Posttraumatic Stress Symptom Severity Mediates the Relationship Between Military Sexual Trauma and Tension Reduction Behaviors in Male and Female Veterans

Abstract

Numerous studies attest to the prevalence and complex negative consequences associated with military sexual trauma (MST). However, relatively less is known about male survivors and about the interaction of psychological problems such as posttraumatic stress disorder (PTSD) symptoms and emotion management difficulties following MST. The current study examined the path of psychological distress following MST in both male and female veterans. We predicted that (a) history of MST would predict more severe PTSD symptoms, which in turn would predict greater use of dysfunctional emotion management strategies (specifically, tension reduction behaviors) and that (b) PTSD symptoms would mediate the relationship between history of MST and tension reduction behaviors. Finally, we explored whether the indirect (i.e., mediating) effect was moderated by gender. Data were obtained from pretreatment paper and pencil assessments administered as part of standard clinical care from 338 veterans seeking treatment at a Veterans Affairs (VA) mental health specialty clinic. Veterans who endorsed MST experienced more severe PTSD symptoms and greater reported use of tension reduction behaviors. Bootstrapping testing the indirect effect revealed that PTSD symptoms mediated the relationship between history of MST and tension reduction behaviors. An exploratory moderated mediation analysis found that the indirect effect did not differ as a function of gender. PTSD symptoms appear to mediate the relationship between MST and tension reduction behaviors in veterans, regardless of gender. While previous research has suggested that civilian men report a greater number of tension reduction behaviors following a sexual assault compared to civilian women, we did not find the same gender differences among veterans. These results may provide support for using trauma-focused treatment even when MST survivors are reporting high-risk tension reduction behaviors.

Keywords

military sexual trauma PTSD veterans emotion management military gender

The Department of Veterans Affairs (VA) defines military sexual trauma (MST) as “sexual harassment that is threatening in character, or physical assault of a sexual nature that occurred while the victim was in the military, regardless of geographic location of the trauma, gender of victim, or the relationship to the perpetrator” (Veterans’ Benefits United States [U.S.] Code, Title 38, Section 1720D, 1992). Data on the prevalence of MST are mixed, with some research suggesting that 4.3% of women and 0.6% of men report experiencing MST in a given year (Department of Defense [DoD], 2016), while other research suggests higher prevalence rates (39.4% of women and 3.9% of men; Wilson, 2016). Despite these differences in rates, it remains evident that sexual trauma continues to be a pervasive problem in the U.S. military, warranting continued efforts to understand MST and its mental health sequelae. In addition, while numerous studies have investigated MST and associated psychological consequences in women, only a few studies have investigated this phenomenon in men (e.g., Gilmore et al., 2016; Kimerling, Gima, Smith, Street, & Frayne, 2007). Given the large number of male veterans affected by MST, it is imperative that researches also investigate MST and related psychopathology in men. Furthermore, while extant literature highlights the increased risk for posttraumatic stress disorder (PTSD) symptoms following MST (Allard, Nunnink, Gregory, Klest, & Platt, 2011), less is known about how survivors manage their emotions following sexual assault. The aim of the current study, therefore, was to examine MST, PTSD symptoms, and methods of emotion management (defined in the following as tension reduction behaviors) among female and male veterans.

Associations Between MST and PTSD

MST is associated with an extensive and complex array of negative mental health outcomes. Extant literature provides ample evidence for the association between MST and resulting psychological and physical problems, including the following: PTSD (Himmelfarb, Yaeger, & Mintz, 2006), depression, anxiety, alcohol abuse, poor quality of life, bodily pain, social dysfunction (Surís, Lind, Kashner, Borman, & Petty, 2004), and dissociation (Luterek, Bittinger, & Simpson, 2011). While Kimerling and colleagues (2007) found that veterans who screened positive for MST had significantly greater odds of several mental health disorders, PTSD is often the most frequently and intensively studied disorder among survivors of MST. In fact, research has demonstrated that MST is more strongly associated with posttraumatic symptomatology than other traumatic experiences, including combat exposure and civilian adult sexual violence (e.g., Klingensmith et al., 2014; for reviews, see Allard et al., 2011 and Kintzie et al., 2015).

