The role of cumulative sexual trauma and difficulties identifying feelings in understanding female veterans' physical health outcomes

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

BACKGROUND

Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality.

METHODS

In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable.

RESULTS

At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide.

CONCLUSIONS

The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.

Opportunities to More Comprehensively Assess Sexual Violence Experience in Veterans Health Administration Medical Records Data

INTRODUCTION

Experience of sexual violence (SV) is prevalent among the Veteran population and associated with many negative mental and physical health outcomes including suicidal behavior, obesity, post-traumatic stress disorder, anxiety, depression, and poor sexual and reproductive functioning. Although Veterans of any gender may experience SV, women Veterans are particularly at risk. Research on SV among Veterans has focused primarily on the experience of SV during military service (military sexual trauma, MST), although Veterans may also experience SV prior to and following military service. The aim of the current study was to construct a more comprehensive method of identifying SV among Veterans Health Administration (VHA) patients as documented in medical records in a national cohort of 325,907 Veterans who used VHA care between 2000 and 2018 in order to inform future research in this area.

METHOD

We used three indicators to identify SV in VHA medical records: (a) the MST screen, (b) the sexual violence item of the intimate partner violence (IPV) screen, and (c) International Classification of Disorders (ICD) codes (versions 9 and 10) representing adult sexual abuse and assault. Univariate descriptive analyses were conducted to determine the exclusivity and overlap of the SV measures.

RESULTS

The universal MST screen was the most commonly identified indicator of SV in the data. However, including the IPV and ICD indicators identified an additional 5% of Veterans who had experienced SV, accounting for thousands of patients.

DISCUSSION

The results of the current study indicate that using the three-pronged approach of SV collection is a more comprehensive method of identifying patient SV experience through VHA medical records and contributes uniquely to the methodology of studying social factors' impact on health care. Clinical screening and documentation of SV allow for the assessment of health impacts and trends through examination of medical records data.

Women Veterans' Attrition from the VA Health Care System

PURPOSE

Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care.

METHODS

A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.

RESULTS

Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.

CONCLUSIONS

Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.

The Impact of Sexual Trauma on the Sexual Health of Women Veterans: A Comprehensive Review

Sexual trauma, particularly childhood sexual trauma, is a potent risk factor for sexual health difficulties among civilian women. Women veterans report elevated rates of sexual trauma compared to their civilian peers, including sexual trauma during military service, perhaps making women veterans even more vulnerable to sexual health difficulties. A comprehensive review of the peer-reviewed literature on the relationship between sexual trauma and sexual health in women veterans was conducted. Inclusion criteria were measurement of sexual trauma and sexual health (i.e., sexual function or sexual satisfaction), a U.S. veteran sample including women veterans, and written in English. This process identified 18 articles. Results indicated that similar to the pattern observed among civilian women, sexual trauma was associated with an increased risk of sexual dysfunction and low sexual satisfaction among women veterans. Sexual pain was the most common sexual dysfunction among women veterans. Comorbid post-traumatic stress disorder and depression were identified as correlates of sexual dysfunction. Gaps in the literature included limited use of validated measures of sexual health and inconsistencies in the assessment of sexual trauma history. Future research is needed on the interrelationships between sexual trauma, sexual health, and mental health to inform treatment recommendations for improving sexual health among women veterans.

Associations Between Sexual Assault and Reproductive and Family Planning Behaviors and Outcomes in Female Veterans

OBJECTIVE

To examine the relationship between lifetime sexual assault (defined as someone having experienced sexual assault in their lifetime) and reproductive health care seeking, contraception usage, and family planning outcomes in female veterans.

METHODS

We conducted a secondary analysis of data collected between 2005 and 2008 from computer-assisted telephone interviews with 1,004 female veterans aged 20-52 years who were enrolled at two Midwestern Department of Veterans Affairs (VA) health care systems. Participants were asked about reproductive, mental, and general health histories, and about lifetime sexual assault. We assessed associations between reproductive histories and contraceptive use among participants who reported lifetime sexual assault, compared with those who had not experienced lifetime sexual assault, by using bivariate and multivariable logistic regression analyses. Lastly, we examined reasons why these participants had not sought Pap test screening.

