Abstract
Military sexual trauma (MST) is highly prevalent among women veterans. Research among MST survivors has focused on individuals receiving care in specific settings, such as mental health services. There is a dearth of knowledge regarding MST prevalence and associations in other settings commonly accessed by women veterans, including reproductive healthcare settings. We examined MST prevalence (overall, by MST type and extent of underreporting) and associations with suicidal ideation and suicide attempts, among women veterans accessing Veterans Health Administration (VHA) reproductive health care. Our sample included 352 post-9/11 women veterans who used VHA reproductive health care in Fiscal Year (FY) 2018 and participated in a cross-sectional survey. Approximately 68.7% screened positive for MST, including 44.9% who reported experiencing military sexual assault. Notably, 30.8% reported MST on the survey, but had a negative MST screen for their most recent MST screen in their VHA medical record. Both military sexual harassment and assault were associated with increased prevalence of experiencing suicidal ideation following military service; however, a significant association among military sexual harassment, past-month suicidal ideation, and post-military suicide attempts was not detected. Military sexual assault was uniquely associated with past-month suicidal ideation and post-military suicide attempts. As MST and underreporting are highly prevalent among women veterans using VHA reproductive health care, rescreening for MST within this population is essential. A trauma-informed approach is recommended irrespective of prior MST screening results and may facilitate suicide prevention in this population. Addressing barriers to MST disclosure and preventing MST and its sequelae remain critical.
Military sexual trauma (MST) is defined as psychological trauma that was caused by sexual assault and/or sexual harassment that occurred during one’s military service (U.S. Government, 2021). Among women veterans, MST is associated with increased prevalence of a broad range of mental and physical health conditions, comorbidity, and suicide (Kimerling et al., 2016; Sumner et al., 2021). Identifying survivors of MST and facilitating engagement in health care remains critical. Efforts to do so are bolstered by Veterans Health Administration (VHA) services available to those with a history of MST.
There is a federal mandate that VHA providers screen all veterans who receive its services for MST, using two standardized screening questions, which the veteran can decline to answer. An affirmative response to either or both questions indicates a positive screen. Screening is generally mandated to occur one time unless the veteran declines to be screened, in which case providers are prompted to rescreen the veteran again in a year. Since screening implementation, approximately 4.27 million veterans within VHA, including 423,348 females, have been screened for MST; of those, 32.8% of females and 1.9% of males have screened positive (Department of Veterans Affairs Office of Mental Health and Suicide Prevention, 2021).
While universal screening for MST has an important role in identifying survivors who may benefit from healthcare to aid their recovery from MST, prevalence rates based on universal screening are likely underestimates. For example, 44.2% of female veterans in a 2019-2020 population-based survey screened positive for MST (Nichter et al., 2022). Indeed, veterans often report higher rates of MST in research, compared to clinical settings, even when identical screening measures are used (Bovin et al., 2019). This is likely due to underreporting during clinical screening (i.e., false negatives)—a phenomenon researchers have begun to explore. In a random sample of veterans with VHA medical records, 15.4% of women veterans screened positive for MST during their first screening; however, an additional 6.4% of women who initially screened negative subsequently screened positive (Gundlapalli et al., 2017). Moreover, a significant number who screened negative for MST had VHA medical record notes indicative of a history of MST, resulting in estimates of 24.5%, rather than 15.4%, of women veterans having experienced MST (Gundlapalli et al., 2017). Further underscoring the underreporting of MST during healthcare encounters, Blais et al. (2018) found that 24.5% of women veterans who screened positive for MST in a research survey indicated that they did not truthfully disclose their true MST status during a prior screening with a healthcare provider. Reasons for nondisclosure included stigma, discomfort with the provider or institution in which screening occurred (e.g., negative prior experiences or lack of perceived safety), and experiential avoidance (Blais et al., 2018). These findings underscore the difficulty of relying solely upon MST screens conducted in clinical settings to ascertain the true prevalence of MST.
