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CE: Military Sexual Trauma in Male Service Members

Eckerlin, Denise M. BSN, RN; Kovalesky, Andrea PhD, RN; Jakupcak, Matthew PhD

AJN, American Journal of Nursing: September 2016 - Volume 116 - Issue 9 - p 34–43
doi: 10.1097/01.NAJ.0000494690.55746.d9
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The experience of military sexual trauma (MST), which can result from assault, battery, or harassment of a sexual nature, may jeopardize the mental health of service members as well as that of their family members, colleagues, and community members. Although a greater proportion of female than male service members are subjected to MST, the Department of Defense estimates that the absolute numbers of affected men and women, across all ranks and branches of military service, are nearly equal because roughly 85% of military members are men. Little research has explored the effects of MST on men. This article discusses the unique ways in which men may experience MST, and examines how social stereotypes of masculinity, myths surrounding sexual assault, and military culture and structure often influence a man's interpretation of an attack and his likelihood of reporting the incident or seeking treatment. It describes current treatments for MST-related mental health conditions and addresses implications for nurses and other health care professionals.

This article examines the unique ways in which men experience military sexual trauma (MST) and explores the influence of stereotypes of masculinity, myths surrounding sexual assault, and military culture and structure on victims. It also describes current treatments for MST-related mental health conditions and how nurses can promote access to care.

Denise M. Eckerlin is an acute care RN on the resource team and cochair of the Resource Team Unit Practice Council at the University of Washington Medical Center, Seattle. Andrea Kovalesky is an associate professor in the School of Nursing and Health Studies at the University of Washington Bothell. Matthew Jakupcak is a clinical psychologist and researcher at the Northwest Mental Illness Research, Education, and Clinical Center in the VA Puget Sound Health Care System, Seattle. Jakupcak's work on this article was supported by the VA Puget Sound Health Care System. Contact author: Denise M. Eckerlin, deck@u.washington.edu. The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

In June 2012, while he was stationed at Vogelweh Air Base in Germany, Trent Smith, a 19-year-old U.S. Airman 1st Class, says he was sexually assaulted in an off-base apartment by a higher-ranking male sergeant, a “unit sponsor” who was entrusted to ease the new recruit's transition to military life.1, 2 Three days later Smith reported the incident in accordance with protocol and received counseling.2 In Smith's description of the events, the male sergeant touched him and coerced him into having sex1:

“I said, ‘No, I don't want to spend the night,’” he reports. But feeling powerless in the situation, he “went along with it.”

Ultimately, an Air Force psychologist diagnosed him with a personality disorder and the Formal Physical Evaluation Board of the U.S. Air Force deemed him unfit for continued duty. The diagnosed personality disorder was said to make it impossible to treat the posttraumatic stress disorder (PTSD) Smith developed in the aftermath of that evening.1, 2 In the end, the unit commander determined that there was no evidence of a crime. The sergeant who had been implicated in the incident was reprimanded for having relations with a lower-ranking service member but was allowed to remain in service.1

Military sexual trauma (MST) is defined by federal law as “psychological trauma, which in the judgment of a mental health professional employed by the Department [of Veterans Affairs (VA)], 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.”3 Although a greater proportion of female than male service members experience MST, the absolute numbers are similar because approximately 85% of military members are men.4 For example, in fiscal year (FY) 2008, VA outpatient facilities treated 48,106 female and 43,693 male veterans who had screened positive for MST, though these numbers represented 21.4% of female and 1.1% of male veterans screened.5 In fact, based on the biennial Workplace and Gender Relations Survey of Active Duty Members, the Department of Defense (DOD) estimates that, in FY2014, a greater number of male (10,600) than female (9,600) active-duty members were sexually assaulted.4 (The DOD estimates these figures in recognition of the fact that the majority of sexual assaults go unreported in the military, as they do in the civilian sector.) Because MST affects similar numbers of active-duty men and women, federal law now specifies that the VA report to Congress the number of individuals, not just female veterans, receiving care for MST and recommend improved treatment options for individuals who have experienced MST.3 While the DOD has adopted interventions to prevent military sexual assault, and the estimated total number of service members as well as the estimated number of female service members experiencing unwanted sexual contact dropped between FY2012 and FY2014, the estimated number of male service members experiencing such contact showed virtually no decline over that same period.6