RESULTS

More than half (62%) of participants reported experiencing lifetime sexual assault. Because there was an association between older age and history of lifetime sexual assault (P<.001), we stratified the analysis by age. Women with a history of lifetime sexual assault were more likely to have had unprotected intercourse for a year or more (adjusted odds ratio [aOR] 2.31, 95% CI 1.35-3.96) and a teen pregnancy (aOR 2.10, 95% CI 1.07-4.12) than women who did not report lifetime sexual assault. When stratified by age, women aged 40-52 years with a history of lifetime sexual assault were more likely to report more than a year of unprotected sex, teen pregnancy, and not seeking prenatal care with their first pregnancy, than women aged 40-52 who did not report lifetime sexual assault. Women who experienced lifetime sexual assault were more likely to report not seeking Pap tests in the past owing to fear and anxiety when compared with women who had not experienced lifetime sexual assault.

CONCLUSION

Female veterans who reported lifetime sexual assault had differences in family planning behaviors compared with women who did not report lifetime sexual assault. These findings have implications for clinicians and VA policymakers when determining family planning and reproductive care delivery needs for female veterans of reproductive age.

The relevance of psychological strength for physical and psychological well-being in trauma-exposed women

Traumatic experiences have consistently been linked to poor health and well-being, particularly in women. Psychological factors have been theorized to directly affect the reporting of physical symptoms and perceptions of general health. Posttraumatic stress disorder (PTSD) has been proposed as a major pathway through which trauma affects health and emotion dysregulation. Trauma is considered to be a key psychological variable in the pathogenesis of PTSD. Fortunately, not all women who have experienced trauma manifest adverse effects. Resilience acts as a psychological protective variable following trauma. The present study tested a hypothetical model of the contribution of resilience, emotional dysregulation, and PTSD symptoms to physical and psychological well-being in a large sample of trauma-exposed women. A transversal study with 753 female participants is used. Structural modeling was used to test linear associations between variables. After experiencing trauma, resilience was negatively and significantly associated with emotional dysregulation, which, in turn, was positively associated with PTSD symptoms. Both resilience and PTSD symptoms were associated with physical and psychological well-being. The results suggest that resilience and emotional dysregulation are relevant to the health and well-being of women with PTSD symptoms and may help guide the development of psychological treatment in this group. Therefore, these findings may be relevant in promoting health and well-being in such women, and may help to identify individuals who would receive the most benefit from interventions addressing emotional regulation and psychological resilience.

Importance of telling the unutterable: Alexithymia among sexually abused children

Child maltreatment is known to be an etiological factor for developing alexithymia which refers to the difficulty to identify and express feelings. Yet, scarce data is available regarding the vulnerability in child victims of sexual abuse to develop alexithymia. The current study aimed to compare level of alexithymia among a sample of school-aged victims of child sexual abuse (CSA) and a comparison group of non-victimized children. Results also investigated the mediational role of alexithymia in the association between CSA and both internalized and externalized behavior problems. The sample involved 429 sexually abused and 98 non-abused children aged 6 to 12 years old and their parents. The Children's Alexithymia Measure (Way et al., 2010) and the Child Behavior Checklist (Achenbach and Rescorla, 2001) were completed by parents. Clinicians filled out an adapted version of the History of Victimization Form to assess CSA characteristics (Hébert and Cyr, 2010). Analyses revealed that victims of CSA presented significantly higher levels of alexithymia compared to their non-abused counterparts. Results also highlighted the role of alexithymia mediating the association between CSA and both internalized and externalized behavior problems. Focussing on alexithymia is a promising avenue to sustain resilience and prevent further difficulties in sexually abused children.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms

BACKGROUND

Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population.

OBJECTIVES

The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population.

STUDY DESIGN

We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)-enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ(2), Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ(2) and Student t tests.

RESULTS

Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V.

CONCLUSION

Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women's health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.

Voluntary and involuntary childlessness in female veterans: associations with sexual assault

OBJECTIVE

To assess associations between lifetime sexual assault and childlessness in female veterans.

DESIGN

Cross-sectional, computer-assisted telephone interview study.

SETTING

Two Midwestern Veterans Administration (VA) medical centers.

PATIENT(S)

A total of 1,004 women aged ≤52 years, VA-enrolled between 2000 and 2008.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Sociodemographic variables, reproductive history and care utilization, and mental health.

RESULT(S)

A total of 620 veterans (62%) reported at least one attempted or completed sexual assault in their lifetime (LSA). Veterans with LSA more often self-reported a history of pregnancy termination (31% vs. 19%) and infertility (23% vs. 12%), as well as sexually transmitted infection (42% vs. 27%), posttraumatic stress disorder (32% vs. 10%), and postpartum dysphoria (62% vs. 44%). Lifetime sexual assault was independently associated with termination and infertility in multivariate models; sexually transmitted infection, posttraumatic stress disorder, and postpartum dysphoria were not. The LSA by period of life was as follows: 41% of participants in childhood, 15% in adulthood before the military, 33% in military, and 13% after the military (not mutually exclusive). Among the 511 who experienced a completed LSA, 23% self-reported delaying or foregoing pregnancy because of their assault.

