Differential Risk for Homelessness among US Male and Female Veterans with a Positive Screen for Military Sexual Trauma

IMPORTANCE:

Military sexual trauma (MST) is associated with adverse physical and mental health outcomes following military separation. Recent research suggests that MST may be a determinant in several factors associated with post deployment homelessness.

OBJECTIVE:

To evaluate MST as an independent risk factor for homelessness and to determine whether risk varies by sex.

DESIGN, SETTING, AND PARTICIPANTS:

A retrospective cohort study of US veterans who used Veterans Health Administration (VHA) services between fiscal years 2004 and 2013 was conducted using administrative data from the Department of Defense and VHA. Included in the study were 601 892 US veterans deployed in Iraq or Afghanistan who separated from the military between fiscal years 2001 and 2011 and subsequently used VHA services.

EXPOSURE:

Positive response to screen for MST administered in VHA facilities.

MAIN OUTCOMES AND MEASURES:

Administrative evidence of homelessness within 30 days, 1 year, and 5 years following the first VHA encounter after last deployment.

RESULTS:

The mean (SD) age of the 601 892 participants was 38.9 (9.4) years, 527 874 (87.7%) were male, 310 854 (51.6%) were white, and 382 361 (63.5%) were enlisted in the Army. Among veterans with a positive screen for MST, rates of homelessness were 1.6% within 30 days, 4.4% within 1 year, and 9.6% within 5 years, more than double the rates of veterans with a negative MST screen (0.7%, 1.8%, and 4.3%, respectively). A positive screen for MST was significantly and independently associated with postdeployment homelessness. In regression models adjusted for demographic and military service characteristics, odds of experiencing homelessness were higher among those who screened positive for MST compared with those who screened negative (30-day: adjusted odds ratio [AOR], 1.89; 95% CI, 1.58-2.24; 1-year: AOR, 2.27; 95% CI, 2.04-2.53; and 5-year: AOR, 2.63; 95% CI, 2.36-2.93). Military sexual trauma screen status remained independently associated with homelessness after adjusting for co-occurring mental health and substance abuse diagnoses in follow-up regression models (30-day: AOR, 1.62; 95% CI, 1.36-1.93; 1-year: AOR, 1.49; 95% CI, 1.33-1.66; and 5-year: AOR, 1.39; 95% CI, 1.24-1.55). In the fully adjusted models, the interaction between MST status and sex was significant in the 30-day and 1-year cohorts (30-day: AOR, 1.54; 95% CI, 1.18-2.02; and 1-year: AOR, 1.46; 95% CI, 1.23-1.74), denoting higher risk for homelessness among males with a positive screen for MST.

CONCLUSIONS AND RELEVANCE:

A positive screen for MST was independently associated with postdeployment homelessness, with male veterans at greater risk than female veterans. These results underscore the importance of the MST screen as a clinically important marker of reintegration outcomes among veterans. These findings demonstrate significant long-term negative effects and inform our understanding of the public health implications of sexual abuse and harassment.

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By:  Brignone E1, Gundlapalli AV2, Blais RK1, Carter ME2, Suo Y2, Samore MH2, Kimerling R3, Fargo JD1.

• 1Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah 2Department of Psychology, Utah State University, Logan.
• 2Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah3Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City4Department of Biomedical Informatics, Univer.
• 3National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California6Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California.
• JAMA Psychiatry. 2016 Apr 20. doi: 10.1001/jamapsychiatry.2016.0101. 

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Sexual Intimate Partner Violence as a Form of Military Sexual Trauma

Military sexual trauma (MST) is known to impact women's health, but little is known about the occurrence of MST perpetrated by a past or current intimate partner. This study identified the occurrence of intimate partner violence (IPV)-related MST in a sample of female veterans. We also examined the associations between MST history (no MST history, IPV-related MST, and MST by a nonintimate partner) and mental and physical health symptoms. 

Participants were 369 female veteran patients of Department of Veteran Affairs (VA) facilities in the New England region of the United States who completed a larger 2012 mail survey that included validated assessments of MST, posttraumatic stress disorder (PTSD Checklist) and depressive symptoms (CES-D), and general physical and mental health functioning (Short Form-36). 

