Reporting sexual assault in the military: who reports and why most servicewomen don't

Electronic Health Record Concordance with Survey-Reported Military Sexual Trauma Among Younger Veterans: Associations with Health Care Utilization and Mental Health Diagnoses

Introduction: Military sexual trauma (MST) is more common among post-9/11 Veterans and women versus older Veterans and men. Despite mandatory screening, the concordance of electronic health record (EHR) documentation and survey-reported MST, and associations with health care utilization and mental health diagnoses, are unknown for this younger group. Materials and Methods: Veterans' Health Administration (VHA) EHR (2001-2021) were merged with data from the observational, nationwide WomenVeterans Cohort Study (collected 2016-2020, n = 1058; 51% women). Experiencing MST was defined as positive endorsement of sexual harassment and/or assault. From the EHR, we derived Veterans' number of primary care and mental health visits in the initial two years of VHA care and diagnoses of posttraumatic stress disorder (PTSD), depression, and anxiety. First, the concordance of EHR MST screening and survey-reported MST was compared. Next, multivariate analyses tested the cross-sectional associations of EHR screening and survey-reported MST with Veterans' health care utilization, and compared the likelihood of PTSD, depression, and anxiety diagnoses by MST group, while covarying demographics and service-related characteristics. With few MST cases among men, multivariate analyses were only pursued for women. Results: Overall, 29% of women and 2% of men screened positive for MST in the EHR, but 64% of women and 9% of men had survey-reported MST. Primary care utilization was similar between women with concordant, positive MST reports in the EHR and survey versus those with survey-reported MST only. Women with survey-reported MST only were less likely to have a PTSD or depression diagnosis than those with concordant, positive MST reports. There was no group difference in women's likelihood of anxiety. Conclusions: EHR MST documentation is discordant for many post-9/11 Veterans-both for men and women. Improving MST screening and better supporting MST disclosure are each critical to provide appropriate and timely care for younger Veterans, particularly women.

Institutional Betrayal and Closeness Among Women Veteran Survivors of Military Sexual Trauma: Associations with Self-Directed Violence and Mental Health Symptoms

Institutional betrayal is defined as harm caused by an institution to an individual in the context of trust and dependence. High institutional betrayal is associated with poorer health outcomes, and high levels of trust, dependence, or identification with the institution (institutional closeness) may exacerbate the negative effects of institutional betrayal. While military sexual trauma is prevalent among women Veterans and associated with high rates of institutional betrayal, studies of the impact of military sexual trauma-related institutional betrayal have been limited in size and scope and have not examined the potential role of institutional closeness. We conducted a secondary analysis of national survey data collected from women Veterans who screened positive for military sexual trauma (n = 229). Hierarchical logistic and linear regression were used to examine associations between predictor variables (institutional betrayal, institutional closeness, and their interaction) and outcomes of interest and adjusted for age, education, and military sexual assault history. Institutional betrayal was associated with increased odds of suicidal ideation and suicide attempt during or following military service, as well as more severe symptoms of depression and posttraumatic stress disorder (PTSD). Institutional betrayal was not associated with non-suicidal self-injury or lifetime substance misuse. Counter to hypotheses, institutional closeness did not moderate relationships between institutional betrayal and mental health symptoms or self-directed violence. Results underscore the necessity of preventing and addressing institutional betrayal among women Veterans who experience military sexual trauma.

What are ambulance personnel experiences of sexual harassment and sexual assault in the workplace? A rapid evidence review

INTRODUCTION

Sexual assault and harassment of ambulance personnel in the workplace is widespread. Prevention via body worn cameras and legal efforts have been positive, however improvement is still needed to ensure the protection of staff from the negative impact of sexual violence at work.

METHODS

A rapid evidence review was conducted following the Cochrane Rapid Review guidance. MEDLINE and CINAHL Complete were searched from inception to February 2023. Screening and data extraction was conducted by one author and verified by the other. Included studies were appraised using a variety of critical appraisal checklists and a narrative synthesis was conducted.

RESULTS

From 46 articles screened, 7 were included in the review representing 3994 ambulance personnel from Australia, Canada, the United States, the United Kingdom and South Korea. Seven themes were identified, including a need for more training, education and resources regarding sexual assault and harassment, differences in perpetrators, poor experiences with organisations, effects on victims outside the workplace, effects on victims within the workplace, barriers to reporting, and increased prevalence of sexual assault and harassment against women.

CONCLUSION

The effect of sexual assault and harassment has far-reaching negative impact on victims' lives. More training and resources are recommended.

Sexual harassment at work within Belgian Defence: a prevalence study

INTRODUCTION

Sexual harassment (SH) at work can have an impact on the general health and well-being and on the productivity of the employee. To date, the Belgian Armed Forces do not have any accurate data about SH. Therefore, this study assessed the prevalence of SH within Belgian Defence.

METHODS

The prevalence of SH and staff mental well-being was investigated in a sample of 399 female soldiers. Using quantitative analysis, we measured the impact on mental well-being and the relation to demographic characteristics. Using a qualitative analysis in a subsample of eight female soldiers, we investigated barriers to reporting SH and the impact on professional performance and psychosocial well-being.

