Military sexual trauma (MST) is the term that the VA and VHA use to refer to sexual assault or repeated, threatening sexual harassment that occurred while the veteran was in the military. As defined in the Veterans Health Care Act of 1992, it is “psychological trauma, which in the judgment of a mental health professional. . . resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment, which occurred while the veteran was serving on active duty.” Sexual harassment is “repeated unsolicited verbal or physical contact of a sexual nature which is threatening in character.” As discussed earlier, the terminology used by the VA differs somewhat from that used by DoD programs.

The majority of published literature deals only with sexual assaults (attempted and completed) and does not address sexual harassment (Anderson & Surís, 2013). It has been argued that the current definition of MST “conflates two related but vastly different phenomena” and that a number of the terms subsumed in the definition have specific legal meanings that can vary within state laws as well. A refinement of the terminology would result in more comparable data across research projects and potentially enable improved treatment for victims of sexual trauma across the board (Shale, 2014).

In 1994 legislation mandated the VA screen all veterans for MST, and in 2004 the VHA began national MST screening for men and women in VA facilities. In 2011, 2.5% of the 4.8 million veterans screened nationally at VA Medical Centers indicated experiencing MST. For women, it was 23% and for men 1.2%. Among the 2.6 million screened at outpatient facilities, the rates were 22.5% for women and 1.1% for men (Anderson & Surís, 2013).

According to VA, currently 1 in 4 women and 1 in 100 men report being the victim of MST, so the percentages have not really changed. A key point often overlooked is that, in terms of overall numbers, there are so many more men in the military that there are in fact significant numbers of both men and women affected by MST. Over 40% of men seen in VA report experiencing MST (VA, 2017).

It is also important to keep in mind that not all veterans receive their medical care at VA facilities. In general, veterans are enrolled in VA healthcare services according to a priority system that takes into account service-connected disabilities and income requirements, with returning combat veterans eligible to enroll in VA health care for 5 years after discharge regardless of disability status or income (CRS, 2016, 2014). In addition, veterans may be eligible for free MST-related care even if they are not eligible for other VA services (VA, 2017).

A recently released VA report indicates that between late 2001 and 2015, approximately 62% of the 1.9 million veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) utilized VA health care (VA, 2017b), which means that the actual numbers of victims of MST are likely even higher when survivors who are not being treated or are being treated under private medical care are taken into account. This also supports the argument that there needs to be sharing of research and experience between civilian and VA clinicians who are treating veterans for MST-related health issues (Kimerling et al., 2007).

VA Response to Military Sexual Trauma (MST)

Each VA hospital must have a designated MST Coordinator who oversees MST screening and assessment, and standardized training materials are available for VHA providers. Every veteran seen at a VA medical facility is screened for MST and any who have experienced MST can get treatment. Treatment does not depend on disability status and those who are not otherwise eligible for healthcare at VA are able to get treatment for MST-related health issues (mental and physical). A variety of requirements for VA facilities address screening, treatment availability and protocols, special treatment centers (including some for women only and others for residential treatment), staff training on MST, and outreach (Kimerling et al, 2007; VA, 2017; Lawhorne Scott, 2014).

It has been a struggle for those affected by sexual violence in the military to be taken seriously and get the care they need. It took two Freedom of Information lawsuits filed by the Service Women’s Action Network (SWAN), with support from the ACLU of Connecticut and the Veterans Legal Services Clinic at Yale Law School, to obtain critical data from the VA about disability claims and benefits for PTSD and two other conditions related to MST. That information was used to push for reforms (ACLU, 2013).

The VA and VHA have been criticized in recent years for severe scheduling delays at many facilities and the deaths of at least 19 veterans due to such delays. Problems at the VA go back to its beginnings, but the increasing number of female veterans entering the system bring new concerns about how to provide appropriate care for them (Pearson, 2014; Kehle-Forbes, 2017). A recent study found that, even though VA has been making changes to provide more gender-sensitive and gender-specific care, there are still problems. Women who have PTSD and those who experienced MST are a particularly high-risk group when it comes to healthcare disparities at VA facilities (Kehle-Forbes, 2017).

Women veterans report feeling “unwelcome” at VA facilities, and many perceive VHA providers to be “under-skilled” and “relatively insensitive” when it comes to treating women. Among women utilizing mental health services, less than 50% felt their needs were well met by the VA. Women who have experienced military sexual trauma can find it particularly disturbing to be placed in a therapy group that is all male or forced to endure lengthy times in waiting rooms full of men. A need to avoid unwanted interactions that raise anxiety levels or act as “triggers”—such as cat calls, flirting, or being propositioned or told they don’t belong at the VA—causes some to forgo treatment at a VA facility (Kehle-Forbes, 2017).