Understanding the true prevalence of MST and the extent of underreporting in different contexts in which women veterans receive health care is essential for equipping VHA providers with requisite knowledge to support women veterans in receiving MST-related care. A potentially important, yet understudied setting for ascertaining the prevalence of MST among women veterans is VHA reproductive health care (RHC). Studies have found significant associations between MST, particularly sexual assault, and various conditions commonly diagnosed, treated, and managed in RHC settings; examples include sexually transmitted infections (e.g., human papillomavirus, herpes, HIV/AIDS, pelvic inflammatory disease, candidiasis/vulvovaginitis) and sexual dysfunction disorders (e.g., sexual arousal disorder, sexual pain disorder, sexual desire disorder; Turchik et al., 2012). Women veterans who have experienced MST are also more likely to receive contraception in VHA settings (Goyal et al., 2014). Yet, we are unaware of studies examining MST prevalence in VHA RHC settings.
In addition, it is important to understand how MST relates to health outcomes, such as suicidal thoughts and behaviors, in RHC settings. In general, positive MST screens have been associated with suicidal ideation (Blais & Monteith, 2019; Monteith et al., 2016), suicide attempt (Kimerling et al., 2007, 2014), and suicide (Kimerling et al., 2016). However, only a subset of studies using the MST screen have provided gender-stratified results (Kimerling et al., 2007, 2016; Pavao et al., 2013). Further, prior examinations have, at times, been limited by assessment of lifetime suicidal ideation or attempts, or use of assessment methods for suicidal ideation or attempt that potentially included nonsuicidal self-injurious thoughts and behaviors (see Monteith, Holliday, Hoyt, et al., 2019 for a detailed review and discussion). Additionally, sexual assault experiences have been more strongly and consistently associated with suicidal ideation than sexual harassment (Blais et al., 2019; Monteith et al., 2016), emphasizing the need to distinguish among MST types. Unfortunately, this is challenging to do with VHA medical record data, in which only data on overall screening results (positive, negative, or decline to respond) are available. Lastly, despite the incidence of false negative MST screens in clinical settings and the potential for such screens to be associated with suicidal thoughts and behaviors due to reasons for nondisclosure (e.g., avoidance, stigma; Angelakis & Gooding, 2021; Kennedy & Prock, 2018), we are unaware of any studies that have examined if MST nondisclosure is associated with suicidal ideation or suicide attempts.
Considering these limitations and the need to understand MST prevalence and associations among women veterans accessing VHA RHC, we used data collected from surveys and supplemented it with VHA medical records to examine the following aims: (1) assess the prevalence of MST (overall, by type, and underreporting during clinical screening) among women veterans accessing VHA RHC and (2) evaluate whether MST is associated with post-military suicidal ideation and suicide attempt history, as well as past-month suicidal ideation.
Method
Participants and Procedures
We conducted a secondary analysis of quantitative data collected from a survey that was part of a larger mixed-methods study intended to understand the prevalence of health conditions and associations with suicidal ideation and attempts among women veterans using VHA RHC. Methods have been described previously (Gaeddert et al., 2020). Inclusion criteria included having separated from military service between October 1, 2009 and September 30, 2018 (FY 2010–2018; i.e., post-9/11), being of reproductive age (18–44 years) at separation, and having used RHC provided and/or paid for by VHA in FY 2018 (in the year prior to survey invitation). RHC included gynecology or women’s surgeries encounters; other medical encounters associated with ICD-10 code(s) for qualifying reproductive health conditions; or procedures and/or Common Procedural Terminology (CPT) codes for common gynecological procedures; or pharmacy fills for medications solely indicated for contraception or reproductive health conditions. A random sample of 2,250 post-9/11 female veterans meeting these criteria was drawn using data from the Department of Veterans Affairs (VA) Corporate Data Warehouse and VA Department of Defense (DoD) Identity Repository and stratified by age and region.
Veterans meeting our eligibility criteria were invited to take part in a survey and were sent up to three invitation letters, spaced 4 weeks apart, from December 2018 to June 2019. Participants who provided consent could respond online or by mailed paper survey (offered to a subset to increase responding). Participants received $20 compensation for completing the survey.
Of mailings sent, 5.7% (n = 129) were returned undeliverable. Of mailings presumably delivered, 15.0% (n = 381) individuals started the survey. Of those, 2.6% (n = 10) were ineligible due to reporting no past military service or current military service, and 5.0% (n = 18) did not complete the survey. Thus, the final analytic sample included 352 women veterans (response rate of 17.9%; Gaeddert et al., 2020). The local Institutional Review Board approved this study. Underlying materials related to this publication can be accessed by contacting the senior author.
