Journal of Traumatic Stress August 2015, 28, 283–288
Sexual Trauma and Combat During Deployment: Associations With Suicidal Ideation Among OEF/OIF/OND Veterans Lindsey L. Monteith,1,2 Deleene S. Menefee,3,4 Jeri E. Forster,1,5 Jill L. Wanner,3,4 and Nazanin H. Bahraini1,2,6 1
Denver Veterans Affairs Medical Center, Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education and Clinical Center (MIRECC), Denver, Colorado, USA 2 Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA 3 Michael E. DeBakey Veterans Affairs Medical Center, VISN 16 MIRECC, Houston, Texas, USA 4 Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA 5 Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA 6 Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
Compelling evidence has emerged on the association between military sexual trauma and suicide attempt; however, research investigating how sexual trauma during deployment relates to suicidal ideation has received considerably less attention and has yielded mixed findings. Furthermore, such research has not accounted for other types of trauma that may occur during deployment. Our objectives were to examine whether sexual trauma during deployment was associated with recent suicidal ideation, adjusting for exposure to combat. Our sample included 199 Operation Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) veterans entering inpatient trauma-focused treatment who completed the Beck Scale for Suicide Ideation (Beck & Steer, 1991) and the Deployment Risk and Resilience Inventory Sexual Harassment and Combat Experiences Scales (King, King, Vogt, Knight, & Samper, 2006). Deployment-related sexual trauma was significantly associated with recent suicidal ideation, adjusting for age and gender (β = .18, ηp 2 = .03) and additionally for combat (β = .17, ηp 2 = .02). These findings underscore the importance of assessing for deployment-related sexual trauma when assessing suicide risk in OEF/OIF/OND veterans in inpatient settings.
According to the Department of Defense Suicide Event Report, 47.5% of active duty service members who died by suicide in 2012 had deployed in support of Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), or New Dawn (OND; Smolenski et al., 2013). In fact, the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) recently found that a current or prior deployment was associated with increased risk for suicide (Schoenbaum et al., 2014). In the Millennium Cohort Study—conducted with current and former service members from all branches of the military—OEF/OIF deployment (with or without combat) was not associated with
suicide (LeardMann, Powell, et al., 2013). Thus, the relationship between deployment and death by suicide may depend on the population and types of deployment stressors experienced. Although deployment is often considered a proxy for combat, service members can be exposed to other types of trauma while deployed, such as sexual harassment or assault. Consistent with the Centers for Disease Control and Prevention (CDC; 2011) nomenclature for self-directed violence, we use the term suicide throughout this manuscript to refer to “death caused by self-directed injurious behavior with any intent to die as a result of the behavior” (p. 23). We also use the terms suicide attempt and suicidal ideation to describe other types of self-directed violence. Among OEF/OIF active duty Army personnel, 11.9% of women and 0.5% of men reported experiencing sexual trauma while deployed (Maguen, Luxton, Skopp, & Madden, 2012). The Veterans Health Administration (VHA) refers to sexual harassment and sexual assault that occurred during active duty or active duty for training as military sexual trauma (MST; Veterans’ Benefits: Counseling and Treatment for Sexual Trauma, 2011). The VHA screens veterans for MST using a brief, 2-item screen, in which participants are asked, “While you
This material is the result of work supported with resources and the use of facilities at the Denver Veterans Affairs Medical Center and VISN 19 MIRECC in Denver, CO, and MEDVAMC in Houston, TX. The views expressed are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. Correspondence concerning this article should be addressed to Lindsey Monteith, Denver VA Medical Center, VISN 19 MIRECC, 1055 Clermont St., Denver, CO 80220. E-mail: [email protected] C 2015 Wiley Periodicals, Inc., A Wiley Company. View this article Copyright online at wileyonlinelibrary.com DOI: 10.1002/jts.22018
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were in the military . . . (1) did you ever receive uninvited or unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or inappropriate verbal remarks?”; or (2) “did someone ever use force or the threat of force to have sexual contact with you against your will?” An affirmative response to either question is considered a positive screen for MST. According to recent estimates by Kimerling and colleagues (2010), 15.1% of women and 0.7% of men who previously deployed for OEF/OIF screened positive for MST. Maguen, Cohen, and colleagues (2012) reported higher rates among OEF/OIF veterans with posttraumatic stress disorder (PTSD): 30.9% of women and 1.1% of men had a positive MST screen. In addition to its association with PTSD, MST is associated with other types of psychiatric disorders, including depressive disorders, dissociative disorders, alcohol abuse, and substance use disorders (Kimerling, Gima, Smith, Street, & Frayne, 2007; Kimerling et al., 2010; Sur´ıs & Lind, 2008). Furthermore, veteran men and women who screened positive for MST were significantly more likely to have had a suicide attempt in the past year (Kimerling et al., 2007; Pavao et al., 2013). Additionally, in a recent study with Marine recruits, those exposed to sexual harassment during recruit training were significantly more likely to attempt suicide in the subsequent decade, adjusting for gender (Gradus, Shipherd, Suvak, Giasson, & Mill, 2013). We are aware of only two studies that examined whether sexual trauma (i.e., sexual harassment or sexual assault) during deployment—measured on a continuous scale—was associated with suicidal ideation. Gradus, Street, Suvak, and Resick (2013) examined a sample of OEF/OIF veterans (n = 2,321) and found that both men and women who experienced sexual trauma while deployed were significantly more likely to report postdeployment suicidal ideation. Lemaire and Graham (2011), however, obtained divergent findings in 1,740 OEF/OIF veterans receiving an initial VHA mental health evaluation; sexual trauma during deployment was not associated with current suicidal ideation. Furthermore, no studies of which we are aware have examined whether deployment-related sexual trauma is associated with a subsequent suicide attempt or suicide. Thus, more research is needed to clarify the impact of sexual trauma during deployment on subsequent suicidal ideation, suicide attempt, and suicide death. Prior research on sexual trauma and suicidal ideation and attempt has been limited by not accounting for other types of trauma that veterans and service members commonly experience. Many service members who experience sexual trauma also experience other types of trauma (e.g., combat) while deployed. In one study with OEF/OIF service members exposed to deployment sexual trauma, 72.7% reported that they also experienced another war-related stressor (e.g., witnessing another person injured or killed) during their deployment (Katz, Cojucar, Beheshti, Nakamura, & Murray, 2012). Dutra and colleagues (2010) examined active duty women who had served in the Army and also found evidence of high levels of exposure to multiple types of deployment trauma: 48.1% of women reported
