Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq.

Abstract

We examined military-related sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans. Of 125 729 veterans who received Veterans Health Administration primary care or mental health services, 15.1% of the women and 0.7% of the men reported military sexual trauma when screened. Military sexual trauma was associated with increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders. Sexual trauma is an important postdeployment mental health issue in this population.

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Military-RelatedSexual
TraumaAmongVeterans
HealthAdministration
PatientsReturningFrom
AfghanistanandIraq
Rachel Kimerling, PhD, Amy E. Street, PhD,
Joanne Pavao, MPH, Mark W. Smith, PhD, Ruth
C. Cronkite, PhD, Tyson H. Holmes, PhD, and
Susan M. Frayne, MD, MPH
Weexaminedmilitary-related
sexual trauma among deployed
Operation Enduring Freedom and
Operation Iraqi Freedom veterans.
Of 125729 veterans who received
VeteransHealth
primary care or mental health ser-
vices, 15.1% of the women and
0.7% of the men reported military
sexual trauma when screened. Mil-
itary sexual trauma was associated
with increased odds of a mental
disorder diagnosis, including post-
traumatic stress disorder, other
anxiety disorders, depression, and
substance use disorders. Sexual
trauma is an important postdeploy-
ment mental health issue in this
population. (Am J Public Health.
Published online ahead of print
June 17, 2010: e1–e4. doi:10.2105/
AJPH.2009.171793)
Administration
Emerging research with US veterans of
Operation Enduring Freedom in Afghanistan
and Operation Iraqi Freedom in Iraq suggests
that the mental health effects of these deploy-
ments are significant. An estimated 19% to
42% of this population have mental health
conditions.1–4One of the potential contributors
to this burden of mental illness is exposure to
sexual assault or harassment during service, re-
ferred to within the Veterans Health Adminis-
tration as military sexual trauma.5Considerable
data attest to the negative mental health conse-
quences of such experiences in both military and
civilian populations,5–13yet no data investigating
military sexual trauma in the context of
postdeployment mental health among the Oper-
ation Enduring Freedom and Operation Iraqi
Freedom cohort are currently available.
Operation Enduring Freedom and Opera-
tion Iraqi Freedom veterans are eligible for 5
years of free care through the Veterans Health
Administration for conditions related to their
military service. This cohort is turning to the
Veterans Health Administration for health care
in record numbers, with nearly 40% enrolled
to date.14The Veterans Health Administration
has recently invested significant resources in the
detection and treatment of military sexual
trauma, implementing universal military sexual
trauma screening in 2002 and providing free
care for all related conditions.5Although military
sexual trauma had been documented in veterans
of previous war eras,15,16Operation Enduring
Freedom and Operation Iraqi Freedom veterans
are the first generation of Veterans Health
Administration users to return from a large-scale
deployment to these comprehensive screening
and treatment services.
For our study, we completed, to our knowl-
edge, the first national, population-based as-
sessment of the mental health profile associated
with a history of military sexual trauma among
deployed Operation Enduring Freedom and
Operation Iraqi Freedom veterans who used
Veterans Health Administration services. We
describe the prevalence of military sexual
trauma and characterized the postdeployment
mental health conditions among patients who
reported a history of military sexual trauma.
METHODS
We included all veterans deployed in service
of Operation Enduring Freedom and Opera-
tion Iraqi Freedom and separated from military
service by September 30, 2006, who used
Veterans Health Administration mental health
or primary care services between October 1,
2001, and September 30, 2007. This cohort
had 21834 women and 142769 men.
Data were extracted from centralized elec-
tronic medical records and coded for military
sexual trauma screen status and International
Classification of Diseases, Ninth Revision,17diag-
noses for mental health conditions with methods
identical to those used in a previous study.5The
Veterans Health Administration Operation En-
during Freedom and Operation Iraqi Freedom
roster was used to identify our cohort and to
provide demographic and military service char-
acteristics.4Weusedthec2analysistodetermine
demographic characteristics, use of Veterans
Health Administration mental health or primary
care services, and military service characteristics
that were associated with military sexual trauma
status in veterans by gender. For each mental
health condition, we modeled the odds of the
diagnosis as a function of military sexual trauma
and adjusted for all demographic characteristics,
health care services use, and military service
characteristics that were significant (P<.05) in c2
analysis. Statistical analyses were conducted in
SPSS, Version14.0 (SPSS Inc, Chicago, IL).
RESULTS
We focused analyses on the members of the
cohort who were screened for military sexual
trauma, 17580 (80.5%) women and 108149
(75.8%) men, exclusive of the small minority
who declined screening (0.8% of women;
0.3% of men). Unscreened patients used fewer
Veterans Health Administration services: me-
dian outpatient visits for unscreened versus
screened patients were 2 versus 6 among
women (P<.001) and 4 versus 7 among men
(P<.001). All other group differences were
either nonsignificant or of minimal effect size,
with the exception that higher proportions of
unscreened men were Hispanic compared with
screened men (21.7% vs 9.4%; P<.001).
Military sexual trauma was reported by
15.1% of the women and 0.7% of the men.
