The Relative Impact of Different Types of Military Sexual Trauma on Long-Term PTSD,Depression,and Suicidality

Abstract

Sexual assault and harassment in the U.S. military are very common. Military sexual trauma (MST) is defined as sexual assault or harassment experienced during military service; yet, the relative impact of sexual assault, harassment, and their combination is not well understood. Given the extent and potential severity of the long-term outcomes of MST, it is critical to evaluate the relative impacts of these types of MST on long-term mental health outcomes. Veterans (n = 2,590; 55% female) completed self-report measures of experiences of sexual assault and harassment perpetrated by coworkers during military service, posttraumatic stress disorder (PTSD), depression, and suicidality. Controlling for combat exposure, all types of MST experiences (Harassment Only, Assault Only, or Both) compared to No MST predicted greater severity of PTSD, depression, and suicidality after military service. Compared to Veterans with No MST, those who experienced Both Assault and Harassment reported significantly more severe PTSD, depression, and suicidality followed by Harassment Only, and then Assault Only. Data suggest that different types of MST experiences have an impact on long-term mental health outcomes, and the combination of Both sexual Assault and Harassment is particularly deleterious.

Keywords

military sexual trauma Veterans sexual assault sexual harassment PTSD depression suicidality

The experience of sexual assault clearly can have substantial and long-lasting impacts across a wide range of outcomes including negative psychological and psychiatric distress (Chivers-Wilson, 2006; Ullman et al., 2005), negative physical health outcomes (Clarke et al., 2021; Wadsworth & Records, 2013; World Health Organization, 2013), and impairment in functioning across major life domains (Millegan et al., 2015). Indeed, sexual trauma is one of the leading causes of posttraumatic stress disorder (PTSD; Chivers-Wilson, 2006; Liu et al., 2017). Within the U.S. military, sexual assault and harassment are far too prevalent, although exact prevalence estimates are difficult to determine for a variety of methodological differences across studies. For example, studies that recruit participants from the population of Veterans who are engaged in Department of Veteran Affairs (VA) health care often show higher estimations of sexual trauma in the military as compared to samples recruited outside of the VA (Wilson, 2018). Exposure to sexual trauma in male Veterans is understudied compare to their female counterparts, further complicating prevalence estimates in this population (Morris et al., 2014).

Definitional differences across studies also contribute to varying prevalence rates. Military sexual trauma (MST) is a distinct term used to describe the experiences of sexual assault and sexual harassment during military service. Specifically, based on the definition provided in Title 38 U.S. Code 1720D, VA identifies a sexual assault or sexual harassment experience that occurs while one is serving in the U.S. Armed Forces (regardless of the reason for the assault/harassment, the identity or military status of the perpetrator, the location of the event, or the relationship of the perpetrator to the victim) as MST. Sexual assault in the context of MST is further defined as “physical assault of a sexual nature or battery of a sexual nature that occurred while the person was serving on duty, regardless of duty status or line of duty determination.” Sexual harassment is defined as “unsolicited verbal or physical contact of a sexual nature which is threatening in character.” Including sexual harassment in the definition of MST captures the significant impact of experiencing sexual harassment in the unique environment and circumstances of military service from which there is often little or no escape. A recent meta-analysis which included studies conducted with Veterans and Servicemembers concluded that approximately 16% of the military population report MST (Wilson, 2018). When types of MST were considered separately, approximately 14% of Servicemembers and Veterans reported experiencing sexual assault and 31% reported sexual harassment. Women are clearly at higher risk for exposure to either experience. Specifically, 24% of women Veterans and Servicemembers reported sexual assault as compared to 2% of men, and similarly, over half of the women (52%) reported sexual harassment as compared to 9% of men.

These unique aspects of serving in the military may amplify the effects of experiencing sexual assault and sexual harassment. Unlike most civilian places of employment, Servicemembers often both live and work together. Deployments include extended periods of time away from home and without the support of family and friends. Furthermore, sexual assault and harassment during military service contributes to a state of fear, confusion, and mistrust in a profession and such an environment can have life-threatening consequences. Sexual assault and harassment during service erodes the unit cohesion that is critical for both the success of military operations and the safety and well-being of the members of the Armed Forces (Independent Review Commission, 2021). Finally, the military structure itself can engender its own set of stigmatizing factors and barriers to reporting experiences of MST resulting in institutional betrayal before and after the experiences are reported (Kelly, 2021). MST survivors report fearing reprisal and/or adverse consequences to reporting these crimes. These fears include experiences of further violence, demotions, unwanted job reassignments, ostracism, loss of support, and disruptions in unit cohesion that can decrease the overall safety of the unit (Millegan et al., 2015; Reinhardt et al., 2016; Rosellini et al., 2017). Thus, the unique circumstances and aspects of military service may compound the negative effects of sexual assault and harassment. This study sought to examine the specific effects of each type of sexual trauma (assault and harassment and its combination) that occurred within the context of the unique occupational environment of military service to isolate and estimate those impacts specifically.

Consistent with findings in the general population, Veterans who experienced sexual assault and harassment during military service are at greater risk for a host of negative outcomes including co-occurring mental health outcomes (e.g., PTSD, anxiety, depression, eating disorders, substance use disorders, and risk for suicidality), physical health outcomes (e.g., increased risk for diabetes mellitus, hypertension, obesity, gastrointestinal risk factors; increased genitourinary, musculoskeletal, and neurological symptoms, and chronic pain, and compromised reproductive health), and significant impairments across major domains of functioning (e.g., relationships with family, romantic, parenting, occupational, and educational impairments) (reviewed in Galovski et al, 2022). PTSD is perhaps the most common psychiatric condition to develop (Kimerling et al., 2010). Depression is also prevalent following experiences of MST (Goldstein et al., 2017; Maguen et al., 2012) and experiences of sexual assault and harassment have been identified as unique risk factors for suicidal ideation and attempts (Blais et al., 2017; Monteith et al., 2015). Given the extent and potential severity of the impact of experiences of sexual assault and harassment during service on the lives of military personnel, it is critical to evaluate the relative impact of these two types of experiences to better understand who might be at highest risk for the development of long-term psychiatric conditions.

