Nicole Baltrushes, MD; Niranjan S. Karnik, MD, PhD, FAPA Victims of military sexual trauma— University of Chicago, Pritzker School of Medicine you see them, too

[email protected]. edu while serving in the military is not

The authors reported no uncommon, and the effects linger long after veterans are potential conflict of interest relevant to this article. home—and seeing civilian physicians like you.

CASE c A 29-year-old veteran (whom we’ll call Jane Practice Doe) served as a medical corpsman in Iraq and has been recommendations pursuing a nursing degree since her honorable dis- › Routinely question veterans charge a year ago. She comes in for a visit and reports a about physical and sexual 3-month history of without suicidal ideation. In ad- assault. C dition, Ms. Doe says, she has had abdominal pain that waxes › Suspect a history of military and wanes for the past month. The pain is diffuse and nonfocal sexual trauma (MST) in and appears to be unaffected by eating or bowel movements. veterans who present with She is unable to identify a particular pattern. multiple physical symptoms. The patient has no significant medical or psychiatric his- B tory, and a physical examination is unremarkable. You advise › Screen patients with a his- her to follow a simplified dietary regimen, avoiding spicy foods tory of MST for posttraumatic and limiting dairy intake, and schedule a follow-up visit in stress disorder and other 2 weeks. psychiatric comorbidities. B ince 2002, some 2.4 million US troops have served in Strength of recommendation (SOR) Iraq and Afghanistan,1 creating a new generation of vet- A Good-quality patient-oriented evidence S erans who need broad-based support to recover from B Inconsistent or limited-quality the physical and psychological wounds of war. All too often, patient-oriented evidence those wounds include sexual assault or harassment, collec- C Consensus, usual practice, opinion, disease-oriented tively known as military sexual trauma (MST). evidence, case series MST is a growing concern for the Veterans Administration (VA) for a number of reasons—an increase in women on the front lines and greater media coverage of patterns of sexual as- sault in the military among them.2 The official lifting of the ban on women in combat announced by the Pentagon in January brought the issue to the forefront, as well.3 In fact, MST should be a concern not only for clinicians within the VA, but also for civilian physicians. There are nearly 22 million American veterans, and the vast majority (>95%) get at least some of their medical care outside of the VA system4—often in outpatient facilities like yours.5 Family physicians need to be aware of the problem and able to give veterans who have suffered from sexual trauma the sensitive care they require.

120 The Journal of Family Practice | MARCH 2013 | Vol 62, No 3 The scope of the problem? not sexually assaulted as children.8 Among No one is sure female Navy recruits, for example, those who How widespread is MST? That question is not reported CSA were 4.8 times more likely to be easily answered. The prevalence rate among raped than those who had no history of CSA.13 female service members is 20% to 43%,6 ac- Combat-related trauma further com- cording to internal reports, while studies plicates the picture. Evidence suggests that outside the military have reported rates that exposure to childhood physical and sexual range from 3% to as high as 71%.5 In a recent was associated with increased risk for anonymous survey of women in combat combat-related posttraumatic stress disorder zones, led by a VA researcher—widely report- (PTSD) among men who served in Vietnam14 ed but still undergoing final review—half of and women who served in Operation Desert those surveyed reported Storm.15 and nearly one in 4 reported sexual assault.7 There are far less data on rates of MST among male service members. The docu- Broaching the subject mented prevalence rate for men is 1.1%, with should be routine a range of 0.03% to 12.4%, but these figures Primary care physicians can play an impor- are based on internal reports of sexual ha- tant role in helping veterans transition back rassment and assault.8 to their civilian lives and local communities, starting with a holistic medical assessment. In a recent Military culture and personal history When you see a patient whose return is rela- survey of are key factors tively recent, inquire about his or her experi- women in While the rate at which MST is reported has ences during deployment. It is important to combat zones, increased over the past 30 years,8 many rea- ask specifically about traumatic experiences, half reported sons for not reporting it—stigma, fear of and to routinely screen for MST. sexual blame, accusations of homosexuality or pro- harassment miscuity, and the threat of charges of fraterni- CASE c When Ms. Doe returns. you begin by and nearly zation among them—still remain.8,9 Military asking about her mood, using open-ended, one in 4 culture is still male-dominated, with an em- nondirective questions. She responds by ad- reported phasis on self-sufficiency that often leaves mitting that she had left important informa- sexual assault. victims of MST feeling as though they have tion off of the intake form she filled out on nowhere to turn. her last visit—most notably, a history of CSA. There are also circumstances military You gently ask about her experiences in the members face that can aggravate the effects military, particularly during the year she spent of sexual trauma. Soldiers on deployment are in Iraq—and whether anything happened typically isolated from their normal support there that you should know. systems, under significant pressure, and un- Haltingly and with much emotion, the able to leave their post, which often means patient tells of her experience with another they have ongoing exposure to the abuser. soldier. She worked with him every day, she z A history of childhood sexual abuse says, and had grown close to him. One eve- (CSA). As many as 50% of female service ning things went further than she expected. members (and about 17% of military men) At first, it was only kissing, but then he forced have reported CSA,10 compared with 25% to himself on her sexually. She has not told any- 27% of women and 16% of men outside of one else about this event, Ms. Doe confides, the military.5,11 That finding may be partially because she wasn’t sure whether she precipi- explained by data showing that nearly half of tated it and felt embarrassed and humiliated cited escaping from by her choice to trust this man. their home environment as a primary reason She did not feel that her supervising of- for enlisting.12 ficers would listen or understand, as roman- Women in the military who have a histo- tic attachments are best avoided in a combat ry of CSA, however, face a significantly higher zone and daily injuries are the norm. She says risk for MST than servicewomen who were that her role as a medic kept her focused on