A sizable number of servicemen and servicewomen experience sexual trauma while on active duty. Such trauma is also significantly associated with separation or retirement from the military and subsequent report of disability or postmilitary unemployment.7 Such incidents threaten not only the mental health of the service members, but that of their families, military units, and communities, both while the service members are on active duty and after they reenter civilian life. Although sexual assault in the military has received increasing media and congressional attention over the past few years, historically MST has been treated as an issue affecting only female service members. This article focuses on male MST, a topic of enormous clinical relevance in need of additional research. It explores the unique ways in which men may experience MST, examining how social stereotypes of masculinity, myths surrounding sexual assault, and military culture and structure influence a man's interpretation of an attack and his likelihood to report the incident or seek treatment. Additionally, the article addresses treatment options for those who have experienced MST-related mental health issues and discusses implications for clinical practice.

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HOW MEN EXPERIENCE MST

Societal stereotypes of masculinity that idealize emotional toughness and self-reliance are challenged when a man is subjected to sexual assault. The dissonance between a man's perception of his masculinity before and after being sexually assaulted may cause him to question his self-identity. He may react in ways that are passive or reclusive, or alternatively, he may demonstrate behaviors that overemphasize masculinity, such as excessive weight training or acting tough to discourage aggression from others.8 Military culture—in which men are expected to be “hypermasculine, physically strong, and heterosexual”9—tends to exacerbate male stereotypes. Male service members subjected to sexual assault may struggle to cope with the feeling that they have failed to live up to the military ideal, believing that they should have been able to protect themselves and fight off their assailant(s).10

The close interpersonal relationships within the military community may be an additional source of stress. Because the assailant is often known to the survivor and to others in the unit, peers may ostracize or express hostility toward the survivor, leaving him bereft of social support.11 Survivors may conclude that they provoked the acts of sexual harassment or assault.9 Self-blame and the possibility of further violations may put the survivor in a constant state of unease.

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MENTAL HEALTH EFFECTS ON MEN

Not all men who experience sexual assault, battery, or harassment develop mental health disorders, though men who have such a history are substantially more likely to receive a mental health diagnosis associated with the incident. For example, in a sample of 108,149 male veterans of the military conflicts Operation Enduring Freedom (OEF) in Afghanistan (October 2001 through December 2014) and Operation Iraqi Freedom (OIF) (March 2003 through August 2010), those who reported having undergone sexual trauma while on active duty were found to be significantly more likely to have a postdeployment mental health diagnosis than those who did not (76.5% versus 51.5%). These diagnoses included anxiety disorders, depressive disorders, alcohol and substance use disorders, adjustment disorders, and PTSD.12 Although little research has been conducted on the effects of MST on men, a broad range of mental health effects have been identified (see Mental Health Effects Associated with Military Sexual Trauma 13-19).

Maladaptive coping. Since many MST survivors are young, they often have yet to establish mature ways of coping with life stressors. MST survivors commonly adopt such maladaptive coping behaviors as substance abuse, eating disorders, self-injury (cutting, for example), and dissociation.13 Since perpetrators of sexual assault are often within the survivor's circle of trust, survivors may feel intense shame, self-blame, and confusion about how to act appropriately in their professional and personal relationships. Many experience sexual dysfunction; emotional distancing from others, including intimate partners, family, and friends; and a distrust of other men.14, 20

