21st Century Military Sexual Assault and Trauma (MST) Sourcebook - VA Medical Course, Defense Department Reports - Rape, Violence, Harassment, Victim Care, Prevention, PTSD, Compensation
Edition: Version 1.0 – 10/2010
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** OVERALL BOOK CONTENTS LIST **
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Military Sexual Trauma (MST) - Veterans Administration Independent Study Course, Assault, Harassment, Rape, Medical Guidelines, Compensation, PTSD, Revictimization, Mental Health, Documentation
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Section 1 * Definitions, VA Mandate, and Prevalence
Section 2 * Relevance to VA Clinicians
Section 3 * Health Correlates of Sexual Trauma
Section 5 * What to Do Next: Responding to MST Disclosure
Section 6 * Referring the Patient to Mental Health and Social Services
Section 7 * Treatment of Mental Health Sequelae
Section 8 * Documentation Issues
Section 9 * Compensation Issues
Section 10 * Complex Patient-Provider Relationship Issues
Section 11 * Medical Procedures for MST Survivors: Avoiding PTSD Flares
Section 12 * Risk for Revictimization
Section 13 * Intimate Partner Violence
Section 14 * Acute Sexual Trauma
Section 15 * Epilogue: How Clinicians can Care for Themselves and Avoid Burnout
Appendix A: Military Sexual Trauma Program in the VA
Appendix B: Advantages of Screening for MST
Appendix C: Resources and Information about Sexual Trauma and Abuse
Appendix D: Information about Sexual Trauma & VA Services
Appendix E: Pharmacotherapy for PTSD
Appendix F: Supplement: Additional Compensation & Pension Claims Issues
Appendix G: Danger Signals in Staff-Patient Relationships
Appendix H: Domestic Violence Screening: Special Issues
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Independent Study Outline - Purpose: Every day, VA clinicians care for women and men who suffer from physical and mental sequelae of sexual harassment and sexual assault which occurred during military service. However, this problem, which has come to be known as “military sexual trauma”, has only recently reached the consciousness of the nation.
Background: This independent study module is a part of the Veterans Health Initiative (VHI). The VHI is a comprehensive program of continuing education designed to improve recognition and treatment of health problems related to military sexual trauma, to include sexual assault and sexual harassment.
Objectives: After completing this independent study, participants will be able to:
1. Describe the VA mandate, and prevalence of military sexual trauma (MST);
2. Describe the relevance of MST to VA clinicians;
3. Identify the health correlates of sexual trauma;
4. Explain the effective screening methods for MST;
5. List the steps when responding to MST disclosure;
6. Explain the referral process of a patient who experienced MST to mental health and social services;
7. Describe the mental health treatment for MST;
8. Describe the documentation requirements for MST treatment and compensation;
9. Explain the compensation issues associated with MST;
10. Describe the complex patient-provider relationship issues associated with MST;
11. Identify the risk factors that could cause PTSD flares in MST survivors;
12. Define revictimization;
13. Assess intimate partner violence;
14. Describe treatment of acute sexual trauma victims; and
15. Recognize how clinicians can care for themselves and avoid burnout.
The expected outcomes of this independent study are to improve the quality of health care provided to veterans who have experienced military sexual trauma. Drug treatments and dosages provided in this study guide should be double-checked prior to prescribing therapy.
Target Audience: This independent study is primarily designed for Department of Veterans Affairs clinicians and interested VA staff. Other health care providers, especially those working in veterans and military health care facilities in the U.S., also are encouraged to complete this study module.
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SECTION 1 - DEFINITIONS, VA MANDATE, AND PREVALENCE
1. Identify the historical events contributing to the development and implementation of the Department of Veterans Affairs (DVA) Military Sexual Trauma (MST) Program.
2. Identify difference between sexual harassment and assault as defined by the DVA.
3. Describe basic MST eligibility requirements.
4. Identify proportions of male and female veterans who screen positive for MST.
What is Sexual Trauma?
Every day, VA clinicians care for women and men who suffer from physical and mental sequelae of sexual harassment and sexual assault which occurred during military service. However, this problem, which has come to be known as “military sexual trauma”, has only recently reached the consciousness of the nation. Military sexual trauma (“MST”) has been defined by the Department of Veterans Affairs as:
sexual harassment that is threatening in character or physical assault of a sexual nature that occurred while the victim was in the military, regardless of geographic location of the trauma, gender of victim, or the relationship to the perpetrator.
VA clinicians are legally obligated to address the substantial physical and mental illness that can follow MST. This Veterans Health Initiative (VHI) will explain how they can help their patients who are suffering from disability related to prior MST.
What led to this emphasis?
The Navy’s Tailhook Incident in 1991 unleashed a groundswell of concern on the part of traumatized women veterans, their advocates, and their Congressional representatives. Hearings held before the Senate Veterans Affairs Committee on June 30, 1992, where women veterans told their gripping stories of sexual harassment and assault while on active duty, energized the system to provide more comprehensive care to women veterans and focused attention on the serious health consequences of sexual trauma for women. More recently, when it became evident that many male veterans have also been the victims of military sexual trauma, Congress updated VA’s mandate to assure gender-neutral access to care for its sequelae. These events are summarized in the following timeline, and additional information about relevant legislation is included in Appendix A.
1991: Tailhook incident: brought MST to public attention
1992: Senate hearings about MST; Public Law 102-585 health care services for women who experienced MST, and other provisions
1994: Public Law 103-452: extended law to include men who experienced MST
1997: Letter from Secretary of Veterans Affairs Jesse Brown to all women veterans regarding MST
1999: Public Law 106-117: extended duration of MST program
Unfortunately, despite efforts on the part of the DOD, episodes of sexual harassment and sexual assault do continue to occur in military troops and in elite military academies. Such events receive ongoing attention in the national media, and their prevalence is substantiated by recent research. About 1 in 4 female VA patients have experienced MST.
