An Overview of Sexual Trauma in the U.S. Military

Uncovering an Epidemic

Over the past two-and-a-half decades, awareness has grown that sexual violence within the U.S. Armed Forces is a far-reaching problem that necessitates intervention. In 1992, Congress required that the Department of Defense (DOD) take action to prevent sexual harassment and sexual assault in the military. The Department of Veteran Affairs (VA) was also directed to provide treatment to veterans and service members (VSM) experiencing the emotional and physical sequelae of sexual violence endured during their service (1, 2). The VA adopted the term military sexual trauma (MST), which captures a spectrum of experiences, defined as

Thus, MST is a term that includes both military sexual assault (MSA) and military sexual harassment (MSH). MSH is further defined as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.” Much of the research on the impact of MST has focused on sexual assault (1, 4). However, survivors often describe sexual harassment in the military setting as pervasive, threatening, and inescapable. MSH has resulted in comparable adverse emotional, physical, social, and occupational outcomes (5, 6). MSA and MSH are also highly correlated—those who experience MSA nearly universally report experiencing MSH, often in escalation to an assault (7). In 2004, DOD established the Sexual Assault Prevention and Response Office (SAPRO) to examine MST in the U.S. military, implement prevention efforts, advance medical care and support for survivors, and improve accountability of both the assailant and the institution.

Prevalence of MSA and MSH in the U.S. Armed Forces

A significant amount of scientific inquiry into MST and its impact since the early 1990s has led to a range of prevalence rates because of the variability in study methodology (8, 9). For example, one review highlighted that prevalence estimates in the literature range from 22% to 45%, depending on method of assessment, sample type, MST definition, and study setting and purpose (1). Efforts to uncover prevalence are complicated by underreporting of sexual trauma, which may be exacerbated by barriers to disclosure, including some that are unique to the military setting (10). This discrepancy in prevalence rates highlights the need for future research to use a consistent definition of MST, specifically distinguishing MSA and MSH to improve understanding of the true scope of this issue (11). A recent meta-analysis examined 69 articles on MST prevalence rates, using the DOD definition. It concluded that, on average, 15.7% of VSM reported experiencing MST when the measure includes both harassment and assault; when these experiences were examined separately, the average was 13.9% for MSA and 31.2% for MSH (12). In general, self-report measures and interviews are associated with higher prevalence rates compared with reviews of VA medical records.

The DOD has made significant efforts to understand rates of MST among those currently serving. Since its establishment, a SAPRO task force has routinely collected and published the number of official reports of sexual assault in the military. Data collected include service members’ restricted (i.e., confidential) and unrestricted (i.e., investigated) reports of sexual assault; sexual harassment complaints are handled by a separate Military Equal Opportunity office. In 2015, DOD confirmed 6,083 total reports (both restricted and unrestricted) of sexual assault and 657 formal complaints of sexual harassment (13). In 2014, the RAND Corporation National Defense Research Institute updated its independent assessment of sexual assault, sexual harassment, and gender discrimination in the military on the basis of current definitions and criteria from the Uniform Code of Military Justice. Their survey of 560,000 U.S. service members indicated that 4.9% of women and 1% of men serving in active duty experienced a sexual assault during 2014; 26% of women and 7% of men serving in active duty experienced sexual harassment or gender discrimination (14).

Risk Factors for Sexual Victimization in the Military

Rates of sexual assault among women in the military are comparable to the lifetime prevalence of sexual assault of civilian women (16.6%) (15). However, some scholars have noted that the restricted period of military service (typically two to six years) compared with lifetime rates is indicative of women’s higher risk of experiencing sexual violence in the military compared with civilian settings (1, 4). Some sociodemographic factors appear to increase the likelihood of experiencing sexual trauma in the military. MST tends to happen earlier in service members’ military career; more than 80% are victimized between the ages of 17 and 24 (16–17). Women are more likely than men to experience MST; racial minorities, sexual minorities, and those who are unmarried are also at higher risk (16, 18, 19). Some aspects of military service also appear to increase risk for MST. The Marines and the Navy have the highest rates of MST, the Air Force has the lowest, and enlisted members report higher rates of MST than officers (14). Finally, high alcohol use, particularly binge drinking among younger military personnel, may contribute to increased rates of sexual violence (20).

