Military Sexual Trauma in the United States: A Comprehensive Review



Abstract

Military sexual trauma (MST) refers to sexual assault or harassment during military service and is a widespread issue with serious effects on U.S. veterans’ health. Studies show that about 38.4% of women veterans and 3.9% of men veterans have experienced MST. MST is more likely than combat exposure to lead to posttraumatic stress disorder (PTSD) and is also linked to depression, suicidality, substance use, eating disorders, and homelessness. The U.S. Department of Veterans Affairs (VA) screens all veterans for MST and offers free related healthcare, but challenges like underreporting, institutional betrayal, and a lack of MST-specific treatments remain. This review summarizes current research on MST’s prevalence, risk factors, health effects, treatments, and related policies in the United States.

Introduction

The U.S. Department of Veterans Affairs uses the term military sexual trauma (MST) to describe psychological trauma from sexual assault or repeated, threatening sexual harassment during military service.[1][2] MST is not a clinical diagnosis but refers to the experience itself, covering a wide range of unwanted sexual behaviors, from verbal coercion to physical assault.[3][4] Over the past thirty years, MST has become recognized as a distinct type of military trauma, as awareness has grown about how common it is and how much it affects mental and physical health compared to other military traumas.[4][5]

The military environment presents unique contextual factors that distinguish MST from sexual trauma in civilian life. These include strict hierarchies, close living and working spaces, cultures that may discourage reporting, and situations where survivors must keep living or working with perpetrators.[1][4] These conditions increase the risk of sexual trauma and can worsen psychological effects, leading to what is called institutional betrayal, which can cause additional harm.[2] This context also frames the review’s focus on epidemiology, risk factors, health consequences, treatment approaches, and the VA systems designed to support survivors.

Epidemiology and Prevalence

It is difficult to know the true rate of MST because definitions, measurement tools, and study groups vary, and underreporting is common. Most MST research has been conducted in the United States, with 58 of 63 studies originating there.[6]

Studies estimate that about 38.4% of U.S. women veterans have experienced MST, with 23.6% reporting sexual assault and 52.5% reporting sexual harassment.[6] For men, the rate is 3.9%.[6] Because most service members are men, the total number of male MST survivors is still large.[7]

VA screening data from the program, which started in 2002, show lower rates: about 24–29% of women and 1.3–1.6% of men screen positive for MST.[4][8] This difference from research estimates is likely due to underreporting in clinical settings, as veterans may not disclose MST because of stigma, shame, or privacy concerns.[9]

Fewer than one in five MST incidents are reported while the person is still in the military.[3] This underreporting makes it harder for survivors to get immediate help and later file disability claims, since there is often no official record of the event.[3]

Risk Factors

Researchers have found both individual and institutional risk factors for MST. People with less power in society or the military, such as those with a lower rank, younger age, or minority status, face a higher risk.[4][5] Women are affected more often, but MST can happen to anyone.[8]

Institutional and environmental factors are important. The military’s strict hierarchy, focus on unit cohesion, geographic isolation, and cultures that may accept sexual harassment all create conditions where sexual trauma can happen and continue.[4][5] Rank-based power differences can be misused by perpetrators and may deter survivors from reporting.[9]

Having experienced trauma before, such as childhood adversity or sexual trauma, before joining the military, increases the risk of MST.[10] Still, MST is a stronger predictor of later PTSD than earlier sexual trauma, combat, or other military stressors.[8][11]

Mental Health Consequences

MST has a major impact on mental health and is linked to much higher rates of several psychiatric conditions:[4][6][8]

- Posttraumatic Stress Disorder (PTSD): PTSD is the most common mental health sequela of MST, with adjusted odds ratios (AORs) ranging from 3.00 to 8.83 across studies. MST is a stronger predictor of PTSD than combat exposure, and MST-related PTSD may present with a distinct symptom constellation compared to combat-related PTSD, including greater interpersonal difficulties, chronic anger, and disrupted attachment.[1][4][8][11]

