No Mission Too Difficult: Responding to Military Sexual Assault

Each year, approximately 1 in 100 men and 5 in 100 women are sexually assaulted while serving on active military duty.¹ Over the past decade, the Department of Defense has invested substantial efforts to address the problem, such as improvements in reporting procedures, surveillance, and primary prevention interventions. However, the high burden of sexual assault-related mental health conditions and disability documented among our nation’s veterans highlights the important but understudied issue of early intervention. Experiences in the early aftermath of assault are critical to long-term well-being. “Secondary victimization” owing to victim-blaming responses from law enforcement or health care providers exacerbates mental health sequelae.² Provision of high-quality, evidence-based mental health care can address mental health conditions before they become chronic, potentially mitigating the long-term health impact and maintaining the occupational capabilities of service members. Building an effective response is central to the systemic change necessary to prevent sexual violence.

THE VALUE OF ADMINISTRATIVE DATA

In this issue of AJPH, Rosellini et al.³ investigate mental health treatment and career consequences of sexual assault during military service among women in the US Army. They examined 2004–2009 Department of Defense administrative data of all female soldiers who lodged official unrestricted reports of sexual assault. Sexually assaulted women were matched to control servicewomen, using propensity scores derived from demographic characteristics, medical history, previous crime victimization, occupational experience, and military environment factors. The primary outcomes examined were military attrition and demotion, mental health diagnoses and treatment, and suicide attempts. Results confirm the high mental health burden and adverse career outcomes suggested by previous studies of military populations and underscore the substantial public health consequences of sexual assault.

Aggregated administrative data can be a powerful tool to benchmark institutional responses to sexual assault. Sexual violence reporting systems tend to be fragmented within and across federal institutions,⁴ limiting such potential. By contrast, Department of Defense law enforcement sexual assault reporting records linked to a wide range of records, including military medical, criminal justice, personnel, and suicide surveillance databases. As a result, the authors were able to conduct a more comprehensive longitudinal evaluation of mental health utilization and occupational outcomes than would be possible using self-report survey data.

PREVENTING SUICIDE AND PRESERVING HUMAN CAPITAL

Sexually assaulted individuals face multiple barriers to care, and rates of mental health utilization in the year following assault are low. Nearly three fourths of Army women who reported assaults received some form of mental health treatment, and they also received a greater intensity of treatment than did controls. Consistent with previous studies documenting substantially elevated rates of treatment for posttraumatic stress disorder associated with military sexual assault, the odds of receiving posttraumatic stress disorder treatment were more than six times greater among women who reported assaults. Among women without mental health treatment, however, reported assault was associated with a threefold increase in the odds of a suicide attempt. This is especially alarming considering data suggesting that a significant proportion of suicide mortality among women veterans is attributable to military sexual trauma.⁵ Perhaps the most significant public health implication of this study is that increasing access to mental health treatment after sexual assault could save lives.

As noted by Rosellini et al.,³ their results also highlight the impact of sexual assault on operational force readiness. Women who reported sexual assault had higher odds of demotion after making a report and of attrition from service among those who received inpatient mental health care than did controls. Effects for demotion are noteworthy: nearly one third of active duty women who place official sexual reports perceive some form of professional retaliation.¹ Demotion may also result from occupational impairment associated with the health consequences of assault. In civilian populations, sexual assault is associated with substantial costs owing to lost productivity.⁶ Further examination of limited duty time and other indicators of decreased productivity could help document the true cost of sexual assault to human capital in the military.

TRADE-OFFS WITH ADMINISTRATIVE DATA

The benefits of administrative data sources for epidemiological studies of military sexual assault are not without significant trade-offs. The unobservable, intimate nature of sexual assault and the pervasive social stigma present challenges to case ascertainment in reporting systems stemming from nondisclosure or underreporting. Survey self-report can yield more sensitive detection through anonymity and clear, behaviorally specific language to capture experiences meeting legal definitions of sexual assault that respondents may not label as such. Challenges for population-based surveys include the complexity and cost required to achieve sample sizes with sufficient statistical precision for estimating sexual assault incidence as well as methods to address nonresponse bias.

Despite the many advantages of the data examined by Rosellini et al., the use of unrestricted sexual assault reports precluded examination of male sexual assaults because of the small numbers of reports placed by men. The annual incidence of sexual assault in the Army is lower among men than women (0.95% vs 4.69%),¹ but because of the gender balance in the active duty forces, more than half of all military sexual assault victims are men. In this light, the absence of available data for men is nearly as striking as the compelling data presented for women. There is a critical need to address gender issues in sexual assault measurement methods and prevention interventions to better address the needs of men.⁷

The focus on unrestricted reports of sexual assault among women service members also merits important considerations when interpreting study results. Across civilian and military settings, the majority of assaults go unreported. Data from reported cases cannot be generalized to all sexually assaulted women in the Army. Women who have not reported assaults may be reluctant to seek mental health services because of the lack of confidentiality of medical records in the military. This may be especially true for the substantial proportions of women whose perpetrator is within their chain of command.¹ Lower rates of treatment of women with unreported assaults among controls would inflate effect sizes for associations between sexual assault and treatment utilization. Conversely, the current effect sizes for associations of sexual assault with suicide attempts may be conservative if suicide attempts were also prevalent among untreated, sexually assaulted controls.

Large administrative databases can be advantageous for exploring novel statistical approaches, such as the machine-learning methods used to generate propensity score matching on sexual assault risk. Risk for sexual assault is determined by the interplay of individual, social, and military culture and organizational factors. Many of the same factors affect risk for poor health outcomes. Too few studies of sexual assault have been designed to address these shared risk factors, while also accounting for interactions among risk factors.

Research quantifying contextual risk factors for sexual violence could enhance efforts for risk prediction. For example, leadership tolerance for sexual harassment and misconduct is associated with increased odds of military sexual assault, even after adjusting for individual risk factors.⁸ Arguably, the most potent risk factors for sexual assault are proximity to a perpetrator and environmental conditions that do not deter perpetration. Recent research using spatial and multilevel models to identify contextual risk for interpersonal violence suggest potential designs that could be used to further explore sexual assault within military environments.

MISSION TO PROVIDE POSTASSAULT MENTAL HEALTH CARE

Sexual assault is a pervasive, yet preventable cost of military service. To date, there are limited data to assess implementation of policies that govern provision of health care services for sexually assaulted service members. Additional research that investigates the timeliness and quality of postassault mental health care could identify strategies to promote access to care. Department of Defense integrated data systems can be used to monitor performance over time. Enhancing the health care response to military sexual assault may also be a useful tool in the battle against suicide among the men and women serving their country in the military.