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. 2021 Oct 8;34(1):12–22. doi: 10.1080/08995605.2021.1964901

Sexual harassment and assault during deployment: Associations with treatment outcomes among Veterans with co-occurring PTSD and SUD

Christine K Hahn a,✉, Amber M Jarnecke a, Casey Calhoun b, Alex Melkonian c, Julianne C Flanagan a,c, Sudie E Back a,c
PMCID: PMC8942369  NIHMSID: NIHMS1733897  PMID: 35340543

ABSTRACT

Sexual trauma is common and increases the risk for posttraumatic stress disorder (PTSD), substance-use disorders (SUD), and depression among Veterans. Limited research has examined the impact of sexual harassment and assault during deployment on treatment outcomes among Veterans with co-occurring PTSD and SUD. The current study examined the frequency of exposure to sexual harassment and assault during deployment as a predictor of treatment outcomes among a primarily male sample of US military Veterans diagnosed with current PTSD and SUD. A secondary analysis was performed using data from a randomized clinical trial examining the efficacy of Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) compared to Relapse Prevention (RP). Data from 69 Veterans (91.3% male) who were deployed while in the service were analyzed using mixed models to determine whether frequency of exposure to sexual harassment and assault during deployment impacted changes in PTSD symptom severity, percent days using substances, and depressive symptoms during treatment. Over one-third of the sample (36.2%) reported exposure to sexual harassment and/or assault during deployment. Frequency of exposure to sexual harassment and assault during deployment was not a predictor of treatment outcome in any of the models, suggesting a similar response to treatment among those with varying frequency of exposure to sexual harassment and assault during deployment. Veterans with co-occurring PTSD and SUD who have been exposed to sexual harassment and assault during deployment may benefit from integrated trauma-focused treatments and treatments focused on decreasing SUD symptoms.

KEYWORDS: Military sexual trauma, integrated treatment, substance use disorders, posttraumatic stress disorder, Veterans

What is the public significance of this article?—Over one-third of Veterans who were diagnosed with both posttraumatic stress disorder (PTSD) and substance use disorder (SUD) reported experiencing sexual harassment and/or assault during military deployments. Symptoms of PTSD, SUD, and depression were not associated with frequency of exposure to sexual harassment and/or assault during military deployments. Frequency of exposure to sexual harassment and/or assault during military deployments did not predict differences in PTSD, SUD, or depressive symptoms during treatment for PTSD and SUD, suggesting that Veterans diagnosed with PTSD and SUD respond well to related treatment across exposure levels to military harassment and/or assault during deployments.

An estimated 15.7% of the Veterans experience military sexual trauma (MST), defined as sexual harassment or sexual assault during military training or service (Title 38 U.S. Code § Sec. 1720D, 2006; Wilson, 2018). Sexual harassment includes acts such as making offensive threatening sexual remarks and pressure to engage in sexual activity by using threats, rewards, or positions of authority and is the most common type of sexual trauma reported by Veterans during military deployments (Katz, Cojucar, Beheshti, Nakamura, & Murray, 2012). Sexual assault includes behaviors ranging from unwanted sexual touching to rape. MST is associated with increased odds of being diagnosed with posttraumatic stress disorder (PTSD), substance use disorders (SUD), and depressive disorders among male and female Veterans (Gilmore et al., 2016; Kimerling et al., 2010; Maguen, Cohen et al., 2012; Suris & Lind, 2008). Further, Veterans with a history of MST report higher rates of co-occurring PTSD and SUD compared to Veterans without a history of MST (Gilmore et al., 2016). MST and co-occurring PTSD and SUD are associated with additional mental and physical health problems (Norman, Haller, Hamblen, Southwick, & Pietrzak, 2018; Suris & Lind, 2008), sexual revictimization (Schry & Beckham, 2016; Ullman, 2015), and greater risk for relapse (Ouimette, Coolhart, Funderburk, Wade, & Brown, 2007; Williams, Frasco, Jacobson, Maynard, & Boyko, 2015). Despite the established prevalence of MST and increased risk for subsequent PTSD and SUD, limited research has examined the effectiveness of interventions among Veterans with co-occurring PTSD and SUD based on exposure to MST.

