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Perspectives in Psychiatric Care
ISSN 0031-5990
Encountering Women Veterans With Military Sexual Trauma Patricia L. Conard, PhD, RN, Cathy Young, DNSc, FNP-BC, LaMicha Hogan, MSN, RN, FNP-BC, and Myrna L. Armstrong, Ed.D., RN, FAAN Patricia L. Conard, PhD, RN, is an Assistant Professor, College of Nursing and Health Sciences, Texas A & M University Corpus Christi, Corpus Christi, Texas, USA; Cathy Young, DNSc, FNP-BC, is an Associate Professor, School of Nursing, Arkansas State University, Jonesboro, Arkansas, USA; LaMicha Hogan, MSN, RN, FNP-BC, is an Assistant Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas, USA; and Myrna L. Armstrong, Ed.D., RN, FAAN, is a Nursing Consultant Professor Emerita, School of Nursing, Texas Tech University Health Sciences Center, Marble Falls, Texas, USA
Search terms: Deployment, harassment, intervention, military, military sexual trauma, PTSD, rape, reintegration, veteran, women Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement There is no conflict of interest. First Received September 12, 2013; Final Revision received October 24, 2013; Accepted for publication November 7, 2013.
PURPOSE: As women veterans (WVs) are returning from Operation Iraqi Freedom and Operation Enduring Freedom with military sexual trauma (MST), the purpose of this article is twofold. First, important exploratory questions that can assist with a thorough assessment and history are presented as well as the applicable treatment for any new, recurrent, or unresolved symptoms that involve MST. DESIGN AND METHODS: Review of multiple literary materials, as well as a clinical situation. FINDINGS: WVs will be encountered in a variety of military or civilian primary and community care healthcare settings. Every woman (and man) in the civilian sector should be asked, “Have you ever served in the military?” PRACTICE IMPLICATIONS: Recognition, acknowledgment, and applicable interventions for MST and associated comorbidities, especially post-traumatic stress disorder, are presented as currently 80–90% of MST experiences have gone unreported. Immediate treatment and follow-up are critical for the well-being of the WVs.
doi: 10.1111/ppc.12055
Currently, there are unprecedented numbers of women serving in the military, whether they are a part of the regular duty component (15%) or from National Guard and Reserve units (18%) (Mattocks, Haskell, Krebs, Justice, & Yano, 2012). Most of these women will make the transition from service member to veteran. These numbers of women veterans (WVs) will now be representing the largest cohort in our nation’s history, almost 12% of the U.S. total fighting force (Department of Veterans Affairs, 2013). This population is expected to grow rapidly, especially when the military opens more training opportunities and occupations for women in direct combat participation (Department of Veterans Affairs, 2013; Institute of Medicine [IOM], 2013). Projected estimations by 2035 document WVs comprising almost 15% of the total nation’s living veterans (National Center for Veterans Analysis and Statistics, 2011). Deployment As never before done,over 150,000 military active duty women (whether regular or deployed National Guard/Reservists) served during Gulf War II in Iraq with Operation Iraqi Freedom (OIF) and in Afghanistan with Operation Enduring 280
Freedom (OEF). Demographically, those deployed are somewhat different from the national picture; 67% were reportedly Caucasian,25% non-Caucasian,and 8% Hispanic; 48% stated they were married, yet more were likely to be divorced (National Center for Veterans Analysis and Statistics, 2011). They were from all branches of service, including Marines (4%), Army (12%), Navy (14%), and Air Force (17%); many were junior grade officers, with at least a college degree (88%) (IOM, 2013). Most of them serving in OIF/OEF ranged in average age from 20–30 years (regular active) to 36 years (National Guard/Reserves). During deployment, military officer, warrant, and enlisted women served alongside their fellow male soldiers in almost every capacity. Even area quarters for hygiene and sleep were in close proximity to their male counterparts. Women also received similar assignments for extended and/or multiple deployments (Seal et al., 2009). Officially, their positions were not in combat, but their expanded role responsibilities were still in battlefield exposure situations, in male-dominated units (IOM, 2013). Common activities included driving military vehicles, delivering fuel, securing unit posts, providing health care, or assuming valuable general logistical support personnel positions, all the while being exposed to similar Perspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
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types of improvised explosive devices, ambushes, and attack dangers. These situations were physically and psychologically exhausting because these women were constantly in a crisis mode, introducing the possibility of an allostatic overload from too much stress (McEwen, 2008). During OIF/OEF, over 850 WVs were injured, and over 150 lost their lives in service to our country (Department of Defense, 2012).
Reintegration As the nation has experienced“troop draw-downs”from OIF/ OEF, some WVs may return “relatively unscathed,” while others will have experienced both visible and/or non-visible physical and emotional scars (IOM, 2013, p. 471). Although these scars have always occurred with battlefield experiences, WVs of OIF/OEF have faced a myriad of higher level challenges while deployed, involving a multitude of traumatic exposures. The top three primary service-related diagnoses (15%) documented “upon their return were Post Traumatic Stress Disorder (PTSD), lower back pain, and migraines” (National Center for Veterans Analysis and Statistics, 2011, p. vi). Regarding health care upon stateside return, if the WVs remain on active duty their medical care will be provided at their assigned military installations. Once discharged (active duty) and/or deactivated (deployed National Guard/ Reservists), eligible service-related care can be obtained at Veterans Administration (VA) hospitals, although for a multitude of reasons, coordination of care difficulties has been frequently reported (IOM, 2013). Currently, about 60% of WVs in OIF/OEF, with compensable disabilities, have used the VA health services or programs, with 90% returning more than once (Department of Veterans Affairs, 2013). To meet the growing care needs for this unique population, advanced practice psychiatric nurses (APPNs) and nurse psychotherapists (NPTs) should be prepared to encounter WVs in a variety of military or civilian healthcare settings, both in primary and community care systems (Allen, Armstrong, Conard, Saladiner, & Hamilton, 2013). The purpose of this article is twofold. First, this article presents information on important exploratory questions that can assist with a thorough assessment and history and, second, applicable treatment for any new, recurrent, or unresolved symptoms that could involve military sexual trauma (MST) is discussed. (A composite) K.T., a 27-year-old obese female, presents to the clinic with complaints of fatigue, generalized body pain, difficulty getting up in the morning. She reports not enjoying her job. Her last clinic visit was 6 years ago. Denies any illicit drug use, but admits to occasional heavy alcohol use. Appearance of the stated age, flat affect, without noticeable distress. Objective data: T 98.4; P 68; R 20; B/P 168/110; Wt 287; BMI 44.79 (elevated from 23.41 6 years ago). Zung Self-reported depression scale—73. Perspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