Sexual dysfunction. When a man is sexually assaulted it can challenge the way he views his masculinity, causing him to question his sexual orientation and affecting his subsequent sexual functioning.20 The affront to his understanding of his sexuality can be further complicated if a physiologic response to sexual stimulation (ejaculation) occurred during the attack.10 Among 368,241 male OEF and OIF veterans, those who had experienced MST were significantly more likely to develop a sexual dysfunction disorder than men who had no MST history (11.4% versus 6.8%).21 Men with a history of MST have also been found to have more persistent sexual disturbances than women with a history of MST.15

PTSD and related risks. PTSD is commonly related to MST. Based on the surveys of 1,700 randomly selected Gulf War I veterans who had applied for VA PTSD disability benefits, Murdoch and colleagues estimated that as many as one in five had experienced an attempted or completed sexual assault.22 Kimerling and colleagues conducted a data analysis of 125,729 OEF and OIF veterans who received Veterans Health Administration (VHA) primary care or mental health services and found that male veterans who screened positive for MST were significantly more likely to have a PTSD diagnosis than male veterans who had no MST history (52.5% versus 31.8%).12 Similarly, through retrospective data analyses of 213,803 OEF and OIF veterans, Maguen and colleagues found that male veterans with a history of MST were more than two and a half times as likely to have a PTSD diagnosis as male veterans without an MST history.16 Both MST and PTSD have been linked to poor physical health and other mental health comorbidities, including somatization disorder, depression, and anxiety.

Somatization, depression, and anxiety. When Street and colleagues surveyed a stratified random sample of nearly 4,000 former reservists, they found that somatic symptoms consistent with somatization disorder and 14 major medical conditions (including diabetes, hypertension, arthritis, and cancer) occurred at a higher frequency in men (and women) who had a history of MST than in those who did not.17 In a study of 276 Vietnam combat veterans (225 with PTSD and 51 without), PTSD presence and severity was significantly related to poorer health as rated by a physician, and somatization was found to be significant in all measures of health self-reported by patients with PTSD.23 In a study of 45 male veterans on a VA inpatient unit, PTSD symptom severity was positively and significantly related to reported somatic symptoms and significantly predicted both depression severity and anxiety sensitivity.24

Suicidal ideation. PTSD can be a risk factor for suicidal ideation in veterans. Jakupcak and colleagues found that OEF and OIF veterans who screened positive for PTSD were 4.45 times more likely to report suicidal ideation than those with a negative PTSD screen, with the risk even higher when there were two or more mental health diagnoses in addition to PTSD.25

The possible compounding effect of multiple mental health disorders on the risk of suicidal ideation may be an important consideration in men with a history of MST. For example, Maguen and colleagues found that male veterans who had a history of MST and screened positive for PTSD were more likely to have three or more mental health comorbidities than male veterans who screened positive for PTSD but had no MST history.16 And analysis of VHA data for 134,894 female and 2,900,106 male veteran outpatients who had been screened for MST found that a positive screen was associated with greater odds of a mental health diagnosis in nearly all categories tested, which included PTSD, dissociative disorders, depressive disorders, and suicide and intentional self-inflicted injury.13 Such studies emphasize the importance of screening for suicidal ideation and other mental health comorbidities in patients with an MST history.

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BARRIERS TO REPORTING SEXUAL ASSAULT

Within the U.S. Armed Forces the report of a military sexual assault is filed as either restricted or unrestricted. Restricted reports allow victims to receive medical counseling and treatment while remaining anonymous to protect their privacy. The choice to file a restricted report is offered as a way to encourage reporting while increasing access to care. Service members who desire adjudication in addition to health care treatment must file an unrestricted report, that is, a formal allegation against their attacker(s), which prompts notification of command and investigation by a Military Criminal Investigation Organization (MCIO). Service members who file unrestricted reports may have to face their perpetrator(s) if, for example, the case is court-martialed.26

In FY2014, the most recent year in which sexual assault prevalence surveys were conducted, the DOD estimated that 20,300 service members experienced a sexual assault, but only 23% of them reported the event.27 In FY2015, 4,736 service members reported having been sexually assaulted during military service.4 If a similar proportion of military sexual assaults went unreported in FY2015 as in FY2014, it would mean that an estimated 20,591 military sexual assaults occurred that year. Men filed 1,082 of the reports in FY2014, which the DOD estimates represents only 10% of the assaults on male service members.27 Barriers that may prevent men from reporting sexual assault and harassment include stigma, lack of knowledge about military sexual assault, myths surrounding sexual assault, the structure and culture of the military, concern for privacy, and mistrust of the military judicial system.