MST and Cumulative Trauma

Those who experience MST tend to have higher rates of other forms of trauma before, during, and after their service. Individuals entering the military have higher rates of exposure to adverse experiences in childhood and adolescence than the general population (21). This appears to be particularly true for individuals who experience MST, which is associated with higher rates of childhood sexual and physical abuse (4, 16–18). Surviving MST is also associated with experiencing sexual assault as an adult outside of military service. In one sample of active-duty Air Force women, the lifetime prevalence of rape was more than twice as high as that in a national sample of civilian women (28% vs. 13%); the majority of initial rapes (75%) in the military occurred before the service member joined the Air Force (9). The nature of military service itself comes with high risk for additional trauma, including combat exposure. In one recent study, 12.5% of male troops and 42% of female troops reported experiencing some form of MST while deployed (22). Seventy-three percent of those who experienced MST during deployment were also exposed to other significant war-zone stressors. Combat exposure during deployment increases the risk for experiencing MST among female veterans of Iraq and Afghanistan (23, 24). Various types of traumatic stressors during deployment each uniquely contribute to subsequent psychopathology, with combat exposure significantly predicting posttraumatic stress disorder (PTSD) and MST significantly predicting major depressive disorder. Combat exposure, MST, and general harassment all have a significant impact on the severity of depressive symptoms (25).

What Makes MST Distinct From Other Forms of Sexual Trauma?

It is important to consider that MST occurs within the context of long-standing military cultural norms. The military was essentially an all-male institution until the mid-20th century, and it continues to be heavily male dominated. Some scholars have implicated overvalued hypermasculinity, promoting traditions of the ideal soldier as strong, nonemotional, aggressive, and dominant (26, 27). These values, in combination with a general acceptance of violence, a view of women as outsiders, the prevalence of rape myths, and power differentials between men and women, lead to environmental conditions that foster objectification of women and sexual violence as a means to assert dominance and control (5, 16, 26, 28). This combination of factors may contribute to an increased acceptance of sexual aggression and minimization of the consequences of sexual misconduct on a cultural level. However, public recognition of MST, subsequent policy changes, and strong leadership promoting a safe environment for all who serve have played important roles in a gradual cultural shift. For example, annual data collection from DOD and the RAND Corporation has indicated that incidents of sexual violence have declined in the past several years, and reporting of such incidents has increased (13, 14). Also, units in which leadership takes reports of MST seriously, demonstrates zero tolerance for sexual harassment, and shows support for service members seeking mental health care have lower rates of sexual assault (29).

Despite this progress, MST continues to occur frequently, and aspects of the military experience contribute to unique challenges in recovery. Given the youth of the majority of victims and the high prevalence of premilitary trauma among service members, individuals who experience MST may have a limited repertoire of coping skills at the time of the trauma (30, 31). Military training, which often occurs during very formative developmental years, instills deep values of strength, mental toughness, and personal responsibility. This socialization can contribute to survivors’ efforts to suppress normal emotional reactions to a sexual trauma (31). Survivors may also take personal responsibility for the attack, leading to a high level of self-blame, which plays a role in the subsequent development of PTSD (32).

Military training also ingrains principles of group cohesion—that is, loyalty, teamwork, sacrifice, trust in comrades, and the suppression of individual needs for the larger good of the unit. Blurred boundaries between work and home contribute to the insular nature of the group; service members often live, work, and socialize on small military bases, especially when stationed internationally. Many individuals join the military seeking such belonging and view comrades as family. This belongingness is disrupted by the experience of sexual assault, which may have been perpetrated by a brother- or sister-in-arms or a commanding officer whose role was to guide and protect. Survivors of MST may experience a strong sense of betrayal and subsequent difficulties in determining whom to trust for support or protection. Survivors of MST may be required to interact with perpetrators on a regular basis, even when off duty (31). This circumstance often leads survivors to describe the consequences of MST as pervasive and inescapable, which may lead to feelings of powerlessness and patterns of learned helplessness. In the aftermath of MST, the fractured cohesion of the insular unit, and the tendency for a unit and its leadership to protect the group rather than the individual survivor, have led some scholars to compare the experience of MST to secretive forms of violence and abuse that can take place within a family system (27).