Important Assessment Questions As there are currently almost 23 million veterans in the nation (IOM, 2013), every adult patient in the civilian sector seen in an APPN/NPT practice should be asked an important, universal, initial assessment question, “Have you ever served in the military?” Because serving one’s country encompasses providing protection in peace and wartime situations, whether stateside, on a battlefield, or within humanitarian situations, this initial screening question should concentrate on service, rather than as a veteran, as some are unclear as to their status (both men and women) (Allen et al., 2013). By using the Military Health History Pocket Card for Clinicians, unique risks and military exposures, as well as different societal support, can become more evident as the service members discuss their specific war/conflict activities (Department of Veterans Affairs, 2013). There are some soldiers who have experienced battlefield trauma who may not offer disclosure until asked, for a multitude of reasons, including mental health stigma, career jeopardy, or being “military proud.” When asked, KT said she had enlisted in ROTC to help pay for her education and after her BSN, was commissioned with an intention of making the military a career. She had been in the Army, a nurse, for 4 years, but left honorably as a Captain about 2 years ago. Assessment: (a) Elevated blood pressure; (b) Obesity; (c) Severe depression. Because of KT’s military experience, as well as recent events uncovering a growing concern with the number of sexual assaults, two further screening questions should be specifically asked: “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?” (Kimerling, Gima, Smith, Street, & Frayne, 2007, p. 636). So far, the military believes as many as 26,000 WVs and 1 in 100 men (numbers based on extrapolations) in 2012 could answer “yes” when asked about MST, a 35% increase from 2010 (Department of Veterans Affairs, 2013; Farris, Schell, & Tanielian, 2013). While acknowledgment of MST has been historically limited, the most active and comprehensive discussion about MST was initially documented in the aftermath of the 1991 Tailhook Convention (National Center for Veterans Analysis and Statistics, 2011). This also coincided with the increased amount of regular and National Guard/Reservists women activated for Gulf War I. At that time, MST became more fully defined and given better acknowledgment and recognition. Now, there are at least 1.8 million living WVs from the nation’s wars/conflicts, including OIF/OEF, with half of them from the entire Gulf War era (August 1990 onward); their 281
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average age is 48 years (Department of Veterans Affairs, 2013). Although this article will focus mainly on the WVs of OIF/OEF, unresolved MST could also be affecting a few, or many, of the other living WV cohort, for example, from the Vietnam War. In a post-Gulf War I survey, Kang, Dalager, Maham, and Ishill (2004) documented findings of “24% of women with a history of sexual harassment and 3.3% with sexual assault” (p. 193). Including assessment screening questions for these WVs is also crucial as comprehensive women’s health services for military related problems were not finally initiated by the VA hospitals until 1988 (Department of Veterans Affairs, 2013). When KT was asked about MST, at first there was no response. She looked at the floor, the door, her hands, and then finally said yes. She was deployed to Iraq and although not in combat, reported she felt safe most of the time, until a very close friend was killed by a road-side bomb. After her friend had been killed she had been with other friends and had drunk too much. She guessed she went to sleep or lost consciousness, but when roused there were two men on top of her. She thinks she lost consciousness again and when she awoke, she was naked and alone. She believed counseling was not needed at the time, as she believed the assault was her fault. MST Unfortunately, the occurrence of MST should not be related to war as it “goes against the values, honor codes, and laws of the US military, but rather harms those who have sworn to serve and protect their country” (Turchik & Wilson, 2010, p. 269). It is “a non-combat violent assault,” which is “a form of high betrayal trauma” (Allen et al., 2013; IOM, 2013, p. 3; Lutwak & Dill, 2013b, p. 359). Any attempt of sexual activity against one’s will, whether on/off the military base, or while on/off duty, is considered MST (Department of Veterans Affairs, 2012). As defined by the VA and Federal Law Title 38 US Code 1720D, MST is the experience of sexual assault or repeated threatening sexual harassment that a veteran may experience during his/her military service (Department of Veterans Affairs, 2012). Rape, forcible sodomy, indecent assault, and any attempts of these violations are considered sexual assault (Williams & Bernstein, 2011). Sexual coercion, unwanted sexual attention, or threatening attempts to initiate a sexual relationship also fall under sexual harassment (Williams & Bernstein, 2011). Sexual trauma in the civilian world is different as it occurs more frequently in social or community settings, and the victim is often assaulted by enemies or strangers. Recent cost figures for a victim of civilian sexual assault average $2,084 for immediate medical care, another $978 for mental health services, followed by the victim paying another 30–34% of outof-pocket moneys; these figures do not include loss of work 282
days and productivity (Farris et al., 2013). This individual culmination cost has been calculated to be $138,204 in 2012. Annual societal impact on the economy for sexual assault is thought to be around $104.5 million. MST is unique in that it usually occurs in the workplace setting and often by someone known (Burgess, Slattery, & Herlihy, 2013). Farris et al. (2013) calls it the “enemy within” (p. 27). Thus, as service women have to continue to live and work in close proximity to their offenders, MST can lead to a heightened emotional and physical distress such as shame, hopelessness, and betrayal (Lutwak & Dill, 2013a). It also could increase subsequent victimization, such as repeated assaults and other abuses (Farris, et al., 2013; Williams & Bernstein, 2011). This allostatic stress load can also be a physiological predictor of cardiac disease (Lee, 2011; McEwen, 2008). KT did report her assault to her superior Commanding Officer, but was told she was at fault for drinking too much and she probably consented. She could not remember. She decided to ignore it, but found that she continually replayed the event in her mind and had difficulty sleeping. She stated that with every male soldier she looked at, she wondered if he had been one of the ones who had raped her. She felt that every time she thought of “it,”“it” was like experiencing the trauma all over again. Her report of being assaulted was negated when she was told that if it had happened, it was her fault for drinking. A combination of stressors, without help in dealing with her issues, resulted in putting on a large amount of weight. A 2011 Pentagon report estimated 80% to 90% of MST experiences go unreported (as cited in Burgess et al., 2013). An early report by Street and Stafford (2002) documents that almost all (97%) victims of MST knew their assailants. Recently, from unrestricted reporting, approximately 84% involved a service member perpetrator, with 25% within the WV’s chain of command (Farris et al., 2013). Even if victims of MST report or do not report occurrences, they still tend to seek treatment for a myriad of negative physical symptoms possibly related to the violence (Valente & Wight, 2007). Common complaints included, but were not limited to, headaches, pelvic pain, menstrual problems, gastrointestinal symptoms, back pain, and chronic fatigue (Suris & Lind, 2008). Confidentiality, fear of repercussions, and commander subjectivity are some reasons for not reporting the MST. In response, the Department of Defense (as cited in Williams & Bernstein, 2011) has developed a two-tiered system of reporting MST while in the military. The first tier is a restricted report, that is, if the victim wants to get medical assistance and remain anonymous. The second tier is an unrestricted report, that is, if the victim wants to seek punishment for their perpetrator, which eliminates situational anonymity. Using the civilian costs to sexual trauma and the Department of Perspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