Most research has focused on MST in general, which can occur at any point during military training or service. However, Veterans have reported high rates of exposure to sexual harassment and assault during military deployments. Less than 1% to 12.5% of male and 12% to 42% of female Veterans report exposure to sexual harassment and/or assault during deployment to Iraq and Afghanistan, with prevalence of sexual trauma during deployment varying based on definition and military population (Katz et al., 2012; Manguen, Cohen et al., 2012; Monteith, Menefee, Forster, Wanner, & Bahraini, 2015). Exposure to sexual harassment and assault during deployment occurs within the context of military duties, may be repeated, and creates a hostile work and living environment (Burns, Grindlay, Holt, Manski, & Grossman, 2014; Monteith, Gerber, Brownstone, Soberay, & Bahraini, 2019; Street, Vogt, & Dutra, 2009). Verbal sexual harassment (e.g., unwanted verbal sexual comments such as pressure for dates) during deployment to Iraq and Afghanistan has been associated with greater symptoms of PTSD, depression, and difficulties with readjustment following deployment (Katz et al., 2012). Further, in a sample of 7,251 active-duty soldiers deployed to Iraq or Afghanistan, sexual harassment and assault during deployment predicted greater post-deployment PTSD and depressive symptoms but did not predict hazardous alcohol use (Maguen, Luxton, 2011). However, among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans, exposure to sexual harassment and assault during deployment was associated with greater PTSD symptoms, alcohol use, and alcohol-related problems (Banducci, McCaughey, Gradus, & Street, 2019; Hahn, Tirabassi, Simons, & Simons, 2015). Moreover, PTSD has been shown to mediate the association between exposure to sexual harassment and assault during deployment and alcohol outcomes. Sexual harassment and assault during deployment may initially be associated with PTSD and depression, and over time it may contribute to substance use outcomes due to, for example, self-medication of distressing symptoms.

Sexual harassment and assault during deployment is a unique form of sexual violence because service members are experiencing harassment and/or assault in the context of an institution they must rely on for basic needs, safety, and survival. MST has been associated with perceptions of betrayal by the military (Holliday & Monteith, 2019). In fact, perceptions of institutional betrayal, such as believing that the military created an environment that made MST likely to happen or made it difficult to seek help after experiencing MST, has been commonly reported among female Veterans and associated with greater risk for PTSD and other negative health outcomes (Monteith, Bahraini, Matarazzo, Soberay, & Smith, 2016; Monteith et al., 2021). Aspects of military deployment such as high stress and pressure to remain silent about experiences of MST to protect the unit may also increase negative outcomes associated with sexual trauma during deployments (Burns et al., 2014; Monteith et al., 2019). Further, experiencing sexual harassment and assault in the context of additional deployment stressors, including combat exposure may exacerbate distress (Cobb Scott et al., 2014; Street et al., 2009). Female Veterans who experienced military sexual assault in addition to other military stressors were at increased risk for co-occurring PTSD and SUD, compared to Veterans who only experienced military sexual assault (Yalch, Hebenstreit, & Maguen, 2018). Moreover, many people report joining the military to escape chaotic situations (Sadler, Booth, Mengeling, & Doebbeling, 2004) and report lifetime history of adverse childhood experiences before joining military services (Blosnich et al., 2021). Greater exposure to sexual harassment and assault during deployment may increase severity of PTSD stemming from other traumatic life events (e.g., combat, childhood trauma), SUD, and depressive symptoms because of the impact of cumulative trauma exposure on stress (Cobb Scott et al., 2014; Kelly, Skelton, Patel, & Bradley, 2011; Schumm & Chard, 2012).

It is important to emphasize that exposure to sexual harassment and assault during deployment impacts both male and female Veterans. Although a higher proportion of women experience MST compared to men (Wilson, 2018), the actual numbers of male and female Veterans who have experienced MST are similar given that there are more men in the military than women (Kimerling, Gima, Smith, Street, & Frayne, 2007). Street, Gradus, Stafford, and Kelly (2007) examined gender differences in outcomes associated with sexual harassment during services in the reserves. Sexual harassment was associated with greater depressive, PTSD, and general mental health symptoms. Although women were more likely to report sexual harassment, men reported higher levels of depression and general mental health symptoms at higher levels of harassment compared to women. Sexual harassment and assault during deployment occurs within the context of a male-dominated environment that traditionally adheres to strict gender-norms and may contribute to stress and long-lasting mental health outcomes among male and female Veterans.

