Sexual Assault and Disabling PTSD in Active Duty Service Women

Sexual Assault and Disabling PTSD in Active Duty Service Women Abstract Introduction Sexual assault in the military is a major concern and may result in significant health problems, such as post-traumatic stress disorder (PTSD). Those developing disabling PTSD symptoms may require a disability evaluation. We examined disability evaluation trends for service women with PTSD to better understand characteristics associated with inability to continue Active Duty service. Methods This is a retrospective review of disability reports and electronic medical records for 322 Active Duty women diagnosed with and treated for PTSD by psychiatrists and psychologists at a large military treatment facility between 2011 and 2014. Service women requiring medical disability evaluation for PTSD (n = 159) were included in the study as “IDES cases” (Integrated Disability Evaluation System – IDES). A similar number of women, randomly selected from those seeking care for PTSD but not requiring disability evaluation during the same period, were included in the “control” group (n = 163). Analyzes done to evaluate differences between groups (IDES cases vs. controls) included demographic and service-related characteristics, history of chronic pain, and PTSD index trauma types, such as pre-military trauma and military sexual trauma (MST). Logistic regression was performed to identify the factors associated with inclusion in IDES. Results MST was the most frequent PTSD index trauma in the IDES group (73.6% vs. 44.8% of control group) and the most significant factor associated with IDES inclusion (OR 2.6, p = 0.032). Those in the IDES group had significantly greater number of mental health visits for PTSD (IDES: m = 68.6 vs. controls: m = 29.6) and more frequent chronic pain history (IDES 40.9% vs. controls 19.6%) than those in the control group. Approximately 65% of women in both groups had a history of childhood abuse, but childhood abuse, as a PTSD index trauma, was negatively associated with IDES inclusion (OR 0.293, p = 0.006). Conclusions Active Duty service women with PTSD and a MST index trauma are much more likely to require disability evaluation (IDES) than those with PTSD due to other trauma types. IDES evaluation for conditions such as PTSD may result in early termination of military service and is a potential downstream consequence of MST. Service women requiring greater numbers of mental health visits for PTSD treatment may benefit from a multidisciplinary approach to treating concurrent health conditions, such as chronic pain. Those providing care for service women should evaluate for MST, chronic pain and pre-military trauma, such as childhood abuse; and aggressively treat these conditions to prevent PTSD and disability. INTRODUCTION A 2014 Government Accountability Office study found that among veterans who experienced military sexual trauma (MST), from 2010 to 2013, post-traumatic stress disorder (PTSD) was the most frequent disability claimed, accounting for 94% of all MST-related claims to the Veterans Administration (VA).1 MST, which includes both sexual assault and sexual harassment is defined by the VA as “Psychological trauma, which in the judgment of the mental health professional employed by the Department resulted from a physical assault or battery of a sexual nature (military sexual assault or MSA2), or sexual harassment (threatening repetitive unsolicited sexual, verbal, or physical contact) while on Active Duty.”3 Recently, 32% of U.S. female veterans surveyed reported experiencing MST during their military career. 11.6% of those surveyed reported “someone used force/threat of force to have sexual contact against their will.”4 In a 2014 DoD report, there was a 53% increase in MSA reported between 2012 and 2013, and from 2013 to 2014 there was an 11% increase in reported MSA – a 70% increase over 2012.5 Approximately, one-quarter of all MSAs are reported6 through official chains. Thus, surveys are conducted to estimate total number of MSAs in a given time period. While reported MSAs have increased in the last several years, estimated MSAs have declined from 26,000 in 2012 to 20,000 in 2014. In 2014, almost 5% of service women reported experiencing MSA, with Naval and Marine Corps service women at highest risk of MSA over other military branches.5 The numerous deleterious effects from MST have been well described4,7,8 and include individual, military and societal costs. In 2012, the total cost of MSA was estimated at 3.6 billion dollars,9 an increase from 2.9 billion dollars in 2010,7 which includes loss of work productivity and health care expenses. Further, MST disrupts unit cohesion and negatively impacts military readiness.10 Veterans experiencing MSA are more likely to have increased rates of depression, alcohol abuse,11 PTSD symptoms,12 and greater mental health and overall health care utilization13 compared to those without a history of MSA. One study showed veteran women with MSA developed PTSD at nine times the rate of those without MSA.14 MST is associated with poor health and increased pain syndromes affecting multiple systems, including neurological, genitourinary, gastrointestinal and musculoskeletal.15 In addition to chronic health problems, veterans with MST have higher rates of homelessness16 and suicide.4 The impact of MST is far-reaching and extends beyond Active Duty, as service members transition into civilian communities and seek medical care through VA, military, or community health care systems. Active Duty service members, with significant health conditions, such as PTSD, may require a disability evaluation (IDES – Integrated Disability Evaluation System) to determine fitness for continued military service. DoD physicians determine which of their service members require IDES based on the member’s health condition and ability to perform military duties consequent to that condition.17 Performance of military duties is evaluated individually for each service member, specific to his/her office, grade, rank, or rating/Military Occupational Specialty (MOS) code, and also includes input from their Command on ability to perform physical readiness tests and specific work duties. Service members with PTSD, able to perform military duties, do not require a disability evaluation and continue serving in the military. For those with disabling injuries and illness during active duty, a consequence of IDES may be medical retirement, prematurely ending the service member’s military career. These individuals are provided compensation, pension, and other benefits as determined by the VA18 and DoD. When Navy and Marine Corps service members are unable to fulfill the full breadth of their military duties, they may be assigned a limited duty status. Limited duty allows injured/ill service members to focus on treatment while military duties are restricted, with the goal of resuming full duties at the end of the limited duty period (typically six months). If the service member is unable to return to full duty after the limited duty period, their physician may refer them into IDES, wherein the member’s ability (“fitness”) to continue military service is adjudicated. IDES evaluations generally follow at least one period of limited duty, although individuals with catastrophic injuries or illness may bypass a limited duty period and enter IDES directly. Alternately, some service members may be given additional limited duty periods if there is a good likelihood of a return to full duty with further treatment. This is the first study, to our knowledge, examining Active Duty women in the military disability evaluation system, IDES, due to PTSD. Most studies in the literature evaluating women in the military with medical conditions either examine those on Active Duty, or as veterans, but not those transitioning out of the military as a result of a health condition. This study evaluates medical records of two groups of Active Duty women obtaining mental health care for PTSD to determine differences in factors, such as demographic and service-related characteristics, PTSD index trauma type, chronic pain, and mental health utilization for those in IDES versus those not in IDES (controls) during a four year period. Our study goals were to: (1) assess for changes in the number of women in IDES for PTSD from 2011 to 2014, (2) compare characteristics of those in IDES to controls, and (3) identify the factors associated with IDES evaluation due to PTSD. METHODS This retrospective case-control study evaluates medical records for service women diagnosed with PTSD between 2011 and 2014 at Naval Medical Center San Diego (NMCSD), a large military treatment facility serving Active Duty, their dependents and retirees in the Southern California region. Selection for cases and controls is shown in Figure 1. Cases were identified as service women (n = 159) in IDES for PTSD. For those in IDES, data were collected from the electronic medical record and from a review of disability reports prepared for IDES purposes. Controls were randomly selected from all service women diagnosed with PTSD, but not in IDES, between 2011 and 2014, to achieve a similar number of controls (n = 163) as those in IDES (n = 159) (Fig. 1). For the controls, only the medical record was reviewed. All service women in the study were diagnosed with PTSD by DoD psychiatrists and/or psychologists. Although subjects did not undergo a standardized Clinician Administered PTSD Scale (CAPS), they each had met with a psychiatrist or psychologist for a comprehensive intake evaluation, during which time a thorough history and mental status exam were conducted. Most were diagnosed with PTSD using DSM-IV19 criteria (IDES 90%, controls 78%); the remainder, using DSM-5.20 Variables collected included demographic (e.g., age, marital status) and service-related information, including service branch, rank, years of service, deployment (yes/no), combat exposure (yes/no), combat as an index trauma for PTSD (yes/no) and service in support of Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) (yes/no). Other variables collected included: childhood abuse (sexual, physical, or mental abuse) before age 18 (yes/no), borderline personality disorder or traits (yes/no), and chronic pain (defined as medical care for any pain condition for more than 6 mo) (yes/no) including, chronic pelvic pain and other chronic pain (e.g., headaches, abdominal pain associated with irritable bowel syndrome, fibromyalgia, back pain and chronic pain syndromes). If the records indicated the presence of MST3, then the number of reported MST events and trauma location (shore or shipboard) were noted. A “shipboard” location was assigned if the MST occurred on a ship, whether deployed or not. All other MSTs were designated “shore”, whether deployed or not. We also reported perpetrator characteristics (Active Duty/civilian, gender), whether the MST3 was a MSA2 or sexual harassment3 and the most recent MST date. The significant trauma(s) responsible for PTSD or index trauma, as recorded by the mental health provider, was noted. These index traumas included: MST(s), combat trauma, “other”, or a combination of traumas. “Other” index trauma preceding PTSD included: domestic violence, childhood abuse, life-threatening experience, significant loss, or a combination of these stressors. Health care utilization included all outpatient mental health visits found in the electronic medical record prior to and during the year of disability evaluation for cases, or prior to and during the year of highest number of mental health visits for controls. Any service woman placed on limited duty for PTSD and subsequently returned to full duty was included in the control group. Figure 1. View largeDownload slide Consort flow diagram – IDES and Controls.1Search: non-civilian woman with outpatient mental health visit for PTSD diagnosis at NMCSD and Branch Clinics between January 1, 2011 and December 31, 2014. 2Inclusion criteria: (1) female Active duty service member obtaining outpatient mental health treatment at NMCSD and/or Branch Clinics between 2011 and 2014, (2) PTSD diagnosis established by a psychiatrist or psychologist using DSM-IV or DSM-5 criteria, and (3) mental health record available for review. 3Exclusion criteria: (1) in IDES (disability system) for a non-PTSD diagnosis, (2) in IDES at a different military treatment facility, (3) in IDES outside study period, and (4) on limited duty during case/control selection. 4Number of controls selected to approximate number of cases in study and matched by year of obtaining the greatest number of mental health visits (controls) to year cases enrolled in IDES (disability system). Figure 1. View largeDownload slide Consort flow diagram – IDES and Controls.1Search: non-civilian woman with outpatient mental health visit for PTSD diagnosis at NMCSD and Branch Clinics between January 1, 2011 and December 31, 2014. 