Skip to main content
NCBI home page
VA Author Manuscripts logoLink to VA Author Manuscripts
. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Psychol Trauma. 2021 Jun 28;14(3):410–420. doi: 10.1037/tra0000647

Military Sexual Trauma: Exploring the Moderating Role of Restrictive Emotionality Among Male Veterans

Louis A Rivera 1, Christopher T H Liang 1, Nicole L Johnson 1, Subhajit Chakravorty 2
PMCID: PMC8712608  NIHMSID: NIHMS1738929  PMID: 34180685

Abstract

Objective:

Military Sexual Trauma (MST) has been found to be positively associated with mental health outcomes, such as posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, symptoms of anxiety, and insomnia severity (Jenkins et al., 2015; O’Brien & Sher, 2013). Male survivors of MST face unique challenges, including concerns associated with hypermasculinity (e.g., restrictive emotionality (RE)). Men with high RE (difficulty expressing emotions) report more negative mental health outcomes compared to men with low RE (Good et al., 1995). The present study investigated whether RE moderated the relationship between MST and negative mental health outcomes, while controlling for combat exposure (CE) and age to further assess confounding variables.

Method:

134 adult male veterans in behavioral health treatment at a large VA medical center in the mid-Atlantic region of the U.S. were recruited. Participants provided self-reported data on MST and symptoms of PTSD, depression, anxiety, and insomnia, as well as their endorsement of restrictive emotionality. PROCESS v3.3 (Hayes, 2017) regression analytic method was used to test main and interaction effects.

Results:

MST was a significant predictor of PTSD symptoms and insomnia severity—but not depressive symptoms—or symptoms of anxiety. RE also moderated the relationship between MST and PTSD symptoms, depressive symptoms, and insomnia, after controlling for CE and age.

Conclusion:

These findings suggest that restricting emotions has a negative influence on men’s mental health functioning. Therefore, assessing male veterans’ experiences of expressing their emotions within the context of masculinity and their military training will likely have implications on trauma processing and treatment outcomes.

Keywords: military sexual trauma, PTSD, hypermasculinity, restrictive emotionality

Military sexual harassment and sexual assault among service members has gained national attention over the years, with an increase in mandatory screenings to assess for military sexual trauma (MST) after the Navy Tailhook scandal (Monteith et al., 2015). MST is defined as sexual harassment and/or sexual assault occurring during active duty or training. The Veterans Affairs (VA) national surveillance data obtained from approximately 1.7 million VA veterans indicated that 22% of women and 1% of men experienced MST (Suris & Lind, 2008). Despite the lower overall prevalence rates of MST among men, the number of identified cases between men and women is very similar due to the ratio of men to women in the military (Hoyt et al., 2011): 29,418 women and 31,797 men screened positive for MST (Kimmerling et al., 2007). Despite these findings, male veterans are widely understudied in this area. Further research is needed to understand the symptom presentation in male veterans who experience MST to inform methods of prevention and intervention and enhance treatment protocols.

The experience of MST is associated with significant mental health concerns and the context in which MST occurs helps to shed light on the significance of this problem. Wertsch (1991) identified common traits embedded in military culture that may contribute to the negative effects of MST, including the endorsement of stoicism, the emphasis on an outward appearance of stability and preparedness, and the proximity and roles of survivors to their perpetrators. In addition, the belief that male sexual trauma survivors are perceived to lose their manhood, disabling them as warriors, (Turchik & Edwards, 2012) likely has implications on their mental health and restriction of emotions.

Men who screen positive for MST are at risk for a range of mental health concerns and have a greater incidence of experiencing PTSD symptoms and depressive symptoms compared to their female counterparts (Hahn et al., 2015; O’Brien & Sher, 2013). Male veterans who experience MST are also more likely to have a mood disorder (Mondragon et al., 2015), and report a greater incidence of endorsing suicidal ideation, depression severity, and PTSD symptoms compared to male veterans with no MST history (O’Brien et al., 2013; Schry et al., 2015). Men with MST also frequently report moderate to severe insomnia (Jenkins et al., 2015). However, the research examining MST and mental health outcomes among male veterans is still evolving. The majority of the previous research has focused primarily on non-Hispanic White female veteran samples (Hahn et al., 2015; Jenkins et al., 2015; Monteith et al., 2015). Further research with men is needed to help identify the unique challenges facing this population in addition to factors that may exacerbate mental health symptoms among male veterans with MST.

Restrictive Emotionality

One factor that may exacerbate mental health symptoms related to MST among men is restrictive emotionality. Previous researchers have called for studies that directly examine masculinity and MST given the negative mental health outcomes associated with hypermasculine norms. Hypermasculinity relates to the promotion and avoidance of emotional expression and the absence of weaknesses or vulnerabilities (Allard et al., 2011; Mondragon et al., 2015). When considering all traditional masculinity constructs, researchers have reported that the restriction of emotions is the strongest predictor of psychological distress (Good et al., 1995; Levant et al., 2015). Restrictive emotionality (RE) is defined as having difficulty and fears about expressing one’s feelings (O’Neil, Good, & Holmes, 1995), which is a pronounced problem for servicemen due to the military’s emphasis on instilling emotional control under duress. Military training may also foster greater adherence to traditional masculine norms such as emotional stoicism and autonomy, likely contributing to the development of a hypermasculine subculture that can shape men’s emotional behaviors long after they have left the military (Jakupcak et al., 2006). Neilson et al. (2020) argue that the suppression of emotions over lengthy periods of time may contribute to the development or exacerbation of PTSD and other mental health symptoms. Motivated to protect their masculinity and not appear weak or feminine, men’s adherence to RE may also influence their decisions to seek help and engage in therapy processes, which can include processing, expression, and discussion of emotion-related cognitions (Neilson et al., 2020).