jfponline.com Vol 62, No 3 | MARCH 2013 | The Journal of Family Practice 121 TABLE 1 Primary care PTSD screen (PC-PTSD)

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: — Have had nightmares about it or thought about it when you did not want to? — Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? — Were constantly on guard, watchful, or easily startled? — Felt numb or detached from others, activities, or your surroundings?

A Yes response to any 3 questions is a positive screen, indicating a need for further investigation and possible referral to a professional. PTSD, posttraumatic stress disorder. Source: National Center for PTSD. http://www.ptsd.va.gov/professional/pages/assessments/pc-ptsd.asp.

the pain of others and enabled her to avoid to have 3 or more comorbid psychiatric con- looking at her own situation. ditions.21 Women appear to be more likely than men to suffer from depression, eating Why does Evidence has shown that, like Ms. Doe, disorders, substance abuse,22 anxiety disor- military sexual most survivors of trauma do not volunteer ders,21 dissociative disorders, and personality assault go such information, but will often respond to disorders.17 unreported? direct and empathic questions from their Research on the mental health conse- Stigma, fear physician.16 Routine screening of all veterans quences of sexual assault in men (in any set- of blame, for MST, which the VA recommends, has been ting) is limited, however, and data on male accusations of shown to increase their use of mental health survivors of MST are particularly sparse. homosexuality resources.17,18 This can be easily incorporated What is known is that men who have expe- or promiscuity, into a medical history or an intake question- rienced sexual trauma have higher rates of and the naire, using this simple 2-question tool:17,18 alcohol abuse23 and self-harm24 than women possibility with a history of sexual trauma, and that MST of being While you were in the military: has a greater association with bipolar disor- charged with • Did you receive uninvited and unwanted der, schizophrenia, and psychosis in men.17 fraternization. sexual attention, such as touching, cor- nering, pressure for sexual favors, or ver- bal remarks? Multiple physical symptoms • Did anyone ever use force or the threat are often trauma-related of force to have sexual contact with you Veterans with a history of MST are also more against your will? likely to report physical symptoms25 and to have a lower health-related quality of life,26 Screen for PTSD, and consider other poorer health status, and more outpatient vis- psychiatric disorders its12 than vets who were not exposed to MST. MST has been found to confer a 9-fold And, while pelvic pain is widely believed risk for PTSD. Indeed, more than 4 in 10 to be associated with female sexual abuse, (42%) women with a history of MST have survivors often present with a wide range of a PTSD diagnosis.19 Thus, if the screen for physical problems. The most common symp- MST is positive—as indicated by a Yes an- toms, similar to those affecting civilian swer to either question—follow up with the survivors, include headache, gastrointestinal 4-question Primary Care PTSD screen (GI) problems, chronic fatigue, severe meno- (TABLE 1) is recommended.20 pause symptoms, and urological problems, Veterans with a history of MST are twice as well as pelvic pain and sexual problems.27 as likely as other veterans to receive a men- Cardiac and respiratory disorders are also tal health diagnosis;17 they’re also more likely common (TABLE 2).17,25