exposure to both combat and sexual trauma while deployed for OIF. Considering the frequent co-occurrence of combat and sexual trauma during deployment, an important step toward understanding the impact of deployment-related sexual trauma is to examine whether its association with suicidal ideation remains significant when accounting for combat. In the World Health Organization World Mental Health Survey, sexual violence was associated with increased odds of having serious suicidal ideation, even when adjusting for other trauma (including combat; Stein et al., 2010); however, to our knowledge, no studies have examined the impact of both sexual trauma and combat on suicidal ideation among veterans or service members. Additionally, we are not aware of any prior research that has examined the association between deployment-related sexual trauma—with or without combat—and suicidal ideation in targeted samples of veterans seeking trauma-focused care. Nonetheless, veterans in PTSD specialty clinics report MST (i.e., sexual trauma at any time during their military service) at disproportionally high rates—53.6% of women and 3.0% of men—compared to other VHA outpatient mental health settings (Valdez et al., 2011). Research examining the impact of MST on suicidal ideation and suicide attempt has typically focused on veterans in other types of outpatient settings. Focusing on veterans in trauma-focused settings may provide a more targeted approach to understanding the impact of sexual trauma on suicidal ideation and suicide attempt in high-risk populations, informing comprehensive assessment of suicide risk in more acute settings. Our objectives were these: (a) to examine whether sexual trauma during deployment (measured on a continuous scale) was associated with recent suicidal ideation among OEF/OIF/OND veterans in inpatient, trauma-focused treatment; and (b) to examine whether this association was significant when adjusting for combat. We hypothesized that, consistent with findings by Gradus, Street, and colleagues (2013), deployment-related sexual trauma would be positively associated with suicidal ideation (Hypothesis 1). Given research suggesting that sexual violence is more robustly associated with suicidal ideation than other types of trauma (Stein et al., 2010), we hypothesized that the association between sexual trauma and suicidal ideation would remain significant after accounting for combat severity (Hypothesis 2).
Method Participants and Procedure The sample consisted of 199 previously deployed OEF/ OIF/OND veterans (171 men, 28 women) entering genderspecific, inpatient, trauma-focused treatment at a large Veterans Affairs medical center from January 2011 to November 2012, who consented for their data to be used for research. The treatment programs provided voluntary trauma-focused
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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treatment to male combat veterans previously deployed for OEF/OIF/OND and to women veterans from various war eras, including OEF/OIF/OND. Admission to either treatment program required a primary Axis I diagnosis (PTSD, mood, or anxiety). Additional Axis I and II disorders were permitted. Veterans with psychosis, imminent suicidality, or requiring substance detoxification were stabilized on a separate unit prior to admission. All veterans admitted to the trauma-focused treatment programs were offered the opportunity to participate in research, which entailed completing self-report measures following admission. Demographics and military service (e.g., branch, time since discharge) were assessed through self-report and medical record review. This research was approved by the Colorado Multiple Institutional Review Board and the Denver Veterans Affairs Research and Development Committee. Women constituted a small proportion of the sample (n = 28; 14.1%). The mean age of participants was 32.45 years (SD = 7.42). Participants identified as Caucasian (n = 122; 61.3%), African American (n = 45; 22.6%), Hispanic (n = 13; 6.5%), multiracial (n = 12; 6.0%), Asian (n = 2; 1.0%), or Other (n = 5; 2.5%). Branch of service was Army n = 135 (67.8%), Marines n = 47 (23.6%), Air Force n = 9 (4.5%), and Navy n = 8 (4.0%). Over half deployed once (n = 109; 54.8%); some reported deploying twice (n = 65; 32.7%) or three or more times (n = 25; 12.6%). Average time in active duty was 6.85 years (SD = 5.61). Mean time since military discharge was 4.07 years (SD = 3.58) based on 178 participants who had data available on time since discharge. Measures The Deployment Risk and Resilience Inventory (DRRI) Sexual Harassment Scale (King, King, Vogt, Knight, & Samper, 2006) assesses “exposure to unwanted sexual touching or verbal conduct of a sexual nature . . . in the war zone that creates a hostile working environment” (p. 98). The scale includes seven items rated on a 4-point scale, ranging from 1 = never to 4 = many times. Respondents indicate how often “unit leaders or other unit members” engaged in each behavior while the respondent was deployed. Items assess sexual harassment (“made crude and offensive sexual remarks directed at me . . . ”) and sexual assault (“forced me to have sex”) during deployment and therefore are referred to throughout this article as sexual trauma. The DRRI facilitates assessment of a range of different experiences that constitute sexual trauma, while also enabling assessment of the frequency of such experiences. Items are summed to produce a total score, ranging from 7 to 28. Higher scores indicate more severe sexual trauma while deployed. The DRRI Sexual Harassment Scale has demonstrated acceptable internal reliability and validity (King et al., 2006) and had adequate internal reliability in the present study (α = .86). The DRRI Combat Experiences Scale (King et al., 2006) was developed to assess combat experiences while deployed. Each item is rated dichotomously (yes/no). Overall responses are summed, with a total score ranging from 0 to 15. Higher
