Objectives. We explored qualitatively US servicewomen’s experiences with and perceptions of military sexual trauma (MST), reporting, and related services.

Methods. From May 2011 to January 2012, we conducted 22 telephone interviews with US servicewomen deployed overseas between 2002 and 2011. We analyzed data thematically with modified grounded theory methods.

Results. Factors identified as contributing to MST included deployment dynamics, military culture, and lack of consequences for perpetrators. Participants attributed low MST reporting to negative reactions and blame from peers and supervisors, concerns about confidentiality, and stigma. Unit cohesion was cited as both a facilitator and a barrier to reporting. Availability and awareness of MST services during deployment varied. Barriers to care seeking were similar to reporting barriers and included confidentiality concerns and stigma. We identified several avenues to address MST, including strengthening consequences for perpetrators.

Conclusions. We identified barriers to MST reporting and services. Better understanding of these issues will allow policymakers to improve MST prevention and services.

Military sexual trauma (MST) refers to sexual assault or repeated, threatening sexual harassment during military service.1 In the 2012 Workplace and Gender Relations Survey of Active Duty Members, 6.1% of active-duty women reported unwanted sexual contact in the previous year, a significant increase over the 4.4% reporting in 2010,2 and approximately 16 times the estimated 0.37% annual incidence of sexual assault among the general population of US women aged 18 to 34 years between 2005 and 2010.3 Two review studies estimated an overall MST prevalence of 20% to 45%, with variations attributed to differing MST definitions, data collection methods, and sample populations; rates were consistently higher among women than men.4,5 In a 2011 representative survey of active-duty military personnel, 21.7% of women and 3.3% of men reported unwanted sexual contact since joining the military by someone in the military6; because this survey was only among active-duty personnel, the total prevalence of MST among servicemembers over their full military career is likely higher because of the longer exposure time.

Despite efforts to prevent and address MST, high prevalence and low reporting persist; the Department of Defense received only 3374 reports in 2012 of an estimated 26 000 active-duty members experiencing unwanted sexual contact.2 There are little data on MST during deployment; however, research suggests the incidence remains high. In a 2006–2009 study of 7251 soldiers returning from Operation Enduring Freedom/Operation Iraqi Freedom, 12% of women (66 of 554) and 0.5% of men (32 of 6697) reported experiencing MST during their deployment.7 The unique circumstances of deployment may have an impact on reporting and accessibility of services.

Military sexual trauma is associated with numerous poor mental and physical health outcomes. Women who experience MST are more likely to have depression, posttraumatic stress disorder, difficulty readjusting after deployment, eating disorders, alcohol abuse, and other mental health comorbidities compared with those who have not experienced MST.4,5,8–13 Survivors of MST also report more physical health symptoms and medical comorbidities, such as pelvic pain, menstrual problems, headaches, and chronic fatigue, and have poorer overall health functioning and health satisfaction.4,5,13 In addition, the unique context of the military, which often requires servicewomen to work in close quarters with their perpetrators after abuse, may affect the severity of MST symptoms.4

Although there is a growing body of literature on MST prevalence and associated health outcomes, there is little qualitative exploration of women’s experiences with MST and the determinants of reporting and uptake of services, particularly during deployment. We were unable to find any studies providing an in-depth exploration of military women’s perceived barriers and facilitators to reporting MST and accessing MST-related services. To fill this gap in the literature, we conducted in-depth interviews with servicewomen who had been deployed overseas between 2002 and 2011 about their experiences with and perceptions of MST prevalence, reporting, and services.

From May 2011 to January 2012, we conducted in-depth interviews with women who had served in the US military about their reproductive health experiences during deployment, including their experiences with and perceptions of MST during deployment. We recruited servicewomen via Facebook advertisements, postings on Craigslist in cities with large military bases nearby, e-mail communication, and postings on military and veteran-related Web sites and Facebook pages. The recruitment message read as follows:

Ibis Reproductive Health is recruiting current and former US military women who were deployed anytime from 2001 to present to participate in a confidential phone interview about their health experiences during deployment. This information will help healthcare providers and policy makers to improve access to health services for military women in the future. It will take 45 minutes to an hour to complete, and participants will receive a $25 gift card to Amazon.

