1
|
McDermott MC, Musilli MG, Brown JE, Melton JL, Miller MJ, Allard RJ, Lutgendorf MA. Female-Specific Health Care of Military Female-Designated Service Members and Veterans: A Systematic Overview of Reviews. Mil Med 2024; 189:e1917-e1930. [PMID: 38537156 DOI: 10.1093/milmed/usae101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/25/2024] [Accepted: 02/28/2024] [Indexed: 08/31/2024] Open
Abstract
INTRODUCTION Since the War in Afghanistan began in 2001, service members have faced significant health effects related to service during war, with female-designated service members facing unique challenges. Numerous high-quality review articles have been published on the health and care of female-designated service members and veterans. Given the increasing volume of literature, we completed an overview of reviews on the health and health care of female-designated military populations. Our objective was to conduct an overview of reviews on the obstetrics and gynecologic health and health care of female-designated military populations since 2000 to understand female-specific health consequences of military service during war and make clinical recommendations. MATERIALS AND METHODS On May 10, 2022, a medical librarian performed a comprehensive search across five databases (Ovid Medline, Embase, CINAHL, PsycINFO, Ovid All EBM Reviews, and Web of Science) for all relevant reviews published from 2000 to May 10, 2022. Results were limited to English language. After the removal of duplicates, 2,438 records were reviewed, and 69 studies were included in the final review. The search strategy and methods were registered with PROSPERO and are reported according to the Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines. Two independent reviewers conducted title and abstract screening and subsequent full text review using Covidence Systematic Review Software. Reviews addressing female-specific and obstetrics and gynecologic health of female-designated service members or veterans, utilizing a clear and systematic methodology, were eligible for inclusion. Quality assessment was conducted by teams of two reviewers. RESULTS A total of 69 studies were included in the final review. Themes included mental health and impact of sexual assault on service members or veterans, veteran health care, issues of menstruation, pregnancy, and urogenital concerns. Areas with few reviews included occupational risks of military service and impact on obstetric outcomes, eating disorders, and menopause. There were insufficient or no reviews on the impact of military service on fertility, access to abortion care, reproductive health outcomes of lesbian, bisexual and transgender service members, surgical treatment of gynecologic conditions, and screening and treatment for breast, gynecologic, and non-pelvic organ cancers. CONCLUSIONS Female-designated military populations serving during periods of war face unique health challenges that should be considered in screening practices and the delivery of trauma informed care. Further research and reviews are needed for female-specific oncology, fertility, abortion access, and sexual and non-binary and expansive gender identities to better capture female-designated service member and veteran health during wartime and beyond.
Collapse
Affiliation(s)
- Megan C McDermott
- Department of Gynecologic Surgery & Obstetrics, Womack Army Medical Center, Ft. Liberty, NC 28310, USA
| | - Megan G Musilli
- Department of Gynecologic Surgery & Obstetrics, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Jill E Brown
- Department of Gynecologic Surgery & Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - John L Melton
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Michael J Miller
- Department of Gynecologic Surgery & Obstetrics, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Rhonda J Allard
- Learning Resource Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Monica A Lutgendorf
- Department of Gynecologic Surgery & Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| |
Collapse
|
2
|
Liang T. Sexual Harassment at Work: Scoping Review of Reviews. Psychol Res Behav Manag 2024; 17:1635-1660. [PMID: 38645480 PMCID: PMC11032108 DOI: 10.2147/prbm.s455753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/16/2024] [Indexed: 04/23/2024] Open
Abstract
Background This article presents a scoping review of reviews on the topic of Sexual Harassment (SH) in the workplace, a subject that has garnered significant global attention. The phenomenon of SH poses a critical challenge to equal opportunity and gender equity in the workplace. Aim The review aims to synthesize existing research, focusing on the antecedents, consequences, and interventions related to SH. Methods The inclusion and exclusion criteria were established based on the research question, which was adapted from the PICO strategy. A protocol was devised following the "DS-CPC" format, which encompasses considerations related to Documents, Studies, Construct, Participants, and Contexts. The search was carried utilizing several automated databases, specifically focusing on the fields of Psychology, Behavioral Sciences, and Health. Preliminary search yielded a total of 468 articles, and the review ultimately encompassed a total of 22 articles. Results This review critically examines the complexity of SH, including the role of bystanders, the perpetuation of myths and misconceptions, and the exploitation of power imbalances by harassers. It also explores the manifestation of SH in male-dominated workplaces and the varying levels of organizational awareness and response to such incidents. The review highlights the importance of fostering an organizational culture that not only acknowledges and protects victims but also implements effective measures to penalize perpetrators. Implications It aims to elucidate the intricacies of SH and advocate for a workplace environment characterized by respect and accountability. Through this comprehensive analysis, the article seeks to inform and guide future research, policy development, and organizational practices concerning SH.
