Military Sexual Trauma: Issues in Caring for Veterans
A National Center for PTSD Fact Sheet
Amy Street, Ph.D. and Jane Stafford, Ph.D.
What is Military Sexual Trauma? Military sexual trauma refers to both sexual
harassment and sexual assault that occurs in military settings. Both men and
women can experience military sexual trauma and the perpetrator can be of the
same or of the opposite gender. A general definition of sexual harassment is
unwelcome verbal or physical conduct of a sexual nature that occurs in the workplace
or an academic or training setting. Sexual harassment includes gender harassment
(e.g., put you down because of your gender), unwanted sexual attention (e.g.,
made offensive remarks about your sexual activities or your body) and sexual
coercion (e.g., implied special treatment if you were sexually cooperative).
Sexual assault is any sort of sexual activity between at least two people in
which one of the people is involved against his or her will. Physical force may
or may not be used. The sexual activity involved can include many different experiences
including unwanted touching, grabbing, oral sex, anal sex, sexual penetration
with an object, and/or sexual intercourse.
People tend to think that only women experience sexual trauma, however, this
is not the case. In 1995 the Department of Defense conducted a large study
of sexual victimization among active duty populations and found rates of sexual
harassment to be 78% among women and 38% among men over a one-year period.
Rates of attempted or completed sexual assault were 6% for women and 1% for
men. Rates of military sexual trauma among veteran users of VA healthcare appear
to be even higher than in general military populations. In one study, 23% of
female users of VA healthcare reported experiencing at least one sexual assault
while in the military.
Does Military Sexual Trauma Occur during Wartime?
Sexual trauma in the military does not occur only during training or peacetime
and in fact, the stress of war may be associated with increases in rates of
sexual harassment and assault.Research with Persian Gulf War military personnel
conducted by Jessica Wolfe and her colleagues found that rates of sexual assault
(7%), physical sexual harassment (33%) and verbal sexual harassment (66%) were
higher than those typically found in peacetime military samples.
Are There Unique Aspects of Sexual Trauma Associated with Military
Service?
While there is almost no empirical data comparing experiences of military
sexual trauma with experiences of sexual harassment and assault that occur
outside of military service, there is some anecdotal evidence that these experiences
are unique and may be associated with qualitatively or quantitatively different
psychological outcomes.
Sexual trauma that is associated with military service most often occurs in
a setting where the victim lives and works.In most cases, this means that victims
must continue to live and work closely with their perpetrators, often leading
to an increased sense of feeling helpless, powerless, and at risk for additional
victimization. In addition, sexual victimization that occurs in this
setting often means that victims are relying on their perpetrators (or associates
of the perpetrator) to provide for basic needs including medical and psychological
care. Similarly, because military sexual trauma occurs within the workplace,
this form of victimization disrupts the career goals of many of its victims. Perpetrators
are frequently peers or supervisors responsible for making decisions about
work-related evaluations and promotions. In addition, victims are often
forced to choose between continuing military careers during which they are
forced to have frequent contact with their perpetrators or sacrificing their
career goals in order to protect themselves from future victimization.
Most military groups are characterized by high unit cohesion, particularly
during combat. While this level of solidarity typically reflects a positive
aspect of military service, the dynamics of cohesion may play a role in the
negative psychological effects associated with sexual harassment and assault
that occurs. Because organizational cohesion is so highly valued within
the military environment, divulging any negative information about a fellow
soldier is considered taboo. Accordingly, many victims are reluctant
to report sexual trauma and many victims say that there were no available methods
for reporting their experiences to those in authority. Many indicate
that if they did report the harassment they were not believed or encouraged
to keep silent about the experience. They may have had their reports ignored,
or even worse, have been themselves blamed for the experience. Having
this type of invalidating experience following a sexual trauma is likely to
have a significant negative impact on the victim’s post-trauma adjustment.
What Type of Psychological Responses are Associated with Military
Sexual Trauma Victimization?