Measures
MST Screen
The standard VA MST screening questions were administered: (1) “When you were in the military, did you ever receive unwanted, threatening, or repeated sexual attention (for example, touching, cornering, pressure for sexual favors, or inappropriate verbal remarks, etc.)?” [military sexual harassment] (2) “When you were in the military, did you have sexual contact against your will or when you were unable to say no (for example, after being forced or threatened or to avoid other consequences)?” [military sexual assault]. Participants had the option to select yes, no, or decline to respond to each question. This screen is typically scored as positive (affirmative response(s) to either or both questions) or negative (negative responses to both questions). There is also precedent for examining item-level responses as a brief, cursory assessment of the presence or absence of military sexual harassment (yes response to the first question) and military sexual assault (yes response to the second question) (Blais, Brignone, et al., 2019; Monteith, Holliday, Schneider, et al., 2019). The MST screen has been administered to over four million veterans in VHA (Department of Veterans Affairs Office of Mental Health and Suicide Prevention, 2021) and has demonstrated construct validity (Mengeling et al., 2019).
We also extracted all MST screening data prior to survey participation from VA electronic medical records, using Corporate Data Warehouse (CDW) data. Variables were created for the most recent MST screening result (positive or negative), ever having a positive MST screen, ever having a negative MST screen, and ever declining the screen. Underreporting (false negative) healthcare screens were operationalized as reporting MST on the survey, but screening negative during the most recent VHA encounter prior to survey completion during which an MST screen was administered. We also created a variable (“electronic medical record false negative”) to capture underreporting from VHA medical records, operationalized as having both a negative and positive MST screen within one’s VHA medical records.
Columbia-Suicide Severity Rating Scale (C-SSRS)
Questions from the C-SSRS self-report screener (Posner et al., 2011) assessed the presence or absence of active suicidal ideation (“thoughts of killing yourself”) in the past- month and post-military service (“after military service”). Postmilitary suicide attempt (“done anything to harm yourself with at least some intent to end your life” after military service) was also assessed. Specifically, individuals who endorsed lifetime suicide attempt(s) were asked to indicate when those events occurred in relation to their military service (i.e., before, during, after). Those who endorsed attempting suicide after their service were coded as having experienced a post-military suicide attempt.
Mental health screeners
Mental health screeners administered during the survey were included as potential covariates. The PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) has strong construct validity and test–retest reliability (Bovin et al., 2016) and was administered to determine provisional PTSD diagnosis. The Patient Health Quesionnaire-8 (PHQ-8; Kroenke et al., 2009) has demonstrated acceptable psychometric performance (Shin et al., 2019) and was used to screen for depression in the past two weeks. The AUDIT Alcohol Consumption Questions (AUDIT-C; Bush et al., 1998) have demonstrated good specificity and sensitivity, including with women (Bradley et al., 2007), and were used to determine a positive (total score ≥3) or negative screen for problematic alcohol use in the past year. Lastly, the Drug Abuse Screening Test (DAST; Skinner, 1982) was used to determine problematic drug abuse in the past year, scored as a dichotomous measure for the regression analyses.
Demographics and military service
To describe the sample, questions assessed demographic and military service characteristics.
Analytic Plan
Analyses were conducted using SAS 9.4 (SAS Institute, Inc, 2016) and R 4.1.2. To examine MST prevalence, we calculated frequencies and percentages, using MST screening results from the survey. Underreporting (false negatives) was calculated for participants with at least one MST screen in their VHA medical record preceding survey participation.
To examine if MST was associated with post-military suicidal ideation, post-military suicide attempt, and past-month suicidal ideation, inclusive of overall MST survey screening results, specific MST types (based on the survey), and underreporting during clinical screening (having a false negative in one’s medical record), Poisson regression with robust standard errors (McNutt et al., 2003; Zou, 2004) was used to calculate prevalence ratios (PR). To identify confounders, bivariate associations were calculated between demographic and military characteristics and each exposure and outcome. Demographic and military characteristics were included in multivariable models if associated with MST screens or MST type and at least one outcome of interest. Time since separation was also included in the post-military suicidal ideation and suicide attempt models to account for time at risk for experiencing these outcomes.
