Military Sexual Trauma
Margret Bell, Ph.D.
MST Support Team,
VA Office of Mental Health Services
Patricia A. Bennett, Ph.D.
Rochester Vet Center
What Is Military Sexual Trauma (MST)?
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VA term for sexual assault or sexual
harassment occurring during military service
Definition in Public Law:
“Physical assault of a sexual nature, battery of a
sexual nature, or sexual harassment” [“repeated,
unsolicited verbal or physical contact of a sexual
nature which is threatening in character”] that
occurred while a veteran was serving on active duty
or active duty for training.
US P.L. 102-585, 1992; 108-422, 2004
What does MST look like?
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A man in the Air Force who was raped by a
superior officer after a party
A woman in the Air Force who was molested
by the doctor when she went in for a routine
visit
A woman in the Navy who was raped by the
man sharing guard duty with her
What does MST look like?
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A woman in the Army whose commanding
officer would do a daily check to make sure
that she was wearing a bra
A woman in the Army whose commanding
officer would kiss her when they were being
chauffeured in a hostile country
A woman in the Marines whose commanding
officer asked her to perform oral sex on him
Prevalence of MST
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VA estimates are 1 in 5 women and 1 in 100
men
• FY2013 : 24.3% women and 1.2% men
• Or, 77,681 women and 57,586 men
Studies of MST prevalence vary according to
the method of assessment & definition used
• 20-43% of women
• 1-4% of men
Risk factors for MST
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MST is associated with
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Entering the military at a younger age
Being of enlisted rank
Less likely to have completed college
History of child sexual abuse
49% of women with MST reported joining the
military to escape their home environment
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Suris and Lind (2008)
How is Sexual Trauma That Occurs in
Military Settings Unique?
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MST occurs in a setting where the victim
lives and works
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Increased feelings of entrapment,
powerlessness, & risk of revictimization
Need to rely on perpetrators for basic needs
Disruption of career goals
Particular aspects of military culture
compound feelings of helplessness and
betrayal
Typically considered to be a complex trauma
Context : Military Culture
• In the military…
• The victim typically knows the perpetrator
• The victim is typically chronologically and
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developmentally young
Risk is typically ongoing
• Repeated, continuing exposure to the
perpetrator
• Given military hierarchy, victim may be
dependent upon the perpetrator and/or his/her
friends in many areas of life
Context:
Military Culture
• Military values may compound
feelings of helplessness, isolation,
and betrayal
• Loyalty
• Teamwork
• Strength
• Self-sufficiency
What Affects Survivors’ Reactions?
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Characteristics of the experiences
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Single event vs. ongoing set of events
Rape vs. sexual harassment
Single perpetrator vs. multiple perpetrators
Known vs. unknown perpetrator
Characteristics of the individual
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Gender
Developmental level at time of the event
Prior trauma experiences
Available coping strategies
Characteristics of the environment
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Response of others at the time
Continued contact with perpetrator
Military culture
How Does Trauma Affect People?
• Physiologically
• Body sensitized to threat
• Prone to all-or-nothing reactions
• Disrupted memory / cognitive processing
• Emotionally
• Normal regulatory systems that promote
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homeostasis are overwhelmed
Tendency towards all-or-nothing reactions
• Cognitively
• Affects how we view the world
• Affects how we view ourselves
• Tendency towards all-or-nothing thinking
Psychological consequences
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Feelings of sadness and depression
Increased anxiety, including panic attacks
Dissociative reactions
Re-experiencing the assault
Feelings of guilt, shame, and self-blame
Use of avoidance
Increased irritability
Psychological consequences
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Increased arousal reactions
Hypervigilance
Negative self-image
Use of alcohol & drugs for coping
Sexual dysfunction
Interpersonal difficulties
Social consequences
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Strained relationships with family, friends, &
partner
Less frequent contact with social network
Less emotional support from social network
Less likely to marry
Diagnoses Associated With MST
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Posttraumatic Stress Disorder
Depression
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Suicidal thoughts and/or suicide attempts
Substance abuse / dependence
Eating disorders
Dissociative disorders
Borderline Personality Disorder / Complex PTSD
Somatization Disorders
Physical health problems (e.g., lower back pain; headaches;
pelvic pain; GI pain/symptoms; sexual dysfunction;
gynecological symptoms; chronic fatigue)
Relative to Other Traumas, MST is
Particularly Associated With…
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Extremes of emotion
Feelings of self-blame
Difficulties trusting self and others and/or trusting too easily
Sensitivity to justice issues and power & control dynamics
• Difficulties with rules and hierarchy
Difficulties establishing appropriate boundaries with others
Difficulties being in environments dominated by men
Revictimization, self-injurious behavior, and suicidal thoughts
Men in particular may evidence:
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Homophobia
Confusion about sexual identity
Hypermasculinity
Hypersexuality
Getting Help
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Therapy is available and free
Rochester Vet Center
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Just call or walk-in
Canandaigua VAMC
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Contact the MST coordinator: Dr. Hoffman
Ask your PCP for a referral
Tammy Franklin, LCSW
Women Veterans Program Manager
In response to the alarming prevalence of sexual
harassment and sexual assault reported by military
Veterans, Congress passed Public Law 102-585 in
November 1992. This law authorized VA to provide
counseling to women Veterans to overcome
psychological trauma resulting from experiences of
sexual assault or sexual harassment during their
military service. Later laws expanded this benefit to
male Veterans as well as female Veterans, repealed
limitations on the required duration of service, and
extended treatment to include not only mental health
conditions related to MST, but physical health
conditions related to MST as well.