As noted by Blais et al. (2019), there are significant limitations in the few studies that have attempted to examine the associations between military sexual assault and mental health outcomes independently from outcomes associated with military sexual harassment. Limitations include restricted assessment time frames (e.g., assessing MST that occurred in the last 3 years only; Millegan et al., 2015), specific study samples (e.g., male MST survivors receiving inpatient treatment; Monteith et al., 2016), and not including direct comparisons of the two types of MST or not controlling for combat exposure (Gibson et al., 2016). In an effort to better understand the association between different types of MST experiences and mental health outcomes, Blais et al. (2019) compared a group of female Servicemembers and Veterans who denied MST to those who reported Harassment-Only MST, and to those who experienced sexual assault MST to understand group differences in PTSD, depression, and suicidality. Results indicated that, as expected, overall experiences of MST were associated with increased posttraumatic stress symptoms, depression, and presence of suicidality. Sexual assault MST was related to more severe outcomes across all three measures. The group reporting experiences of sexual harassment only reported more severe PTSD as compared to the No-MST group, but the magnitude of the effect between harassment and PTSD was substantially less than the association between sexual assault and PTSD severity. Investigators highlighted the importance of distinguishing between the types of MST in screenings and clinical assessments to detect potential indicators of risk for elevated distress.

Studies examining the breadth and scope of the complex sequelae of military sexual assault and harassment are also necessary to identify targets for interventions. The unique aspects of military service and suffering through MST experiences while in service may warrant specific intervention or enhancements of existing interventions. Such modifications require first identifying the specific contributions of the different types of MST experiences on different aspects of mental health and then considering these associations in the context of the military environment. Given that combat exposure is another type of trauma that occurs more frequently within military service, it is also helpful to partial out the effects of this type of trauma when attempting to isolate the effects of military service-related sexual assault and harassment on Veterans’ current mental health. This study sought to build on previous research in a number of ways. First, we sought to isolate the effects of military sexual assault, military sexual harassment, and the cumulative effect of experiencing Both Assault and Harassment on PTSD, depression, and suicidality in a sample of trauma-exposed Veterans. To further isolate the impact of these MST experiences on these mental health outcomes in a sample of Veterans, we also controlled for exposure to combat trauma, consistent with methodology from previous research (e.g., Calhoun et al., 2016). This study was conducted in a national sample of Veterans and multiple aspects of military sexual assault and military sexual harassment were assessed using standardized instruments (vs screening questions used in previous studies) to clearly define the participants’ nuanced experiences of sexual assault and harassment in the context of their military service. Finally, to more precisely consider the effects of military service-related sexual assault and harassment, we constrained our definition of sexual assault and sexual harassment in the military to experiences which were perpetrated by someone associated with the workplace during military service (Servicemembers, unit leaders, or civilians in the workplace). This is a departure from the VA definition of MST which includes any sexual assault or harassment by any perpetrator while the victim is in service. We first sought to quantify the specific types of harassment and sexual assault experiences Veterans were reporting and to understand the risks of these experiences separately for men and women. We hypothesized that the cumulative effect of experiences of both sexual assault and harassment would place individuals at highest risk for PTSD (consistent with the findings of Blais et al., 2019), and other mental health outcomes (depression and suicidality), but that sexual assault only would have a stronger association with outcomes as compared to experiences of harassment only. We hypothesized that these associations would be significant even after controlling for exposures to combat trauma. Finally, given the dearth of literature on the impact of MST on male survivors (Hoyt, et al., 2011; Morris et al., 2014), we conducted exploratory analyses to determine if the models differed by gender.

Method

Participants were Veterans who enrolled in the Longitudinal Investigation on Gender, Health, and Trauma study, a nationwide mail-based survey assessing trauma exposure, neighborhood/community violence, psychosocial functioning, and mental and physical health outcomes. Potential participants were located using the VA/DoD Identity Repository, a VA-managed database of all separated service personnel. To capture the original study aims, Veterans between the ages of 18 and 50 years who resided in high-crime areas (living in zip codes that are at least two times the national crime average) were oversampled. We also oversampled for women Veterans to ensure equal representation. A total of 28,000 Veterans were selected to participate. About a third of Veterans (n = 8,954) had non-deliverable addresses, leaving a national sample totaling 19,046 Veterans. Of this sample, 3,669 Veterans opted to participate (19% response rate). Veterans were mailed invitations to participate using the modified Dillman method (Dillman et al., 2014). Veterans were also mailed a survey packet, study fact sheet, and $5 as a pre-incentive for participation. All Veterans who returned the survey received an additional $20. This study included a subsample of Veterans (n = 2,590) who reported a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013) Criterion A traumatic event necessary for a diagnosis of PTSD and subsequently completed the PTSD Symptom Checklist for DSM-5 (PCL-5; Weathers et al., 2013).

