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Sexual revictimization is heightened among military service members and veterans and is associated with greater posttraumatic stress symptoms (PTSS) and severity. The heightened distress following revictimization may be due to posttraumatic cognitions (PTC), which include negative beliefs about the self and world, and self-blame. Moreover, it is unclear whether men and women experience different levels of PTC. The current study tested PTC (overall and subdomains) as a possible mediator between sexual revictimization and PTSS severity, and gender as a possible moderator of these associations. Revictimization was defined across time periods (military sexual assault [MSA] only vs. premilitary sexual trauma + MSA) and in military rape frequency (0, 1, 2+). Participants were 400 ( n = 200 [50%] male) service members/veterans with a history of MSA and completed online, anonymous, self-report questionnaires. PTC mediated the association between revictimization and PTSS severity. A significant interaction of gender suggested that men reported high overall PTC and PTC about the self regardless of revictimization; by contrast, overall PTC and PTC about the self were lower for women in response to MSA only and increased with revictimization. Results also showed men were more sensitive to PTC about self-blame as it pertains to more severe PTSS compared to women. There were no unique gender interactions when assessing revictimization by rape frequency, although PTC (overall, all subdomains) significantly mediated the association between rape frequency and PTSS severity. PTC may be a beneficial target when treating PTSS in men, and may be especially heightened in women who have experienced revictimization.

Although military sexual trauma (MST) is associated with an increased risk of suicide, suicide attempts, and suicidal ideation among service members and veterans, there is limited knowledge regarding the mechanisms of MST and suicidality among men. The current study examined whether MST was associated with sexual compulsivity and/or erectile dysfunction and if these, in turn, explained elevated suicidal thoughts and the likelihood of engaging in future suicidal behavior after accounting for mental health, military, and demographic characteristics. Service members and veterans who reported their gender as male (N = 508) were recruited via social media and completed online self-report measures assessing MST, erectile dysfunction, sexual compulsivity, suicidal ideation frequency, and the likelihood of engaging in future suicidal behavior. Path analysis was used to examine the study hypotheses. In total, 67 participants (13.2%) reported a history of MST; of these individuals, 27 (40.3%) reported suicidal ideation in the past 12 months, and 29 (43.9%) reported an increased likelihood of engaging in future suicidal behavior. MST was associated with increased sexual compulsivity, which, in turn, predicted more frequent suicidal ideation as well as a higher self-reported likelihood of engaging in future suicidal behavior. MST was associated with higher levels of erectile dysfunction, but erectile dysfunction was not associated with suicidal ideation in the adjusted model. Although the data were cross-sectional, precluding determinations of causality, the results support assessing and intervening with regard to sexual compulsivity to mitigate the risk for suicide-related outcomes among men who experience MST.

OBJECTIVE Higher posttraumatic stress disorder (PTSD) symptoms are associated with poorer romantic relationship satisfaction in military samples. Studies have examined PTSD symptom clusters and their association with relationship satisfaction, but these studies are limited to the pre-Diagnostic and Statistical Manual (DSM)-5 PTSD models or samples of women. The current study explored the best fitting model of PTSD using contemporary symptoms and examined the association of symptom clusters and relationship satisfaction in a sample of partnered male service members/veterans who reported exposure to a probable Criterion A event. METHOD Factor analyses of 6 competing PTSD models were compared using confirmatory factor analysis in a sample of 499 men. Path analysis was then used to examine which symptom clusters were uniquely associated with relationship satisfaction after accounting for covariates in a subsample of 217 men who reported probable Criterion A exposure. RESULTS The Anhedonia and Hybrid Models had the best fit to the data in both the larger sample and subsample of men reporting probable trauma exposure. Models had comparable model fit, thus symptom clusters from both models were examined as predictors of relationship satisfaction in 2 separate analyses adjusted for covariates. In both analyses, only higher anhedonia symptoms were associated with lower romantic relationship satisfaction. CONCLUSIONS Data was cross-sectional so causality cannot be inferred, but it appears that poorer relationship satisfaction is more common when symptoms of anhedonia are high. Interventions to improve relationship satisfaction among those reporting posttraumatic stress symptoms may be most effective if they focus on reducing anhedonia. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective The current study examined the moderating role of gender on the association of military sexual trauma (MST) type (harassment-only vs. assault) and posttraumatic stress symptoms (PTSS) using the 6-factor Anhedonia Model. Methods Participants were 1321 service members/veterans. Two-part hurdle models assessed the moderating role of gender on the association of MST type with the presence (at least "moderate" symptoms endorsed within each cluster) or severity of PTSS and symptom clusters. Results Among those who experienced assault MST, women were at higher risk for the presence of intrusive, avoidance, negative affect, and anhedonia symptoms, and higher risk for more severe negative affect symptoms. Among those who experienced harassment-only MST, men were at higher risk of more severe PTSS symptoms overall and in the intrusive and dysphoric arousal symptom clusters. No other significant differences were observed. Conclusions Gathering information on MST type may be helpful in treatment planning.

Suicide rates continue to increase among service members/veterans. Military sexual harassment/assault (MSH/A) may increase risk of suicide, but little is known about the collective magnitude of associations between MSH/A and suicide outcomes, including ideation, plan, attempt, and mortality. The current meta-analysis addressed this literature gap while testing potential moderators of gender, marital status, discharge status, and military branch. PsycINFO, PubMed, Dissertations/Theses, relevant citation lists, and conference brochures were reviewed for papers that included quantitative analyses in English, U.S. military samples, and measures of MSH/A and suicide ideation/plan/attempt/mortality. The search resulted in 22 studies ( N = 10,898,875) measuring the association of MSH/A with suicide ideation ( k = 15), plans ( k = 1), attempts ( k = 14), and mortality ( k = 2), with papers published from 2007–2021. MSH/A was associated with suicide ideation ([Formula: see text] = .14) and attempts ([Formula: see text] = .11, ps < .05). The association of MSH/A and suicide ideation and attempts was higher among women relative to men, those identifying as married versus not married, those actively serving compared to discharged, and those reporting service in the Air Force relative to all other branches. The association of MSH/A with suicide plans and mortality was not calculated due to the small number of studies reporting those effect sizes ( ks = 1–2). The effect sizes observed suggest MSH/A is part of a larger network of risk factors for suicide. Moderators indicate that suicide risk is higher among specific groups, and prevention strategies would be most effective if they targeted these individuals. This research area would be strengthened by additional studies of plans and mortality.