VA is mandated to provide:
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Treatment for conditions related to MST
Training and Education on MST to ALL staff
Outreach to Veterans about services available
It is VA policy that all Veterans must be screened for
experiences of MST using the clinical reminder in the
computerized patient record system.
Universal screening is good clinical practice:
 Many patients do not spontaneously disclose a
trauma history and asking about MST can be the
first step in getting them the help they need.
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Understanding that a patient has a history of MST may
provide context for his or her presenting problems.
Knowing that a patient has experienced MST helps
tailor care and avoid engaging in behaviors that
may cause unnecessary distress.
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VA treatment for all mental and physical health
conditions related to MST is free and unlimited in
duration. Veterans do not need to have a disability
rating, did not have to report the incident(s) at the
time, or need to have other documentation that
MST occurred in order to receive free MST-related
care.
VA has specialized treatment programming
available for MST survivors. Providers have special
evidence-based training related to MST and PTSD.
EVERY VA facility has an MST Coordinator who
serves as a point person for MST-related issues.
The MST Coordinator serves as a resource to both
veterans and VA employees.
Canandaigua VA/ROPC offers:
 Individual and group therapy, including gender specific groups
 Domiciliary Care for men and women with a secured, women’s
only wing
 Designated Women’s Health Providers who have MST related
training
 “Relaxation” therapy massage chair (ROPC) available to relieve
anxiety before exams for patients with PTSD/MST
Batavia VA offers:
 Batavia VA has a Residential Treatment Program that serves
men and women Veterans struggling with PTSD related to
war zone experiences, Military Sexual Trauma, and other inservice trauma. The experience of trauma while serving in
the military is a requirement for admission; however, if one
has also experienced civilian trauma, it may be addressed in
treatment as well.
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VA MST Coordinators:
 Canandaigua VA and Rochester Outpatient Clinic:
 Dr. Debra Hoffman, MST Coordinator (585) 393-7929
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Vet Center
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www.vetcenter.gov
(585) 232-5040e
VA Intranet MST Resource
Homepage
 http://vaww.mst.va.gov
 Education and resources for VA
Employees
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VA Internet website
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www.mentalhealth.va.gov/msthome.asp
Information for Veteranstnities
Military Sexual Trauma: An
Evidence- Based Approach
to Treatment
Margret Bell, Ph.D.
MST Support Team,
VA Office of Mental Health Services
Debra Hoffman, Ph.D.
MST Coordinator
Canandaigua VAMC
MST Survivors Need…
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Practical assistance (e.g., finding safe housing)
Sense of safety
Sense of control
To talk about their experiences
To not talk about their experiences
Help in managing symptoms and regaining stability
emotionally
To know they’re not crazy
To re-establish boundaries, internally and externally
A Case Example-In her own words
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60 year old Caucasian veteran of the US
Marine Corps
Kidnapped, beaten and sexually assaulted
by an acquaintance while stationed in San
Diego
Tried to “forget about it”, but 40 years later
she is triggered by a routine gynecological
exam
Decides to attend a residential treatment
program for women with PTSD
Case Example-In her own words
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Letter to rapist
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Letter to Marine corps
So What Do We Do?
