerbated the complexity of Apple licensing revalidation and the secure transfer of data from the classroom to project personnel. The instructor staff's limited technical knowledge to perform certain technical tasks was challenging.

CONCLUSIONS

The results demonstrated the feasibility of deploying a mobile app for tablet-based training in a military educational environment. Although successful, the study was not without technical challenges. This paper gives examples of technical lessons learned and recommendations for conducting the study differently, with the aim that the knowledge gained may be helpful to other researchers encountering similar requirements.

State of the Knowledge of VA Military Sexual Trauma Research

Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department's efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power (e.g., lower rank) are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings (e.g., interpersonal betrayal, victim-blaming) as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal (e.g., fear of reprisal or ostracism, having to work/live alongside a perpetrator). MST's most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective.

Intimate Partner Violence (IPV) in Military and Veteran Populations: A Systematic Review of Population-Based Surveys and Population Screening Studies

Intimate partner violence (IPV) may be a major concern in military and veteran populations, and the aims of this systematic review were to (1) provide best available estimates of overall prevalence based on studies that are most representative of relevant populations, and (2) contextualise these via examination of IPV types, impacts, and context. An electronic search of PsycINFO, CINHAL, PubMed, and the Cochrane Library databases identified studies utilising population-based designs or population screening strategies to estimate prevalence of IPV perpetration or victimisation reported by active duty (AD) military personnel or veterans. Random effects meta-analyses were used for quantitative analyses and were supplemented by narrative syntheses of heterogeneous data. Thirty-one studies involving 172,790 participants were included in meta-analyses. These indicated around 13% of all AD personnel and veterans reported any recent IPV perpetration, and around 21% reported any recent victimisation. There were higher rates of IPV perpetration in studies of veterans and health service settings, but no discernible differences were found according to gender, era of service, or country of origin. Psychological IPV was the most common form identified, while there were few studies of IPV impacts, or coercive and controlling behaviours. The findings demonstrate that IPV perpetration and victimisation occur commonly among AD personnel and veterans and highlight a strong need for responses across military and veteran-specific settings. However, there are gaps in understanding of impacts and context for IPV, including coercive and controlling behaviours, which are priority considerations for future research and policy.

Posttraumatic Stress Symptom Severity Mediates the Relationship Between Military Sexual Trauma and Tension Reduction Behaviors in Male and Female Veterans

Numerous studies attest to the prevalence and complex negative consequences associated with military sexual trauma (MST). However, relatively less is known about male survivors and about the interaction of psychological problems such as posttraumatic stress disorder (PTSD) symptoms and emotion management difficulties following MST. The current study examined the path of psychological distress following MST in both male and female veterans. We predicted that (a) history of MST would predict more severe PTSD symptoms, which in turn would predict greater use of dysfunctional emotion management strategies (specifically, tension reduction behaviors) and that (b) PTSD symptoms would mediate the relationship between history of MST and tension reduction behaviors. Finally, we explored whether the indirect (i.e., mediating) effect was moderated by gender. Data were obtained from pretreatment paper and pencil assessments administered as part of standard clinical care from 338 veterans seeking treatment at a Veterans Affairs (VA) mental health specialty clinic. Veterans who endorsed MST experienced more severe PTSD symptoms and greater reported use of tension reduction behaviors. Bootstrapping testing the indirect effect revealed that PTSD symptoms mediated the relationship between history of MST and tension reduction behaviors. An exploratory moderated mediation analysis found that the indirect effect did not differ as a function of gender. PTSD symptoms appear to mediate the relationship between MST and tension reduction behaviors in veterans, regardless of gender. While previous research has suggested that civilian men report a greater number of tension reduction behaviors following a sexual assault compared to civilian women, we did not find the same gender differences among veterans. These results may provide support for using trauma-focused treatment even when MST survivors are reporting high-risk tension reduction behaviors.

Servicemen's Perceptions of Male Sexual Assault and Barriers to Reporting During Active Component and Reserve/National Guard Military Service

Despite growing recognition of the high rates of sexual violence experienced by men serving in the U.S. military, male victimization, specifically sexual assault in military (SAIM), is an understudied topic. We qualitatively describe servicemen's awareness and perceptions of male SAIM, and their understanding of common barriers to servicemen reporting sexual assault. Participants included Midwestern Active Component and Reserve and National Guard servicemen, actively serving or Veteran, who had returned from Iraq or Afghanistan deployments during Operation Enduring/Iraqi Freedom eras. Eleven focus groups were held with 34 servicemen (20 Reserve/National Guard and 14 Active Component). Qualitative analyses used inductive and deductive techniques. Servicemen reported a lack of awareness of male SAIM, a tendency to blame or marginalize male victims, and substantial barriers to reporting sexual assault. Reserve/National Guard participants emphasized barriers such as a perception of greater stigma due to their unique status as citizen-soldiers, an ethos of unit conformity and leadership modeling, and a lack of confidence in leadership and the SAIM reporting process. In contrast, Active Component servicemen emphasized the deployment location and sex of victim and perpetrator as key reporting barriers. Findings make an important contribution to the scant literature on risk and protective factors for male SAIM and servicemen's perceptions of sexual violence and assault reporting barriers by their service type and location. This work has implications for routine screening for sexual violence experiences of male service members and Veterans. Providers' knowledge of gender stereotypes regarding sexual assault, assault risks and experiences of deployed servicemen, and potential barriers to SAIM disclosure is vital for patient-centered care delivery. Additional research to address factors that influence post-SAIM care engagement of males is indicated.

