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Sexual Assault in the Military and Increased Odds of Sexual Pain Among Female Veterans

Pulverman, Carey S. PhD; Creech, Suzannah K. PhD; Mengeling, Michelle A. PhD; Torner, James C. PhD; Syrop, Craig H. MD, MHCDS; Sadler, Anne G. PhD, RN

doi: 10.1097/AOG.0000000000003273
Contents: Violence: Original Research
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OBJECTIVE: To examine whether the relationship between childhood sexual abuse and sexual function in civilian women is also found among female veterans, and to consider the additional effects of sexual assault in the military.

METHODS: Using a retrospective cohort design, participants (N=1,004) from two midwestern Department of Veterans Affairs medical centers and associated clinics completed a telephone-assisted interview on sexual assault, sexual pain, and mental health. Binary logistic regression was used to compare the rates of sexual pain between women with no sexual assault history, histories of childhood sexual abuse alone, histories of sexual assault in the military alone, and histories of childhood sexual abuse and sexual assault in the military.

RESULTS: Female veterans with histories of childhood sexual abuse and sexual assault in the military reported the highest rates of sexual pain (χ2(3)=40.98, P<.001), posttraumatic stress disorder (PTSD, χ2(3)=88.18, P<.001), and depression (χ2(3)=56.07, P<.001), followed by women with sexual assault in the military histories alone, women with childhood sexual abuse histories alone, and women with no sexual assault. Female veterans with histories of childhood sexual abuse and sexual assault in the military were 4.33 times more likely to report sexual pain, 6.35 times more likely to report PTSD, and 3.91 times more likely to report depression than female veterans with no sexual assault.

CONCLUSION: The relationship between sexual assault and sexual pain in female veterans is distinct from their civilian peers. For female veterans, sexual assault in the military is more detrimental to sexual function (specifically sexual pain) than childhood sexual abuse alone, and the combination of childhood sexual abuse and sexual assault in the military confers the greatest risk for sexual pain. Given this difference in sexual health, treatments for sexual dysfunction related to a history of childhood sexual abuse in civilian women may not be adequate for female veterans. Female veterans may require a targeted treatment approach that takes into account the particular nature and consequences of sexual assault in the military.

Sexual assault in the military was associated with higher rates of sexual pain, depression, and posttraumatic stress disorder compared with childhood sexual assault.

VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, the Central Texas Veterans Healthcare System, Temple, and Dell Medical School, University of Texas at Austin, Austin, Texas; the University of Iowa Carver College of Medicine, the Center for Comprehensive Access & Delivery Research and Evaluation (CADRE) and the VA Office of Rural Health (ORH), Veterans Rural Health Resource Center, Iowa City Veterans Affairs Health Care System, and the University of Iowa College of Public Health, Iowa City, Iowa.

Corresponding author: Carey S. Pulverman, PhD, VA VISN 17 Center of Excellence for Research on Returning War Veterans, 4800 Memorial Drive (151C), Waco, TX 76711; email: pulverman@utexas.edu.

This research was funded by the Department of Veterans Affairs (NRI 04-194, Dr. Anne Sadler, PI), but the views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs (DVA) or the United States government. The DVA funders were not involved in the study design, data collection, analysis, data interpretation, writing of the paper or decision to submit it for publication. The writing of this manuscript was partially supported by the Office of Academic Affiliations Advanced Fellowship Program in Mental Illness, Research, and Treatment, and the VISN 17 Center of Excellence for Research on Returning War Veterans.

Financial Disclosure University of Iowa Health Ventures contracted for Dr. Syrop's time from his department. That work was related to tele-health and unrelated to the submitted research. Money was paid to him from the Louisiana Hospital Association. He provided a one-day training program on physician engagement. This work was unrelated to the submitted paper. His spouse is employed by the Department of Veterans Affairs. The other authors did not report any potential conflicts of interest.

Peer reviews and author correspondence are available at http://links.lww.com/AOG/B382.