Little is known about the impact of exposure to sexual harassment and assault during deployment on treatment outcomes among Veterans who have co-occurring PTSD and SUD. Although sexual harassment and assault during deployment may impact risk for developing mental health diagnoses and severity of symptoms, preliminary research suggests that treatments for PTSD are effective for Veterans who report past exposure to MST. Evidence-based treatments for PTSD, including Prolonged Exposure (PE; Foa, Hembree, Rothbaum, & Rauch, 2019) and Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2017), are effective in reducing PTSD symptoms among Veterans who have experienced MST (Eftekhari et al., 2013; Suris, Link-Malcolm, Chard, Ahn, & North, 2013). Further, the limited extant data suggest that Veterans with a history of MST have comparable treatment responses to evidence-based treatment for PTSD as compared to those with other forms of trauma exposure (Rauch et al., 2009; Tiet, Leyva, Blau, Turchik, & Rosen, 2015; Voelkel, Pukay-Martin, Walter, & Chard, 2015). Taken together, previous research suggests that Veterans may have similar reductions in symptoms during treatment regardless of exposure to sexual harassment and assault during deployments.

Research on interventions targeting both PTSD and SUD is an area of growing interest (Back, 2010; Flanagan, Korte, Killeen, & Back, 2016; Simpson, Lehavot, & Petrakis, 2017; Vujanovic & Back, 2019). Concurrent Treatment of PTSD and SUD Using Prolonged Exposure (COPE; Back et al., 2014) is a manualized, evidence-based treatment that consists of 12 sessions combining cognitive-behavioral treatment for SUD with PE (imaginal and in vivo exposure). Previous studies of COPE (Back et al., 2012; Persson et al., 2017; Ruglass et al., 2017) demonstrate significant reductions in both PTSD and SUD symptoms. Back et al. (2019) recently conducted an RCT to evaluate the efficacy of COPE among treatment-seeking military Veterans with co-occurring PTSD and SUD. Veterans assigned to the COPE condition had a significantly greater reduction in PTSD symptoms and consumed fewer drinks per day during follow-up than Veterans assigned to Relapse Prevention, a cognitive-behavioral therapy for SUD only. Both groups had a significant reduction in SUD symptom severity. However, it is unknown if exposure to sexual harassment and assault during deployment impacted treatment outcomes. An important next step in this line of research is to examine if the efficacy of COPE and Relapse Prevention differs based on the frequency of exposure to sexual harassment and assault during deployment, as effective interventions for Veterans who have co-occurring PTSD and SUD are especially needed for this high-risk subpopulation.

To date, no studies have examined whether frequency of exposure to sexual harassment and assault during deployment impacts treatment outcomes for Veterans with co-occurring PTSD and SUD. Thus, the goal of the current study was to conduct secondary analyses from the above referenced RCT (Back et al., 2019) to test the association between frequency of exposure to sexual harassment and assault during deployment and treatment outcomes among Veterans with co-occurring PTSD and SUD who were randomized to receive COPE or Relapse Prevention. Previous research suggests that although MST may be associated with greater PTSD, SUD, and depressive symptoms (Hahn et al., 2015; Maguen, Cohen et al., 2012; Sexton, Raggio, McSweeney, Autheir, & Rauch, 2017), Veterans with histories of MST respond well to trauma-focused treatment (Rauch et al., 2009; Tiet et al., 2015; Voelkel et al., 2015). Thus, we hypothesized that greater frequency of exposure to sexual harassment and assault during deployment would be associated with greater symptoms of PTSD, depression, and SUD symptoms at the onset of treatment, but that symptoms would reduce during the course of treatment regardless of exposure level to sexual harassment and assault during deployments. This line of research is needed to inform further development of behavioral interventions and dissemination of treatments for co-occurring PTSD and SUD to Veterans exposed to sexual harassment and assault during deployments.

