sexual assault in the military research paper

Sexual assault in the military

Affiliation.

• 1 School of Social Work, Center for Innovation and Research on Veterans and Military Families, University of Southern California, 1150 South Olive, Suite 1400, Los Angeles, CA, 90015-2211, USA, [email protected].
• PMID: 25980511
• DOI: 10.1007/s11920-015-0596-7

Military sexual assault is a pervasive problem throughout the military services, despite numerous initiatives to end it. No doubt the military's lack of progress stems from the complexity of sexual assaults, yet in order to develop effective strategies and programs to end sexual assault, deep understanding and appreciation of these complexities are needed. In this paper, we describe the root causes and numerous myths surrounding sexual assault, the military cultural factors that may unintentionally contribute to sexual assault, and the uncomfortable issues surrounding sexual assault that are often ignored (such as the prevalence of male sexual assault within the military). We conclude by offering a broad, yet comprehensive set of recommendations that considers all of these factors for developing effective strategies and programs for ending sexual assault within in the military.

Publication types

• Alcohol Drinking
• Gender Identity
• Homosexuality, Male
• Military Personnel* / psychology
• Military Personnel* / statistics & numerical data
• Organizational Culture*
• Organizational Innovation
• Power, Psychological*
• Rape* / prevention & control
• Rape* / psychology
• Rape* / statistics & numerical data
• Sexual Harassment* / prevention & control
• Sexual Harassment* / psychology
• Sexual Harassment* / statistics & numerical data
• Stereotyping
• United States / epidemiology
• Young Adult

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Department of Defense Releases Fiscal Year 2022 Annual Report on Sexual Assault in the Military

Today, the Department of Defense (DOD) released the Fiscal Year 2022 Annual Report on Sexual Assault in the Military.

This year's report, which is required annually by Congress, contains reporting data, military justice case outcomes, and updates on the DOD's efforts to prevent and respond to sexual assault. This year's report does not contain sexual assault prevalence data, which the Department assesses via scientific survey and allows the Department to better understand the full scope of the problem.

The Department's leaders are taking major actions and implementing unprecedented resources to prevent misconduct, assist victims with recovery, and hold offenders appropriately accountable. The Department and Military Services continued to support and execute initiatives directed by the Secretary of Defense that impact the Sexual Assault Prevention and Response mission, including recommendations by the Independent Review Commission on Sexual Assault in the Military (IRC). 

"From Day One on the job, Secretary Austin has prioritized stopping sexual assault in the military," said Ms. Elizabeth Foster, Executive Director of the Office of Force Resiliency.  "The Department is making unprecedented investments in countering this problem, and has made significant progress in implementing key reforms, such as standing-up the Offices of Special Trial Counsel, building a dedicated and specialized workforce focused on preventing sexual assault, and improving the training and structure of sexual assault response personnel to empower survivors. Cultural change of this magnitude will take time, but we owe it to our Service members to sustain momentum and ensure these efforts take hold throughout the force."

The Secretary of Defense has also directed the Department to focus on specific actions intended to eradicate harmful behaviors, including sexual assault and sexual harassment. The Department will also continue its efforts to professionalize the sexual assault response workforce, hire a dedicated integrated prevention workforce, and further assess the prevalence of sexual assault and sexual harassment in the force.  

"Our national military strategy depends upon a lethal, resilient, and agile Joint Force," said Dr. Nate Galbreath, (Acting) Director of DoD's Sexual Assault Prevention and Response Office.  "Taking care of our people is central to fielding combat-credible capabilities that are respected worldwide. Our initiatives this year empowered leaders to identify threats to readiness and restore the health of both their units and Service members impacted by sexual assault and other misconduct. We are on track to make the reforms and investments necessary to counter sexual assault in the military."

The Fiscal Year 2022 Annual Report on Sexual Assault in the Military and fact sheet with the topline results are available on https://www.sapr.mil/ .

The Actions to Address and Prevent Sexual Assault and Sexual Harassment in the Military Memo can be found here .

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‘A Poison in the System’: The Epidemic of Military Sexual Assault

Nearly one in four U.S. servicewomen reports being sexually assaulted in the military. Why has it been so difficult to change the culture?

Florence Shmorgoner was raped by a fellow Marine in 2015. After she reported it and N.C.I.S. investigated, a commander decided not to press charges against her assailant. Credit... Danna Singer for The New York Times

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By Melinda Wenner Moyer

• Published Aug. 3, 2021 Updated Oct. 11, 2021

Pfc. Florence Shmorgoner woke up one afternoon in 2015 and realized that she was in someone else’s bed in someone else’s room. Something was wrong. The 19-year-old had been playing video games in her friend’s room in the barracks with the door open — the rule at their base at Twentynine Palms in California was that if male and female Marines were together in the same room, the door had to be left open. Although it was midafternoon, at some point she had dozed off on his bed. Now the door was closed, and her friend was groping her. She felt as if she was having an out-of-body experience, as if she was watching what was happening but not actually experiencing it. He took off her clothes and penetrated her.

Afterward, she got off the bed and couldn’t look at him. “I told him, ‘You know I didn’t want to,’” she recalls. “And I remember this distinctly — he goes, ‘I know.’”

Shmorgoner left, went back to her room and tried to scrub her skin raw in the shower. It didn’t occur to her to tell anyone what had happened, and she didn’t particularly want to. She was the only woman in the training course she was taking to become a computer-and-telephone-repair technician, and she didn’t get along with the few other women she had met in her barracks — women in the Marines often felt a competitive animosity toward one another, Shmorgoner says. She also didn’t know what resources were available to Marines in the aftermath of sexual assault . “I don’t remember that we were told who the victim advocate was when I was in Twentynine Palms,” she says. “I really didn’t have the resources to report if I wanted to.”

Shmorgoner fell into a deep depression. She saw her assailant a few times a week — they lived in the same building and used the same gym — and he acted as if nothing had happened. She was terrified that she would be attacked again, either by him or someone else. “Even walking from my room to where we ate, the chow hall — it was a task I had to prep myself for every day. It was almost a sit-down conversation with myself of, OK, it’s time to go to the chow hall. You’re going to pass all of these males and you need to prepare yourself. Just look down and keep walking,” Shmorgoner told me.

Soon, her fear gave way to self-loathing. She woke up every morning angry that she’d woken up at all. She began to believe that she deserved the attack and that the world would be better off without her. “It kind of tied back into the misogynistic view of myself,” she says. “I’m not as fast. I’m not as strong. It was a very weird rabbit hole that I went down of, well, maybe it was my fault. And maybe I was asking for it. And maybe I’m the bad person, and I’m the burden. And I’m just better off gone.”

Over the next four years, Shmorgoner tried to kill herself six times. She can still feel the scars on her wrists, but they are now mostly hidden by tattoos. Somehow, she always stopped just short of cutting deeply enough to die. “I don’t know what stopped me,” she says. “I was very prepared and pretty unafraid to take my own life.” Shmorgoner bore the pain and trauma of her rape without telling anyone, all while deploying to Bahrain, Japan and Australia as a computer-and-telephone technician and then returning to the United States to work on Marine Corps Air Station Miramar in San Diego in the same role.

In 2017, she met Ecko Arnold, another Marine who had also been sexually assaulted while on active duty. “Everything she told me about herself, I saw it in myself,” she recalls. That’s when Shmorgoner, whose friends call her Shmo, finally opened up. She told Arnold what happened, and Arnold encouraged Shmorgoner to report her rape. Shmorgoner first filed what in the military is called a restricted report in October 2017. This category of report allows a complainant to disclose what happened and receive counseling and health care, but the details remain confidential, with no investigation pursued. A month later, she filed an unrestricted report, too, initiating a rape investigation.

The Naval Criminal Investigative Service (N.C.I.S.) then began investigating. Shmorgoner had to tell the investigating agent, over and over again and in painstaking detail, what she could remember from that afternoon. By that point, her assailant was in Hawaii, and N.C.I.S. organized and recorded a phone call between her and the perpetrator to see if he would confess to the rape. The agent coached her on what to say and how to say it. It was the first time she had an extended conversation with her assailant since the assault, and she was terrified. “That was probably the most difficult thing I’ve ever done,” she says.

Shmorgoner started the telephone conversation casually, asking him about Hawaii and his job. Then she shifted the conversation to the assault. “I told him: ‘Hey, that really hurt me. I didn’t want to, we weren’t romantically involved,’” she says. “He ended up apologizing and said, ‘I’m sorry.’” An N.C.I.S. officer who was in the room with her signaled that she’d gotten what they needed and that she could end the call.

At this point, Shmorgoner assumed that the case was clear-cut — they had a recorded confession in hand. She was floored when a Marine commander and the N.C.I.S. recommended against a court-martial. They told her that, despite the confession, her assailant’s character witnesses had said good things about him and there was no physical evidence to prove that a rape had happened. They warned Shmorgoner that a court-martial would probably be hard on her and that she might not want to go through with it because it was unlikely to end with a conviction. (N.C.I.S. declined to comment for this article, referring all questions to the Marine commandant’s office, which confirmed that N.C.I.S. investigated the case and that a commander recommended against a court-martial but would not confirm that there was a recorded confession. Shmorgoner declined to name her assailant, so The Times was unable to contact him for comment.)

Shmorgoner was heartbroken and confused, but she agreed — she didn’t want to go through a trial if it was only going to end in an acquittal. And she had seen what had happened to Arnold after reporting her assault and transferring. “She was sexually harassed,” Shmorgoner says. “There were things that people said about her that were beyond awful.” One male colleague, she remembers, told Arnold that she deserved what happened to her.

Shmorgoner then asked N.C.I.S. if the military could at least take some kind of administrative action against her perpetrator. Again, she says, she was told no.

The rape investigation was closed in 2018, and Shmorgoner says her attacker was able to serve out his Marine contract and receive an honorable discharge. She fell deeper into depression and despair. “My viewpoint of the Marine Corps really changed from then on, to it’s an institution that doesn’t really look after the people that comprise it,” she recalls. “We’re not in the business of taking care of people — it seemed to me that we were in the business of using them.”

For decades, sexual assault and harassment have festered through the ranks of the armed forces with military leaders repeatedly promising reform and then failing to live up to those promises. Women remain a distinct minority, making up only 16.5 percent of the armed services, yet nearly one in four servicewomen reports experiencing sexual assault in the military, and more than half report experiencing harassment, according to a meta-analysis of 69 studies published in 2018 in the journal Trauma, Violence & Abuse. (Men are victims of assault and harassment, too, though at significantly lower rates than women.) One key reason troops who are assaulted rarely see justice is the way in which such crimes are investigated and prosecuted. Under the Uniform Code of Military Justice, military commanders decide whether to investigate and pursue legal action — responsibilities that in the civilian world are overseen by dedicated law enforcement.

Some politicians have been fighting, and failing, for years to change these military laws. Every year since 2013, Senator Kirsten Gillibrand of New York has introduced legislation to move the decision to prosecute major military crimes, including sex crimes, out of the hands of commanders and into those of independent prosecutors. And every year, it has failed to move forward. Historically, the Pentagon has vehemently opposed the idea, saying that it would undermine institutional leadership. During a 2019 Senate hearing, Vice Adm. John G. Hannink, judge advocate general of the Navy, testified that removing authority over serious crimes from commanders “would have a detrimental impact on the ability of those commanders — and other commanders — to ensure good order and discipline.”

But this year has seen the arrival of a new administration, the end of a 20-year war in Afghanistan and the United States military’s reckoning with many of the politically heated questions also being debated across America, including demands to change the names of bases named after Confederate leaders, accusations of racial bias and sexism across the armed services and right-wing backlash over the supposed teaching of “critical race theory” to service members. It’s a combination of events that could help shepherd into the Pentagon some of the most significant policy reforms in a generation.

The bill that Gillibrand reintroduced in April, the Military Justice Improvement and Increasing Prevention Act, has far more bipartisan support than ever. In May, Gen. Mark Milley, the chairman of the Joint Chiefs of Staff, indicated that he no longer opposes the bill. Senator Joni Ernst, a Republican from Iowa, a sexual-assault survivor and a retired lieutenant colonel in the National Guard, is now co-sponsoring the legislation, after previously opposing it. Ernst has said that she had a change of heart because she spent years working to address the issue of military sexual assault within the existing system, yet “we are not seeing a dent in the numbers.”