Collapse
Affiliation(s)
- Tao Liang
- East China University of Political Science and Law, Shanghai, 201620, People’s Republic of China
| |
Collapse
|
3
|
Mills-Finnerty C, Staggs H, Bittoni C, Wise N. Affective neuroscience: applications for sexual medicine research and clinical practice. Sex Med Rev 2024; 12:127-141. [PMID: 38281754 DOI: 10.1093/sxmrev/qead048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 10/03/2023] [Accepted: 10/26/2023] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Affective neuroscience is the study of the brain substrates of emotional, embodied experiences. Affective neuroscience theory (ANT) is based on experimental evidence that all mammals are hardwired with 7 primary subcortical emotional operating systems, or "core emotions," that have overlapping but distinct circuits buried in the deep, ancient parts of the brain. Imbalances in the 7 core emotions can affect multiple aspects of the individual's psychosocial well-being (eg, depression, anxiety, substance abuse). Here, we propose that core emotions can also influence sexual function and, specifically, that imbalances in core emotions are the bridge connecting psychiatric symptoms (eg, anhedonia) to sexual dysfunction (eg, anorgasmia). OBJECTIVES In this targeted review and commentary, we outline potential connections between ANT and sexual medicine research and clinical practice. We summarize ANT by defining the 3-level BrainMind and core emotions; examining how they relate to personality, behavior, and mental health; and determining the implications for sexual health research and clinical practice. METHODS A targeted literature review was conducted. Case studies were adapted from client files and clinician interviews and then anonymized. RESULTS We propose a novel organizational schema for implementing affective balance therapies for sexual dysfunction, which integrate psychoeducational, somatic, and cognitive therapeutic approaches under the ANT framework. We provide 3 patient case studies (anorgasmia, hypersexuality, spinal cord injury) outlining the implementation of this approach and patient outcomes. CONCLUSION ANT has practical translational applications in sexual health research and clinical practice. By integrating our understanding of the role of core emotions in human sexuality, clinicians can better tailor treatments to address sexual dysfunction.
Collapse
Affiliation(s)
- Colleen Mills-Finnerty
- Mental Illness Research, Education, and Clinical Care, Palo Alto Veterans Health Care System, Palo Alto, CA 94304, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA 94304, United States
| | - Halee Staggs
- Mental Illness Research, Education, and Clinical Care, Palo Alto Veterans Health Care System, Palo Alto, CA 94304, United States
| | - Celeste Bittoni
- Department of Psychology, University of Padova, Padova 2 35122, Italy
| | - Nan Wise
- Department of Psychology, Rutgers University, Newark, NJ 07102, United States
| |
Collapse
|
4
|
Lazar A, Gewirtz-Meydan A, Rosenbaum TY. War-Time Stress and Sexual Well-Being in Israel. INTERNATIONAL JOURNAL OF SEXUAL HEALTH : OFFICIAL JOURNAL OF THE WORLD ASSOCIATION FOR SEXUAL HEALTH 2024; 36:1-14. [PMID: 38596811 PMCID: PMC10903651 DOI: 10.1080/19317611.2024.2317169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/03/2024] [Indexed: 04/11/2024]
Abstract
Objective This study explored the relationship between war-related stressors and sexual well-being among a civilian population during the 2023 Israel-Hamas War, emphasizing a comprehensive assessment of sexual satisfaction, function, and distress. We aimed to investigate how direct exposure, media exposure, and acute stress symptoms during the war contribute to various dimensions of sexual well-being using a quasi-longitudinal online survey method. Methods An online survey with a convenience sample of 1033 Israeli adults, utilizing measures of direct and media exposure to war stress, acute stress symptoms, and various aspects of sexual well-being, both pre-war and present was distributed. Data analysis involved Pearson correlations and hierarchical regression. Results There were significant associations between stress-related variables and sexual well-being, highlighting the differential contribution of direct exposure, media exposure, and acute stress symptoms. Direct exposure to stress was uniquely associated with sexual dysfunction, while media exposure and acute stress symptoms contributed significantly to predicting various aspects of sexual well-being. Conclusions Recognizing the multifaceted impact of stress during wartime on sexual well-being is crucial for developing comprehensive mental health interventions that address individual and societal factors. This study contributes valuable insights into the relationships between stress-related variables and sexual well-being during wartime, emphasizing the need for holistic approaches in addressing the intimate challenges individuals face during times of conflict.
