Military Sexual Trauma MST: Increasing Awareness

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Military Sexual Trauma (MST)Increasing Awareness

• Roksana Korchynsky, Ph.D.
• MST Coordinator, VAPHS
• VISN 4 MST POC
• Roksana.Korchynsk_at_va.gov

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Presentation Outline

• Defining MST rates of MST
• Unique aspects of military sexual trauma
• Clinical relevance of MST
• Screening for MST
• MST Clinical Reminder

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(No Transcript)
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What is Military Sexual Trauma (MST)?

• 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

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What is MST? (cont.)

• Sexual assault - Any sort of sexual activity in
  which someone is involved against his or her
  will. This occurs when someone is
• Coerced into participation (e.g., with threats),
• Not capable of consenting to participation (e.g.,
  when intoxicated),
• Physically forced into participation.
• Can involve unwanted touching, grabbing, oral
  sex, anal sex, sexual penetration with an object
  and/or sexual intercourse.

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What is MST? (cont.)

• Sexual harassment - Repeated, unsolicited, and
  threatening verbal or physical contact of a
  sexual nature. Examples include
• Unwanted sexual attention, such as cornering,
• touching, or verbal remarks
• Implied negative consequences for refusing to be
  sexually cooperative (or implied faster
  promotions or better treatment in exchange for
  being sexually cooperative)

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How Common is MST?

• Based on a 2002 DoD study of sexual victimization
  among active duty personnel, 54 of women and 23
  of men reported having experienced sexual
  harassment in the previous year.
• Rates of attempted or completed sexual assault
  3 of women and 1 of men.

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How Common is MST? (cont.)

• Based on a 2000 national survey of 3,632 women
  veterans using VA healthcare, 23 reported at
  least one sexual assault while on active duty
  (Skinner et al.).
• Rates of sexual assault while in the military are
  higher than lifetime rates among women in the
  general population.

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How Common is MST? (cont.)

• Based on VAs 2002 national MST surveillance data
  from approx. 1.7 million VA patients, 22 of
  women and 1 of men have experienced MST.
• Even though MST is far more common in women, 54
  of all VA patients who screen positive for MST
  are men.

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Military Sexual Trauma (?)

• The term MST indexes a wide variety of events
  that, while unquestionably distressing, may or
  may not have been traumatic in the DSM-IV
  Criterion A sense.
• Does not mean that those events arent
  problematic or dont lead to lasting effects, but
  highlights that not all victims have reactions
  rising to the level of disorder.
• Many victims cope remarkably well.

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How is ST Different in the Military?

• In the military
• Victim typically knows the perpetrator
• Victim is typically chronologically
  developmentally younger
• Risk is typically on-going because
• Victim perpetrator live work together
• Victim may be dependent upon perpetrator and/or
  perpetrators associates for basic necessities
  (food, shelter, protection, medical care)
• No way to leave leaving means going AWOL

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How is ST Different in the Military?(Cont.)

• In the military
• High value placed upon loyalty teamwork
• Taboo to divulge negative information about peers
• MST is that much more incomprehensible to victims
• High value placed upon strength
  self-sufficiency
• Reduces social support available, increases
  likelihood of invalidating response
• Being a victim conflicts with desired identity
• Disruption of career goals

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How is ST Different in the Military?(Cont.)

• In the military
• The same institution is responsible for the care
  of the victim the adjudication of the
  perpetrator
• Increased sense of betrayal, being alone,
  helplessness, entrapment

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Sexual Trauma is a Particularly Toxic
Stressor
Probability of Developing PTSD

(Kessler et al, 1995)
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Sexual Trauma is a Particularly Toxic Stressor
(cont.)
Study of Gulf War Veterans Probability of
Developing PTSD
(Kang et al., 2005)
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Clinical Relevance of MST

• Skinner et al. survey women with ST had
• More problems readjusting after discharge from
  the military
• More difficulty getting keeping jobs
• More health problems
• More anxiety and anger
• 3 times more depression (50 were MDD)
• 2 times more alcohol abuse (40 were alcohol
  abuse)

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Clinical Relevance of MST (Cont.)

• Mary Kosss (1992) research found that women with
  ST histories had more physical symptoms across
  nearly all body systems than women without ST
  histories.
• And twice as many physician visits than women
  without ST.

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Clinical Relevance of MST (Cont.)

• Sexual trauma survivors have increased health
  risks such as
• Substance abuse
• Eating disorders/obesity
• Transmitting or acquiring HIV
• Poor compliance with treatment
• Self-mutilation/suicidal ideation or attempts

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Clinical Relevance of MST (Cont.)

• Common physical sxs associated with ST
• STDs
• Chronic pain
• Gastrointestinal Disorders
• Gynecological Problems
• Dissociation/memory loss
• Non-specific immune-system disorders
• (Chronic Fatigue Syndrome, Lupus, Fibromyalgia)

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Clinical Relevance of MST (Cont.)