Most studies on RE have focused on civilians and found that RE is positively associated with depressive symptoms and psychological distress (Gerdes & Levant, 2018; Good et al., 1996; Wong et al., 2006) and negatively associated with health-promoting behaviors (e.g., nutrition, physical activity, stress management; Houle et al., 2015). Only a few studies have assessed RE in a predominantly veteran population that has experienced MST (Juan et al., 2017; O’Brien et al., 2008). O’Brien et al. (2008) found that difficulty identifying feelings was related to persistence of sexual abuse trauma symptoms and dissociative symptoms. Juan et al. (2017) also found that emotional inexpressiveness fully mediated the relationship between MST and depression. However, previous researchers have not identified the moderating effects of RE on the relationship between MST and mental health outcomes. This research is needed because many of the therapeutic techniques used to treat mental health symptoms as a result of MST (e.g., PTSD) use strategies aimed at modulating different components of emotion. Therefore, the interaction of MST and high RE will likely have a negative impact on men’s mental health functioning and subsequent recovery from trauma.

Combat Exposure and Age

In addition to RE, researchers argue that combat exposure (CE) and age are variables that confound mental health outcomes associated with MST (Katz et al., 2012; Maguen et al., 2012). CE and war-related stressors have been found to increase symptoms of psychological distress and PTSD (Katz et al., 2012), as well as insomnia severity (Jenkins et al., 2015). The influence of CE has led researchers to control for CE when assessing the influence of MST on psychological outcomes given the detrimental effects associated with experiencing multiple traumas (e.g., Clarke-Walper et al., 2014; Monteith et al., 2015). Maguen et al. (2012) and Seal et al. (2007) found younger veterans to be at greatest risk to have a PTSD diagnosis compared to older veterans. However, this is contradictory to the late-onset stress symptomatology often found in older veterans. Previous research in this area is inclusive but highlights the importance of assessing the effect of age on mental health symptoms. Controlling for CE and age may help to better understand how MST and RE are associated with distress symptoms.

The Current Study

Much of the previous MST research has been conducted on predominantly female samples, and although research addressing female veterans is critical, attention to male veterans is also needed to help inform prevention and intervention methods. This study examined the relationship between MST and four mental health outcomes: PTSD symptoms, depressive symptoms, symptoms of anxiety, and insomnia severity among male veterans and whether RE moderated this relationship after controlling for CE and age. We hypothesized that MST will be positively associated with all four mental health outcomes and RE would serve as a moderator, such that the positive association between MST and distress symptoms will be stronger for those with higher RE compared to those with lower RE.

Method

Participants

A total of 138 self-identified male veterans in behavioral health treatment at a large VA medical center in the mid-Atlantic region of the United States participated in the study. In using Stevens’ (2009) recommendation that z scores of around three should be considered potential outliers, four outliers were identified for the total MST score and removed from the dataset resulting in a final sample of 134 male veterans. No differences were found on the sociodemographic variables of age, race/ethnicity, level of education, and military branch between those included and excluded in the study. All participants met the following inclusion criteria: male-identified, 18-75 years of age, receiving behavioral health treatment in the VA, and not under the obvious influence of a substance at the time of the study. Exclusion criteria were female-identified, active psychosis, over age 75 or exhibiting dementia-related symptoms, and unable to communicate in English.

Using convenience sampling methodology, prospective participants were recruited through flyers posted in behavioral health specialty clinics (e.g., opioid treatment program, PTSD, inpatient unit) of the VA and through direct referrals from behavioral health providers. No protected health information was collected, and each participant was informed of the confidential nature of the study, and provided oral consent. Participants completed the surveys on a computer in a private office space within the behavioral health clinic. Veterans who were uncomfortable using a computer completed the surveys orally with the first author. Survey questionnaires were located on the VA’s version of Research Electronic Data Capture (REDCap), a secure web application and online database portal, which allows for the storage of participants’ deidentified data. Participants required 25-30 minutes to complete the survey and received a $10 gift card to a convenience store.

Participants were middle-aged (M = 55; SD = 12.9), largely Black/African-American (44%) and non-Hispanic White (41%), with a high school diploma (38.8%) or some college (28.4%). The vast majority of the sample voluntarily joined the military (97%), with the remainder having been drafted (3%). The average length of time in service was 57 months (range = 5-252 months, SD = 45.4 months). Of the 134 participants, 81 served in the Army (60.4%), 23 in the Navy (17.2%), 19 in the Marine Corps (14.2%), and 11 in the Air Force (8.2%). When asked whether they had served in combat, 85 participants said “No” (63.4%) and 49 said “Yes” (36.6%). Of those who served in combat, one served in Korea (.7%), 14 served in Vietnam (10.4%), six served in the Gulf War (4.5%), and 28 served in Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF; 20.9%). Table 1 displays the demographic characteristics.

Table 1.

Demographic Characteristics (N = 134)

Characteristic Mean (SD) or N (%)
Age (mean overall sample) 55 (12.9)
Racial/Ethnicity
  Black/African American 59 (44%)
  Asian 1 (.7%)
  White/Caucasian 55 (41%)
  Latino/a/Hispanic 10 (7.5%)
  Pacific Islander 1 (.7%)
  Biracial or Multiracial 8 (6%)
Education
  Some High School 11 (8.2%)
  High School Diploma 52 (38.8%)
  GED 19 (14.2%)
  Some College 38 (28.4%)
  Associates/Technical Degree 10 (7.5%)
  Bachelor’s Degree 3 (2.2%)
  Graduate/Professional 1 (.7%)
  Degree
Entry into Military
  Drafted 4 (3%)
  Voluntary 130 (97%)
Time in Military (in months) 57 (45.4)
Number of Tours
  0 28 (20.9%)
  1 70 (52.2%)
  2 20 (14.9%)
  3 6 (4.5%)
  4 or more 10 (7.5%)
Branch
  Army 81 (60.4%)
  Navy 23 (17.2%)
  Marine Corps 19 (14.2%)
  Air Force 11 (8.2%)
Rank in Military
  Enlisted 132 (98.5%)
  Officer 2 (1.5%)
Served in Combat
  No 85 (63.4%)
  Yes 49 (36.6%)
Combat Era (those who served in combat)
  Korea 1 (.7%)
  Vietnam 14 (10.4%)
  Gulf War 6 (4.5%)
  OEF/OIF 28 (20.9%)
Open in a new tab

Measures

Demographics.

Veterans completed a demographic questionnaire exploring their age, race/ethnicity, highest level of education during time of service, form of entry into the military (e.g., draft, volunteer), branch, length of service, number of tours, rank, CE status (i.e., “Have you served in combat during your time in the military?”), and combat era.

