Unseen Battles

Defining Sexual Assault and MST

The terms “rape,” “sexual assault,” “sexual trauma,” and “sexual harassment” are often used interchangeably in the literature and frequently not differentiated or defined, causing confusion. The reader does not know, for example, whether terms like “trauma” and “victimization” include physical violation or harassment only. Lack of uniformity is not just limited to literature. In a report by the Naval Inspector General (2004), the findings describe how Naval personnel display considerable confusion between the terms “sexual harassment” and “sexual abuse.” This ambiguity can lead to reduced accuracy of prevalence rates of MST. Indeed, Suris and Smith (2011), recommend that the Veterans Affairs (VA) itself better refine its own MST screening process to report rates of harassment and sexual assault separately instead of combining them.

Adding to the problem is that over the years, the definitions of “rape,” “sexual assault,” “sexual trauma,” and “sexual harassment” have changed. Some of the more commonly and currently used definitions for these terms follow. According to the National Women’s Study by Resick (1993), sexual assault is defined as any type of sexual conduct, including vagina, anal, or oral sex achieved or attempted without the person’s consent and with the use of threat or force. Resick also defines sexual harassment as uninvited and unwanted sexual advances, physical contact, verbal comments, and/or similar behavior of a sexual nature, for example, jokes or references to body parts. As of January 6, 2012, Attorney General Eric Holder provided a new definition of rape, which is “the penetration, no matter how slight, of the vagina or anus with a body part or object, or oral penetration by a sex organ of another person, without the consent of the victim” (Federal Bureau of Investigation, 2012, January 6), which will be added to the Uniform Crime Reports for 2012 (Federal Bureau of Investigation, 2012).

According to the Department of Veterans Affairs (2004), MST is defined as “sexual harassment that is threatening in character or physical assault of a sexual nature that occurred while the victim was in the military, regardless of geographic location of the trauma, gender of victim, or the relationship to the perpetrator.” Sexual activity against one’s will as well as ongoing, threatening harassment are both part of their definition of MST. This definition also includes being coerced or pressured into sexual acts. Perpetrators can be male or female, known or unknown, superior or subordinate, or military or civilian. According to Hyun, Pavao, and Kimmerling (2009), sexual assault and sexual harassment are classified together under the same rubric because MST is thought of as an occupational hazard. For purposes of this article, MST refers to unwanted physical or verbal contact of a sexual nature that occurred in a military setting; sexual trauma is defined as any attempted or completed sexual assault.

Of note, MST by definition is sexual trauma that occurs while on active duty. Thus, MST can be examined in a veteran population who has already been discharged as well as an active duty population. Therefore, the traumatic event of interest does not change; the actual time when it is assessed is what varies—while on active duty or after active duty (veteran).

Civilian and Military Prevalence of Sexual Trauma

Gender Differences

While the information provided below is not a thorough comparison of gender differences, it is intended to underscore some of the unique aspects of male MST. There are similarities and differences in how civilian males and females respond to sexual assault that can inform our understanding of men with MST as well. For instance, among civilians, females and males who are sexually assaulted tend to have difficulty trusting others (Kakhnovets & Holohan, 2007). Both men and women experience increased feelings of shame and vulnerability (Calderwood, 1987; Kakhnovets & Holohan, 2007). In addition, sleep patterns and interpersonal relationships are both disrupted (Kaufman, DiVasto, Jackson, Voorhees, & Christy, 1980). However, for civilian men, there tends to be a higher rate of psychiatric symptoms (41.2% vs. 11.3% for women), psychiatric hospitalizations (51.7% vs. 17.9% for women; Kimmerling, Rellini, Kelly, Judson, & Learman, 2002), and reported distress (Elliott et al., 2004; Tewksbury, 2007). Among civilians, men with sexual assault histories tend to be more likely than women to report alcohol abuse (Burnam et al., 1988; Coxell, King, Mezey, & Gordon, 2000; Ratner et al., 2003). Although these findings describe nonmilitary populations, they may help increase our understanding of how men in the military may respond to sexual assault.