The increased risk for posttraumatic distress related to MST compared to other sexual trauma may be due to its relatively higher level of betrayal. Trauma high in betrayal is perpetrated by someone upon whom the victim is dependent (Freyd, 1996) and has been repeatedly associated with more negative outcomes compared to trauma with little or no betrayal (e.g., Freyd, Klest, & Allard, 2005; Goldsmith, Freyd, & DePrince, 2012). MST is most typically perpetrated by a superior or other individual the victim is dependent on such as a fellow service member (DoD, 2009; Sadler, Booth, Cook, & Doebbeling, 2003). Moreover, MST victims are also dependent on the institution in which the abuse is perpetrated (i.e., the military), and this institution has traditionally been unsupportive or even punishing to disclosers of MST (Fontana & Rosenheck, 1998; Turchik & Wilson, 2010). When MST survivors are discharged from the military, they continue to be reliant on the institution that betrayed them for MST-related health care. The Veterans Health Administration (VHA) offers free health care to veterans for MST-related health conditions, regardless of discharge status. However, many survivors of MST never report their trauma to a VHA provider (see Wolff & Mills, 2016). Holliday and Monteith (2019) theorize that beliefs about safety and trust are distorted following MST with accompanying institutional betrayal. MST survivors may therefore forgo seeking health care at a VHA due to concerns of not being believed or being punished in some way (similar to MST survivors’ experiences while in the military; Holliday & Monteith, 2019).

Smith and Freyd (2013) found that institutional betrayal contributed to increased posttraumatic distress in female survivors of sexual trauma. In addition, recent research demonstrated that female veterans who experienced MST with accompanying institutional betrayal reported more severe PTSD and depression symptoms compared to female veterans who did not experience institutional betrayal (Andresen, Monteith, Kugler, Cruz, & Blais, 2019). Overall, these findings suggest that due to the potential high level of betrayal associated with MST, survivors are at an increased risk for severe psychopathology.

Associations Between MST and Emotion Management

Survivors of MST may experience difficulty managing their emotions (i.e., emotion dysregulation; Luterek et al., 2011). Emotion dysregulation is a multifaceted construct and often manifests as a wide range of risky behaviors including substance abuse (Hahn, Tirabassi, Simons, & Simons, 2015; Jakupcak et al., 2010), disordered eating (Moulton, Newman, Power, Swanson, & Day, 2015), self-injurious behavior (Chaplo, Kerig, Bennett, & Modrowski, 2015), and risky sexual behaviors (Messman-Moore, Walsh, & DiLillo, 2010; Ullman & Vasquez, 2015). Many of these behaviors (e.g., self-injurious behavior) may be conceptualized as tension reducing behaviors (Klonsky, 2007). In other words, these behaviors may serve to distract from or reduce intense, distressing, and unwanted emotions.

Previous research suggests that men may be more likely to engage in tension reducing behaviors that result in externalizing disorders (e.g., alcohol use disorder), whereas women may be more likely to engage in tension reducing behaviors that result in internalizing disorders (e.g., anxiety or depression; Kendler & Myers, 2014). Male survivors of sexual assault (compared to female survivors) are more likely to report violence, behavioral problems, and substance abuse following an assault (Darves-Bornoz, Choquet, Ledoux, Gasquet, & Manfredi, 1998). Furthermore, Elliott, Mok, and Briere (2004) found that men who have been sexually assaulted are especially liked to engage in tension reducing behaviors (e.g., self-destructive behavior, aggression, thrill-seeking).