Measures

Military sexual trauma

The Deployment Risk and Resilience Inventory-2 (DRRI-2; Vogt et al., 2013) consists of 17 subscales assessing key deployment-related risk and resilience factors connected to post-deployment mental health. This study used the MST subscale to determine the presence and type of MST. This subscale consists of eight items measuring exposure to sexual contact or verbal remarks instigated by other military members, commanding officers, or civilians during military service. Veterans rated each of the eight items on a four-point Likert scale (0 = never; 3 = many times). To determine the type of MST, the eight items were coded as either indicative of Harassment Only or Assault Only (see Table 3 for items). We used dummy variables to represent group membership, with the number of dummy variables equal to J − 1 (i.e., 4 – 1 = 3). Veterans were grouped as No MST, Harassment Only, Assault Only, or Both Harassment and Assault. Veterans in the No MST group reported 0 (never) to all eight items. Veterans in the Harassment Only group responded with a 1 or higher (once or twice) to one or more of the Harassment items only. Veterans in the Assault-Only group responded with a 1 or higher to one or more of the assault items only. Veterans in the Both Harassment and Assault group indicated a 1 or higher on at least one harassment item and at least one assault item. Internal consistency for the Harassment-Only items measured was α = .79 and the Assault-Only items measured was α = .83. The No MST group was the reference group.

Exposure to combat

A modified scale, which included items from the DRRI-2 Combat Experiences (e.g., you fired your weapon at enemy combatants) and Aftermath of Battle (e.g., you saw civilians after they had been severely wounded or disfigured) subscales, was used to assess combat exposure (direct involvement in combat and/or exposure to the consequences of combat). This brief combined scale was developed and validated for a National Academies of Sciences, Engineering, and Medicine (2018) study of Veterans’ military experiences and use of Veterans Health Administration (VHA) health care. This scale assessed the frequency of these events on a four-point Likert scale (0 = never; 3 = many times). Internal consistency of this scale in the current sample was excellent (α = .93). Participants who endorsed one or more items as “1” or greater were considered to have been exposed to combat.

PTSD symptoms

The PCL-5 (Weathers et al., 2013) is a 20-item measure that assesses PTSD symptoms across four symptom categories, including reexperiencing, hyperarousal, avoidance, and alterations in mood/cognitions. Because the PCL-5 is not given to participants who deny experiencing a Criterion A event, Veterans were only included in the current study if they experienced at least one DSM-5 (APA, 2013) Criterion A event and completed a PCL-5. Veterans were instructed to select their most severe traumatic event (index trauma) and anchor their PCL-5 responses to that event (index trauma). Items on the PCL-5 are rated on a five-point Likert scale (0 = not at all; 4 = extremely). Scores on the PCL-5 range from 0 to 80, with clinically significant levels of PTSD at or above 33. The PCL-5 has been determined to be psychometrically sound when administered in Veteran samples (Bovin et al., 2015). Internal consistency for the current sample was excellent (α = .97).

Depressive symptoms

The Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) is a widely used nine-item measure that assesses the presence and severity of depressive symptoms. Items are rated on a four-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). Scores range from 0 to 27. A score of 10 or higher is consider a possible indicator of major depression. Internal consistency for this sample was excellent (α = .93).

Suicidality

The Suicide Behaviors Questionnaire—Revised (SBQ-R; Osman et al., 2001) is a four-item assessment of suicidal behaviors and cognitions. Suicidality is assessed via multiple-choice questions about lifetime suicide attempts, past-year suicidal ideation, talking about committing suicide, and the likelihood of a future attempt. Each item has a different response scale. A total score is calculated by summing responses to all four items, with higher scores indicating greater severity. The clinical cutoff scores for the SBQ-R are ≥7 for the general population and ≥8 for clinical samples. Internal consistency for this sample was found to be good (α = .84). Participants were provided resources (e.g., Veteran Crisis Line) as well as a direct line to study staff that could be used for questions, concerns, or in the event of distress.

Analytic Plan

Group differences in demographics, military characteristics, and mental health outcome (PTSD, depression, suicidality) were first assessed using between-group ANOVAs followed by Tukey’s post hoc tests. Gender differences in experiences of MST as measured by the DRRI were then assessed using chi square analyses. Hierarchical linear regression analysis was then used to examine the relationship between the experience of MST (Harassment Only, Assault Only, or Both Harassment and Assault) and PTSD, depression, and suicidality, controlling for combat exposure. In each model, combat exposure was entered at Step 1, and MST type (Harassment Only, Assault Only, or Both Harassment and Assault) was entered at Step 2. We used dummy variables to represent group membership. In these analyses, we used the absence of an MST experience (No MST) as the reference category against which Harassment Only, Assault Only, and Both Harassment and Assault groups were compared. For these data, the regression coefficients for each dummy variable are equal to the difference in conditional means on the dependent variable between a specific MST type (Harassment Only, Assault Only, or Both Harassment and Assault) group and the reference category. The intercept is interpreted as the conditional mean on the dependent variable when all predictors in the model are 0. In these data, a Veteran scoring 0 on combat identified “not having experienced combat” and a Veteran with values of 0 on the three MST experience dummy variables falls into the “No MST” category. Taken together, the intercept is the conditional mean for Veterans who (a) identify as not experiencing combat and (b) fall into the “No MST” group, while the regression slope is the difference between the conditional means for the No MST group and Harassment Only, Assault Only, or Both Harassment and Assault groups.

Results

The mean age of participants was 37.69 years (SD = 7.5, range: 19–51) and the gender distribution was 55% female and 45% male. Approximately half of the Veterans sampled (n = 1,318; 51%) reported at least one experience of MST during military service on the DRRI-2 (Vogt et al., 2013). The most often endorsed type of experience of MST was Harassment Only (n = 669; females = 382; males = 285), followed by Both Harassment and Assault (n = 611 ; females = 525; males = 82) and Assault Only (n = 38; females = 29; males = 9). Overall study demographics and demographics by condition are displayed in Table 1.