Lack of knowledge. Knowledge about military sexual assault may be an important tool in combating the myths that dissuade men from reporting assaults and harassment. Yet Holland and colleagues found that the quality of education concerning military sexual assault varied among the different branches of service.28 In a study sample that included more than 24,000 active-duty personnel, only 17.9% correctly answered all six questions about military sexual assault resources and protocol, while 33.1% answered three or fewer of these questions correctly.

The fact that the Air Force, the branch of the armed forces that provides the most comprehensive sexual assault training, has among the lowest rates of sexual assault may underscore the importance of education as a critical factor in preventing MST.28 Underestimation of the importance of military sexual assault education may contribute to a culture that perpetuates myths surrounding sexual assault and sexual harassment. Holland and colleagues found that servicewomen were more likely than servicemen to recognize the need for military sexual assault education and to retain its content.28 In fact, many servicemen believe that if a military unit consists exclusively of men, there is no need for training on sexual assault prevention.29 Men, in particular, may feel it is unnecessary to learn about sexual assault because they have accepted the societal myth that heterosexual men cannot be sexually assaulted.9 Denial of the fact that any man, regardless of sexual orientation, can experience MST presents an immense obstacle to reporting sexual assault and harassment.

MST myths. The myths surrounding MST concern not only the sex and sexual orientation of service members who have experienced it, but those of the assailants as well. Many people believe that a woman cannot perpetrate sexual trauma. However, in a small number of sexual assault cases, the perpetrator is a woman. Of the 3,920 investigations of sexual assaults in the military completed in FY2015, there were a total of 4,330 alleged perpetrators, 3% (139) of whom were women and 81% (3,523) of whom were men.6 The sex of the remaining 15% (668) was unknown or unavailable. Data collected from unrestricted reports of sexual assaults by or against service members suggest that in nearly half the cases in which the perpetrator is a woman, the survivor is a man.6 Because men “are socialized to be strong, sexually aggressive, and always in control,”30 they may be even less likely to report MST if the perpetrator is a woman.

Many people mistakenly believe that sexual assault is about sex. But sexual assault is best understood as a violent attempt to obtain power and control over another person.10 Young recruits are often the ones targeted. In FY2015, 65% of completed investigations of unrestricted reports showed the assaulted service member to be 24 years of age or younger.6 A young serviceman may feel intimidated about reporting someone above his rank. He may even decide that an assault is not important enough to report, compared with the violence, such as combat, more commonly associated with military service. Or he may believe that men are better able to cope with sexual trauma and less deserving or in need of treatment than women.9

Military structure and culture. The very structure of the military—which may continue to keep a service member who has suffered a sexual assault in a susceptible and powerless position—presents a barrier to reporting. The housing and working arrangements of units stationed together for extended periods of time often means that service members who report assaults must continue working side by side, possibly in combat, with those who have violated them.14

Regardless of his sexual orientation, a male service member who has been sexually violated may worry about how others within his unit will perceive his sexuality if he reports a sexual assault.9 He may also worry that he will be seen as disloyal and a traitor to his unit, and that he will face retaliation.29