2Inclusion criteria: (1) female Active duty service member obtaining outpatient mental health treatment at NMCSD and/or Branch Clinics between 2011 and 2014, (2) PTSD diagnosis established by a psychiatrist or psychologist using DSM-IV or DSM-5 criteria, and (3) mental health record available for review. 3Exclusion criteria: (1) in IDES (disability system) for a non-PTSD diagnosis, (2) in IDES at a different military treatment facility, (3) in IDES outside study period, and (4) on limited duty during case/control selection. 4Number of controls selected to approximate number of cases in study and matched by year of obtaining the greatest number of mental health visits (controls) to year cases enrolled in IDES (disability system). Records were reviewed and categorized by six M.D., PhD, or MPH-level researchers. Approximately 57% of the data were reviewed by a second researcher as verification to ensure fidelity. The inter-rater reliability ranged from 0.818 to 1, indicating very good agreement among the reviewers. For discrepancies in the reviewed data, both researchers came to a consensus, and the final data were entered for analysis. This study was approved by the NMCSD Institutional Review Board. Means and standard deviations were reported for continuous variables. To statistically test for differences on continuous variables as a function of IDES/control group, a student’s t-test was used. For categorical variables, frequencies and percentages are presented. To statistically test for associations between these categorical variables in IDES/control group, a chi-square test was used. A logistic regression was performed by including individually significant variables from the bivariate analyses (p < 0.05) to determine adjusted odds ratios of being in IDES. Statistical analysis was performed using the Statistical Package for the Social Sciences version 21. RESULTS The number of service women enrolled into IDES for PTSD from 2011–2014 rose steadily and significantly (p = 0.001) when measured against the total number of women in the Navy during the same time period (Fig. 2 , Table I Table I. Naval Service Women in IDES for PTSD, MST-precipitated PTSD in IDES and Controls as a Function of Women in the Navy in Given Year 2011 2012 2013 2014 Total DoD Officer & Enlisted (Navy) 52416 53151 55986 57327 In IDES for PTSD 19 (0.036%) 39 (0.073%) 43 (0.077%) 58 (0.101%) In IDES for MST-precipitated PTSD 14 (0.027%) 21 (0.040%) 38 (0.068%) 44 (0.077%) Controls with PTSD 19 40 46 58 Controls with MST-precipitated PTSD 7 (0.013%) 16 (0.030%) 21 (0.038%) 29 (0.051%) 2011 2012 2013 2014 Total DoD Officer & Enlisted (Navy) 52416 53151 55986 57327 In IDES for PTSD 19 (0.036%) 39 (0.073%) 43 (0.077%) 58 (0.101%) In IDES for MST-precipitated PTSD 14 (0.027%) 21 (0.040%) 38 (0.068%) 44 (0.077%) Controls with PTSD 19 40 46 58 Controls with MST-precipitated PTSD 7 (0.013%) 16 (0.030%) 21 (0.038%) 29 (0.051%) 2011, 2013 and 201421–23; 201223; note we had greater number of controls in 2012 and 2013 than numbers in IDES. Table I. Naval Service Women in IDES for PTSD, MST-precipitated PTSD in IDES and Controls as a Function of Women in the Navy in Given Year 2011 2012 2013 2014 Total DoD Officer & Enlisted (Navy) 52416 53151 55986 57327 In IDES for PTSD 19 (0.036%) 39 (0.073%) 43 (0.077%) 58 (0.101%) In IDES for MST-precipitated PTSD 14 (0.027%) 21 (0.040%) 38 (0.068%) 44 (0.077%) Controls with PTSD 19 40 46 58 Controls with MST-precipitated PTSD 7 (0.013%) 16 (0.030%) 21 (0.038%) 29 (0.051%) 2011 2012 2013 2014 Total DoD Officer & Enlisted (Navy) 52416 53151 55986 57327 In IDES for PTSD 19 (0.036%) 39 (0.073%) 43 (0.077%) 58 (0.101%) In IDES for MST-precipitated PTSD 14 (0.027%) 21 (0.040%) 38 (0.068%) 44 (0.077%) Controls with PTSD 19 40 46 58 Controls with MST-precipitated PTSD 7 (0.013%) 16 (0.030%) 21 (0.038%) 29 (0.051%) 2011, 2013 and 201421–23; 201223; note we had greater number of controls in 2012 and 2013 than numbers in IDES. ).21–23 Figure 2. View largeDownload slide PTSD disability referrals (IDES) for Naval service women at NMCSD from 2011 to 2014, as a function of the total number of women in the Navy for a given year. Comparison of change in proportion from 2011-2014 in IDES for PTSD (p = .001). Figure 2. View largeDownload slide PTSD disability referrals (IDES) for Naval service women at NMCSD from 2011 to 2014, as a function of the total number of women in the Navy for a given year. Comparison of change in proportion from 2011-2014 in IDES for PTSD (p = .001). A comparison of demographic and service-related characteristics by group is given in Table II. The majority of women in both groups were Caucasian (IDES 56.3%, control 47.2%), not married (IDES 66%, control 66.7%), in the Navy (IDES 90.6%, control 84%), and of similar enlisted rank (E6 or below, 91.2% IDES, 87.7% controls). The women in the control group were slightly older (28.5 vs. 26.7 yr, p = 0.039) and had been in the service longer (7.7 vs. 5.6 yr, p = 0.001) than those in IDES. Both groups had equivalent levels of combat exposure (IDES 13.2%, control 19.9%) and deployment history in support of OEF and/or OIF (IDES 25.8%, control 27.3%). The presence of chronic pain was found more frequently in the IDES group than in the control group (40.9% and 19.6%, respectively). Table II. Comparison of IDES vs. Controls Characteristics IDES (159) Controls (163) n (%)a p-Value n (%)a Age (mean, SD) 26.7 (6.8) 28.5 (8.0) 0.039* Race 0.366  Caucasian 89 (56.3) 75 (47.2)  Asian/Pacific Islander 12 (7.6) 9 (5.7)  African American 33 (20.9) 41 (25.8)  Hispanic 16 (10.1) 24 (15.1)  Other 8 (5.1) 10 (6.3) Marital status 0.905  Married 54 (34.0) 54 (33.3)  Not Married 105 (66.0) 108 (66.7) Service branch 0.010*  Navy 144 (90.6) 137 (84.0) 0.079  Marines 15 (9.4) 17 (10.4) 0.765  Other+ 0 (0) 9 (5.5) 0.003* Rank 0.035*  E1–E3 47 (29.6) 48 (29.4) 0.982  E4–E6 98 (61.6) 95 (58.3) 0.539  E7–E9+ 3 (1.9) 14 (8.6) 0.007*  O1–O10 11 (6.9) 6 (3.7) 0.194 Years of service at the time of referral to IDES or comparable MH care (mean, sd) 5.6 (4.9) 7.7 (6.2) 0.001* Status  IDES 159 (100) N/A  RTD from limited duty for PTSD N/A 26 (16.0)  Never on limited duty for PTSD N/A 137 (84.0) Previous trauma prior to age 18 yr 102 (64.2) 108 (66.7) 0.636  Childhood sexual abuse 76 (47.8) 83 (51.2)  Physical/emotional childhood abuse 74 (46.5) 80 (49.4) Total chronic pain 65 (40.9) 32.0 (19.6) <0.001**  Other chronic pain+ 63 (39.6) 27 (16.6) <0.001**  Chronic pelvic pain 15 (9.4) 10 (6.1) 0.269 Significant trauma responsible for PTSD <0.001**  Military Sexual Trauma+# 117 (73.6) 73 (44.8) <0.001**  Combat 18 (11.3) 28 (17.2) 0.133  Other+ 58 (36.5) 92 (56.4) 0.001*  Domestic violence 5 (8.6) 6 (6.5) 0.631  Childhood abuse+ 15 (25.9) 47 (51.1) 0.002*  Life-threatening experience 6 (10.3) 12 (13.0) 0.62  Significant loss 6 (10.3) 14 (15.2) 0.393  Combination+ 23 (39.7) 13 (14.1) <0.001** Deployed 95 (60.1) 115 (70.6) 0.05  Combat exposedb 21 (13.2) 32 (19.9) 0.109  OEF/OIF 41 (25.8) 44 (27.3) 0.755 Location of sexual assault 0.808  Shore 81 (73.0) 50 (74.6)  Shipboard 30 (27.0) 17 (25.4) Number of MST 0.964  Single 76 (65.0) 47 (65.3)  Multiple 41 (35.0) 25 (34.7)  Unknown 0 (0) 1 (1.4) Perpetrator 0.363  Gender not specified 40 (34.2) 32 (41.1)  Malec 75 (64.1) 43 (58.9)  Female with male 2 (1.7) 0 (0)  Active duty 107 (95.5) 56 (93.3) 0.536 Number of mental health visits (mean, sd) 68.6 (47.7) 29.6 (25.4) <0.001** Borderline personality disorder or traits 44 (27.7) 31 (19.0) 0.066 Characteristics IDES (159) Controls (163) n (%)a p-Value n (%)a Age (mean, SD) 26.7 (6.8) 28.5 (8.0) 0.039* Race 0.366  Caucasian 89 (56.3) 75 (47.2)  Asian/Pacific Islander 12 (7.6) 9 (5.7)  African American 33 (20.9) 41 (25.8)  Hispanic 16 (10.1) 24 (15.1)  Other 8 (5.1) 10 (6.3) Marital status 0.905  Married 54 (34.0) 54 (33.3)  Not Married 105 (66.0) 108 (66.7) Service branch 0.010*  Navy 144 (90.6) 137 (84.0) 0.079  Marines 15 (9.4) 17 (10.4) 0.765  Other+ 0 (0) 9 (5.5) 0.003* Rank 0.035*  E1–E3 47 (29.6) 48 (29.4) 0.982  E4–E6 98 (61.6) 95 (58.3) 0.539  E7–E9+ 3 (1.9) 14 (8.6) 0.007*  O1–O10 11 (6.9) 6 (3.7) 0.194 Years of service at the time of referral to IDES or comparable MH care (mean, sd) 5.6 (4.9) 7.7 (6.2) 0.001* Status  IDES 159 (100) N/A  RTD from limited duty for PTSD N/A 26 (16.0)  Never on limited duty for PTSD N/A 137 (84.0) Previous trauma prior to age 18 yr 102 (64.2) 108 (66.7) 0.636  Childhood sexual abuse 76 (47.8) 83 (51.2)  Physical/emotional childhood abuse 74 (46.5) 80 (49.4) Total chronic pain 65 (40.9) 32.0 (19.6) <0.001**  Other chronic pain+ 63 (39.6) 27 (16.6) <0.001**  Chronic pelvic pain 15 (9.4) 10 (6.1) 0.269 Significant trauma responsible for PTSD <0.001**  Military Sexual Trauma+# 117 (73.6) 73 (44.8) <0.001**  Combat 18 (11.3) 28 (17.2) 0.133  Other+ 58 (36.5) 92 (56.4) 0.001*  Domestic violence 5 (8.6) 6 (6.5) 0.631  Childhood abuse+ 15 (25.9) 47 (51.1) 0.002*  Life-threatening experience 6 (10.3) 12 (13.0) 0.62  Significant loss 6 (10.3) 14 (15.2) 0.393  Combination+ 23 (39.7) 13 (14.1) <0.001** Deployed 95 (60.1) 115 (70.6) 0.05  Combat exposedb 21 (13.2) 32 (19.9) 0.109  OEF/OIF 41 (25.8) 44 (27.3) 0.755 Location of sexual assault 0.808  Shore 81 (73.0) 50 (74.6)  Shipboard 30 (27.0) 17 (25.4) Number of MST 0.964  Single 76 (65.0) 47 (65.3)  Multiple 41 (35.0) 25 (34.7)  Unknown 0 (0) 1 (1.4) Perpetrator 0.363  Gender not specified 40 (34.2) 32 (41.1)  Malec 75 (64.1) 43 (58.9)  Female with male 2 (1.7) 0 (0)  Active duty 107 (95.5) 56 (93.3) 0.536 Number of mental health visits (mean, sd) 68.6 (47.7) 29.6 (25.4) <0.001** Borderline personality disorder or traits 44 (27.7) 31 (19.0) 0.066 aPercentages are based on the sample size for each group and exclude individuals with missing data. bParticipant was combat exposed but trauma was not necessarily responsible for PTSD. cWhen gender known 97.5% were males in IDES, and 100% were males in controls. RTD, return to duty. +Significant sub-categories. **Significant p < 0.001; *Significant p < 0.05. #Majority of participants with Military Sexual Trauma was due to military sexual assault (97%), remaining due to sexual harassment (3%). Table II. Comparison of IDES vs. Controls Characteristics IDES (159) Controls (163) n (%)a p-Value n (%)a Age (mean, SD) 26.7 (6.8) 28.5 (8.0) 0.039* Race 0.366  Caucasian 89 (56.3) 75 (47.2)  Asian/Pacific Islander 12 (7.6) 9 (5.7)  African American 33 (20.9) 41 (25.8)  Hispanic 16 (10.1) 24 (15.1)  Other 8 (5.1) 10 (6.3) Marital status 0.905  Married 54 (34.0) 54 (33.3)  Not Married 105 (66.0) 108 (66.7) Service branch 0.010*  Navy 144 (90.6) 137 (84.0) 0.079  Marines 15 (9.4) 17 (10.4) 0.765  Other+ 0 (0) 9 (5.5) 0.003* Rank 0.035*  E1–E3 47 (29.6) 48 (29.4) 0.982  E4–E6 98 (61.6) 95 (58.3) 0.539  E7–E9+ 3 (1.9) 14 (8.6) 0.007*  O1–O10 11 (6.9) 6 (3.7) 0.194 Years of service at the time of referral to IDES or comparable MH care (mean, sd) 5.6 (4.9) 7.7 (6.2) 0.001* Status  IDES 159 (100) N/A  RTD from limited duty for PTSD N/A 26 (16.0)  Never on limited duty for PTSD N/A 137 (84.0) Previous trauma prior to age 18 yr 102 (64.2) 108 (66.7) 0.636  Childhood sexual abuse 76 (47.8) 83 (51.2)  Physical/emotional childhood abuse 74 (46.5) 80 (49.4) Total chronic pain 65 (40.9) 32.0 (19.6) <0.001**  Other chronic pain+ 63 (39.6) 27 (16.6) <0.001**  Chronic pelvic pain 15 (9.4) 10 (6.1) 0.269 Significant trauma responsible for PTSD <0.001**  Military Sexual Trauma+# 117 (73.6) 73 (44.8) <0.001**  Combat 18 (11.3) 28 (17.2) 0.133  Other+ 58 (36.5) 92 (56.4) 0.001*  Domestic violence 5 (8.6) 6 (6.5) 0.631  Childhood abuse+ 15 (25.9) 47 (51.1) 0.002*  Life-threatening experience 6 (10.3) 12 (13.0) 0.62  Significant loss 6 (10.3) 14 (15.2) 0.393  Combination+ 23 (39.7) 13 (14.1) <0.001** Deployed 95 (60.1) 115 (70.6) 0.05  Combat exposedb 21 (13.2) 32 (19.9) 0.109  OEF/OIF 41 (25.8) 44 (27.3) 0.755 Location of sexual assault 0.808  Shore 81 (73.0) 50 (74.6)  Shipboard 30 (27.0) 17 (25.4) Number of MST 0.964  Single 76 (65.0) 47 (65.3)  Multiple 41 (35.0) 25 (34.7)  Unknown 0 (0) 1 (1.4) Perpetrator 0.363  Gender not specified 40 (34.2) 32 (41.1)  Malec 75 (64.1) 43 (58.9)  Female with male 2 (1.7) 0 (0)  Active duty 107 (95.5) 56 (93.3) 0.536 Number of mental health visits (mean, sd) 68.6 (47.7) 29.6 (25.4) <0.001** Borderline personality disorder or traits 44 (27.7) 31 (19.0) 0.066 Characteristics IDES (159) Controls (163) n (%)a p-Value n (%)a Age (mean, SD) 26.7 (6.8) 28.5 (8.0) 0.039* Race 0.366  Caucasian 89 (56.3) 75 (47.2)  Asian/Pacific Islander 12 (7.6) 9 (5.7)  African American 33 (20.9) 41 (25.8)  Hispanic 16 (10.1) 24 (15.1)  Other 8 (5.1) 10 (6.3) Marital status 0.905  Married 54 (34.0) 54 (33.3)  Not Married 105 (66.0) 108 (66.7) Service branch 0.010*  Navy 144 (90.6) 137 (84.0) 0.079  Marines 15 (9.4) 17 (10.4) 0.765  Other+ 0 (0) 9 (5.5) 0.003* Rank 0.035*  E1–E3 47 (29.6) 48 (29.4) 0.982  E4–E6 98 (61.6) 95 (58.3) 0.539  E7–E9+ 3 (1.9) 14 (8.6) 0.007*  O1–O10 11 (6.9) 6 (3.7) 0.194 Years of service at the time of referral to IDES or comparable MH care (mean, sd) 5.6 (4.9) 7.7 (6.2) 0.001* Status  IDES 159 (100) N/A  RTD from limited duty for PTSD N/A 26 (16.0)  Never on limited duty for PTSD N/A 137 (84.0) Previous trauma prior to age 18 yr 102 (64.2) 108 (66.7) 0.636  Childhood sexual abuse 76 (47.8) 83 (51.2)  Physical/emotional childhood abuse 74 (46.5) 80 (49.4) Total chronic pain 65 (40.9) 32.0 (19.6) <0.001**  Other chronic pain+ 63 (39.6) 27 (16.6) <0.001**  Chronic pelvic pain 15 (9.4) 10 (6.1) 0.269 Significant trauma responsible for PTSD <0.001**  Military Sexual Trauma+# 117 (73.6) 73 (44.8) <0.001**  Combat 18 (11.3) 28 (17.2) 0.133  Other+ 58 (36.5) 92 (56.4) 0.001*  Domestic violence 5 (8.6) 6 (6.5) 0.631  Childhood abuse+ 15 (25.9) 47 (51.1) 0.002*  Life-threatening experience 6 (10.3) 12 (13.0) 0.62  Significant loss 6 (10.3) 14 (15.2) 0.393  Combination+ 23 (39.7) 13 (14.1) <0.001** Deployed 95 (60.1) 115 (70.6) 0.05  Combat exposedb 21 (13.2) 32 (19.9) 0.109  OEF/OIF 41 (25.8) 44 (27.3) 0.755 Location of sexual assault 0.808  Shore 81 (73.0) 50 (74.6)  Shipboard 30 (27.0) 17 (25.4) Number of MST 0.964  Single 76 (65.0) 47 (65.3)  Multiple 41 (35.0) 25 (34.7)  Unknown 0 (0) 1 (1.4) Perpetrator 0.363  Gender not specified 40 (34.2) 32 (41.1)  Malec 75 (64.1) 43 (58.9)  Female with male 2 (1.7) 0 (0)  Active duty 107 (95.5) 56 (93.3) 0.536 Number of mental health visits (mean, sd) 68.6 (47.7) 29.6 (25.4) <0.001** Borderline personality disorder or traits 44 (27.7) 31 (19.0) 0.066 aPercentages are based on the sample size for each group and exclude individuals with missing data. bParticipant was combat exposed but trauma was not necessarily responsible for PTSD. cWhen gender known 97.5% were males in IDES, and 100% were males in controls. RTD, return to duty. +Significant sub-categories. **Significant p < 0.001; *Significant p < 0.05. #Majority of participants with Military Sexual Trauma was due to military sexual assault (97%), remaining due to sexual harassment (3%). More women in IDES had PTSD following MST (73.6%) than those in the control group (44.8%). The majority of MSTs in both groups were single events (65%), perpetrated by an Active Duty male (IDES 97.5%, controls 100%; when gender specified) on shore (IDES 73%, control 74.6%). Approximately 65% of both groups had a history of childhood abuse, but those in the control group had PTSD subsequent to childhood abuse more frequently (51.1% vs. 25.9%) than those in IDES. The number of mental health visits was higher in the IDES (m = 68.6) versus control group (m = 29.6). Most of the controls were never on limited duty for PTSD (84%) and 16% of the controls that were on limited duty for PTSD returned to full duty thereafter. Before using the statistically significant variables from Table II as predictors in the logistic regression model, collinearity among potential predictors was first assessed. Redundancy was evident among age, years of service, and rank. Age and years of service were strongly correlated (r = 0.86, p < 0.001); strong effect sizes were also evident for the relationship between rank and both age and years of service (η = 0.64 and 0.65, respectively, both p’s <0.001). Given this collinearity, only years of service were included as a predictor in the logistic regression analysis. The logistic regression model included IDES for PTSD as the dependent variable and service branch, years of service at the time of referral into IDES or comparable mental health care, MST, total chronic pain, number of mental health visits, and childhood abuse associated with PTSD as the independent variables (all p’s < 0.05) (Table III) Table III. Logistic Regression of Likelihood of Association with IDES vs Controls IDES (Yes = 1) B SE Wald Sig. Odds Ratio Exp(B) Years of service −0.066 0.039 2.879 0.090 0.936 MST 0.958 0.448 4.577 0.032* 2.606 Total chronic pain 0.959 0.501 3.667 0.055 2.610 Number of mental health visits 0.034 0.007 20.953 0.000** 1.035 Childhood abuse −1.228 0.451 7.430 0.006* 0.293 Service branch (Marines vs. Navy) 0.784 0.668 1.376 0.241 2.190 Service branch (Others vs. Navy) 20.691 27697.83 0.000 0.999 0.000 Constant −1.735 0.511 11.524 0.001 0.176 IDES (Yes = 1) B SE Wald Sig. Odds Ratio Exp(B) Years of service −0.066 0.039 2.879 0.090 0.936 MST 0.958 0.448 4.577 0.032* 2.606 Total chronic pain 0.959 0.501 3.667 0.055 2.610 Number of mental health visits 0.034 0.007 20.953 0.000** 1.035 Childhood abuse −1.228 0.451 7.430 0.006* 0.293 Service branch (Marines vs. Navy) 0.784 0.668 1.376 0.241 2.190 Service branch (Others vs. Navy) 20.691 27697.83 0.000 0.999 0.000 Constant −1.735 0.511 11.524 0.001 0.176 *p < 0.05; **p < 0.001. Table III. Logistic Regression of Likelihood of Association with IDES vs Controls IDES (Yes = 1) B SE Wald Sig. Odds Ratio Exp(B) Years of service −0.066 0.039 2.879 0.090 0.936 MST 0.958 0.448 4.577 0.032* 2.606 Total chronic pain 0.959 0.501 3.667 0.055 2.610 Number of mental health visits 0.034 0.007 20.953 0.000** 1.035 Childhood abuse −1.228 0.451 7.430 0.006* 0.293 Service branch (Marines vs. Navy) 0.784 0.668 1.376 0.241 2.190 Service branch (Others vs. Navy) 20.691 27697.83 0.000 0.999 0.000 Constant −1.735 0.511 11.524 0.001 0.176 IDES (Yes = 1) B SE Wald Sig. Odds Ratio Exp(B) Years of service −0.066 0.039 2.879 0.090 0.936 MST 0.958 0.448 4.577 0.032* 2.606 Total chronic pain 0.959 0.501 3.667 0.055 2.610 Number of mental health visits 0.034 0.007 20.953 0.000** 1.035 Childhood abuse −1.228 0.451 7.430 0.006* 0.293 Service branch (Marines vs. Navy) 0.784 0.668 1.376 0.241 2.190 Service branch (Others vs. Navy) 20.691 27697.83 0.000 0.999 0.000 Constant −1.735 0.511 11.524 0.001 0.176 *p < 0.05; **p < 0.001. . The full model was statistically significant (Nagelkerke R2 = 0.452, p < 0.001). After adjusting for other predictors, MST (B = 0.958, OR 2.6, p = 0.032) and mental health visits (B = 0.034, OR 1.04, p < 0.001) were positively associated with IDES inclusion. PTSD due to childhood abuse was negatively associated with IDES inclusion (B = −1.228, OR 0.293, p = 0.006). DISCUSSION From 2011 to 2014, we found an increased rate of disability evaluation for PTSD, the majority subsequent to MST (Table I). This upward trend in disability evaluation (IDES) for PTSD may reflect the known military-wide rise in MSA in recent years.4 MST-type was categorized similarly in both groups: 97% as MSA and 3% as sexual harassment. This level of MSA is significantly greater than most previous reports.4,5 Booth et al8 found female veterans with PTSD symptoms reported military rape as the experience that affected them more than other types of trauma. Certain factors associated with MSA characterize this trauma as unique. These factors include: perpetrators are usually fellow Active Duty service members (>85%)7, a military co-worker (49%),7 or in the victim’s chain-of-command (23%)7; assault reporting and prosecution handled through the military chain-of-command23; and fear of retaliation.24 Following an MST, co-location of the perpetrator with the victim,25 a sense of betrayal26 and impaired unit cohesion27 may contribute to the development of PTSD and occupational dysfunction. Overall, the rates of E1-E6 service women in our study were higher (91.2% IDES, 87.7% controls) than in the global Navy community (74.5%).22 Additional analysis by rank showed a lower representation of officer to enlisted ratios in our study (1:13.5 IDES, 1:26.2 Controls) compared with the Navy as a whole (1 officer: 5.2 enlisted).22 We know officers are not immune to experiencing MSA and believe higher rank may be a proxy for factors such as socio-economic status, educational achievement, type of duties assigned, work setting, and degree of power and influence relative to enlisted service members, potentially conferring some protection from PTSD development. Further, much is known about general stigma towards mental health care in the military, and this is felt to be that much more palpable in higher ranking enlisted service members, and amongst officers. A 2016 study by Yamawaki et al28 reviewed the 2012 Workplace and Gender Relations Survey of Active Duty service members and revealed that being female, or an officer, are significant predictors for greater stigma associated with seeking mental health care in the military. Other significant predictors of greater stigma included: lower satisfaction toward leaders, coworkers, and one’s work. In that all of these are frequently present in victims of MSA, we believe that this stigma might disproportionately cause those of higher rank to avoid reporting this traumatic experience. Childhood abuse, as an index trauma for PTSD, was more frequent in the control group and negatively predicted inclusion in the IDES group. Levels of previous childhood abuse in our overall sample were twice that seen in studies that included larger samples of veteran women29, but similar to a 2011 study of veteran women receiving inpatient mental health care.30 Childhood abuse was the most frequent PTSD index trauma in the control group (51.1%), followed by MST (44.8%). While previous research has shown early childhood trauma may increase the risk of having further trauma or PTSD development in adulthood,31 others have examined resiliency in childhood trauma survivors.30 Those with greater resiliency may be less likely to develop mental illness or functional impairment as a result of childhood trauma.30 Resiliency may be one reason why service women with PTSD secondary to childhood abuse required disability evaluation less frequently than those with other trauma types. Survivors of childhood abuse, as a function of the passage of time from the inciting event, may have also developed coping skills or engaged in treatment, both potentially mitigating the functional impact of that childhood abuse. Deployment history, MST and perpetrator characteristics were comparable in both groups. Women in both groups had similarly served in support of Operation Enduring Freedom and/or Operation Iraqi Freedom and had similar combat exposure history. Service women in the control group had slightly more deployments compared to those in IDES (p = 0.050). Although most MSTs were single events up to 35% of women experienced multiple MSTs. Sadler et al32 have shown that MST recurrence is not uncommon if there has been a previous MST, and reported 37% of women acknowledged rape at least twice during military service. It is noteworthy that 25% of the MSTs occurred shipboard, despite the probability of other service members being near. Most (75%) MSTs, however, occurred on a shore location, whether deployed or not. In our study, women in IDES for PTSD, in large part subsequent to MST, had more than twice the number of mental health visits compared to controls. Possible reasons for greater mental health care utilization in the IDES group include (1) more women having MST, the majority of which was MSA; (2) PTSD severity, resistance to treatment and interaction with other chronic conditions; (3) increased access to health care through sexual assault response coordinators and victim advocates; and (4) potential greater compliance with mental health treatment as a consequence of LIMDU and IDES status. Koss et al33 found women who have been victims of violent assault have increased medical utilization and in the National Health and Resilience in Veterans Study,4 MST was found to be an independent predictor of mental health care utilization. Increased mental health visits for those in IDES beyond those seen in the control group could serve as a marker of more resistant PTSD symptoms, and lead to a closer examination of other factors preventing wellness, including untreated chronic pain. Access to health care may be another reason for increased mental health visits in the IDES group. In recent years, there has been a greater focus on MSA training across the DoD. This training includes information about services and care available for sexual assault victims through victim advocate and sexual assault response coordinators.7 It is possible that access to services has improved due to these efforts and resulted in increased mental health visits over previous years. Trauma severity, comorbid conditions, such as chronic pain, and access to care may be a few reasons why more women in the IDES group had increased mental health visits. In the univariate analysis, women in IDES with PTSD more frequently had chronic pain (all types) than those in the control group (IDES 40.9%, control 19.6%). Pain syndromes and poorer overall health are associated with MST.15 Female veterans with PTSD, rape either in the military or post-military, chronic pain, or a history of childhood sexual assault have been shown to have significantly worse physical health status than those without these conditions.29 In our multivariate analysis, however, chronic pain did not significantly increase the likelihood of inclusion in IDES for women with PTSD. This could be for multiple reasons, including varying pain severity and functionality, temporal relationship of pain to PTSD onset, and pain treatment types and response, none of which are