"A Woman in A Man's World": A Pilot Qualitative Study of Challenges Faced by Women Veterans During and After Deployment

Women Veterans face gender-specific challenges to military life and post-deployment readjustment, including gender-based discrimination and military sexual trauma. Despite recent military initiatives to address these issues, women still experience unique challenges during military service. This study examines spontaneous comments about gender-specific challenges to military life that were made by participants in a qualitative study of women's transitions to civilian life after deployment to Iraq or Afghanistan.

METHODS

Women Veterans who were enrolled at a New England VA hospital and who had deployed to the U.S. conflicts in Iraq and Afghanistan participated in this qualitative study (N = 22). Interview queries and initial coding structure were developed through an extensive literature review. An iterative coding process generated additional themes identified in the data. For this project, codes regarding self-initiated reports of gender-specific challenges that fell outside the scope of the study's initial interview agenda were reviewed for thematic analysis.

RESULTS

The following three self-initiated themes emerged among 12 respondents: 1) gender-based scrutiny and discrimination; 2) the military's inadequate position and response to military sexual trauma; and 3) disadvantages to women service members living in a male-dominated environment. Across all three themes emerged a sub-theme in which women perceived their unique needs to be inconvenient and/or disregarded. Respondents described how these challenges disrupted their lives during and after military service.

CONCLUSION

Results imply gender-specific challenges and military sexual trauma remain critical concerns for women Veterans well after deployment had ended, and that improved policy may have long-term health implications.

A Resource Building Virtual Care Programme: improving symptoms and social functioning among female and male rural veterans

Background: Veterans have higher rates of PTSD and depression compared to the general population and experience substantial functional impairment. Impairment in social functioning has been a significant concern among Veterans, particularly rural Veterans, who have limited access to mental health care and are at risk for social isolation. Objective: A mixed-method study was implemented to evaluate the feasibility and effectiveness of webSTAIR, a web-based skills training programme, paired with home-based telehealth sessions. It was hypothesized that the programme would lead not only to reductions in PTSD and depression but also to improvements in social functioning. Method: Participants were 80 trauma-exposed Veterans enrolled in rural-serving VHA facilities with clinically elevated symptoms of either PTSD or depression. The study directed substantial outreach efforts to rural women Veterans and those who have experienced military sexual trauma (MST). Results: Significant improvements were obtained with PTSD and depression symptoms as well as in social functioning, emotion regulation, and interpersonal problems at post-treatment and 3-month follow-up. Ratings of therapeutic alliance were high as were reports of overall satisfaction in the programme. There were no differences by gender or MST status in symptom outcomes or satisfaction. Conclusions: The results support the feasibility and effectiveness of this integrated telehealth web-based skills training programme for both male and female Veterans as well as for those with and without MST. The focus on resource building and improved functioning make this programme of particular interest. Further testing is warranted.

Structuring the Invisible War: Base and Community Influences on Military Sexual Assault Occurrence

INTRODUCTION

This study examined the relationship between military sexual assault and structural factors including base (e.g., base density) and community (e.g., economic deprivation) characteristics.

METHODS

Data on military sexual assault against men and women for fiscal years 2013-2016 were drawn from Sexual Assault Prevention and Response Office's 2017 report, "Sexual Assault Received at Military Installations and Combat Areas of Interest." Base information was pulled from fiscal years 2012 and 2013 Department of Defense's Base Structure Reports. Community-level information was drawn from 5-year American Community Survey estimates (2008-2012). Analyses were conducted in 2019. Negative binomial models were used to examine predictors of military sexual assault.

RESULTS

Compared with civilian personnel, higher concentrations of military personnel on bases increased military sexual assault (incident rate ratio=1.01, p=0.025). Compared with Air Force-controlled installations, Navy and Marine bases were associated with higher military sexual assault prevalence (incident rate ratio=2.22, p<0.001; incident rate ratio=2.38, p<0.001, respectively). Community economic disadvantage was inversely related to military sexual assault (incident rate ratio=0.69, p=0.001), whereas residential mobility (incident rate ratio=1.07, p=0.002), percentage of racial/ethnic minorities (incident rate ratio=1.02, p=0.024 black; incident rate ratio=1.03, p<0.001 Hispanic), and percentage of residents who are veterans (incident rate ratio=1.13, p<0.001) were positively related to military sexual assault.

CONCLUSIONS

Military sexual assault prevalence is associated with the structural characteristics of military installations and characteristics of the communities in which these installations are located. Findings suggest that further research on structural predictors of military sexual assault is needed and prevention programs and services may benefit from more community engagement.

Prevalence of Self-Reported Intimate Partner Violence Victimization Among Military Personnel: A Systematic Review and Meta-Analysis

BACKGROUND

Research on intimate partner violence (IPV) in the military has tended to focus on military personnel as perpetrators and civilian partners/spouses as victims. However, studies have found high levels of IPV victimization among military personnel. This article systematically reviews studies of the prevalence of self-reported IPV victimization among military populations.

METHODS

Searches of four electronic databases (Embase, Medline, PsycINFO, and Web of Science) were supplemented by reference list screening. Meta-analyses of the available data were performed, where possible, using the random effects model.

RESULTS

This review included 28 studies with a combined sample of 69,808 military participants. Overall, similar or higher prevalence rates of physical IPV victimization were found among males compared to females and this was supported by a meta-analytic subgroup analysis: pooled prevalence of 21% (95% confidence interval [CI] = [17.4, 24.6]) among males and 13.6% among females (95% CI [9.5, 17.7]). Psychological IPV was the most prevalent type of abuse, in keeping with findings from the general population. There were no studies on sexual IPV victimization among male personnel. Evidence for the impact of military factors, such as deployment or rank, on IPV victimization was conflicting.

