Victims of military sexual trauma—you see them, too

Multiple physical symptoms are often trauma-related

Veterans with a history of MST are also more likely to report physical symptoms²⁵ and to have a lower health-related quality of life,²⁶ poorer health status, and more outpatient visits¹² than vets who were not exposed to MST. And, while pelvic pain is widely believed to be associated with female sexual abuse, survivors often present with a wide range of physical problems. The most common symptoms, similar to those affecting civilian rape survivors, include headache, gastrointestinal (GI) problems, chronic fatigue, severe menopause symptoms, and urological problems, as well as pelvic pain and sexual problems.²⁷ Cardiac and respiratory disorders are also common (TABLE 2).^17,25

Compared with their unaffected counterparts, women with a history of MST are more likely to be obese and sedentary, to smoke and drink, and to have had a hysterectomy before the age of 40 years.²⁸ They are also more than twice as likely as other female veterans to say that they were treated for a heart attack within the past year.²⁵ Data on the physical symptoms of male survivors of MST are extremely limited, but one study found an association with pulmonary and liver disease and human immunodeficiency virus and acquired immune deficiency syndrome.¹⁷

TABLE 2
Common physical symptoms reported by female MST survivors*^17,25

A cluster of nonspecific findings?
Patients with a history of MST often present with complex and nonspecific signs and symptoms, making it difficult for a primary care physician to arrive at a diagnosis. MST and combat-related trauma should be considered in such cases, as well as in veterans who present with complaints involving multiple organ systems.^21,25

Refer, treat—or do both

Once you have evidence that a patient is a survivor of MST, you need to consider a mental health referral or consultation and address physical symptoms. All honorably discharged veterans are eligible to receive VA treatment for MST, regardless of their disability rating or eligibility for other services. If a veteran indicates that he or she would like to seek psychotherapy or see a specialist outside of the VA system, it will fall to you to help the patient find the most appropriate treatment. (You’ll find links to VA and nonmilitary resources in the box.) Either way, patient acuity is a guide to the optimal approach.

Inpatient treatment will likely be needed for a patient who reveals thoughts of self-harm or harming others. If the patient is safe and stable enough for outpatient treatment, a therapist or psychiatrist with experience in treating sexual trauma is a good first step. Cognitive behavioral therapy and trauma-focused therapy have both been shown to have good outcomes in patients with sexual trauma and PTSD.²⁹ Depending on the individual’s key presenting issues, a consultation with a substance abuse specialist, gynecologist, or other specialist may be helpful, as well.

As a family physician, you are in a position to build a long-term, trusting relationship with such a patient, which may be therapeutic in itself.⁹ In building such a relationship, keep in mind that the experience of serving in the military could make a patient particularly sensitive, or resistant, to your advice; you’ll need to strive for a collaborative approach.

CASE You tell Ms. Doe that the incident she described was indeed sexual violence—and specifically known as military sexual trauma. Her feelings about it are likely surfacing now due to the time away from the military—and by the fact that she’s beginning to date. In addition to spending some time listening to her story, you advise Ms. Doe to start seeing a therapist. You suggest she consider VA treatment services, and direct her to its MST web site (www.mentalhealth.va.gov/msthome.asp). Before she leaves, you make it clear that you will continue to see and support her through this difficult time, and you schedule a follow-up visit.