Concern for privacy. Another factor that complicates reporting is that the person to whom the victim must report might be the assailant or a friend of the assailant.11, 29 Furthermore, reporting up the chain of command does not guarantee that an incident will remain confidential. In a study that included 647 service members representing various ranks and branches across the U.S. Armed Forces, participants indicated that privacy concerns and fear of retaliation (both personal and professional) may dissuade service members from reporting sexual victimization.11 Reports of reprisal after reporting a sexual assault are not uncommon. Preliminary findings from the fourth quarter of the FY2014 Survivor Experience Survey showed that 80% (121) of the 151 responding service members who had reported a sexual assault ultimately made an unrestricted report, and 66% of them felt that they faced retaliation, either professional (6%), social (27%), or both (33%).31

Mistrust of the military judicial system. Some MST survivors do not report a sexual assault because they do not trust the military judicial process. Because of a lack of transparency in the process, there is a widespread perception that many such reports are dismissed with the assailants facing no repercussions.29 In FY2014 there were 3,648 alleged sexual assault perpetrators with reported case outcomes.27 The DOD did not take action against 1,023 of those accused because the case was outside its legal authority (431), the subject was a service member prosecuted by a civilian or foreign authority (64), or the report against the alleged perpetrator was determined to be unfounded (528). Of the remaining 2,625 alleged perpetrators, only 1,550 were determined to warrant a disciplinary action: 998 had court-martial charges initiated against them, 318 entered proceedings for nonjudicial punishment, and 234 received an administrative discharge or “other adverse administrative action.”27 Often the service member making the report becomes the subject of an investigation and faces charges under the Uniform Code of Military Justice for offenses such as fraternization, illegal use of substances, and adultery.29

The National Defense Authorization Act (NDAA). Recognizing that sexual assault survivors have to overcome many obstacles in order to report the crime, the DOD continues to work on implementing protections for survivors and reinforcing already existing laws.32 In 2013, the DOD clarified its policy on adult sexual assault cases, noting that command-directed investigations of sexual assaults are prohibited, and all unrestricted reports must be referred to an MCIO. The NDAA for FY2014 now states that for all cases of sexual assault, the Article 32 (preliminary hearing) officer must be a judge advocate. The law also allows the service member reporting the assault to decline to testify against the accused at this hearing and, regarding allegations of penetrative sexual assault, limits prosecutorial decisions to military commanders of grade O-6 or higher (colonel/captain or general/admiral, for example), further requiring them to consult with a judge advocate before deciding on a course of action. The DOD does not, however, support the proposal to transfer prosecutorial discretion from commanders to judge advocates, citing a lack of evidence that doing so would reduce the incidence or improve reporting of sexual assaults. Because subordinates look to their commanders for leadership, the DOD maintains that taking power away from commanders may diminish their ability to prevent sexual assaults. Although these protections may encourage more sexual assault survivors to seek the medical care and justice they need and deserve, the DOD acknowledges that further improvements are necessary.32

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PROMOTING ACCESS TO CARE

Because MST can have a significantly negative effect on mental health, it is important that a qualified mental health professional evaluate those who have been sexually traumatized to determine if they have a mental health condition that requires treatment. Barriers to reporting, however, make it difficult for survivors to initiate and remain engaged in therapy. Additionally, those who have learned to dissociate vulnerable emotions may find it difficult to acknowledge that they require therapy after being sexually assaulted or harassed.

Studies have found that men with a history of MST are less likely than their female counterparts to seek treatment in the VA.18 To address this disparity, one study compared the effects of distributing a male-targeted brochure with those of distributing a sex-neutral brochure to male veterans in the VA system who had screened positive for MST but had not received care.33 The male-targeted brochure pictured only men and addressed sex-specific issues such as masculinity, sexual orientation, and the meaning of an involuntary or forced ejaculation. The men demonstrated a preference for the male-targeted brochure, though there was no significant increase in the number of men who sought treatment within six months of the intervention. Although male-targeted information may be preferred by men, more research is needed to determine whether and how such educational interventions can increase help-seeking behaviors among men who have experienced MST.