Collapse
Affiliation(s)
- Aryeh Lazar
- Department of Psychology, Faculty of Humanities and Social Sciences, Ariel University, Ariel, Israel
| | - Ateret Gewirtz-Meydan
- School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | | |
Collapse
|
5
|
Travis KJ, Huang AJ, Maguen S, Inslicht S, Byers AL, Seal KH, Gibson CJ. Military Sexual Trauma and Menopause Symptoms Among Midlife Women Veterans. J Gen Intern Med 2024; 39:411-417. [PMID: 37957529 PMCID: PMC10897107 DOI: 10.1007/s11606-023-08493-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/13/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Sexual assault and/or sexual harassment during military service (military sexual trauma (MST)) can have medical and mental health consequences. Most MST research has focused on reproductive-aged women, and little is known about the long-term impact of MST on menopause and aging-related health. OBJECTIVE Examine associations of MST with menopause and mental health outcomes in midlife women Veterans. DESIGN Cross-sectional. PARTICIPANTS Women Veterans aged 45-64 enrolled in Department of Veterans Affairs (VA) healthcare in Northern California between March 2019 and May 2020. MAIN MEASURES Standardized VA screening questions assessed MST exposure. Structured-item questionnaires assessed vasomotor symptoms (VMS), vaginal symptoms, sleep difficulty, depressive symptoms, anxiety symptoms, and posttraumatic stress disorder (PTSD) symptoms. Multivariable logistic regression analyses examined associations between MST and outcomes based on clinically relevant menopause and mental health symptom thresholds. KEY RESULTS Of 232 participants (age = 55.95 ± 5.13), 73% reported MST, 66% reported VMS, 75% reported vaginal symptoms, 36% met criteria for moderate-to-severe insomnia, and almost half had clinically significant mental health symptoms (33% depressive symptoms, 49% anxiety, 27% probable PTSD). In multivariable analyses adjusted for age, race, ethnicity, education, body mass index, and menopause status, MST was associated with the presence of VMS (OR 2.44, 95% CI 1.26-4.72), vaginal symptoms (OR 2.23, 95% CI 1.08-4.62), clinically significant depressive symptoms (OR 3.21, 95% CI 1.45-7.10), anxiety (OR 4.78, 95% CI 2.25-10.17), and probable PTSD (OR 6.74, 95% CI 2.27-19.99). Results did not differ when military sexual assault and harassment were disaggregated, except that military sexual assault was additionally associated with moderate-to-severe insomnia (OR 3.18, 95% CI 1.72-5.88). CONCLUSIONS Exposure to MST is common among midlife women Veterans and shows strong and independent associations with clinically significant menopause and mental health symptoms. Findings highlight the importance of trauma-informed approaches to care that acknowledge the role of MST on Veteran women's health across the lifespan.
Collapse
Affiliation(s)
- Kate J Travis
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
| | - Alison J Huang
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Shira Maguen
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA
| | - Sabra Inslicht
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA
| | - Amy L Byers
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA
| | - Karen H Seal
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA
| | - Carolyn J Gibson
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco Weill Institute for Neurosciences, San Francisco, CA, USA.
