文章基本信息

标题：The Veterans Health Administration and Military Sexual Trauma
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作者：Rachel Kimerling ; Kristian Gima ; Mark W. Smith 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2007
卷号：97
期号：12
页码：2160-2166
DOI：10.2105/AJPH.2006.092999
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence. Methods. We analyzed VHA administrative data for 185 880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003. Results. Screening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged. Conclusions. The VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Women’s health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans. The persistence of sexual violence within the US armed forces is a fact long recognized by military officials, policymakers, health care professionals, and the media. The risk of exposure to sexual violence within the military is high. The annual incidence of experiencing sexual assault is 3% among active duty women and 1% among active duty men. Sexual coercion (e.g., quid pro quo promises of job benefits or threats of job loss) and unwanted sexual attention (e.g., touching, fondling, or threatening attempts to initiate a sexual relationship) occur at an annual rate of 8% and 27%, respectively, among women and 1% and 5% among men. 1 Research on deployment stress finds that such experiences constitute important duty-related hazards. 2 The Veterans Health Administration (VHA) has adopted the term military sexual trauma (MST) to refer to severe or threatening forms of sexual harassment and sexual assault sustained in military service. In response to such widespread exposure in the military and the lasting deleterious consequences of sexual violence, the VHA has implemented a universal screening program for MST. For patients that screen positive, treatment for any MST-related injury, illness, or psychological condition is provided free of charge regardless of eligibility or co-pay status. These policies may represent the most comprehensive health policy response to sexual violence of any major US health care system. To our knowledge, we are the first to study the VHA’s MST program, which provides an unparalleled opportunity to investigate the feasibility and clinical utility of screening for sexual violence and provides unique data to characterize the burden of illness associated with MST. US epidemiological data indicate significant deleterious health and mental health correlates for sexual trauma. Among traumatic events, rape holds the highest conditional risk for posttraumatic stress disorder (PTSD); these data and data specific to military samples confirm that sexual trauma poses a risk for developing PTSD as high as or higher than combat exposure. 3 ^– 5 In addition to PTSD, civilian and veteran women exposed to sexual assault or sexual harassment exhibit a range of other mental health and medical conditions. 6 ^– 15 These data have led to a greater awareness of sexual trauma issues among physicians and to the development of interventions and guidelines for the treatment and referral of sexual trauma in health care settings. 16 ^– 18 These health sequelae may be magnified among veterans, because a number of issues uniquely associated with military settings may intensify the effect of this experience. 19 Perpetrators are typically other military personnel, and victims often must continue to live and work with their assailants daily, which increases the risk for distress and for subsequent victimization. Unit cohesion may create environments where victims are strongly encouraged to keep silent about their experiences, have their reports ignored, or are blamed by others for the sexual assault, all of which have been linked to poorer outcomes among civilian assault survivors. 20 Preliminary studies of MST among women veterans support this hypothesis and have found increased self-reports of depression, substance abuse, and gynecological, urological, neurological, gastrointestinal, pulmonary, and cardiovascular conditions. 6 ^, 10 The VHA was first authorized to provide outreach and counseling for sexual assault to women veterans after a series of hearings on veteran women’s issues in 1992. Increased attention to these issues led Congress to extend services to male veterans shortly thereafter. In 1999, the VA’s responsibility was extended from counseling to “all appropriate [MST-related] care and services” and universal screening was initiated. Most recently, Public Law 108-422, signed in 2004, made the VA’s provision of sexual trauma services a permanent benefit. Screening programs and treatment benefits apply only to sexual trauma that occurred during military service. Each VA hospital now has a designated coordinator to oversee MST screening and treatment, and standardized training materials for MST screening are available to all VHA providers. 21 Universal screening is accomplished through the use of a clinical reminder in the electronic medical record. An alert remains visible to all clinicians until screen results are entered. Documentation of a positive screen enables the provider to code the visit as MST related so that care is delivered free of charge. The extent to which these resources have encouraged providers to screen for MST has not been evaluated. Most research from civilian sectors suggest that only a minority of patients are screened for violence by their health care providers. 22 However, VHA screening is integrated with standard clinical procedures, and training on the sensitive nature of MST screening is required at each VA hospital. Both of these factors are reliably associated with better screening compliance. 22 ^, 23 The utility of screening policies to address this widespread veterans’ health issue is complicated because MST is not a syndrome, diagnosis, or construct associated with clear treatment indications. This stands in contrast to most other health care screening targets, such as cervical cancer or depression. Contrary to the American Medical Association’s recommendation for universal screening for violence against women, 24 ^, 25 the US Preventive Services Task Force concluded that the evidence does not currently support this approach, citing a lack of intervention research and insufficient evidence that screening ultimately improves health status. 26 Rebuttals to the Task Force conclusions emphasize the necessity of a broader view: violence against women is a risk or maintaining factor for a variety of health conditions and therefore a key treatment consideration for these patients. 27 This perspective is especially relevant for addressing MST in the VHA health care system. Quantifying the types of health impairment associated with positive screens for MST is a first step toward evaluating the utility of universal screening. If screening detects clinically significant information, a positive screen would be an important factor in selecting appropriate treatment. Further evaluation of screening and treatment programs can then assess access to care according to the specific health outcomes found to be relevant to veteran men and women who have experienced sexual trauma. MST has been primarily considered a women’s issue. Men comprise the majority of the armed forces, however, and the incidence of sexual harassment and assault reported by men during military service is significant. The approach to MST should therefore attend to both women and men and examine gender associated with MST as an initial step in the development of gender-specific interventions. Ours is the first examination of nationwide screening data for MST in the VHA and directly informs continued efforts to develop a gender-specific response to the health-related costs of military service and war. Specifically, we examined 3 issues: (1) whether universal screening detects a substantial population of VHA patients who report MST, (2) whether a greater burden of medical and mental illness is found among patients who screen positive for MST compared with patients who screen negative, and (3) whether the burden of illness associated with MST varies by patient gender.