Military sexual trauma screen status was sig-
nificantly related to several demographic
characteristics, health care services use, and
military service characteristics (Table 1).
Each of the most frequently reported mental
health conditions in the sample was signifi-
cantly more likely among women and men who
reported military sexual trauma than among
those who did not (Table 2), even after we
adjusted for demographic characteristics,
health care services use, and military service
characteristics. For both women and men, the
odds of each mental health condition did not
differ substantially between adjusted and un-
adjusted estimates, suggesting that associations
between military sexual trauma and these
conditions are distinct from the associations of
demographic characteristics, health care
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services use, and military service characteristics
with these conditions.
DISCUSSION
Although the issue of sexual trauma among
deployed Operation Enduring Freedom and
Operation Iraqi Freedom service members
continues to receive significant attention from
the media18,19and advocacy groups,20until now
no data have been available to quantify the
significant mental health burden of illness asso-
ciated with military sexual trauma in this pop-
ulation. Consistent with other research, we
observed high rates of postdeployment mental
health conditions among all Operation Enduring
Freedom and Operation Iraqi Freedom pa-
tients.21Women and men who reported a his-
tory of military sexual trauma were signifi-
cantly more likely than those who did not to
receive a mental health diagnosis, including
TABLE 1—Demographics, Health Care Services Use, and Military Service Characteristics of Operation Enduring Freedom and Operation Iraqi
Freedom Veterans Health Administration Outpatients and Military Sexual Trauma Screen Results: October 1, 2001, to September 30, 2007
WomenMen
Screened Positive for
Military Sexual Trauma
(n=2648), %
Screened Negative for
Military Sexual Trauma
(n=14932), %P
Screened Positive for
Military Sexual Trauma
(n=732), %
Screened Negative for
Military Sexual Trauma
(n=107417), %P
Demographics
Age, y.95.006
18–24 35.836.2 24.029.7
25–34 38.6 38.536.6 35.4
35–44
‡45
Race/ethnicity
17.917.5 26.0 22.8
7.7 7.813.4 12.1
<.001 .097
White59.3 49.6 64.1 68.3
Black 25.534.6 20.117.3
Hispanic10.010.0 10.79.4
Other/unknown5.25.7 5.24.9
Marital status.003 .007
Married32.730.2 49.1 46.9
Never married 56.8 60.343.5 47.8
Divorced/separated/widowed10.5 9.5 7.4 5.3
Health insurance21.5 23.0 .0919.0 27.0<.001
Service connection>50%27.6 13.7 <.001 27.616.6<.001
Veterans Health Administration services
use before Operation Enduring Freedom and
Operation Iraqi Freedom
7.3 5.8.002 9.25.5 <.001
Time in Veterans Health Administration care>12 mo88.7 87.2.04 84.385.4.41
Military service characteristics
Component <.001<.001
Active duty54.9 47.053.346.0
National Guard/Reserve45.1 53.046.7 54.0
Rank.92.53
Enlisted 93.393.3 94.794.1
Officer 6.76.75.35.9
Branch .002<.001
US Air Force12.713.0 9.7 7.7
US Army 69.171.766.470.3
US Navy/Coast Guard14.412.214.6 9.1
Marines 3.83.19.3 12.9
Multiple deployments32.235.3.00235.837.1.46
Most recent deployment>6 mo duration50.9 53.2.0351.958.3.001
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posttraumatic stress disorder (PTSD), other anx-
iety disorders, depression, and substance use
disorders. These results are consistent with data
suggesting that patients who experience military
sexualtraumafrequentlypresentwithsubstantial
mentalhealthtreatmentneeds.15,22,23Effectsizes
for the relation of military sexual trauma to
PTSD were substantially stronger among women
compared with men, suggesting that military
sexual trauma may be a particularly relevant
gender-specific clinical issue in PTSD treatment
settings.
The results of this study bear several caveats.
The rate of military sexual trauma and the rate
of mental illness reported in this study likely
represent conservative estimates because both
tend to be underreported.24–27Although sig-
nificant proportions of Operation Enduring
Freedom and Operation Iraqi Freedom veterans
use Veterans Health Administration services,
these data do not necessarily generalize to other
health care settings. Our analyses were cross-
sectional, so the exact timing of military sexual
trauma, deployment, and the onset of mental
health conditions cannot be determined. Thus,
no conclusion can be drawn about causal re-
lations between military sexual trauma and
mental health. Finally, although frequency and
length of deployment (measured in this study)
may serve as proxies for combat exposure,
research accounting for a broader range of
service-related stressors, including both military
sexual trauma and combat exposure, is needed.