• Common emotional sxs associated with ST
• Anxiety
• Depression
• Panic
• Rage
• Shame
• Guilt

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Medical Procedures Why they can problematic for
ST patients

• Patient-provider relationship resembles some
  aspects of the victim-perpetrator relationship
• Power differential
• Inflicting pain
• Touch
• Lack of control over the situation

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Procedures That Can Be Traumatic

• Pelvic exams/pap smears
• Breast exams/mammograms
• Colonoscopy
• Other invasive exam (e.g., rectal, oral, nasal)
• Funduscopic exam
• Standing behind the patient
• Physical restraints or chemical sedation
• Enclosures

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Helping Patients Through a Procedure

• Increase sense of control
• Patient education
• Asking permissionlet her know you will stop if
  she asks you to
• Brainstorm strategies with the patient
• Seeing procedure suite in advance, sedation,
  wearing headphones, chaperone or family member
  present

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Helping Patients Through a Procedure (Cont.)

• Use non-threatening terms
• Bills not blades of speculum
• Foot rests not stirrups
• Team approach
• Coordinate with mental health professional

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• Screening for MST

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Patient Barriers to Disclosing

• Shame
• Self blame
• Damaged self esteem
• Lack of Trust
• Sense of betrayal
• Previous reactions to disclosure
• How the Question is Asked
• Tone of voice/manner of speech
• Language used

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Provider Barriers to Asking

• Lack of knowledge
• Over-identification
• Fear of offending
• Time pressures (fear of opening
• Pandoras Box)
• Resources (feeling powerless to fix the
  situation)

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Screening for Violence/Trauma

• Domestic violence screening by primary care
  providers (Rodriguez, M.A., 1999)
• With evidence of injury 21 dont routinely
  screen
• New patients 90 dont routinely screen
• At check ups 91 dont routinely screen
• Sexual abuse screening (Friedman, L.S., 1992)
• Primary care 85 never screen at annual
  visits

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VAs Response to MST Screening

• Rates of MST screening in the VA
• (Kimerling, R., 2007)
• 74 of women and 71 of men
• were screened for MST

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How to Screen for MST Step 1 Creating the
Environment

• Privacy
• Nonverbal communication
• Patient is dressed
• Patient and clinician are at same level
• Unhurried speech, relaxed body stance
• Eye contact
• No interruptions
• Non-judgmental tone

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How to Screen for MST Step 2 Setting the Stage
for Inquiry

• Because many studies have shown that sexual
  violence is common in the military, we ask all
  our VA patients about this.

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How to Screen for MST Step 3 Ask Direct
Questions

• Ask the two behaviorally-specific screening
  questions in the MST clinical reminder
• While in the military
• Did you ever receive uninvited or unwanted sexual
  attention, such as touching, cornering, pressure
  for sexual favors, or verbal remarks?
• Did someone ever use force or the threat of force
  to have sexual relations with you against your
  will?

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How to Screen for MST Step 4 Your Response

• Validate Im sorry that happened to you during
  your military service.
• Educate Many veterans have had similar
  experiences during the service.

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How to Screen for MST Step 4 Your Response
(Cont.)

• Assessing current status Do you feel you are
  currently having physical or emotional effects
  from what happened to you?
• Assessing level of support Have you been able
  to discuss this with anyone before?
• Reassure that help is available and make a
  referral if patient wants help now, but never
  insist.

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How to Screen for MST Step 4 Your Response
(Cont.)

• Assessing interest in a referral We have
  specially trained counselors who could speak to
  you about this issue. Is that something you
  would be interested in?
• Normalize Many of my patients, who have had
  similar experiences, have found it helpful to
  speak with a counselor.
• If a referral is declined, it can always be
  re-offered at a later visit.

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• Completing the MST
• Clinical Reminder

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MST Clinical Reminder

• All veterans must be screened for MST!
• MST Clinical Reminder is mandatory and good
  documentation
• Completion of reminder
• Updates veterans status in medical record and in
  MST monitoring database
• Activates MST checkbox on encounter forms and
  gives veteran access to free care

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MST Clinical Reminder (Cont.)

• A patient can respond yes, no, or declines
  to answer
• It is possible to change a veterans MST status
  if he/she subsequently discloses

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Eligibility

• A veteran does not need to be service-connected
  nor have previously reported a sexually traumatic
  event to be eligible for MST services.
• Even veterans that do not meet general
  eligibility requirements for VA health care are
  treated for physical and mental health
  consequences of MST (coded ineligible or
  humanitarian).
• The veteran with a dishonorable discharge may
  also be eligible for free MST-related care.

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Summary Take Home Points

• MST is unfortunately common and can have a
  profound affect on a patients physical and
  psychological well-being
• MST screening is good clinical care patients
  want us to ask!
• MST treatment is available and at no cost to the
  patient