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An examination of sexual harassment, gender discrimination, stalking, and sexual assault among female and male veterans and associations with PTSD and depression

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An examination of sexual harassment, gender discrimination, stalking, and sexual assault among female and male veterans and associations with PTSD and depression

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An Examination of Sexual Harassment, Gender Discrimination, Stalking, and Sexual Assault
among Female and Male Veterans and Associations with PTSD and Depression

by
Carrie L. Lucas, MSW, MPA, LICSW
August 2017 Degree Conferral
PhD (Social Work)

Graduate School
University of Southern California

Dissertation Guidance Committee
Carl Castro, PhD (Chair)
Julie Cederbaum, PhD, MSW, MPH
Richard John, PhD

The views expressed in this dissertation are those of the author and do not reflect the official
policy or position of the U.S. Air Force, U.S. Department of Defense, or U.S. Government.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 2
Dedication
This dissertation is dedicated to my husband, my sons, my family, and my friends. To my
husband, Aaron, who has wholeheartedly joined me on this journey in pursuit of helping active-
duty service members and their families, thank you for loving me and for your endless support.
To my sons, thank you for giving me a reason to get up each day. To my mom, in heaven, for
your endless love, pride in my accomplishments, and belief in me; I miss you. To my dad, thank
you for always being a solid sounding board and showing me life is a journey of learning. To my
siblings, John, Michael, and Michelle, for always being there for me and loving me just the way I
am. To my Grandma, Beverly, for showing me women can conquer all. To my in-laws, for
always being there when it’s most needed. To my lifelong friends, thank you for supporting me
from many miles away. To the dear USC friends I’ve made along the way—thank you for your
friendship, listening ears, and support—especially Taylor, along with many others. Finally, to the
Air Force service members and families I have had and will have the privilege to serve, we will
not fail.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 3
Acknowledgements
I am truly thankful and humbled by the generosity shown to me these past three years and
take the opportunity to say thank you.
To Dr. Carl Castro, for the tremendous support and faith you had in my abilities and for
your encouragement, guidance, kindness, and advice. I am grateful for your dedication to my
success.
To Dr. Julie Cederbaum, for your expeditious, thorough feedback and for investing your
time in this junior scholar. I greatly appreciate your commitment to my success.
To Dr. Jeremy Goldbach, Dr. Suzanne Wenzel, Dr. Benjamin Henwood, Dr. Richard
John, and many other faculty members at USC, for your support and guidance through this
process, which allowed for rich growth and a life-altering experience.
To the USC Suzanne Dworak-Peck School of Social Work doctoral program for your
faith in my abilities and generous financial support.
To Dr. (Lt Col) Rachel Foster, for your support, feedback, and ultimately, for believing in
my potential to succeed. I would not have been considered at USC if not for you.
Finally, I feel deeply indebted to the U.S. Air Force and the Air Force Institute of
Technology, which provided me the opportunity to return to school to complete this degree at
USC, which would not have been attainable otherwise.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 4
Table of Contents
Dedication ....................................................................................................................................... 2
Acknowledgements ......................................................................................................................... 3
List of Tables .................................................................................................................................. 6
Abstract ........................................................................................................................................... 7
Chapter One: Overview of the Three Manuscripts ......................................................................... 9
Introduction and Rationale ........................................................................................................ 9
Sexual Harassment ............................................................................................................ 10
Gender Discrimination ...................................................................................................... 12
Stalking ............................................................................................................................. 13
Sexual Assault ................................................................................................................... 14
Theoretical Framework ........................................................................................................... 16
Dissertation Goal and Structure .............................................................................................. 17
Manuscript 1 ..................................................................................................................... 17
Manuscript 2 ..................................................................................................................... 18
Manuscript 3 ..................................................................................................................... 18
Summary ................................................................................................................................. 19
References ............................................................................................................................... 20
Chapter Two: Manuscript 1 .......................................................................................................... 28
An Examination of Stalking among Female and Male Veterans and Associations with PTSD
and Depression ........................................................................................................................ 28
Abstract ................................................................................................................................... 28
Background ............................................................................................................................. 29
Methods................................................................................................................................... 32
Study Overview and Participants ...................................................................................... 32
Measures ........................................................................................................................... 33
Data Analysis .................................................................................................................... 35
Results ..................................................................................................................................... 35
Stalking Experiences among Female and Male Veterans ................................................. 36
Characteristics and Associations of Stalking Experiences ............................................... 36
Variables Associated with Stalking: Comparing Female and Male Veterans .................. 38
Stalking Experiences and Associations with PTSD and Depression ................................ 38
Discussion ............................................................................................................................... 39
References ............................................................................................................................... 43
Chapter Three: Manuscript 2 ........................................................................................................ 59
An Examination of Sexual Harassment, Gender Discrimination, Stalking, and Sexual Assault
among Female Veterans and Associations with PTSD and Depression ................................. 59
Abstract ................................................................................................................................... 59
Background ............................................................................................................................. 60
Reported Rates of Sexual Trauma .................................................................................... 60
Assessments and Evaluations of Sexual Trauma .............................................................. 61
Sexual Harassment and Gender Discrimination ............................................................... 62
Stalking ............................................................................................................................. 62
Sexual Assault ................................................................................................................... 63
Purpose of this Study ........................................................................................................ 63
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 5
Methods................................................................................................................................... 64
Study Overview and Participants ...................................................................................... 64
Measures ........................................................................................................................... 64
Data Analysis .................................................................................................................... 67
Results ..................................................................................................................................... 68
Military-Related Sexual Trauma Experiences and Associations with PTSD ................... 69
Military-Related Sexual Trauma Experiences and Associations with Depression ........... 70
Discussion ............................................................................................................................... 70
Limitations ........................................................................................................................ 73
Conclusions ....................................................................................................................... 73
References ............................................................................................................................... 74
Chapter Four: Manuscript 3 .......................................................................................................... 88
An Examination of Sexual Harassment, Gender Discrimination, Stalking, and Sexual Assault
among Male Veterans and Associations with PTSD and Depression .................................... 88
Abstract ................................................................................................................................... 88
Background ............................................................................................................................. 89
Reported Rates of Sexual Trauma .................................................................................... 89
Sexual Trauma and Impact on Health and Mental Health ................................................ 90
Purpose of this Study ........................................................................................................ 92
Methods................................................................................................................................... 93
Study Overview and Participants ...................................................................................... 93
Measures ........................................................................................................................... 93
Data Analysis .................................................................................................................... 97
Results ..................................................................................................................................... 97
Military-Related Sexual Trauma Experiences and Associations with PTSD ................. 100
Military-Related Sexual Trauma Experiences and Associations with Depression ......... 101
Discussion ............................................................................................................................. 102
Limitations ...................................................................................................................... 104
Conclusions ..................................................................................................................... 105
References ............................................................................................................................. 106
Chapter Five: Conclusions, Future Directions, and Recommendations ..................................... 121
Major Findings ...................................................................................................................... 121
Manuscript 1 ................................................................................................................... 121
Manuscript 2 ................................................................................................................... 122
Manuscript 3 ................................................................................................................... 123
Limitations and Future Research .......................................................................................... 124
Implications and Recommendations ..................................................................................... 125
References ............................................................................................................................. 127

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 6
List of Tables
Table 1.1. Reported Rates of Sexual Traumas among Women .................................................... 26
Table 1.2. Reported Rates of Sexual Traumas among Men ......................................................... 27
Table 2.1. Correlations of Variables among Female and Male Veterans ..................................... 50
Table 2.2. Sample Characteristics and Trauma Experiences of Female and Male Veterans ........ 51
Table 2.3. Stalking Experiences among Female and Male Veterans ............................................ 53
Table 2.4. Characteristics of Female and Male Veterans With and Without Stalking ................. 55
Table 2.5. Stalking, Probable PTSD, and Probable Depression among Female and Male Veterans
........................................................................................................................................... 58
Table 3.1. Sample Characteristics and Sexual Trauma Experiences of Female Veterans ............ 81
Table 3.2. Participant Characteristics With and Without MRST among Female Veterans .......... 84
Table 3.3. MRST, Probable PTSD, and Probable Depression among Female Veterans .............. 87
Table 4.1. Sample Characteristics and Sexual Trauma Experiences of Male Veterans ............. 112
Table 4.2. Participant Characteristics With and Without Singular MRST or Combinations of
MRST among Male Veterans ......................................................................................... 115
Table 4.3. Singular MRST, Combinations of MRST, Probable PTSD, and Probable Depression
among Male Veterans ..................................................................................................... 118