122 The Journal of Family Practice | MARCH 2013 | Vol 62, No 3 Military sexual trauma

TABLE 2 Common physical symptoms reported by female MST survivors*17,25

Reproductive/gynecological Pulmonary • Dysmenorrhea • Sinus congestion • Severe premenstrual symptoms • Allergies • Menometrorrhagia • Cough • Chronic pelvic pain

GI Neurologic/rheumatologic • Indigestion • Severe headache • Diarrhea and constipation • Chronic back pain • Dysphagia/odynophagia • Knee/foot pain/aching/stiffness • Irritable bowel syndrome

Other CVD/CVD risk factors • Chronic fatigue • HTN Half of all • Vision problems • Obesity female soldiers • Hearing problems • Sedentary lifestyle report childhood sexual abuse, • Weight loss • Alcohol use problem and 49% cite • Smoking escape from • Hysterectomy <40 y their home

*This is a selection of the symptoms and risk factors MST survivors present with; it is not an exhaustive list. environment as CVD, cardiovascular disease; GI, gastrointestinal; HTN, hypertension; MST, military sexual trauma. a primary reason for enlisting.

Compared with their unaffected coun- who present with complaints involving mul- terparts, women with a history of MST are tiple organ systems.21,25 more likely to be obese and sedentary, to smoke and drink, and to have had a hyster- ectomy before the age of 40 years.28 They are Refer, treat—or do both also more than twice as likely as other female Once you have evidence that a patient is a veterans to say that they were treated for a survivor of MST, you need to consider a men- heart attack within the past year.25 Data on tal health referral or consultation and address the physical symptoms of male survivors of physical symptoms. All honorably discharged MST are extremely limited, but one study veterans are eligible to receive VA treatment found an association with pulmonary and for MST, regardless of their disability rating or liver disease and human immunodeficien- eligibility for other services. If a veteran indi- cy virus and acquired immune deficiency cates that he or she would like to seek psycho- syndrome.17 therapy or see a specialist outside of the VA system, it will fall to you to help the patient A cluster of nonspecific findings? find the most appropriate treatment. (You’ll Patients with a history of MST often pres- find links to VA and nonmilitary resources ent with complex and nonspecific signs and in the box on page 124.) Either way, patient symptoms, making it difficult for a primary acuity is a guide to the optimal approach. care physician to arrive at a diagnosis. MST Inpatient treatment will likely be needed and combat-related trauma should be con- for a patient who reveals thoughts of self- sidered in such cases, as well as in veterans harm or harming others. If the patient is safe