Among female veterans, 24–46% report a history of childhood sexual abuse,1–3 and 23–33% report a history of sexual assault in the military.1,4–6 Female veterans also report elevated rates of sexual assault in adulthood both premilitary and postmilitary service.7,8 Sexual assault negatively affects the physical, mental, and sexual health of female veterans.9–11 Sexual function is one of the least explored domains of sexual assault sequelae in this population.12

One of the limitations of the literature on sexual assault and sexual function in female veterans is the failure to differentiate between the effect of sexual assault at different developmental stages, such as childhood and adulthood (including premilitary service, during military service, and post military service), on sexual function. In contrast, a substantial literature has linked sexual assault, particularly childhood sexual abuse, to sexual dysfunction in civilian women.13,14 It remains unknown whether the robust relationship between childhood sexual abuse and sexual function identified in civilian women also applies to female veterans. Female veterans may also be exposed to sexual assault in the military, which is a particularly detrimental type of assault.15,16 Sexual assault in the military confers more risk for posttraumatic stress disorder (PTSD) than other types of military trauma such as combat trauma,15 and civilian trauma.16 Three studies found that sexual assault in the military confers more risk for PTSD than sexual assault at other developmental stages (ie, childhood, premilitary adulthood, and postmilitary adulthood).8,16,17 Among female veterans, sexual assault in the military may also confer a heightened risk for sexual dysfunction.

The current study compares the effect of sexual assault at distinct developmental stages, childhood (childhood sexual abuse), during military service (sexual assault in the military), and the combination of both childhood and during military service (childhood sexual abuse and sexual assault in the military) on female veterans' sexual and mental health. We hypothesized that sexual assault in the military would be associated with a higher risk of sexual pain, depression, and PTSD than childhood sexual abuse. We further hypothesized that sexual pain would be associated with depression and PTSD respectively. We conducted one exploratory analysis on the relative effect of sexual assault, depression, and PTSD on risk of sexual pain, but did not propose a hypothesis for this question.

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METHODS

Institutional Review Board approval was obtained from the University of Iowa, the Iowa City Veterans Affairs Health Care System, and the Central Texas Veterans Health Care System. This is a secondary analysis of data collected for a larger project titled, Sexual Violence and Women Veterans’ Gynecologic Health.18

This study employed a retrospective cohort design with Department of Veterans Affairs (VA)–enrolled female veterans. There are several reasons women may have enrolled in the VA, including to obtain health care, complete a disability claim, enroll in a registry, or in response to a veteran outreach program. The Veterans Health Information System and Technology Architecture system was used to identify female veterans who were no more than 51 years of age enrolled at two large midwestern VA Health Care Systems or associated centrally based outlying clinics within the 5 years before the data collection period (June 2005–August 2008). Female veterans who enrolled during the data collection period were also periodically identified and added to the study sample. A total of 2,414 women were identified through this process, and 1,004 completed the interview (see Fig. 1 for participant recruitment).

Fig. 1.

Fig. 1.

Participants were mailed an introductory letter describing the study, consent form, and a preaddressed postage-paid return envelope. Interested women were invited to sign and return the consent form and to call a toll-free number to schedule the interview session. Women were also invited to call the number to ask questions or to decline participation. Women who declined participation were inquired for their reasons to decline and asked three gynecologic health–related questions as the original study focused on the relationship between sexual assault and gynecologic health in female veterans (for full text of questions see Ref. 18). Two weeks after the mailed letters, follow-up telephone calls (up to eight) were made to potential participants who did not respond to the letters until contact was achieved or potential participants were classified as unreachable. Issues with inaccurate contact information were addressed via the local white pages, the VA’s Computerized Record System, and Accurint (a confidential LexisNexis tool). When telephone contact was established with female veterans they were screened for the following exclusion criteria related to the gynecologic health focus of the study: had in-utero diethylstilbestrol exposure, were currently receiving treatment with immunosuppressants, or were older than 51 years of age at the time of recruitment (note that women may have turned 52 years old by the time of their interview). Eligible women were invited to schedule an interview session. Women were required to return their signed consent forms via mail before participation.

The interview session was conducted by a trained female interviewer using a computer-assisted telephone interview in which the interviewer read questions and standardized answer choices verbatim to participants. To promote safety and confidentiality, participants completed the interview at a time, and from a phone and location, of their choosing. The interviewer entered responses directly into the computer system. At the end of the interview participants were informed that they might be re-contacted for interview quality assurance purposes. The performance of interviewers was monitored by re-calling a random sample of 3% of study participants to confirm data accuracy, which was confirmed by re-assessing a small number of questions and comparing the original answers to the quality assurance interview answers. The quality assurance interviews took less than two minutes each, in an effort not to burden participants. The computer-assisted telephone interview allowed the interviewer to skip items that were no longer relevant to each participant. The interview included questions on demographics, military history, sexual assault exposure, and physical, gynecologic, mental, and sexual health. Interviews lasted an average of 1 hour and 16 minutes, and the majority (89%) were completed in a single telephone call session. Participants were compensated monetarily for their time ($30).