How Common is MST? Among active duty military, about 5 to 6 % of women have experienced military sexual assault, and about 78% military sexual harassment. Following discharge from the military, a national cross-sectional, community-based telephone survey found 30% of women who served in the Vietnam era or later had been sexually assaulted. In a group of women serving in the Gulf War, 8% experienced attempted or completed sexual assault during their deployment, even though that conflict was of relatively short duration, and occurred after the Tailhook incident had led to system-wide policy changes.
The prevalence is much higher among women in a VA population, as a number of studies have shown. In a national survey of 3,632 women veterans using VA, 23% reported a history of military sexual assault and 55% reported a history of sexual harassment while on active duty. Among female patients at the Baltimore VA, 41% had a history of rape, and 60% of those rapes occurred while on active duty. These rates of sexual assault while in the military are higher than lifetime rates among women in the general population.
This situation is not unique to women; in VA health care settings, MST is a mainstream health care issue for men as well. Based on VA’s 2002 national MST surveillance data from approximately 1.7 million VA patients, about 22% of women and 1% of men have experienced MST. Thus, among VA patients, women are 20 times more likely to be victimized during their military tour than men are. However, there are 20 times more men than women in the VA system. Therefore, the actual numbers of men and women who screen positive for MST in VA are about equal. Even though MST is far more common in women, 54% of all VA patients who screen positive for MST are men. Military sexual harassment is also common: about 38% of men receiving VA care have experienced sexual harassment while in the military.
While the focus of this VHI is upon MST, it is important to remember that military service represents a small slice of most VA patients’ lives. Many veterans have also been exposed to other types of violence, such as child abuse and domestic violence. Later sections touch on these issues.
How has VA responded? The Department of Veterans Affairs (VA) is concerned about MST because it is known that any type of trauma can have enduring effects on a person’s physical and mental health (Section 3). Enabling legislation authorizes VA to provide confidential, priority counseling and treatment to eligible veterans for MST-related physical and psychological problems.
Who is eligible and how do they access care?
Any veteran who believes he/she experienced MST can apply at any VA medical facility (VAMC), Readjustment Counseling Service (Vet Center) or Veterans Benefits Office (VBA) for counseling and treatment of any MST-related injury, illness, or psychological condition, without obligation for copayment. Veterans do not need to have a service-connected (SC) rating to receive these services. Even veterans with less than 24 months of active duty service (who otherwise would not be eligible for VA services) are eligible to receive this particular benefit. Reservists and members of National Guard units who were activated to full-time status in the Armed Forces are also eligible, unless the Reservist/National Guard member’s service was on “active duty for training” (ADT). A Reservist/National Guard member who has received a service-connected rating for MST is eligible to receive MST counseling and treatment as well. It is important to know that sexual trauma counseling can be provided even if a veteran did not report the incident when it occurred. (See VHA Under Secretary for Health Information Letter (IL) 10-97-037 of November 27, 1997 for specifics of eligibility details, e.g., if veteran was not dishonorably discharged.)
The VA clinician does not need to determine whether the self-reported MST occurred; the patient’s statement that it did suffices. Instead, the VA licensed health care provider must decide whether any of the patient’s presenting physical or mental health problems resulted from the trauma, which occurred while the veteran was serving on active duty. If so, the patient can receive VA care for those problems without obligation for copayment. Counseling services may be contracted to community providers if, in the opinion of a VA mental health professional, receipt of these services in VA facilities is not feasible (e.g., because of geographic inaccessibility) or is not clinically advisable.
Do veterans have to be “service-connected” to get this benefit?
MST counseling is provided independent of the Veterans Benefits Administration (VBA) claims process. When veterans are screened for MST, they are informed that they are not required to have a service-connected rating from the MST incident in order to begin or continue treatment. Indeed, MST counseling can be helpful for veterans who are considering filing a claim, because:
1. The claims process can be very traumatic for some veterans; counseling can help veterans as they think through whether or not to apply. If they decide to apply, ongoing counseling can help to support them through the process.
2. If a mental health diagnosis (e.g., PTSD) is identified and documented in the mental health setting, this can help to substantiate a future claim.
Several VHA Directives have been published that establish policy and provide guidance to VA facilities on the delivery, documentation, and tracking of MST counseling and services. Key documents include:
VHA Directives related to MST
Military Sexual Trauma Software - VHA Directive 99-039 dated August 27, 1999. http://www.va.gov/wvhp/docs/199039.pdf
Military Sexual Trauma Software Mandate - VHA Directive 2000-008 (expires December 31, 2004) http://www.va.gov/wvhp/docs/VHA_DIRECTIVE_2000-008.doc
Eligibility Criteria for VA Health care to Veterans Seeking Counseling or Treatment for Sexual Trauma - USH Information Letter 10-97-037, November 1997 http://www.va.gov/publ/direc/health/infolet/109737.htm
Table 1 below shows in a simplified way how the VA MST counseling and treatment benefit differs from the VBA MST compensation & pension benefit.
VA MST Counseling & Treatment Benefit vs. VBA MST Compensation & Pension Benefit
How is MST determined? MST Counseling & Treatment Benefit (Based on Public Laws 102-585, 103-452, 106-117) - Veteran states that he/she experienced MST * VBA MST Compensation & Pension Benefit (“Service-connected disability” claims) - Veteran successfully proves to the Compensation & Pension Board that he/she experienced MST.
How is eligibility determined? MST Counseling & Treatment Benefit (Based on Public Laws 102-585, 103-452, 106-117) * MST Counseling & Treatment Benefit (Based on Public Laws 102-585, 103-452, 106-117)
What is the benefit? MST counseling, and/or medical care for problems, which the clinician believes are related to the MST without co-payment obligation. * Medical care for the condition for which they received the service-connected status, without co-payment obligation (and possibly other benefits).
