Victims of Military Sexual Trauma— University of Chicago, Pritzker School of Medicine You See Them, Too

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 Sexual assault 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 depression 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 assault 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 abuse 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 sexual harassment 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 women in the military 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 mental health 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.

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