At least 70 senators and President Biden have indicated their support for Gillibrand’s bill this year. But it still faces staunch opposition from the leaders of the Armed Services Committee — Senators Jack Reed, Democrat of Rhode Island, and James M. Inhofe, Republican of Oklahoma. Reed blocked an attempt by Gillibrand in May to bring the bill to a floor vote, saying that he found the legislation too broad because it seeks to change how the military handles all serious crimes, not just sexual assaults. In July, a bill with provisions put forward by both Gillibrand and Reed was incorporated into the annual defense bill, the National Defense Authorization Act, which will most likely be taken up by Congress for a vote later this year.

Yet support for change is also now coming from the Pentagon itself. In late April, a Pentagon-organized independent commission on military sexual assault made the first of a series of recommendations to Secretary of Defense Lloyd J. Austin III that included removing commanders from prosecutorial decisions for sexual-assault and related crimes. In a statement in late June, Austin said that he supported this recommendation, and in early July, Biden said that he, too, supported the change.

Col. Don Christensen, a retired chief Air Force prosecutor who is now president of Protect Our Defenders, a nonprofit organization dedicated to reducing rape and sexual assault in the military, says that this year is different in large part because of the murder of Specialist Vanessa Guillén, whose body was found in Texas in June 2020. Guillén had reportedly been sexually harassed by a fellow soldier before her death, and an Army investigation revealed a culture of harassment and bullying at Fort Hood where she was based. “The independent review of what was going on at Fort Hood was incredibly damning,” Christensen told me. In April 2021, according to The Intercept, the Army also had to suspend 22 instructors from Fort Sill in Oklahoma after a trainee was sexually assaulted.

If these policy changes move forward, prosecutions will no longer be at the whim of commanders and influenced so easily by military politics. Decisions may happen faster, too, Christensen says; right now, prosecutorial decisions go up the chain of commanders one by one, culminating in a final decision made by a commander of senior rank, which can take many months. But these prosecutorial reforms won’t eradicate the military’s sexual-assault problem, because the issue is rooted in military culture, not its justice system. “I hope it makes an impact, but I’m not sure,” says Col. Ellen Haring, a retired Army officer and research fellow at the nonprofit Service Women’s Action Network, which advocates for improved policies that affect women in the military. “It doesn’t get to the root problem, which is, why are the assaults happening in the first place?”

Sexual assault is often the initial signal event in a long line of painful traumas that can culminate in post-traumatic stress disorder, depression and suicide. In a 2019 study, scientists at the Denver Veterans Affairs Medical Center, the University of Utah and the University of Colorado surveyed more than 300 servicewomen and female veterans who had experienced a sexual assault and found that 29 percent were currently contemplating suicide. From 2007 to 2017, the age-adjusted suicide rate among women veterans rose by 73 percent; according to Department of Defense data, in 2019, women accounted for 31 percent of all suicide attempts among active-duty service members.

Because a military sexual assault triggers multiple traumas, victims frequently experience feelings of betrayal, isolation and worthlessness that can sap them of the will to keep going. For one thing, military sexual assaults happen in an environment in which, multiple surveys show, women feel they are repeatedly treated as if they don’t belong. And women are typically assaulted by the men they serve with — sometimes even their direct superiors — so they have to continually see and work with their assailants, wondering if it will happen again.

After their attacks, victims also rarely see justice. Of the more than 6,200 sexual-assault reports made by United States service members in fiscal year 2020, only 50 — 0.8 percent — ended in sex-offense convictions under the Uniform Code of Military Justice, roughly one-third as many convictions as in 2019. It’s unclear why sexual-assault convictions have gone down, but it’s part of a much larger trend: Courts-martial dropped by 69 percent from 2007 to 2017, according to Military Times, perhaps because commanders are instead choosing administrative punishments, which are bureaucratically easier but also result in milder punishments for the perpetrators, such as deductions in rank or administrative discharges.

Even when convicted, perpetrators often don’t spend time in prison. “Many people don’t receive a single day of confinement,” Christensen says. He pointed to the case of Brock Turner, the Stanford swimmer who was convicted of three counts of sexual assault but spent only three months in prison. “The uproar that was caused in California and across the nation by his sentence is kind of a weekly occurrence in the military,” he says. “That’s the lie that is perpetrated before Congress constantly — that ‘Oh, commanders are crushing these people. They want to hold them accountable,’” Christensen adds. “No, they don’t.”

Many service members leave the military soon after experiencing sexual trauma — and not voluntarily. Not only are military rapists rarely punished, but their victims are often punished for reporting what happened. According to a 2018 survey of active-duty service members by the Department of Defense, 38 percent of servicewomen who reported their assaults experienced professional retaliation afterward.

From 2009 to 2015, more than 22 percent of service members who left the military after reporting a sexual assault received a less-than-fully-honorable discharge, according to a 2016 investigation by the Department of Defense’s Office of the Inspector General. That’s nearly one and a half times more than the percentage of overall service members who received less-than-fully-honorable discharges from 2002 to 2013, according to data compiled in a March 2016 report by Swords to Plowshares, a veterans advocacy group.

‘I’m still kind of stuck picking up the pieces.’

Although veterans can apply to change their discharge status, it’s typically a long and losing battle: It can take up to 24 months for discharge-review boards to decide on a case, according to a report published by the Veterans Legal Clinic at the Legal Services Center of Harvard Law School in 2020. On average, fewer than 15 percent of discharge-upgrade requests across the military were approved in fiscal year 2018, the report found.

Called bad-paper discharges, these administrative separations can cut veterans off from jobs and V.A. services, as well as education benefits via the G.I. Bill. (Veterans can apply to get a character-of-service upgrade to access V.A. health care, but few are granted.) Since 2010, the V.A. has been required by law to provide health care services to any veteran who has experienced a military sexual assault, regardless of discharge or disability status — but in reality, many are turned away and told they’re ineligible. The 2020 Veterans Legal Clinic report found that the V.A. has denied services to as many as 400,000 potentially eligible veterans. “They’re summarily just kicked out,” says Rose Carmen Goldberg, a California lawyer who for years represented veterans who survived military sexual trauma. “It is very, very frustrating.”

The original assault, the absence of a reliable system of justice and the lingering isolation can send victims into spirals of anger and self-blame and cause them to self-medicate with alcohol or drugs. They are twice as likely as other women veterans to later experience intimate-partner violence. (After her assault, Shmorgoner herself was in a relationship with a man who became abusive.) Women veterans who suffer a military sexual assault are also roughly twice as likely as other women veterans to become homeless. Yet many don’t “realize what the pain they were experiencing stemmed from,” says Sara Kintzle, a research professor in the University of Southern California Suzanne Dworak-Peck School of Social Work, so they don’t know what kind of help they need.

Even when veterans can get V.A. health care, they don’t always feel safe enough to pursue it. In many V.A. clinics, women find themselves surrounded by men, some of whom harass and assault them, compounding their traumas: A 2019 study found that one in four female veterans was harassed by other veterans during visits to V.A. health care facilities.

In September 2019, Andrea N. Goldstein, then a lead staff member for the Women Veterans Task Force on the House Veterans’ Affairs Committee and a reserve Navy intelligence officer, was assaulted at the V.A. Medical Center in Washington while she was waiting for a smoothie at the center’s cafe. As she recalls, a man approached her, pressed his body against her and told her she looked like she could use a good time. When she later reported the incident, no charges were brought against the man, and Curtis Cashour, then the V.A. deputy assistant secretary for public and intergovernmental affairs, told a journalist to dig into her past and see if she had made similar allegations before.

“There’s this very real life-or-death situation,” Goldstein says, “where if women are being deferred from care because they’re getting harassed, or even physically assaulted, they’re not accessing life-saving care.”

Seven women and a service dog in training named Jax sat in a circle on the floor of a dark, sparsely furnished cabin at the Omega Institute in Rhinebeck, N.Y. Everyone was crying, and every few minutes a box of tissues slid across the floor for moral support. The women had come from all around the country in June 2019 to attend an annual healing retreat for survivors of military sexual assault.

These women and others in attendance used aliases with me during the retreat, introducing themselves as the adjectives they thought described them: Joyful, Caring, Grateful, Awesome, Lovely, Crazy Cool, Sassy and Diva, sunny names that belied the deep pain they all were clearly experiencing. Over the two days I was there, many of the women opened up and told me their real names.

At this gathering on the second day, the first veteran to talk was Kellie-Lynn Shuble, a 47-year-old former Army combat medic who was sitting cross-legged in a green T-shirt. Her voice shaking, Shuble told the group how she’d first been sexually harassed by a lieutenant colonel — although she reported it, he went on to be promoted — and then, while deployed in Kuwait and Iraq, she was raped three times by different soldiers. She never reported those assaults. Given how the Army had handled her harassment investigation, she felt it would be useless, and she feared retaliation.

On her third deployment, in August 2006, she suffered her final assault, which would lead to her discharge. While outside filling sandbags, she got into a disagreement with a first sergeant over a Gatorade. Suddenly, he ordered her to get on her knees, pressed the barrel of a loaded handgun against her forehead and started unbuckling his pants. He demanded she perform oral sex.

Shuble said she then stood up and told him, “If you’re going to shoot me, you better shoot me now and you will have to shoot me in the back.” Immediately after that, Shuble told a peer what happened and that person reported her for threatening to kill the first sergeant. Within 72 hours, Shuble said, she was on a military transport plane back to the United States. There, she was medically evaluated and eventually deemed unfit for service. She didn’t fight the decision for the same reasons that she hadn’t reported the men who assaulted her. (The Army would not comment on the harassment investigation, but a spokesperson said that “there is no place in the Army for corrosive behaviors like sexual harassment and assault.”)

After leaving the Army, Shuble struggled. Over the nearly 13 years she spent as a soldier, she picked up many military-style mannerisms — talking loudly, cursing, standing erect with her feet planted wide — all of which made it harder to transition back to civilian life. She was told by those around her that she was too brash, too different, and that made her feel more isolated and alone.

Later that summer, Kate Hendricks Thomas, a Marine veteran and a behavioral-medicine researcher at George Mason University, told me how difficult the transition into civilian life can be for women. “When I left the military, on one of my first job interviews, I was criticized for my handshake being too firm,” Thomas said. “I gave a talk and my stance was a little too wide to be feminine and somebody said, ‘You look like you’re standing funny.’” Kintzle, the U.S.C. professor, agrees: “The kind of characteristics that the military fosters aren’t necessarily characteristics that the civilian world celebrates in women,” she said.

Shuble’s experience was also made harder by the PTSD she developed from her sexual and combat traumas. She described her PTSD as two monkeys clinging to her back that she couldn’t reach to throw off. “You’re carrying that extra 50 pounds every day — sleeping, dreaming, waking — with everything you do,” she said. She is angry a lot. She often can’t sleep. She has considered suicide. She was homeless for about a year and a half, the only woman living in a veterans’ sanctuary with her service dog.

In 2011, the Veterans Benefits Administration lowered the threshold of evidence for veterans to “prove” they were sexually assaulted, which helps them qualify for PTSD-related disability benefits. A 2018 report by the V.A. Inspector General found that the agency nevertheless denied 46 percent of all medical claims related to military sexual-trauma-induced PTSD and that nearly half of those denied claims were improperly processed.

For women at the Omega retreat, the military had won their trust and allegiance and then betrayed them over and over again, fueling feelings of doubt and shame and making them second-guess their self-worth. “When the organization lets you down in that profound way — I feel like that’s one of the reasons the trauma is so powerful, because it gets at the core of identity,” Thomas said.