RESULTS

The prevalence of non-physical SH is 36.1% over the last 12 months and 64.4% over the course of a career. Physical SH has a prevalence of 16.1% and 43.4%, respectively. Rape prevalence was reported to be 1.4% over the past 12 months, 9% over the course of their career.One in three female soldiers suffer from reduced mental well-being, which was significantly associated with SH. In the interviews, female employees report an impact of SH on professional and personal performance. The willingness to report is low due to misunderstanding, disinformation and psychosocial insecurity.

CONCLUSION

High prevalence numbers were found suggesting an important impact on the professional performance and mental well-being of female military personnel. Organisational changes may create more willingness among victims to report incidents to the designated services.

Adversity during military service: the impact of military sexual trauma, emotional bullying and physical assault on the mental health and well-being of women veterans

INTRODUCTION

Despite making up about 11% of the UK military, there remains limited investigation on the impact of adversity women experience during their service in the UK military. Military adversity can result in a range of well-being difficulties that may persist following transition out of military. The present study therefore examined the prevalence and correlates of different types of military adversity (defined as sexual harassment, sexual assault, emotional bullying and physical assault) within a community sample of UK women veterans.

METHODS

Participants were recruited from a UK charity supporting women veterans. 750 women veterans completed an online survey collecting information on sociodemographic and military factors, military adversity, as well as mental health and well-being difficulties. Associations between variables were explored using multivariate logistic regressions.

RESULTS

The findings indicate a high prevalence of military adversity (22.5% sexual harassment, 5.1% sexual assault, 22.7% emotional bullying and 3.3% physical assault). Younger women, those who held an officer rank during service and those who reported having a combat or combat support role during service were most at risk of military adversity. All types of adversity were significantly associated with probable post-traumatic stress disorder. Sexual harassment was additionally significantly associated with physical somatisation; sexual assault with alcohol difficulties; and emotional bullying with common mental health difficulties, low social support and loneliness.

CONCLUSIONS

This study indicates that UK women veterans are at risk of a range of adverse experiences during military service and provides evidence of the impact of such adversities on mental health and well-being. Further research is required to better understand these relationships.

Military Sexual Trauma Among Women Veterans Using Veterans Health Administration Reproductive Health Care: Screening Challenges and Associations with Post-Military Suicidal Ideation and Suicide Attempts

Military sexual trauma (MST) is highly prevalent among women veterans. Research among MST survivors has focused on individuals receiving care in specific settings, such as mental health services. There is a dearth of knowledge regarding MST prevalence and associations in other settings commonly accessed by women veterans, including reproductive healthcare settings. We examined MST prevalence (overall, by MST type and extent of underreporting) and associations with suicidal ideation and suicide attempts, among women veterans accessing Veterans Health Administration (VHA) reproductive health care. Our sample included 352 post-9/11 women veterans who used VHA reproductive health care in Fiscal Year (FY) 2018 and participated in a cross-sectional survey. Approximately 68.7% screened positive for MST, including 44.9% who reported experiencing military sexual assault. Notably, 30.8% reported MST on the survey, but had a negative MST screen for their most recent MST screen in their VHA medical record. Both military sexual harassment and assault were associated with increased prevalence of experiencing suicidal ideation following military service; however, a significant association among military sexual harassment, past-month suicidal ideation, and post-military suicide attempts was not detected. Military sexual assault was uniquely associated with past-month suicidal ideation and post-military suicide attempts. As MST and underreporting are highly prevalent among women veterans using VHA reproductive health care, rescreening for MST within this population is essential. A trauma-informed approach is recommended irrespective of prior MST screening results and may facilitate suicide prevention in this population. Addressing barriers to MST disclosure and preventing MST and its sequelae remain critical.

Barriers to Reporting Sexual Violence: A Qualitative Analysis of #WhyIDidntReport

The present study conducted thematic analyses of tweets including #WhyIDidntReport (N = 500) to examine barriers to reporting sexual victimization. Barriers to reporting were identified across individual, interpersonal, and sociocultural levels of the social ecology. Common barriers to reporting included labeling of the experience, age, fear, privacy concerns, self-blame, betrayal/shock, the relation/power of the perpetrator, negative reactions to disclosure, and the belief-or personal experience-that reporting would not result in justice and societal norms.

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.

Veterans Health Administration Screening for Military Sexual Trauma May Not Capture Over Half of Cases Among Midlife Women Veterans

BACKGROUND

Approximately 1 in 3 women veterans endorse military sexual trauma (MST) during Veterans Health Administration (VHA) screening. Higher rates have been reported in anonymous surveys.

OBJECTIVE

We compared MST identified by VHA screening to survey-reported MST within the same sample and identified participant characteristics associated with discordant responses.

METHODS

Cross-sectional data were drawn from an observational study of women veterans aged 45-64 enrolled in VHA care in Northern California, with data from mail- and web-based surveys linked to VHA electronic health records (EHRs). Between March 2019 and May 2020, participants reported sociodemographic characteristics, current depressive (Patient Health Questionnaire-9) and posttraumatic stress (PTSD checklist for DSM-5) symptoms, and MST (using standard VHA screening questions) in a survey; depression and posttraumatic stress disorder diagnoses (ICD-10 codes) and documented MST were identified from EHRs. Associations between sociodemographic characteristics, mental health symptoms and diagnoses, and discordant MST reports (EHR-documented MST vs. MST reported on survey, not in EHR) were examined with multivariable logistic regression.