DISCUSSION

Prevalence rates varied widely, influenced by methodological variation among studies. The review highlighted the lack of research into male IPV victimization in the military and the relative absence of research into impact of IPV. It is recommended that future research disaggregates results by gender and considers the impact of IPV, in order that gender differences can be uncovered.

Experiences of Sexual Harassment, Stalking, and Sexual Assault During Military Service Among LGBT and Non-LGBT Service Members

Sexual victimization, including sexual harassment and assault, remains a persistent problem in the U.S. military. Service members identifying as lesbian, gay, bisexual, or transgender (LGBT) may face enhanced risk, but existing research is limited. We examined experiences of sexual harassment, stalking, and sexual assault victimization during service in a sample of LGBT and non-LGBT active duty service members. Service members who identified as LGBT (n = 227 LGB, n = 56 transgender) or non-LGBT (n = 276) were recruited using respondent-driven sampling for an online survey. Logistic regression models examined the correlates of sexual and stalking victimization. Victimization was common among LGBT service members, including sexual harassment (80.7% LGB, 83.9% transgender), stalking (38.6% LGB, 30.4% transgender), and sexual assault (25.7% LGB, 30.4% transgender). In multivariable models, LGB identity remained a significant predictor of sexual harassment, OR = 4.14, 95% CI [2.21, 7.78]; stalking, OR = 1.98, 95% CI [1.27, 3.11]; and assault, OR = 2.07, 95% CI [1.25, 3.41]. A significant interaction between LGB identity and sex at birth, OR = 0.34, 95% CI [0.13, 0.88], suggests an elevated sexual harassment risk among male, but not female, LGB service members. Transgender identity predicted sexual harassment and assault at the bivariate level only. These findings suggest that LGBT service members remain at an elevated risk of sexual and/or stalking victimization. As the military works toward more integration and acceptance of LGBT service members, insight into victimization experiences can inform tailored research and intervention approaches aimed at prevention and care for victims.

Experiences of Perceived Gender-based Discrimination Among Women Veterans: Data From the ECUUN Study

BACKGROUND

Experiences of discrimination are associated with poor health behaviors and outcomes. Understanding discrimination in health care informs interventions to improve health care experiences.

OBJECTIVE

Describe the prevalence of, and variables associated with, perceived gender-based discrimination in the Veterans Affairs (VA) Healthcare System among women Veterans.

DESIGN

A cross-sectional, telephone-based survey of a random national sample of young female Veterans.

PARTICIPANTS

Female VA primary care patients aged 18-45 years.

MAIN MEASURES

The primary outcome was perceived gender-based discrimination in VA health care. Logistic and linear regression models were used to determine associations between any perceived discrimination and cumulative perceived discrimination with patient and health service characteristics.

KEY RESULTS

Among 2294 women Veterans, 33.7% perceived gender-based discrimination in VA. Perceiving gender-based discrimination was associated with medical illness [adjusted odds ratio (aOR)=1.67, 95% confidence interval (CI)=1.34, 2.08], mental illness (aOR=2.06, 95% CI=1.57, 2.69), and military sexual trauma (aOR=2.65, 95% CI=2.11, 3.32). Receiving most health care from the same VA provider (aOR=0.73, 95% CI=0.57, 0.94) and receiving care at a VA site with a women's health clinic (aOR=0.76, 95% CI=0.61, 0.95) were associated with reduced odds of any perceived gender-based discrimination. Among those who perceived gender-based discrimination (n=733), perceived discrimination scores were higher among women with increased age, medical illness, or history of military sexual trauma and lower among those who saw the same VA provider for most medical care.

CONCLUSIONS

One third of women Veterans perceived gender-based discrimination in VA. Obtaining most medical care from the same VA provider and having a women's health clinic at one's VA were associated with less perceived discrimination.

Service-Women's Responses to Sexual Harassment: The Importance of Identity Work and Masculinity in a Gendered Organization

Using data from in-depth interviews with 38 U.S. service-women, this article explores women's responses to sexual harassment in the military workplace. I argue that in an extremely gendered and masculine institution, sexual harassment threatens service-women's identities as military insiders, presenting an identity dilemma for them. To resolve this dilemma, women prioritize their masculinity and downplay and excuse harassment. In contrast, service-women who have experienced sexual assault or combat confront sexual harassment. I argue that this is possible because for these two groups of women, sexual harassment does not present an identity dilemma. I show how masculinity is used to downplay and normalize harassment as well as to resist it.

Identifying factors associated with suicidal ideation and suicide attempts following military sexual trauma

BACKGROUND

As increasing research demonstrates that military sexual trauma (MST) is associated with suicidal ideation and attempts, discerning factors that place MST survivors at risk for these outcomes is critical. The present study aimed to: (1) characterize suicidal ideation and attempts among MST survivors; (2) identify factors associated with post-MST suicide attempts, post-MST suicidal ideation, and past-week suicidal ideation.

METHODS

A convenience sample of 108 veterans (66 women, 42 men) who reported a history of MST participated in this cross-sectional study. Pre-MST suicidal ideation and attempt, childhood physical and sexual abuse, military sexual assault, institutional betrayal, and posttraumatic cognitions about self, world, and self-blame were examined, with age and gender as covariates.