Given
the range of sexual victimization experiences that veterans report (ranging
from inappropriate
sexual jokes or flirtation, to pressure for sexual favors, to completed
forcible rape) there are a wide range of emotional reactions reported by
veterans in response to these events. Even in the aftermath of severe forms
of victimization, there is no one way that victims will respond. Instead,
the intensity, duration, and trajectory of psychological responses will
all vary based on factors like the veterans’ previous trauma history, their
appraisal of the traumatic event, and the quality of their support systems
following the trauma. In addition, the victim’s gender may play a role
in the intensity of the post-trauma reactions. While the types of
psychological reactions experienced by men and women are often similar,
the experience
of sexual victimization may be even more stigmatizing for men than it is
for women because these victimization experiences fall so far outside of
the proscribed male gender role. Accordingly, men may experience
more severe symptomatology than women, may be more likely to feel shame
about
their victimization, and may be less likely to seek professional help.
Among both men
and women in the active duty military, sexual harassment is associated with
poorer psychological well-being, more physical problems and lower satisfaction
with health and work. Female veterans who use VA healthcare and report
a history of sexual trauma while in the military also report a range of negative
outcomes, including poorer psychological and physical health, more readjustment
problems following discharge (i.e., difficulties finding work, alcohol and
drug problems), and a greater incidence of not working due to mental health
problems. Studies of sexual assault among civilian populations identify
posttraumatic stress disorder (PTSD) as a frequent outcome. Sexual
assault victimization is associated with high lifetime rates of PTSD in both
men (65%) and women (45.9%). Interestingly, these rates are higher
than the rate reported by men following combat exposure (38.8%). Major
depressive disorder (MDD) is another common reaction following sexual assault,
with research suggesting that almost a third of sexual assault victims have
at least one period of MDD during their lives. Victims of sexual assault
may also report increased substance use, perhaps as a means of managing other
psychological symptoms. One large-scale study found that compared to
non-victims, rape survivors were 3.4 times more likely to use marijuana,
6 times more likely to use cocaine, and 10 times more likely to use other
major drugs. In addition to these psychological conditions, victims of sexual
trauma may continue to struggle with a range of other symptoms that interfere
with their quality of life. Common emotional reactions include anger
and shame, guilt or self-blame. Victims of sexual trauma may report
problems in their interpersonal relationships, including difficulties with
trust, difficulties engaging in social activities or sexual dysfunction. Male
victims of sexual trauma may also express concern about their sexuality or
their masculinity.
How Has the VA Responded to the Problem of Military Sexual Trauma?
Given the alarming prevalence rates of sexual harassment and sexual assault
among military veterans, it has been necessary for the VA to respond actively
to the healthcare needs of veterans impacted by these experiences. In
July 1992, a series of hearings on women veterans’ issues by the Senate
Veterans Affairs Committee first brought the problem of military sexual trauma
to policy makers’ attention. Congress responded to these hearings
by passing Public Law 102-585, which was signed into law in November of 1992. Among
other things, Public Law 102-805 authorized health care and counseling to women
veterans to overcome psychological trauma resulting from experiences of sexual
assault or sexual harassment during their military service. Later laws
expanded this benefit to male veterans as well as female veterans, repealed
limitations on the required duration of service, and extended the provision
of these benefits until the year 2005. Following the passage of these
public laws, a series of VA directives mandated universal screening of all
veterans for a history of military sexual trauma and mandated that each facility
identify a Military Sexual Trauma Coordinator to oversee the screening and
treatment referral process.
Are There Screening, Assessment or Treatment Issues That Are Unique
to Sexual Assault and Harassment?