Military Sexual Trauma.

MST was measured using the seven-item sexual harassment scale from the Deployment Risk and Resilience Inventory-2 (DRRI-2; Vogt et al., 2013). The sexual harassment scale is used to assess exposure to sexual harassment (i.e., gossip/rumors regarding sexual behavior, crude sexual remarks), threats for not engaging in sexual activities, and sexual assault (i.e., unwanted sexual touching, attempted touching/rape, and/or rape) from unit members, other unit leaders, or civilians during time in the military. Item responses range from 0 (never) to 3 (many times). Possible scores range from 0 to 24, with higher scores indicative of more sexual harassment/sexual assault experiences. The Sexual Harassment Scale has demonstrated good psychometric properties, with a previous coefficient alpha of .86, adequate test-rest reliability (i.e., average 1-month test-retest coefficient of .86), and evidence of good scale validity (King et al., 2006). Internal consistency for the current sample was .82.

Restrictive Emotionality.

The Restrictive Emotionality (RE) subscale of the Gender Role Conflict Scale (GRCS-RE; O’Neil et al., 1986) assesses participants’ difficulty and/or reluctance to express emotions. GRCS-RE consists of ten items on a 6-point Likert-type scale ranging from 1 (strongly disagree) to 6 (strongly agree). Items are summed to create a total score, with possible scores ranging from 10-60. Higher scores reflect greater levels of RE. Internal consistency of the measure is considered good with a Cronbach’s alpha of .82 for the RE subscale and a four-week test-retest reliability of .76 (O’Neil et al., 1986). The GRCS-RE had strong construct and convergent validity with other measures assessing masculinity (Good et al., 1995). Internal consistency for the current sample was .95.

Symptoms of Post-Traumatic Stress Disorder.

The Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5; Weathers et al., 2013). The PCL-5 is a 20-item scale that measures symptoms of PTSD outlined by the DSM-5. Participants respond to items on a 5-point Likert-type scale, with scores ranging from 0 (not at all) to 4 (extremely). Item scores are summed, with higher scores indicating more PTSD symptoms. The PCL-5 has shown good psychometric properties in a predominant veteran sample, with a previous coefficient alpha of .96 and a test-retest reliability over a one-week interval of .84 (Bovin et al., 2016). With respect to convergent validity, the PCL-5 measure was positively correlated with other PTSD symptom measures (Weathers et al., 1993). Internal consistency for the current sample was .96.

Depressive Symptoms.

The Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR; Rush et al., 2003) is a 16-item measure that assesses symptoms of depression. Each item corresponds with the following prompt: “Please circle the one response to each item that best describes you for the past seven days.” Each item on the QIDS-SR reflects the nine DSM-IV symptom domains and is based on an item-by-item severity scale of 0 to 3. The highest score from each of the nine domains is summed to create a total score ranging from 0-27. Higher scores indicate greater depression symptom severity. The QIDS-SR has demonstrated good psychometric properties, with a previous coefficient alpha of .86 in adults seeking outpatient care (Rush et al., 2003), and sensitivity of 77.55% and specificity of 56.25% in veterans (Suris et al., 2016). The QIDS-SR had strong convergent and concurrent validity with other depression measures (Rush et al., 2003). Internal consistency for the current sample was .87.

Symptoms of Anxiety.

The Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006) is a seven-item measure that assesses anxiety symptom severity. Participants respond to items on a 4-point Likert-type scale with scores ranging from 0 (not at all) to 3 (nearly every day). Scores are summed to create a total composite score, and higher scores represent greater anxiety symptom severity. The GAD-7 has good psychometric properties, with a previous Cronbach alpha of .88 in a veteran sample (Kroenke et al., 2016). Previous research has also demonstrated strong construct and convergent validity between the GAD-7 and other anxiety symptom measures (Spitzer et al., 2006). Internal consistency for the current sample was .91.

Insomnia.

The Insomnia Severity Index (ISI; Morin et al., 2011) is a seven-item assessment measuring severity of insomnia, satisfaction with sleep pattern, effect of sleep on daytime and social functioning, and concern about current sleep. Items are rated on a 5-point Likert Scale with 0 (no problem) to 4 (very severe problem), yielding a total summed score ranging from 0 to 28. ISI total scores are classified into four severity categories: 0-9 (no insomnia), 10-14 (mild), 15-21 (moderate), and 22-28 (severe). Higher scores indicate severe insomnia. The ISI has good psychometric properties, with a previous Cronbach alpha of .91 and strong convergent validity with the Pittsburgh Sleep Quality Index (Morin et al., 2011). Internal consistency for the current sample was .88.

Analytic Plan

The present study used a cross-sectional research design of treatment-seeking male veterans attending behavioral health services at a large VA medical center. SPSS 25 was used to manage missing data and to check multivariate normality. There were no missing data for the present study. Data were checked for outliers and multivariate normality by examining univariate normality for each of the dependent variables through the use of skewness and kurtosis statistics and probability plots. Skewness and kurtosis were both acceptable based on Lomax’s (2001) recommendation. Multivariate normality was also checked by examining bivariate normality through scatterplots. Stevens (2009) states that a U- or V-shape on the scatterplots poses a problem. Multicollinearity was assessed for the variables based upon Studenmund’s (2011) recommendation that the variance inflation factors (VIFs) greater than 5 are problematic. The assumption of univariate normality and multivariate normality was met, and multicollinearity was also acceptable. Descriptive statistics and correlations were assessed for all of the variables using SPSS 25.

PROCESS v3.3 (Hayes, 2017) regression analytic method was used to test both main effects of MST on PTSD symptoms, depressive symptoms, symptoms of anxiety, and insomnia severity, as well as the interaction effects of MST and RE on mental health outcomes. To test this two way-interaction, four separate regression analyses were conducted to include PTSD symptoms, depressive symptoms, symptoms of anxiety, and insomnia severity as dependent variables, MST as the predictor variable, and RE as the moderator variable. According to PROCESS, the dependent variable was entered first, independent variable second, the moderator third, and the covariates (CE and age) fourth. Model-fit statistics are provided by PROCESS through R-squared values. PROCESS was also used to test the simple slopes of MST on distress symptoms at different levels of RE (low = 1 SD below the mean, mean, and high = 1 SD above the mean), which is specified in PROCESS. PROCESS also computes specific values to facilitate the plotting of significant two-way interactions to examine the specific region of significance.