Table 1.

Demographics and Outcome Measures by MST Category.

	Full Sample	No MST	Harassment Only	Assault Only	Both
Demographic variable	n = 2,590	n = 1,245	n = 669	n = 38	n = 611
	n (%) or M (SD)	n (%) or M (SD)	n (%) or M (SD)	n (%) or M (SD)	n (%) or M (SD)
Gender
Female	1,397 (53.9%)	462 (37.1%)	378 (56.5%)	28 (73.7%)	515 (84.3%)
Male	1,156 (44.6%)	769 (61.8%)	283 (42.3%)	9 (23.7%)	82 (13.4%)
Transgender	8 (0.3%)	3 (0.2%)	2 (0.3%)	0 (0.0%)	3 (0.5%)
Other gender	15 (0.6%)	3 (0.2%)	5 (0.7%)	1 (2.6%)	6 (1.0%)
Race and ethnicity
Native American or Alaska Native	141 (5.4%)	56 (4.5%)	46 (6.9%)	2 (5.3%)	36 (5.9%)
Black/African American	704 (27.2%)	360 (28.9%)	156 (23.3%)	19 (50.0%)	160 (26.2%)
Asian	123 (4.7%)	59 (4.7%)	31 (4.6%)	2 (5.3%)	29 (4.7%)
Native Hawaiian or Pacific Islander	82 (3.2%)	39 (3.1%)	18 (2.7%)	1 (2.6%)	22 (3.6%)
White/European	1641 (63.4%)	763 (61.3%)	455 (68.0%)	19 (50.0%)	393 (64.3%)
Other race	186 (7.2%)	78 (6.3%)	56 (8.4%)	3 (7.9%)	45 (7.4%)
Hispanic/Latino	317 (12.2%)	114 (11.6%)	84 (12.6%)	5 (13.2%)	79 (12.9%)
Age	37.69 (7.52)	38.07 (7.74)	36.80 (7.40)	38.47 (5.42)	37.83 (7.17)
Marital status
Never married	666 (25.7%)	318 (25.5%)	188 (28.1%)	7 (18.4%)	145 (23.7%)
Married	1154 (44.6%)	599 (48.1%)	302 (45.1%)	18 (47.4%)	226 (37.0%)
Separated/divorced	726 (28.0%)	313 (25.1%)	166 (24.8%)	11 (28.9%)	228 (37.3%)
Widowed	20 (0.8%)	9 (0.7%)	6 (0.9%)	0 (0.0%)	5 (0.8%)
Annual household income
<$25,000	509 (19.7%)	248 (19.9%)	107 (16.0%)	9 (23.7%)	140 (22.9%)
$25,000–$74,999	1108 (42.8%)	530 (42.6%)	290 (43.3%)	19 (50.0%)	264 (43.2%)
$75,000–$99,999	358 (13.8%)	155 (12.4%)	95 (14.2%)	5 (13.2%)	101 (16.5%)
≥$100,000	540 (20.8%)	283 (22.7%)	161 (24.1%)	4 (10.5%)	87 (14.2%)
Education level
Some high school, high school diploma, or GED	236 (9.1%)	146 (11.7%)	46 (6.9%)	1 (2.6%)	40 (6.5%)
Post high school voc/tech training, some college, or associates degree	1141 (44.1%)	547 (43.9%)	302 (45.1%)	12 (31.6%)	270 (44.2%)
Bachelor’s degree	689 (26.6%)	311 (25.0%)	179 (26.8%)	13 (34.2%)	180 (29.5%)
Graduate degree	487 (18.8%)	228 (18.3%)	136 (20.3%)	9 (23.7%)	107 (17.5%)
Military service characteristics
Endorsed combat exposure	1509 (58.3%)	720 (57.8%)	429 (64.1%)	27 (71.1%)	330 (54.0%)
Number of deployments	1.99 (2.25)	2.12 (2.23)	2.05 (2.49)	1.35 (1.02)	1.70 (2.04)
Years in service	8.17 (6.36)	8.57 (6.71)	8.06 (6.20)	9.50 (7.51)	7.43 (5.64)
Years since separation	9.62 (8.04)	9.64 (8.41)	8.78 (7.63)	8.47 (7.60)	10.54 (7.68)
Outcome measures
PTSD (PCL-5)	27.06 (22.70)	22.17 (21.44)	26.98 (21.79)	33.82 (23.75)	37.06 (22.83)
Depression (PHQ-9)	8.89 (7.31)	7.46 (6.93)	9.20 (7.08)	10.45 (8.34)	11.50 (7.52)
Suicidal behaviors (SBQ)	3.40 (4.18)	2.62 (3.70)	3.66 (4.15)	4.97 (4.77)	4.69 (4.75)

Note. Percentages are calculated out of the subsample presented in the column header. MST = military sexual trauma; SD = standard deviation; voc/tech = vocational or technical; PTSD = posttraumatic stress disorder. Outcome measures: PCL-5 = PTSD checklist for DSM-5; PHQ-9 = patient health questionnaire-9; SBQ = suicidal behaviors questionnaire.