Materials and methods

Participants

Participants enrolled in the study (N = 81) were Veterans of the United States military, aged 18–65, who met DSM-IV diagnostic criteria for current PTSD (assessed with the DSM-IV Clinician-Administered PTSD Scale; CAPS; Blake et al., 1995) and SUD (assessed with the MINI International Neuropsychiatric Interview (MINI; Sheehan et al., 1998). As part of a larger trial (Back et al., 2019), participants were recruited through VA treatment clinics, internet advertisements, and flyers placed in community clinics and local hospitals. Veterans were excluded if they had psychiatric or medical conditions requiring intensive levels of care including current suicidality and/or homicidality with intent or active psychosis. Participants who were taking psychotropic medications had to be stabilized on the medication for at least 4 weeks prior to study start. The full sample (N = 81) was randomized to receive COPE or Relapse Prevention. For the purposes of the current study, we examined Veterans in the sample who were deployed during their service (n = 69). Among the 69 Veterans who were deployed, 50 participants reported at least one deployment in Iraq or Afghanistan and 38 participants reported deployment during other US conflicts. Among these participants, the majority of the sample identified as male (91.3%), White (62.3%) or Black (34.8%) and met criteria for an alcohol use disorder (89.9%) (see Table 1). The average age of participants in the sample was 39.01 (SD = 9.96). Average years of service were 9.81 (SD = 7.90). The branch of military reported were Army (56.5%), Navy (11.6%), Marines (14.5%), Air Force (8.6%), and National Guard (7.2%). The majority of Veterans reported a rank of E-4 or above (87.0%) and a current military status of being discharged (59.4%); 8.7% reported other than honorable discharge from the military. The remainder of Veterans reported being retired (26.1%), in-active reserve (8.7%), reserve (4.3%), or active (1.4%).

Table 1.

Baseline demographic and clinical characteristics (N = 69)

  Total N = 69 Male
N = 63 (91.3%)		 Female
N = 6 (8.7%)
Sample Characteristic N (%) or M (SD)
Treatment Condition      
 COPE 47 (68.1%) 43 (68.3%) 4 (66.7%)
 RP 22 (31.9%) 20 (31.7%) 2 (33.3%)
Race      
 Black 24 (34.8%) 22 (34.9%) 2 (33.3%)
 White 43 (62.3%) 40 (63.5%) 3 (50.0%)
 More Than One Race/Other 2 (2.9%) 1 (1.6%) 1 (16.7%)
Age, number of years 39.01 (9.96) 38.95 (10.1%) 39.67 (9.3%)
Substance Use Disorder      
 Alcohol Use Disorder 62 (89.9%) 57 (82.5%) 5 (50.0%)
 Cannabis Use Disorder 6 (8.7%) 4 (4.8%) 2 (66.7%)
 Cocaine Use Disorder 9 (13.0%) 8 (12.7%) 1 (16.7%)
 Opioid Use Disorder 8 (11.6%) 8 (12.7%) 0
 Sedative/Hypnotic Use Disorder 1 (1.4%) 1 (1.6%) 0
Number of Treatment Sessions Completed 8.23 (4.52) 8.0 (4.58%) 10.67(3.27%)
Average Number of Lifetime Traumas 11.14 (2.77) 11.16 (2.80) 11.00 (2.76)
Index Trauma      
 Military Sexual Trauma 4 (5.8%) 2 (3.2%) 2 (33.3%)
 Military Combat Trauma 33 (47.8%) 31 (49.2%) 2 (33.3%)
 Other Military Trauma 22 (31.9%) 22 (34.9%) 0
 Other Trauma 10 (14.5%) 8 (12.7%) 2 (33.3%)
Baseline PTSD Severity (PCL) 62.23 (10.23) 63.10 (10.1%) 53.17 (6.4%)
Baseline Percent Days Used Substance (TLFB) 49.33 (34.92) 46.61 (34.6%) 77.89 (26.7%)
Baseline Depression Severity (BDI-II) 28.54 (11.11) 28.90 (11.2%) 24.83 (10.9%)
Sexual Harassment and Assault During Deployment (Any) 25 (36.2%) 20 (31.7%) 5 (83.3%)
 Harassment Exposure (Any) 24 (34.8%) 19 (30.2%) 5 (83.3%)
 Coercion Exposure (Any) 8 (11.6%) 4 (6.3%) 4 (66.7%)
 Assault Exposure (Any) 8 (11.6%) 4 (6.3%) 4 (66.7%)
Sexual Harassment and Assault During Deployment Total Scores (DRRI) 1.79 (3.72) 1.10 (2.5%) 10.4 (5.9%)
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PTSD = Posttraumatic Stress Disorder; MST = Military Sexual Trauma. Total scores on the PTSD Checklist – Military Version (PCL- M; Weathers et al., 1994) ranged from 40 to 84; Total scores on the Beck Depression Inventory-II (BDI-II; Beck et al., 1996) ranged from 0 to 52; DRRI total scores = total scores on the Sexual Harassment Scale on the Deployment Risk and Resilience Inventory (DRRI) One female participant had missing data for DRRI items.