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Defense amounts of reported and estimated unreported cases, they estimate MST to cost $3.6 billion, just in 2012 (Farris et al., 2013). Comorbidities Kimerling, Street, Gima, and Smith (2008) found that detection of MST associated with the positive screening questions was three times more likely to be at risk for other mental and health conditions, including depression, anxiety disorders, and substance abuse (Department of Veterans Affairs, 2012); and eating disorders (Forman-Hoffman, Mengeling, Booth, Torner, & Sadler, 2012), heart rate variability (Lee, 2011; McEwen, 2008), and impaired interpersonal functioning (Suris, Lind, Kashner, & Borman, 2007). Early work after Gulf War I documented those who reported being sexually assaulted by a fellow soldier were nine times more likely to develop PTSD (Friedman, Schnurr, & McDonaugh-Coyle, 1994). These comorbidities are what seem to create the heightened impact for MST, when comparing an assault by enemies or strangers in the civilian sector (Farris, et al., 2013; McEwen, 2008; Suris & Lind, 2008). While KT had not been in combat, she had been in an area of frequent attacks, suffering the loss of a close friend, and within 2 weeks had been the victim of sexual assault. At the end of her tour, she did not reenlist. Following her discharge from the military, she did go for STI testing and a gynecologic exam; the results of the PAP smear were abnormal and required further treatment with a LEAP procedure. She has not shared the MST experiences with her family because she did not want them to think negatively of her or the situation. She relates difficulty dating and has not been in a relationship since the loss of her friend and the assault. She denies any suicidal ideations, but thinks it wouldn’t bother her if she died, although she is concerned if she left her mother, since she is an only child. She verbalized concern over her weight, admitted that she probably was depressed, and stated she was willing to try medication. She wanted to hold off a little while on the counseling as she was concerned her mother would want to know why she was seeing a counselor. Now, she was experiencing the four classic symptoms of PTSD: re-experiencing, avoidance, numbing, and hyper-vigilance; related symptomology includes insomnia, hypertension, and significant weight gain. Guilt, shame, and non-trust within themselves, others, and their environment are present with this anxiety disorder, resulting in deep emotional psychological wounds; Lutwak and Dill describe it as “conditioned fear” (2013a, p. 1039). If weapons, easily accessible during wartime/conflicts, are inPerspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
volved as part of the assault threat, a higher incidence with MST and PTSD has been found to be present (Himmelfarb, Yaeger, & Mintz, 2006). The National Center for PTSD (Department of Veterans Affairs National Center for PTSD, 2010) website (http://www.ptsd.VA.Gov) lists several brief questionnaires that can help in providing effective assessment screening for PTSD, complete with a description, sample items, and references. Higher risk with PTSD seems to be well documented,related to when and where traumatic events such as MST for the WVs have occurred (Himmelfarb et al., 2006; Kang et al., 2004; Lutwak & Dill, 2013a).Recent research is now beginning to document that over 50% of WVs may have experienced some type of childhood or domestic physical and/or sexual abuse before military induction (IOM, 2013), producing an even greater impact on how the WVs react to new (stress-filled) situations (McEwen, 2008, p. 13). Thus, APPN/ NPTs should diligently screen and document for this relevant evidence as the WV may have“worse PTSD outcomes after the MST, than if it was a civilian assault” (Suris & Lind, 2008, p. 184). Additionally, children of WVs with PTSD seem to demonstrate increased emotional and behavioral problems (Lutwak & Dill, 2013a). Suicides are also a problem, with the Army reporting the highest overall record of them in 2012; 22 veterans are taking their own lives daily.Yet, overall solid suicide evidence remains limited.The most recent report from the Department of Veterans Affairs on suicide data is only based on the information captured from 21 states over 12 years (1999–2011); they also caution the use of these data as it does not include California and Texas,home to the highest repository of veterans (Kemp & Bossarte, 2013). In the report, less than 3% of all suicides are women and they tend to be white, married, widowed, or divorced, possess at least a high school education, with the largest number centered around 40–49 years of age. McFarland, Kaplan, and Huguet (2010)“suggest a hidden epidemic of suicide among young women with military service” (p. 177), and this seems realistic giving other documented evidence thatWVs tend to suffer higher rates of depression (IOM, 2013).As KT’s Zung score reveals signs of depression,frequent questioning regarding suicidal ideation is essential, as well as a severity assessment of PTSD, as they are correlative factors (Lutwak & Dill, 2013a). Remember, all WVs have been trained with weapons and/or may have access to weapons, so another assessment screening question is, “Have you thought about hurting yourself?” If affirmative, “Do you have a plan?” or “Have you thought about how you would do it?”If yes to a plan, then ask“What is your plan?” Practice Implications This section provides a presentation of applicable treatment for any new, recurrent, or unresolved symptoms that could involve MST. Because MST is viewed as a stressor rather 283
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than a diagnosis, detection and early intervention are key to providing needed interventions (Himmelfarb et al., 2006; Kang et al., 2004; McEwen, 2008; Valdez et al., 2011). Three weeks after her initial visit her blood pressure was still elevated, and she had gained an additional 15 lbs of weight. Her Zung was still greater than 70, but she thought she was a little better. She refused to talk about her assault because she had more problems sleeping following her initial disclosure to the NP. Yet, she was not ready to go for counseling, although she did ask about after-hours or weekend counseling sessions. She continues to deny any suicidal ideations and asked if she could text the provider if she needed. Stated she would really like to talk to her mother about the assault, but still did not believe that it was fair to burden her. About 10 days after this visit, she texted and indicated she was feeling better and had decided that counseling might help. She asked that an appointment be made and it was made with a counselor who specialized in working with sexual assault victims. WVs presenting to primary care clinics may have multiple vague complaints of not feeling well, insomnia, anxiety, elevated blood pressure, abdominal pain, urgency or frequency of urine, dyspareunia, or other symptoms. Often, WVs may want to judge and punish themselves for their beliefs of shortcomings. It is unlikely they will voice their major complaint as MST in the history of present illness. Electronic patient charts are designed to aid the APPN/NPT in finding some underlying problems. The Review of Systems (ROS) can provide further subjective information about depression, anxiety, insomnia, and/or suicidal thoughts. If any of the psychiatric portions of the ROS is positive, further evaluation should be done for underlying mental health issues such as depression, anxiety, or other psychiatric illness. The Zung Self-Rated Depression Scale is a free tool that consists of 20 questions, with score interpretation. Scores of 49 or below are considered normal, scores of 50–69 indicate depression, and scores of greater than 70 indicate severe depression, with the maximum score as 80. APPN/NPTs should not neglect the importance of obtaining a thorough sexual history in addition to the psychiatric components of the history and physical exam. If answers to the MST screening questions are affirmative, APPN/NPTs will want to determine if MST counseling is appropriate. Counseling or medications cannot change these traumatic events, but do often help the survivor deal with situations in a more productive manner. Counselors should recommend specific interventions in dealing with sexual assault, and if it occurs in the combat zone, WVs also need therapy for trauma. With the shortage of MST therapists, the VA is currently trying to overcome some of the financial and 284
