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Commentaries

Revealing the Importance of Military Sexual Trauma and Its Consequences

See Article by Klingensmith et al.

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Revealing the Importance of Military Sexual Trauma and Its Consequences

Although the 1949 Geneva Convention explicitly prohibited forced prostitution and rape during wartime, it took decades to address this issue in public debates as well as in scientific research. Since the early 1990s, and the occurrence of mass rapes in the war in the Balkans and in Rwanda, sexual violence as a weapon of war has become a focus of humanitarian intervention and international relations.1 Hence, sexual violence in armed conflicts is no longer a neglected topic. But sexual violence is not only a problem between enemies in armed conflicts: it is also an issue in the military itself. In the early 1990s, as a result of the Tailhook scandal, military sexual trauma (MST) arose as a relevant topic in public debates in the United States. As a result, the first interventions and training programs for health care providers in the US Veterans Affairs (VA) system were developed.2 Several studies have investigated the prevalence of MST in US veterans from different war theaters (eg, Vietnam, Afghanistan, Iraq), with prevalence rates ranging widely.3-9

The study by Klingensmith and colleagues10 uses data from the National Health and Resilience in Veterans Study, a nationally representative survey including more than 1,400 US veterans. This large and nonselective sample contributes important empirical evidence to describe the magnitude of MST and its health outcomes. The study found that 7.6% of the participants screened positive for MST, which includes unwanted sexual attention such as touching, cornering, pressure for sexual favors, or sexual remarks. Although the proportion of women in the sample is quite low, the results underline that women are at a much higher risk of experiencing MST: 32.4% of women, but only 4.8% of men, screened positive for MST. Those participants who screened positive for MST were at increased risk of mental health problems (eg, depression, social phobia, suicidality, posttraumatic stress disorder, generalized anxiety disorder) and somatic symptoms. Moreover, MST is associated with an increased use of mental health treatment, such as psychotropic drug use or psychotherapy/counseling. These results emphasize the importance of prevention of MST, of specific training for health care providers in the VA system, and of tailored interventions for the veterans. How significant this study’s contribution is to the debate around MST and its prevention becomes evident when comparing current research in other countries.

For a long time, the German army (Bundeswehr) was a male institution. MST played a tangential role. Women were allowed to serve exclusively in the medical service. In 2001, women were introduced into all careers and areas of the German army, and today around 10% of the staff are female. In 2005, a first survey was conducted to assess the integration process of women in the German army.11 Female soldiers were asked to report their experiences of MST, while male soldiers were asked whether they knew about MST. According to the survey, 58% of the women reported experiences of sexual remarks, and 19% of the women reported unwanted sexual attention such as touching or cornering, mostly single events. More severe forms of MST, such as rape or sexual assault, were reported by 4.6% of the women. These data underline that MST is a relevant issue in the German army as well. In most cases, the offenders were male, and the victims were female. Unfortunately, according to the survey, 76% of the women did not report their experiences of MST.11

In 2011, 10 years after the introduction of women into all areas of the German army, a second survey with a slightly different methodology was conducted.12 Both male and female soldiers were asked to report their experiences of MST. Twenty-four percent of the female soldiers and 3% of the male soldiers reported unwanted sexual attention such as touching or cornering. More severe forms of MST such as rape or sexual assault were reported by 3% of female soldiers.12 Both studies point in the same direction: MST, especially against female soldiers, is an important issue in the German army. It needs explicit attention. Interventions to prevent MST must be developed and implemented as soon as possible.

Looking at the figures reported above, it appears that the problem of MST is much larger in the German army than in the US army, but the figures from these studies should be handled cautiously. A simple comparison of the numbers makes little sense, since the surveys differ with respect to their methodology. Nevertheless, they underline the importance of MST in the US as well as the German forces. To combat MST, it will be important to raise awareness of it in the forces as well as in society, to protect the victims, and to encourage them to come forward and report incidents to allow the prosecution of offenders. However, the military fosters a specific environment, including a specific team spirit and strong hierarchy. Especially in active duty, the soldiers spend most of their time with their comrades under quite demanding and burdening conditions. Thus, as Wolfe et al stated, "Military settings may be prone to increase sexual aggression toward women."8(p51) Certain characteristics of that setting, such as the high male-to-female ratio, the traditionally male environments, and the predominance of male supervisors, may play an important role in the high prevalence of MST.

Although today the presence of women is more common in the military, even in the higher ranks, the problem still exists. MST must be part of a public debate, as this is the only way to fight it and to destigmatize the victims of MST. Let’s tackle MST, and not just in the United States.

Author affiliations: University of Leipzig, Department of Medical Psychology and Medical Sociology, Leipzig, Germany.

Potential conflicts of interest: None reported.

Funding/support: None reported.

REFERENCES

1. Sexual violence as a weapon of war. The State of the World’s Children 1996. UNICEF. http://www.unicef.org/sowc96pk/sexviol.htm; http://www.ohchr.org/en/newsevents/pages/rapeweaponwar.aspx. Accessed September 5, 2014.

2. Military Sexual Trauma. Department of Veterans Affairs. http://www.publichealth.va.gov/docs/vhi/military_sexual_trauma.pdf. Updated January 2004. Accessed September 5, 2014.

3. 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

4. Fontana A, Schwartz LS, Rosenheck R. Posttraumatic stress disorder among female Vietnam veterans: a causal model of etiology. Am J Public Health. 1997;87(2):169-175. PubMed doi:10.2105/AJPH.87.2.169

5. Kang H, Dalager N, Mahan C, et al. The role of sexual assault on the risk of PTSD among Gulf War veterans. Ann Epidemiol. 2005;15(3):191-195. PubMed doi:10.1016/j.annepidem.2004.05.009

6. Kimerling R, Gima K, Smith MW, et al. The Veterans Health Administration and military sexual trauma. Am J Public Health. 2007;97(12):2160-2166. PubMed doi:10.2105/AJPH.2006.092999

7. 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

8. Wolfe J, Sharkanksy 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

9. Sadler AG, Booth BM, Nielson D, et al. Health-related consequences of physical and sexual violence: women in the military. Obstet Gynecol. 2000;96(3):473-480. PubMed doi:10.1016/S0029-7844(00)00919-4

10. 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

11. Kümmel G. Truppenbild mit Dame – Eine sozialwissenschaftliche Untersuchung zur Integration von Frauen in der Bundeswehr [Picture of the troops with a lady – An investigation of the integration of women in the Bundeswehr]. Sozialwissenschaftliches Institut der Bundeswehr. March 2008. http://www.mgfa.de/html/einsatzunterstuetzung/downloads/forschungsbericht82.pdf

12. Kümmel G. Truppenbild ohne Dame? Eine sozialwissenschaftliche Begleituntersuchung zum aktuellen Stand der Integration von Frauen in die Bundeswehr [Picture of the troops without a lady? an investigation of the current status of integration of women in the Bundeswehr]. Zentrum für Militärgeschichte und Sozialwissenschaften in der Bundeswehr. January 2014. http://www.mgfa-potsdam.de/html/einsatzunterstuetzung/downloads/140124studiefrauen2014.pdf. Accessed September 5, 2014.

Submitted: September 4, 2014. Accepted September 4, 2014.

Corresponding author: Heide Glaesmer, PhD, University of Leipzig, Department of Medical Psychology and Medical Sociology, Philipp-Rosenthal-Str. 55, 04103 Leipzig, Germany (heide.glaesmer@medizin.uni-leipzig.de).

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