Procedures

Potential participants were screened by research staff via telephone or in person, and those who met eligibility criteria were invited to enroll in the larger trial. During the first study visit, participants read and signed consent forms, approved by the local Institutional Review Board and VA Research and Development, and completed a comprehensive baseline assessment that included semi-structured clinical interviews and self-report assessments. Following the baseline assessment, participants were randomized (2:1) to receive 12 weekly, 90-minute sessions of COPE or Relapse Prevention. Prior to initiating each therapy session, participants completed assessments evaluating PTSD symptom severity, substance use, and depressive symptom severity. Although abstinence was not required of participants, it was encouraged. See (Back et al., 2019) for more details on procedures.

Measures

Sexual harassment and assault during military deployments

Exposure to sexual harassment and assault during deployment was assessed at baseline by the Sexual Harassment Scale on the Deployment Risk and Resilience Inventory (DRRI; King, King, Vogt, Knight, & Samper, 2006). This scale consists of 7 items assessing exposure to unwanted sexual verbal conduct (e.g., “During deployment the people I worked with made crude and offensive sexual remarks directed at me, either publicly or privately”), sexual coercion (e.g., “During deployment the people I worked with used a position of authority to pressure me into unwanted sexual activity”) and sexual assault (e.g., “During deployment the people I worked with physically forced me to have sex”) from unit members, commanding officers, or civilians during deployments. Items were rated on a 4-point Likert scale (0 = Never, 1 = Once or Twice, 2 = Several Times, 3 = Many Times). Consistent with previous research that used the newer DRRI-2 (Vogt et al., 2013) to assess exposure to sexual harassment and assault, total scores were created by summing responses to each item and range from 0 to 21 (Hahn et al., 2015; Smith et al., 2011). Internal consistency in this sample for this scale was good (α = 0.89).

PTSD symptom severity

The PTSD Checklist – Military Version (PCL-M) (Weathers, Litz, Herman, Huska, & Keane, 1994) measured PTSD symptom severity at baseline and weekly throughout treatment. The PCL-M consists of 17 items designed to assess DSM-IV PTSD symptoms. The measure demonstrates good psychometric properties (Wilkins, Lang, & Norman, 2011). Higher scores reflect great PTSD symptom severity with possible range of 17 to 85. The recommended cutoff for a probable PTSD diagnosis when screening in VA specialty PTSD clinics using the DSM-IV measure is 50 (Prins, Kimerling, Yeager, & Magruder, 2010). Internal consistency was good to excellent across assessment periods in the current sample (α’s = 0.86– 0.96).

Substance use

The Timeline Followback (TLFB) (Sobell & Sobell, 1992) is a calendar-based method for collecting self-report assessments of alcohol and drug use (frequency and amount). At baseline, substance use was assessed 60 days prior to the baseline appointment. During weekly treatment sessions, substance use was assessed since the previous visit. The percent days used variable characterizes substance use frequency (i.e., number of days used any substance divided by the number of days assessed and multiplied by 100). The TLFB has good psychometric properties, correlating well with self- and other reports of substance use and yielding high test–retest correlations (Carey, 1997).

Depression symptom severity

The Beck Depression Inventory-II (BDI-II) (Beck, Steer, & Brown, 1996) is a 21-item, self-report questionnaire designed to assess the severity of depressive symptoms. The BDI-II has exhibited superior internal consistency and reliability across clinical and nonclinical samples (Beck et al., 1996). In the current study, the BDI-II was administered at baseline and weekly throughout treatment. Higher scores reflect greater depressive symptom severity. Internal consistency was excellent across assessment periods (α’s = 0.91– 0.96).

Statistical analysis

Analyses were conducted on secondary data; therefore, a power analysis was not conducted (Dziak, Dierker, & Abar, 2020). Descriptive statistics were used to characterize participants at baseline. Bivariate correlations examined whether participants differed in treatment variables (i.e., PTSD symptoms, substance use, depression, number of sessions completed) at baseline by frequency of exposure to sexual harassment and assault during deployment. Mixed models, which account for multiple assessment timepoints (i.e., sessions) within individuals, were conducted in SPSS v. 25. These mixed models were used to determine whether frequency of exposure to sexual harassment and assault during deployments impacted treatment response. Specifically, three independent models examined how session (i.e., coded 0 = baseline to 12 = Session 12 of treatment) and frequency of exposure to sexual harassment and assault during deployment impacted PTSD symptom severity, percent days used, and depressive symptom severity while accounting for treatment condition (1 = COPE; −1 = RP). Models also examined whether there was an effect of frequency of exposure to sexual harassment and assault during deployment by session and frequency of exposure to sexual trauma by treatment condition. The predictor variables were centered in all models. Models were specified with random intercepts and an identity covariance structure. Parameter estimates, standard errors, p-values, and 95% confidence intervals (CIs) are reported for the mixed models.

