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DHI 08-136 – HSR Study

DHI 08-136
Combat, Sexual Assault, and Post-Traumatic Stress in OIF/OEF Military Women
Anne G. Sadler, PhD RN
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: July 2008 - June 2011
This research addresses the radically changing DoD and VA health care delivery needs of two priority populations: 1) combat exposed women and 2) women sexually assaulted during military service (SAIM). There is limited understanding of the complex relationship between these traumatic exposures and women's health outcomes (e.g., post-traumatic stress disorder (PTSD), traumatic brain injury (TBI) and subsequent health service use or barriers to care.

The objectives of this study were to investigate antecedent risk factors for SAIM and subsequent heath consequences in Regular Military (RM) servicewomen and to compare these findings with our HSR&D funded study of Reserve and National Guard (RNG) servicewomen (DHI 05-059).

Aims 1). Identify and describe organizational, situational, and individual risk factors for physical and SA (sexual assault) in women who have or are currently serving in the RM in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) by deployment status (deployed to combat related regions (Iraq or Afghanistan (I/A) once, deployed to I/A more than once, deployed to non-combat related areas outside of the continental United States (US), and serving within the continental US.

Aim 2). Determine associations among current mental and physical health (e.g., PTSD, TBI, PCS12 & MCS12 scores), physical and sexual assault during OEF/OIF, and health risk behaviors by deployment status.

Aim 3). Identify internal and external barriers to DoD, VA, and civilian health services in relationship to women's deployment and victimization status and the association between PTSD and TBI.

Aim 4). Identify and describe differences between RM and RNG populations for each of these objectives.

This cross sectional study used a mixed methods design including two sequential phases: 1.) qualitative focus groups (n=22 women) to refine the RNG study interview specific to RM populations, and (n= 14 men) to compare RM servicemen's perceptions with RM servicewomen's specific to women's deployment experiences; 2.) quantitative computer-assisted telephone interviews (CATI) of 729 RM servicewomen. Servicewomen were sampled from fives states of service accession (IA, IL, KS, MO, NE), Army and Air Force service branches, and stratified and randomly sampled by deployment status (with US Academy trained officers over-sampled). Consenting participants completed a CATI assessing socio-demographic variables, trauma exposures, health history, current health status, military environmental factors (organizational and situational factors), military and VA health care and barriers to this care, and self reported service use. Descriptive analyses and multiple logistic regressions were used.

Phase 1 focus groups with female RM identified similar factors as those identified by our RNG study but provided detailed descriptions of the RM vocational impact of deployment, SA trauma exposures and barriers to health care. Consistent themes in both populations included (but are not limited to): post-deployment readjustment concerns, access to care issues, stigma of mental health (MH) care, family readjustment, chronic health conditions, PTSD symptoms, leadership stressors, social support and isolation. Findings from our two groups with Academy trained officers suggested themes consistent with those we determined in both officer and enlisted focus groups with RNG. Phase 1 focus groups with RM males revealed that men's and women's perceived risk factors for women's traumatic/dangerous deployment experiences (including SA) differ.

SA is a significant health concern for RM servicewomen. Deployed women (Iraq/Afghanistan or elsewhere) were found to have an elevated risk of SA during military service (SAIM) compared to those never deployed. However, SAIM was not more likely to occur during a deployment. SAIMs occurring during deployment, as compared to characteristics of SAIMs occurring when not deployed, were: less likely to describe either the perpetrator(s) or victim as under the influence of drugs or alcohol during the assault; not more likely to occur at night; more likely to occur on-base and on bases where it was very risky for military personnel to enter and leave the base, and where the victim worked in close proximity to the perpetrator and continued to work in close proximity after the SAIM.

RM servicewomen deployed to I/A were found to have adverse health outcomes (PTSD, depression). In contrast to our RNG study, there were no differences in mental or physical health seeking by deployment status. RM servicewomen reporting SAIM were more likely to have sought MH care in the past year compared to non-assaulted peers.

