Mental Health Beliefs, Access, and Engagement with Military Sexual Trauma-Related Mental Health Care.

BACKGROUND: Military sexual trauma (MST) is associated with negative mental health outcomes. Mental health beliefs, such as stigma or secondary victimization, have been identified as possible barriers to care; however, it is unclear whether such beliefs impact receiving care. OBJECTIVE: To assess if mental health beliefs impact MST-related mental health care access and engagement. DESIGN: Veterans completed a survey following detection of MST. Survey data were linked to Veteran's Health Administration administrative data in order to examine associations with outpatient MST-related care in the year following MST detection. PARTICIPANTS: A national sample of women and men Veterans (N = 1,185) with newly detected MST who reported a perceived need for MST-related mental health treatment. MAIN MEASURES: Building on prior work that identified four latent classes of mental health beliefs (Hahn et al., J Trauma Stress 34:394-404, 2020; low barrier, stigma-related beliefs, negative perceptions of care, high barrier), we examined associations with outpatient mental health care indicated by a provider as related to MST. Care was examined in total, as well as the specific categories of medication management, individual psychotherapy, and group psychotherapy. KEY RESULTS: Access to care following MST detection was high: most (71.6%) Veterans had an MST-related mental health visit within 30 days, and nearly all (83.6%) within 180 days, with the median number of days to receiving care being 2. Negative perceptions of care predicted a lower likelihood of treatment engagement (3+ encounters) with MST-related individual psychotherapy (OR = 0.65, 95% CI (0.43-0.96)), whereas the stigma-related beliefs and high barrier classes did not. CONCLUSIONS: There appears to be excellent access to mental health care among Veterans with a perceived need for MST-related mental health treatment. However, treatment beliefs that represented negative perceptions of care may serve as barriers to engagement. Interventions targeting negative perceptions of care during early encounters could help promote subsequent engagement.

The Relationship Between Provider Gender Preferences and Perceptions of Providers Among Veterans Who Experienced Military Sexual Trauma.

Previous research has demonstrated that most veterans who have experienced military sexual trauma (MST) have provider gender preferences. Although provider gender mismatch, defined as not receiving a provider of the gender of one's preference, may deter veterans from disclosing MST or seeking MST-related care, there is little research that has examined this issue. The current study aimed to explore how provider gender mismatch is related to veterans' comfort with providers, perception of their providers' competency, and their endorsement of perceived provider barriers when communicating about MST. The current study was conducted as part of a larger national survey of veterans' barriers to accessing MST-related care. Participants in the study were identified using Veterans Health Administration (VHA) administrative data. Criteria for inclusion in the overall study were being enrolled in VHA health care, having screened positive for MST, and having received at least one VHA outpatient service. A subset of eligible veterans who had endorsed MST, reported a provider gender preference, and endorsed discussing MST with a VHA provider (N = 1,591) were included in the current study. Results demonstrated that provider gender preference mismatch was associated with greater endorsement of perceived provider barriers, less comfort with providers, and lower perceived provider competency in women; and greater perceived provider barriers and less comfort with providers among men. The study demonstrates that provider gender preferences may affect care for veterans who have experienced MST, and that the impact may differ for men and women. These findings may be used to improve patient-centered care and inform future research regarding veterans' provider gender preferences.

Factors Associated with Sexual Satisfaction among Veterans Who Have Experienced Military Sexual Trauma.

Veterans who have experienced military sexual trauma (MST) report lower sexual satisfaction than veterans without a history of MST. The current study examined the relationship between demographic, physical health, mental health, and trauma variables and sexual satisfaction among a national sample of U.S. veterans who endorsed MST. Results demonstrated that lower sexual satisfaction was associated with uncoupled relationship status, poor physical health, and symptoms of depression, post-traumatic stress disorder, and sexual dysfunction among male and female veterans. Several additional factors were related to lower sexual satisfaction among female veterans. Findings highlight the importance of gender-targeted assessment, prevention, and treatment of sexual satisfaction problems.

An Examination of the Gender Inclusiveness of Current Theories of Sexual Violence in Adulthood: Recognizing Male Victims, Female Perpetrators, and Same-Sex Violence.