Approximately half (49%) of the women in this sample reported a history of MST, of which 27 (15%) were categorized as IPV-related MST. Few differences in health measures were observed among women with IPV-related MST compared with women who experienced MST by a nonintimate partner or women with no MST history. However, women who experienced IPV-related MST had similarly severe health symptoms as women who reported MST by a nonintimate partner and more severe PTSD symptoms than women without a history of MST. 

Some women veterans have experienced MST at the hands of an intimate partner and face health impacts. This topic warrants additional attention in clinical and research efforts.

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By: Mercado R1, Ming Foynes M2, Carpenter SL2, Iverson KM2.

• 1Harvard South Shore Psychiatry Residency Program.
• 2Women's Health Sciences Division.  

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Military Sexual Trauma in US Veterans: Results from the National Health and Resilience in Veterans Study

To evaluate the prevalence of military sexual trauma (MST) among US veterans, identify sociodemographic and military characteristics of MST, and examine the relationships between MST and psychiatric comorbidities, functioning/quality of life, and mental health treatment utilization.

Data were analyzed from the National Health and Resilience in Veterans Study, a contemporary, nationally representative survey of 1,484 US veterans conducted September-October 2013. Poststratification weights were applied to analyses to permit generalizability of results to the US veteran population. Outcomes measured include history of MST, trauma histories, lifetime and current DSM-IV mental disorders, functioning and quality of life, and utilization of mental health treatment.

The overall prevalence of MST was 7.6% and was higher among female than male veterans (32.4% vs 4.8%) and younger than older veterans (22.8% among veterans aged 18-29 years vs 4.5% among veterans aged 60+ years). After adjustment for sociodemographic and military characteristics, MST was associated with elevated rates of current major depressive disorder, posttraumatic stress disorder, and generalized anxiety disorder; past history of suicide attempt and current suicidal ideation; and decreased mental and cognitive functioning and quality of life. MST was also associated with increased current utilization of psychotropic medication and psychotherapy or counseling, independent of psychiatric morbidities.

7.6% of US veterans screen positive for MST, with substantially higher rates among female and younger veterans. MST is associated with elevated rates of several psychiatric morbidities and suicidality, reduced functioning and quality of life, and increased mental health treatment utilization, independent of other sociodemographic, military, and mental health factors. These results suggest that MST is prevalent among US veterans and associated with elevated health burden. Findings can help inform efforts to identify at-risk veterans and characterize the concomitant health burden and needs associated with MST in this population.

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By: Klingensmith K1, Tsai J, Mota N, Southwick SM, Pietrzak RH.

• 1Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.  

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The Influence of Military Sexual Trauma on Returning OEF/OIF Male Veterans

Military sexual trauma (MST) encompasses experiences of sexual harassment and/or assault that occur during active duty military service. MST is associated with postdeployment mental health, interpersonal, and physical difficulties and appears to be more influential in the development of posttraumatic stress disorder (PTSD) than other active duty experiences, including combat, among women veterans. 

Although some literature suggests that men who experience MST also evidence significant postdeployment difficulties, research in this area is lacking. The current study evaluated a large sample of returning male veterans (N = 961) who served in Iraq and/or Afghanistan. Veterans were referred for treatment in a trauma and anxiety specialty clinic at a large VA hospital. 

Of this sample, 18% reported MST perpetrated by a member of their unit. Results indicated veterans who reported MST were younger, less likely to be currently married, more likely to be diagnosed with a mood disorder, and more likely to have experienced non-MST sexual abuse either as children or adults. 

Analyses revealed that MST was negatively associated with postdeployment social support and positively associated with postdeployment perceived emotional mistreatment, but was not associated with postdeployment loss of romantic relationship, job loss, or unemployment after statistically controlling for other trauma exposures and current social support. 