Sources of support that the military offers to survivors are not available if the survivor is not willing to report; survivors often cite barriers to reporting, including the fear of not being believed, stigma of assault, disruption of unit cohesion, fear of retaliation, fear of accusations of fraternization, and lack of awareness of the reporting system or available resources (26, 31). For male survivors of same-sex assault, fear of being labeled homosexual is a unique barrier to reporting. Survivors’ disinclination to seek justice and support appears to have merit in some cases. Some survivors describe the aftermath of reporting a sexual assault as more painful than the assault itself (10, 31). Women who report a sexual assault are more likely to be demoted and discharged from military service (33). Seeking support may be particularly challenging in a combat zone, where personnel may not be properly trained to handle sexual assault, medical resources may be limited, and command may be unwilling to separate victim and perpetrator if the mission is deemed to require their cooperation (28). Finally, geographical moves based on assignment often isolate individuals from important sources of social support that would otherwise be available (e.g., friends and family). Such social support is a well-established protective factor against the development of pathology in the aftermath of trauma (34).

Male Survivors of MST

As the understanding of MST advances, it becomes increasingly clear that sexual assault in the military is not just a women’s issue. One review of reported rates of male victimization across studies found that, on average, 1.1% of military men experience MST over the course of their career. Prevalences ranged from 0.03% to 12.4%, with significantly higher rates found in studies that used anonymous survey methodology (35). As a result of the higher ratio of men to women in the military, the raw numbers of men and women who experience MST are comparable. The 2014 RAND Corporation workplace study identified qualitative differences in men’s experience of MST; specifically, male survivors of sexual assault were more likely to have experienced multiple assaults, to have endured assaults by multiple assailants (i.e., gang rape), and to describe the incident as hazing motivated by abuse and humiliation (14).

Traditionally masculine values promoted within military culture may increase the stigma of sexual assault and support seeking in the aftermath of MST for men (36). Male survivors of MST often report concerns that others will perceive the assault as an indication of weakness, femininity, or homosexual orientation (37). Male survivors are less likely than their female counterparts to formally report their experience to authorities and less apt to seek support from loved ones after their experience (14, 37, 38). In addition, relatively fewer men than women use MST-related care provided by the VA, despite evidence that the link between MST and adverse mental health outcomes is at least as strong for male as for female VSM (39–41). In addition to stigma, men’s reservations about seeking care include minimization of the seriousness of sexual trauma and its impact, worry about reactions of health providers to their disclosure, fear of not being believed, self-blame, concerns about privacy, and lack of awareness of or access to male-specific MST services (42). Given the well-established role of social support in recovery from traumatic experiences, men’s reservations about seeking support may contribute to greater chances that MST will lead to PTSD in men relative to women (2). For any trauma survivor, the tasks of reestablishing safety, trust, and control are paramount to recovery. In addition to these tasks, male survivors of MST often encounter questions related to what sexual assault means to masculinity and sexual identity (regardless of a VSM’s identified sexual orientation). Some studies have suggested that male survivors of MST experience sexual dysfunction (e.g., low sexual desire, sexual dissatisfaction, engaging in unwanted sex, or hypersexuality) at higher rates than women (43).

MST and LGBT VSM

To discern the unique impact of MST on an individual who identifies as LGBT, it is critical to understand cultural and policy changes in the acceptance of LGBT individuals into military service. Before 1993, potential service members were screened for and excluded on the basis of nonheterosexual orientation; after entry, if an individual was identified as homosexual, he or she risked other than honorable discharge. In 1991, an attempt to reduce discrimination against gay and lesbian service members resulted in policy that allowed gay and lesbian individuals to serve on the condition that they kept their sexual orientation quiet; the policy became widely known as “Don’t Ask, Don’t Tell” (DADT). If a service member’s orientation became known to command, however, it could be grounds for inquiry and disciplinary action including discharge. In 2011, DADT was repealed, allowing gay and lesbian individuals to serve openly. In 2016, the Pentagon also lifted the ban preventing transgender individuals from serving openly in the military, although it is uncertain if this protection will be preserved under the current administration. This history is relevant in work with MST survivors; each individual’s experience of sexual assault, subsequent reporting, and support seeking may have varied greatly depending on his or her period of service (i.e., before, during, or after DADT). Before the repeal of DADT, a sexual assault perpetrated by a member of the same sex often resulted in survivors fearing accusations of consensual same-sex behavior and resulting discharge regardless of their identified sexual orientation (44).