Finally, bivariate associations between mental health screeners and the independent and dependent variables of interest were evaluated. Specifically, analyses were repeated with the mental health screeners included as additional covariates in sensitivity analyses, to allow for assessment of the impact of adjustment on study findings and discussion of clinical implications.
An alpha of 0.05 was used to assess statistical significance across analyses. While we recognize that multiple comparisons can inflate Type I error, all PR are presented with 95% Confidence Intervals (CI), and p-values allow readers to judge clinical and statistical significance, in accordance with Perneger (1998) and Rothman (1990).
Results
Participant Characteristics
Sample demographic, military service, and mental health characteristics are presented in Table 1. The majority of participants identified as cisgender women and heterosexual. The mean age at survey completion was 34 years. The majority of the sample identified as White and non-Hispanic. Level of education widely varied. Most participants were currently married or in an unmarried relationship. Most were currently employed. Branch of military service varied considerably, with Army the most common; over three-quarters indicated their highest rank as enlisted. Most participants had deployed, and over half had experienced combat. The most common discharge type was honorable. As expected, the mean number of years since most recent separation was low (4.88), ranging from 0 to 9. Nearly half of participants screened positive for current depression and PTSD, and less than one-third for problematic alcohol use. Only a minority screened positive for problematic drug abuse. Nearly 30% reported post-military suicidal ideation, 12% post-military suicide attempt, and 10% past-month suicidal ideation.
Sample Characteristics (n = 352).
Note. AUDIT-C = Alcohol Use Disorders Identification Test—Consumption; CI = confidence intervals; DAST = Drug Abuse Screening Test; PHQ-8 = Patient Health Quesionnaire-8; PCL-5 = PTSD Checklist—DSM-5; LGBQ = Lesbian, gay, bisexual, or queer; SD = standard deviation.
Participants could choose more than one option.
For models, other than honorable and dishonorable were included with general to create a binary discharge variable.
Collapsed into none-low versus moderate-severe for modeling.
Prevalence of MST
MST variable frequencies and proportions are reported in Table 2. Overall, 68.7% of the sample screened positive for MST on the survey. Specifically, 67.2% and 42.5% reported experiencing military sexual harassment and military sexual assault, respectively. Yet only 36.5% of the overall sample ever had a positive MST screen in their VHA medical record. Nearly one-third of the sample (30.8%) had a negative MST screen as their most recent VHA screen, but reported MST on the survey. Furthermore, of participants who ever had a negative MST screen in their VHA medical records, 10.5% later had a positive MST screen. Of participants who ever screened positive for MST in their VHA medical records, 20.5% had a prior negative screening result.
Prevalence of Military Sexual Trauma (MST) among Women Veterans in VA Reproductive Health Care (n = 352).
Notes. CI = confidence interval; EMR = electronic medical record.
60.2% (n = 142) of participants who endorsed experiencing military sexual harassment also endorsed experiencing military sexual assault.
95.3% (n = 142) of participants who endorsed experiencing military sexual assault also endorsed experiencing military sexual harassment.
Defined as having a positive MST screen on the survey and a negative MST screen in the EMR prior to completing the survey.
Defined as ever having a positive MST result in the EMR among participants with at least one negative EMR MST screen.
Defined as ever having a negative MST result in EMR among participants with any positive MST screen in their EMR.
Associations Between MST and Suicidal Ideation and Suicide Attempt
Post-military suicidal ideation
Crude and adjusted models for post-military suicidal ideation are presented in Table 3. In the adjusted model, which accounted for years since separation, women veterans who screened positive for MST on the survey had 3.20 times the prevalence of post-military suicidal ideation, compared to those who screened negative. When examining MST type, military sexual harassment and assault were associated with 2.08 and 3.81 times the prevalence of post-military suicidal ideation in adjusted models. A statistically significant association between false negatives (based on survey responses and medical records) and post-military suicidal ideation was not detected. When we conducted sensitivity analyses that also adjusted for PTSD, depression, and alcohol use, the statistical significance of results was unchanged: The effect size was similar for military sexual harassment, somewhat attenuated for military sexual assault, and substantially attenuated for false negatives from medical records.
Robust Poisson Regression Models Examining Associations between Military Sexual Trauma (MST) and Post-Military Suicidal Ideation (n = 346).
Note. CI = confidence interval; EMR = electronic medical record; PR = prevalence ratio. Values significant at p < .05 are in bold.