Sexual harassment and violence is a grave public health concern and risk for revictimization increases following initial exposure. Studies of sexual revictimization in military samples are generally limited to women and are focused on rates of posttraumatic stress disorder (PTSD), with no examination of how revictimization relates to interpersonal outcomes, such as relationship or sexual satisfaction. The current study addressed these gaps in a sample of 833 women and 556 men service members/veterans. Self-reported outcomes of PTSD, depression, suicidal ideation, sexual function, and relationship satisfaction were compared across those reporting exposure to sexual harassment and violence before the military only (i.e., pre-military), during the military only (i.e., military sexual harassment and violence [MSV]), before and during the military (i.e., revictimization), and to no exposure. More than half of women (51.14%, n = 426) reported revictimization and only 5.79% ( n = 28) of men reported revictimization. Among women, those reporting MSV or revictimization tended to report higher PTSD, depression, and suicidal ideation relative to pre-military sexual violence and no sexual violence exposure. No interpersonal outcomes were significantly different among these sexual violence groups. Among men, revictimization was associated with higher PTSD, depression, and sexual compulsivity. PTSD and depression were also higher among those reporting MSV only. No effects were found for premilitary sexual trauma exposure only or relationship satisfaction for either group. Findings highlight the particularly bothersome nature of MSV, whether it occurred alone or in tandem with premilitary sexual violence. Findings also show unique gender differences across outcomes, suggesting interventions following sexual harassment and violence may differ for men and women.

Civilian literature shows a strong, consistent association between exposure to sexual violence and poor romantic relationship satisfaction. The impact of sexual violence that occurred during military service, or military sexual trauma (MST), on romantic relationship satisfaction among partnered men service members/veterans (SM/Vs) is understudied. However, a recent study conducted in women observed that MST that involved an assault was associated with poorer relationship satisfaction through higher sexual dysfunction and lower sexual satisfaction. The current study extended the literature by examining sexual function as a mediator of the association of exposure to MST and romantic relationship satisfaction among partnered men SM/Vs (N = 499). Participants completed self-report measures of MST exposure, romantic relationship satisfaction, erectile dysfunction, and compulsive sexual behavior, as well as a demographic inventory. The average score on relationship satisfaction was in the distressed range. Sixty-four participants (12.83%) reported MST exposure. MST exposure was related to lower relationship satisfaction through higher compulsive sexual behavior. The model explained 16% of the variance in relationship satisfaction. The indirect effect of erectile dysfunction was nonsignificant. Current findings are consistent with research in women SM/Vs: the association of MST and romantic relationship satisfaction appears to be indirect, through the effects of sexual function. Couples' therapy may be most effective if it addresses sexual health concerns among men MST survivors, particularly engagement in compulsive sexual behaviors. Due to low endorsement of MST that involved assault, the impact of MST severity could not be examined.

Sexual dysfunction is associated with disorders commonly diagnosed in service members/veterans (SM/Vs; e.g., depression, posttraumatic stress disorder) and increased risk for suicide in service women. Theory indicates depression may play an important role in predicting sexual dysfunction in the presence of certain mental health challenges, such as disordered eating symptoms. Given the risk for depression and incidence of eating disorders in women SM/Vs, the current study examined whether depressive symptoms mediated the association of disordered eating symptoms and sexual dysfunction in women SM/Vs. Participants (n = 494) were recruited via social media and completed measures of sexual function, disordered eating symptoms, depressive symptom severity, a demographic inventory, and measures of relationship satisfaction and trauma exposure (covariates). Based on self-report measures, probable sexual dysfunction, eating disorder, and depressive disorders were found among 58.70%, 38.5%, and 44.13% of participants, respectively. The relationship of higher disordered eating symptoms and lower sexual function was indirect, through higher depressive symptoms (indirect effect: −0.57, 95% confidence interval: −0.82, −0.34). Findings underscore the importance of screening for sexual function, particularly when disordered eating behavior or depression is present. Integrating treatment for sexual function into existing treatments for women SM/Vs with disordered eating and depression symptoms may be valuable.

Military sexual trauma (MST), defined as experiencing sexual harassment or assault during military service, is associated with a host of deleterious outcomes, including sexual dysfunction. Less is known about how MST may relate to risk for future victimization. This systematic review identified 10 studies that examined the association between MST and revictimization. Studies generally indicated that the more frequent or severe MST was, the more strongly it was associated with risk for future victimization. Most of these studies did not statistically evaluate the role of gender in the relation between MST and sexual revictimization, suggesting an important avenue for future research. Clinicians working with survivors of MST, particularly those who have experienced military sexual assault, may need to address issues of sexual safety with these veterans. [ Psychiatr Ann . 2020;50(10):444–451.]

Background Exposure to military sexual trauma (MST) in veterans is associated with suicidal ideation. Previous research suggests there are mechanisms of this association, including posttraumatic stress disorder (PTSD) and depression. Research has yet to examine whether comorbid PTSD and depression mediate the association of MST and suicide and intentional self-inflicted injury, and whether this comorbidity confers a greater risk for suicide relative to PTSD-only and depression-only. The current study addressed this gap in our knowledge. Methods Screening results identifying MST exposure, PTSD and depression diagnoses, suicide and intentional self-inflicted injury, and demographic covariates in 435,690 Iraq/Afghanistan veterans were extracted from Veterans Health Administration (VHA) medical records. Veterans were included if they attended VHA from 2004-2014. Mediation was tested with path analyses. Results Suicide and intentional self-inflicted injury was observed in 16,149 (3.71%) veterans. The indirect effect of suicide and intentional self-inflicted injury, given a positive screen for MST, was highest among veterans with comorbid PTSD and depression diagnoses (indirect effect=3.18%, 95% confidence interval [CI] [3.01%, 3.32%]), with smaller probabilities observed for both PTSD-only (indirect effect=-0.18%, 95% CI [-0.20%, -0.14%]) and depression-only (indirect effect=0.56%, 95% CI [0.51%, 0.62%]; ps Limitations Data were limited to VHA-enrolled Iraq/Afghanistan veterans. Conclusions To reduce suicide risk among veterans with a history of MST, treatments may be most effective if they target comorbid PTSD and depression. Future research should examine the mechanisms through which comorbid PTSD and depression result in heightened risk for suicide and intentional self-inflicted injury.