Screening for MST

In order to comply with its mandate, the VA employs universal screening for MST accomplished with onscreen forms and reminders in its patient tracking computer system. A 2007 study noted that in civilian life only a minority of patients were screened for violence by their healthcare providers, although anecdotal evidence suggest that 10 years later that is changing. While universal screening is often contraindicated, the same study found that for MST screening it was not only feasible but yielded valuable information for VA providers (Kimerling et al., 2007).

The study found that screening reached 70% of all patients and the data collected demonstrated that MST is prevalent among veterans seeking care at VA—thus making it an important issue for VHA facilities (Kimerling et al, 2007).

The nature of MST requires that the questions used for screening be constructed so as to be appropriately sensitive and most likely to yield usable responses. It is best to avoid loaded words such as rape or sexual harassment because they can be perceived as too intrusive and may have different meanings from one person to the next (VA, 2017a).

The VA screening instrument has proven useful; it asks, “While you were in the military: (a) Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?; (b) Did someone ever use force or threat of force to have sexual contact with you against your will? (Kimerling et al, 2007; VA, 2017a).

Followup assessment employs detailed questionnaires, of which there are at least two commonly used but none that are specifically target for military sexual trauma assessment (VA, 2017a).

Responses to and Effects of MST

Some common responses to MST that may be seen in both male and female survivors include:

• strong emotions—depression; intense sudden emotional reactions; feeling angry or irritable all the time
• emotional numbness —feeling emotionally “flat”; difficulty feeling emotions such as love or happiness
• trouble sleeping—difficulty falling asleep or staying asleep; disturbing nightmares
• difficulties with attention, concentration, and memory
• problems with alcohol or other drugs—drinking excessively or using drugs on a daily basis; using alcohol or drugs to deal with memories or emotional reactions; drinking to fall asleep
• difficulty with reminders of the trauma—feeling edgy or jumpy; not feeling safe; excessive avoidance of possible triggers
• difficulties in relationship—feeling isolated or disconnected from others; abusive relationships; difficulty with authority figures or employers; difficulty trusting others
• physical health problems—sexual difficulties, chronic pain, weight or eating problems, GI tract problems (VA, 2015)

The type, severity, and duration of responses to MST in a particular individual can be affected by many things, including:

• Prior history of trauma
• Responses from others at the time of the event
• Whether the mst occurred one time or was repeated
• Gender
• Race/ethnicity
• Religion
• Sexual orientation
• Other cultural variables (VA, 2015)

The connection between the development of psychiatric sequelae, physical health issues, and poorer quality of life is consistent across the research (Anderson & Surís, 2013). The most common diagnoses associated with MST are post traumatic stress disorder (PTSD), depression and other mood disorders, and substance use disorders (VA, 2015). Other strongly associated diagnoses include anxiety disorders, dissociative disorders, eating disorders, and personality disorders. A mental health diagnosis is two to three times more likely in victims of sexual assault in the military, and women veterans with MST are nine times more likely to develop PTSD than are women veterans who did not experience MST (Anderson & Surís, 2013; Kimerling et al., 2007).

There are unique characteristics of MST that distinguish it from experiences of sexual trauma in civilian life. First, MST happens when a person is on active duty and thus virtually always where they live and work, and usually they are forced to continue working and living with or near the perpetrator. Unlike a civilian, they cannot simply quit their job and go someplace else.

Second, the perpetrator may be someone who outranks and/or supervises them, thus threatening their ability to get the immediate support and care they need, maintain personal security, or advance in their job.

Third, strong unit cohesion is highly valued in the military and critical to its success. Making a report threatens that cohesion and a person may feel they risk being ostracized if they do so. In some cases, victims have been warned not to make reports and cause trouble.

Finally, speaking up and/or seeking mental health services are perceived to threaten the ability to deploy and/or career advancement (VA, 2017a; Hall, 2016; Anderson & Surís, 2013).

Sexual violence in the military can be affected by other factors as well. In a culture that encourages being “tough” and self-sufficient, minimizing the effects of sexual trauma can make it hard for the victim and others to identify and manage emotions. The relatively young age of many in the military can lead to developmental issues that affect later personal relationships. Limited social support and prior trauma experiences (childhood and/or pre-military) also play a role in military sexual trauma (Hall, 2016).