jfponline.com Vol 62, No 3 | MARCH 2013 | The Journal of Family Practice 123 have good outcomes in patients with sexual trauma and PTSD.29. Depending on the indi- Military sexual trauma: vidual’s key presenting issues, a consultation VA and nonmilitary with a substance abuse specialist, gyne- resources cologist, or other specialist may be helpful, Department of Veterans Affairs as well. Military sexual trauma As a family physician, you are in a po- www.mentalhealth.va.gov/msthome.asp sition to build a long-term, trusting rela- tionship with such a patient, which may be National Center for PTSD therapeutic in itself.9 In building such a rela- www.ptsd.va.gov tionship, keep in mind that the experience of Vet center serving in the military could make a patient www.vetcenter.va.gov particularly sensitive, or resistant, to your ad- Women Veterans Health Care vice; you’ll need to strive for a collaborative www.womenshealth.va.gov/womenshealth/ approach. trauma.asp CASE c You tell Ms. Doe that the incident she Other resources: described was indeed sexual violence—and American Psychiatric Association specifically known as military sexual trauma. www.psych.org “The Her feelings about it are likely surfacing now Invisible War,” American Psychological Association due to the time away from the military—and www.apa.org an Academy by the fact that she’s beginning to date. In Award- Give an Hour addition to spending some time listening to nominated www.giveanhour.org her story, you advise Ms. Doe to start seeing documentary National Alliance on Mental Illness a therapist. You suggest she consider VA about military Veterans Resource Center treatment services, and direct her to its sexual trauma, www.nami.org/veterans MST web site (www.mentalhealth.va.gov/ can be seen msthome.asp). Before she leaves, you make it on DVD or at clear that you will continue to see and support community her through this difficult time, and you sched- screenings and stable enough for outpatient treatment, ule a follow-up visit. JFP (invisiblewar a therapist or psychiatrist with experience movie.com). in treating sexual trauma is a good first step. Correspondence Niranjan S. Karnik, MD, PhD, FAPA, University of Chicago, Cognitive behavioral therapy and trauma- Pritzker School of Medicine, 5841 South Maryland, MC focused therapy have both been shown to 3077, Chicago, IL 60637; [email protected]

References 1. US Department of Veterans Affairs. Analysis of VA health care uti- female veterans: a critical review. Trauma Violence Abuse. lization among Operation Enduring Freedom (OEF), Operation 2007;8:384-400. Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans. 6. Suris A, Lind L. Military sexual trauma: a review of prevalence Cumulative from 1st Qtr FY 2002 through 1st Qtr FY 2012 (Octo- and associated health consequences in veterans. Trauma Vio- ber 1, 2001 – December 31, 2011). Released March 2012. Avail- lence Abuse. 2008;9:250-269. able at: http://www.publichealth.va.gov/docs/epidemiology/ healthcare-utilization-report-fy2012-qtr1.pdf. Accessed Feb- 7. Zoroya G. Study: sex assault more common than DoD says. Army ruary 14, 2013. Times. December 27, 2012. Available at: http://www.armytimes. com/news/2012/12/gannett-va-study-says-sex-assault- 2. Kaplan S. Military sexual trauma: a little-known veteran Is- more-common-than-pentagon-reports-122712. Accessed sue. National Public Radio Web site. May 13, 2010. Avail- February 12, 2013. able at: http://www.npr.org/templates/story/story. php?storyId=126783956. Accessed February 14, 2013. 8. Hoyt T, Klosterman Rielage J, Williams LF. Military sexual trau- ma in men: a review of reported rates. J Trauma Dissociation. 3. Pellerin C. Dempsey: Allowing women in combat strengthens 2011;12:244-260. joint force. US Department of Defense Web site. January 24, 2013. Available at: http://www.defense.gov/news/newsarticle. 9. Bell ME, Reardon A. Experiences of sexual harassment and sexual aspx?id=119100. Accessed February 14, 2013. assault in the military among OEF/OIF veterans: implications for 4. National Center for Veterans Analysis and Statistics. Profile of vet- health care providers. Social Work Health Care. 2011;50:34-50. erans: 2009 data from the American Community Survey. January 10. Rosen LN, Martin L. The measurement of childhood trauma 2011. Available at: http://www.va.gov/vetdata/docs/Special- among male and female soldiers in the US Army. Mil Med. Reports/Profile_of_Veterans_2009_FINAL.pdf. Accessed Feb- 1996;161:342-345. ruary 14, 2013. 11. Perez-Fuentes G, Olfson M, Villegas L, et al. Prevalence and cor- 5. Zinzow HM, Grubaugh AL, Monnier J, et al. Trauma among relates of child sex abuse: a national study. Comprehensive Psy-