Women of any military status, who had been deployed overseas anytime from 2001 or later, and who were 18 years of age or older were eligible to participate. We recruited participants until thematic saturation was reached. Two research team members trained in qualitative data collection conducted the interviews in English via telephone. All study participants gave oral informed consent to participate and have their interview audio recorded.

The data for this analysis are part of a larger study focused on US servicewomen’s sexual and reproductive health experiences during deployment. Military sexual trauma was described to participants as “sexual assault or rape during military service, including any type of sexual contact that is achieved or attempted without consent.” We asked participants open-ended questions about MST frequency during deployment and associated factors, personal experience with MST and experience of others known personally during deployment, facilitators and barriers to MST reporting and access to services during and after deployment, and suggestions for improving MST services.

All interviews were digitally recorded and transcribed verbatim. We analyzed data thematically in ATLAS.ti 6.2 (ATLAS.ti GmbH, Berlin, Germany) with modified grounded theory methods.14 Two researchers coded each transcript to ensure intercoder reliability. We developed initial codes a priori based on research questions; we made subsequent revisions to the codebook as new inductive themes surfaced. We summarized codes and organized them thematically with representative quotes extracted, and the research team cross-validated provisional findings. Quotations are identified by participant’s country and year of most recent deployment and whether she reported personal MST experience.

Twenty-two women completed in-depth interviews. We screened 2 additional participants but found them ineligible because of their most recent deployment being before 2001. Most participants self-identified as White. Most of the women were in the military for 6 to 15 years and had been deployed 1 time. At the time of their most recent deployment, one third were aged 18 to 24 years, one third were aged 25 to 29 years, and one third were aged 30 years or older. Most participants had at least some college, were single, and were lower enlisted rank or rate (E-1 to E-6) at the time of their most recent deployment. Slightly more than half had served in the Army. Seven participants (32%) reported experiencing MST during deployment (Table 1). An additional 6 participants (27%) described MST incidents involving other servicewomen they knew personally. One participant ended her interview before final demographic information was collected and therefore is missing data for some demographic variables.

Table

TABLE 1— Background Characteristics of US Servicewomen Deployed Overseas Between 2002 and 2011

TABLE 1— Background Characteristics of US Servicewomen Deployed Overseas Between 2002 and 2011

CharacteristicNo. (%)
Total participants22 (100)
Age at most recent deployment,a y
 18–247 (31.8)
 25–297 (31.8)
 ≥ 307 (31.8)
Education level at most recent deploymenta
 High school2 (9.1)
 Some college8 (36.4)
 Bachelor’s degree9 (40.9)
 Master’s degree2 (9.1)
Marital status at most recent deploymenta
 Single14 (63.6)
 Married5 (22.7)
 Separated or divorced2 (9.1)
Race/ethnicitya
 White, non-Hispanic19 (86.4)
 Hispanic2 (9.1)
Time in military, current, y
 1–54 (18.2)
 6–109 (40.9)
 11–156 (27.3)
 16–201 (4.5)
 21–252 (9.1)
Service branch at most recent deployment
 Army12 (54.5)
 Navy4 (18.2)
 National Guard4 (18.2)
 Marine Corps2 (9.1)
Rank/rate at most recent deployment
 E-1 to E-33 (13.6)
 E-4 to E-613 (59.1)
 E-7 to E-91 (4.5)
O-1 to O-35 (22.7)
Number of deployments, current
 01 (4.5)
 114 (63.6)
 26 (27.3)
 ≥ 31 (4.5)
Experienced MST during deployment
 Yes7 (31.8)
 No15 (68.2)

Note. MST = military sexual trauma.

aPercentages do not total 100 because of missing data.

Factors Contributing to Military Sexual Trauma During Deployment

Participants attributed the occurrence of MST during deployment to factors primarily within 3 categories: deployment dynamics, military culture, and lack of consequences. Some respondents felt certain behaviors by servicewomen put them at risk for MST.

Deployment dynamics.

Several women cited stressors unique to deployment as contributing to MST. These included the long duration of deployment, deprivation of sexual activity, high stress levels, high prevalence of risk behaviors such as alcohol use, and changes in perceptions of “normal” behavior that may occur during war.

Military culture.