scores reflect more combat exposure. The DRRI Combat Experiences Scale has demonstrated acceptable internal reliability, criterion validity, and discriminant validity (King et al. 2006; Vogt, Proctor, King, King, & Vasterling, 2008). Internal reliability was adequate in the present study (α = .88). The Beck Scale for Suicide Ideation (BSS; Beck & Steer, 1991) is a self-report measure of the severity of suicidal ideation in the past week. Items are rated on a scale ranging from 0 to 2. The first 19 items are summed to produce a total score of suicidal ideation in the past week, ranging from 0 to 38. Higher scores indicate more severe suicidal ideation. Items 20 and 21, which assess lifetime suicide attempt and wish to die during the most recent suicide attempt, are not included in the overall score. The BSS has demonstrated high internal reliability and adequate construct and concurrent validity (Beck & Steer, 1991; Beck, Steer, & Ranieri, 1988). In the present study, the BSS was used to assess recent suicidal ideation. Internal reliability was high (α = .93). Data Analysis All analyses assumed a two-sided test of the hypothesis, with an overall significance level established a priori at p < .05. Analyses were performed in SAS v9.3. Due to positive skew (1.11), suicidal ideation scores were transformed to improve normality by adding a constant of 1 and then using a natural log transformation. The transformation improved the skew (.22). Therefore, the transformed version was used in subsequent analyses. As a first step, means, standard deviations, and bivariate correlations were calculated for all variables of interest. Hierarchical linear regression was used to test our hypotheses, with suicidal ideation as the dependent variable. The first step included the potential confounders (age and gender for the first hypothesis; age, gender, and combat for the second hypothesis), and deployment-related sexual trauma was added as the second step. Model 1 was used to test the first hypothesis (without combat); Model 2 was used to test our second hypothesis (with combat). Given the low number of women in the sample, a stratified gender analysis was not possible. The proportion of women was large enough, however, to adequately adjust for the effect of gender in the analysis and was similar to approaches taken by others (e.g., Gradus, Shipherd, et al, 2013). Notably, we had no missing data for our variables of interest. Results Table 1 provides a description of participants. Over one fourth (n = 55; 27.6%) of participants reported experiencing sexual trauma while deployed. Sixty percent (n = 120; 60.3%) reported experiencing suicidal ideation in the past week. Deploymentrelated sexual trauma was correlated with gender (r = .49, p < .001) and suicidal ideation (r = .18, p = .01) in bivariate analyses. Results regarding the association between deploymentrelated sexual trauma and suicidal ideation are reported in
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Table 1 Means, Standard Deviations, and Correlations for the Total Sample Variable 1. Age (years) 2. Gender (M = 0, W = 1) 3. Suicidal ideation 4. Suicidal ideation (transformed) 5. Deployment sexual trauma 6. Combat exposure
M
SD
1.
2.
3.
4.
5.
32.45 – 5.65 0.54 8.33 10.03
7.42 – 7.00 0.51 3.08 3.96
.30** .16* .16* .07 −.16*
.10 .09 .49** −.37**
.93** .18** .01
.17* .02
−.06
Note. N = 199; n = 28 women. M = men; W = women. * p < .05. ** p < .01.
Table 2. Deployment-related sexual trauma was significantly associated with suicidal ideation, adjusting for age and gender (Model 1; adjusted R2 = .04) and explained an additional 2.5% of the variance over the potential confounders, F(1, 195) = 5.04, p = .026. For each one point increase in deploymentrelated sexual trauma, there was a 7.2% increase in suicidal ideation, 95% confidence interval (CI) [0.8, 13.9]. The association between deployment-related sexual trauma and suicidal ideation remained significant when accounting for combat severity (Model 2; adjusted R2 = .04). The inclusion of sexual trauma accounted for an additional 2.2% of the variance in suicidal ideation, F(1, 194) = 4.51, p = .035. For each one point increase in deployment-related sexual trauma, there was a 6.9% increase in suicidal ideation, 95% CI [0.5%, 13.6%].
Discussion Although violence is an inherent part of combat, the aggressions that occur in the midst of war and conflict are often not restricted to the battlefield. Tragically, many who served in the U.S. operations in Iraq and Afghanistan have experienced sexual violence at the hands of other service members or commanding officers. The increased risk of sexual trauma among
those deployed to a combat zone (LeardMann, Pietrucha, et al., 2013), and the link between deployment and death by suicide in certain military populations (e.g., Army personnel; Schoenbaum et al., 2014), highlight the complex yet interrelated nature of different forms of violence. Apart from combat, however, few studies have examined how sexual violence during deployment relates to suicidal self-directed violence. Considering the frequent co-occurrence of combat and sexual trauma during deployment, we examined whether sexual trauma during deployment associated with recent suicidal ideation when taking combat into account. In our sample of OEF/OIF/OND veterans entering voluntary inpatient, traumafocused treatment, sexual trauma during deployment (measured continuously) was associated with recent suicidal ideation— adjusting for age and gender. These findings were consistent with those obtained by Gradus, Street, and colleagues (2013), in which deployment-related sexual trauma was associated with postdeployment suicidal ideation. Our findings also extended knowledge on sexual trauma and suicidal ideation by considering the role of combat. Interestingly, adding combat-related experiences to the equation did not substantively change our results. Deployment-related sexual trauma continued to display a significant association with suicidal ideation, even when accounting for the severity of
Table 2 Hierarchical Regression of Association Between Deployment-Related Sexual Trauma and Suicidal Ideation Variable
B
SE
95% CI
β
Model 1 Age Gender (M = 0, W = 1) Deployment sexual trauma
0.03* −0.16 0.07*
Age Gender (M = 0, W = 1) Combat exposure Deployment sexual trauma
0.03* −0.09 0.01 0.07*
0.01 0.28 0.03
[0.003, 0.05] [−0.72, 0.40] [0.01, 0.13]
.17 −.05 .18
0.01 0.31 0.02 0.03
[0.004, 0.05] [−0.69, 0.52] [−0.03, 0.06] [0.01, 0.13]
.17 −.03 .05 .17
Model 2
Note. N = 199. SE = standard error; M = men; W = women. * p < .05.
