The Relationship Between Provider Gender Preferences and Perceptions of Providers Among Veterans Who Experienced Military Sexual Trauma

Abstract

Previous research has demonstrated that most veterans who have experienced military sexual trauma (MST) have provider gender preferences. Although provider gender mismatch, defined as not receiving a provider of the gender of one’s preference, may deter veterans from disclosing MST or seeking MST-related care, there is little research that has examined this issue. The current study aimed to explore how provider gender mismatch is related to veterans’ comfort with providers, perception of their providers’ competency, and their endorsement of perceived provider barriers when communicating about MST. The current study was conducted as part of a larger national survey of veterans’ barriers to accessing MST-related care. Participants in the study were identified using Veterans Health Administration (VHA) administrative data. Criteria for inclusion in the overall study were being enrolled in VHA health care, having screened positive for MST, and having received at least one VHA outpatient service. A subset of eligible veterans who had endorsed MST, reported a provider gender preference, and endorsed discussing MST with a VHA provider (N = 1,591) were included in the current study. Results demonstrated that provider gender preference mismatch was associated with greater endorsement of perceived provider barriers, less comfort with providers, and lower perceived provider competency in women; and greater perceived provider barriers and less comfort with providers among men. The study demonstrates that provider gender preferences may affect care for veterans who have experienced MST, and that the impact may differ for men and women. These findings may be used to improve patient-centered care and inform future research regarding veterans’ provider gender preferences.

Keywords

adult victims sexual assault male victims reporting/disclosure

Introduction

Military sexual trauma (MST) is a Department of Veterans Affairs (VA)-specific term that refers to “a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the veteran was serving on active duty or active duty for training, or inactive duty training” (U.S. Code, Title 38 § 1720D). A recent study utilizing VA administrative data found that 24.5% of women and 1.7% of men have reported experiencing MST (Gundlapalli et al., 2017). It should be noted that given the higher proportion of men within the Veterans Health Administration (VHA), that although women are more likely to experience MST, the total number of men and women who have reported MST are similar with about 60% being women and 40% men (U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, 2019). MST experiences have been related to a greater likelihood of several mental health conditions including depression and posttraumatic stress disorder (PTSD; Kimerling et al., 2007).

The VHA has a mandated universal MST screening policy to facilitate veterans’ access to free MST-related mental and physical health care. Universal screening has been demonstrated as the preferred method to assess for a history of sexual trauma as it alleviates the patient’s responsibility to initiate disclosure of sexual assault experiences and may improve access to sexual trauma–specific care (Kimerling et al., 2008; Probst et al., 2011). However, several barriers may prevent veterans from receiving MST-related care, such as veterans’ choice not to disclose even when asked directly, lack of knowledge about available MST resources, gender-related barriers, stigma-related barriers, and provider-related factors (Andresen & Blais, 2019; Holland et al., 2016; Sadler et al., 2018; Turchik, Bucossi, & Kimerling, 2014; Turchik et al., 2013).

Perceived provider-related factors, such as lack of provider–patient communication, provider insensitivity, or provider discrimination may affect whether veterans access care or stay in treatment (Holland et al., 2016; Kimerling et al., 2011; Sayer et al., 2009; Vogt, 2011). Research suggests veterans with PTSD are less likely to be satisfied with the emotional support they receive from their primary care provider (Desai et al., 2005) and a major barrier to sexual assault disclosure among women is the fear of their provider’s reaction (McCauley et al., 1998).

The gender of the provider may also play an important role for veterans who have experienced MST (Kimerling et al., 2015; Turchik, Bucossi, & Kimerling, 2014; Turchik et al., 2013). Research has shown that most veterans have a provider gender preference when seeking care for MST-related issues (Turchik, McBain, Garneau-Fournier, 2020; Turchik, Bucossi, & Kimerling, 2014; Turchik et al., 2013). A recent study of a national sample of VHA-enrolled veterans with MST histories found that among women, 77.6% had a preference for a female provider, 1.0% for a male provider, and 21.4% reported no preference. Among men, 43.5% had a preference for a female provider, 13.7% for a male provider, and 42.8% reported no preference (Turchik, McBain, Garneau-Fournier, 2020).

VHA policy encourages providers to consider patients’ provider gender preference when treating MST-related issues (U.S. Department of Veterans Affairs, VHA, 2017a). It is currently unclear how often veterans’ preferences are considered or how these preferences may affect MST-related care. For women veterans, gender-specific resources, including women-only treatment settings are available within the VHA; however, such resources are not always available or possible, which may deter some women from accessing MST-related care (Bean-Mayberry et al., 2011; Kimerling et al., 2015). Initial research findings indicate 13.7% of veteran men and 1.0% of women prefer male providers (Turchik, McBain, Garneau-Fournier, 2020; Turchik, Bucossi, & Kimerling, 2014). No known studies have explored specific services for veterans who have a male provider preference, or for veteran men with any gender preference. Whereas it may not always be feasible to match a veteran with a provider of their choice, more information is needed to determine how often patients are receiving gender-targeted services (e.g., women-exclusive waiting room) and providers who match their gender preference.

Among women veterans, provider gender mismatch, defined as not receiving a provider of one’s gender preference, may act as a deterrent to disclosing MST or seeking MST-related care (Kimerling et al., 2015). Initial research with women veterans suggests those who are granted their request for a female provider as much as desired are twice as likely to perceive VHA care as meeting their needs (Kimerling et al., 2015). Women veterans endorsing beliefs that VHA providers are not skilled in treating women, that VHA providers are insensitive to the concerns of women, or that veterans cannot see a female provider as requested, have been associated with attrition from VHA care (Hamilton et al., 2013).

Among veteran men, little information is available concerning how provider preferences may affect access to care or patient–provider relationships. In one qualitative study, veteran men who preferred a female provider emphasized their belief that female providers would be more compassionate and sensitive than male providers (Turchik et al., 2013). Men who preferred a male provider reported they would feel more emasculated or embarrassed discussing MST with a female provider or that only a male provider would be able to understand the male-specific issues that arise from sexual trauma.