Background Military sexual trauma (MST) is associated with increased risk for posttraumatic stress disorder (PTSD) and depression diagnoses, as well as suicidal ideation/behavior (SI/B). Little is known about the differential effect of gender on the association of MST and the aforementioned mental health outcomes. As females are the fastest growing subpopulation of the Veterans Health Administration (VHA), it is imperative to assess possible between-gender differences in the association of MST with PTSD, depression, and SI/B. Methods Participants were 435,690 (n = 382,021, 87.7% men) 9/11 era veterans seen for care at the VHA between 2004 and 2014. Demographics, gender, PTSD and depression diagnoses, SI/B, and MST screen status were extracted from medical records. Adjusted logistic regression models assessed the moderating effect of gender on the association of MST with PTSD and depression diagnoses, as well as SI/B. Results Women with MST had a larger increased risk for a PTSD diagnosis (predicted probability =0.56, 95% confidence interval [CI] [0.56, 0.56]) and comparable risk for a depression diagnosis (predicted probability = 0.63, 95% CI [0.63, 0.64]) compared to men with MST. Men were more likely to have evidence of SI/B (predicted probability = 1.07, 95% CI [0.10, 0.11]) relative to women, but the interaction between gender and MST was nonsignificant. Limitations Data were limited to veterans seeking care through VHA and the MST screen did not account for MST severity. Conclusions Non-VHA settings may consider screening for MST in both men and women, given that risk for PTSD and depression is heightened among female survivors of MST.

Research in civilians and women shows negative social support is more deleterious for posttraumatic stress disorder (PTSD) symptoms than are the buffering effects of positive social support. However, this is understudied in male military samples. Moreover, appraisals of social support appear to be the mechanism of the association of social support type and PTSD severity, but appraisals as mediators have not been explored in military samples.Previously deployed male service members/veterans (SM/Vs;The magnitude of the association of negative social support and PTSD symptom severity (standardized estimate = .33;Causality cannot be inferred. Positive support exhibits a weaker relationship with PTSD because its effect is dependent on how an individual appraises the support whereas negative support has a direct relationship with PTSD regardless of appraisals. Findings suggest positive support interventions should focus on individual perceptions whereas negative support interventions should focus on decreasing how often these interactions occur. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Military sexual trauma (MST) is a significant public health issue associated with adverse psychiatric outcomes, including heightened risk for suicide, posttraumatic stress disorder, depression, and substance use disorders. Recently, research has begun exploring gender-linked disparities in mental health outcomes for individuals who experience MST. The current study assessed whether women who screened positive for MST were at disproportionately higher risk for diagnoses of alcohol-use disorder (AUD) or drug-use disorder (DUD) relative to men. Veterans Health Administration (VHA) clinical data were extracted for 435,690 military veterans who separated from the military between 2004 and 2011 and had at least 5 years of follow-up data after their initial VHA visit until the end of fiscal year 2014. Logistic regression models examined the main and interactive effects of gender and screening positively for MST as predictors of AUD and DUD. MST positive screens were associated with increased rates of both AUD and DUD across genders. Although rates of both AUD and DUD were higher among men, the increased rate of diagnosis associated with MST positive screens was proportionally higher for women than men (interaction adjusted odds ratios = 1.43 and 1.17 for AUD and DUD, respectively), indicating the presence of a gender-linked health risk disparity. This disparity was more pronounced for AUD than DUD (p < .01). The current study adds to previous literature documenting increased risk for women exposed to MST. These findings support efforts to reduce the occurrence of MST and continued use of MST screening measures within the VHA. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Extant research demonstrates that a history of military sexual trauma (MST) is associated with PTSD and depression diagnoses as well as heightened risk for suicidal ideation and death by suicide. P...

Little is known about the association of military sexual trauma (MST) and relationship satisfaction among partnered female service members/veterans (SM/Vs). Extant civilian literature shows a strong association between sexual trauma and poorer relationship outcomes, and theory suggests that sexual function and satisfaction may mediate this association. Given that as many as 40% of female SM/Vs report MST and roughly half of female veterans are partnered and in their peak sexual years, it is critical to understand the association of MST, relationship satisfaction, sexual function, and sexual satisfaction in this population. Female SM/Vs (N = 817) completed a demographic inventory, self-report measures of MST, relationship satisfaction, sexual function, and sexual satisfaction. One hundred fifty-one (18.48%) participants did not experience MST. Three hundred eighty-eight (47.49%) reported that they experienced harassment-only MST, and 278 (34.03%) reported assault MST. At the bivariate level, lower relationship satisfaction was associated with lower sexual function and satisfaction with large effect sizes. Assault MST was associated with lower relationship satisfaction and sexual function and satisfaction with small-to-medium effect sizes. No differences in relationship satisfaction, sexual satisfaction, and function between those with harassment-only and no MST were observed. Mediation analyses demonstrated that lower sexual function and satisfaction mediated the association of assault MST and relationship satisfaction. Couples' therapy offered to SM/Vs with MST should screen for type of MST, sexual function, and satisfaction. Addressing the sequelae of MST and increasing sexual function and satisfaction in these partnerships may be critical treatment targets.Se sabe muy poco acerca de la asociación del trauma sexual militar (TSM) y la satisfacción con la relación entre las mujeres militares/veteranas en pareja. La bibliografía existente sobre los civiles indica una asociación fuerte entre el trauma sexual y malos resultados en las relaciones, en consecuencia, la teoría sugiere que la disfunción sexual y la insatisfacción sexual pueden mediar esta asociación. Teniendo en cuenta que hasta el 40% de las mujeres veteranas informan TSM y que aproximadamente la mitad de las mujeres veteranas está en pareja y en el pico de sus años sexuales, es fundamental comprender la asociación del TSM, la satisfacción con la relación, la disfunción sexual y la insatisfacción sexual en esta población. Un grupo de mujeres militares/veteranas (N = 817) completaron una encuesta sobre datos demográficos, mediciones autoinformadas de TSM, satisfacción con la relación, función sexual y satisfacción sexual. Ciento cincuenta y una (18.48%) participantes no sufrieron TSM. Trescientas ochenta y ocho (47.49%) informaron que sufrieron TSM por acoso solamente, y 278 (34.03%) informaron TSM por agresión sexual. A nivel bivariado, una menor satisfacción con la relación estuvo asociada con una menor función y satisfacción sexual con mayores tamaños del efecto. El TSM por agresión sexual estuvo asociado con una menor satisfacción con la relación y la función y la satisfacción sexual con tamaños del efecto entre pequeños y medianos. No se observaron diferencias en la satisfacción con la relación, la satisfacción sexual y la función sexual entre aquellas con acoso solamente y ningún TSM. Los análisis de mediación demostraron que una menor función sexual y una menor satisfacción sexual mediaron la asociación del TSM por agresión sexual y la satisfacción con la relación. La terapia de pareja ofrecida a las veteranas con TSM debería detectar el tipo de TSM, la función sexual y la satisfacción sexual. Abordar las secuelas del TSM y reducir la disfunción y la insatisfacción sexual en estas asociaciones pueden ser objetivos fundamentales de tratamiento.有伴侣的女性从军人员/退伍女兵们这类人群其在军旅期间遭遇的性侵伤害(MST)和她们的伴侣关系满意度之间有什么样的相关性,人们对此知之甚少。现有的民生方面的研究表明性侵造成的伤害和低质量的伴侣关系之间有很强的关联性,理论也表明性方面的功能障碍和性生活不满意度可能对这种关联性起到调和作用。如果退伍女兵中40%都报告经历过MST,而退伍女兵中大概有一半都是有伴侣的,且处于性生活能力最高峰的那段时间,那么了解这部分人群的MST,关系满意度,性生活功能障碍,性生活满意度等具有重要意义。参与研究的被试有817名女性从军人员/退伍女兵,她们完成了人口统计方面的调查表,MST,关系满意度,性功能,性满意方面的自我测评汇报。151名(18.48%)参与研究者没有经历过MST。388位 (47.49%)位被调查者表示只是经历了性骚扰,278名(34.03%)表示经历了性侵行为。 只看两个变量而言,较低的关系满意度和偏低的性功能水平和性满意度有关联,且效应值很大。性侵类的MST和较低的关系满意度,性功能,性生活满意度有关联,效应值由小到中等的样子。仅遭遇过性骚扰或没有经历过MST的人员中关于关系满意度,性生活满意度和性功能方面的差异并未发现。调节变量的分析表明较低的性功能和性生活满意度对与性侵类MST和性生活满意度之间的关联性有调和作用。 针对经历过MST的退伍女兵的伴侣治疗应该筛查出MST的类型,性功能情况,性满意度。关键性的治疗目标包括:关注MST后遗症,减少性功能障碍,减少性生活不满意程度等等。.