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combat exposure. This is in line with international research in which interpersonal trauma was more strongly associated with suicidal ideation than other types of trauma, such as combat and natural disasters (Stein et al., 2010). Furthermore, our findings are consistent with research conducted with civilians, in which sexual violence (e.g., sexual assault, molestation) was associated with increased odds of experiencing both suicidal ideation and suicide attempt (Belik, Cox, Stein, Asmundson, & Sareen, 2007; Davidson, Hughes, George, & Blazer, 1996; Kilpatrick et al., 1985; Ullman & Brecklin, 2002). These findings highlighted the importance of assessing other deployment experiences, such as sexual trauma—irrespective of the severity of combat exposure—when assessing suicide risk among OEF/OIF/OND veterans in inpatient, trauma-focused settings. Although the VHA has implemented a universal screen for MST, it is not intended to provide a continuous assessment of sexual trauma, which may limit thoroughly assessing the types and severity of sexual trauma experienced. Measures like the DRRI, however, may be able to supplement the MST screen to provide a more comprehensive assessment of the nature and severity of deployment-related sexual trauma. Although it is not yet validated as a diagnostic tool, the DRRI may be particularly useful in facilitating a dialogue between the provider and patient about the range of deployment experiences—such as sexual harassment or assault —that may impact postdeployment health. Notable strengths of this study included the use of validated measures of suicidal ideation, sexual trauma, and combat, which yielded continuous assessments of the severity of these constructs. We utilized a clinical sample at elevated risk for suicide—as evidenced by the fact that approximately 60% reported suicidal ideation in the past week. Prior research on sexual trauma and suicidal ideation has not included age in the model; however, our results suggested that age may be an important factor, as it was associated with suicidal ideation in our bivariate and multivariate analyses. Limitations included the small number of women in the sample, time since exposure to sexual trauma, and focusing on participants in specialized, inpatient treatment. Due to the small number of women (n = 28) who participated, we were unable to run analyses separately by gender. The representation of women in our sample (14.1%), however, mirrors the VHA population, in which women represent approximately 12.2% of OEF/OIF/OND veterans utilizing VHA care (U. S. Department of Veterans Affairs, 2014). Women in our sample reported higher levels of exposure to deployment-related sexual trauma than men. We attempted to address this by adjusting for gender. All of the prior research studies that have examined the association between sexual trauma during deployment or military service with suicidal ideation or attempt separately by gender have consistently found this association to be significant for both men and women (Gradus, Street, et al., 2013; Kimerling, Gima, Smith, Street, & Frayne, 2007; Pavao et al., 2013). Stratifying analyses by gender, however, may be important to consider in future research aimed at identifying variables
that explain the association between deployment sexual trauma and suicidal ideation, in which gender differences have been found (c.f. Gradus, Street et al., 2013). Our focus on a specific clinical population (OEF/OIF/OND veterans in inpatient, trauma-focused VA treatment) may have limited the generalizability of our findings to other cohorts, including outpatients and veterans not seeking VHA PTSDspecific care. On the other hand, examining this population is important, given its high risk for adverse outcomes. In addition, the cross-sectional design is a limitation to inferring causality; however, participants were veterans who had been discharged from the military years ago, whereas suicidal ideation was assessed as a recent occurrence (within the past week); thus, the sequence of events was in the appropriate order. Suicidal ideation was positively skewed in our sample, suggesting that the majority of participants endorsed low levels of the severity of suicidal ideation in the past week. This may limit generalizability to veterans experiencing more severe levels of suicidal ideation. Finally, our measure of deployment-related sexual trauma assessed events perpetrated by unit leaders or members; consequently, sexual trauma perpetrated by civilians or while not deployed was not assessed. Our findings add to a relatively understudied, yet growing body of research highlighting the association between sexual violence and suicidality and offer several important avenues for future research. To date, the limited amount of research on sexual trauma during military service and suicidal ideation has focused on sexual trauma during deployment with OEF/OIF/OND veterans. Focusing on sexual trauma during deployment however, represents only a snapshot of the range of lifetime experiences that may lead to suicide risk and neglects to consider other trauma that may occur throughout the lifespan. Thus, an important area for future research will be to examine whether these findings extend to sexual trauma that occurs outside of deployment, pre- and postmilitary trauma, and other cohorts of veterans. Examining whether deploymentrelated sexual trauma relates to suicide and suicide attempt is also essential to assessing the impact of sexual trauma on the range of suicidal self-directed violence. A critical next step will be to identify variables that explain this association. Lastly, identifying protective factors that mitigate the association between sexual trauma and suicidal ideation will be important for suicide prevention efforts. References Beck, A. T., & Steer, R. A. (1991). Beck Scale for Suicide Ideation. San Antonio, TX: Psychological Corporation. Beck, A. T., Steer, R. A., & Ranieri, W. F. (1988). Scale for suicide ideation: Psychometric properties of a self-report version. Journal of Clinical Psychology, 44, 499–505. doi:10.1002/1097-4679(198807)44:43.0.CO;2-6 Belik, S. L., Cox, B. J., Stein, M. B., Asmundson, G. J., & Sareen, J. (2007). Traumatic events and suicidal behavior: Results from a national mental health survey. Journal of Nervous and Mental Disease, 195, 342–349. doi:10.1097/01.nmd.0b013e318060a869
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King, L. A., King, D. W., Vogt, D. S., Knight, J., & Samper, R. E. (2006). Deployment Risk and Resilience Inventory: A collection of measures for studying deployment-related experiences of military personnel and veterans. Military Psychology, 18, 89–120. doi:10.1207/s15327876mp1802_1 LeardMann, C. A., Pietrucha, A., Magruder, K. M., Smith, B., Murdoch, M., Jacobson, I. G., . . . & Smith, T. C. (2013). Combat deployment is associated with sexual harassment or sexual assault in a large, female military cohort. Women’s Health Issues, 23, e215–e223. doi:10.1016/j.whi.2013.05.002 LeardMann, C. A., Powell, T. M., Smith, T. C., Bell, M. R., Smith, B., Boyko, E. J., & . . . Hogue, C. W. (2013). Risk factors associated with suicide in current and former US military personnel. Journal of the American Medical Association, 310, 496–506. doi:10.1001/jama.2013.65164 Lemaire, C. M., & Graham, D. P. (2011). Factors associated with suicidal ideation in OEF/OIF veterans. Journal of Affective Disorders, 130, 231– 238. doi:10.1016/j.jad.2010.10.021