LGBT-identifying individuals serving in the military are at disproportionate risk for victimization; they report higher rates of lifetime physical assault, sexual assault, and discrimination than non-LGBT peers (45–47). As one would expect, the experience of MST is associated with adverse mental and physical health consequences among this population (e.g., PTSD, mood disorders, personality disorders; 46). More important, the consequences of sexual assault experienced by LGBT individuals may be compounded by exposure to stigmatization and discrimination related to sexual minority status. Of particular concern among the LGBT population is the increased risk of suicide. LGBT service members have demonstrated a 10-fold increase in past-year suicide attempts compared with non-LGBT military peers, an effect that is likely amplified by the experience of sexual assault (45, 48). Health providers caring for LGBT VSM should stay informed regarding LGBT culture as it pertains to military experience and take care to prevent perpetuation of the harmful consequences of heterosexism, cisgenderism, and other forms of sexual minority-based discrimination. Cultural competence may include assessment of the extent to which a survivor may have been targeted for harassment or assault as a result of sexual minority status. Providers should also avoid implicitly or explicitly attributing emotional and functional difficulties resulting from discrimination or traumatic victimization to survivors’ sexual orientation or gender identity (46).

MST and Impact on the Family System

Because MST is an interpersonal trauma that often involves a high level of betrayal, it frequently results in a long-standing impact on survivors’ relational functioning. Survivors may struggle with a sense of safety with and trust in others and find it more manageable to isolate themselves from support systems. After accounting for other traumatic stressors, MST predicts difficulties with connecting to social support after return from deployment and particular difficulty in readjusting to romantic relationships (49). Women who have experienced MST are more likely to report a history of multiple marriages and twice as likely to report that military experience interfered with their desire to have children (22). Qualitatively, survivors’ partners often describe a lack of understanding of MST, apprehension about discussing the sexual assault with their partner, feelings of failure regarding the inability to protect their loved one, and lack of knowledge about how to provide support (50). The adverse impact of military stressors and PTSD on parenting satisfaction and efficacy is well documented and likely extends to the experience of MST, although more research in this area is warranted (51). Clinical interventions designed to educate loved ones, cultivate their support, and build skills related to fostering connection is a vital direction for future research and clinical development given the important role of healthy relationships in trauma recovery.

MST and Mental Health Outcomes

The experience of MST has not surprisingly been associated with numerous adverse mental health outcomes, including PTSD, depression, anxiety, substance use disorders, eating disorders, dissociative disorders, and personality disorders (1, 2, 4, 8). For veterans who experience both MST and combat, the impact of MST predicts more deleterious physical and mental health consequences, even after controlling for the impact of combat exposure (52). There is also some evidence that PTSD secondary to MST is more severe and less responsive to treatment than PTSD resulting from other forms of trauma (1, 53). Men who screen positive for MST are at higher risk for bipolar disorder and psychotic disorders including schizophrenia (2). Compared with women, male survivors of MST may also be at greater risk for developing a substance use disorder (54). Correspondingly, a recent study of veterans of Iraq and Afghanistan found that MST was a unique predictor of PTSD severity and alcohol-related problems independent of combat exposure (55). Results in this area of substance use have been mixed, however; multiple studies have not demonstrated links between MST and problematic substance use (56, 57).

Of particular concern is emerging evidence that the experience of MST increases risk of suicidal behavior. Suicidal ideation and attempts are higher among both men and women with a history of MST (8, 48, 58, 59). Death by suicide is significantly elevated among both male and female survivors of MST, with hazard ratios of 1.69 and 2.27 for men and women, respectively, even after accounting for other military stressors (48). One recent study found that perceived loss of value as a member of the military family and institutional betrayal predicted increased odds of suicide attempts among those who experienced MST (58). Given the complexity of symptom presentation, individuals reporting MST should be screened thoroughly not only for PTSD but also for several commonly comorbid mental health conditions as well as suicide risk.

MST and Physical Health Outcomes

Nonrecovery from traumatic stressors has a well-documented impact on a variety of physical health outcomes (60, 61). MST is no exception, with numerous studies demonstrating adverse physical health correlates among MST survivors (4). The link between MST and negative physical health outcomes may be explained by chronic tension or circulation of stress hormones in the case of PTSD or may develop as a result of unhealthy coping strategies (e.g., smoking, substance use, dysregulated eating, risky sexual behavior). Common medical complaints include pelvic pain and menstrual problems, back pain, headaches, gastrointestinal problems, hypothyroidism, and chronic fatigue. Cardiovascular risk factors (e.g., obesity, smoking, sedentary lifestyle) are also higher among survivors of MST (62). A cross-sectional analysis of a national sample of VA outpatients also exhibited a moderate association between liver disease and chronic obstructive pulmonary disorder among men and women who screened positive for MST (2). Men who experience MST also have a higher rate of positive HIV status (1, 2).

