The role of cumulative sexual trauma and difficulties identifying feelings in understanding female veterans' physical health outcomes

doi:10.1016/j.genhosppsych.2007.11.006

General Hospital Psychiatry

Volume 30, Issue 2, March–April 2008, Pages 162-170

https://doi.org/10.1016/j.genhosppsych.2007.11.006 Get rights and content

Abstract

Objective

To examine the role of alexithymia (difficulties identifying one's emotions) in understanding the link between PTSD symptoms and negative health outcomes in sexually victimized female veterans. We hypothesized that having experienced multiple types of sexual trauma across the lifespan, experiencing greater severity of PTSD symptoms, and reporting difficulties in identifying emotions would be associated with increased negative health outcomes.

Method

Anonymous cross-sectional survey of a convenience sample of 456 female veterans enrolled in a VA clinic within the prior year. Data collected included demographics, lifetime trauma exposure, psychological and medical symptoms, emotion recognition problems (alexithymia), health-risk behaviors, and health care utilization.

Results

A total of 57.5% of participants reported a lifetime history of sexual trauma. After controlling for sexual trauma history, PTSD symptoms, and other well-established predictors of health care utilization in the VA medical system such as pre-disposing, enabling and need-based factors, hierarchical regression analyses showed that alexithymia independently explained unique variance in participants' physical health complaints and in their odds of reporting at least one outpatient urgent care visit in the past year.

Conclusions

These data suggest that emotion recognition problems may contribute to poorer health outcomes in sexually traumatized women veterans beyond what is explained by sexual trauma exposure, health risk behaviors and PTSD. Psychological interventions that enhance emotion identification skills for women who have experienced sexual trauma could improve health perceptions and reduce need for acute health care.

Section snippets

Participants and data collection

In 2002, we conducted an anonymous cross-sectional mailed survey of 1500 women veterans who had received health care from a Women Veterans Comprehensive Health Care Clinic located within a Veterans Affairs Medical Center (VAMC) between January 1, 2001, and December 31, 2001. The Women's Clinic uses a primary care model to provide comprehensive, integrated, multidisciplinary medical care for women veterans. Women were randomly selected from a list of all female patients enrolled in a VAMC

Participant characteristics

Demographic characteristics of the 456 female veterans in the sample are presented in Table 1. As shown in Table 2, sexual victimization experiences were commonly reported by women veterans. Overall, 57.5% of participants (n=262) reported experiencing some type of sexual victimization in their lifetime. Nearly half of female veterans reported sexual victimization experiences before the age of 18 (45.8%), one third reported sexual victimization after the age of 18 (32.2%) and nearly one quarter

Discussion

In this sample of female veterans, self-reported emotion recognition skill deficits were associated with both physical health complaints and the use of acute urgent care services. Even after controlling for predisposing, enabling and need-based factors, such as health risk behaviors (e.g., smoking, exercise and obesity, medical comorbidities, depression and alcohol abuse), history of cumulative sexual trauma exposure, and PTSD symptoms, we found that difficulties identifying feelings remained

Acknowledgments

Drs. Polusny and Murdoch are core investigators for the Center for Chronic Disease Outcomes Research (CCDOR). CCDOR is a VA Health Services and Research Service Center of Excellence. Portions of this study were presented at the 36th Annual Convention of the Association for the Advancement of Behavioral Therapy in Reno, Nevada, 2002. The authors would like to acknowledge the following individuals for their assistance with this project: Linda Van Egeren, Ph.D.; Jessica Schultz; Rachel Schultze;

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Cited by (31)

