Military Sexual Trauma – A Risk Factor for Suicide From Science to Practice Using Research to Prevent Suicide Issue Key Findings Research on MST that is particularly relevant to suicide risk management includes the following: • Analysis of Veterans Health Administration records has shown that MST is a distinct risk factor for suicide, even after accounting for psychiatric comorbidity.1 • Sexual assault-related posttraumatic stress disorder predicts both suicide attempt frequency and nonsuicidal self-injury (itself a significant risk factor for eventual death by suicide).6,13,14 • Members of marginalized or minority groups may face additional barriers to engaging in care, including MST-related care, thus increasing suicide risk.15,16 Military sexual trauma (MST) refers to experiences of sexual harassment or sexual assault that occur during military service. MST is not a diagnosis, and Veterans who have experienced MST vary in terms of their reactions to MST and their treatment needs and preferences. Despite this variation, research has consistently shown that experiences of MST are associated with suicide risk, even when controlling for comorbid mental health conditions.1,2,3 MST is also frequently associated with other known risk factors for suicide, including depression and substance use disorders.4,5 In addition, preliminary research suggests that 1 in 4 MST survivors report nonsuicidal self-injury,6 an important finding given that nonsuicidal self-injury is significantly associated with suicidal ideation, suicide planning, and suicide attempts, even when controlling for demographics, depression, and posttraumatic stress severity. 7 Implications Though experiences of MST are not necessarily predictive of suicidality in every MST survivor, they are strongly associated with a constellation of suicide risk factors. These risks are not limited to the immediate aftermath of MST and may continue to have a significant impact on overall health outcomes well after the experiences themselves. In addition to carefully assessing and monitoring suicide risk in MST survivors over time, clinicians should also be aware of the extent to which MST influences associated risk factors, treatment pathways, and other health outcomes. Understanding how experiences of MST have influenced survivors’ sense of meaning and purpose is often an important part of both managing suicide risk and promoting recovery from MST. MST survivors who identify as members of marginalized groups (e.g., racial, ethnic, gender, and sexual minorities) may be particularly at risk for suicide after experiencing MST. Research has identified a link between the chronically high levels of stress faced by members of stigmatized minority groups and suicide; this link combined with the association between MST and suicide may further amplify suicide risk. 8 In addition, some MST survivors report experiencing racial discrimination as part of or in conjunction with MST 9 and may have felt targeted for MST because of their identity or background. A similar pattern may exist for sexual minority Veterans.10,11,12 These experiences may amplify “minority stress”8 and further contribute to suicide risk.
Military Sexual Trauma – A Risk Factor for Suicide Ways You Can Help • In assessment and treatment planning, ask sensitive, open-ended questions about possible traumatic experiences, including sexual trauma outside of the military, even if the Veteran has previously denied experiencing MST.17 • Use MST-sensitive strategies in clinical practice (e.g., offer choices, explain rationale for questions and procedures, attend to the dynamics of the patient-provider relationship).18 • Be attentive to nonverbal signs and potential barriers to care, and invite input regarding treatment preferences. Individuals who have experienced MST may be reluctant to disclose that fact or seek care due to shame, stigma, or prior negative experiences. • Express interest in learning about the Veteran’s background (e.g., race/ethnicity, sexual orientation, gender, disability, socio-economic status, spirituality) and ways in which these factors may influence suicide risk, MST experiences, health care experiences, and recovery. • Assess Veterans for nonsuicidal self-injury and other risk factors for suicide as frequently and thoroughly as clinically relevant, even among Veterans with few obvious risk factors for suicide. • Use evidence-based trauma treatments in your clinical practice and familiarize yourself with trauma-informed, evidence-based guidelines. While MST can contribute to a variety of mental and physical health