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 7
Abstract
Military sexual trauma among female service members and veterans has been well
documented and has become more known among male veterans due to recent research. The
primary focus of research has been undertaken using the U.S. Department of Defense umbrella
term military sexual trauma, which includes military sexual harassment (MSH) and military
sexual assault (MSA) and their impact on mental and physical health. Military sexual trauma
will be expanded by assessing (1) sexual traumas with more than one question per sexual trauma
and (2) for other potential sexual traumas, i.e. gender discrimination and stalking. This expansion
will be defined as military-related sexual trauma (MRST), which includes the experiences of
MSH, gender discrimination, stalking, and MSA during military service.
This three-manuscript dissertation aimed to (1) more concisely assess and highlight
reported rates of MRST experiences, (2) highlight characteristics of veterans who experience
MRST, and (3) evaluate MRST experiences and associations with PTSD and depression among
female and male veterans. This dissertation was guided by trauma theory, which suggests that
psychological trauma is not a specific traumatic event that affects an individual, but also includes
the unique response of one’s social group (i.e. the military). It is possible veterans did not fully
address their MRST experiences while in the military due to potential negative career
implications and thus, experience negative mental health outcomes as veterans. It is also highly
possible that veterans experienced more than one MRST while serving in the military, known as
cumulative trauma. Cumulative trauma is addressed in this dissertation by evaluating
combinations of MRST experiences among female and male veterans.
Chapter One presents (a) a discussion of the current literature on sexual harassment,
gender discrimination, stalking, and sexual assault and associations with health and mental health
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 8
among women and men, (b) trauma theory as the theoretical framework used to guide the three
manuscripts, and (c) a brief introduction and description of each manuscript. Because stalking
has not been fully evaluated among female and male veteran populations, Chapter Two
(Manuscript 1) evaluated (a) types of stalking, (b) characteristics of veterans who experienced
stalking within and between genders, and (c) stalking associations with PTSD and depression.
Validated as associated with probable PTSD and depression, stalking was included in
combination with MSH, gender discrimination, and MSA in the second and third manuscripts.
Chapter Three (Manuscript 2) examined combinations of MRST among female veterans and
highlights (a) reported rates of MRST, (b) significant characteristic differences, and (c)
significant associations with PTSD and depression. Chapter Four (Manuscript 3) examined
combinations of MRST among male veterans and highlights (a) reported rates of MRST, (b)
significant characteristic differences, and (c) significant associations with PTSD and depression.
Finally, Chapter Five discusses pertinent dissertation conclusions, future directions, and
recommendations to include: (1) individually assessing for MRST experiences, (2) assessing for
gender discrimination and stalking along with MSH and MSA, and (3) evaluating combinations
of MRST to better understand cumulative trauma and associations with health outcomes.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 9
Chapter One: Overview of the Three Manuscripts
Introduction and Rationale
The topic of military sexual trauma among service members and veterans has grown in
the last 10 years; to date, there has been greater emphasis on the experiences of women
(Kimerling, Gima, Smith, Street, & Frayne, 2007; Kimerling et al., 2010; Schuyler, Kintzle,
Lucas, Moore, & Castro, 2016; Street, Stafford, Mahan, & Hendricks, 2008) as compared to men
(Hoyt, Rielage, & Williams, 2011; Kimerling et al., 2007; Schuyler et al., 2016). The primary
focus of the research has been undertaken using the U.S. Department of Defense’s umbrella term
military sexual trauma, which includes a two-item screener to evaluate the experiences of
military sexual harassment (MSH) and military sexual assault (MSA; Kimerling et al., 2007).
The primary outcomes of interest related to military sexual trauma have been mental (Goldstein,
Dinh, Donalson, Hebenstreit, & Maguen, 2017; Kimerling et al., 2007; Kimerling et al., 2010;
Murdoch, Pryor, Polusny, & Gackstetter, 2007; Schuyler et al., 2016) and physical health
(Schuyler et al., 2016; Street et al., 2008).
Military sexual trauma must be more clearly defined to highlight sexual trauma
experiences during military service to provide the appropriate treatment (Williamson, Holliday,
Holder, North, & Suris, 2017). The current evaluation of military sexual trauma includes two
questions: “While you were in the military: (a) Did you receive uninvited and unwanted sexual
attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?; (b) Did
someone ever use force or threat of force to have sexual contact with you against your will?”
(yes/no; Kimerling et al., 2007, p. 2161). Military sexual trauma will be expanded by assessing
(1) sexual traumas with more than one question per sexual trauma and (2) for other potential
sexual traumas, i.e. gender discrimination and stalking. Within this dissertation, this expansion
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 10
will be defined as military-related sexual trauma (MRST), which includes the experiences of
MSH, gender discrimination, stalking, and MSA during military service. MRST experiences are
described within the measures of this dissertation.
When considering the four MRST experiences, less is known about stalking among
female and male veterans (Clancy et al., 2006; Dardis, Amoroso, & Iverson, 2016; Dardis,
Shipherd, & Iverson, 2016), so it will be helpful to first understand stalking experiences among
female and male veterans and its association with mental health. Once stalking experiences and
the associations with mental health are understood, it can be included with other known MRSTs
(i.e., sexual harassment, gender discrimination, and sexual assault). Also, as it is highly unlikely
veterans have only experienced one type of MRST, the inclusion of all four MRSTs will allow
for the experiences to be combined to analyze the experience of only experiencing one MRST
versus combinations of MRST.
Sexual Harassment
The civilian and military literatures feature various definitions of sexual trauma, with few
comparing the impact of more than one sexual trauma (DeSouza & Fansler, 2003; Rospenda,
Richman, & Shannon, 2009; Schuyler et al., 2016; Williamson et al., 2017). This makes it
difficult to assess the impact of each trauma independently from or in combination with other
traumas. For example, experiences of gender discrimination have been evaluated as sexual
harassment using the Sexual Experiences Questionnaire (DeSouza & Fansler, 2003; Fitzgerald,
Magley, Drasgow, & Waldo, 1999; Street, Gradus, Stafford, & Kelly, 2007; Street et al., 2008)
making it unclear if negative outcomes are related to sexual harassment or gender discrimination.
Women. As shown in Table 1.1, reported rates of sexual harassment among women are
40%–75% of civilians (Willness, Steel, & Lee, 2007), 21% of active-duty members (Morral,
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 11
Gore, & Schell, 2016), and 51% of veterans (Street, Gradus, Giasson, Vogt, & Resick, 2013).
The reported rate of sexual harassment for female veteran populations appears to be double the
rate of female active-duty populations. Although the reasons for this discrepancy are not known,
it is possible that female active-duty members are less likely to indicate that they have
experienced sexual harassment due to concerns about career impact and stigma associated with
reporting sexual harassment (Fayazrad, 2014; Rasmussen & Zaglifa, 2013).
Sexual harassment significantly affects the mental health of female civilians (Rospenda et
al., 2009) and depression and health concerns of female reservists (Street et al., 2008). The study
by Street et al. (2008) analyzed MSH only separate from female reservists who experienced
MSH and MSA, which provides stronger evidence for the negative associations with depression
and health concerns. However, this study did not include other potential sexual traumas, i.e.
gender discrimination and stalking, so the findings may not be fully indicative of MSH only
experiences. Sexual harassment has also been evaluated with gender discrimination, with the
experience of sexual harassment or gender discrimination negatively affecting depression and
anxiety among female civilians (DeSouza & Fansler, 2003) and female active-duty members
(Street et al., 2007). While these studies (DeSouza & Fransler, 2003; Street et al., 2007) highlight
the impact of sexual harassment because sexual harassment (1) wasn’t analyzed separately from
gender discrimination and (2) stalking and sexual assault were not included, the findings may not
be indicative of sexual harassment experiences.
Men. As shown in Table 1.2, reported rates of sexual harassment experienced by men are
13%–31% for civilians (Willness et al., 2007), 7% for active-duty members (Morral et al., 2016),
and 11% for veterans (Street et al., 2013). Similar to female populations, male veterans are more
likely to report sexual harassment in comparison to male active-duty members. The assessment
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 12
of sexual harassment among men has also featured varying evaluations in the civilian and
military literature (DeSouza & Fansler, 2003; Kimerling et al., 2007; Kimerling et al., 2010).
This makes it difficult to assess how the impact of sexual harassment alone or in combination
with gender discrimination, stalking, and sexual assault affects male veterans.
Unlike women, male civilians who experienced sexual harassment or gender
discrimination did not significantly differ on measures of depression and anxiety (DeSouza &
Fansler, 2003). However, the opposite was found in a study of male active-duty members; the
presence of MSH or gender discrimination was significantly related to PTSD and depression
when compared to participants who did not experience MSH or gender discrimination (Street et
al., 2007). Because sexual harassment and gender discrimination were evaluated in a way that
allowed for either to be present (DeSouza & Fransler, 2003; Street et al., 2007), it is not clear if
sexual harassment, gender discrimination, or both affected the outcomes.
Gender Discrimination
As shown in Table 1.1, researchers report that among women, 24% of civilians
(Rospenda et al., 2009), 13% of active-duty members (Morral et al., 2016), and 52% of veterans
(Street et al., 2007) have experienced gender discrimination. The rates among female veterans
appear to be quadruple that of active-duty members. As shown in Table 1.2, among men, 13% of
civilians (Rospenda et al., 2009), 2% of active-duty members (Morral et al., 2016), and 17% of
veterans (Street et al., 2007) reported experiencing gender discrimination. The rate among male
veterans appears to be more than 5 times higher than the rate among active-duty members. As
with sexual harassment this disparity between rates of gender discrimination in veterans versus
active duty members may be due to concerns about career impact and reporting stigma
(Fayazrad, 2014; Rasmussen & Zaglifa, 2013).
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 13
In a national study of female and male civilians, gender discrimination was not
significantly related to mental health outcomes for women or men (Rospenda et al., 2009). In
contrast, female active-duty members who experienced gender discrimination were found to
have significant associations with psychological well-being compared to women who did not
(Leskinen, Cortina, & Kabat, 2011). To the best of this author’s knowledge, there was no
literature focused on male military populations. Within the known literature on female military
populations (Leskinen et al., 2011), as other potential sexual traumas (i.e. sexual harassment,
stalking, and sexual assault) were not assessed, it is possible the presence of gender
discrimination did not solely lead to the observed outcomes.
Stalking
As shown in Table 1.1, researchers report that among women, 8%–15% of civilians
(Breiding et al., 2014), 1%–9% of active-duty members (Cook et al., 2015), and 64% of veterans
(Dardis, Amoroso, et al., 2016) experienced stalking. The reported rate among female veterans is
more than triple the reported rates of female civilians and six times that of active-duty members.
As shown in Table 1.2, among men, 2%–6% of civilians (Breiding et al., 2014; Tjaden &
Thoennes, 2000), 1%–2% of active-duty members (Cook et al., 2015), and 4%–15% of veterans
(Clancy et al., 2006) reported experiencing stalking. Similar to female veterans, male veterans
reported increased rates of stalking compared to male active-duty members, but not when
compared to male civilians.
In a civilian population, women who experienced stalking were significantly more likely
to have a chronic mental illness and use painkillers or tranquilizer compared to those who did not
(Davis, Coker, & Sanderson, 2002). In the same study, women and men who experienced
stalking were significantly more likely to have depression and use recreational drugs compared
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 14
to those who had not been stalked (Davis et al., 2002). Stalking has also been studied in the
context of intimate partner violence (IPV) and significantly associated with PTSD among female
civilians (Basile, Arias, Desai, & Thompson, 2004) and veterans (Dardis, Amoroso, et al., 2016).
As stalking has been primarily evaluated as IPV among veterans (Dardis, Amoroso, et al., 2016),
stalking that has occurred outside of IPV and its associations with mental health is unknown.
Also, as other potential sexual traumas (i.e. sexual harassment, gender discrimination, and sexual
assault) were not assessed, it is possible the presence of stalking did not solely affect the
outcomes.
Sexual Assault
A review of the literature found numerous studies on MSA and its impact on mental
health among military populations. Throughout the literature on military populations, MSA has
been evaluated in three ways, as: (a) MSH or MSA, (b) MSA, or (c) MSH and MSA. When
evaluating MSH or MSA, the impact of each is uncertain, as it may be the experience of MSH,
the experience of MSA, or the experience of both MSH and MSA that is impacting the
outcomes. Arguably, the evaluation of having experienced both MSH and MSA shows clear
associations with the findings. The next step is to also include gender discrimination and stalking
to further delineate how combinations of MRSTs are associated with mental health.
Women. As shown in Table 1.1, among women, 18% of civilians (Tjaden & Thoennes,
2000), 28% of active-duty members (Barlas, Higgins, Pflieger, & Diecker, 2013), and 9%–41%
of veterans (Schuyler et al., 2016; Suris & Lind, 2008) reported experiencing sexual assault. In
the literature among military populations, MSH or MSA are often evaluated together. For
example, among veteran populations, women who experienced MSH or MSA were significantly
more likely to have PTSD, depression, anxiety, alcohol use, substance use, and adjustment
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 15
disorders compared to women who did not (Kimerling et al., 2007; Kimerling et al., 2010). In
both of these studies, MSH was not analyzed independently of MSA, so it is quite possible that
the experience of MSA accounted for these health outcomes. In fact, the presence of MSA alone
has also been found to be an indicator of PTSD among female active-duty members (Wolfe et
al., 1998) and female veterans (Kang, Dalager, Mahan, & Ishii, 2005; Luterek, Bittenger, &
Simpson, 2011; Schuyler et al., 2016) and an indicator of depression among female veterans
(Schuyler et al., 2016). It is also common among military populations for the experiences of both
MSH and MSA to be analyzed together. For example, in two studies, female active-duty
members (Murdoch et al., 2007) and reservists (Street et al., 2008) who experienced both MSH
and MSA were significantly more likely to have PTSD, depression, anxiety, or somatic concerns
compared to those who did not. The next step is to include other MRSTs (i.e. gender
discrimination and stalking) to further evaluate the impact on mental health.
Men. As shown in Table 1.2, reported rates among men are 3% of civilians (Tjaden &
Thoennes, 2000), 6% of active-duty members (Barlas et al., 2013), and 3%–12% of veterans
(Schuyler et al., 2016; Suris & Lind, 2008) experienced sexual assault. Among military
populations, MSH or MSA are also often assessed together among male veterans. For example,
in a veteran population, men who experienced MSH or MSA were significantly more likely to
have PTSD, depression, anxiety, alcohol use, substance use, and adjustment disorders compared
to those who did not (Kimerling et al., 2007; Kimerling et al., 2010). The presence of MSA
among male veterans has also been assessed and found to be an indicator of both PTSD and
depression when compared to male veterans who did not experience MSA (Schuyler et al.,
2016). MSH and MSA have also been evaluated together in male military populations. Studies
on active-duty and reserve populations have found men who experienced both MSH and MSA
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 16
were significantly more likely to have PTSD, depression, anxiety, and somatic concerns
compared to those who did not (Murdoch et al., 2007; Street et al., 2008). Again, the next step is
to include other MRSTs (i.e. gender discrimination and stalking) to further understand how
combinations of MRSTs are associated with mental health.
Theoretical Framework
This dissertation was guided by trauma theory. Trauma theory emphasizes how traumatic
experiences are external events that become integrated into the psyche (Bloom, 1999) and affect
mental health. Trauma theory suggests that psychological trauma is not a specific traumatic event
that affects an individual, but how “the individual’s mind and body reacts in its own unique way
to the traumatic experience in combination with the unique response of the individual’s social
group” (Bloom, 1999, p. 6). The military environment may affect how a victim of MRST
responds to and processes the MRST while in the military, particularly because potential career
implications are associated with reporting MRSTs (Burgess, Slattery, & Herlihy, 2013; Rosellini
et al., 2017). Due to potential negative reactions of the social group (i.e., the military), it is
possible veterans did not fully address their MRST experiences while in the military and thus,
experience negative mental health outcomes as veterans. It is also highly possible that veterans
experienced more than one MRST while serving in the military. The experience of more than
one MRST, known as cumulative trauma, causes an increased risk for mental health concerns
(Turner & Lloyd, 1995). The literature has shown multiple traumas are commonly associated
with PTSD and have implications for assessment and treatment (Briere, Agee, & Dietrich, 2016;
Kessler, 2000). Not only is it important to clarify (1) stalking experiences of female and male
veterans, but (2) how gender discrimination and stalking exist among MSH and MSA to identify
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 17
how combinations of these experiences (cumulative trauma) are affecting the mental health of
female and male veterans.
Dissertation Goal and Structure
This three-manuscript dissertation sought to advance our understanding of MSH, gender
discrimination, stalking, and MSA and their associations with PTSD and depression. The current
literature has primarily focused on the presence of MSH and MSA among veterans, with
minimal literature on gender discrimination and stalking. It is unknown how the combination of
these four MRSTs are experienced by female and male veterans. As stalking has not been fully
evaluated among female and male veteran populations, the first manuscript evaluated its
presence and associations with mental health. As the experience of stalking was associated with
probable PTSD and depression it was included in the second and third manuscripts that evaluated
the combinations of the four MRSTs (cumulative trauma) and associations with PTSD and
depression. The aims of the three manuscripts are as follows:
Manuscript 1: Examine types of stalking experiences among female and male veterans
and associations with PTSD and depression.
Manuscript 2: Examine combinations of sexual harassment, gender discrimination,
stalking, and sexual assault among female veterans and associations with PTSD and depression.
Manuscript 3: Examine combinations of sexual harassment, gender discrimination,
stalking, and sexual assault among male veterans and associations with PTSD and depression.
Manuscript 1
In the literature on civilian populations, stalking has been primarily evaluated with regard
to intimate partner violence, with minimal literature on female and male veterans. Because little
is known about stalking and veteran populations, the purpose of this study was to examine (a)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 18
types of stalking experienced, (b) characteristics of individuals who experienced stalking within
and between genders, and (c) associations with probable PTSD and depression among female
and male veterans. Descriptive statistics were used to evaluate types of stalking and
characteristics of veterans who experienced stalking. Stratified by gender, logistic regressions
were used to examine the relationship of stalking and probable PTSD and depression.
Manuscript 2
The military literature regarding female service members and veterans has focused on
MSH and MSA and its associations with mental health. This manuscript examined the
combinations of MRSTs (i.e., MSH, gender discrimination, stalking, and MSA) and associations
with probable PTSD and depression among female veterans. Descriptive statistics were used to
evaluate characteristics of female veterans with combinations of MRST experiences compared to
no MRST. Two logistic regression models were used to examine the relationship of MRST
experiences and probable PTSD and depression.
Manuscript 3
The military literature regarding male veterans has also focused on MSH and MSA and
their associations with mental health. This manuscript examined the combinations of MRSTs
(i.e., MSH, gender discrimination, stalking, and MSA) and associations with probable PTSD and
depression among male veterans. Descriptive statistics were used to evaluate characteristics of
male veterans who only experienced one MRST and combinations of MRST compared to no
MRST. Two logistic regression models were used to examine the relationship of MRST and
probable PTSD and depression.
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 19
Summary
It is highly likely female and male veterans experienced more than one MRST during
their military service, known as cumulative trauma (Turner & Lloyd, 1995). By further
evaluating combinations of MRST experiences (i.e. MSH, gender discrimination, stalking, and
MSA) we will have a stronger understanding of how MRSTs are associated with PTSD and
depression. As the known research on veterans and stalking is in regard to IPV (Campbell et al.,
2003; Dardis, Amoroso, et al., 2016), the goal of manuscript 1 is to demonstrate stalking
(regardless if IPV or not) is associated with PTSD and depression among female and male
veterans, making this a unique contribution of this dissertation. Moreover, previous studies have
demonstrated that varying evaluations of sexual harassment, gender discrimination, and sexual
assault have negatively affected the health and mental health of civilian and military populations.
Manuscripts 2 and 3 provide more information on (a) how stalking is present among other
MRSTs, (b) how combinations of the four MRSTs are experienced among female and male
veterans, and (c) how combinations of MRST are associated with mental health. Findings from
these dissertation manuscripts are important because they highlight combinations of MRST
experiences among female and male veterans and thus, provide a better understanding of MRST
experiences and associations with mental health.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 20
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MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 26
Table 1.1. Reported Rates of Sexual Traumas among Women
Variable % Reference
Sexual harassment
Civilian 40–75 Willness et al. (2007)
Active duty 21 Morral et al. (2016)
Veteran 51 Street et al. (2013)
Gender discrimination
Civilian 24 Rospenda et al. (2009)
Active duty 13 Morral et al. (2016)
Veteran 52 Street et al. (2007)
Stalking
Civilian 8–15 Breiding et al. (2014); Tjaden and Thoennes (2000)
Active duty 1–9 Cook et al. (2015)
Veteran 64 Dardis, Amoroso, et al. (2016)
Sexual assault
Civilian 18 Tjaden and Thoennes (2000)
Active duty 28 Barlas et al. (2013)
Veteran 9–41 Schuyler et al. (2016); Suris and Lind (2008)