- San Francisco Veteran Affairs Health Care System, San Francisco, CA, USA.
| |
Collapse
|
6
|
Alpert E, Baier AL, Galovski TE. Psychiatric Issues in Women Veterans. Psychiatr Clin North Am 2023; 46:621-633. [PMID: 37500255 DOI: 10.1016/j.psc.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Women veterans have unique life experiences and mental health needs, perhaps in part related to their high rates of exposure to traumatic events including military sexual trauma, combat trauma, and intimate partner violence. We review mental health difficulties among women veterans and describe related functional impairment. Evidence-based treatments are available, but barriers to care remain, including providers' lack of awareness of the unique needs of women veterans. Efforts are needed to increase access to evidence-based interventions, remove barriers to care, and improve provider competency working with this population to maximize clinical outcomes.
Collapse
Affiliation(s)
- Elizabeth Alpert
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, 150 South Huntington Avenue (116B-3), Boston, MA 02130, USA; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Allison L Baier
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, 150 South Huntington Avenue (116B-3), Boston, MA 02130, USA; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Tara E Galovski
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, 150 South Huntington Avenue (116B-3), Boston, MA 02130, USA; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| |
Collapse
|
7
|
Esopenko C, de Souza N, Wilde EA, Dams-O'Connor K, Teng E, Menefee DS. Characterizing the Influence of Exposure to Military Sexual Trauma and Intimate Partner Violence on Mental Health Outcomes among Female Veterans. JOURNAL OF INTERPERSONAL VIOLENCE 2023; 38:8476-8499. [PMID: 36866584 DOI: 10.1177/08862605231156193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Military sexual trauma (MST) has deleterious long-term psychological consequences. Among female U.S. military members, MST is associated with increased risk for future interpersonal victimization, such as experiencing intimate partner violence (IPV). Few studies have investigated the implications of the cumulative effects of IPV and MST on psychological functioning. This study examined rates of co-exposure to MST, IPV, and their cumulative impact on psychological symptoms. Data were collected from 308 female Veterans (FVets; age: M = 42, SD = 10.4) enrolled in an inpatient trauma-focused treatment program in a Veterans Administration (VA) hospital. Data were collected at program admission on symptoms of posttraumatic stress disorder (PTSD), depression, and current suicidal ideation. Lifetime trauma exposure was assessed using semi-structured interviews that identified adverse childhood events (ACEs) and combat theater deployment as well as MST and IPV. Group differences on psychological symptoms were examined among those exposed to MST, IPV, MST + IPV, and compared to FVets with ACEs or combat exposure, but no other adulthood interpersonal trauma (NAIT). Half of the sample (51%) reported experiencing both MST and IPV, approximately 29% reported MST, 10% reported IPV, and 10% reported NAIT. FVets in the MST + IPV group had worse PTSD and depression symptoms than either the MST or IPV groups. The NAIT group had the lowest scores on these measures. There were no group differences in current suicidal ideation; however, 53.5% reported at least one previous suicide attempt. FVets in this sample reported significant lifetime exposure to MST and IPV, with the majority having experienced MST + IPV. Exposure to MST + IPV was associated with greater PTSD and depression symptom severity, yet an overwhelming proportion reported current and past suicidal ideation regardless of trauma exposure history. These results demonstrate the importance of assessing for lifetime interpersonal trauma history when developing and providing mental and medical health interventions for FVets.
Collapse
Affiliation(s)
| | | | - Elisabeth A Wilde
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kristen Dams-O'Connor
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ellen Teng
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
- Veterans Integrated System Network (VISN) 16 Mental Illness Research and Clinical Care Center (MIRECC), Houston, TX, USA
| | - Deleene S Menefee
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
- Veterans Integrated System Network (VISN) 16 Mental Illness Research and Clinical Care Center (MIRECC), Houston, TX, USA
| |
Collapse
|
8
|
Stockman D, Haney L, Uzieblo K, Littleton H, Keygnaert I, Lemmens G, Verhofstadt L. An ecological approach to understanding the impact of sexual violence: a systematic meta-review. Front Psychol 2023; 14:1032408. [PMID: 37292501 PMCID: PMC10244654 DOI: 10.3389/fpsyg.2023.1032408] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 05/08/2023] [Indexed: 06/10/2023] Open
Abstract
Aim A systematic meta-review was conducted to examine (1) the broad range of negative and positive individual and interpersonal changes following adult sexual violence, as well as (2) the risk/protective factors at multiple levels of the social ecology (e.g., individual, assault, and micro/meso/exo/macro/chronosystem factors)-influencing the impact of sexual violence. Methods Searches of Web of Science, Pubmed, and ProQuest resulted in inclusion of 46 systematic reviews or meta-analyses. Review findings were extracted for summary and a deductive thematic analysis was conducted. Results Experiencing sexual violence is associated with many negative individual and sexual difficulties as well as revictimization risk. Only a limited number of reviews reported on interpersonal and positive changes. Factors at multiple levels of the social ecology play a role in the intensity of these changes. Reviews including macrolevel factors were non-existent, however. Conclusion Reviews on sexual violence are fragmented in nature. Although the use of an ecological approach is often lacking, adopting such a perspective in research is necessary for a fuller understanding of the multiple influences on survivor outcomes. Future research should evaluate the occurrence of social and positive changes following sexual violence, as well as the role of macrolevel factors in influencing post-assault outcomes.
