Predictors of PTSD among Rape Victims in the Military

AN ANALYSIS OF FACTORS PREDICTING POSTTRAUMATIC STRESS DISORDER PREVALENCE RATES IN VICTIMS AND PERPETRATORS OF MILITARY SEXUAL TRAUMA A Doctoral Dissertation Research Submitted to the Faculty of Argosy University, Phoenix College of Psychology and Behavioral Sciences In Partial Fulfillment of the Requirements for the Degree of Doctor of Education by Erika Hansen October 2012 ii AN ANALYSIS OF FACTORS PREDICTING POSTTRAUMATIC STRESS DISORDER PREVALENCE RATES IN VICTIMS AND PERPETRATORS OF MILITARY SEXUAL TRAUMA Copyright © 2012 Erika Hansen All rights reserved iii AN ANALYSIS OF FACTORS PREDICTING POSTTRAUMATIC STRESS DISORDER PREVALENCE RATES IN VICTIMS AND PERPETRATORS OF MILITARY SEXUAL TRAUMA A Doctoral Dissertation Research Submitted to the Faculty of Argosy University, Phoenix College of Psychology and Behavioral Sciences In Partial Fulfillment of the Requirements for the Degree of Doctor of Education by Erika Hansen Argosy University October 2012 Dissertation Committee Approval: Digitally signed by Dan Friedman DN: cn=Dan Friedman, o, ou, [email protected], c=US Date: 2012.10.19 13:04:19 -05'00' Dan Friedman ________________________________ Daniel Friedman, Psy.D. Sherry Rieder, PhD Digitally signed by Sherry Rieder, PhD DN: cn=Sherry Rieder, PhD, o=Argosy University, ou, [email protected], c=US Date: 2012.10.19 15:05:55 -04'00' ________________________________ Sherry Rieder, Ph.D. 10-19-2012 ________________________________ Date Teresa L.CollinsJones, Ph.D. ________________________________ Digitally signed by Teresa L.Collins-Jones, Ph.D. DN: cn=Teresa L.Collins-Jones, Ph.D., o=Argosy University Online, ou=Assistant Dean, [email protected], c=US Date: 2012.10.19 14:12:30 -05'00' Name of Program Chair iv AN ANALYSIS OF FACTORS PREDICTING POSTTRAUMATIC STRESS DISORDER PREVALENCE RATES IN VICTIMS AND PERPETRATORS OF MILITARY SEXUAL TRAUMA Abstract of Doctoral Dissertation Research Submitted to the Faculty of Argosy University, Phoenix College of Psychology and Behavioral Sciences In Partial Fulfillment of The Requirements for the Degree of Doctor of Education by Erika Hansen Argosy University October 2012 Dan Friedman, Psy.D. Sherry Rieder, Ph.D. Department: College of Psychology and Behavioral Sciences v ABSTRACT Utilizing a logistic regression model, this study examined how rank, income, and military sexual trauma type predicted frequency of posttraumatic stress disorder (PTSD) for the female victim and the rank and income predicted frequency of PTSD for the male perpetrator. In this sample of 26 military sexual trauma criminal cases over half of the female victims, or 53.8%, had been diagnosed with PTSD. A lower proportion of PTSD, or 7.7%, was found among male perpetrators. The results supported the null hypothesis that financial status, rank, and type of sexual trauma did not predict PTSD in the victims of military sexual trauma. They also showed that the rank and financial status predicted PTSD of the perpetrator. This research delineated a potentially high proportion of mental health problems for victims of military sexual trauma and the need for programs to address these concerns for veterans and active military personnel, as PTSD is not something that goes away but rather is a lifetime of severe injury. Programs equipped to help military sexual trauma victims with co-occurring mental health diagnoses are also highly recommended, given the high correspondence of co-occurring disorders among these victims. vi ACKNOWLEDGEMENTS I would like to express my sincere gratitude to committee chair Dan Friedman, Psy.D. and committee member Sherry Rieder, Ph.D. for their support for this dissertation. Furthermore, I could not have done this research without the support of Westlaw Next reference attorneys who assisted me in finding cases and crucial studies. I would like to acknowledge support for my statistical analysis from Roberto Crackel, Dr. Mosier, and Dr. Baxter. Furthermore, I would like to express gratitude to each of the clients, counselors, and community agencies I have had the privilege of working with. vii DEDICATION This study is dedicated to every victim of rape, military sexual trauma, and terror. viii TABLE OF CONTENTS Page CHAPTER ONE: THE PROBLEM ....................................................................................1 Introduction ..........................................................................................................................1 Problem Statement ...............................................................................................................1 Importance of the Study .......................................................................................................3 Research Questions ..............................................................................................................3 Limitations ...........................................................................................................................4 Definitions............................................................................................................................4 CHAPTER TWO: REVIEW OF THE LITERATURE .......................................................6 Introduction ..........................................................................................................................6 Databases .............................................................................................................................6 The History of Sexual Trauma in War .................................................................................7 Sexual Trauma in the Military .............................................................................................8 Adjudicating Military Sexual Trauma Cases .....................................................................11 Psychological Consequences of Military Sexual Trauma .................................................12 PTSD ..................................................................................................................................13 PTSD and the Military .......................................................................................................14 PTSD’s Physiological and Psychological Affects ...................................................14 Memory Deficits ......................................................................................................16 History of Abuse .....................................................................................................16 Other Areas of Concern Related to PTSD ...............................................................17 Military Sexual Trauma and PTSD....................................................................................17 Gender Differences Related to Military Sexual Trauma-Related PTSD ...........................19 Military Sexual Trauma Treatment ....................................................................................21 Effectiveness of Treatment ......................................................................................23 Differences by Race .................................................................................................24 Veteran Population.................................................................................................. 25 Predictive Variables Related to Prevalence of PTSD Among Victims and Perpetrators of Military Sexual Trauma ........................................................................... 26 Predictive Variable of Rank Among Victims ..........................................................26 Predictive Variable of Rank Among Perpetrators ...................................................27 Predictive Variable of Financial Status ...................................................................28 Predictive Variable of Type of Sexual Trauma .......................................................31 CHAPTER THREE: METHODOLOGY ..........................................................................33 Research Design.................................................................................................................33 Dependent and Independent Variables ....................................................................33 Categorical and Continuous Variables.....................................................................34 Research Question and Hypotheses .........................................................................34 Population and Sampling Procedures ......................................................................34 Power .......................................................................................................................35 ix Statistical Analysis .............................................................................................................35 Methodological Assumptions and Limitations ..................................................................36 CHAPTER FOUR: RESULTS ..........................................................................................37 Introduction ........................................................................................................................37 Variables ............................................................................................................................37 Military Sexual Trauma Type ............................................................................................37 Military Type ...........................................................................................................38 PTSD of Sample ......................................................................................................39 Results Hypothesis #1 ........................................................................................................40 Results Hypothesis #2 ........................................................................................................41 Summary ............................................................................................................................42 Limitations .........................................................................................................................43 CHAPTER FIVE: SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS ......45 Summary ............................................................................................................................45 Analytical Conclusion........................................................................................................46 Research Implications ........................................................................................................47 Clinical Recommendations ................................................................................................48 Accurate Diagnosis ..................................................................................................49 Blame the Victim .....................................................................................................50 Recommendations ..............................................................................................................51 Prevention Programs ..........................................................................................................52 Future Implications ............................................................................................................55 REFERENCES ..................................................................................................................57 1 CHAPTER ONE: THE PROBLEM Introduction Sexual assaults among the U.S. military increased by 11% from 2008 to 2009 and were at 16% for combat areas among service members (Youseff, 2010; Bumiller, 2010). Consequently, research and reports on how to treat women in the military are focusing on strategies to help alleviate the trauma associated with these assaults, which has come to be known as military sexual trauma (Kimerling et al., 2010; Rowe, Gradus, Pineles, Batten, & Davison, 2009; Fontana, Schwartz, & Rosenheck 1997; Coronel & Rosca, 1993). Research has indicated that 87% of the military sexual trauma incidences were perpetrated by males on female victims (Bumiller, 2010). Research has also indicated that 50% of the victims of military sexual trauma suffered PTSD as a result of their attacks (Cater & Leach, 2011). Sexual trauma among females in the military is a serious problem, as 50% of military sexual trauma victims were found to have developed PTSD after suffering a sexual attack (Cater & Leach, 2011). The current research focused on factors such as rank, income, and the type of trauma inflicted to predict the development of PTSD for female victims and rank and income to predict PTSD of the male perpetrators of military sexual trauma. Problem Statement Military sexual trauma is a growing concern for females, as research shows that 15% of women in the military have been sexually traumatized while serving (Kimerling et al., 2010). Problems arising from military sexual trauma include PTSD, depression, and increased physical symptoms of these disorders (Kimerling et al., 2010). Women who are military sexual trauma victims with PTSD therefore had high incidences for 2 physical conditions such as liver, heart, and weight problems (Kimerling, Gima, Smith, Street, & Frayne, 2007). There were more than 3,000 unrestricted reports of military sexual assault in 2009 (Bumiller, 2010); however the Department of Defense (DOD) estimates that the actual number of assaults was more than 19,000 (“Fighting For,” 2011). Unrestricted reports are military reports that can lead to public criminal charges, as opposed to restricted reports that do not seek criminal charges (“Fighting For,” 2011). Out of the 3,000 unrestricted reports only 529 of those accused were court-martialed and 53% manifested with a conviction (“Fighting For,” 2011). This research used data from unrestricted reports that resulted in criminal court hearings for military sexual trauma. It examined two hypotheses of the relationship between rank, financial status, and type of assault and the prediction of PTSD diagnosis in victims and perpetrators of military sexual trauma. This study sought to predict occurrence rates of PTSD among the victims and perpetrators in criminal military sexual trauma hearings to help bridge a gap in the research for this population. It was believed that the results of this research would help build models for prevention as well as for better clinical assessment and treatment for women in the military who experience military sexual trauma to better address psychological issues resulting from these experiences. There are other factors that should be taken into account when addressing the issue of military sexual trauma. Minority women experience higher rates of sexual harassment (Buchanan & Fitzgerald, 2008) and military sexual trauma during war (Goldstoff, 2010). Age is also a factor related to military sexual trauma, as younger victims tend to be targeted for sex abuse (Grant, 2000). Furthermore, victims of military 3 sexual trauma were associated with fewer years in the military (Collins, 2010). Other factors include rank, financial status, and education. Those with less rank have limited ability to gather resources and file a case (Riger, 1993). Because there is a disparity between males and females as women work for lower wages in the same job, this can result in financial abuse (Luce & Brenner, 2004). Education level was a relevant factor since education has not decreased financial subordination (Taylor, 2008). Importance of the Study Research studies have assessed the high level of military sexual trauma and the psychological injuries sustained by victims such as PTSD, depression, and alcohol and drug dependence (Kimerling et al., 2010). However, there is a need to bridge a gap in the research to understand what variables predict PTSD in victims and perpetrators of military sexual trauma. The rationale for this research is based on the growing rate of sexual trauma in the military (Youseff, 2010; Bumiller, 2010) and the increased risk for PTSD and lifetime prevalence of PTSD among military sexual trauma victims (Kimerling et al., 2010). Research Questions This study examined how rank, income, and type of military sexual trauma predict PTSD for the female victim and how rank and income predict PTSD in the male perpetrator. The two hypotheses for this study were the following: (a) Financial status of victims, their rank, and the type of sexual trauma incurred would predict the development of PTSD in victims; and (b) Rank of the perpetrator and financial status of the perpetrator would predict the development of PTSD in perpetrators. 