Objective Preliminary research suggests that perceptions of institutional betrayal are associated with more severe symptoms of posttraumatic stress disorder (PTSD) and depression, as well as suicide attempts in military sexual trauma (MST) survivors. However, results have not been replicated. Additionally, associations of institutional betrayal with specific PTSD symptom clusters or sexual function are understudied. Method Female service members/veterans who reported experiencing MST (N = 679) completed self-report measures of PTSD and depression symptom severity, suicidal ideation, and sexual function. Institutional betrayal was assessed from free-text descriptions of self-reported index traumas. Results Institutional betrayal was significantly associated with more severe depression and PTSD symptoms, including avoidance, negative alterations in cognitions and mood, re-experiencing, and dysphoric arousal. Conclusions Targeting specific PTSD and depressive symptoms through evidence-based treatment may be important for managing institutional betrayal sequelae. Future research should identify specific strategies to help support survivors in their recovery following institutional betrayal.

The presence of a post-traumatic stress disorder (PTSD) diagnosis or higher PTSD severity is associated with higher overall sexual dysfunction in female service members/veterans. However, the mechanisms linking PTSD to specific components of women's sexual arousal function, like lubrication and mental arousal, are unknown.We conducted a survey among 464 women who reported probable Criterion A exposure for PTSD. Path analysis examined (1) the association of PTSD with sexual arousal, (2) whether specific PTSD symptom clusters were uniquely associated with sexual arousal, and (3) whether this association is indirect, through the effects of higher depression severity and lower romantic relationship satisfaction. Arousal was operationalized to measure both mental (subjective arousal) and physical (lubrication) experiences.Higher PTSD severity was associated with lower lubrication and arousal function. The association of PTSD severity with arousal was indirect, through lower romantic relationship satisfaction (estimate: -0.12; 95% CI: [-0.014, -0.007]) and higher depression (estimate: -0.08, 95% CI: [-0.012, -0.002]). The association of PTSD severity with lubrication was also indirect, but only through lower relationship satisfaction (estimate: -0.10, 95% CI: [-0.013, -0.006]). PTSD symptom clusters were not uniquely associated with arousal and lubrication through mediated pathways.Data were from a cross-sectional study using a convenience sample. Criterion A exposure could not be confirmed.PTSD may lead to arousal and lubrication dysfunction by contributing to higher depression severity and strained romantic relationships. Interventions targeting reductions in depressive symptoms and bolstering relationship satisfaction may minimize the burden of PTSD on sexual arousal concerns.

Studies show that more positive relationship satisfaction can mitigate the effects of posttraumatic stress disorder (PTSD) and depression severity on hazardous drinking in military samples. However, past studies were not circumscribed to female service members/veterans (SM/V), who represent the fastest growing demographic in the military. Moreover, studies did not examine moderators of specific symptom clusters of PTSD and depression with hazardous drinking. Indeed, recent studies have shown that the more depressive and cognitive clusters are associated with greater dysfunction. The current study extended this literature in a convenience sample of 584 female SM/V who completed self-report measures of hazardous drinking, PTSD, depression, and relationship satisfaction. PTSD or depression severity, relationship satisfaction, and their interaction, were examined as correlates of hazardous drinking after accounting for relationship, demographic, and military characteristics. For both overall PTSD and depression severity, higher relationship satisfaction weakened their association with hazardous drinking. Such results were consistent when global scores were replaced with PTSD-related negative alterations in cognitions and mood and somatic depression symptom clusters, but not for PTSD-related dysphoric arousal, anhedonia, or non-somatic depression symptom clusters. Findings suggest that to lessen the association of PTSD or depressive symptoms with problematic drinking, interventions aimed at improving relationship satisfaction may be worth considering among women in relationships. Moreover, symptom cluster analyses show that the cognitive and depressive components of PTSD, as well as the physical symptoms of depression, are most problematic, pinpointing specific areas of function on which to intervene.