RESULTS

In this sample of midlife women veterans (n = 202; mean age 56, SD = 5), 40% had EHR-documented MST, and 74% reported MST on the survey. Sociodemographic characteristics, mental health symptoms, and diagnosed depression were not associated with discordant MST responses. Women with an EHR-documented PTSD diagnosis had fivefold higher odds of having EHR-documented MST (vs. survey only; odds ratio 5.2; 95% confidence interval 2.3-11.9).

CONCLUSIONS

VHA screening may not capture more than half of women who reported MST on the survey. VHA screening may underestimate true rates of MST, which could lead to a gap in recognition and care for women veterans.

Moral Injury as a Mediator of the Associations Between Sexual Harassment and Mental Health Symptoms and Substance Use Among Women Veterans

Moral injury is an array of symptoms theorized to develop in response to morally injurious events, defined as events that challenge one's core moral beliefs and expectations about the self, others, and world. Recent measures of moral injury have distinguished self-directed moral injury (e.g., moral injury symptoms that emerge following the perpetration of morally injurious events) from other-directed moral injury, the symptoms of which are believed to stem from one's response to actions that others have committed (e.g., within-rank violence, failures of leadership, and acts of betrayal committed by trusted others or institutions). Using a convenience sample of 154 primarily former military women, the present study examined if other-directed moral injury symptoms (e.g., anger, betrayal, and mistrust) associated with military experience would mediate the association between military sexual harassment and mental health and substance abuse symptoms. Results demonstrated that 85.8% (n = 127) of the of this sample of women veterans reported experiencing sexual harassment during their military service. Using a single mediation model, we further demonstrated that other-directed moral injury mediated the association between sexual harassment experience and mental health symptoms. Given the percentage of women veterans who reported sexual harassment, these results suggest that additional training for military members, and particularly, military leaders, is necessary to begin to reduce sexual harassment. In addition, mental health providers who work with current and former military members should consider how other-directed moral injury may be associated with mental health symptoms among women veterans who have experienced sexual harassment while in the military.

Defeated No More: Meaning-Making After Military Sexual Trauma

INTRODUCTION

Military sexual trauma (MST) has been a concern within our U.S. military for many years. Many interventions have been found to benefit this population, although meaning-based interventions are still lacking in this area. The purpose of this phenomenological study is to understand the meaning-making process and themes that arise for female military veterans as they narrate their experience(s) of MST.

MATERIALS AND METHODS

The qualitative study consisted of six female participants, from different areas across the nation, who all reported experiencing MST during their time in service. Their experiences of MST included both sexual harassment and sexual assault. Participants completed a semi-structured interview that was analyzed using an axial coding method to discover the major themes of each participant's interview. The participants discussed the positive and negative aspects of their journey following their MST experience(s). This study's procedures were approved by Adler University's Institutional Review Board.

RESULTS

Many found the interview to be a healing experience on their path of post-traumatic growth (PTG). There were eight major themes that arose from the data analysis under the three main domains of (1) creating a work or doing a deed, (2) experiencing something or encountering someone in a way to produce PTG, and (3) altering one's attitude toward unavoidable suffering. The eight themes were as follows: advocacy, adaptive coping, sense of family unit, psychological clarity, meaningful mantra, survivor mentality code, view of self in the world, and resiliency.

CONCLUSIONS

All participants endorsed engagement in some type of activity that fell into one of the three major domains identified above. This finding helped highlight the PTG that participants were able to experience through their meaning-making journey. There were several recommendations and study implications that were derived from this research study. With the themes introduced from this study, future treatment planning for individual survivors of MST can be better informed by the utilization of meaning-making techniques. Family and group meaning-based interventions would also be an area of continued exploration for this population. Future implications for practice are also included within this article. Significant limitations of the study include amount of participants, lack of diversity in sample population, qualitative study results, and lack of a more-personal interviewing process.

Experiencing Sexual Assault and/or Stalking-Related Behavior is Associated with Binge Drinking and Substance Use Consequences in Deployed U.S. Servicewomen

BACKGROUND

Being deployed is a risk factor for poor postdeployment mental health outcomes in U.S. servicewomen, including harmful drinking. However, to our knowledge, no studies have examined deployment-related sexual assault and exposure to stalking-related behavior in relation to binge drinking and substance use consequences in this population.

METHODS

A community sample of post-9/11 servicewomen from the Midwest, including both veterans and those actively serving (N = 991), completed computer-assisted telephone interviews after deployment. Logistic regression models examined associations between deployment-related sexual assault (attempted or completed) and stalking-related behavior (e.g., being left unwanted things, having property vandalized), and the likelihood of reporting binge drinking and substance use consequences after controlling for covariates.