accounted for in this study. Additionally, it is possible those with significant pain syndromes may have entered IDES as a result of the pain condition, rather than PTSD, and would not have been included in this study. Although this study elucidated several important findings on the topic of PTSD and IDES, several limitations of the study should be noted. All contributing factors to MST and PTSD (e.g., alcohol use at the time of assault, secondary victimization, and involvement in the military’s legal process) were not elicited as they were inconsistently reported in the medical records reviewed. Our measured “years in service” may have varied by as much as 11 mo depending on when records were reviewed (e.g., earlier vs. later in the same calendar year). These differences would have averaged out over the 322 cases reviewed and should be seen as relative, rather than precise measurements. It is likely that treatment varied for study participants thereby influencing the severity and/or chronicity of PTSD; however, it was not the purpose of this study to evaluate treatments provided for the study population. To mitigate this, we matched cases against controls by the year they obtained mental health care, as these groups were most likely provided similar evidence-based treatment in the same military environment. Health care utilization included the number of outpatient mental health visits only and not inpatient, emergency department visits, or non-mental health outpatient visits – most likely underestimating total health care utilization. Higher numbers of mental health visits may be associated with a higher severity of illness and not necessarily the type of index trauma. We selected our controls from service women obtaining care from 2011 to 2014 for PTSD and realize that some of these individuals may require disability evaluation in the future. Women transitioning out of the military, as a consequence of IDES, have compensation and benefits determined by the VA. Future studies should be directed at these veterans to determine if PTSD severity, chronic illness and ability to perform work or attain higher education improve post-military, and whether factors such as (1) compensation and pension resulting from IDES and (2) access to health care through the VA or other health care system are associated with improved outcomes. Prospective, multicenter studies should be conducted evaluating the scope of PTSD preceded by MST in service members and those factors leading to disability and medical retirement from Active Duty. These studies should focus on (1) factors associated with continued service (resiliency); (2) institutional military barriers and provider behaviors towards those with MST and PTSD, and, particularly those in the IDES process; and (3) service member’s loss of military connectedness and potential clinical factors inhibiting PTSD remission. Understanding factors promoting wellness over disability in these women may be helpful to improving resiliency in those with MST and PTSD. We acknowledge men also experience MST and PTSD and hope similar research is conducted to evaluate the impact of these factors on continued military service. Prospective studies are needed evaluating MST outcomes, such as PTSD and disability evaluation, in all service members. We recognize that such study would be difficult given the high numbers of MST that go unreported. It could be worthwhile to study whether a multidisciplinary approach, integrating mental health, primary care, physical therapy and other specialties can prevent the onset of PTSD or consequent disability for those with chronic pain, particularly with a history of MST. Research should be done evaluating early intensive treatment for those who have suffered an MST, particularly if younger, lower ranking or with a history of significant pre-military trauma, e.g., childhood abuse, and its effect on PTSD development and occupational dysfunction. In conclusion, the recent rise in rates of disability evaluation for PTSD with a MST index trauma is of great concern. PTSD subsequent to MST has numerous personal repercussions in addition to a negative economic impact and impaired military readiness. We believe MST prevention and education, both on shore and shipboard locations, resiliency building and timely evaluation and treatment of chronic pain, MST, and PTSD, in particular for younger enlisted service members, may help reduce the number of women requiring disability evaluation in the future. Acknowledgements The authors wish to thank CDR Jeffrey Millegan, MD, (Naval Center for Combat & Operational Stress Control (NCCOSC)) for his critical review of the manuscript, Mr Jeffrey Hayworth (Ret Commander, USN) for encouragement to undertake this study, and Dr Scott Roesch (NCCOSC) for his consultation and guidance with statistical analysis. CDR Millegan, Mr Hayworth and Dr Roesch have no conflicts of interest to declare. Previous Presentations (oral) Institute on Violence, Abuse and Trauma, 8/30/2016, San Diego, CA Naval Medical Center San Diego Academic Research Competition, 4/21/2017, San Diego, CA REFERENCES 1 Military Sexual Trauma. Improvements made but VA can do more to track and improve the consistency of disability claim decisions. In: Requesters USGAoRtC, ed 2014 . Available at https://www.gao.gov/products/GAO-14-477; accessed October 16, 2016. 2 Sexual Assault Prevention and Response (SAPR) Program. Number 6495.01 In. Available at https://www.hsdl.org/?view&did=761622; accessed March 9, 2017 . 3 Title 38 US Code 1720D:261. In. Available at https://www.gpo.gov/fdsys/pkg/USCODE-2011-title38/pdf/USCODE-2011-title38-partII-chap17-subchapII-sec1720D.pdf; accessed February 14, 2017 . 4 Klingensmith K , Tsai J , Mota N , Southwick SM , Pietrzak RH : Military sexual trauma in US veterans: results from the National Health and Resilience in Veterans Study . J Clin Psychiatry 2014 ; 75 ( 10 ): e1133 – 9 . Google Scholar CrossRef Search ADS PubMed 5 Bicksler B , Farris C , Dastidar MG , et al. : Sexual assault and sexual harassment in the U.S. Military. In: Morral A, R., Gore K, Schell T, eds.2014. Available at http://sapr.mil/public/docs/reports/FY14_Annual/FY14_Annual_Report_Annex_1_RAND.pdf; accessed August 3, 2015 . 6 DoD Releases FY15 Annual Report on Sexual Assault in the Military. In: Defense USDo, ed 2016 . Available at http://sapr.mil/public/docs/reports/FY15_Annual/FY15_Annual_Report_on_Sexual_Assault_in_the_Military.pdf; accessed February 15, 2017. 7 Farris C , Schell TL , Tanielian T : Physical and psychological health following military sexual trauma. 2013 . http://www.rand.org/content/dam/rand/pubs/occasional_papers/OP300/OP382/RAND_OP382.pdf; accessed August 15, 2016. 8 Booth BM , Mengeling M , Torner J , Sadler AG : Rape, sex partnership, and substance use consequences in women veterans . J Trauma Stress 2011 ; 24 ( 3 ): 287 – 94 . Google Scholar CrossRef Search ADS PubMed 9 Farris C , Schell TL , Tanielian T : Enemy within. military sexual assault inflicts physical, psychological, financial pain. In: Rand Corporation; 2013. Available at https://www.rand.org/pubs/periodicals/rand-review/issues/2013/summer/enemy-within.html; accessed February 15, 2017. 10 Sexual Assault in the Military . 2013 Statutory Enforcement Report. In: 2013: 238. Available at http://www.usccr.gov/pubs/09242013_Statutory_Enforcement_Report_Sexual_Assault_in_the_Military.pdf; accessed February 15, 2017. 11 Hankin CS , Skinner KM , Sullivan LM , Miller DR , Frayne S , Tripp TJ : Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military . J Trauma Stress 1999 ; 12 ( 4 ): 601 – 12 . Google Scholar CrossRef Search ADS PubMed 12 Kessler RC , Sonnega A , Bromet E , Hughes M , Nelson CB : Posttraumatic stress disorder in the National Comorbidity Survey . Arch Gen Psychiatry 1995 ; 52 ( 12 ): 1048 – 60 . Google Scholar CrossRef Search ADS PubMed 13 Golding JM , Stein JA , Siegel JM , Burnam MA , Sorenson SB : Sexual assault history and use of health and mental health services . Am J Community Psychol 1988 ; 16 ( 5 ): 625 – 44 . Google Scholar CrossRef Search ADS PubMed 14 Surís A , Lind L , Kashner TM , Borman PD , Petty F : Sexual assault in women veterans: an examination of PTSD risk, health care utilization, and cost of care . Psychosom Med 2004 ; 66 ( 5 ): 749 – 56 . Google Scholar CrossRef Search ADS PubMed 15 O’Brien BS , Sher L : Military sexual trauma as a determinant in the development of mental and physical illness in male and female veterans . Int J Adolesc Med Health 2013 ; 25 ( 3 ): 269 – 74 . Google Scholar PubMed 16 Decker SE , Rosenheck RA , Tsai J , Hoff R , Harpaz-Rotem I : Military sexual assault and homeless women veterans: clinical correlates and treatment preferences . Womens Health Issues 2013 ; 23 ( 6 ): e373 – 380 . Google Scholar CrossRef Search ADS PubMed 17 DON disability evaluation system (DES) summary. SECNAVINST 1850.4E. In: Navy US, ed. Washington, DC2002. Available at http://www.secnav.navy.mil/mra/CORB/Documents/SECNAV%20INST%201850_4e.pdf; accessed August 15, 2016 . 18 38 U.S.C §§1110 and 1131 - Basic Entitlement. In: Office USGP, ed. Vol Supplement 5. 2006 Edition ed: U.S. Government Publishing Office. Available at https://www.gpo.gov/fdsys/pkg/USCODE-2011-title38/pdf/USCODE-2011-title38.pdf; accessed February 15, 2017. 19 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, pp 463 – 468 . Washington, DC, American Psychiatric Association , 2000 . 20 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, pp 271–280. Arlington, VA, American Psychiatric Association , 2013. 21 DoD Personnel, Workforce Reports and Publications. https://www.dmdc.osd.mil/appj/dwp/dwp_reports.jsp; Active Duty Military Personnel by Service by Rank/Grade (Updated Monthly) FY 2001-FY 2011 (Women Only); Excel tab 1109f for FY 2011; accessed August 10, 2017. 22 2013 Demographics. Profile of the Military Community. In:2013. http://download.militaryonesource.mil/12038/MOS/Reports/2013-Demographics-Report.pdf; page 17; accessed June 29, 2015 . 23 DoD Instruction 5505.18. In:Jan 25, 2013 . Available at http://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/550518p.pdf; accessed November 2, 2017. 24 Morral AR , Gore KL : Sexual Assault and Sexual Harassment in the Military: Top-line Estimates for Active Duty Service Members from the 2014 RAND Military Workplace Study.In:2014. Available at https://www.rand.org/content/dam/rand/pubs/research_reports/RR800/RR870/RAND_RR870.pdf; accessed November 2, 2017. 25 Surìs A , Lind L , Kashner TM , Borman PD : Mental health, quality of life, and health functioning in women veterans: differential outcomes associated with military and civilian sexual assault . J Interpers Violence 2007 ; 22 ( 2 ): 179 – 97 . Google Scholar CrossRef Search ADS PubMed 26 Kelley LP , Weathers FW , Mason EA , Pruneau GM : Association of life threat and betrayal with posttraumatic stress disorder symptom severity . J Trauma Stress 2012 ; 25 ( 4 ): 408 – 15 . Google Scholar CrossRef Search ADS PubMed 27 Laws H , Mazure CM , McKee SA , Park CL , Hoff R : Within-unit relationship quality mediates the association between military sexual trauma and posttraumatic stress symptoms in veterans separating from military service . Psychol Trauma 2016 ; 8 ( 5 ): 649 – 56 . Google Scholar CrossRef Search ADS PubMed 28 Yamawaki N , Kelly C , Dresden BE , Busath GL , Riley CE : The predictive effects of work environment on stigma toward and practical concerns for seeking mental health services . Mil Med 2016 ; 181 ( 11 ): e1546 – 52 . Google Scholar CrossRef Search ADS PubMed 29 Booth BM , Davis TD , Cheney AM , Mengeling MA , Torner JC , Sadler AG : Physical health status of female veterans: contributions of sex partnership and in-military rape . Psychosom Med 2012 ; 74 ( 9 ): 916 – 24 . Google Scholar CrossRef Search ADS PubMed 30 Kelly UA , Skelton K , Patel M , Bradley B : More than military sexual trauma: interpersonal violence, PTSD, and mental health in women veterans . Res Nurs Health 2011 ; 34 ( 6 ): 457 – 67 . Google Scholar CrossRef Search ADS PubMed 31 Schumm JA , Briggs-Phillips M , Hobfoll SE : Cumulative interpersonal traumas and social support as risk and resiliency factors in predicting PTSD and depression among inner-city women . J Trauma Stress 2006 ; 19 ( 6 ): 825 – 36 . Google Scholar CrossRef Search ADS PubMed 32 Sadler AG , Booth BM , Cook BL , Doebbeling BN : Factors associated with women’s risk of rape in the military environment . Am J Ind Med 2003 ; 43 ( 3 ): 262 – 73 . Google Scholar CrossRef Search ADS PubMed 33 Koss MP , Koss PG , Woodruff WJ : Deleterious effects of criminal victimization on women’s health and medical utilization . Arch Intern Med 1991 ; 151 ( 2 ): 342 – 7 . Google Scholar CrossRef Search ADS PubMed Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Loading next page...
 
/lp/ou_press/sexual-assault-and-disabling-ptsd-in-active-duty-service-women-uAZUUMOch0
Publisher
Association of Military Surgeons of the United States
Copyright
Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.