RESULTS

Seventy-five percent of participants reported experiencing post-MST suicidal ideation, and 40.7% reported attempting suicide following MST. Pre-MST suicide attempt and posttraumatic cognitions about self were associated with post-MST suicide attempt. Pre-MST suicidal ideation, military sexual assault, childhood physical abuse, and posttraumatic cognitions about self were associated with post-MST suicidal ideation. Lastly, pre-MST suicidal ideation and posttraumatic cognitions about self were associated with past-week suicidal ideation; results were unchanged when accounting for recent PTSD or depressive symptoms.

LIMITATIONS

The cross-sectional design, retrospective self-report, and small sample are limitations.

CONCLUSIONS

Addressing negative posttraumatic beliefs about self may be important for managing suicide risk among MST survivors. Assessing for pre-MST suicidal ideation and attempt is likely also warranted. Further understanding of the longitudinal impact of posttraumatic beliefs about self on subsequent risk for suicidal ideation and attempt is warranted.

Seeking help for the health sequelae of military sexual trauma: a theory-driven model of the role of institutional betrayal

Although rates vary, approximately 38.4% of women and 3.9% of men report experiencing military sexual trauma (MST). MST is associated with numerous psychosocial consequences, increased propensity for physical and mental health diagnoses, suicide, and an elevated likelihood of revictimization. Consequently, medical and mental health care for MST-related health sequelae is often warranted for individuals who have experienced MST; however, many MST survivors forgo or delay MST-related care, despite the fact that the Veterans Health Administration (VHA) provides free healthcare for MST-related health conditions. One potential explanation for this phenomenon is that survivors of MST feel betrayed by the military institution that they served when the MST occurred due to the institutional response to MST or perceptions that the institution failed to prevent MST from occurring. Perceptions of institutional betrayal may, in turn, decrease survivors' likelihood of disclosing MST and utilizing necessary treatment through VHA or affiliated institutions. A theoretical model of the role of institutional betrayal on help-seeking is proposed in which institutional betrayal serves as a potential barrier to utilizing MST-related healthcare. Potential mediators of this association (e.g., distrust, beliefs about safety) are also posited. This model offers utility in conceptualizing institutional factors that may influence helping-seeking following MST. By testing and refining such models, institutions and providers may be better-equipped to support MST survivors in obtaining necessary healthcare.

Sexual Assault and Disabling PTSD in Active Duty Service Women

INTRODUCTION

Sexual assault in the military is a major concern and may result in significant health problems, such as post-traumatic stress disorder (PTSD). Those developing disabling PTSD symptoms may require a disability evaluation. We examined disability evaluation trends for service women with PTSD to better understand characteristics associated with inability to continue Active Duty service.

METHODS

This is a retrospective review of disability reports and electronic medical records for 322 Active Duty women diagnosed with and treated for PTSD by psychiatrists and psychologists at a large military treatment facility between 2011 and 2014. Service women requiring medical disability evaluation for PTSD (n = 159) were included in the study as "IDES cases" (Integrated Disability Evaluation System - IDES). A similar number of women, randomly selected from those seeking care for PTSD but not requiring disability evaluation during the same period, were included in the "control" group (n = 163). Analyzes done to evaluate differences between groups (IDES cases vs. controls) included demographic and service-related characteristics, history of chronic pain, and PTSD index trauma types, such as pre-military trauma and military sexual trauma (MST). Logistic regression was performed to identify the factors associated with inclusion in IDES.

RESULTS

MST was the most frequent PTSD index trauma in the IDES group (73.6% vs. 44.8% of control group) and the most significant factor associated with IDES inclusion (OR 2.6, p = 0.032). Those in the IDES group had significantly greater number of mental health visits for PTSD (IDES: m = 68.6 vs. controls: m = 29.6) and more frequent chronic pain history (IDES 40.9% vs. controls 19.6%) than those in the control group. Approximately 65% of women in both groups had a history of childhood abuse, but childhood abuse, as a PTSD index trauma, was negatively associated with IDES inclusion (OR 0.293, p = 0.006).

CONCLUSIONS

Active Duty service women with PTSD and a MST index trauma are much more likely to require disability evaluation (IDES) than those with PTSD due to other trauma types. IDES evaluation for conditions such as PTSD may result in early termination of military service and is a potential downstream consequence of MST. Service women requiring greater numbers of mental health visits for PTSD treatment may benefit from a multidisciplinary approach to treating concurrent health conditions, such as chronic pain. Those providing care for service women should evaluate for MST, chronic pain and pre-military trauma, such as childhood abuse; and aggressively treat these conditions to prevent PTSD and disability.

Military Sexual Assault in Transgender Veterans: Results From a Nationwide Survey

There is limited understanding about the frequency of military sexual assault (MSA) in transgender veterans, characteristics associated with MSA, or subsequent mental and behavioral health problems. To address this gap, we used an online national survey of 221 transgender veterans to identify prevalence of MSA and to assess its association with demographic characteristics, past history of sexual victimization, and stigma-related factors. We also evaluated the association between MSA and several mental and behavioral health problems. Overall, 17.2% of transgender veterans experienced MSA, but rates differed significantly between transgender women (15.2%) and transgender men (30.0%). Using adjusted regression models, MSA was associated with adult sexual assault prior to military service, odds ratio (OR) = 4.05, 95% CI [1.62, 10.08], and distal minority stress during military service, OR = 2.98, 95% CI [1.28, 6.91]. With respect to health outcomes, MSA was associated with past-month posttraumatic stress disorder (PTSD) symptom severity, B = 10.18, 95% CI [3.45, 16.91]; current depression symptom severity, B = 3.71, 95% CI [1.11, 6.30]; and past-year drug use, OR = 3.17, 95% CI [1.36, 7.40]. Results highlight the vulnerability of transgender veterans to MSA, and the need for military prevention programs that acknowledge transgender individuals' heightened risk. Furthermore, clinicians should consider clinical screening for PTSD, depression, and drug use in transgender veterans who have a history of MSA.

