Sexual Trauma Linked to Depression, PTSD, Chronic Pain

Deborah Brauser

May 21, 2018

NEW YORK — Trauma, especially sexual trauma, is linked to an increased risk for several mental illnesses and chronic medical conditions, new research suggests.

Dr Gen Shinozaki

As expected, the study of almost 400 male and female military personnel showed that a history of military-related trauma was significantly associated with posttraumatic stress disorder (PTSD).

However, among only women, other risk factors for PTSD included a history of adverse childhood events and a history of military sexual trauma (MST). MST in women was also significantly linked to risk for major depressive disorder (MDD) and chronic conditions, such as fatigue and fibromyalgia.

The researchers noted that about 30% of female veterans have reported being sexually assaulted during their time of service.

Military trauma overall, but not MST specifically, was significantly associated with risk for MDD and chronic medical conditions in men. However, the investigators noted that sexual assault was reported by only five of the male participants, which may have resulted in these assessments being underpowered.

"The take-away message is that if you're working with this patient population, you really should ask about their history, which could be the root cause of their illness," lead author Gen Shinozaki, MD, associate professor of psychiatry at the University of Iowa Carver College of Medicine, Iowa City, told Medscape Medical News.

He presented his study at a press conference and poster session here at the American Psychiatric Association (APA) 2018 annual meeting.


Shinozaki added that the findings could be generalizable to all patients who have suffered a past trauma. Ranna Parekh, MD, deputy medical director for the APA and director of the organization's Division of Diversity and Health Equity, agreed — although she noted that more studies are needed.

Dr Ranna Parekh

"The military has always been ahead of the curve, and military research helps the entire field because they begin to ask the tough questions," she commented to Medscape Medical News.

Parekh noted that the APA recently partnered with the Society of Uniformed Services Psychiatrists to create a series of three courses for APA members who treat military personnel, veterans, and their families.

"Unfortunately, a large number of service members, particularly women, experience sexual assault during their service," she said.

"Just last week the Pentagon shared that more 6700 Defense Department employees reported being sexually assaulted in the 2017 year, which is a 10% increase in reports from the year before," said Parekh. "So research that explores how military sexual trauma and other traumas affect service members' mental and physical health is particularly important."

For this study, the investigators enrolled 388 military personnel (52% men; mean age, approximately 35 years) and used computer-assisted telephone interviews to ask about military deployment, combat experience, history of MST, and other types of trauma. The PTSD Checklist for DSM-5, the Center for Epidemiologic Studies–Depression scale, and the Adverse Childhood Experience Questionnaire were also administered.

Among all participants, 63 reported experiencing an attempted or completed sexual assault. These included 58 of the 187 women interviewed (31%).

Increased Risk

For the female participants, significantly more of those with a history of MST had MDD than those without MST (39.7% vs 23.3%; P = .03). They were also more likely to have medical comorbidities, which was defined in this study as a combination of fatigue, diabetes, chronic pain, and fibromyalgia (46.6% vs 24%; P = .004).

MST was also linked to PTSD — 32.8% of women with MST also had PTSD, compared to 7% of those who did not have a history of MST.

The investigators note that they are now conducting methylation analysis "to identify epigenetic biomarkers modulating the relationship between traumatic experience and subsequence consequences, such as PTSD and MDD."

Parekh, who moderated the press conference, noted that the prevalence of MST found in the women in this study was, unfortunately, not a surprise. She added that she would have liked to have seen information on more men who have experienced MST, as well as information on transgender service members.

"Still, I want to give the researchers credit for bringing to light something we've all sort of known," she said.

"When you have a research design that is well done, it starts to bring notice to what we've seen anecdotally. Then we can start looking at prevention and treatment and how we can change the larger culture, which is what we really need to get at," added Parekh.

She noted that she "would have loved" to have heard more about the women with a history of MST who did not have PTSD. "That might help us to better understand what their points of resilience were."

Overall, "I thought this study was great. Is it generalizable? I think we need a little more research from the military side before we can extrapolate to the larger population, but I think it's definitely fascinating," Parekh said.

"We should definitely be asking our female and male patients about trauma, including sexual trauma, and taking the time to work to get an honest response."

"Tragic" but Not Surprising

Asked to comment, retired Army Colonel Elspeth Cameron Ritchie, MD, chairman of psychiatry at Washington Hospital Center in Washington, DC, told Medscape Medical News that she also wasn't surprised by the findings.

Dr Elspeth Cameron Ritchie

"We've long seen an association with depression and PTSD with military sexual trauma. But this study is updated and has a fairly large sample sizes," said Ritchie.

"What I don't see here is when these people had their trauma. What age were these veterans when they experienced this?" she asked.

Ritchie noted that among women who enter the military, there is about a 25% to 45% prevalence rate of prior sexual trauma; the prevalence varies, depending on the definition of sexual trauma.

"One of the tragedies is that often when women come in, they're trying to find a more stable environment. So if they are retraumatized, that can add to a past history of depression and PTSD and can increase vulnerability for military sexual trauma–related symptoms in the future," she said.

Asked whether the current "Me Too" movement has led to a sea change, making it easier for women to come forward to report these types of problems, Ritchie said, "not yet."

"There are still consequences if you come forward with sexual assault, which is true in the military and in the civilian world. One of the challenges is, even if a system is supportive of the claim of sexual assault, it's still incredibly difficult to go through the process," she said.

Ritchie noted that that's why it's important for clinicians to ask about a past history of sexual trauma. However, "I wouldn't rush right there. It's important to build up a therapeutic alliance first to make sure your patient is comfortable," she said.

When asked about the study's finding that only a few men experienced MST, Ritchie said that this is an area that is still very underreported. "Any kind of male-on-male contact, despite the repeal of 'don't ask/don't tell,' is still very much frowned on. And my experience is that men who have had unwanted sexual contact from other men are really hesitant to report it," she said.

"So it's important for caregivers to ask all patients if they've served in the military, build a relationship, and then ask about adverse experiences," concluded Ritchie.

Dr Shinozaki, Dr Parekh, and Dr Ritchie have reported no relevant financial relationships.

American Psychiatric Association (APA) 2018. Abstract P5-207, presented May 7, 2018.

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