Results

Full correlational data and descriptive statistics can be found in Table 2. A total of four regression analyses were conducted using PROCESS v3.3, including four dependent variables, one moderator variable: Restrictive Emotionality (See Table 3), and two covariates: combat exposure (CE) and age.

Table 2.

Correlations and Descriptive Statistics for Variables in the Model (N = 134)

Variables 1 2 3 4 5 6 7 8
1. MST -
2. PTSD .23** -
3. Dep .10 .67** -
4. Anxiety .02 .58** .68** -
5. Insomnia .24** .65** .67** .59** -
6. RE .21* .44** .55** .40** .42** -
7. CE −.17* .29** .24** .17 .13 .09 -
8. Age −.02 −.34** −.27** −.31** −.22* −.01 −.37** -
M 2.62 46.09 16.06 12.72 17.66 39.08 .37 55.30
Range 0-14 0-80 4-26 0-21 0-28 10-60 0-1 22-74
SD 3.45 20.78 5.34 5.94 6.78 15.36 .48 12.90
Skewness 1.30 −.78 −.47 −.25 −.66 −.35 .56 −.96
Kurtosis .90 −.16 −.51 −.88 .06 −1.17 −1.71 −.25
Open in a new tab

Note. MST = Military Sexual Trauma; PTSD = Posttraumatic Stress Disorder Symptoms; Dep = Depressive Symptoms; RE = Restrictive Emotionality; CE = Combat Exposure

**

Correlation is significant at the 0.01 level (2-tailed).

*

Correlation is significant at the 0.05 level (2-tailed).

Table 3.

Interaction Effects of RE on MST in Predicting Mental Health Outcomes (N = 134)

Regression Analysis Predictors B SE F R2 ΔR2
PTSD Symptoms 14.91 .37* .02
MST 1.25*** .45
RE .50* .10
MST X RE −.06*** .03
CE 7.77*** 3.36
Age −.38** .12
Depressive Symptoms 18.99 .43* .05
MST .07 .11
RE .18* .02
MST X RE −.02** .01
CE 1.15 .82
Age −.08** .03
Symptoms of Anxiety 9.63 .27* .02
MST −.07 .14
RE .16* .03
MST X RE −.01 .01
CE .04 1.03
Age −.13** .04
Insomnia 9.43 .27* .03
MST .38*** .16
RE .16* .03
MST X RE −.02*** .01
CE .74 1.18
Age −.08 .04
Open in a new tab

Note. Unstandardized (B) regression coefficients are reported. SE = standard error. MST is ‘centered’ to a mean of zero. MST = Military Sexual Trauma; RE = Restrictive Emotionality; CE = Combat Exposure.

*

p < .001

**

p < .01

***

p < .05

Main Effect of MST and RE on Negative Mental Health Outcomes

MST was positively associated with PTSD symptoms (b = 1.25, p = .006) and insomnia severity (b = 0.38, p = .017). The relationship between MST and depressive and anxiety symptoms was not significant. RE was positively associated with PTSD symptoms (b = .505, p < .001), depressive symptoms (b = .183, p < .001), anxiety symptoms (b = .157, p < .001), and insomnia severity (b = .163, p < .001).

The Interaction Effect of MST and RE on Negative Mental Health Outcomes

RE significantly moderated the relationship between MST and PTSD symptoms (b = −0.056, p = .040), depressive symptoms (b = −0.021, p = .001), and insomnia severity (b = −0.02, p = .036), after controlling for CE and age. RE did not significantly moderate the relationship between MST and symptoms of anxiety (see Table 3). CE was a significant predictor of PTSD symptoms (b = 7.77, p = .022), but not for depressive symptoms, symptoms of anxiety, or insomnia severity. Age was also a significant predictor of PTSD symptoms (b = −0.377, p = .003), depressive symptoms (b = −0.08, p = .015), and symptoms of anxiety (b = −0.13, p = .001), but not for insomnia severity. Table 4 displays the correlations between the mental health outcomes in the regression model.

Table 4.

Correlations between Dependent Variables from Regression Analysis

PTSD Depression Anxiety Insomnia
PTSD -
Depression 0.504* -
Anxiety 0.430* 0.546* -
Insomnia 0.508* 0.538* 0.471* -
Open in a new tab

Note.

*

p < .001

Simple Slopes

The testing of simple slopes for MST predicting PTSD symptoms (see Figure 1), depressive symptoms (see Figure 2), and insomnia severity (see Figure 3) at each level of RE (−1 SD, mean, +1 SD) was conducted. Twenty-eight (20.9%) participants scored in the low RE range (−1 SD of RE or lower), 80 (59.7%) scored at the mean, and 26 (19.4%) scored in the high RE range (+1 SD of RE or higher). For low RE, as MST increased, PTSD scores increased by 2.10 units (p = .002). For average RE, as MST increased, PTSD scores increased by 1.25 units (p = .006). For high RE, MST did not significantly predict PTSD symptoms (p = .47). In addition, for low RE, as MST scores increased, depression scores increased by .40 (p = .015). For average (p = .53) and high RE (p = .06), MST did not significantly predict depressive symptoms. Regarding insomnia severity, for low RE, as MST scores increased, insomnia severity increased by .69 units (p = .004). For average RE, as MST scores increased, insomnia severity increased by .38 units (p = .017). For high RE, MST did not significantly predict insomnia severity (p = .69).

Figure 1.

Figure 1.

Open in a new tab

Interaction effect of MST and restrictive emotionality on PTSD symptoms

Note. *p < .01

Figure 2.

Figure 2.

Open in a new tab

Interaction effect of MST and restrictive emotionality on depressive symptoms

Note. *p < .05

Figure 3.

Figure 3.

