Victims of military sexual trauma—you see them, too

Women in the military who have a history of CSA, however, face a significantly higher risk for MST than servicewomen who were not sexually assaulted as children.⁸ Among female Navy recruits, for example, those who reported CSA were 4.8 times more likely to be raped than those who had no history of CSA.¹³

Combat-related trauma further complicates the picture. Evidence suggests that exposure to childhood physical and sexual abuse was associated with increased risk for combat-related posttraumatic stress disorder (PTSD) among men who served in Vietnam¹⁴ and women who served in Operation Desert Storm.¹⁵

Broaching the subject should be routine

Primary care physicians can play an important role in helping veterans transition back to their civilian lives and local communities, starting with a holistic medical assessment. When you see a patient whose return is relatively recent, inquire about his or her experiences during deployment. It is important to ask specifically about traumatic experiences, and to routinely screen for MST.

CASE When Ms. Doe returns. you begin by asking about her mood, using open-ended, nondirective questions. She responds by admitting that she had left important information off of the intake form she filled out on her last visit—most notably, a history of CSA. You gently ask about her experiences in the military, particularly during the year she spent in Iraq—and whether anything happened there that you should know.

Haltingly and with much emotion, the patient tells of her experience with another soldier. She worked with him every day, she says, and had grown close to him. One evening things went further than she expected. At first, it was only kissing, but then he forced himself on her sexually. She has not told anyone else about this event, Ms. Doe confides, because she wasn’t sure whether she precipitated it and felt embarrassed and humiliated by her choice to trust this man.

She did not feel that her supervising officers would listen or understand, as romantic attachments are best avoided in a combat zone and daily injuries are the norm. She says that her role as a medic kept her focused on the pain of others and enabled her to avoid looking at her own situation.

Evidence has shown that, like Ms. Doe, most survivors of trauma do not volunteer such information, but will often respond to direct and empathic questions from their physician.¹⁶ Routine screening of all veterans for MST, which the VA recommends, has been shown to increase their use of mental health resources.^17,18 This can be easily incorporated into a medical history or an intake questionnaire, using this simple 2-question tool:^17,18

While you were in the military:

• Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
• Did anyone ever use force or the threat of force to have sexual contact with you against your will?

Screen for PTSD, and consider other psychiatric disorders
MST has been found to confer a 9-fold risk for PTSD. Indeed, more than 4 in 10 (42%) women with a history of MST have a PTSD diagnosis.¹⁹ Thus, if the screen for MST is positive—as indicated by a Yes answer to either question—follow up with the 4-question Primary Care PTSD screen (TABLE 1) is recommended.²⁰

Veterans with a history of MST are twice as likely as other veterans to receive a mental health diagnosis;¹⁷ they’re also more likely to have 3 or more comorbid psychiatric conditions.²¹ Women appear to be more likely than men to suffer from depression, eating disorders, substance abuse,²² anxiety disorders,²¹ dissociative disorders, and personality disorders.¹⁷

Research on the mental health consequences of sexual assault in men (in any setting) is limited, however, and data on male survivors of MST are particularly sparse. What is known is that men who have experienced sexual trauma have higher rates of alcohol abuse²³ and self-harm²⁴ than women with a history of sexual trauma, and that MST has a greater association with bipolar disorder, schizophrenia, and psychosis in men.¹⁷

TABLE 1
Primary care PTSD screen (PC-PTSD)