State of the Knowledge of VA Military Sexual Trauma Research.

Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department's efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power (e.g., lower rank) are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings (e.g., interpersonal betrayal, victim-blaming) as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal (e.g., fear of reprisal or ostracism, having to work/live alongside a perpetrator). MST's most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective.

Clinical Complexity in Women Veterans: A Systematic Review of the Recent Evidence on Mental Health and Physical Health Comorbidities.

A recent evidence map focused on women veterans underscored the limited number of articles published on mental health comorbid with physical health conditions in this population. The quality of this small body of research has yet to be evaluated. The aim of this systematic review was to evaluate and synthesize research published between 2008 and 2015 and identified in the Women Veterans' Health Research Evidence Map as related to mental and physical health comorbidities among women veterans. Following PRISMA guidelines, 23 published studies were identified and 21 were included in the review. In general, significant associations between several mental health conditions (e.g., depression, posttraumatic stress disorder, substance use disorders) and physical health disorders (e.g., cardiovascular disease, diabetes, gastrointestinal disorders, hypertension, obesity, pain, and urinary symptoms) and health behaviors (e.g., preventative care and treatment adherence) were noted. The majority of studies were rated as low risk of bias, with selection and detection bias most frequently observed across studies. Additionally, gaps in the recent literature were observed, including the need for further investigation of the role of medical conditions in complicating mental health symptoms and care provision. Results underscore the importance of healthcare providers attending to women veterans' mental and physical health simultaneously and irrespective of setting. Further, while the Department of Veterans Affairs continues to make sizable gains in its focus on women veterans' health, continued research on several health domains is needed to ensure adequate understanding of the health needs of women veterans.

Barriers to PTSD treatment-seeking by women veterans who experienced military sexual trauma decades ago: The role of institutional betrayal.

BACKGROUND: While some barriers to PTSD treatment engagement among veterans are well-identified, e.g., stigma, little is known about the barriers to VA PTSD treatment-seeking among women veterans who experienced military sexual trauma (MST) decades ago. PURPOSE: To explore the barriers to PTSD treatment-seeking of women veterans with PTSD related to MST experienced prior to 2000. METHOD: Data were collected from women veterans (n = 14) who had experienced MST and sought VA PTSD treatment. Data analyses utilized a constructivist grounded theory approach. FINDINGS: The context of the MST experience, including the military environment at the time, the era in which they experienced MST and the response of others to their reporting or disclosure of MST created decades-long barriers to PTSD treatment-seeking. DISCUSSION: Understanding institutional betrayal as a barrier to PTSD treatment-seeking among women veterans who experienced MST decades ago is necessary to develop effective targeted outreach and programs for this population.

Community-based PTSD treatment for ethnically diverse women who experienced intimate partner violence: a feasibility study.

The objectives of this study were to: (1) Determine the feasibility of a community-based intervention for Latinas with PTSD who experienced IPV; (2) Explore the intervention effectiveness in reducing PTSD and improving quality of life, social support and self-efficacy. This was a feasibility study, using intervention pre-test/post-test qualitative and quantitative data. The experience of living through and surviving IPV was far more important than ethnicity in cultural identity. Significant reductions in PTSD and MDD and increased self-efficacy were sustained 6-months post-intervention. Culturally relevant mental health IPV interventions can be feasible and appropriate across ethnic groups.

Addressing Fear of Negative Consequences of Overdose Response: A Qualitative Study of the Perceptions of Service Industry Workers Who Encounter an Opioid Overdose in an Urban Commercial District in Atlanta, Georgia.