Open in a new tab

Interaction effect of MST and restrictive emotionality on insomnia severity

Note. *p < .01 **p < .05

Discussion

MST in male veterans is an understudied issue. To our knowledge, this is the first study to directly examine the association between MST, RE, PTSD, depressive symptoms, symptoms of anxiety, and insomnia severity, and test whether RE exacerbated the relationship between MST and mental health symptoms in a sample of male veterans. When examining the main effects of MST on mental health outcomes, the results suggest that experiencing MST is linked to PTSD symptoms and sleep-related concerns. Vandrey et al. (2014) argued that there is high comorbidity between PTSD symptoms and sleep difficulties given that sleep disturbance, including insomnia and nightmares, is the primary presenting concern among individuals with PTSD. This was reflected in the present study where PTSD symptoms and insomnia were strongly correlated. In addition, because most MST is perpetrated by fellow service members, many of whom depend upon one another for survival, the development of PTSD symptoms and sleep difficulties in particular is likely due to the interpersonal nature of the trauma along with repeated exposures to the perpetrator after the sexual trauma has occurred (Allard et al., 2011).

Although unexpected, MST was not associated with depressive symptoms or symptoms of anxiety, which is contradictory to previous findings. However, when considering our sample, it is not uncommon for men to avoid or reject behaviors that are socially constructed as feminine, such as revealing or expressing emotions like sadness or fear (Neilson et al., 2020). Gros et al. (2012) also highlight studies that show comorbidity estimates ranging from 62% to 92% between PTSD symptoms and symptoms of other mood and anxiety disorders. When considering the results of the present study, the overlapping symptoms may have been captured within PTSD symptomatology which may help to explain the non-significant relationship between MST and depression and anxiety symptoms.

RE was also positively associated with all of the mental health outcomes in the present study, which supports previous findings that RE is one of the strongest predictors of psychological distress for men (Shepard, 2002). Neilson et al. (2020) argues that the avoidance or restriction of emotions, particularly those associated with fear and sadness, may be adaptive when exposed to trauma, but may contribute to the development or exacerbation of PTSD and distress symptoms over time. Thus, male veterans who restrict their emotions, especially more vulnerable emotions (e.g., sadness, fear, shame), are likely at greater risk of developing mental illness (Neilson et al., 2020). This connection between RE and mental illness is especially problematic given that conformity to masculine norms like RE has been associated with negative psychological help-seeking (Wong et al, 2017) and treatment dropout (Neilson et al., 2020).

As expected, RE moderated the relationship between MST and PTSD symptoms, depressive symptoms, and insomnia, but not anxiety symptoms after controlling for CE and age. As mentioned, this is likely due to the significant overlap in symptoms and the comorbidity between PTSD and anxiety (Gros et al., 2012). However, the pattern of results in the present study sheds light on the PTSD symptom clusters most relevant to negative alterations in cognitions and mood (i.e., negative affect and decreased interest in activities related more to depressed mood) and alterations in arousal and reactivity (i.e., difficulty sleeping related to insomnia).

The interaction between MST and RE exacerbated self-reported PTSD symptoms, depressive symptoms, and insomnia after controlling for CE and age. The relationship between MST and PTSD, and depressive and insomnia symptoms strengthened at lower and average levels of RE. This suggests that even the slightest difficulty with RE has a negative impact on male veterans’ mental health functioning. Men’s RE has been found to be closely related to alexithymia (Wong et al., 2006), which may develop in response to overwhelming stress in order to avoid experiencing unbearable emotions (Hemming et al., 2019). Although this was not a variable in the present study, veterans at lower and average levels of RE may have also struggled with identifying emotions (i.e., alexithymia) which in combination with MST may have led to an increase in mental health symptoms. In addition, Elder et al., (2017) found that men with a history of MST perceived themselves as weak and began to restrict all emotions except anger. Therefore, those with lower levels of RE who express anger more readily may not identify themselves as adhering to RE. However, difficulties restricting other emotions such as shame and fear has been found to exacerbate PTSD and other symptoms (Neilson et al., 2020).

Although it was anticipated that the relationship between MST and the negative mental health outcomes in this study would be stronger at higher levels of RE, the results were not statistically significant when testing the simple slopes. When considering the mean age of the sample, many of the participants would have been out of the military for over 20 years and may have had time to work through difficulties with avoidance and restriction of emotions, especially given the recruitment of male veterans in treatment. Wong et al. (2006) also argued that men with high RE may struggle less with an inability to be expressive and more with an unwillingness to express their feelings. This likely aligns with military culture, in which servicemen and women are taught to endorse stoicism and the outward appearance of stability and preparedness (Neilson et al, 2020). Thus, the non-significant findings at higher levels of RE may have to do more with restricting emotions as a function of their military training rather than a deficit in emotional expression. Therefore, the current conceptualization of RE may not account for individual nuances between men’s ability versus their unwillingness to express emotions. New instrumentation in this area is warranted to explore the restriction of emotions as a product of military training rather than solely assessing RE from an interpersonal context.

The results from the current study also suggest that male veterans who experience CE endorse elevated PTSD symptoms, which supports previous research findings (Hahn et al., 2015; Katz et al., 2012). We chose to control for CE because of its strong association with PTSD and distress symptoms and thus, failing to account for CE could lead to significantly biased parameter estimates when examining the relationship between MST and negative mental health outcomes (Calhoun et al., 2018). Therefore, CE is a variable that should be controlled for in MST and mental health research. In addition, age was also a significant predictor of PTSD symptoms, depressive symptoms, and symptoms of anxiety: as age increased, negative mental health outcomes decreased, which aligns with Maguen et al.’s (2012) findings. Thus, veterans younger in age may experience elevated distress symptoms compared to their older counterparts though researchers caution against these findings. For example, Yarvis et al. (2012) argued that measures that assess PTSD symptoms like the PCL-5 may not capture the essence of traumatic stress in older populations, and suggest using the PCL-M (military) when screening PTSD symptomology in older veterans.

Limitations

Limitations of the current study include the use of treatment-seeking veterans, which may not generalize to non-clinical samples of male veterans and active-duty personnel. The convenience sampling methodology may have also limited the generalizability of the results given that those participating were most likely motivated for treatment. The present study also did not account for type or length of treatment or treatment modality, which may have significantly impacted our findings. In addition, the passage of time since the most recent exposure to trauma may have had an impact on the results but was not a focus in the present study. Given the use of self-reports, many of the veterans may have underreported their symptomology and experiences of trauma including MST. The small sample size may have also limited statistical power. Given that MST was assessed using the frequency of each experience rather than the severity, the measure may have limited the variability in responses to detect a significant relationship between MST and some of the mental health outcomes in the present study. In addition, the men who completed the survey on the computer alone (nearly half of the sample) may, with the greater sense of anonymity and reduced perceived threat to their masculinity, have been more open about their mental health symptoms than men who completed the study with the first author.