Interviewees suggested that certain aspects of military culture, namely widespread sexism, low ratios of women to men, and men outranking women, contribute to an environment conducive to high MST incidence among women. One woman in the Marine Corps explained,

You train people to be tough, invincible, on top of the world, in charge of everything, but at the same time there’s no mechanism for taking that away when you’re talking about sexual conquest [Bahrain 2002, personal MST experience].

Lack of consequences.

Several participants reported that military leadership had failed to adequately address the issue of MST and that assailants rarely faced consequences. They felt a tolerant environment perpetuated MST because there were few risks or deterrents to committing assault. As a Navy member who had served for 22 years described,

They just turn a blind eye to it. I’ve seen it all my life. They just look the other way and they pretend it didn’t happen [Iraq 2004–2005, no personal MST experience].

Blaming women.

Participants depicted a culture of blaming women who experience MST. In some cases, women who had been assaulted blamed themselves. One woman said,

There was a big part of me that was like, “these things wouldn’t have happened to me if I had been more guarded, if I had not trusted the wrong people, if I had not been so friendly” [Cuba 2004–2005, personal MST experience].

In other cases, participants who had not experienced MST felt that some women who were assaulted were irresponsible, citing alcohol use, not having a “battle buddy,” and poor judgment in attire.

Reporting of Military Sexual Trauma

Of the 7 women who experienced MST, 4 reported the incidents, 2 did not report, and 1 did not specify. The majority of interviewees felt that servicewomen in general typically do not report MST during deployment, citing several factors that discourage reporting.

Negative reactions.

One frequently mentioned deterrent was negative reactions from peers or superiors, including disbelief, blame, criticism of character, and lack of support. As one woman said,

Honestly, if I was assaulted while in the military, I can pretty much guarantee I would probably not report it, just because the first thing they do—it’s like the ’50s in the military all over again: “she was asking for it.” Yeah, she walked outside whoooo [Kuwait 2010, no personal MST experience].

Confidentiality.

Concerns about confidentiality were also common, with participants describing a small-group environment that contributes to rumor spreading and lack of privacy. One participant noted that low numbers of women can compromise anonymity even when one is filing a restricted report, which is theoretically confidential:

If there’s 1 female or 2 females in the unit and it comes down that “there’s 1 female raped or sexually assaulted in this unit. Oh, there’s only 2 of ’em!” Hmmmmm, not too hard to figure out [Afghanistan 2006–2007, personal MST experience].

Other barriers.

Other barriers to reporting included embarrassment or stigma, fear of negative career impact, and confusion about what behaviors constitute sexual harassment or assault.

Unit cohesion.

Unit cohesion was considered both a facilitator and a barrier to MST reporting. In some cases, the closeness of individuals in the unit contributed to an environment supportive of reporting, as described by an Army officer:

[Deployment] was generally very traumatic, and when you live in close quarters like that with people, you become close whether you want to or not, and so—I think there’s probably a level of comfort that comes there with just being around people that you’re really close with and needing to tell somebody [Iraq 2003, no personal MST experience].

In other cases, however, the pressure to maintain unit cohesion was thought to discourage women from reporting. A National Guard member explained,

When you’re in a team environment, you report something bad that happened to you, you’re the one responsible for breaking up the team. Even if something bad happened to you, you’re still gonna be the “bad person” [Iraq 2005–2006, no personal MST experience].

Other facilitators.

Respondents identified several other factors that facilitated reporting. First, some suggested that MST reporting may be easier after returning to the United States from deployment, because women would have separation from their assailants. Second, a need for medical care may motivate women to report. One woman who experienced and reported 5 separate incidents explained, “I wanted to make sure I was checked. Make sure that there was nothing wrong” (Djibouti 2003–2004, personal MST experience). Third, some women may report to establish a record in case of future incidents involving the perpetrator. For example, one interviewee explained,

Once we got back to the US, I made a decision to write a memorandum for record and have it put in his file. So that if he did it again, it would show a pattern of behavior and hurt him. But if it was 1 single flip-out moment, then it would not ruin his career [Iraq 2003–2004, personal MST experience].