In the absence of effective internal emotion regulation skills, survivors of interpersonal trauma (IPT; such as MST) may engage in external activities to regulate trauma-related emotions, such as compulsive sexual behavior, binging and purging, self-harm, and suicidality (Briere & Spinazzola, 2005). Studies on male survivors of civilian sexual assault suggest that men have significantly higher rates of psychiatric hospitalizations, psychiatric symptoms, reported distress (Kimerling, Ouimette, & Wolfe, 2002), substance abuse (Ratner et al., 2003), and self-harming behavior (Coxell, King, Mezey, & Gordon, 1999) as compared to female survivors. Male sexual assault survivors are also at greater risk than female sexual assault survivors for increased anger, anxious arousal, impaired self-image, dysfunctional sexual behavior, and defensive avoidance (Elliott et al., 2004). While existing research has examined tension-reducing behaviors among male survivors of civilian sexual assault, less is known these behaviors among male MST survivors. Although previous research suggests that men are more likely to engage in external tension reducing behaviors, military socialization (e.g., hiding “weaknesses” such as emotions) may result in less variability of trauma reactions between male and female veterans.

Associations Between PTSD Symptoms and Emotion Management

Symptoms of PTSD can include unwanted re-experiencing of the traumatic event (through distressing dreams or memories), changes in beliefs about oneself (e.g., distorted self-blame) and the world, and increased arousal and hypervigilance (American Psychiatric Association [APA], 2013). Another core symptom of PTSD is internal and external avoidance of any trauma-related stimuli (APA, 2013). It is believed that this avoidance may interfere with trauma and therefore may serve to maintain PTSD symptoms over time.

Among IPT survivors, tension reduction behaviors (e.g., self-harm, aggression) may be conceptualized as a form of dysfunctional behavioral avoidance that are on the high-risk end of the avoidance spectrum. Due to the high-risk nature of these symptoms, health care providers will oftentimes prioritize these behaviors in treatment prior to starting a trauma-focused therapy (e.g., Cloitre, Koenen, Cohen, & Han, 2002). That said, if these dysfunctional behaviors are serving to distract from/manage one’s trauma-related emotions, it may not be possible to replace these problematic behaviors without simultaneously working to reduce one’s symptoms of PTSD. Should PTSD symptoms mediate the relationship between history of MST and tension reduction behaviors, this may provide support for providing PTSD treatment despite the presence of high-risk dysfunctional behaviors in veteran populations.

Overview and Hypotheses

To our knowledge, there is no empirical evidence investigating MST, PTSD symptoms, and externally focused tension reduction behaviors among male and female MST survivors. Given the strong relationship between MST and PTSD, as well as evidence from existing literature examining associations between PTSD secondary to MST and emotion management difficulties, we hypothesized that history of MST would predict more severe PTSD symptoms, which in turn would predict greater reported use of tension reduction behaviors among treatment-seeking veterans presenting to an outpatient VA clinic. Furthermore, if tension reduction behaviors serve as a form of dysfunctional behavioral avoidance (i.e., a symptom of PTSD) following MST exposure, then PTSD symptoms should also mediate the relationship between MST and use of tension reduction behaviors.

The current study utilized a measure of tension reduction behaviors that focuses on one’s tendency to reduce distress “through self-destructive or self-injurious behaviors, aggression, thrill-seeking, dysfunctional eating, dramatic behavior, and/or throwing or hitting things when upset” (Trauma Symptom Inventory–2nd edition [TSI-2]; Briere, 2011, pp. 18-19). Given previous research that suggests that male survivors of civilian sexual trauma may be especially likely to engage in these types of externally oriented tension reducing behaviors (Elliott et al., 2004), and to have different posttraumatic reactions than women (Kimerling et al., 2007), we also explored the moderating role of gender on PTSD symptoms and tension reduction behaviors.

Method

Participants and Procedure

Data were collected from 338 veterans (44.4% men) presenting for treatment to the VA San Diego Healthcare System’s MST and IPT Clinic over a 20-month period (May 2015—January 2017). Veterans completed paper and pencil self-report surveys at pre-treatment as part of standard clinical care and consented to have their data used for research purposes, as approved by the local VA Institutional Review Board and Research and Development oversight committees. The instruments used in the current study represent a subset of the measures administered as part of standard clinical care. Demographic information is presented in Table 1 and indicates that the sample was diverse and generally representative of the MST and IPT clinic. One hundred sixty-five female (48.8%) and 82 male (24.3%) veterans endorsed a history of MST, based on their self-reported trauma history and a review of their medical chart, for an overall count of 247 veterans (73.1%) reporting MST in the current sample.