2. RELEVANCE TO VA CLINICIANS
Learning Objectives
1. Describe at least two (2) clinical reasons why a health care provider should ask about MST and other experiences of violence.
2. Describe at least two (2) reasons, from a patient’s perspective, why a health care provider should ask about MST and other experiences of violence.
Why should I ask?
Primary care clinicians and other VA medical providers may be familiar with the high prevalence of MST in their female and male patients, but skeptical about its relevance to their practices. Why should medical providers concern themselves with their patients’ MST histories? Consider these facts:
Exposure to violence can affect physical health. Sexual trauma is associated with high rates of physical symptoms and medical conditions clearly in the domain of medical providers (Section 3).
Sexual trauma is also associated with increased rates of psychological distress, such as post-traumatic stress disorder (PTSD), depression, and substance use disorders.
Patients with mental illness typically present to the medical setting, rather than the mental health setting. Therefore, for patients suffering from ongoing psychological distress, medical providers are in a strong position to connect patients with definitive treatment (Section 6).
Sexual trauma can have complex effects upon patient-provider interactions.
For example, routine medical procedures like colonoscopy or dental examinations might terrify a sexual trauma survivor. Likewise, boundary issues and interpersonal struggles can arise in the care of patients with trauma histories. Frustrating behaviors like heavy health care utilization or poor adherence to lifestyle modifications may become less perplexing and more amenable to intervention when understood in the context of a trauma history. For routine medical care to proceed smoothly, the clinician should consider such life experiences when using the strategies described in Sections 10 and 11.
Acknowledging the sexual trauma history can be validating for the patient. This can communicate acceptance and can strengthen the patient-provider relationship. Patients are typically open to discussing this issue. However, they rarely raise the topic unless asked explicitly. It is up to the clinician to ask (Section 4).
(See Appendix B for additional information about the relevance of this issue to medical providers.)
3. HEALTH CORRELATES OF SEXUAL TRAUMA
Learning Objectives
1. Identify medical and psychological sequelae of sexual trauma.
2. Identify the effects of MST on utilization of and access to health care.
Considerable research has demonstrated that sexual trauma is associated with increased medical and mental health problems and health care utilization, described next. Various mechanisms for these associations have been explored.
Is physical health really worse in patients with a MST history?
Numerous studies, mostly of women, have found a relationship between physical health and a history of sexual trauma. Compared to those without a sexual trauma history, women reporting sexual harassment or sexual assault histories are more likely to perceive their health as poor. They experience higher levels of physical symptoms during the first year following sexual assault, and these symptoms can persist for years following MST. In women who use VA services, those who report military sexual assault report more frequent health problems and are more likely to be unemployed due to physical limitations.
Specific physical symptoms have consistently been seen with higher frequency among sexual trauma survivors. Table 1 below lists the specific categories of physical symptoms, and other symptoms associated with sexual trauma survivors.
Physical symptoms seen with increased frequency in sexual trauma survivors:
Chronic pain - Low back pain, headaches, pelvic pain
Gynecologic - Sexual dysfunction, menstrual abnormalities, menopausal symptoms, reproductive difficulties
Gastrointestinal - Diarrhea, indigestion, nausea, swallowing difficulties
Other - Chronic fatigue, sudden weight changes, palpitations
In addition to physical symptoms, medical conditions have also been identified with increased frequency in patients with sexual trauma histories. Disease inventories (using self-report methodologies) indicate that medical conditions more common in sexual trauma survivors include:
arthritis; obesity; diabetes; hypertension; hyperlipidemia; myocardial infarction; chronic lung disease; endometriosis; miscarriage; and infertility.
One study that included both men and women and used objective measures of disease found that older women who reported a history of sexual assault had increased risk of breast cancer and arthritis, while older men who reported sexual assault history had increased risk of thyroid disease.
Given the association between history of sexual trauma and increased medical and mental health problems, it is not surprising that there is also increased utilization of medical services among women with sexual trauma histories compared with nonvictimized women and women who have experienced other crimes, despite the fact that their pre-assault health care utilization was not elevated. Typically patients with a sexual trauma history present to medical (not mental health) providers.
Why do sexual trauma survivors have more physical illness?
A number of mechanisms for the association between sexual assault and physical illness have been proposed.
1. A possibility is that this reflects a lower threshold for reporting symptoms or higher rates of somatization disorders.
However, this would not explain higher rates of diagnosed disease in patients with a sexual trauma history.
2. There could be direct health effects of the assault; for example:
4-30% of sexual assault victims contract a sexually transmitted disease during the assault; 4% sustain serious physical injuries; and 5% of women of childbearing age become pregnant.
3. Indirect mechanisms. Individuals with histories of sexual trauma are more likely to engage in behaviors that can lead to future health problems, such as: tobacco use; substance use disorders; or high-risk sexual behaviors (e.g., multiple partners, unprotected sex, prostitution).
4. Physiologic mechanisms. A substantial body of scientific evidence has documented sustained neuroendocrine derangements in people with sexual trauma histories. For example, dysregulation of the hypothalamic-pituitary-adrenal axis and adrenergic dysfunction after sexual trauma are well established, and can persist for years after the trauma. These physiologic abnormalities may explain in part why patients with a sexual trauma history have a greater burden of physical illness.
How does MST influence psychological health?
A history of sexual assault in women has been associated with increased risk of:
depression; post-traumatic stress disorder (PTSD); suicidal ideation and attempts (especially among patients with PTSD); panic disorder; generalized anxiety disorder; obsessive-compulsive disorder; and substance abuse and dependence.