4 Limitations The scope of this research was to ascertain the variables that affect PTSD rates among military sexual trauma victims and perpetrators. As such, it is purely quantitative research. A mixed-methods approach, including personal interviews, could in the future provide a valuable framework for better understanding this population. Given that this research is exploratory, it is ground breaking or baseline research. There are no known other studies of this type nor designs to compare the current study to for replication. Resource factors such as time, money, and military access to personnel records such as veterans or active duty personnel records, which limited the scope of the methodology. Therefore, this study did not compare military sexual trauma military sexual trauma cases with civilian sexual trauma cases or veteran sexual trauma cases. This research is intended to provide a rationale for providing specific legal victim services to aid the process of seeking support. It includes recommendations for preventing this problem, through research, clinical, and assessment of military sexual trauma victims. Definitions Conviction is defined as “the act or process of judicially finding someone guilty of a crime; the state of having proved guilty” (Garner, 2004, p. 358). Case law is defined as “the law to be found in the collection of reported cases that form all or art of the body of law within a given jurisdiction” (Garner, 2004, p. 229). Logistic regression was defined by Marczyk, DeMatteo, & Festinger (2005) as: “to determine whether and to what degree a set of hypothesized risk factors might predict the onset of a certain condition” (p. 224). 5 Military sexual trauma was defined by Rowe et al. (2009) as: “sexual assault or repeated, unsolicited, threatening acts of sexual harassment that occurs during military service” (p. 388). PTSD is mental health disorder 309.81 in Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM–IV–TR; American Psychiatric Association, 2000), including 6 criteria A-F: (a) where a person either experiences, witnesses, or learns about a life threat to the self or other with a response of terror; (b) re-experiencing the traumatic life threatening event in dreams, feelings, or physiological responses; (c) a continuous avoidance of the triggers to the traumatic event and numbing of the self, with thoughts, feelings, activities, and memory problems recalling; (d) continual arousal of symptoms that were not there before the traumatic life threatening event that affect sleep, concentration, and or anger or hypervigilence; (e) greater than one month of the symptoms; and (f) adaptive functioning disturbed with social, work, and family relationships (APA, 2000). Verdict was defined by Garner (2004) as: “a jury’s finding or decision on the factual issue of a case” (p. 1592). 6 CHAPTER TWO: REVIEW OF THE LITERATURE Introduction As previously noted, military sexual trauma can create a lifetime of mental and physical illness for its victims and is therefore a growing concern. Research has shown that as many as 15% of women in the military have suffered from military sexual trauma and problems arising from it, including PTSD and depression (Kimerling et al., 2010). Further, research has shown that these problems can occur over a lifetime and that many do not seek help for them. This study examined how rank, income, and military sexual trauma type predict PTSD for female victims and the male perpetrators. The literature review examined the potential influencing factors for military sexual trauma and the psychological consequences related to military sexual trauma. It also explored the history of sexual trauma in war and issues related to the adjudication of military sexual trauma cases. Databases The following databases were used for this literature review: EBSCOhost, PsycINFO Military Collection, ProQuest, Google, and Argosy University libraries. The following key words were used: PTSD and CBT, military sexual trauma, female military sexual trauma and PTSD, empowerment and minority women, minority female slavery, slavery, morality and gender, moral development, empowerment, empowerment and women, self-efficacy, internal locus of control, work empowerment, meditation and PTSD, meditation, CBT for PTSD, women’s rights, women’s financial barriers and forensic psychology and law. 7 The History of Sexual Trauma in War To understand why military sexual trauma is as great a problem as it is, it is helpful to know more about the history of sexual trauma in war. Sexual trauma occurs in many countries during wartime. The best known form of it is rape, defined as unlawful, nonconsensual sexual intercourse between a man and a woman and threats that cause the woman to believe she will die or be harmed if she does not consent. Rape is used as a weapon against women and children during war (Goldstoff, 2010). Different countries have upheld different standards at different times in history regarding rape during wartime. Rape was used as a war tactic in Belgium during World War I and during World War II in the Nazi’s genocide of the Jews (Goldstoff, 2010). The Japanese were also known to have raped Chinese women in Nanking during World War II (Goldstoff, 2010). During WWII approximately 200,000 Chinese, Filipino, and Indonesian women were raped by the Japanese Army (Goldstoff, 2010). These acts led to the Control Council Law no. 10 at the Nuremberg and Tokyo Tribunals in 1945 that upheld rape as a crime (“Treatment of Sexual Violence,” n.d.). Rape was also used by the Pakistani when they battled in Bangladesh in 1971. Goldstoff (2010) contended that the U.S. Army engaged in rape during the Vietnam War as a way to gain submission, although the particular cases, data, and statistics were not recorded. Rape is a crime that historically has not led to sizable convictions; instead, it has lead to physical and social wounds (Obama, 2012) such as unwanted pregnancies, sexually transmitted diseases, and being cast out at the end of wartime, in addition to psychological wounds such as PTSD (Goldstoff, 2010). 8 A number of sanctions have been passed against rape. In the United States, the Lieber Code, established in 1863 to govern how soldiers should conduct themselves in wartime, stated that rape was a crime punishable by death (Goldstoff, 2010). Article 3 in the convention signed in Geneva in 1929 by the United States and other powers allotted females rights to be respected for their sex although it did not explicitly protect them from rape. For example, article 3 stated: “Prisoners of war have the right to have their person and their honor respected. Women shall be treated with all the regard due to their sex. Prisoners retain their full civil status” (Lillian Goldman Law Library, 2008a). The Geneva Convention in 1949 afforded the following rights for women against rape in article 27 stating “Women shall be especially protected against any attack on their honor, in particular against rape, enforced prostitution, or any form of indecent assault” (Lillian Goldman Law Library, 2008b, p. 1). In 1993 Article 5 of the International Criminal Tribunal Council of Yugoslavia and Rwanda was created for the prosecution of serious violations against humanity who raped during wartime (“Statute of the International Tribunal,” 1993). In 1998, Hazim Delic, a Serbian military official, was charged for his rapes (Goldstoff, 2010). In 1996, the Bosnian military was indicted by its government for raping Muslim women during the Bosnian War, (Goldstoff, 2010) that rape became an international crime during the Bosnian War. In 2008, an international standard for charging rape as a crime was established when the United Nations Security Council passed Resolution 1820 to protect victims of sexual violence by advocating complete cessation of these acts (Goldstoff, 2010). 9 Sexual Trauma in the Military Sexual trauma is also historically and currently a problem in the military, with rape being the most prevalent type of trauma experienced. Military sexual trauma vitiates the success of building a cohesive team of men and women who can live, work, and create successful missions. For example military sexual trauma in the presence of war exasperates already severe traumas, highlighting the need for strong support in treatment and community. However, military culture may get in the way of supporting victims of military sexual trauma because telling on a member of the team is seen as “often the accuser is seen as disloyal to the unit” (Cater & Leach, 2011, p. 34). Cater & Leach (2011) identified the misuse of power dynamics, including (a) officer leadership positions supporting military sexual trauma, (b) younger victims were in greater risk, and (c) negative consequences for reporting military sexual trauma as factors as contributing to the continuance of military sexual trauma. A case involving a female soldier deployed to Afghanistan well illustrates the issues facing women in the military and the severe consequences of a sexual assault. Spc. Karlene E. Hemerly Fluck-Kroll was deployed in Afghanistan from 2002 to 2003, during which time a sergeant sexually assaulted her. Her privacy was violated by a hidden camera that she discovered in her bathroom late at night while she was undressing. As she put it, “He violated me. He saw me. He saw parts of my body he would never have seen had he not had a camera. He raped me with a camera” (Collins, 2010, p. 4). She was subsequently diagnosed with PTSD, and was further noted as “. . . often paranoid and depressed, avoids intimacy with her husband, and is afraid to take her kids out of the house” (Collins, 2010, p. 4). Fluck-Kroll’s symptoms involved panic 10 attacks, flashbacks, and increased pulse rate when she was in situations such as grocery stores or public facilities when she was with her children. This was because she worried about being violated again and about the safety of her children (Collins, 2010). Fluck-Kroll’s case is one of the few that ended in court. She stated that she did not regret reporting her attacker because it prevented him from violating someone else. She further stated, You have to stick up for yourself because no one else is going to do it . . . If you don't step forward and try to help yourself put someone else away who has violated you, no one else is going to do it. No one else knows it happened. (Collins, 2010, p. 4) Her attacker, who it was found had previously conducted a similar attack on another solder, was punished by being sent home and imprisoned for five months. After six years of feeling paranoid about the integrity and safety of her body Fluck-Kroll still had PTSD symptoms as of 2010. She had a strong aversion to public facilities and bringing her children to them as well. Her continuing PTSD was caused by five minutes of rape with a camera. Her case illustrates a strong need for effective treatments for victims of military sexual trauma, regardless of when symptoms manifest. Military sexual trauma is utilized by other countries in wartime and is a mechanism to torture. Military sexual trauma is not limited to perpetrators within the U.S. military. Some victims are prisoners of war and are assaulted by members of the military in other countries that the U.S. is in conflict with during wartime. Perhaps the best-known case involved Jessica Lynch, who was serving in a gender-integrated unit in Iraq when her unit was attacked. She was captured by the enemy, tortured, and raped (Donnelly, 2010), and her wounds were recorded on videotape. 