Table 1.

Descriptive Statistics and Two-Tailed Bivariate Correlations Among all Study Variables.

Variables	1	2	3	4	5	6	7
1. Age	—
2. Gender	.37**	—
3. Race	.01	−.09	—
4. Trauma count	.20**	.19**	−.07	—
5. MST	.00	−.38**	.05	.04	—
6. PCL-5 score	−.09	.09	−.09	.27**	.17**	—
7. TRB score	−.19**	.01	−.14*	.16**	.10	.44**	—
M	42.98	.45	.49	4.29	.74	50.39	10.88
SD	13.28	.50	.50	2.36	.44	14.88	6.98
Min	20	0	0	0	0	9	0
Max	78	1	1	13	1	80	29
N	322	337	319	324	336	329	338

Note. Gender was coded as 0 = “female” and 1 = “male”; race was coded as 1 = “non-Hispanic white” and 0 = “all others”; MST was coded as 0 = “no history of MST” and 1 = “history of MST”; MST = military sexual trauma; PCL-5 = posttraumatic stress disorder checklist–5th edition (possible range = 0-80); TRB = tension reduction behavior scale (possible range = 0-30).

p < .05. **p < .01.

Measures

Participants were asked to complete the following measures: a demographics questionnaire, the Life Events Checklist–5th edition (LEC-5; Weathers, Blake, et al., 2013a), the PTSD Checklist–5th edition (PCL-5; Weathers, Litz, et al., 2013b), and the Tension Reduction Behavior (TRB) subscale of the TSI-2 (Briere, 2011).

Demographics questionnaire

Demographic information (e.g., age, gender, race/ethnicity) was obtained through a brief intake questionnaire and chart review. Of note, participants were asked to select gender descriptor(s) they identified with, including nonbinary ones, and not their biological sex.

Trauma history

Trauma history was obtained using the LEC-5 (Weathers, Blake, et al., 2013a). The LEC-5 is a self-report assessment of exposure to potentially traumatic events in accordance with the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013). The LEC-5 lists 16 different events that may result in PTSD symptoms and asks participants to endorse if and how they experienced the event in their lifetime (e.g., Happened to me; Witnessed it; Learned about it; Part of my job; Not Sure). The original LEC had strong psychometric properties and showed strong convergent validity with other measures of lifetime trauma exposure (Gray, Litz, Hsu, & Lombardo, 2004). Regarding test–retest reliability, Gray and colleagues (2004) also found that the original LEC was reasonably stable over approximately 7 days. As very few changes were made to the LEC-5, it is expected that the LEC-5 has strong psychometric properties (Weathers, Blake, et al., 2013a).

MST was defined in the current study as participant endorsement (i.e., “Happened to me”) of one of the following items on the LEC-5: “Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)” or “Other unwanted or uncomfortable sexual experience.” To be categorized as MST, the sexual trauma had to reportedly occur during military service; we added a question on the LEC-5 that assessed whether the trauma(s) occurred during military service. In addition, medical chart reviews were also conducted to confirm history of MST. If MST endorsement was documented in the chart but not the LEC-5, participants were coded as having experienced MST. We coded MST as a dichotomous variable (0 = no history of MST, 1 = history of MST). To control for potential effects of non-MST events (e.g., childhood abuse, combat) on analyses, other traumatic events endorsed by participants as having “Happened to me” were summed to create a total “other” trauma count variable.

PTSD symptoms

To assess PTSD symptoms, the PCL-5 (Weathers, Litz, et al., 2013b) was administered. The PCL-5 is a 20-item questionnaire that corresponds to the 20 PTSD symptoms as reported by the DSM-5 (APA, 2013). These items (e.g., “repeated, disturbing, and unwanted memories of the stressful experience”) are rated using a 5-point Likert-type scale ranging from 0 (not at all) to 4 (extremely). Participants were instructed to complete the PCL-5 with regard to their most impactful trauma, and participants were asked to think about the severity of their symptoms over the past month. PCL-5 item scores were summed to create a PCL-5 total score. A total score of 33 or higher on the PCL-5 is indicative of “probable” PTSD (Bovin et al., 2016). Bovin and colleagues (2016) found that the PCL-5 is a psychometrically sound self-report measure, especially for use in a veteran population. The internal consistency estimate for the PCL-5 in the current study was α = .93.