Collapse
Affiliation(s)
- Dagmar Stockman
- Department of Experimental Clinical and Health Psychology, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - Laura Haney
- Department of Psychology, East Carolina University, Greenville, NC, United States
| | - Kasia Uzieblo
- Department of Criminology, Vrije Universiteit Brussel, Brussel, Belgium
- Forensic Care Specialists, Van der Hoeven Clinic, Utrecht, Netherlands
| | - Heather Littleton
- Lyda Hill Institute for Human Resilience, University of Colorado Colorado Springs, Colorado Springs, CO, United States
| | - Ines Keygnaert
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - Gilbert Lemmens
- Department of Head and Skin, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Lesley Verhofstadt
- Department of Experimental Clinical and Health Psychology, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
9
|
Zaccari B, Sherman ADF, Febres-Cordero S, Higgins M, Kelly U. Findings from a pilot study of Trauma Center Trauma-Sensitive Yoga versus cognitive processing therapy for PTSD related to military sexual trauma among women Veterans. Complement Ther Med 2022; 70:102850. [PMID: 35820575 PMCID: PMC9704511 DOI: 10.1016/j.ctim.2022.102850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The study objective was to explore the preliminary efficacy of trauma-sensitive yoga compared to cognitive processing therapy (CPT) for women Veterans with posttraumatic stress disorder (PTSD) related to military sexual trauma (MST) in a pilot randomized control trial (RCT). We then compared these results to published interim results for the subsequent full-scale RCT. METHOD The analytic sample included women Veterans (N = 41) with PTSD related to MST accessing healthcare in a southeastern Veterans Affairs Health Care System. The majority were African American, non-Hispanic (80.5 %). The protocol-driven group interventions, Trauma Center Trauma-Sensitive Yoga (TCTSY; n = 17) and the evidence-based control condition, CPT (n = 24), were delivered weekly for 10 and 12 sessions, respectively. Multilevel linear models (MLM) were used to compare changes over time between the two groups. RESULTS The primary outcomes presented here are PTSD symptom severity and diagnosis, assessed using the Clinician Administered PTSD Scale (CAPS) and the PTSD Symptom Checklist (PCL) total scores. PTSD symptom severity on both clinician-administered (CAPS) and self-reported (PCL) measures, improved significantly (p < .005) over time, with large within group effect sizes (0.90-0.99) consistent with the subsequent RCT. Participants in the TCTSY group showed clinically meaningful improvements earlier than the CPT group participants from baseline on the CAPS and PCL Total scores. CONCLUSIONS Results support published findings of the effectiveness of TCTSY in the treatment for PTSD related to MST among women Veterans, particularly African American women. TCTSY warrants consideration as an adjunctive, precursor, or concurrent treatment to evidence-based psychotherapies. Future research should include patient preference, men with sexual trauma, and civilian populations.
Collapse
Affiliation(s)
- Belle Zaccari
- Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA; Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Athena D F Sherman
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA, USA.
| | - Sarah Febres-Cordero
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA, USA.
| | - Melinda Higgins
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA, USA.
| | - Ursula Kelly
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA, USA; Atlanta VA Health Care System, Decatur, GA, USA.
| |
Collapse
|
10
|
Galovski TE, Street AE, Creech S, Lehavot K, Kelly UA, Yano EM. State of the Knowledge of VA Military Sexual Trauma Research. J Gen Intern Med 2022; 37:825-832. [PMID: 36042078 PMCID: PMC9481813 DOI: 10.1007/s11606-022-07580-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Tara E Galovski
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Street, Boston, MA, 02130, USA.