Background Posttraumatic stress disorder (PTSD) is associated with sexual difficulties but the nuances of this relationship remain elusive. Research has increased in recent years, most notably following publication of several reviews in 2015. Aim This systematic review examines the relationship between PTSD and sexual difficulties in veterans/military personnel. Methods A systematic review was conducted using PRISMA guidelines in PsycINFO and PubMed databases for studies examining a diagnosis of PTSD or PTSD severity in relation to a range of sexual difficulties. Forty-three studies were identified that met inclusion and exclusion criteria for this review. RESULTS PTSD was associated with increased risk of experiencing at least one sexual difficulty. PTSD was most clearly associated with overall sexual function, sexual desire, sexual satisfaction, and sexual distress. Results were mixed for sexual arousal, orgasm function, erectile dysfunction, premature ejaculation, sexual pain, and frequency of sexual activity. PTSD symptom clusters of avoidance and negative alterations in cognition/mood were most commonly associated sexual difficulties. Few studies compared results by gender and trauma type. Clinical Implications Clinicians should inquire about sexual health in relation to PTSD symptoms and target avoidance and negative mood symptoms by incorporating sexual exposure assignments and sexual activation exercises when appropriate. Strengths & Limitations This systematic review synthesizes an extensive literature that has grown substantially in the past 5 years and includes studies with low to moderate risk of bias. Limitations of the existing literature include challenges differentiating between PTSD and depression, inconsistent measurement of PTSD and trauma histories, inconsistent operationalization and measurement of sexual outcomes, and largely cross-sectional study designs. CONCLUSION PTSD is linked to a range of sexual outcomes. The current literature suggests that PTSD is associated with sexual difficulties related to both the sexual response cycle (ie, sexual desire) and one’s emotional relationship to sexual activity (eg, sexual distress). More research is needed to increase confidence in findings.

Background: The mental health burden of posttraumatic stress disorder (PTSD) is high in U.S. military samples. Social support is one of the most robust protective factors against PTSD and a recent meta-analysis indicates that this relationship is even stronger in military samples compared to civilian samples. Yet no meta-analyses have explored factors impacting this association in veterans and military service members (VSMs). Objective: The current meta-analysis examined demographic, social support, and military characteristics that may moderate the relationship of PTSD severity and social support among U.S. VSMs. Method: A search identified 37 cross-sectional studies, representing 38 unique samples with a total of 18,766 individuals. Results: The overall random effects estimate was −.33 (95% CI: −.38, −.27, Z = −10.19, p, HIGHLIGHTS • Factors that impact the association of PTSD severity and social support among U.S. military service members are understudied. • A meta-analysis of 38 cross-sectional samples (N = 18,766) showed that higher levels of social support were associated with less severe PTSD symptoms. • Social support received from non-military sources had a stronger relationship with PTSD symptoms than support received from military sources. • Few studies have examined the relationship between social negativity and PTSD severity in military samples despite evidence that social negativity is a more robust predictor than positive forms of support.

Introduction Suicide is a leading cause of death in military service members/veterans (SM/Vs). Positive social exchanges (e.g., emotional support) buffer against suicide risk but the influence of negative social exchanges (e.g., unwanted advice) is understudied. Method The current study explored (1) the contributions of positive and negative social exchanges as simultaneous correlates of suicide ideation and risk, (2) whether positive social exchanges mitigated the association of negative social exchanges and suicide ideation and risk, and (3) if facets of social exchanges were uniquely related to suicide ideation and risk. SM/Vs men (N = 508) completed self-report questionnaires. Results Roughly 27% endorsed suicide ideation. Between 23.62 and 41.14% reported elevated suicide risk. Adjusted analyses revealed higher negative social exchanges, particularly insensitive behaviors, and lower positive social exchanges were associated with higher suicide ideation and risk. The magnitude of positive and negative social exchanges with suicide ideation or risk was statistically similar. Higher positive social exchanges did not attenuate the association of negative social exchanges and suicide ideation or risk (p > 0.05). Conclusion Higher negative social exchanges are equally strong correlates of suicide ideation and risk as positive social exchanges. Decreasing insensitive behaviors may reduce suicide ideation and risk in men SM/Vs.

Healthy sexual function among women service members/veterans (SM/Vs) is associated with higher quality of life, lower incidence and severity of mental health diagnoses, higher relationship satisfaction, and less frequent suicidal ideation. Although trauma exposure has been established as a predictor of poor sexual function and satisfaction in women SM/Vs, no study to date has examined whether specific trauma types, such as military sexual trauma (MST), increase risk for sexual issues. Moreover, the possible mechanisms of this association have not been explored. The current study examined whether posttraumatic stress disorder (PTSD) and depression symptom clusters mediated the association of trauma type and sexual function and satisfaction in 426 trauma-exposed women SM/Vs. Two hundred seventy participants (63.4%) identified MST as their index trauma. Path analyses demonstrated that MST was related to poorer sexual function and lower satisfaction relative to the other traumas ( χ2[28, N = 426] = 43.3, p = 0.03, CFI = 1.00, TLI = 0.99, and RMSEA = 0.04), and this association was mediated by higher non-somatic depressive symptoms and PTSD symptom clusters of anhedonia and negative alterations in cognition and mood (NACM). Causality cannot be inferred due to the cross-sectional nature of the data. However, our findings suggest that interventions aimed at decreasing sexual issues among female SM/Vs with MST should target depressogenic symptoms, whether the origin is depression or PTSD. Longitudinal research exploring the etiological processes that contribute to sexual dysfunction among those with MST is needed.