When veterans do access V.A. treatment, they often improve, although some sexual-assault survivors find the recommended regimens difficult. One popular approach used by the V.A. to treat PTSD is prolonged-exposure therapy, which requires that veterans repeatedly revisit the trauma memory and recount it aloud in detail, which can be challenging for sexual-assault survivors. Another common treatment is cognitive-processing therapy, or C.P.T., which teaches veterans to identify and change inaccurate and distressing thoughts about each of their traumas. But Shuble, for one, found C.P.T. excruciating, because the therapy focused on one trauma at a time and she had experienced countless between her sexual traumas and her combat experiences. “It was awful,” she said. “It was not effective for me.”

The women at the Omega Institute were receiving a form of therapy developed by the psychologist Lori S. Katz, an energetic woman who has worked for the V.A. since 1991 and has run this retreat every year since 2015 (except during the pandemic) at the institute, which offers scholarships for room, board and tuition but not for travel costs. Her program, called Warrior Renew, is based in part on the idea that people process information both rationally and emotionally, and that permanent healing requires tapping into that emotional side through metaphors and imagery. Through this holistic approach, veterans learn to manage their trauma symptoms, resolve feelings of anger, self-blame and injustice, identify problematic patterns in their lives (such as harmful relationships) and cope with feelings of loss.

All trauma survivors, Katz explained to the women at the retreat, come back to the questions: Why did this happen to me? What did I do? “You look back at the event with hindsight, and you say: ‘I should never have gone in this car. I should never have agreed to do that. What’s wrong with me? I’m so stupid.’ And we blame ourselves. We inevitably come to that,” Katz said. The women in the room, some of whom were crying, all nodded along. Military commanders sometimes blame victims for their assaults, too, compounding the problem. “There’s a focus on ‘Well, what was she doing? What was she wearing?’ And that has nothing to do with what happened,” Katz said.

Perhaps most important, the Warrior Renew program occurs in a group setting, where the women can bond and build relationships that will help prevent them from feeling isolated enough to act on suicidal thoughts. “One of the things that can thwart that risk is connection,” Katz said to the women at the retreat. “You guys have a connection, and you have a new family and people who do understand it. That’s a really important part of the healing.” As one of the women at the retreat, who called herself Awesome, said to the group at one point, “We’re queens, and we’re here to fix each other’s crowns.”

Shuble had never shared her assaults with a group before, and when she finished, she could hardly speak. The room was buzzing with grief, with pride, with anger. All of the women in the room believed her — it was as if they were giving Shuble, for the first time, a steady foundation on which to rest her heavy and unsteady pain. With tears streaming down her face, Shuble turned to Katz and thanked her. “It’s been the first real healing that I’ve gotten,” she said.

Next, a woman named Jessica raised her hand. She told the group about the time she jumped off a second-floor balcony and shattered her pelvis to escape a Navy sailor who was trying to kill her. Shelly, a blond woman with wide-set eyes and pink sneakers, spoke up, saying that she was tied up, threatened with a razor blade and raped in Japan on a Navy deployment when she was 19; even though she reported it the next day, her assailant walked. Linda, a quiet woman with short highlighted hair, described being raped multiple times in service, including by commanders and an Army chaplain.

By the end of the Omega session, the floor was freckled with tear-soaked tissues, and Katz spoke up. “You’re brilliant and you’re beautiful and you’re strong and you’ve got a voice and you are anything but worthless,” she said to the women, who nodded in response, some more convincingly than others. Then, quietly, she asked how many of the seven women in the circle had considered suicide. Every hand went up. She asked how many had actually acted on it, and four of the seven raised their hands.

What the women kept coming back to in the discussions were not the specific horrific assaults they had endured, but the ways in which the military had failed them over and over again — and the ways in which these failings had shaped their lives and identities years, even decades, later. Many of the women were stuck in cycles of self-blame that caused them to make terrible choices; most suffered from mental and physical disabilities that made it hard for them to function or hold a job.

Jennifer Leigh Johnson, a Navy veteran, may end up paralyzed because of her gang rape by fellow servicemen in Bahrain 20 years ago: The assault injured her back so badly that she was given steroid injections for the pain, yet as a side-effect of these injections, she developed a rare degenerative spinal disease. (Lt. Cmdr. Patricia Kreuzberger, a Navy spokeswoman, would not comment on Johnson’s case, but said by email that the service “continually strives to foster an environment of dignity and respect, where sexual assault and sexual harassment are never tolerated, condoned or ignored.” )

“Trauma doesn’t scare me anymore,” Johnson said one evening while lying on the floor on a pile of pillows. “It’s surviving the trauma that scares the [expletive] out of me. Because the four hours,” she said, referring to the rape, “yeah — that was horrible and hurtful. But it ended. This never ends.”

Under increasing pressure and scrutiny, the military and the V.A. have been taking some steps to better support survivors of sexual trauma. Since 2011, service members who experience military sexual assault and file an unrestricted report can request a transfer to a new unit or installation, as Arnold, Shmorgoner’s friend, did, so they don’t have to work and live with their rapists. Since 2013, service members also have the option of asking for special victims’ counsels, who provide them with information, resources and support after sexual assault. But according to Goldberg, there aren’t enough of these counselors, so they tend to be overwhelmed and unable to give each case the attention it deserves. “I’ve heard anecdotally about victims just not being able to reach their special victims’ counsel, not having enough time with them, not really getting to benefit from the program,” she says.

The V.A. is also trying to reach and support more veterans who have experienced military sexual trauma. It has mailed out more than 475,000 letters to veterans with other-than-honorable discharges informing them of available V.A. services. With a universal screening program, the V.A. now asks every veteran receiving health care whether they experienced a sexual trauma during service, and those who did are told about the support they can receive. There are also now designated veterans service representatives, located within five central offices, who specialize in processing military sexual-trauma-related claims, and the V.A. has eliminated follow-up phone calls that could retraumatize veterans.

In January 2021, President Trump signed into law the Deborah Sampson Act, a comprehensive bill named after the woman who posed as a man during the Revolutionary War in order to serve in the Continental Army. The law includes provisions to monitor and address sexual harassment and sexual assault at V.A. health centers, and requires V.A. centers to make it easier for women to report harassment or assault; it also requires V.A. employees to report harassment they observe (and be punished if they don’t). The department “is committed to a culture rooted in our mission and core values where everyone is treated with civility, compassion and respect. Everyone should feel welcomed and safe when doing business with V.A.,” a spokesperson for the V.A. said in a statement.

If Gillibrand’s bill becomes law, it will herald a major shift — a voting out of the old way of doing things, and an admission by the government that the military-justice system must finally change. It won’t, however, be a panacea. If independent military prosecutors, rather than commanders, handle the prosecutorial decision-making process, more accused rapists and other assailants may be brought to court-martial. But without sentencing reform, they may not ultimately be held more accountable.

For that, the military will need a pervasive shift in its culture and the mind-set of its leaders. Yet Christensen, the retired Air Force lawyer, says that in recent months he has noticed increasing backlash against the notion that servicewomen are being mistreated and deserve more respect. “There’s been a poison in the system — of disbelief,” he says, and some in the military now argue that the push for reform reflects nothing but a politically correct, anti-male witch hunt. Shmorgoner says she noticed these reactions, too. Men, she suggests, are “angry that women are finally standing up for themselves.”

Looking back, Shmorgoner says that perhaps she should have expected what happened to her. She was warned about the Marine Corps before she joined — by her recruiter.

Shmorgoner grew up with a passion for riding horses, competing in show-jumping events from age 7. But after graduating from high school in 2014, she decided that instead of continuing to compete, she wanted to serve her country. Her parents emigrated from the Soviet Union to the United States before she was born, and she felt joining the military was “almost a way to thank them for giving me this opportunity to live here,” she says. She made an appointment to meet with a Marine recruiter. “I think I was the very first female that he put in the Marine Corps,” she says. “He sat me down, and he told me, ‘You’re going to have a rough time.’” Yet Shmorgoner didn’t understand — she thought he was either patronizing her or using reverse psychology. “He was genuinely trying to warn me,” she says, “and I thought it was a challenge.”

The only reason she re-enlisted after the rape investigation was to encourage other women in her situation to report — just as learning about Arnold’s assault helped her come forward. “I thought, Maybe I could do that for someone else,” she says. Almost immediately, a woman was transferred into her battalion because of a sexual assault. “Within like three days of her arriving, her noncommissioned officers were giving her a hard time and making her feel as though she was a problem,” Shmorgoner recalls. But Shmorgoner was there, ready to support her.

Two years ago, Shmorgoner’s PTSD symptoms started affecting her more at work after she transferred to Camp Pendleton in California. On bad days, she would have six or seven panic attacks: Her heart would race, she would start visibly shaking and she would sit behind her desk trying to make herself as small as possible. Sometimes these attacks came on randomly; other times they were triggered by seeing a male Marine who resembled her assailant. Every time she started working with a new unit or under a new commander, she had to tell them about her assault and PTSD so they would understand her panic attacks, as well as her propensity to close and lock her office door when she worked. “It was just so exhausting mentally and emotionally,” she says, to have to explain “why I am the way I am.”

Around the same time, she started receiving intensive therapy to treat her depression, anxiety and PTSD. That was only because she was asked to complete a mental-health history form and filled out portions she wasn’t supposed to — sections intended for her superiors — which included questions about prior suicide attempts. “I just checked the boxes, for ‘all of the above,’ and I sent it up to my leadership, and they pulled me aside,” she recalls. “I was like, ‘Yeah, this is what happened.’”

The military, she says, can be blind to mental health issues because they simmer unseen beneath the surface. Mental health is often treated as a joke, as an aspect of military life that is kind of beside the point. When colleagues asked her how she was doing, she would sometimes say, “I wake up every day wishing I didn’t.” But everyone always assumed she was just trying to be funny. In the Marine Corps, “We joke about suicide in a very odd, dysfunctional and, frankly, toxic way,” she says.

In April 2020, Shmorgoner’s psychologist recommended that she be medically evaluated by the Marine Corps to determine if her PTSD was interfering with her ability to do her job. “I didn’t even feel comfortable standing duty,” Shmorgoner says, referring to having to work alone to guard the front desk of the barracks for 24 hours straight. “And with the suicidal ideations, they didn’t want me armed while on duty by myself.”

The results of the evaluation, which took longer than usual because of the pandemic, came back in early May of this year: The Marine Corps deemed her unfit for service because of her PTSD and eligible for medical retirement with V.A. benefits. At first, the news felt like yet another punishment for having been raped. Shmorgoner joined the Marine Corps hoping to stay in service for 20 years. Then she was assaulted, and everything unraveled — while her assailant suffered no apparent consequences. “My life has changed significantly over the last six years, and from everything that I know, his life has not,” she says. “I’m still kind of stuck picking up the pieces.”

Shmorgoner officially left the Marines in June. And although she is disappointed and angry and misses her colleagues, she’s relieved to get a fresh start. Earlier this year, Shmorgoner got married to a fellow Marine with two children who has since left the military. In July, she landed her dream job as a horse trainer at a training-and-breeding facility in Maryland, and she’s becoming close with the other women she works with. She is finding it easier to befriend civilian women than the women she met in the Marines. “I don’t think any of us meant to, but we all had a kind of a metaphorical wall up with our emotions — just because we were taught that that’s how Marines should be,” she explains. The women she has met this summer, on the other hand, seem willing to “build friendships and to be emotionally available.” She has also started seeing a therapist through the local V.A. Being so far removed from the Marine environment is helping her heal. “I’ve noticed I’ve gotten quite a bit better,” she says. She has been having fewer panic attacks, as few as one a day.

The biggest noticeable change came a few weeks ago. A man catcalled her while she was walking to a gas station, shouting, “Hey, mama, how you doing?” It was something that in the past would have immediately triggered a panic attack. This time, she felt anxious and gripped her keys, but she didn’t falter. “I just kept walking.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). You can find a list of additional resources at SpeakingOfSuicide.com/resources.

Melinda Wenner Moyer is a contributing editor at Scientific American magazine and a regular contributor to The New York Times, The Washington Post and other publications. Her first book, “How to Raise Kids Who Aren’t Assholes,” was published in July. Danna Singer is an American photographer based in Philadelphia. In 2020, she was named a Guggenheim fellow; she currently holds the position of lecturer at the Yale School of Art and Rowan University.