Research has suggested that many veterans who have experienced MST have provider gender preferences when accessing MST-related care (Turchik, McBain, Garneau-Fournier, 2020). However, no research has examined how not receiving the provider of one’s gender preference is related to patient–provider interactions around the topic of MST. Given that VHA providers typically act as the primary referral source and gateway to accessing MST-related care, it is important to understand how VHA providers may affect veterans accessing and receiving such care. The current study will first identify the percentage of veterans who endorsed a provider gender preference and did not receive a VA provider of their gender preference when discussing MST (to be referred to as “provider gender preference mismatch”) among a national sample of veterans who have experienced MST. Based on the current literature, we expect that not receiving the provider of one’s gender preference will be related to greater perceived provider-related barriers (e.g., minimizing, acting uncomfortable) when communicating about MST, greater discomfort with gender preference mismatched providers, and lower ratings of providers’ competence when discussing MST. It is believed these relationships will remain even when controlling for demographic factors (i.e., age, race, military status), mental health factors (i.e., depression, PTSD), and premilitary sexual trauma that have been found to influence patient–provider relationships and care satisfaction (Desai et al., 2005; McCauley et al., 1998).

Method

Participants

The current study was conducted as part of a larger national survey of veterans’ barriers to accessing MST-related care. Participants in the study were identified using VHA administrative data. Criteria for inclusion in the study were being enrolled in VHA health care, having screened positive for MST between August 2013 and March 2014, and having received at least one VHA outpatient service during that same time. Veterans were excluded if they were legally conserved, cognitively impaired, legally blind, and/or listed as homeless (due to vulnerability and lack of a mailing address). Of the 11,084 veterans who met eligibility requirements, 8,681 veterans were then randomly selected and sent an initial recruitment letter. Participants were invited to complete a survey assessing their views and experiences around seeking VHA services; however, due to privacy concerns, they were not informed that they had been selected due to their past endorsement of MST.

A total of 2,682 (31%) opted into the study and 2,220 returned a survey, resulting in a survey completion rate of 82.8%. Veterans who responded to the survey were statistically more likely to be women, older in age, less likely to be Hispanic, and more likely to be White. A total of 415 veterans did not complete the survey, 36 withdrew from the study, six were not locatable, and five denied using VHA services and were deemed ineligible. Analyses revealed no significant differences between survey completers and noncompleters.

A proportion of veterans were excluded from the final sample of the study due to returning an incomplete survey (n = 16), invalid response patterns (n = 2), and missing or endorsement of “other” gender (n = 7). Veterans who did not endorse MST in the survey (n = 198), failed to report their provider gender preference (n = 34), or did not report having communicated about MST or received MST-related care (n = 372), were removed, leaving a final sample of 1,591.

Participants’ ages ranged from 21 to 89 years with an average age of 49 years. The sample identified as 67.7% White, 22.2% Black, 1.4% Asian, and 8.8% Other. A total of 7.8% of participants identified as Hispanic. The majority of participants identified as women (70.6%), heterosexual (90.1%), served in the army (49.8%), and served after the Vietnam War era (79.0%).

Measures

All data used in the current study were gathered through a mailed self-report survey. Measures for the current study were embedded within a larger national survey. All participants had screened positive for MST in the last 12 months using the VHA two-item health care screener that states the following: “While you were in the military, 1) did you ever receive uninvited and unwanted sexual attention (e.g., touching, cornering, pressure for sexual favors, verbal remarks)?” and “2) did anyone ever use force or the threat of force to have sex with you against your will?”

Demographics and past trauma

Participant demographics including age, gender, race, ethnicity, sexual orientation, and relationship status were assessed along with relevant military service information including branch of service, service era, military status, and military rank. Veterans’ premilitary sexual trauma history was also assessed and included any history of childhood sexual assault (CSA) or premilitary adult sexual assault (ASA). CSA was measured using the following item based on the Childhood Sexual Victimization Questionnaire (Finkelhor, 1979; Risin & Koss, 1987):

Before age 18, did an adult or someone five years older than you such as a parent, relative, family friend, or stranger engage in sexual contact with you (for example touched or fondled you in a sexual way, or attempted to or had oral, anal, or vaginal intercourse with you)?

Response options were yes or no. ASA was measured separately by adapting one item used as part of both the Predeployment Life Events Scale and Postdeployment Risk and Resilience Inventory–2 (DRRI-2), a psychometrically valid and reliable instrument for assessing deployment risk and resilience factors (Vogt et al., 2013). Participants were asked, “Did you experience unwanted sexual activity as a result of force, threat of harm, or manipulation during adulthood but before your military service (after age 18)?” Response options were yes or no.

Depression screener

The Patient Health Questionnaire–2 (PHQ-2; Kroenke et al., 2003) was used to screen for depression. Scores on the PHQ-2 range from 0 to 6, and a positive screen is a score of 3 or higher. The PHQ-2 has demonstrated good reliability (α = .83) and validity (Kroenke et al., 2003), and is commonly used by the VHA and in studies of the veteran population (Corson et al., 2004; Seal et al., 2008). The Cronbach’s alpha for the PHQ-2 in the current study was .90.

PTSD screener

The Primary Care PTSD Screen (PC-PTSD; Prins et al., 2003) was used to screen for PTSD. The PC-PTSD is a four-item abbreviated screening instrument that measures the four dimensions of PTSD (i.e., reexperiencing, numbing, avoidance, and hyperarousal) according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000). Scores on the PC-PTSD range from 0 to 4, and a positive PTSD screen is a score of 3 or higher. This measure has demonstrated good test–retest reliability (r = .80) and yielded a sensitivity of .91 and specificity of .80 with a cutoff score of 3 in a sample of veterans (Kimerling et al., 2006). In the current study, the PC-PTSD demonstrated a high level of internal consistency (α = .97).

Provider gender preference match status

To determine whether veterans communicated about MST to their preferred gender provider, participants were asked, “If you were to want or need help with any concerns related to an experience of military sexual trauma, what gender of VA health care provider would you prefer?” and prompted to endorse female, male, or no preference. Second, participants were asked “Have any VA provider(s) ever asked you about military sexual trauma?” (yes/no), and in the case of an affirmative response, participants were asked to indicate whether they had discussed MST with a male, female, or multiple providers—both male and female. Participants were considered matched if they endorsed a gender preference and reported speaking to a provider of their gender preference. Participants were considered mismatched if they endorsed a gender preference and reported speaking to a provider who did not match their gender preference. Participants who endorsed a gender preference and reported speaking to multiple providers, both male and female, were considered mixed matched. All participants who endorsed no provider gender preference were labeled as no preference.

Comfort with provider

Participants were asked to describe their level of comfort discussing MST with a range of VHA health care providers using a five-item scale developed for this study. The stem stated, “When discussing military sexual trauma, how comfortable were you with each of the following types of VHA health care providers?” Participants were asked to rate their comfort level with primary care physicians, mental health clinicians, nurses, administrative staff, and an optional additional type of provider they wished to add. Participants selected one of the following options for each type of provider: uncomfortable (coded as 1), neutral (coded as 2), or comfortable (coded as 3). The scores were averaged over the type of providers with whom they had discussed MST, with scores ranging from 1 to 3.