Although the majority of adulthood sexual violence involves a male perpetrator and a female victim, there is also substantial evidence that members of both genders can be victims and perpetrators of sexual violence. As an alternative to viewing sexual violence within gender-specific terms, we advocate for the use of a gender inclusive conceptualization of sexual aggression that takes into account the factors that contribute to sexual victimization of, and victimization by, both men and women. The goal of the current review is to examine the need and importance of a gender inclusive conceptualization of sexual violence and to discuss how compatible our current theories are with this conceptualization. First, we examine evidence of how a gender-specific conceptualization of sexual violence aids in obscuring assault experiences that are not male to female and how this impacts victims of such violence. We specifically discuss this impact regarding research, law, public awareness, advocacy, and available victim treatment and resources. Next, we provide an overview of a number of major sexual violence theories that are relevant for adult perpetrators and adult victims, including neurobiological and integrated biological theories, evolutionary psychology theory, routine activity theory, feminist theory, social learning and related theories, typology approaches, and integrated theories. We critically examine these theories' applicability to thinking about sexual violence through a gender inclusive lens. Finally, we discuss further directions for research, clinical interventions, and advocacy in this area. Specifically, we encourage sexual violence researchers and clinicians to identify and utilize appropriate theoretical frameworks and to apply these frameworks in ways that incorporate a full range of sexual violence.

Functional correlates of military sexual assault in male veterans.

Despite research findings that similar numbers of male and female veterans are affected by military sexual trauma (MST), there has been considerably less research on the effects of MST specific to male veterans. The aim of the present study was to provide preliminary data describing functional correlates of military sexual assault (MSA) among male Iraq/Afghanistan-era veterans to identify potential health care needs for this population. We evaluated the following functional correlates: posttraumatic stress disorder (PTSD) symptoms, depression symptoms, alcohol use, drug use, suicidality, social support, violent behavior in the past 30 days, incarceration, disability eligibility status, and use of outpatient mental health treatment. We compared 3 groups: (a) male veterans who endorsed a history of MSA (n = 39), (b) a general non-MSA sample (n = 2,003), and (c) a matched non-MSA sample (n = 39) identified by matching algorithms on the basis of factors (e.g., age, education, adult premilitary sexual trauma history, childhood sexual and physical trauma history, and race) that could increase veterans' vulnerability to the functional correlates examined. MSA in men was associated with greater PTSD symptom severity, greater depression symptom severity, higher suicidality, and higher outpatient mental health treatment, above and beyond the effects of vulnerability factors. These findings suggest that, for male veterans, MSA may result in a severe and enduring overall symptom profile requiring ongoing clinical management.

Military sexual assault, gender, and PTSD treatment outcomes of U.S. Veterans.

This study examined whether gender and military sexual assault (MSA) were associated with psychiatric severity differences at initiation of treatment for posttraumatic stress disorder (PTSD) and whether MSA and gender predicted psychiatric treatment outcomes. Male (n = 726) and female (n = 111) patients were recruited from 7 U.S. Department of Veterans Affairs (VA) PTSD specialty intensive treatment programs and completed an intake survey; 69% (n = 574) of the participants completed a 4-month postdischarge follow-up survey. Measures included current PTSD and depressive symptoms, aggressive/violent behaviors, alcohol and drug use severity, and quality of life. Multilevel multivariate regression analyses were conducted to examine the main and interaction effects of gender and MSA on psychiatric treatment outcomes at 4-month follow-up, including demographics, baseline severity, hostile fire, and treatment length of stay. Baseline PTSD severity did not differ by gender or MSA status, but women had more severe depressive symptoms (d = 0.40) and less aggressive/violent symptoms (d = -0.46) than men. Gender, MSA status, and the interaction between gender and MSA did not predict treatment outcomes as hypothesized. Male and female veterans with and without MSA responded equally well to treatment in VA PTSD intensive treatment programs.

An examination of the factors related to dating violence perpetration among young men and women and associated theoretical explanations: a review of the literature.

This article provides a review of the literature on dating violence (DV) perpetration, specifically sex similarities and differences in the correlates and predictors of DV perpetration and the utility of current theories to explain young men's and women's DV perpetration. Overall, many of the correlates and predictors of DV perpetration are similar among young men and women (e.g., witnessing interparental violence, experiencing child abuse, alcohol abuse, traditional gender roles, relationship power dynamics). However, young women's perpetration of DV is more strongly related to internalizing symptoms (e.g., depression), trait anger and hostility, and experiencing DV victimization than young men's perpetration, whereas young men's perpetration of DV is more consistently related to lower socioeconomic status and educational attainment, antisocial personality characteristics, and increased relationship length than young women's perpetration. Each theory offers insights into but does not fully account for the correlates and predictors of DV perpetration. Sociocultural theories may be useful in explaining the use of coercive control in relationships, and learning/intergenerational transmission of violence theories may be useful in explaining bidirectional couple violence. Future research should focus on integrative theories, such as in the social-ecological theory, in order to explain various forms of DV. Our understanding of young men's and young women's DV perpetration is limited by cross-sectional research designs, methodological inconsistencies, a lack of sex-specific analytic approaches, and a lack of focus on contextual factors; more multivariate and longitudinal studies are needed. Further, as DV prevention programming is often presented in mixed-sex formats, a critical understanding of sex differences and similarities in DV perpetration could ultimately refine and improve effectiveness of programming efforts aimed at reducing DV.