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• v.15(4); Fall 2017

An Overview of Sexual Trauma in the U.S. Military

This article discusses the scope and impact of military sexual trauma (MST) in the U.S. Armed Forces. The authors explore aspects of the military setting that may make recovery from this form of sexual violence particularly difficult. Risk factors for MST as well as associated mental, physical, sexual, and relational health consequences are reviewed. The authors also introduce clinical issues unique to male and lesbian, gay, bisexual, and transgender (LGBT) survivors. Finally, first-line psychotherapies and pharmacotherapies for subsequent mental health difficulties are reviewed, as are strategies for reducing barriers to health care for this population.

Uncovering an Epidemic

Over the past two-and-a-half decades, awareness has grown that sexual violence within the U.S. Armed Forces is a far-reaching problem that necessitates intervention. In 1992, Congress required that the Department of Defense (DOD) take action to prevent sexual harassment and sexual assault in the military. The Department of Veteran Affairs (VA) was also directed to provide treatment to veterans and service members (VSM) experiencing the emotional and physical sequelae of sexual violence endured during their service ( 1 , 2 ). The VA adopted the term military sexual trauma (MST), which captures a spectrum of experiences, defined as

psychological trauma, which in the judgment of a . . . mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty, active duty for training, or inactive duty training. ( 3 )

Thus, MST is a term that includes both military sexual assault (MSA) and military sexual harassment (MSH). MSH is further defined as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.” Much of the research on the impact of MST has focused on sexual assault ( 1 , 4 ). However, survivors often describe sexual harassment in the military setting as pervasive, threatening, and inescapable. MSH has resulted in comparable adverse emotional, physical, social, and occupational outcomes ( 5 , 6 ). MSA and MSH are also highly correlated—those who experience MSA nearly universally report experiencing MSH, often in escalation to an assault ( 7 ). In 2004, DOD established the Sexual Assault Prevention and Response Office (SAPRO) to examine MST in the U.S. military, implement prevention efforts, advance medical care and support for survivors, and improve accountability of both the assailant and the institution.

Prevalence of MSA and MSH in the U.S. Armed Forces

A significant amount of scientific inquiry into MST and its impact since the early 1990s has led to a range of prevalence rates because of the variability in study methodology ( 8 , 9 ). For example, one review highlighted that prevalence estimates in the literature range from 22% to 45%, depending on method of assessment, sample type, MST definition, and study setting and purpose ( 1 ). Efforts to uncover prevalence are complicated by underreporting of sexual trauma, which may be exacerbated by barriers to disclosure, including some that are unique to the military setting ( 10 ). This discrepancy in prevalence rates highlights the need for future research to use a consistent definition of MST, specifically distinguishing MSA and MSH to improve understanding of the true scope of this issue ( 11 ). A recent meta-analysis examined 69 articles on MST prevalence rates, using the DOD definition. It concluded that, on average, 15.7% of VSM reported experiencing MST when the measure includes both harassment and assault; when these experiences were examined separately, the average was 13.9% for MSA and 31.2% for MSH ( 12 ). In general, self-report measures and interviews are associated with higher prevalence rates compared with reviews of VA medical records.

The DOD has made significant efforts to understand rates of MST among those currently serving. Since its establishment, a SAPRO task force has routinely collected and published the number of official reports of sexual assault in the military. Data collected include service members’ restricted (i.e., confidential) and unrestricted (i.e., investigated) reports of sexual assault; sexual harassment complaints are handled by a separate Military Equal Opportunity office. In 2015, DOD confirmed 6,083 total reports (both restricted and unrestricted) of sexual assault and 657 formal complaints of sexual harassment ( 13 ). In 2014, the RAND Corporation National Defense Research Institute updated its independent assessment of sexual assault, sexual harassment, and gender discrimination in the military on the basis of current definitions and criteria from the Uniform Code of Military Justice. Their survey of 560,000 U.S. service members indicated that 4.9% of women and 1% of men serving in active duty experienced a sexual assault during 2014; 26% of women and 7% of men serving in active duty experienced sexual harassment or gender discrimination ( 14 ).

Risk Factors for Sexual Victimization in the Military

Rates of sexual assault among women in the military are comparable to the lifetime prevalence of sexual assault of civilian women (16.6%) ( 15 ). However, some scholars have noted that the restricted period of military service (typically two to six years) compared with lifetime rates is indicative of women’s higher risk of experiencing sexual violence in the military compared with civilian settings ( 1 , 4 ). Some sociodemographic factors appear to increase the likelihood of experiencing sexual trauma in the military. MST tends to happen earlier in service members’ military career; more than 80% are victimized between the ages of 17 and 24 ( 16 – 17 ). Women are more likely than men to experience MST; racial minorities, sexual minorities, and those who are unmarried are also at higher risk ( 16 , 18 , 19 ). Some aspects of military service also appear to increase risk for MST. The Marines and the Navy have the highest rates of MST, the Air Force has the lowest, and enlisted members report higher rates of MST than officers ( 14 ). Finally, high alcohol use, particularly binge drinking among younger military personnel, may contribute to increased rates of sexual violence ( 20 ).

MST and Cumulative Trauma

Those who experience MST tend to have higher rates of other forms of trauma before, during, and after their service. Individuals entering the military have higher rates of exposure to adverse experiences in childhood and adolescence than the general population ( 21 ). This appears to be particularly true for individuals who experience MST, which is associated with higher rates of childhood sexual and physical abuse ( 4 , 16 – 18 ). Surviving MST is also associated with experiencing sexual assault as an adult outside of military service. In one sample of active-duty Air Force women, the lifetime prevalence of rape was more than twice as high as that in a national sample of civilian women (28% vs. 13%); the majority of initial rapes (75%) in the military occurred before the service member joined the Air Force ( 9 ). The nature of military service itself comes with high risk for additional trauma, including combat exposure. In one recent study, 12.5% of male troops and 42% of female troops reported experiencing some form of MST while deployed ( 22 ). Seventy-three percent of those who experienced MST during deployment were also exposed to other significant war-zone stressors. Combat exposure during deployment increases the risk for experiencing MST among female veterans of Iraq and Afghanistan ( 23 , 24 ). Various types of traumatic stressors during deployment each uniquely contribute to subsequent psychopathology, with combat exposure significantly predicting posttraumatic stress disorder (PTSD) and MST significantly predicting major depressive disorder. Combat exposure, MST, and general harassment all have a significant impact on the severity of depressive symptoms ( 25 ).

What Makes MST Distinct From Other Forms of Sexual Trauma?

It is important to consider that MST occurs within the context of long-standing military cultural norms. The military was essentially an all-male institution until the mid-20th century, and it continues to be heavily male dominated. Some scholars have implicated overvalued hypermasculinity, promoting traditions of the ideal soldier as strong, nonemotional, aggressive, and dominant ( 26 , 27 ). These values, in combination with a general acceptance of violence, a view of women as outsiders, the prevalence of rape myths, and power differentials between men and women, lead to environmental conditions that foster objectification of women and sexual violence as a means to assert dominance and control ( 5 , 16 , 26 , 28 ). This combination of factors may contribute to an increased acceptance of sexual aggression and minimization of the consequences of sexual misconduct on a cultural level. However, public recognition of MST, subsequent policy changes, and strong leadership promoting a safe environment for all who serve have played important roles in a gradual cultural shift. For example, annual data collection from DOD and the RAND Corporation has indicated that incidents of sexual violence have declined in the past several years, and reporting of such incidents has increased ( 13 , 14 ). Also, units in which leadership takes reports of MST seriously, demonstrates zero tolerance for sexual harassment, and shows support for service members seeking mental health care have lower rates of sexual assault ( 29 ).

Despite this progress, MST continues to occur frequently, and aspects of the military experience contribute to unique challenges in recovery. Given the youth of the majority of victims and the high prevalence of premilitary trauma among service members, individuals who experience MST may have a limited repertoire of coping skills at the time of the trauma ( 30 , 31 ). Military training, which often occurs during very formative developmental years, instills deep values of strength, mental toughness, and personal responsibility. This socialization can contribute to survivors’ efforts to suppress normal emotional reactions to a sexual trauma ( 31 ). Survivors may also take personal responsibility for the attack, leading to a high level of self-blame, which plays a role in the subsequent development of PTSD ( 32 ).

Military training also ingrains principles of group cohesion—that is, loyalty, teamwork, sacrifice, trust in comrades, and the suppression of individual needs for the larger good of the unit. Blurred boundaries between work and home contribute to the insular nature of the group; service members often live, work, and socialize on small military bases, especially when stationed internationally. Many individuals join the military seeking such belonging and view comrades as family. This belongingness is disrupted by the experience of sexual assault, which may have been perpetrated by a brother- or sister-in-arms or a commanding officer whose role was to guide and protect. Survivors of MST may experience a strong sense of betrayal and subsequent difficulties in determining whom to trust for support or protection. Survivors of MST may be required to interact with perpetrators on a regular basis, even when off duty ( 31 ). This circumstance often leads survivors to describe the consequences of MST as pervasive and inescapable, which may lead to feelings of powerlessness and patterns of learned helplessness. In the aftermath of MST, the fractured cohesion of the insular unit, and the tendency for a unit and its leadership to protect the group rather than the individual survivor, have led some scholars to compare the experience of MST to secretive forms of violence and abuse that can take place within a family system ( 27 ).

Sources of support that the military offers to survivors are not available if the survivor is not willing to report; survivors often cite barriers to reporting, including the fear of not being believed, stigma of assault, disruption of unit cohesion, fear of retaliation, fear of accusations of fraternization, and lack of awareness of the reporting system or available resources ( 26 , 31 ). For male survivors of same-sex assault, fear of being labeled homosexual is a unique barrier to reporting. Survivors’ disinclination to seek justice and support appears to have merit in some cases. Some survivors describe the aftermath of reporting a sexual assault as more painful than the assault itself ( 10 , 31 ). Women who report a sexual assault are more likely to be demoted and discharged from military service ( 33 ). Seeking support may be particularly challenging in a combat zone, where personnel may not be properly trained to handle sexual assault, medical resources may be limited, and command may be unwilling to separate victim and perpetrator if the mission is deemed to require their cooperation ( 28 ). Finally, geographical moves based on assignment often isolate individuals from important sources of social support that would otherwise be available (e.g., friends and family). Such social support is a well-established protective factor against the development of pathology in the aftermath of trauma ( 34 ).

Male Survivors of MST

As the understanding of MST advances, it becomes increasingly clear that sexual assault in the military is not just a women’s issue. One review of reported rates of male victimization across studies found that, on average, 1.1% of military men experience MST over the course of their career. Prevalences ranged from 0.03% to 12.4%, with significantly higher rates found in studies that used anonymous survey methodology ( 35 ). As a result of the higher ratio of men to women in the military, the raw numbers of men and women who experience MST are comparable. The 2014 RAND Corporation workplace study identified qualitative differences in men’s experience of MST; specifically, male survivors of sexual assault were more likely to have experienced multiple assaults, to have endured assaults by multiple assailants (i.e., gang rape), and to describe the incident as hazing motivated by abuse and humiliation ( 14 ).

Traditionally masculine values promoted within military culture may increase the stigma of sexual assault and support seeking in the aftermath of MST for men ( 36 ). Male survivors of MST often report concerns that others will perceive the assault as an indication of weakness, femininity, or homosexual orientation ( 37 ). Male survivors are less likely than their female counterparts to formally report their experience to authorities and less apt to seek support from loved ones after their experience ( 14 , 37 , 38 ). In addition, relatively fewer men than women use MST-related care provided by the VA, despite evidence that the link between MST and adverse mental health outcomes is at least as strong for male as for female VSM ( 39 – 41 ). In addition to stigma, men’s reservations about seeking care include minimization of the seriousness of sexual trauma and its impact, worry about reactions of health providers to their disclosure, fear of not being believed, self-blame, concerns about privacy, and lack of awareness of or access to male-specific MST services ( 42 ). Given the well-established role of social support in recovery from traumatic experiences, men’s reservations about seeking support may contribute to greater chances that MST will lead to PTSD in men relative to women ( 2 ). For any trauma survivor, the tasks of reestablishing safety, trust, and control are paramount to recovery. In addition to these tasks, male survivors of MST often encounter questions related to what sexual assault means to masculinity and sexual identity (regardless of a VSM’s identified sexual orientation). Some studies have suggested that male survivors of MST experience sexual dysfunction (e.g., low sexual desire, sexual dissatisfaction, engaging in unwanted sex, or hypersexuality) at higher rates than women ( 43 ).