Availability and Utilization of Military Sexual Trauma Services

Respondents were generally aware of counseling services available during deployment through a chaplain, a Combat Stress office, or other mental health channels. In interviewees’ experiences, services during deployment from individuals specifically trained to handle sexual assault cases were more limited. One woman noted,

You’re lucky if you can refer yourself to psychiatry and get yourself in to see a psychiatrist. Other than that, when I was there, there was no Sexual Assault Response person, there was no Victim Advocate, there was nothing [Afghanistan 2006–2007, personal MST experience].

Interviewees generally felt medical care would be available after a sexual assault during deployment, though the extent may be limited. Overall, most participants believed more services would be available to women after they returned home from deployment.

Six participants discussed service utilization in the context of their own experiences with sexual assault. Of these, half sought physical or mental health care during deployment and half did not. Three women sought care outside the military after deployment. One participant described concerns over confidentiality and career impact as motivation for seeking care from a civilian provider:

Some things in the military records are career-enders… . It doesn’t matter what it’s for, they see that you’ve been in there for mental health and they’ll re-evaluate you—are you really stable enough to be a soldier? [Djibouti 2003–2004, personal MST experience].

In general, participants reported that women often do not seek care, even in cases where services are available. Reasons cited included lack of confidentiality, lack of knowledge, not wanting to report, and stigma or shame. An Army officer speaking about one of her soldiers who was assaulted during deployment explained,

There was a combat stress unit on our base, but I don’t believe that [my soldier] would’ve gone for the—nah, she wouldn’t have gone. I mean, nobody went. There was a stigma associated with that. And even given what happened to her, I think in most circumstances, people would understand, but because it was deployment and because our OPTEMPO [i.e., pace of military operations] was so hard, and we saw some pretty nasty combat at that time, so I think there was not a lot of sympathy for—anything [Iraq 2004–2005, no personal MST experience].

Suggestions for Improvement

Participants offered several suggestions for improving MST services. The most common were better investigation and prosecution, increased awareness of the issue and available services, provision of MST services by nonmilitary providers, and a culture shift.

Better investigation and prosecution.

Several interviewees suggested that strengthened investigation and prosecution of incidents was needed. As one woman stated, “Really punishing people who do this stuff would help, probably. Not treating rape victims like they’re on trial would probably help” (Cuba 2004–2005, personal MST experience).

Increased awareness.

Participants felt the military should raise awareness about MST through better predeployment briefings about MST, including where and how to access care, and improved ongoing outreach for soldiers after deployment. One woman explained,

You can’t just say it once and say, “OK, this option’s out there if you need help.” People won’t grab onto that, it needs to just keep being drilled in and at some point you’re going to want the help [Iraq 2004–2005, personal MST experience].

Another women who was assaulted during her tour in Afghanistan reported,

I really had no idea who to go to if I even wanted to report certain things. You don’t know who the SARCs [Sexual Assault Response Coordinators] are, you don’t know who the Victim Advocates are, you really don’t have an understanding a lot of times of what your options are if you’re a victim of assault [Afghanistan 2006–2007, personal MST experience].

Independence of military sexual trauma services.

Another recurring recommendation was to make MST services available from independent providers outside the military or the unit to increase confidentiality and reduce judgment and stigma. Military providers were perceived as more likely to see sexual assault survivors as “weak” for seeking care or to have biased opinions, which discouraged some women from seeking their care. One participant deployed to Afghanistan in 2006–2007 commented that her unit’s Victim Advocate was “not friendly to women.”

Culture shift.

Some participants felt that to prevent MST, measures to address certain aspects of military culture, such as gender norms and high stress levels, should be put in place. For instance, one woman stated,

[Preventing MST would] probably require some cultural change in the military. There’s kind of a weird culture surrounding sex and gender expectations in the military and it maybe needs to change. Maybe less stress—that’s hard to do on a battlefield, but reducing stress might help, too [Cuba 2004–2005, personal MST experience].

Other women commented on the need for norms that support rather than condemn reporting and the people who experience MST, such as one woman deployed to Kuwait:

I think by making it okay to report, that would be a huge change. I know the military’s trying not to sweep this under the rug, but they’ve made it seem like you’re “bad” to report it… . It very much seems to be the victim’s fault, which is absurd. I can’t even tell you how many letters I’ve seen labeled “I have zero tolerance of sexual assault in my squadron.” And you know what that says to me? You may have “zero tolerance”; that means you want “zero reporting” [Kuwait 2010, no personal MST experience].