Results

Demographic and baseline characteristics

Characteristics of the sample are presented with raw data in Table 1. Over one-third (36.2%) of the sample reported exposure to sexual harassment and/or assault during deployment, with 34.8% of the total sample reporting experiencing sexual harassment, 11.6% reporting sexual coercion, and 11.6% reporting sexual assault during deployment. Total scores on the DRRI sexual harassment and assault items ranged from 0 to 18 and the average total score for frequency of exposure to the items was 1.79 (SD = 3.72). The most common types of sexual harassment and assault during deployment reported were “gossiped about my sex life/spread rumors” (39.18%) and “made crude/offensive sexual remarks to me” (27.40%). Most participants (85.5%) selected a military-related index trauma (i.e., traumatic event that was the focus of treatment); 5.8% of participants’ index trauma was MST. Table 2 presents bivariate correlations examining the associations between frequency of exposure to sexual harassment and assault during deployment and baseline PTSD severity, baseline percent days used, baseline depressive symptom severity, and number of treatment sessions completed. Sexual harassment and assault during deployment was not significantly associated with any of the baseline variables examined.

Table 2.

Bivariate correlations between exposure to sexual harassment and assault during deployment and baseline clinical variables

Variable Sexual Harassment and Assault Exposure PTSD Severity Percent Days Used Substance
DST -    
PTSD Severity −0.071 -  
Percent Days Used Substance 0.053 −0.094 -
Depression Severity −0.001 0.549** −0.153
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Note. DST = Deployment Sexual Trauma (i.e., sexual harassment and assault) PTSD = Posttraumatic Stress Disorder. ** denotes p < 0.001.

Number of sessions completed

Participants completed an average of 8.2 treatment sessions and the number of treatment sessions completed did not differ by treatment condition (t = 1.38, p = .176) nor MST exposure (t = −0.99, p = .326).

Frequency of exposure to sexual harasment and assault during deployment and treatment outcomes

PTSD symptoms, percent days used, and depressive symptoms appeared to decrease from baseline to Session 12. Results from the mixed models are presented in Table 3. For each of the three models, the random intercept was statistically significant, indicating variability in baseline levels of the outcome variable. Across each of the three models, session number significantly predicted the outcome, suggesting that participants reported decreases in PTSD symptom severity, percent days used, and depression symptom severity over the course of treatment even controlling for the other variables in the model. Frequency of exposure to sexual harassment and assault during deployment did not significantly predict treatment outcome in any of the models, suggesting that individuals with more exposure to sexual harassment and assault during deployment showed similar treatment outcomes to individuals with less exposure to sexual harassment and assault during deployment while accounting for treatment condition. Likewise, there were not significant effects of session by frequency of exposure to sexual harassment and assault during deployment, nor treatment condition by frequency of exposure to sexual harassment and assault during deployment in any of the models. This suggests that symptom decreases over sessions did not vary by frequency of exposure to sexual harassment and assault during deployment. Likewise, any differences in outcome variables by treatment condition did not differ by frequency of exposure to sexual harassment and assault during deployment.

Table 3.

