Health Services Research & Development

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Spotlight: April is Sexual Assault Awareness and Prevention Month

April 2015


Military sexual trauma (MST) is the term that VA uses when referring to sexual assault or repeated, threatening sexual harassment that occurred while a Veteran was in the military. Both men and women have experienced MST during their service. Data from VA's national screening program indicates that about 1 in 4 women and 1 in 100 men have experienced MST, keeping in mind that this reflects only the rate of MST among Veterans who have chosen to seek VA healthcare - and to report MST.1 Intimate partner violence (IPV) includes physical attacks, sexual assault or coercion, threats of violence, verbal assaults, and stalking by a current or former intimate partner, and also is a serious public health challenge. Approximately 29% of women and 10% of men in the U.S. have experienced rape, physical violence, and/or stalking by an intimate partner, and research suggests that IPV is common in women Veterans, particularly those who access VA healthcare services.2

Military sexual trauma can result in both mental and physical illness, including: PTSD, depression, substance abuse, as well as higher rates of headaches, gastrointestinal difficulties, sexual dysfunction, chronic pain, and chronic fatigue.1 Therefore, it is important for MST to be diagnosed and treated early.

HSR&D and Research on Sexual Assault and Prevention

Following are descriptions of just a few select studies that HSR&D and QUERI investigators conduct on research to improve prevention of and treatment for sexual assault.

OEF/OIF Servicewomen Reluctant to Report Military Sexual Assault

This study sought to identify factors associated with officially reporting sexual assault while in-military (SAIM), examining demographic, military, and sexual assault characteristics, as well as perceptions and experiences of reporting. Investigators identified a Midwestern community sample of active component (n=674) and Reserve and National Guard (n=665) servicewomen. Interviews were conducted from 3/10 through 12/11, and data were analyzed in 2013. Participants in this study were provided with definitions of restricted (law enforcement is not informed, nor does the command structure become involved) and unrestricted (law enforcement and the command structure are notified, and a criminal investigation is initiated) reporting before being asked about their use of either option. Findings show:

  • Of the 1,339 OEF/OIF servicewomen in this study, 18% of the active component service members and 12% of the Reserve/National Guard members experienced SAIM. Despite increased knowledge about how to report SAIM, there was no increase in rates of reporting compared to earlier VA-enrolled samples; the number of servicewomen who knew how to officially report increased from 57% to 65%, but the rates of reporting were similar, 26% vs. 25%.
  • Restricted reporting was rated more positively, but unrestricted reporting was used more often (40 vs. 15 reports).
  • Experiences of servicewomen who reported SAIM reinforced concerns of those who did not report, such as loss of confidentiality, adverse treatment by peers, no action taken against the perpetrator.
  • Officers were less likely to report SAIM than enlisted servicewomen (10% vs. 28%).

Until SAIM can be prevented, addressing reporting outcomes (e.g., ensuring confidentiality, preventing reprisal, investigating offenders) is needed for service members to believe that reporting is in their best interest and that of the larger military community.

Mengeling M, Booth B, Tomer J, and Sadler A. Reporting sexual assault in the military: Who reports and why most servicewomen don't. American Journal of Preventive Medicine. July 2014;47(1):17-25.

Intimate Partner Violence: Current State of Knowledge in Regard to Women Veterans

This study, partly funded by HSR&D, sought to provide an overview of the risk and impact of experiencing intimate partner violence (IPV) among women Veterans, who currently make up 10% of the Veteran population, and who appear particularly likely to report IPV (research has shown prevalence ranges from 24% to 29% of past-year IPV). Investigators also examined evidence-based treatment for IPV and identified future priorities for research and clinical programming. Findings show:

  • Risk factors or risk markers for IPV include pre-military trauma, military sexual trauma, post-traumatic stress disorder (PTSD), and depression. For example, women who have experienced IPV exhibit rates of PTSD that range from 31% to 84%, and the prevalence of depression among women who have experienced IPV is estimated to be 48%.
  • When compared to non-Veteran women, women Veterans have higher rates of lifetime IPV (33 vs 24%).
  • Common comorbidities associated with IPV include traumatic brain injury (TBI) and homelessness. Women Veterans are up to four times more likely to be homeless than non-Veteran women and may become homeless as a consequence of experiencing IPV.
  • The literature shows that women Veterans who experienced both sexual and physical assault were more likely to report chronic health conditions and significantly lower health-related quality of life for 10 or more years after military service.

Recently, both the U.S. Preventive Services Task Force and the Institute of Medicine issued recommendations supporting the screening and identification of women at risk for IPV. Since publication, VA has implemented a national Domestic Violence/Intimate Partner Violence Assistance program which recommends universal screening of reproductive aged women using the five-item E-HITS (Extended Hurt/Insult/Threaten/Scream) tool. Recent VA research has established the clinical utility of the E-HITS in a sample of women VA patients.

Gerber MR, Iverson KM, Dichter ME, et al. Women Veterans and intimate partner violence: Current state of knowledge and future directions. Journal of Women's Health. April 2014;23(4):302-309.