U. S. Department of Veterans Affairs. (2014). Analysis of VA health care utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans. Retrieved from http://www.publichealth.va.gov/docs/epidemiology/healthcare-utilizationreport-fy2014-qtr3.pdf Valdez, C., Kimerling, R., Hyun, J. K., Mark, H. F., 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 Veterans’ Benefits: Counseling and Treatment for Sexual Trauma. (2011). 38 U.S.C. § 1720D. Retrieved from http://www.gpo.gov/fdsys/pkg/USCODE2011-title38/html/USCODE-2011-title38-partII-chap17-subchapII-sec 1720D.htm Vogt, D. S., Proctor, S. P., King, D. W., King, L. A., & Vasterling, J. J. (2008). Validation of scales from the Deployment Risk and Resilience Inventory in a sample of Operation Iraqi Freedom veterans. Assessment, 15, 391–403. doi:10.1177/1073191108316030
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Sexual Trauma and Combat During Deployment: Associations With Suicidal Ideation Among OEF/OIF/OND Veterans Lindsey L. Monteith,1,2 Deleene S. Menefee,3,4 Jeri E. Forster,1,5 Jill L. Wanner,3,4 and Nazanin H. Bahraini1,2,6 1
Denver Veterans Affairs Medical Center, Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education and Clinical Center (MIRECC), Denver, Colorado, USA 2 Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA 3 Michael E. DeBakey Veterans Affairs Medical Center, VISN 16 MIRECC, Houston, Texas, USA 4 Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA 5 Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA 6 Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
Compelling evidence has emerged on the association between military sexual trauma and suicide attempt; however, research investigating how sexual trauma during deployment relates to suicidal ideation has received considerably less attention and has yielded mixed findings. Furthermore, such research has not accounted for other types of trauma that may occur during deployment. Our objectives were to examine whether sexual trauma during deployment was associated with recent suicidal ideation, adjusting for exposure to combat. Our sample included 199 Operation Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) veterans entering inpatient trauma-focused treatment who completed the Beck Scale for Suicide Ideation (Beck & Steer, 1991) and the Deployment Risk and Resilience Inventory Sexual Harassment and Combat Experiences Scales (King, King, Vogt, Knight, & Samper, 2006). Deployment-related sexual trauma was significantly associated with recent suicidal ideation, adjusting for age and gender (β = .18, ηp 2 = .03) and additionally for combat (β = .17, ηp 2 = .02). These findings underscore the importance of assessing for deployment-related sexual trauma when assessing suicide risk in OEF/OIF/OND veterans in inpatient settings.
According to the Department of Defense Suicide Event Report, 47.5% of active duty service members who died by suicide in 2012 had deployed in support of Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), or New Dawn (OND; Smolenski et al., 2013). In fact, the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) recently found that a current or prior deployment was associated with increased risk for suicide (Schoenbaum et al., 2014). In the Millennium Cohort Study—conducted with current and former service members from all branches of the military—OEF/OIF deployment (with or without combat) was not associated with
suicide (LeardMann, Powell, et al., 2013). Thus, the relationship between deployment and death by suicide may depend on the population and types of deployment stressors experienced. Although deployment is often considered a proxy for combat, service members can be exposed to other types of trauma while deployed, such as sexual harassment or assault. Consistent with the Centers for Disease Control and Prevention (CDC; 2011) nomenclature for self-directed violence, we use the term suicide throughout this manuscript to refer to “death caused by self-directed injurious behavior with any intent to die as a result of the behavior” (p. 23). We also use the terms suicide attempt and suicidal ideation to describe other types of self-directed violence. Among OEF/OIF active duty Army personnel, 11.9% of women and 0.5% of men reported experiencing sexual trauma while deployed (Maguen, Luxton, Skopp, & Madden, 2012). The Veterans Health Administration (VHA) refers to sexual harassment and sexual assault that occurred during active duty or active duty for training as military sexual trauma (MST; Veterans’ Benefits: Counseling and Treatment for Sexual Trauma, 2011). The VHA screens veterans for MST using a brief, 2-item screen, in which participants are asked, “While you
This material is the result of work supported with resources and the use of facilities at the Denver Veterans Affairs Medical Center and VISN 19 MIRECC in Denver, CO, and MEDVAMC in Houston, TX. The views expressed are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. Correspondence concerning this article should be addressed to Lindsey Monteith, Denver VA Medical Center, VISN 19 MIRECC, 1055 Clermont St., Denver, CO 80220. E-mail: [email protected] C 2015 Wiley Periodicals, Inc., A Wiley Company. View this article Copyright online at wileyonlinelibrary.com DOI: 10.1002/jts.22018
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were in the military . . . (1) did you ever receive uninvited or unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or inappropriate verbal remarks?”; or (2) “did someone ever use force or the threat of force to have sexual contact with you against your will?” An affirmative response to either question is considered a positive screen for MST. According to recent estimates by Kimerling and colleagues (2010), 15.1% of women and 0.7% of men who previously deployed for OEF/OIF screened positive for MST. Maguen, Cohen, and colleagues (2012) reported higher rates among OEF/OIF veterans with posttraumatic stress disorder (PTSD): 30.9% of women and 1.1% of men had a positive MST screen. In addition to its association with PTSD, MST is associated with other types of psychiatric disorders, including depressive disorders, dissociative disorders, alcohol abuse, and substance use disorders (Kimerling, Gima, Smith, Street, & Frayne, 2007; Kimerling et al., 2010; Sur´ıs & Lind, 2008). Furthermore, veteran men and women who screened positive for MST were significantly more likely to have had a suicide attempt in the past year (Kimerling et al., 2007; Pavao et al., 2013). Additionally, in a recent study with Marine recruits, those exposed to sexual harassment during recruit training were significantly more likely to attempt suicide in the subsequent decade, adjusting for gender (Gradus, Shipherd, Suvak, Giasson, & Mill, 2013). We