Key barriers to seeking MH care among RM servicewomen included fear their chain of command might determine they are unfit for deployment, unit leadership would treat them differently, their unit would have less confidence in them, and they could be prescribed medicine that would interfere with their ability to do their military job.

The majority of servicewomen who experienced SAIM did not use either restricted or unrestricted reporting. Those who did report were more likely to use an unrestricted than a restricted report. The majority who used restricted reporting contacted a SA response coordinator (SARC) within 2 weeks of the assault. Most viewed their restricted reporting experience as positive, whereas half who used unrestricted reporting viewed the experience as negative. Percentages of those reporting SAIM were not significantly different between RNG compared to RM. No differences were found in physical or emotional health status between RM servicewomen using either reporting route and SAIM peers who did not report. The majority of RM women who experienced SAIM never received emotional counseling from a mental health clinician to help them deal with the assault; those who did, got counseling anywhere from within the first 24 hours up to nine years later.

Deployment does not appear to elevate risk of SAIM; however, SAIM remains a public health concern, as does deployment, given significant health related consequences and barriers to care. We found identifiable risk factors associated with RM women's violence exposures by deployment status. Subsequent population-based and intervention studies are needed to address these identifiable risk factors. Our findings suggest that gender-specific interventions focused on primary prevention of violence are warranted to address risk factors for SAIM. Interventions to improve restricted and unrestricted reporting outcomes and promote military women's early access to care following combat or SA trauma exposures are indicated.

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Journal Articles

  1. Cucciare MA, Mengeling MA, Han X, Torner J, Sadler AG. Associations between Augmentee Status, Deployment Stress Preparedness and Depression, Post-Traumatic Stress Disorder, and Binge Drinking in U.S. Servicewomen. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2020 May 1; 30(3):207-213. [view]
  2. Cucciare MA, Sadler AG, Mengeling MA, Torner JC, Curran GM, Han X, Booth BM. Associations between deployment, military rank, and binge drinking in active duty and Reserve/National Guard US servicewomen. Drug and Alcohol Dependence. 2015 Aug 1; 153:37-42. [view]
  3. Lehavot K, Der-Martirosian C, Simpson TL, Sadler AG, Washington DL. Barriers to care for women veterans with posttraumatic stress disorder and depressive symptoms. Psychological Services. 2013 May 1; 10(2):203-12. [view]
  4. Sadler AG, Mengeling M, Fraley SS, Torner J, Booth B. Correlates of Sexual Functioning in Women Veterans: Mental Health, Gynecologic Health, Health Status, and Lifetime Sexual Assault History. International journal of sexual health : official journal of the World Association for Sexual Health. 2012 Jan 1; 24(1):60-77. [view]
  5. Cucciare MA, Mengeling MA, Han X, Kennedy K, Torner J, Sadler AG. Experiencing Sexual Assault and/or Stalking-Related Behavior is Associated with Binge Drinking and Substance Use Consequences in Deployed U.S. Servicewomen. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2022 Jan 3; 32(4):402-410. [view]
  6. Sadler AG, Mengeling MA, Cook BL, Torner JC. Factors Associated with U.S. Military Women Keeping Guns or Weapons Nearby for Personal Security Following Deployment. Journal of women's health (2002). 2021 Jan 1; 30(1):103-112. [view]
  7. Mengeling MA, Booth BM, Torner JC, Sadler AG. Post-sexual assault health care utilization among OEF/OIF servicewomen. Medical care. 2015 Apr 1; 53(4 Suppl 1):S136-42. [view]
  8. Vander Weg MW, Mengeling MA, Booth BM, Torner JC, Sadler AG. Prevalence and correlates of cigarette smoking among operation Iraqi freedom-era and operation enduring freedom-era women from the Active Component military and Reserve/National Guard. Medical care. 2015 Apr 1; 53(4 Suppl 1):S55-62. [view]
  9. Mengeling MA, Booth BM, Torner JC, Sadler AG. Reporting sexual assault in the military: who reports and why most servicewomen don't. American journal of preventive medicine. 2014 Jul 1; 47(1):17-25. [view]
  10. Cheney A, Reisinger HS, Booth B, Mengeling M, Torner J, Sadler AG. Servicewomen’s strategies to staying safe during military service. Gender Issues. 2015 Mar 1; 32(1):1-18. [view]
  11. Sadler AG, Booth BM, Torner JC, Mengeling MA. Sexual assault in the US military: A comparison of risk in deployed and non-deployed locations among Operation Enduring Freedom/Operation Iraqi Freedom active component and Reserve/National Guard servicewomen. American Journal of Industrial Medicine. 2017 Nov 1; 60(11):947-955. [view]
  12. Sadler AG, Mengeling MA, Booth BM, O'Shea AM, Torner JC. The Relationship Between US Military Officer Leadership Behaviors and Risk of Sexual Assault of Reserve, National Guard, and Active Component Servicewomen in Nondeployed Locations. American journal of public health. 2017 Jan 1; 107(1):147-155. [view]
HSR&D or QUERI Articles