Other characteristics of MST are very similar to those of civilian victims of sexual trauma. In both arenas, victims are unlikely to make official reports to authorities. How authorities (legal, medical, or other formal sources of assistance) respond can make a great deal of difference for victims. If authorities negate a victim’s experience, mental health difficulties are usually exacerbated and victims may be less likely to seek treatment or confide in family or friends. Positive responses, on the other hand, can reduce some of the effects of MST (VA, 2017a).

Gender Differences

Only a few studies of MST have included males, but in those that have, gender differences have been observed (Anderson & Surís, 2013). Because the experience of sexual victimization is so far outside the norm for men in the typical male gender role, they feel even more stigmatized. This in turn may make their symptoms more severe, increase feelings of shame, and make them less likely to request professional help (VA, 2017a). Men may experience more trauma symptoms and longer lasting sexual problems than do women (Anderson & Surís, 2013).

Men are often reluctant to acknowledge they have been victims of MST. Many are not aware that sexual assault has much more to do with power and dominance than it does with sexuality or sexual orientation and may see it as something that only happens to women. Thus, sexual assault may affect their self-perception of being a man, and trying to prove their masculinity may lead to promiscuity and unfaithfulness to a partner. Male veterans who survive MST may also experience confusion about their sexual identity and wonder if they were targeted because the perpetrator thought they were gay. Others, believing their perpetrator was gay, may develop an extreme (but often unwarranted) hatred of gay men (Anderson & Surís, 2013).

Both men and women on active duty who are victims of sexual harassment have poorer psychological well-being, more physical problems, and lower satisfaction with health and work. Female veterans using VA healthcare who report sexual trauma also report poorer health (psychological and physical) and greater adjustment problems (difficulties finding work or the development of alcohol or drug problems), and they are more likely to have been unable to work because of mental health issues (VA, 2017a).

When compared with female veterans who did not experience MST, those who did have more physical symptoms that include headaches, chronic fatigue, pelvic pain, menstrual problems, and gastrointestinal symptoms (Anderson & Surís, 2013). Two recent studies of women veterans focused on eating disorders, which are strongly associated with trauma. In the first, eating disorders were found to be twice as likely among those who had experienced MST, but were not associated with combat exposure (Breland et al., 2017); the second study also found connections between the disorders and military trauma (Arditte Hall et al., 2017).

Among both male and female survivors of MST, liver disease and chronic pulmonary disease are shown to have a moderate association, while obesity, hypothyroidism, and weight loss are significantly associated in women, and with AIDS in men (Anderson & Surís, 2013). Most of the medical disorders associated with MST have an important behavioral component, which suggests the importance of providing mental health services (Kimerling et al., 2007).

Mental health conditions also present gender differences, with most showing a relationship to MST in both men and women, but generally an even stronger link in one or the other; for example, the association of PTSD to MST is strong in both men and women, but it is almost three times stronger among women than among men.

The link between MST and adjustment disorders is stronger among men, and, while both alcohol and anxiety disorders are more common among men and women who report MST, the link is stronger among women than among men. On the other hand, the relation of MST to bipolar disorders and schizophrenia or psychoses while strong among both men and women, is stronger among men.

Interestingly, dissociative, eating, and depressive disorders, which are typically reported as more common in women, occur equally in men and women when associated with MST (Kimerling et al., 2007).

Prevalence

Figures for the prevalence of military sexual trauma vary due to many factors, including how the data was collected, why it was being collected, and among whom the data was sought. While one literature review in 2008 found prevalence rates from 0.4% to 71%, the majority of studies found rates that range from 20% to 43%. In the civilian population, the lifetime average prevalence rate of sexual assault is 25%; however, military prevalence rates are usually based on a time period of 2 to 6 years (periods of active duty), thus suggesting a much higher prevalence rate and risk for assault among active duty military personnel (Anderson & Surís, 2013; Johnson et al., 2015).

As noted earlier, VA records indicate prevalence rates among those screened for MST in VA health centers and outpatient facilities of approximately 23% for women and a little over 1% for men. There are no studies available that indicate prevalence rates of MST among those veterans who do not receive their care at VA facilities. And, because of the differences in the definitions used by VA and DoD, it is not possible to make direct comparisons of the prevalence data each of those entities collects (Anderson & Surís, 2013).