Perceived provider barriers

An eight-item scale called Perceived Provider Barriers to MST Communication (PPBMC) was created for the purposes of this study to measure veterans’ perceived provider-related barriers to communicating about MST. The study used a modified version of Lepore and Ituarte’s (1999) Social Constraints Scale (SCS), a 15-item self-report questionnaire that measures perceived negative social responses to trauma-related disclosure. The stem for each question asked, “When attempting to discuss military sexual trauma, did your VHA provider(s) . . .” Questions assessed both negative (e.g., acting uncomfortable) and positive (e.g., making the veteran feel understood) provider behaviors. Responses were coded 0 = never, 1 = rarely, 2 = sometimes, 3 = often, for a total score range of 0 to 24, with higher total scores indicating more perceived barriers. Positive items were reverse scored. The Cronbach’s alpha for this scale was .86 demonstrating good internal consistency.

Perceived provider competency

Participants were asked to provide a rating of their providers’ competency by answering the following question created for the study: “Overall, how professional and skilled was your VHA health care provider(s) when discussing military sexual trauma?” Rating choices ranged from 1 = very unprofessional and unskilled to 5 = very professional and skilled.

Procedures

The current study was approved by Stanford University’s Institutional Review Board, VA Palo Alto Health Care System, and VA Palo Alto Health Care System’s Institutional Review Board. Veterans who opted into the study were mailed a cover letter, study and Health Insurance Portability and Accountability Act (HIPAA) information sheets, the survey, an MST-specific resource list that included crisis numbers and local MST point-of-contacts, and a US$5 store gift card. To ensure confidentiality, the survey was devoid of all personally identifiable information and marked with the participant’s unique participant identification number. Participants were asked to return the survey in an enclosed self-addressed reply envelope. Participants who returned the survey were sent a thank you letter and a US$15 store gift card.

Data Analysis

The current study employed a cross-sectional design using self-reported survey data. Data analyses were conducted using SPPS (version 25) and SAS (version 9.4) for multiple imputation. Missing data analysis revealed that missing data for each variable were less than 4% which is considered quite low (Tabachnick & Fidell, 2007). Multiple imputation (10 imputations) was used to adjust for missing data in the primary data analyses. Given that previous literature suggests gender-specific differences between men and women who have experienced MST (e.g., Turchik, Bucossi, & Kimerling, 2014; Turchik et al., 2013; Turchik, Rafie, et al., 2014), the main analyses were stratified by gender.

Six one-way analyses of variance (ANOVAs) were conducted to examine how veterans’ gender preference and provider gender match status related to veterans’ ratings of perceived provider barriers, perceived provider competence, and comfort with provider. If provider preferences were significant, each ANOVA was followed by an analysis of covariance (ANCOVA) to test the relationship, while controlling for demographic factors (i.e., age, race, ethnicity, sexual orientation, relationship status, service era, military status, military rank), mental health factors (i.e., depression, PTSD), and premilitary sexual trauma (i.e., CSA, ASA). These factors were included given the significant co-occurrence of mental health and premilitary sexual trauma in veterans who have experienced MST (Mattocks et al., 2012). Bonferroni post hoc tests were then used to further examine the pairwise comparisons.

Results

Veterans’ Experiences With VHA Providers

For the total sample (N = 1,591), the mean perceived provider barriers total score was 5.41 (SD = 5.66, range = 0–24). For overall comfort with VHA providers, the mean score was 1.94 (SD = 0.70, range = 1–3). Veterans’ ratings of VHA providers’ competence had a mean score of 4.08 (SD = 1.13, range = 1–5). Among men, the mean perceived provider barriers score was 5.94 (SD = 5.80), the mean overall comfort score was 1.89 (SD = 0.73), and the mean perceived provider competence rating was 4.05 (SD = 1.15). Among women, the mean perceived provider barriers score was 5.19 (SD = 5.45), overall comfort had a mean score of 1.96 (SD = 0.70), and the mean rating of perceived provider competence was 4.09 (SD = 1.12).

Prevalence of Provider Gender Preference Mismatch

Among men (n = 468), 13.7% (n = 64) reported a preference for a male provider, 43.4% (n = 203) reported a preference for a female provider, and 42.9% (n = 201) reported no preference. Among women (n = 1,123), 1.0% (n = 11) reported a preference for a male provider, 77.7% (n = 873) reported a preference for a female provider, and 21.3% (n = 239) reported no preference. See Table 1 for provider gender preference match status among men and women veterans.

Table 1.

Provider Gender Preference Match Status Among Veterans Who Reported Communicating With a Provider About MST.

Provider Gender Preference Match Status	Total Veterans (N = 1,591)	Women (n = 1,123)	Men (n = 468)
Provider Gender Preference Match Status	n (%)	n (%)	n (%)
Mismatched	134 (8.4)	78 (6.9)	56 (12.0)
Matched	725 (45.6)	592 (52.7)	133 (28.4)
No preference	440 (27.7)	239 (21.3)	201 (42.9)
Mixed matched	292 (18.4)	214 (19.1)	78 (16.7)

Note. MST = military sexual trauma.

Provider Gender Preference and Comfort, Provider Barriers, and Provider Competence

Men

The one-way ANOVAs revealed that there were significant differences on perceived provider barriers, F(3, 464) = 6.34, p < .001, η² = .04, and comfort with provider, F(3, 464) = 6.37, p < .001, η² = .04, across the provider gender preference match categories for men. There were no significant differences on perceived provider competence across the provider gender match categories, F(3, 464) = 1.01, p = .390, η² = .007. See Table 2 to examine significant differences across gender match categories.

Table 2.

Examining Effects of Provider Gender Preference Match Status on Comfort With Providers, Perceived Provider Barriers, and Perceived Provider Competence (N = 1,591).

Variable	Sample M (SE)	Mismatched	Matched	No Preference	Mixed Match	ANOVA F	ANCOVA F
Men
Comfort	1.89 (0.03)	1.69^a	1.89	2.04^ab	1.68^b	6.37***	1.87
Barriers	5.94 (0.27)	8.58^abef	5.73^ae	5.00^bf	6.78	6.34***	3.46*
Competence	4.05 (0.05)	3.80	4.06	4.10	4.07	1.01	0.91
Women
Comfort	1.96 (0.02)	1.88^a	1.95^b	2.15^abc	1.84^c	8.13***	3.22**†
Barriers	5.19 (0.16)	7.39^abef	4.64^ace	5.04^bdf	6.07^cd	8.13***	6.09***
Competence	4.09 (0.03)	3.71^abcefg	4.10^ae	4.12^bf	4.15^cg	3.10*	3.29*

Note. Post hoc differences between provider preference match status groups are indicated with alphabetical superscripts, with a to d used to indicate differences in the ANOVAs and e to g used to indicate differences in the ANCOVAs when taking the covariates into account. Matching superscripts in the same row indicate a significant difference between groups. ANOVA = analysis of variance; ANCOVA = analysis of covariance; SE = standard error.