facility accessibility issues with the use of telemedicine, a delivery modality that seems effective (Lutwak & Dill, 2013a). During the discussion with the WVs, several things should be stressed. First and foremost, WVs can recover from these invisible psychological wounds. Positive actions for recovery and reduction of the allostatic stress load include exercise; identifying comfort situations, places, and people; use of relaxation techniques; and uplifting self-talk, good nutrition, and adequate rest/sleep (McEwen, 2008). It should be stressed that abuse of drugs or alcohol, social isolation, work addiction, or the denial of their symptoms will only further interfere or delay recovery. The VA has a National Center for PTSD with specific guidelines. Psychotherapy may utilize one or more of the following: • Cognitive therapy that addresses cognitive patterns • Exposure therapy may use virtual reality programs to allow patient to safely confront the traumatic situation • Eye movement desensitization and reprocessing (EMDR) combines exposure therapy with eye movements. Research on EMDR is divided on the effectiveness (Department of Veterans Affairs National Center for PTSD, 2010). Medications often used for treatment of hopelessness, depression, and anxiety following MST may include: • Serotonin reuptake inhibitors (SSRIs): Sertraline HCl (Zoloft) and paroxetine (Paxil) have both been approved by the Food and Drug Administration for PTSD. If cost is a factor and the patient is uninsured, citalopram (Celexa), another SSRI, is available at generic drug prices per month (Monthly Prescribing Reference, 2013). • Anxiolytics may be used for acute anxiety. Buspirone (Buspar) may be used to treat anxiety, fear, tension, dizziness, and irritability, and has low abuse potential. • Prazosin, a drug long used to treat hypertension, has shown to significantly reduce nightmares related to PTSD, although it is not approved for this indication (Kung, Espinel, & Lapid, 2012). Follow-up is critical for the well-being of the WV experiencing MST. If started on SSRIs, follow-up should be in 2 weeks and monthly thereafter. At the return visit, administer the Zung Self-Rated Depression Scale again to determine any changes in the level of depression. In addition, review if counseling has or has not been initiated. Socioeconomic factors such as financial constraints or lack of transportation may need to be addressed. MST is an immediate treatable health concern (Himmelfarb et al., 2006), and there are now applicable materials and assistance for WVs with MST (see Table 1). Treatment for any physical or mental health condition related to MST is provided free at VA facilities (Department of Veterans Affairs, 2012). Cost-effectiveness regarding medical expenses for OIF/OEF WVs will also be of concern as their Perspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
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Table 1. Resources for Women Veterans With Military Sexual Trauma • Veterans can speak with existing VA healthcare provider • Contact the MST coordinator at their nearest VA Medical Center at http://www.va.gov • Contact their local Vet Center at http://www.vetcenter.va.gov • Safe Helpline at 1-877-995-5247 for victims of MST • VA general information hotline at 1-800-827-1000 • Afterdeployment.org • Myduty.mil • I-855-VA-WOMEN • http://www.ptsd.va.gov • http://www.mentalhealth.va.gov/msthome.asp • Online chat room for victims of MST at http://www.sapr.mil
service-related problems tend to “peak several decades after the war in which they served” (Allen et al., 2013; IOM, 2013, p. 3). Left without timely interventions, “depending on the level of functional impairment,” an estimated 2-year cost for PTSD and the associate comorbidities are estimated to be $16,000 per case; those costs in 2035 could reach as high as $50,000 (Geiling, Rosen, & Edwards, 2012, p. 1239). Then, to treat their depression over 50 years, the costs for one veteran with PTSD could reach as high as $1,250,000 (Geiling et al., 2012). Interventional health promotion programs will certainly be important to avoid lingering sequelae which could lead to other chronic medical problems. Summary As more WVs return from the nation’s war/conflicts, APPN/ NPTs will be encountering WVs within their military and civilian practice, in both primary and community center care. Knowledge of the discussed military assessment questions will be important during the initial history and physical session, as MST is a growing concern that historically has often not been reported. If affirmative, other mental and health conditions such as PTSD should be considered, along with timely interventions using patient-centered clinical guidelines to promote positive outcomes for WVs. References Allen, P. E., Armstrong, M. L., Conard, P. L., Saladiner, J. E., & Hamilton, M. J. (2013). Veteran’s healthcare considerations for curriculum content. Journal of Nursing Education, 52(11), 634–640. doi:10.3928/01484834-20131011-01 Burgess, A., Slattery, D., & Herlihy, P. (2013). Military sexual trauma: A silent syndrome. Journal of Psychosocial Nursing, 51(2), 20–26. Department of Defense. (2012). Military casualty information. Retrieved from http://siadapp.dmdc.osd.mil/personnel/ CASUALTY/castop.htm Department of Veterans Affairs. (2012). Military sexual trauma. Retrieved from http://www.mentalhealth.va.gov/msthome.asp
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Department of Veterans Affairs. (2013). Women veterans health care. Retrieved from http://www.womenshealth.va.gov/ WOMENSHEALTH/facts.asp Department of Veterans Affairs National Center for PTSD. (2010). Overview of Psychotherapy for PTSD. Retrieved from http://www.ptsh.va.gove/professional/pages/overview -treatment-research.asp Farris, C., Schell, T. L., & Tanielian, T. (2013). Enemy within: Military sexual assault inflicts physical, psychological, financial pain. Rand Review, 37(1), 27–29. Forman-Hoffman, V., Mengeling, M., Booth, B., Torner, J., & Sadler, A. (2012). Eating disorders, post-traumatic stress, and sexual trauma in women veterans. Military Medicine, 177, 1161–1168. Friedman, M., Schnurr, P., & McDonaugh-Coyle, A. (1994). Post traumatic stress in the military veteran: Iraqi War clinician’s guide. Washington, DC: Department of Veterans Affairs. Geiling, J., Rosen, J. M., & Edwards, R. D. (2012). Medical costs of war in 2035: Long-term care challenges for veterans of Iraq and Afghanistan. Military Medicine, 177(11), 1235–1244. doi:10.7205/MILMED-D-12-00031 Himmelfarb, N., Yaeger, D., & Mintz, J. (2006). Posttraumatic stress disorder in female veterans with military and civilian sexual trauma. Journal of Traumatic Stress, 19(6), 837–846. doi:10.1002/jts.20163 Institute of Medicine. (2013). Returning home from Iraq and Afghanistan: Assessment of readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press. Retrieved from http://www.nap.edu Kang, H., Dalager, N., Maham, C., & Ishil, E. (2004). The role of sexual assault on the risk of PTSD among Gulf War veterans. Annals of Epidemiology, 15(3), 191–195. doi:10.1016/j.annepidem.2004.05.009 Kemp, J., & Bossarte, R. (2013). Suicide data report, 2012. Department of Veterans Affairs, Mental Health Services, Suicide Prevention Program. Kimerling, R., Gima, K., Smith, M., Street, A., & Frayne, S. (2007). The Veterans Health Administration and military sexual trauma. American Journal of Public Health, 97(12), 2160–2166. doi:10.2105/AJPH.2006.092999 Kimerling, R., Street, A., Gima, K., & Smith, M. (2008). Evaluation of universal screening for military-related sexual trauma. Psychiatric Services, 59(6), 635–640. Kung, S., Espinel, Z., & Lapid, M. I. (2012). Treatment of nightmares with prazosin: A systematic review. Mayo Clinic Proceedings, 87(9), 890–900. doi:10.1016/j.mayocp .2012.05.015 Lee, E. A. D. (2011). Military sexual trauma exposure and heart rate variability outcomes in female veterans (Dissertation). University of Tennessee Health Science Center, Memphis. Lutwak, N., & Dill, C. (2013a). An innovative method to deliver treatment of military sexual trauma and post-traumatic stress disorder. Military Medicine, 178, 1039–1340. doi:10.7205/MILMED-D-13-00226