Evaluations of Sexual Assault Prevention Programs in Military Settings: A Synthesis of the Research Literature

The prevention of sexual assault (SA) in the U.S. military is a significant priority. This study applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to a literature search that identified research evaluating SA prevention programs conducted within military settings. Only six studies published between 2005 and 2016 met criteria for inclusion in the review. Studies demonstrated high heterogeneity in the: (1) conceptual framework of the prevention approach; (2) target population and timing of administration; (3) study recruitment methods; (4) methodological design; (5) method of delivery, program dosage and theory of change; and (6) outcome administration and efficacy. Scientific rigor according to the Oxford Center for Evidence-based Medicine was also variable. Several gaps in the research base were identified. Specifically, research evaluating SA prevention programs have only been conducted among U.S. Army and U.S. Navy samples. Most studies did not examine whether program participation was associated with reductions in rates of sexual violence. Studies also lacked utilization of a long-term follow-up period. Additionally, studies did not reflect the types of SA prevention programs currently being implemented in military settings. Taken together, further research is needed to enhance the evidence base for SA prevention in the military, and to evaluate the effectiveness of the approaches currently being conducted with service members.

Women Veterans' Experiences of Intimate Partner Violence and Non-Partner Sexual Assault in the Context of Military Service: Implications for Supporting Women's Health and Well-Being

Women who have served in the military in the United States experience high rates of intimate partner violence (IPV) and non-partner sexual assault (SA). The military setting presents challenges and opportunities not experienced in other employment contexts that may compound the negative impacts of IPV/SA on women's lives. The purpose of this study was to explore the intersection of women's experiences of IPV/SA and military service through analysis of women veterans' narrative accounts. We conducted in-depth face-to-face qualitative interviews with 25 women veterans receiving primary care at a U.S. Veterans Affairs Medical Center. We draw upon Adler and Castro's (2013) Military Occupational Mental Health Model to frame our understanding of the impact of IPV/SA as a stressor in the military cultural context and to inform efforts to prevent, and support women service members who have experienced, these forms of violence. Our findings highlight the impact of IPV/SA on women's military careers, including options for entering and leaving military service, job performance, and opportunities for advancement. Women's narratives also reveal ways in which the military context constrains their options for responding to and coping with experiences of IPV/SA. These findings have implications for prevention of, and response to, intimate partner or sexual violence experienced by women serving in the military and underscore the need for both military and civilian communities to recognize and address the negative impact of such violence on women service members before, during, and after military service.

Deployment-Related Military Sexual Trauma Predicts Heavy Drinking and Alcohol Problems Among Male Reserve and National Guard Soldiers

BACKGROUND

Military sexual trauma (MST) is associated with a range of deleterious mental and physical health consequences; however, far less attention has been paid to the associations between MST and negative health behaviors, such as substance abuse. This study examined 2 focal research questions: (i) What is the prevalence of experiencing MST during deployment among male Reserve and National Guard soldiers? and (ii) to what extent is the degree of MST exposure during deployment associated with frequent heavy drinking and alcohol problems postdeployment?

METHODS

Data from male soldiers who had been deployed (N = 248) were drawn from the baseline wave of Operation: SAFETY (Soldiers And Families Excelling Through the Years) an ongoing study examining health among U.S. Army Reserve and National Guard and their partners. Participants were recruited over a 15-month period (Summer 2014 to Fall 2015) from units in New York State. Deployments occurred prior to the baseline wave of the study. Analyses examined the relation between degree of MST exposure during soldiers' most recent deployment and (i) frequent heavy drinking and (ii) alcohol problems, measured at baseline, controlling for posttraumatic stress disorder symptoms and age.

RESULTS

17.3% of the male service members reported experiencing MST during their most recent deployment. Further, greater MST exposure was associated with a greater likelihood of engaging in frequent heavy drinking (adjusted risk ratio [aRR] = 1.03, 95% CI [1.01, 1.05]) and experiencing alcohol problems (aRR = 1.03, 95% CI [1.01, 1.06]) at baseline.

CONCLUSIONS

Findings demonstrate that MST rates are high among male Reserve and National Guard soldiers, and greater MST exposure is associated with an increased likelihood of engaging in frequent heavy drinking and experiencing alcohol problems among a population already at risk for problematic alcohol use.

Sexual assault in the US military: A comparison of risk in deployed and non-deployed locations among Operation Enduring Freedom/Operation Iraqi Freedom active component and Reserve/National Guard servicewomen

BACKGROUND

To determine whether sexual assault in the military (SAIM) among active component and Reserve/National Guard servicewomen is more likely to occur in deployed or non-deployed locations; and which location poses greater risk for SAIM when time spent in-location is considered.

METHODS

A total of 1337 Operation Enduring Freedom/Operation Iraqi Freedom era servicewomen completed telephone interviews eliciting socio-demographics, military and sexual assault histories, including attempted and completed sexual assault.

RESULTS

Half of the sample had been deployed (58%). Overall 16% (N = 245) experienced SAIM; a higher proportion while not deployed (15%; n = 208) than while deployed (4%; n = 52). However, the incidence of SAIM per 100 person-years was higher in deployed than in non-deployed locations: 3.5 vs 2.4. Active component and Reserve/National Guard had similar deployment lengths, but Reserve/National Guard had higher SAIM incidence rates/100 person-years (2.8 vs 4.0).