MST and LGBT VSM

To discern the unique impact of MST on an individual who identifies as LGBT, it is critical to understand cultural and policy changes in the acceptance of LGBT individuals into military service. Before 1993, potential service members were screened for and excluded on the basis of nonheterosexual orientation; after entry, if an individual was identified as homosexual, he or she risked other than honorable discharge. In 1991, an attempt to reduce discrimination against gay and lesbian service members resulted in policy that allowed gay and lesbian individuals to serve on the condition that they kept their sexual orientation quiet; the policy became widely known as “Don’t Ask, Don’t Tell” (DADT). If a service member’s orientation became known to command, however, it could be grounds for inquiry and disciplinary action including discharge. In 2011, DADT was repealed, allowing gay and lesbian individuals to serve openly. In 2016, the Pentagon also lifted the ban preventing transgender individuals from serving openly in the military, although it is uncertain if this protection will be preserved under the current administration. This history is relevant in work with MST survivors; each individual’s experience of sexual assault, subsequent reporting, and support seeking may have varied greatly depending on his or her period of service (i.e., before, during, or after DADT). Before the repeal of DADT, a sexual assault perpetrated by a member of the same sex often resulted in survivors fearing accusations of consensual same-sex behavior and resulting discharge regardless of their identified sexual orientation ( 44 ).

LGBT-identifying individuals serving in the military are at disproportionate risk for victimization; they report higher rates of lifetime physical assault, sexual assault, and discrimination than non-LGBT peers ( 45 – 47 ). As one would expect, the experience of MST is associated with adverse mental and physical health consequences among this population (e.g., PTSD, mood disorders, personality disorders; 46 ). More important, the consequences of sexual assault experienced by LGBT individuals may be compounded by exposure to stigmatization and discrimination related to sexual minority status. Of particular concern among the LGBT population is the increased risk of suicide. LGBT service members have demonstrated a 10-fold increase in past-year suicide attempts compared with non-LGBT military peers, an effect that is likely amplified by the experience of sexual assault ( 45 , 48 ). Health providers caring for LGBT VSM should stay informed regarding LGBT culture as it pertains to military experience and take care to prevent perpetuation of the harmful consequences of heterosexism, cisgenderism, and other forms of sexual minority-based discrimination. Cultural competence may include assessment of the extent to which a survivor may have been targeted for harassment or assault as a result of sexual minority status. Providers should also avoid implicitly or explicitly attributing emotional and functional difficulties resulting from discrimination or traumatic victimization to survivors’ sexual orientation or gender identity ( 46 ).

MST and Impact on the Family System

Because MST is an interpersonal trauma that often involves a high level of betrayal, it frequently results in a long-standing impact on survivors’ relational functioning. Survivors may struggle with a sense of safety with and trust in others and find it more manageable to isolate themselves from support systems. After accounting for other traumatic stressors, MST predicts difficulties with connecting to social support after return from deployment and particular difficulty in readjusting to romantic relationships ( 49 ). Women who have experienced MST are more likely to report a history of multiple marriages and twice as likely to report that military experience interfered with their desire to have children ( 22 ). Qualitatively, survivors’ partners often describe a lack of understanding of MST, apprehension about discussing the sexual assault with their partner, feelings of failure regarding the inability to protect their loved one, and lack of knowledge about how to provide support ( 50 ). The adverse impact of military stressors and PTSD on parenting satisfaction and efficacy is well documented and likely extends to the experience of MST, although more research in this area is warranted ( 51 ). Clinical interventions designed to educate loved ones, cultivate their support, and build skills related to fostering connection is a vital direction for future research and clinical development given the important role of healthy relationships in trauma recovery.

MST and Mental Health Outcomes

The experience of MST has not surprisingly been associated with numerous adverse mental health outcomes, including PTSD, depression, anxiety, substance use disorders, eating disorders, dissociative disorders, and personality disorders ( 1 , 2 , 4 , 8 ). For veterans who experience both MST and combat, the impact of MST predicts more deleterious physical and mental health consequences, even after controlling for the impact of combat exposure ( 52 ). There is also some evidence that PTSD secondary to MST is more severe and less responsive to treatment than PTSD resulting from other forms of trauma ( 1 , 53 ). Men who screen positive for MST are at higher risk for bipolar disorder and psychotic disorders including schizophrenia ( 2 ). Compared with women, male survivors of MST may also be at greater risk for developing a substance use disorder ( 54 ). Correspondingly, a recent study of veterans of Iraq and Afghanistan found that MST was a unique predictor of PTSD severity and alcohol-related problems independent of combat exposure ( 55 ). Results in this area of substance use have been mixed, however; multiple studies have not demonstrated links between MST and problematic substance use ( 56 , 57 ).

Of particular concern is emerging evidence that the experience of MST increases risk of suicidal behavior. Suicidal ideation and attempts are higher among both men and women with a history of MST ( 8 , 48 , 58 , 59 ). Death by suicide is significantly elevated among both male and female survivors of MST, with hazard ratios of 1.69 and 2.27 for men and women, respectively, even after accounting for other military stressors ( 48 ). One recent study found that perceived loss of value as a member of the military family and institutional betrayal predicted increased odds of suicide attempts among those who experienced MST ( 58 ). Given the complexity of symptom presentation, individuals reporting MST should be screened thoroughly not only for PTSD but also for several commonly comorbid mental health conditions as well as suicide risk.

MST and Physical Health Outcomes

Nonrecovery from traumatic stressors has a well-documented impact on a variety of physical health outcomes ( 60 , 61 ). MST is no exception, with numerous studies demonstrating adverse physical health correlates among MST survivors ( 4 ). The link between MST and negative physical health outcomes may be explained by chronic tension or circulation of stress hormones in the case of PTSD or may develop as a result of unhealthy coping strategies (e.g., smoking, substance use, dysregulated eating, risky sexual behavior). Common medical complaints include pelvic pain and menstrual problems, back pain, headaches, gastrointestinal problems, hypothyroidism, and chronic fatigue. Cardiovascular risk factors (e.g., obesity, smoking, sedentary lifestyle) are also higher among survivors of MST ( 62 ). A cross-sectional analysis of a national sample of VA outpatients also exhibited a moderate association between liver disease and chronic obstructive pulmonary disorder among men and women who screened positive for MST ( 2 ). Men who experience MST also have a higher rate of positive HIV status ( 1 , 2 ).

MST and Sexual Health

Although sexual functioning complications after sexual assault are well documented in the general population, little data exist regarding sexual health correlates and MST. The few studies that exist have indicated that MST is linked to decreased sexual satisfaction, with some indication that male veterans with a history of MST exhibit more persistent sexual problems than women ( 1 , 43 ). One study examining female survivors of MST found that emotional health–related quality of life was the strongest mediator between the experience of MST and sexual dissatisfaction ( 63 ). Medicaid claims data indicate that female trauma survivors are at greater risk than their nonvictimized counterparts for a wide variety of pelvic health conditions, including irritable bowel syndrome, chronic pelvic pain, and musculoskeletal problems ( 64 ). This higher risk for pelvic health conditions is thought to be related to problems with high-tone abdominal, lumbar, hip girdle, and pelvic floor muscles, the muscles that surround the genitals ( 65 ). As part of a comprehensive work-up for individuals who experience MST, the review of symptoms should query for pelvic and lumbopelvic pain, urinary tract symptoms, gastrointestinal symptoms, and sexual dysfunction or dyspareunia. A pelvic floor expert can complete a history and physical exam. This exam can identify painful and nonrelaxing muscles; check for normal nerve function around the back, abdomen, and genitals; and check for strength, endurance, and coordination of the pelvic, core, and lower-extremity muscles. During the exam, the pelvic floor expert may look at (and touch) the low back, pelvic girdle, abdomen, and genitals, both externally and internally. For men, this could involve placing fingers inside the rectum; for women, this could involve placing fingers inside the vagina, rectum, or both ( 66 ). A trauma-sensitive pelvic health examination of an MST survivor is crucial because VSM with history of MST and PTSD experience more fear, distress, and embarrassment during pelvic examination ( 67 ).

Evidence-Based Treatment for PTSD Secondary to MST: A Stage-Based Approach

Given the often complex trauma histories of MST survivors, best practices involve the stage-based clinical approaches to treatment, such as the three-stage model proposed by Judith Herman in 1997 ( 68 – 69 ). Stage 1 of Herman’s model focuses on assisting the survivor to stabilize and establish a sense of safety with self and others. Clinical goals in this stage may include reducing suicidal ideation or self-harm behavior, reducing problematic substance use, setting boundaries in harmful relationships, and addressing basic needs such as stable housing and medical care. Protocols such as skills training in affective and interpersonal regulation, seeking safety, or dialectical behavior therapy are often indicated in this stage of treatment ( 70 – 73 ). During this initial stage, the survivor is also developing a sense of safety with the therapist or treatment team. Pharmacotherapy may be particularly helpful in achieving stabilization during this stage.

When stabilization and basic safety have been established, the survivor moves to stage 2, remembering and grieving past trauma and integrating the experience into his or her life as a whole. If the survivor has a diagnosis of PTSD, a trauma-focused treatment is most often indicated at this stage of treatment. Many of the treatment approaches studied for PTSD secondary to civilian sexual trauma have been found to be effective in treating PTSD resulting from MST. Allard and colleagues noted, however, that because of the unique combination of stressors experienced by survivors of MST in addition to potential gender differences, it is necessary to study treatment outcomes in MST survivors specifically ( 1 ). Most research on treatment of the sequelae of MST has focused on treatment of PTSD. The most empirical support for treatment of PTSD secondary to sexual assault has been found for cognitive-behavioral therapies, including prolonged exposure and cognitive processing therapy ( 74 – 76 ). There is also research supporting the use of eye movement desensitization and reprocessing and stress inoculation training ( 77 , 78 ).

The third and final stage of treatment for survivors of MST involves reconnection and reintegration into the community. Stage 3 is often an appropriate time to integrate family and loved ones into treatment. Survivors’ focus shifts to the present and future as they set goals related to purposeful work, passions and interests, and meaningful connection to others. Johnson and colleagues noted that a staggered approach of providing coping skills, trauma processing, and reconnection allows time for treatment engagement and creation of safe boundaries before delving into trauma processing. It also enables providers to determine whether trauma processing is necessary and which trauma-focused approach is best suited to a given survivor ( 79 ). Survivors present to treatment at different levels of preparedness for trauma-focused therapy and may move through stage 1 at different rates. Survivors may also not move through stages in a linear process and may need to revisit the goals and skills of each stage depending on changing circumstances or psychosocial stressors ( 68 , 69 ).

MST and Pharmacotherapy

In considering treatment options from a pharmacological perspective, it is important to consider the degree to which MST is separate from combat PTSD or other forms of PTSD. As we argued earlier, there are fundamental differences in the nature of the MST injury that need to be addressed from psychotherapeutic and psychosocial perspectives. Nemeroff and colleagues found that individuals with major depression who had a history of childhood sexual abuse tended to be nonresponsive to traditional pharmacotherapies for depression ( 80 ). These same subjects tended to respond more favorably to psychotherapy. These researchers also found that those individuals who underwent combined psychotherapy and pharmacotherapy had only marginal improvements over the psychotherapy-only subjects. Despite the focus on depression in the Nemeroff et al. study, this finding has prompted many providers to recommend evidence-based psychotherapies as first-line treatments for trauma spectrum disorders.