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Lutwak, N., & Dill, C. (2013b). Military sexual trauma increases risk of post-traumatic stress disorder and depression thereby amplifying the possibility of suicidal ideation and cardiovascular disease. Military Medicine, 178, 359–364. doi:10.7205/MILMED-D-12-00427 Mattocks, K., Haskell, S., Krebs, E., Justice, A., & Yano, E. (2012). Women at war: Understanding how women veterans cope with combat and military sexual trauma. Social Science & Medicine, 74, 537–545. doi:10.1016/j.socscimed.2011.10.039 McEwen, B. S. (2008). Central effects of stress hormones in health and disease: Understanding the protective and damaging effects of stress and stress mediators. European Journal of Pharmacology, 583, 174–185. doi:10.1016/j.ejphar.2007.11.071 McFarland, B. H., Kaplan, M. S., & Huguet, N. (2010). Self-inflicted deaths among women with U.S. military service: A hidden epidemic? Psychiatric Service, 61(12), 1177. doi:10.1176/appi.ps.61.12.1177 Monthly Prescribing Reference. (2013). New York: Haymarket Media Publication. Retrieved from http://www.eMOR.com National Center for Veterans Analysis and Statistics. (2011 November). America’s women veterans: Military service history and VA benefit utilization statistics. Washington, DC: Department of Veterans Affairs. Seal, K., Metzler, T., Gima, K., Bertenthal, D., Maguen, S., & Marmar, C. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. American Journal of Public Health, 99, 1651–1658. doi:10.2105/AJPH.2008.150284
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Street, A., & Stafford, J. (2002). Military sexual trauma. In Iraq War clinician’s guide (pp. 66–69). Retrieved from http://www .ptsd.va.gov/professional/manuals/manual-pdf/iwcg/Iraq _clinician_guide_ch_9.pdf Suris, A., & Lind, L. (2008). Military sexual trauma: A review of prevalence and associated health consequences in veterans. Trauma, Violence & Abuse, 9(4), 250–269. doi:10.1177/1524838008324419 Suris, A., Lind, L., Kashner, T. M., & Borman, P. (2007). Mental health, quality of life, and health functioning in women veterans: Differential outcomes associated with military and civilian sexual assault. Journal of Interpersonal Violence, 22(2), 179–197. doi:10.1097/01.psy.0000138117.58559.7b Turchik, J., & Wilson, S. (2010). Sexual assault in the U.S. military: A review of the literature and recommendations for the future. Aggression and Violent Behavior, 15, 267–277. doi:10.1016/j.avb.2010.01.005 Valdez, C., Kimerling, R., Hyun, J., Mark, H., Saweikis, M., & Pavao, J. (2011). Veterans Health Administration mental health treatment settings of patients who report military sexual trauma. Journal of Trauma and Dissociation, 12, 232–243. doi:10.1080/15299732.2011.551510 Valente, S., & Wight, C. (2007). Military sexual trauma: Violence and sexual abuse. Military Medicine, 172, 259–265. Williams, I., & Bernstein, K. (2011). Military sexual trauma among U.S. female veterans. Archives of Psychiatric Nursing, 25(2), 138–147. doi:10.1016/j.apnu.2010.07.003
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Perspectives in Psychiatric Care
ISSN 0031-5990
Encountering Women Veterans With Military Sexual Trauma Patricia L. Conard, PhD, RN, Cathy Young, DNSc, FNP-BC, LaMicha Hogan, MSN, RN, FNP-BC, and Myrna L. Armstrong, Ed.D., RN, FAAN Patricia L. Conard, PhD, RN, is an Assistant Professor, College of Nursing and Health Sciences, Texas A & M University Corpus Christi, Corpus Christi, Texas, USA; Cathy Young, DNSc, FNP-BC, is an Associate Professor, School of Nursing, Arkansas State University, Jonesboro, Arkansas, USA; LaMicha Hogan, MSN, RN, FNP-BC, is an Assistant Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas, USA; and Myrna L. Armstrong, Ed.D., RN, FAAN, is a Nursing Consultant Professor Emerita, School of Nursing, Texas Tech University Health Sciences Center, Marble Falls, Texas, USA
Search terms: Deployment, harassment, intervention, military, military sexual trauma, PTSD, rape, reintegration, veteran, women Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement There is no conflict of interest. First Received September 12, 2013; Final Revision received October 24, 2013; Accepted for publication November 7, 2013.
PURPOSE: As women veterans (WVs) are returning from Operation Iraqi Freedom and Operation Enduring Freedom with military sexual trauma (MST), the purpose of this article is twofold. First, important exploratory questions that can assist with a thorough assessment and history are presented as well as the applicable treatment for any new, recurrent, or unresolved symptoms that involve MST. DESIGN AND METHODS: Review of multiple literary materials, as well as a clinical situation. FINDINGS: WVs will be encountered in a variety of military or civilian primary and community care healthcare settings. Every woman (and man) in the civilian sector should be asked, “Have you ever served in the military?” PRACTICE IMPLICATIONS: Recognition, acknowledgment, and applicable interventions for MST and associated comorbidities, especially post-traumatic stress disorder, are presented as currently 80–90% of MST experiences have gone unreported. Immediate treatment and follow-up are critical for the well-being of the WVs.
doi: 10.1111/ppc.12055
Currently, there are unprecedented numbers of women serving in the military, whether they are a part of the regular duty component (15%) or from National Guard and Reserve units (18%) (Mattocks, Haskell, Krebs, Justice, & Yano, 2012). Most of these women will make the transition from service member to veteran. These numbers of women veterans (WVs) will now be representing the largest cohort in our nation’s history, almost 12% of the U.S. total fighting force (Department of Veterans Affairs, 2013). This population is expected to grow rapidly, especially when the military opens more training opportunities and occupations for women in direct combat participation (Department of Veterans Affairs, 2013; Institute of Medicine [IOM], 2013). Projected estimations by 2035 document WVs comprising almost 15% of the total nation’s living veterans (National Center for Veterans Analysis and Statistics, 2011). Deployment As never before done,over 150,000 military active duty women (whether regular or deployed National Guard/Reservists) served during Gulf War II in Iraq with Operation Iraqi Freedom (OIF) and in Afghanistan with Operation Enduring 280
Freedom (OEF). Demographically, those deployed are somewhat different from the national picture; 67% were reportedly Caucasian,25% non-Caucasian,and 8% Hispanic; 48% stated they were married, yet more were likely to be divorced (National Center for Veterans Analysis and Statistics, 2011). They were from all branches of service, including Marines (4%), Army (12%), Navy (14%), and Air Force (17%); many were junior grade officers, with at least a college degree (88%) (IOM, 2013). Most of them serving in OIF/OEF ranged in average age from 20–30 years (regular active) to 36 years (National Guard/Reserves). During deployment, military officer, warrant, and enlisted women served alongside their fellow male soldiers in almost every capacity. Even area quarters for hygiene and sleep were in close proximity to their male counterparts. Women also received similar assignments for extended and/or multiple deployments (Seal et al., 2009). Officially, their positions were not in combat, but their expanded role responsibilities were still in battlefield exposure situations, in male-dominated units (IOM, 2013). Common activities included driving military vehicles, delivering fuel, securing unit posts, providing health care, or assuming valuable general logistical support personnel positions, all the while being exposed to similar Perspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
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types of improvised explosive devices, ambushes, and attack dangers. These situations were physically and psychologically exhausting because these women were constantly in a crisis mode, introducing the possibility of an allostatic overload from too much stress (McEwen, 2008). During OIF/OEF, over 850 WVs were injured, and over 150 lost their lives in service to our country (Department of Defense, 2012).