Demographic characteristics were assessed including age, sexual orientation, race, ethnicity, and educational history.

Lifetime sexual assault was defined as any sexual act that occurred without a woman’s consent and involved the use of threat or force, and included attempted and completed penetration of the vagina, mouth, or rectum. This definition was based on the existing definition of sexual assault from the American Medical Association19 and the American College of Obstetricians and Gynecologists.20 The definition of lifetime sexual assault was read aloud to women by the female interviewer, and women reporting any lifetime sexual assault were asked about sexual assault during four developmental periods: 1) childhood before 18 years of age, 2) between age 18 and entrance into military service (ie, premilitary adulthood), 3) during military service (ie, sexual assault in the military), and 4) after separating from the military through the present day (ie, postmilitary adulthood). Both attempted and completed sexual assault experiences were assessed. We compared sexual pain between women reporting attempted sexual assault and completed sexual assault, and there was a significant difference (χ2(1)=7.78, P<.01), with more women in the completed assault group reporting sexual pain. We compared sexual pain between women reporting no sexual assault and women reporting attempted sexual assault and there was no significant difference (χ2(1)=0.64 [not significant]). Therefore, all subsequent analyses compared women with completed assault histories, to women with no sexual assault history or attempted sexual assault histories only.

Participants were categorized into four groups: 1) no sexual assault; 2) childhood sexual abuse only; 3) sexual assault in the military only; and 4) at least childhood sexual abuse and sexual assault in the military. Women in the childhood sexual abuse–only group and the sexual assault in the military–only group reported sexual assault only during that single developmental period. Given the high rates of revictimization (ie, reporting multiple sexual assaults across the lifespan) in our sample, women in the at least childhood sexual abuse and sexual assault in the military group reported both childhood sexual abuse and sexual assault in the military, and may have also experienced sexual assault during premilitary or postmilitary adulthood. We also examined our research questions with the group of women with childhood sexual abuse and sexual assault in the military only histories (ie, only childhood sexual abuse and only sexual assault in the military histories, no assault during premilitary or postmilitary adulthood) and results did not change, thus we report findings for the more inclusive at least childhood sexual abuse and sexual assault in the military group. Those who experienced premilitary or postmilitary sexual assault (or both premilitary and postmilitary sexual assault) but who did not experience both childhood sexual abuse and sexual assault in the military were excluded from the multivariate analyses.

Sexual pain was assessed with one item based on the sexual function items from the Study of Women’s Health Across the Nation, a large epidemiologic study of health in women during the middle years.21 Current female sexual pain was assessed with the following dichotomous item: “Does it hurt you to have sexual intercourse or penetration (yes/no)?” Sexual pain was analyzed as a dichotomous variable.

Depression was assessed with the Composite International Diagnostic Interview Short Form.22 This measure assesses for a major depressive episode in the past two weeks based on criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR.23 The Composite International Diagnostic Interview Short Form has a sensitivity of 89.6% and specificity of 93.9% for a major depressive episode.22 This measure was used to provide a dichotomous rating, thus participants were classified as having a current depressive episode or no depressive episode.

Posttraumatic stress disorder was assessed with the Posttraumatic Symptom Scale,24 a 17-item measure on the symptoms of PTSD from the DSM-IV, which provides a screening diagnosis of PTSD.23 This measure has a sensitivity of 88% and a specificity of 96% with the Structured Clinical Interview for DSM-III for PSTD.25 To meet criteria for a diagnosis of PSTD, participants had to experience a traumatic event that 1) threatened their bodily integrity or the bodily integrity of others and 2) their response to that event included “fear, helplessness, or horror” (pg. 467).26 During the assessment of lifetime trauma history, identification of their most traumatic event was accomplished with the question, “Which experience bothers you the worst?” Responses were used to determine a dichotomous screening diagnosis of PTSD (PTSD or no PTSD). We also analyzed the total score on the Posttraumatic Symptom Scale as a measure of PTSD severity. Internal consistency for the Posttraumatic Symptom Scale in the current sample was excellent (α=0.94).

