Victims of military sexual trauma—you see them, too

CASE A 29-year-old veteran (whom we’ll call Jane Doe) served as a medical corpsman in Iraq and has been pursuing a nursing degree since her honorable discharge a year ago. She comes in for a visit and reports a 3-month history of depression without suicidal ideation. In addition, Ms. Doe says, she has had abdominal pain that waxes and wanes for the past month. The pain is diffuse and nonfocal and appears to be unaffected by eating or bowel movements. She is unable to identify a particular pattern.

The patient has no significant medical or psychiatric history, and a physical examination is unremarkable. You advise her to follow a simplified dietary regimen, avoiding spicy foods and limiting dairy intake, and schedule a follow-up visit in 2 weeks.

Since 2002, some 2.4 million US troops have served in Iraq and Afghanistan,¹ creating a new generation of veterans who need broad-based support to recover from the physical and psychological wounds of war. All too often, those wounds include sexual assault or harassment, collectively known as military sexual trauma (MST).

MST is a growing concern for the Veterans Administration (VA) for a number of reasons—an increase in women on the front lines and greater media coverage of patterns of sexual assault in the military among them.² The official lifting of the ban on women in combat announced by the Pentagon in January brought the issue to the forefront, as well.³

In fact, MST should be a concern not only for clinicians within the VA, but also for civilian physicians. There are nearly 22 million American veterans, and the vast majority (>95%) get at least some of their medical care outside of the VA system⁴—often in outpatient facilities like yours.⁵ Family physicians need to be aware of the problem and able to give veterans who have suffered from sexual trauma the sensitive care they require.

The scope of the problem? No one is sure

How widespread is MST? That question is not easily answered. The prevalence rate among female service members is 20% to 43%,⁶ according to internal reports, while studies outside the military have reported rates that range from 3% to as high as 71%.⁵ In a recent anonymous survey of women in combat zones, led by a VA researcher—widely reported but still undergoing final review—half of those surveyed reported sexual harassment and nearly one in 4 reported sexual assault.⁷

There are far less data on rates of MST among male service members. The documented prevalence rate for men is 1.1%, with a range of 0.03% to 12.4%, but these figures are based on internal reports of sexual harassment and assault.⁸

Military culture and personal history are key factors
While the rate at which MST is reported has increased over the past 30 years,⁸ many reasons for not reporting it—stigma, fear of blame, accusations of homosexuality or promiscuity, and the threat of charges of fraternization among them—still remain.^8,9 Military culture is still male-dominated, with an emphasis on self-sufficiency that often leaves victims of MST feeling as though they have nowhere to turn.

There are also circumstances military members face that can aggravate the effects of sexual trauma. Soldiers on deployment are typically isolated from their normal support systems, under significant pressure, and unable to leave their post, which often means they have ongoing exposure to the abuser.

A history of childhood sexual abuse (CSA). As many as 50% of female service members (and about 17% of military men) have reported CSA,¹⁰ compared with 25% to 27% of women and 16% of men outside of the military.^5,11 That finding may be partially explained by data showing that nearly half of women in the military cited escaping from their home environment as a primary reason for enlisting.¹²