- Depression: MST is associated with significantly elevated rates of major depressive disorder (AOR 2.32–2.64).[8]

- Suicidality: Both suicidal ideation (AOR 1.76–2.37) and suicide attempts or mortality (AOR 1.95–2.21) are significantly associated with MST exposure. Perceptions of institutional betrayal — the belief that the military failed to prevent, respond to, or adjudicate the trauma — independently predict suicidal self-directed violence beyond the effects of MST itself.[2][8]

- Substance Use Disorders: MST is associated with increased rates of alcohol and drug use disorders (AOR 1.63–2.26).[8]

- Eating Disorders: MST exposure is associated with disordered eating (AOR 1.94).[8]

- Homelessness: Veterans with MST histories are at significantly increased risk of homelessness (AOR 1.89–2.63).[8]

The kind and mix of MST experiences affect how severe the outcomes are. Veterans who went through both sexual assault and harassment have worse PTSD, depression, and suicidality than those who experienced only one type.[12] This shows why it is important to look at all types of MST, not just sexual assault.

Gender affects how MST relates to mental health. Both men and women are impacted, but some studies suggest women have higher rates of PTSD after MST than men.[8]

Physical Health Consequences

MST is linked to many physical health problems, not just mental health issues. These include heart disease, chronic pain, liver and kidney disease, reproductive problems, sexual dysfunction, and sexually transmitted infections.[4][5] The reasons are complex and may involve chronic stress, risky health behaviors like substance use or disordered eating, and difficulty accessing healthcare.[5]

Women veterans who have experienced MST report more chronic health problems and use healthcare services more often than those who have not.[5] When MST is combined with other military exposures, such as environmental hazards or injuries, physical health risks can increase further. These findings lead to the distinct clinical features of MST-related PTSD, which shape treatment considerations.

Unique Clinical Features of MST-Related PTSD

PTSD from MST is different from PTSD caused by combat in several important ways, which affect how it should be treated:[1][11]

1. MST commonly involves multiple or ongoing traumatic events rather than a single discrete index trauma, complicating the application of standard trauma-focused therapies designed around a single worst event.

2. The interpersonal nature of MST — involving betrayal by a fellow service member or superior — disrupts fundamental capacities for trust, attachment, and intimacy in ways that combat trauma typically does not.

3. Survivors may have been required to continue living and working with the perpetrator, creating a sustained threat environment without the possibility of escape.

4. Chronic anger, emotional withdrawal, resentment, and difficulties in interpersonal relationships are prominent features.

5. Institutional betrayal — the perception that the military institution failed to protect the survivor or respond appropriately — adds a layer of systemic trauma that compounds individual-level effects.[2]

These differences mean that MST-related PTSD may fit better within a complex trauma framework, which has implications for choosing and ordering treatments.[11] This helps explain the subsequent treatment approaches.

Treatment Approaches

There is no psychotherapy designed just for MST-related PTSD.[1] The VA currently uses standard PTSD treatments, mainly Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE), which are recommended as first-line options by VA/DoD guidelines.[1][4]

However, new research suggests these therapies may not work as well for MST-related PTSD as they do for combat-related PTSD.[1] This may be because MST often involves trauma from relationships, multiple traumatic events, and problems with emotions and relationships that CPT and PE do not directly address. These limits have prompted the investigation of alternative and complementary approaches.