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.
| | - Amy E Street
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Street, Boston, MA, 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Suzannah Creech
- VA VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas VA, Waco, TX, USA
- Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Keren Lehavot
- VA HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Ursula A Kelly
- Atlanta VA Health Care System, Atlanta, GA, USA
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| |
Collapse
|
11
|
Livingston WS, Fargo JD, Blais RK. Depression symptoms as a potential mediator of the association between disordered eating symptoms and sexual function in women service members and veterans. MILITARY PSYCHOLOGY 2022. [DOI: 10.1080/08995605.2022.2052661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | | | - Rebecca K. Blais
- Department of Psychology, Utah State University, Logan, Utah
- Psychology Department, Arizona State University, Tempe, Arizona
| |
Collapse
|
12
|
Monteith LL, Schneider AL, Holliday R, Bahraini NH. Assessing Institutional Betrayal Among Female Veterans Who Experienced Military Sexual Trauma: A Rasch Analysis of the Institutional Betrayal Questionnaire.2. JOURNAL OF INTERPERSONAL VIOLENCE 2021; 36:10861-10883. [PMID: 33403916 DOI: 10.1177/0886260520983959] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
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.
Collapse
Affiliation(s)
- Lindsey L Monteith
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Alexandra L Schneider
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA
| | - Ryan Holliday
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nazanin H Bahraini
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
13
|
Moreau C, Bedretdinova D, Duron S, Bohet A, Panjo H, Bajos N, Meynard JB. From sexual harassment to sexual assault: Prevalence and correlates of sexual trauma in the French military. PLoS One 2021; 16:e0259182. [PMID: 34788297 PMCID: PMC8598035 DOI: 10.1371/journal.pone.0259182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 09/23/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Sexual harassment (SH) is prevalent in military settings and dependent on the workplace environment. Few studies have investigated this issue in non-US military settings nor have examined how contextual and individual factors related to Military Sexual Trauma (MST) vary by gender. METHODS This study draws on a national sexual survey in the French military including 1268 servicemen and 232 servicewomen. We examined four sexual stressors (repeated sexual comments, sexual coercion, repeated unwanted verbal sexual attention and sexual assault (SA)) and two combined measures of verbal SH (comments, unwanted attention) and MST (all forms). We conducted multivariate logistic regressions to identify contextual and individual factors related to these outcomes. RESULTS 36.7% of women and 17.5% of men experienced MST in the last year and 12.6% and 3.5% reported SA. Factors associated with verbal SH differed from those related to SA. The odds of verbal SH were elevated among men who had sex with men (OR = 3.5) and among women officers (OR = 4.6) while the odds of SA were elevated among men less than 25 years (OR = 3.5) and women with less than a high school diploma (OR = 10.9). The odds of SH increased by 20% to 80% when men worked in units with higher female representation, higher prevalence of MST (sexual comments, or sexual assault, coercion, repeated unwanted attention) and lower acceptance of women in the miliatry. The odds of SA also increased by 70% among men working in units with higher female representation and higher prevalence of sexual oppression. The odds of SA against women were particular high (OR = 5.7) in units with a high prevalence of sexual assault, coercion, or repeated unwanted attention. CONCLUSION MST is common in the French military, with women experiencing more severe forms than men. Our resuls call for programmatic action to reduce workplace factors related to verbal SH and SA in the French military.