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 27
Table 1.2. Reported Rates of Sexual Traumas among Men
Variable % Reference
Sexual harassment
Civilian 13–31 Willness et al. (2007)
Active-duty 7 Morral et al. (2016)
Veteran 11 Street et al. (2013)
Gender discrimination
Civilian 13 Rospenda et al. (2009)
Active-duty 2 Morral et al. (2016)
Veteran 17 Street et al. (2007)
Stalking
Civilian 2–6 Breiding et al. (2014); Tjaden and Thoennes (2000)
Active-duty 1–2 Cook et al. (2015)
Veteran 4–15 Clancy et al. (2006)
Sexual assault
Civilian 3 Tjaden and Thoennes (2000)
Active-duty 6 Barlas et al. (2013)
Veteran 3–12 Schuyler et al. (2016); Suris and Lind (2008)

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 28
Chapter Two: Manuscript 1
An Examination of Stalking among Female and Male Veterans and Associations with
PTSD and Depression
In preparation for submission to Journal of Traumatic Stress
(Carrie Lucas, Julie Cederbaum, Sara Kintzle, and Carl Castro)
Abstract
Stalking has been found to be associated with mental health concerns and primarily evaluated
among civilian populations. As such, this study evaluated stalking in two community, non-
clinical samples of veterans (N = 1,980), including: (a) types of stalking, (b) characteristics of
veterans who experienced stalking within and between genders, and (c) stalking associations
with PTSD and depression. Types of stalking varied by gender: female veterans most frequently
experienced unwanted messages, emails, or phone calls (37.2%) and male veterans most
frequently experienced someone showing up unannounced or uninvited (23.5%). Female and
male veterans 18 to 39 years old were significantly more likely to have experienced stalking (p <
.001 and p < .001, respectively) than not. Female veterans were significantly more likely to
experience stalking than male veterans (58.5% vs 34.6%, p < .001, respectively). Female
veterans who experienced stalking were significantly more likely to have probable PTSD (OR =
1.88; 95% CI = 1.04, 3.39) and depression (OR = 2.54; 95% CI = 1.38, 4.58) compared to those
who did not. Male veterans who experienced stalking were significantly more like to have
probable PTSD (OR = 3.08; 95% CI = 2.27, 4.18) and depression (OR = 2.78; 95% CI = 2.05,
3.79) compared to those who did not. As this study highlights the presence and impact of
stalking, it is strongly suggested (1) clinical providers assess for the presence of stalking to
inform treatment and (2) stalking be evaluated in combination with other sexual traumas.
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 29
An Examination of Stalking among Female and Male Veterans and Associations with
PTSD and Depression
Veterans can experience potentially traumatizing events while serving in the military,
including military sexual trauma (Kimerling, Gima, Smith, Street, & Frayne, 2007; Kimerling et
al., 2010; Schuyler, Kintzle, Lucas, Moore, & Castro, 2016). The U.S. Department of Defense
(DoD) has defined military sexual trauma (Kimerling et al., 2007) as military sexual harassment
(Morral, Gore, & Schell, 2016; Street, Gradus, Giasson, Vogt, & Resick, 2013) and military
sexual assault (Barlas, Higgins, Pflieger, & Diecker, 2013; Schuyler et al., 2016). Currently,
stalking is not a focus of the DoD and, therefore, is less commonly assessed and evaluated. The
literature on stalking in military populations that does exist has focused on (a) rates of stalking
experiences among female and male students attending military academies (Cook et al., 2015),
(b) rates of intimate partner stalking among female veterans and associations with post-traumatic
stress disorder (PTSD; Dardis, Amoroso, & Iverson, 2016; Dardis, Shipherd, & Iverson, 2016),
and (c) rates of stalking experiences among male veterans (Clancy et al., 2006). An examination
of stalking among female and male veterans would expand the current literature by providing
more information on what types of stalking is experienced, gender differences, and possible
associations with PTSD and depression.
Background
Stalking became a focus in the literature in the 1990s and beyond, with a specific focus
on civilian populations (Spitzberg & Cupach, 2003). Despite being a part of the literature for
more than 20 years, there is still no globally agreed on definition of stalking (Mester, Birger, &
Margolin, 2006), with varying legal definitions throughout the United States (Kapley & Cooke,
2007; Tjaden, 2009). A commonality appears to be that most legal state definitions feature
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 30
components such as credible threat and the presence of fear (Tjaden, 2009). In the military, the
Uniform Code of Military Justice (UCMJ) Article 120a defines stalking as involving repeated
proximity or verbal or written threats that place an individual in reasonable fear of death or
bodily harm (UCMJ, 2006). The UCMJ definition is similar to many state-level definitions as it
includes the presence of fear.
In line with legal definitions of stalking, the presence of fear is a common inclusion
criterion of stalking in the research literature (Baum, Catalano, Rand, & Rose, 2009; Purcell,
Pathé, Baksheev, MacKinnon, & Mullen, 2012). However, some scholars have argued that the
presence of stalking should be defined by victims of stalking (Alexy, Burgess, Baker, & Smoyak,
2005; McKeon, McEwan, & Luebbers, 2015) and not be solely reliant on the presence of fear
(Dietz & Martin, 2007; Podaná & Imríšková, 2016). Requiring the presence of fear denies
stalking as a crime unless the victim feels fearful (Dietz & Martin, 2007), which is inappropriate.
Stalking is stalking whether or not the victim is fearful. Further, most definitions include the
necessity of a repetitiveness of stalking behaviors (Hamid & Maple, 2013; Lyndon, Bonds-
Raacke, & Cratty, 2011; Mullen, Pathé, & Purcell, 2009; Podaná & Imríšková, 2016; UCMJ,
2006). The need for more than one stalking incident highlights the behavior is more likely to be
disruptive and threatening. More recently, cyberstalking has been included in stalking definitions
and can occur at any time through the use of technology (Alexy et al., 2005; Hamid & Maple,
2013; Lyndon et al., 2011).
The current literature highlights the universal nature of stalking (found among both
civilian and military populations). Among women, rates of stalking ranged from 8% to 15%
among civilians (Breiding et al., 2014; Tjaden & Thoennes, 2000), 1% to 9% among active-duty
members (Cook et al., 2015), and 64% among veterans (Dardis, Amoroso, et al., 2016). Rates
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 31
among men are lower than those among women, with 2% to 6% of civilians (Breiding et al.,
2014; Tjaden & Theonnes, 2000), 1% to 2% of active-duty service members (Cook et al., 2015),
and 4% to 15% of veterans (Clancy et al., 2006) experiencing stalking. It is evident the reported
rate of stalking among female veterans (Dardis, Amoroso, et al., 2016) is six times higher than
female active-duty members (Cook et al., 2015). It is also evident the rates among male veterans
(Clancy et al., 2006) is at least double that among male active-duty service members (Cook et al.,
2015). These discrepancies are concerning, because they may indicate stalking is not reported
during active-duty service, but rather reported once individuals leave the military.
The presence of stalking is concerning because the potential trauma has been found to
negatively affect the mental and physical health of civilian populations. In studies on female
civilians, stalking has been found to significantly affect PTSD, depression, chronic mental
illness, use of painkillers and alcohol, somatization, and physical health compared to women
who did not experience stalking (Basile, Arias, Desai, & Thompson, 2004; Davis, Coker, &
Sanderson, 2002; Lacey, Dilworth McPherson, Samuel, Powell Sears, & Head, 2013; Mechanic,
Uhlmansiek, Weaver, & Resick, 2000). Among female and male civilians, the experience of
stalking was significantly associated with anxiety, depression, PTSD, appetite disturbance,
headaches, physical illness, and insomnia compared to those who did not (Kuehner, Gass, &
Dressing, 2012; Spitzberg & Cupach, 2003).
The literature on civilian populations has indicated that women experience stalking at
significantly higher rates than men (Basile, Swahn, Chen, & Saltzman, 2006; Menard & Cox,
2016; Tjaden & Thoennes, 2000). Other significant characteristic differences among female
civilians that have experienced stalking compared to those that have not are being under the age
of 55 (Basile et al., 2006), between 18 to 24 years old (Baum et al., 2009), non-Hispanic (Baum
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 32
et al., 2009), American Indian or Alaska Native (Fisher, Cullen, & Turner, 2000), unmarried
(Basile et al., 2006; Fisher et al., 2000), and having experienced sexual assault (Buhi, Clayton, &
Hepler Surrency, 2009; Fisher et al., 2000). Among female veterans, lesbian or bisexual women
are significantly more likely to have been stalked than their heterosexual peers (Dardis,
Shipherd, et al., 2016).
The literature regarding stalking among military populations and its impact on mental and
physical health is limited. For example, studies have combined the presence of stalking with
other types of intimate partner violence (IPV; Campbell et al., 2003; Dardis, Shipherd, et al.,
2016), making it difficult to distinguish the unique effects of stalking experiences on mental or
physical health. However, in one study of female veterans, the presence of stalking alone was
significantly associated with PTSD (Dardis, Amoroso, et al., 2016). Among male veterans,
stalking has been highlighted as present, but its impacts on health or mental health has not been
evaluated (Clancy et al., 2006). The major objectives of this study were to evaluate stalking, as
defined by the participants, including: (a) types of stalking among female and male veterans, (b)
characteristics of veterans who experienced stalking within and between genders, and (c) the
impact of stalking on the current mental health of female and male veterans.
Methods
Study Overview and Participants
Data used for this study were drawn from two community-based, nonclinical studies
involving veterans (N = 1,980; Castro & Kintzle, 2017; Kintzle, Matthews Rasheed, & Castro,
2016). Both studies used targeted recruitment strategies to achieve maximum representativeness
of the veteran populations in Chicago and San Francisco.
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 33
Convenience sampling strategies were used. The primary sampling strategy involved
partnering with area agencies serving veterans and college veteran agencies. Two methods were
used to collect agency data: (a) agencies sent an invitation to veterans with a link to take the
survey online and (b) agencies worked with researchers to organize on-the-ground data
collection events in their agencies where veterans could complete a paper-and-pencil survey in
person or received the online survey link to complete at a later time. Other sampling strategies
used print advertisements and social media to build a presence in both Chicago and San
Francisco, including use of Facebook, Twitter, LinkedIn, and mass emails.
All participants received a $15 gift card for completing the survey, which took 30 to 90
minutes. When available, instruments with established validity and reliability were used. All data
collection procedures were approved by the Institutional Review Board of an affiliated
university.
Measures
Assessment of demographic information and military-related variables. Age
(collected as a continuous variable) was recoded as a categorical variable: 18–39, 40–59, or 60
years and older. Race/ethnicity categories were: non-Hispanic White, Black or African
American, Hispanic or Latino, and other. Sexual orientation was dichotomized as (a)
heterosexual or (b) lesbian, gay, or bisexual. Level of education was categorized as: some high
school/GED/high school diploma, some college or associate degree, bachelor’s degree, or
master’s or doctoral degree. Marital status categories were: (a) single, divorced, separated, or
widowed, or (b) married, in a domestic partnership, or in a long-term relationship. Branch of
service categories were: Air Force, Army, Coast Guard, Marine Corps, or Navy. A variable for
service era specified whether participants served before or after September 11, 2001. Rank
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 34
categories ranged from enlisted to officer (E1–O10), including warrant officers (W1–W5). This
variable was recoded as a categorical variable: E1–E4, E5–E7, E8–E9 or W1–W4, and O1–O10.
Deployment was dichotomized (yes or no). Military sexual assault was dichotomized (yes or no).
Deployment and military sexual assault were included as control variables as they are known risk
factors for PTSD and depression (Hoge et al., 2004; Schuyler et al., 2016).
Assessment of stalking during military service. Stalking was assessed with four
questions based on a review of the UCMJ (2006) and the Loveisrespect (2013) website that is
focused on ending abuse. Questions were behaviorally based, did not require fear, and referenced
experiences encountered during military service, on- or off-duty and on- or off-base: (a)
“someone showing up at your home or workplace unannounced or uninvited”; (b) “someone
following you or waiting for you at places”; (c) “someone sending you unwanted messages,
emails, or phone calls”; and (d) “someone using social media to track or follow you”
(Loveisrespect, 2013; UCMJ, 2006). Participants were asked how often each type of stalking
occurred (never, 1 time, 2–4 times, or 5+ times). Two or more experiences of any stalking
experience constituted stalking. For example, if participants experienced someone showing up
unannounced one time and someone using social media to track them one time, this constituted
stalking (dichotomized; yes vs. no).
Assessment of probable PTSD. Probable PTSD was measured by the 20-item PTSD
Checklist for the DSM-5 (Blevins, Weathers, Davis, Witte, & Domino, 2015). The measure asks
participants to rate how much they were affected by exposure to a stressful event, using items
such as, “In the past month, how much were you bothered by repeated, disturbing, and unwanted
memories of the stressful event?” Scores range from 0 to 80, and a clinical cutoff score of 33 was
used to indicate probable PTSD (Weathers et al., 2013). In this study, Cronbach’s alpha was .97.
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 35
Assessment of probable depression. Probable depression was measured using the 9-
item Patient Health Questionnaire (Spitzer, Kroenke, & Williams, 1999). This measure consists
of items that assess how often a person has been bothered by depression symptoms during the
last 2 weeks, such as “feeling down, depressed, or hopeless.” Scores range from 0 to 27, and a
clinical cutoff score of 10 was used to indicate probable moderate to severe depression (Kroenke,
Spitzer, & Williams, 2001). In this study, Cronbach’s alpha was .93.
Data Analysis
Descriptive statistics and logistic regression analyses were carried out in SAS 9.4. First, a
correlation of variables was examined to verify the demographic variables of interest did not
have high correlation prior to any statistical analysis (Table 2.1). Because service era was
correlated (greater than .40) with both age and deployment, it was removed from further
analysis. All other demographic variables were maintained in this study. Descriptive statistics
were then used to explore the demographic characteristics of individuals who experienced
stalking among female and male veterans, types of stalking experienced by female and male
veterans, and differences within and between female and male veterans. Statistically significant
demographic variables for each gender were included as confounding variables in the logistic
regression models. Four logistic regression models were conducted: (a) female veterans’
experience of stalking and impact on PTSD, (b) female veterans’ experience of stalking and
impact on depression, (c) male veterans’ experience of stalking and impact on PTSD, and (d)
male veterans’ experience of stalking and impact on depression.
Results
Demographic characteristics and trauma experiences of the sample are presented in Table
2.2. Among veterans, 15.9% were female and 84.1% were male; 58.5% of women and 34.6% of
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 36
men reported stalking experiences while in the military. The veteran participants primarily
served in the Army (49.7% of women and 53.3% of men). Participants were primarily E1 to E4
with regard to rank (52.1% of women and 46.4% of men). Clinical levels of PTSD were 50.7%
of women and 36.9% of men, while 46.8% of women and 36.2% of men reported clinical levels
of depression.
Stalking Experiences among Female and Male Veterans
Individual stalking experiences were evaluated by gender (Table 2.3). The most prevalent
type of stalking experienced by female veterans was receiving unwanted messages, emails, or
phone calls (37.2%), whereas male veterans most frequently experienced someone showing up
unannounced or uninvited (23.5%). Combinations of stalking experiences, i.e., those occurring
two or more times, were also evaluated. Women were more likely to experience someone
showing up unannounced or uninvited combined with following or waiting (24.1%), whereas
men were more likely to experience someone showing up unannounced or uninvited combined
with messages, email, or phone calls (12.2%).
Characteristics and Associations of Stalking Experiences
Chi-square and Fisher’s exact test analyses were conducted to identify variables
significantly associated with stalking among female and male veterans (Table 2.4). Female
veterans who experienced stalking had significant differences in age, with participants ages 18-
39 years old (57.4%) being significantly more likely to experience stalking compared to the same
age who did not experience stalking (34.8%) and participants 60+ years old were significantly
less likely to experience stalking (6.2%) compared to the same age who did not experience
stalking (14.8%; χ
2
[2] = 15.41, p < .001). Female participants who experienced stalking were
more likely to be non-Hispanic White (53.1%) than those who did not experience stalking
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 37
(39.1%; χ
2
[3]