Reintegration As the nation has experienced“troop draw-downs”from OIF/ OEF, some WVs may return “relatively unscathed,” while others will have experienced both visible and/or non-visible physical and emotional scars (IOM, 2013, p. 471). Although these scars have always occurred with battlefield experiences, WVs of OIF/OEF have faced a myriad of higher level challenges while deployed, involving a multitude of traumatic exposures. The top three primary service-related diagnoses (15%) documented “upon their return were Post Traumatic Stress Disorder (PTSD), lower back pain, and migraines” (National Center for Veterans Analysis and Statistics, 2011, p. vi). Regarding health care upon stateside return, if the WVs remain on active duty their medical care will be provided at their assigned military installations. Once discharged (active duty) and/or deactivated (deployed National Guard/ Reservists), eligible service-related care can be obtained at Veterans Administration (VA) hospitals, although for a multitude of reasons, coordination of care difficulties has been frequently reported (IOM, 2013). Currently, about 60% of WVs in OIF/OEF, with compensable disabilities, have used the VA health services or programs, with 90% returning more than once (Department of Veterans Affairs, 2013). To meet the growing care needs for this unique population, advanced practice psychiatric nurses (APPNs) and nurse psychotherapists (NPTs) should be prepared to encounter WVs in a variety of military or civilian healthcare settings, both in primary and community care systems (Allen, Armstrong, Conard, Saladiner, & Hamilton, 2013). The purpose of this article is twofold. First, this article presents information on important exploratory questions that can assist with a thorough assessment and history and, second, applicable treatment for any new, recurrent, or unresolved symptoms that could involve military sexual trauma (MST) is discussed. (A composite) K.T., a 27-year-old obese female, presents to the clinic with complaints of fatigue, generalized body pain, difficulty getting up in the morning. She reports not enjoying her job. Her last clinic visit was 6 years ago. Denies any illicit drug use, but admits to occasional heavy alcohol use. Appearance of the stated age, flat affect, without noticeable distress. Objective data: T 98.4; P 68; R 20; B/P 168/110; Wt 287; BMI 44.79 (elevated from 23.41 6 years ago). Zung Self-reported depression scale—73. Perspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
Important Assessment Questions As there are currently almost 23 million veterans in the nation (IOM, 2013), every adult patient in the civilian sector seen in an APPN/NPT practice should be asked an important, universal, initial assessment question, “Have you ever served in the military?” Because serving one’s country encompasses providing protection in peace and wartime situations, whether stateside, on a battlefield, or within humanitarian situations, this initial screening question should concentrate on service, rather than as a veteran, as some are unclear as to their status (both men and women) (Allen et al., 2013). By using the Military Health History Pocket Card for Clinicians, unique risks and military exposures, as well as different societal support, can become more evident as the service members discuss their specific war/conflict activities (Department of Veterans Affairs, 2013). There are some soldiers who have experienced battlefield trauma who may not offer disclosure until asked, for a multitude of reasons, including mental health stigma, career jeopardy, or being “military proud.” When asked, KT said she had enlisted in ROTC to help pay for her education and after her BSN, was commissioned with an intention of making the military a career. She had been in the Army, a nurse, for 4 years, but left honorably as a Captain about 2 years ago. Assessment: (a) Elevated blood pressure; (b) Obesity; (c) Severe depression. Because of KT’s military experience, as well as recent events uncovering a growing concern with the number of sexual assaults, two further screening questions should be specifically asked: “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?” (Kimerling, Gima, Smith, Street, & Frayne, 2007, p. 636). So far, the military believes as many as 26,000 WVs and 1 in 100 men (numbers based on extrapolations) in 2012 could answer “yes” when asked about MST, a 35% increase from 2010 (Department of Veterans Affairs, 2013; Farris, Schell, & Tanielian, 2013). While acknowledgment of MST has been historically limited, the most active and comprehensive discussion about MST was initially documented in the aftermath of the 1991 Tailhook Convention (National Center for Veterans Analysis and Statistics, 2011). This also coincided with the increased amount of regular and National Guard/Reservists women activated for Gulf War I. At that time, MST became more fully defined and given better acknowledgment and recognition. Now, there are at least 1.8 million living WVs from the nation’s wars/conflicts, including OIF/OEF, with half of them from the entire Gulf War era (August 1990 onward); their 281
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average age is 48 years (Department of Veterans Affairs, 2013). Although this article will focus mainly on the WVs of OIF/OEF, unresolved MST could also be affecting a few, or many, of the other living WV cohort, for example, from the Vietnam War. In a post-Gulf War I survey, Kang, Dalager, Maham, and Ishill (2004) documented findings of “24% of women with a history of sexual harassment and 3.3% with sexual assault” (p. 193). Including assessment screening questions for these WVs is also crucial as comprehensive women’s health services for military related problems were not finally initiated by the VA hospitals until 1988 (Department of Veterans Affairs, 2013). When KT was asked about MST, at first there was no response. She looked at the floor, the door, her hands, and then finally said yes. She was deployed to Iraq and although not in combat, reported she felt safe most of the time, until a very close friend was killed by a road-side bomb. After her friend had been killed she had been with other friends and had drunk too much. She guessed she went to sleep or lost consciousness, but when roused there were two men on top of her. She thinks she lost consciousness again and when she awoke, she was naked and alone. She believed counseling was not needed at the time, as she believed the assault was her fault. MST Unfortunately, the occurrence of MST should not be related to war as it “goes against the values, honor codes, and laws of the US military, but rather harms those who have sworn to serve and protect their country” (Turchik & Wilson, 2010, p. 269). It is “a non-combat violent assault,” which is “a form of high betrayal trauma” (Allen et al., 2013; IOM, 2013, p. 3; Lutwak & Dill, 2013b, p. 359). Any attempt of sexual activity against one’s will, whether on/off the military base, or while on/off duty, is considered MST (Department of Veterans Affairs, 2012). As defined by the VA and Federal Law Title 38 US Code 1720D, MST is the experience of sexual assault or repeated threatening sexual harassment that a veteran may experience during his/her military service (Department of Veterans Affairs, 2012). Rape, forcible sodomy, indecent assault, and any attempts of these violations are considered sexual assault (Williams & Bernstein, 2011). Sexual coercion, unwanted sexual attention, or threatening attempts to initiate a sexual relationship also fall under sexual harassment (Williams & Bernstein, 2011). Sexual trauma in the civilian world is different as it occurs more frequently in social or community settings, and the victim is often assaulted by enemies or strangers. Recent cost figures for a victim of civilian sexual assault average $2,084 for immediate medical care, another $978 for mental health services, followed by the victim paying another 30–34% of outof-pocket moneys; these figures do not include loss of work 282