CONCLUSION(S)

This study demonstrated associations between sexual assault history and pregnancy termination, delay or avoidance (voluntary childlessness), and infertility (involuntary childlessness) among female veterans. Improved gender-specific veteran medical care must attend to these reproductive complexities.

Betrayal trauma: associations with psychological and physical symptoms in young adults

Betrayal trauma, or trauma perpetrated by someone with whom a victim is close, is strongly associated with a range of negative psychological and physical health outcomes. However, few studies have examined associations between different forms of trauma and emotional and physical symptoms. The present study compared betrayal trauma to other forms of trauma as predictors of young adults' psychological and physical symptoms, and explored potential mediators. A total of 185 university undergraduate students completed the Brief Betrayal Trauma Survey, the Trauma Symptom Checklist, the Toronto Alexithymia Scale, and the Pennebaker Inventory of Limbic Languidness. For each set of symptoms, simultaneous multiple regressions assessed the relative contributions of low versus high betrayal trauma to psychological and physical health reports. Structural equation models examined traumatic stress symptoms and alexithymia as mediators of the relationship between betrayal trauma and physical health symptoms. A total of 151 participants (82%) reported exposure to at least 1 of 11 forms of trauma queried (M = 2.08, SD = 1.94); 96 participants (51.9%) reported at least 1 betrayal trauma. Traumas characterized by high betrayal predicted alexithymia, anxiety, depression, dissociation, physical health complaints, and the number of days students reported being sick during the past month, whereas other traumas did not. Structural equation modeling revealed that traumatic stress symptoms and alexithymia mediated the association between betrayal trauma and physical health complaints. These results indicate that betrayal trauma is associated with young adults' physical and mental health difficulties to a greater extent than are other forms of trauma. Results may inform assessment, intervention, and prevention efforts.

Cumulative abuse: do things add up? An evaluation of the conceptualization, operationalization, and methodological approaches in the study of the phenomenon of cumulative abuse

For women, any one type of abuse rarely occurs in isolation of other types, and a single abusive experience is often the exception rather than the norm. The importance of this concept of the cumulative nature of abuse and its negative impact on health has been well recognized within the empirical literature, however there has been little consensus on what to call this phenomenon or how to study it. For the most part researchers have operated on the premise that it is the sheer number of different types of cumulating abuse experiences that is primarily responsible for worse health outcomes among women. And although this simplistic 'more is worse' approach to conceptualizing and operationalizing cumulative abuse has proven to be a powerful predictor of poorer health, it contradicts growing empirical evidence that suggests not all victimizations are created equal and that some victimizations may have a more deleterious effect on health than others. Embedded in abuse histories are individual and abuse characteristics as well as other life adversities that need to be considered in order to fully understand the spectrum and magnitude of cumulative abuse and its impact on women's health. Furthermore, given the long-term and persistent effects of abuse on health it becomes imperative to not only evaluate recent abusive experiences, but rather all abuse experiences occurring across the lifespan. This review highlights and evaluates the conceptual, operational, and methodological challenges posed by our current methods of studying and understanding the phenomenon of cumulative abuse and suggests that this phenomenon and its relationship to health is much more complex than research is currently portraying. This paper calls for the urgent need for interdisciplinary collaboration in order to more effectively and innovatively study the phenomenon of cumulative abuse.

Effects of parents' experiential avoidance and PTSD on adolescent disaster-related posttraumatic stress symptomatology

Despite the importance of family context to adolescents' reactions following disaster, little research has examined the role of parents' functioning on adolescents' disaster-related posttraumatic stress disorder (PTSD) symptoms. Using data from 288 adolescents (ages 12 to 19 years) and 288 parents exposed to a series of severe tornadoes in a rural Midwestern community, this study tested a conceptual model of the interrelationships between individual and parental risk factors on adolescents' disaster-related PTSD symptoms using structural equation modeling. Results showed that the psychological process of experiential avoidance mediated the relationship between family disaster exposure and PTSD for both adolescents and their parents. Parents' PTSD symptoms independently predicted adolescents' PTSD symptoms. Further, parents' postdisaster functioning amplified the effects of adolescent experiential avoidance on adolescents' disaster-related PTSD symptoms. Findings highlight the importance of family context in understanding adolescents' postdisaster reactions. Clinical implications are discussed.