Between-group ANOVAs followed by Tukey’s honestly significant difference (HSD) tests for multiple comparisons yielded significant variation in mental health outcomes for PTSD F(3, 2559) = 64.38, p < .001, depression F(3, 2559) = 44.86, p < .001, and suicidality F(3, 2554) = 37.50, p < .001 among MST conditions. On average, the No MST group reported the least severe PTSD symptoms (M = 22.17, SD = 21.44), depression (M = 7.46, SD = 6.93), and suicidality (M = 2.62, SD = 3.70) while the Both Harassment and Assault group reported the most severe PTSD symptoms (M = 37.06, SD = 22.83), depression (M = 11.50, SD = 7.52), and suicidality (M = 4.69, SD = 4.75) (see Table 2). Experiences of MST endorsed on the DRRI-2 (Vogt et al., 2013) by gender are presented in Table 3. Overall, women Veterans were at higher risk for each of the types of MST assessed by the DRRI compared to men Veterans (ps < .001) with the magnitude of gender differences varying in risk across the different types of experiences endorsed.

Table 2.

Tukey’s Post Hoc Tests of Differences between Groups on PTSD Severity, Depression, and Suicidal Behaviors Outcomes.

Comparison: PTSD		Mean 1	Mean 2	Mean Difference (Mean 1–Mean 2)	SE	df	p
Group 1	Group 2	Mean 1	Mean 2	Mean Difference (Mean 1–Mean 2)	SE	df	p
No MST	Harassment only	22.17	26.98	−4.81	1.05	3	<.001
No MST	Assault only	22.17	33.82	−11.65	3.61	3	.007
No MST	Both	22.17	37.06	−14.90	1.08	3	<.001
Harassment only	Assault only	26.98	33.82	−6.84	3.65	3	.240
Harassment only	Both	26.98	37.06	−10.09	1.23	3	<.001
Assault only	Both	33.82	37.06	−3.25	3.66	3	.812
Comparison: depression		Mean 1	Mean 2	Mean difference (Mean 1–Mean 2)	SE	df	p
Group 1	Group 2	Mean 1	Mean 2	Mean difference (Mean 1–Mean 2)	SE	df	p
No MST	Harassment only	7.46	9.20	−1.74	.34	3	<.001
No MST	Assault only	7.46	10.45	−2.99	1.18	3	.054
No MST	Both	7.46	11.50	−4.04	.35	3	<.001
Harassment only	Assault only	9.20	10.45	−1.25	1.19	3	.719
Harassment only	Both	9.20	11.50	−2.31	.40	3	<.001
Assault only	Both	10.45	11.50	−1.06	1.19		.812
Comparison: suicidal behaviors		Mean 1	Mean 2	Mean difference (Mean 1–Mean 2)	SE	df	p
Group 1	Group 2	Mean 1	Mean 2	Mean difference (Mean 1–Mean 2)	SE	df	p
No MST	Harassment only	2.62	3.66	−1.04	.20	3	<.001
No MST	Assault only	2.62	4.97	−2.35	.68	3	.003
No MST	Both	2.62	4.69	−2.07	.20	3	<.001
Harassment only	Assault only	3.66	4.97	−1.32	.68	3	.219
Harassment only	Both	3.66	4.69	−1.03	.23	3	<.001
Assault only	Both	4.97	4.69	.28	.69		.976

Note. PTSD = posttraumatic stress disorder; SE = standard error.

Table 3.

Experiences of MST Endorsed on the DRRI-2.

	DRRI-2 Item	Full MST Sample	Females	Males	Chi Square	p
Item	DRRI-2 Item	n (%)	n (%)	n (%)	Chi Square	p
1	Made crude and offensive sexual remarks directed at me, either publicly or privately^†	1112 (84.4)	804 (86.2)	302 (80.5)	6.52*	.011
2	Spread negative rumors about my sexual activities^†	773 (58.6)	603 (64.8)	165 (44.1)	46.99***	<.001
3	Tried to talk me into participating in sexual acts when I didn’t want to^†	600 (45.5)	518 (55.6)	79 (21.1)	128.08***	<.001
4	Offered me a specific reward or special treatment to take part in sexual behavior^†	298 (22.7)	264 (28.3)	33 (8.8)	57.93***	<.001
5	Used a position of authority to pressurize me into unwanted sexual activity^‡	404 (30.7)	361 (38.8)	42 (11.2)	95.92***	<.001
6	Threatened me with some sort of retaliation if I was not sexually cooperative (e.g., the threat of a negative review or physical violence)^‡	257 (19.5)	219 (23.6)	37 (9.9)	31.61***	<.001
7	Touched me in a sexual way against my will^‡	541 (41.0)	471 (50.5)	67 (17.9)	117.52***	<.001
8	Physically forced me to have sex^‡	225 (17.1)	202 (21.7)	21 (5.6)	48.73***	<.001

Note. Percentage is out of the total number of respondents of that gender for each item.

†

Item used to define Harassment category.

‡

Item used to define Assault category.

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

In each regression model, combat exposure was entered at Step 1 and explained <1% of the variance in PTSD symptom severity, depression symptom severity, and suicidality (adjusted R² range: .01–.02). The inclusion of MST types (Harassment Only, Assault Only, or Both Harassment and Assault) was entered in Step 2 and accounted for 4% to 9% of the variance. Results revealed that all experiences of MST (Harassment, Assault, or Both) significantly predicted PTSD (Bs from 4.44 to 15.09, ps < .001), depression (Bs from 1.66 to 4.08, ps < .001), and suicidality (Bs from 1.05 to 2.38, ps < .016–.001). Membership in the Both Harassment and Assault group yielded the strongest relationship with PTSD (β = .28), depression (β = .24), and suicidality (β = .21). On average, participants in the Both Harassment and Assault group scored 15.09 points higher on the PCL-5, 4.08 points higher on the PHQ-9, and 2.06 points higher on the SBQ-R than those in the No MST group. Membership in the Harassment Only group had the second strongest relationship with PTSD (β = .09), depression (β = .10), and suicidality (β = .11) with participants scoring on average 4.44 points higher on the PCL-5, 1.66 points higher on the PHQ-9, and 1.05 points higher on the SBQ-R than those in the No MST group. The Assault Only group held the third strongest relationship with PTSD (β = .06), depression (β = .05), and suicidality (β = .07) with participants scoring 10.91 points higher on the PCL-5, 2.84 points higher on the PHQ-9, and 2.38 points higher on the SBQ-R than those in the No MST group. These results indicate a significant difference in the conditional means for individuals who did not experience MST and those who experienced Harassment, Assault, or Both. See Table 4 for further details.