days and productivity (Farris et al., 2013). This individual culmination cost has been calculated to be $138,204 in 2012. Annual societal impact on the economy for sexual assault is thought to be around $104.5 million. MST is unique in that it usually occurs in the workplace setting and often by someone known (Burgess, Slattery, & Herlihy, 2013). Farris et al. (2013) calls it the “enemy within” (p. 27). Thus, as service women have to continue to live and work in close proximity to their offenders, MST can lead to a heightened emotional and physical distress such as shame, hopelessness, and betrayal (Lutwak & Dill, 2013a). It also could increase subsequent victimization, such as repeated assaults and other abuses (Farris, et al., 2013; Williams & Bernstein, 2011). This allostatic stress load can also be a physiological predictor of cardiac disease (Lee, 2011; McEwen, 2008). KT did report her assault to her superior Commanding Officer, but was told she was at fault for drinking too much and she probably consented. She could not remember. She decided to ignore it, but found that she continually replayed the event in her mind and had difficulty sleeping. She stated that with every male soldier she looked at, she wondered if he had been one of the ones who had raped her. She felt that every time she thought of “it,”“it” was like experiencing the trauma all over again. Her report of being assaulted was negated when she was told that if it had happened, it was her fault for drinking. A combination of stressors, without help in dealing with her issues, resulted in putting on a large amount of weight. A 2011 Pentagon report estimated 80% to 90% of MST experiences go unreported (as cited in Burgess et al., 2013). An early report by Street and Stafford (2002) documents that almost all (97%) victims of MST knew their assailants. Recently, from unrestricted reporting, approximately 84% involved a service member perpetrator, with 25% within the WV’s chain of command (Farris et al., 2013). Even if victims of MST report or do not report occurrences, they still tend to seek treatment for a myriad of negative physical symptoms possibly related to the violence (Valente & Wight, 2007). Common complaints included, but were not limited to, headaches, pelvic pain, menstrual problems, gastrointestinal symptoms, back pain, and chronic fatigue (Suris & Lind, 2008). Confidentiality, fear of repercussions, and commander subjectivity are some reasons for not reporting the MST. In response, the Department of Defense (as cited in Williams & Bernstein, 2011) has developed a two-tiered system of reporting MST while in the military. The first tier is a restricted report, that is, if the victim wants to get medical assistance and remain anonymous. The second tier is an unrestricted report, that is, if the victim wants to seek punishment for their perpetrator, which eliminates situational anonymity. Using the civilian costs to sexual trauma and the Department of Perspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
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Defense amounts of reported and estimated unreported cases, they estimate MST to cost $3.6 billion, just in 2012 (Farris et al., 2013). Comorbidities Kimerling, Street, Gima, and Smith (2008) found that detection of MST associated with the positive screening questions was three times more likely to be at risk for other mental and health conditions, including depression, anxiety disorders, and substance abuse (Department of Veterans Affairs, 2012); and eating disorders (Forman-Hoffman, Mengeling, Booth, Torner, & Sadler, 2012), heart rate variability (Lee, 2011; McEwen, 2008), and impaired interpersonal functioning (Suris, Lind, Kashner, & Borman, 2007). Early work after Gulf War I documented those who reported being sexually assaulted by a fellow soldier were nine times more likely to develop PTSD (Friedman, Schnurr, & McDonaugh-Coyle, 1994). These comorbidities are what seem to create the heightened impact for MST, when comparing an assault by enemies or strangers in the civilian sector (Farris, et al., 2013; McEwen, 2008; Suris & Lind, 2008). While KT had not been in combat, she had been in an area of frequent attacks, suffering the loss of a close friend, and within 2 weeks had been the victim of sexual assault. At the end of her tour, she did not reenlist. Following her discharge from the military, she did go for STI testing and a gynecologic exam; the results of the PAP smear were abnormal and required further treatment with a LEAP procedure. She has not shared the MST experiences with her family because she did not want them to think negatively of her or the situation. She relates difficulty dating and has not been in a relationship since the loss of her friend and the assault. She denies any suicidal ideations, but thinks it wouldn’t bother her if she died, although she is concerned if she left her mother, since she is an only child. She verbalized concern over her weight, admitted that she probably was depressed, and stated she was willing to try medication. She wanted to hold off a little while on the counseling as she was concerned her mother would want to know why she was seeing a counselor. Now, she was experiencing the four classic symptoms of PTSD: re-experiencing, avoidance, numbing, and hyper-vigilance; related symptomology includes insomnia, hypertension, and significant weight gain. Guilt, shame, and non-trust within themselves, others, and their environment are present with this anxiety disorder, resulting in deep emotional psychological wounds; Lutwak and Dill describe it as “conditioned fear” (2013a, p. 1039). If weapons, easily accessible during wartime/conflicts, are inPerspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
volved as part of the assault threat, a higher incidence with MST and PTSD has been found to be present (Himmelfarb, Yaeger, & Mintz, 2006). The National Center for PTSD (Department of Veterans Affairs National Center for PTSD, 2010) website (http://www.ptsd.VA.Gov) lists several brief questionnaires that can help in providing effective assessment screening for PTSD, complete with a description, sample items, and references. Higher risk with PTSD seems to be well documented,related to when and where traumatic events such as MST for the WVs have occurred (Himmelfarb et al., 2006; Kang et al., 2004; Lutwak & Dill, 2013a).Recent research is now beginning to document that over 50% of WVs may have experienced some type of childhood or domestic physical and/or sexual abuse before military induction (IOM, 2013), producing an even greater impact on how the WVs react to new (stress-filled) situations (McEwen, 2008, p. 13). Thus, APPN/ NPTs should diligently screen and document for this relevant evidence as the WV may have“worse PTSD outcomes after the MST, than if it was a civilian assault” (Suris & Lind, 2008, p. 184). Additionally, children of WVs with PTSD seem to demonstrate increased emotional and behavioral problems (Lutwak & Dill, 2013a). Suicides are also a problem, with the Army reporting the highest overall record of them in 2012; 22 veterans are taking their own lives daily.Yet, overall solid suicide evidence remains limited.The most recent report from the Department of Veterans Affairs on suicide data is only based on the information captured from 21 states over 12 years (1999–2011); they also caution the use of these data as it does not include California and Texas,home to the highest repository of veterans (Kemp & Bossarte, 2013). In the report, less than 3% of all suicides are women and they tend to be white, married, widowed, or divorced, possess at least a high school education, with the largest number centered around 40–49 years of age. McFarland, Kaplan, and Huguet (2010)“suggest a hidden epidemic of suicide among young women with military service” (p. 177), and this seems realistic giving other documented evidence thatWVs tend to suffer higher rates of depression (IOM, 2013).As KT’s Zung score reveals signs of depression,frequent questioning regarding suicidal ideation is essential, as well as a severity assessment of PTSD, as they are correlative factors (Lutwak & Dill, 2013a). Remember, all WVs have been trained with weapons and/or may have access to weapons, so another assessment screening question is, “Have you thought about hurting yourself?” If affirmative, “Do you have a plan?” or “Have you thought about how you would do it?”If yes to a plan, then ask“What is your plan?” Practice Implications This section provides a presentation of applicable treatment for any new, recurrent, or unresolved symptoms that could involve MST. Because MST is viewed as a stressor rather 283
