Rebecca K. Blais

Differential Risk for Homelessness Among US Male and Female Veterans With a Positive Screen for Military Sexual Trauma

IMPORTANCE Military sexual trauma (MST) is associated with adverse physical and mental health outcomes following military separation. Recent research suggests that MST may be a determinant in several factors associated with postdeployment homelessness. OBJECTIVE To evaluate MST as an independent risk factor for homelessness and to determine whether risk varies by sex. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of US veterans who used Veterans Health Administration (VHA) services between fiscal years 2004 and 2013 was conducted using administrative data from the Department of Defense and VHA. Included in the study were 601 892 US veterans deployed in Iraq or Afghanistan who separated from the military between fiscal years 2001 and 2011 and subsequently used VHA services. EXPOSURE Positive response to screen for MST administered in VHA facilities. MAIN OUTCOMES AND MEASURES Administrative evidence of homelessness within 30 days, 1 year, and 5 years following the first VHA encounter after last deployment. RESULTS The mean (SD) age of the 601 892 participants was 38.9 (9.4) years, 527 874 (87.7%) were male, 310 854 (51.6%) were white, and 382 361 (63.5%) were enlisted in the Army. Among veterans with a positive screen for MST, rates of homelessness were 1.6% within 30 days, 4.4% within 1 year, and 9.6% within 5 years, more than double the rates of veterans with a negative MST screen (0.7%, 1.8%, and 4.3%, respectively). A positive screen for MST was significantly and independently associated with postdeployment homelessness. In regression models adjusted for demographic and military service characteristics, odds of experiencing homelessness were higher among those who screened positive for MST compared with those who screened negative (30-day: adjusted odds ratio [AOR], 1.89; 95% CI, 1.58-2.24; 1-year: AOR, 2.27; 95% CI, 2.04-2.53; and 5-year: AOR, 2.63; 95% CI, 2.36-2.93). Military sexual trauma screen status remained independently associated with homelessness after adjusting for co-occurring mental health and substance abuse diagnoses in follow-up regression models (30-day: AOR, 1.62; 95% CI, 1.36-1.93; 1-year: AOR, 1.49; 95% CI, 1.33-1.66; and 5-year: AOR, 1.39; 95% CI, 1.24-1.55). In the fully adjusted models, the interaction between MST status and sex was significant in the 30-day and 1-year cohorts (30-day: AOR, 1.54; 95% CI, 1.18-2.02; and 1-year: AOR, 1.46; 95% CI, 1.23-1.74), denoting higher risk for homelessness among males with a positive screen for MST. CONCLUSIONS AND RELEVANCE A positive screen for MST was independently associated with postdeployment homelessness, with male veterans at greater risk than female veterans. These results underscore the importance of the MST screen as a clinically important marker of reintegration outcomes among veterans. These findings demonstrate significant long-term negative effects and inform our understanding of the public health implications of sexual abuse and harassment.

Non-routine Discharge From Military Service: Mental Illness, Substance Use Disorders, and Suicidality

INTRODUCTION Mental illness and substance use disorders among newly returned military service members pose challenges to successful reintegration into civilian life and, in extreme cases, may lead to outcomes such as incarceration, homelessness, and suicide. One potential early indicator for these difficulties is non-routine discharge from military service. METHODS Using data from the Veterans Health Administration (VHA) for 443,360 active duty service Veterans who deployed to Afghanistan and Iraq and subsequently utilized VHA services between Fiscal Years 2004 and 2013, this study examined risk for receiving a VHA-documented diagnosis of mental illness, substance use disorders, and suicidality as a function of discharge type, controlling for demographic and military service covariates. Analyses were conducted in 2016. RESULTS In total, 126,314 Veterans (28.5%) had a non-routine military service discharge. Compared with routinely discharged Veterans, odds for nearly all diagnostic outcomes were significantly greater among Veterans discharged for disqualification or misconduct, including personality disorders (AOR=9.21 and 3.29, respectively); bipolar/psychotic disorders (AOR=3.98 and 3.40); alcohol/substance use disorders (AOR=1.55 and 4.42); and suicidal ideation and behaviors (AOR=2.81 and 2.77). Disability-discharged Veterans had significantly higher odds for diagnoses of anxiety disorders (AOR=1.97) and bipolar/psychotic disorders (AOR=3.93). CONCLUSIONS Non-routine service discharge strongly predicts VHA-diagnosed mental illness, substance use disorders, and suicidality, with particularly elevated risk among Veterans discharged for disqualification or misconduct. Results emphasize the importance of discharge type as an early marker of adverse post-discharge outcomes, and suggest a need for targeted prevention and intervention efforts to improve reintegration outcomes among this vulnerable subpopulation.

Sexual vs. Non-sexual trauma, sexual satisfaction and function, and mental health in female veterans

ABSTRACT Trauma in general, and sexual assault in particular, is associated with serious mental health and functional problems. The quality of sexual satisfaction/function may be particularly impacted by sexual assault, and such sexual problems may account for some of the broader mental health and functioning impairments in sexual assault survivors. Accordingly, we examined self-reports of sexual health and mental health in a sample of 255 female veterans in committed, monogamous relationships who provided data regarding sexual assault (n = 153) or nonsexual trauma (n = 102). Trauma type was not associated with differences in sexual function, but sexual trauma was associated with significantly lower sexual satisfaction, greater posttraumatic stress disorder (PTSD) and depressive symptoms, and higher suicidal ideation. Furthermore, the indirect effect of trauma type on all mental health outcomes was significant via sexual satisfaction but not via sexual function. Finally, trauma type moderated the association of sexual function with suicidality, such that the association was significantly positive in those with a history of sexual assault but nonsignificant in those with nonsexual trauma. These results suggest that (1) female veterans’ experience of sexual assault is related to sexual satisfaction, which in turn is related to mental health outcomes, and (2) a history of sexual assault may increase the importance of sexual functioning with regard to suicidality.