Table 4.

Results of Hierarchical Linear Regression Models Predicting Mental Health Outcomes.

Model	Variable	B	SE	Β	t	p	sr²	R ²	ΔR²
PTSD	Step 1							0.070***	0.070***
	Harassment	4.81	1.05	0.09	4.58	<.001	0.008
	Assault	11.65	3.61	0.06	3.23	.001	0.004
	Both	14.90	1.08	0.28	13.77	<.001	0.069
PTSD	Step 1							0.014***	0.014***
	Combat exposure	5.38	0.91	0.12	5.91	<.001	0.013
	Step 2							0.085***	0.072***
	Combat exposure	5.71	0.88	0.12	6.49	<.001	0.015
	Harassment	4.44	1.05	0.09	4.24	<.001	0.007
	Assault	10.91	3.59	0.06	3.04	.002	0.003
	Both	15.09	1.08	0.28	14.00	<.001	0.071
Depression	Step 1							0.050***	0.050***
	Harassment	1.74	0.34	0.10	5.07	<.001	0.010
	Assault	2.99	1.18	0.05	2.54	.011	0.002
	Both	4.04	0.35	0.24	11.46	<.001	0.049
Depression	Step 1							0.006***	0.006***
	Combat exposure	1.12	0.29	0.08	3.79	<.001	0.006
	Step 2							0.056***	0.051***
	Combat exposure	1.18	0.29	0.08	4.10	<.001	0.006
	Harassment	1.66	0.34	0.10	4.84	<.001	0.009
	Assault	2.84	1.18	0.05	2.41	.016	0.002
	Both	4.08	0.35	0.24	11.57	.000	0.050
Suicidal behaviors	Step 1							0.042***	0.042***
	Harassment	1.04	0.20	0.11	5.26	<.001	0.010
	Assault	2.36	0.68	0.07	3.48	.001	0.005
	Both	2.07	0.20	0.21	10.17	<.001	0.039
Suicidal behaviors	Step 1							0.001	0.001
	Combat exposure	−0.23	0.17	−0.03	−1.33	.184	0.001
	Step 2							0.043***	0.042***
	Combat exposure	−0.21	0.17	−0.03	−1.28	.201	0.001
	Harassment	1.05	0.20	0.11	5.31	<.001	0.011
	Assault	2.38	0.68	0.07	3.51	<.001	0.005
	Both	2.06	0.20	0.21	10.10	<.001	0.039

Note. Combat exposure, harassment, assault, and both were coded 0 = no and 1 = yes. SE = standard error; sr² = squared semi-partial correlation.

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

Stratifying by gender, we found a similar pattern of results across the models such that all experiences of MST (Harassment Only, Assault Only, and the combination of Both) significantly predicted PTSD for females (Bs from 3.50 to 14.92 ps < .05) and males (Bs from 6.00 to 18.24, ps < .001); depression for females (Bs from 1.47 to 4.10 ps < .05) and for males (Bs from 2.0 to 5.3, ps < .05); and suicidality for females (Bs from 1.06 to 2.63, ps < .001) and for males (Bs from 1.27 to 2.68, ps < .05). Similarly, membership in the Both Harassment and Assault group yielded the strongest relationship (females βs from .26 to .32; males βs from .16 to .20), followed by Harassment Only (female βs from .06 to .11; males βs from .11 to .13) and Assault Only (female βs from .05 to .09; males βs from .03 to .07).

Discussion

Military service is unique from most other types of employment for many reasons including the relatively high risk for exposure to life-threatening circumstances (e.g., combat), separation from family and friends for extended periods of time (e.g., deployments), significant residential mobility during service including international stations, reliance on fellow unit members for both physical protection and interpersonal support, internal system of law governance, hierarchical command structure, and the lack of certain liberties and freedoms enjoyed by civilians. While these unique job conditions and circumstances are necessary for the effective operation of a national defense system and, indeed, often contribute to the personal growth and success of Servicemembers, the unique nature of service in the Armed Forces can also amplify the impact of crimes that occur in the context of military service. Clearly, MST is a crime that occurs very often with long-lasting impacts and negative effects on the mental and physical health and functioning of members of the military population (Galovski et al., 2022). This study sought to further explicate the extent of different types of MST experiences, isolate those that occur specifically in the occupational context, and assess their relative impacts on mental health in a national sample of trauma-exposed Veterans.

Results indicated that approximately half of our trauma-exposed sample reported experiences of MST. Considering the two components of MST separately, harassment was experienced by nearly all of the participants (95%) who reported MST. This study is one of the first to more closely examine specific experiences of MST in a national sample that included equal numbers of males and females. For both men and women, being directly targeted and subjected to crude or sexual remarks was the most common form of sexual harassment reported, while being offered a reward or special treatment in return for sexual favors was the least common. The fact that crude sexual remarks was so widely endorsed suggests a pervasive climate of sexual harassment during service. These types of remarks may vary widely in severity and in their impact on victims, but taken together, these remarks contribute to a general atmosphere in which harassment may be normative or even a typical part of Servicemembers’ experiences. This climate of common crude, sexual remarks are not only harmful themselves, but this may also set a tone of indifference to, or a perception of latitude about, additional perpetrations that may translate to increased severity of experiences of MST. Differences emerged between men and women across types of sexual harassment, with women clearly being at higher risk for exposure to each type of sexual harassment compared to their male counterparts. The gap between the relative risk for harassment widened between men and women as the type of harassment escalated in severity.