Masculine stereotypes that may limit reporting of sexual assault have been shown to impact the subjective experiences of shame. It is hypothesized that while both men and women may feel shocked, horrified, and disgusted after a sexual assault, men may feel increased shame, shock, and humiliation related to their belief that rape can only happen to women (Kakhnovets & Holohan, 2007). Davies (2002) reports that negative attributions occur in male victims that exceed those expected for most other victims of sexual assault. Specifically, the traditional view of males is one of power and sexual assertiveness or domination; thus, most men never even consider that they can be raped.

Also, after an assault, most men blame themselves intensely and wonder why they could not have overpowered the assailant and prevented the assault. Civilian men, unlike women, tend to question their sexual identity after a sexual assault, wondering if their masculinity has been impacted (Davies, 2002; Kakhnovets & Holohan, 2007; Tewksbury, 2007). Shame and fear of potential homosexuality, along with questions about manliness, are concerns unique to males (Davies, 2002; Tewksbury, 2007). Kakhnovets and Holohan (2007) also explain that some men report ejaculation during a sexual assault (which can be a common physiological response), adding additional layers of confusion and disgust.

In addition, men tend not to report and thus they tend to be more isolated from sources of help and support than females in the aftermath of sexual assault (Kakhnovets & Holohan, 2007; Scarce, 1997; Tewksbury, 2007). Relatedly, Foa, Zinbarg, and Rothbaum (1992) reported that more detrimental sequelae are associated with stress that is unpredictable and uncontrollable. As such, the impact of MST on men’s health may thus be greater (Shipherd et al., 2009).

Research data suggest that, as compared to women, civilian men are more likely to have had multiple assailants or to have been assaulted by an authority figure (Kakhnovets & Holohan, 2007; Kaufman et al., 1980; McLean, Balding, & White, 2005). In order to survive such attacks, the need to remain submissive or frozen may be lifesaving. This may be particularly difficult for men to grapple with later, as they expect to be able to defend themselves in any situation through use of force or raw strength (Rentoul & Appleboom, 1997). It has been discussed previously that there is an importance of physical strength and power in the military; thus, MST may be particularly damaging to military men, leading to intensified effects of sexual assault (O’Brien et al., 2008).

Medical and Psychiatric Sequelae of MST in Men

Research indicates that there are both medical and psychiatric consequences related to MST; however, there is very little data available specifically regarding men. For example, medical conditions such as chronic pulmonary disease and liver disease have both been shown to have moderate associations with MST for male and female outpatients who screened positive for MST (Kimmerling et al., 2007). In addition, AIDS was more common for male outpatients with MST than for women (Kimmerling et al., 2007). Most recently, Turchik et al. (2012) reported that, as compared to men without MST, men with MST were more likely to have certain sexually transmitted infections (e.g., syphilis and herpes, as well as HIV/AIDS) and sexual dysfunction disorders (e.g., sexual desire disorder and sexual arousal disorder). Further research is needed in this area to more fully delineate the associations among specific health conditions and MST, as this research is correlational in nature and therefore limited in its usefulness.

Other correlational studies have found that as compared to individuals without MST, individuals with MST have a 2–3 times greater likelihood to have a mental health diagnosis, with the most common being PTSD (Kimmerling et al., 2007; Kimmerling et al., 2010). Kimmerling et al. (2007) indicated the conditions with the strongest associations to MST for men were dissociative disorders and personality disorders. Additionally, for male veterans, there was a significantly stronger association between MST and bipolar disorders, psychosis, and schizophrenia, than in females with MST. Among veterans returning from Iraq and Afghanistan specifically, Kimmerling et al. (2010) reported that for men who screened positive for MST, PTSD was the most common mental health condition (52.5%), followed by depressive disorders (46.6%). However, no information is provided regarding experienced traumas while deployed, which could include combat. Therefore, causality cannot be inferred from this study. There are very few studies examining the psychiatric consequences of MST in male veterans specifically. Those that are available are correlational and thus limited in their usefulness.