BACKGROUND: The increased contamination of illicit drugs with fentanyl in the United States drug market has contributed to escalating mortality from drug overdose. Leisure and hospitality service industry workers are encountering opioid-triggered overdoses in their workplaces, such as restaurants and bars. Consequently, this increases the need for overdose education and naloxone distribution (OEND) training, which has been limited. We aimed to describe the experiences among service industry workers encountering an overdose in their workplace. METHODS: We conducted in-depth qualitative interviews with service industry workers in Little Five Points (L5P), Atlanta, between October 2019 and April 2020 and triangulated methods with participant observations and fieldwork. Purposive criterion sampling methods were applied to recruit from different establishments in the L5P commercial district, which comprised restaurants, bars, retail shops, and theaters. After an initial seed sample was identified by engaging key stakeholders during fieldwork (business owners, managers, and the business association), a snowball sample followed for a final sample of N = 15. To contextualize the local population of harm reduction workers, people who use drugs and/or obtain safer drug consumption supplies in L5P (sterile syringes, safer using kits, naloxone), and service industry workers and their customers in L5P, the first author volunteered with an Atlanta syringe services program from October 2019 to April 2020. The first author conducted participant observations during the syringe exchange program and field notes were taken during observation (44 hours). This engagement ensured a rich, thick description. We used a pragmatic approach to thematic data analysis for this study. Data were analyzed iteratively and inductively from interviews and observations. Two independent researchers reviewed transcripts to identify passages in the data related to the question of interest. The passages were contextualized within the full data set independently to understand the relationships in developing a theory of what was commonly occurring across participants' experiences, and these relationships led to emerging salient themes regarding encountering an opioid overdose at work. RESULTS: One salient theme related to overdose response emerged with the service industry workers included fear of negative consequences of overdose response, specifically, fear of disease transmission from artifacts of drug use and overdose response, including the spread of blood-borne disease, violence, and exposure to unintentional overdose. When discussing drug use, participants' beliefs about the potential for personal danger from drug use artifacts (syringes and discarded drugs) and violence were identified as barriers to opioid overdose responses. CONCLUSIONS/IMPLICATIONS FOR OCCUPATIONAL HEALTH PRACTICE: Our findings provide valuable insights for tailoring OEND training for service industry workers to confront fears associated with opioid overdose response in their places of work to decrease mortality from the opioid epidemic. Harm reduction approaches need to be sensitive to the places in which overdose occurs and who the overdose responder is likely to be, which requires appropriately tailoring OEND training for service industry workers.

Yoga vs Cognitive Processing Therapy for Military Sexual Trauma-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: First-line treatment for posttraumatic stress disorder (PTSD) in the US Department of Veterans Affairs (VA), ie, trauma-focused therapy, while effective, is limited by low treatment initiation, high dropout, and high treatment refraction. Objective: To evaluate the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) vs first-line cognitive processing therapy (CPT) in women veterans with PTSD related to military sexual trauma (MST) and the hypothesis that PTSD outcomes would differ between the interventions. Design, Setting, and Participants: This multisite randomized clinical trial was conducted from December 1, 2015, to April 30, 2022, within 2 VA health care systems located in the southeast and northwest. Women veterans aged 22 to 71 years with MST-related PTSD were enrolled and randomized to TCTSY or CPT. Interventions: The TCTSY intervention (Hatha-style yoga focusing on interoception and empowerment) consisted of 10 weekly, 60-minute group sessions, and the CPT intervention (cognitive-based therapy targeting modification of negative posttraumatic thoughts) consisted of 12 weekly, 90-minute group sessions. Main Outcome and Measures: Sociodemographic data were collected via self-report survey. The primary outcome, PTSD symptom severity, was assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and PTSD Checklist for DSM-5 (PCL-5). Assessments were conducted at baseline, midintervention, 2 weeks post intervention, and 3 months post intervention. Results: Of 200 women veterans who consented to participate, the intent-to-treat sample comprised 131 participants (mean [SD] age, 48.2 [11.2] years), with 72 randomized to TCTSY and 59 randomized to CPT. Treatment was completed by 47 participants (65.3%) in the TCTSY group and 27 (45.8%) in the CPT group, a 42.6% higher treatment completion rate in the TCTSY group (P = .03). Both treatment groups improved over time on the CAPS-5 (mean [SD] scores at baseline: 36.73 [8.79] for TCTSY and 35.52 [7.49] for CPT; mean [SD] scores at 3 months: 24.03 [11.55] for TCTSY and 22.15 [13.56]) and the PCL-5 (mean [SD] scores at baseline: 49.62 [12.19] for TCTSY and 48.69 [13.62] for CPT; mean [SD] scores at 3 months: 36.97 [17.74] for TCTSY and 31.76 [12.47]) (P < .001 for time effects). None of the group effects or group-by-time effects were significant. Equivalence analyses of change scores were not significantly different between the TCTSY and CPT groups, and the two one-sided test intervals fell within the equivalence bounds of plus or minus 10 for CAPS-5 for all follow-up time points. Conclusions and Relevance: In this comparative effectiveness randomized clinical trial, TCTSY was equivalent to CPT in reducing PTSD symptom severity, with both groups improving significantly. The higher treatment completion rate for TCTSY indicates its higher acceptability as an effective and acceptable PTSD treatment for women veterans with PTSD related to MST that could address current VA PTSD treatment limitations. Trial Registration: ClinicalTrials.gov Identifier: NCT02640690.