  1. Sadler AG. Women and Post-Deployment Health. HSR&D FORUM: Translating Research into Quality Health Care for Veterans. 2011 May 1; 6. [view]
Conference Presentations

  1. Ryan GL, Reisinger HS, Booth BM, Mengeling M, Summers KM, Torner J, Sadler AG. "I Can’t Be a Mother and Be in the Military": Military-related Role Stress and Behavioral Alterations of Servicewomen. Paper presented at: VA Women's Health Research Conference; 2014 Jul 31; Arlington, VA. [view]
  2. Sadler AG, Mengeling M, Erschens H, Franciscus CL, Smith J, Torner J, Booth BM. Interpersonal Violence and OEF/OIF Reserve and National Guard War Veterans. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD. [view]
  3. Sadler AG, Mengeling M, Torner J, Booth BM. Rape in active component and reserve/ national guard servicewomen: Deployed and non-deployed environments. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2013 Nov 5; Boston, MA. [view]
  4. Mengeling M, Sadler AG, Torner J, Booth B. Reporting In-Military Sexual Assault and Current Mental Health of OEF/OIF Active Component, Reserve, and National Guard Servicewomen. Paper presented at: AcademyHealth Annual Research Meeting; 2012 Jun 23; Orlando, FL. [view]
  5. Ryan GL, Mengeling M, Booth BM, Torner J, Syrop CH, Sadler AG. The Impact of Lifetime Sexual Assault and Post-Traumatic Stress Disorder on Voluntary and Involuntary Childlessness in American Women Veterans. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2013 Nov 7; Philadelphia, PA. [view]
  6. Bradley CS, Nygaard IE, Hillis SL, Torner J, Lu X, Sadler AG. The Impact of Mental Health Conditions on Incidence and Remission of Overactive Bladder. Paper presented at: American Urogynecologic Society Annual Scientific Meeting; 2014 Jul 23; Washington, DC. [view]
  7. Bradley CS, Nygaard IE, Hillis SL, Torner J, Lu X, Sadler AG. The Impact of Mental Health Conditions on Incidence and Remission of Overactive Bladder in Recently Deployed Women Veterans. Paper presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA. [view]
  8. Sadler AG, Mengeling M, Booth B, Torner J. The Military Environment: Implications for Women’s Sexual Assault Risk and Sexuality. Paper presented at: Society for the Scientific Study of Sexuality Annual Meeting; 2013 Nov 15; San Diego, CA. [view]
  9. Mengeling M, Booth BM, Torner J, Sadler AG. Unique barriers to seeking mental health care while deployed: OEF/OIF servicewomen's perceptions and provider effects. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2013 Nov 6; Boston, MA. [view]

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Epidemiology
Keywords: Operation Enduring Freedom, Operation Iraqi Freedom
MeSH Terms: none

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