Tension reduction behaviors

The TRB subscale of the TSI-2 (Briere, 2011) was used to measure maladaptive external attempts at reducing or distracting from distressing emotions. The TSI-2 is a 136-item self-report measure that evaluates posttraumatic distress and has demonstrated adequate to excellent internal consistency (Briere, 2011). The TSI-2 TRB subscale comprised 10 items, rated using a 4-point Likert-type Scale ranging from 0 (never) to 3 (often). The TRB subscale measures a self-reported tendency to reduce distress “through self-destructive or self-injurious behaviors, aggression, thrill-seeking, dysfunctional eating, dramatic behavior, and/or throwing or hitting things when upset” (Briere, 2011, pp. 18-19). Higher total scores on the TRB subscale reflect poor emotion and behavioral regulation skills (Briere, 2011). The internal consistency estimate for the TRB subscale in the current study was α = .85.

Analytic Strategy

Data screening and analyses were conducted using IBM SPSS Statistics 25.0. We ran bivariate correlations to determine associations between our demographic, predictor, mediator, and outcome variables. We also conducted chi-square analyses and independent samples t tests to assess for gender differences on all study variables. Finally, we utilized the SPSS macro PROCESS (Hayes, 2013) to test our mediation and moderated mediation hypotheses. PROCESS utilizes bootstrapping (e.g., repeatedly sampling from the data set and estimating the indirect effect in each resampled data set) to test the significance of the indirect (i.e., mediating) effect (Hayes, 2013). For the mediation and moderated mediation analyses, our independent variable was history of MST (coded as 0 = no history of MST, 1 = history of MST), our dependent variable was tension reduction behaviors (modeled as a continuous variable with the TRB subscale sum score), our mediator variable was PTSD symptoms (modeled as a continuous variable with the PCL-5 sum score), and our moderator variable was gender (coded as 0 = female and 1 = male).

Results

Data were entered into SPSS and quality checked twice by two different research assistants. Data were inspected for univariate outliers and out-of-range values. One veteran had a PCL-5 sum score of “1”; this was determined to be an outlier, and therefore, this participant’s data were removed from all subsequent analyses. One veteran identified as transgender on the gender identity question. As the current study was interested in examining comparisons between veterans identifying as either male or female, this individual’s data were removed from analyses. Regarding missing data, 16 veterans chose not to respond to the age item, 19 veterans chose not to respond to the race item, and two veterans chose not to respond to the MST item. Nine veterans had incomplete PCL-5 data and 14 veterans had incomplete LEC-5 data. All data were assumed to be missing at random. Bivariate correlation analyses were conducted to show variable relationships (see Table 1). Age and race (coded as 1 = non-Hispanic white and 0 = all others) were negatively correlated with TRB subscale score (r = −.193, p = .001 and r = −.144, p = .010, respectively); additionally, the total “other” trauma count variable was positively correlated with TRB subscale score (r = .156, p = .005). Due to these significant correlations with our outcome variable of interest, age, race, and total “other” trauma count were included as study covariates in our mediation and moderated mediation analyses (i.e., all model pathways were adjusted to account for their influence; Preacher & Hayes, 2004).

A chi-square analysis determined that women were more likely than men to endorse a history of MST, χ²(1, N = 335) = 48.44, p < .001, Cramer’s V = .38. There were no gender differences among participants who identified as White or as a racial minority, χ²(1, N = 319) = 2.54, p = .111. A series of independent samples t tests (adjusting for Bonferroni) determined that male veterans were older than female veterans (men: M = 48.60, SD = 13.07; women: M = 38.70, SD = 11.78; t[320] = −7.13, p < .001, d = .80). In addition, male veterans reported a higher total “other” trauma count than female veterans (men: M = 4.81, SD = 2.38; women: M = 3.90, SD = 2.27; t[322] = −3.53, p < .001, d = .39). There were no gender differences on the TRB subscale variable (t[335] = −0.14, p = .892) or the PCL-5 sum variable (t[327] = −1.57, p = .117).