Impact of gender on reactions to military sexual assault and harassment.

Research has shown that experiences ofmilitary sexual assault and harassment can have a negative impact on veterans' health and functioning, even years or decades later, thus clearly identifying this as an important area of concern for social workers. In addition to understanding the scope and general impact of military sexual assault and harassment, social workers also must thoroughly understand how different cultural factors may intersect with veterans' experiences. To this end, this article reviews the current knowledge base on how veterans' life experiences related to gender can affect their experience of and recovery from military sexual assault and harassment, highlights common gender-specific issues, and discusses implications for practice.

Female Sexual Victimization Among College Students: Assault Severity, Health Risk Behaviors, and Sexual Functioning.

The purpose of the present study was to examine the relationship between college women's sexual victimization experiences, health risk behaviors, and sexual functioning. A sample of 309 college women at a mid-sized Midwestern university completed measures assessing sexual victimization, sexual risk taking, substance use behaviors, sexual desire, sexual functioning, prior sexual experiences, and social desirability. Severity of sexual victimization was measured using a multi-item, behaviorally specific, gender-neutral measure, which was divided into four categories based on severity (none, sexual contact, sexual coercion, rape). Within the sample, 72.8% (n = 225) of women reported at least one experience of sexual victimization since age 16. Results from MANCOVAs and a multinomial logistic regression, controlling for social desirability and prior sexual experience, revealed that sexual victimization among female students was related to increased drug use, problematic drinking behaviors, sexual risk taking, sexual dysfunction, and dyadic sexual desire. In addition, findings indicated that women exposed to more severe forms of sexual victimization (i.e., rape) were most likely to report these risk-taking behaviors and sexual functioning issues. Implications for sexual assault risk reduction programming and treatment are discussed.

Preferences for gender-targeted health information: a study of male veterans who have experienced military sexual trauma.

No prior research has examined men's opinions or preferences regarding receiving health education materials related to sexual violence. The objective of the current study was to investigate whether male veteran patients who have experienced military sexual trauma (MST) prefer gender-targeted versus gender-neutral printed health information and whether receipt of this information increased utilization of outpatient mental health services in the following 6-month period. In-person 45-minute interviews were conducted with 20 male veterans receiving health care services at a large Veterans Health Administration facility to evaluate opinions on a gender-targeted and a gender-neutral brochure about MST. An additional 153 veterans received psychoeducational materials through the mail and participated in the completion of a survey as part of a psychoeducational intervention. Our results demonstrate that male veterans prefer gender-targeted information about sexual trauma compared to gender-neutral information. Whereas veterans in the study had clear preferences for gender-targeted materials, receipt of information about MST (whether gender-targeted or gender-neutral) did not increase utilization of mental health care in the 6 months following receipt of these materials. These results demonstrated that materials about sexual trauma are acceptable to men and should be gender-targeted. Further research is needed to examine strategies to increase access to mental health care among male Veterans who have experienced MST.

Military sexual trauma among homeless veterans.

BACKGROUND: Military sexual trauma (MST) is the Veteran Health Administration's (VHA) term for sexual assault and/or sexual harassment that occurs during military service. The experience of MST is associated with a variety of mental health conditions. Preliminary research suggests that MST may be associated with homelessness among female Veterans, although to date MST has not been examined in a national study of both female and male homeless Veterans. OBJECTIVE: To estimate the prevalence of MST, examine the association between MST and mental health conditions, and describe mental health utilization among homeless women and men. DESIGN AND PARTICIPANTS: National, cross-sectional study of 126,598 homeless Veterans who used VHA outpatient care in fiscal year 2010. MAIN MEASURES: All variables were obtained from VHA administrative databases, including MST screening status, ICD-9-CM codes to determine mental health diagnoses, and VHA utilization. KEY RESULTS: Of homeless Veterans in VHA, 39.7 % of females and 3.3 % of males experienced MST. Homeless Veterans who experienced MST demonstrated a significantly higher likelihood of almost all mental health conditions examined as compared to other homeless women and men, including depression, posttraumatic stress disorder, other anxiety disorders, substance use disorders, bipolar disorders, personality disorders, suicide, and, among men only, schizophrenia and psychotic disorders. Nearly all homeless Veterans had at least one mental health visit and Veterans who experienced MST utilized significantly more mental health visits compared to Veterans who did not experience MST. CONCLUSIONS: A substantial proportion of homeless Veterans using VHA services have experienced MST, and those who experienced MST had increased odds of mental health diagnoses. Homeless Veterans who had experienced MST had higher intensity of mental health care utilization and high rates of MST-related mental health care. This study highlights the importance of trauma-informed care among homeless Veterans and the success of VHA homeless programs in providing mental health care to homeless Veterans.