Nevertheless, pharmacotherapies can play a key role in the treatment of PTSD secondary to MST. Selective serotonin reuptake inhibitors (SSRIs) continue to be the mainstay of pharmacological treatment for PTSD ( 81 , 82 ). This class of medications appears to help reduce the anxiety and mood symptoms associated with PTSD and can help patients gain a better quality of life. Despite this well-established finding, care must be taken in the use of medications for the treatment of PTSD. In particular, caution should be exercised in the use of benzodiazepines for the treatment of PTSD-related anxiety symptoms. Rothbaum and colleagues have demonstrated that use of these compounds may worsen PTSD treatment outcomes ( 83 ). Current theories hold that this is likely because this class of medications interferes with the extinction paradigms used in psychotherapy that have the best general outcomes for the treatment of PTSD.

Finally, care should also be taken to consider the psychosexual side effects of pharmacotherapies ( 84 ). Although sexual trauma is fundamentally a physical and emotional attack on another person, its impact on the victim often results in sexual dysfunction, orientation confusion, and psychosomatic symptoms of the sexual body. These complex dynamics take time to address therapeutically but can in the interim lead to significant stress and tension in relationships. Sexual pleasure is also an important part of many individuals’ quality of life, and sexual dysfunction is often reported as one of the leading causes of medication discontinuation across many classes of pharmacological therapy. In the case of PTSD, sexual side effects can be profound for men and women who take SSRIs. Using the lowest effective dose and providing some degree of education about these side effects is an important part of treatment. For some patients, sexual side effects may be transient during the initiation or up-titration phase of treatment, and regular monitoring can help reduce patient fears about and discomfort with discussing these issues.

Overall, pharmacotherapy should certainly be considered when addressing MST and when a diagnosis appropriate for pharmacological treatment is established. PTSD might be comorbid with other mood disorders that would benefit from SSRI therapy, and therefore the clinician should do a careful broad assessment. Pharmacotherapy might also be considered if PTSD is comorbid with substance use disorders, which are often a coping strategy for survivors of sexual violence.

Underutilization and Improving Access to Care

Several factors often prevent survivors from receiving necessary mental health and medical care. In addition to stigma, survivors may encounter many logistical barriers to care (e.g., transportation issues, geographical limitations, child care needs, and limited employment leave). For those diagnosed with PTSD, a high level of avoidance symptoms may also hinder treatment initiation or adherence. Some survivors report finding military reminders and the male-dominated environment characteristic of the VA triggering; many seek care in the private sector ( 85 ). To reduce these barriers, providers in private settings should prepare to appropriately assess and treat mental and physical health problems that MST survivors may bring to treatment. In the VA setting, women’s health and trauma clinics should take measures to promote comfort, privacy, and accessibility of MST-related care. Male survivors may benefit from gender-specific psychoeducational materials, outreach, and programming to reduce stigma related to male sexual assault. Finally, research has suggested that survivors of MST may prefer and respond well to telehealth interventions that do not require entry into VA settings, at least early in treatment. Telehealth interventions may also help reduce geographic and other logistical barriers to care ( 86 ).

Conclusions

Although evidence exists that overall rates of MST have declined in recent years, this form of violence remains prevalent. Aspects of the military setting may make recovery from MST particularly difficult and result in mental, physical, and relational health consequences. Health providers in both the private and the government sectors must prepare to assess for incidence and consequences of MST in presenting VSM and consider unique issues that may arise with male and LGBT survivors. Comprehensive clinical care includes assessment of potential mental and physical health sequelae of MST, including a range of potential mental health consequences in addition to PTSD. Suicidality should be carefully monitored. Health of the pelvic floor muscles and resulting functional difficulties, an often overlooked consequence of sexual trauma, should also be assessed and treatment offered when indicated. Providers should also consider the impact of MST on VSMs’ social support and consider treatment of the couple or family system when warranted. Finally, further research and development of methods for reducing stigma and barriers to care for this population is critical to enable delivery of care to those who have served.

The authors report no financial relationships with commercial interests.

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• Spring 2024 | VOL. 22, NO. 2 Autism Across the Lifespan CURRENT ISSUE pp.147-262
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An Overview of Sexual Trauma in the U.S. Military

• Ashton M. Lofgreen , Ph.D. ,
• Kathryn K. Carroll , L.C.S.W. ,
• Sheila A. Dugan , M.D. ,
• Niranjan S. Karnik , M.D., Ph.D.

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This article discusses the scope and impact of military sexual trauma (MST) in the U.S. Armed Forces. The authors explore aspects of the military setting that may make recovery from this form of sexual violence particularly difficult. Risk factors for MST as well as associated mental, physical, sexual, and relational health consequences are reviewed. The authors also introduce clinical issues unique to male and lesbian, gay, bisexual, and transgender (LGBT) survivors. Finally, first-line psychotherapies and pharmacotherapies for subsequent mental health difficulties are reviewed, as are strategies for reducing barriers to health care for this population.

Uncovering an Epidemic

psychological trauma, which in the judgment of a . . . mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty, active duty for training, or inactive duty training. ( 3 )

Thus, MST is a term that includes both military sexual assault (MSA) and military sexual harassment (MSH). MSH is further defined as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.” Much of the research on the impact of MST has focused on sexual assault ( 1 , 4 ). However, survivors often describe sexual harassment in the military setting as pervasive, threatening, and inescapable. MSH has resulted in comparable adverse emotional, physical, social, and occupational outcomes ( 5 , 6 ). MSA and MSH are also highly correlated—those who experience MSA nearly universally report experiencing MSH, often in escalation to an assault ( 7 ). In 2004, DOD established the Sexual Assault Prevention and Response Office (SAPRO) to examine MST in the U.S. military, implement prevention efforts, advance medical care and support for survivors, and improve accountability of both the assailant and the institution.

Prevalence of MSA and MSH in the U.S. Armed Forces

A significant amount of scientific inquiry into MST and its impact since the early 1990s has led to a range of prevalence rates because of the variability in study methodology ( 8 , 9 ). For example, one review highlighted that prevalence estimates in the literature range from 22% to 45%, depending on method of assessment, sample type, MST definition, and study setting and purpose ( 1 ). Efforts to uncover prevalence are complicated by underreporting of sexual trauma, which may be exacerbated by barriers to disclosure, including some that are unique to the military setting ( 10 ). This discrepancy in prevalence rates highlights the need for future research to use a consistent definition of MST, specifically distinguishing MSA and MSH to improve understanding of the true scope of this issue ( 11 ). A recent meta-analysis examined 69 articles on MST prevalence rates, using the DOD definition. It concluded that, on average, 15.7% of VSM reported experiencing MST when the measure includes both harassment and assault; when these experiences were examined separately, the average was 13.9% for MSA and 31.2% for MSH ( 12 ). In general, self-report measures and interviews are associated with higher prevalence rates compared with reviews of VA medical records.

The DOD has made significant efforts to understand rates of MST among those currently serving. Since its establishment, a SAPRO task force has routinely collected and published the number of official reports of sexual assault in the military. Data collected include service members’ restricted (i.e., confidential) and unrestricted (i.e., investigated) reports of sexual assault; sexual harassment complaints are handled by a separate Military Equal Opportunity office. In 2015, DOD confirmed 6,083 total reports (both restricted and unrestricted) of sexual assault and 657 formal complaints of sexual harassment ( 13 ). In 2014, the RAND Corporation National Defense Research Institute updated its independent assessment of sexual assault, sexual harassment, and gender discrimination in the military on the basis of current definitions and criteria from the Uniform Code of Military Justice. Their survey of 560,000 U.S. service members indicated that 4.9% of women and 1% of men serving in active duty experienced a sexual assault during 2014; 26% of women and 7% of men serving in active duty experienced sexual harassment or gender discrimination ( 14 ).

Risk Factors for Sexual Victimization in the Military

Rates of sexual assault among women in the military are comparable to the lifetime prevalence of sexual assault of civilian women (16.6%) ( 15 ). However, some scholars have noted that the restricted period of military service (typically two to six years) compared with lifetime rates is indicative of women’s higher risk of experiencing sexual violence in the military compared with civilian settings ( 1 , 4 ). Some sociodemographic factors appear to increase the likelihood of experiencing sexual trauma in the military. MST tends to happen earlier in service members’ military career; more than 80% are victimized between the ages of 17 and 24 ( 16 – 17 ). Women are more likely than men to experience MST; racial minorities, sexual minorities, and those who are unmarried are also at higher risk ( 16 , 18 , 19 ). Some aspects of military service also appear to increase risk for MST. The Marines and the Navy have the highest rates of MST, the Air Force has the lowest, and enlisted members report higher rates of MST than officers ( 14 ). Finally, high alcohol use, particularly binge drinking among younger military personnel, may contribute to increased rates of sexual violence ( 20 ).

MST and Cumulative Trauma

Those who experience MST tend to have higher rates of other forms of trauma before, during, and after their service. Individuals entering the military have higher rates of exposure to adverse experiences in childhood and adolescence than the general population ( 21 ). This appears to be particularly true for individuals who experience MST, which is associated with higher rates of childhood sexual and physical abuse ( 4 , 16 – 18 ). Surviving MST is also associated with experiencing sexual assault as an adult outside of military service. In one sample of active-duty Air Force women, the lifetime prevalence of rape was more than twice as high as that in a national sample of civilian women (28% vs. 13%); the majority of initial rapes (75%) in the military occurred before the service member joined the Air Force ( 9 ). The nature of military service itself comes with high risk for additional trauma, including combat exposure. In one recent study, 12.5% of male troops and 42% of female troops reported experiencing some form of MST while deployed ( 22 ). Seventy-three percent of those who experienced MST during deployment were also exposed to other significant war-zone stressors. Combat exposure during deployment increases the risk for experiencing MST among female veterans of Iraq and Afghanistan ( 23 , 24 ). Various types of traumatic stressors during deployment each uniquely contribute to subsequent psychopathology, with combat exposure significantly predicting posttraumatic stress disorder (PTSD) and MST significantly predicting major depressive disorder. Combat exposure, MST, and general harassment all have a significant impact on the severity of depressive symptoms ( 25 ).

What Makes MST Distinct From Other Forms of Sexual Trauma?

It is important to consider that MST occurs within the context of long-standing military cultural norms. The military was essentially an all-male institution until the mid-20th century, and it continues to be heavily male dominated. Some scholars have implicated overvalued hypermasculinity, promoting traditions of the ideal soldier as strong, nonemotional, aggressive, and dominant ( 26 , 27 ). These values, in combination with a general acceptance of violence, a view of women as outsiders, the prevalence of rape myths, and power differentials between men and women, lead to environmental conditions that foster objectification of women and sexual violence as a means to assert dominance and control ( 5 , 16 , 26 , 28 ). This combination of factors may contribute to an increased acceptance of sexual aggression and minimization of the consequences of sexual misconduct on a cultural level. However, public recognition of MST, subsequent policy changes, and strong leadership promoting a safe environment for all who serve have played important roles in a gradual cultural shift. For example, annual data collection from DOD and the RAND Corporation has indicated that incidents of sexual violence have declined in the past several years, and reporting of such incidents has increased ( 13 , 14 ). Also, units in which leadership takes reports of MST seriously, demonstrates zero tolerance for sexual harassment, and shows support for service members seeking mental health care have lower rates of sexual assault ( 29 ).

Despite this progress, MST continues to occur frequently, and aspects of the military experience contribute to unique challenges in recovery. Given the youth of the majority of victims and the high prevalence of premilitary trauma among service members, individuals who experience MST may have a limited repertoire of coping skills at the time of the trauma ( 30 , 31 ). Military training, which often occurs during very formative developmental years, instills deep values of strength, mental toughness, and personal responsibility. This socialization can contribute to survivors’ efforts to suppress normal emotional reactions to a sexual trauma ( 31 ). Survivors may also take personal responsibility for the attack, leading to a high level of self-blame, which plays a role in the subsequent development of PTSD ( 32 ).