Adjusted for years since separation.
Adjusted for years since separation, PTSD, depression, and alcohol use screening results.
Defined as having a positive MST screen on the survey and a negative screen in the EMR prior to survey completion.
Defined as having a positive MST screen in the EMR among participants with at least one negative MST screen in their EMR.
Post-military suicide attempt
Crude and adjusted models for post-military suicide attempt are presented in Table 4. In the models adjusted for years since separation, women veterans who screened positive for MST on the survey had 3.02 times the prevalence of a post-military suicide attempt compared to those who screened negative. A significant association between military sexual harassment and post-military suicide attempts was not detected in crude or adjusted models. However, military sexual assault was significantly associated with post-military suicide attempts in the adjusted model: women veterans who endorsed experiencing military sexual assault had 3.84 times the prevalence of a post-military suicide attempt compared to those who screened negative for any MST type. A statistically significant association between MST false negatives and post-military suicide attempts was not detected. In sensitivity analyses adjusting for mental health screeners, the direction of findings was consistent and effect sizes remained large, but were no longer statistically significant.
Robust Poisson Regression Models Examining Associations between Military Sexual Trauma (MST) and Post-Military Suicide Attempt (n = 347).
Note. CI = confidence interval; EMR = electronic medical record; PR = prevalence ratio. Values significant at p < .05 are in bold.
Adjusted for years since separation.
Adjusted for years since separation, PTSD, depression, and alcohol use screening results.
Defined as having a positive MST screen on the survey and a negative screen in the EMR prior to survey completion.
Defined as having a positive MST screen in the EMR among participants with at least one negative MST screen in their EMR.
Past-month suicidal ideation
Crude and adjusted models for past-month suicidal ideation are reported in Table 5. In the crude model, women veterans who screened positive for MST on the survey reported 4.05 times higher prevalence of past-month suicidal ideation, compared to those who screened negative. Women who reported experiencing military sexual harassment had elevated prevalence of past-month suicidal ideation compared to women with no MST history, but this was not statistically significant. In contrast, women who reported experiencing military sexual assault had 4.86 times higher prevalence of past-month suicidal ideation, compared to those who screened negative for MST. Statistically significant associations were not detected between false negatives and past-month suicidal ideation. After adjusting for mental health symptoms, effect sizes remained large for MST and military sexual assault, but were attenuated and no longer statistically significant.
Robust Poisson Regression Models Examining Associations Between Military Sexual Trauma (MST) and Past-Month Suicidal Ideation (n = 342).
Note. CI = confidence interval; EMR = electronic medical record; PR = prevalence ratio. Values significant at p < .05 are in bold.
Adjusted for PTSD, depression, and alcohol use screening results.
Defined as having a positive MST screen on the survey and a negative screen in the EMR prior to survey completion.
Defined as having a positive MST screen in the EMR among participants with at least one negative MST screen in their EMR.
Discussion
Determining if MST has occurred can help with understanding treatment presentation, identifying if health conditions are MST related, and ensuring that survivors receive appropriate MST-related health care. Unfortunately, our findings suggest that MST is highly prevalent, but remains frequently underreported during clinical screening among women veterans using VHA RHC. The vast discrepancy in the prevalence of positive MST screens gleaned from VHA medical records alone (36.5%) compared to our research survey (68.7%) is striking. Notably, 30.8% of the sample underreported MST within their VHA records (i.e., had a false negative MST screen), based upon reporting MST in our survey. While we did not explore reasons for this, stigma, shame, fear, embarrassment, and avoidance can deter disclosing and reporting MST (Mengeling et al., 2014; Monteith et al., 2020; Wolff & Mills, 2016). As a substantial portion of negative MST screens within RHC settings are likely false negatives (i.e., underreported), our findings point to an important phenomenon with major relevance to the detection of MST and provision of services to address MST sequelae, including suicidal ideation and attempts.