To compare the rates of sexual dysfunction between groups of women with distinct sexual assault histories, we used binary logistic regression, regressing sexual dysfunction on developmental stage of sexual assault. We compared sexual function among women with no sexual assault history, women with childhood sexual abuse histories only, women with sexual assault in the military histories only, and women with both childhood sexual abuse and sexual assault in the military histories. We also used binary logistic regression to compare the rates of screening depression diagnosis and screening PSTD diagnosis among women with distinct sexual assault histories. One-way analysis of variance was used to test for differences in PTSD severity between women with distinct sexual assault histories. We planned the following contrasts: compare the no sexual assault group and the three trauma groups; compare the childhood sexual abuse–only and sexual assault in the military–only groups; and compare the sexual assault in the military only, and childhood sexual abuse and sexual assault in the military groups on PTSD symptom severity. For all tests the significance level was set at 0.05 and the Bonferroni correction was used to account for multiple tests. The exploratory analysis examining the relationship between lifetime sexual assault history, mental health (depression and PTSD), and sexual health was conducted with binary logistic regression, including all possible interactions.

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RESULTS

A total of 1,004 female veterans participated in the study. The age of participants ranged from 20 to 52 years old at the time of the interview, with a mean of 38.33 (SD±8), and the majority identified as non-Hispanic, Caucasian, and heterosexual. See Table 1 for demographic characteristics of the study sample.

Table 1.

Table 1.

A small number of women (n=4) declined to report lifetime sexual assault history, therefore the current analyses focused on the 1,000 women with complete sexual assault history data (Table 2).

Table 2.

Table 2.

The study sample was approximately evenly split between female veterans without histories of lifetime sexual assault (48.7%) and female veterans with histories of lifetime sexual assault (50.9%). Women reported the developmental periods (childhood before age 18, premilitary adulthood, military service, and postmilitary adulthood) in which they experienced sexual assault. We report the numbers of women uniquely exposed to sexual assault in each developmental stage, and the combination of childhood sexual abuse and sexual assault in the military, as these groupings are most relevant to the current research question. Note that women in the childhood sexual abuse and sexual assault in the military group may have also been exposed to sexual assault during premilitary and postmilitary adulthood as well, thus this group represents women with at least childhood sexual abuse and sexual assault in the military histories.

We examined age, race, ethnicity, and level of education as potential confounders that might affect our research question. None of these showed a systematic relationship with sexual pain (age: χ2(1)=0.002 [not significant]; race: χ2(5)=7.06 [not significant]; ethnicity [Hispanic or non-Hispanic] χ2(1)=0.514 [not significant]; education: χ2(4)=5.072 [not significant]). Therefore, we did not include any of these variables in the binary logistic regression models.

There was a significant relationship between developmental stage of sexual assault (no sexual assault, childhood sexual abuse only, sexual assault in the military only, and childhood sexual abuse and sexual assault in the military) and sexual pain (χ2(3)=40.98, P<.001). The odds ratios (ORs) for sexual pain based on developmental stage of sexual assault are reported in Table 3, with the no sexual assault group as the reference group. Women with histories of childhood sexual abuse and sexual assault in the military were most likely to report sexual pain, and were 4.33 times more likely to report sexual pain than women without histories of sexual assault. Women who had histories of sexual assault only in the military were 2.37 times more likely to report sexual pain than women without histories of sexual assault. Women with histories of childhood sexual abuse only were 1.75 times more likely to report sexual pain than women without histories of sexual assault.

Table 3.

Table 3.

There was a significant relationship between developmental stage of sexual assault (no sexual assault, childhood sexual abuse only, sexual assault in the military only, and childhood sexual abuse and sexual assault in the military) and depression (χ2(3)=56.07, P<.001). The ORs for depression based on developmental stage of sexual assault are reported in Table 3, with the no sexual assault group as the reference group. Women with histories of childhood sexual abuse and sexual assault in the military were most likely to report depression and were 3.91 times more likely to report depression than women with no sexual assault history. Women who had histories of sexual assault only in the military were 3.18 times more likely to report depression than women with no sexual assault history. Women with histories of childhood sexual abuse only were 2.65 times more likely to report depression than women with no sexual assault history.

There was a significant relationship between developmental stage of sexual assault (no sexual assault, childhood sexual abuse only, sexual assault in the military only, and childhood sexual abuse and sexual assault in the military) and screening diagnosis of PTSD (χ2(3)=88.18, P<.001). The ORs for screening diagnosis of PTSD based on developmental stage of sexual assault are reported in Table 3, with the no sexual assault group as the reference group. Women with histories of childhood sexual abuse and sexual assault in the military were most likely to receive a screening diagnosis of PTSD and were 6.35 times more likely to receive a screening diagnosis of PTSD than women with no sexual assault history. Women with histories of sexual assault only in the military were 5.55 times more likely to receive a screening diagnosis of PTSD than women with no sexual assault history. Women who had histories of childhood sexual abuse only were 2.20 times more likely to receive a screening diagnosis of PTSD than women with no sexual assault history.