Military training also ingrains principles of group cohesion—that is, loyalty, teamwork, sacrifice, trust in comrades, and the suppression of individual needs for the larger good of the unit. Blurred boundaries between work and home contribute to the insular nature of the group; service members often live, work, and socialize on small military bases, especially when stationed internationally. Many individuals join the military seeking such belonging and view comrades as family. This belongingness is disrupted by the experience of sexual assault, which may have been perpetrated by a brother- or sister-in-arms or a commanding officer whose role was to guide and protect. Survivors of MST may experience a strong sense of betrayal and subsequent difficulties in determining whom to trust for support or protection. Survivors of MST may be required to interact with perpetrators on a regular basis, even when off duty ( 31 ). This circumstance often leads survivors to describe the consequences of MST as pervasive and inescapable, which may lead to feelings of powerlessness and patterns of learned helplessness. In the aftermath of MST, the fractured cohesion of the insular unit, and the tendency for a unit and its leadership to protect the group rather than the individual survivor, have led some scholars to compare the experience of MST to secretive forms of violence and abuse that can take place within a family system ( 27 ).

Sources of support that the military offers to survivors are not available if the survivor is not willing to report; survivors often cite barriers to reporting, including the fear of not being believed, stigma of assault, disruption of unit cohesion, fear of retaliation, fear of accusations of fraternization, and lack of awareness of the reporting system or available resources ( 26 , 31 ). For male survivors of same-sex assault, fear of being labeled homosexual is a unique barrier to reporting. Survivors’ disinclination to seek justice and support appears to have merit in some cases. Some survivors describe the aftermath of reporting a sexual assault as more painful than the assault itself ( 10 , 31 ). Women who report a sexual assault are more likely to be demoted and discharged from military service ( 33 ). Seeking support may be particularly challenging in a combat zone, where personnel may not be properly trained to handle sexual assault, medical resources may be limited, and command may be unwilling to separate victim and perpetrator if the mission is deemed to require their cooperation ( 28 ). Finally, geographical moves based on assignment often isolate individuals from important sources of social support that would otherwise be available (e.g., friends and family). Such social support is a well-established protective factor against the development of pathology in the aftermath of trauma ( 34 ).

Male Survivors of MST

As the understanding of MST advances, it becomes increasingly clear that sexual assault in the military is not just a women’s issue. One review of reported rates of male victimization across studies found that, on average, 1.1% of military men experience MST over the course of their career. Prevalences ranged from 0.03% to 12.4%, with significantly higher rates found in studies that used anonymous survey methodology ( 35 ). As a result of the higher ratio of men to women in the military, the raw numbers of men and women who experience MST are comparable. The 2014 RAND Corporation workplace study identified qualitative differences in men’s experience of MST; specifically, male survivors of sexual assault were more likely to have experienced multiple assaults, to have endured assaults by multiple assailants (i.e., gang rape), and to describe the incident as hazing motivated by abuse and humiliation ( 14 ).

Traditionally masculine values promoted within military culture may increase the stigma of sexual assault and support seeking in the aftermath of MST for men ( 36 ). Male survivors of MST often report concerns that others will perceive the assault as an indication of weakness, femininity, or homosexual orientation ( 37 ). Male survivors are less likely than their female counterparts to formally report their experience to authorities and less apt to seek support from loved ones after their experience ( 14 , 37 , 38 ). In addition, relatively fewer men than women use MST-related care provided by the VA, despite evidence that the link between MST and adverse mental health outcomes is at least as strong for male as for female VSM ( 39 – 41 ). In addition to stigma, men’s reservations about seeking care include minimization of the seriousness of sexual trauma and its impact, worry about reactions of health providers to their disclosure, fear of not being believed, self-blame, concerns about privacy, and lack of awareness of or access to male-specific MST services ( 42 ). Given the well-established role of social support in recovery from traumatic experiences, men’s reservations about seeking support may contribute to greater chances that MST will lead to PTSD in men relative to women ( 2 ). For any trauma survivor, the tasks of reestablishing safety, trust, and control are paramount to recovery. In addition to these tasks, male survivors of MST often encounter questions related to what sexual assault means to masculinity and sexual identity (regardless of a VSM’s identified sexual orientation). Some studies have suggested that male survivors of MST experience sexual dysfunction (e.g., low sexual desire, sexual dissatisfaction, engaging in unwanted sex, or hypersexuality) at higher rates than women ( 43 ).

MST and LGBT VSM

To discern the unique impact of MST on an individual who identifies as LGBT, it is critical to understand cultural and policy changes in the acceptance of LGBT individuals into military service. Before 1993, potential service members were screened for and excluded on the basis of nonheterosexual orientation; after entry, if an individual was identified as homosexual, he or she risked other than honorable discharge. In 1991, an attempt to reduce discrimination against gay and lesbian service members resulted in policy that allowed gay and lesbian individuals to serve on the condition that they kept their sexual orientation quiet; the policy became widely known as “Don’t Ask, Don’t Tell” (DADT). If a service member’s orientation became known to command, however, it could be grounds for inquiry and disciplinary action including discharge. In 2011, DADT was repealed, allowing gay and lesbian individuals to serve openly. In 2016, the Pentagon also lifted the ban preventing transgender individuals from serving openly in the military, although it is uncertain if this protection will be preserved under the current administration. This history is relevant in work with MST survivors; each individual’s experience of sexual assault, subsequent reporting, and support seeking may have varied greatly depending on his or her period of service (i.e., before, during, or after DADT). Before the repeal of DADT, a sexual assault perpetrated by a member of the same sex often resulted in survivors fearing accusations of consensual same-sex behavior and resulting discharge regardless of their identified sexual orientation ( 44 ).

LGBT-identifying individuals serving in the military are at disproportionate risk for victimization; they report higher rates of lifetime physical assault, sexual assault, and discrimination than non-LGBT peers ( 45 – 47 ). As one would expect, the experience of MST is associated with adverse mental and physical health consequences among this population (e.g., PTSD, mood disorders, personality disorders; 46 ). More important, the consequences of sexual assault experienced by LGBT individuals may be compounded by exposure to stigmatization and discrimination related to sexual minority status. Of particular concern among the LGBT population is the increased risk of suicide. LGBT service members have demonstrated a 10-fold increase in past-year suicide attempts compared with non-LGBT military peers, an effect that is likely amplified by the experience of sexual assault ( 45 , 48 ). Health providers caring for LGBT VSM should stay informed regarding LGBT culture as it pertains to military experience and take care to prevent perpetuation of the harmful consequences of heterosexism, cisgenderism, and other forms of sexual minority-based discrimination. Cultural competence may include assessment of the extent to which a survivor may have been targeted for harassment or assault as a result of sexual minority status. Providers should also avoid implicitly or explicitly attributing emotional and functional difficulties resulting from discrimination or traumatic victimization to survivors’ sexual orientation or gender identity ( 46 ).

MST and Impact on the Family System

Because MST is an interpersonal trauma that often involves a high level of betrayal, it frequently results in a long-standing impact on survivors’ relational functioning. Survivors may struggle with a sense of safety with and trust in others and find it more manageable to isolate themselves from support systems. After accounting for other traumatic stressors, MST predicts difficulties with connecting to social support after return from deployment and particular difficulty in readjusting to romantic relationships ( 49 ). Women who have experienced MST are more likely to report a history of multiple marriages and twice as likely to report that military experience interfered with their desire to have children ( 22 ). Qualitatively, survivors’ partners often describe a lack of understanding of MST, apprehension about discussing the sexual assault with their partner, feelings of failure regarding the inability to protect their loved one, and lack of knowledge about how to provide support ( 50 ). The adverse impact of military stressors and PTSD on parenting satisfaction and efficacy is well documented and likely extends to the experience of MST, although more research in this area is warranted ( 51 ). Clinical interventions designed to educate loved ones, cultivate their support, and build skills related to fostering connection is a vital direction for future research and clinical development given the important role of healthy relationships in trauma recovery.

MST and Mental Health Outcomes

The experience of MST has not surprisingly been associated with numerous adverse mental health outcomes, including PTSD, depression, anxiety, substance use disorders, eating disorders, dissociative disorders, and personality disorders ( 1 , 2 , 4 , 8 ). For veterans who experience both MST and combat, the impact of MST predicts more deleterious physical and mental health consequences, even after controlling for the impact of combat exposure ( 52 ). There is also some evidence that PTSD secondary to MST is more severe and less responsive to treatment than PTSD resulting from other forms of trauma ( 1 , 53 ). Men who screen positive for MST are at higher risk for bipolar disorder and psychotic disorders including schizophrenia ( 2 ). Compared with women, male survivors of MST may also be at greater risk for developing a substance use disorder ( 54 ). Correspondingly, a recent study of veterans of Iraq and Afghanistan found that MST was a unique predictor of PTSD severity and alcohol-related problems independent of combat exposure ( 55 ). Results in this area of substance use have been mixed, however; multiple studies have not demonstrated links between MST and problematic substance use ( 56 , 57 ).

Of particular concern is emerging evidence that the experience of MST increases risk of suicidal behavior. Suicidal ideation and attempts are higher among both men and women with a history of MST ( 8 , 48 , 58 , 59 ). Death by suicide is significantly elevated among both male and female survivors of MST, with hazard ratios of 1.69 and 2.27 for men and women, respectively, even after accounting for other military stressors ( 48 ). One recent study found that perceived loss of value as a member of the military family and institutional betrayal predicted increased odds of suicide attempts among those who experienced MST ( 58 ). Given the complexity of symptom presentation, individuals reporting MST should be screened thoroughly not only for PTSD but also for several commonly comorbid mental health conditions as well as suicide risk.

MST and Physical Health Outcomes

Nonrecovery from traumatic stressors has a well-documented impact on a variety of physical health outcomes ( 60 , 61 ). MST is no exception, with numerous studies demonstrating adverse physical health correlates among MST survivors ( 4 ). The link between MST and negative physical health outcomes may be explained by chronic tension or circulation of stress hormones in the case of PTSD or may develop as a result of unhealthy coping strategies (e.g., smoking, substance use, dysregulated eating, risky sexual behavior). Common medical complaints include pelvic pain and menstrual problems, back pain, headaches, gastrointestinal problems, hypothyroidism, and chronic fatigue. Cardiovascular risk factors (e.g., obesity, smoking, sedentary lifestyle) are also higher among survivors of MST ( 62 ). A cross-sectional analysis of a national sample of VA outpatients also exhibited a moderate association between liver disease and chronic obstructive pulmonary disorder among men and women who screened positive for MST ( 2 ). Men who experience MST also have a higher rate of positive HIV status ( 1 , 2 ).

MST and Sexual Health

Although sexual functioning complications after sexual assault are well documented in the general population, little data exist regarding sexual health correlates and MST. The few studies that exist have indicated that MST is linked to decreased sexual satisfaction, with some indication that male veterans with a history of MST exhibit more persistent sexual problems than women ( 1 , 43 ). One study examining female survivors of MST found that emotional health–related quality of life was the strongest mediator between the experience of MST and sexual dissatisfaction ( 63 ). Medicaid claims data indicate that female trauma survivors are at greater risk than their nonvictimized counterparts for a wide variety of pelvic health conditions, including irritable bowel syndrome, chronic pelvic pain, and musculoskeletal problems ( 64 ). This higher risk for pelvic health conditions is thought to be related to problems with high-tone abdominal, lumbar, hip girdle, and pelvic floor muscles, the muscles that surround the genitals ( 65 ). As part of a comprehensive work-up for individuals who experience MST, the review of symptoms should query for pelvic and lumbopelvic pain, urinary tract symptoms, gastrointestinal symptoms, and sexual dysfunction or dyspareunia. A pelvic floor expert can complete a history and physical exam. This exam can identify painful and nonrelaxing muscles; check for normal nerve function around the back, abdomen, and genitals; and check for strength, endurance, and coordination of the pelvic, core, and lower-extremity muscles. During the exam, the pelvic floor expert may look at (and touch) the low back, pelvic girdle, abdomen, and genitals, both externally and internally. For men, this could involve placing fingers inside the rectum; for women, this could involve placing fingers inside the vagina, rectum, or both ( 66 ). A trauma-sensitive pelvic health examination of an MST survivor is crucial because VSM with history of MST and PTSD experience more fear, distress, and embarrassment during pelvic examination ( 67 ).