11 Adjudicating Military Sexual Trauma Cases Justice for military sexual trauma is scant evidenced in only 20% of cases court marshaled for sexual assault victims (Collins, 2010). Furthermore, according to the U.S. Department of Defense, it is estimated that 20% of sexual assaults are not reported (Collins, 2010). Therefore, it is valuable to understand what types of factors affect the few cases that actually make it to a hearing given the lifetime prevalence for injuries these female victims often sustain. Political leaders are making strides to bring better awareness to sexual assaults for military and for civilian populations. For example, President Barack Obama stated the need for greater prevention, protection and legal proceedings for victims of sexual assault in a proclamation issued during National Sex Assault Awareness and Prevention Month in 2012. In a speech announcing the proclamation, Obama stated: . . . we must do more to raise awareness about the realities of sexual assault; confront and change insensitive attitudes wherever they persist; enhance training and education in the criminal justice system; and expand access to critical health, legal, and protection services for survivors. (Obama, 2012, p. 1) Victims of military sexual trauma have several pathways for seeking justice. Because PTSD lasts a lifetime, to prevent new attacks the victim can seek civil and criminal convictions that can alleviate distresses and damages with physical/medical, social, psychological, financial, and occupational injuries to her life. The factors that affect a victim filing a criminal and civil suit depend upon the crime date and the jurisdiction she resides in and their ability to accomplish due processes for her. It also depends on the statute of limitations; these vary from state to state, although some states give 10 years to prosecute (“Statutes of Limitations,” 2012). Within the civil courts legal arguments against the defendant would depend on the personal characteristics of the case, 12 such as her gender, race, status as a worker, and so on. Legal approaches could include tort, negligence, contractual, and constitutional domains. Factors such as who was the attacker, where it occurred, who knew about it or supported it, such as the availability of witnesses and evidence, and her financial ability to mount a legal battle, will be imperative to her case as well. A highly publicized incident of military sexual trauma took place during the 1991 Tail Hook Association Convention held in Las Vegas as the military was celebrating the end of the Persian Gulf War. Navy Lt. Paula Coughlin was sexually assaulted by a group of male aviators (Donnelly, 2007), and reported what happened to ABC News. As a result of her assault, 152 naval officers resulted in punishments that lead to fines, job losses and resignations (Donnelly, 2007). This incidence of military sexual trauma caused a great deal of embarrassment, shame, and concern for the morale of the Navy and military at large. It also heightened awareness of the issue of military sexual trauma and has caused mixed messages for violence against women. For example, the idea that violence against women in one context such as the Las Vegas hotel incident was wrong, but violence against women during combat was alright was introduced into political military warfare decisions following this incident (Donnelly, 2010). Psychological Consequences of Military Sexual Trauma The issue of obtaining valid data is a concern in discussing the psychological consequences of military sexual trauma because not every participant will provide certain or complete information. For example, in a study of 556 veterans who had high incidence rate of PTSD symptoms, younger participants declined to state whether they had experienced military sexual trauma (Weiss & Gorman, 2005). It appears that the idea 13 of self-reporting military sexual trauma is something that not many people are willing to do, which leads to the conclusion that accurate reporting of incidences of military sexual trauma is still in its infancy. Thus, this problem appears to be more prolific than reported prevalence rates would suggest. PTSD PTSD is an anxiety disorder that affects approximately 8% of the population in the United States (APA, 2000). According to the DSM-IV-TR (2000), PTSD has six different criteria, including:(a) encountering a traumatizing life experience where the person witnessed or experienced an event involving a threat to life, injury, or integrity to self or another and an emotional response of fear, horror, and helplessness; (b) the event is re-experienced by the person in images, dreams, feelings, physiological distress, that resemble the event; (c) consistent avoidance of anything associated with the trauma and numbing response with three symptoms involving avoiding activities, thoughts, affect change, avoiding people, hopeless about future, inability to remember the traumatic event; (d) consistent symptoms of greater arousal with two involving sleep disturbance, anger and irritability, concentration problems, hyper vigilance, and exaggerated startle response; (e) symptoms persisting for more than one month; and (f) the psychological problem causes distress with social, occupational, or other important areas of functioning. PTSD has also been shown to change the brain, leading to verbal and visual memory impairments (Brewin, Kleiner, Vasterling, & Field, 2007) and often includes medical issues related to the liver, heart, and weight (Kimerling et al., 2007). PTSD is an important disorder to treat, as it has been associated with a high magnitude of harm in terms of impairment and morbidity (Johnson & Zlotnick, 2009). 14 Research shows lifetime prevalence of PTSD in military sexual trauma victims; e.g., PTSD symptoms may not go away during the course of their life (Cater & Leach, 2011). PTSD and the Military PTSD has been a psychological problem known for centuries in the military. For example, military personnel encounter threats to their own lives and others around them that for many years was called “combat neurosis” (Grant, 2000). Research indicated a high incidence of PTSD in current military populations as an example, 18% of service members returning from Iraq have been diagnosed with it (Power, 2010). Furthermore, there appears to be a gender difference related to risk for developing PTSD, as research shows that men typically develop PTSD in combat while women develop it as a result of military sexual trauma (Hoyt, Klosterman, & Williams, 2011). In 2006, the prevalence rate for mental health problems was 13.3% of soldiers suffering from mental health problems, compared to 18.8% in 2007 and 22% in 2006 (“Army Mental Health,” 2010). Those who served in Iraq and Afghanistan were often deployed several times, and those who had multiple deployments indicated higher psychological and family problems (“Army Mental Health,” 2010). The types of problems military face were delineated by Power (2010) as: (a) PTSD (where prevalence rates reached 18.5 % of those who served in Iraq and Afghanistan), (b) depression, (c) substance abuse problems, and (d) suicide where the Army has reached a historical high prevalence rate and one out of five suicides in the United States is a veteran (Power, 2010). PTSD’s Physiological and Psychological Affects Halligan, Michael, Wilhelm, Clark, and Ehlers (2006) found that trauma survivors with PTSD consistently have higher heart rates, blood pressure, skin conductance, and 15 facial electromyogram responses on exposure to trauma reminders than trauma survivors not diagnosed with PTSD. Similar findings have been reported in military populations. In a study of 56 female veterans who reported multiple types of sexual trauma across their lifetime, it was found that these individuals experienced a greater severity of PTSD symptoms and had a greater frequency of alexithymia, or the inability to identify one’s emotions, which explained unique differences in their physical health complaints (Polusny, Dickinson, Murdoch, & Thuras, 2008). In a sample of 185,880 female veterans and 4,139,886 males, among the 70% who completed the screener positive screenings had co-morbid conditions of PTSD and physical conditions (Kimerling et al., 2007) such as liver and heart problems, and specifically for females weight problems (Kimerling et al., 2007). In a study of 120 active duty veterans statistically significant relationships for PTSD and depression were documented in those seeking mental health services (Bryan & Corso, 2011). In a study that explored the relationship between PTSD, depression, and suicidal ideation, the authors found a significant relationship between PTSD and suicidal ideation but did not find a relationship between depression, PTSD, and suicidal ideation, which suggested that depression and PTSD symptoms might relate to suicidal ideation and suicidal behaviors differently (Bryan & Corso, 2011). Military sexual trauma and post-deployment physical and medical conditions were not found to change symptoms of PTSD among 83 female veterans who served during the 1990-1991 Gulf War (Smith et al., 2011). However 74 to 100% of the PTSD symptoms were related to sexual assault for physical and medical conditions (Smith et al., 2011). Furthermore, there was a relationship between sexual assault during active duty and development of PTSD symptoms that manifested in physical and medical 16 conditions (Smith et al, 2011). For example problems manifested in:(a) gastrointestinal problems, (b) genital problems, and (c) neurological problems (Smith et al., 2011). The current study did not include medical issues in its scope of inquiry. They are briefly noted here, as they are clearly issues of concern related to the overall discussion of military sexual trauma and PTSD. Based on existing research, it is believed that physical and medical issues are also important variables to assess in future studies. Memory Deficits PTSD affects memory, causing deficits as was found in a meta-analysis of 27 studies contending that verbal memories greater than visual memories are negatively impacting both civilian and military populations (Brewin et al., 2007). Therefore, PTSD is not without the cognitive obstacles of memory problems that affect verbal and visual memory circuits of traumatized woman, causing further harm to the person. History of Abuse PTSD was present at accelerated rates among a group of 204 active duty Army soldiers who both had both physical and sexual abuse in their childhood. A total of 46% of the sample had child physical abuse histories and 25% had child sexual abuse histories, identifying the high prevalence rates of soldiers with childhood abuse and the development of PTSD as a psychological problem (Seifert, Polusny & Murdoch, 2011). Aosved, Long, and Voller (2011) found sexual trauma prevalent among 1,002 primarily White, single, male civilian college students. Child sexual abuse further exasperated and was related to adult sexual assault experiences, re-victimization, and greater rates of PTSD, depression, hostility, and stress (Aosved et al., 2011). Research indicated that child sexual abuse, re-victimization, and adult sexual assault among men 17 and women in civilian and non-civilian populations are areas of concern in need of further analysis. However, they were not within the scope of the research for the current study. Other Areas of Concern Related to PTSD Military sexual trauma also increases chances for complex PTSD trauma, referred to as disorders of extreme distress not otherwise specified, with problems such as somatization, dissociation, emotional regulation, interpersonal problems, and problems with self perception (Luterek, Bittinger & Simpson, 2011). Furthermore, 45 to 70% of female victims of military sexual trauma reported depressive symptoms (Rowe et al., 2009). The risk of developing co-morbid disorders such as substance abuse, risky behaviors, and eating problems appears to greater impact those who are victims of military sexual trauma (Rowe et al, 2009). Military Sexual Trauma and PTSD Research shows that PTSD rates exceed 50% for male and female victims of military sexual trauma (Cater & Leach, 2011). Research also shows that there is a wide range of PTSD prevalence rates, with lifetime prevalence rates of PTSD among military sexual trauma victims range from 8 to 56% (Cater & Leach, 2011; DeRoma, Root, & Smith, 2003; Himmelfarb, Yaegar, & Mintz, 2006; Hoyt et al., 2011; Katz, Bloor, Cojucar, & Draper, 2007; Kimerling et al., 2007; Kimerling et al., 2010; Murdoch et al., 2010; Murdoch et al., 2011). Therefore a wide range of PTSD prevalence rates is present, with more than 50% of military sexual trauma victims suffering with PTSD (Cater & Leach, 2011). 18 Military sexual trauma among 196 female veterans was associated with higher prevalence rates of PTSD than in male veterans (Himmelfarb et al., 2006). Lifetime prevalence rates of PTSD among veteran victims of rape were 38% in a sample of 336 female outpatients (DeRoma et al., 2003). Among these same veteran service members the military rape rate was 8.7% (DeRoma et al., 2003). Kimerling et al. (2010) documented military sexual trauma rates of veterans at 15.1% among 21,834 females and .7% among 142,759 males. The participants in this study were veterans deployed during Operation Enduring Freedom and Operation Iraqi Freedom seeking services at either Veterans Administration (VA) mental health facilities or primary care settings. Multiple incidences of sexual assaults among 336 female veterans resulted in lifetime prevalence rates of PTSD (DeRoma et al., 2003). Veteran service members were also found to suffer a high severity of depression and anxiety symptoms (DeRoma et al., 2003). The depression and anxiety was present among cumulative rape victims who were present in combat and as civilians at a greater extent than among those who experienced rape in combat alone (DeRoma et al., 2003). In another study of 18 women who served in Iraq, 56% of the women experienced military sexual trauma (Katz et al., 2007). Kimerling et al. (2007) conducted the largest study to date of military sexual trauma among active duty men and women to determine factors of military sexual trauma by race, age, marital status, and psychological problem. Their sample consisted of 4 million men and over 185,000 females; their findings indicated that White, young females suffered the highest prevalence rates of military sexual trauma for this population (Kimerling et al., 2007). Furthermore, the presence of 19 medical and psychological co-morbid disorders such as PTSD and pulmonary diseases were associated with military sexual trauma (Kimerling et al., 2007). Gender Differences Related to Military Sexual Trauma-Related PTSD Military sexual trauma affects men and women. For example, Kitfield (2012) stated that 25 percent of women and 27 percent of men who claimed unwanted sexual contact said that the assaults occurred in combat zones (Kitfield, 2012, p. 1). In reserve zones military sexual trauma was documented by Funk (2005), who found that sexual assaults, including rape, were reported by 23 percent of women and 3.5 percent of men. Funk further stated that only 1.1 percent of men and 1.5 percent of women said they sought care at the VA for their trauma (2005). Military sexual trauma for women was 60% and for men 27% as of 2001 in a VA study of the National Guard, with the bulk of these instances reported as during active duty training. Females have not been included in as many studies of military sexual trauma even though this problem tends to involve female victims and male perpetrators (Morris, 1996). For instance, criminal conviction studies in the military population with military sexual trauma have a gap in the literature that fails to include females who have suffered military sexual trauma (Morris, 1996). This study’s focus on women who experienced military sexual trauma is based on the severity, degree, and frequency of harm relative to women’s experiences However, research among the veteran population representing differences by gender for trauma showed several themes including differences by gender in combat experiences, PTSD, military sexual trauma, and social readjustment (Street, Vogt, & Dutra, 2009). A study by Haskell et al. (2010) found that 48% of females were depressed 20 as opposed to 39% for males. However 21% of female military sexual trauma victims screened positive for PTSD as opposed to 33% of men in this sample (Haskell et al., 2010). A meta-analytic review among men and women documented higher likelihood of PTSD for women experiencing higher rates of sexual trauma compared to men (Tolin & Foa, 2008). Haskell et al. (2010) recorded the frequency of military sexual trauma at 14% for women and 1% for men. This study was among a sample of 1,032 men and 197 women with a clearly skewed sample; as such mixed results were likely to occur (Haskell et al., 2010). The problem of military sexual trauma is clearly at a great burden rate for females and males; some studies show that women experience military sexual trauma at a greater proportion (Hoyt et al., 2011). Cater and Leach (2011) found that military sexual trauma created lifetime PTSD with men at 65.9% versus women who had 45.9% from military sexual trauma (Cater & Leach, 2011). These rates varied from men in combat with PTSD prevalence rates of 38.8% recorded (Cater & Leach, 2011). Furthermore, in another study universal screening from military resources discovered almost similar incidences of military sexual trauma (Kimerling et al., 2007). For example, 31,797 incidences of men’s military sexual trauma and 29,418 cases of women’s military sexual trauma were documented (Kimerling et al., 2007). These similar results demonstrate both men and women are clearly suffering from problems such as PTSD. In some instances greater rates are experienced for females with military sexual trauma and combat for males (Hoyt et al., 2011). 