More than military sexual trauma: interpersonal violence, PTSD, and mental health in women veterans.

Military sexual trauma (MST) is reported by 20-40% of female veterans. The purpose of this study of female veterans referred for MST treatment was to examine the relationships between lifetime trauma (physical, sexual, and psychological) and posttraumatic stress disorder (PTSD), depression, physical health, and quality of life using retrospective cross-sectional data from medical records. Of the 135 participants, 95.4% reported at least one trauma in addition to MST, most notably sexual abuse as adult civilians (77.0%) and as children (52.6%). PTSD, depression, and sleep difficulty rates were clinically significant. Chronic pain (66.4%) was associated with childhood abuse, physical health, sleep difficulties, and coping. Integrating mental and physical health treatment is necessary to treat MST and PTSD in female veterans.

An evolving integrative treatment program for military sexual trauma (MST) and one veteran's experience.

Military sexual trauma (MST) increases the risk for Posttraumatic Stress Disorder (PTSD) and multiple other comorbidities, presenting substantial challenges for nurses and psychiatric and medical clinicians. A specialized VA Medical Center outpatient program is patterned after Herman's three-phased, empirically-supported, recovery treatments. We use a case example of a female veteran MST survivor to illustrate our treatment model. She presented to our program meeting diagnostic criteria for PTSD, Major Depressive Disorder, and a history of substance abuse. Post-treatment she demonstrated improved scores on measures of PTSD, quality of life, and socialization. This model shows promise for treatment of MST survivors with PTSD.

Feminist intersectionality: bringing social justice to health disparities research.

The principles of autonomy, beneficence, non-maleficence, and justice are well established ethical principles in health research. Of these principles, justice has received less attention by health researchers. The purpose of this article is to broaden the discussion of health research ethics, particularly the ethical principle of justice, to include societal considerations--who and what are studied and why?--and to critique current applications of ethical principles within this broader view. We will use a feminist intersectional approach in the context of health disparities research to firmly establish inseparable links between health research ethics, social action, and social justice. The aim is to provide an ethical approach to health disparities research that simultaneously describes and seeks to eliminate health disparities.

Symptoms of PTSD and major depression in Latinas who have experienced intimate partner violence.

The purpose of this study was to describe symptoms of PTSD and major depression in abused Latinas and to explore the relationships among intimate partner violence (IPV) experiences, these symptoms, and health related quality of life (HRQOL). The rate of PTSD was 69.7% and of major depressive disorder (MDD) was 57.6%. The comorbidity of PTSD and MDD was 54.5%. PTSD and MDD were not consistently correlated with IPV, although some significant relationships were found. PTSD and MDD symptoms were highly correlated with HRQOL. The impact of PTSD and MDD on psychological well-being and functioning in Latinas needs further investigation.

"I'm a mother first": The influence of mothering in the decision-making processes of battered immigrant Latino women.

Healthcare providers (HCPs) may be perplexed by the decision-making processes of battered Latino women in situations involving intimate partner violence (IPV). In particular, decisions may appear contradictory and hazardous to the women's children. The findings of this interpretive descriptive study reveal that the mothering role was central to battered Latina mothers' decisions. The mothers strove to prioritize, protect, and provide for their children in every way, including managing the abuse and avoiding IPV disclosure to HCPs. Disparate understandings of the women's decisions and mothering create a Catch-22 between battered Latina mothers and their HCPs. A trusting mother-HCP relationship is necessary for effective screening and intervention for IPV. This requires HCPs' understanding of these mothers' decisions and changes in clinical practice.