Implications

The present study adds to our understanding of the influence of RE on men’s mental health functioning. Neilson et al. (2020) argue that men who avoid or reject behaviors that are socially constructed as feminine, including the expression of emotions, may negatively influence processes within therapy such as the processing, expression, and discussion of emotion and related cognitions. In fact, two of the most widely and empirically supported therapies for PTSD—prolonged exposure (PE) and cognitive processing therapy (CPT)—include explicit discussion of emotions, cognitions, and behaviors related to the traumatic event (Neilson et al., 2020). PE treatment in particular helps veterans engage in emotional processing especially during and after imaginal exposures, and CPT provides psychoeducation about emotions and allows clients to challenge problematic thoughts that lead to painful emotions. Because RE and other emotion-related constructs such as alexithymia are linked to psychological distress (Wong et al., 2006), clinicians may consider bringing more of a focus to RE and masculinity by including self-report measures to assess changes in identifying and expressing emotions following treatment. Neilson et al. (2020) also suggest that helping veterans flexibly shift the ways in which they enact their masculine roles and restrictive emotionality may help them maintain their views of themselves as men. In addition, clinicians may find it helpful to provide psychoeducation about how boys are socialized to believe that showing emotion is a sign of weakness/feminine and the lack of training boys/men receive in identifying and expressing emotions beyond the expression of anger. Treatment, including existing trauma-focused treatments, can help clients identify how gender role socialization shaped their beliefs and attitudes about emotions while helping them think more flexibly by identifying the pros and cons of expressing their emotions. In addition, male clinicians have the opportunity to model and mirror appropriate expressions of emotions through disclosing their own emotional experiences in session with their male clients.

Due to the results showing that RE moderated the relationship between MST and depression and insomnia severity, clinicians may continue or start to help veterans assess and challenge their maladaptive thoughts, beliefs, and attitudes about their emotional experiences, which aligns with CBT principles. The goal would be to help clients begin to see emotions on a spectrum, which will likely have positive outcomes on their mood and sleep difficulties. Future research should also examine how treatment outcomes and processes in therapy are affected by veterans’ adherence to traditional masculine ideology.

The results from this study suggest that the relationship between MST and PTSD symptoms, depressive symptoms, and insomnia severity strengthens at lower and average RE and not at higher levels of RE. Thus, other masculinity factors may be at play including achieving power and status, and the restrictions of feelings and thoughts with other men which is important given that restriction of emotions and lower social support has been associated with PTSD (Neilson et al., 2020). Therefore, helping veterans learn to not restrict their emotions with other men may help them improve the quality of their support systems.

Because distress symptoms were exacerbated for participants with lower levels of RE, some level of restricting emotions does seem to have an influence on men’s mental health associated with MST and should be a focus in therapy. For example, making the connection between masculinity and mental health while also helping men challenge stereotypical gender norms is warranted. In addition, the findings from the present study can be used to inform presentations and workshops that are offered to military personnel before they are discharged from the military. For example, normalizing the importance of seeking help, processing traumas, and working through difficult emotions may be the start of helping veterans reintegrate with society and begin recovery.

The present research study aimed to bring attention to the specific challenges faced by male veterans who experience MST; however, there is a dearth of research examining mental health outcomes associated with MST in those who identify as gay, lesbian, bisexual, and transgender (LGBT) (Monteith et al., 2019); in those with an eating disorder (Blais et al., 2017); and based on racial/ethnic background (Dohrenwend et al., 2008). Therefore, there is a need to study the unique experiences of these populations to inform prevention and intervention methods.

Conclusion

Research regarding male MST is a relatively recent development even though sexual trauma experienced by men has been documented throughout history. The findings from the present study add to the MST literature by focusing on contextual factors that may exacerbate negative mental health outcomes associated with sexual trauma in male veterans. Based on the findings, RE in combination with MST was found to have a negative effect on male veterans’ mental health functioning. Future research may benefit from understanding how different cultural underpinnings of masculinity—such as RE—influence mental health outcomes in those who experience MST. Such research may produce results and clinical recommendations that enhance the implementation and dissemination of prevention and treatment programs, likely reducing the negative impact of MST on our male veterans.