= 10.81, p < .05). In regard to sexual orientation, female veterans who are lesbian
or bisexual were significantly more likely to experience stalking (23.1%) compared to those who
did not experience stalking (8.7%; χ
2
[1] = 9.83, p < .01). Female veterans who were E8 to E9 or
W1 to W5 were significantly more likely to have experienced stalking (9.3%) than to not have
experienced stalking (0.9%; p < .01). Female veterans who experienced stalking were
significantly more likely to also have experienced military sexual assault (57.0%) when
compared to those who did not experience stalking (24.3%; χ
2
[1] = 28.31, p < .001). In regard to
mental health, female veterans who experienced stalking were significantly more likely to have
probable PTSD (62.1%; χ
2
[1] = 19.50, p < .001) and depression (58.4%; χ
2
[1] = 21.88, p < .001)
compared to female veterans who did not experience stalking (35.1% and 29.8%, respectively).
Male veterans who experienced stalking also had significant differences in age, with
participants ages 18 to 39 years old being significantly more likely to have experienced stalking
(57.9%) than not (21.5%) and participants 60+ years old being significantly less likely to have
experienced stalking (15.5%) than not (52.2%; χ
2
[2] = 240.52, p < .001; Table 2.4). Male
veterans who experienced stalking were more likely to be Latino (15.7%) compared to those who
did not experience stalking (9.2%; χ
2
[3] = 24.23, p < .001). Male veterans who served in the
Navy were significantly less likely to have experienced stalking (13.5%) when compared to
those in the Navy who did not experience stalking (20.7%; χ
2
[4] = 30.54, p < .001). Male
veterans who were E8 to E9 or W1 to W5 were significantly more likely to have experienced
stalking (15.2%) than to not have experienced stalking (3.5%; χ
2
[3] = 64.85, p < .001). Male
veterans who had deployed were significantly more likely to have experienced stalking (83.7%)
than not (75.8%; χ
2
[1] = 12.04, p < .001). Male veterans who experienced stalking were also
significantly more likely to have experienced sexual assault (41.8%) when compared to those
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 38
who did not experience stalking (3.5%; χ
2
[1] = 326.48, p < .001). In regard to mental health,
male veterans were significantly more likely to have probable PTSD (64.7%; χ
2
[1] = 245.30, p <
.001), and depression (65.5%; χ
2
[1] = 270.06, p < .001) compared to male veterans who did not
experience stalking (22.5% and 21.4%, respectively).
Variables Associated with Stalking: Comparing Female and Male Veterans
Overall, among veterans who experienced stalking, women were significantly more likely
to experience stalking than men (58.5% vs. 34.6%; χ
2
[2] = 57.61, p < .001; Table 2.4). Among
veterans who experienced stalking, demographic characteristics were analyzed between genders
and significant differences were found. For example, regarding sexual orientation, female
veterans who identified as sexual minorities were significantly more likely to have experienced
stalking (23.1%) than their male counterparts (5.2%; χ
2
[1] = 45.37, p < .001). Male veterans who
experienced stalking were more likely to be married (64.5%) than female veterans (40.7%; χ
2
[1]
= 28.51, p < .001). Female veterans who experienced stalking were more likely to have also
experienced military sexual assault (57.0%) than male veterans (41.8%; χ
2
[1] = 11.10, p < .001).
No significant difference existed between female and male veterans who had experienced
stalking in terms of probable PTSD or depression.
Stalking Experiences and Associations with PTSD and Depression
Stalking experiences were significantly associated with both probable PTSD and
depression among female and male veterans (Table 2.5). After adjusting for age, race/ethnicity,
sexual orientation, rank, and military sexual assault, female veterans who experienced stalking
were significantly more likely to have probable PTSD (OR = 1.88; 95% CI = 1.04, 3.39; R
2
=
.225) and probable depression (OR = 2.54; 95% CI = 1.38, 4.58; R
2
= .222) than female veterans
who did not. After adjusting for age, race/ethnicity, branch, rank, deployment, and military
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 39
sexual assault, male veterans who experienced stalking were significantly more likely to have
probable PTSD (OR = 3.08; 95% CI = 2.27, 4.18; R
2
= .382) and probable depression (OR =
2.78; 95% CI = 2.05, 3.79; R
2
= .425) than male veterans who did not.
Discussion
Much of the research exploring stalking has focused on civilian populations. Research
exploring military populations has primarily focused on female veterans (Dardis, Amoroso, et
al., 2016; Dardis, Shipherd, et al., 2016) and male veterans (Clancy et al., 2006) independent of
each other. These studies failed to account for different types of stalking experiences and
significant differences within and between genders. As such, this study sought to expand the
literature by identifying types of stalking by gender, characteristics within and between genders,
and the associations of stalking and mental health.
Similar to previous findings among civilian populations (Black et al., 2011; Menard &
Cox, 2016; Truman, 2010), female veterans were significantly more likely to experience stalking
than male veterans in this sample. The overall percentage of female veterans who experienced
stalking (57%) was similar to a previous study exploring female veterans’ lifetime IPV stalking
(64%; Dardis, Amoroso, et al., 2016). The percentage of male veterans who experienced stalking
while in the military was exceptionally higher (35%) than in a previous study of pre-9/11 male
veterans (4%; Clancy et al., 2006). The higher rate among male veterans may be due to our
sample also including post-9/11 male veterans.
Consistent with previous literature, female veterans who experienced stalking were more
likely to be sexual minorities (Dardis, Shipherd, et al., 2016). Not surprisingly, the current study
highlights that sexual minority female veterans are significantly more likely to have been stalked
than sexual minority male veterans. Previous literature on female veterans did not evaluate the
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 40
characteristics of those who did or did not experience stalking. In this study, female veterans
who experienced stalking were more likely to be 18–39 years old, White, a sexual minority, a
senior enlisted or warrant officer, and have experienced military sexual assault. Among male
veterans, those who experienced stalking were more to be 18–39 years old, Latino, a senior
enlisted or warrant officer, have deployed, and have experienced military sexual assault. It is
possible higher ranks (i.e., E8–E9 or W1–W5) reported more stalking while in the military
because achieving these ranks requires more years of service and time for the stalking to occur.
These characteristics have not been highlighted in the previous literature on military populations.
The current study adds to the literature by highlighting type of stalking experienced. For
example, findings regarding stalking experienced by female veterans are in line with previous
findings among civilian and military populations. Among female veterans, 36% are likely to
have experienced unwanted messages, emails, or phone calls, whereas the primary types of
stalking experienced by female civilians are unwanted phone calls (79%) and unwanted phone
messages (58%; Black et al., 2011). In the literature on military populations, female veterans
primarily reported being followed, watched, or spied on (66%) and experiencing unwanted
phone calls (65%; Dardis, Amoroso, et al., 2016). The current findings are similar to previous
findings on female veterans. However, these findings highlight stalking experiences while in the
military, whereas previous studies on female veterans highlighted lifetime stalking by an
intimate partner (Dardis, Amoroso, et al., 2016; Dardis, Shipherd, et al., 2016). Among male
veterans, the primary type of stalking experienced is someone showing up unannounced or
uninvited (29%), whereas male civilians most often experienced unwanted phone messages
(76%) and having someone show up uninvited or unannounced (58%; Black et al., 2011). This
study provides new information on types of stalking experienced by male veterans.
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 41
Similar to the literature on civilian populations (Basile et al., 2004; Buhi et al., 2009;
Fisher et al., 2000; Kuehner et al., 2012), the current found both female and male veterans who
experienced stalking had significant associations with military sexual assault, PTSD, and
depression. These findings highlight more than one type of military-related sexual trauma
occurred among both female and male veterans who experienced stalking. In the literature on
civilian populations, PTSD and depression (Basile et al., 2004; Kuehner et al., 2012) have been
found to be significantly associated with stalking. However, limited research on stalking and
PTSD has occurred among military populations (Dardis, Amoroso, et al., 2016). The current
study demonstrates that stalking was significantly associated with female and male veterans’
clinical levels of PTSD and depression, after controlling for gender-specific significant factors.
These findings highlight the importance of fully evaluating female and male veterans
when they seek health and mental health services. Currently, the Veterans Health Administration
evaluates all patients for the presence of military sexual harassment and military sexual assault
(Kimerling et al., 2007), but does not assess for the presence of stalking. Current practices should
include assessing for the experience of stalking while in the military as it adds another potential
sexual trauma that is significant among veterans who have experienced military sexual assault.
Individuals who experience cumulative traumas are known to have increased risk for mental
health concerns (Turner & Lloyd, 1995) and sexual traumas must be known to inform treatment
(Williamson, Holliday, Holder, North, & Suris, 2017). Further, future research should include
many forms of military-related sexual trauma to evaluate cumulative trauma and mental health
among military populations.
Despite the importance of the current findings in highlighting the presence of stalking in
the military, characteristics of stalked veterans, and links with current mental health, the present
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 42
study had some limitations. Participants self-selected into the study, making response bias
possible. Another limitation is the retrospective, self-report format of the data collection. Also
participants were from two metropolitan cities, making the responses unable to be generalized to
veterans from smaller or more isolated communities. Finally, these data did not capture when the
stalking occurred during military service. Future research should expand on these findings by
assessing when stalking occurs during military service. Despite these limitations, this study
assessed stalking experiences in general by not specifying perpetration (i.e. IPV), allowing for
stalking experiences, other than just IPV, to be known. This study also used a nonclinical
sample, highlighting the characteristics of veterans who are not necessarily actively seeking help
and thus, providing more generalizable findings.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 43
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MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 50
Table 2.1. Correlations of Variables among Female and Male Veterans
1 2 3 4 5 6 7 8 9 10 11 12 13
1. Age -- -.05 .11 .12 .04 -.08 -.50 -.29 .25 -.11 -.21 -.06 -.13
2. Race/ethnicity -.06 -- -.19 .00 .07 .09 .10 .00 .07 .00 .05 .00 .02
3. Sexual orientation .03 .00 -- .11 -.13 -.07 -.10 -.12 .15 -.17 -.17 -.17 -.18
4. Education .03 .06 .05 -- -.03 .04 .01 .01 .39 .01 -.13 -.19 -.23
5. Marital .22 .02 .02 .00 -- -.06 -.04 .00 .03 -.02 .03 .07 .09
6. Branch -.04 .10 .10 -.06 .00 -- .10 .08 .05 .08 .03 .03 -.07
7. Era -.73 .05 .05 .00 -.16 .00 -- .43 .15 -.02 -.05 .00 .05
8. Deployment -.15 .04 .04 .11 -.01 .16 .25 -- .07 .06 .02 .19 .16
9. Rank .05 .02 .02 .36 .04 -.07 .13 .21 -- -.05 -.04 -.13 -.18
10. MSA -.31 -.05 -.10 .04 -.05 -.06 .23 .09 .02 -- .35 .28 .19
11. Stalking -.28 -.02 -.03 .02 -.01 -.06 .28 .09 .04 .48 -- .26 .27
12. PTSD -.33 -.06 -.02 -.11 .01 -.06 .26 .12 -.07 .41 .41 -- .61
13. Depression -.39 -.07 -.02 -.11 .02 -.06 .31 .13 -.05 .43 .42 .67 --
Note. Correlations reported for women in top section and men in bottom section. Figures in bold are statistically significant at p < .05. MSA, military sexual
assault; PTSD, posttraumatic stress disorder.
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 51
Table 2.2. Sample Characteristics and Trauma Experiences of Female and Male Veterans
Total Women Men
n (%) n (%) n (%)

