Military Sexual Trauma Complicates PTSD for Female Veterans

Troy Brown

November 09, 2012

Editor's note: Female veterans who experience military sexual trauma (MST) often find it difficult to seek help; even with treatment, they can live with the symptoms of posttraumatic stress disorder (PTSD) for years, according to a presentation at the American Psychiatric Nurses Association (APNA) 26th Annual Conference, held October 7 to 10 in Pittsburgh, Pennsylvania.

Ursula Kelly, PhD, ANP-BC, PMHNP-BC, assistant professor at the Emory University School of Nursing and a nurse scientist at Atlanta Veterans Affairs (VA) Medical Center in Georgia, works with female veterans who have experienced MST. She is currently conducting research on factors that influence the ability of these women to seek treatment for PTSD.

Dr. Kelly spoke with Medscape Medical News about her presentation in a telephone interview.

Medscape: What prompted you to study this issue?

Dr. Kelly: We have a treatment team dedicated to military sexual trauma and we all observed that many patients come to us after having had PTSD symptoms for years, or even decades. I really wanted to know what kept them from coming in sooner, and what could we do to help women access care more easily.

Medscape: Why is it important for psychiatric nurses to know about this?

Dr. Kelly: The VA is the largest employer of nurses in the country. It's important for psychiatric nurses to learn that it's not strictly a psychological process; there are situational factors that influence [women's] treatment-seeking.

The VA is a very male-dominated environment. For women who experience sexual trauma while serving in the military and who have PTSD, there are incredible challenges for them — sometimes just walking into the building.

It would help for nurses to have a broader view of where women are coming from and what outside factors have influenced their decision to seek treatment or not.

Medscape: Why is your research focused on women?

Dr. Kelly: The number of veterans who are women continues to grow. The VA system was designed to treat the healthcare needs of men; women have specific healthcare needs, so there's a bit of a disconnect in some areas.

More importantly, women have historically been either invisible or ignored within the VA; there's been a historic lack of treatment available for women. [This] population...has not had [much] attention for a long time. That is changing, for sure. There's public discourse around women in the military and PTSD, and even military sexual trauma. It's an issue that people are just understanding is a problem, but we still need to learn how to help these veterans.

Medscape: What factors prevent women from seeking treatment?

Dr. Kelly: Very little research has been done in this area. In studies of male veterans, things like stigma around PTSD and negative views about mental health treatment are well documented; it's likely that may be the case for women. We're not done with the data collection or data analysis, but what we've found so far in this study is that, for women, the stigma is much less about PTSD and more about the MST.

The male-dominated environment is a very big issue, particularly for women who have been sexually traumatized in the military, most of whom have also been traumatized outside of their military service.

There are very high rates of interpersonal trauma, both in childhood and in adulthood, in this population of veterans. They're really coming in with a lot of cumulative trauma. We need to understand how that plays into coming in for treatment that is specifically billed as PTSD related to MST.

Medscape: What factors make it easier for women to seek treatment?

Dr. Kelly: A few factors have come up in our analysis. Some of the women who have sought treatment at our clinic didn't know that services were available. So for some women, just knowing that these services are available helps.

For other women, it was getting enough messages from people around them — whether it was family members, friends, or healthcare providers — that they needed help. For people who are experiencing a lot of symptoms of PTSD, and who have been for years, they may view their behavior as normal. "Doesn't everyone stay inside all day? Doesn't everybody check the perimeter of their house before they go to sleep?"

The other important factor is having someone in their life who is really supportive and encourages them to get treatment, so that it doesn't have to be a secret and so they get support and encouragement even when treatment gets tough, as it often does.

Medscape: How effective are current treatments?

Dr. Kelly: We don't know how effective treatment is for MST. For PTSD in general, there are evidence-based treatments that are primarily trauma-focused; however, only about a third of all veterans with PTSD actually seek treatment. Even among those who are receiving evidence-based treatment, about another third continue to suffer from PTSD symptoms for years. There's a fairly high dropout rate as well.

We do know that those treatments are effective for women who experience sexual assault as civilians.

There are additional components that need to be addressed when the PTSD is related to MST. Unlike civilian sexual assault, a woman who is raped in the military often experiences that within a unit; the rapist may be a peer or peers or may be her commanding officer. The woman has to continue to live there, in the presence of the perpetrator, for however long she is there. That affects her ability to get help at the time because, if she reports it, she has to live with whatever consequences there might be. These tend to be very negative, very problematic and, for many women, serve as obvious barriers to them disclosing the MST, which means they're then living with all of that, sometimes for years. Women may also fear being seen as weak or a poor soldier for seeking help.

Also, being assaulted by someone whom you should be able to trust is more damaging than being assaulted by a stranger, psychologically and emotionally.

Medscape: How can nurses improve services and treatment for female veterans who have experienced MST?

Dr. Kelly: Nurses can improve services by making sure our veterans know they exist, and by understanding what's behind some of the behaviors they see in female veterans in a context that really frames them as indicative of someone who has PTSD and lots of trauma.

Some of the behaviors that result from symptoms of PTSD can be looked upon as highly problematic by healthcare providers. Veterans may appear really angry and be somewhat difficult to work with; they may miss lots of appointments. If nurses can understand that it's not that they're being disrespectful or irresponsible, it's because they have PTSD and couldn't get themselves out of the house, that will really help.

Understand that for some female veterans who have PTSD, the PTSD is related to sexual trauma; don't automatically assume that it's combat related. Understanding that can shift the way you approach a patient when you're talking about it.

Medscape: Do you have any future research planned?

Dr. Kelly: I hope to have IRB approval in a week or so for a really exciting study. We're going to provide a trauma-sensitive yoga intervention for female veterans with PTSD who experienced MST. There are evidence-based treatments, but they're all trauma-focused, which means it's very hard work; women have to revisit the trauma, talk about it, write about it, and work through it in an emotionally very difficult way. There are women who won't or can't go there. Because sexual trauma can cause women to be disconnected from their bodies and disconnected from themselves, yoga presents itself as an embodied mental health treatment that may provide a pathway to healing for some women that straight cognitive and emotional therapy does not.

It's important for the yoga to be trauma-sensitive, because for women who have experienced sexual trauma, some components of yoga could be very triggering — some of the poses, some of the language from instructors. It's important to structure sessions so that women feel in control of what's happening, not that they're being told to do this, then do that, where they might feel a loss of control.

Medscape: Where can nurses learn more?

Dr. Kelly: The best resource is the National Center for PTSD. It has information about PTSD across the board, not just specific to veterans or active military. It's a tremendous resource, for consumers and patients and for professionals and researchers.

Dr. Kelly has disclosed no relevant financial relationships.