Introduction Compulsive sexual behavior (CSB) is understudied in military service members/veterans despite elevated risk for psychological disorders that are associated with CSB, including posttraumatic stress disorder (PTSD), depression, and alcohol misuse. Civilian research shows that sexual trauma is associated with higher CSB. Among military service members/veterans, sexual trauma that occurred before military service is identified as a risk factor for CSB, but the impact of screening positive for sexual trauma that occurred during military service (military sexual harassment[MSH]/military sexual assault[MSA]) on CSB is unknown. Moreover, screening positive for MSH/A confers a higher risk for distress relative to sexual trauma that occurred before or after military service, suggesting that MSH/A may be a robust predictor of CSB. The current study examined whether screening positive for MSH/A was associated with higher CSB after accounting for mental health and demographic characteristics. The current study specifically focused on men service members/veterans given that men show higher engagement and distress associated with CSB relative to women. Materials and Method Male service member/veterans (n = 508) completed self-report measures of CSB, MSH/A, PTSD and depression severity, hazardous drinking, and age. CSB was regressed on MSH/A, PTSD and depression severity, hazardous drinking, and age to determine if MSH/A was uniquely associated with CSB after accounting for other risk factors. Results A total of 9.25% to 12.01% of the sample reported scores suggestive of high levels of CSB. The regression of CSB on MSH/A screen status, PTSD, depression, alcohol use, and age explained 22.3% of the variance. Screening positive for MSH/A, higher PTSD symptoms, and higher depression symptoms were associated with higher CSB, but age or alcohol use were not. Conclusion Screening positive for MSH/A appears to be a unique risk factor for higher CSB above and beyond the effects of depression and PTSD. Since screening for CSB is not part of routine mental health care, clinicians may consider a positive screen for MSH/A as a possible indicator that CSB may be of clinical concern. Previous research on MSH/A and individual and sexual health outcomes suggest that distinguishing between MSH/A severities (harassment only vs. assault) is critical as the most dysfunction is observed with sexual trauma that involves assault. Owing to low endorsement of MSA, this study did not examine differences between MSA and MSH. Future research in this area would be strengthened by exploring MSH/A severities as a correlate of CSB.

Objectives Risk for suicide among female service members/veterans (SM/Vs) is increasing, suggesting a need for additional studies of risk factors in this population. This study examined relationship satisfaction as a correlate of suicidal ideation (SI) after accounting for established risk factors for SI. Method Partnered female SM/Vs (N = 818) completed a demographic inventory and measures of SI, relationship satisfaction, sexual function, posttraumatic stress disorder (PTSD), and depression. Results After accounting for covariates, lower relationship satisfaction, higher depression and PTSD severity, and minority race were associated with the presence of SI. PTSD and depression severity did not moderate this association, suggesting that regardless of mental health symptoms, relationship satisfaction is associated with increased SI risk. Conclusions Screening for relationship satisfaction may identify SI risk in partnered female SM/Vs. Future studies should explore relationship satisfaction as a risk factor for suicidal attempts as not all SM/Vs who experience SI will attempt suicide.

OBJECTIVE Posttraumatic stress disorder (PTSD) symptoms of detachment, anhedonia, and hyperarousal are associated with poorer relationship satisfaction. Such findings are limited to earlier models of PTSD and samples that were almost exclusively male. The association of current PTSD symptom clusters with relationship satisfaction in partnered female service members/veterans (SM/Vs) are understudied. METHODS This study examined the association of PTSD (PTSD Checklist-5 [PCL-5]) symptom clusters identified in the anhedonia model and relationship satisfaction (Couples' Satisfaction Index-4) in 477 partnered female SM/Vs. RESULTS Higher anhedonia and dysphoric arousal were associated with lower relationship satisfaction. Among those who scored 31+ on the PCL-5 (n = 255, 53.46%), which is a suggested cutoff for a probable PTSD diagnosis, only higher anhedonia was associated with poorer relationship satisfaction. CONCLUSIONS The association of PTSD symptom clusters with relationship satisfaction are similar for male and female SM/Vs. Interventions to improve relationship satisfaction may focus on reducing anhedonia and dysphoric arousal.

Background Sexual satisfaction and function are vastly understudied in female service members/veterans (SM/Vs). Military sexual trauma (MST) is associated with poorer sexual satisfaction and function, but the mechanism through which MST relates to sexual satisfaction and function is unknown. Posttraumatic stress disorder (PTSD) is one of the most frequent diagnoses following MST, and those with poorer sexual satisfaction and function experience higher PTSD symptoms, particularly numbing and anhedonia symptom clusters. In this study, we examined which symptom clusters (re-experiencing, avoidance, negative alterations in cognition and mood [NACM], anhedonia, dysphoric and anxious arousal) mediated the relationship between MST and sexual satisfaction and function. Method Female SM/Vs (N = 1,189) completed self-report measures of MST severity (none, harassment only, assault), PTSD, sexual satisfaction, and sexual function, as well as a demographic inventory. Results Anhedonia and dysphoric arousal fully mediated the association between assault MST and sexual satisfaction and function. NACM fully mediated the association between harassment and assault MST and sexual satisfaction. Finally, dysphoric arousal significantly mediated the association of harassment MST with sexual satisfaction and function. Limitations Data was cross-sectional and based on self-report. Conclusions The relationship between MST and sexual satisfaction and function may be mediated through specific PTSD symptom clusters. As there are no evidenced-based treatments to improve sexual satisfaction and function in female SM/Vs, additional research is needed to develop and pilot interventions. Among those with a history of MST, targeting NACM, anhedonia, and dysphoric arousal may be most effective in addressing sexual concerns.

Objective Department of Veterans Affairs estimates of military sexual trauma (MST) suggest 27% of female veterans have experienced MST. However, Department of Defense data (Department of Defense, 2014) show that a subgroup of active-duty women do not report sexual assaults to a military authority, suggesting barriers to disclosure exist among military samples. No study of female veterans has examined rates of nondisclosure among those with previous screens for MST; these data could inform screening efforts and establishment of safe havens for candid disclosures. Method Using an explanatory sequential mixed-methods survey, a history of MST, and postservice MST disclosures during screening and their associations with demographic, assault, and screening-setting characteristics were evaluated in 359 female veterans. Open-ended responses regarding barriers to disclosure were analyzed using editing analysis style. Results Eighty-one percent (n = 289) reported MST. Of these, 50% (n = 143) reported a prior screening and 25% (n = 35) reported they did not disclose their true MST status. Veterans who experienced MST by a unit-member assailant were significantly less likely to disclose (adjusted odds ratio = 4.75, 95% confidence interval = 1.20-18.30). Disclosure barriers included stigma, experiential avoidance, and discomfort with the screening setting. Conclusion Creative interventions to reduce nondisclosure among female veterans, with specific attention to those assaulted by a unit member, are urgently needed. (PsycINFO Database Record

Service members/veterans (SM/Vs) underuse mental health care. Attribution theory suggests that attributions for psychological distress might inform help-seeking. Given recent mental health campaign...