CONCLUSIONS

A higher proportion of servicewomen experienced SAIM while not deployed; however, adjusting for time in each location, servicewomen were at greater risk during deployment.

Characteristics and Health Care Preferences Associated with Cardiovascular Disease Risk among Women Veterans

BACKGROUND

Women veterans are at increased risk for cardiovascular disease (CVD), but little is known about comorbidities and healthcare preferences associated with CVD risk in this population.

METHODS

We describe the prevalence of CVD-relevant health behaviors, mental health symptoms, and health care use characteristics and preferences among participants of the National Survey of Women Veterans (conducted 2008-2009).

FINDINGS

Fifty-four percent of respondents were at risk for CVD (defined as a diagnosis of hypertension, diabetes, current tobacco use, or obesity without CVD). In unadjusted analysis, ORs for being at risk for CVD were greater among those interested in gender-specific clinical settings (OR, 2.0; 95% CI, 1.2-3.4) and gender-specific weight loss programs (OR, 1.8; 95% CI, 1.1-2.9). ORs were also greater for women who were physically inactive (OR, 1.9; 95% CI, 1.1-3.3), with current symptoms of depression (OR, 2.5; 95% CI, 1.1-6.1), anxiety (OR, 2.1; 95% CI, 1.2-3.6), and posttraumatic stress disorder (OR, 2.4; 95% CI, 1.2-4.8). Adjusting for age, race/ethnicity, marital status, education level, employment, and source of health care use, the ORs for CVD risk were higher for women with current posttraumatic stress disorder symptoms (2.5; 95% CI, 1.1-5.3) and gender-specific health care preferences (2.0; 95% CI, 1.1-3.4), and gender-specific weight loss programs (1.9; 95% CI, 1.1-3.2).

CONCLUSIONS

Risk for CVD was common and preferences for gender-specific care and posttraumatic stress disorder were associated with being at risk for CVD. Women's health clinics may be a good location for targeted CVD prevention interventions for women veterans both in and outside the Veterans Health Administration.

Military-related sexual assault in Canada: a cross-sectional survey

BACKGROUND

Most research on military-related sexual assault is based on the United States military and has important limitations, such as low response rates. We sought to estimate the lifetime prevalence of sexual assault, assess its relation to military service and identify the circumstances, correlates and associations with mental disorders of military-related sexual assault among Canadian military personnel.

METHODS

We used the 2013 Canadian Forces Mental Health Survey, a cross-sectional representative survey of Canadian Regular Force personnel (n = 6696). The sample was weighted to be representative of the entire Canadian Armed Forces Regular Force population in 2012 (n = 67 776), as per Statistics Canada requirements. We assessed lifetime trauma exposure and past-year mental disorders using the Composite International Diagnostic Interview. We defined lifetime military-related sexual assault as forced sexual activity or unwanted sexual touching that occurred on deployment or in another military workplace, or was perpetrated by Department of National Defence or Canadian Armed Forces personnel. We defined all other sexual assault as non-military-related sexual assault.

RESULTS

Self-reported sexual assault was more prevalent among women (non-military-related sexual assault 24.2%, military-related sexual assault 15.5%) than men (5.9% and 0.8%, respectively). About a quarter of women with military-related sexual assault reported experiencing at least 1 event on deployment. After covariates were controlled for, military-related sexual assault was independently associated with any lifetime and any past-year mental disorder (adjusted odds ratio 2.9 and 3.0, respectively) and lifetime and past-year posttraumatic stress disorder (adjusted odds ratio 4.3 and 4.1, respectively).

INTERPRETATION

Canadian military women are at increased risk for sexual assault and military-related sexual assault relative to their male counterparts. Deployment may be a period of elevated risk for military-related sexual assault, and women who reported military-related sexual assault are more likely to have experienced mental disorders, especially posttraumatic stress disorder.

Sexual Assault Victimization and Mental Health Treatment, Suicide Attempts, and Career Outcomes Among Women in the US Army

OBJECTIVES

To examine associations of administratively recorded sexual assault victimization during military service with subsequent mental health and negative career outcomes among US Army women controlling for nonrandom victimization exposure.

METHODS

We used data from the Army Study to Assess Risk and Resilience in Servicemembers to apply propensity score methods to match all 4238 female Regular Army soldiers with administratively recorded sexual assault victimization during 2004 to 2009 to 5 controls per case with similar composite victimization risk. We examined associations of this victimization measure with administratively recorded mental health treatment, suicide attempt, and Army career outcomes over the subsequent 12 months by using survival analysis for dichotomous outcomes and conditional generalized linear models for continuous outcomes.

RESULTS

Women with administratively recorded sexual assault had significantly elevated odds ratios (ORs) of subsequent mental health treatment (any, OR = 2.5; 95% confidence interval [CI] = 2.4, 2.6; specialty, OR = 3.1; 95% CI = 2.9, 3.3; inpatient, OR = 2.8; 95% CI = 2.5, 3.1), posttraumatic stress disorder treatment (any, OR = 6.3; 95% CI = 5.7, 6.9; specialty, OR = 7.7; 95% CI = 6.8, 8.6; inpatient, OR = 6.8; 95% CI = 5.4, 8.6), suicide attempt (OR = 3.0; 95% CI = 2.5, 3.6), demotion (OR = 2.1; 95% CI = 1.9, 2.3), and attrition (OR = 1.2; 95% CI = 1.1, 1.2).

CONCLUSIONS

Sexual assault victimization is associated with considerable suffering and likely decreased force readiness.