An Overarching Framework for Treatment
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Judith Lewis Herman’s Trauma and Recovery:
The fundamental stages of recovery are…
1. Establishing safety
2. Remembering and mourning
3. Reconnection and meaning-making
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Not necessarily a linear progression through
these stages
Parallels common distinction between skillsbuilding (stabilization) and trauma processing
(exposure) work
A Loose Categorization of Some Commonly
Used Evidence-Based Protocols
Establish
safety
Seeking Safety
Dialectical Behavior Therapy
(DBT)
Cognitive Processing
Therapy (CPT)
Prolonged Exposure (PE)
Acceptance & Commitment
Therapy (ACT)
Remember
and mourn
Reconnect and
make meaning
Questions?
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Phone: 585-259-6568
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Email: Debra.Hoffman@va.gov
Kimberly D. Kalish, Ph.D.
Consulting Psychologist: Warrior Salute
Clinical Assistant Professor of Psychiatry, School of
Medicine & Dentistry, University of Rochester
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Be familiar with the definition of MST
• Understand the importance of MST
Screening and Assessment
• Follow best practice approaches in the
screening/assessment of MST
Sexual assault or repeated,
threatening sexual harassment
that a veteran experienced during
his or her military service
Unwelcome verbal or physical
conduct of a sexual nature that
occurs in the workplace or
academic or training setting
Any sort of sexual activity
between at least two people in
which one of the people is
involved against his or her will
• Prevalence
• Impact/Related Symptoms
• Highly Underreported
• Active duty military:
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5-6% women and 1% of men: military sexual assault
• 78% of women and 38% of men: military sexual
harassment
• All of VA data
• 1 in 4 females have experienced MST
• 1 in 100 men have experienced MST
2004; http://www.va.gov.vhi
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 psychological well-being, physical health
 satisfaction with health, work
 difficulties finding work, alcohol, drug use
MDD, PTSD: men (65%), women (45.9%)
Anger, shame, guilt, self-blame
Relationship disturbances
• Stigma
• Shame
• Military Culture
• Fear of Consequences (real or perceived)
• Mandated universal screening
• Medical record auto prompt
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Compassion
Privacy
Confidentiality
Avoid labels
Normalize
“While you were in the military:
• (a) Did you receive uninvited and unwanted
sexual attention, such as touching, cornering,
pressure for sexual favors, or verbal
remarks?;
• (b) Did someone ever use force or threat of
force to have sexual contact with you against
your will?”
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• No specific MST measures
• The Sexual Experience Questionnaire
• Sexual Experiences Survey
• The National Women's Study Interview
• Life Events Checklist
• PTSD Measures (e.g., PTSD Checklist, CAPS)
• Depression (PHQ-9, BDI)
• Substance Abuse Assessment
• Full Clinical Diagnostic Interview
• No specific MST measures
• The Sexual Experience Questionnaire
• Sexual Experiences Survey
• The National Women's Study Interview
• Life Events Checklist
• PTSD Measures (e.g., PTSD Checklist, CAPS)
• Depression (PHQ-9, BDI)
• Substance Abuse Assessment
• Full Clinical Diagnostic Interview
In your life, have you ever had any experience that was so
frightening, horrible, or upsetting that, in the past month, you:
Have had nightmares about it or thought about it when you did
not want to?
YES NO
Tried hard not to think about it or went out of your way to avoid
situations that reminded you of it?
YES NO
Were constantly on guard, watchful, or easily startled?
YES NO
Felt numb or detached from others, activities, or your
surroundings?
YES NO
¾ “yes” responses = positive screen.
Positive screen warrants further investigation
Positive screen warrants suicidal ideation screen
• Records from law enforcement, crisis centers, counseling
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centers, hospitals, or physicians.
Pregnancy tests or tests for sexually transmitted diseases.
Statements from family, friends, professionals, service
members
Request for transfer to another military duty assignment.
Deterioration in work performance.
Substance abuse.
Episodes of depression, panic attacks, or anxiety without an
identifiable cause.
Unexplained economic or social behavioral changes.
Relationship issues, such as divorce.
Sexual dysfunction.
• Respect
• Empathize/Validate
• Support
• Patient’s perceptions
• Educate/normalize
• Clinician’s perceptions
• Triage (SAFETY, refer)
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Negative questioning
Labeling
Implicit assumptions about the patient
Body language
Pushing
• MST assessment is an important part of any
comprehensive assessment
• Screening and assessment for MST must be
done with respect and sensitivity
• Next Steps: Safety, Referral
Thank you for attending
the 2014 Serve. Honor.
Support. Symposium, and
for all that you do to
support the Veterans and
military service members
in our community!