†

Although the overall test indicated significant differences in comfort scores for women, there were no significant post hoc differences between the individual groups.

p < .05. **p < .01. ***p < .001.

The one-way ANCOVA examining perceived provider barriers among men was significant, F(17, 449) = 2.41, p = .003, η² = .08. There was a significant effect of gender preferences on perceived provider barriers after controlling for the covariates, F(3, 449) = 3.46, p = .016, partial η² = .03. Of the covariates, younger age was related to greater perceived provider barriers, F(1, 449) = 5.27, p = .022, partial η² = .01.

The one-way ANCOVA examining comfort with provider among men was significant, F(17, 449) = 3.99, p < .003, η² = .08. However, there was no significant effect of gender preferences on comfort with provider after controlling for the covariates, F(3, 449) = 1.87, p = .14, partial η² = .01. Of the covariates, younger age, F(1, 449) = 4.20, p = .041, partial η² = .01, and a positive depression screen, F(1, 449) = 11.26, p = .001, partial η² = .03, were related to lower reported comfort with provider.

The one-way ANCOVA examining perceived provider competence was not significant among men, F(17, 449) = 0.94, p = .508, η² = .03. See Supplemental Table 1 for covariate mean scores for the outcomes among men.

Women

The one-way ANOVAs revealed that there were significant differences on perceived provider barriers, F(3, 1,119) = 8.13, p < .001, η² = .02, comfort with provider, F(3, 1,119) = 8.13, p < .001, η² = .02, and perceived provider competence, F(3, 1,119) = 3.10, p = .026, η² = .009, across the provider gender preference match categories for women. See Table 2 to examine significant differences across gender match categories.

The one-way ANCOVA examining perceived provider barriers among women was significant, F(17, 1,104) = 4.35, p < .001, η² = .06. There was a significant effect of gender preferences on perceived provider barriers after controlling for the covariates, F(3, 1,104) = 6.09, p < .001, partial η² = .02. Of the covariates, both a positive depression screen, F(1, 1,104) = 6.63, p = .010, partial η² = .01, and a positive PTSD screen, F(1, 1,104) = 6.81, p = .009, partial η² = .01, were related to greater perceived provider barriers.

The one-way ANCOVA examining comfort with providers among women was significant, F(17, 1,104) = 4.55, p < .001, η² = .07. There was a significant effect of gender preferences on perceived provider barriers after controlling for the covariates, F(3, 1,104) = 3.22, p = .002, partial η² = .01. Of the covariates, both a positive depression screen, F(1, 1,104) = 8.68, p = .003, partial η² = .01, and a positive PTSD screen, F(1, 1,104) = 7.51, p = .006, partial η² = .01, were related to lower comfort with providers.

The one-way ANCOVA examining perceived provider competence among women was significant, F(17, 1,104) = 2.96, p < .001, η² = .04. There was a significant effect of gender preferences on perceived provider competence after controlling for the covariates, F(3, 1,104) = 3.29, p = .020, partial η² = .01. Of the covariates, younger age, F(1, 1,104) = 10.41, p = .001, partial η² = .01, and sexual minority status, F(1, 1,104) = 5.85, p = .016, partial η² = .01, were related to lower perceived provider competence. See Supplemental Table 2 for covariate mean scores for the outcomes among women.

Discussion

The primary aim of this study was to explore the relationship between receiving the provider gender of one’s preference and veterans’ comfort with VHA providers, veterans’ perception of the competency of their providers, and veterans’ endorsement of perceived provider barriers when discussing MST. Findings suggest not receiving the provider of one’s preference is related to greater perceived provider barriers, lower perceived competency of providers, and lower comfort with providers among women; and greater perceived provider barriers and lower comfort among men.

Consistent with previous research (Turchik, Bucossi, & Kimerling, 2014; Turchik et al., 2013; Turchik, Rafie, et al., 2014), most veterans (57.1% of men and 78.7% of women) expressed a gender provider preference. Most women preferred a female provider and men reported more mixed provider preferences. Most participants reported receiving the provider of their gender preference on at least one occasion (64.0%) or reported no provider gender preference (27.7%). Whereas only 8.4% of veterans did not receive the provider gender of their choice, it appears men may be significantly less likely to get a provider of their choice compared with women (12.0% vs. 6.9%) despite fewer men having a preference.

Male rape myths and stigma around discussing sexual trauma are common among patients and providers (Anderson & Quinn, 2009; Davies, 2002; Turchik & Edwards, 2012). Providers often know less about sexual trauma among men and may feel less comfortable talking about sexual trauma (Davies, 2002). As a result, men may not be asked as often if they have a preference and may be less willing to state a preference. Given that men are less likely to receive adequate MST-related care (Brignone et al., 2017; Turchik et al., 2012), provider gender preference mismatch could be a contributing barrier for men attempting to access MST-related services.

Of veterans who experienced provider gender preference mismatch, 95% of women and 55% of men reported a preference for a female provider. Veterans’ decisions regarding where to seek MST-related treatment may dictate the likelihood of receiving a provider of their gender preference. Given that most of those who were provider gender preference mismatched desired a female provider, it is possible veterans are discussing MST in non–mental health settings that are traditionally composed of a greater number of male clinicians (e.g., primary care) and are, therefore, incidentally increasing their likelihood of being mismatched. Previous research has suggested victims of sexual assault tend to seek care from primary care settings, a setting with a higher availability of male providers, compared with mental health care settings that often have a greater percentage of female providers (Zinzow et al., 2008).

For men, provider gender preference mismatch was related to greater perceived provider barriers and comfort with provider, but was not related to perceived provider competency. However, the relationship with comfort was not significant in the presence of the covariates, with age and depression perhaps being more important factors in determining men’s comfort with providers. The lack of significant findings related to comfort with providers may also be related to masculinity, which has also been found to contribute to underreporting of symptoms (Himmelstein & Sanchez, 2014), and could possibly contribute to less endorsement of discomfort during interactions with mismatched providers. Alternatively, because men had more mixed preferences, mismatched status may not be as strongly related to comfort. The absence of significant findings may also be attributed to the smaller sample size of men compared with women and less power to detect small differences.