The psychological effects of sexual trauma in men have not received adequate attention. Like women, the majority of men who are sexually assaulted go on to develop PTSD symptoms. Men are at higher risk for completed suicide than women; poor social supports, older age, and comorbid addiction or depression all convey added risk of suicide.
In addition to these psychiatric diagnoses, sexual trauma is also associated with psychological symptoms and social issues, although such reactions to trauma are certainly not universal. Sexual trauma can be associated with:
self-blame and shame; difficulties with trust; problems in psychological defense mechanisms (repression, denial or normalization of the trauma); poor self-esteem and body image; gender identity fragility (especially in men, who are more likely than women to have experienced same-sex assaults); sexual problems; impulsivity; anger; perpetration of violence; problems with readjustment after military service; and work difficulties.
There is some evidence that sexual trauma experienced during the military may have a more deleterious impact on mental health than sexual trauma occurring outside the military context. Further, veterans whose war-zone experiences (e.g., combat) are complicated by MST may have an amplification of the effects of war zone trauma. Thus, VA clinicians care for patients who have a high prevalence of exposure to traumas that can have particularly severe effects.
MST survivors who have had repeated victimization experiences are likely to present with more complex and severe problems that may benefit from mental health referral.
For patients reporting multiple victimization experiences, the severity of mental health sequelae tends to be even more pronounced. For example, sexually revictimized women are more likely to have a lifetime diagnosis of PTSD, report problems with shame, experience difficulties in interpersonal functioning and engage in high risk sexual behavior. While less research has addressed the consequences of multiple victimization among males, one study found that rates of revictimization were comparable among male and female sexual assault victims. Given their increased risk of more severe mental health sequelae, women and men who have had repeated victimization experiences may be particularly likely to benefit from a mental health referral.
Does everyone develop chronic problems after sexual assault?
In spite of the research showing consistently high rates of medical and psychological sequelae, which can persist for years after the trauma, it is important to remember that some patients with sexual trauma histories continue to function quite well. Primary care providers see three classes of patient:
1. Patients who have processed the trauma and are currently doing well
2. Patients who seem to be doing well, but who actually have undetected current distress related to the prior MST (their silent suffering may not be clinically evident)
3. Patients who have obvious current psychological distress (e.g., anxiety, interpersonal difficulties) or diagnosed psychiatric conditions (e.g., PTSD)
To reach patients with ongoing distress, clinicians need to first identify the trauma history and then determine how the patient is currently coping. Since many medical providers have not been trained how to identify a sexual trauma history, the next section addresses this issue.
4. SCREENING FOR MST
Learning Objectives
1. Develop the skills to effectively screen patients for history of MST.
2. Identify two sexual trauma-screening tools.
3. Recognize gender-specific differences in the experiences of sexual assault victims.
4. Recognize provider responses that might offend patients with MST history.
Why screen all patients for MST?
All VA patients should be screened for MST because:
1. VA mandates universal screening (Public Law 103-45); and
2. screening of VA patients has positive clinical effects.
MST is common and is often associated with physical and mental health sequelae amenable to intervention. However, many patients do not spontaneously disclose a trauma history. Therefore, the first step in helping patients is to identify the MST history.
But won’t I upset the patient if I ask? How do I avoid being offensive?
Many caring clinicians worry that asking about an MST history may offend or upset the patient. However, studies conducted in the private sector provide reassurance that, although most patients have never been asked about a history of sexual trauma, the majority of men and women would like their physicians to ask routinely. In surveys, patients say that if asked, they would answer truthfully, and they believe providers can help.
All the same, there are barriers to disclosure, some unique to veterans. Veterans who reported MST while still in the military often state that subsequent to the report they were transferred to less desirable positions or experienced other negative consequences, such as escalation of the trauma or being court-martialed for fraternization. Some who pursued the complaint or pressed charges report that this process was worse than the MST itself. Regardless of the veteran’s sexual orientation, veterans may be especially reticent about revealing same-sex assaults or harassment because of policies in the military about homosexuality. In light of such concerns, veterans may be hesitant to spontaneously reveal this information to government employees. Affected veterans may also be concerned about how they will be viewed by their family, friends, and others in the community. Male veterans may have particular concerns about disclosure due to the gender-related stigmas. Therefore, clinicians need to develop skills that allow them to ask in the least threatening way possible.
How do I screen?
The next sections dissect the screening process. Important elements include:
Establishing a comfortable climate for disclosure. For example: assuring a lack of interruptions and a private setting, assuming a nonjudgmental stance, using unhurried speech and making good eye contact.
Deciding on screening modality. Three major options are: a written, self-administered intake form; screening by the clinic nurse in a private room, or screening by the clinician (e.g., when taking the social history).
Introducing the line of questioning. For example: Violence is common in our society, so I ask all my patients about this. Asking the question. For example: “While you were in the military:
Did you receive uninvited and unwanted sexual attention, such as touching or cornering, pressure for sexual favors, or verbal remarks? [Sexual harassment]
Did someone ever use force or the threat of force to have sexual contact with you against your will? [Sexual assault]”
Once a clinician has established a routine for asking, these steps can proceed smoothly.
How do I establish a comfortable climate for disclosure? While most patients are willing to disclose a trauma history to their medical providers, patients may feel threatened by the prospect. Survivors of sexual assault often feel that others blame them for what happened. While clinicians may perceive the health care environment as safe, to a patient it may feel perilous. For example, the patient may dread the prospect of being touched during the physical exam (Section 11). It is, therefore, essential to create a warm, safe and non-judgmental environment in which the veteran may disclose an MST history, and to assure his or her confidentiality in accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations (see http://www.aspe.hhs.gov/admnsimp) and VA policy.