ISSN
0026-4075
eISSN
1930-613X
D.O.I.
10.1093/milmed/usy048
Publisher site
See Article on Publisher Site

Abstract

Abstract Introduction Sexual assault in the military is a major concern and may result in significant health problems, such as post-traumatic stress disorder (PTSD). Those developing disabling PTSD symptoms may require a disability evaluation. We examined disability evaluation trends for service women with PTSD to better understand characteristics associated with inability to continue Active Duty service. Methods This is a retrospective review of disability reports and electronic medical records for 322 Active Duty women diagnosed with and treated for PTSD by psychiatrists and psychologists at a large military treatment facility between 2011 and 2014. Service women requiring medical disability evaluation for PTSD (n = 159) were included in the study as “IDES cases” (Integrated Disability Evaluation System – IDES). A similar number of women, randomly selected from those seeking care for PTSD but not requiring disability evaluation during the same period, were included in the “control” group (n = 163). Analyzes done to evaluate differences between groups (IDES cases vs. controls) included demographic and service-related characteristics, history of chronic pain, and PTSD index trauma types, such as pre-military trauma and military sexual trauma (MST). Logistic regression was performed to identify the factors associated with inclusion in IDES. Results MST was the most frequent PTSD index trauma in the IDES group (73.6% vs. 44.8% of control group) and the most significant factor associated with IDES inclusion (OR 2.6, p = 0.032). Those in the IDES group had significantly greater number of mental health visits for PTSD (IDES: m = 68.6 vs. controls: m = 29.6) and more frequent chronic pain history (IDES 40.9% vs. controls 19.6%) than those in the control group. Approximately 65% of women in both groups had a history of childhood abuse, but childhood abuse, as a PTSD index trauma, was negatively associated with IDES inclusion (OR 0.293, p = 0.006). Conclusions Active Duty service women with PTSD and a MST index trauma are much more likely to require disability evaluation (IDES) than those with PTSD due to other trauma types. IDES evaluation for conditions such as PTSD may result in early termination of military service and is a potential downstream consequence of MST. Service women requiring greater numbers of mental health visits for PTSD treatment may benefit from a multidisciplinary approach to treating concurrent health conditions, such as chronic pain. Those providing care for service women should evaluate for MST, chronic pain and pre-military trauma, such as childhood abuse; and aggressively treat these conditions to prevent PTSD and disability. INTRODUCTION A 2014 Government Accountability Office study found that among veterans who experienced military sexual trauma (MST), from 2010 to 2013, post-traumatic stress disorder (PTSD) was the most frequent disability claimed, accounting for 94% of all MST-related claims to the Veterans Administration (VA).1 MST, which includes both sexual assault and sexual harassment is defined by the VA as “Psychological trauma, which in the judgment of the mental health professional employed by the Department resulted from a physical assault or battery of a sexual nature (military sexual assault or MSA2), or sexual harassment (threatening repetitive unsolicited sexual, verbal, or physical contact) while on Active Duty.”3 Recently, 32% of U.S. female veterans surveyed reported experiencing MST during their military career. 11.6% of those surveyed reported “someone used force/threat of force to have sexual contact against their will.”4 In a 2014 DoD report, there was a 53% increase in MSA reported between 2012 and 2013, and from 2013 to 2014 there was an 11% increase in reported MSA – a 70% increase over 2012.5 Approximately, one-quarter of all MSAs are reported6 through official chains. Thus, surveys are conducted to estimate total number of MSAs in a given time period. While reported MSAs have increased in the last several years, estimated MSAs have declined from 26,000 in 2012 to 20,000 in 2014. In 2014, almost 5% of service women reported experiencing MSA, with Naval and Marine Corps service women at highest risk of MSA over other military branches.5 The numerous deleterious effects from MST have been well described4,7,8 and include individual, military and societal costs. In 2012, the total cost of MSA was estimated at 3.6 billion dollars,9 an increase from 2.9 billion dollars in 2010,7 which includes loss of work productivity and health care expenses. Further, MST disrupts unit cohesion and negatively impacts military readiness.10 Veterans experiencing MSA are more likely to have increased rates of depression, alcohol abuse,11 PTSD symptoms,12 and greater mental health and overall health care utilization13 compared to those without a history of MSA. One study showed veteran women with MSA developed PTSD at nine times the rate of those without MSA.14 MST is associated with poor health and increased pain syndromes affecting multiple systems, including neurological, genitourinary, gastrointestinal and musculoskeletal.15 In addition to chronic health problems, veterans with MST have higher rates of homelessness16 and suicide.4 The impact of MST is far-reaching and extends beyond Active Duty, as service members transition into civilian communities and seek medical care through VA, military, or community health care systems. Active Duty service members, with significant health conditions, such as PTSD, may require a disability evaluation (IDES – Integrated Disability Evaluation System) to determine fitness for continued military service. DoD physicians determine which of their service members require IDES based on the member’s health condition and ability to perform military duties consequent to that condition.17 Performance of military duties is evaluated individually for each service member, specific to his/her office, grade, rank, or rating/Military Occupational Specialty (MOS) code, and also includes input from their Command on ability to perform physical readiness tests and specific work duties. Service members with PTSD, able to perform military duties, do not require a disability evaluation and continue serving in the military. For those with disabling injuries and illness during active duty, a consequence of IDES may be medical retirement, prematurely ending the service member’s military career. These individuals are provided compensation, pension, and other benefits as determined by the VA18 and DoD. When Navy and Marine Corps service members are unable to fulfill the full breadth of their military duties, they may be assigned a limited duty status. Limited duty allows injured/ill service members to focus on treatment while military duties are restricted, with the goal of resuming full duties at the end of the limited duty period (typically six months). If the service member is unable to return to full duty after the limited duty period, their physician may refer them into IDES, wherein the member’s ability (“fitness”) to continue military service is adjudicated. IDES evaluations generally follow at least one period of limited duty, although individuals with catastrophic injuries or illness may bypass a limited duty period and enter IDES directly. Alternately, some service members may be given additional limited duty periods if there is a good likelihood of a return to full duty with further treatment. This is the first study, to our knowledge, examining Active Duty women in the military disability evaluation system, IDES, due to PTSD. Most studies in the literature evaluating women in the military with medical conditions either examine those on Active Duty, or as veterans, but not those transitioning out of the military as a result of a health condition. This study evaluates medical records of two groups of Active Duty women obtaining mental health care for PTSD to determine differences in factors, such as demographic and service-related characteristics, PTSD index trauma type, chronic pain, and mental health utilization for those in IDES versus those not in IDES (controls) during a four year period. Our study goals were to: (1) assess for changes in the number of women in IDES for PTSD from 2011 to 2014, (2) compare characteristics of those in IDES to controls, and (3) identify the factors associated with IDES evaluation due to PTSD. METHODS This retrospective case-control study evaluates medical records for service women diagnosed with PTSD between 2011 and 2014 at Naval Medical Center San Diego (NMCSD), a large military treatment facility serving Active Duty, their dependents and retirees in the Southern California region. Selection for cases and controls is shown in Figure 1. Cases were identified as service women (n = 159) in IDES for PTSD. For those in IDES, data were collected from the electronic medical record and from a review of disability reports prepared for IDES purposes. Controls were randomly selected from all service women diagnosed with PTSD, but not in IDES, between 2011 and 2014, to achieve a similar number of controls (n = 163) as those in IDES (n = 159) (Fig. 1). For the controls, only the medical record was reviewed. All service women in the study were diagnosed with PTSD by DoD psychiatrists and/or psychologists. Although subjects did not undergo a standardized Clinician Administered PTSD Scale (CAPS), they each had met with a psychiatrist or psychologist for a comprehensive intake evaluation, during which time a thorough history and mental status exam were conducted. Most were diagnosed with PTSD using DSM-IV19 criteria (IDES 90%, controls 78%); the remainder, using DSM-5.20 Variables collected included demographic (e.g., age, marital status) and service-related information, including service branch, rank, years of service, deployment (yes/no), combat exposure (yes/no), combat as an index trauma for PTSD (yes/no) and service in support of Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) (yes/no). Other variables collected included: childhood abuse (sexual, physical, or mental abuse) before age 18 (yes/no), borderline personality disorder or traits (yes/no), and chronic pain (defined as medical care for any pain condition for more than 6 mo) (yes/no) including, chronic pelvic pain and other chronic pain (e.g., headaches, abdominal pain associated with irritable bowel syndrome, fibromyalgia, back pain and chronic pain syndromes). If the records indicated the presence of MST3, then the number of reported MST events and trauma location (shore or shipboard) were noted. A “shipboard” location was assigned if the MST occurred on a ship, whether deployed or not. All other MSTs were designated “shore”, whether deployed or not. We also reported perpetrator characteristics (Active Duty/civilian, gender), whether the MST3 was a MSA2 or sexual harassment3 and the most recent MST date. The significant trauma(s) responsible for PTSD or index trauma, as recorded by the mental health provider, was noted. These index traumas included: MST(s), combat trauma, “other”, or a combination of traumas. “Other” index trauma preceding PTSD included: domestic violence, childhood abuse, life-threatening experience, significant loss, or a combination of these stressors. Health care utilization included all outpatient mental health visits found in the electronic medical record prior to and during the year of disability evaluation for cases, or prior to and during the year of highest number of mental health visits for controls. Any service woman placed on limited duty for PTSD and subsequently returned to full duty was included in the control group. Figure 1. View largeDownload slide Consort flow diagram – IDES and Controls.1Search: non-civilian woman with outpatient mental health visit for PTSD diagnosis at NMCSD and Branch Clinics between January 1, 2011 and December 31, 2014. 2Inclusion criteria: (1) female Active duty service member obtaining outpatient mental health treatment at NMCSD and/or Branch Clinics between 2011 and 2014, (2) PTSD diagnosis established by a psychiatrist or psychologist using DSM-IV or DSM-5 criteria, and (3) mental health record available for review. 3Exclusion criteria: (1) in IDES (disability system) for a non-PTSD diagnosis, (2) in IDES at a different military treatment facility, (3) in IDES outside study period, and (4) on limited duty during case/control selection. 4Number of controls selected to approximate number of cases in study and matched by year of obtaining the greatest number of mental health visits (controls) to year cases enrolled in IDES (disability system). Figure 1. View largeDownload slide Consort flow diagram – IDES and Controls.1Search: non-civilian woman with outpatient mental health visit for PTSD diagnosis at NMCSD and Branch Clinics between January 1, 2011 and December 31, 2014. 