are aware of only two studies that examined whether sexual trauma (i.e., sexual harassment or sexual assault) during deployment—measured on a continuous scale—was associated with suicidal ideation. Gradus, Street, Suvak, and Resick (2013) examined a sample of OEF/OIF veterans (n = 2,321) and found that both men and women who experienced sexual trauma while deployed were significantly more likely to report postdeployment suicidal ideation. Lemaire and Graham (2011), however, obtained divergent findings in 1,740 OEF/OIF veterans receiving an initial VHA mental health evaluation; sexual trauma during deployment was not associated with current suicidal ideation. Furthermore, no studies of which we are aware have examined whether deployment-related sexual trauma is associated with a subsequent suicide attempt or suicide. Thus, more research is needed to clarify the impact of sexual trauma during deployment on subsequent suicidal ideation, suicide attempt, and suicide death. Prior research on sexual trauma and suicidal ideation and attempt has been limited by not accounting for other types of trauma that veterans and service members commonly experience. Many service members who experience sexual trauma also experience other types of trauma (e.g., combat) while deployed. In one study with OEF/OIF service members exposed to deployment sexual trauma, 72.7% reported that they also experienced another war-related stressor (e.g., witnessing another person injured or killed) during their deployment (Katz, Cojucar, Beheshti, Nakamura, & Murray, 2012). Dutra and colleagues (2010) examined active duty women who had served in the Army and also found evidence of high levels of exposure to multiple types of deployment trauma: 48.1% of women reported
exposure to both combat and sexual trauma while deployed for OIF. Considering the frequent co-occurrence of combat and sexual trauma during deployment, an important step toward understanding the impact of deployment-related sexual trauma is to examine whether its association with suicidal ideation remains significant when accounting for combat. In the World Health Organization World Mental Health Survey, sexual violence was associated with increased odds of having serious suicidal ideation, even when adjusting for other trauma (including combat; Stein et al., 2010); however, to our knowledge, no studies have examined the impact of both sexual trauma and combat on suicidal ideation among veterans or service members. Additionally, we are not aware of any prior research that has examined the association between deployment-related sexual trauma—with or without combat—and suicidal ideation in targeted samples of veterans seeking trauma-focused care. Nonetheless, veterans in PTSD specialty clinics report MST (i.e., sexual trauma at any time during their military service) at disproportionally high rates—53.6% of women and 3.0% of men—compared to other VHA outpatient mental health settings (Valdez et al., 2011). Research examining the impact of MST on suicidal ideation and suicide attempt has typically focused on veterans in other types of outpatient settings. Focusing on veterans in trauma-focused settings may provide a more targeted approach to understanding the impact of sexual trauma on suicidal ideation and suicide attempt in high-risk populations, informing comprehensive assessment of suicide risk in more acute settings. Our objectives were these: (a) to examine whether sexual trauma during deployment (measured on a continuous scale) was associated with recent suicidal ideation among OEF/OIF/OND veterans in inpatient, trauma-focused treatment; and (b) to examine whether this association was significant when adjusting for combat. We hypothesized that, consistent with findings by Gradus, Street, and colleagues (2013), deployment-related sexual trauma would be positively associated with suicidal ideation (Hypothesis 1). Given research suggesting that sexual violence is more robustly associated with suicidal ideation than other types of trauma (Stein et al., 2010), we hypothesized that the association between sexual trauma and suicidal ideation would remain significant after accounting for combat severity (Hypothesis 2).
Method Participants and Procedure The sample consisted of 199 previously deployed OEF/ OIF/OND veterans (171 men, 28 women) entering genderspecific, inpatient, trauma-focused treatment at a large Veterans Affairs medical center from January 2011 to November 2012, who consented for their data to be used for research. The treatment programs provided voluntary trauma-focused
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treatment to male combat veterans previously deployed for OEF/OIF/OND and to women veterans from various war eras, including OEF/OIF/OND. Admission to either treatment program required a primary Axis I diagnosis (PTSD, mood, or anxiety). Additional Axis I and II disorders were permitted. Veterans with psychosis, imminent suicidality, or requiring substance detoxification were stabilized on a separate unit prior to admission. All veterans admitted to the trauma-focused treatment programs were offered the opportunity to participate in research, which entailed completing self-report measures following admission. Demographics and military service (e.g., branch, time since discharge) were assessed through self-report and medical record review. This research was approved by the Colorado Multiple Institutional Review Board and the Denver Veterans Affairs Research and Development Committee. Women constituted a small proportion of the sample (n = 28; 14.1%). The mean age of participants was 32.45 years (SD = 7.42). Participants identified as Caucasian (n = 122; 61.3%), African American (n = 45; 22.6%), Hispanic (n = 13; 6.5%), multiracial (n = 12; 6.0%), Asian (n = 2; 1.0%), or Other (n = 5; 2.5%). Branch of service was Army n = 135 (67.8%), Marines n = 47 (23.6%), Air Force n = 9 (4.5%), and Navy n = 8 (4.0%). Over half deployed once (n = 109; 54.8%); some reported deploying twice (n = 65; 32.7%) or three or more times (n = 25; 12.6%). Average time in active duty was 6.85 years (SD = 5.61). Mean time since military discharge was 4.07 years (SD = 3.58) based on 178 participants who had data available on time since discharge. Measures The Deployment Risk and Resilience Inventory (DRRI) Sexual Harassment Scale (King, King, Vogt, Knight, & Samper, 2006) assesses “exposure to unwanted sexual touching or verbal conduct of a sexual nature . . . in the war zone that creates a hostile working environment” (p. 98). The scale includes seven items rated on a 4-point scale, ranging from 1 = never to 4 = many times. Respondents indicate how often “unit leaders or other unit members” engaged in each behavior while the respondent was deployed. Items assess sexual harassment (“made crude and offensive sexual remarks directed at me . . . ”) and sexual assault (“forced me to have sex”) during deployment and therefore are referred to throughout this article as sexual trauma. The DRRI facilitates assessment of a range of different experiences that constitute sexual trauma, while also enabling assessment of the frequency of such experiences. Items are summed to produce a total score, ranging from 7 to 28. Higher scores indicate more severe sexual trauma while deployed. The DRRI Sexual Harassment Scale has demonstrated acceptable internal reliability and validity (King et al., 2006) and had adequate internal reliability in the present study (α = .86). The DRRI Combat Experiences Scale (King et al., 2006) was developed to assess combat experiences while deployed. Each item is rated dichotomously (yes/no). Overall responses are summed, with a total score ranging from 0 to 15. Higher