To test our mediation hypotheses, we utilized the approach set forth by Preacher and Hayes (2004). This approach tests the significance of the direct and indirect effects of the independent variable on the dependent variable via ordinary least squares regression (OLS) analysis, using the bootstrapping method to create confidence intervals (CIs) of the indirect effect. If the resulting CIs do not include zero, it can be concluded that there is a significant mediation effect. This method is recommended because it has greater power than the Sobel test for testing mediation (Hayes, 2009). Furthermore, bootstrapping does not require data to be normally distributed (Hayes, 2013).

Our first mediation analysis tested the hypothesis that exposure to MST predicts more severe PTSD symptoms, which in turn predicts greater reported use of tension reduction behaviors (n = 304; see Figure 1). Furthermore, we hypothesized that PTSD symptoms would mediate the relationship between MST and tension reduction behaviors. Age, race, and total “other” trauma count were included as covariates in the mediation model. MST predicted PTSD symptoms after controlling for age, race, and total “other” trauma count (B = 6.29, SE = 1.81, p < .001, R² = .13). Furthermore, PTSD symptoms predicted tension reduction behaviors after controlling for age, race, and total “other” trauma count (B = .18, SE = .03 p < .001, R² = .23); MST did not predict tension reduction behaviors after controlling for age, race, and total “other” trauma count (B = .16, SE = .82, p = .848). In accordance with recommendations made by Mallinckrodt, Abraham, Wei, and Russell (2006), 10,000 bootstrap resamples were conducted and used to test the indirect (mediation) effect. The 95% CIs for the indirect effect did not contain zero; therefore, the path between MST and tension reduction behaviors was mediated by PTSD symptoms. These findings are summarized in Table 2.

Figure 1.

The mediation of MST and tension reduction behaviors by PTSD symptoms.

Table 2.

Simple Mediation of Military Sexual Trauma and Tension Reduction Behaviors by Posttraumatic Stress Disorder Symptoms.

	B	SE	LL 95% CI	UL 95% CI
Direct effect of MST on tension reduction behaviors
	.16	.82	−1.45	1.76
Indirect effects
Bootstrap results	1.16	.36	.48	1.91

Note. n = 304. Bootstrap sample size = 10,000; MST = military sexual trauma; B = unstandardized coefficient; SE = standard error; LL = lower limit; UL = upper limit; CI = confidence interval. Age, race, and total “other” trauma count were entered into the model as covariates, but are not depicted.

We also conducted an exploratory moderated mediation analysis to test whether the indirect effect from MST to tension reduction behaviors through PTSD symptoms would vary based on gender (i.e., male or female). The moderated mediation tested whether gender moderated the path between PTSD symptoms and tension reduction behaviors (see Figure 2). After controlling for age, race, and total “other” trauma count, the interaction term (PTSD symptoms × gender; path mb) was not significantly associated with tension reduction behaviors. These findings are summarized in Table 3.

Figure 2.

Moderated mediation of gender on PTSD symptoms and tension reduction behaviors.

Table 3.

Moderated Mediation of Gender on Posttraumatic Stress Disorder Symptoms and Tension Reduction Behaviors.

	B	SE	LL 95% CI	UL 95% CI
Total and direct effects
Path a	6.29	1.81	2.72	9.85
Path b	.18	.03	.12	.25
Path c′	.42	.93	−1.41	2.24
Path m	.72	2.68	−4.56	6.01
Path mb	−.00	.05	−.10	.09
Indirect effects as a function of gender
Female	1.15	.39	.44	2.01
Male	1.13	.39	.43	1.96

Note. n = 304. Bootstrap sample size = 10,000; B = unstandardized coefficient; SE = standard error; LL = lower limit; UL = upper limit; CI = confidence interval. Age, race, and total “other” trauma count were entered into the model as covariates, but are not depicted.