RESULTS

U.S. servicewomen experiencing deployment-related sexual assault and/or stalking-related behavior were more likely to report binge drinking in the past 4 weeks and at least one negative consequence of substance use in the past year. Also, 21.56% of the sample reported experiencing any deployment-related sexual assault and/or stalking-related behavior, 17.34% reported any stalking-related behavior and no sexual assault, 2.42% reported both sexual assault and stalking-related behavior, and 1.80% reported sexual assault and no stalking-related behavior. The most commonly endorsed behaviors were being followed or spied on (9.09%), receiving unsolicited correspondence (8.34%-8.74%), and having someone show up at places you were (6.90%).

CONCLUSIONS

U.S. servicewomen experiencing sexual assault and/or stalking-related behavior during deployment may be at higher risk for binge drinking and experiencing negative consequence of substance use when compared with their peers not reporting these stressors.

Assessing Institutional Betrayal Among Female Veterans Who Experienced Military Sexual Trauma: A Rasch Analysis of the Institutional Betrayal Questionnaire.2

Military sexual trauma (MST; i.e., sexual harassment and/or sexual assault during one's military service) is highly prevalent among female veterans and is associated with numerous adverse health and psychosocial sequelae. When institutions fail to prevent sexual trauma from happening or respond in an unsupportive manner (i.e., institutional betrayal [IB]), MST survivors typically report more severe health-related outcomes. Although the Institutional Betrayal Questionnaire.2 (IBQ.2) was developed to assess IB, no studies have examined the factor structure or dimensionality of the IBQ.2 among MST survivors. In addition, initial research has reported differing factor structures for this measure. The present study examined the dimensionality and factor structure of the IBQ.2, and tested for differential item functioning (DIF) based on whether military sexual assault was experienced. The sample comprised 235 female veterans who reported a history of MST in an anonymous national survey. Rasch analysis suggested multidimensionality and DIF based on history of military sexual assault. Exploratory factor analysis and parallel analysis suggested the IBQ.2 comprises three factors: (1) Environment Leading to MST, (2) Institutional Response to MST, and (3) Institutional Belongingness following MST. Although these results suggest that the IBQ.2 is multidimensional, the three-factor model had significant issues with respect to dimensionality, item fit, and person separation and reliability. Thus, using the full IBQ.2 may be more advantageous. Further examination of the IBQ.2 is warranted to ensure optimal assessment of IB in relation to MST, irrespective of whether the MST comprised sexual harassment or sexual assault, as well as to ensure that the IBQ.2 is culturally meaningful for MST survivors.

Trauma, social media, and #WhyIDidntReport: An analysis of twitter posts about reluctance to report sexual assault

Recent social trends regarding sexual violence and gender have included elements of "hashtag activism," which involves using social media tools for cultural awareness and change. For example, the Twitter hashtag: #WhyIDidntReport was created for survivors of sexual victimization to share their barriers to reporting. In this project, 600 tweets attached to this hashtag were analyzed using a combination of grounded theory and content analysis methods. Results were organized into a conceptual map, with a central category (power), connected to three other ecological categories (culture, community systems, and relationships) and one category of survivor experiences. Each category has subcategories which illustrate certain contextual and internal barriers to reporting assault. The model shows how these barriers intersect and interact, and often further traumatize those who have been assaulted. The model offers implications for professionals working with those who have survived sexual trauma, as well as those studying the dynamics of abuse.

"I've Never Told Anyone": A Qualitative Analysis of Interviews With College Women Who Experienced Sexual Assault and Remained Silent

The purpose of this study was to gain an understanding of the decision made by some college women who are raped to tell no one. In-depth interviews were conducted with 15 college women between the ages of 19-24 who had never shared their sexual assault with anyone prior to speaking to the researchers. This study provides a systematic investigation of the factors underlying women's decisions to remain silent. The knowledge and understanding gained from these in-depth interviews offer insight for individuals and institutions to support these students and for the development of future efforts encouraging women survivors to tell someone.

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.

The association between social support and posttraumatic stress symptoms among survivors of betrayal trauma: a meta-analysis

Background: Betrayal traumas have a particularly deleterious effect on mental health. Although social support is a robust predictor of posttraumatic stress disorder (PTSD) symptom severity, it is not clear what factors may impact this relationship among betrayal trauma survivors. Objective: This study sought to describe the association between social support and PTSD symptom severity among survivors of betrayal trauma and examine whether methodological, sample, trauma, and social support characteristics moderated this association. Method: A comprehensive search identified 29 studies that assessed the cross-sectional association between PTSD symptom severity and social support among 6,510 adult betrayal trauma survivors. Results: The average effect size (r = -.25; 95% CI: -.30, -.20) was small to medium, with significant heterogeneity between studies (I² = 71.86). The association between PTSD and social support was stronger when the trauma was perpetrated by a romantic partner compared to mixed perpetrators, even after accounting for covariates. There was also a significant effect of support type depending on whether the support was provided in the context of trauma disclosure. Specifically, positive reactions to trauma disclosure were not associated with PTSD symptoms whereas general positive social support (not disclosure focused) was associated with fewer PTSD symptoms. Negative reactions to trauma disclosure were associated with more PTSD symptoms. None of the included studies measured general negative social support outside of trauma disclosure. Conclusions: Our findings suggest that social support may be a particularly important buffer against PTSD symptoms when experiencing traumatic betrayal by an intimate partner. Additionally, our results suggest that social support interventions for those experiencing betrayal trauma should focus on reducing negative responses to disclosure and bolstering general satisfaction with social support.