Results reflect the detrimental associations of MST on male veterans and the need for more research in this area. These findings also highlight the need for treatment interventions that address social and interpersonal functioning in addition to symptoms of depressive disorders

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By: Mondragon SA1, Wang D1, Pritchett L1, Graham DP1, Plasencia ML1, Teng EJ1.

• 1Michael E. DeBakey VA Medical Center.  

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Functional Correlates of Military Sexual Assault in Male Veterans

Despite research findings that similar numbers of male and female veterans are affected by military sexual trauma (MST), there has been considerably less research on the effects of MST specific to male veterans. 

The aim of the present study was to provide preliminary data describing functional correlates of military sexual assault (MSA) among male Iraq/Afghanistan-era veterans to identify potential health care needs for this population. We evaluated the following functional correlates: posttraumatic stress disorder (PTSD) symptoms, depression symptoms, alcohol use, drug use, suicidality, social support, violent behavior in the past 30 days, incarceration, disability eligibility status, and use of outpatient mental health treatment. 

We compared 3 groups: (a) male veterans who endorsed a history of MSA (n = 39), (b) a general non-MSA sample (n = 2,003), and (c) a matched non-MSA sample (n = 39) identified by matching algorithms on the basis of factors (e.g., age, education, adult premilitary sexual trauma history, childhood sexual and physical trauma history, and race) that could increase veterans' vulnerability to the functional correlates examined. 

MSA in men was associated with greater PTSD symptom severity, greater depression symptom severity, higher suicidality, and higher outpatient mental health treatment, above and beyond the effects of vulnerability factors. These findings suggest that, for male veterans, MSA may result in a severe and enduring overall symptom profile requiring ongoing clinical management.

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By: Schry AR1, Hibberd R2, Wagner HR1, Turchik JA3, Kimbrel NA1, Wong M1, Elbogen EE1, Strauss JL4, Brancu M1; Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center Workgroup.

• 1Veterans Affairs Mid-Atlantic Mental Illness Research.
• 2Durham Veterans Affairs Medical Center.
• 3Veterans Affairs Palo Alto Health Care System.
• 4Duke University School of Medicine, and Mental Health Services  

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Military Sexual Trauma among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment

Military sexual trauma (MST) includes sexual harassment or sexual assault that occurs during military service and is of increasing public health concern. The population prevalence of MST among female and male veterans who served during Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) has not been estimated to our knowledge. The purpose of this study is to assess the population prevalence and identify military correlates of MST, sexual harassment, and sexual assault among OEF/OIF veterans.

MST was assessed in the 2009-2011 National Health Study for a New Generation of U.S. Veterans, a survey of 60,000 veterans who served during the OEF/OIF eras (response rate, 34%, n=20,563). Weighted prevalence estimates and AORs of MST, sexual harassment, and sexual assault among women and men were calculated. Gender-stratified logistic regression models controlled for military and demographic characteristics. Data analyses were conducted in 2013-2014.

Approximately 41% of women and 4% of men reported experiencing MST. Deployed men had lower risk for MST compared with non-deployed men, though no difference was found among women. 

However, veterans reporting combat exposure during deployment had increased risk for MST compared with those without, while controlling for OEF/OIF deployment. 

Among women, Marines and Navy veterans had increased risk for MST compared with Air Force veterans. MST was significantly higher among veterans who reported using Veterans Affairs healthcare services.

These prevalence estimates underscore the importance of public awareness and continued investigation of the public health impact of MST.

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By: Barth SK1, Kimerling RE2, Pavao J2, McCutcheon SJ3, Batten SV4, Dursa E5, Peterson MR5, Schneiderman AI5.

• 1Department of Veterans Affairs, Office of Public Health, Post Deployment Health, Epidemiology Program, Washington, District of Columbia. Electronic address: shannon.barth@va.gov.
• 2Department of Veterans Affairs, VHA Mental Health Services and National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California.
• 3Department of Veterans Affairs, VHA Mental Health Services, Washington, District of Columbia.
• 4Booz Allen Hamilton, Washington, District of Columbia.
• 5Department of Veterans Affairs, Office of Public Health, Post Deployment Health, Epidemiology Program, Washington, District of Columbia.