consequences, posttraumatic stress disorder (PTSD) is one of the most common. Example treatment guidelines are available at https://www.healthquality.va.gov/guidelines/mh/ptsd. • When MST has affected a Veteran’s sense of meaning and purpose, strengthen reasons for living by helping the Veteran identify values and engage in values-consistent behaviors and activities. There is no single cause of suicide. It is often the result of a complex interaction of risk and protective factors at the individual, interpersonal, community, and societal levels. To prevent Veteran suicide, we must maximize protective factors and minimize risk factors at all of these levels. References 1 Kimerling, R., K. Makin-Byrd, S. Louzon, R. Ignacio, & J. McCarthy. 2016. Military sexual trauma and suicide mortality. American Journal of Preventive Medicine 50, no. 5:684–91. Rosellini, A., J., A. E. Street, R. J. Ursano, et al. 2017. Sexual assault victimization and mental health treatment, suicide attempts, and career outcomes among women in the US Army. American Journal of Public Health 107, no. 5:732–39. Monteith, L. L., D. S. Menefee, J. E. Forster, J. L. Wanner, and N. H. Bahraini. 2015. Sexual trauma and combat during deployment: Associations with suicidal ideation among OEF/OIF/ OND veterans. Journal of Traumatic Stress 28, no. 4:283–88. Seelig, A. D., A. C. Rivera, T. M. Powell, et al. 2017. Patterns of smoking and unhealthy alcohol use following sexual trauma among US Service members. Journal of Traumatic Stress 30, no. 5:502–11. Gradus, J. L., A. E. Street, K. Kelly, and J. Stafford. 2008. Sexual harassment experiences and harmful alcohol use in a military sample: Differences in gender and the mediating role of depression. Journal of Studies on Alcohol and Drugs 69, no. 3:348–51. Holliday, R., N. B. Smith, and L. L. Monteith. 2018. An initial investigation of nonsuicidal self-injury among male and female survivors of military sexual trauma. Psychiatry Research 268:335–39. Bryan, C., and A. Bryan. 2014. Nonsuicidal self‐injury among a sample of United States military personnel and veterans enrolled in college classes. Journal of Clinical Psychology 70, no. 9:874–85. Meyer, I. H. 2003. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin 129, no. 5:674. Buchanan, N. T., I. H. Settles, and K. C. Woods. 2008. Comparing sexual harassment subtypes among Black and White women by military rank: Double jeopardy, the jezebel, and the cult of true womanhood. Psychology of Women Quarterly 32, no. 4:347–61. 10 Brown, G. R., and K. T. Jones. 2016. Mental health and medical health disparities in 5135 transgender veterans receiving healthcare in the Veterans Health Administration: A case– control study. LGBT Health 3, no. 2:122–131. 11 Mattocks, K. M., M. R. Kauth, T. Sandfort, A. R. Matza, J. C. Sullivan, and J. C. Shipherd. 2014. Understanding health-care needs of sexual and gender minority veterans: how targeted research and policy can improve health. LGBT Health 1, no. 1:50–7. 12 Blosnich, J. R., A. J. Gordon, and M. J. Fine. 2015. Associations of sexual and gender minority status with health indicators, health risk factors, and social stressors in a national sample of young adults with military experience. Annals of Epidemiology 25, no. 9:661–67. 13 Dixon-Gordon, K. L., M. T. Tull, & K. L. Gratz. 2014. Self-injurious behaviors in posttraumatic stress disorder: An examination of potential moderators. Journal of Affective Disorders 166:359-67. 14 Cooper, J., N. Kapur, R. Webb, M. Lawlor, E. Guthrie, K. Mackway-Jones, and L. Appleby. 2005. Suicide after deliberate self-harm: a 4-year cohort study. American Journal of Psychiatry 162, no. 2:297–303. 15 Ray-Sannerud, B. N., C. J. Bryan, N. S. Perry, and A. O. Bryan. 2015. High levels of emotional distress, trauma exposure, and self-injurious thoughts and behaviors among military personnel and veterans with a history of same sex behavior. Psychology of Sexual Orientation and Gender Diversity 2, no. 2:130. 16 Blosnich, J., M. M. Foynes, and J. C. Shipherd. 2013. Health disparities among sexual minority women veterans. Journal of Women’s Health 22, no. 7:631–36. 17 Sexton, M. B., M. T. Davis, R. E. Anderson, D. C. Bennett, E. Sparapani, and K. E. Porter. 2018. Relation between sexual and gender minority status and suicide attempts among veterans seeking treatment for military sexual trauma. Psychological services 15, no. 3:357-362. 18 Substance Abuse and Mental Health Services Administration. 2014. Trauma-informed care in behavioral health services. Treatment Improvement Protocol (TIP) Series 57, HHS Publication no. (SMA) 13-4801. 2 3 4 5 6 7 8 9