MST and Sexual Health

Although sexual functioning complications after sexual assault are well documented in the general population, little data exist regarding sexual health correlates and MST. The few studies that exist have indicated that MST is linked to decreased sexual satisfaction, with some indication that male veterans with a history of MST exhibit more persistent sexual problems than women (1, 43). One study examining female survivors of MST found that emotional health–related quality of life was the strongest mediator between the experience of MST and sexual dissatisfaction (63). Medicaid claims data indicate that female trauma survivors are at greater risk than their nonvictimized counterparts for a wide variety of pelvic health conditions, including irritable bowel syndrome, chronic pelvic pain, and musculoskeletal problems (64). This higher risk for pelvic health conditions is thought to be related to problems with high-tone abdominal, lumbar, hip girdle, and pelvic floor muscles, the muscles that surround the genitals (65). As part of a comprehensive work-up for individuals who experience MST, the review of symptoms should query for pelvic and lumbopelvic pain, urinary tract symptoms, gastrointestinal symptoms, and sexual dysfunction or dyspareunia. A pelvic floor expert can complete a history and physical exam. This exam can identify painful and nonrelaxing muscles; check for normal nerve function around the back, abdomen, and genitals; and check for strength, endurance, and coordination of the pelvic, core, and lower-extremity muscles. During the exam, the pelvic floor expert may look at (and touch) the low back, pelvic girdle, abdomen, and genitals, both externally and internally. For men, this could involve placing fingers inside the rectum; for women, this could involve placing fingers inside the vagina, rectum, or both (66). A trauma-sensitive pelvic health examination of an MST survivor is crucial because VSM with history of MST and PTSD experience more fear, distress, and embarrassment during pelvic examination (67).

Evidence-Based Treatment for PTSD Secondary to MST: A Stage-Based Approach

Given the often complex trauma histories of MST survivors, best practices involve the stage-based clinical approaches to treatment, such as the three-stage model proposed by Judith Herman in 1997 (68–69). Stage 1 of Herman’s model focuses on assisting the survivor to stabilize and establish a sense of safety with self and others. Clinical goals in this stage may include reducing suicidal ideation or self-harm behavior, reducing problematic substance use, setting boundaries in harmful relationships, and addressing basic needs such as stable housing and medical care. Protocols such as skills training in affective and interpersonal regulation, seeking safety, or dialectical behavior therapy are often indicated in this stage of treatment (70–73). During this initial stage, the survivor is also developing a sense of safety with the therapist or treatment team. Pharmacotherapy may be particularly helpful in achieving stabilization during this stage.

When stabilization and basic safety have been established, the survivor moves to stage 2, remembering and grieving past trauma and integrating the experience into his or her life as a whole. If the survivor has a diagnosis of PTSD, a trauma-focused treatment is most often indicated at this stage of treatment. Many of the treatment approaches studied for PTSD secondary to civilian sexual trauma have been found to be effective in treating PTSD resulting from MST. Allard and colleagues noted, however, that because of the unique combination of stressors experienced by survivors of MST in addition to potential gender differences, it is necessary to study treatment outcomes in MST survivors specifically (1). Most research on treatment of the sequelae of MST has focused on treatment of PTSD. The most empirical support for treatment of PTSD secondary to sexual assault has been found for cognitive-behavioral therapies, including prolonged exposure and cognitive processing therapy (74–76). There is also research supporting the use of eye movement desensitization and reprocessing and stress inoculation training (77, 78).

The third and final stage of treatment for survivors of MST involves reconnection and reintegration into the community. Stage 3 is often an appropriate time to integrate family and loved ones into treatment. Survivors’ focus shifts to the present and future as they set goals related to purposeful work, passions and interests, and meaningful connection to others. Johnson and colleagues noted that a staggered approach of providing coping skills, trauma processing, and reconnection allows time for treatment engagement and creation of safe boundaries before delving into trauma processing. It also enables providers to determine whether trauma processing is necessary and which trauma-focused approach is best suited to a given survivor (79). Survivors present to treatment at different levels of preparedness for trauma-focused therapy and may move through stage 1 at different rates. Survivors may also not move through stages in a linear process and may need to revisit the goals and skills of each stage depending on changing circumstances or psychosocial stressors (68, 69).