Estimates from mixed models

  B SE p-value 95% Confidence Interval
PTSD Severity        
Fixed Effects        
 Intercept 61.82 1.65 .000 58.54 to 65.10
 Session −1.77 0.11 .000 −1.97 to −1.56
 Treatment Group 3.24 1.59 .045 0.07 to 6.41
 DST Exposure −0.20 0.43 .635 −1.06 to 0.65
 Session x DST Exposure −0.01 0.03 .799 −0.06 to 0.05
 Treatment Group x DST Exposure −0.17 0.41 .685 −0.99 to 0.66
Random Effects        
 Residual 80.71 4.91 .000 71.63 to 90.93
 Intercept 131.15 25.60 .000 89.46 to 192.26
Percent Days Used Substance        
Fixed Effects        
 Intercept 43.44 3.93 .000 35.60 to 51.27
 Session −1.93 0.23 .000 −2.38 to −1.48
 Treatment Group 2.39 3.81 .532 −5.23 to 10.01
 DST Exposure 0.52 1.03 .616 −1.54 to 2.57
 Session x DST Exposure −0.01 0.06 .884 −0.12 to 0.11
 Treatment Group x DST Exposure 0.07 0.99 .943 −1.91 to 2.06
Random Effects        
 Residual 383.69 23.25 .000 340.72 to 432.08
 Intercept 773.78 152.44 .000 525.93 to 1138.44
Depression Severity        
Fixed Effects        
 Intercept 28.76 1.38 .000 26.02 to 31.50
 Session −1.17 0.08 .000 −1.33 to −1.00
 Treatment Group 1.69 1.33 .208 −0.96 to 4.35
 DST Exposure 0.05 0.36 .884 −0.66 to 0.77
 Session x DST Exposure −0.03 0.02 .192 −0.07 to 0.01
 Treatment Group x DST Exposure −0.22 0.34 .518 −0.91 to 0.46
Random Effects        
 Residual 51.68 3.14 .000 45.88 to 58.21
 Intercept 92.52 17.85 .000 63.39 to 135.06
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PTSD = Posttraumatic Stress Disorder; DST = Deployment Sexual Trauma (i.e., sexual harassment and assault). p < 0.05 is considered statistically significant.

Discussion

This is the first study to our knowledge to examine frequency of exposure to sexual harassment and assault during deployment as a predictor of PTSD, substance use, and depressive symptoms among Veterans with co-occurring PTSD and SUD. The percentage of Veterans in the current sample who reported exposure to sexual harassment and/or assault during deployment was higher than previous research (Katz et al., 2012; Manguen, Cohen et al., 2012; Monteith et al., 2015). The current results suggest that Veterans with co-occurring PTSD and SUD may be a high-risk group for exposure to sexual harassment and assault during military deployments. A strength of this study is that the sample consisted primarily of men (91%) with greater than one-third reporting at least one exposure to sexual harassment and/or assault during deployment. Sexual harassment during deployment was more common than sexual assault. Male Veterans have generally been understudied compared to women with regard to the impact of MST on mental health, and in treatment studies for MST (Hoyt, Klosterman Rielage, & Williams, 2011). Results encourage further research on sexual harassment and assault during deployments and MST in general among male and female Veterans with co-occurring PTSD and SUD.

In the current study, Veterans reported a decrease in PTSD, SUD, and depressive symptoms during COPE, an integrated trauma-focused treatment, and RP, an SUD-only treatment, across frequency of exposure to sexual harassment and assault during deployments. This builds upon prior PTSD treatment research showing that Veterans with PTSD and a history of MST experience similar reductions in PTSD and depressive symptoms compared to Veterans with non-MST related traumatic events (Rauch et al., 2009; Tiet et al., 2015; Voelkel et al., 2015). In the current sample, most Veterans who reported sexual harassment and/or assault during deployment selected another military-related event as their most traumatic life event or index trauma. Thus, Veterans with co-occurring PTSD and SUD who experienced non-sexual trauma related traumatic life events may benefit from COPE and RP across exposure levels to sexual harassment and assault during deployment. Clinicians should include integrated treatments in their treatment recommendations for Veterans who report co-occurring PTSD, SUD, and exposure to sexual harassment and assault during deployments.

We examined exposure to sexual harassment and assault using multiple items and assessed for frequency of exposure during deployment. Notably, exposure to sexual harassment and assault during deployment was not associated with pre-treatment severity of PTSD, SUD, or depression. Although this finding conflicts with previous research that reported Veterans with a history of MST (compared to those without) and greater exposure to MST had more severe PTSD and SUD symptoms (Hahn et al., 2015; Maguen, Cohen et al., 2012; Sexton et al., 2017), the current results are not necessarily surprising given that variability in PTSD and SUD symptom levels was reduced (i.e., increased homogeneity) as a function of the study’s specific inclusion criteria (i.e., treatment-seeking Veterans who met criteria for both PTSD and SUD). Further, Veterans primarily reported exposure to verbal sexual harassment and results may have been different among a sample of Veterans who primarily experienced sexual assault.