2Inclusion criteria: (1) female Active duty service member obtaining outpatient mental health treatment at NMCSD and/or Branch Clinics between 2011 and 2014, (2) PTSD diagnosis established by a psychiatrist or psychologist using DSM-IV or DSM-5 criteria, and (3) mental health record available for review. 3Exclusion criteria: (1) in IDES (disability system) for a non-PTSD diagnosis, (2) in IDES at a different military treatment facility, (3) in IDES outside study period, and (4) on limited duty during case/control selection. 4Number of controls selected to approximate number of cases in study and matched by year of obtaining the greatest number of mental health visits (controls) to year cases enrolled in IDES (disability system). Records were reviewed and categorized by six M.D., PhD, or MPH-level researchers. Approximately 57% of the data were reviewed by a second researcher as verification to ensure fidelity. The inter-rater reliability ranged from 0.818 to 1, indicating very good agreement among the reviewers. For discrepancies in the reviewed data, both researchers came to a consensus, and the final data were entered for analysis. This study was approved by the NMCSD Institutional Review Board. Means and standard deviations were reported for continuous variables. To statistically test for differences on continuous variables as a function of IDES/control group, a student’s t-test was used. For categorical variables, frequencies and percentages are presented. To statistically test for associations between these categorical variables in IDES/control group, a chi-square test was used. A logistic regression was performed by including individually significant variables from the bivariate analyses (p < 0.05) to determine adjusted odds ratios of being in IDES. Statistical analysis was performed using the Statistical Package for the Social Sciences version 21. RESULTS The number of service women enrolled into IDES for PTSD from 2011–2014 rose steadily and significantly (p = 0.001) when measured against the total number of women in the Navy during the same time period (Fig. 2 , Table I Table I. Naval Service Women in IDES for PTSD, MST-precipitated PTSD in IDES and Controls as a Function of Women in the Navy in Given Year 2011 2012 2013 2014 Total DoD Officer & Enlisted (Navy) 52416 53151 55986 57327 In IDES for PTSD 19 (0.036%) 39 (0.073%) 43 (0.077%) 58 (0.101%) In IDES for MST-precipitated PTSD 14 (0.027%) 21 (0.040%) 38 (0.068%) 44 (0.077%) Controls with PTSD 19 40 46 58 Controls with MST-precipitated PTSD 7 (0.013%) 16 (0.030%) 21 (0.038%) 29 (0.051%) 2011 2012 2013 2014 Total DoD Officer & Enlisted (Navy) 52416 53151 55986 57327 In IDES for PTSD 19 (0.036%) 39 (0.073%) 43 (0.077%) 58 (0.101%) In IDES for MST-precipitated PTSD 14 (0.027%) 21 (0.040%) 38 (0.068%) 44 (0.077%) Controls with PTSD 19 40 46 58 Controls with MST-precipitated PTSD 7 (0.013%) 16 (0.030%) 21 (0.038%) 29 (0.051%) 2011, 2013 and 201421–23; 201223; note we had greater number of controls in 2012 and 2013 than numbers in IDES. Table I. Naval Service Women in IDES for PTSD, MST-precipitated PTSD in IDES and Controls as a Function of Women in the Navy in Given Year 2011 2012 2013 2014 Total DoD Officer & Enlisted (Navy) 52416 53151 55986 57327 In IDES for PTSD 19 (0.036%) 39 (0.073%) 43 (0.077%) 58 (0.101%) In IDES for MST-precipitated PTSD 14 (0.027%) 21 (0.040%) 38 (0.068%) 44 (0.077%) Controls with PTSD 19 40 46 58 Controls with MST-precipitated PTSD 7 (0.013%) 16 (0.030%) 21 (0.038%) 29 (0.051%) 2011 2012 2013 2014 Total DoD Officer & Enlisted (Navy) 52416 53151 55986 57327 In IDES for PTSD 19 (0.036%) 39 (0.073%) 43 (0.077%) 58 (0.101%) In IDES for MST-precipitated PTSD 14 (0.027%) 21 (0.040%) 38 (0.068%) 44 (0.077%) Controls with PTSD 19 40 46 58 Controls with MST-precipitated PTSD 7 (0.013%) 16 (0.030%) 21 (0.038%) 29 (0.051%) 2011, 2013 and 201421–23; 201223; note we had greater number of controls in 2012 and 2013 than numbers in IDES. ).21–23 Figure 2. View largeDownload slide PTSD disability referrals (IDES) for Naval service women at NMCSD from 2011 to 2014, as a function of the total number of women in the Navy for a given year. Comparison of change in proportion from 2011-2014 in IDES for PTSD (p = .001). Figure 2. View largeDownload slide PTSD disability referrals (IDES) for Naval service women at NMCSD from 2011 to 2014, as a function of the total number of women in the Navy for a given year. Comparison of change in proportion from 2011-2014 in IDES for PTSD (p = .001). A comparison of demographic and service-related characteristics by group is given in Table II. The majority of women in both groups were Caucasian (IDES 56.3%, control 47.2%), not married (IDES 66%, control 66.7%), in the Navy (IDES 90.6%, control 84%), and of similar enlisted rank (E6 or below, 91.2% IDES, 87.7% controls). The women in the control group were slightly older (28.5 vs. 26.7 yr, p = 0.039) and had been in the service longer (7.7 vs. 5.6 yr, p = 0.001) than those in IDES. Both groups had equivalent levels of combat exposure (IDES 13.2%, control 19.9%) and deployment history in support of OEF and/or OIF (IDES 25.8%, control 27.3%). The presence of chronic pain was found more frequently in the IDES group than in the control group (40.9% and 19.6%, respectively). Table II. Comparison of IDES vs. Controls Characteristics IDES (159) Controls (163) n (%)a p-Value n (%)a Age (mean, SD) 26.7 (6.8) 28.5 (8.0) 0.039* Race 0.366  Caucasian 89 (56.3) 75 (47.2)  Asian/Pacific Islander 12 (7.6) 9 (5.7)  African American 33 (20.9) 41 (25.8)  Hispanic 16 (10.1) 24 (15.1)  Other 8 (5.1) 10 (6.3) Marital status 0.905  Married 54 (34.0) 54 (33.3)  Not Married 105 (66.0) 108 (66.7) Service branch 0.010*  Navy 144 (90.6) 137 (84.0) 0.079  Marines 15 (9.4) 17 (10.4) 0.765  Other+ 0 (0) 9 (5.5) 0.003* Rank 0.035*  E1–E3 47 (29.6) 48 (29.4) 0.982  E4–E6 98 (61.6) 95 (58.3) 0.539  E7–E9+ 3 (1.9) 14 (8.6) 0.007*  O1–O10 11 (6.9) 6 (3.7) 0.194 Years of service at the time of referral to IDES or comparable MH care (mean, sd) 5.6 (4.9) 7.7 (6.2) 0.001* Status  IDES 159 (100) N/A  RTD from limited duty for PTSD N/A 26 (16.0)  Never on limited duty for PTSD N/A 137 (84.0) Previous trauma prior to age 18 yr 102 (64.2) 108 (66.7) 0.636  Childhood sexual abuse 76 (47.8) 83 (51.2)  Physical/emotional childhood abuse 74 (46.5) 80 (49.4) Total chronic pain 65 (40.9) 32.0 (19.6) <0.001**  Other chronic pain+ 63 (39.6) 27 (16.6) <0.001**  Chronic pelvic pain 15 (9.4) 10 (6.1) 0.269 Significant trauma responsible for PTSD <0.001**  Military Sexual Trauma+# 117 (73.6) 73 (44.8) <0.001**  Combat 18 (11.3) 28 (17.2) 0.133  Other+ 58 (36.5) 92 (56.4) 0.001*  Domestic violence 5 (8.6) 6 (6.5) 0.631  Childhood abuse+ 15 (25.9) 47 (51.1) 0.002*  Life-threatening experience 6 (10.3) 12 (13.0) 0.62  Significant loss 6 (10.3) 14 (15.2) 0.393  Combination+ 23 (39.7) 13 (14.1) <0.001** Deployed 95 (60.1) 115 (70.6) 0.05  Combat exposedb 21 (13.2) 32 (19.9) 0.109  OEF/OIF 41 (25.8) 44 (27.3) 0.755 Location of sexual assault 0.808  Shore 81 (73.0) 50 (74.6)  Shipboard 30 (27.0) 17 (25.4) Number of MST 0.964  Single 76 (65.0) 47 (65.3)  Multiple 41 (35.0) 25 (34.7)  Unknown 0 (0) 1 (1.4) Perpetrator 0.363  Gender not specified 40 (34.2) 32 (41.1)  Malec 75 (64.1) 43 (58.9)  Female with male 2 (1.7) 0 (0)  Active duty 107 (95.5) 56 (93.3) 0.536 Number of mental health visits (mean, sd) 68.6 (47.7) 29.6 (25.4) <0.001** Borderline personality disorder or traits 44 (27.7) 31 (19.0) 0.066 Characteristics IDES (159) Controls (163) n (%)a p-Value n (%)a Age (mean, SD) 26.7 (6.8) 28.5 (8.0) 0.039* Race 0.366  Caucasian 89 (56.3) 75 (47.2)  Asian/Pacific Islander 12 (7.6) 9 (5.7)  African American 33 (20.9) 41 (25.8)  Hispanic 16 (10.1) 24 (15.1)  Other 8 (5.1) 10 (6.3) Marital status 0.905  Married 54 (34.0) 54 (33.3)  Not Married 105 (66.0) 108 (66.7) Service branch 0.010*  Navy 144 (90.6) 137 (84.0) 0.079  Marines 15 (9.4) 17 (10.4) 0.765  Other+ 0 (0) 9 (5.5) 0.003* Rank 0.035*  E1–E3 47 (29.6) 48 (29.4) 0.982  E4–E6 98 (61.6) 95 (58.3) 0.539  E7–E9+ 3 (1.9) 14 (8.6) 0.007*  O1–O10 11 (6.9) 6 (3.7) 0.194 Years of service at the time of referral to IDES or comparable MH care (mean, sd) 5.6 (4.9) 7.7 (6.2) 0.001* Status  IDES 159 (100) N/A  RTD from limited duty for PTSD N/A 26 (16.0)  Never on limited duty for PTSD N/A 137 (84.0) Previous trauma prior to age 18 yr 102 (64.2) 108 (66.7) 0.636  Childhood sexual abuse 76 (47.8) 83 (51.2)  Physical/emotional childhood abuse 74 (46.5) 80 (49.4) Total chronic pain 65 (40.9) 32.0 (19.6) <0.001**  Other chronic pain+ 63 (39.6) 27 (16.6) <0.001**  Chronic pelvic pain 15 (9.4) 10 (6.1) 0.269 Significant trauma responsible for PTSD <0.001**  Military Sexual Trauma+# 117 (73.6) 73 (44.8) <0.001**  Combat 18 (11.3) 28 (17.2) 0.133  Other+ 58 (36.5) 92 (56.4) 0.001*  Domestic violence 5 (8.6) 6 (6.5) 0.631  Childhood abuse+ 15 (25.9) 47 (51.1) 0.002*  Life-threatening experience 6 (10.3) 12 (13.0) 0.62  Significant loss 6 (10.3) 14 (15.2) 0.393  Combination+ 23 (39.7) 13 (14.1) <0.001** Deployed 95 (60.1) 115 (70.6) 0.05  Combat exposedb 21 (13.2) 32 (19.9) 0.109  OEF/OIF 41 (25.8) 44 (27.3) 0.755 Location of sexual assault 0.808  Shore 81 (73.0) 50 (74.6)  Shipboard 30 (27.0) 17 (25.4) Number of MST 0.964  Single 76 (65.0) 47 (65.3)  Multiple 41 (35.0) 25 (34.7)  Unknown 0 (0) 1 (1.4) Perpetrator 0.363  Gender not specified 40 (34.2) 32 (41.1)  Malec 75 (64.1) 43 (58.9)  Female with male 2 (1.7) 0 (0)  Active duty 107 (95.5) 56 (93.3) 0.536 Number of mental health visits (mean, sd) 68.6 (47.7) 29.6 (25.4) <0.001** Borderline personality disorder or traits 44 (27.7) 31 (19.0) 0.066 aPercentages are based on the sample size for each group and exclude individuals with missing data. bParticipant was combat exposed but trauma was not necessarily responsible for PTSD. cWhen gender known 97.5% were males in IDES, and 100% were males in controls. RTD, return to duty. +Significant sub-categories. **Significant p < 0.001; *Significant p < 0.05. #Majority of participants with Military Sexual Trauma was due to military sexual assault (97%), remaining due to sexual harassment (3%). Table II. Comparison of IDES vs. Controls Characteristics IDES (159) Controls (163) n (%)a p-Value n (%)a Age (mean, SD) 26.7 (6.8) 28.5 (8.0) 0.039* Race 0.366  Caucasian 89 (56.3) 75 (47.2)  Asian/Pacific Islander 12 (7.6) 9 (5.7)  African American 33 (20.9) 41 (25.8)  Hispanic 16 (10.1) 24 (15.1)  Other 8 (5.1) 10 (6.3) Marital status 0.905  Married 54 (34.0) 54 (33.3)  Not Married 105 (66.0) 108 (66.7) Service branch 0.010*  Navy 144 (90.6) 137 (84.0) 0.079  Marines 15 (9.4) 17 (10.4) 0.765  Other+ 0 (0) 9 (5.5) 0.003* Rank 0.035*  E1–E3 47 (29.6) 48 (29.4) 0.982  E4–E6 98 (61.6) 95 (58.3) 0.539  E7–E9+ 3 (1.9) 14 (8.6) 0.007*  O1–O10 11 (6.9) 6 (3.7) 0.194 Years of service at the time of referral to IDES or comparable MH care (mean, sd) 5.6 (4.9) 7.7 (6.2) 0.001* Status  IDES 159 (100) N/A  RTD from limited duty for PTSD N/A 26 (16.0)  Never on limited duty for PTSD N/A 137 (84.0) Previous trauma prior to age 18 yr 102 (64.2) 108 (66.7) 0.636  Childhood sexual abuse 76 (47.8) 83 (51.2)  Physical/emotional childhood abuse 74 (46.5) 80 (49.4) Total chronic pain 65 (40.9) 32.0 (19.6) <0.001**  Other chronic pain+ 63 (39.6) 27 (16.6) <0.001**  Chronic pelvic pain 15 (9.4) 10 (6.1) 0.269 Significant trauma responsible for PTSD <0.001**  Military Sexual Trauma+# 117 (73.6) 73 (44.8) <0.001**  Combat 18 (11.3) 28 (17.2) 0.133  Other+ 58 (36.5) 92 (56.4) 0.001*  Domestic violence 5 (8.6) 6 (6.5) 0.631  Childhood abuse+ 15 (25.9) 47 (51.1) 0.002*  Life-threatening experience 6 (10.3) 12 (13.0) 0.62  Significant loss 6 (10.3) 14 (15.2) 0.393  Combination+ 23 (39.7) 13 (14.1) <0.001** Deployed 95 (60.1) 115 (70.6) 0.05  Combat exposedb 21 (13.2) 32 (19.9) 0.109  OEF/OIF 41 (25.8) 44 (27.3) 0.755 Location of sexual assault 0.808  Shore 81 (73.0) 50 (74.6)  Shipboard 30 (27.0) 17 (25.4) Number of MST 0.964  Single 76 (65.0) 47 (65.3)  Multiple 41 (35.0) 25 (34.7)  Unknown 0 (0) 1 (1.4) Perpetrator 0.363  Gender not specified 40 (34.2) 32 (41.1)  Malec 75 (64.1) 43 (58.9)  Female with male 2 (1.7) 0 (0)  Active duty 107 (95.5) 56 (93.3) 0.536 Number of mental health visits (mean, sd) 68.6 (47.7) 29.6 (25.4) <0.001** Borderline personality disorder or traits 44 (27.7) 31 (19.0) 0.066 Characteristics IDES (159) Controls (163) n (%)a p-Value n (%)a Age (mean, SD) 26.7 (6.8) 28.5 (8.0) 0.039* Race 0.366  Caucasian 89 (56.3) 75 (47.2)  Asian/Pacific Islander 12 (7.6) 9 (5.7)  African American 33 (20.9) 41 (25.8)  Hispanic 16 (10.1) 24 (15.1)  Other 8 (5.1) 10 (6.3) Marital status 0.905  Married 54 (34.0) 54 (33.3)  Not Married 105 (66.0) 108 (66.7) Service branch 0.010*  Navy 144 (90.6) 137 (84.0) 0.079  Marines 15 (9.4) 17 (10.4) 0.765  Other+ 0 (0) 9 (5.5) 0.003* Rank 0.035*  E1–E3 47 (29.6) 48 (29.4) 0.982  E4–E6 98 (61.6) 95 (58.3) 0.539  E7–E9+ 3 (1.9) 14 (8.6) 0.007*  O1–O10 11 (6.9) 6 (3.7) 0.194 Years of service at the time of referral to IDES or comparable MH care (mean, sd) 