Review of Male MST Experimental Studies

To date, there have only been two known peer-reviewed studies that provide noncorrelational information on (and insight into) men with MST. See Table 1. The first, by O’Brien, Gaher, Pope, and Smiley (2008), examined alexithymia and its relation to persistent trauma symptomatology among male and female veterans with MST in a residential treatment program. Alexithymia is defined as inability to label, understand, and process feelings. Since the ability to process trauma-related emotions is essential in exposure-based PTSD treatments, any difficulties identifying and describing emotions is thought to have deleterious effect on treatment. The researchers specifically examined what impact alexithymia had on treatment outcomes, including Trauma Symptom Checklist-40 (TSC-40). The TSC-40 is a 40-item self-report instrument that measures six aspects of posttraumatic stress and other symptoms found in some traumatized individuals: Anxiety, Depression, Dissociation, Sexual Abuse Trauma Index (SATI), Sexual Problems, and Sleep Disturbance. Several pertinent findings were delineated. First, men with MST reported more trauma symptoms than women at baseline. These trauma symptoms included sexual problems (such as low sex drive or not enjoying sex) and Sexual Abuse Trauma Index symptoms (such as fear of men or bad thoughts during sex). Second, men exhibited longer lasting symptoms (including sexual problems and sexual abuse trauma symptoms) as compared to females. Third, O’Brien et al. (2008) also reported that men and women did not differ significantly on scales that measured alexithymia, suggesting that this condition may be specifically related to the trauma and not a preexisting circumstance.

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Table 1.

Salient Characteristics of Men With MST.

Finding	Source
• Men with MST reported more trauma symptoms and longer lasting symptoms (including sexual problems and sexual abuse trauma symptoms) as compared to females	O’Brien, Gaher, Pope, and Smiley (2008)
• Men with recent MST, as compared to women, had increased PTSD symptoms. • MST was more damaging to men’s perceived health than to women’s perceived health. • Men had worse perceptions of their physical health associated with higher levels of MST	Shipherd, Pineles, Gradus, and Resick (2009)
• AIDS was more common for male outpatients with MST than for women • Chronic pulmonary disease and liver disease had moderate associations with MST for male and female outpatients	Kimmerling, Gima, Smith, Street, and Frayne (2007)
• The strongest links to MST for men were dissociative disorders and personality disorders • There is also a strong association between men with MST and bipolar disorders, psychosis, and schizophrenia	Kimmerling, Gima, Smith, Street, and Frayne (2007)
• For men who screened positive for MST, PTSD was the most common mental health condition	Kimmerling et al. (2010)

Note. MST = military sexual trauma; PTSD = posttraumatic stress disorder.

Shipherd, Pineles, Gradus, and Resick (2009) examined surveys that were mailed to male and female Marines with recent MST (previous 6 months). Data for this research were gathered from a larger study of 1,847 Marine recruits who arrived at boot camp in 1997. Marines (317 total: 226 women and 91 men) who identified themselves as experiencing MST in the last 6 months were included as participants. The sample was then reevaluated 21 months later with a mailed survey. The primary measure utilized was the Sexual Experiences Questionnaire-Department of Defense (DoD) (Fitzgerald, Magley, Drasgow, & Waldo, 1999), which was administered upon arrival at boot camp and then again 21 months later. This instrument was used to designate four types of MST: gender harassment sexist hostility, gender harassment sexual hostility, unwanted sexual attention, and sexual coercion, creating an MST index score. While both men and women had declines in their perceived physical health after MST, men had worse perceptions of their physical health associated with higher levels of MST. See Table 2 for a comparison of these two experimental studies.

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Table 2.

Comparison of Experimental Studies.

Article	How MST Is Defined	Population Studied	Measures Used	Limitations
O’Brien, Gaher, Pope, and Smiley (2008)	Patient report of MST	175 Men and women veterans with MST in a residential treatment program	The Trauma Symptom Checklist-40 (TSC-40)	Authors did not delineate how they ascertained patient report of MST. However, since the patients reported MST and were admitted to a VA Health care System treatment program, one may conclude that the Department of Veterans Affairs criteria was utilized to define MST
			The Toronto Alexithymia Scale (TAS-20)
Shipherd, Pineles, Gradus, and Resick (2009)	The Sexual Experiences Questionnaire-DoD	Male and female marines with recent (past 6 months) MST	Sexual Experiences Questionnaire-DoD	Participants with MST included those who had been raped as well as those who had experienced harassment, such as being “whistled” at

Note. MST = military sexual trauma; VA = Veterans Affairs.