The physical setting and clinical approach influence the patient’s perception of how receptive and empathic the clinician will be. How does the clinician set the tone? Table 1 gives some examples of how the environment can shape the patient’s experience and influence his/her comfort with disclosure.
MST Environment and Patient Perception
Environment that may feel threatening to patient: 1. A stark, cold exam room with the patient waiting, shivering, in a johnny 2. Clinician frequently leaves the room or accepts multiple telephone interruptions 3. Clinician leaves the exam room door open.
Environment that may feel secure to patient: 1. Tranquil pictures are hanging on the walls, and ambient temperature is comfortable 2. Clinician attends to the patient without interruption 3. Clinician sits at the same level and makes good eye contact 4. Clinician’s speech is unhurried (despite the tremendous time pressures of the current health care environment) 5. Questioning is non-judgmental; if the patient declines to respond to the inquiry, his/her wish is respected 6. Inquiry occurs in a private setting, where confidentiality can be assured.
Who should screen, and where?
VA facilities handle MST screening logistics in a variety of ways. Table 2 presents common acceptable approaches for screening patients with MST. Since screening for MST is a clinical procedure, it is not advisable for administrative staff (e.g., clerks) to perform the screening.
MST Screening Logistics
Approach - Intake forms: patient completes a self-administered form, which includes questions about MST, while at home or in the waiting room - Advantages: Efficient: decreases the chance that these questions will be overlooked in the course of a busy encounter Normalizing: every patient receives the form, so they know they are not being singled out Sets the tone: communicates to the patient that the clinician is open to discussing these issues, and, if one of many questions on the form, conveys the concept that the MST history is one aspect of overall health - Special Considerations: Privacy: the patient should complete the form in a spot where others will not be looking over his/her shoulder, and return it to the clinician, or to the clerk in a closed folder Assistance: patients who are illiterate or vision-impaired can have the form administered verbally in a private room Follow-up: clinicians can run through the form in the patient’s presence, inviting the patient to expand on positive or negative responses; e.g., “I see you marked ‘no’. The reason we ask is that many patients have had such experiences, and they may not be aware that they are entitled to receive counseling.”
Approach: Intake by nurse: the nurse screens for an MST history in a private room during routine clinical intake; Advantages: Efficient: divides responsibilities between care providers; assures systematic screening; Private: conducted behind closed doors Team: conveys to patient that nurses and other clinicians function as a team; some perceive nurses as less threatening than primary care providers Special Considerations: Repeated disclosure: some patients find it intrusive to have to reveal this history to multiple providers
Approach: Screening by primary care provider: the clinician includes questions in the course of the clinical interview (e.g., as part of the Social History); Advantages: Clinical assessment: the clinician is able not only to screen for MST, but also to conduct additional assessment regarding its current clinical impact and need for further intervention Patient-provider relationship: the clinician can express empathy and convey the idea that addressing sequelae of MST is just one aspect of overall care; Logistics: clinicians need to find a comfortable approach that allows them to remember to screen every patient.
How do I introduce this line of questioning?
Clinicians find different ways to incorporate questions about sexual trauma into the medical interview. Many incorporate it into the social history, when they are asking about home life, sexual behaviors, depressive symptoms, etc. Normalizing statements can help introduce the questioning, e.g.,
“Violence is common in our society, so I ask all my patients about this.”
“Many of my patients have had upsetting experiences in their lives which may still bother them today.”
“In response to increased awareness that many men and women have experienced sexual harassment or sexual assault during their military service, VA has launched a national effort to identify those veterans who may be in need of services, so all veterans are now being asked about certain experiences.”
Linking the question to a patient’s complaint or echoing his/her concerns may be useful, e.g., “I see many patients who have problems like yours, and some have had distressing experiences in their lives, such as being hurt by a partner or being forced to have sex against their will. Has anything like that ever happened to you?”
However, this type of approach must be used judiciously, lest the patient misinterpret it as suggesting that the clinician is dismissing his/her symptoms as "all in my head'. These types of introductory statements can be followed with more specific questions, presented in the next section.
Are there specific questions I can Use?
The Trauma Questionnaire (TQ) was developed by VA clinicians and validated in a VA setting. Item 5 asks about military sexual harassment, and Item 6 asks about military sexual assault; it also includes questions about other lifetime traumas such as domestic violence.
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Trauma Questionnaire - Some people experience traumatic events during their military service. We are trying to find out about these events and how they affect veterans’ lives. We also want to find out if veterans want mental health help addressing these or other concerns. To answer a question, please check yes, no, or don’t know. Thank you for your time
(Yes, No, Don't Know:)
1. Have you ever been involved in a major accident or disaster?
2. Have you ever been physically assaulted or been a victim of a violent crime?
3. At any time, has a spouse or partner (significant other) ever threatened to physically hurt you in any way?
4. At any time, has a spouse or partner (significant other) ever hit you, kicked you, or physically hurt you in any way? Did this happen to you while you were in the military?
5. Have you ever received uninvited and unwanted sexual attention (e.g., touching or cornering, pressure for sexual favors, verbal remarks?)
5. Did this happen to you while you were in the military?
6. Has anyone ever used force or the threat of force to have sex with you against your will?
7. Were you ever sexually assaulted or touched in a sexual way, by a person 5 or more years older than you, when you were younger than 13?
8. Would you like to talk to a mental health worker about any of the above problems?
9. Do you have any mental health questions or concerns that are not on this questionnaire?
10. Would you like to talk to a mental health worker about these other problems?
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Besides Items 5 and 6 of this questionnaire (which can be administered in written or verbal format), other specific questions can be used such as:
“Has anyone ever touched you in a sexual way or had you touch them in a sexual way that made you uncomfortable?”
“Have you had a sexual experience that you did not want?”