Among men who were mismatched, 55.4% had a female preference and 44.6% had a male preference. Given men’s more nuanced gender preferences, multiple factors are likely involved in the relationship between mismatch and perceived provider barriers. A past study found that some veteran men reported preference for a female provider as they believed that female providers are better listeners or more empathetic (Turchik, Rafie, et al., 2014). Among men who reported a female preference and received a male provider, negative beliefs about male providers’ attitudes about male sexual trauma (Holland et al., 2016) and a fear of being shamed (Turchik et al., 2013) may have influenced the perception of the patient–provider interaction and increased perceived provider barriers. Those who received a male provider may have also objectively experienced more provider barriers. Existing literature with civilian samples suggests male providers are more likely to endorse negative stereotypes about men who have experienced sexual assault (Anderson & Quinn, 2009) and are less likely to engage in patient-centered communication compared with female providers (Roter et al., 2014).

Veteran men who reported a male preference and received a female provider also reported greater perceived provider barriers than those who were matched with their preference. In previous studies of men’s preferences, men who endorsed a preference for a male provider reported they believed female providers would not understand the male-specific issues that arise or believed they would feel emasculated by discussing the problem with a female provider (Turchik et al., 2013). For these men, male preference may be more related to a global perception that a female provider will misunderstand them and to men’s endorsement of male role norms (i.e., masculinity, self-reliance, medical distrust), which have been found to directly and indirectly influence men’s preference for a male provider (Himmelstein & Sanchez, 2016).

Women who discussed MST with a gender mismatched provider reported greater perceived provider barriers than those who were matched. Among women, provider mismatch primarily represented being assigned to a male provider. Gender concordance among women may contribute to greater rates of patient-centered communication and patient disclosure of psychosocial concerns (Roter et al., 2014). Given that most women veterans report a female gender preference, the potential reduction in patient-centered communication in mismatched (i.e., gender discordant) conditions could lead to greater perceived provider barriers (e.g., minimization, lack of expressed concern, discomfort with disclosure), resulting in lower comfort and ultimately poorer perceived provider competence (Roter et al., 2014). Consistent with other studies of gender and patient–provider relationships (Hamilton et al., 2013; Kimerling et al., 2015), women who were mismatched had more negative perceptions of providers than those who were matched. Provider gender preference mismatch may contribute to women veterans’ perception that VHA is not sensitive to the requests of women who have experienced MST (Hamilton et al., 2013) or may exacerbate the mistrust experienced following a sexual trauma.

Women reported that discussing MST with a gender preference mismatched provider (generally a male provider) was significantly more uncomfortable than with a matched provider (generally a female provider), which is consistent with the existing sexual assault literature (e.g., Chowdhury-Hawkins et al., 2008; Fowler et al., 1992; Fowler & Wagner, 1993; Lee et al., 2007; Leibowitz et al., 2008). In general, women who have experienced MST have been found to prefer female providers, as female providers are often perceived to be safer, more understanding, and less likely to cue reminders of a perpetrator who is most likely to be male (Turchik, Bucossi, & Kimerling, 2014). Women with no preference were significantly more comfortable discussing MST when compared with women who had a provider gender preference regardless of match status. Women with no preference may represent women who are generally more comfortable with providers regardless of gender. It is also possible that women without preference may represent those who have had a positive experience talking to a male provider about MST in the past (Fowler & Wagner, 1993; Turchik, Bucossi, & Kimerling, 2014).

The finding that gender preference mismatch was related to lower perceived provider competence among women may be related to gender preference acting as a proxy for desirable characteristics within a provider (e.g., caring, easy to talk to, nurturing; McCauley et al., 1998) that may be related to femininity-specific gender stereotypes. Women looking for female-stereotyped qualities who receive a male provider may perceive their male provider as less skilled given their preconceived ideas about characteristics of a male provider (i.e., self-reliance, dominance, emotional control). Furthermore, male providers may be aware of a veteran’s preference for a female provider (Bergman et al., 2015), feel less confident or comfortable discussing sexual trauma, and subsequently be perceived as less skilled when discussing MST. Previous studies within VHA have demonstrated female veterans have global beliefs that VHA lacks in its skill in managing female-specific care (Hamilton et al., 2013). It is likely these beliefs extend to MST-related care and are perhaps even magnified given the gender-related and sensitive nature of MST. In fact, women who have experienced MST are more likely to rate overall coordination of care less favorably than women without an MST history (Kimerling et al., 2011).

Several covariates were found to significantly affect veterans’ perception of VHA providers, even when accounting for provider gender match status. More specifically, younger age was significantly related to lower comfort and greater barriers among men and lower competence among women. These findings align with Hamilton et al.’s (2013) study of attrition from VHA care in which younger women were less likely to rate their provider as skilled in treating women veterans. Findings that greater reported depression and PTSD symptoms were related to experiences with providers are also consistent with existing literature suggesting that psychiatric symptoms are related to dissatisfaction with VHA outpatient care (e.g., Desai et al., 2005). Finally, sexual minority status was also related to lower perceived skill among women, which may align to a recent finding indicating that many sexual minority veterans report experiencing discrimination in health care and poorer quality provider communication (Ruben et al., 2019).

With the exception of age and sexual minority status, the majority of demographic, military, and premilitary sexual trauma variables were not found to be significant covariates in the current study. This indicates that although there may be group differences in veterans’ ratings of provider interactions, these may not be as salient when factoring in provider gender preferences, symptomology, and age. The lack of significant differences by race and ethnicity may be related to VHA efforts to provide high-quality care to all veterans, which consequently may be improving veterans’ satisfaction with their care (Zickmund et al., 2018). The lack of significance of CSA and ASA may suggest that experiences of premilitary trauma themselves may be less salient than sexual trauma–related distress or that the quantity of sexual assault experiences may not be as influential as PTSD or depression when discussing MST with VHA providers. Further research is needed to further examine these factors and their relationships to the current study’s outcomes.

Although this study provides novel and valuable data on veterans’ experience of discussing MST with VHA providers, it is not without limitations. Given that the study only included veterans who identified their gender as “male” or “female,” the results do not account for the experiences of transgender and nonbinary veterans. Although the study drew from a representative national sample, there were demographic differences among those who chose to participate in the study and this may affect its generalizability. These results may also not be generalizable to veterans seeking care outside of VHA or those who have not reported their MST. The current study used cross-sectional data, limiting the ability to draw conclusive causal relationships among study variables. Although the study sought to examine the interactions between veterans and providers when discussing MST, it relied solely on self-report data rather than actual observed interactions between veterans and providers. This study also did not assess the extent to which MST was discussed and addressed, or the strength of provider gender preferences. Whether the level of MST disclosure and/or the individual importance of gender preference matching influenced the dependent variables is unknown and should be examined in future studies. Furthermore, in the interest of providing a manageable and brief questionnaire for participants, study-specific measures assessing patient comfort, perceived provider barriers, and perceived competence asked participants to aggregate their experiences with VHA providers if they had discussed MST with multiple providers. Therefore, it is unclear whether participants’ responses represented an experience with one provider with whom the participant had a particularly salient experience or a generalization of multiple experiences with providers.