"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.

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.

Lifetime History of Sexual Assault and Emergency Department Service Use among Women Veterans

BACKGROUND

Although sexual assault survivors are at increased risk for adverse physical and mental health outcomes and tend to use more health care services, little is known about women veterans' lifetime history of experiencing sexual assault (lifetime sexual assault [LSA]) and emergency department (ED) use. We sought to examine associations between experiencing LSA, mental health diagnoses, and ED use among women veterans.

METHODS

Computer-assisted telephone interviews were conducted with 980 women veterans enrolled at two Veterans Affairs (VA) Medical Centers to assess history of experiencing LSA, health care use, sociodemographic characteristics, and military history. Administrative data provided VA use, mental health, and medical diagnoses. Logistic regression analyses examined associations between experiencing LSA and mental health diagnoses and past 5-year ED use. Classification tree analysis characterized ED use in participant subgroups.

RESULTS

Sixty-four percent of participants visited a VA or non-VA ED during the previous 5 years. Women veterans with histories of mental health diagnoses and who experienced sexual assault had an odds of ED use almost two times greater than those with no history of experiencing sexual assault and no mental health diagnoses. The odds were similar for experiencing attempted (adjusted odds ratio, 1.85) and completed (adjusted odds ratio, 1.95) sexual assault. Classification tree analysis identified reliance on VA care and the composite variable representing experiencing LSA and mental health diagnoses as factors that best discriminated ED users from nonusers.

CONCLUSIONS

Experiencing LSA is associated with greater ED use in women veterans enrolled in the VA. Whether finding this reflects greater emergent health care needs, suboptimal access and treatment for conditions that could be managed in other settings, lack of health care coordination, or some combination of these factors is unclear.

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.

Abortion Need among U.S. Servicewomen: Evidence from an Internet Service

INTRODUCTION

U.S. servicewomen have high rates of unintended pregnancy, but federal policy prohibits abortion provision at military treatment facilities and military insurance coverage of abortion, except in cases of rape, incest, or a life-endangering pregnancy. Such restrictions pose challenges to abortion access for servicemembers, particularly during deployment. We aimed to explore the experiences of U.S. servicewomen when accessing abortion during overseas tours and deployment.

METHODS

We reviewed de-identified data from email inquiries and online consultation forms from U.S. servicewomen or military spouses seeking medication abortion from the telemedicine service Women on Web between January 2010 and December 2017. We used descriptive statistics and inductively coded textual responses to describe client characteristics, circumstances of pregnancy, reasons for abortion, and barriers to abortion care.

RESULTS

Our sample included data for 323 individuals. Reasons for abortion related to military service included disruption of deployment, fear of military reprimand, and potential career impacts. Additionally, servicemembers faced barriers to abortion access related to overseas military deployment or tour, including a lack of legal abortion in-country, limited financial resources, language barriers, travel restrictions, and a lack of confidentiality.

CONCLUSIONS

U.S. military servicewomen stationed in countries where safe, legal abortion is restricted or unavailable face deployment-related barriers to abortion care, which compound those barriers they may face regardless of deployment status. Removal of federal bans on the provision and coverage of abortion care and improved education about existing regulations could improve access to timely abortion care and in some cases allow servicewomen who wish to obtain abortion care to remain deployed.

Sexual Assault Prevention: A Randomized Control Trial of a Standard Military Intervention and a Motivational Interview Enhancement

Despite increased efforts to prevent sexual assault in military environments, the problem continues at an alarming rate. Sexual assault prevention programs (SAPP) attempt to respond to this issue, yet little is known about their effectiveness within a military environment. This randomized controlled trial examined the potential efficacy of the 2015 United States Air Force (USAF) SAPP compared to that same program with an additional motivational interviewing (MI) enhancement. The MI enhancement involved both self-guided and group discussions designed to elicit change talk toward preventing sexual assault through bystander interventions. Research questions included the general efficacy of the USAF's SAPP in shifting factors linked to sexual assault, specifically participants' endorsement of beliefs associated with sexual assault, beliefs eceived the pretest via e-mailabout intervening as a bystander when confronted with a hypothetical sexual assault situation, and participants' reported willingness to intervene to stop a sexual assault. Fifty-one college students participated, of whom 64% had a history of military involvement. Primary outcome measures included bystanders' willingness and confidence to intervene as well as indicators of rape myth acceptance. Participants in the standard USAF SAPP showed no significant change in willingness or confidence to intervene as bystanders from pretest to posttest. By contrast, those who received a relatively short MI enhancement showed statistically significant increases in their willingness to intervene as bystanders. Neither group showed changes in sexual assault myths. Enhancing SAPPs with a motivational enhancement effort seems justified, especially given the relative low resources involved in introducing such a program.