Evidence-Based Treatment for PTSD Secondary to MST: A Stage-Based Approach

Given the often complex trauma histories of MST survivors, best practices involve the stage-based clinical approaches to treatment, such as the three-stage model proposed by Judith Herman in 1997 ( 68 – 69 ). Stage 1 of Herman’s model focuses on assisting the survivor to stabilize and establish a sense of safety with self and others. Clinical goals in this stage may include reducing suicidal ideation or self-harm behavior, reducing problematic substance use, setting boundaries in harmful relationships, and addressing basic needs such as stable housing and medical care. Protocols such as skills training in affective and interpersonal regulation, seeking safety, or dialectical behavior therapy are often indicated in this stage of treatment ( 70 – 73 ). During this initial stage, the survivor is also developing a sense of safety with the therapist or treatment team. Pharmacotherapy may be particularly helpful in achieving stabilization during this stage.

When stabilization and basic safety have been established, the survivor moves to stage 2, remembering and grieving past trauma and integrating the experience into his or her life as a whole. If the survivor has a diagnosis of PTSD, a trauma-focused treatment is most often indicated at this stage of treatment. Many of the treatment approaches studied for PTSD secondary to civilian sexual trauma have been found to be effective in treating PTSD resulting from MST. Allard and colleagues noted, however, that because of the unique combination of stressors experienced by survivors of MST in addition to potential gender differences, it is necessary to study treatment outcomes in MST survivors specifically ( 1 ). Most research on treatment of the sequelae of MST has focused on treatment of PTSD. The most empirical support for treatment of PTSD secondary to sexual assault has been found for cognitive-behavioral therapies, including prolonged exposure and cognitive processing therapy ( 74 – 76 ). There is also research supporting the use of eye movement desensitization and reprocessing and stress inoculation training ( 77 , 78 ).

The third and final stage of treatment for survivors of MST involves reconnection and reintegration into the community. Stage 3 is often an appropriate time to integrate family and loved ones into treatment. Survivors’ focus shifts to the present and future as they set goals related to purposeful work, passions and interests, and meaningful connection to others. Johnson and colleagues noted that a staggered approach of providing coping skills, trauma processing, and reconnection allows time for treatment engagement and creation of safe boundaries before delving into trauma processing. It also enables providers to determine whether trauma processing is necessary and which trauma-focused approach is best suited to a given survivor ( 79 ). Survivors present to treatment at different levels of preparedness for trauma-focused therapy and may move through stage 1 at different rates. Survivors may also not move through stages in a linear process and may need to revisit the goals and skills of each stage depending on changing circumstances or psychosocial stressors ( 68 , 69 ).

MST and Pharmacotherapy

In considering treatment options from a pharmacological perspective, it is important to consider the degree to which MST is separate from combat PTSD or other forms of PTSD. As we argued earlier, there are fundamental differences in the nature of the MST injury that need to be addressed from psychotherapeutic and psychosocial perspectives. Nemeroff and colleagues found that individuals with major depression who had a history of childhood sexual abuse tended to be nonresponsive to traditional pharmacotherapies for depression ( 80 ). These same subjects tended to respond more favorably to psychotherapy. These researchers also found that those individuals who underwent combined psychotherapy and pharmacotherapy had only marginal improvements over the psychotherapy-only subjects. Despite the focus on depression in the Nemeroff et al. study, this finding has prompted many providers to recommend evidence-based psychotherapies as first-line treatments for trauma spectrum disorders.

Nevertheless, pharmacotherapies can play a key role in the treatment of PTSD secondary to MST. Selective serotonin reuptake inhibitors (SSRIs) continue to be the mainstay of pharmacological treatment for PTSD ( 81 , 82 ). This class of medications appears to help reduce the anxiety and mood symptoms associated with PTSD and can help patients gain a better quality of life. Despite this well-established finding, care must be taken in the use of medications for the treatment of PTSD. In particular, caution should be exercised in the use of benzodiazepines for the treatment of PTSD-related anxiety symptoms. Rothbaum and colleagues have demonstrated that use of these compounds may worsen PTSD treatment outcomes ( 83 ). Current theories hold that this is likely because this class of medications interferes with the extinction paradigms used in psychotherapy that have the best general outcomes for the treatment of PTSD.

Finally, care should also be taken to consider the psychosexual side effects of pharmacotherapies ( 84 ). Although sexual trauma is fundamentally a physical and emotional attack on another person, its impact on the victim often results in sexual dysfunction, orientation confusion, and psychosomatic symptoms of the sexual body. These complex dynamics take time to address therapeutically but can in the interim lead to significant stress and tension in relationships. Sexual pleasure is also an important part of many individuals’ quality of life, and sexual dysfunction is often reported as one of the leading causes of medication discontinuation across many classes of pharmacological therapy. In the case of PTSD, sexual side effects can be profound for men and women who take SSRIs. Using the lowest effective dose and providing some degree of education about these side effects is an important part of treatment. For some patients, sexual side effects may be transient during the initiation or up-titration phase of treatment, and regular monitoring can help reduce patient fears about and discomfort with discussing these issues.

Overall, pharmacotherapy should certainly be considered when addressing MST and when a diagnosis appropriate for pharmacological treatment is established. PTSD might be comorbid with other mood disorders that would benefit from SSRI therapy, and therefore the clinician should do a careful broad assessment. Pharmacotherapy might also be considered if PTSD is comorbid with substance use disorders, which are often a coping strategy for survivors of sexual violence.

Underutilization and Improving Access to Care

Several factors often prevent survivors from receiving necessary mental health and medical care. In addition to stigma, survivors may encounter many logistical barriers to care (e.g., transportation issues, geographical limitations, child care needs, and limited employment leave). For those diagnosed with PTSD, a high level of avoidance symptoms may also hinder treatment initiation or adherence. Some survivors report finding military reminders and the male-dominated environment characteristic of the VA triggering; many seek care in the private sector ( 85 ). To reduce these barriers, providers in private settings should prepare to appropriately assess and treat mental and physical health problems that MST survivors may bring to treatment. In the VA setting, women’s health and trauma clinics should take measures to promote comfort, privacy, and accessibility of MST-related care. Male survivors may benefit from gender-specific psychoeducational materials, outreach, and programming to reduce stigma related to male sexual assault. Finally, research has suggested that survivors of MST may prefer and respond well to telehealth interventions that do not require entry into VA settings, at least early in treatment. Telehealth interventions may also help reduce geographic and other logistical barriers to care ( 86 ).

Conclusions

Although evidence exists that overall rates of MST have declined in recent years, this form of violence remains prevalent. Aspects of the military setting may make recovery from MST particularly difficult and result in mental, physical, and relational health consequences. Health providers in both the private and the government sectors must prepare to assess for incidence and consequences of MST in presenting VSM and consider unique issues that may arise with male and LGBT survivors. Comprehensive clinical care includes assessment of potential mental and physical health sequelae of MST, including a range of potential mental health consequences in addition to PTSD. Suicidality should be carefully monitored. Health of the pelvic floor muscles and resulting functional difficulties, an often overlooked consequence of sexual trauma, should also be assessed and treatment offered when indicated. Providers should also consider the impact of MST on VSMs’ social support and consider treatment of the couple or family system when warranted. Finally, further research and development of methods for reducing stigma and barriers to care for this population is critical to enable delivery of care to those who have served.

The authors report no financial relationships with commercial interests.

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• Navy Chief Petty Officer Convicted of Attempted Espionage at San Diego Court-Martial

The Navy has convicted a chief petty officer of attempted espionage, among other charges, at a court-martial in San Diego after the sailor was charged with sharing classified documents under the guise of writing research papers.

The Naval Criminal Investigative Service said in a press release Friday that, following a seven-day trial , Chief Petty Officer Bryce Pedicini, who was previously assigned to the USS Higgins, was found guilty at a general court-martial of attempted espionage, failure to obey a lawful order, and attempted violation of a lawful general order.

The conviction comes at a time when a growing number of sailors appear to be falling for Chinese efforts to recruit spies and obtain classified information and, while it is not known what country Pedicini tried to spy for, he is at least the third sailor in about a year to face espionage-related charges.

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Pedicini is set to be sentenced by a military judge on May 7, according to NCIS.

Charging documents released by the Navy showed that Pedicini was accused of delivering two sets of classified national defense documents -- referred to as "Article 1112" and "Article 1223" in the legal paperwork -- to "a citizen and employee of a foreign government" between November 2022 and February 2023 in Hampton Roads, Virginia.

The charging documents go on to say that the pair of articles were made up of several sections and Pedicini delivered them both over several instances.

In its statement, NCIS said that "Pedicini engaged with the foreign government representative under the guise of writing research papers" and noted that this is "a tactic increasingly used by foreign adversaries to obtain classified and unclassified national defense information."

The charging documents also say that Pedicini provided "images of a [secret-level classification] computer screen to a citizen and employee of a foreign government" in mid-May in Yokosuka , Japan.

Yokosuka is the Japanese city just outside of Tokyo that hosts a U.S. Navy base as well as Pedicini's former ship, the Higgins.

According to records provided by the Navy, Pedicini is originally from Tennessee and enlisted in the service in 2008. His awards include a Navy and Marine Corps Achievement Medal, three Good Conduct Medals, and two Sea Service Deployment Ribbons.

NCIS Director Omar Lopez said in the statement that "this guilty verdict holds Mr. Pedicini to account for his betrayal of his country and fellow service members" and that "although the overwhelming majority of Department of the Navy service members are honorable and faithful public servants, NCIS stands ready to expose those who are not."

In August, the Department of Justice announced that Petty Officer Second Class Wenheng Zhao -- who went by the name Thomas Zhao -- was arrested for transmitting sensitive U.S. military information to a Chinese intelligence officer. Zhao had sent more than 50 technical and mechanical manuals for various systems of the USS Essex and similar ships to his Chinese handlers, court documents said.

Zhao was sentenced to just over two years in federal prison in January.

In the same August announcement, the Justice Department also said it had arrested and charged Jinchao Wei, a machinist's mate who was also assigned to the Essex, and charged him with multiple counts of conspiring and sending defense information to a foreign citizen.

Wei's trial is currently set to begin in December, according to court records.

Court records claim that both sailors received thousands of dollars for their activities and that Wei even "boasted that while other U.S. Navy sailors were driving cabs to make extra money, all he had to do was leak secrets."

Related: Trial of Navy Chief Petty Officer Accused of Espionage Kicks Off in San Diego

Konstantin Toropin

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The Navy isn’t sure when its badly-needed ‘mini’ carrier USS Boxer will get repaired

Neither of the two San Diego shipyards large enough to handle the 843-foot vessel has room currently for the amphibious assault ship

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No quick fix is in the offing for the USS Boxer, the amphibious assault ship that experienced mechanical problems in early April, forcing it to return to San Diego 10 days after deploying to the Indo-Pacific.

“As inspections and assessments are continuing, a decision on the most efficient way to execute repairs in still being determined,” the Navy said in an emailed statement to The San Diego Union-Tribune.

The 843-foot ship, which carries Marine amphibious forces and a variety of aircraft, is currently docked at Naval Station San Diego. The ship’s latest problem was first reported by the US Naval Institute.

The Navy did not respond to the Union-Tribune’s questions about the nature of the Boxer’s mechanical problems and whether repairs are being delayed by congestion at San Diego ship repair yards.

The piers at BAE Systems and General Dynamics-NASSCO that are large enough to handle Boxer are currently occupied by other warships.

The Navy also did not respond to a question asking whether it is considering sending Boxer to a shipyard in Oregon or Washington. The ship had been scheduled to deploy to the Indo-Pacific to help deal with growing tensions with China, and was carrying elements of the 15th Marine Expeditionary Unit from Camp Pendleton.

The so-called “mini” aircraft carrier is regarded as one of the most important ships in the Navy due to its ability to rapidly project Marines ashore.

The shipyard issue represents one of the biggest problems the Navy currently faces.

“The Navy’s ship maintenance backlog has grown to $1.8 billion, and the Navy has increasingly deferred maintenance on critical systems,” the Government Accountability Office said in a 2022 report.

The nearly 30-year-old Boxer has experienced numerous mechanical problems in recent years. The trip it began on April 1 marked the first time in five years that the ship had left on deployment.

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