21 Military sexual trauma is a growing concern for female veterans with rates varying from approximately 20 to 40 % of veterans suffering with military sexual trauma (Suris & Lind, 2008). Kimerling et al. (2010) documented in the largest scale among military sexual trauma studies that female victims suffered with higher instances of PTSD, depression, and severity of psychological distress than males. Furthermore, in a sample of 196 female veterans military sexual trauma was higher prevalence then premilitary and post-military sexual trauma (Himmelfarb et al., 2006). The problem of military sexual trauma is clearly at a great burden rate for females and males (Hoyt et al., 2011). Based on the review of the literature on this topic, suggestions for future studies include: (a) sample sizes with equal male to female ratios to obtain better precision among comparison studies, (b) studying differences by gender for combat exposure, and (c) greater study of female sexual trauma experiences among active duty military (Street et al., 2009). Military Sexual Trauma Treatment The need for effective responses to military sexual trauma has been explored by 17 military task forces (Cater & Leach, 2011). From 1992 to 1999 the VA authorized mental health services for military sexual trauma victims. In 2004, the U.S. Congress passed legislation making these services a permanent aid to victims (Kimerling et al., 2007). In 2003, the cost for mental health services for military sexual trauma to reserves was reported as $900 million over a span of 5 to 10 years; not including the costs for inflation and for new service members estimated at $12 million annually. Mental health services for military sexual trauma are currently offered to veterans at no charge (Kimerling et al., 2007). For example, according to a press release on the Department of 22 Veterans Affairs’ Inspector General’s intention to review veteran’s access to health care, disabilities resulting from military sexual trauma, physical or invisible, must be treated like other service-connected wounds, and that the VA has an obligation to provide and pay for the care (“Inspector General to Review,” 2009). However a report made in 2009 by the Department of Veterans Affairs’ Inspector General as an outpatient clinic failed to give a free of charge service to a veteran seeking military sexual trauma counseling (“Evans Releases,” 2005). The VA determines eligibility based on a screen test; eligibility is met if it is positive for a military sexual trauma injury. Problems associated with the delivery of services in light of the presence of screeners and services offered at no charge are delineated as (a) challenges to getting screened, (b) lack of patients’ syndrome criteria diagnosed to meet the treatment, (c) gender differences for universal utility (Kimerling et al., 2007). The greater frequency of psychological disorders present in individuals who suffered from military sexual trauma builds the rationale for free, effective treatment that is easily accessible. Research shows that patients with military sexual trauma have greater problems such as PTSD, anxiety, depression, and substance abuse. It also reinforces the high prevalence of PTSD and likelihood for co-occurring disorders as a result of military sexual trauma for men and women. However, research also shows that 95% of veterans who have suffered military sexual trauma are not obtaining services for it, which affects medical, educational, financial, and mortality rates for these veterans (Valente & Wight, 2007). Furthermore, nearly half of those who are eligible for mental health services in the military choose to not seek services (Power, 2010). Strategies to provide aid to military families have four goals according to Power (2010), including: (a) 23 increasing military access to adequate care, (b) improving the quality of care accessible to the military, and (c) facilitating emotional and mental aid with evidence-based therapies, and (d) creating an effective behavioral health plan for federal, national, local, and tribal organizations. Importantly, although these services are provided for sexual assault victims, only 25% of 643 men and 38% of 173 women in a study of sexual assault victims from a VA study actually received mental health services (Zinzow, Grubaugh, Frueh, & Magruder, 2008). Therefore, it is important to note that although services are available for victims they are often not utilized. Looking at why this occurs is important to understand as well to help alleviate the shame, blame, or re-victimization that can take place for victims. Effectiveness of Treatment Hall, Sedlacek, Berenbauch, and Dieckman (2007) studied the effectiveness of military sexual trauma treatment among 44 providers of these services in multiple service settings. Results suggested that the factors affecting the service providers were at the local level as opposed to the state or national level for factors of the perception of organizational support and practices in the environment of the organizational support (Hall, Sedlacek, Berenbauch, & Dieckman, 2007). This study was helpful for determining the perspective of effectiveness of military sexual trauma treatment from the health providers’ perspective. It leaves space to then research the effectiveness of treatment from the clients’ perspective since the level of environmental perception of provider support was assessed. 24 Differences by Race Some studies suggest that there might be differences between African American women and White women regarding obtaining mental health services. In a study of 526 women veterans at a VA primary care clinic, it was found that African American women stated a greater desire for mental health services than White women, but that both groups similarly used the mental health resources provided at this clinic (Bosworth et al., 2000); there was no difference comparing the African American group to the White control group as far as obtaining services. However higher rates of wanting these services were reported among the African American female veterans (Bosworth et al., 2000). Therefore both groups of women utilized mental health services but White women were less willing to disclose about it. 25 Veteran Population Another military population that has faced challenges in seeking treatment was present among Vietnam veterans. This is because they were recovering and integrating into their lives based upon rejection and the unpopularity of the war, which further exasperated psychological distress that was present (Dobson, Grayson, Marshall, & O’Toole, 1998). Dobson, Grayson, Marshall, and O’Toole (1998) conducted a study of Vietnam veterans to examine the association between postwar experiences and treatmentseeking behavior. According to Dobson et al., the factors that affected treatment seeking among Vietnam veterans involved, in addition to being in war and morbidity issues, “predeployment personality, self-efficacy, veterans’ attitudes toward their deployment, deployment experiences, and negative life events” (p. 580). Results indicated that the greater the need for community psychological services, the greater the trend for seeking psychological services (Dobson et al., 1998). Dobson et al. further stated that the lack of acceptance of the postwar experiences led many veterans to reject their history, status, and membership as a veteran. The results of this study suggest that treatment-seeking behaviors of the military are important to consider as they relate to all the variables such as age, race, gender, and social and economic status to meet the clients where they are and to increase the standard of care to give the best and most effective treatment for the military population. The rationale for free treatment, effective treatment, and access to treatment may be related to also the greater frequency of psychological disorders present in individuals who suffered from military sexual trauma. This research reinforces the high prevalence 26 of PTSD and likelihood for co-occurring disorders as a result of military sexual trauma for men and women. Predictive Variables Related to Prevalence of PTSD Among Victims and Perpetrators of Military Sexual Trauma This literature review now turns to a discussion of existing studies exploring the predictive variables related to prevalence of PTSD among victims and perpetrators of military sexual trauma. Predictive Variable of Rank Among Victims Riger (1993) offered an excellent discussion of empowerment research that helps explain why rank is an important variable in studying military sexual trauma. She noted the differences between “power to” that is often associated with empowerment, stemming from greater self-esteem and confidence different than the “power over” concept allowing for decision making and obtaining resources that empower a person (Riger, 1993). She also noted two limitations in understanding empowerment also present in ideas regarding women’s cultural and gender-related roles that are diversity issues presented as assumptions: “(1) focusing on the idea of individualism which can lead to competition amongst the empowered. (2) Preference for traditionally masculine concepts of mastery, power, control over traditional feminine concern of cooperation and communion“ (Riger, 1993, p. 279). The issues of self-esteem and confidence are important when looking at etiology for risk factors among military sexual trauma victims. For example, self esteem was relevant in military populations among victims including other factors such as: (a) women working in fields traditionally held by men; (b) greater 27 likelihood for sexual harassment; (c) low self esteem females; and (d) females who were previously harassed (Duncan, 1997). Predictive Variable of Rank Among Perpetrators The power over concept is represented in the current study as rank and financial status. Rank is designed to distinguish power differences in the military that are based on education status, achievement level, and number of years in the military. This research assumed that a power over difference such as rank would be present among female victims and male perpetrators of military sexual trauma, as affirmed by Obama (2012), “Tragically, these crimes take their greatest toll on young people; women between the ages of 16 and 24 are at greatest risk of rape and sexual assault, and many victims, male and female, first experience abuse during childhood” (p. 1). The factor of power over is directly comparable to the factors affecting whether a victim of military sexual trauma will be capable of standing up to her perpetrator. For example, this it because her position of her lower power status as a female, as a worker in a hierarchy, and by the possibility her attacker is above her status. A lack of equal power is present for persons marginalized by society such as females, minorities, minors, alternative life style individuals and low social and economic status individuals and is a risk factor for attacks on their lives (Grant, 2000). It is believed that these factors are also heightened in the military culture, which also has the same power differences based on income, gender, race, sexual preference, and rank. Riger (1993) also pointed out that interventions that exhibit empowerment at the individual and community level to then miss the “power over” or decision-making tools for gaining resources to make a change. The power over refers to the political context a 28 person comes from that enables a person to work through any type of change upon her life. Riger further stated, “Empowerment is sometimes equated with participation, as if changing procedures will automatically lead to changes in context or in the redistribution of resources” (p. 282). Risk factors for what causes a person in the military to harm another military person has been documented as a need for control that can be referred to as the power differences military personnel go through depending upon their level of training (Williams & Bernstein, 2010). Level of training is related to income, rank, gender, and therefore power over concepts are important in this context for military sexual trauma. Predictive Variable of Financial Status Women have not developed an equal foothold in financial arenas in the work force in the face of the passage of laws that are supposed to afford those rights. For example, women work in similar occupations as men for different pay, which is against the federal law that was passed over 50 years ago. In 1963 the Equal Pay Act banned gender discrimination for wages. However, equal pay based on gender is still a legal battle. For example, according to Luce & Brenner (2004), as of 2004 women earned 77 cents per hour for every dollar men earned, which is not as bad as in 1964 where it was 59 cents for every dollar. These financial barriers to equal pay for equal work are at the core of the disempowerment and disrespect that women experience in the work force and as members of society. Therefore, financial status is an important predictor demographic variable for this study. Equal pay based on gender is a problem regardless of the educational status of the workers. Although women now make up 57% of bachelor’s degrees, 61% of master’s 29 degrees, and half of doctoral degrees (Taylor, 2008) discrimination based on gender is still present in a number of professional fields. This is a problem regardless of whether a woman is educated with a college degree or a postgraduate degree. For example, women who work oftentimes work not only for less wages but also work more hours than men. This is because of the household division of labor that women traditionally do the cooking, cleaning, and child rearing at greater proportion to men. This has caused women to take part-time jobs to handle the overload of working more hours than men or if possible to hire domestic help (Luce & Brunner, 2004). Too much work can cause further psychological distress experienced in the ability to make a living, take care of the family, and deal with the