Perceived barriers to care and provider gender preferences among veteran men who have experienced military sexual trauma: a qualitative analysis.

Research suggests that there may be unique barriers to accessing care among men who have experienced sexual trauma. The primary goal of the current research was to elucidate potential barriers to accessing military sexual trauma (MST)-related care for male veterans. A secondary goal was to explore whether veterans have preferences regarding the gender of clinicians providing MST-related care. Qualitative analyses were used to examine data collected from semistructured interviews conducted with 20 male veterans enrolled in Veterans Health Administration care who reported MST but who had not received any MST-related mental health care. Veterans identified a number of potential barriers, with the majority of reported barriers relating to issues of stigma and gender. Regarding provider gender preferences, veterans were mixed, with 50% preferring a female provider, 25% a male provider, and 25% reporting no gender preference. These preliminary data suggest that stigma, gender, and knowledge-related barriers may exist for men regarding seeking MST-related care. Interventions to address potential barriers, such as outreach interventions and providing gender-specific psychoeducation, may increase access to care for male veterans who report MST.

Utilization and intensity of outpatient care related to military sexual trauma for veterans from Afghanistan and Iraq.

Little research has examined factors associated with the utilization of outpatient health care services related to sexual assault experiences. The Veterans Health Administration provides free outpatient treatment services to veterans who report military sexual trauma (MST); this system provides a unique opportunity to examine factors related to the utilization of mental health and non-mental health outpatient services by patients with sexual trauma. The current study examined sociodemographic, military service factors, and primary diagnoses related to utilization and utilization intensity of MST-related care among 4,458 Operation Enduring Freedom/Operation Iraqi Freedom Veterans in a 1-year period after reporting an experience of MST. Of the veterans who reported MST, 75.9% received MST-related care. The most notable factor that influenced receipt and intensity of MST-related care was gender, where male veterans used less care than female veterans. These results have important treatment implications for both veteran and civilian sexual trauma survivors.

Exploring the intention-behavior relationship in the prediction of sexual risk behaviors: can it be strengthened?

Many theoretical models examining health risk behaviors, such as sexual risk taking, assume intentions directly predict behavior, and intentions are sometimes measured as a proxy for behavior. Given that there is often a discrepancy between intentions and behaviors (e.g., Sheeran, 2002 ), this study addressed factors that predict intention-behavior congruence. Specifically, utilizing a prospective design, the goal of the study was to determine if characteristics of university students' last sexual encounter predicted whether those students who intended to use condoms, contraception, or dual methods did so in their last sexual encounter with both relationship and casual partners. The seven tested variables were condom planning and preparatory behaviors, mood, sexual arousal, substance use, perceived partner attractiveness, intention certainty, and intention stability. Data were collected from 520 American undergraduate students at a medium-sized university. The six discriminant function analyses examining the intention-behavior relationship were able to correctly classify between 74% and 92% of the participants concerning whether intenders engaged in safe sex behaviors. The variables that best discriminated between behavior engagement over the six analyses were intention stability, intention certainty, and engagement in condom preparatory behaviors. The implications of these results for sexual risk prevention and intervention research are discussed.

Is risky sexual behavior continuous or categorical? A taxometric analysis of the Sexual Risk Survey.

Risky sexual behaviors are behaviors that involve the possibility of an adverse outcome, such as contracting a sexually transmitted infection or unwanted pregnancy. The question of whether risky sexual behavior exists as a discrete class (i.e., taxon) or as a dimensional construct has not previously been explored. The authors performed a set of taxometric analyses on 4 factor scales derived from the Sexual Risk Survey (Turchik & Garske, 2009) with data from 1,103 college students. The results provided consistent support for a dimensional latent structure in which variations in reported risky sexual behavior reflect differences in degree and not differences in kind. The implications of these findings for the assessment of risky sexual behavior are discussed.

Parent and adolescent satisfaction with mental health services: does it relate to youth diagnosis, age, gender, or treatment outcome?