The PTSD severity data violated the assumptions of normality and homogeneity of variance; therefore we used the Kruskal-Wallis test, which is a nonparametric test that does not hold these assumptions. There was a significant difference in PTSD severity between the trauma groups (H(3)=90.35, P<.001). Jonckheere’s test revealed a significant pattern in the data—that PTSD severity increased linearly from the no sexual assault group to the childhood sexual abuse–only group to the sexual assault in the military–only group and to the childhood sexual abuse and sexual assault in the military group (J=144,159.5, z=9.222, P<.001). Three planned follow-up comparisons were conducted with the Mann-Whitney Test, and the Bonferroni correction was applied to account for conducting multiples tests, therefore the new significance criterion was set at .0167. A follow-up contrast indicated there was a significant difference in PTSD severity between the no sexual assault group and the three sexual assault groups combined (U=59,975.00, z=−8.21. P<.001, r=.28, a small-to-medium effect). The severity of PTSD was higher for women with histories of sexual assault than it was for women without histories of sexual assault. A follow-up contrast indicated there was a significant difference in PTSD severity between the childhood sexual abuse–only group and the sexual assault in the military–only group (U=6,025.5, z=−3.913, P<.001, r=0.24, a small effect). Women with histories of sexual assault in the military only reported significantly more severe PTSD than women who had histories of childhood sexual abuse only. A follow-up contrast indicated no difference in PTSD severity between women who had a history of sexual assault in the military only and women with a history of childhood sexual abuse and sexual assault in the military (U=5,440.0, z=−0.372, P=.710 [not significant]). Thus, women who had histories of sexual assault only while in the military reported comparable PTSD severity with women who had experienced both childhood sexual abuse and sexual assault in the military.

There was a significant bivariate relationship between sexual pain and depression (χ2(1)=17.45, P<.001), with the no depression group as the reference group. The OR for this analysis was 1.94 (95% CI 1.43–2.63). There was also a significant relationship between sexual pain and screening diagnosis of PSTD (χ2(1)=27.32, P<.001), with the no PTSD group as the reference group. The OR for this analysis was 2.37 (95% CI 1.72–3.25). Both depression and PTSD were associated with increased odds of sexual pain.

To further explore the relationship between sexual assault history and mental and sexual health we conducted an exploratory examination of the relationship between lifetime sexual assault, depression, and PTSD, and the four potential interactions. The overall model was significant (χ2(7)=53.487, P<.001), yet the only individual variable that remained significant was lifetime sexual assault (Table 4). This suggests that when all variables are accounted for, lifetime sexual assault is strongly associated with sexual pain.

Table 4.

Table 4.

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DISCUSSION

We found that women with histories of childhood sexual abuse and sexual assault in the military reported the highest rates of sexual pain, with 4.33 greater odds of sexual pain than female veterans with no sexual assault history. The cumulative effect of multiple sexual assaults across the lifespan, and, moreover during military service, may increase the risk for sexual pain. A pattern was observed in which women with childhood sexual abuse and sexual assault in the military histories reported the highest rates of sexual pain, followed by women with sexual assault in the military histories alone, women with childhood sexual abuse histories alone, and women with no sexual assault history. This suggests that among female veterans, sexual assault in the military confers more risk for sexual pain than childhood sexual abuse. This finding is distinct from the pattern long observed in civilian women that childhood sexual abuse confers a greater risk for sexual pain than adulthood sexual assault.13,14 This is an extremely important distinction between the sexual health of civilian women and female veterans.

High comorbidity between mental health concerns and sexual pain was also identified in the current study. Similar to the findings for sexual dysfunction, the highest rates of depressive episodes and PTSD screening diagnoses were among female veterans with histories of childhood sexual abuse and sexual assault in the military. Depressive episodes and PTSD screening diagnoses respectively were most common among female veterans with histories of childhood sexual abuse and sexual assault in the military, followed by women with histories of sexual assault in the military alone, histories of childhood sexual abuse alone, and no sexual assault history. Additionally, PTSD severity did not differ between women with histories of childhood sexual abuse alone and sexual assault in the military, alone. Results support a growing literature suggesting that sexual assault in the military confers a greater risk for PTSD than sexual assault at other developmental stages.8,16,17