Discussion

The goal of the current study was to better understand the path of psychological distress following MST in both male and female veterans. Specifically, the current study examined associations between MST exposure, PTSD symptoms, and tension reduction behaviors among veterans presenting for mental health treatment at a VA mental health specialty clinic. As hypothesized, MST predicted more severe PTSD symptoms, which in turn predicted greater reported use of tension reduction behaviors. Furthermore, PTSD symptoms mediated the relationship between MST and tension reduction behaviors, even after controlling for age, race, and lifetime exposure to non-MST traumatic events. It is likely that individuals who experience MST and subsequent symptoms of PTSD have difficulty managing their emotions and therefore turn to maladaptive tension reduction behaviors (e.g., self-destructive or self-injurious behaviors, aggression, dysfunctional eating) as a means to regulate themselves. In addition, our moderated mediation analyses revealed that associations between MST, PTSD symptoms, and tension reduction behaviors did not differ as a function of gender.

In line with previous research (Wilson, 2016), female veterans in the current study reported higher rates of MST than male veterans. That said, the prevalence of MST endorsed by men was higher in the current study (24%) compared to previous literature. However, this was likely due to the nature of the clinic (veterans in the current sample were seeking treatment at a VA clinic specializing in MST and other IPT). Although male veterans reported a higher total count of lifetime exposure to non-MST traumatic events (compared to female veterans), history of MST still uniquely predicted PTSD symptoms (and PTSD symptoms still significantly mediated the relationship between MST and tension reduction behaviors) in male veterans. Interestingly, we did not find gender differences on our measure of PTSD symptoms (PCL-5). Previous research has shown that women are twice as likely than men to suffer from a trauma-related disorder (Kobayashi, Cowdin, & Mellman, 2012). This may be because women are especially likely to experience IPT (such as a sexual assault), which has the potential to lead to more severe symptoms of PTSD (Cortina & Kubiak, 2006). As both men and women in the current sample reported instances of IPT, this may explain our nonsignificant gender differences on the PCL-5.

Furthermore, it is of interest that we did not find gender differences on our measure of tension reduction behaviors (TRB subscale of the TSI-2). This is in contrast to Elliott and colleagues’ (2004) finding that sexually assaulted civilian men reported a greater number of tension reduction behaviors (also measured by the TRB subscale; M = 7.1) than sexually assaulted civilian women (M = 4.0). Both male and female veterans in the current sample endorsed an average of 11 tension reduction behaviors. This discrepant finding may be due to military men and women who are survivors of MST having more in common than civilian men and women who are survivors of civilian sexual assault. Military socialization may result in decreasing differences between men and women on some variables important to trauma reactions. For example, both male and female veterans have endorsed the perceived value of hiding “weaknesses” and remaining in control of one’s emotions, both which could impact psychological functioning following trauma (Lorber & Garcia, 2010). In addition, the context and characteristics of MST may be more similar than that of civilian sexual assault. Perpetrators of MST are likely individuals upon whom their victims are dependent (regardless of the gender of the victim), and there may be more variability in terms of the relationship to the perpetrator for female victims compared to male victims of civilian sexual assault. As discussed earlier, level of closeness and dependence between victim and perpetrator is positively associated with level of distress following a sexual assault (e.g., Freyd et al., 2005).