Women Veterans who Experience Intimate Partner Violence at Higher Risk for Illness

Studies have shown that intimate partner violence (IPV) victimization is associated with a variety of health conditions, including mental health problems, as well as greater healthcare utilization, yet little is known about the IPV experiences of contemporary women Veterans. This study sought to fill gaps in knowledge by examining demographic and clinical characteristics of women Veterans who have disclosed IPV victimization to a VA healthcare provider. Investigators conducted a five-year retrospective chart review (2005-2009) of women Veterans age 55 and younger (n=531) who had received primary care at one VAMC in 2009. Findings show:

  • Lifetime IPV was documented in about one-quarter (24%) of women Veterans' medical records and was associated with higher risk of many medical conditions and with increased healthcare use.
  • Women Veterans with documented IPV had higher rates of military sexual trauma, injury/poisoning, mental health disorders, infectious or parasitic diseases, and digestive system disorders.
  • More than 95% of women Veterans with documented IPV had a mental health diagnosis, including: 60% with episodic mood disorders, 57% with neurotic disorders, 48% with PTSD, and 72% with depression (not otherwise specified). In addition, 45% reported military sexual trauma.
  • Compared with women who had no documented IPV, those with documented IPV had a higher average number of healthcare encounters per month and were more likely to have visited the emergency department - and to have had a mental health/behavioral health/social work visit during the study period.

Study findings, coupled with the redesign of VA clinical practice through Patient Aligned Care Teams and a focus on gender-specific care, suggest that it may be an optimal time to establish a comprehensive IPV assessment and response program within the VA healthcare system.

Dichter M and Marcus S. Intimate partner violence victimization among women Veterans: Health, healthcare service use, and opportunities for intervention. Military Behavioral Health. October 2013;1(2):107-113.

Health Factors Associated with Sexual Intimate Partner Violence among Women Veterans

Partly funded by HSR&D, this study sought to identify specific health status and health risk behaviors associated with sexual intimate partner violence (IPV) among women Veterans. Based on data collected through interviews with 249 women Veterans who received VA healthcare, investigators found that among those who reported experiencing sexual IPV: 58% reported a diagnosis of PTSD; 81% reported a diagnosis of depression, bipolar disorder, or anxiety; 79% reported difficulty sleeping; 71% reported chronic pain; 45% reported smoking cigarettes; and 27% reported problem drinking. Controlling for age, race, and income, compared with those who reported no IPV experience, those who reported sexual IPV were 3.07 times more likely to report poor or fair overall health; 2.85 times more likely to report a PTSD diagnosis; 2.82 times more likely to report a diagnosis of depression, bipolar disorder, or anxiety; 2.52 times more likely to report difficulty sleeping, 3.15 times more likely to report smoking cigarettes; and 3.84 times more likely to report problem drinking.

Dichter M, Marcus S, Wagner C, and Bonomi A. Associations between psychological, physical, and sexual intimate partner violence and health outcomes among women Veteran VA patients Social Work in Mental Health. January 2015;12:5-6.

Yoga for Women Veterans with PTSD and Military Sexual Trauma

This HSR&D pilot study sought to establish the feasibility of conducting a study of a trauma-sensitive yoga intervention in women Veterans with PTSD who experienced military sexual trauma (MST). Specifically, investigators sought to assess the feasibility of recruitment, retention, and intervention implementation - and to determine the viability of obtaining biological and psycho-physiological data as outcomes for yoga and PTSD research in this population. Two cohorts of women Veterans seeking MST-related PTSD treatment in a VA medical center were randomized to a 10-week trauma-sensitive yoga intervention (n=17) or a 12-week Cognitive-Processing Therapy-Cognitive (CPT-C) intervention (n=25). Data were collected at baseline, mid-intervention, 2-weeks post-intervention, and 3-months post-intervention. Findings show:

  • Intervention completion, defined as 7/10 yoga sessions and 10/12 CPT-C, was 58% for women Veterans in the yoga group and 36% for women Veterans in the CPT-C group.

  • Women Veterans in the yoga group experienced improvements in:
    • PTSD severity (25% decrease vs 8% decrease in the CPT-C group),
    • Depression (45% decrease vs 17% increase in the CPT-C group), and
    • Chronic pain levels (36% decrease vs 16% increase in the CPT-C group).

Results support the design of a larger study to evaluate the effectiveness of trauma-sensitive yoga in reducing PTSD and depression symptoms, chronic pain, and biological and physiological stress in women Veterans who experienced MST. Trauma-sensitive yoga may be an effective alternative or adjunct to current first-line PTSD treatment (i.e. CPT) that could be implemented in VA nationally.

References:

  1. VA Mental Health. Military Sexual Trauma.
  2. Gerber M, Iverson K, Dichter M, et al. Women Veterans and intimate partner violence: Current state of knowledge and future directions. Journal of Women's Health. April 2014;23(4):302-309.

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