scores reflect more combat exposure. The DRRI Combat Experiences Scale has demonstrated acceptable internal reliability, criterion validity, and discriminant validity (King et al. 2006; Vogt, Proctor, King, King, & Vasterling, 2008). Internal reliability was adequate in the present study (α = .88). The Beck Scale for Suicide Ideation (BSS; Beck & Steer, 1991) is a self-report measure of the severity of suicidal ideation in the past week. Items are rated on a scale ranging from 0 to 2. The first 19 items are summed to produce a total score of suicidal ideation in the past week, ranging from 0 to 38. Higher scores indicate more severe suicidal ideation. Items 20 and 21, which assess lifetime suicide attempt and wish to die during the most recent suicide attempt, are not included in the overall score. The BSS has demonstrated high internal reliability and adequate construct and concurrent validity (Beck & Steer, 1991; Beck, Steer, & Ranieri, 1988). In the present study, the BSS was used to assess recent suicidal ideation. Internal reliability was high (α = .93). Data Analysis All analyses assumed a two-sided test of the hypothesis, with an overall significance level established a priori at p < .05. Analyses were performed in SAS v9.3. Due to positive skew (1.11), suicidal ideation scores were transformed to improve normality by adding a constant of 1 and then using a natural log transformation. The transformation improved the skew (.22). Therefore, the transformed version was used in subsequent analyses. As a first step, means, standard deviations, and bivariate correlations were calculated for all variables of interest. Hierarchical linear regression was used to test our hypotheses, with suicidal ideation as the dependent variable. The first step included the potential confounders (age and gender for the first hypothesis; age, gender, and combat for the second hypothesis), and deployment-related sexual trauma was added as the second step. Model 1 was used to test the first hypothesis (without combat); Model 2 was used to test our second hypothesis (with combat). Given the low number of women in the sample, a stratified gender analysis was not possible. The proportion of women was large enough, however, to adequately adjust for the effect of gender in the analysis and was similar to approaches taken by others (e.g., Gradus, Shipherd, et al, 2013). Notably, we had no missing data for our variables of interest. Results Table 1 provides a description of participants. Over one fourth (n = 55; 27.6%) of participants reported experiencing sexual trauma while deployed. Sixty percent (n = 120; 60.3%) reported experiencing suicidal ideation in the past week. Deploymentrelated sexual trauma was correlated with gender (r = .49, p < .001) and suicidal ideation (r = .18, p = .01) in bivariate analyses. Results regarding the association between deploymentrelated sexual trauma and suicidal ideation are reported in
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Table 1 Means, Standard Deviations, and Correlations for the Total Sample Variable 1. Age (years) 2. Gender (M = 0, W = 1) 3. Suicidal ideation 4. Suicidal ideation (transformed) 5. Deployment sexual trauma 6. Combat exposure
M
SD
1.
2.
3.
4.
5.
32.45 – 5.65 0.54 8.33 10.03
7.42 – 7.00 0.51 3.08 3.96
.30** .16* .16* .07 −.16*
.10 .09 .49** −.37**
.93** .18** .01
.17* .02
−.06
Note. N = 199; n = 28 women. M = men; W = women. * p < .05. ** p < .01.
Table 2. Deployment-related sexual trauma was significantly associated with suicidal ideation, adjusting for age and gender (Model 1; adjusted R2 = .04) and explained an additional 2.5% of the variance over the potential confounders, F(1, 195) = 5.04, p = .026. For each one point increase in deploymentrelated sexual trauma, there was a 7.2% increase in suicidal ideation, 95% confidence interval (CI) [0.8, 13.9]. The association between deployment-related sexual trauma and suicidal ideation remained significant when accounting for combat severity (Model 2; adjusted R2 = .04). The inclusion of sexual trauma accounted for an additional 2.2% of the variance in suicidal ideation, F(1, 194) = 4.51, p = .035. For each one point increase in deployment-related sexual trauma, there was a 6.9% increase in suicidal ideation, 95% CI [0.5%, 13.6%].
Discussion Although violence is an inherent part of combat, the aggressions that occur in the midst of war and conflict are often not restricted to the battlefield. Tragically, many who served in the U.S. operations in Iraq and Afghanistan have experienced sexual violence at the hands of other service members or commanding officers. The increased risk of sexual trauma among
those deployed to a combat zone (LeardMann, Pietrucha, et al., 2013), and the link between deployment and death by suicide in certain military populations (e.g., Army personnel; Schoenbaum et al., 2014), highlight the complex yet interrelated nature of different forms of violence. Apart from combat, however, few studies have examined how sexual violence during deployment relates to suicidal self-directed violence. Considering the frequent co-occurrence of combat and sexual trauma during deployment, we examined whether sexual trauma during deployment associated with recent suicidal ideation when taking combat into account. In our sample of OEF/OIF/OND veterans entering voluntary inpatient, traumafocused treatment, sexual trauma during deployment (measured continuously) was associated with recent suicidal ideation— adjusting for age and gender. These findings were consistent with those obtained by Gradus, Street, and colleagues (2013), in which deployment-related sexual trauma was associated with postdeployment suicidal ideation. Our findings also extended knowledge on sexual trauma and suicidal ideation by considering the role of combat. Interestingly, adding combat-related experiences to the equation did not substantively change our results. Deployment-related sexual trauma continued to display a significant association with suicidal ideation, even when accounting for the severity of
Table 2 Hierarchical Regression of Association Between Deployment-Related Sexual Trauma and Suicidal Ideation Variable
B
SE
95% CI
β
Model 1 Age Gender (M = 0, W = 1) Deployment sexual trauma
0.03* −0.16 0.07*
Age Gender (M = 0, W = 1) Combat exposure Deployment sexual trauma
0.03* −0.09 0.01 0.07*
0.01 0.28 0.03
[0.003, 0.05] [−0.72, 0.40] [0.01, 0.13]
.17 −.05 .18
0.01 0.31 0.02 0.03
[0.004, 0.05] [−0.69, 0.52] [−0.03, 0.06] [0.01, 0.13]
.17 −.03 .05 .17
Model 2
Note. N = 199. SE = standard error; M = men; W = women. * p < .05.