Experiencing sexual assault only (i.e., in the absence of sexual harassment) was a relative rarity; however, the experience of any sexual assault was common among those who had experienced MST insofar as nearly half (48%) of those who reported MST described experiencing a sexual assault. The most common type of sexual assault described by Veterans was being touched in a sexual way against one’s will while the least common form of assault was being physically forced to have sex. Although this latter experience was the least common item to be endorsed, this type of sexual violence was unfortunately not rare with almost 17% of Veterans who reported MST describing this specific type of crime. The same pattern of gender differences emerged in sexual assaults as it emerged with sexual harassment such that women were at significantly higher risk for each type of sexual violence compared to their male counterparts.

With respect to the impact of MST on mental health outcomes within this sample of trauma-exposed Veterans, those who did not experience MST reported the least severe symptoms of posttraumatic stress, depression, and suicidality. Not surprisingly and consistent with previous research, experiences of MST clearly increase the risk for long-term, negative mental health outcomes, even when controlling for combat. This study aimed to understand the relative impact of the different types of MST experienced in the context of military service on Veterans’ mental health. First, considering symptoms of PTSD and depression, experiences of any type of MST resulted in statistically and clinically significant increases on symptom severity in comparison to the group who denied experiencing MST. As hypothesized, experience with both sexual harassment and assault during service was the strongest predictor of current PTSD and symptoms of depression as well as suicidality, followed by experiences with Harassment Only and then sexual Assault Only. The pervasive nature of sexual harassment in the workplace has clearly been linked to depression (Rugulies et al., 2020), particularly in an employment situation such as the military where escape from this environment is not possible (Maguen et al., 2012). According to the DSM-5 (APA, 2013), the development of PTSD requires a Criterion A event which is defined as direct exposure to an actual or threatened death, serious injury, or sexual violence. Sexual assault clearly meets the definition of Criterion A, and it is not surprising that risk for PTSD increases for people who experience sexual assaults during service. However, these results also suggest that the added factor of also experiencing sexual harassment amplifies the risk for poor outcomes. There are several possible reasons for this amplification. For example, experiences of harassment may certainly serve as reminders of prior sexual assaults (including premilitary traumas) and trigger existing PTSD and depressive symptoms. Sexual harassment might also be experienced as more threatening and dangerous for those with lived experiences of sexual violence. In many cases, sexual harassment might precede sexual assault and increase negative mental health outcomes including thoughts of self-blame (e.g., “I should have realized I was in danger when I was being harassed. The sexual assault is my fault. I did not heed the warning signs.”) and other types of posttraumatic stress symptoms. Finally, ongoing sexual harassment might contribute to further isolation for those who experience sexual assault, leading to fewer actual or perceived resources and supports needed to intervene with mental health symptoms that may occur following the sexual assault. These results have important clinical implications including not only consistently and thoroughly assessing for each type of MST experience in the Veteran population, but also understanding mental health symptoms that stem from the unique impact of each type of experience as well as the potential for amplification of symptoms when Both Assault and Harassment are experienced.

The contributions of harassment experiences in the absence of sexual assault during military service to PTSD and depression severity and suicidality were substantial. The relationship between harassment and depression has been fairly well established in the literature as described above. The relationship between harassment (in the absence of sexual assault during the same timeframe) and PTSD might be explained in part by the significant variability within the range of experiences of harassment (vs the more homogeneous nature of sexual assault). It is possible that more severe forms of sexual harassment (e.g., those that meet DSM-5 Criterion A of PTSD) might be particularly damaging. With respect to the relationship between harassment and suicidality, Monteith et al. (2016) found that sexual assault, but not harassment, predicted suicidality in a sample of Veterans who had experienced MST during deployment and concluded that more severe forms of MST seem to be driving this relationship. This study’s results differed in the clear and independent relationship between harassment and suicidality. Methodological differences (assessment of harassment, sampling framework, definition of MST) certainly may have contributed to these differences. The chronicity and frequency of the harassment as well as variability in the relationship of the perpetrator to the victim (e.g., power differential across military rank) may also play a role in the extent to which experiences of harassment during service continue to influence the mental health of Veterans years later and may warrant further consideration.

Finally, we were also interested in gender differences in the observed associations between MST type and mental health outcomes. Interestingly, our results show that while women are at higher risk for experiencing MST, the pathways from MST to increased PTSD, depression, and suicidality do not differ. These results differed a bit from those of a previous study which found that the association of MST to mental health conditions was significantly stronger for women than for men (Kimerling et al., 2007, 2010). Variations in study methodology might account for these different results. First, we controlled for combat experiences which may contribute to the PTSD severity but was not controlled for in previous studies (e.g., Kimerling et al., 2010). The Kimerling studies used VA administrative data and two MST screening questions to detect MST in a national sample of Veterans engaged in health care in the VA. Underreporting of MST among men in particular may be occur more often when relying on medical record data given that men may be particularly likely to underreport experiences of MST when asked directly in a clinical encounter (vs being asked to disclose on an anonymous paper and pencil measure). This could be due to the hypermasculine stereotype of the male combat Veteran compounded by historical rape myths suggesting that experiences of rape are unique to women (Polunsy & Murdoch, 2005). This study used an anonymous survey which may have increased the likelihood of reporting MST experiences and we relied on the DRRI eight-item subscale to assess more nuanced experiences of MST in this national sample. Furthermore, this study builds on previous work by including a nationwide sample of Veterans who may or may not be engaged in VA care, resulting in more results that may be more generalizable to the full Veteran population. With respect to suicidality, our results are consistent with previous studies (Kimerling, et al., 2007; Monteith, et al., 2015; Pavao, et al., 2013) that found that the association between MST and suicidality has been consistently significant for both men and women Veterans.