Lifetime Sexual Assault and Sexually Transmitted Infections Among Women Veterans

OBJECTIVE

Women veterans report a high prevalence of sexual assault. Unfortunately, there are limited data on the reproductive health sequelae faced by these women. Our objective was to evaluate the association between completed lifetime sexual assault (LSA) and sexually transmitted infections (STIs) among a cohort of women veterans, adjusting for sexual risk behaviors.

MATERIALS AND METHODS

We conducted a retrospective study among women veterans aged 51 years or younger who enrolled for care at two Veterans Administration (VA) healthcare sites between 2000 and 2008. Participants completed a telephone interview assessing reproductive health and sexual violence history. We compared the frequencies of past STI diagnoses among those who had and had not experienced LSA. We used logistic regression to assess the effect of sexual assault with history of an STI diagnosis after adjusting for age, sexual risk behaviors, and substance abuse treatment.

RESULTS

Among 996 women veterans, a history of STIs was reported by 32%, including a lifetime history of gonorrhea (5%), chlamydia (15%), genital herpes infection (8%), and human papillomavirus infection (15%), not mutually exclusive; 51% reported LSA. Women with a history of LSA were significantly more likely to report a history of STIs (unadjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.45-2.50; adjusted OR 1.49, 95% CI 1.07-2.08).

CONCLUSIONS

Women veterans who have experienced LSA are at increased risk for lifetime STI diagnoses. To adequately address the reproductive health needs of the growing population of women veterans, STI risk assessments should include queries of military service and LSA histories.

(Missing) Knowledge About Sexual Assault Resources: Undermining Military Mental Health

In 2005, the Department of Defense reformed military sexual assault (MSA) prevention and response efforts. However, research suggests that some Service members may not be informed of MSA resources. We examined how lacking such knowledge may undermine psychological well-being (i.e., symptoms of depression and posttraumatic stress) among MSA survivors as well as Service members who feel unsafe from MSA. The data were collected by the DoD in 2010 and sampled active duty Service women and men. Experiencing MSA, feeling unsafe from MSA, and lacking knowledge of MSA resources predicted greater psychiatric symptoms. Service members who felt unsafe from MSA reported greater psychiatric symptoms as a function of lacking knowledge of MSA resources. Findings suggest that education about sexual assault resources may be critical for the protection of mental health-among survivors and nonvictims alike.

The Relationship Between US Military Officer Leadership Behaviors and Risk of Sexual Assault of Reserve, National Guard, and Active Component Servicewomen in Nondeployed Locations

OBJECTIVES

To determine if military leader behaviors are associated with active component and Reserve-National Guard servicewomen's risk of sexual assault in the military (SAIM) for nondeployed locations.

METHODS

A community sample of 1337 Operation Enduring Freedom and Operation Iraqi Freedom-era Army and Air Force servicewomen completed telephone interviews (March 2010-December 2011) querying sociodemographic and military characteristics, sexual assault histories, and leader behaviors. We created 2 factor scores (commissioned and noncommissioned) to summarize behaviors by officer rank.

RESULTS

A total of 177 servicewomen (13%) experienced SAIM in nondeployed locations. Negative leader behaviors were associated with increased assault risk, at least doubling servicewomen's odds of SAIM (e.g., noncommissioned officers allowed others in unit to make sexually demeaning comments; odds ratio = 2.7; 95% confidence interval = 1.8, 4.1). Leader behavior frequencies were similar, regardless of service type. Negative leadership behavior risk factors remained significantly associated with SAIM risk even after adjustment for competing risk. Noncommissioned and commissioned officer factor scores were highly correlated (r = 0.849).

CONCLUSIONS

The association between leader behaviors and SAIM indicates that US military leaders have a critical role in influencing servicewomen's risk of and safety from SAIM.

See Something, Do Something: Predicting Sexual Assault Bystander Intentions in the U.S. Military

Sexual assault is a pervasive problem in the U.S. military, especially against women. Bystander intervention is increasingly promoted as important for reducing sexual violence, and it may be particularly helpful in contexts with high rates of sexual violence. Bystander training encourages and enables people to intervene safely and stop sexual violence. In this study, we drew from an ecological model to investigate intrapersonal, microsystem, and exosystem factors that predicted Service members' assumption of personal responsibility to intervene in an alcohol-involved sexual assault. Moreover, we examined how these predictors played a role in decisions about how to intervene: confronting the perpetrator, assisting the victim, or finding someone to help. We analyzed data from 24,610 active duty personnel collected by the Department of Defense. Several factors significantly related to Service members' bystander intentions: gender, rank, morale, attitudes about sexual assault, training, and trust in the military sexual assault system predicted the likelihood and method of bystander intervention. These findings help identify how and why people intervene (or fail to intervene) when they witness situations that could develop into sexual violence.

Developing a Risk Model to Target High-risk Preventive Interventions for Sexual Assault Victimization among Female U.S. Army Soldiers

Sexual violence victimization is a significant problem among female U.S. military personnel. Preventive interventions for high-risk individuals might reduce prevalence, but would require accurate targeting. We attempted to develop a targeting model for female Regular U.S. Army soldiers based on theoretically-guided predictors abstracted from administrative data records. As administrative reports of sexual assault victimization are known to be incomplete, parallel machine learning models were developed to predict administratively-recorded (in the population) and self-reported (in a representative survey) victimization. Capture-recapture methods were used to combine predictions across models. Key predictors included low status, crime involvement, and treated mental disorders. Area under the Receiver Operating Characteristic curve was .83-.88. 33.7-63.2% of victimizations occurred among soldiers in the highest-risk ventile (5%). This high concentration of risk suggests that the models could be useful in targeting preventive interventions, although final determination would require careful weighing of intervention costs, effectiveness, and competing risks.

