Few who experience sexual assault seek health care immediately. Yet many become heavy users of health care resources in the years postassault because sexual violence has been linked with both acute and chronic health consequences. Chronic physical health problems among sexually assaulted women include higher rates of gynecologic and gastrointestinal symptoms, chronic pain syndromes, sexual dysfunction, and functional impairment.1–6 Chronic mental health (MH) outcomes associated with sexual assault include posttraumatic stress disorder, major depression, substance abuse, panic disorders, and suicidal ideation.7–10 Previous studies of sexual assault in-military (SAIM) have demonstrated the relationship between trauma exposures, including sexual violence, and chronic health problems.9,11
Research has shown that military personnel and veterans experience higher rates of trauma exposure in comparison with the general population.12 The Department of Defense’s (DoD) annual estimates of unwanted sexual contact for service women are 6% among Active Duty and 3% among the Reserve Component.13,14 Among women veterans, 30%–45% have experienced military sexual trauma (MST).12 Among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) women veterans receiving care at the Veterans Health Administration (VHA), 15% have screened positive for MST.15 Both the DoD and VHA have undertaken efforts to improve responses to sexual assault.
Utilization of appropriate and timely medical and MH care postassault may help to attenuate risk for chronic illness linked with trauma exposure. However, few women with a history of sexual violence, with or without serious injury, seek or receive immediate assault-specific medical care.16,17 Affected individuals, especially those who do not require urgent postassault medical or MH intervention, may not associate their sexual assault experience to their current or chronic health problems. Nevertheless, it has been shown that those with a history of sexual assault have higher rates of medical utilization postassault3,18,19 and few health care providers are aware of these histories.5,20
Understanding factors associated with utilization of postassault health care is critical to identify potentially modifiable factors that prevent servicewomen from seeking postassault care. The analysis presented here is part of a larger study whose primary goal was to identify the antecedent risks and subsequent health consequences of physical and sexual assault in servicewomen serving during OEF/OIF. This paper addresses one of the study’s aims, which was to characterize factors associated with post-SAIM medical and MH care utilization and identify reasons servicewomen did not seek care. These analyses represent necessary steps toward ensuring all military servicewomen receive both timely post-SAIM health care and appropriate lifetime trauma-related health care.
Sample and Sources of Data
Two mutually exclusive populations of Reserve and National Guard (RNG) and Active Component (AC) servicewomen were sampled. At the time of study participation, some servicewomen were still serving, whereas others had separated from service (eg, veterans). All participants had served in the Army or Air Force, and resided, served, or had enlisted from a Midwestern state (Iowa, Illinois, Missouri, Nebraska, and Kansas); this geographic region was chosen to facilitate in-person focus groups, which were used to guide refinement of the study interview. A sampling frame was used to stratify enlisted servicewomen by deployment history (never, deployed to Iraq or Afghanistan (I/A) once, deployed to I/A more than once, and deployed somewhere other than I/A) and to oversample officers. Defense Manpower Data Center provided contact information and select demographic and military variables.
A computer-assisted telephone interview (CATI) was used to query servicewomen’s demographic and military characteristics, lifetime sexual assault history, SAIM, and postassault SAIM health care receipt. Interviewers called participants using participants’ preferred landline or cell telephone number. CATIs21 allow study interviewers to conduct telephone interviews and enter participant responses directly into the computer. The computer screen displays the queries and allows the interview to be tailored to participant responses (ie, skipping questions that are no longer applicable based on prior participant responses).
RNG and AC interviews were conducted from March 2010 to September 2010 and from October 2010 to December 2011, respectively. The average interview took 1.5 hours and most (73%) were completed in 1 call. Additional information regarding sampling and recruitment are available elsewhere.22 Both studies received IRB approval from the authors’ university and VHA institutions.