Collapse
Affiliation(s)
- Caroline Moreau
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, France
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Dina Bedretdinova
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, France
| | - Sandrine Duron
- French Military Center for Epidemiology and Public Health, Marseille, France
- INSERM, UMR S 912, « Economic and Social Sciences for Health and Processing of Medical Information » (SESSTIM), Marseille, France
| | - Aline Bohet
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, France
| | - Henri Panjo
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, France
| | - Nathalie Bajos
- IRIS Institute of Interdisciplinary Research on Social Issues, U997 Inserm—EHESS, Aubervilliers, France
| | - Jean Baptiste Meynard
- French Military Center for Epidemiology and Public Health, Marseille, France
- INSERM, UMR S 912, « Economic and Social Sciences for Health and Processing of Medical Information » (SESSTIM), Marseille, France
- French Military Medical Academy, Ecole du Val-de-Grâce, Paris, France
| |
Collapse
|
14
|
Pulverman CS, Creech SK. The Impact of Sexual Trauma on the Sexual Health of Women Veterans: A Comprehensive Review. TRAUMA, VIOLENCE & ABUSE 2021; 22:656-671. [PMID: 31438778 DOI: 10.1177/1524838019870912] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
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.
Collapse
Affiliation(s)
- Carey S Pulverman
- VHA VISN 17 Center of Excellence for Research on Returning War Veterans, The Central Texas Veterans Health Care System, Waco, TX, USA
- Dell Medical School, 441903University of Texas at Austin, Austin, TX, USA
| | - Suzannah K Creech
- VHA VISN 17 Center of Excellence for Research on Returning War Veterans, The Central Texas Veterans Health Care System, Waco, TX, USA
- Dell Medical School, 441903University of Texas at Austin, Austin, TX, USA
| |
Collapse
|
15
|
Rausch D, Rettenberger M. Predictors of Sexual Satisfaction in Women: A Systematic Review. Sex Med Rev 2021; 9:365-380. [PMID: 34099432 DOI: 10.1016/j.sxmr.2021.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The increasing research interest in sexual satisfaction corresponds to a large amount of studies which focus on different singular determinants without establishing a common model for its explanation. OBJECTIVES The purpose of this review is to systematically identify and evaluate the structure and results of the current research about sexual satisfaction in heterosexual women in a long-term relationship. METHODS A systematic literature search using Web of Knowledge, ProQuest and PSYNDEX was conducted from January 2004 to October 2019. In total, 1,649 studies published in the last 15 years were extracted from the databases with a systematic keyword search. Through a multistage evaluation process 204 studies met the inclusion criteria and described findings about sexual satisfaction as dependent variable. RESULTS Research interest in sexual satisfaction increased notably in the last 5 years. Empirical analyses were predominantly based on data from North America whereas a considerably smaller share of research analyzed samples from Europe or Asia. Relationship variables were the most frequently analyzed predictors and included in more than half of the identified studies. Sexual behavior was most often analyzed in the form of frequency of sexual interactions. Contrariwise, sexual practices, communication about sexuality and sexual desire, and sexual thoughts received limited attention. Demographics were considered in one third of all studies. The inclusion of control variables was rare. Some important studies considered variables closely related to sexual satisfaction such as sexual dysfunction. CONCLUSION Relationship satisfaction and the frequency of sexual interactions are identified as the most frequently confirmed predictors of sexual satisfaction across all evaluated studies. Results about the effects of pornography consumption, religion, and relationship duration showed the greatest inconsistency. In general, identified effects were often believed to result from mediator variables like sexual desire or distracting thoughts. Rausch D, Rettenberger M. Predictors of Sexual Satisfaction in Women: A Systematic Review. Sex Med Rev 2021;9:365-380.
Collapse
Affiliation(s)
- Diana Rausch
- Department of Psychology, Johannes Gutenberg-University Mainz (JGU), Mainz, Germany.
| | - Martin Rettenberger
- Department of Psychology, Johannes Gutenberg-University Mainz (JGU), Mainz, Germany; Centre for Criminology (Kriminologische Zentralstelle - KrimZ), Wiesbaden, Germany.