Studies of mental health care for military
sexual trauma among veterans of previous
service eras have focused on experiences that
were detected at times considerably more distal
from military service. The Veterans Health
Administration’s ability to detect military sex-
ual trauma in this recently returned cohort will
help focus early interventions for this popula-
tion. However, survivors of sexual trauma often
delay disclosure and treatment of their experi-
ences,28and Operation Enduring Freedom
and Operation Iraqi Freedom Veterans report
stigma associated with help-seeking.29Thus, the
population of Operation Enduring Freedom and
Operation Iraqi Freedom veterans seeking Vet-
erans Health Administration care for military
sexual trauma may increase with time. These
data highlight the need to ensure adequate
access to and capacity of mental health care for
military sexual trauma and associated postde-
ployment mental health conditions. j
About the Authors
Rachel Kimerling is with the National Center for Post-
traumatic Stress Disorder and the Center for Health Care
Evaluation, VA Palo Alto Health Care System, Menlo Park,
CA. Amy E. Street is with the National Center for Post-
traumatic Stress Disorder, VA Boston Health Care System,
Boston, MA, and the Department of Psychiatry, Boston
University School of Medicine, Boston. Joanne Pavao is
with the National Center for Posttraumatic Stress Disorder,
VA Palo Alto Health Care System, Menlo Park. Mark W.
Smith is with the Health Economics Resource Center, VA
Palo Alto Health Care System, Menlo Park, and the Center
for Primary Care and Outcomes Research, Stanford
University School of Medicine, Stanford, CA. Ruth C.
Cronkite is with the Center for Health Care Evaluation, VA
Palo Alto Health Care System, Menlo Park, and the Center
for Primary Care and Outcomes Research, Stanford Uni-
versity School of Medicine, Stanford. Tyson H. Holmes is
with Department of Psychiatry and Behavioral Sciences,
Stanford University School of Medicine, Stanford. Susan M.
Frayne is with the Center for Health Care Evaluation, VA
Palo Alto Health Care System, Menlo Park, and the
Division of General Internal Medicine at Stanford Uni-
versity School of Medicine, Stanford.
Correspondence should be sent to Rachel Kimerling, PhD,
VA Palo Alto Health Care System, National Center for
PTSD, 795 Willow Rd (334-PTSD), Menlo Park, CA
94025 (e-mail: rachel.kimerling@va.gov). Reprints can
be ordered at http://www.ajph.org by clicking on the
‘‘Reprints/Eprints’’ link.
This brief was accepted November 9, 2009.
Contributors
R. Kimerling conceptualized the study. R. Kimerling and
A.E. Street wrote the brief. J. Pavao analyzed the data.
T.H. Holmes provided statistical consultation. All authors
collaborated on study conceptualization, interpreted
the findings, and reviewed and edited drafts of the
brief.
Acknowledgments
Funding was provided by the Health Services Research
and Development Service, US Department of Veterans
Affairs (IAE 05-291 and SDR 07-331).
Note. The views expressed in this brief are those of
the authors and do not necessarily reflect the position or
policy of the Department of Veterans Affairs. The fund-
ing source had no role in study design, data collection,
analysis, interpretation, manuscript preparation, or de-
cision to publish the manuscript.
Human Participant Protection
All research was approved by the human subjects re-
search institutional review board at the Stanford Uni-
versity School of Medicine.
TABLE 2—Military Sexual Trauma Screen Results and Mental Health Conditions of Operation Enduring Freedom and
Operation Iraqi Freedom Veterans Health Administration Outpatients: October 1, 2001, to September 30, 2007
Mental Health Condition
Women Men
Screened Positive
for Military Sexual
Trauma, %
Screened Negative
for Military Sexual
Trauma, %OR (95% CI)AOR (95% CI)a
Screened Positive
for Military Sexual
Trauma, %
Screened Negative
for Military Sexual
Trauma, %OR (95% CI) AOR (95% CI)a
Any mental health condition75.746.63.57 (3.25, 3.92) 3.28 (2.97, 3.62) 76.551.53.07 (2.58, 3.64) 3.08 (2.57, 3.67)
Depressive disorders 56.230.32.96 (2.72, 3.22) 2.64 (2.41, 2.88) 46.6 25.92.49 (2.15, 2.88) 2.32 (1.99, 2.70)
Posttraumatic stress disorder 51.121.5 3.82 (3.51, 4.16) 3.83 (3.49, 4.21)52.531.8 2.37 (2.05, 2.74) 2.53 (2.16, 2.97)
Other anxiety disorders 29.116.6 2.05 (1.87, 2.26) 1.80 (1.64, 1.99) 28.316.12.06 (1.75, 2.42) 1.98 (1.68, 2.34)
Alcohol and substance
use disorders
13.9 5.2 2.89 (2.53, 3.29) 2.51 (2.19, 2.87)22.012.71.93 (1.62, 2.30) 1.84 (1.53, 2.20)
Adjustment disorders20.6 13.4 1.68 (1.51, 1.86) 1.68 (1.50, 1.87) 20.913.4 1.71 (1.43, 2.04) 1.72 (1.44, 2.06)
Note. AOR=adjusted odds ratio; CI=confidence interval; OR=odds ratio.
aThe AOR compares likelihood of the specified mental health condition in military sexual trauma positive versus military sexual trauma negative patients, adjusting for age, race/ethnicity, marital
status, health insurance, service connection greater than 50%, Veterans Health Administration services use before Operation Enduring Freedom or Operation Iraqi Freedom, time in Veterans Health
Administration care greater than 12 months, component, branch, multiple deployment, and recent deployment of more than 6 months’ duration.
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