Additional suggestions.

Additional recommendations included ensuring access to emergency contraception during deployment, mandating mental health treatment after an assault to reduce care-seeking stigma, improving the accessibility and confidentiality of medical services, having a reporting system that allows women to report assault to women, and creating an anonymous hotline for soldiers overseas.

Military sexual trauma is an important concern because of its high prevalence and numerous negative physical and mental health impacts. Interviewees identified factors contributing to the high prevalence of MST during deployment as well as barriers to reporting and uptake of services. Some barriers, including fear of being blamed or not believed, stigma, and confidentiality concerns were similar to those commonly reported by civilian survivors of sexual assault.15–17 However, earlier research suggests secondary victimization (i.e., interactions resulting in negative feelings such as guilt, depression, anxiety, or distrust) may be more common in military versus civilian legal and medical services.18 Thus, the degree to which these barriers affect care-seeking behaviors may differ between military and civilian populations. In addition, our findings highlight challenges unique to the military context, particularly unit cohesion and the implications of “breaking up the team,” as well as the fear that reporting MST and seeking counseling could be detrimental to one’s career.

We identified several avenues for policy change to address MST. First, many participants felt that the military should strengthen investigation and prosecution of reported incidents; improving the military’s response to MST reports could help deter assailants and may increase reporting and care seeking.

Second, interviewees highlighted the need to increase awareness among servicemembers regarding definitions and regulations related to MST as well as of available services. Suggestions included mandating MST briefings before, during, and after deployment to provide continued messaging on policies related to MST and guidance on how to access care. A 2012 study by the US Government Accountability Office also underscored the need for greater training of Sexual Assault Response Coordinators and Victim Advocates, who were not always aware of the services available at their deployment location.19

Finally, ensuring timely access to confidential MST-related medical care, including access to emergency contraception for pregnancy prevention, is critical. Military personnel have 2 MST reporting options: unrestricted, which initiates an official investigation, and restricted, which does not involve any investigative procedure.19 Although both options theoretically allow servicemembers to receive confidential medical treatment and counseling, many women expressed concerns regarding the confidentiality of MST reporting systems and health services.

This study has several limitations. First, these findings represent the views of a small, nonrepresentative, predominantly White, convenience sample and have limited generalizability. Second, we included perceptions of women without first-hand experience of MST; although these views further our understanding of military culture, perceived barriers and facilitators to reporting and care seeking may differ from those actually faced by women with MST experience. Third, our interviews focused on women’s experiences and thus do not necessarily reflect the perspectives of men who experience MST. Although only 3.3% of men versus 21.7% of women reported unwanted sexual contact since joining the military by someone in the military,6 this proportion reflects a large absolute number of men who experience MST, and future qualitative research including this male population is needed. Finally, 59% of participants completed their most recent deployment in 2005 or earlier; as such, our study may be subject to recall bias, and the activities of the Sexual Assault Prevention and Response Office created in 2005 may not be fully reflected in all of our data. However, we noted no systematic differences in responses between women deployed before and after 2005.

This study provides new insight into women’s perceptions of and experiences with MST during deployment. These data can help military policymakers better respond to MST during deployment, and in turn may help increase MST reporting and improve service delivery.

Acknowledgments

This research was supported by grants from The William and Flora Hewlett Foundation and the Wallace A. Gerbode Foundation.

Human Participant Protection

This study was approved by the Allendale Investigational Review Board.

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Bridgit Burns, MPH, Kate Grindlay, MSPH, Kelsey Holt, MA, Ruth Manski, BA, and Daniel Grossman, MDAt the time of the study, Bridgit Burns, Kate Grindlay, Kelsey Holt, and Ruth Manski were with Ibis Reproductive Health, Cambridge, MA. Daniel Grossman is with Ibis Reproductive Health, Oakland, CA, and the Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco. “Military Sexual Trauma Among US Servicewomen During Deployment: A Qualitative Study”, American Journal of Public Health 104, no. 2 (February 1, 2014): pp. 345-349.

https://doi.org/10.2105/AJPH.2013.301576

PMID: 24328617