Although over one-third of Veterans reported exposure to sexual harassment and/or assault during deployment, only 4 of the participants (2 = men; 2 = women) who had exposure to sexual trauma during deployment identified that they wanted to focus PTSD treatment on a sexual assault-related index trauma. We can presume that exposure to other forms of traumatic events were more distressful and related to the Veterans’ PTSD than sexual harassment and assault during deployment, and therefore were the focus of treatment. It is also possible that Veterans feel more comfortable seeking PTSD treatment for combat experiences or other types of traumatic events than for sexual harassment and assault during deployments. Survivors of MST have reported shame, fear of others knowing about their experiences of MST, and concern that they would not be believed by providers as barriers to seeking mental health treatment (Turchik et al., 2013, 2014). In addition, there may be unique gender concerns in seeking treatment for MST related to masculine stereotypes such as male Veterans being concerned about their sexuality being judge (Morris, Smith, Farooqui, & Surís, 2014; Turchik et al., 2013). Clinicians working with Veterans with PTSD and SUD should assess for sexual harassment and assault during deployment at initial intake procedures and remain attuned to potential indicators of MST and barriers to disclosing MST throughout treatment (Morris et al., 2014). Continued research is needed to test the effectiveness of treatments in reducing PTSD symptoms specifically tied to sexual harassment and assault during deployment and substance use among Veterans. Given previous research demonstrating perceived institutional betrayal related to MST is associated with negative health outcomes (Monteith et al., 2016, 2021), researchers should also consider the impact of institutional betrayal following sexual harassment and assault during deployment on SUD and PTSD treatment outcomes.

Several limitations of the study warrant consideration. Although the inclusion of male Veterans with exposure to sexual harassment and assault during deployments is a relative strength, the small number of women in the study limits the ability to examine potential gender differences in treatment outcomes. Given gender differences in MST prevalence and mental health and substance use outcomes among Veterans (Gilmore et al., 2016), it is possible that the association of exposure to sexual harassment and assault during deployments and treatment outcomes may differ for male and female Veterans. Researchers have reported that although male Veterans with a history of MST may have higher rates of SUD compared to female Veterans (Averill, Smith, Holens, Sippel, & Bellmore, 2019), the association between MST and SUD is stronger for female compared to male Veterans (Gilmore et al., 2016; Goldbert et al., 2019). However, other research shows that male survivors of MST report more PTSD symptoms compared to female Veterans (Morris et al., 2014). Therefore, future studies should include a large enough sample of both male and female survivors of sexual harrasmsent and assault during military deployments to allow for gender comparisons of treatment outcomes. Further, most Veterans in the current sample reported alcohol use disorder, but treatment outcomes may differ across different SUDs. Future research with larger sample sizes should compare the impact of sexual harassment and assault on treatment outcomes based on type of SUD.

Most individuals who reported sexual harassment and assault during deployment did not indicate the events were their index trauma, and we did not assess everyone for PTSD related to sexual harassment and assault. Future research should examine potential differences in treatment outcome among individuals who indicated sexual harassment and assault is their index trauma compared to individuals who have been exposed to sexual violence but identify another life event as their index trauma. Further, although sexual harassment during military services is associated with a range of negative health outcomes (Hahn et al., 2015; Katz et al., 2012; Maguen, Cohen et al., 2012), researchers have also reported that harassment has different associations with mental health outcomes compared to assault (Blaise, Birgnone, Fargo, Livingston, & Andresen, 2019). Future research using larger sample sizes should compare treatment outcomes based on type of sexual violence experiences. Finally, we examined sexual harassment and assault during deployment. Future research on the impact of MST experienced at any time during military service on PTSD/SUD treatment outcomes is needed.

In summary, the findings indicate that across frequency of exposure levels to sexual harassment and assault during deployment, Veterans reported a similar reduction in PTSD, SUD, and depressive symptoms during treatment. Sexual harassment and assault during deployment, particularly verbal sexual harassment, was prevalent among this predominantly male sample with co-occurring PTSD and SUD. Given the prevalence of sexual harassment and assault during deployment and substantial psychological impact of MST future research is needed to further test treatments among Veterans with co-occurring PTSD and SUD who have been exposed to MST.

Funding Statement

This work was supported by the National Institute on Drug Abuse under Grant (R01DA030143, U54DA016511) and the National Institute on Alcohol Abuse and Alcoholism under Grants (K23AA027307 and K23AA023845). The data that support the findings of this study are available from the last author, [S. E. B.], upon reasonable request.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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