multiple roles that women now are forced to become. Women have been serving the military since the American Revolution as nurses, however it was in 1941 when President Franklin D. Roosevelt approved a bill that created the Women's Army Auxiliary Corps (“Highlights in the History,” n.d.). The roles of women in the military started out as helping as nurses and by 1953 a female reached the rank of commission as a medical officer in the Army (“Highlights in the History,” n.d.). Furthermore, in 1971 a female reached the rank of brigadier general and in 1988 the first female astronaut was selected for NASA (“Highlights in the History,” n.d.). Therefore, women have made great strides in the military in a variety of roles. Education levels do not affect the gender discrimination in the form of unequal pay, as it also affects top-educated professionals. For example, pay discrimination was present even among highly influential leaders, such as female attorneys, who were paid less than male counterparts (Monroe & Chiu, 2010). At the same time female college 30 professors entered the military with lower pay ranks as men with similar qualifications (Monroe & Chiu, 2010). Research shows that women today maintain a financially unequal foothold compared to men in the same job with the same education. In the military, personnel rely on political laws, by the executive and legislative branches, specifying the roles of males and females in the work force. For example, historically the political branches of law decided women as incapable of working in combat positions, based on the rationale that: (a) women are physically weaker, (b) co-ed groups are less cohesive, and (c) men are likely to feel protective of female co-workers and this is distractive (Dieckmann, 2011). Therefore the women’s income is limited based on the dynamics that take place between women and men who work in the same roles. Although women are financially lacking equality based on their rights to work in combat positions leading to higher rank and financial status, women are engaging in dangerous environments without the higher pay (Dieckmann, 2011). Therefore, women have less control over the dangers they face as compared to men and do not receive the adequate pay for these danger zone efforts. Another problem women are experiencing in the military is a high proportion of female exploitation in the form of sexual harassment, which is related to cultural norms. Predictive Variable of Type of Sexual Trauma Military sexual trauma research has not extensively examined the predictive role of type of sexual trauma among military personnel who seek criminal court proceedings. However sexual trauma type has been demonstrated as important in this population to study due to the high risk factor of rape in developing PTSD (Kimerling et al., 2007). According to a press release issued in 2005 by Illinois Representative Lane Evans, 31 military sexual trauma type includes “sexual harassment, sexual assault and rape” (“Evans Releases,” 2005, para. 2) and was defined as such for this research. Furthermore, the prevalence rate for rape among females was 11% and for males was 1.2% (“Evans Releases,” 2005). Therefore rape is a significant type of sexual trauma however other types of sexual trauma occur, which is why this study will assess the three different types of sexual trauma. There are startling rates of rape in military sexual trauma among veterans. For example, 33% of female veterans were raped and in this number of victims multiple rapes occurred for 37% of the group and gang rape occurred for 14% (Corbett, 2007). Consequently, “rape holds the highest conditional risk for (PTSD)” (Kimerling et al. 2007, p. 2160). Military sexual trauma is measured in this study as rape, sexual assault, and other sexual harassment. Sexual trauma incidences was studied in an active duty population of 611, in which more than 50% of men and women reported they experienced at least one or more sexual stressors (Murdoch et al., 2010). The strongest predictors for military sexual trauma in this study were socio-demographics and tolerance in the work environment (Murdoch et al., 2010). High stress environments and childhood traumas were found to exasperate sexual trauma (Murdoch et al., 2010). In another study of Air Force women military sexual trauma was documented as more than one in four Air Force women had been raped (“More Research Needed,” 2007). Also in this study the risk factors for PTSD were pre-military rape and joining the military (“More Research Needed,” 2007). Research suggested that types of sexual stressors need to be further examined, which is 32 why the current study delineated type of sexual trauma as a variable to study among military sexual trauma victims in addition to rank and financial status. Military sexual trauma can be verbal harassment. Verbal forms of military sexual trauma were documented as 80% of females in the Air Force heard sexist remarks daily (Duncan, 1997). Lim and Corina (2005) echoed this finding in a study of civilian populations. In a study of two separate populations of women, numbering 833 and 1,424 individuals, noncivil behaviors and sexual harassment were military sexual trauma types (Lim & Cortina, 2005). Therefore, verbal harassment that is military sexual trauma may be indicative of factors in the workplace for power differences by gender, and control over one’s environment (Lim & Cortina, 2005). Assessment problems for ascertaining accurate information regarding sexual trauma among service members is a problem. This was documented among 118 men and 96 women with a scale called the Sexual Harassment Core Measure created for college women (Murdoch et al., 2011). The problem was with the reliability of the test, which was worse among men and soldiers based on the assessment’s assumption that college education level of reading was acceptable (Murdoch et al., 2011). This research indicates the importance for psychological assessments to be grounded in educationally appropriate levels for comprehension of military personnel participants. 33 CHAPTER THREE: METHODOLOGY Research Design This study used a logistic regression model to examine two hypotheses that could explain how rank, income, and sexual trauma type predict PTSD among female victims and how rank and income predict PTSD among male perpetrators. The study analyzed 26 criminal cases of military sexual trauma involving female victims and male perpetrators regarding PTSD bridging a gap to further understand this population. Dependent and Independent Variables The dependent variable for this research is PTSD. PTSD was defined as the dependent variable based on research showing a high incidence of it developing after an incidence of military sexual trauma (Cater & Leach, 2011). PTSD diagnosis is based on a clinical disorder that often has multiple etiologies and may have been present prior to the diagnosis during the military sexual trauma case. This research assessed the psychological consequences of military sexual trauma in a literature review among male and female veteran populations with qualitative and quantitative approaches that represented the high risk for mental and physical illnesses (Cater & Leach, 2011). The independent variables for this research were defined as rank, income level, and type of military sexual trauma inflicted. Rank was chosen, as a power-over concept (Riger, 1993) affects abilities to gather resources. It also relates to number of years in the military, since younger ages have been linked with greater number of military sexual trauma victims, (Obama, 2012; Schmid, 2010). Income level was chosen as there is a disparity between the wages paid males and females where women work for lower wages in the same job, providing a financial abuse (Luce & Brenner, 2004). Type of sexual 34 trauma inflicted was chosen based on research showing rape as a high risk factor in developing PTSD (Kimerling et al, 2007). Categorical and Continuous Variables Categorical variables, according to Marczyk et al. (2005), can “take on specific values within a defined range of values. For example, gender, an independent variable is a categorical variable because you can either be male or female” (p. 47). Continuous variables can “ theoretically take on any value along a continuum” (p. 48). Continuous variables for this design include independent variables of financial status, rank, and dependent variables of PTSD. Research Question and Hypotheses The research question that formed the basis for this research was: Is there an association between rank, financial status, and the type of sexual trauma incurred and the development of PTSD in victims and perpetrators of military sexual trauma. Based on this question, two hypotheses were developed: (a) Financial status of victims, their rank, and the type of sexual trauma incurred would predict the development of PTSD in victims; and (b) Rank of the perpetrator and financial status of the perpetrator would predict the development of PTSD in perpetrators. Population and Sampling Procedures The population for this study was female victims of military sexual trauma by an adult male perpetrator who is in the military. Based on the search terms used, 26 records were found that met the criteria of military sexual trauma male perpetrator, female victim, and a rape or sexual assault that caused PTSD. 35 The following criteria were used to locate cases relevant for this study: military sexual trauma female victim, male perpetrator, both in the military the female was caused PTSD based on rape or sexual assault. Stratified sampling was utilized since it was only possible to select cases based on the aforementioned criteria via Westlaw. This study utilized archival research databases including Westlaw, which delineated 26 criminal cases of military sexual trauma involving women. For cases to assess for this quantitative logistic regression study the following search terms were used: military army air-force navy coast-guard for sexual trauma, guilty, PTSD, sexual assault, rape, raped, and victim. Power According to Cohen (1992) power is based upon several factors, such as the alpha level or statistical significance level, the sample size, and the population. For this study, which included 26 cases with an alpha level at .05, a sample size of 40, according to Cohen, equaled a power of 0.48. Post hoc tests were conducted using statistical software to provide further clarity on the power of the study’s design. Statistical Analysis Logistic regression was utilized for testing the two hypotheses. The independent variables of rank, income, and military sexual trauma type for the female victim and rank and income for the perpetrator and dependent variable PTSD for the female victim and male perpetrator quantified the hypothesis research questions. The demographic variables for this design were also quantified with SPSS software. As such, logistic regression was utilized for the two hypotheses and statistical frequency analysis was used to compile the demographic variables. 36 Methodological Assumptions and Limitations Methodological limitations of quantitative research, the approach chosen for this study, reflect the absence of qualitative or mixed methods designs. For example, this study did not interview the victims or defendants in the cases that were analyzed. Furthermore, this design included only certain factors, such as rank and financial status, as variables. Other demographic variables, such as race and marital status, were not included because they are not included in the cases analyzed for this study. The limitations of this research are also related to in the lack of random sampling and the limited number of cases that fit the study criteria. Furthermore, it was not possible to confirm the validity off actors potentially influencing PTSD given the complexity of this diagnosis. Moreover, not all cases included the same criteria, because one of the cases did not delineate information for whether the female victim was a military service person although she was the wife of a military service person. Therefore, the number of females in the military versus not in the military was quantified as a demographic variable. 37 CHAPTER FOUR: RESULTS Introduction PTSD diagnosis is based on a clinical disorder that often has multiple etiologies and may have been present prior to the diagnosis during the military sexual trauma case. This study sought to predict occurrence rates of PTSD among the victims and perpetrators in criminal military sexual trauma hearings to help bridge a gap in the research for this population. It was believed that the results of this research would help build models for prevention as well as for better clinical assessment and treatment for women in the military who experience military sexual trauma. This inquiry used data from 26 unrestricted reports of military sexual trauma that resulted in criminal court hearings. It examined two hypotheses of the relationship between rank, financial status, and type of assault and the prediction of PTSD diagnosis in victims and perpetrators of military sexual trauma, specifically: (a) Financial status of victims, their rank, and the type of sexual trauma incurred would predict the development of PTSD in victims; and (b) Rank of the perpetrator and financial status of the perpetrator would predict the development of PTSD in perpetrators. Variables Military Sexual Trauma Type The type of military sexual trauma was organized by rape, sexual harassment/assault, or other that was neither rape nor sexual harassment but was nonetheless classified as military sexual trauma. Out of the 26 military sexual trauma cases studied the type of sexual trauma was delineated with 80.8% rape, 15.4% sexual 38 harassment/assault, and 3.8% with other sexual trauma. Table 1 depicts these military sexual trauma categories for the sample. Table 1 Type of Military Sexual Trauma Frequency Percent 26 100 21 80.8 Sexual harassment/assault 4 15.4 Other 1 3.8 Total 26 100 N Valid Rape Military Type The sample consisted of military personnel in each branch of the department of defense with: (a) 3.8% Coastguard, (b) 23.1% Marine, (c) 23.1% Army, (d) 11.5% Navy, and (e) 38.5% Air Force. For 25 of the cases both the victim and perpetrator were in the same military branch and for one case the perpetrator and the victim’s husband were in the same military branch. Table 2 represents these data. Table 2 Sample Distribution by Service Branch N % Coast Guard 1 3.8 Marine 6 23.1 Army 6 23.1 39 Navy 3 11.5 Air Force 10 38.5 Total 26 100 PTSD of Sample Over half of the victims had in the study population had PTSD, represented by 53.8% of the female victims who were diagnosed with PTSD. The male perpetrators had a lower proportion of PTSD diagnoses with 7.7%. The dependent variable PTSD was measured according to the inclusion of the diagnosis for the victim and the perpetrator in the facts of the criminal cases. The inclusion of PTSD in the diagnoses of the victims in the study population was based on the findings of expert, licensed mental health