The term Military Sexual Trauma (MST) is widely used; however, it has not been defined consistently across studies.12 The VHA conducts MST screening, which includes incidents of sexual harassment and unwanted physical contact. Therefore, we use the term “sexual assault in-military” (SAIM) to indicate that this study’s definition of MST is more narrowly defined than VHA’s (ie, does not include sexual harassment). Questions used to measure SAIM were guided by the definition of the American Medical Association and American College of Obstetrician and Gynecologists23,24 and adapted from those used in the National Women’s Study and the National Violence Against Women Survey,16,25 which are widely used measures.2,3,26,27 Respondents were asked separately about attempted and completed sexual assault (SA) (“During your lifetime, has anyone, male or female, using force or threat of harm, ever attempted to sexually assault you? By attempted SA, I mean that an attempt was made but penetration did not occur.” And “During your lifetime, has a man or boy, using force or threat of harm, ever made you have sex by putting his penis in your vagina; or has a male or female put their tongue, fingers or objects in your vagina or anus? By completed SA I mean that penetration did occur during the assault.”) Participants who indicated that they had experienced lifetime SA were asked follow-up questions to determine whether SA occurred during military service. Over a third (36%) of RNG participants had prior AC service and some had experienced SAIM during AC service. RNG servicewomen who experienced SAIM solely during their AC military service were not included in these analyses because post-SAIM care receipt was queried only for RNG service.
Post-SAIM Health Care Receipt
Servicewomen who experienced a sexual assault during military service were queried about post-SAIM health care receipt and focused on current service (ie, AC or RNG).
Questions were prefaced with the following directions: “The next questions ask about possible injuries that might have occurred as a direct result of any attempted or completed assault you experienced while serving in the military [for RNG: Reserve or National Guard], and about medical care following the assault or assaults. Please indicate “yes” to all that apply.” Questions specific to post-SAIM care included: (1) “Did you receive medical care for this or any SA” and (2) “Did you ever receive emotional counseling from a MH clinician to help you deal with an assault.” Women who responded yes were asked when they first utilized care following the assault(s) (ie, within 24 h, 1 mo, 6 mo, 1 y, and >1 y post-SAIM). In cases in which multiple SAIMs were experienced, the earliest time care was received for any SAIM is presented.
Demographic (ie, current marital status), military [ie, whether currently serving in the military (active duty vs. veteran), and deployment histories], and SAIM characteristics (ie, completed SAIM, servicewomen’s use of alcohol or drugs before SAIM, on-duty SAIM, injuries, and making a DoD SAIM report) were self-report data collected from the CATI. In addition, past year health care use (ie, routine physical, specific physical, routine gynecologic, and MH) was self-reported. Additional demographic (ie, age, race, education) and current military service type (ie, AC vs. RNG) data were obtained from the Defense Manpower Data Center.
Reasons for not Seeking Post-SAIM Care
Reasons why women might not have received medical or MH attention following any SAIM were adapted from the Mental Health Advisory Team (MHAT V).28 Statements that subjects could agree or disagree with were asked with Likert scale response options ranging from strongly disagree to strongly agree. Topics queried included: access to care, emotional consequences (eg, too embarrassing), confidentiality concerns, perceived peer response, leadership reprisal, and career consequences. Coefficient α values computed from study data were: 0.80 for the medical care items, 0.87 for the MH care items.
Bivariate analyses examined utilization of post-SAIM health care separately for medical and MH care using individual logistic regressions to produce odds ratios and confidence intervals. Likert scales were dichotomized: 4-point (eg, strongly disagree, disagree vs. agree, strongly agree) for medical care; 5-point (eg, strongly agree, agree vs. neither agree nor disagree, disagree, strongly disagree) for MH care.29,30 Frequencies were calculated for the number who endorsed each reason for not seeking care specific to SAIM. Bivariate results were used to fit separate medical and MH multivariate logistic regression models to characterize factors associated with care utilization. The selection of variables was determined by a bivariate P-value cutoff of 0.25 or whether the variables were deemed important to include regardless of statistical significance [ie, age, service type (ie, AC or RNG)]. Variable interactions were investigated. Variables that were no longer significant when included in the multivariate model were removed to achieve parsimony. Data were analyzed using SAS, version 9.3.31
The study response rate was 57% (1597/2813). Comparisons between participants and nonparticipants have been published previously.22 Nonparticipants tended to be younger and less likely to have graduated from college than participants. For the larger study, 1339 servicewomen were interviewed. Eighteen percent (123/674) in the AC sample experienced SAIM during AC service and 13% (84/665) in the RNG sample experienced SAIM during RNG service. A subset of RNG servicewomen (6%) self-reported SAIM occurring solely during their AC service; however, these servicewomen were not included, as post-SAIM health care receipt was not queried for their prior AC service. One AC servicewoman refused answering questions about post-SAIM health care, resulting in the final sample size of 207 used in all subsequent analyses.