The present study also builds upon knowledge of MST sequelae by discerning the specific types of MST that are associated with suicidal ideation and suicide attempt history among women veterans using VHA RHC. Although military sexual harassment was associated with increased prevalence of suicidal ideation following separation from military service, it was not associated with suicide attempt in the same timeframe nor with past-month suicidal ideation. In contrast, military sexual assault was associated with heightened prevalence of both suicidal ideation and suicide attempt following separation from military service, as well as suicidal ideation in the past month. These findings are consistent with a burgeoning knowledge base that suggests that military sexual assault is associated with particularly high risk for negative mental health outcomes (e.g., PTSD symptom severity, suicidal ideation; Blais et al., 2019; Monteith et al., 2016), whereas military sexual harassment is associated with elevated risk, but the magnitude of this is smaller. The present study also contributes new knowledge regarding the association of military sexual assault with suicide attempts—a critical focus given that suicide attempts are less prevalent, have different correlates, are more strongly associated with subsequent suicide risk, and have the potential for long-lasting injury (Klonsky et al., 2014, 2015).
We conducted sensitivity analyses to account for recent mental health symptoms, including PTSD, depression, and alcohol use. For post-military suicidal ideation, associations remained significant, though in some cases attenuated, for MST, military sexual harassment, and military sexual assault. This suggests that current mental health symptoms are unlikely to fully mediate the heightened risk for post-military suicidal ideation. In contrast, for post-military suicide attempt and past-month suicidal ideation, associations were no longer significant, although effect sizes remained large. Consistent with some prior findings (Gradus et al., 2013; Kimerling et al., 2016), this underscores the import of determining additional modifiable factors which explain these associations. For example, interpersonal and institutional factors have been associated with suicidal ideation among women veteran MST survivors (Monteith, Holliday, Hoyt, et al., 2019). Considering the broader context of this study, research is needed that examines whether health conditions treated in RHC settings, such as HIV/AIDS, sexual arousal disorder, sexual pain disorder, and sexual desire disorder (Turchik et al., 2012), are associated with suicidal ideation and attempt among women veteran survivors of MST.
Lastly, a unique contribution of the present study was exploring if underreporting of MST (i.e., false negative screens) was associated with suicidal ideation and suicide attempts. Counter to expectation, there were no significant differences in the likelihood of reporting suicidal ideation or suicide attempts between women veterans with and without false negative screening results. Importantly, these findings do not negate the need to examine whether underreporting of MST is associated with other potential health outcomes, such as medical and mental health symptom severity, nor do they lessen the importance of routine screening for MST to identify women veterans who may be at elevated risk for suicide.
Another study found that women veterans who declined to respond to the MST screen had a risk for suicide that appeared to exceed that of women veterans who screened positive; however, the confidence intervals overlapped slightly: 90.4 per 100,000 person–years (95% CI: 40.6, 201.1) versus 33.4 (95% CI: 27.3, 40.7), respectively, and were wide for those who declined screening (Kimerling et al., 2016). Unfortunately, the number of women veterans who declined to be screened in the present study was too low to allow for similar analyses. Thus, research to understand the experiences of women veterans who decline MST screening remains warranted.
Clinical, Policy, and Research Implications
There are important clinical, policy, and research implications of our findings. First, our findings suggest that MST is highly prevalent among post-9/11 women veterans accessing RHC and that continued efforts to prevent MST are essential. Women MST survivors have described experiencing MST in a broader institutional context where they are discriminated against, objectified, and blamed for experiencing MST (Burns et al., 2014; Brownstone et al., 2018). Women also experience higher rates of gender discrimination than men during their service (Calkins et al., 2021). These experiences can make it difficult to find a sense of belonging, support, and community (Brownstone et al., 2018)—factors which can be protective against suicide (Monteith, Holliday, Hoyt, et al., 2019). Further, women MST survivors have described experiencing MST at particularly vulnerable times in their careers, such as at the beginning of their military service (Brownstone et al., 2018), resulting in fear, silencing, a sense of powerlessness, and not formally reporting MST due to concerns about retaliation (Brownstone et al., 2018). Such factors may help to understand the high prevalence of MST underreporting in the present study, as well as associations between MST and suicidal ideation and attempt.
In addition, gender discrimination, sexual harassment, and sexual assault have been discussed as existing on the same continuum (Calkins et al., 2022). While we did not examine gender discrimination in the present study, this is an important area for future research to examine as it relates to both suicide risk and sexual harassment and assault. Continued efforts to prevent MST likely require addressing gender-based discrimination and the broader institutional context in which MST occurs. Recommendations by Calkins et al. (2022) for reducing sexual harassment and assault through improving unit and command climates (e.g., encouraging reporting, modeling appropriate behavior, encouraging professional language) remain pertinent.