References

  1. Allard CB, Nunnink S, Gregory AM, Klest B, & Platt M (2011). Military sexual trauma research: A proposed agenda. Journal of Trauma & Dissociation, 12, 324–345. 10.1080/15299732.2011.542609 [DOI] [PubMed] [Google Scholar]
  2. Blais RK, Brignone E, Maguen S, Carter ME, Fargo JD, & Gundlapalli AV (2017). Military sexual trauma is associated with post-deployment eating disorders among Afghanistan and Iraq veterans. The International Journal of Eating Disorders, 50, 808–816. doi: 10.1002/eat.22705 [DOI] [PubMed] [Google Scholar]
  3. Bovin MJ, Marx BP, Weathers FW, Gallagher MW, Rodriquez P,…Keane TM (2016). Psychometric properties of the ptsd checklist for diagnostic and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychological Assessment, 28, 1379–1391. doi: 10.1037/pas0000254 [DOI] [PubMed] [Google Scholar]
  4. Calhoun PS, Schry AR, Dennis PA, Wagner R, Kimbrel NA, Bastian LA, Beckham JC, Kudler H, & Straits-Troster K (2018). The association between military sexual trauma and the use of VA and non-VA healthcare services among female veterans with military service in Iraq and Afghanistan. Journal of Interpersonal Violence, 33, 2439–2464. doi: 10.1177/0886260515625909 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Dohrenwend BP, Turner JB, Turse NA, Lewis-Fernandez R, Yager TJ (2008). War-related posttraumatic stress disorder in Black, Hispanic, and majority White Vietnam veterans: the roles of exposure and vulnerability. Journal of Traumatic Stress, 21, 133–141. doi: 10.1002/jts.20327 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Elder WB, Domino JL, Mata-Galán EL, & Kilmartin C (2017). Masculinity as an avoidance symptom of posttraumatic stress. Psychology of Men & Masculinity, 18, 198 –207. 10.1037/men0000123 [DOI] [Google Scholar]
  7. Gerdes ZT, & Levant RF (2018). Complex relationships among masculine norms and health/well-being outcomes: Correlation patterns of the conformity to masculine norms inventory subscales. American Journal of Men’s Health, 12, 229–240. doi: 10.1177/1557988317745910 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Good GE, Robertson JM, O’Neil JM, Fitzgerald LF, Stevens M, DeBord KA, . . . Braverman DG (1995). Male gender role conflict: Psychometric issues and relations to psychological distress. Journal of Counseling Psychology, 42(1), 3–10. 10.1037/0022-0167.42.1.3 [DOI] [Google Scholar]
  9. Good GE, Robertson JM, Fitzgerald LF, Stevens M, & Bartels KM (1996). The relation between masculine role conflict and psychological distress in male university counseling center clients. Journal of Counseling & Development, 75, 44–49. [Google Scholar]
  10. Gros DF, Price M, Magruder KM, & Frueh BC (2012). Symptom overlap in posttraumatic stress disorder and major depression. Psychiatry research, 196, 267–270. 10.1016/j.psychres.2011.10.022 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Hahn AM, Tirabassi CK, Simons RM, & Simons JS (2015). Military sexual trauma, combat exposure, and negative urgency as independent predictors of PTSD and subsequent alcohol problems among OEF/OIF veterans. Psychological Services, 12, 378–383. doi: 10.1037/ser0000060 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Hayes AF (2017). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach 2nd Edition. New York, NY: Guildford Press [Google Scholar]
  13. Hemming L, Haddock G, Shaw J, & Pratt D (2019). Alexithymia and its associations with depression, suicidality, and aggression: An overview of the literature. Frontiers in Psychiatry, 10, 203. 10.3389/fpsyt.2019.00203 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Houle J, Meunier S, Coulombe S, Tremblay G, Gaboury I, Montigny F,…Lavoie B (2015). Masculinity ideology among male workers and its relationship to self-reported health behaviors. International Journal of Men’s Health, 14, 163–182. doi: 10.3149/jmh.1402.163 [DOI] [Google Scholar]
  15. Hoyt T, Rielage JK, & Williams LF (2011). Military sexual trauma in men: A review of reported rates. Journal of Trauma & Dissociation, 12, 244 –260. doi: 10.1080/15299732.2011.542612 [DOI] [PubMed] [Google Scholar]
  16. Jakupcak M, Osborne T, Michael S, Cook J, Albrizio P, & McFall M (2006). Anxiety sensitivity and depression: Mechanisms for understanding somatic complaints in veterans with posttraumatic stress disorder. Journal of Traumatic Stress, 19, 471–479. doi: 10.1002/jts.20145 [DOI] [PubMed] [Google Scholar]
  17. Jenkins MM, Colvonen PJ, Norman SB, Afari N, Allard CB, & Drummond SP (2015). Prevalence and mental health correlates of insomnia in first-encounter veterans with and without military sexual trauma. SLEEP, 38, 1547–1554. doi: 10.5665/sleep.5044 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Juan MJD, Nunnink SE, Butler EO, & Allard CB (2017). Gender role stress mediates depression among veteran men with military sexual trauma. Psychology of Men & Masculinity, 18(3), 243–250. doi: 10.1037/men0000120 [DOI] [Google Scholar]
  19. Katz LS, Cojucar G, Beheshti S, Nakamura E, & Murray M (2012). Military sexual trauma during deployment to Iraq and Afghanistan: Prevalence, readjustment, and gender differences. Violence and Victims, 27, 487–499. doi: 10.1891/0886-6708.27.4.487 [DOI] [PubMed] [Google Scholar]
  20. Kimmerling R, Gima K, Smith MW, Street A, & Frayne S (2007). The veteran’s health administration and military sexual trauma, American Journal of Public Health, 97, 2160–2166. doi: 10.2105/AJPH.2006.092999 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. King L, King D, Vogt D, Knight J, & Samper R (2006). Deployment Risk and Resilience Inventory: A Collection of Measures for Studying Deployment-Related Experiences of Military Personnel and Veterans. Military Psychology, 18, 89–120. [Google Scholar]
  22. Kroenke K, Wu J, Yu Z, Bair MJ, Kean J, Stump T, …Monahan P (2016). The patient health questionnaire anxiety and depression scale (PHQ-ADS): Initial validation in three clinical trials. Psychosomatic Medicine, 78, 716–727. doi: 10.1097/PSY.0000000000000322 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Levant RF, Wong YJ, Karakis E, & Welsh M (2015). Mediated moderation of the relationship between the endorsement of restrictive emotionality and alexithymia. Psychology of Men & Masculinity, 16, 459 – 467. doi: 10.1037/a0039739 [DOI] [Google Scholar]
  24. Lomax RG (2001). Statistical Concepts: A Second Course for Education and the Behavioral Sciences (2nd edition). Mahwah, NJ: Lawrence Erlbaum Associates. [Google Scholar]