1,980 (100.0) 315 (15.9) 1,665 (84.1)
Age (n = 1,977)
18–39 718 (36.2) 159 (50.5) 559 (33.6)
40–59 571 (28.9) 128 (40.6) 443 (26.7)
60+ 688 (34.8) 28 (8.9) 660 (39.7)
Race/ethnicity (n = 1,976)
Non-Hispanic White 1,233 (62.4) 145 (46.0) 1,088 (65.5)
Black or African American 326 (16.5) 88 (27.9) 238 (14.3)
Latino or Hispanic 232 (11.7) 39 (12.4) 193 (11.6)
Other 185 (9.4) 43 (13.7) 142 (8.6)
Sexual orientation (n = 1,961)
Heterosexual 1,648 (84.0) 262 (83.7) 1,584 (96.1)
Lesbian, gay, or bisexual 313 (16.0) 51 (16.3) 64 (3.9)
Education (n = 1,950)
Some HS, GED, HS diploma 258 (13.2) 27 (8.7) 231 (14.1)
Some college or associate degree 731 (37.5) 136 (43.7) 595 (36.3)
Bachelor’s degree 526 (27.0) 78 (25.1) 448 (27.3)
Master’s or doctoral degree 435 (22.3) 70 (22.5) 365 (22.3)
Marital status (n = 1,980)
Single, divorced, separated, or widowed 806 (40.7) 181 (57.5) 625 (37.5)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 52
Married, domestic partnership, or long-term
relationship
1,174 (59.3) 134 (42.5) 1,040 (62.5)
Service branch (n = 1,960)
Air Force 243 (12.4) 52 (16.7) 191 (11.6)
Army 1,034 (52.8) 155 (49.7) 879 (53.3)
Coast Guard 45 (2.3) 14 (4.5) 31 (1.9)
Marine Corps 272 (13.9) 23 (7.4) 249 (15.1)
Navy 366 (18.7) 68 (21.8) 298 (18.1)
Rank (n = 1,912)
E1–E4 905 (47.3) 161 (52.1) 744 (46.4)
E5–E7 589 (30.8) 93 (31.1) 496 (30.9)
E8–E9 or W1–W5 128 (6.7) 16 (5.2) 112 (7.0)
O1–O10 290 (15.2) 39 (12.6) 251 (15.7)
Deployment (n = 1,950) 1,495 (76.7) 214 (68.6) 1,281 (78.2)
Military sexual assault (n = 1,649) 351 (21.3) 120 (44.6) 234 (17.0)
Stalking (n = 1,733) 666 (38.4) 162 (58.5) 504 (34.6)
Probable PTSD (n = 1,738) 679 (39.1) 141 (50.7) 538 (36.9)
Probable depression (n = 1,741) 660 (37.9) 130 (46.8) 530 (36.2)
Note. HS, high school. PTSD measured using the 20-item PTSD Checklist for the DSM-5 with a cutoff of 33
(Weathers et al., 2013). Depression measured using the 9-item Patient Health Questionnaire with a cutoff score of
10 (Kroenke et al., 2001).
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 53
Table 2.3. Stalking Experiences among Female and Male Veterans
Unannounced or Uninvited Following or Waiting Message, Email, or Phone Social Media
n (%) n (%) n (%) n (%)
Women (n = 277)

Never 151 (54.5) 159 (57.4) 136 (49.1) 191 (69.0)
One time (not stalking) 47 (17.0) 53 (19.1) 38 (13.7) 23 (8.3)
Two or more times (stalking)
Unannounced or uninvited 79 (23.5)
Following or waiting 48 (24.1) 65 (29.0)
Message, email, or phone 46 (22.2) 47 (22.9) 103 (37.2)
Social media 36 (16.7) 30 (14.3) 54 (23.5) 63 (24.8)
Men (n = 1,460)
Never 957 (65.6) 1,111 (76.2) 1,082 (74.2) 1,138 (78.0)
One time (not stalking) 158 (10.8) 154 (10.6) 116 (8.0) 99 (6.8)
Two or more times (stalking)
Unannounced or uninvited 343 (23.5)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 54
Following or waiting 144 (12.2) 194 (13.3)
Message, email, or phone 181 (14.9) 125 (10.2) 261 (17.9)
Social media 164 (13.3) 111 (9.0) 154 (12.0) 223 (15.3)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 55
Table 2.4. Characteristics of Female and Male Veterans With and Without Stalking
Stalking No Stalking Women vs.
Men Women Men Women Men Women Men
n (%)
162 (58.5)
n (%)
504 (34.6)
n (%)
115 (41.5)
n (%)
952 (65.4)
χ
2
(df) or
Fisher’s exact
χ
2
(df) or
Fisher’s exact
χ
2
(df) or
Fisher’s exact
Experienced stalking 57.61 (1)***
Age 15.41 (2)*** 240.52 (2)*** 12.12 (2)**
18–39 93 (57.4) 292 (57.9) 40 (34.8) 205 (21.5)
40–59 59 (36.4) 134 (26.6) 58 (50.4) 250 (26.3)
60+ 10 (6.2) 78 (15.5) 17 (14.8) 497 (52.2)
Race/ethnicity 10.81 (3)* 24.23 (3)*** 4.87 (3)
Non-Hispanic White 86 (53.1) 288 (57.3) 45 (39.1) 660 (69.4)
Black or African American 31 (19.1) 86 (17.1) 42 (36.5) 128 (13.5)
Latino or Hispanic 20 (12.4) 79 (15.7) 13 (11.3) 87 (9.2)
Other 25 (15.4) 50 (9.9) 15 (13.0) 76 (8.0)
Sexual orientation 9.83 (1)** 1.20 (1) 45.37 (1)***
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 56
Heterosexual 123 (76.9) 476 (94.8) 105 (91.3) 902 (96.1)
Lesbian, gay, or bisexual 37 (23.1) 26 (5.2) 10 (8.7) 37 (3.9)
Education 4.27 (3) 2.23 (3) 7.85 (3)*
Some HS, GED, HS 17 (10.6) 60 (12.0) 7 (6.2) 134 (14.3)
Some college or AA degree 76 (47.2) 180 (36.1) 45 (39.8) 338 (36.2)
Bachelor’s degree 33 (20.5) 148 (30.0) 31 (27.4) 251 (26.8)
Master’s or doctoral degree 35 (21.7) 111 (22.2) 30 (26.6) 212 (22.7)
Marital status 1.06 (1) 0.82 (1) 28.51 (1)***
Single 96 (59.3) 179 (35.5) 61 (53.0) 361 (37.9)
Married 66 (40.7) 325 (64.5) 54 (47.0) 591 (62.1)
Service branch † 30.54 (4)*** 12.38 (4)*
Air Force 24 (14.8) 57 (11.3) 22 (19.1) 116 (12.2)
Army 80 (49.4) 283 (56.2) 58 (50.4) 496 (52.1)
Coast Guard 11 (6.8) 22 (4.4) 3 (2.6) 8 (0.8)
Marine Corps 13 (8.0) 74 (14.7) 5 (4.4) 135 (14.2)
Navy 34 (21.0) 68 (13.5) 27 (23.5) 197 (20.7)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 57
Rank †** 64.85 (3)*** 7.86 (3)*
E1–E4 86 (53.1) 212 (42.4) 59 (51.3) 455 (48.2)
E5–E7 45 (27.8) 142 (28.4) 35 (30.4) 292 (30.9)
E8–E9 or W1–W5 15 (9.3) 76 (15.2) 1 (0.9) 33 (3.5)
O1–O10 16 (9.9) 70 (14.0) 20 (17.4) 165 (17.5)
Deployment 0.18 (1) 12.04 (1)*** 17.65 (1)***
Yes 111 (68.5) 421 (83.7) 76 (66.1) 719 (75.8)
Military sexual assault 28.31 (1)*** 326.48 (1)*** 11.10 (1)***
Yes 90 (57.0) 203 (41.8) 27 (24.3) 31 (3.5)
Probable PTSD 19.50 (1)*** 245.30 (1)*** 0.35 (1)
Yes 100 (62.1) 317 (64.7) 40 (35.1) 209 (22.5)
Probable depression 21.88 (1)*** 270.06 (1)*** 2.63 (1)
Yes 94 (58.4) 324 (65.5) 34 (29.8) 198 (21.4)
Note. *p < .05. **p < .01. ***p < .001. †Fisher’s exact test. HS, high school; AA, Associate; Single, single, divorced, separated, or widowed; Married, married,
domestic partnership, or long-term. PTSD measured using the PCL-5 with a clinical cutoff of 33 (Weathers et al., 2013). Depression measured using the PHQ-9
with a clinical cutoff of 10 (Kroenke et al., 2001).
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 58
Table 2.5. Stalking, Probable PTSD, and Probable Depression among
Female and Male Veterans
Probable PTSD Probable Depression
OR 95% CI OR 95% CI
Women
a

No Stalking (Ref) 1 1
Stalking 1.88 (1.04, 3.39) 2.54 (1.38, 4.58)
Adjusted R
2
.225 .222
Men
b