A third (32%) of servicewomen received post-SAIM care (25% MH; 16% medical) (Table 1). Approximately a quarter (18/67) of those who got care received both medical and MH health care. Only 4 servicewomen received medical and MH care in the same time period [within 30 d (n=3) or 6 mo (n=1) after the sexual assault], and all others (n=14) received medical care sooner than MH care. Receipt of medical care primarily occurred within the first month post-SAIM, whereas MH care receipt ranged from immediately to more than a year post-SAIM. Most sought care on a military base; however, approximately a third sought care from a civilian provider and a tenth sought MH care at a VHA facility.
Servicewomen who experienced SAIM had a median age of 31 years (range, 18–59 y) (Table 2). The majority were white (70%), almost half were married (45%), and a third (30%) were college graduates. Approximately four fifths of the sample were enlisted (80%), currently serving (84%), and had ever been deployed (81%); 59% had at least 1 deployment to Iraq and/or Afghanistan. Histories of post-SAIM care utilization did not differ statistically for servicewomen ever deployed. Almost 60% had served solely in the AC.
Over half of the servicewomen who experienced SAIM experienced a completed sexual assault and almost half experienced >1 SAIM. Many servicewomen (78%) identified US military personnel as perpetrators. Less than half (40%) of servicewomen with SAIM history had used alcohol or drugs before the assault. Over half (56%) experienced a SAIM that occurred on-base and nearly a fifth (17%) experienced a SAIM that occurred while on-duty. Approximately a quarter (27%) had physical injuries as a result of a SAIM; 18% had vaginal injuries. A quarter of servicewomen made an official SAIM report to DoD.
Servicewomen who sought post-SAIM medical care did not differ on demographic measures but did differ significantly on several military and assault measures in bivariate analysis (Table 2). Women who utilized postassault medical care were more likely to be serving in the AC, have experienced a completed SAIM (as opposed to attempted SAIM), acknowledged using alcohol or drugs before SAIM, have physical or vaginal injuries, and were more likely to have made a DoD SAIM report (P<0.05 for all comparisons). Notably, although those who experienced physical or vaginal injuries were more likely to get medical care, less than a third (n=19/68) of the servicewomen who had one of these injuries received care.
Servicewomen who sought post-SAIM MH care did not differ on military measures but did differ significantly on several demographic and assault measures (Table 2). Women who received MH care were more likely to be white, to have had a SAIM occur on-duty, to have SAIM-associated vaginal tears, and to have made an official DoD SAIM report (P<0.05 for all comparisons).
All 207 participants had seen a health care provider in the past year. Routine or specific physical examinations and routine gynecologic examinations were not significantly associated with receipt of post-SAIM health care (Table 2). However, those who had received post-SAIM MH care were more likely to have received MH care in the past year.
Independent Measures Associated With Post-SAIM Care
Multiple logistic regression was used to identify independent measures associated with receipt of medical care and MH post-SAIM (Table 3). There were no statistically significant interactions in the final medical and MH care models. Factors associated with receipt of post-SAIM medical care included having experienced a completed SAIM and a DoD SAIM report. Those who received medical care were also more likely to have received MH care. Servicewomen who utilized MH care were more likely to be white, have experienced an on-duty SAIM, and to have made a DoD SAIM report. In addition, those who received MH care were also more likely to receive medical care. Those who made a DoD SAIM report and who utilized medical care were more likely to have also utilized MH care. Likewise, those who made a DoD SAIM report and received MH care were more likely to have gotten medical care.