Background The effects of sexual trauma on long-term health care utilization and costs are not well understood due to infrequent documentation of sexual trauma history in health care systems. The Veteran's Health Administration provides a unique opportunity to address this constraint as sexual trauma is actively screened for as part of routine care. Methods We used a retrospective cohort design to analyze Veteran's Health Administration mental health and medical service utilization and costs as a function of a positive screen for exposure to military sexual trauma (MST) among Veterans of recent conflicts in Iraq and Afghanistan. We computed adjusted 5-year estimates of overall utilization and costs, and utilization and costs determined not to be related to MST. Results The cohort included 426,223 men and 59,611 women. A positive MST screen was associated with 50% higher health care utilization and costs relative to a negative screen. Overall, a positive relative to negative MST screen was associated with a 5-year incremental difference of 34.6 encounters and $10,734 among women, and 33.5 encounters and $11,484 among men. After accounting for MST-related treatment, positive MST screen was associated with 11.9 encounters and $4803 among women, and 19.5 encounters and $8001 among men. Conclusions Results demonstrate significant and consistent differences in health care utilization and costs between Veterans with a positive relative to negative MST screen. Even after accounting for MST-related care, a positive screen was associated with significantly higher utilization and costs. MST-related needs may be more readily recognized in women relative to men.

Introduction Mental illness and substance use disorders among newly returned military service members pose challenges to successful reintegration into civilian life and, in extreme cases, may lead to outcomes such as incarceration, homelessness, and suicide. One potential early indicator for these difficulties is non-routine discharge from military service. Methods Using data from the Veterans Health Administration (VHA) for 443,360 active duty service Veterans who deployed to Afghanistan and Iraq and subsequently utilized VHA services between Fiscal Years 2004 and 2013, this study examined risk for receiving a VHA-documented diagnosis of mental illness, substance use disorders, and suicidality as a function of discharge type, controlling for demographic and military service covariates. Analyses were conducted in 2016. Results In total, 126,314 Veterans (28.5%) had a non-routine military service discharge. Compared with routinely discharged Veterans, odds for nearly all diagnostic outcomes were significantly greater among Veterans discharged for disqualification or misconduct, including personality disorders (AOR=9.21 and 3.29, respectively); bipolar/psychotic disorders (AOR=3.98 and 3.40); alcohol/substance use disorders (AOR=1.55 and 4.42); and suicidal ideation and behaviors (AOR=2.81 and 2.77). Disability-discharged Veterans had significantly higher odds for diagnoses of anxiety disorders (AOR=1.97) and bipolar/psychotic disorders (AOR=3.93). Conclusions Non-routine service discharge strongly predicts VHA-diagnosed mental illness, substance use disorders, and suicidality, with particularly elevated risk among Veterans discharged for disqualification or misconduct. Results emphasize the importance of discharge type as an early marker of adverse post-discharge outcomes, and suggest a need for targeted prevention and intervention efforts to improve reintegration outcomes among this vulnerable subpopulation.

Objective Evaluate the association of military sexual trauma (MST) screen status with eating disorder diagnoses among veterans within 1- and 5-years after initiating Veterans Health Administration (VHA) care, and whether the association varied by sex. Method Retrospective cohort study of US Afghanistan/Iraq veterans who used VHA services between FY 2004 and 2014 (N = 595,525). This study used VHA administrative data to assess the presence of eating disorder diagnoses in medical records within 1- and 5-years of initiating VHA care, and whether a positive screen for MST was associated with eating disorders. Results Three percent (n = 18,488) screened positive for MST. At 1- and 5-year follow up, 0.1% (n= 513, 74% female), and 0.2% (n = 504, 71% female) were diagnosed with an eating disorder, respectively. In regression models adjusted for demographic variables, military service, and psychiatric comorbidities, the presence of an eating disorder diagnosis was nearly two times higher among those with a positive screen for MST in the 1-year (adjusted odds ratio [AOR] = 1.94, 95% confidence interval [CI] = 1.57–2.40) and 5-year (AOR = 1.86, 95%CI = 1.49–2.32) cohorts. The increased likelihood conferred by MST for an eating disorder diagnosis was differentially stronger among male veterans than female veterans in the 1-year cohort only (AOR = 2.13, 95%CI = 1.01–4.50). Discussion Veterans with a positive screen for MST, especially male veterans, had a nearly two-fold increased likelihood of having an eating disorder diagnosis. Screening for eating disorders may be important in both male and female veterans who report MST.

Objective Treatment for posttraumatic stress disorder (PTSD) is a commonly sought mental health service among military service members and veterans (SM/Vs). Such treatment is typically individually-based, despite many SM/Vs reporting a desire for greater partner involvement in treatment. This review examined couple-based treatments for PTSD among SM/Vs and their romantic partners. Method A database search conducted in July, 2018 yielded 167 studies, of which 16 (10%) met inclusion criteria. Brief intervention summaries, effect sizes, and distress change scores (where applicable) are reported. Results The 16 studies tested 7 interventions, which showed a reduction in self-rated and clinician-rated PTSD symptoms with large effect sizes observed in most studies. Relationship outcomes also improved for SM/Vs and their partners, with effect sizes ranging from small-to-medium for SM/Vs and small-to-large for partners. Conclusions Couple-based interventions show success in reducing PTSD symptoms and improving relationship outcomes, offering several alternatives to individual-based interventions among partnered SM/Vs.

Background Despite national screening efforts, military sexual trauma (MST) is underreported. Little is known of racial/ethnic differences in MST reporting in the Veterans Health Administration (VHA). Objective This study aimed to compare patterns of MST disclosure in VHA by race/ethnicity. Research design Retrospective cohort study of MST disclosures in a national, random sample of Veterans who served in Afghanistan and Iraq and completed MST screens from October 2009 to 2014. We used natural language processing (NLP) to extract MST concepts from electronic medical notes in the year following Veterans' first MST screen. Measure(s) Any evidence of MST (positive MST screen or NLP concepts) and late MST disclosure (NLP concepts following a negative MST screen). Multivariable logistic regressions, stratified by sex, tested racial/ethnic differences in any MST evidence, and late disclosure. Results Of 6618 male and 6716 female Veterans with MST screen results, 1473 had a positive screen (68 male, 1%; 1405 female, 21%). Of those with a negative screen, 257 evidenced late MST disclosure by NLP (44 male, 39%; 213 female, 13%). Late MST disclosure was usually documented during mental health visits. There were no significant racial/ethnic differences in MST disclosure among men. Among women, blacks were less likely than whites to have any MST evidence (adjusted odds ratio=0.75). In the subsample with any MST evidence, black and Hispanic women were more likely than whites to disclose MST late (adjusted odds ratio=1.89 and 1.59, respectively). Conclusions Combining NLP results with MST screen data facilitated the identification of under-reported sexual trauma experiences among men and racial/ethnic minority women.