Women Veterans’ Attrition from the VA Health Care System
2022, Women's Health Issues
Citation Excerpt :
This point may be particularly true for women of color given the racial/ethnic disparities that have been documented in health care encounters (Cooper et al., 2012). Moreover, these examinations may exacerbate existing mental health symptoms among women veterans if their service-related condition is sensitive in nature (Kehle-Forbes et al., 2017; Miles-McLean et al., 2015; Polusny, Dickinson, Murdoch, & Thuras, 2008). Although some women veterans experienced disappointment and sought care elsewhere, other women may have continued their care despite waning trust in VA or in the Veterans Benefits Administration.
Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans’ perspectives on why they left or continued to use VA health care.
A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.
Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.
Understanding the drivers of patients’ decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.
Importance of telling the unutterable: Alexithymia among sexually abused children
2020, Psychiatry Research
Citation Excerpt :
Results also mirror those of Hébert and her colleagues (2018) indicating acute levels of alexithymia among adolescent victims of CSA using a self-report measure. Retrospective studies among adults victims of CSA also identified this association between sexual victimization and alexithymia (Polusny et al., 2008; Thomas et al., 2011). Thus the current finding lend support to the claim that alexithymia is a mechanism explaining how victims deal with negative feelings engendered by traumatic event namely CSA (Krystal, 1988; Polusny and Follette, 1995).
Child maltreatment is known to be an etiological factor for developing alexithymia which refers to the difficulty to identify and express feelings. Yet, scarce data is available regarding the vulnerability in child victims of sexual abuse to develop alexithymia. The current study aimed to compare level of alexithymia among a sample of school-aged victims of child sexual abuse (CSA) and a comparison group of non-victimized children. Results also investigated the mediational role of alexithymia in the association between CSA and both internalized and externalized behavior problems. The sample involved 429 sexually abused and 98 non-abused children aged 6 to 12 years old and their parents. The Children's Alexithymia Measure (Way et al., 2010) and the Child Behavior Checklist (Achenbach and Rescorla, 2001) were completed by parents. Clinicians filled out an adapted version of the History of Victimization Form to assess CSA characteristics (Hébert and Cyr, 2010). Analyses revealed that victims of CSA presented significantly higher levels of alexithymia compared to their non-abused counterparts. Results also highlighted the role of alexithymia mediating the association between CSA and both internalized and externalized behavior problems. Focussing on alexithymia is a promising avenue to sustain resilience and prevent further difficulties in sexually abused children.
Emotional granularity in PTSD
2020, Emotion in Posttraumatic Stress Disorder: Etiology, Assessment, Neurobiology, and Treatment
Emotion granularity and emotion differentiation are constructs that refer to individual differences in the ability to make nuanced distinctions among similarly valenced emotional states (Barrett, 2004; Kashdan, Barrett, & McKnight, 2015). Some have argued that increased emotional granularity represents an evolutionary adaptation that helped humans become more adroit in navigating our increasingly complex social worlds (Barrett, 2017; Smidt & Suvak, 2015), and there is a small, but growing, body of empirical studies documenting inverse relationships between emotional granularity and a variety of psychosocial functioning problems and mental disorders including schizophrenia, borderline personality disorder, major depression, autism, and alcohol problems (for reviews, see Kashdan et al., 2015; Smidt & Suvak, 2015). Despite a growing body of research supporting the importance of emotional granularity, it is a relatively new construct with many gaps remaining in research supporting its construct validity. This chapter focuses on the following question: what is the association between emotional granularity and PTSD? Unfortunately, there is an absence of empirical research directly examining this association. Therefore we review research examining associations among PTSD and constructs related to emotional granularity (e.g., alexithymia and emotional clarity), before using existing theory and research to map out mechanisms that may contribute to a link between PTSD and emotional granularity. In doing so, we build a case that the association between PTSD and emotional granularity warrants further investigation that could not only help to elucidate emotional processes associated with PTSD but also increase our understanding of the nature and importance of emotional granularity.
Hysterectomy risk in premenopausal-aged military veterans: Associations with sexual assault and gynecologic symptoms
2016, American Journal of Obstetrics and Gynecology
Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population.
The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population.
We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)–enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ², Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ² and Student t tests.
Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V.
Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women’s health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.
Voluntary and involuntary childlessness in female veterans: Associations with sexual assault
2014, Fertility and Sterility
To assess associations between lifetime sexual assault and childlessness in female veterans.
Cross-sectional, computer-assisted telephone interview study.
Two Midwestern Veterans Administration (VA) medical centers.
A total of 1,004 women aged ≤52 years, VA-enrolled between 2000 and 2008.
None.
Sociodemographic variables, reproductive history and care utilization, and mental health.
A total of 620 veterans (62%) reported at least one attempted or completed sexual assault in their lifetime (LSA). Veterans with LSA more often self-reported a history of pregnancy termination (31% vs. 19%) and infertility (23% vs. 12%), as well as sexually transmitted infection (42% vs. 27%), posttraumatic stress disorder (32% vs. 10%), and postpartum dysphoria (62% vs. 44%). Lifetime sexual assault was independently associated with termination and infertility in multivariate models; sexually transmitted infection, posttraumatic stress disorder, and postpartum dysphoria were not. The LSA by period of life was as follows: 41% of participants in childhood, 15% in adulthood before the military, 33% in military, and 13% after the military (not mutually exclusive). Among the 511 who experienced a completed LSA, 23% self-reported delaying or foregoing pregnancy because of their assault.
This study demonstrated associations between sexual assault history and pregnancy termination, delay or avoidance (voluntary childlessness), and infertility (involuntary childlessness) among female veterans. Improved gender-specific veteran medical care must attend to these reproductive complexities.
Systematic Review of Women Veterans’ Health: Update on Successes and Gaps
2011, Women's Health Issues
We assessed the state of women veterans’ health research by conducting a systematic review of scientific literature published from 2004 to 2008, updating a prior review spanning the history of this literature to 2004.
We identified articles by searching scientific databases and contacting experts. Relevant articles were independently evaluated by two physician reviewers. We categorized 195 articles by study design, funding source, period of military service, research topic, and health condition.
More research was published during this 5-year review (n = 195) than in the 25 years beforehand (n = 182). The 195 studies included five trials, but only one randomized trial, a study that examined treatment outcomes for women with posttraumatic stress disorder (PTSD). The large number of articles focused on Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) soldiers’ health issues (n = 23) reflects the growing participation of women in these conflicts. High rates of positive PTSD symptoms (range, 10%–19%) and other mental health disorders were found among OEF/OIF returning military women. The recent post-deployment literature underscores the need for repeated PTSD/mental health screening in returning veterans, and points to continuity of care needs for psychiatric and gynecological problems which occur in the field. The psychiatric and access/utilization literature confirmed the positive relationship between military sexual trauma and PTSD and the associated negative health effects.
Although most VA women’s health research remains observational, methods are evolving toward an analytical focus. Even though successes are evident in the breadth and depth of publications, remaining gaps in the literature include post-deployment readjustment for veterans/families, and quality-of-care interventions/outcomes for physical and mental conditions.