Associations between Augmentee Status, Deployment Stress Preparedness and Depression, Post-Traumatic Stress Disorder, and Binge Drinking in U.S. Servicewomen

BACKGROUND

Being deployed without one's home unit (individual-augmentee) and low perceived deployment preparedness are risk factors for mental health symptoms and substance use in male service members. However, these relationships have not been examined specifically in U.S. servicewomen. This study sought to fill this gap by examining associations between augmentee status and deployment stress preparedness (independent variables) and depression, probable post-traumatic stress disorder (PTSD), and binge drinking (dependent variables) in a sample of U.S. servicewomen.

METHODS

A community sample of service women from the Midwest, including both veterans and those serving at the time of data collection (N = 991), completed structured telephone interviews. Logistic regression was used to examine associations between augmentee status, deployment stress preparedness, and the likelihood of reporting depression, probable PTSD, and binge drinking after controlling for covariates.

RESULTS

Findings showed that U.S. servicewomen in the Reserve/Guard who deployed as individual-augmentees were more likely to screen positive for depression, report probable PTSD, and disclose recent binge drinking than servicewomen in the Reserve/Guard deployed with their home unit. Also, among servicewomen deployed as individual-augmentees, those in the Reserve/Guard were more likely to report binge drinking than servicewomen in the active component. No statistically significant associations between deployment stress preparedness and mental health symptoms or binge drinking were observed.

CONCLUSIONS

Servicewomen in the Reserve/Guard who deployed as individual-augmentees may be at increased risk for depression, probable PTSD, and hazardous drinking when compared with their active component and Reserve/Guard peers deployed with their home units.

Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury

Objective: Potentially morally injurious experiences (PMIE) (events that transgress an individual's subjective moral standards) have been associated with psychologically distressing moral emotions such as shame and guilt. Military leaders and clinicians have feared that those with PMIEs may be less likely to seek help due to the withdrawing nature of shame/guilt; however, to date, help-seeking patterns of military personnel with PMIEs has not been explored. Our objective is to address this research gap. Method: Data from a nationally-representative mental health survey of active Canadian military personnel were analysed. To assess the association between exposure to three PMIEs and past-year help-seeking across different provider categories (i.e. professionals, para-professionals (those delegated with mental health advisory tasks but are not licenced to practice as medical professionals), non-professionals), a series of logistic regressions were conducted, controlling for exposure to other deployment and non-deployment-related psychological trauma, psychiatric variables, military factors, and sociodemographic variables. Analytical data frame included only personnel with a history of Afghanistan deployment (N = 4854). Results: Deployed members exposed to PMIEs were more likely to seek help from their family doctor/general practitioner (OR = 1.72; 95%CI = 1.25-2.36), paraprofessionals (OR = 1.72; 95%CI = 1.25-2.36), and non-professionals (OR = 1.44; 95%CI = 1.06-1.95) in comparison to members not exposed to PMIEs. Those exposed to PMIEs were also more likely to seek professional care from the civilian health care system (OR = 1.94; 95%CI = 1.27-2.96). Conclusion: Contrary to long-held, but untested, assumptions regarding the impact of PMIEs on help-seeking, we found those with PMIEs are more likely to seek help from gatekeeper professionals (i.e. general practitioners), para-professionals, and non-professionals rather than specialized mental health professionals (e.g. psychologists). Increased utilization of civilian professionals raises concerns that active military members may be avoiding military health services. Clinically, this highlights the need to increase awareness of moral injury to ensure that actively serving military members are provided with appropriate advice and treatment.

Sexual risk reduction interventions for patients attending sexual health clinics: a mixed-methods feasibility study

BACKGROUND

Sexually transmitted infections (STIs) continue to represent a major public health challenge. There is evidence that behavioural interventions to reduce risky sexual behaviours can reduce STI rates in patients attending sexual health (SH) services. However, it is not known if these interventions are effective when implemented at scale in SH settings in England.

OBJECTIVES

The study (Santé) had two main objectives - (1) to develop and pilot a package of evidence-based sexual risk reduction interventions that can be delivered through SH services and (2) to assess the feasibility of conducting a randomised controlled trial (RCT) to determine effectiveness against usual care.

DESIGN

The project was a multistage, mixed-methods study, with developmental and pilot RCT phases. Preparatory work included a systematic review, an analysis of national surveillance data, the development of a triage algorithm, and interviews and surveys with SH staff and patients to identify, select and adapt interventions. A pilot cluster RCT was planned for eight SH clinics; the intervention would be offered in four clinics, with qualitative and process evaluation to assess feasibility and acceptability. Four clinics acted as controls; in all clinics, participants would be consented to a 6-week follow-up STI screen.

SETTING

SH clinics in England.

PARTICIPANTS

Young people (aged 16-25 years), and men who have sex with men.

INTERVENTION

A three-part intervention package - (1) a triage tool to score patients as being at high or low risk of STI using routine data, (2) a study-designed web page with tailored SH information for all patients, regardless of risk and (3) a brief one-to-one session based on motivational interviewing for high-risk patients.

MAIN OUTCOME MEASURES

The three outcomes were (1) the acceptability of the intervention to patients and SH providers, (2) the feasibility of delivering the interventions within existing resources and (3) the feasibility of obtaining follow-up data on STI diagnoses (primary outcome in a full trial).