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DO: Use questions that describe the specific behavior in simple terms (e.g., “someone forced you to have sex against your will”)
DON'T: Use jargon or emotionally loaded terms (e.g., “rape”, “sexual assault”, “domestic violence”, “sexual abuse”, “incest”) that the patient may not recognize as applying to him/her (e.g., a woman may not realize that a husband can rape a wife, or may think that if she was intoxicated it could not have been a sexual assault)
DO: Take a non-judgmental stance (e.g., “many of my patients have had disturbing experiences which can influence their health and well-being”)
DON'T: Use negative questioning (e.g., “you were never sexually assaulted, were you?”)
* * * * * * * * * * * *
Section 5 discusses how to respond if the patient discloses that he/she has indeed experienced MST, but first we turn to some concrete concerns many clinicians have about the screening process.
What should I expect the patient will tell me?
Patients who report an MST history may or may not disclose details about the trauma to their health care providers. However, it is helpful for clinicians to have some understanding of the range of experiences commonly seen in MST.
Perpetrator: The perpetrator(s) may be male or female, and may be military personnel (a colleague or supervisor) or a civilian. The veteran may or may not have known the perpetrator(s).
Circumstances of assault: The assault may occur on or off base, in a combat zone or stateside. Rape (of both men and women) can be a form of torture of prisoners of war. Witnesses may have been present, either participating in the assault, passively observing, or attempting to rescue the victim. A weapon may or may not have been used. The perpetrator and/or the victim may have been under the influence of alcohol or drugs. Besides threatening the patient physically (perhaps leading the victim to fear for his/her life), the perpetrator may have threatened the victim’s military career or the victim’s family if the victim did not submit. The assault may have been a single incident, or may have occurred repeatedly. The victim may or may not have had a history of prior childhood trauma.
Nature of assault: Sexual harassment of both men and women is common, and can include uninvited and unwanted sexual attention, such as touching or cornering, pressure for sexual favors, or verbal remarks. Sexual assault involves the use of force (or threat of force) to have sexual contact against the victim’s will. Among the common forms of sexual contact are oral, anal, or (for women) vaginal penetration. Associated with the assault may be other forms of injury, including fractures, lacerations, and head trauma, as well as sexually transmitted diseases and pregnancy.
Response to assault: The victim may or may not have sought medical attention following the assault to treat injuries, sexually transmitted diseases, or psychological distress. If he/she did seek medical attention for injuries, he/she may or may not have revealed their cause to the treating clinician. The victim may or may not have told a friend or supervisor about the assault. If so, the victim may have had positive experiences (e.g., being believed and comforted, seeing successful personnel or legal actions against the perpetrator) or negative experiences (e.g., being ridiculed or discredited, being demoted or transferred, or being court-martialed for fraternization).
Gender effects: While there are many similarities between the experiences of women and men who are sexually assaulted, there are also differences by gender.
Women
Women are often a numeric minority, not only in the military (where there may be limited numbers of other women in whom they can confide), but also in the VA health care setting. Since women are most often attacked by men, they may feel threatened in a VA setting (with its preponderance of male patients), where women, by virtue of their minority status, can stand out as different. (Of note, men are also most often attacked by men, so they can likewise feel threatened by a VA setting.) Women’s acculturation tends to emphasize the primacy of relationships, with a sexual assault representing a severe violation of trust. Women veterans are less likely than male veterans to be married, and may have lower social supports. Finally, military service generally involves a gender-nonstereotypic role for women; this could be either a resilience factor (e.g., if the woman perceived herself as a maverick) or a vulnerability factor (e.g., if the women perceived herself as an outsider). VA primary care providers should be prepared for the possibility that their female patients will raise such issues. Some may just want to articulate such experiences in a validating clinical setting. For others, there may be management implications. For example, some women veterans will specifically request to have a female primary care provider, and some will be more comfortable receiving care in a setting where there are other women in the waiting room (such as in a designated women’s clinic). For both women and men, the trustworthiness of the clinician can have great importance.
Men
Men also have distinct experiences with MST. A common theme among men who have been raped is a perception that the trauma significantly reflects on and/or affects the survivor’s own masculinity or sexual orientation.36, 37 While most women are raped by members of the opposite sex, most men experience rape by other men. Heterosexual men may fear that they betrayed some feminine or homosexual quality that provoked the attack. Homosexual men may come to relate to their sexual orientation with an overwhelming sense of vulnerability. Men who have been raped tend to feel personally responsible for the attack, and ashamed for not having been powerful enough to repel or escape their attackers. (Women trained as soldiers may feel similar shame.) They may hide their victimization from others and may hesitate to share this history with a health care provider, especially male providers (lest they be thought of as “less manly” than the provider). When men do seek help, they may feel revictimized in the process. Some of their sense of revictimization may be entirely subjective (secondary to the patient’s personal fears and beliefs) but some providers have unconscious negative reactions to male survivors related to traditional gender role stereotypes. All these factors may prevent male MST survivors from getting the help they need. Therefore, even though MST is less prevalent in men, it is extremely important that men receive routine MST screening. When men disclose a history of MST, they should be reassured that many other men have had similar experiences, and that no one deserves to be treated in that way. Both men and women need to understand that sexual assault is a crime of power and control, not sexual passion. Clinicians need to respond to both men and women in a non-judgmental, affirming manner.
How do I avoid opening Pandora’s Box?
Many providers fear that screening for sexual trauma will open a floodgate: the patient will need to reveal details about the trauma, and will express strong emotions of pain and anger. Clinicians may face a dilemma, feeling unprepared to cope with detailed disclosure and worried about derailing a busy clinic, yet recognizing that information about a patient’s sexual trauma history is relevant to medical care.