professionals, hired by the prosecution’s legal team, to assess, diagnose, and build an argument for the victim’s physical and mental damages. Furthermore, 53.8% of the female sample of military sexual trauma population suffered with PTSD which is similar to the frequency in the overall military sexual trauma population, which research shows is over 50%. However limitations occur with PTSD validity in this study since it is an indirect variable that was not measured through a standard assessment for each victim and perpetrator. Furthermore, there is no way to know if victims in the study cases who did not mention PTSD really did not have PTSD, or if PTSD preceded the military sexual trauma. This is a further limitation that needs to be acknowledged. Table 3 represents these data. 40 Table 3 PTSD of Victim and Perpetrator Frequency Victim Diagnosed PTSD Not Diagnosed PTSD Total Perpetrator Diagnosed PTSD Not Diagnosed PTSD Total Percent Cumulative Percent 14 53.8 53.8 12 46.2 100 26 100 100 2 7.7 7.7 24 92.3 100 26 100 Results Hypothesis #1 The first hypothesis was: Financial status, rank and type of sexual trauma of victims predict PTSD among the victims. The financial status of the victim was measured as the following: (a) 20-30,000 with 50%, (b) 31-40,000 with 0%, (c) 41,000-50,000 0%, (d) under 20,000 7.7%, and (e) not known 42.3%. The independent variable of rank of victims was measured by the following criteria: (a) 0-2 years in the military with 19.2%; (b) 3-5 years in the military with 0%; (c) 6-10 years in the military with 3.8 %; (d) 11-15 years with 0%; (e) greater than 15 years with 0%; and (f) not known 76.9%. Independent variable military sexual trauma type was measured as the following: (a) rape with 80.8%, (b) sexual harassment/assault with 15.4%, (c) and other sexual trauma with 3.8%. The dependent variable is PTSD of the client with the following criteria: (a) diagnosed with PTSD 53.8%, (b) not diagnosed with PTSD 46.2%. Results of the logistic regression indicate that the three predictor model provides a nonsignificant predictor over the constant-only model, chi square (3, N=26)= 2.149, 41 p<.509. The model summary accounts for 11% of the variance, a nonsignificant chisquare means that the predicted probabilities match the observed probabilities with the outcome of p value of .509. The Exp (B) for rank of victims =.853. The Exp (B) for financial status= 1.149. The Exp (B) for military sexual trauma type=2.388. The hypothesis that financial status, rank and type of sexual trauma of victims predict PTSD among the victims was supported p= .695, Exp (B)= .857, B=-.154. Results Hypothesis #2 The second hypothesis was: Rank and financial status of perpetrators predict PTSD of perpetrators. The first independent variable for this question, financial status of perpetrator, was measured as the following: (a) 20-30,000 with 50%, (b) 31-40,000 with 0%, (c) 41,000-50,000 0%, (d) under 20,000 7.7%, and (e) not known 42.3%. The independent variable rank of the perpetrator was measured as the following: (a) 0-2 years with 15.4%, (b) 6-10 years with 3.8%, (c) 11-15 years with 7.7%, (d) greater than 15 years with 7.7%, (e) not known with 65.4%. The dependent variable is PTSD of the perpetrator measured as: (a) PTSD with 7.7%, (b) no PTSD with 92.3%. For this two predictive logistic regression analysis the predictive accuracy is 92.3%. The model accounts for 100% of the variance according to the Cox and Snell model summary. Results of the logistic analysis indicate that the two-predictor model provides a statistically significant improvement over the constant-only model, chi square (2, N= 26) = 14.102, p<.001. The hypothesis that rank and financial status predict PTSD of the perpetrator was not supported, p = .001, b = 2.485, Exp(B)= 12.000. 42 Summary The results for the perpetrators were significant predicting PTSD with the variables of rank and financial status not significant for the victims. For example rank and financial status of the perpetrator predicted the presence of PTSD among the perpetrator p = .001, b = 2.485, Exp(B)= 12.000. Conversely, rank, financial status, and military sexual trauma type did not predict PTSD among the victims. Therefore this sample did not demonstrate the same results for the perpetrator and the victim as Schmid (2010) found, where military sexual trauma victims were classified as female, young, low ranking, and perpetrators as male, young and low ranking. This research helps to better understand military sexual trauma victims’ legal needs based upon the high proportion of conviction rates for unrestricted cases and psychologically based upon high rates of PTSD. The legal needs of military sexual trauma victims are important to understand since out of the 3,000 unrestricted reports only 529 were court-martialed, and 53% manifested with a conviction (“Fighting For,” 2011). With this sample of 26 military sexual trauma cases 25 were convicted. This research demonstrated the legal needs of military sexual trauma victims that make it to court actually have a high proportion of conviction rates. Psychologically, the needs of military sexual trauma victims are better understood with this sample of 26 criminal military sexual trauma cases since female victims suffered with PTSD. The influencing factors of rank and financial status are important to study given the limitations women have in achieving equality due to restrictions women face in achieving combat position. For example, in military populations women for the last 70 years have been part of the Department of Defense; yet today remain incapable of 43 performing combat positions. Historically women are incapable of working in combat positions, based on the rationale that: (a) women are physically weaker, (b) co-ed groups are less cohesive, and (c) men tend to act in a protective role of female co-workers and this is distractive (Dieckmann, 2011). This leads to lack of financial empowerment compared to male military personnel (Dieckmann, 2011). This research also aimed to better understand perpetrators’ background, with rank and financial status to make suggestions for clinical prevention of military sexual trauma. Prevention programs are made possible by understanding if the service persons are working at the same or different levels of income and rank. The PTSD risk factors also help to make better treatment of military sexual trauma. Further research could look at the relationship between PTSD and committing military sexual trauma by qualitative research that allows for interviews to take place and consultations. Therefore, programs for victims and perpetrators in the research and in clinical assessment and treatment can be further explored in this population to look at prevention of military sexual trauma. Limitations The dependent variable, PTSD of the victim and perpetrator, is limited in determining causation but is helpful in predictions for this research. PTSD diagnosis is based on a clinical disorder that often has multiple etiologies and may have been present prior to the diagnosis during the military sexual trauma case. There is no clear way to therefore maintain that military sexual trauma causes PTSD but it is a predictor and related to the suffering of these sexual assaults to the victim. Furthermore, the criteria for PTSD is limited in validity since the determination was based on the presence of the diagnosis in the facts of the criminal conviction case, not all cases include mental health 44 expert witnesses, and it is not possible to distinguish which cases of victims and perpetrators had the presence of PTSD prior to the rape incident. Therefore, limited scope of information was available for these cases to rule out preceding cases or not diagnosed cases to determine “causation” such as the time of onset, the symptoms, and severity. The independent variables of rank and financial status were not easy to identify in each case, therefore, a high degree of this information was not known, which changes the results’ generalizability. This limitation in information meant that years in the military and a military chart for 2012 (U.S. Department of Defense, 2012) were utilized to assess an estimation of the income level for several of the cases. However, even with this accurate military chart it must be noted that pay changes do occur over the years and this account may be somewhat inaccurate. Another limitation was that it was not possible to account for living expenses that military personnel are granted because this information was not readily available; as such these extra financial income levels were not included. Furthermore, this sample was extremely skewed for criminal conviction rates as 25 out of 26 were guilty convictions, which limits generalizability in terms of a normative sample. Therefore, this is why the dependent variable chosen was not criminal convictions because it was so skewed. Future studies might warrant a more normative sample by making the sample include nonmilitary personnel, minors, or gaining source data by Department of Defense records that the general population does not have access to. 45 CHAPTER FIVE: SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Summary Military sexual trauma is a growing concern for females because 15% of women in the military suffered this problem in 2009 and problems arising from this included PTSD, depression, and lifetime prevalence rates (Kimerling et al., 2010). There were over 3,000 unrestricted reports for sexual assault in 2009 (Bumiller, 2010) however the Department of Defense estimated that the number was more than 19,000 (“Fighting For,” 2011). Out of the 3,000 unrestricted reports only 529 were court-martialed, and 53% manifested with a conviction (“Fighting For,” 2011). Military sexual trauma victims can make either a restricted or unrestricted report; the latter allows legal investigation, medical assistance, and a report from the commander officer (Schmid, 2010). Military sexual trauma research documented women suffer greater than men in frequency distribution of PTSD (Hoyt et al., 2011; Kimerling et al., 2007); lifetime PTSD prevalence rates, (Cater & Leach, 2011; Ford, 1999; DeRoma et al., 2003; Himmelfarb et al., 2006; Hoyt et al., 2011; Minnow et al., 2005; Murdoch et al., 2010;), and affecting Veteran populations (Himmelfarb et al., 2006; Kimerling et al., 2010; Suris & Lind, 2008). Research and reports on how to treat women in the military are targeting alleviating military sexual trauma (Coronel & Rosca, 1993; Fontana et al., 1997; Kimerling et al, 2010; Rowe et al., 2009). The current study analyzed 26 criminal cases of military sexual trauma involving female victims and male perpetrators regarding PTSD bridging a gap to further understand this population. 46 Military sexual trauma prevalence rates have mixed outcomes. This research looked at risk factors such as predictors of PTSD, the most frequented mental health disorder that is a risk factor for military sexual trauma. This research also accounts for the frequency rate of convictions that 25 out of 26 criminal cases lead to conviction. Therefore this research aimed to better understand the risk factors for PTSD that are rank and income for this study as risk factors can help better understand how to prevent the problem. Prevention of military sexual trauma is needed given that “rape holds the highest conditional risk for posttraumatic stress disorder (PTSD)” (Kimerling et al., 2007, p. 2160). This research fills a gap in understanding co-ed populations. For example, military sexual trauma research looking at conviction rates provided frequency reports of rape and assault with male-only military personnel populations (Morris, 1996). Furthermore, co-ed populations are needed to better understand military sexual trauma since 87 percent of the military sexual trauma incidences were male on female (Bumiller, 2010). Therefore, this study bridges a gap in a coed population, looking at not only at frequency of military sexual trauma but relationship and predictor variables to look at prevention, and risk factors of the problem for male perpetrators and female victims. For example regardless of rank or income female victims of military sexual trauma are suffering with PTSD. However male perpetrators of military sexual trauma are suffering with PTSD that is predictive of their income and rank. Analytical Conclusion The results for this research indicate the independent variables of rank and financial status predicted the dependent variable, PTSD, among the perpetrators and not 47 for the victims. These results vary from reports documented by Schmid (2010), where military sexual trauma victims were classified as female, young, low ranking, and perpetrators as male, young and low ranking. Therefore, PTSD occurs in victims regardless of a relationship by rank or financial status. However, limitations of PTSD validity in the diagnosis are present in this study. For example this sample is not as large as the military so the validity in getting similar results is limited. Also this study included the actual conviction rates for unrestricted cases. The bulk of military sexual trauma research regards restricted cases that are not instances of legal remedy occurring by a criminal case. Restricted cases are confidential in the military, as it is what researchers ascertain by self-report for military sexual trauma research. A particularly high proportion of military sexual trauma type is rape at 80.8%. The crime rate for rape in the military versus civilian populations was studied in peacetime and wartime (Morris, 1996). Importantly, results indicated in wartime incidents of rape were higher than in civilian populations (Morris, 1996). However these studies are with male only populations, and did not include females (Morris, 1996). Research Implications A research implication for this research is related to the obstacles of gaining accurate information for client’s self report of military sexual trauma (Schmid, 2010). For example, it is estimated that only 10% of military sexual trauma is actually self reported (Schmid, 2010). Therefore, the specific frequency of this problem is underreported which is also not depicted in the courts based on how the victim is not reporting on the unofficial research level, let alone on the criminal report level leading to a court hearing. The factors that inhibit or impact a victim for reporting need to be better 48 understood in order to correct obstacles that prevent the victim from gaining support to report the crime. Clinical Recommendations PTSD is a high risk factor among military sexual trauma victims and is often is a lifetime prevalent problem. Lifetime prevalence rates of PTSD for female veterans of military sexual trauma rape was 38% among a sample of 336 female outpatient veterans and military rape rate was 8.7% (DeRoma et al., 2003). Women veterans are experiencing severe harm related military sexual trauma warranting legal, psychological, social, and most importantly political change to put an end to these large-scale problems. Therefore, programs