124 The Journal of Family Practice | MARCH 2013 | Vol 62, No 3 Military sexual trauma

chiatry. 2013;54:16-27. 12. Sadler AG, Booth BM, Mengeling MA, et al. Life span and re- peated during military service: effects on health status and outpatient utilization. J Womens Health (Larchmt). 2004;13:799-811. Visit us @ 13. Merrill LL, Newell CE, Thomsen CJ, et al. Childhood abuse and sexual revictimization in a female Navy recruit sample. J Trauma Stress. 1999;12:211-225. jfponline.com 14. Bremner JD, Southwick SM, Johnson DR, et al. Childhood physi- cal abuse and combat-related posttraumatic stress disorder in Vietnam veterans. Am J Psychiatry. 1993;150:235-239. 15. Engel CC Jr, Engel AL, Campbell SJ, et al. Posttraumatic stress disorder symptoms and precombat sexual and physical abuse in Desert Storm veterans. J Nerv Ment Dis. 1993;181:683-688. 16. Friedman LS, Samet JH, Roberts MS, et al. Inquiry about victim- ization experiences. A survey of patient preferences and physi- cian practices. Arch Intern Med. 1992;152:1186-1190. 17. Kimerling R, Gima K, Smith MW, et al. The Veterans Health Ad- ministration and military sexual trauma. Am J Public Health. Continue aspirin after a 2007;97:2160-2166. 18. Kimerling R, Street AE, Gima K, et al. Evaluation of universal bleeding episode? screening for military-related sexual trauma. Psychiatr Serv. 2008;59:635-640. Maryam Derogar, MD 19. Surís A, Lind L, Kashner TM, et al. Sexual assault in women veter- ans: an examination of PTSD risk, health care utilization, and cost of care. Psychosom Med. 2004;66:749-756. 2 ways to listen to 20. Ouimette P, Wade M, Prins A, et al. Identifying PTSD in primary

care: comparison of the Primary Care-PTSD screen (PC-PTSD) . this audiocast: and the General Health Questionnaire-12 (GHQ). J Anxiety Dis- ord. 2008;22:337-343. 1. Go to jfponline.com 21. Maguen S, Cohen B, Ren L, et al. Gender differences in military sexual trauma and mental health diagnoses among Iraq and Af- 2. Scan this QR code ghanistan veterans with posttraumatic stress disorder. Womens Health Issues. 2012;22:e61-e66. 22. Skinner KM, Kressin N, Frayne S, et al. The prevalence of military sexual assault among female Veterans’ Administration outpa- tients. J Interpers Violence. 2000;15:291-310. 23. Cucciare MA, Ghaus S, Weingardt KR, et al. Sexual assault and substance use in male veterans receiving a brief alcohol interven- tion. J Stud Alcohol Drugs. 2011;72:693-700. INSTANT poll 24. Coxell A, King M, Mezey G, et al. Lifetime prevalence, character- Do you recommend that parents give honey to istics, and associated problems of non-consensual sex in men: cross sectional survey. BMJ. 1999;318:846-850. young children with viral URIs? 25. Frayne SM, Skinner KM, Sullivan LM, Tripp TJ, Hankin CS, Kres- sin NR, Miller DR. Medical profile of women Veterans Adminis- tration outpatients who report a history of sexual assault occur- ring while in the military. J Womens Health Gend Based Med. 1999;8:835-845. 26. Sadler AG, Booth BM, Nielson D, et al. Health-related conse- Online exclusive quences of physical and sexual violence: women in the military. Obstet Gynecol. 2000;96:473-480. • A llergic rhinitis: What’s best for your 27. Petter LM, Whitehill DL. Management of female sexual assault. Am Fam Physician. 1998;58:920-926, 929-930. patients? 28. Frayne SM, Skinner KM, Sullivan LM, et al. Sexual assault while in the military: violence as a predictor of cardiac risk? Violence Vict. 2003;18:219-225. Photo rounds Friday  29. Nemeroff C, Heim C, Thas ME, et alo. Differential responses to psychotherapy versus pharmacotherapy in patients with chronic Test your diagnostic skills. forms of major depression and childhood trauma. P Natl Acad Sci Usa. 2003;100:14293-14296. Physician’s Briefing News  Today’s headlines in family practice

Get updates from us on

Facebook and Twitter

www.facebook.com/JFamPract http://twitter.com/JFamPract

jfponline.com www.jfponline.com 125