The reality is that patients show a range of disclosure styles. For example, some patients disclose with a flat or even cheerful affect, showing no overt signs of distress. Others may be visibly anxious, express a need to leave the room or become tearful or angry. An occasional patient will start to go into great detail about the trauma, perhaps even dissociating from the clinic context and begin to re-experience the trauma as if it were happening in the present tense.
Clinicians can usually manage the disclosure process in a way that conveys empathy while at the same time placing limits on time and depth of disclosure. Usually it is enough to listen empathically.
While some patients will only be comfortable stating that the MST occurred (without providing any details), most patients will provide limited details, such as:
when the trauma happened; who attacked them; what type of assault it was (e.g., sexual assault, use of a weapon); what injuries they sustained; whether they received treatment afterward; and whether they have felt comfortable enough to disclose this information to anyone else previously.
These types of details may be relevant to a medical provider.
However, if a patient begins to disclose in greater detail (e.g., a moment-by moment account of what happened during the assault) or if the patient appears profoundly distressed by even minor disclosure, it is helpful for the clinician to gently limit the disclosure process. In doing so, the clinician needs to avoid implying that the information provided was disgusting or shameful, or that the patient, who likely feels very vulnerable at this point, was wrong to have shared this information. The clinician also must avoid giving the impression that he/she does not believe the patient. Instead, it should be clear that this limit-setting is an act of caring. For example, the clinician might say:
“I’m sorry that this happened to you. No one deserves to be hurt like that. I am very glad that you were willing to share this information with me, as it will help me to do a better job as I provide your medical care. I am going to ask that we not discuss the details of this trauma today, because that is best done with a counselor who has special training in knowing how to help you work through a very upsetting past experience. Many of my patients who have had experiences like yours have found it very helpful to talk with one of our counselors. Would you be interested in that?”
After disclosing sensitive information, patients sometimes have feelings of shame and regret about having “exposed” themselves. To address such reactions, at the end of the visit it may be helpful to reassure the patient that if any concerns arise before the next visit, he/she is welcome to call.
Does clinician gender matter? Should male clinicians ask females about MST?
Both male and female providers can successfully screen for MST. However, since most perpetrators of MST are men, male clinicians may have concerns that patients (both women and men) who have experienced MST will have generalized negative feelings about men. This is sometimes true, and an occasional patient will specifically request to see a clinician of a particular gender; if this request can be honored, it is generally advisable to do so. However, for most patients, a clinician of either gender will be acceptable. That being said, clinicians need to remember that the clinician’s characteristics (e.g., gender, race, age, manner of speech) can potentially remind any MST survivor of his/her assailant. Efforts to minimize the patient’s level of fear during the clinical encounter (Section 11) can help to decrease the intensity of such “transference” reactions. Some patients find it helpful to discuss these issues directly with their mental health providers. By exploring maladaptive Post-traumatic beliefs (e.g., “all men are dangerous”) in the setting of mental health therapy, patients can learn to develop beliefs that are more helpful. In fact, for patients who were assaulted by men, it can potentially be helpful to experience a positive, safe professional relationship with a male medical provider.
What if I have my own Trauma history?
Many clinicians have their own trauma histories. For them, asking the patient about sexual trauma can potentially trigger painful memories. Occasionally this imposes an excessive burden on the clinician. In this case, the patient still needs to be screened, so arrangements should be made for a colleague to conduct the screening. More commonly, clinicians who have a trauma history are able to maintain enough emotional distance to allow them to ask these questions effectively. If they do, it is essential that they remain vigilant about maintaining appropriate boundaries (e.g., not disclosing their own trauma history to the patient or becoming overly involved in the patient’s story); see Section 10 for more information about boundaries. They also need to monitor themselves for symptoms of vicarious traumatization or burnout (Section 15). Discussing difficult clinical situations with a trusted colleague can help to lessen the impact of an emotionally charged encounter and offer a different perspective.
5. WHAT TO DO NEXT: RESPONDING TO MST DISCLOSURE
Learning Objectives
1. Describe logical steps the provider should take once the patient discloses an MST history.
2. Identify effective key elements in responding effectively to patients who disclose a history of MST.
3. List principles guiding provider responses to patient’s MST disclosure.
My patient just disclosed an MST history. What do I do next?
Primary care providers may worry about how to respond to a patient’s MST disclosure. Fortunately, there are concrete steps the clinician can follow which will help the process to go much more smoothly. This is always a sensitive topic, but with practice, medical providers can become comfortable discussing it, and gratified by the fact that they help their patients in doing so.
The first steps after the patient discloses an MST history include:
Validation/empathy - e.g., “I’m sorry that you experienced sexual trauma during the military.”
Educating - e.g., “Many veterans have experienced sexual trauma during the military.”
Assessing current status, including health sequelae of trauma, and current safety - e.g., “Do you feel that you are currently having physical or emotional effects from the trauma?”
Assessing level of support - e.g., “Have you been able to discuss this with anyone previously?”
Key elements of the initial response to disclosure of MST are represented by the mnemonic “RESPECT”, as depicted in Table 1 (next page). These concepts help primary care providers to avoid some common pitfalls, such as
negative questioning (e.g., “you were never sexually assaulted, were you?)
labeling (e.g., when speaking with the patient, referring to “people like you”; or when speaking with colleagues, referring to “that crazy patient”)
implicit assumptions about the patient (e.g., “She probably brought it on by going out drinking with the guys”)
trust issues (e.g., patient not trusting the provider may minimize disclosure of trauma)
control issues (e.g., provider controlling the interview with an authoritative stance or a loud voice, or allowing little time for patient to talk)
denial - e.g., provider believes that patient would not have had such an experience(s)
boundary crossings (e.g., around professional boundaries, duration of clinical encounter, etc.) (Section 10)
Guiding Principles of Provider Response to MST disclosure
Principle: R - respect / Concept: Be respectful and validating of the veteran’s MST experience. Convey a non-judgmental, non-shaming stance. The role of the medical provider is to provide health care, not to determine the truthfulness of the disclosure. In one study of rape survivors, those who felt that they were believed had fewer subsequent emotional and physical health problems / Concrete Steps/Examples: Listen attentively to the patient’s story in a private setting. • Validate: convey to the patient that he/she did not invite the MST and did nothing to deserve it, and that the consequences he/she attributes to the abuse are valid, e.g., “no one deserves to be hurt in that way”. • Maintain appropriate boundaries around the disclosure process, e.g., not pressing the patient to disclose more than he/she is ready to (Section 4).