The adapted scale (i.e., PPBMC) used in this study to assess PPBMC demonstrated good internal consistency in the current study but requires further psychometric evaluation. Furthermore, given that recent research suggests that negative reactions to sexual assault survivors are distinct from positive reactions and have unique effects on outcomes (Dworkin et al., 2019), future research may also want to examine positive and negative reactions separately. Furthermore, the results of the current study may be more specific to veterans’ comfort and reactions to discussing MST with VA providers in general (and at screening), and the effects may be different when applied to the context of receiving MST-specific treatment from a provider. Future studies should examine veterans’ gender preferences specifically within the context of MST-related treatment.

Results from the current study underline the importance of gender and gender preferences in discussion of MST-related care, and support the guidelines outlined in the VHA handbook related to gender-specific care and gender preference (U.S. Department of Veterans Affairs, VHA, 2017b). When discussing MST with a provider of a nonpreferred gender, veterans reported experiencing more perceived provider barriers than those who received the provider gender of their choice. Although findings of the current study may inform tertiary prevention efforts (e.g., sensitive and appropriate screening practices, information to minimize negative consequences after disclosure of MST; Dworkin et al., 2019), they especially highlight the importance of developing and improving health care providers’ competence and sensitivity in providing MST-related care. The need for offering specialized training in trauma-informed care, and regularly evaluating and providing feedback to all VHA health care providers have been noted within the literature (Foynes et al., 2018; Holland et al., 2016). A brief web-based training about MST has been recently mandated for VHA mental health and primary care providers (U.S. Department of Veterans Affairs, VHA, 2017a). However, the training is not given to all VA staff, and there is no research yet on the effect of such training on providers or veterans. Ultimately, the current study provides insights that will facilitate future research related to veterans’ experiences discussing MST with providers and will help inform clinical practice training guidelines to improve access to MST-related care.

The current study yields novel information on how veterans who have experienced MST perceive patient–provider interactions regarding MST and has illustrated that veterans’ gender preferences can affect patient–provider variables. However, it is still unclear how strong these provider gender preferences are and to what extent they affect engagement and long-term satisfaction with care. Further research could provide a more nuanced study of the strength and meaning of these preferences, and their potential effects on additional factors such as initial access to care, dropout rates, patient satisfaction, long-term engagement in care, and treatment outcomes.

Supplemental Material

sj-pdf-1-jiv-10.1177_0886260520944536 – Supplemental material for The Relationship Between Provider Gender Preferences and Perceptions of Providers Among Veterans Who Experienced Military Sexual Trauma

Supplemental material, sj-pdf-1-jiv-10.1177_0886260520944536 for The Relationship Between Provider Gender Preferences and Perceptions of Providers Among Veterans Who Experienced Military Sexual Trauma by Sacha A. McBain, Jade Garneau-Fournier and Jessica A. Turchik in Journal of Interpersonal Violence

Footnotes

Acknowledgements

Special thanks to Russell Dubois, Sharfun Ghaus, and Drs. Tammy Torres and Laura Petersen for their assistance in data collection; Xiatong Han for her assistance with missing data analysis; Dr. Rachel Kimerling for input on the larger study; and Drs. Matthew Cordova, Josef I. Ruzek, and Janice Habarth for their feedback on the study.

Authors’ Note

All authors have had changes in affiliation since the research was initially conducted. Dr. McBain is now affiliated with the University of Arkansas for Medical Sciences. Dr. Garneau-Fournier is now affiliated with the University of Central Florida. Dr. Turchik is now an independent researcher living in the United Kingdom.

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 research was supported by funding by the VA Health Services Research & Development (HSR&D), Career Development Award (CDA Grant 12-273) awarded to Jessica Turchik, PhD, as well as resources and support by the Center for Innovation to Implementation (Ci2i) and the National Center for PTSD, Dissemination & Training Division at VA Palo Alto Health Care System. Writing of this article was also supported by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs.

ORCID iD

Sacha A. McBain

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Sacha A. McBain, PhD, is an assistant professor in the Departments of Psychiatry and Surgery at University of Arkansas for Medical Sciences in Little Rock, Arkansas. Her research focuses on improving access to evidence-based trauma treatment through implementation science and multidisciplinary collaboration.

Jade Garneau-Fournier, PhD, is a licensed psychologist at the University of Central Florida. Her research focuses on sexual health among veterans who have experienced military sexual trauma (MST). Her clinical interests include eating disorders and body image concerns, trauma, sexual assault, gender affirmative care, training, and supervision.

Jessica A. Turchik, PhD, is a clinical psychologist whose research for the past 15 years has focused on the topics of sexual trauma and sexual risk taking. She has particularly focused on MST and the impact of MST for male and female veterans within the Veterans Affairs health care system.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

Anderson

Quinn

(2009). Gender differences in medical students’ attitudes towards male and female rape victims. Psychology, Health & Medicine, 14(1), 105–110. https://doi.org/10.1080/135485008002241928

Andresen

F. J.

Blais

R. K.

(2019). Higher self-stigma is related to lower likelihood of disclosing military sexual trauma during screening in female veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 11(4), 372–378. https://doi.org/10.1037/tra0000406

Bean-Mayberry

Yano

E. M.

Washington

D. L.

Goldzweig

Batuman

Huang

… Shekelle

P. G.

(2011). Systematic review of women veterans’ health: update on successes and gaps. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 21(4), S84–S97. https://doi.org/10.1016/j.whi.2011.04.022

Bergman

A. A.

Frankel

R. M.

Hamilton

A. B.

Yano

E. M.

(2015). Challenges with delivering gender-specific and comprehensive primary care to women veterans. Women’s Health Issues, 25(1), 28–34. https://doi.org/10.1016/j.whi.2014.10.004

Brignone

Gundlapalli

A. V.

Blais

R. K.

Kimerling

Barrett

T. S.

Nelson

R. E.

… Fargo

J. D.

(2017). Increased health care utilization and costs among veterans with a positive screen for military sexual trauma. Medical Care, 55(9), S70–S77. https://doi.org/10.1097/MLR.0000000000000767

Chowdhury-Hawkins

McLean

Winterholler

Welch

(2008). Preferred choice of gender for staff providing care to victims of sexual assault in Sexual Assault Referral Centres (SARCs). Journal of Forensic and Legal Medicine, 15, 363–367. https://doi.org/10.1016/j.jflm.2008.01.005

Corson

Gerrity

M. S.

Dobscha

S. K.

(2004). Screening for depression and suicidality in VA primary care setting: 2 items are better than 1 item. American Journal of Managed Care, 10(11 pt 2), 839–845.

