A Proposal to Refine the Definition of Military Sexual Trauma for Purposes of Treatment and Research

A Proposal to Refine the Definition of Military Sexual Trauma for Purposes of Treatment and Research

John H. Shale, MD, JD

In their article on military sexual trauma (MST), Klingensmith et al1 write that MST results in significant psychiatric morbidities, decreased quality of life, and increased health burdens. The authors make clear that the definition used in their study comes from the Department of Veterans Affairs (VA).

The VA-generated definition2 they cite appears under the heading, "What Is Sexual Trauma?" on page 1 of a 196-page study guide for VA clinicians published in January 2004 and is as follows: "Military sexual trauma (MST) has been defined by the Department of Veterans Affairs as: sexual harassment that is threatening in character or physical assault of a sexual nature [emphasis in the original]."

Klingensmith and colleagues have addressed the wide disparities of prevalence in previous studies and point to "variability in samples and differences in how MST is defined and assessed."1(p e1133) A simple review of the titles of references they cite sustains their assertion about definitions. Many of the articles address military or veteran populations, using similar phrases such as "military-related sexual trauma,"3-5 but some articles appeared before the 2004 publication of the VA’s definition of MST.4-6

A recent article in The Lancet suggests that the purpose of medical research is "to advance knowledge for the good of society; to improve the health of people worldwide; or to find better ways to treat or prevent disease."7(p347) The focus of the article is to criticize how research is done, and it quotes an estimate that 85% of biomedical research is "wasteful or inefficient." What is not mentioned is that medical research, or any other research for that matter, depends on clear and accurate definitions that are generally accepted. The lack of such definitions has real-world impact in some areas including research into MST. Since posttraumatic stress disorder (PTSD) was included in DSM-III in 1980, the definition of the disorder and the predicate, precipitating trauma have both evolved. Thus, we have arguably clear, accurate, and generally accepted definitions of both the trauma and the diagnostic criteria in successive editions of the DSM.

I submit, however, that the current definition of MST is inadequate. There are 2 issues here. The greater one is that MST conflates 2 related but vastly different phenomena. Moreover, both of these terms, sexual assault and physical assault of a sexual nature, are of legal provenance, not medical. They may be carefully defined for purposes of including what must be proven in court, but that hardly eliminates controversy. Further, the definitions of rape, sexual assault, and sexual harassment, while similar, vary from one jurisdiction to another. Yet, the legal system, in my view, is the best source of clear, accurate definitions.

Rape, a serious felony, is usually defined as forced sexual intercourse, including vaginal, anal, or oral penetration, but there are variations from state to state. Penetration may be by a body part or an object, and any penetration, however slight, is sufficient to complete the crime. Perhaps partly due to jurisdictional disparities in definitions, there remains great controversy about the annual number of rapes, depending on the source of the statistics. This controversy dates back almost 30 years.8 To some extent, this debate is due to the nature of our legal system, inherited from English common law. It is an adversarial one in which advocates on either side offer evidence to support their positions, and that evidence often includes statistics that vary by orders of magnitude partly because of definitions of rape or sexual assault, the source of the statistics, or both.

Sexual assault is typically defined by websites that focus on sex crimes as the nonconsensual touching of an intimate part of another for purposes of sexual gratification, sexual arousal, or the humiliation/degradation of the victim.9 At law, however, sexual assault is actually defined as battery and may be prosecuted as a felony or misdemeanor. California’s sexual battery law (Penal Code Section 243.4) prohibits touching an intimate part of another person without consent for the purposes of sexual gratification, arousal, or abuse.

Sexual harassment is a relatively new term, which may help explain why Vietnam-era veterans reported substantially lower rates of MST overall. It also has many definitions and is commonly adjudicated by civil court process.

A dictionary10 definition of the term is as follows:

Sexual harassment: noun: harassment (typically of a woman) in a workplace, or other professional or social situation, involving the making of unwanted sexual advances or obscene remarks.

Sexual harassment is a term that does not appear in the criminal law of many jurisdictions. For example, it does not appear in the penal code in California, our most populous state and one that is generally seen as progressive and whose laws tend to influence courts and legislatures in many other states.

The one common form of sexual harassment that is widely recognized at law is the quid pro quo of sexual favors to get or keep a job. This appears in California employment law along with hostile work environment.11 Hostile work environment sexual harassment consists of harassing conduct that is so severe or pervasive that it creates a hostile work environment for employees. Supervisors, coworkers, and even subordinates can engage in conduct that gives rise to hostile work environment. Harassing conduct includes slurs, taunts, intimidation, ridicule, groping, and grabbing.

An employee does not have to be the direct target of the harassing conduct in order to file a claim. For instance, a woman who witnesses her female coworkers being groped and propositioned can bring a claim for hostile work environment sexual harassment. Recently, the California Supreme Court held that employer actions, such as termination and demotion, could also constitute hostile work environment harassing conduct absent any sexual implication.12

In Federal law, sexual harassment is defined in United States Equal Employment Opportunity Commission guidelines as "unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature" or offensive comments that tend to create "a hostile or offensive work environment."13 Unlike most laws, however, there is no "reasonable person standard"; the definition of what constitutes an offense has become idiosyncratic to the individual asserting the offense. Moreover, sexual harassment is viewed as a form of sex discrimination that occurs in the workplace. Persons who are victims of sexual harassment may sue under Title VII of the Civil Rights Act.14

I submit that to do research on types of trauma that are statistically associated with and likely causal of psychiatric morbidity and mortality, we must have clear, accurate, and generally accepted definitions of those precipitating traumas. Clarity of definition would also aid in developing questionnaires and evaluation instruments.