Reasons for not Seeking Care
Lastly, servicewomen who did not receive any type of post-SAIM care were asked why they did not seek care. The most frequently endorsed reason servicewomen did not seek post-SAIM medical care was because they did not think it was needed (87%). Among this subgroup, almost half had experienced a completed SAIM. In addition, 21 servicewomen were physically injured, 7 had vaginal injuries, and 7 had both physical and vaginal injuries and still said that care was not needed. The next most commonly endorsed reasons included being too embarrassed (45%), concerns about confidentiality (44%), being blamed for the SAIM (43%), and fears that seeking medical care would adversely impact their career (39%). Servicewomen could endorse multiple reasons (Table 4). Notably, more than a fourth of servicewomen who did not seek medical care were afraid of reprisal from the assault perpetrator (27%), or military peers (26%), and had concerns about disrespectful treatment (25%). Fewer servicewomen endorsed reasons for not getting medical care because it was not offered (16%) or because they felt they would not get adequate treatment (13%). Less than 5% of servicewomen said that they did not receive medical care because it was discouraged by their leadership.
The most frequently endorsed reason servicewomen did not seek post-SAIM MH care was because they were too embarrassed (50%). Between 30% to 40% endorsed reasons associated with military career impact: being viewed as weak, harmful to career, and reduced unit member confidence in a MH care seeker. Women endorsed similar frequencies for concerns about confidentiality and being blamed for the SAIM. A little less than a fifth of women said that they were concerned that seeking post-SAIM MH care would adversely affect their security clearance or that they did not know where to go for MH care. About 10% said that their leadership discouraged the use of MH services and that it was too difficult to get to a military MH specialist during service.
Identifying both the factors associated with postassault care utilization and reasons why women do not seek postassault care is necessary to ensure servicewomen with SAIM receive both timely post-SAIM health care and appropriate lifetime trauma-related health care. Few OEF/OIF AC and RNG servicewomen in this sample utilized medical care post-SAIM. Those most likely to have used medical care experienced the most severe SAIMs (ie, physically injured, completed sexual assault). This finding is not unexpected as research has shown that women who officially report to authorities are more likely to have been physically injured during the sexual assault. However, data from the civilian literature estimate that only about one third of those with a history of sexual assault resulting in injuries seek medical care.16,17 In this study, the most frequently endorsed reason for not seeking medical care was a belief that it was not needed. Servicewomen who experience SAIM, even those who have no overt physical injuries, need to be encouraged to seek post-SAIM health care, because they are all potentially at risk for other serious negative health outcomes.32
Studies have shown reporting sexual assault to authorities is most individuals’ primary link to getting medical treatment and other forms of assistance,17 a finding confirmed with this study’s data. However, there are well-documented barriers to reporting.33–36 This study provides data demonstrating that barriers to seeking post-SAIM medical care, such as being too embarrassed, confidentiality concerns, and potential negative career consequences/reprisals, are similar to those for DoD SAIM reporting.13,14,16,22,27 It is unknown whether DoD reporting facilitates post-SAIM medical care utilization or whether medical care utilization empowers DoD reporting. This may be an unnecessary distinction as both DoD reporting and medical care utilization require servicewomen to disclose their experiences to formal social systems, systems that many believe will not or cannot help or, even worse, could cause psychological harm.35 Therefore, addressing the stigma associated with acknowledging sexual assault and preventing secondary traumatization may increase DoD reporting rates, post-SAIM medical care receipt, and may ultimately support primary prevention efforts.