Principle: E - empathy / Concept: Empathy is the ability to understand or experience the emotional state of another. This can be as simple as acknowledging the patient’s current feelings before moving on to another topic. Providers may find it challenging to maintain an empathic stance with patients whose MST has caused them to become hostile, emotionally distant, distrustful, or needy (Section 10). / Concrete Steps/Examples: Convey an authentic and empathic stance, e.g., “I can see that talking about this MST issue makes you very sad.” Express regret about the patient’s experience: “I am sorry that you experienced sexual trauma during the military.”
Principle: S - Support / Concept: People who experience sexual trauma may have difficulty with interpersonal relationships. Furthermore, there are societal taboos around sexual trauma that can penalize and isolate the victim. Therefore, veterans with an MST history often have a limited social support network / Concrete Steps/Examples: Determine what kind of social support the patient is currently experiencing, e.g., “Who is supportive of you in your life now? Do you currently have anyone you can confide in about your feelings around the MST?” • Remember that primary care providers and other VA clinicians are often an important part of a veteran’s support network.
Principle: P - patient perceptions and preferences / Concept: Patients vary in their perceptions of whether or not the MST history is affecting their lives currently in terms of physical or emotional health and what type of help, if any, is needed. Attention to a patient’s preferences and perceptions communicates respect. / Concrete Steps/Examples: Seek to understand the patient’s perceptions, e.g., “How has the MST experience affected your life and health?” • Ask the patient about his/her preferences regarding help with MST (Section 6).
Principle: E - educate / Concept: Sharing information about MST communicates to the patient that the clinician cares about this topic, and takes this issue seriously. / Concrete Steps/Examples: Teach patients about MST prevalence and sequelae, e.g., “Many veterans have experienced MST. Some may have health problems related to MST such as chronic pain, PTSD, depression or problems with drugs and alcohol.” (See Appendices C and D for Resources & MST patient information)
Principle: C - clinician beliefs about MST / Concept: Hearing the patient’s history of MST can be burdensome to clinicians, potentially contributing to clinician burnout. This may be particularly true for clinicians who have themselves experienced past trauma. / Concrete Steps-Examples: Be aware of your own beliefs about MST and mindful of professional boundaries. • Seek support when needed (Section 15). • Learn more through continuing education, e.g., in annual meetings of the Society for General Internal Medicine (http://www.sgim.org) or the American College of Physicians (http://www.acponline.org) or the International Society for Traumatic Stress Studies (http://www.istss.org). Many state medical societies also have ongoing educational programs.
Principle: T - Triage / Concept: While many survivors of MST are stable and will not require immediate assistance, a few may require expedited referral for mental health or crisis services. / Concrete Steps-Examples: Safety: Assess for current suicidal or homicidal behaviors or ideation, and screen for ongoing family violence (Section 13). • Psychosis: Determine whether the patient has experienced anything unusual or frightening, or fears that people are out to get him/her. • Substance use: Screen for problematic use of alcohol and other substances. • Stabilization: For patients in acute crisis (medical or psychological), address the acute issues, and defer intervention for the MST history until the patient is stabilized
6. REFERRING THE PATIENT TO MENTAL HEALTH AND SOCIAL SERVICES
Learning Objectives
1. Identify barriers to patient’s willingness to accept a mental health referral and provider strategies to overcome them.
2. Describe steps providers should take if a patient refuses a mental health referral for MST counseling.
3. Identify VA resources and array of health care experts specializing in the treatment of trauma patients.
Which patients need a mental health referral?
All patients with a sexual trauma history should be offered the option of a mental health referral. However, it should be noted that not every person who has experienced trauma wants or needs the help of a mental health specialist. Some patients have already processed the trauma, either on their own or with assistance. Furthermore, trauma does not inevitably result in symptoms or impairment. It would seem logical then to only offer a mental health referral to patients who report current symptoms or difficulties related to past trauma. However, patients may have coped by making it appear to others that they are doing well when in fact they are experiencing considerable emotional distress and are struggling to function. Therefore, mental health consultation should be offered to all patients with a history of MST and not solely based on whether they are reporting symptoms or not.
Referral to mental health is even more important if active psychological symptoms are identified. As discussed in Section 3, a number of psychiatric conditions are common in patients with MST histories, such as PTSD, major depression, and substance use disorders. Since primary care clinicians may be less familiar with how to screen for PTSD, a brief screening instrument is included in Table 1 (next page).
Referring the Patient to Mental Health and Social Services
Primary Care PTSD Screen
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you (YES, NO)
1. have had nightmares about it or thought about it when you did not want to?
2. tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3. were constantly on guard, watchful, or easily startled?
4. felt numb or detached from others, activities, or your surroundings
While this cannot be used to make a definitive diagnosis of PTSD, current research suggests that a positive response to two items should suggest the patient may have PTSD and should undergo additional evaluation. These items could be included on a primary care intake form, along with the sexual trauma screening questions and domestic violence screening questions. Screens for depression and substance abuse are routine in most VA primary care clinics, and are not included here.