HSR&D Home » Research » DHI 08-136 – HSR&D Study
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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DRA: Military and Environmental Exposures, Health Systems, Mental, Cognitive and Behavioral Disorders
Keywords: Operation Enduring Freedom, Operation Iraqi Freedom
MeSH Terms: none