Increased Health Care Utilization and Costs Among Veterans With a Positive Screen for Military Sexual Trauma

Background: The effects of sexual trauma on long-term health care utilization and costs are not well understood due to infrequent documentation of sexual trauma history in health care systems. The Veteran’s Health Administration provides a unique opportunity to address this constraint as sexual trauma is actively screened for as part of routine care. Methods: We used a retrospective cohort design to analyze Veteran’s Health Administration mental health and medical service utilization and costs as a function of a positive screen for exposure to military sexual trauma (MST) among Veterans of recent conflicts in Iraq and Afghanistan. We computed adjusted 5-year estimates of overall utilization and costs, and utilization and costs determined not to be related to MST. Results: The cohort included 426,223 men and 59,611 women. A positive MST screen was associated with 50% higher health care utilization and costs relative to a negative screen. Overall, a positive relative to negative MST screen was associated with a 5-year incremental difference of 34.6 encounters and

Sexual dysfunction is associated with suicidal ideation in female service members and veterans

10,734 among women, and 33.5 encounters and

Assailant identity and self-reported nondisclosure of military sexual trauma in partnered women veterans.

11,484 among men. After accounting for MST-related treatment, positive MST screen was associated with 11.9 encounters and

Military sexual trauma is associated with post-deployment eating disorders among Afghanistan and Iraq veterans

4803 among women, and 19.5 encounters and

Higher self-stigma is related to lower likelihood of disclosing military sexual trauma during screening in female veterans.

8001 among men. Conclusions: Results demonstrate significant and consistent differences in health care utilization and costs between Veterans with a positive relative to negative MST screen. Even after accounting for MST-related care, a positive screen was associated with significantly higher utilization and costs. MST-related needs may be more readily recognized in women relative to men.

Chronic Health Conditions Among US Veterans Discharged From Military Service for Misconduct

BACKGROUND Suicide is a leading cause of premature death among military service members/veterans (SM/Vs). The Interpersonal Theory of Suicide (Joiner, 2007) proposes that higher thwarted belonging, perceived burdensomeness, and acquired capability confer increased risk for suicide. However, no studies have examined the association of sexual dysfunction, a possible component of thwarted belonging and perceived burdensomeness, with suicidal ideation. The present study explored whether sexual dysfunction was associated with suicidal ideation when accounting for mental health, demographic, and military characteristics among female SM/Vs. METHOD Female SM/Vs (n = 710) completed an anonymous online survey assessing demographics, mental health, military characteristics, sexual dysfunction, and suicidal ideation. RESULTS One hundred fifty-nine participants (22.39%) reported suicidal ideation during the preceding two weeks. A multivariable ordinal regression adjusted for age, marital status, probable posttraumatic stress disorder (PTSD), probable depression, race/ethnicity, Army service, and deployment history. Lower sexual functioning (adjusted odds ratio [AOR] = 0.98, 95% confidence interval[CI] = 0.95-0.99), probable PTSD (AOR = 2.54, 95% CI = 1.61-4.01), and probable depression (AOR = 5.28, 95% CI = 3.34-8.34) were associated with suicidal ideation. Post-hoc analyses examined the association of suicidal ideation with specific components of sexual functioning: difficulties with sexual arousal (AOR = 0.87, 95% CI = 0.79-0.97) and sexual satisfaction (AOR = 0.85, 95% CI = 0.75-0.96) were associated with suicidal ideation. LIMITATIONS Data were cross-sectional and limited to self-report. DISCUSSION Sexual dysfunction is associated with suicidal ideation, accounting for established mental health, military, and demographic characteristics among female SM/Vs. Efforts to prevent suicidal ideation in female SM/Vs may be enhanced by screening for and treating sexual dysfunction, particularly sexual arousal and satisfaction.

Specific PTSD symptom clusters mediate the association of military sexual trauma severity and sexual function and satisfaction in female service members/veterans

Objective: Department of Veterans Affairs estimates of military sexual trauma (MST) suggest 27% of female veterans have experienced MST. However, Department of Defense data (Department of Defense, 2014) show that a subgroup of active-duty women do not report sexual assaults to a military authority, suggesting barriers to disclosure exist among military samples. No study of female veterans has examined rates of nondisclosure among those with previous screens for MST; these data could inform screening efforts and establishment of safe havens for candid disclosures. Method: Using an explanatory sequential mixed-methods survey, a history of MST, and postservice MST disclosures during screening and their associations with demographic, assault, and screening-setting characteristics were evaluated in 359 female veterans. Open-ended responses regarding barriers to disclosure were analyzed using editing analysis style. Results: Eighty-one percent (n = 289) reported MST. Of these, 50% (n = 143) reported a prior screening and 25% (n = 35) reported they did not disclose their true MST status. Veterans who experienced MST by a unit-member assailant were significantly less likely to disclose (adjusted odds ratio = 4.75, 95% confidence interval = 1.20–18.30). Disclosure barriers included stigma, experiential avoidance, and discomfort with the screening setting. Conclusion: Creative interventions to reduce nondisclosure among female veterans, with specific attention to those assaulted by a unit member, are urgently needed.