| |
Collapse
|
16
|
Military Sexual Trauma: An Update for Nurse Practitioners. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2020.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
17
|
Sexual Dysfunction and Distress Among Childhood Sexual Abuse Survivors: The Role of Post-Traumatic Stress Disorder. J Sex Med 2020; 17:2267-2278. [DOI: 10.1016/j.jsxm.2020.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 12/21/2022]
|
18
|
Garneau-Fournier J, McBain S, Turchik JA. Factors Associated with Sexual Satisfaction among Veterans Who Have Experienced Military Sexual Trauma. JOURNAL OF SEX & MARITAL THERAPY 2020; 46:721-735. [PMID: 32847446 DOI: 10.1080/0092623x.2020.1808548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Veterans who have experienced military sexual trauma (MST) report lower sexual satisfaction than veterans without a history of MST. The current study examined the relationship between demographic, physical health, mental health, and trauma variables and sexual satisfaction among a national sample of U.S. veterans who endorsed MST. Results demonstrated that lower sexual satisfaction was associated with uncoupled relationship status, poor physical health, and symptoms of depression, post-traumatic stress disorder, and sexual dysfunction among male and female veterans. Several additional factors were related to lower sexual satisfaction among female veterans. Findings highlight the importance of gender-targeted assessment, prevention, and treatment of sexual satisfaction problems.
Collapse
Affiliation(s)
- Jade Garneau-Fournier
- Pacific Graduate School of Psychology at Palo Alto University, Palo Alto, CA, USA
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Sacha McBain
- Pacific Graduate School of Psychology at Palo Alto University, Palo Alto, CA, USA
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jessica A Turchik
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA, USA
| |
Collapse
|
19
|
Morgan L. Understanding sexual offences in UK military and veteran populations: delineating the offences and setting research priorities. BMJ Mil Health 2020; 168:146-148. [PMID: 32345675 DOI: 10.1136/bmjmilitary-2020-001453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 11/04/2022]
Abstract
Recent publications have highlighted the need to address inappropriate behaviours, including discrimination, bullying and sexual harassment, within the British Armed Forces; however, no UK work to date pays sufficient attention to sexual offences as defined by the Sexual Offences Act (2003). In trying to ascertain prevalence, nature and consequences of sexual offences in military and veteran populations, one is faced with majority United States (US) research with different definitions of offences, different populations and different research methods. These and UK publications use various terminology, often ill-defined and used interchangeably (eg, harassment, abuse, violence, assault, trauma), meaning it is not always clear what is being discussed, and the criminal acts of sexual offences have become lost, oversimplified and blurred by their incorporation into wider discussions of sexual harassment and inappropriate behaviour. As a result, there is lack of clarity around the topic, and insufficient recognition and weight is given to the nature and complexity involved in understanding sexual offences and their consequences. It is important to distinguish between different types of unlawful behaviour: each are associated with different physical and psychological health outcomes for victims, and management of perpetrators will differ. Some behaviours will be managed through education and awareness programmes; other behaviours necessitate a prison sentence. This article highlights that understanding sexual offences in military and veteran populations is more complex than existing UK publications have acknowledged, and sets out some of the issues that research needs to consider if we are to develop prevention and management strategies.
Collapse
Affiliation(s)
- Louise Morgan
- Centre for Veterans' Health, King Edward VII's Hospital, London W1G 6AA, UK
| |
Collapse
|
20
|
"I want to feel like I used to feel": a qualitative study of causes of low libido in postmenopausal women. ACTA ACUST UNITED AC 2019; 27:289-294. [PMID: 31834161 DOI: 10.1097/gme.0000000000001455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Low libido is common among women over 60 and negatively impacts well-being and relationship satisfaction. Causes of low libido in this age group are not well understood. We used qualitative methods to explore older women's perceptions of causes of low libido. METHODS We conducted 15 individual interviews and 3 focus groups (total N = 36) among sexually active women 60 and older who screened positive for low libido using a validated instrument. Interviews were audio-recorded, transcribed, and coded using a codebook developed by two investigators. Codes were examined, and themes related to causes of low libido emerged. RESULTS Women noted a number of different factors that contributed to low libido. The common factors that women discussed included postmenopausal vaginal symptoms, erectile dysfunction in male partners, fatigue and bodily pain, life stressors, and body image concerns. Women often found ways to adapt to these factors. These adaptations required open communication between partners regarding sex, and some women noted these conversations were difficult or not successful. CONCLUSIONS A wide variety of factors contribute to low libido in women over 60, but many of these factors are addressable. Low libido in older women should not be automatically attributed to "normal" aging or to menopause; providers should take an approach to assessment and treatment that addresses biological, interpersonal and social, and psychological factors. : Video Summary: http://links.lww.com/MENO/A499.
Collapse
|