RESULTS

We identified 33 relevant trials from the systematic review, including videos, peer support, digital and brief one-to-one sessions. Patients and SH providers showed preferences for one-to-one and digital interventions, and providers indicated that these intervention types could feasibly be implemented in their settings. There were no appropriate digital interventions that could be adapted in time for the pilot; therefore, we created a placeholder for the purposes of the pilot. The intervention package was piloted in two SH settings, rather than the planned four. Several barriers were found to intervention implementation, including a lack of trained staff time and clinic space. The intervention package was theoretically acceptable, but we observed poor engagement. We recruited patients from six clinics for the follow-up, rather than eight. The completion rate for follow-up was lower than anticipated (16% vs. 46%).

LIMITATIONS

Fewer clinics were included in the pilot than planned, limiting the ability to make strong conclusions on the feasibility of the RCT.

CONCLUSION

We were unable to conclude whether or not a definitive RCT would be feasible because of challenges in implementation of a pilot, but have laid the groundwork for future research in the area.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16738765.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 12. See the NIHR Journals Library website for further project information.

Silent Witnesses: Faculty Reluctance to Report Medical Students' Professionalism Lapses

PURPOSE

Assessing students' professionalism is a critical component of medical education. Nonetheless, faculty reluctance to report professionalism lapses remains a significant barrier to the effective identification, management, and remediation of such lapses. The authors gathered information from faculty who supervise medical students to better understand their perceived barriers to reporting.

METHOD

In 2015-2016, data were collected using a group concept mapping methodology, which is an innovative, asynchronous, structured mixed-methods approach using qualitative and quantitative measures to identify themes characterizing faculty reluctance to report professionalism lapses. Participants from four U.S. and Canadian medical schools brainstormed, sorted, and rated statements about perceived barriers to reporting. Multidimensional scaling and hierarchical cluster analyses were used to analyze these data.

RESULTS

Of 431 physicians invited, 184 con-tributed to the brainstorming task (42.7%), 48 completed the sorting task (11.1%), and 83 completed the rating task (19.3%). Participants identified six barriers or themes to reporting lapses. The themes "uncertainty about the process," "ambiguity about the 'facts,'" "effects on the learner," and "time constraints" were rated highest as perceived barriers. Demographic subgroup analysis by gender, years of experience supervising medical students, years since graduation, and practice discipline revealed no significant differences (P > .05).

CONCLUSIONS

The decision to report medical students' professionalism lapses is more complex and nuanced than a binary choice to report or not. Faculty face challenges at the systems level and individual level. The themes identified in this study can be used for faculty development and to improve processes for reporting students' professionalism lapses.

“Who Are You Going to Tell? Who’s Going to Believe You?”

Researchers have identified disclosure as an important part of sexual assault recovery among civilian survivors. However, few researchers have examined the process of military sexual trauma (MST) disclosure, including the barriers and facilitators, positive and negative reactions from disclosure recipients, and positive and negative impacts of disclosure on survivors. Twenty-three women veteran MST survivors completed semi-structured qualitative interviews that assessed disclosure experiences; responses were coded using directed content analysis. Among the 20 women veterans who disclosed MST (87%), most volunteered information that they had disclosed to informal (74%, n = 17), military (70%, n = 16), and medical sources (52%, n = 12). Among women who reported that they disclosed MST to military personnel, all reported at least one negative reaction to the disclosure, including 50% ( n = 8) who reported perceived retaliation for disclosure. Women who reported they disclosed to military personnel identified some barriers (e.g., feared consequences) that women who disclosed to non-military personnel did not. We suggest that the responses of recipients to disclosure may contribute to the impact on participants, including dissatisfaction and disillusionment with the military. We discuss unique aspects of the military context that may contribute to negative reactions. Practitioners can use this information to increase empathy and understanding of the complexity of disclosure and to help survivors process and contextualize these experiences during therapy. Additional online materials for this article are available on PWQ’s website at http://journals.sagepub.com/doi/suppl/10.1177/0361684318796783

Predicting Sexual Assault Perpetration in the U.S. Army Using Administrative Data

INTRODUCTION

The Department of Defense uses a universal prevention framework for sexual assault prevention, with each branch implementing its own branch-wide programs. Intensive interventions exist, but would be cost effective only if targeted at high-risk personnel. This study developed actuarial models to identify male U.S. Army soldiers at high risk of administratively recorded sexual assault perpetration.

METHODS

This study investigated administratively recorded sexual assault perpetration among the 821,807 male Army soldiers serving 2004-2009. Administrative data were also used to operationalize the predictors. Penalized discrete-time (person-month) survival analysis (conducted in 2016) was used to select the smallest possible number of stable predictors to maximize number of sexual assaults among the 5% of soldiers with highest predicted risk of perpetration (top-ventile concentration of risk). Separate models were developed for assaults against non-family and intra-family adults and minors.

RESULTS

There were 4,640 male soldiers found to be perpetrators against non-family adults, 1,384 against non-family minors, 380 against intra-family adults, and 335 against intra-family minors. Top-ventile concentration of risk was 16.2%-20.2% predicting perpetration against non-family adults and minors and 34.2%-65.1% against intra-family adults and minors. Final predictors consisted largely of measures of prior crime involvement and the presence and treatment of mental disorders.