5.6 (4.9) 7.7 (6.2) 0.001* Status  IDES 159 (100) N/A  RTD from limited duty for PTSD N/A 26 (16.0)  Never on limited duty for PTSD N/A 137 (84.0) Previous trauma prior to age 18 yr 102 (64.2) 108 (66.7) 0.636  Childhood sexual abuse 76 (47.8) 83 (51.2)  Physical/emotional childhood abuse 74 (46.5) 80 (49.4) Total chronic pain 65 (40.9) 32.0 (19.6) <0.001**  Other chronic pain+ 63 (39.6) 27 (16.6) <0.001**  Chronic pelvic pain 15 (9.4) 10 (6.1) 0.269 Significant trauma responsible for PTSD <0.001**  Military Sexual Trauma+# 117 (73.6) 73 (44.8) <0.001**  Combat 18 (11.3) 28 (17.2) 0.133  Other+ 58 (36.5) 92 (56.4) 0.001*  Domestic violence 5 (8.6) 6 (6.5) 0.631  Childhood abuse+ 15 (25.9) 47 (51.1) 0.002*  Life-threatening experience 6 (10.3) 12 (13.0) 0.62  Significant loss 6 (10.3) 14 (15.2) 0.393  Combination+ 23 (39.7) 13 (14.1) <0.001** Deployed 95 (60.1) 115 (70.6) 0.05  Combat exposedb 21 (13.2) 32 (19.9) 0.109  OEF/OIF 41 (25.8) 44 (27.3) 0.755 Location of sexual assault 0.808  Shore 81 (73.0) 50 (74.6)  Shipboard 30 (27.0) 17 (25.4) Number of MST 0.964  Single 76 (65.0) 47 (65.3)  Multiple 41 (35.0) 25 (34.7)  Unknown 0 (0) 1 (1.4) Perpetrator 0.363  Gender not specified 40 (34.2) 32 (41.1)  Malec 75 (64.1) 43 (58.9)  Female with male 2 (1.7) 0 (0)  Active duty 107 (95.5) 56 (93.3) 0.536 Number of mental health visits (mean, sd) 68.6 (47.7) 29.6 (25.4) <0.001** Borderline personality disorder or traits 44 (27.7) 31 (19.0) 0.066 aPercentages are based on the sample size for each group and exclude individuals with missing data. bParticipant was combat exposed but trauma was not necessarily responsible for PTSD. cWhen gender known 97.5% were males in IDES, and 100% were males in controls. RTD, return to duty. +Significant sub-categories. **Significant p < 0.001; *Significant p < 0.05. #Majority of participants with Military Sexual Trauma was due to military sexual assault (97%), remaining due to sexual harassment (3%). More women in IDES had PTSD following MST (73.6%) than those in the control group (44.8%). The majority of MSTs in both groups were single events (65%), perpetrated by an Active Duty male (IDES 97.5%, controls 100%; when gender specified) on shore (IDES 73%, control 74.6%). Approximately 65% of both groups had a history of childhood abuse, but those in the control group had PTSD subsequent to childhood abuse more frequently (51.1% vs. 25.9%) than those in IDES. The number of mental health visits was higher in the IDES (m = 68.6) versus control group (m = 29.6). Most of the controls were never on limited duty for PTSD (84%) and 16% of the controls that were on limited duty for PTSD returned to full duty thereafter. Before using the statistically significant variables from Table II as predictors in the logistic regression model, collinearity among potential predictors was first assessed. Redundancy was evident among age, years of service, and rank. Age and years of service were strongly correlated (r = 0.86, p < 0.001); strong effect sizes were also evident for the relationship between rank and both age and years of service (η = 0.64 and 0.65, respectively, both p’s <0.001). Given this collinearity, only years of service were included as a predictor in the logistic regression analysis. The logistic regression model included IDES for PTSD as the dependent variable and service branch, years of service at the time of referral into IDES or comparable mental health care, MST, total chronic pain, number of mental health visits, and childhood abuse associated with PTSD as the independent variables (all p’s < 0.05) (Table III) Table III. Logistic Regression of Likelihood of Association with IDES vs Controls IDES (Yes = 1) B SE Wald Sig. Odds Ratio Exp(B) Years of service −0.066 0.039 2.879 0.090 0.936 MST 0.958 0.448 4.577 0.032* 2.606 Total chronic pain 0.959 0.501 3.667 0.055 2.610 Number of mental health visits 0.034 0.007 20.953 0.000** 1.035 Childhood abuse −1.228 0.451 7.430 0.006* 0.293 Service branch (Marines vs. Navy) 0.784 0.668 1.376 0.241 2.190 Service branch (Others vs. Navy) 20.691 27697.83 0.000 0.999 0.000 Constant −1.735 0.511 11.524 0.001 0.176 IDES (Yes = 1) B SE Wald Sig. Odds Ratio Exp(B) Years of service −0.066 0.039 2.879 0.090 0.936 MST 0.958 0.448 4.577 0.032* 2.606 Total chronic pain 0.959 0.501 3.667 0.055 2.610 Number of mental health visits 0.034 0.007 20.953 0.000** 1.035 Childhood abuse −1.228 0.451 7.430 0.006* 0.293 Service branch (Marines vs. Navy) 0.784 0.668 1.376 0.241 2.190 Service branch (Others vs. Navy) 20.691 27697.83 0.000 0.999 0.000 Constant −1.735 0.511 11.524 0.001 0.176 *p < 0.05; **p < 0.001. Table III. Logistic Regression of Likelihood of Association with IDES vs Controls IDES (Yes = 1) B SE Wald Sig. Odds Ratio Exp(B) Years of service −0.066 0.039 2.879 0.090 0.936 MST 0.958 0.448 4.577 0.032* 2.606 Total chronic pain 0.959 0.501 3.667 0.055 2.610 Number of mental health visits 0.034 0.007 20.953 0.000** 1.035 Childhood abuse −1.228 0.451 7.430 0.006* 0.293 Service branch (Marines vs. Navy) 0.784 0.668 1.376 0.241 2.190 Service branch (Others vs. Navy) 20.691 27697.83 0.000 0.999 0.000 Constant −1.735 0.511 11.524 0.001 0.176 IDES (Yes = 1) B SE Wald Sig. Odds Ratio Exp(B) Years of service −0.066 0.039 2.879 0.090 0.936 MST 0.958 0.448 4.577 0.032* 2.606 Total chronic pain 0.959 0.501 3.667 0.055 2.610 Number of mental health visits 0.034 0.007 20.953 0.000** 1.035 Childhood abuse −1.228 0.451 7.430 0.006* 0.293 Service branch (Marines vs. Navy) 0.784 0.668 1.376 0.241 2.190 Service branch (Others vs. Navy) 20.691 27697.83 0.000 0.999 0.000 Constant −1.735 0.511 11.524 0.001 0.176 *p < 0.05; **p < 0.001. . The full model was statistically significant (Nagelkerke R2 = 0.452, p < 0.001). After adjusting for other predictors, MST (B = 0.958, OR 2.6, p = 0.032) and mental health visits (B = 0.034, OR 1.04, p < 0.001) were positively associated with IDES inclusion. PTSD due to childhood abuse was negatively associated with IDES inclusion (B = −1.228, OR 0.293, p = 0.006). DISCUSSION From 2011 to 2014, we found an increased rate of disability evaluation for PTSD, the majority subsequent to MST (Table I). This upward trend in disability evaluation (IDES) for PTSD may reflect the known military-wide rise in MSA in recent years.4 MST-type was categorized similarly in both groups: 97% as MSA and 3% as sexual harassment. This level of MSA is significantly greater than most previous reports.4,5 Booth et al8 found female veterans with PTSD symptoms reported military rape as the experience that affected them more than other types of trauma. Certain factors associated with MSA characterize this trauma as unique. These factors include: perpetrators are usually fellow Active Duty service members (>85%)7, a military co-worker (49%),7 or in the victim’s chain-of-command (23%)7; assault reporting and prosecution handled through the military chain-of-command23; and fear of retaliation.24 Following an MST, co-location of the perpetrator with the victim,25 a sense of betrayal26 and impaired unit cohesion27 may contribute to the development of PTSD and occupational dysfunction. Overall, the rates of E1-E6 service women in our study were higher (91.2% IDES, 87.7% controls) than in the global Navy community (74.5%).22 Additional analysis by rank showed a lower representation of officer to enlisted ratios in our study (1:13.5 IDES, 1:26.2 Controls) compared with the Navy as a whole (1 officer: 5.2 enlisted).22 We know officers are not immune to experiencing MSA and believe higher rank may be a proxy for factors such as socio-economic status, educational achievement, type of duties assigned, work setting, and degree of power and influence relative to enlisted service members, potentially conferring some protection from PTSD development. Further, much is known about general stigma towards mental health care in the military, and this is felt to be that much more palpable in higher ranking enlisted service members, and amongst officers. A 2016 study by Yamawaki et al28 reviewed the 2012 Workplace and Gender Relations Survey of Active Duty service members and revealed that being female, or an officer, are significant predictors for greater stigma associated with seeking mental health care in the military. Other significant predictors of greater stigma included: lower satisfaction toward leaders, coworkers, and one’s work. In that all of these are frequently present in victims of MSA, we believe that this stigma might disproportionately cause those of higher rank to avoid reporting this traumatic experience. Childhood abuse, as an index trauma for PTSD, was more frequent in the control group and negatively predicted inclusion in the IDES group. Levels of previous childhood abuse in our overall sample were twice that seen in studies that included larger samples of veteran women29, but similar to a 2011 study of veteran women receiving inpatient mental health care.30 Childhood abuse was the most frequent PTSD index trauma in the control group (51.1%), followed by MST (44.8%). While previous research has shown early childhood trauma may increase the risk of having further trauma or PTSD development in adulthood,31 others have examined resiliency in childhood trauma survivors.30 Those with greater resiliency may be less likely to develop mental illness or functional impairment as a result of childhood trauma.30 Resiliency may be one reason why service women with PTSD secondary to childhood abuse required disability evaluation less frequently than those with other trauma types. Survivors of childhood abuse, as a function of the passage of time from the inciting event, may have also developed coping skills or engaged in treatment, both potentially mitigating the functional impact of that childhood abuse. Deployment history, MST and perpetrator characteristics were comparable in both groups. Women in both groups had similarly served in support of Operation Enduring Freedom and/or Operation Iraqi Freedom and had similar combat exposure history. Service women in the control group had slightly more deployments compared to those in IDES (p = 0.050). Although most MSTs were single events up to 35% of women experienced multiple MSTs. Sadler et al32 have shown that MST recurrence is not uncommon if there has been a previous MST, and reported 37% of women acknowledged rape at least twice during military service. It is noteworthy that 25% of the MSTs occurred shipboard, despite the probability of other service members being near. Most (75%) MSTs, however, occurred on a shore location, whether deployed or not. In our study, women in IDES for PTSD, in large part subsequent to MST, had more than twice the number of mental health visits compared to controls. Possible reasons for greater mental health care utilization in the IDES group include (1) more women having MST, the majority of which was MSA; (2) PTSD severity, resistance to treatment and interaction with other chronic conditions; (3) increased access to health care through sexual assault response coordinators and victim advocates; and (4) potential greater compliance with mental health treatment as a consequence of LIMDU and IDES status. Koss et al33 found women who have been victims of violent assault have increased medical utilization and in the National Health and Resilience in Veterans Study,4 MST was found to be an independent predictor of mental health care utilization. Increased mental health visits for those in IDES beyond those seen in the control group could serve as a marker of more resistant PTSD symptoms, and lead to a closer examination of other factors preventing wellness, including untreated chronic pain. Access to health care may be another reason for increased mental health visits in the IDES group. In recent years, there has been a greater focus on MSA training across the DoD. This training includes information about services and care available for sexual assault victims through victim advocate and sexual assault response coordinators.7 It is possible that access to services has improved due to these efforts and resulted in increased mental health visits over previous years. Trauma severity, comorbid conditions, such as chronic pain, and access to care may be a few reasons why more women in the IDES group had increased mental health visits. In the univariate analysis, women in IDES with PTSD more frequently had chronic pain (all types) than those in the control group (IDES 40.9%, control 19.6%). Pain syndromes and poorer overall health are associated with MST.15 Female veterans with PTSD, rape either in the military or post-military, chronic pain, or a history of childhood sexual assault have been shown to have significantly worse physical health status than those without these conditions.29 In our multivariate analysis, however, chronic pain did not significantly increase the likelihood of inclusion in IDES for women with PTSD. This could be for multiple reasons, including varying pain severity and functionality, temporal relationship