need to meet veteran and active military personnel military sexual trauma needs since PTSD is not something that goes away but rather is a lifetime of severe injury. This research delineates a potentially high proportion of mental health problems for victims of military sexual trauma. For example, PTSD was present for 53.8 % of female military sexual trauma victims and 7.7% for the military sexual trauma perpetrators. These results suggest the females are suffering with significantly higher proportion of PTSD, which parallels the rate of PTSD among military sexual trauma victims that exceeds 50% (Cater & Leach, 2011). Given the high correspondence of cooccurring disorders among military sexual trauma victims (Kimerling et al., 2010) programs equipped to help military sexual trauma victims with co-occurring mental health diagnosis are also highly recommended. A program emphasizing training and dissemination for resources of preventing on-site sexual harassment likely could help alleviate some of these problems. Furthermore, a better working environment that 49 minimizes sexual harassment issues could be implemented if changes occur on a largescale task force that has no tolerance for rape in the military. Service providers need to understand why so many military sexual trauma victims fail to seek services. For example, military sexual trauma psychological services are provided for sexual assault victims, however only 25% of 643 men and 38% of 173 women in a study of sexual assault victims from a VA study actually received mental health services (Zinzow et al., 2008). However Kitfield (2012) reported that as of 2010 there were 700,000 military sexual trauma counseling services offered free of charge. Therefore, there is a need for a greater understanding of clients who clearly need clinical help but fail to gain treatment. Accurate Diagnosis Clinical implications relevant to military service members are undergirded by the presence of an accurate diagnosis that enables them to then seek services. Problems in accurate diagnosis for military personnel are an issue (“Fighting For,”2011). For example, diagnosis of borderline personality disorder is frequently given to military sexual trauma victims and this diagnosis leads to the military personnel’s automatic discharge (“Fighting For,” 2011). This is because suspicion for false diagnosis of borderline personality disorder is frequently a problem for female military sexual trauma victims since symptoms can cross over (“Fighting For,” 2011). Therefore, accuracy for assessment and clinical diagnosis are imperative for a victim in seeking services. The ethical rationale of discharging military personnel from mental health services on the basis of a mental health disorder appears to occur. Diagnosis of military personnel as a way to discharge a victim is a further harm to these military sexual trauma 50 military personnel victims. Therefore, victims who are diagnosed whether accurately or not as borderline personality disorder are suffering because they are discharged on the basis of a particular diagnosis, discriminating to a person serving this country, raped, and then at a loss for seeking services. Discharging on the basis of a diagnosis may “blame the victim” and is discriminating against a person on the basis of what is outside their control, their mental health problem (“Fighting For,”2011). It further posits a need for better accuracy in mental health diagnosis. Also better education about the wide spectrum of symptoms a person could display when in crisis, after a rape, and the complex PTSD spectrums that can be based on a lifetime of sexual assaults. Blame the Victim Historically victims have been blamed for perpetrator acts and psychological and societal support reflects these injustices (Moriarty, 2003). Then the victim has other obstacles to alleviate her already disempowered life when attacked by a perpetrator because likely she will have other sets of problems. Problems such as an insecure attachment early in life can lead to greater vulnerability to developing risk factors for being a victim (Davies, 2005) such as with low self esteem, (Grant, 2000) or mood disorder, (Herman, 1992), and ways to cope with that such as substance abuse disorders, (Brems, Johnson, Neal, & Freeman, 2004). Importantly, service members who are diagnosed with personality disorders such as borderline personality disorder is a problem for the victim because it leads to a discharge from the military and this has been a problem for decades (“Fighting For,” 2011). A personality disorder is also a criteria for a veteran to not receive any veteran 51 benefits, a stigma that punishes the victim for coming forward, seeking treatment, and retaliation against her aggressor (“Fighting For,” 2011). Recommendations Currently the U.S. military has a department that created a prevention program for sexual assault called the United States Department of Sexual Assault Prevention and Response (U.S. Department of Defense, 2012). Schmid (2010) indicated in the military prevention programs the following issues remain to meet the needs of military sexual trauma: (a) responses to victims of military sexual trauma in the research, assessment, and clinical treatment psychologically, and (b) the legal, prosecution responses. The legal response among military sexual trauma in this sample shows a high significance of guilty rates, with 25 out of 26 cases guilty. Therefore, this research is helping to answer imperative answers about this population needs psychologically and legally, although coupled with limitations. Smith (2011) distinguished the criteria for medical liability of victims suffering with PTSD with the following elements demonstrating: (a) PTSD in DSM-IV requires criteria A of an “external factor” causing the psychological diagnosis; (b) the agent who caused the injury; (c) the damages caused to the person based on the evidence of the injury; and (d) placing liability for civil and criminal damages. Therefore, the legal consequences of military sexual trauma require proper documentation and assessment that are psychological and legal responses. PTSD in these cases was measured as the dependent variable according to the inclusion of the diagnosis for the victim and the perpetrator in the facts of the criminal cases. The inclusion of PTSD is based upon the facts presented by the prosecution legal team. They will often hire an expert, licensed mental health professional to assess, diagnose, and to 52 build an argument for the victim’s physical and mental damages. Also victims often go to clinics for help and are diagnosed there and then have records released to courts. These risk factors of PTSD among military sexual trauma in this sample is comparable to the military sexual trauma population, since 53.8% of the female sample here suffered with PTSD and in the research I found it is over 50% among the victims of military sexual trauma to suffer with PTSD. However limitations occur with PTSD validity here since it is an indirect variable that is not measured through a standard assessment for each victim and perpetrator here. Furthermore, there is not any way to know if victims in cases that did not mention PTSD really did not have PTSD, or if PTSD precedes the military sexual trauma, which is a further limitation that needs to be acknowledged. Prevention Programs The independent variables of financial status and rank predicted PTSD rates for perpetrators of military sexual trauma, which delineates a difference between victims and perpetrator outcomes for this research. This is impacted by a difference in rank and financial empowerment among females in military populations has occurred for women for the last 70 years (Dieckmann, 2011). Historically the political branches of law decided women as incapable of working in combat positions, based on the rationale that: (a) women are physically weaker, (b) co-ed groups are less cohesive, and (c) men tend to act in a protective role of female co-workers and this is distractive (Dieckmann, 2011).Females who remain incapable of performing combat positions leads to lack of financial empowerment compared to male military personnel (Dieckmann, 2011). Understanding risk factors, predictors, and clinical diagnosis associated with perpetrators and victims helps to better understand military sexual trauma. A particularly 53 high proportion of military sexual trauma type was rape, with 80.8%. High rape incidences are reported in the research because 33% of female Veterans were raped while serving the US military and in this number of victims multiple rapes occurred for 37% of the group and gang rape occurred for 14% (Corbett, 2007). The strongest relationships among perpetrators of premilitary rape were those who were abused as children physically and sexually (Merrill, Thomsen, Gold, & Milner, 2001). Furthermore, understanding perpetrators previous assaults were studied among 10% of Navy recruits who admitted they raped prior to military entry (Merrill et al., 2001). Therefore, perpetrators in the military may have sexual and physical abuse backgrounds, which can be a risk factor for PTSD. Therefore, these results are consistent with abused men who are then re-enacting their abuses. Further research could ask qualitative approaches about the history of abuse and mental illness among perpetrators and victims of military sexual trauma to answer these questions. A prevention program could make assessments of self-report in recruiting that discriminate by not allowing sex offenders join up on the basis of breaking moral codes that military personnel are supposed to uphold. Programs that educate, teach, and coordinate military personnel on how to communicate power struggles, what sexual harassment is, respect for others, and the need to get leaders involved to help assert support for victims are all apart of the process of bringing better awareness to this problem (Schmid, 2010). These ideas were expressed with a need to change on political levels by: (a) affecting leadership in the military to change the responses of the military culture towards women in the military, (b) statutes and policies to specify protection in the form of codes that require and delineate specific 54 results legally to punish perpetrators that are enforced, and (c) executive action to formulate prevention programs to change this problem from the onset (Schmid, 2010). Once these programs are created to prevent military sexual trauma, program evaluations, client satisfaction surveys, and research studies can further delineate the issues that are still occurring. Military sexual trauma prevention programs are not currently published in the research, which represents the need for outcome research to evaluate this program. Free military sexual trauma treatment is available for qualified military personnel (Kimerling et al., 2010). Access to treatment is for a variety of problems such as cooccurring psychological disorders of PTSD, anxiety, depression, and substance abuse problems (Kimerling et al., 2010). These results elucidate the foundation for creating programs to prevent military sexual trauma. However, future research can make comparisons among veteran samples, active duty, reserve populations, and make programs based on the differences or similarities for the military population and their needs to prevent sexual trauma. Based on the aforementioned findings, the following suggestions may help prevent military sexual trauma: (a) revise the discharge of a military sexual trauma victim on the basis of certain psychological diagnosis; (b) rule out accepting recruits into the military on the basis of previous rape and or assess for previous criminal records with greater discrimination; (c) continue to research among veteran, active duty, and reserve groups for military sexual trauma predictors and relationship variables to better understand the needs of this population; and (d) program evaluation research for the prevention programs that are currently in use for the department of defense. 55 Future Implications Given this research is cutting edge without any other studies looking at predicting PTSD among female victims and male perpetrators of military sexual trauma, these variables will allow for preliminary attempts to predict variables about PTSD with this population. Future studies could make a comparison for sexual assault victims by the military in civilian populations and among minors. This research made statements about how prevention programs and victim supports programs are needed for military services. For example, based upon the legitimacy of bullying and torture that 16 victims dealt with in pursuing damages for military sexual trauma in the current case Cioca et al. v Rumsfeld et al.(“Fighting For,” 2011) this is an immediate concern. In this case that is now in court since 2011, 16 service persons from the military are filing a class action for constitutional offenses against the government for military sexual trauma. Therefore, this research provides a rationale for that military sexual trauma is a strong risk factor for severe injury with PTSD. Furthermore, work related injuries in moving up the rank are negative implications for service members seeking counseling services for military sexual trauma create a lack of confidentiality for service members when seeking security clearance positions, that could potentially threaten a rank or income promotion (Maze, 2011). This type of issue then blames the victim further and is a problem for seeking services to treat her injury she may then suffer in her career further. Another serious problem among military sexual trauma victims is “lesbian baiting” problems. For example, according to “Fighting For” (2011), “Under DADT, women faced the possibility of being discharged 56 for refusing to sleep with men who were harassing them. DADT was used as a threat and tool of punishment to put down anyone who didn't conform” (p. 7). Future directions of research should aim to uncover medical and psychological treatment for military sexual trauma. For instance, further support systems for military sexual trauma victims to disseminate information to victims regarding legal support; medical support, and mental health support are likely if there is a strong predictor for military sexual trauma verdict. This research is also important as a better understanding of the predictor variables for military sexual trauma, such as rank and financial status, can help create prevention programs that better meet perpetrator and victim needs. For example, stronger leadership might be helpful for supervising young female recruits who work in close courters with older, higher-ranking males. Direction on what to do when military sexual trauma occurs, such as whom to tell, who can help, and what support is available is needed. Therefore, the hypothesis outcomes will guide the potential implications for this research providing prevention and education for what is needed to mitigate and better understand the military sexual trauma problem in the military. 