Among the subsample of study servicewomen who utilized post-SAIM medical care, more than half accessed care within 24 hours of the sexual assault. A DoD Task Force on Care for Victims of Sexual Assault found that 52% received medical care within 7 days of the alleged sexual assault.37 The timing of medical care following a completed sexual assault is particularly important for prevention of pregnancy and sexually transmitted infections (STI). The Department of Justice’s gold standard of care, adopted by the DoD,38 includes guidelines for prophylactic treatment options for possible exposure to human immunodeficiency virus and other STIs; assessment of pregnancy risk and options for emergency contraception; and any necessary follow-up care and referrals for behavioral health services, if necessary or requested by the individual. Unfortunately, studies in civilian populations have shown that many who sought postrape medical care did so too late to benefit from prophylactic treatments that could have prevented pregnancy or STIs.32
In this study, more servicewomen utilized post-SAIM MH care than medical care, and MH care was received often months after the SAIM. The percentage of OEF/OIF AC and RNG servicewomen who utilized MH care post-SAIM is similar to those reported in civilian studies20,39 and in a VA-enrolled women veteran sample,27 which found that few women seek postassault MH care. Furthermore, those who do utilize MH care are more likely to be white,40,41 which we also found to be due to the fact that white servicewomen were more likely than minority servicewomen to have utilized post-SAIM MH care. Further investigation of barriers to seeking post-SAIM MH care among this subpopulation of servicewomen is warranted as this suggests likely MH care disparities.
Most importantly, after SAIM the majority of servicewomen did not utilize either medical or MH health care. The reasons servicewomen acknowledged for not getting care were generally the same for both types of care (ie, medical vs. MH care) and suggests that these barriers are linked more closely with sexual assault than with care type. Notably, the majority of servicewomen had routine physical and gynecologic examinations within the past year. Therefore, primary care and women’s health care providers may be best positioned to conduct routine screening to identify women with health care needs related to histories of sexual assault. Routine screening has been implemented in VHA42 and the American College of Obstetricians and Gynecologists strongly recommend that all women be screened for a history of sexual abuse.43
Strengths of this study are inclusion of both AC and RNG, active duty and veterans, ever deployed and not deployed, and whether a DoD SAIM report was made, in addition to a comprehensive interview. Potential sources of bias introduced through CATI data collection methods from participants (eg, faulty memories, exaggeration, dishonesty, and courtesy bias) were minimized by sharing the purpose and goals of the study before participation and during participation, providing definitions to standardize understanding of key measures (eg, sexual assault). Potential interviewer bias was minimized using extensive training, standardized interviews, and quality control protocols. A potential limitation is that our sampling frame focused on Midwestern states and therefore may not be nationally representative or generalizable to all servicewomen. Also, the number of servicewomen who utilized post-SAIM care was small, which potentially limited the number of independent measures the logistic regression models were able to identify and resulted in wider confidence intervals for the odds ratios. A larger sample of servicewomen utilizing care may allow identification of additional demographic, military, and/or assault characteristics. Lastly, this study queried servicewomen about their most recent service (ie, AC, RNG). Information about post-SAIM health care utilization for RNG servicewomen who experienced SAIM during their AC service was not collected and therefore it is unknown whether these experiences are consistent with servicewomen who served solely in the AC.
Of all personal crimes, sexual assault has been considered the most serious and traumatic, short of homicide.44,45 One of the first steps in addressing an individual’s immediate and long-term health, and in potentially mitigating the health effects of SAIM, is promotion of immediate medical and MH health care postassault. Civilian, military, and VHA providers should understand the importance of their role in helping patients with SAIM to heal by recognizing that most servicewomen who have experienced SAIM do not get post-SAIM physical or MH care, but do continue to access routine health care. Screening for Veteran status and for sexual assault histories and multidisciplinary care approaches are necessary to the provision of optimal women’s health care.
In summary, we found that few servicewomen received post-SAIM health care and therefore, assault-specific health consequences were likely unaddressed. Given the severe and chronic consequences of sexual assault, our study findings emphasize the need for military, VHA, and civilian providers to sensitively query SAIM history to provide timely and appropriate care throughout women’s lifespans. Providers must also recognize the importance of their role in patient education and addressing physical and emotional care needs of sexual violence.
The authors gratefully acknowledge Holly Strehlow, BA, for her contribution as the CATI Lab Director and Carrie Franciscus, BS, MA, for her invaluable database support.
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