Screening for Sexual Trauma Improves Access to Care

Routine screening of veterans for a history of sexual trauma that occurred while in military service is an efficient way to identify affected individuals and increase their access to care, according to an analysis of Veterans Health Administration records.

The Department of Veterans Affairs (VA) mandated universal screening for military sexual trauma (MST) for both men and women beginning in 1999. Screening was backed by an offer of “all appropriate care and services” to treat sexual trauma occurring during military service.

“It was important to evaluate this system to see if universal screening was appropriate and if the use of mental health services increased afterward,” said Rachel Kimerling, Ph.D., of the Veterans Administration Health Care System in Palo Alto, Calif., at the International Society for Traumatic Stress Studies meeting in Baltimore last November.

An article by Kimerling and colleagues on the same research appeared in the December 2007 American Journal of Public Health.

The definition of military sexual trauma includes sexual assault and sexual harassment, coercion, and unwanted sexual attention. Sexual trauma in the armed forces may involve complicating factors that lack parallels in the civilian world. Such events, or the fear of reporting them, may disrupt the victim's career path, since perpetrators may be peers or supervisors. Reporting sexual trauma may also be seen as a form of betrayal of unit solidarity, one of the highest values in military organizations.

“This means that victims must continue to live and work closely with their perpetrators, often leading to an increased sense of feeling helpless, powerless, and at risk for additional victimization,” wrote Amy Street, Ph.D., and Jane Stafford, Ph.D., in the “Iraq War Clinician Guide” published by the VA's National Center for Posttraumatic Stress Disorder.

Kimerling and colleagues used the Veterans Health Administration (VHA) Out-patients Events File to identify more than 4 million men and 185,000 women who made at least one visit to a VHA medical facility in 2003. The VHA uses a computerized medical record with a pop-up reminder that prompts clinicians to screen for sexual trauma. The reminder stays on the screen until the clinician enters a response.

The sexual-trauma screening includes just two questions: “While you were in the military: (a) Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks? (b) Did someone ever use force or threat of force to have sexual contact with you against your will?”

Data from 2003 were available for 134,894 women and 2,900,106 men. Although the screening is called “universal,” only about 70 percent of patients were screened. That rate is not far below rates of screening for alcohol abuse (80 percent) or cervical cancer (90 percent) in the VA.

Both men and women with positive screens were more likely to be white, younger, never married, and have a service-connected disability than those who screened negative. Men who screened positive were likely to be separated or divorced, as well.

The rates of positive responses to the MST screen were much higher for women than for men, but the preponderance of men in the VA system meant that absolute numbers were similar. About 22 percent of women (29,418) screened positive, compared with 1 percent of men (31,797).

“This highlights the issue of military sexual trauma in males,” said Kimerling.

Women were three times and men twice as likely to have a psychiatric diagnosis if they also screened positive for MST.

The association of posttraumatic stress disorder, alcohol use, and anxiety disorders with MST was stronger among women. The relationship of adjustment disorder, bipolar disorder, and schizophrenia or other psychoses to MST was stronger among men.

Only a few nonpsychiatric medical conditions were associated with MST, including weight loss, obesity, and hypothyroidism among women; AIDS among men; and chronic lung or liver disease among both. Risky health behaviors that may lead to these conditions are more frequent among patients exposed to trauma than others.

On average, screening 5.5 women and 7.2 men moved one person into treatment, said Kimerling. “Universal screening is efficient and increases access to care.”

The study marks just the beginning of bringing to light the“ significant burden” of morbidity related to military sexual trauma, she emphasized.

An abstract of “The Veterans Health Administration and Military Sexual Trauma” is posted at<www.ajph.org/cgi/content/abstract/97/12/2160>.▪