By Olivia Bentley, Ph.D.

June 5, 2023

This blog discusses the ways Military Health Service providers can be ready for service members’ disclosures of sexual harm in a health care setting. We start with some general concepts that are important to know, followed by ways to establish and hold space for conversations about sex, sexual behavior, and sexual assault.

Important Context

Sexual harm is a widespread experience and individuals vary in how they label their experiences.

In the general population, over half of women and one third of men have experienced sexual violence with physical contact.¹ The Department of Defense’s Sexual Assault Prevention and Response Office estimated that 8.4% of active duty women and 1.5% of active duty men experienced sexual assault or unwanted sexual contact (i.e., 35,875 service members).² Approximately 29% of active duty women and 7% of active duty men experienced sexual harassment, which is comparable to civilian population data.^1-2 Sexual harassment and sexual assault appear connected as part of a spectrum of power-based violence. SAPRO estimates do not capture specific prevalence of non-binary or transgender service members. According to estimates on victimization of lesbian, bisexual, and gay service members, this group is significantly overrepresented, making up approximately 43% of all sexual assaults despite being only approximately 12% of the military population.³ According to national estimates, one in five girls and one in 20 boys are sexually victimized as children.^4-5 These numbers may be even greater in the military community, as one in five military veterans have experienced childhood physical or sexual abuse.⁶

Altogether, it is likely that you, as an MHS provider, will encounter a patient who has experienced some form of sexual harm, whether prior, during, or after military service. SAPRO estimates that only one in five service members report an experience of sexual harm.² It is important to consistently examine how to adjust or alter current practices to ensure that providers aren’t unintentionally deterring disclosure, as sexual harm is already underreported.

MHS providers are mandated to report service members’ experiences of sexual assault.

The Health Care Management for Patients Associated with a Sexual Assault Department of Defense Instruction (DODI 6310.09) states that if a patient discloses a sexual assault, then a provider must immediately notify a Sexual Assault Response Coordinator  or Victim Advocate. If a patient discloses a sexual assault by an intimate partner, then a report to the Family Advocacy Program is required.

Institutional culture, environment, and policy affect the risk of sexual harm.

DODI 6310.09 requires providers to offer gender responsive, trauma-informed, and culturally competent care. The DOD re-centered their primary sexual assault prevention plan to address the connections between harmful behaviors and shared risk factors, such as unhealthy climate, social norms, and access to services.⁷ Providers may respond more effectively to disclosures of sexual assault if they are educated on shared risk factors that can influence sexual assault and affect the experience of recovery and disclosure.

Preparing for Disclosure

Share what you know about the sexual assault reporting process at the start of treatment to promote patient agency and choice regarding disclosure of sexual assault.

It is important for providers to closely examine policies and how they may affect the therapeutic relationship, including the potential harms to the therapeutic relationship that may arise from mandated reporting. Consistent with trauma-informed care,⁸ providers should be transparent about the reporting process prior to patient disclosure, ensure patients fully understand what will happen every step of the way after disclosure, and make a plan for how to address potential harms of reporting on the therapeutic relationship. If you are new to the MHS or haven’t made a report before, it may be helpful to call a SARC to familiarize yourself with the processes and help you prepare a patient for next steps. SAPRO is the leading agency for resources and advocacy for patients who disclose sexual assault.

When appropriate and relevant, find opportunities to initiate conversations with patients on sexuality, consent, and personal safety to signal that you are interested and willing to talk about any sexual experiences.

The Centers for Disease Control and Prevention recommends psychoeducation around sexuality and healthy intimate relationships as a strategy for preventing sexual violence.¹ These conversations can be integrated with all clients - not just those who have experienced sexual assault. Therapy may include prompts around the following topics:

• Exploration of client’s own sexuality, sexual projects or plans, and boundaries⁹
• Psychoeducation on consent, sexual assault, etc.
• Boundary communication with partners
• Strategies for enhancing personal safety/safety planning
• How to avoid harming others in sexual relationships/encounters

Some patients and providers may feel uncomfortable bringing up the topic of sex in therapy. Providers have a responsibility to facilitate patient choice about whether to talk about sexual experiences. If providers don’t make space available to talk about sex and normalize discussions, then patients may not feel comfortable with the topic and the opportunity is missed. However, not all patients are comfortable or ready to talk about their sexuality or sexual behavior. When we prompt conversations about sex and sexual health, we create opportunities to engage in a discussion. Whereas it’s important for providers to be sensitive to meet the patient where they are, providers can also signal to patients their openness to the topic, offer support and listen to the patient when they are ready to talk about sexual experiences. Providers may need to become more comfortable talking about sex themselves to comfortably facilitate these important discussions. Providers may also benefit from self-examination of their own beliefs about sex within the context of their surrounding culture.¹⁰

Summary and Take-aways

Hopefully, after reading this blog, you feel more confident in discussing sexual assault with patients who disclose it. When you are transparent about limits to confidentiality and reporting requirements upfront and indicate you are open to conversations about sex and sexual health, the patient can make a choice about how and when they want to talk about their experience of sexual assault or their own beliefs and behaviors around sex.

Resources

CDC Sexual Health

Navy Medicine Reproductive Sexual Health

References

1. Centers for Disease Control and Prevention. (2022). Preventing sexual violence. https://www.cdc.gov/violenceprevention/pdf/sv/SV-factsheet_2022.pdf
2. Department of Defense. (2022). Department of defense annual report on sexual assault in the military. https://www.sapr.mil/sites/default/files/public/docs/reports/AR/DOD_Annual_Report_on_Sexual_Assault_in_the_Military_FY2021.pdf
3. Morral, A. R., & Schell, T. L. (2021). Sexual assault of sexual minorities in the U.S. military. RAND. https://www.rand.org/pubs/research_reports/RRA1390-1.html
4. Finkelhor, D. (2020). Trends in adverse childhood experiences (ACEs) in the United States. Child abuse & neglect, 108, 104641. https://doi.org/10.1016/j.chiabu.2020.104641
5. Gewirtz-Meydan, A., & Finkelhor, D. (2020). Sexual abuse and assault in a large national sample of children and adolescents. Child Maltreatment, 25(2), 203-214. https://doi.org/10.1177/107755951987397
6. Nichter, B., Hill, M., Norman, S., Haller, M., & Pietrzak, R. H. (2020). Associations of childhood abuse and combat exposure with suicidal ideation and suicide attempt in U.S. military veterans: A nationally representative study. Journal of Affective Disorders, 276, 1102–1108. https://doi.org/10.1016/j.jad.2020.07.120
7. Office of the Under Secretary of Defense (May, 2022). Prevention plan of action 2.0 2022-2024. U.S. Department of Defense. https://www.sapr.mil/sites/default/files/PPoA_2.0.pdf
8. Psychological Health Center of Excellence. (2018). “Health care provider’s guide to trauma-informed care.” https://www.qmo.amedd.army.mil/ptsd/PHCoE_TraumaProviderBrochure_v0.9_Final%20508_07MAR2018_.pdf
9. Hirsch, J. S., & Khan, S. (2020). Sexual citizens: A landmark study of sex, power, and assault on campus. WW Norton & Company.
10. Herbitter, C., Vaughan, M. D., & Pantalone, D. W. (2021). Mental health provider bias and clinical competence in addressing asexuality, consensual non-monogamy, and BDSM: a narrative review. Sexual and Relationship Therapy, 1-24. https://doi.org/10.1080/14681994.2021.1969547 

Dr. Bentley is a licensed professional clinical counselor and contracted subject matter expert at the Psychological Health Center of Excellence.