Military Sexual Trauma and Sexual Health in Women Veterans: A Systematic Review.

INTRODUCTION: Sexual trauma during military service is prevalent among women veterans and is associated with multiple negative physical and mental health sequelae. The high prevalence of military sexual trauma (MST), sexual harassment and assault during military service, has prompted the Veterans Health Administration to enact several policies to address the detrimental health impacts of this experience. MST also negatively impacts veterans' sexual health, yet the field lacks a systematic review of the relationship between MST and sexual health among women veterans. AIM: To systematically review the existing research on the impact of MST on sexual health in women veterans. METHODS: The published literature examining MST and sexual health in women veterans prior to July 19, 2018, was reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews. Articles were abstracted and evaluated for risk of bias. MAIN OUTCOME MEASURES: 6 articles were identified that met inclusion criteria; they generally evidenced a low risk of bias and thus a high quality of evidence. Results indicated that MST is associated with sexual dysfunction and low sexual satisfaction among women veterans. Other mental health concerns were also commonly comorbid with female sexual dysfunction in this population. This body of literature is small and methodologically limited by over-reliance on observational study design, use of non-validated and single-item measures of sexual health, and failure to comprehensively assess trauma history, including sexual and non-sexual trauma. CONCLUSIONS: Sexual dysfunction is a salient health issue for women veterans who experienced MST. Additional research is needed with improved designs, validated measures of sexual function, and comprehensive assessment of trauma to learn about the specific impact of MST on women veterans' sexual health. We present recommendations for future directions in terms of research, clinical practice, education, and policy. Pulverman CS, Christy AY, Kelly UA. Military Sexual Trauma and Sexual Health in Women Veterans: A Systematic Review. Sex Med Rev 2019;7:393-407.

The PTSD Toolkit for Nurses: Assessment, intervention, and referral of veterans.

Approximately 20% of veterans suffer from posttraumatic stress disorder (PTSD). NPs are well positioned to provide early detection and assist veterans with access to life-saving treatment. The PTSD Toolkit for Nurses helps nurses improve their skills in assessing PTSD and provides a specialized intervention and referral procedure that promotes help-seeking behavior among veterans.

Screening for Obstructive Sleep Apnea in Veterans Seeking Treatment of Posttraumatic Stress Disorder.

Disrupted sleep is an often intractable symptom of posttraumatic stress disorder (PTSD); however, non-PTSD-related causes of disrupted sleep are rarely considered in clinical practice. Study objectives were to determine obstructive sleep apnea (OSA) risk among veterans seeking PTSD treatment and to investigate the relationship between OSA risk and PTSD symptom severity. Veterans (N = 264; 25.8% female) completed measures of PTSD symptoms and OSA risk factors. The rate of OSA risk was 72.7% for the whole sample, 77.2% among men, and 59.7% among women. OSA risk was not significantly correlated with PTSD symptom severity. Detection and treatment of OSA in veterans with PTSD may result in decreased insomnia in affected individuals.

Theories of intimate partner violence: from blaming the victim to acting against injustice: intersectionality as an analytic framework.

Intimate partner violence (IPV) has garnered increasing public and academic attention in the past several decades. Theories about the causes, prevention, and intervention for IPV have developed in complexity. This article provides an overview of the historical roots of IPV, as well as a description and critique of historical and contemporary theories of IPV causes and women's responses to IPV. This is followed by a discussion of the most current theoretical developments and application of critical theories to the problem of IPV. The article concludes with theoretically based implications for nursing practice and research with women who are experiencing IPV.

Integrating intersectionality and biomedicine in health disparities research.

Persisting health disparities have lead to calls for an increase in health research to address them. Biomedical scientists call for research that stratifies individual indicators associated with health disparities, for example, ethnicity. Feminist social scientists recommend feminist intersectionality research. Intersectionality is the multiplicative effect of inequalities experienced by nondominant marginalized groups, for example, ethnic minorities, women, and the poor. The elimination of health disparities necessitates integration of both paradigms in health research. This study provides a practical application of the integration of biomedical and feminist intersectionality paradigms in nursing research, using a psychiatric intervention study with battered Latino women as an example.