CONCLUSIONS

Administrative data can be used to develop actuarial models that identify a high proportion of sexual assault perpetrators. If a system is developed to consolidate administrative predictors routinely, then predictions could be generated periodically to identify those in need of preventive intervention. Whether this would be cost effective, though, would depend on intervention costs, effectiveness, and competing risks.

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.

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.

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.

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.

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.

Post-sexual assault health care utilization among OEF/OIF servicewomen

BACKGROUND AND OBJECTIVES

Few who experience sexual assault seek health care immediately. Yet many become heavy users of health care resources in the years postassault because sexual violence has been linked with both acute and chronic health consequences. Our objective was to investigate servicewomen's medical and mental health (MH) care utilization after sexual assault in-military (SAIM) and identify reasons for not seeking care.

METHODS

In a retrospective cross-sectional Midwestern community sample of OEF/OIF Active Component and Reserve/National Guard servicewomen, currently serving and veterans, computer-assisted telephone interviews were conducted with 207 servicewomen who experienced SAIM.

RESULTS

A quarter (25%) received post-SAIM MH care and 16% medical care. Utilization of medical care tended to be sooner (within the first month) and MH care later (6 mo to 1+ y). Most sought care on a military base, a third from civilian providers, and 10% sought MH from Veterans Health Administration. Servicewomen were more likely to have utilized medical care if they had experienced a completed SAIM and made a Department of Defense SAIM report and MH care if they were white, experienced on-duty SAIM, and made a Department of Defense SAIM report. The most common reason for not seeking medical care was due to belief that care was not needed. Reasons for not utilizing medical or MH care included embarrassment, confidentiality concerns, and fear of adverse career consequences.

CONCLUSIONS

Few servicewomen utilized post-SAIM care, thus assault-specific health consequences were likely unaddressed. Given the severe and chronic consequences of sexual assault, our findings emphasize need for military, Veterans Health Administration, and civilian providers to query SAIM history to provide timely and optimal care.

Prevalence and correlates of cigarette smoking among operation Iraqi freedom-era and operation enduring freedom-era women from the Active Component military and Reserve/National Guard

BACKGROUND

Tobacco use adversely affects the health and readiness of military personnel. Although rates of cigarette smoking have historically been elevated among men serving in the military, less is known about tobacco use in servicewomen.

OBJECTIVES

To examine the prevalence and correlates of tobacco use among women serving in the Active Component (AC) and Reserve/National Guard (RNG) as well as factors associated with starting to smoke during military service.

METHODS

Cross-sectional surveys of 1320 women serving in the AC or RNG were used to examine cigarette use in servicewomen. Associations between self-reported tobacco use history, sociodemographics, military service, and psychosocial factors were investigated using logistic regression analyses.

RESULTS

Thirty-six percent of servicewomen had a lifetime history of cigarette use, with 18% reporting current smoking. Thirty-one percent of lifetime smokers initiated smoking during military service. Factors associated with current smoking included pay grade, marital status, use of psychotropic medications, past-year alcohol use, and lifetime illicit drug or illegal prescription medication use. An enlisted pay grade, being white, and a history of deployment were all associated with starting to smoke during military service.

CONCLUSIONS

Although progress has been made in reducing the gap in tobacco use between military and civilian populations, nearly 1 in 5 servicewomen in our sample smoked cigarettes. Further efforts are needed to address tobacco use in this population. In addition to providing resources to assist smokers with quitting, additional attention should be given to preventing smoking initiation, particularly among deployed female personnel.

Understanding the elevated suicide risk of female soldiers during deployments

BACKGROUND

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) has found that the proportional elevation in the US Army enlisted soldier suicide rate during deployment (compared with the never-deployed or previously deployed) is significantly higher among women than men, raising the possibility of gender differences in the adverse psychological effects of deployment.

METHOD

Person-month survival models based on a consolidated administrative database for active duty enlisted Regular Army soldiers in 2004-2009 (n = 975,057) were used to characterize the gender × deployment interaction predicting suicide. Four explanatory hypotheses were explored involving the proportion of females in each soldier's occupation, the proportion of same-gender soldiers in each soldier's unit, whether the soldier reported sexual assault victimization in the previous 12 months, and the soldier's pre-deployment history of treated mental/behavioral disorders.

RESULTS

The suicide rate of currently deployed women (14.0/100,000 person-years) was 3.1-3.5 times the rates of other (i.e. never-deployed/previously deployed) women. The suicide rate of currently deployed men (22.6/100,000 person-years) was 0.9-1.2 times the rates of other men. The adjusted (for time trends, sociodemographics, and Army career variables) female:male odds ratio comparing the suicide rates of currently deployed v. other women v. men was 2.8 (95% confidence interval 1.1-6.8), became 2.4 after excluding soldiers with Direct Combat Arms occupations, and remained elevated (in the range 1.9-2.8) after adjusting for the hypothesized explanatory variables.

CONCLUSIONS

These results are valuable in excluding otherwise plausible hypotheses for the elevated suicide rate of deployed women and point to the importance of expanding future research on the psychological challenges of deployment for women.