No Stalking (Ref) 1 1
Stalking 3.08 (2.27, 4.18) 2.78 (2.05, 3.79)
Adjusted R
2
.382 .425
Note. Values in bold statistically significant at p < .05. OR, odds ratio; CI, confidence
interval; Ref, Reference. PTSD measured using the PCL-5 with a clinical cutoff of 33
(Weathers et al., 2013). Depression measured using the PHQ-9 with a clinical cutoff of 10
(Kroenke et al., 2001).
a
Adjusted for age, race/ethnicity, sex orientation, rank, and military sexual assault.
b
Adjusted for age, race/ethnicity, branch, rank, deployment, and military sexual assault.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 59
Chapter Three: Manuscript 2
An Examination of Sexual Harassment, Gender Discrimination, Stalking, and Sexual
Assault among Female Veterans and Associations with PTSD and Depression
In preparation for American Journal of Public Health
(Carrie Lucas, Julie Cederbaum, Sara Kintzle, and Carl Castro)
Abstract
The purpose of this study is to understand combinations of military-related sexual trauma
(MRST; i.e., sexual harassment, gender discrimination, stalking, and sexual assault) among
female veterans and highlight associations with posttraumatic stress disorder (PTSD) and
depression. Two community samples of 315 female veterans were used. Among female veterans,
most experienced some type of MRST (90.3%) with a majority experiencing a combination of
more than one MRST (84.0%). Female veterans who experienced sexual harassment, gender
discrimination, and stalking (19.3%) had 4.52 the odds of PTSD and 3.79 the odds of depression
compared to those who experienced no MRST. Participants who experienced all four types of
MRST (32.7%) had 10.85 the odds of PTSD and 8.16 the odds of depression compared to those
who experienced none. The association of combinations of MRST with PTSD and depression
highlight (1) the need to expand the current assessment of MRST experiences among female
veterans and (2) it is essential for health and mental health providers to recognize the impact of
cumulative MRSTs and provide (a) correct assessment, (b) treatment, and (c) evaluation among
female veterans.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 60
An Examination of Sexual Harassment, Gender Discrimination, Stalking, and Sexual Assault
among Female Veterans and Associations with PTSD and Depression
Military sexual trauma is a well-documented experience among female service members
and veterans with negative implications for mental and physical health (Kimerling, Gima, Smith,
Street, & Frayne, 2007; Kimerling et al., 2010; Murdoch, Pryor, Polusny, & Gackstetter, 2007;
Schuyler, Kintzle, Lucas, Moore, & Castro, 2016; Street, Stafford, Mahan, & Hendricks, 2008).
Military sexual trauma is an umbrella term used by the Department of Defense (DoD) that
includes military sexual harassment (MSH) and military sexual assault (MSA; Kimerling et al.,
2007) and does not include gender discrimination or stalking. As such, this umbrella term limits
our understanding of other potential military-related sexual trauma (MRST). Within this study,
MRST experiences include MSH, gender discrimination, stalking, and MSA. As little is known
about gender discrimination and stalking (Lucas, Cederbaum, Kintzle, & Castro, in progress;
Street, Gradus, Stafford, & Kelly, 2007), this study sought to include MSH, gender
discrimination, stalking, and MSA to more fully understand combinations of MRST experiences.
It is important to individually assess MRST experiences, but evaluate combinations of MRST
experiences to link traumatic experiences to the correct treatment (Williamson, Holliday, Holder,
North, & Suris, 2017) and better understand associations with mental health.
Background
Reported Rates of Sexual Trauma
The rates of sexual harassment, gender discrimination, stalking, and sexual assault have
been reported in the existing literature. Research conducted in female civilian and military
populations have shown sexual harassment is experienced by 40%–75% of civilians (Willness,
Steel, & Lee, 2007), 21% of active-duty service members (Morral, Gore, & Schell, 2016), and
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 61
51% of veterans (Street, Gradus, Giasson, Vogt, & Resick, 2013). The reported rates of gender
discrimination among women have been found to be 24% among civilians (Rospenda, Richman,
& Shannon, 2009), 13% among active-duty members (Morral et al., 2016), and 52% among
veterans (Street et al., 2007). The reported rates of stalking are 8%–15% for female civilians
(Breiding et al., 2014; Tjaden & Thoennes, 2000), 1%–9% for female active-duty members
(Cook et al., 2015), and 59%–64% for female veterans (Dardis, Amoroso, & Iverson, 2016;
Lucas, Cederbaum, et al., in progress). Finally, sexual assault is reported by 18% of female
civilians (Tjaden & Thoennes, 2000), 28% of female active-duty members (Barlas, Higgins,
Pflieger, & Diecker, 2013), and 41% of female veterans (Schuyler et al., 2016).
In sum, female veterans reported higher rates of gender discrimination, stalking, and
MSA compared to their civilian counterparts. Although reasons for this discrepancy have not
been confirmed, researchers in the field have suggested it may be linked to female veterans being
in a predominantly male and hyper-masculine environment (Castro, Kintzle, Schuyler, Lucas, &
Warren, 2015) lending to more opportunities for sexual trauma to occur compared to female
civilians. Similarly, in every sexual trauma category, higher rates are reported among female
veterans (i.e., have left the military) compared to female active-duty members (i.e. still in the
military). Although reasons for this increase in reporting are unclear, a potential link to lower
reporting rates while in the military may be due to the potential negative career impact
(Rasmussen & Zaglifa, 2013; Rosellini et al., 2017).
Assessments and Evaluations of Sexual Trauma
The civilian and military literatures feature various assessments and evaluations of sexual
trauma. In regard to assessment, the Sexual Experiences Questionnaire has been used and
includes gender discrimination as sexual harassment (Fitzgerald, Magley, Drasgow, & Waldo,
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 62
1999; Street et al., 2007; Street, Stafford, Mahan, & Hendricks, 2008) and the DoD definition of
military sexual trauma has been used (Kimerling et al., 2007; Schuyler, et al. 2016). In regard to
evaluation, many studies focus on (a) one type of sexual trauma (Rospenda et al., 2009; Schuyler
et al., 2016) or (b) the experience of one sexual trauma or another sexual trauma (DeSouza &
Fransler, 2003; Kimerling et al., 2010). These varying approaches to evaluation make it difficult
to assess the impact of cumulative traumas.
Sexual Harassment and Gender Discrimination
Sexual harassment has significant negative mental health consequences for female
civilians (Rospenda et al., 2009) and negative impacts on PTSD, depression, and medical
conditions of female reservists (Goldstein, Dinh, Donalson, Hebenstreit, & Maguen, 2017; Street
et al., 2008). Sexual harassment has also been evaluated with gender discrimination. The
presence of sexual harassment or gender discrimination has been found to have significant
negative consequences in regard to depression and anxiety among female civilians (DeSouza &
Fansler, 2003) and female active-duty members (Street et al., 2007). These studies highlight the
negative outcomes of sexual harassment or gender discrimination on women, yet lack clarity
regarding which sexual trauma is negatively impacting outcomes and how combinations of
MRST experiences affect female veterans.
Stalking
Stalking has been found to have significant negative health consequences, such as PTSD,
depression, and physical health among female civilians (Basile, Arias, Desai, & Thompson,
2004; Davis, Coker, & Sanderson, 2002; Lacey, Dilworth McPherson, Samuel, Powell Sears, &
Head, 2013; Mechanic, Uhlmansiek, Weaver, & Resick, 2000). Among military populations,
stalking has been primarily analyzed as intimate partner violence (Campbell et al., 2003; Dardis,
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 63
Shipherd, & Iverson, 2016), with minimal research on stalking independent of intimate partner
violence (Lucas, Cederbaum, et al., in progress). The previous studies have shown stalking to
have negative mental health consequences in regard to PTSD (Dardis, Amoroso, et al., 2016;
Lucas, Cederbaum, et al., in progress) and depression (Lucas, Cederbaum, et al., in progress).
Therefore, it is important to include stalking as a MRST and (1) independently assess each
MRST (i.e. MSH, gender discrimination, stalking, and MSA) and (2) evaluate how the
accumulation of MRSTs impact mental health.
Sexual Assault
Among female veterans, MSA has been found to have significant negative impacts on
PTSD, depression, and physical health (Goldstein et al., 2017; Schuyler et al., 2016). Also
among military populations, MSH and MSA have been analyzed together, with the experience of
both having significant negative health impacts on PTSD, depression, and anxiety among female
active-duty members (Murdoch et al., 2007) and depression and somatic symptoms among
female reservists (Street et al., 2008). Assessing MSH and MSA together allows for a more
defined understanding that female veterans experience both MSH and MSA while in the military
and having experienced both is negatively impacting mental health. The next step is to evaluate
MSH and MSA combined with other MRSTs (i.e. gender discrimination and stalking) to
evaluate how they are experienced and their impact on mental health.
Purpose of this Study
To further assess MRST experienced by female veterans, it is important to (1) expand
assessment items, (2) include gender discrimination and stalking with MSH and MSA, and (3)
evaluate combinations of MRST experiences to examine cumulative trauma, as it is known to
have significant negative impacts on mental health (Turner & Lloyd, 1995). Female veterans
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 64
were able to select multiple types of MRST experiences. This helped to highlight reported rates
of MRST, demographic characteristics of those who experienced combinations of MRST, and
associations of combinations of MRST (cumulative trauma) on current mental health among
female veterans.
Methods
Study Overview and Participants
Female participants were drawn from two community-based, nonclinical studies of
veterans (N = 315; Castro & Kintzle, 2017; Kintzle, Matthews Rasheed, & Castro, 2016).
Among the 315 female participants, 85.4% completed all MRST items resulting in an analytical
sample of 269. Both community-based studies used targeted recruitment strategies to achieve
maximum representativeness of veterans. The sampling frames were defined for Chicago and the
San Francisco Bay Area through advisement with area experts. The researchers used multiple
convenience sampling strategies. See Kintzle et al., 2016 for a detailed description of study
recruitment and methodology. All participants received a $15 gift card for completing the
survey, which took on average 30 to 90 minutes. When available, researchers used instruments
with established validity and reliability. All data collection procedures were approved by the
Institutional Review Board of an affiliated university.
Measures
Assessment of demographic information and military-related variables. Due to
distribution and for purposes of analyses demographic and military-related variables were
recoded. Age (continuous) was recoded as a categorical variable: 18–39, 40–59, and 60 years or
older. Race/ethnicity was recoded as a categorical variable: non-Hispanic White or other (i.e.
Black, Latino, American Indian/Alaska Native, Asian, or Hawaiian/Pacific Islander). Level of
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 65
education was categorized as some high school, GED, or high school diploma; some college or
associate degree; bachelor degree; and master’s or doctoral degree. Sexual orientation was
dichotomized as (a) heterosexual or (b) lesbian or bisexual. Marital status categories were: (a)
single, divorced, separated, or widowed and (b) married, in a domestic partnership, or long-term
relationship. Branch of service categories were Air Force, Army, Coast Guard, Marine Corps, or
Navy. A variable for era specified whether participants served before or after September 11,
2001 (i.e., pre-9/11 or post-9/11). Rank categories ranged from enlisted to officer (E1–O10),
including warrant officers (W1–W5). This variable was recoded as a categorical variable: E1–
E4, E5–E7, E8–E9 or W1–W4, and O1–O10. Deployment was dichotomized (yes or no).
Deployment was included as a control variable as it is a known risk factor for PTSD and
depression (Hoge et al., 2004).
Assessment of military sexual harassment. MSH was assessed with six questions
adapted from the Military Equal Opportunity memorandum (U.S. Department of Defense, 2015)
and a 2014 RAND survey (Morral et al., 2016). Questions referenced experiences encountered
during military service, both on- or off-duty and on- or off-base, such as “someone repeatedly
telling jokes of a sexual nature” or “someone repeatedly making sexual comments, gestures, or
body movements” (Morral et al., 2016). All six items were combined into one variable and
dichotomized (experienced MSH or not). One experience of MSH was defined as having
experienced MSH.
Assessment of gender discrimination during military service. Gender discrimination
was assessed with three questions adapted from the Military Equal Opportunity memorandum
(U.S. Department of Defense, 2015) and the 2014 RAND survey (Morral et al., 2016). Questions
referenced experiences during military service, both on- or off-duty and on- or off-base. They
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 66
included: (a) “someone suggesting that you don’t act like a man/woman is supposed to (For
example, by calling you [men] ‘gay’ or ‘a fag’ or [women] ‘butch’ or ‘a dyke’)”; (b) “someone
saying that men/women are not as good as women/men at your particular job or that men/women
should be prevented from having your job”; and (c) “someone mistreating, ignoring, excluding
or insulting you because of your gender.” All three items were combined into one variable and
dichotomized (experienced gender discrimination or not). Being designated as having
experienced gender discrimination occurred if the woman reported experiencing any item one
time.
Assessment of stalking during military service. Four questions assessed stalking
experiences. Questions were based on a review of the Uniform Code of Military Justice (2006)
and the website Loveisrespect (2013) that is focused on ending abuse. Items included: “someone
showing up at your home or workplace unannounced or uninvited” or “someone using social
media to track or follow you” (Loveisrespect, 2013; Uniform Code of Military Justice, 2006).
Participants were asked how often each type of stalking occurred (never, 1 time, 2–4 times, or 5+
times). Two or more experiences of any stalking experience constituted stalking. The variable
was dichotomized (experienced stalking or not).
Assessment of military sexual assault. Five questions adapted from a U.S. Department
of Justice special report on rape and sexual assault victimization among college women
(Sinozich & Langton, 2014) and the Uniform Code of Military Justice (2006) were used to assess
MSA. The questions asked about nonconsensual or unwanted sexual contact experienced during
military service involving: (a) a military member or civilian, (b) someone known to the
participant, or (c) a stranger. Examples of dichotomous items are: “oral sex (i.e., someone’s
mouth or tongue making contact with your genitals, or your mouth or tongue making contact
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 67
with someone else’s genitals)” or “vaginal intercourse (i.e., someone’s penis being put in your
vagina).” All five items were combined and dichotomized (experienced MSA or not) with any
one experience constituting MSA.
Assessment of probable PTSD. Probable PTSD was measured using the 20-item PTSD
Checklist for the DSM-5 (PCL-5; Blevins, Weathers, Davis, Witte, & Domino, 2015). The
measure asks participants to rate how affected they were by exposure to a stressful event during
the past month. Participants rated each item from 0 (not at all) to 4 (extremely) with scores
ranging from 0 to 80. A clinical cutoff score of 33 indicated probable PTSD (Weathers et al.,
2013). In this study, Cronbach’s alpha was .97.
Assessment of probable depression. Probable depression was measured using the 9-
item Patient Health Questionnaire (PHQ-9; Spitzer, Kroenke, & Williams, 1999). This measure
consists of items that assess how often a person has been bothered by depression symptoms
during the last 2 weeks. Participants rated each item from 0 (not at all) to 3 (nearly every day).
Scores can range from 0 to 27. A clinical cutoff score of 10 indicated probable depression
(moderate to severe depression; Kroenke, Spitzer, & Williams, 2001). In this study, Cronbach’s
alpha was .92.
Data Analysis
Descriptive statistics and logistic regression analyses were conducted in SAS 9.4. The
four types of MRST (i.e., MSH, gender discrimination, stalking, and MSA) were combined to
reflect combined MRST experiences among female veterans. Due to this combination, varying
MRST variables emerged that accounted for individualized experiences of MRST. Subsamples
smaller than 40 were not included in the analysis due to limited power. Analyses tested
differences between demographic characteristics of those who experienced combinations of
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 68
MRST compared to those who did not experience any MRST using chi-square and Fisher’s exact
tests. Demographic characteristics that statistically differed were included in the logistic
regression models. Via two logistic regression models, i.e. one for PTSD and one for depression,
the odds of experiencing clinical levels of PTSD and depression were calculated among those
who experienced MRST compared to those who experienced no MRST. In the logistic regression
models, MRST experiences were compared to no MRST via the CLASS command in SAS.
Results
Demographic characteristics and sexual trauma experiences of female veterans are
presented in Table 3.1. In this sample, 50.5% of participants were 18–39 years old. In regard to
race, participants were primarily other (non-White; 54.0%), heterosexual (87.6%); single,
divorced, separated, or widowed (57.5%); and had completed some college or an associate
degree (43.7%). The majority of participants served in the Army (49.7%); served post-9/11
(64.7%); had been deployed (68.6%); and served as E1 to E4 with regard to rank (52.1%).
Military-Related Sexual Trauma Experiences among Female Veterans
Among female veterans, 86.2% experienced MSH, 78.3% experienced gender
discrimination, 58.5% experienced stalking, and 44.6% experienced MSA (Table 3.1). Among
female veterans, clinical levels of PTSD and depression were present among 50.7% and 46.8%
of participants, respectively. The majority of participants experienced at least one MRST
(90.3%) with most experiencing more than one MRST (84.0%; Table 3.2). Among those who
experienced MRST, 17.1% experienced MSH and gender discrimination; 19.3% experienced
MSH, gender discrimination, and stalking; and 32.7% experienced all four types (i.e., MSH,
gender discrimination, stalking, and MSA).