Nudity as a Disinhibiting Cue in a Date Rape Analogue

Situational factors likely play a role in date rape. The sexual inhibition hypothesis suggests that men are typically sexually inhibited by violence and non-consent, but that inhibition can also be disrupted. We attempted to determine if female nudity reduces inhibition of sexual arousal to non-consensual cues in sexually non-aggressive men. In two studies, heterosexual men (aged 18-25) were presented with six 2-min audiotaped narratives depicting consensual sexual interactions, non-consensual sexual interactions (rape), and non-sexual interactions (neutral) involving a man and a woman. In the first study, 20 participants saw pictures depicting nude or clothed women while listening to the stories. In the second study, 20 other participants saw videos depicting nude or clothed women exercising, also while listening to the stories. Genital responses and subjective sexual arousal were measured. Results suggested that nudity may have a disinhibitory effect on sexual arousal to non-consensual cues, but only when presented in the form of moving images.

Does the Factor Structure of Military Sexual Stressors in Men Correspond to Women's? A Confirmatory Factor Analysis Using the Sexual Harassment Inventory

OBJECTIVES

Unwanted sexual stressors experienced by military men and women are associated with a host of negative physical and mental health problems. Government officials are making it a priority to put a stop to these unwanted sexual experiences. However, the measure typically used measures sexual stressors much better for women than for men. The purpose of the present study was to test the factor structure of an alternative measure, the Sexual Harassment Inventory (SHI), to examine whether sexual stressors experienced by men correspond to women's experiences.

METHODS

We used three preexisting datasets in which the SHI was used to assess active and former military members' sexual stressor experiences. We conducted an exploratory factor analysis to identify women's response patterns and a confirmatory factor analysis to determine whether men's response patterns corresponded to women's.

RESULTS

Findings showed that the SHI has evidence of factorial validity in female service members and adequate, but not exceptional, factorial fit for male service members.

CONCLUSIONS

It is imperative that more work be done to better understand how men experience and perceive potential military sexual stressors and how those perceptions and experiences compare to women's.

Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment

INTRODUCTION

Military sexual trauma (MST) includes sexual harassment or sexual assault that occurs during military service and is of increasing public health concern. The population prevalence of MST among female and male veterans who served during Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) has not been estimated to our knowledge. The purpose of this study is to assess the population prevalence and identify military correlates of MST, sexual harassment, and sexual assault among OEF/OIF veterans.

METHODS

MST was assessed in the 2009-2011 National Health Study for a New Generation of U.S. Veterans, a survey of 60,000 veterans who served during the OEF/OIF eras (response rate, 34%, n=20,563). Weighted prevalence estimates and AORs of MST, sexual harassment, and sexual assault among women and men were calculated. Gender-stratified logistic regression models controlled for military and demographic characteristics. Data analyses were conducted in 2013-2014.

RESULTS

Approximately 41% of women and 4% of men reported experiencing MST. Deployed men had lower risk for MST compared with non-deployed men, though no difference was found among women. However, veterans reporting combat exposure during deployment had increased risk for MST compared with those without, while controlling for OEF/OIF deployment. Among women, Marines and Navy veterans had increased risk for MST compared with Air Force veterans. MST was significantly higher among veterans who reported using Veterans Affairs healthcare services.

CONCLUSIONS

These prevalence estimates underscore the importance of public awareness and continued investigation of the public health impact of MST.

Associations between deployment, military rank, and binge drinking in active duty and Reserve/National Guard US servicewomen

BACKGROUND

Prior studies of mostly male U.S. service members suggest service characteristics such as deployment with combat exposure and lower rank may be a risk factor for alcohol misuse. However, these relationships have not been examined among servicewomen who may be at high risk for experiencing deployment-related stressors and associated health consequences. This cross-sectional report of US servicewomen in the Reserve or National Guard (RNG) and active component (AC) sought to examine these associations.

METHODS

A Midwestern community sample of currently serving and veteran servicewomen (N=1339) completed structured telephone interviews. The Generalized Linear Model was used to examine associations between service characteristics, any binge drinking, and frequency of recent binge drinking after adjusting for demographics.

RESULTS

After adjusting for demographics, deployment to Iraq or Afghanistan was associated with greater odds of reporting a binge drinking episode, compared to no deployment, among servicewomen in the AC but not RNG. Deployment to Iraq or Afghanistan was also associated with more days binge drinking in both groups compared to servicewomen not deployed. Lower ranking servicewomen also reported higher odds of a binge drinking episode and higher frequency of binge drinking in both the RNG and AC.

CONCLUSIONS

Service characteristics including deployment to Iraq or Afghanistan (vs. those not deployed) and lower rank (vs. officers) may be a risk factor for recent binge drinking and higher frequency of binge drinking among servicewomen, after adjusting for demographic covariates. Public health and clinical implications are discussed.

Sexual assault in the military

Military sexual assault is a pervasive problem throughout the military services, despite numerous initiatives to end it. No doubt the military's lack of progress stems from the complexity of sexual assaults, yet in order to develop effective strategies and programs to end sexual assault, deep understanding and appreciation of these complexities are needed. In this paper, we describe the root causes and numerous myths surrounding sexual assault, the military cultural factors that may unintentionally contribute to sexual assault, and the uncomfortable issues surrounding sexual assault that are often ignored (such as the prevalence of male sexual assault within the military). We conclude by offering a broad, yet comprehensive set of recommendations that considers all of these factors for developing effective strategies and programs for ending sexual assault within in the military.