Davies

(2002). Male sexual assault victims: A selective review of the literature and implications for support services. Aggression and Violent Behavior, 7(3), 203–214. https://doi.org/10.1016/S1359-1789(00)00043-4

10.

Desai

Stefanovics

Rosenheck

(2005). The role of psychiatric diagnosis in satisfaction with primary care: Data from the Department of Veterans Affairs. Medical Care, 43(12), 1208–1216. https://doi.org/10.1097/01.mlr.0000185747.79104.90

11.

Dworkin

E. R.

Brill

C. D.

Ullman

S. E.

(2019). Social reactions to disclosure of interpersonal violence and psychopathology: A systematic review and meta-analysis. Clinical Psychology Review, 72, Article 101750. https://doi.org/10.1016/j.cpr.2019.101750

12.

Finkelhor

(1979). What’s wrong with sex between adults and children? Ethics and the problem of sexual abuse. American Journal of Orthopsychiatry, 40, 692–697. https://doi.org/10.111/j.1939-0025.1979.tb02654.x

13.

Fowler

W. E.

Wagner

W. E.

Iachini

Johnson

J. T.

(1992). The impact of sex of psychological examiner on sexually abused girls’ preference for and anticipated comfort with male versus female counselors. Child Study Journal, 22(1), 1–10.

14.

Fowler

W. E.

Wagner

W. G.

(1993). Preference for and comfort with male versus female counselors among sexually abused girls in individual treatment. Journal of Counseling Psychology, 40(1), 65–72. https://doi.org/10.1037//0022-0167.40.1.65

15.

Foynes

M. M.

Makin-Byrd

Skidmore

W. C.

King

M. W.

Bell

M. E.

Karpenko

(2018). Developing systems that promote veterans’ recovery from military sexual trauma: Recommendations from the Veterans Health Administration national program implementation. Military Psychology, 30(3), 270–281. https://doi.org/10.1080/08995605.2017.1421818

16.

Gundlapalli

A. V.

Brignone

Divita

Jones

A. L.

Redd

Suo

… Fargo

J. D.

(2017). Using structured and unstructured data to refine estimates of military sexual trauma status among US military veterans. Studies in Health Technology and Informatics, 238, 128–131.

17.

Hamilton

A. B.

Frayne

S. M.

Cordasco

K. M.

Washington

D. L.

(2013). Factors related to attrition from VA healthcare use: Findings from the national survey of women veterans. Journal of General Internal Medicine, 28, 510–517. https://doi.org/10.1007/s11606-013-2347-y

18.

Himmelstein

M. S.

Sanchez

D. T.

(2014). Masculinity impediments: Internalized masculinity contributes to healthcare avoidance in men and women. Journal of Health Psychology, 21(7), 1283–1292. https://doi.org/10.1177/1359105314551623

19.

Himmelstein

M. S.

Sanchez

D. T.

(2016). Masculinity in the doctor’s office: Masculinity, gendered doctor preference and doctor-patient communication. Preventative Medicine, 84, 34–40. https://doi.org/10.1016/j.ypmed.2015.2015.12.008

20.

Holland

K. J.

Rabelo

V. C.

Cortina

L. M.

(2016). Collateral damage: Military sexual trauma and help-seeking barriers. Interpersonal Violence, 6(2), 253–261. https://doi.org/10.1037/a0039467

21.

Kimerling

Gima

Smith

M. W.

Street

Frayne

(2007). The Veterans Health Administration and military sexual trauma. American Journal of Public Health, 97(12), 2160–2166. https://doi.org/10.2105/ajph.2006.092999

22.

Kimerling

Pavao

Greene

Karpenko

Rodriguez

Saweikis

Washington

D. L.

(2015). Access to mental health care among women veterans: Is VA meeting women’s needs. Medical Care, 53(4 Suppl. 1), S97–S104. https://doi.org/10.1097/MLR.0000000000000272

23.

Kimerling

Pavao

Valdez

Mark

Hyun

J. K.

Saweikis

(2011). Military sexual trauma and patient perceptions of Veteran Health Administration health care quality. Women’s Health Issues, 21(4), S145–S151. https://doi.org/10.1016/j.whi.2011.04.007

24.

Kimerling

Street

A. E.

Gima

Smith

M. W.

(2008). Evaluation of universal screening for military-related sexual trauma. Psychiatric Services, 59(6), 635–640. https://doi.org/10.1176/ps.2008.59.6.635

25.

Kimerling

Trafton

J. A.

Nguyen

(2006). Validation of a brief screen for post-traumatic stress disorder with substance use disorder patients. Addictive Behaviors, 31(11), 2074–2079. https://doi.org/10.1016/j.addbeh.2006.02.008

26.

Kroenke

Spitzer

R. L.

Williams

J. B.

(2003). The Patient Health Questionnaire-2: Validity of a two-item depression screener. Medical Care, 41(11), 1284–1292. https://doi.org/10.1097/01.MLR.0000093487.78664.3C

27.

Lee

T. T.

Westrup

D. A.

Ruzek

J. I.

Keller

Weitlauf

J. C.

(2007). Impact of clinician gender on examination anxiety among female veterans with sexual trauma: A pilot study. Journal of Women’s Health, 16(9), 1291–1299. https://doi.org/10.1089/jwh.2006.0208

28.

Leibowitz

R. Q.

Jeffreys

M. D.

Copeland

L. A.

Noel

P. H.

(2008). Veterans’ disclosure of trauma to healthcare providers. General Hospital Psychiatry, 30(2), 100–103. https://doi.org/10.1016/j.genhosppsych/2007.11.004

29.

Lepore

S. J.

Ituarte

P. H. G.

(1999). Optimism about cancer enhances mood by reducing negative social interactions. Cancer Research, Therapy, and Control, 8, 165–174. https://doi.org/10.1002/pon.3418

30.

Mattocks

K. M.

Haskell

S. G.

Krebs

E. E.

Justice

A. C.

Yano

E. M.

Brandt

(2012). Women at war: Understanding how women veterans cope with combat and military sexual trauma. Social Science and Medicine, 74(4), 537–545. https://doi.org/10.1016/j.socscimed.2011.10.039

31.