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 69
Characteristics and Associations of Military-Related Sexual Trauma Experiences
Descriptive statistics, chi-square, and Fisher’s exact test analyses were conducted to
identify significant differences between participants who experienced MRST compared to no
MRST (Table 3.2). Significant differences existed between participants who experienced
combinations of MRST and those who experienced no MRST, including sexual orientation and
deployment. With regard to sexual orientation, participants who experienced all four types of
MRST were significantly more likely to identify as lesbian or bisexual (p = .007) compared to no
MRST. Participants who experienced (a) MSH and gender discrimination or (b) all four types
compared to no MRST were significantly more likely to have deployed (χ
2
[1] = 4.19, p = .041
and χ
2
[1] = 5.90, p = .015, respectively). Due to significant associations with MRST experiences,
sexual orientation and deployment were included in regression models.
Military-Related Sexual Trauma Experiences and Associations with PTSD
In the first regression model, which analyzed probable PTSD, sexual minority
participants were not significantly more likely to have probable PTSD (OR = 1.61; 95% CI =
0.71, 3.67; Table 3.3). Participants who experienced deployment had 3.78 the odds of probable
PTSD compared to those who had not deployed (95% CI = 1.88, 7.60). Participants who
experienced MSH and gender discrimination were not significantly more likely to have probable
PTSD compared to those who experience no MRST (OR = 2.92; 95% CI = 0.83, 10.28).
Participants who experienced MSH, gender discrimination, and stalking had 4.52 the odds of
probable PTSD compared to those who experienced no MRST (95% CI = 1.30, 15.78).
Participants who experienced all four types had 10.85 the odds of probable PTSD compared to
those who experienced no MRST (95% CI = 3.21, 36.69).

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 70
Military-Related Sexual Trauma Experiences and Associations with Depression
In the second logistic regression model, which analyzed the odds of probable depression,
sexual minority participants were not more likely to have probable depression (OR = 1.58; 95%
CI = 0.71, 3.55; Table 3.3). Participants who experienced deployment had 2.65 the odds of
probable depression compared to those who had not deployed (95% CI = 1.35, 5.29). Participants
who experienced MSH and gender discrimination were not significantly more likely to have
probable depression compared to those who experienced no MRST (OR = 2.99; 95% CI = 0.86,
10.40). Participants who experienced MSH, gender discrimination, and stalking had 3.79 the
odds of probable depression compared to those who experienced no MRST (95% CI = 1.10,
13.01). Participants who experienced all four types had 8.16 the odds of probable depression
compared to those who experienced no MRST (95% CI = 2.47, 26.96).
Discussion
Findings indicate that the majority of female veterans in this sample experienced
combinations of MRST (84.0%). This finding adds to the literature by highlighting multiple
types of MRST that occur while women serve in the military, providing added detail to findings
in prior studies (Goldstein et al., 2017; Kimerling et al., 2010; Schuyler et al., 2016). By
individually assessing the types of MRST experienced by women, this study concisely identified
varying MRST experiences. For example, MSH in this study was reported among 86% of female
veterans, which (a) indicates the assessment of MSH may have captured a more realistic rate due
to being higher than found in previous studies among female veterans, 65% and 51%,
respectively (Goldstein et al., 2017; Street et al., 2013) and (b) verifies that analyzing MSH
without accounting for other MRSTs may show associations with mental health that are not truly
indicative of MSH alone. This emphasizes why it is important to individually assess MRSTs
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 71
prior to analyzing combinations of MRSTs to link the correct traumatic experiences to treatment
(Williamson et al., 2017). Gender discrimination (78%) was also higher than the previous
literature (39%; Street et al., 2007). Both stalking and MSA had similar rates when compared to
the current literature (Dardis, Amoroso, et al., 2016; Schuyler et al., 2016) suggesting that the
report of these experiences is more consistent. By individually assessing, then combining and
analyzing varying MRST experiences, this study more clearly defined demographic and mental
health differences among female veterans who experienced MRST.
Stalking had not previously been combined with other forms of MRST; in this work, all
significant findings included stalking, highlight how the presence of specific combinations of
MRST are different among female veterans. Similar to previous findings on stalking (Dardis,
Shipherd, et al., 2016; Lucas, Cederbaum, et al., in progress) and MSA (Lucas, Goldbach,
Kintzle, & Castro, under review), the current findings regarding stalking highlight that sexual
minority female veterans are significantly more likely to experience all four types of MRST (i.e.,
MSH, gender discrimination, stalking, and MSA). However, this finding expands the current
literature by highlighting that not only are they more likely to experience stalking and MSA, but
they are more likely to have experienced MSH and gender discrimination. The findings also lend
support to the argument of cumulative trauma having significant negative mental health
outcomes (Turner & Lloyd, 1995), as our findings show that increases in MRST experiences had
corresponding increased odds of probable PTSD and depression.
The current findings also highlight the association between (a) MSH and gender
discrimination and (b) all four types of MRSTs and deployment. This finding is similar to
previous studies that have shown 32%–42% of female service members report experiencing
some form of MSH or MSA while deployed (Burns, Grindlay, Holt, Manski, & Grossman, 2014;
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 72
Katz, Cojucar, Beheshti, Nakamura, & Murray, 2012). However, the current study did not assess
for when the MRST occurred, so it is unknown whether or not the participants experienced
MRST while in theater or in garrison.
In contrast to the current literature on MSH and depression (Street et al., 2008), this
investigation found the experience of MSH and gender discrimination did not significantly affect
PTSD or depression among female veterans. This finding is not surprising because MSH without
the threat of injury or death does not qualify as trauma and is unlikely to lead to a diagnosis of
PTSD (Williamson et al., 2017). The same is arguably true for gender discrimination. Because
MSH is typically analyzed in combination with MSA (Kimerling et al., 2007; Kimerling et al.,
2010; Murdoch & Nichol, 1995), these findings highlight that when MSH occurs separately from
MSA, it does not necessarily affect the mental health of female veterans. Therefore, it is
recommended that health care professionals fully evaluate for many types of MRST to clearly
link MRST experiences to treatment.
Minimal literature is available on stalking among female veterans and its negative impact
on mental health (Dardis, Amoroso, et al., 2016; Lucas, Cederbaum, et al., in progress). This
study highlights how stalking occurs in combination with MSH, gender discrimination, and MSA
and significantly affects PTSD and depression among female veterans. These findings emphasize
the importance of including as many types of MRST in future research as possible to clearly
define which experiences are linked to mental health outcomes. For example, the previous
literature has generally focused on the experience of MSA (Schuyler et al., 2016) and MSH or
MSA (Kimerling et al., 2007; Kimerling et al., 2010). The current study’s inclusion of gender
discrimination and stalking shows that a large portion of female veterans who experienced MSA
also experienced the other three types of MRST. This highlights that MSA does not typically
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 73
exist separately from other forms of MRST among female veterans. It is recommended that in
practice and research settings that data be collected individually for each MRST through the use
of multiple item questions and analyzed together to (1) more clearly define MRST experiences,
(2) allow for implementation of the most appropriate treatment, and (3) provide research findings
that more concisely show the impact of MRST experiences on health outcomes.
Limitations
Limitations of this study include possible response bias due to self-selection into the
study. Because the participants of this study were from two large cities (Chicago and San
Francisco), the responses are not generalizable to veterans who may be more isolated or in
smaller communities. Finally, the overall sample size did not allow for testing of singular MRST
(experiencing only one MRST) or other combinations of MRST categories. This same approach
applied to a larger sample of female veterans may yield singular MRST or combinations of
MRST experiences that will explicate MRST experiences and their impact on mental health in
this population.
Conclusions
This clearly outlined approach to defining MRST experiences among female veterans
allowed for more concise indicators of MRST experiences and their impact on clinical levels of
PTSD and depression. These findings emphasize that it is essential for health and mental health
providers to evaluate female veterans for many types of MRST to more accurately assess,
analyze, and treat varying experiences of MRST as they negatively affect the mental health of
female veterans. Future research should continue to include many types of MRST to correctly
assess individualized experiences and their impact on mental health among military populations.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 74
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MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 81
Table 3.1. Sample Characteristics and Sexual Trauma Experiences of
Female Veterans
n (%)
Total 315 (100.0)
Age (n = 315)
18–39 159 (50.5)
40–59 128 (40.6)
60+ 28 (8.9)
Race (n = 315)
White (non-Hispanic) 145 (46.0)
Other 170 (54.0)
Sexual orientation (n = 301)
Heterosexual 262 (87.6)
Lesbian or bisexual 39 (12.4)
Education (n = 311)
Some HS, GED, or HS diploma 27 (8.7)
Some college or associate degree 136 (43.7)
Bachelor degree 78 (25.1)
Master’s or doctoral degree 70 (22.5)
Marital status (n = 315)
Single, divorced, separated, or widowed 181 (57.5)
Married, domestic partner, or long-term relationship 134 (42.5)
Service branch (n = 312)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 82
Air Force 52 (16.7)
Army 155 (49.7)
Coast Guard 14 (4.5)
Marine Corps 23 (7.4)
Navy 68 (21.8)
Era (n = 312)
Pre-9/11 110 (35.3)
Post-9/11 202 (64.7)
Rank (n = 309)
E1–E4 161 (52.1)
E5–E7 93 (30.1)
E8–E9 or W1–W5 16 (5.2)
O1–O10 39 (12.6)
Deployment (n = 312)
Yes 214 (68.6)
Military sexual harassment (n = 275)
Yes 237 (86.2)
Gender discrimination (n = 276)
Yes 216 (78.3)
Stalking (n = 277)
Yes 162 (58.5)
Military sexual assault (n = 269)
Yes 120 (44.6)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 83
Military-related sexual trauma (n = 269)
None 26 (9.7)
Probable PTSD (n = 278)
Yes 141 (50.7)
Probable depression (n = 278)
Yes 130 (46.8)
Note. HS, high school. PTSD measured using the PCL-5 with a clinical cutoff of 33
(Weathers et al., 2013). Depression measured using the PHQ-9 with a clinical cutoff
of 10 (Kroenke et al., 2001).

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 84
Table 3.2. Participant Characteristics With and Without MRST among Female Veterans
No MRST MSH, GD MSH, GD, ST MSH, GD, ST, MSA
n (%) n (%) or χ
2
(df), p
or Fisher’s exact p
n (%) or χ
2
(df), p
or Fisher’s exact p
n (%) or χ
2
(df), p or
Fisher’s exact p
Total 26 (9.7) 46 (17.1) 52 (19.3) 88 (32.7)
Age .256 .397 .109
18–39 13 (50.0) 15 (32.6) 29 (55.8) 57 (64.8)
40–59 9 (34.6) 25 (54.4) 20 (38.5) 27 (60.7)
60+ 4 (15.4) 6 (13.0) 3 (5.8) 4 (4.6)
Race .65 (1), 0.421 3.15 (1), .076 .79 (1), .372
White (non-Hispanic) 11 (42.3) 24 (52.2) 33 (63.5) 46 (52.3)
Other 15 (57.7) 22 (47.8) 19 (36.5) 42 (47.7)
Sexual orientation .647 .050 .007
Heterosexual 25 (96.2) 42 (91.3) 40 (76.9) 62 (72.1)
Lesbian or bisexual 1 (3.8) 4 (8.7) 12 (23.1) 24 (27.9)
Education .505 .921 .943
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 85
Some HS, GED, or HS diploma 2 (8.0) 2 (4.4) 7 (13.5) 7 (8.1)
Some college or associate degree 13 (52.0) 18 (39.1) 24 (46.2) 40 (46.0)
Bachelor degree 4 (16.0) 14 (30.4) 10 (19.2) 19 (21.8)
Master’s or doctoral degree 6 (24.0) 12 (26.1) 11 (21.2) 21 (24.1)
Marital status 1.05 (1), .305 0.24 (1), .627 0.03 (1), 869
Single, divorced, separated, or widowed 14 (53.9) 19 (41.3) 31 (59.6) 49 (55.7)
Married, domestic partner, or long-term
relationship
12 (46.2) 27 (58.7) 21 (40.4) 39 (44.3)
Service branch .537 .985 .308
Air Force 5 (19.2) 9 (19.6) 8 (15.4) 12 (13.6)
Army 15 (57.7) 20 (43.5) 31 (59.6) 38 (43.2)
Coast Guard 0 (0.0) 3 (6.5) 1 (1.9) 10 (11.4)
Marine Corps 2 (7.7) 2 (4.4) 3 (5.8) 8 (9.1)
Navy 4 (15.4) 12 (26.1) 9 (17.3) 20 (22.7)
Era .948 (1), .330 0.12 (1), .732 0.00 (1), .961
Pre-9/11 9 (34.6) 11 (23.9) 16 (30.8) 30 (34.1)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 86
Post-9/11 17 (65.4) 35 (73.9) 36 (69.2) 58 (65.9)
Rank .397 1.00 .053
E1–E4 16 (61.5) 19 (41.3) 31 (59.6) 38 (43.2)
E5–E7 6 (23.1) 15 (32.6) 14 (26.9) 28 (31.8)
E8–E9 or W1–W5 0 (0.0) 1 (2.2) 0 (0.0) 14 (15.9)
O1–O10 4 (15.4) 11 (23.9) 7 (13.5) 8 (7.0)
Deployment 4.19 (1), .041 3.37 (1), .066 5.90 (1), .015
Yes 13 (50.0) 34 (73.9) 37 (71.2) 66 (75.0)
Note. Figures in bold are statistically significant. The following subgroups were not included due to small sample sizes: MSH only (n = 9); GD only
(n = 3); ST only (n = 3); MSH and ST (n = 9); GD and ST (n = 1); MSA only (n = 2); MSH and MSA (n = 5); MSH, GD, and MSA (n = 20); MSH,
ST, and MSA (n = 4); and GD, ST, and MSA (n = 1). MRST, military-related sexual trauma; MSH, military sexual harassment; GD, gender
discrimination; ST, stalking; MSA, military sexual assault; HS, high school. PTSD measured using the PCL-5 with a clinical cutoff of 33 (Weathers
et al., 2013). Depression measured using the PHQ-9 with a clinical cutoff of 10 (Kroenke et al., 2001).