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TREATMENT FOR MEN WITH MST

Most studies on MST treatment have focused on the female experience; few studies have sought to identify which treatments might be more successful in men.34 Because there is a dearth of research on men who experience MST, there are no evidence-based protocols that address men's specific concerns, though two studies found that, among MST survivors, men have more persistent psychological symptoms and show less improvement with treatment than women.15, 35

Psychotherapeutic approaches. Studies validating the effectiveness of psychotherapeutic approaches in treating men with MST-related PTSD are vital as the two conditions are strongly associated. Future research should examine whether the experience of sexual trauma is different for men from that of other military traumas, such as combat, and which types of treatment are more effective for each condition.

In the VA, the recommended psychotherapeutic approaches for treating PTSD are trauma-focused cognitive behavioral psychotherapies, such as cognitive processing therapy (CPT), prolonged exposure, eye movement desensitization, and reprocessing therapies.36 One randomized controlled trial compared the effectiveness of treating MST-related PTSD in 73 female and 13 male veterans with 12 sessions of either CPT or present-centered therapy (PCT).37 Whereas CPT challenges the patient's beliefs about a traumatic event, incorporating discussion of the event as well as relaxation techniques, PCT focuses not on the trauma, but on helping patients alter maladaptive behaviors, providing information about the potential impact of trauma on their lives and teaching problem-solving strategies. PCT is not currently recommended as a first-line approach for treating PTSD within the VA.36 Following treatment, investigators found that clinician-assessed posttraumatic and depressive symptoms were significantly reduced in both the CPT and PCT groups, though self-reported symptoms were significantly reduced in only the CPT group. The investigators suggest that PCT may be a promising alternative therapy for MST-related PTSD in patients who are unwilling or unable to engage with their past trauma.37

Although men were included in this study, because they were underrepresented and disproportionately randomized into the CPT group per the study design, no conclusions can be drawn about the effectiveness of either therapy specifically on men with MST-related PTSD.34, 37 Additionally, a subsequent analysis of the men randomly assigned to receive CPT therapy found that, though they experienced a significant reduction of symptoms with CPT after 12 sessions, at six-month follow-up, there was no significant difference between their mean pretreatment and posttreatment depressive symptoms.34

Pharmaceutical treatments. For treating MST-related PTSD, the VA recommends monotherapy with a selective serotonin reuptake inhibitor, such as sertraline (Zoloft) or paroxetine (Paxil)—both of which have been approved by the Food and Drug Administration for PTSD treatment—or fluoxetine (Prozac).36 Alternatively, monotherapy with the serotonin norepinephrine reuptake inhibitor venlafaxine (Effexor XR) may be used. All are listed by the VA as first-line agents for PTSD treatment. Other evidence-based monotherapy for PTSD may include mirtazapine (Remeron), nefazodone, phenelzine (Nardil), or the tricyclic antidepressants amitriptyline or imipramine (Tofranil). The atypical antipsychotics risperidone (Risperdal), olanzapine (Zyprexa), or quetiapine (Seroquel) may be used as an adjunct to antidepressant therapy. The α-blocker prazosin (Minipress) may be used for sleep disturbances and nightmares.

Unfortunately the stigma associated with a mental health diagnosis, along with concerns over maintaining privacy, may negatively influence a veteran's decision to take such medications. Nonpharmacologic treatment approaches, such as yoga, mindfulness-based stress reduction, and acupuncture, may be helpful for a variety of mental health issues veterans face, but they have not been extensively studied in men with MST histories.38

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IMPLICATIONS FOR CLINICAL PRACTICE

Health care professionals in all settings, including primary care settings, hospitals, and mental health care facilities, need to be aware of the existence and health implications of MST in male veterans. Although the VA provides free care for MST-related health problems to veterans, including those who do not qualify for other VA benefits and, with the approval of the Veterans Benefits Administration, those who received an “other than honorable” discharge,39 many choose to seek treatment in non-VA health care settings. In fact, a survey of 20,563 OEF and OIF veterans, 16,211 male and 4,352 female, found that 10,331 (nearly 64%) of the men used non-VA health care services or none at all, 341 of whom screened positive for MST.40 Providers who are well informed about the prevalence of MST in men and knowledgeable about resources available through the VA and the local community are invaluable in providing optimal health care services to MST survivors.