Of note, as described above, the divergent ways in which MST is measured and defined may cause inconsistencies when interpreting and comparing findings. In the Shipherd et al. (2009) study, participants with MST included those who experienced sexual coercion as well as those who experienced harassment, such as being “whistled” at. In the O’Brien et al. (2008) study, participants with MST were defined as those who had admitted MST, had current PTSD symptoms, and were about to enter a specialized residential treatment program for PTSD secondary to MST; it is unclear if they included sexual harassment and/or sexual assault in their definition. Lack of uniformity across subject samples makes generalization of these findings problematic. In addition, these two noncorrelational studies did not use a gold standard instrument (e.g., Clinician-Administered PTSD Scale (CAPS)) for diagnosing and assessing frequency and severity of PTSD symptoms, thus presenting another obstacle to comparing PTSD symptom severity between studies.

Conclusion

The VA system has recognized the need to address MST and as such has implemented screening processes and treatment options. According to VA data and a recent review by Hoyt et al. (2011), approximately the same number of men and women report experiencing MST while on active duty, yet most of the published literature on MST is focused on women. The authors examined multiple articles and studies for this article which examined various important issues surrounding men and MST. A summary of these issues along with recommendations follow below. Implications of this review for research, practice, and policy are outlined in Table 3.

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Table 3.

Implications of the Review for Research, Practice, and Policy.

• Due to a lack of standardized definition of MST across studies, meaningful comparisons of data are difficult. Future research on men with MST should aim at maintaining uniformity of terms, as suggested in this article	• There are differences between men and women who experience MST. While it is understood that unique factors, such as masculine stereotypes, contribute to these dissimilarities, more data are needed in order to more fully explore this area
• Psychiatric and medical associations of MST in men include dissociative disorders, personality disorders, bipolar disorder, AIDS, and sexually transmitted infections. However, this arises from very limited numbers of studies. Additional studies are needed	• Due to the unique characteristics of men with MST, clinicians who treat this population may need specific guidance and training. It is suggested that additional instruction and preparation be offered to those who deal with males with MST
• The authors recommend that more experimental studies would be extremely beneficial. While correlational data are helpful, study designs that are experimental in nature would yield increasingly more specific information

Note. MST = military sexual trauma.

Problems defining sexual assault, sexual trauma, and MST were reviewed. There is lack of uniformity among all of these terms, which makes comparing results across studies problematic. Imprecise definitions of MST lead to problems in accurately identifying prevalence rates. Additional issues contributing to unclear prevalence rates include assessing different populations (active duty, treatment seeking, veteran, recruits), low rates of reporting MST, and unique military factors. The authors suggest that in the future, utilizing standard terminology to define MST, such as the definition used in this article, will allow for not only more precise measurements of the estimates of MST but also for informative comparisons of results across studies. The recommended definition of MST is “unwanted physical contact of a sexual nature or repeated, threatening verbal contact of a sexual nature that occurred in a military setting that is traumatizing.”

It is well established that sexual trauma, including MST, leads to medical and psychiatric sequelae. However, there is limited research on consequences of MST in men, and most of the available data are correlational in nature. In the two noncorrelational peer-reviewed studies addressing male MST, findings describe ways in which men are affected differently. They report stronger symptoms at the start of a treatment program and also report longer lasting symptoms. It was determined that as compared to female, males perceive their health as more damaged. While these findings are interesting, their generalizability and usefulness are limited. More epidemiological and experimental research is urgently needed for this population. Furthermore, there may be additional differences between how males and females respond to MST. As such, the authors suggest future studies comparing these two groups would be informative.

The available literature provides a basis for modifying or designing treatment specifically for men with MST. For example, because males with MST report stronger symptoms initially, have longer lasting symptoms, and perceive that their health is more damaged, these issues should be addressed in treatment. The VA and clinicians who treat men with MST need to be aware of these concerns at the outset of treatment so as to better respond to men’s specific needs.