Following an investigation into harassment at Ft. Hood in Texas, Secretary of the Army Ryan D. McCarthy stated that it had found “major flaws” at Ft. Hood and a command climate “that was permissive of sexual harassment and sexual assault.” He ordered that 14 officials, including several high-ranking leaders, be relieved of command or suspended. He promised sweeping reform that would extend far beyond Ft. Hood. McCarthy invited those who don’t trust the chain of command to go directly to him with their reports of harassment.

NYTimes, December 8, 2020

 

As a society, our view of, and attitudes toward, sexual violence—how we define it, how we treat its victims, how (or if) we punish the perpetrators, and what we try to do to prevent it—have been changing. In many people’s minds, sexual assault is synonymous with rape (an act of unwanted sexual intercourse), an act perpetrated by males against females, and, while generally considered a crime, its investigation, prosecution, and punishment are often affected by variations in state laws, social mores, and local attitudes. Negative perceptions and judgments of victims have figured prominently in our social view of sexual assault.

Military sexual trauma (MST) is defined by law as “Physical assault of a sexual nature, battery of a sexual nature, or sexual harassment [“repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character”] that occurred while a veteran was serving on active duty or active duty for training.” Some studies suggest that over half of female veterans suffer from MST. This does not mean that men are entirely spared.

According to the Department of Defense, 5.7% of male service members have experienced military sexual harassment and 1.6% have been sexually assaulted. These estimates are probably low, given the reluctance to report and disclose these traumas, even in a healthcare setting (Livingston and Blaise, 2024). Military sexual assault is strongly associated with PTSD and suicidal ideation and suicide attempts, leading to calls for better understanding of how to address suicide risk among survivors of MST.

Veterans suffering from MST should know that they can get help free of charge, even if they do not have a disability rating. There is no time limit, and they do not need to have documented the incidents at the time that they occurred. A VA provider can make a referral to the community, so veterans who live far from a VA center can receive counseling if they want it.

In additional to suicidal ideation and even suicide attempts, MST is strongly associated with sexual dysfunction disorders like sexual arousal disorder, sexual pain disorder and sexual desire disorder. (Monteith et al., 2023). Various analyses suggest that between 23.6%-52.5% of female veterans report MST. Some non-DoD studies estimate that up to 8.9% of male veterans have reported unwanted sexual attention or assault while in the military (Doucette et al., 2022). Risk factors for MST in both men and women include early-life exposures to violence, especially warfare or domestic violence, and child abuse. High-stress environments, such as are typical in the military, especially during deployment, are also predictors for MST. Non-white service members are also at higher risk for sexual predation, as are lower enlisted personnel.

Male service members are also three times likelier than their female colleagues to perceive their sexual victimization as a hazing ritual, or simple bullying, suggesting that the predictors for MST are different for men than they are for women (Doucette et al., 2022).

A recent study suggests an association of MST with a greater risk of all physical health conditions except cancer. This ranged from 9% greater odds of rheumatic disease to 5.4 times greater odds of PTSD (Sumner et al., 2021). Though most studies of female veterans with MST have focused on those of reproductive age, the consequences can follow women throughout their lives. A recent study of female veterans aged 45-64 examined associations between MST, menopause and mental health. The study concluded that exposure to MST is common among midlife women veterans and shows strong and independent associations with clinically significant menopause and mental health symptoms, highlighting the importance of trauma-informed care for female veterans (Travis et al., 2024).

5.1 Screening for MST

Many veterans do not report MST the first time they are screened. But the strong association between MST and suicidal ideation and post-military suicide attempts makes it essential that this population be rescreened, multiple times if necessary. Many veterans screen as positive for MST in research studies, but they give conflicting answers during screenings in clinical settings. In one random sample of female veterans, 15.4% of respondents screened positive for MST during their first screening; however, an additional 6.4% who had previously screened negative switched their answers in a follow-up screening (Monteith et al., 2023). Reproductive healthcare clinics may be a promising setting for uncovering MST and offering treatment options, since many of the conditions arising from MST are related to sexual and reproductive health.

However, individuals who have experienced MST may blame themselves for what happened. They may fear retaliation, negative social consequences, or a breach in confidentiality. Many people are reluctant to talk about trauma, and that could explain why they do not endorse MST in screenings.

One study found that 60% of women veterans who had not screened positive for MST in a clinical setting reported MST by survey, indicating that the screenings provided by the VA were not capturing all the patients with MST. Researchers suggest that providers communicate empathetically with patients in a confidential setting with no other family members nearby and be prepared to re-screen respondents and offer them resources to address their trauma. Some women may not realize that sexual harassment is a form of MST, though persistent harassment has been shown to have negative health repercussions (Hargrave et al., 2022).

The VA’s National Center for PTSD recommends the following for providers screening a veteran for MST (Street et al., 2023):

• Create a context that facilitates disclosure; it is a necessary first step. Perform screening in a private setting without risk of interruptions. Ensure that your speech is unhurried and has a supportive tone. Make good eye contact and ensure that your nonverbal behavior conveys your comfort with the topic and the sense that this is an important issue.
• Next, help Veterans feel at ease by normalizing the screening process—say something like, “Stressful life experiences like the ones I'm going to ask about next unfortunately occur so frequently that I ask all my clients whether they experienced them.” When asking the screening questions use language that describes behavior and avoids technical or legal language (e.g., avoid “rape” or “sexual assault”) and negative phrasing (e.g., “nothing like that has ever happened to you, right?”). The questions used as part of the VA's universal MST screening program provide an example of this approach:
  1. When you were in the military, did you ever receive unwanted sexual attention you found threatening (for example, touching, cornering, pressure for sexual favors, sexual texts or online messages, or inappropriate verbal remarks, etc.)?
  2. Did you have sexual contact against your will or when you were unable to say no (for example, after being forced or threatened or to avoid other consequences)?
• Finally, respond supportively regardless of the Veteran’s answer to screening questions. This can include providing support, education, and connection to resources for Veterans who respond “yes” and leaving the door open for future conversations if the Veteran responds “no” (e.g., “I'm glad to hear that. Since those experiences can be tough to talk about, I wanted to ask about them specifically so that you know it’s ok for us to talk about difficult topics.”).

For mental health professionals who provide care for those who have experienced MST, conducting a solid functional assessment is an important starting place for delivering effective treatment. When the traumatizing event is MST, this assessment should include gathering basic information about the MST experience that may be associated with the complexity of the following symptoms (e.g., was the experience sexual harassment, sexual assault or both?; was it a single incident or an ongoing series of events?; what support was received from others at the time?). The type and course of treatment will determine and whether a more detailed assessment of the specifics of an MST experience is necessary.

Although PTSD is one of the most common mental health diagnoses among individuals who experienced MST, not everyone who experiences MST will go on to develop PTSD. As such, diagnostic assessment should include clear elaboration of any PTSD symptoms but also a focus on any additional relevant psychiatric and physical health comorbidities.

Finally, understanding the extent to which an individual is dissatisfied with their functioning in important life domains (e.g., relationships, work/school, housing/finances, health management) will provide important information for the focus of care.

Prolonged exposure and cognitive processing therapy are strongly recommended for survivors, though some may wish to prioritize psychoeducation and developing adaptive skills.