Assessing sexual health. Using a holistic approach to patient care that incorporates an awareness of the many factors that can influence a patient's health may improve outcomes for veterans who have experienced MST. For instance, nurses can ask patients if they have any concerns about their sexual health, which can be affected by both mental and physical illnesses as well as by medications taken to treat those illnesses. Research suggests that patients feel it is appropriate for nurses to address sexual health and that they would prefer that the nurse initiate the conversation.41 Although nurses generally acknowledge that a patient's sexual well-being has a significant effect on quality of life and its assessment is within their professional domain, sexual health remains largely overlooked in the clinical setting.42, 43 Asking patients if they have any concerns about their sexual health may provide opportunities to help male MST survivors who might have issues surrounding sexuality and sexual functioning. The nurse can provide educational materials to the patient, communicate any issues to the patient's health care team, and assist team members in making referrals for further care.

Using available VA resources. The VA has resources available to help non-VA health care providers assess the health care needs of veterans (see Military Sexual Trauma Resources for Health Care Providers and Veterans). One such resource, the VA's Community Provider Toolkit, includes information on military culture, related mental health issues, and opportunities to connect with VA services. The VA even provides a military health history pocket card to assist clinicians in assessing the unique health issues of those who serve or have served in the military (www.va.gov/oaa/pocketcard). The pocket card offers insight into specific health concerns for each era of military service and suggests ways to phrase questions when speaking to veterans. For example, the provider is encouraged to seek the patient's permission to explore particular topics, with questions such as, “Would it be okay to talk about sexual harassment or trauma that you might have experienced while serving in the military?” Although the pocket card addresses stress and adjustment, direct screening for suicide risk is not part of this assessment. When appropriate, screening for suicidal ideation should be incorporated into the health care evaluation.

Establishing a trusting and therapeutic relationship with an MST survivor may be difficult because MST survivors have often been victimized by someone they thought to be trustworthy.44 MST survivors may also feel let down by an institution that they believed they could depend on.45 Male sexual assault victims, in particular, tend to be hesitant to disclose their experience(s) because they worry about the way their providers may react.9 Clinicians who are aware of their own biases and beliefs regarding sexual assault may avoid reacting in a way that could exacerbate these worries in male patients.

Patient teaching. It is important to provide patients with information about sexual trauma that dispels common myths, explains the wide range of emotions and reactions that may be part of the MST experience, and discusses how such reactions may affect daily life (see Military Sexual Trauma: Information for Patients). If self-destructive behaviors are part of a patient's reactions, the nurse can try to help the patient establish healthier coping responses.

Nurses may consider involving social workers, mental health NPs, counselors, or other health care professionals who can work with the patient to develop long-term therapeutic relationships. These professionals can be another important resource in the recovery of a veteran with an MST history. They can reinforce and provide additional information about surviving a sexual assault, while helping the patient connect with community resources.

Patient advocacy. Substance abuse, PTSD, and various other mental health disorders related to MST may impair a veteran's ability to work. If a patient with MST is having difficulty maintaining employment, nurses can advocate for vocational rehabilitation. One study found that U.S. military men who experienced an instance of sexual harassment they found frightening reported greater psychological distress, impaired ability to complete work-related tasks, and decreased job satisfaction than U.S. military women who had experienced a frightening incident of sexual harassment.19 Murdoch and colleagues found that among Gulf War I male veterans who had applied for VA PTSD disability benefits, men with a history of military sexual assault were about twice as likely to report that they were unemployed than men without such a history.22 Referrals for vocational rehabilitation may help male veterans with an MST-related mental health condition regain a sense of self-worth through work that matches their skills and abilities.