Although the current study did not examine the mechanisms that may lead to sexual pain after sexual assault in the military, prior literature on the robust relationship between sexual assault in the military and PTSD suggests potential areas for future exploration. Certain elements of the military environment may increase the risk for PTSD after sexual assault in the military including the presence of weapons,27 leadership that condones sexual harassment,28–30 and loss of trust in the military institution.31 These elements might also affect female veterans’ sexual function. Although sexual assault in the military may be a single event, it often occurs in the context of a continuum of sexual violence exposures ranging from chronic sexual harassment including sexual remarks or gestures, pressure for dates, and degrading comments about women’s bodies, and the ongoing threat of sexual assault.11,32 In response to the chronic nature of sexual assault in the military risks, female veterans may attempt to suppress their own sexuality, and this chronic suppression of sexuality, avoidance of sexual expression, and perhaps changes in beliefs about sex, gender roles, and safety, may continue to affect female veterans’ sexual function after military service. Additionally, exposure to chronic stress related to the threat of sexual assault in the military may induce physiologic or hormonal changes that effect sexual function.33,34 Future investigation of the correlates of sexual pain specifically and sexual dysfunction more broadly, in female veterans with and without histories of sexual assault in the military would help to better understand the development of dysfunction and any unique treatment needs.

This study had some methodologic limitations that warrant mention. This was an observational study, thus we are unable to comment on the direction of effects. As with much psychological research, the study relied on participant self-report, which is subject to social desirability bias. In an effort to reduce social desirability bias, the interviewers were highly trained in sensitivity to sexual assault and interview questions were carefully worded to avoid stigmatizing participants. The sample was composed of female veterans enrolled in two midwestern VA medical centers and associated outlying clinics, therefore our results may not generalize to female veterans from other parts of the country, or to female veterans who are not enrolled in the VA. However we examined the healthcare use of this sample in a prior publication and found that 32% were sole VA users, 56% were dual users, and 12% were nonusers of VA care,35 therefore results can generalize to female veterans with a range of health care usage. The sample was composed of women 51 years and under at the time of recruitment, thus results may not generalize to women older than 51 years old. The majority of the sample (89.1%) identified as non-Hispanic and Caucasian, thus results may not generalize to women from other ethnic or racial backgrounds. We used a single-item measure of sexual function that assessed only the sexual pain domain of women's sexual function. Female sexual dysfunction includes domains for sexual desire, arousal, orgasm, and pain.23,36 The measure of depression used, the Composite International Diagnostic Interview Short Form, assesses only for a current major depressive episode, not for major depressive disorder. It is possible that participants did not meet the criteria for a major depressive episode on the day of the interview but would have qualified for a major depressive disorder if the full criteria had been used, which may have affected our results for depression. Given that childhood sexual abuse and sexual assault in the military were the focus of this study and that only a small number of women reported sexual assault during premilitary or postmilitary adulthood only, we did not evaluate the effect of sexual assault during these two periods on female veterans' sexual health. Prior research on female veterans suggests that these periods are important to female veterans' mental health.8 Additionally, our childhood sexual abuse and sexual assault in the military group was not limited to women assaulted only during those periods; rather, women in that group also may have been assaulted during premilitary and postmilitary adulthood, limiting the specificity of our findings. Future research could be improved though larger samples that allow for an evaluation of all four developmental periods, and their discrete combinations, on sexual function.

Despite these limitations, study findings have important implications for research and clinical care of female veterans. The literature on female veterans' sexual function could be improved through the use of comprehensive and validated measures of women's sexual function, such as the Female Sexual Function Index,37 the Female Sexual Distress Scale,38 and the Sexual Satisfaction Scale for Women.39 In addition to more studies focused on female veterans' sexual health specifically, ongoing studies on female veterans' health could add sexual function measures to provide baseline data on sexual function in female veterans. The differences in sexual pain noted between women with different sexual assault histories add support to calls for comprehensive assessment of lifetime sexual assault in research on female veterans.1,8 Similar to the research implications, health care providers should be more comprehensive in their assessment of sexual assault history. Clinical care would also be improved through assessment of sexual dysfunction among all female veterans, particularly those with histories of childhood sexual abuse and sexual assault in the military. Providers might also consider seeking additional training in women's sexual health and developing relationships with community providers who specialize in sexual health. The growing numbers of women serving in the military and prevalence of sexual assault in this population call for further research on the effects of sexual assault on the sexual function of female veterans and will aid in the development of targeted treatments for this population.

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