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Psychiatric–Medical ComorbidityThe role of cumulative sexual trauma and difficulties identifying feelings in understanding female veterans' physical health outcomes

Abstract

Objective

Method

Results

Conclusions

Section snippets

Participants and data collection

Participant characteristics

Discussion

Acknowledgments

Child Abuse Negl

Appl Prev Psychol

Gen Hosp Psychiatry

J Psychosom Res

J Psychosom Res

Clin Psychol Rev

Sexual abuse history: prevalence, health effects, mediators, and psychological treatment

Psychosoma Med

Assessment of psychological distress and disability after sexual assault in adults

Life span and repeated violence against women during military service: effects on health status and outpatient utilization

J Women's Health

Posttraumatic stress disorder and extent of trauma exposure as correlates of medical problems and perceived health among women with childhood abuse

Women Health

Sexual assault history and women's reproductive and sexual health

Psychol Women Q

The relationship of childhood sexual abuse and depression with somatic symptoms and medical utilization

Psychol Med

Sexual assault in women veterans: an examination of PTSD risk, health care utilization, and cost of care

Psychosomc Med

Understanding relationships among trauma, posttraumatic stress disorder, and health outcomes

Relationships among trauma exposure, chronic posttraumatic stress disorder symptoms, and self-reported health in women: replication and extension

J Traum Stress

Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder

Psychiatr Serv

Posttraumatic stress disorder and war-zone exposure as correlates of perceived health in female Vietnam war veterans

J Consult Clin Psychol

Trauma, posttraumatic stress disorder, and health status

Experiential avoidance as a mediator of the effects of adolescent sexual victimization on negative adult outcomes

Violence Vict

Sexual assault history and physical health in randomly selected Los Angeles women

Health Psychol

Trauma, posttraumatic stress disorder, and health risk behaviors

Sexual assault among North Carolina women: prevalence and health risk factors

J Epidemiol Community Health

Sexual assault while in the military: violence as a predictor of cardiac risk?

Violence Vict

Sexual trauma, posttraumatic stress disorder, and health behavior

Behav Med

Clinical considerations for treating sexually revictimized women

Natl Cent PTSD Clin Q

Psychiatric–Medical Comorbidity
The role of cumulative sexual trauma and difficulties identifying feelings in understanding female veterans' physical health outcomes