of pain to PTSD onset, and pain treatment types and response, none of which are accounted for in this study. Additionally, it is possible those with significant pain syndromes may have entered IDES as a result of the pain condition, rather than PTSD, and would not have been included in this study. Although this study elucidated several important findings on the topic of PTSD and IDES, several limitations of the study should be noted. All contributing factors to MST and PTSD (e.g., alcohol use at the time of assault, secondary victimization, and involvement in the military’s legal process) were not elicited as they were inconsistently reported in the medical records reviewed. Our measured “years in service” may have varied by as much as 11 mo depending on when records were reviewed (e.g., earlier vs. later in the same calendar year). These differences would have averaged out over the 322 cases reviewed and should be seen as relative, rather than precise measurements. It is likely that treatment varied for study participants thereby influencing the severity and/or chronicity of PTSD; however, it was not the purpose of this study to evaluate treatments provided for the study population. To mitigate this, we matched cases against controls by the year they obtained mental health care, as these groups were most likely provided similar evidence-based treatment in the same military environment. Health care utilization included the number of outpatient mental health visits only and not inpatient, emergency department visits, or non-mental health outpatient visits – most likely underestimating total health care utilization. Higher numbers of mental health visits may be associated with a higher severity of illness and not necessarily the type of index trauma. We selected our controls from service women obtaining care from 2011 to 2014 for PTSD and realize that some of these individuals may require disability evaluation in the future. Women transitioning out of the military, as a consequence of IDES, have compensation and benefits determined by the VA. Future studies should be directed at these veterans to determine if PTSD severity, chronic illness and ability to perform work or attain higher education improve post-military, and whether factors such as (1) compensation and pension resulting from IDES and (2) access to health care through the VA or other health care system are associated with improved outcomes. Prospective, multicenter studies should be conducted evaluating the scope of PTSD preceded by MST in service members and those factors leading to disability and medical retirement from Active Duty. These studies should focus on (1) factors associated with continued service (resiliency); (2) institutional military barriers and provider behaviors towards those with MST and PTSD, and, particularly those in the IDES process; and (3) service member’s loss of military connectedness and potential clinical factors inhibiting PTSD remission. Understanding factors promoting wellness over disability in these women may be helpful to improving resiliency in those with MST and PTSD. We acknowledge men also experience MST and PTSD and hope similar research is conducted to evaluate the impact of these factors on continued military service. Prospective studies are needed evaluating MST outcomes, such as PTSD and disability evaluation, in all service members. We recognize that such study would be difficult given the high numbers of MST that go unreported. It could be worthwhile to study whether a multidisciplinary approach, integrating mental health, primary care, physical therapy and other specialties can prevent the onset of PTSD or consequent disability for those with chronic pain, particularly with a history of MST. Research should be done evaluating early intensive treatment for those who have suffered an MST, particularly if younger, lower ranking or with a history of significant pre-military trauma, e.g., childhood abuse, and its effect on PTSD development and occupational dysfunction. In conclusion, the recent rise in rates of disability evaluation for PTSD with a MST index trauma is of great concern. PTSD subsequent to MST has numerous personal repercussions in addition to a negative economic impact and impaired military readiness. We believe MST prevention and education, both on shore and shipboard locations, resiliency building and timely evaluation and treatment of chronic pain, MST, and PTSD, in particular for younger enlisted service members, may help reduce the number of women requiring disability evaluation in the future. Acknowledgements The authors wish to thank CDR Jeffrey Millegan, MD, (Naval Center for Combat & Operational Stress Control (NCCOSC)) for his critical review of the manuscript, Mr Jeffrey Hayworth (Ret Commander, USN) for encouragement to undertake this study, and Dr Scott Roesch (NCCOSC) for his consultation and guidance with statistical analysis. CDR Millegan, Mr Hayworth and Dr Roesch have no conflicts of interest to declare. Previous Presentations (oral) Institute on Violence, Abuse and Trauma, 8/30/2016, San Diego, CA Naval Medical Center San Diego Academic Research Competition, 4/21/2017, San Diego, CA REFERENCES 1 Military Sexual Trauma. Improvements made but VA can do more to track and improve the consistency of disability claim decisions. In: Requesters USGAoRtC, ed 2014 . Available at https://www.gao.gov/products/GAO-14-477; accessed October 16, 2016. 2 Sexual Assault Prevention and Response (SAPR) Program. Number 6495.01 In. Available at https://www.hsdl.org/?view&did=761622; accessed March 9, 2017 . 3 Title 38 US Code 1720D:261. In. Available at https://www.gpo.gov/fdsys/pkg/USCODE-2011-title38/pdf/USCODE-2011-title38-partII-chap17-subchapII-sec1720D.pdf; accessed February 14, 2017 . 4 Klingensmith K , Tsai J , Mota N , Southwick SM , Pietrzak RH : Military sexual trauma in US veterans: results from the National Health and Resilience in Veterans Study . J Clin Psychiatry 2014 ; 75 ( 10 ): e1133 – 9 . Google Scholar CrossRef Search ADS PubMed 5 Bicksler B , Farris C , Dastidar MG , et al. : Sexual assault and sexual harassment in the U.S. Military. In: Morral A, R., Gore K, Schell T, eds.2014. Available at http://sapr.mil/public/docs/reports/FY14_Annual/FY14_Annual_Report_Annex_1_RAND.pdf; accessed August 3, 2015 . 6 DoD Releases FY15 Annual Report on Sexual Assault in the Military. In: Defense USDo, ed 2016 . Available at http://sapr.mil/public/docs/reports/FY15_Annual/FY15_Annual_Report_on_Sexual_Assault_in_the_Military.pdf; accessed February 15, 2017. 7 Farris C , Schell TL , Tanielian T : Physical and psychological health following military sexual trauma. 2013 . http://www.rand.org/content/dam/rand/pubs/occasional_papers/OP300/OP382/RAND_OP382.pdf; accessed August 15, 2016. 8 Booth BM , Mengeling M , Torner J , Sadler AG : Rape, sex partnership, and substance use consequences in women veterans . J Trauma Stress 2011 ; 24 ( 3 ): 287 – 94 . Google Scholar CrossRef Search ADS PubMed 9 Farris C , Schell TL , Tanielian T : Enemy within. military sexual assault inflicts physical, psychological, financial pain. In: Rand Corporation; 2013. Available at https://www.rand.org/pubs/periodicals/rand-review/issues/2013/summer/enemy-within.html; accessed February 15, 2017. 10 Sexual Assault in the Military . 2013 Statutory Enforcement Report. In: 2013: 238. Available at http://www.usccr.gov/pubs/09242013_Statutory_Enforcement_Report_Sexual_Assault_in_the_Military.pdf; accessed February 15, 2017. 11 Hankin CS , Skinner KM , Sullivan LM , Miller DR , Frayne S , Tripp TJ : Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military . J Trauma Stress 1999 ; 12 ( 4 ): 601 – 12 . Google Scholar CrossRef Search ADS PubMed 12 Kessler RC , Sonnega A , Bromet E , Hughes M , Nelson CB : Posttraumatic stress disorder in the National Comorbidity Survey . Arch Gen Psychiatry 1995 ; 52 ( 12 ): 1048 – 60 . Google Scholar CrossRef Search ADS PubMed 13 Golding JM , Stein JA , Siegel JM , Burnam MA , Sorenson SB : Sexual assault history and use of health and mental health services . Am J Community Psychol 1988 ; 16 ( 5 ): 625 – 44 . Google Scholar CrossRef Search ADS PubMed 14 Surís A , Lind L , Kashner TM , Borman PD , Petty F : Sexual assault in women veterans: an examination of PTSD risk, health care utilization, and cost of care . Psychosom Med 2004 ; 66 ( 5 ): 749 – 56 . Google Scholar CrossRef Search ADS PubMed 15 O’Brien BS , Sher L : Military sexual trauma as a determinant in the development of mental and physical illness in male and female veterans . Int J Adolesc Med Health 2013 ; 25 ( 3 ): 269 – 74 . Google Scholar PubMed 16 Decker SE , Rosenheck RA , Tsai J , Hoff R , Harpaz-Rotem I : Military sexual assault and homeless women veterans: clinical correlates and treatment preferences . Womens Health Issues 2013 ; 23 ( 6 ): e373 – 380 . Google Scholar CrossRef Search ADS PubMed 17 DON disability evaluation system (DES) summary. SECNAVINST 1850.4E. In: Navy US, ed. Washington, DC2002. Available at http://www.secnav.navy.mil/mra/CORB/Documents/SECNAV%20INST%201850_4e.pdf; accessed August 15, 2016 . 18 38 U.S.C §§1110 and 1131 - Basic Entitlement. In: Office USGP, ed. Vol Supplement 5. 2006 Edition ed: U.S. Government Publishing Office. Available at https://www.gpo.gov/fdsys/pkg/USCODE-2011-title38/pdf/USCODE-2011-title38.pdf; accessed February 15, 2017. 19 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, pp 463 – 468 . Washington, DC, American Psychiatric Association , 2000 . 20 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, pp 271–280. Arlington, VA, American Psychiatric Association , 2013. 21 DoD Personnel, Workforce Reports and Publications. https://www.dmdc.osd.mil/appj/dwp/dwp_reports.jsp; Active Duty Military Personnel by Service by Rank/Grade (Updated Monthly) FY 2001-FY 2011 (Women Only); Excel tab 1109f for FY 2011; accessed August 10, 2017. 22 2013 Demographics. Profile of the Military Community. In:2013. http://download.militaryonesource.mil/12038/MOS/Reports/2013-Demographics-Report.pdf; page 17; accessed June 29, 2015 . 23 DoD Instruction 5505.18. In:Jan 25, 2013 . Available at http://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/550518p.pdf; accessed November 2, 2017. 24 Morral AR , Gore KL : Sexual Assault and Sexual Harassment in the Military: Top-line Estimates for Active Duty Service Members from the 2014 RAND Military Workplace Study.In:2014. Available at https://www.rand.org/content/dam/rand/pubs/research_reports/RR800/RR870/RAND_RR870.pdf; accessed November 2, 2017. 25 Surìs A , Lind L , Kashner TM , Borman PD : Mental health, quality of life, and health functioning in women veterans: differential outcomes associated with military and civilian sexual assault . J Interpers Violence 2007 ; 22 ( 2 ): 179 – 97 . Google Scholar CrossRef Search ADS PubMed 26 Kelley LP , Weathers FW , Mason EA , Pruneau GM : Association of life threat and betrayal with posttraumatic stress disorder symptom severity . J Trauma Stress 2012 ; 25 ( 4 ): 408 – 15 . Google Scholar CrossRef Search ADS PubMed 27 Laws H , Mazure CM , McKee SA , Park CL , Hoff R : Within-unit relationship quality mediates the association between military sexual trauma and posttraumatic stress symptoms in veterans separating from military service . Psychol Trauma 2016 ; 8 ( 5 ): 649 – 56 . Google Scholar CrossRef Search ADS PubMed 28 Yamawaki N , Kelly C , Dresden BE , Busath GL , Riley CE : The predictive effects of work environment on stigma toward and practical concerns for seeking mental health services . Mil Med 2016 ; 181 ( 11 ): e1546 – 52 . Google Scholar CrossRef Search ADS PubMed 29 Booth BM , Davis TD , Cheney AM , Mengeling MA , Torner JC , Sadler AG : Physical health status of female veterans: contributions of sex partnership and in-military rape . Psychosom Med 2012 ; 74 ( 9 ): 916 – 24 . Google Scholar CrossRef Search ADS PubMed 30 Kelly UA , Skelton K , Patel M , Bradley B : More than military sexual trauma: interpersonal violence, PTSD, and mental health in women veterans . Res Nurs Health 2011 ; 34 ( 6 ): 457 – 67 . Google Scholar CrossRef Search ADS PubMed 31 Schumm JA , Briggs-Phillips M , Hobfoll SE : Cumulative interpersonal traumas and social support as risk and resiliency factors in predicting PTSD and depression among inner-city women . J Trauma Stress 2006 ; 19 ( 6 ): 825 – 36 . Google Scholar CrossRef Search ADS PubMed 32 Sadler AG , Booth BM , Cook BL , Doebbeling BN : Factors associated with women’s risk of rape in the military environment . Am J Ind Med 2003 ; 43 ( 3 ): 262 – 73 . Google Scholar CrossRef Search ADS PubMed 33 Koss MP , Koss PG , Woodruff WJ : Deleterious effects of criminal victimization on women’s health and medical utilization . Arch Intern Med 1991 ; 151 ( 2 ): 342 – 7 . Google Scholar CrossRef Search ADS PubMed Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Journal

Military MedicineOxford University Press

Published: Apr 6, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off