Alternative and complementary approaches under investigation include:

- Group Therapy: A recent randomized clinical trial evaluated a group therapy specifically designed for MST-related PTSD symptoms among veterans. This intervention addressed the interpersonal consequences unique to MST, including disrupted trust, attachment difficulties, and chronic anger. Group-based approaches may offer particular benefits for MST survivors by providing a corrective interpersonal experience and reducing isolation.[1]

- Stage-Based Treatment Models: For veterans with complex trauma, it may help to first focus on emotion regulation and relationships before processing trauma. Examples include Skills Training in Affective and Interpersonal Regulation (STAIR), Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT). These approaches recognize that building skills and stability may be needed before trauma-focused work in complex cases.[11]

- Multimodal Short-Term Therapy Groups: Pilot programs have explored multimodal group interventions specifically for male veterans with MST, incorporating psychoeducation, skills training, and peer support.[7]

- Mind-Body Interventions: Yoga, mindfulness-based stress reduction, and other mind-body approaches are being investigated as adjunctive treatments.[4]

- Technology-Based Interventions: Mobile apps, telehealth, and online resources can help more veterans get care, especially those in rural areas or who cannot attend in-person treatment.[5]

VA Screening and Healthcare System

The U.S. VA runs the world’s most comprehensive healthcare system for MST. Its main features include:[3][4][5]

- Universal Screening: Since 2002, all veterans seen at VA facilities have been screened for MST using a brief validated screening instrument. This represents the only system-wide, standardized screening program for military sexual trauma globally.

- Free Healthcare: All veterans who screen positive for MST are eligible for free healthcare for MST-related physical and mental health conditions, regardless of service-connected disability status, length of service, era of service, or whether the trauma was reported during military service.

- No Documentation Required: Veterans do not need to provide proof or documentation of MST to receive MST-related care.

- MST Coordinators: Every VA medical facility has a designated MST Coordinator who assists veterans in navigating available services and accessing appropriate care.

Disability Benefits and Claims

Veterans may pursue service-connected disability compensation through the Veterans Benefits Administration (VBA) for conditions caused or worsened by MST.[3] The claims process for MST-related conditions presents unique challenges:

- MST-related PTSD claims require establishing a nexus between the in-service traumatic experience and a currently diagnosed condition.

- Because MST is frequently unreported during service, standard service records may not contain corroborating evidence. Alternative forms of evidence — including behavioral changes documented in personnel records, performance evaluations, lay statements from fellow service members or family, and records of substance use or mental health treatment — may be used to substantiate the stressor.[3]

- Claims examiners have described the adjudication process as involving considerable ambiguity, with significant discretion exercised in evaluating the credibility and sufficiency of alternative evidence.[3]

- Benefits are granted for the resulting disability (e.g., PTSD, depression), not for the MST experience itself.[3]

Institutional Betrayal

More research shows that institutional betrayal worsens the effects of MST.[2] Institutional betrayal happens when the military, which veterans trust, does not prevent sexual trauma, responds poorly to reports, retaliates against those who report, or does not hold perpetrators accountable. Feeling betrayed by the institution can increase the risk of suicide among veterans with MST, even after accounting for how severe the trauma was.[2] This means that the military's response to MST is important for both policy and clinical care.

Future Directions

Several priorities for future research and policy have been identified:[1][4][5]

1. Development and evaluation of MST-specific evidence-based treatments that address the unique interpersonal and complex trauma features of MST-related PTSD.

2. Expansion of research on MST among men, racial and ethnic minorities, sexual and gender minorities, and other underrepresented populations.

3. Investigation of the long-term physical health trajectories of MST survivors and the mechanisms linking MST to chronic disease.

4. Improvement of military prevention programs, reporting mechanisms, and institutional responses to reduce both the incidence of MST and the compounding effects of institutional betrayal.

5. Enhancement of the disability claims process to reduce barriers for MST survivors, particularly regarding evidentiary standards and examiner training.

6. International collaboration to establish MST prevalence data and support systems outside the United States, where research remains extremely limited.[6]

Conclusion

Military sexual trauma is a widespread and serious issue that deeply affects the mental and physical health of U.S. veterans. Although the VA has created the most thorough MST screening and healthcare system, there are still major gaps in treatment, claims processing, and prevention. MST’s unique personal and institutional aspects set it apart from other military traumas and require specific clinical and policy solutions. Ongoing research, new treatments, and system changes are needed to help the many veterans affected by MST.

References