The current study has both strengths and limitations. Strengths include adding novel information to the limited research on male MST survivors. In addition, the current study was the first to explore mechanisms underlying the relationship between MST and tension reduction behaviors among male and female veterans. Furthermore, we were able to control for lifetime history of non-MST traumatic events in an attempt to determine the unique impact of MST on psychological functioning. However, although novel, this study is not without limitations. First, the current sample comprised veterans from only one VA health care facility and therefore results may not be generalizable to other VA facilities. In addition, as the current sample included treatment-seeking veterans presenting to an MST & IPT clinic, this sample likely comprised individuals already experiencing high levels of distress and/or emotion regulation difficulties. Furthermore, the sample included veterans who were willing to disclose their MST to a VHA provider. It is therefore unclear how these results would generalize to the larger MST population. That said, the current sample was diverse concerning gender, race/ethnicity, and age. Second, the study was cross-sectional in nature and therefore one cannot draw firm conclusions regarding causation. It is possible that some veterans in the current sample experienced PTSD symptoms, as well as tension reduction behaviors, prior to experiencing MST. Future prospective, longitudinal studies are needed to determine the true directionality of influence among study variables. Third, the constructs of interest were obtained via retrospective reporting, which may be subject to recall bias. Furthermore, the authors utilized a measure of emotion dysregulation that focuses on self-destructive or self-harm behaviors, aggression, and thrill-seeking. There are other facets of emotion regulation that are not captured by the TRB subscale of the TSI-2. Finally, the current study measured MST as a dichotomous variable, which may have implications for the study’s findings. The use of dichotomous measures (e.g., MST exposure: yes vs. no) does not allow for consideration of within-group variations based on frequency/severity of exposure. In other words, by grouping together all veterans who endorsed at least one MST experience, the current study constructed these participants as a homogeneous group. This measurement strategy may have masked important variations in MST severity. Futures studies may elect to measure MST continuously, rather than dichotomously, to assess the potential impact of within-group variations.

In summary, results from the current study suggest that both male and female survivors of MST experience heightened PTSD symptoms, which in turn leads to greater reported use of tension reduction behaviors. In addition, PTSD symptoms appear to mediate the relationship between MST and tension reduction behaviors in veterans, regardless of gender. These efforts to manage emotions may manifest as self-destructive and even harmful behaviors, which may function as a means to cope with MST-related distress. These findings may provide support for the utilization of trauma-focused treatment even when both male and female MST survivors are endorsing the usage of multiple high-risk tension reduction behaviors. While some providers may be inclined to stabilize a client (i.e., reduce high-risk behaviors) prior to starting trauma-focused treatment, it may not be possible for a client to replace these behaviors without simultaneously working to reduce their PTSD symptoms. Future studies could assess the possible function of these tension reduction behaviors by utilizing semi-structured interviews to examine the perceived function of behaviors such as thrill-seeking or self-harm among male and female survivors of MST. In addition, future research should assess for closeness and dependence on perpetrator to determine whether level of betrayal contributes to psychological outcomes following MST.

Future research should also continue to examine the similarities and differences of MST versus civilian sexual assault. While previous research on civilian sexual assault has found different posttraumatic reactions as a function of gender, findings from the current study do not support this claim among survivors of MST. Female veterans in the current sample reported similar mean ratings of PTSD symptoms and tension reduction behaviors as male veterans. Military socialization may pressure all survivors of MST to find external means to manage their emotions, such as through aggression, thrill-seeking, and dysfunctional eating. Findings from the current study also suggest that clinicians should be prepared for survivors of MST to present to treatment with significantly more engagement in high-risk tension reduction behaviors compared to survivors of other traumatic events, including survivors of civilian sexual trauma. These behaviors should be carefully monitored and discussed during trauma-focused treatment, especially during the early stages of trauma-processing.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This material is based upon the work funded in part by a Luzerne Foundation Research Grant (Principal investigator: Carolyn B. Allard) and supported by the Office of Academic Affiliations, Department of Veterans Affair and with resources and the use of facilities at the VA San Diego Health Care System and University of California San Diego Departments of Psychiatry and Psychology. The contents do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.

ORCID iD

Susan M. Hannan

Author Biographies

Susan M. Hannan, PhD, is a visiting assistant professor in the Psychology Department at Lafayette College. Her research is broadly focused on traumatic stress, including the examination of risk and resilience factors (e.g., emotion regulation) related to psychological outcomes following trauma exposure.

Katie B. Thomas, PhD, is a clinical psychologist at the Milwaukee VA Medical Center and assistant professor in the Medical College of Wisconsin Department of Psychiatry and Behavioral Medicine. Her research interests are in interpersonal trauma, emotion regulation, and self-harm behavior.

Carolyn B. Allard, PhD, ABPP, is the PhD program director at the California School of Professional Psychology at Alliant International University, associate professor of psychiatry at the University of California San Diego, and research psychologist at the Veterans Affairs San Diego Healthcare System. Her research focuses on identifying mechanisms of posttraumatic distress and treatment outcomes for interpersonal trauma survivors.

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