McCauley

Yurk

R. A.

Jenckes

M. W.

Ford

D. E.

(1998). Inside “Pandora’s box”: Abused women’s experiences with clinicians and health services. Journal of General Internal Medicine, 13, 549–555. https://doi.org/10.1046/j.1525-1497.1998.00166.x

32.

Prins

Ouimette

Kimerling

Cameron

R. P.

Hugelshofer

D. S.

Shaw-Hegwer

… Sheikh

J. I.

(2003). The primary care PTSD screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9(1), 9–14. https://doi.org/10.1185/135525703125002360

33.

Probst

D. R.

Turchik

J. A.

Zimak

E. H.

Huckins

J. L.

(2011). Assessment of sexual assault in clinical practice: Available screening tools for use with different adult populations. Journal of Aggression, Maltreatment & Trauma, 20(2), 199–226. https://doi.org/10.1080/10926771.2011.546754

34.

Risin

L. I.

Koss

M. P.

(1987). The sexual abuse of boys: Prevalence and descriptive characteristics of childhood victimizations. Journal of Interpersonal Violence, 2, 309–323. https://doi.org/10.1177/088626087002003006

35.

Roter

D. L.

Erby

L. H.

Adams

Buckingham

C. D.

Vail

Realpe

… Hall

J. A.

(2014). Talking about depression: An analogue study of physician gender and communication style on patient disclosures. Patient Education and Counseling, 96, 339–345. https://doi.org/10.1016/j.pec.2014.05.006

36.

Ruben

M. A.

Livingston

N. A.

Berke

D. S.

Matza

A. R.

Shipherd

J. C.

(2019). Lesbian, gay, bisexual, and transgender veterans’ experiences of discrimination in health care and their relation to health outcomes: A pilot study examining the moderating role of provider communication. Health Equity, 3(1), 480–488. https://doi.org/10.1089/heq.2019.0069

37.

Sadler

A. G.

Cheney

A. M.

Mengeling

M. A.

Booth

B. M.

Torner

J. C.

Young

L. B.

(2018). Servicemen’s perceptions of male sexual assault and barriers to reporting during active component and reserve/national guard military service. Journal of Interpersonal Violence. https://doi.org/10.1177/0886260518780407

38.

Sayer

N. A.

Friedemann-Sanchez

Spoont

Murdoch

Parker

L. E.

Chiros

Rosenheck

(2009). A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry, 72(3), 238–255. https://doi.org/10.1521/psyc.2009.72.3.238

39.

Seal

K. H.

Bertenthal

Maguen

Gima

Chu

Marmar

C. R.

(2008). Getting beyond “don’t ask; don’t tell”: An evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan. Amercian Journal of Public Health, 98(4), 714–720. https://doi.org/10.2105/AJPH.2007.115519

40.

Tabachnick

B. G.

Fidell

L. S.

(2007). Using multivariate statistics (5th ed.). Pearson Education.

41.

Turchik

J. A.

Bucossi

M. M.

Kimerling

(2014). Perceived barriers to care and gender preferences among veteran women who experienced military sexual trauma: A qualitative analysis. Military Behavioral Health, 2(2), 180–188. https://doi.org/10.1080/21635781.2014.892410

42.

Turchik

J. A.

Edwards

K. M.

(2012). Myths about male rape: A literature review. Psychology of Men and Masculinity, 13(2), 211–226. https://doi.org/10.1037/a0023207

43.

Turchik

J. A.

McBain

S. A.

Garneau-Fournier

(2020). Perceived need for care, provider gender preferences, & perceived barriers among veterans who experienced military sexual trauma. Unpublished manuscript.

44.

Turchik

J. A.

McLean

Rafie

Hoyt

Rosen

C. S.

Kimerling

(2013). Perceived barriers to care and provider gender preferences among veteran men who have experienced military sexual trauma: A qualitative analysis. Psychological Services, 10(2), 213–222. https://doi.org/10.1037/a0029959

45.

Turchik

J. A.

Pavao

Hyun

Mark

Kimerling

(2012). Utilization and intensity of outpatient care related to military sexual trauma for veterans from Afghanistan and Iraq. Journal of Behavioral Health Services & Research, 39(3), 220–234. https://doi.org/10.1007/s11414-012-9272-4

46.

Turchik

J. A.

Rafie

Rosen

C. S.

Kimerling

(2014). Preferences for gender-targeted health information: A study of male veterans who have experience military sexual trauma. American Journal of Men’s Health, 8(3), 240–248. https://doi.org/10.1177/1557988313508304

47.

U.S. Code, Title 38 § 1720D, Counseling and treatment for sexual trauma.

48.

U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention. (2019). Summary of military sexual trauma-related outpatient care, fiscal year 2018.

49.

U.S. Department of Veterans Affairs, Veterans Health Administration. (2017a). VHA Directive 1115.01: Military Sexual Trauma (MST) mandatory training and reporting requirements for VHA mental health and primary care providers. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5381.

50.

U.S. Department of Veterans Affairs, Veterans Health Administration. (2017b). VHA Directive 1330.01: Healthcare services for women Veterans. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5332

51.

Vogt

(2011). Mental health-related beliefs as a barrier to service use for military personnel and veterans: A review. Psychiatric Services, 62(2), 135–142. doi:10.1176/appi.ps.62.2.135

52.

Vogt

Smith

B. N.

King

L. A.

King

D. W.

Knight

Vasterling

J. J.

(2013). Deployment Risk and Resilience Inventory-2 (DRRI-2): An updated tool for assessing psychosocial risk and resilience factors among service members and veterans. Journal of Traumatic Stress, 26, 710–717. https://doi.org/10.1002/jts.21868

53.

Zickmund

S. L.

Burkitt

K. H.

Gao

Stone

R. A.

Jones

A. L.

… Fine

M. J.

(2018). Racial, ethnic, and gender equity in veteran satisfaction with health care in the Veterans Affairs health care system. Journal of General Internal Medicine, 33(3), 305–331. https://doi.org/10.1007/s11606-017-4221-9

54.

Zinzow

H. M.

Grubaugh

A. L.

Frueh

B. C.

Magruder

K. M.

(2008). Sexual assault, mental health, and service use among male and female veterans seen in Veterans Affairs primary care clinics: A multi-site study. Psychiatry Research, 159(1–2), 226–236. https://doi.org/10.1016/j.psychres.2007.04.008

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.10 MB

0.00 MB

0.10 MB