Promoting social support. Research has found that having access to social support may help reduce the negative impact of a traumatic experience.46 Nurses should try to assess the degree of support veterans receive from family members, local veterans groups, or faith communities. Does the veteran have any special interest or hobby that could be pursued with a group? When MST survivors establish supportive care networks, they know there are people who will listen to them and are interested in their well-being.

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Military Sexual Trauma Resources for Health Care Providers and Veterans

The following online resources provide valuable information for health care providers and veterans alike:

* VETWOW (http://vetwow.com) provides information and resources for active-duty service members and veterans, health care providers, and support persons as well as advice and advocacy for those who have experienced military sexual trauma (MST).

* Rape, Abuse and Incest National Network (www.rainn.org/get-information) offers information, support, and help for those who have experienced sexual violence.

* MaleSurvivor (www.malesurvivor.org/find-support) offers discussion forums for male survivors of sexual abuse, a therapist directory, and male survivor support groups.

* Protect Our Defenders (www.protectourdefenders.com) offers pro bono legal counsel for MST survivors, peer-to-peer support, information on military justice, and stories from MST survivors.

* Although it doesn't replace in-person treatment with a qualified provider, the Department of Veterans Affairs (VA) PTSD Coach Online (www.ptsd.va.gov/apps/ptsdcoachonline/tools_menu.htm) offers advice on managing posttraumatic stress disorder (PTSD)–related symptoms, suggests coping skills, and provides self-assessment tools.

* On Benefits.gov's MST page (www.benefits.gov/benefits/benefit-details/4749), the Veterans Health Administration describes the VA MST health care program through which veterans can receive free care for conditions resulting from sexual assault or harassment that occurred while they were in military service.

* This VA MST Web page (www.mentalhealth.va.gov/msthome.asp) links to local VA facilities that provide care for associated mental health conditions. It describes VA MST programs and services, includes articles and fact sheets about MST, and features testimonials by MST survivors.

* The Department of Defense provides this secure Self Helpline Web site (www.safehelpline.org) and phone number, (877) 995-5247, through which MST survivors can access help 24/7.

* The Vet Center Program (www.vetcenter.va.gov) provides veterans with postdeployment readjustment counseling, bereavement counseling, and referrals to veteran services.

* The VA's Community Provider Toolkit (www.mentalhealth.va.gov/communityproviders/index.asp) assists health care providers with assessing and treating veterans.

* The VA home page (www.va.gov) includes information about VA health care, benefits (such as financial assistance, education, and training), and other resources available to veterans.

* The VA's National Center for PTSD (www.ptsd.va.gov/professional/continuing_ed/index.asp) provides continuing education resources for professionals concerned with trauma. Its MST Web page (www.ptsd.va.gov/public/types/violence/military-sexual-trauma-general.asp) offers information about MST-related PTSD, treatment for associated problems, and VA services through which veterans can get help.

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Military Sexual Trauma: Information for Patients

* Strength and Recovery: Men Overcoming Military Sexual Trauma (www.mentalhealth.va.gov/docs/Men_Overcoming_MST.pdf) is a Department of Veterans Affairs (VA) brochure addressed to men who have been subjected to military sexual trauma (MST).

* Military Sexual Trauma (www.mentalhealth.va.gov/docs/MST-BrochureforVeterans.pdf) is a VA brochure for veterans who have undergone MST that explains potential aftereffects and related VA services.

* Military Sexual Trauma (www.mentalhealth.va.gov/docs/mst_general_factsheet.pdf) is a VA fact sheet about MST.

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REFERENCES

1. Cloud DS Air Force member's allegation of sex assault brings him more grief. Los Angeles Times 2013 Dec 30. http://articles.latimes.com/2013/dec/30/nation/la-na-military-male-rape-20131231.
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Keywords:

military; military sexual trauma; posttraumatic stress disorder; sexual assault; sexual trauma

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