Given that a history of MST within our sample was more common than not, it is essential that VHA RHC providers adopt a trauma-informed approach (c.f. Gerber, 2019; Monteith et al., 2022) as a standard of care when working with women veterans (c.f. Owens et al., 2021). The manner in which MST screening occurs is critical and should be framed as voluntary, with the rationale for screening clearly provided. It is important to explain that the information gleaned from screening can be used to identify associated healthcare needs, to connect veterans with appropriate treatment, and to explain that VHA provides additional MST-related services that survivors may be eligible for. Informing veterans that there is an option to decline to respond to screening is also important, especially given that this has different clinical repercussions (e.g., prompts providers to offer rescreening) than a negative screen. Similarly, our findings emphasize the importance of providers rescreening their women veteran patients for MST, which may be particularly beneficial as rapport and trust are established (Hoffmire et al., 2022).
Our findings also suggest that women veterans who have experienced any MST type may be at increased risk for experiencing suicidal ideation, but that those who have experienced military sexual assault may be at particularly heightened risk for suicidal ideation and suicide attempt following military service. Additional findings from the qualitative aims of this broader study suggest that women veterans perceive suicide risk management and prevention in VA RHC settings to be acceptable and desired, yet this is a largely unmet opportunity (Hoffmire et al., 2022). Although prior literature provides considerations for trauma-informed suicide prevention with women veterans (Monteith et al., 2022) and survivors of MST (Holliday et al., 2020), understanding of how to address suicide risk among women MST survivors in RHC settings is needed, as there may be unique considerations for suicide prevention in such settings.
Limitations
The current study has several limitations to consider. First, analyses represented an exploratory aim of the overall project and thus may have been underpowered, resulting in imprecise estimates, as evidenced by some wide confidence intervals. This consideration is particularly important when considering low frequency outcomes, such as past-month suicidal ideation and post-military suicide attempt. Second, the cross-sectional design limits our understanding of the potential mediating role of mental health symptoms in the association between MST and suicidal ideation and attempt. Based on prior research (c.f. Monteith, Holliday, Hoyt, et al., 2019), we expect that mental health symptoms likely partially mediate these associations; however, we were unable to conduct formal mediation analyses due to the cross-sectional nature of our data and thus included sensitivity analyses instead. Third, although sociodemographic variables were included as potential covariates (though not identified as adjustment variables based on bivariate analyses), they were not integrated into our analyses via stratified analyses. Finally, the women veteran population is diverse, particularly with respect to race and ethnicity. Incorporating other experiences, such as sexism, gendered racism, and the unique experiences of racialized women veterans (Crenshaw et al., 1991; Thomas et al., 2008) into subsequent research will be crucial in understanding suicide risk and prevention among women veterans who experience MST.
Conclusions
In sum, MST remains pervasive, with markedly high rates among women veterans accessing VHA RHC. Such experiences, particularly involving sexual assault, are associated with suicidal ideation and suicide attempt following military separation; nonetheless, continued understanding of factors driving risk, above and beyond mental health symptoms, remains warranted. Findings also underscore that a sizable portion of MST survivors in VHA RHC are not initially identified through routine screening due to underreporting of MST during routine clinical screening. Ensuring that women veterans have access to trauma-informed care, inclusive of reproductive health care, and mental health services, is essential. Continued efforts to refine trauma-informed screening to address barriers to disclosure are critical to identify and connect women veteran survivors to optimal, evidence-based care for the sequelae of MST.
Footnotes
Authors’ Note
The views expressed are those of the authors and do not necessarily represent the views or policy of the VA or the United States Government. Dr. Brenner reports grants from the VA, DoD, NIH, and the State of Colorado, editorial renumeration from Wolters Kluwer, and royalties from the American Psychological Association and Oxford University Press. She consults with sports leagues via her university affiliation. Dr. Jodie G. Katon is now affiliated with VA Greater Los Angeles, Los Angeles, CA, USA.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: The material presented is based upon work supported by the Department of Veterans Affairs (VA) Health Services Research and Development Service [Award Number: 1I21HX002526-01A1; PI: Hoffmire] and the VA Rocky Mountain MIRECC for Suicide Prevention.