So how do we refine the definitions of trauma in MST to achieve consensus definitions and more consistent and accurate research results? At a minimum, the 2 parts that make up the current VA definition of MST must be studied separately. But more must be done to make the definitions clear, accurate, and generally accepted.

MST is clearly the purview of the Department of Defense and the VA, with emphasis on the latter. Further, the VA has probably the largest database of patients suffering the results of sexual trauma. It also has a tradition of doing research and an infrastructure to support research. Such work would include both developing clear and accurate definitions and designing research protocols.

But the military is not the only, or even the main, source of sexual trauma. For more than half a century, the American Psychiatric Association and members of the American Psychological Association have worked together to refine the criteria for diagnosis of mental disorders. In the case of PTSD, these organizations developed the diagnostic criteria and defined the causal stressors. They also have extensive experience in research. The role of these organizations could be to define the parameters of the traumas that lead to specific diagnoses and then perhaps help design instruments for research and evaluation.

These organizations would seem to meet the criteria set forth in The Lancet that those who make these kinds of decisions should be knowledgeable, but disinterested, in the sense that they are motivated "to defend an environment conducive to research that is for the benefit and health of people worldwide, not merely as one element of economic policy making."7(p347)

Public awareness of the damage caused by sexual assault and sexual harassment over the last 3 decades resulted in pressure on legislatures to make significant changes in laws. This has run the gamut from preventive measures such as required sexual harassment training in the workplace to the Sexually Violent Predator laws that meet constitutional protections against double jeopardy for civil commitment after the completion of prison sentences.15 Concomitantly, there has been increasing interest in medical and psychiatric research in the area of sexual trauma. Now is the time to refine the definitions to be used for this research so that the research and the resultant findings are comparable and we can better develop treatment for victims of sexual trauma.

Author affiliations: University of Utah School of Medicine, Salt Lake City.

Potential conflicts of interest: None reported.

Funding/support: None reported.

REFERENCES

1. Klingensmith K, Tsai J, Mota N, et al. Military sexual trauma in US veterans: results from the National Health and Resilience in Veterans Study. J Clin Psychiatry. 2014;75(10):e1133-e1139. doi:10.4088/JCP.14m09244

2. Department of Veterans Affairs. Military sexual trauma (independent study course). http://www.publichealth.va.gov/docs/vhi/military_sexual_trauma.pdf. Published January 2004. Accessed August 1, 2014.

3. Kimerling R, Street AE, Pavao J, et al. Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq. Am J Public Health. 2010;100(8):1409-1412. PubMed doi:10.2105/AJPH.2009.171793

4. Wolfe J, Sharkansky EJ, Read JP, et al. Sexual harassment and assault as predictors of PTSD symptomatology among US female Persian Gulf War military personnel. J Interpers Violence. 1998;13(1):40-57. doi:10.1177/088626098013001003

5. Fontana A, Rosenheck R. Duty-related and sexual stress in the etiology of PTSD among women veterans who seek treatment. Psychiatr Serv. 1998;49(5):658-662. PubMed

6. Skinner K, Kressin N, Frayne S, et al. The prevalence of military sexual assault among female Veterans’ Administration outpatients. J Interpers Violence. 2000;15(3):291-310. doi:10.1177/088626000015003005

7. What is the purpose of medical research? The Lancet. 2013;381(9864):347. doi:10.1016/s0140-6736(13)60149-x. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960149-X/fulltext. Accessed August 12, 2014.

8. Kadish SH, Shulhofer SJ. Criminal Law and Its Processes. 6th ed. Boston, MA: Little Brown & Co Law & Business; 1995:317.

9. Joyful Heart Foundation. Sexual assault and rape: about the issue. http://joyfulheartfoundation.org/learn/sexual-assault-rape/about-issue?gclid=Cj0KEQjwhLCgBRCf0fPH043IlJwBEiQAf8P8U4zHdow16Twu-sDEEyjRXlk_MyO32Lx9vY8botcJeMcaAm6O8P8HAQ. Accessed August 4, 2014.

10. Sexual harassment. Oxford Dictionaries website. http://www.oxforddictionaries.com/us/definition/american_english/sexual-harassment. Accessed September 23, 2014.

11. Fair Employment and Housing—Sexual Harassment. California Department of Fair Employment and Housing website. http://www.dfeh.ca.gov/Publications_StatLaws_SexHarrass.htm. Accessed September 25, 2014.

12. Roby v McKesson HBOC, 146 CalApp 4th 63 (2009).

13. Sexual Harassment. US Equal Employment Opportunity Commission website. http://www.eeoc.gov/laws/types/sexual_harassment.cfm. Accessed September 25, 2014.

14. Civil Rights Act of 1964, 42 USC §2000e et seq.

15. Kansas v Hendricks, 521 US 346 (1997). (Kansas v Hendricks 521 US 346, 1997).

Submitted: September 22, 2014; accepted September 22, 2014.

Corresponding author: John H. Shale, MD, JD, VA SLC Health Care System, VA Community Based Outpatient Clinic, 982 Chambers St, Ogden UT 84403 (john.shale@va.gov).

J Clin Psychiatry 2014;75(10):e1190-e1191 (doi:10.4088/JCP.14com09537).

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