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Evaluating the VA's Assessment of Military Sexual Trauma in Veterans
Anne G. Sadler, PhD RN
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: July 2009 - September 2012
The VA is federally mandated to screen, identify, and assist Veterans who experienced Military Sexual Trauma (MST). To achieve this, the VA requires that every Veteran be asked the same two questions regarding experiences with sexual assault and harassment during their military service. Screening generally occurs in face to face encounters between patients and clinicians providing medical and not trauma-related or psychologically-based care, and who may have received no training on how to ask MST questions or how to respond to answers. Data from VA Medical Centers, based on this two-item MST screener1, indicate that ~1% of male veterans and 14-24% of female veterans have disclosed military sexual trauma (MST) histories in response to the previously unstudied two-question screener. This rate is considerably less than that found by investigators studying active-duty military and using comprehensive survey measures. For example, rates of sexual harassment and sexual assault disclosure by men in active duty is significantly higher than the MST screener rates seen in male veterans, and similar gaps have been shown for female veterans. That VA rates of sexual harassment/assault are substantially lower than those obtained using a comprehensive tool is a concern not just because MST screening is federally mandated for veterans, but also because MST can lead to "depression; alcohol and/or substance abuse; suicidal thoughts; recurring and intrusive thoughts and dreams about the trauma incident; non-specific health problems; and relationship problems" (VA Pamphlet 10-114).
To obtain veterans' understandings of the two unstudied MST screening questions, their understanding of Congressional and VA definitions of sexual harassment and assault, and how being provided Congressional/VA definitions changes their understanding of the screening questions (or not), and their understanding of other sexual harassment/assault assessment approaches that are more comprehensive; and also whether they find more comprehensive approaches improve their ability to describe their own definitions of MST.
An in-person, qualitative interview study of a sample of male and female veterans stratified across four VA sites (Iowa City, Pittsburgh, Miami, and Philadelphia) was conducted. Recruitment varied by site IRB approved protocols, but included mailed letters of invitation to a random sampling of potential participants who had been asked the VA MST-screening questions in the last 2 years and direct invitation by research staff in clinics. Interested veterans were administered the Sexual Experiences Questionnaire (SEQ), a comprehensive sexual harassment/assault measure routinely used by Department of Defense. SEQ and VA MST-screening responses were used to characterize and direct recruitment of potential participants into true MST positive, false MST negative, and true MST negative subgroups. Analyses of resultant qualitative data explored each subgroup's understandings of the screening questions and of federal definitions of sexual harassment/assault.
When participants were asked to tell in their own words what the provided MST screening questions meant, they frequently used language consistent with that of the VA MST screeners. Yet, when participants next were asked to categorize specific behavior as: 1) sexual harassment, 2) sexual assault, or 3) neither, behaviors including physical contact were more likely to be identified as sexual assault than verbal behaviors that did not. For example, participants categorized 'physical assault of a sexual nature or battery of a sexual nature' as sexual assault (100%).
Behaviors such as 'being put down because of one's gender' (67%), and 'unwelcome sexual attention, such as 'flirting, when one has made it clear it's not welcome' were more likely to be viewed as sexual harassment (96%). Notably, behaviors including a sexual component, but no mention of physical force, were often split between harassment and assault: 'unwelcome verbal conduct of a sexual nature that occurs in the workplace or an academic or training setting' (48% harassment vs.48% assault); 'any sort of sexual activity NOT involving physical force between at least two people in which one of the people is involved against his or her will' (36% harassment vs.62% assault). There were no statistically significant differences in these findings by gender, or between MST positive versus negative Veterans.
Participants were also asked to categorize 23 behaviors as 1) definitely MST, 2) definitely not MST, and 3) maybe MST. Nine of the 23 behaviors were classified as 'definitely MST' by 90% or more of participants. Examples of these included 'implying faster promotions or better treatment for being sexually cooperative' (93%), 'making someone feel threatened with some sort of retaliation for not being sexually cooperative' (97%) and 'sex without someone's consent or against their will' (100%). Behaviors where approximately half of participants viewed the behavior as MST were 'putting someone down because of their sex' (53%) and 'treating someone "differently" because of their sex' (52%).
There were no statistically significant differences by gender, however, women were as or more likely to classify a behavior as 'definitely MST' compared to men for 21 of the 23 behaviors. For example, 'displaying, using, or distributing sexist or suggestive materials' was more likely to be classified as 'definitely MST' by women (87%), whereas men were more likely to classify this behavior as 'definitely NOT MST' (20%) or 'maybe MST' (23%).
When veterans were provided with VA and Congressional categories of sexual harassment and sexual assault behaviors, they were unlikely to modify their assignments of behaviors as harassment or assault to be congruent.
Only 27% of participants remembered answering the 2-item VA MST screen, even though all had documented screening in the past 2 years.
MST screening should be conducted to optimally allow men and women to accurately self-report experiences of sexual harassment and assault during military service. Our findings indicate that behavior specific examples may be needed to improve both screening validity and service members' comfort with their self-report.
Required 2-question, MST case-finding test currently in use
1.)When you were in the military, did you ever receive uninvited and unwanted sexual attention (e.g., touching, cornering, pressure for sexual favors, verbal remarks)?
2.)When you were in the military, did anyone ever use force or the threat of force to have sex with you against your will?
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DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems
Keywords: Deployment Related, Screening, Women - or gender differences
MeSH Terms: none