  25. Maguen S, Cohen B, Ren L, Bosch J, Kimerling R, & Seal K (2012). Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder. Women’s Health Issues, 22, 61–66. doi: 10.1016/j.whi.2011.07.010 [DOI] [PubMed] [Google Scholar]
  26. Mondragon SA, Wang D, Pritchett L, Graham DP, Plasencia ML, & Teng EJ (2015). The influence of military sexual trauma on returning OEF/OIF male veterans. Psychological services, 12, 402–411. doi: 10.1037/ser0000050 [DOI] [PubMed] [Google Scholar]
  27. Monteith LL, Gerber HR, Brownstone LM, Soberay KA, & Bahraini NH (2019). The phenomenology of military sexual trauma among male veterans. Psychology of Men & Masculinities, 20, 115–127. 10.1037/men0000153 [DOI] [Google Scholar]
  28. Monteith LL, Menefee DS, Forster JE, Wanner JL, & Bahraini NH (2015). Sexual trauma and combat during deployment: Associations with suicidal ideation among OEF/OIF/OND veterans. Journal of Traumatic Stress, 28, 283–288. doi: 10.1002/jts.22018 [DOI] [PubMed] [Google Scholar]
  29. Morin CM, Belleville G, Belanger L, & Ivers H (2011). The insomnia severity index: Psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep, 34, 601–608. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Neilson EC, Singh RS, Harper KL, & Teng EJ (2020). Traditional masculinity ideology, posttraumatic stress disorder (PTSD) symptom severity, and treatment in service members and veterans: A systematic review. Psychology of Men & Masculinities. Advance online publication. 10.1037/men0000257 [DOI] [Google Scholar]
  31. O’Brien BS, & Sher L (2013). Military sexual trauma as a determinant in the development of mental and physical illness in male and female veterans. International Journal of Adolescent Medicine and Health, 25, 269–274. doi: 10.1515/ijamh-201300061 [DOI] [PubMed] [Google Scholar]
  32. O’Brien CO, Gaher RM, Pope C, Smiley P (2008). Difficulty identifying feelings predicts the persistence of trauma symptoms in a sample of veterans who experienced military sexual trauma. The Journal of Nervous and Mental Disease, 196, 252–255. doi: 10.1097/NMD.0b013e318166397d [DOI] [PubMed] [Google Scholar]
  33. O’Neil JM, Good GE, & Holmes S (1995). Fifteen years of theory and research on men’s gender role conflict: New paradigms for empirical research. In Levant R & Pollack WS (Eds.), A new psychology of men (pp. 129 –163). New York: Basic Books. [Google Scholar]
  34. O’Neil JM, Helms BJ, Gable RK, David L, & Wrightsman LS (1986). Gender-role conflict scale: College men’s fear of femininity. Sex Roles, 14, 335–350. doi: 10.1007/BF00287583 [DOI] [Google Scholar]
  35. Rush AJ, Trivedi MH, Ibrahim HM, Carmody TJ, Arnow B, Klein DK, … Keller MB (2003). The 16-Item quick inventory of depressive symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biological Psychiatry, 54, 573–583 [DOI] [PubMed] [Google Scholar]
  36. Seal KH, Bertenthal D, Miner CR, Sen S, & Marmar C (2007). Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167, 476–482. doi: 10.1001/archinte.167.5.476 [DOI] [PubMed] [Google Scholar]
  37. Schry AR, Hibberd R, Wagner HR, Turchik JA, Kimbrel NA, Wong M,..Brancu M (2015). Functional correlates of military sexual assault in male veterans. Psychological Services, 12, 384–393. doi: 10.1037/ser0000053 [DOI] [PubMed] [Google Scholar]
  38. Shepard DS (2002). A negative state of mind: Patterns of depressive symptoms among men with high gender role conflict. Psychology of Men & Masculinity, 3, 3–8. doi: 10.1037//1524-9220.3.1.3 [DOI] [Google Scholar]
  39. Spitzer RL, Kroenke K, Williams JB, & Lowe B (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166, 1092–1097. doi: 10.1001/archinte.166.10.1092 [DOI] [PubMed] [Google Scholar]
  40. Stevens JP (2009). Applied multivariate statistics for the social sciences (5th Edition). New York: Routledge. [Google Scholar]
  41. Studenmund AH (2011). Using econometrics: A practical guide. New York: Pearson [Google Scholar]
  42. Suris A, Holder N, Holliday R, & Clem M (2016). Psychometric validation of the 16-item quick inventory of depressive symptomatology self-report version (QIDS-SR16) in military veterans with PTSD. Journal of Affective Disorders, 202, 16–22. 10.1016/j.jad.2016.05.029 [DOI] [PubMed] [Google Scholar]
  43. Suris A, & Lind L (2008). Military sexual trauma: A review of prevalence and associated health consequences in veterans. Trauma Violence Abuse, 9, 250–269. doi: 10.1177/1524838008324419 [DOI] [PubMed] [Google Scholar]
  44. Turchik JA, & Edwards KM (2012). Myths about male rape: A literature review. Psychology of Men & Masculinity, 13, 211–226. doi: 10.1037/a0023207 [DOI] [Google Scholar]
  45. Vandrey R, Babson KA, Herrmann ES, & Bonn-Miller MO (2014). Interactions between disordered sleep, post-traumatic stress disorder, and substance use disorders. International Review of Psychiatry, 26, 237–247. doi: 10.3109/09540261.2014.901300 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Vogt D, Smith BN, King LA, King DW, Knight J, & Vasterling JJ (2013). Deployment risk and resilience inventory-2 (DRRI-2): An updated tool for assessing psychosocial risk and resilience factors among service members and veterans. Journal of Traumatic Stress, 26, 710–717. [DOI] [PubMed] [Google Scholar]
  47. Weathers F, Litz B, Herman D, Huska J, & Keane T (1993). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. [Google Scholar]
  48. Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, & Schnurr PP (2013). The PTSD Checklist for DSM-5 (PCL-5). PTSD: National Center for PTSD. www.ptsd.va.gov [Google Scholar]
  49. Wertsch M (1991). Military brats: Legacies of childhood inside the fortress. New York, NY: Harmony Books. [Google Scholar]
  50. Wong YJ, Ho MR, Wang S, & Miller IK (2017). Meta-analyses of the relationship between conformity to masculine norms and mental health-related outcomes. Journal of Counseling Psychology, 64, 80–93. doi: 10.1037/cou0000176 [DOI] [PubMed] [Google Scholar]
  51. Wong YJ, Pituch KA, Rochlen AB (2006). Men’s restrictive emotionality: An investigation of associations with other emotion-related constructs, anxiety, and underlying dimensions. Psychology of Men & Masculinity, 7, 113–126. doi: 10.1037/1524-9220.7.2.113 [DOI] [Google Scholar]
  52. Yarvis JS, Yoon E, Amenuke M, Simien-Turner S, & Landers GD (2012). Assessment of ptsd in older veterans: The posttraumatic stress disorder checklist: Military version (PCL-M). Advances in Social Work, 13, 185–202 [Google Scholar]

RESOURCES