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than a diagnosis, detection and early intervention are key to providing needed interventions (Himmelfarb et al., 2006; Kang et al., 2004; McEwen, 2008; Valdez et al., 2011). Three weeks after her initial visit her blood pressure was still elevated, and she had gained an additional 15 lbs of weight. Her Zung was still greater than 70, but she thought she was a little better. She refused to talk about her assault because she had more problems sleeping following her initial disclosure to the NP. Yet, she was not ready to go for counseling, although she did ask about after-hours or weekend counseling sessions. She continues to deny any suicidal ideations and asked if she could text the provider if she needed. Stated she would really like to talk to her mother about the assault, but still did not believe that it was fair to burden her. About 10 days after this visit, she texted and indicated she was feeling better and had decided that counseling might help. She asked that an appointment be made and it was made with a counselor who specialized in working with sexual assault victims. WVs presenting to primary care clinics may have multiple vague complaints of not feeling well, insomnia, anxiety, elevated blood pressure, abdominal pain, urgency or frequency of urine, dyspareunia, or other symptoms. Often, WVs may want to judge and punish themselves for their beliefs of shortcomings. It is unlikely they will voice their major complaint as MST in the history of present illness. Electronic patient charts are designed to aid the APPN/NPT in finding some underlying problems. The Review of Systems (ROS) can provide further subjective information about depression, anxiety, insomnia, and/or suicidal thoughts. If any of the psychiatric portions of the ROS is positive, further evaluation should be done for underlying mental health issues such as depression, anxiety, or other psychiatric illness. The Zung Self-Rated Depression Scale is a free tool that consists of 20 questions, with score interpretation. Scores of 49 or below are considered normal, scores of 50–69 indicate depression, and scores of greater than 70 indicate severe depression, with the maximum score as 80. APPN/NPTs should not neglect the importance of obtaining a thorough sexual history in addition to the psychiatric components of the history and physical exam. If answers to the MST screening questions are affirmative, APPN/NPTs will want to determine if MST counseling is appropriate. Counseling or medications cannot change these traumatic events, but do often help the survivor deal with situations in a more productive manner. Counselors should recommend specific interventions in dealing with sexual assault, and if it occurs in the combat zone, WVs also need therapy for trauma. With the shortage of MST therapists, the VA is currently trying to overcome some of the financial and 284
facility accessibility issues with the use of telemedicine, a delivery modality that seems effective (Lutwak & Dill, 2013a). During the discussion with the WVs, several things should be stressed. First and foremost, WVs can recover from these invisible psychological wounds. Positive actions for recovery and reduction of the allostatic stress load include exercise; identifying comfort situations, places, and people; use of relaxation techniques; and uplifting self-talk, good nutrition, and adequate rest/sleep (McEwen, 2008). It should be stressed that abuse of drugs or alcohol, social isolation, work addiction, or the denial of their symptoms will only further interfere or delay recovery. The VA has a National Center for PTSD with specific guidelines. Psychotherapy may utilize one or more of the following: • Cognitive therapy that addresses cognitive patterns • Exposure therapy may use virtual reality programs to allow patient to safely confront the traumatic situation • Eye movement desensitization and reprocessing (EMDR) combines exposure therapy with eye movements. Research on EMDR is divided on the effectiveness (Department of Veterans Affairs National Center for PTSD, 2010). Medications often used for treatment of hopelessness, depression, and anxiety following MST may include: • Serotonin reuptake inhibitors (SSRIs): Sertraline HCl (Zoloft) and paroxetine (Paxil) have both been approved by the Food and Drug Administration for PTSD. If cost is a factor and the patient is uninsured, citalopram (Celexa), another SSRI, is available at generic drug prices per month (Monthly Prescribing Reference, 2013). • Anxiolytics may be used for acute anxiety. Buspirone (Buspar) may be used to treat anxiety, fear, tension, dizziness, and irritability, and has low abuse potential. • Prazosin, a drug long used to treat hypertension, has shown to significantly reduce nightmares related to PTSD, although it is not approved for this indication (Kung, Espinel, & Lapid, 2012). Follow-up is critical for the well-being of the WV experiencing MST. If started on SSRIs, follow-up should be in 2 weeks and monthly thereafter. At the return visit, administer the Zung Self-Rated Depression Scale again to determine any changes in the level of depression. In addition, review if counseling has or has not been initiated. Socioeconomic factors such as financial constraints or lack of transportation may need to be addressed. MST is an immediate treatable health concern (Himmelfarb et al., 2006), and there are now applicable materials and assistance for WVs with MST (see Table 1). Treatment for any physical or mental health condition related to MST is provided free at VA facilities (Department of Veterans Affairs, 2012). Cost-effectiveness regarding medical expenses for OIF/OEF WVs will also be of concern as their Perspectives in Psychiatric Care 50 (2014) 280–286 © 2014 Wiley Periodicals, Inc.
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Table 1. Resources for Women Veterans With Military Sexual Trauma • Veterans can speak with existing VA healthcare provider • Contact the MST coordinator at their nearest VA Medical Center at http://www.va.gov • Contact their local Vet Center at http://www.vetcenter.va.gov • Safe Helpline at 1-877-995-5247 for victims of MST • VA general information hotline at 1-800-827-1000 • Afterdeployment.org • Myduty.mil • I-855-VA-WOMEN • http://www.ptsd.va.gov • http://www.mentalhealth.va.gov/msthome.asp • Online chat room for victims of MST at http://www.sapr.mil
service-related problems tend to “peak several decades after the war in which they served” (Allen et al., 2013; IOM, 2013, p. 3). Left without timely interventions, “depending on the level of functional impairment,” an estimated 2-year cost for PTSD and the associate comorbidities are estimated to be $16,000 per case; those costs in 2035 could reach as high as $50,000 (Geiling, Rosen, & Edwards, 2012, p. 1239). Then, to treat their depression over 50 years, the costs for one veteran with PTSD could reach as high as $1,250,000 (Geiling et al., 2012). Interventional health promotion programs will certainly be important to avoid lingering sequelae which could lead to other chronic medical problems. Summary As more WVs return from the nation’s war/conflicts, APPN/ NPTs will be encountering WVs within their military and civilian practice, in both primary and community center care. Knowledge of the discussed military assessment questions will be important during the initial history and physical session, as MST is a growing concern that historically has often not been reported. If affirmative, other mental and health conditions such as PTSD should be considered, along with timely interventions using patient-centered clinical guidelines to promote positive outcomes for WVs. References Allen, P. E., Armstrong, M. L., Conard, P. L., Saladiner, J. E., & Hamilton, M. J. (2013). Veteran’s healthcare considerations for curriculum content. Journal of Nursing Education, 52(11), 634–640. doi:10.3928/01484834-20131011-01 Burgess, A., Slattery, D., & Herlihy, P. (2013). Military sexual trauma: A silent syndrome. Journal of Psychosocial Nursing, 51(2), 20–26. Department of Defense. (2012). Military casualty information. Retrieved from http://siadapp.dmdc.osd.mil/personnel/ CASUALTY/castop.htm Department of Veterans Affairs. (2012). Military sexual trauma. Retrieved from http://www.mentalhealth.va.gov/msthome.asp
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