57 References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Aosved, A. C., Long, P. J., & Voller, E. K. (2011). Sexual revictimization and adjustment in college men. Psychology of Men & Masculinity, 12,(3), 285-296.doi: 10.1037/a0020828 Army mental health advisory team recommends increasing provider-to-service member ratio in theater. (2010). Retrieved from http://www.usmedicine.com/articles/armymental-health-advisory-team-recommends-increasing-provider-toservicemember-ratio-in-theater.html Bosworth, H. B., Parsey, K. S., Butterfield, M. I., McIntyre, L. M., Oddone, E. Z., Stechuchak, K. M., & Bastian, L. A. (2000). Racial variation in wanting and obtaining mental health services among women veterans in a primary care clinic. Journal of National Medicine Association, 92(5), 231-236. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10881472 Brems C., Johnson, M. E., Neal, D., & Freeman, M. (2004).Childhood abuse history and substance use among men and women receiving detoxification services. American Journal of Drug and Alcohol Abuse, 30, 799–821. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/15624550 Brewin, C. R., Kleiner, J. S., Vasterling, J. J., & Field, A. P. (2007). Memory for emotionally neutral information in posttraumatic stress disorder: A meta-analytic investigation. Journal of Abnormal Psychology 116,(3), 448-463. doi: 10.1037/0021-843X.116.3.448 Bryan, C. J., & Corso, K. A. (2011). Depression, PTSD, and suicidal ideation among active duty veterans in an integrated primary care clinic. Psychological Services, 8,(2), 94-103.doi:10.1037/a0023451 Buchanan, N. T., & Fitzgerald, L. F. (2008). Effects of racial and sexual harassment on work and the psychological well-being of African American women. Journal of Occupational Health Psychology, 13, 137–151.doi:10.1037/1076-8998.13.2.137 Bumiller, E. (2010, March 17). Sex assault reports rise in military. The New York Times.Retrieved from http://www.nytimes.com. Cater, J.K., & Leach, J. (2011). Veterans, military sexual trauma and PTSD: Rehabilitation planning implications. Journal of Applied Rehabilitation Counseling, 42(2), 33-40. Retrieved from http://www.proquest.com 58 Cohen, J. (1992). Statistical power analysis. Current Directions in Psychological Science, 1(3), 98. Retrieved fromhttp://www.jstor.org/pss/20182143 Collins, E. M. (2010). Surviving sexual assault. Retrieved from http://www.army.mil/article/44333/Surviving_sexual_assault/ Corbett, S. (2007, March 18). The women’s war. The New York Times.Retrieved fromwww.nytimes.com Coronel, S., & Rosca, N. (1993). For the boys: Filipinas expose years of sexual slavery by the U.S. and Japan. Ms. Magazine, 10-17. Davies, D. (2004). Child development, Third Edition: a practitioner's guide (social work practice with children and families). New York, NY: Guilford Press. DeRoma, V. M., Root, L. P., & Smith, S. (2003). Socio-environmental context of sexual trauma and well being of women veterans. Military Medicine, 168, 399-403. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pubmed/12775177 Dieckmann, C. M. (2011). Equal pay for equal work? The distribution effects of the assignment policy for military women. Columbia Journal of Gender and Law. 22(1), 250. Retrieved from https://westlaw.com Dobson, M., Grayson, D. A., Marshall, R. E., & O’Toole, B. I. (1998).Postwar experiences and treatment-seeking behavior in a community counseling setting. Journal of Traumatic Stress, 11,(3), 579-587. doi: 10.1023/A:1024464915138 Duncan, A. D. (1997). Sexual harassment liability from a behavioral scientist’s perspective. American Bar Association Center for Continuing Legal Education.Retrieved fromhttps://westlaw.com Donnelly, E. (2007). Constructing the co-ed military. Duke Journal of Gender Law & Policy, 14(2/4). Retrieved from http://scholarship.law.duke.edu/djglp/vol14/iss2/4 Evans releases military sexual trauma report suppressed by administration. (2005.) [Press release]. Retrieved from https://fednews.com Fighting for military women. (2011). Trial, 47(10), 1-9. Retrieved fromhttps://westlaw.com Fontana, A., Schwartz, L. A., & Rosenheck, R. (1997).Posttraumatic stress disorder among female Vietnam veterans who seek treatment. American Journal of Public Health, 87, 169-175. Funk, D. (2005, Oct. 17). Study: 60 percent of women in reserves suffer sex trauma. Marine Corps Times, 30. Retrieved from http://www.proquest.com 59 Garner, B. A. (2004). Black’s law dictionary (8thed.). St Paul, MN: Thomson West. Goldstoff, M. G. (2010). Security Council Resolution 1820: An imperfect but necessary resolution to protect citizens from rape in war zones. Cardozo Journal of Law and Gender,16, 491-517.Retrieved from http://www.cardozolawandgender.com/uploads/2/7/7/6/2776881/163_goldstoff.pdf Grant, R. (2000). A comprehensive and integrative approach to the diagnosis and treatment of trauma. Oakland, CA: Author. Hall, M. E., Sedlacek, A. R., Berenbach, J. A. R., & Dieckmann, N. F. (2007). Military sexual trauma services for women veterans in the Veterans Health Administration: The patient-care practice environment and perceived organizational support. Psychological Services 4(4), 229-238. doi: 10.1037/15411559.4.4.229 Halligan, S. L., Michael, T., Wilheim, F. H., Clark, D. M., & Ehlers, A. (2006). Reduced heart rate responding to trauma reliving in trauma survivors with PTSD: correlates and consequences. Journal of Traumatic Stress, 19,(5), 721–734. doi: 10.1002/jts.20167 Haskell, S. G., Gordon, K. S., Mattocks, K., Duggal, M., Erdos, J., Justice, A., & Brandt, C. A. (2010). Gender differences in rates of depression, PTSD, pain, obesity, and military sexual trauma among Connecticut war veterans of Iraq and Afghanistan. Journal of Women’s Health, 19(2), 267-271.doi: 10.1089=jwh.2008.1262 Herman, J. (1992). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York, NY: Basic Books. Highlights in the history of military women.(n.d.) Retrieved from http://www.womensmemorial.org/Education/timeline.html Himmelfarb, N., Yaeger, D., & Mintz, J. (2006). PTSD in female veterans with military and civilian sexual trauma. Journal of Traumatic Stress, 19, 837-846. Hoyt, T., Klosterman, R. J., & Williams, L. F. (2011). Military sexual trauma in men: A review of reported rates. Journal of Trauma Dissociation, 12(3), 244-260. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/21534094 Inspector general to review Veterans Affairs military sexual trauma billing policy nationwide due to Akaka oversight. (2009). [Press release]. Retrieved from http://www. proquest.com Johnson, D. M., & Zlotnick, C. (2009). HOPE for battered women with PTSD in domestic violence shelters. Professional Psychology: Research and Practice, 60 40(3), 234-241. doi: 10.1037/a0012519 Katz, L. S., Bloor, L. E., Cojucar, G., & Draper, T. (2007). Women who served in Iraq seeking mental health services: Relationships between military sexual trauma, symptoms, and readjustment. Psychological Services 4,(4), 239-249. doi: 10.1037/1541-1559.4.4.239 Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. (2007). The Veterans Health Administration and military sexual trauma.American Journal of Public Health, 97(12), 2160-2166. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17971558 Kimerling, R., Street, A. E., Pavao, J., Smith, M. W., Cronkite, R. C, Holmes, T. Y. T. H., & Frayne, S. M. (2010). Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq. American Journal of Public Health, 100, 1409-1412.doi: 10.2105/AJPH.2009.1717193. Kitfield, J. (2012, September). The military's rape problem. National Journal. Retrieved fromhttp://www.nationaljournal.com/magazine/the-military-srape-problem-20120913?page=1 Lillian Goldman Law Library (2008a). Convention between the United States of America and other powers, relating to prisoners of war; July 27, 1929. Retrieved from http://avalon.law.edu/20th_century/geneva02.asp Lillian Goldman Law Library (2008b). Geneva Convention (III) relative to the treatment of prisoners of war; August 12, 1949. Retrieved from http://avalon.law.yale.edu/20th_century/geneva03.asp Lim, S., & Cortina, L.M. (2005).Interpersonal mistreatment in the workplace: The interface and impact of general incivility and sexual harassment. Journal of Applied Psychology, 90(3) , 483-496. Retrieved from http://www.proquest.com Luce, S., & Brenner, M. (2004). Women and class: What has happened in forty years? Monthly Review, 58(3), 80-91. Retrieved from http://monthlyreview.org/2006/07/01/women-and-class-what-has-happened-inforty-years Luterek, J. A., Bittinger, J. N., &Simpson, T. L. (2011). Posttraumatic sequelae associated with military sexual trauma in female veterans enrolled in VA outpatient mental health clinics. Journal of Trauma & Dissociation, 12, 261-274. doi: 10.1080/15299732.2011.551504 61 Marczyk, G., DeMatteo, D., & Festinger, D. (2005). Essentials of research design and methodology. Hoboken, NJ: John Wiley & Sons, Inc. Maze, R. (2011). Assault victims raise clearance concerns. Army Times, 8-8. Retrieved from http://www.proquest.com Merrill, L. L., Thomsen, C. J., Gold, S. K., & Milner, J. S. (2001). Childhood abuse and premilitary sexual assault in male Navy recruits. Journal of Consulting and Clinical Psychology, 69(2), 252-261. doi:10.1037//0022-006X.69.2.25 Monroe K. R., & Chiu, W. F., 2010.The profession gender equality in the academy: The pipeline problem. Political Science & Politics, 43, 2), 303-308. doi:http://dx.doi.org/10.1017/S104909651000017X More research needed (2007). Air Force Times, 44-44. Retrieved from http://www.proquest.com Moriarty, L. J. (2003). Controversies in victimology. Cincinatti, OH: Anderson Publishing Co. Morris, M. (1996). By force of arms: rape, war and military culture. Duke Law Journal, 45, 651. Retrieved from https://westlaw.com Murdoch, M., Pryor, J. B., Griffin, J. M., Ripley, D. C., Gackstetter, G. D., Polusy, M. A., & Hudges, J. S. (2011). Unreliability and error in the military’s “gold standard” measure of sexual harassment by education and gender. Journal of Trauma & Dissociation, 12(3), 216–231. doi: 10.1080/15299732.2011.551506 Murdoch, M., Pryor, J.B., Polusny, M. A., Wall, M. M., Cowper, R., & Gackstetter, G. D. (2010). The association between military sexual stress and psychiatric symptoms after controlling for other stressors.Journal of Psychiatric Research, 44, (16), 1129-1136. doi: 10.1016/j.jpsychires.2010.09.009 Obama, B. (2012). Proclamation 8794-National Sexual Assault Awareness and Prevention Month, 2012. Retrieved from http://www.proquest.com Polusny, M.A., Dickinson, K.A., Murdoch, M., & Thuras, P. (2008). The role of cumulative sexual trauma and difficulties identifying feelings in understanding female veterans' physical health outcomes. General Hospital Psychiatry, 30(2), 170. doi: 10.1016/j.genhosppsych.2007.11.006 Power, K. (2010). SAMHSA’s Eight Strategic Initiatives. Military Families. Retrieved from: http://www.samhsa.gov/militaryFamilies 62 Riger, S. (1993). What’s wrong with empowerment. American Journal of Community Psychology, 21(3), 279-292.b. Retrieved from http://www.springerlink.com/content/p512521t04002551/ Rowe, E. L., Gradus, J. L., Pineles, S. L., Batten, S. V., & Davison, E. H. (2009). Military sexual trauma in treatment seeking women veterans. Military Psychology 21, 387-395. doi: 10.1080/08995600802565768. Schmid, M.N. (2010). Combating a different enemy: Proposals to change the culture of sexual assault in the military. Lancaster, PA: Villanova University. Retrieved from https://westlaw.com Seifert, A. E., Polusny, M. A., & Murdoch, M. (2011). The association between childhood physical and sexual abuse and functioning and psychiatric symptoms in a sample of U.S. Army soldiers. Military Medicine 176, (2), 176-181. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21366080 Smith, B. N., Shipherd, J. C., Schuster, J. L., Vogt, D. S., King, L. A., & King, D.W. (2011).Posttraumatic stress symptomatology as a mediator of the association between military sexual trauma and post-deployment physical health in women. Journal of Trauma & Dissociation, 12, 275–289. doi: 10.1080/15299732.2011.551508 Smith, D. M. (2011). Diagnosing liability: The legal history of posttraumatic stress disorder. Temple Law Review, 84(1), 1-70. Retrieved from https://sites.temple.edu/lawreview/archive/ Statutes of limitation for prosecuting rape and or sexual assault.(n.d.) Retrieved from: http://www.relieffundforsexualassaultvictims.org/resources/statutesoflimitationcri m-D.pdf Statute of the International Tribunal for the prosecution of persons responsible for serious violations of international humanitarian law committed in the territory of the former Yugoslavia since 1991, U.N. Doc. S/25704 at 36, annex (1993) and S/25704/Add.1 (1993), adopted by Security Council on 25 May 1993, U.N. Doc. S/RES/827 (1993).Retrieved http://www1.umn.edu/humanrts/icty/statute.html Street, A. E., Vogt, D. & Dutra, L. (2009). A new generation of women veterans: Stressors faced by women deployed to Iraq and Afghanistan. Clinical Psychology Review 29,(8), 685-694. doi: 10.1016/j.cpr.2009.08.007 Suris, A. & Lind, L. (2008). Military sexual trauma: a review of the prevalence and associated health consequences in Veterans. Trauma, Volence, & Abuse, 9, (4), 250-269. Retrieved from http://tva.sagepub.com/content/9/4/250.abstract 63 Taylor, S. (2008). Selective concern on sex balances. Retrieved from http://proquest.umi.libproxy.edmc.edu/pqdweb?index=28&did=1885793611&Src Tolin, D. F., & Foa, E. B. (2008). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Trauma: Theory, Research, Practice, and Policy, 1, 37-85. doi: 10.1037/1942-9681.S.1.37 Treatment of sexual violence in international law.(n.d.). Retrieved fromhttp://www.iccwomen.org/resources/crimeschart.htm U. S. Department of Defense (2012).Department of Defense annual report on sexual assault in the military, fiscal year 2011. Retrieved from http://www.sapr.mil/media/pdf/reports/Department_of_Defense_Fiscal_Year_201 1_Annual_Report_on_Sexual_Assault_in_the_Military.pdf Valente, S., & Wight, C. (2007). Military sexual trauma: violence and sexual abuse. Military Medicine, 172(3), 259-265. Retrieved from http://search.proquest.com.libproxy.edmc.edu/docview/217048812/fulltextPDF/1 31A299BA5074D46FAE/10?accountid=34899 Weiss J .J., & Gorman, J. M. (2005). Antidepressant adherence and suicide risk in depressed youth. American Journal of Psychiatry, 162, 756–1757.Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16135644 Williams, I., & Bernstein, K. (2011). Military sexual trauma among U.S. female veterans. Archives of Psychiatric Nursing 25, (2), 138-147. doi: 10.1016/j.apnu.2010.07.003 Youseff, N., (2010, March 16). Reports of sexual assault in military rose 11 percent in 2009. McClatchy Newspapers. Retrieved fromhttp://www.mcclatchydc.com/2010/03/16/90507/reports-of-sexual-assault-inmilitary.html Zinzow, H. M., Grubaugh, A. L., Frueh, B. C., & Magruder, K. M. (2008). Sexual assault, mental health, and service use among male and female veterans seen in Veterans Affairs primary care clinics: A multi-site study. Psychiatry Research 159(1-2), 226-236. doi: 10.1016/j.psychres.2007.04.008