Routine screening of veterans for a history of sexual trauma that
occurred while in military service is an efficient way to identify affected
individuals and increase their access to care, according to an analysis of
Veterans Health Administration records.
The Department of Veterans Affairs (VA) mandated universal screening for
military sexual trauma (MST) for both men and women beginning in 1999.
Screening was backed by an offer of "all appropriate care and
services" to treat sexual trauma occurring during military service.
"It was important to evaluate this system to see if universal
screening was appropriate and if the use of mental health services increased
afterward," said Rachel Kimerling, Ph.D., of the Veterans Administration
Health Care System in Palo Alto, Calif., at the International Society for
Traumatic Stress Studies meeting in Baltimore last November.
An article by Kimerling and colleagues on the same research appeared in the
December 2007 American Journal of Public Health.
The definition of military sexual trauma includes sexual assault and sexual
harassment, coercion, and unwanted sexual attention. Sexual trauma in the
armed forces may involve complicating factors that lack parallels in the
civilian world. Such events, or the fear of reporting them, may disrupt the
victim's career path, since perpetrators may be peers or supervisors.
Reporting sexual trauma may also be seen as a form of betrayal of unit
solidarity, one of the highest values in military organizations.
"This means that victims must continue to live and work closely with
their perpetrators, often leading to an increased sense of feeling helpless,
powerless, and at risk for additional victimization," wrote Amy Street,
Ph.D., and Jane Stafford, Ph.D., in the "Iraq War Clinician Guide"
published by the VA's National Center for Posttraumatic Stress Disorder.
Kimerling and colleagues used the Veterans Health Administration (VHA)
Out-patients Events File to identify more than 4 million men and 185,000 women
who made at least one visit to a VHA medical facility in 2003. The VHA uses a
computerized medical record with a pop-up reminder that prompts clinicians to
screen for sexual trauma. The reminder stays on the screen until the clinician
enters a response.
The sexual-trauma screening includes just two questions: "While you
were in the military: (a) Did you receive uninvited and unwanted sexual
attention, such as touching, cornering, pressure for sexual favors, or verbal
remarks? (b) Did someone ever use force or threat of force to have sexual
contact with you against your will?"
Data from 2003 were available for 134,894 women and 2,900,106 men. Although
the screening is called "universal," only about 70 percent of
patients were screened. That rate is not far below rates of screening for
alcohol abuse (80 percent) or cervical cancer (90 percent) in the VA.
Both men and women with positive screens were more likely to be white,
younger, never married, and have a service-connected disability than those who
screened negative. Men who screened positive were likely to be separated or
divorced, as well.
The rates of positive responses to the MST screen were much higher for
women than for men, but the preponderance of men in the VA system meant that
absolute numbers were similar. About 22 percent of women (29,418) screened
positive, compared with 1 percent of men (31,797).
"This highlights the issue of military sexual trauma in males,"
Women were three times and men twice as likely to have a psychiatric
diagnosis if they also screened positive for MST.
The association of posttraumatic stress disorder, alcohol use, and anxiety
disorders with MST was stronger among women. The relationship of adjustment
disorder, bipolar disorder, and schizophrenia or other psychoses to MST was
stronger among men.
Only a few nonpsychiatric medical conditions were associated with MST,
including weight loss, obesity, and hypothyroidism among women; AIDS among
men; and chronic lung or liver disease among both. Risky health behaviors that
may lead to these conditions are more frequent among patients exposed to
trauma than others.
On average, screening 5.5 women and 7.2 men moved one person into
treatment, said Kimerling. "Universal screening is efficient and
increases access to care."
The study marks just the beginning of bringing to light the"
significant burden" of morbidity related to military sexual
trauma, she emphasized.
An abstract of "The Veterans Health Administration and
Military Sexual Trauma" is posted at<www.ajph.org/cgi/content/abstract/97/12/2160>.▪