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combat exposure. This is in line with international research in which interpersonal trauma was more strongly associated with suicidal ideation than other types of trauma, such as combat and natural disasters (Stein et al., 2010). Furthermore, our findings are consistent with research conducted with civilians, in which sexual violence (e.g., sexual assault, molestation) was associated with increased odds of experiencing both suicidal ideation and suicide attempt (Belik, Cox, Stein, Asmundson, & Sareen, 2007; Davidson, Hughes, George, & Blazer, 1996; Kilpatrick et al., 1985; Ullman & Brecklin, 2002). These findings highlighted the importance of assessing other deployment experiences, such as sexual trauma—irrespective of the severity of combat exposure—when assessing suicide risk among OEF/OIF/OND veterans in inpatient, trauma-focused settings. Although the VHA has implemented a universal screen for MST, it is not intended to provide a continuous assessment of sexual trauma, which may limit thoroughly assessing the types and severity of sexual trauma experienced. Measures like the DRRI, however, may be able to supplement the MST screen to provide a more comprehensive assessment of the nature and severity of deployment-related sexual trauma. Although it is not yet validated as a diagnostic tool, the DRRI may be particularly useful in facilitating a dialogue between the provider and patient about the range of deployment experiences—such as sexual harassment or assault —that may impact postdeployment health. Notable strengths of this study included the use of validated measures of suicidal ideation, sexual trauma, and combat, which yielded continuous assessments of the severity of these constructs. We utilized a clinical sample at elevated risk for suicide—as evidenced by the fact that approximately 60% reported suicidal ideation in the past week. Prior research on sexual trauma and suicidal ideation has not included age in the model; however, our results suggested that age may be an important factor, as it was associated with suicidal ideation in our bivariate and multivariate analyses. Limitations included the small number of women in the sample, time since exposure to sexual trauma, and focusing on participants in specialized, inpatient treatment. Due to the small number of women (n = 28) who participated, we were unable to run analyses separately by gender. The representation of women in our sample (14.1%), however, mirrors the VHA population, in which women represent approximately 12.2% of OEF/OIF/OND veterans utilizing VHA care (U. S. Department of Veterans Affairs, 2014). Women in our sample reported higher levels of exposure to deployment-related sexual trauma than men. We attempted to address this by adjusting for gender. All of the prior research studies that have examined the association between sexual trauma during deployment or military service with suicidal ideation or attempt separately by gender have consistently found this association to be significant for both men and women (Gradus, Street, et al., 2013; Kimerling, Gima, Smith, Street, & Frayne, 2007; Pavao et al., 2013). Stratifying analyses by gender, however, may be important to consider in future research aimed at identifying variables
that explain the association between deployment sexual trauma and suicidal ideation, in which gender differences have been found (c.f. Gradus, Street et al., 2013). Our focus on a specific clinical population (OEF/OIF/OND veterans in inpatient, trauma-focused VA treatment) may have limited the generalizability of our findings to other cohorts, including outpatients and veterans not seeking VHA PTSDspecific care. On the other hand, examining this population is important, given its high risk for adverse outcomes. In addition, the cross-sectional design is a limitation to inferring causality; however, participants were veterans who had been discharged from the military years ago, whereas suicidal ideation was assessed as a recent occurrence (within the past week); thus, the sequence of events was in the appropriate order. Suicidal ideation was positively skewed in our sample, suggesting that the majority of participants endorsed low levels of the severity of suicidal ideation in the past week. This may limit generalizability to veterans experiencing more severe levels of suicidal ideation. Finally, our measure of deployment-related sexual trauma assessed events perpetrated by unit leaders or members; consequently, sexual trauma perpetrated by civilians or while not deployed was not assessed. Our findings add to a relatively understudied, yet growing body of research highlighting the association between sexual violence and suicidality and offer several important avenues for future research. To date, the limited amount of research on sexual trauma during military service and suicidal ideation has focused on sexual trauma during deployment with OEF/OIF/OND veterans. Focusing on sexual trauma during deployment however, represents only a snapshot of the range of lifetime experiences that may lead to suicide risk and neglects to consider other trauma that may occur throughout the lifespan. Thus, an important area for future research will be to examine whether these findings extend to sexual trauma that occurs outside of deployment, pre- and postmilitary trauma, and other cohorts of veterans. Examining whether deploymentrelated sexual trauma relates to suicide and suicide attempt is also essential to assessing the impact of sexual trauma on the range of suicidal self-directed violence. A critical next step will be to identify variables that explain this association. Lastly, identifying protective factors that mitigate the association between sexual trauma and suicidal ideation will be important for suicide prevention efforts. References Beck, A. T., & Steer, R. A. (1991). Beck Scale for Suicide Ideation. San Antonio, TX: Psychological Corporation. Beck, A. T., Steer, R. A., & Ranieri, W. F. (1988). Scale for suicide ideation: Psychometric properties of a self-report version. Journal of Clinical Psychology, 44, 499–505. doi:10.1002/1097-4679(198807)44:43.0.CO;2-6 Belik, S. L., Cox, B. J., Stein, M. B., Asmundson, G. J., & Sareen, J. (2007). Traumatic events and suicidal behavior: Results from a national mental health survey. Journal of Nervous and Mental Disease, 195, 342–349. doi:10.1097/01.nmd.0b013e318060a869
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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
