Contributed by Sherril Sego, FNP-C, DNP

The issue of posttraumatic stress disorder (PTSD) in military veterans is commonly acknowledged. The mindset of “just get over it” has long been understood to be both unrealistic and scientifically unfounded. Even the realization that trauma leading to PTSD does not have to be directly related to combat is well-established. What is not widely discussed is the definite gender gap in PTSD due to sexual trauma in female veterans. 

Military sexual trauma (MST) includes any sexual activity in which a service member is involved against his or her will. These acts range from sexual harassment to rape.  Every year, an estimated 1 in 4 females and 1 in 100 males in the military experience some event that meets the accepted definition of sexual trauma: “Psychological trauma that resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the veteran was serving on active duty, active duty for training, or inactive duty training.”

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As with civilian sexual assault, the reporting rate of sexual assault in the military is thought to be as low as 25% of actual incidents. Some facts related to this low number are fear of retribution or retaliation, continued contact with the perpetrator due to duty assignment, and lack of follow-through from the chain of command. Male MST reporting rates are believed to be even lower due to the stigma attached.

The evolution of the recognition and treatment of MST by both the Department of Defense (DoD) and the US Department of Veterans Affairs (VA) has been long and agonizing. The number of women actively serving in the military is now about 14%, or well over 200,000. In the 15 years of the global war on terror, nearly 300,000 women have been deployed to a designated combat zone.

Of all reported cases of MST, more than 25% occurred in this type of environment. It is due to this, as well as the previously mentioned conditions, that MST differs from civilian sexual assault. Despite the increasing number of women in the military, it is still predominantly a “man’s world.” Add to that basic demographic a high-adrenalin environment and the increased assimilation of women into all areas of service, and some would call it the perfect storm for sexual assault.

In light of these facts, the VA screens all veterans for MST at their initial visit. Even in this setting, patients are often hesitant to report the assault. Repeated screening after there has been time to establish a more trusting patient/provider relationship often reveals an unreported incident.

MST itself is not an actual diagnosis, but PTSD that is subsequent to MST meets DSM-5 criteria. Differentiating MST as an event from PTSD due to MST must follow the established criteria for PTSD due to any incident. The following questions help guide a more accurate diagnosis and potential treatment:

“In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: 

  1. Have had nightmares about it or thought about it when you did not want to? 
  2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? 
  3. Were constantly on guard, watchful, or easily startled? 
  4. Felt numb or detached from others, activities, or your surroundings?”

As with any form of PTSD, treatment is often guided by the symptoms and their severity. Psychotherapeutic counseling coupled with pharmacologic management of symptoms of depression, anxiety, insomnia, nightmares, panic attacks, and others is recommended. For patients expressing relationship difficulties, couples education and therapy should be offered.

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Regardless of the statistics and social implications, public education should be very clear: Sexual assault is NEVER okay, “asked for,” or “no big deal.” The DoD is making large strides in educating troops and commanding officers about the zero tolerance policy of sexual assault, but change has been slow in this huge, complex organization.

Primary care providers should be alert to the signs and symptoms that might indicate prior sexual assault in male or female patients. Veteran or not, this is an issue that needs widespread understanding and attention from healthcare professionals. 

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