Military sexual trauma (MST), and assault as opposed to harassment-only MST in particular, is associated with lower sexual function among female service members/veterans (SM/Vs). Recent research revealed that higher posttraumatic stress disorder (PTSD) symptom clusters of anhedonia and dysphoric arousal mediated the association of assault MST and sexual function. Such clusters represent the depressive symptoms of PTSD, and theories of sexual function suggest that depression worsens sexual function. The impact of depression on the association of MST and sexual function has yet to be tested.Using path analysis, the study examined whether depression severity mediated the association of MST and sexual function after accounting for demographics and mediators of PTSD-related anhedonia and dysphoric arousal. Female SM/Vs (N = 697) completed measures of MST (history, severity), depression, PTSD-related anhedonia and dysphoric arousal, sexual function, and a demographic inventory.One hundred twenty-two (17.50%) indicated that they did not experience MST, 336 (48.21%) reported that they experienced harassment-only MST, and 239 (34.29%) reported assault MST. Fit indices evidenced strong model fit, χUse of cross-sectional data in a convenience sample of female SM/Vs.Even after accounting for established covariates and mediators of assault MST and sexual function, depression accounted for a significant amount of variance in this association. Treatment of poor sexual function must address depressive symptoms. As medications for depression can exacerbate sexual issues, psychotherapy may be the most effective treatment strategy.

Low relationship satisfaction is associated with mental health disorders in service members/veterans (SM/Vs), yet eating disordered behavior (EDB) and sexual function and satisfaction in SM/Vs are understudied. Those with EDB may experience bodily discomfort that may be associated with low relationship satisfaction because of avoidance of physical contact and intimacy, suggesting that sexual satisfaction and function may modify the association of EDB and relationship satisfaction. As the majority of female SM/Vs are partnered, it is imperative to study the association of sexual function and satisfaction with EDB and relationship satisfaction. Partnered female SM/Vs (N = 479) completed an online survey assessing demographic characteristics (e.g., relationship duration, deployment history), EDB, sexual satisfaction and function, and relationship satisfaction measures. Thirty-three percent, 20%, and 58% of the sample reported scores consistent with relational distress, probable eating disorder, and sexual dysfunction, respectively. After adjusting for covariates, EBD was negatively associated with relationship satisfaction with a small-to-medium effect size. Sexual satisfaction and function had a significant indirect effect on the association of EDB and relationship satisfaction, suggesting that sexual satisfaction and function accounted for some of the variance between these 2 variables. Screening for EDB, sexual satisfaction, and sexual function among partnered female SM/Vs may provide critical insight into mechanisms of relational distress. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Purpose Posttraumatic stress disorder (PTSD), depressive disorders (DD), and substance use disorders (SUD) are prevalent among veterans. A positive military sexual trauma (MST) screen is associated with higher likelihood of each of these disorders. The current study examined the associations between MST, gender, and co-occurring PTSD, DD, and SUD among veterans receiving services at the Department of Veterans Affairs to inform assessment and treatment. We were specifically interested in the interactions between MST and gender on co-occurring disorders. Methods The sample included 494,822 Department of Veterans Affairs service–seeking veterans (12.5% women) deployed to Iraq and Afghanistan who recently separated from the military and were screened for MST between 2004 and 2013. Main Findings Veterans with positive MST screens had higher odds than those with negative screens of individual and co-occurring PTSD, DD, and SUD. The association between positive MST screens and diagnostic outcomes, including PTSD, was stronger for women than for men, and the association between positive MST screens and some diagnostic outcomes, including DD, was stronger for men than for women. Conclusions These results highlight the importance of assessing for and recognizing the potential MST and gender interactions in the clinical context among veterans with co-occurring PTSD, DD, and/or SUD.

Extant military studies show that stigma has a variable association with seeking mental health treatment and mental health distress. Previous studies used a general measure of stigma that does not ...

Veterans who are discharged from military service due to misconduct are vulnerable to negative health-related outcomes, including homelessness, incarceration, and suicide. We used national data from the Veterans Health Administration for 218,608 veterans of conflicts in Iraq and Afghanistan that took place after the events of September 11, 2001, to compare clinical diagnoses between routinely-discharged (n = 203,174) and misconduct-discharged (n = 15,433) veterans. Misconduct-discharged veterans had significantly higher risk for all mental health conditions (adjusted odds ratio [AOR] range, 2.5-8.0) and several behaviorally linked chronic health conditions (AOR range, 1.2-5.9). Misconduct-discharged veterans have serious and complex health care needs; prevention efforts should focus on behavioral risk factors to prevent the development and exacerbation of chronic health conditions among this vulnerable population.

Objective Recent prevalence estimates indicate 38% of female service members/veterans (SM/Vs) report military sexual trauma (MST). This estimate is higher than Veterans Affairs estimates, which suggest 28% report MST during screening. The discrepant estimate suggests possible barriers to disclosing MST, which are not well-identified in the literature. The current study examined whether being assaulted by a fellow unit member and stigma for seeking help to treat the sequelae of MST from self, unit leader/command, and romantic partners were correlates of MST nondisclosure among 209 female SM/Vs. Method Participants completed a self-report questionnaire assessing MST nondisclosure, MST assailant characteristics, and stigma from the aforementioned sources as well as demographic, military, and mental health characteristics. Logistic regression analyses adjusting for military rank, MST severity, age, marital status and satisfaction, and probable mental health diagnoses determined whether being assaulted by a fellow unit member (yes/no) or stigma from various sources were associated with MST nondisclosure. Results Thirty-seven (17.70%) participants did not disclose MST during a previous screening. At the bivariate level, participants who did not disclose MST reported higher self-stigma and anticipated enacted stigma from unit leader/command and romantic partner. After adjusting for covariates, only higher self-stigma was associated with MST nondisclosure. Conclusions Female veterans who report higher self-stigma were less likely to disclose their MST during screening. Such findings are consistent with previous literature demonstrating that self-stigma, relative to other forms of stigma, relates to lower help-seeking behaviors. Efforts to increase the disclosure of MST during screening should focus on reducing self-stigma. (PsycINFO Database Record (c) 2019 APA, all rights reserved).