Consumer satisfaction with treatment is important information for providers of mental health services. The goal of the current study was to examine the relationship between youth and parent satisfaction ratings and the following youth variables: gender, age, primary diagnosis, and changes in functioning and symptomatology after 6 months of services. Results demonstrated that in a large sample of youth receiving community mental health services satisfaction with services differed as a function of the adolescents' clinician-derived primary diagnosis, age, and reported changes in symptoms and functioning. Although significant, these variables accounted for only a small portion of the variance in satisfaction. Additionally, the relationship between parent and youth ratings of satisfaction was low, but significant. The implications of these findings are discussed as well as future directions for clinicians and researchers.

Working alliance as a mediator of client attachment dimensions and psychotherapy outcome.

Studies that employ multidimensional attachment measures to explore the impact of attachment style on psychotherapy process and outcome are virtually absent in the literature. Further, the role of the working (therapeutic) alliance as a mediator of the influence of attachment on treatment outcome has not been formally investigated. In order to address these gaps in the research, archival data from 66 psychotherapy clients treated at a university graduate program training clinic were used to examine the influence of three adult attachment dimensions (Comfort with Closeness, Comfort Depending on Others, and Rejection Anxiety) on the therapeutic alliance and outcome, as well as to assess whether the alliance mediates the relationship between attachment and therapy outcome. Both Comfort with Closeness and Comfort Depending on Others were significantly related to alliance and outcome, whereas Rejection Anxiety was not significantly related to either variable. Alliance was a significant partial mediator of the effect of Comfort with Closeness on outcome. The results suggest that multidimensional measures of attachment capture important influences on alliance and psychotherapy and that Comfort with Closeness promotes successful outcome by virtue of its influence on alliance.

Personality, sexuality, and substance use as predictors of sexual risk taking in college students.

Sexual risk taking among college students is common and can lead to serious consequences, such as unintended pregnancies and sexually transmitted infections. This study utilized responses from 310 undergraduate psychology students aged 18 to 23 to examine personality, sexuality, and substance use predictors of sexual risk behaviors over a six-month period. Data were collected from 2005 to 2006 at a medium-sized Midwestern U.S. university. Results indicated that greater alcohol and recreational drug use, higher extraversion, and lower agreeableness were related to sexual risk taking in men. For women, greater alcohol and drug use, higher sexual excitation, and lower sexual inhibition were predictive of sexual risk taking. Among women, but not men, sensation seeking was found to mediate the relationship between the four significant substance use, personality, and sexuality variables and sexual risk taking. Implications for sexual risk behavior prevention and intervention programming are discussed.

Prediction of sexual assault experiences in college women based on rape scripts: a prospective analysis.

Although script theory has been applied to sexual assault (e.g., H. Frith & C. Kitzinger, 2001; A. S. Kahn, V. A. Andreoli Mathie, & C. Torgler, 1994), women's scripts of rape have not been examined in relation to predicting sexual victimization experiences. The purpose of the current study was to examine how elements of women's sexual assault scripts predicted their sexual assault experiences over a follow-up period. The authors used data from a baseline and follow-up session for 339 undergraduate women. The results suggest that women who constructed narratives containing certain elements were more likely to report a sexual assault over the academic quarter. Specifically, narratives containing the woman utilizing nonforceful resistance, the woman having less control over the outcome of the situation, the assault happening outdoors, the assault being more severe, and the woman having known the perpetrator less time were predictive of reported sexual victimization over the 8-week follow-up period. Additionally, having a history of adolescent sexual victimization was also predictive of reported sexual victimization over the quarter. These findings have important implications in sexual assault risk-reduction programming, which are discussed.

Measurement of sexual risk taking among college students.

Current measures of sexual risk taking are either too narrowly focused to be used with college students or do not have adequate psychometric properties. The goal of the current study was to develop a broad and psychometrically sound measure of sexual risk taking. A total of 613 undergraduate students (302 men, 311 women) at a mid-sized Midwestern university in the U.S. were surveyed to develop and gather reliability and validity information on a new measure of sexual risk, the Sexual Risk Survey (SRS). The measure was found to be multifactorial with five factors. The measure was found to have good internal consistency and test-retest reliability. The SRS also demonstrated evidence of convergent and concurrent validity by its relationships with reported number of sexual partners and history of infidelity as well as measures of sensation seeking, sexual desire, substance use, sexual excitation and inhibition, and sexual health consequences. Social desirability was not found to be related to sexual risk taking scores and threat of sexual disclosure was only weakly related. An investigation of sex differences revealed that men reported greater intentions to engage in sexual risk behaviors and greater overall sexual risk taking behavior compared to women. The SRS provides researchers with a valid and comprehensive measure of sexual risk taking that can be used to clarify inconsistent findings in the literature and to assess outcome in programs designed to prevent and reduce sexual risk behaviors among college students.