Screening. It is important to screen
all veterans for a history of sexual harassment and assault. Not only
is universal screening mandated by VA, it also represents good clinical practice
given the high prevalence rates of military sexual trauma among male and
female veterans and the reluctance of many sexual trauma survivors to volunteer
information about their trauma histories. Screening for all forms of
trauma exposure should be approached with compassion and sensitivity, but
screening for a history of sexual trauma requires particular care because
of the stigma associated with this type of victimization. For accurate
screening, good rapport with the veteran is essential, as is close attention
to issues of confidentiality (e.g., not screening in the presence of other
providers or family members). Regardless of the care taken by the interviewer,
the victims’ shame and self-blame may prevent or delay disclosure,
particularly for male victims or for victims who have experienced punishment
or disbelief following previous disclosures.
When screening for a history of sexual trauma it is important to avoid words
like “rape” and “sexual harassment.” Asking the
question, “While you were in the military, were you ever raped?” assumes
that the victimized person knows how rape is defined and perceives what happened
to them as a rape. Additionally, these words are “loaded terms” for
many people and a victim may respond negatively in order to avoid the social
stigma that goes along with being a rape victim. A method of screening
that is likely to yield fairly accurate results without being perceived by
the veteran as too intrusive involves two general questions that use descriptive,
non-judgmental wording (i.e., While you were in the military did you ever experience
any unwanted sexual attention, like verbal remarks, touching, or pressure for
sexual favors?; Did anyone ever use force or the threat of force to have sex
with you against your will?).
Assessment. At this time, there are no
published measures specifically designed to assess sexual trauma that occurs
as part of military service. While most checklist measures that assess for
trauma exposure include at least one question about sexual assault, generally
these
measures do not assess sexual harassment. However, there are a number of existing
self-report measures and structured interviews specifically designed to assess
sexual harassment and/or sexual assault. The Sexual Experience Questionnaire
by Louise Fitzgerald is the most widely used measure of sexual harassment.
One of the most widely used measures of sexual assault, the Sexual Experiences
Survey
by Mary Koss and her colleagues, is a self-report measure that assesses a variety
of unwanted sexual experiences including those
associated with substance use. An example of an interview developed for
the purpose of assessing sexual assault is The National Women’s Study interview
developed by Heidi Resnick and her colleagues. It includes a series of
behaviorally specific questions that ask about a variety
of unwanted sexual experiences.
Treatment While the
consequences of sexual harassment and assault can be severe and complex, there
are treatments available that can significantly reduce psychological symptoms
and improve a victim’s quality of life. There is very little empirically-based
information on the treatment of sexual harassment or on the treatment of any
sexual trauma associated with military service. However, there is a wealth
of information available on the treatment of sexual assault in civilian populations
that can be used to inform treatment of veteran populations.
Interventions for sexual trauma often involve addressing immediate health and safety concerns (particularly in the case of an acute trauma), normalizing post-trauma reactions by providing education about trauma and psychological reactions to traumatic events, providing the victim with validation, supporting existing adaptive coping strategies and facilitating the development of new coping skills, like muscle relaxation or deep breathing. Treatment interventions may also include exploring affective and cognitive reactions including fear, self-blame, anger and disillusionment, some form of exposure therapy and/or some form of cognitive restructuring. Clinicians looking for more in depth information on the treatment of sexual trauma are referred to Foa and Rothbaum1 and Resick and Schnicke.2
Related Fact Sheets
Child
sexual abuse
Details the effects of sexual abuse on children, and adults exposed to sexual
abuse as children
Female
sexual assault
Defines sexual assault among females and gives an overview of its immediate
and long-term effects
Male
sexual assault
Defines sexual assault among males and gives an overview of its immediate and
long-term effects
Treating
women with a history of sexual trauma
A fact sheet for medical providers working with women who have a history of
sexual trauma
References
1. Foa, E. B., & Rothbaum, B. O. (1998). Treating
the trauma of rape: Cognitive-behavioral therapy for PTSD.
New York: Guilford.
2. Resick, P. S., & Schnicke, M. K. (2002). Cognitive
processing therapy for rape victims: A treatment manual
. Newbury Park, CA: Sage.
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