MST and Pharmacotherapy

In considering treatment options from a pharmacological perspective, it is important to consider the degree to which MST is separate from combat PTSD or other forms of PTSD. As we argued earlier, there are fundamental differences in the nature of the MST injury that need to be addressed from psychotherapeutic and psychosocial perspectives. Nemeroff and colleagues found that individuals with major depression who had a history of childhood sexual abuse tended to be nonresponsive to traditional pharmacotherapies for depression (80). These same subjects tended to respond more favorably to psychotherapy. These researchers also found that those individuals who underwent combined psychotherapy and pharmacotherapy had only marginal improvements over the psychotherapy-only subjects. Despite the focus on depression in the Nemeroff et al. study, this finding has prompted many providers to recommend evidence-based psychotherapies as first-line treatments for trauma spectrum disorders.

Nevertheless, pharmacotherapies can play a key role in the treatment of PTSD secondary to MST. Selective serotonin reuptake inhibitors (SSRIs) continue to be the mainstay of pharmacological treatment for PTSD (81, 82). This class of medications appears to help reduce the anxiety and mood symptoms associated with PTSD and can help patients gain a better quality of life. Despite this well-established finding, care must be taken in the use of medications for the treatment of PTSD. In particular, caution should be exercised in the use of benzodiazepines for the treatment of PTSD-related anxiety symptoms. Rothbaum and colleagues have demonstrated that use of these compounds may worsen PTSD treatment outcomes (83). Current theories hold that this is likely because this class of medications interferes with the extinction paradigms used in psychotherapy that have the best general outcomes for the treatment of PTSD.

Finally, care should also be taken to consider the psychosexual side effects of pharmacotherapies (84). Although sexual trauma is fundamentally a physical and emotional attack on another person, its impact on the victim often results in sexual dysfunction, orientation confusion, and psychosomatic symptoms of the sexual body. These complex dynamics take time to address therapeutically but can in the interim lead to significant stress and tension in relationships. Sexual pleasure is also an important part of many individuals’ quality of life, and sexual dysfunction is often reported as one of the leading causes of medication discontinuation across many classes of pharmacological therapy. In the case of PTSD, sexual side effects can be profound for men and women who take SSRIs. Using the lowest effective dose and providing some degree of education about these side effects is an important part of treatment. For some patients, sexual side effects may be transient during the initiation or up-titration phase of treatment, and regular monitoring can help reduce patient fears about and discomfort with discussing these issues.

Overall, pharmacotherapy should certainly be considered when addressing MST and when a diagnosis appropriate for pharmacological treatment is established. PTSD might be comorbid with other mood disorders that would benefit from SSRI therapy, and therefore the clinician should do a careful broad assessment. Pharmacotherapy might also be considered if PTSD is comorbid with substance use disorders, which are often a coping strategy for survivors of sexual violence.

Underutilization and Improving Access to Care

Several factors often prevent survivors from receiving necessary mental health and medical care. In addition to stigma, survivors may encounter many logistical barriers to care (e.g., transportation issues, geographical limitations, child care needs, and limited employment leave). For those diagnosed with PTSD, a high level of avoidance symptoms may also hinder treatment initiation or adherence. Some survivors report finding military reminders and the male-dominated environment characteristic of the VA triggering; many seek care in the private sector (85). To reduce these barriers, providers in private settings should prepare to appropriately assess and treat mental and physical health problems that MST survivors may bring to treatment. In the VA setting, women’s health and trauma clinics should take measures to promote comfort, privacy, and accessibility of MST-related care. Male survivors may benefit from gender-specific psychoeducational materials, outreach, and programming to reduce stigma related to male sexual assault. Finally, research has suggested that survivors of MST may prefer and respond well to telehealth interventions that do not require entry into VA settings, at least early in treatment. Telehealth interventions may also help reduce geographic and other logistical barriers to care (86).

Conclusions

Although evidence exists that overall rates of MST have declined in recent years, this form of violence remains prevalent. Aspects of the military setting may make recovery from MST particularly difficult and result in mental, physical, and relational health consequences. Health providers in both the private and the government sectors must prepare to assess for incidence and consequences of MST in presenting VSM and consider unique issues that may arise with male and LGBT survivors. Comprehensive clinical care includes assessment of potential mental and physical health sequelae of MST, including a range of potential mental health consequences in addition to PTSD. Suicidality should be carefully monitored. Health of the pelvic floor muscles and resulting functional difficulties, an often overlooked consequence of sexual trauma, should also be assessed and treatment offered when indicated. Providers should also consider the impact of MST on VSMs’ social support and consider treatment of the couple or family system when warranted. Finally, further research and development of methods for reducing stigma and barriers to care for this population is critical to enable delivery of care to those who have served.