This study is not without limitations. The data are cross-sectional and rely on retrospective report of MST experiences and self-report of current symptoms. As such, it is not possible to infer causality; however, the temporal nature of the events is such that we can determine that the MST experience preceded the current distress. The anonymous nature of the survey questions hopefully increased the likelihood of accurately reporting MST experiences and current distress. Other factors such as prior trauma history, military stressors, and current stressors might also contribute to current distress levels. Because this was a nonclinical sample, it is possible that some of the most severe distress (e.g., inpatient clinical samples) is not reflected in this data. These results may not generalize well to the overall Veteran population given our strategy of oversampling for Veterans in high-crime areas, including a trauma-exposed sample, and oversampling for women. That said, this sampling strategy did result in the inclusion of participants from the full range of current living environments including high-crime neighborhoods—a demographic which may not be well represented in other large-scale survey studies. Finally, the nature of data collection via survey is a limitation in this type of study. As a result, we may have misclassified the nature of the MST as harassment or assault in some cases. For example, “offered me a specific reward or special treatment to take part if sexual behavior” was designated as sexual harassment because is not clear that the sexual behavior took place or not. The nuanced assessment of MST experiences via the DRRI standardized measure does build on previous studies that relied only on screening items accessed through medical records.

In summary, results of this study leave little doubt that experiencing MST contributes to long-term negative mental health outcomes. While experiencing sexual assault clearly confers great risk for poor mental health, this risk is not unique to sexual assault alone. Experiences of sexual harassment clearly and uniquely contribute to PTSD, depression, and suicidality. More research is needed to understand the specific aspects of sexual harassment (frequency, nature, duration, and/or chronicity) that are particularly associated with long-term negative mental health. The extent to which MST experiences affect the long-term PTSD, depression, and suicidality for women Veterans as compared to men warrants additional investigation given the inconsistencies across studies to date. Our data suggest that while the risk of exposure to sexual violence may be greater for women than men while serving in the military, once exposed to MST, both men and women are at high risk for developing long-term negative mental health outcomes. Continuous efforts to assess and detect both women and men Veterans’ exposure to these crimes during service is a critical step in identifying and mitigating this risk with available options of evidence-based interventions.

Footnotes

Acknowledgements

We thank Drs. Margret Bell and Jessica Keith of the VA Office of Mental Health & Suicide Prevention’s Military Sexual Trauma Support Team for their invaluable input and wisdom in helping the study team to code the DRRI items as sexual assault or harassment and in article editing.

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) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Tara E. Galovski

Mercedes G. Woolley

Elizabeth Alpert

Author Biographies

Tara E. Galovski, PhD, is the Director of the Women’s Health Sciences Division of the National Center for PTSD and an Associate Professor of Psychiatry at Boston University School of Medicine. She earned her Doctorate in Clinical Psychology in 2001 from the University at Albany—State University of New York and completed her internship at the Jackson State University, MS Consortium. She is interested in exploring the effects of exposure to traumatic events and advancing our understanding of mechanisms driving the success of psychological interventions designed to treat PTSD and comorbid psychiatric disorders. She has conducted five federally funded (NIH, SAMHSA, and VA) clinical trials as PI or Co-PI, all designed to further test and develop modifications of and augmentations to Cognitive Processing Therapy (CPT) within a variety of populations exposed to different types of trauma including combat, sexual trauma, domestic violence, community violence, and motor vehicle accidents.

Lauren B. McSweeney, PhD, is a health science specialist at the Women’s Health Sciences Division of the National Center for PTSD. She earned her PhD in Clinical Psychology from Eastern Michigan University, completed her internship at the VA Ann Arbor Healthcare System/University of Michigan—Ann Arbor and her postdoctoral fellowship at Emory University School of Medicine/Emory Healthcare Veterans Program. Dr. McSweeney is strongly committed to the scientific practice of psychology and the provision of evidence-based treatments for PTSD, anxiety, and mood disorders. Her research focuses on trauma and stress-related disorders in Veterans.

Mercedes G. Woolley, BA earned her bachelor’s degree in psychology from Smith College in 2020. She is currently a Research Assistant at the Women’s Health Sciences Division of the National Center for PTSD, where she has worked under the direction of Dr. Tara Galovski. Her interests are in treatment process and outcome research for PTSD, anxiety, and co-occurring conditions. She will enter the combined clinical/counseling psychology doctoral program at Utah State University in fall 2022.

Elizabeth Alpert, PhD, is an advanced fellow in women’s health in the Women’s Health Sciences Division of the National Center for PTSD. She received her PhD in Clinical Psychology from the University of Delaware and completed her clinical internship at VA Boston Healthcare System. Her research focuses on processes of treatment engagement and symptom reduction in evidence-based treatments for PTSD, as well as using this knowledge to develop interventions to optimize patient outcomes in PTSD treatments.

Yael I. Nillni, PhD, is an Assistant Professor and a Clinical Psychologist in the Women’s Health Sciences Division of the National Center for PTSD at VA Boston Healthcare System and Boston University School of Medicine. Her research focuses on the intersection of trauma, PTSD, and women’s reproductive health, particularly in the perinatal period.

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