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 87
Table 3.3. MRST, Probable PTSD, and Probable Depression among Female Veterans
Model 1 Model 2
Probable PTSD Probable Depression
OR 95% CI OR 95% CI
MRST (n = 269)
No MRST (n = 26; Ref) 1 1
MSH and GD (n = 46) 2.92 0.83, 10.28 2.99 0.86, 10.40
MSH, GD, and stalking (n = 52) 4.52 1.30, 15.78 3.79 1.10, 13.01
MSH, GD, stalking, and MSA (n = 88) 10.85 3.21, 36.69 8.16 2.47, 26.96
Sexual orientation (n = 301)
Heterosexual (n = 262; Ref) 1 1
Lesbian or bisexual (n = 39) 1.61 0.71, 3.67 1.58 0.71, 3.55
Deployment (n = 312)
No deployment (n = 214; Ref) 1 1
Deployment (n = 98) 3.78 1.88, 7.60 2.65 1.33, 5.29
Adjusted R
2
.272 .210
Note. Values in bold statistically significant at p < .05. PTSD measured using the PCL-5 with a clinical
cutoff of 33 (Weathers et al., 2013). Depression measured using the PHQ-9 with a clinical cutoff of 10
(Kroenke et al., 2001). OR, odds ratio; CI, confidence interval; MRST, military-related sexual trauma; Ref,
reference category; MSH, military sexual harassment; GD, gender discrimination; MSA, military sexual
assault.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 88
Chapter Four: Manuscript 3
An Examination of Sexual Harassment, Gender Discrimination, Stalking, and Sexual
Assault among Male Veterans and Associations with PTSD and Depression
In preparation for American Journal of Public Health
(Carrie Lucas, Julie Cederbaum, Sara Kintzle, and Carl Castro)
Abstract
This study sought to determine the presence of military-related sexual trauma (MRST; i.e.,
sexual harassment, gender discrimination, stalking, and sexual assault) and highlight associations
with posttraumatic stress disorder (PTSD) and depression among male veterans. Two
community, nonclinical samples of 1,665 male veterans were utilized. A total of 67.5% male
veterans experienced some form of MRST. Male veterans who experienced sexual harassment
and gender discrimination (12.7%) had 1.90 the odds of PTSD and 2.06 the odds of depression
compared to those who experienced no MRST. Participants who experienced all four types of
MRST (14.3%) had 22.77 the odds of PTSD and 16.60 the odds of depression compared to those
who experienced no MRST. The associations between combinations of MRST experiences and
current PTSD and depression among male veterans are concerning, especially as those who
experienced military sexual assault also experienced all other types of MRST. It is critical for
health and mental health providers to recognize the impact of varying types of combinations of
MRSTs among male veterans to ensure appropriate screening, treatment, and evaluation.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 89
An Examination of Sexual Harassment, Gender Discrimination, Stalking, and Sexual Assault
among Male Veterans and Associations with PTSD and Depression
Military sexual trauma experienced by male veterans has become more known in the last
10 years due to research efforts to highlight its prevalence and impact (Hoyt, Rielage, &
Williams, 2011; Kimerling, Gima, Smith, Street, & Frayne, 2007; Schuyler, Kintzle, Lucas,
Moore, & Castro, 2016). A majority of the research has focused on the Department of Defense
umbrella term military sexual trauma, which assesses the negative effects of military sexual
harassment (MSH) and military sexual assault (MSA) on mental and physical health (Kimerling
et al., 2007; Kimerling et al., 2010; Murdoch, Pryor, Polusny, & Gackstetter, 2007; Schuyler et
al., 2016). As military sexual trauma does not include the assessment of gender discrimination or
stalking, little is known about them and their impact on mental health among male veterans
(Lucas, Cederbaum, Kintzle, & Castro, in progress; Street, Gradus, Stafford, & Kelly, 2007). To
increase our knowledge this study will include MSH, gender discrimination, stalking, and MSA
and will be referred to as military-related sexual trauma (MRST).
Background
Reported Rates of Sexual Trauma
Research conducted with men in both civilian and military populations has shown sexual
harassment rates are 13%–31% for civilians (Willness, Steel, & Lee, 2007), 7% for active-duty
members (Morral, Gore, & Schell, 2016), and 11% for veterans (Street, Gradus, Giasson, Vogt,
& Resick, 2013). The reported rates of gender discrimination among men are 13% for civilians
(Rospenda, Richman, & Shannon, 2009), 2% for active-duty members (Morral et al., 2016), and
17% for veterans (Street et al., 2007). The reported rates of stalking among men are 2%–6% for
civilians (Breiding et al., 2014; Tjaden & Thoennes, 2000), 1%–2% for active-duty members
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 90
(Cook et al., 2015), and 4%–34% for veterans (Clancy et al., 2006; Lucas, Cederbaum, et al., in
progress). With regard to sexual assault among men, the reported rates are 3% for civilians
(Tjaden & Thoennes, 2000), 6% for active-duty members (Barlas, Higgins, Pflieger, & Diecker,
2013), and 3%–12% for veterans (Schuyler et al., 2016; Suris & Lind, 2008).
When reviewing reported rates, male veterans report similar rates in all four categories
compared to male civilians. However, with regard to gender discrimination and stalking, an
evident increase in reporting has occurred for male veterans compared to male active-duty
members, with rates up to 10 times higher. These higher reporting rates after military service are
concerning because they may reflect low reporting while in the military due to the potential
negative career impact (Rasmussen & Zaglifa, 2013). These increases in rates highlight why it is
essential to include gender discrimination and stalking when (1) assessing MRST and (2)
evaluating MRST associations with mental health among male veterans.
Sexual Trauma and Impact on Health and Mental Health
The civilian and military literatures feature varying evaluations of sexual trauma, such as
the Sexual Experiences Questionnaire (DeSouza & Fransler, 2003) and the two-item screener
used by the DoD to assess military sexual trauma (Kimerling et al., 2007; Kimerling et al.,
2010). This makes it difficult to evaluate the impact of singular trauma (experience of only one
trauma) and cumulative traumas.
Sexual harassment and gender discrimination. Research on the presence of sexual
harassment or gender discrimination has shown no differences with regard to depression and
anxiety among male civilians (DeSouza & Fansler, 2003), whereas male active-duty members
had significant differences in post-traumatic stress disorder (PTSD) and depression (Street et al.,
2007). However, (1) it is unclear if the sexual harassment or gender discrimination is impacting
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 91
the outcomes or (2) how the inclusion of stalking and MSA would potentially alter the impact on
outcomes. Separate from sexual harassment, there has been limited research on gender
discrimination that has shown negative mental health consequences among male civilians
(Rospenda et al., 2009). Also, as gender discrimination has been frequently defined as sexual
harassment when using the Sexual Experiences Questionnaire (Fitzgerald, Magley, Drasgow, &
Waldo, 1999; Street et al., 2007; Street, Stafford, Mahan, & Hendricks, 2008) the true impact of
gender discrimination on mental health is not clear. Assessing gender discrimination separate
from MSH, along with stalking and MSA, will allow for a better understanding of how these
MRST experiences affect the mental health of male veterans.
Stalking. Among male civilians, stalking is significantly associated with anxiety,
depression, PTSD, appetite disturbance, headaches, physical illness, and insomnia (Kuehner,
Gass, & Dressing, 2012; Spitzberg & Cupach, 2003). The literature on male veterans indicates
stalking has a negative impact on PTSD and depression (Lucas, Cederbaum, et al., in progress).
Therefore, it is important to include stalking alongside sexual harassment, gender discrimination,
and stalking to assess its relationship to other MRST experiences and associations with mental
health.
Sexual assault. The presence of sexual assault among male civilians is significantly
associated with somatic symptoms, depression, anxiety, alcohol use, substance use, and physical
health (Tewksbury, 2007). Among male veterans, the presence of MSA is an indicator of both
PTSD and depression (Schuyler et al., 2016). The military literature has also combined the study
of MSA with MSH, sometimes evaluating (1) MSH or MSA or (2) MSH and MSA. Male
veterans who experienced MSH or MSA were significantly more likely to have PTSD,
depression, anxiety, alcohol use, substance use, and adjustment disorders (Kimerling et al., 2007;
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 92
Kimerling et al., 2010). In these studies, it is unclear if it is the presence of MSH, MSA, or both
that is causing negative health outcomes.
Studies that have analyzed the presence of MSH and MSA have found male active-duty
members and reservists who experienced both had negative health consequences including
PTSD, depression, anxiety, and somatic concerns (Murdoch et al., 2007; Street et al., 2008).
Assessing individually for MSH and MSA and then evaluating the combination of MSH and
MSA allows for a clearer picture that shows both sexual traumas are present for male active-duty
members and reservists and negatively affecting their mental health. The next step is to include
gender discrimination and stalking with MSH and MSA to further evaluate their impact on
mental health. It is possible that gender discrimination and stalking are also present for male
veterans and influencing the findings.
Purpose of this Study
This study used trauma theory, which suggests trauma continues to affect individuals’
negatively over time (Bloom, 1999) and that experiences of cumulative trauma are linked to
increased risk for mental health concerns (Turner & Lloyd, 1995). To further assess the MRST
experienced by male veterans, it is important to include MSH, gender discrimination, stalking,
and MSA. It is unclear how singular MRST (experiencing only one MRST) and combinations of
MRST may be affecting the mental health of male veterans. Survey items provided an
opportunity for male veterans to select specific types of MRST experienced. This helped
highlight the presence of MRST, demographic characteristics of those who experience singular
MRST and combinations of MRST, and the associations of singular MRST and combinations of
MRST on current mental health among male veterans.
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 93
Methods
Study Overview and Participants
Male participants were drawn from two community-based, nonclinical studies involving
veterans (N = 1,665; Castro & Kintzle, 2017; Kintzle, Matthews Rasheed, & Castro, 2016).
Among male participants, 81.9% completed all MRST items resulting in an analytical sample of
1,364. Both studies used targeted recruitment strategies to achieve maximum representativeness
of the veteran populations in Chicago and San Francisco. Sample frames and convenience
sampling strategies can be reviewed elsewhere (Kintzle et al., 2016). All participants received a
$15 gift card for completing the survey, which took 30 to 90 minutes. All data collection
procedures were approved by the Institutional Review Board of an affiliated university.
Measures
The following demographic and military-related variables were recoded due to
distribution and for purposes of analyses. Age (continuous) was recoded as a categorical
variable: 18–39, 40–59, and 60 years or older. Race/ethnicity categories were non-Hispanic
White; Black or African American; Hispanic or Latino; and other. Sexual orientation was a
dichotomized as (a) heterosexual or (b) gay or bisexual. Level of education was categorized as
some high school, GED, or high school diploma; some college or associate degree; bachelor’s
degree; and master’s or doctoral degree. Marital status categories were: single, divorced,
separated, or widowed; and married, in a domestic partnership, or long-term relationship. Branch
of service categories were Air Force, Army, Coast Guard, Marine Corps, or Navy. A variable for
service era specified whether participants served before or after September 11, 2001. Rank was
recoded as a categorical variable: E1–E4, E5–E7, E8–E9 or W1–W4, and O1–O10. Deployment
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 94
was dichotomized (yes vs. no). Deployment was included as a control variable as it is a known
risk factor for PTSD and depression (Hoge et al., 2004).
Assessment of military sexual harassment. MSH was assessed with six questions
adapted from the definition found in the Military Equal Opportunity memorandum (U.S.
Department of Defense, 2015) and a 2014 RAND survey (Morral et al., 2016). Questions
referenced experiences encountered during military service, both on- or off-duty and on- or off-
base: (a) “someone repeatedly telling jokes of a sexual nature”; (b) “someone repeatedly making
sexual comments, gestures, or body movements”; (c) “someone displaying, showing, or sending
sexually explicit materials, such as pictures or videos”; (d) “someone repeatedly asking you
questions about your sex life or sexual interests”; (e) “someone talking or sharing sexually
explicit pictures or videos of you”; and (f) “someone making you feel that you could receive a
workplace benefit in exchange for doing something sexual, or that you could be punished or
treated unfairly if you didn’t do something sexual” (Morral et al., 2016). Participants were asked
how often each type of MSH happened (never, 1 time, 2–4 times, and 5+ times). All six items
were combined into one variable and dichotomized (experienced MSH or not). If a participant
experienced any of the six types of MSH one time, he was considered to have experienced MSH.
Assessment of gender discrimination during military service. Gender discrimination
was assessed with three questions adapted from the Military Equal Opportunity memorandum
(U.S. Department of Defense, 2015) and the 2014 RAND survey (Morral et al., 2016). Questions
referenced experiences encountered during military service, both on- or off-duty and on- or off-
base: (a) “someone suggesting that you don’t act like a man/woman is supposed to (For example,
by calling you [men] ‘gay’ or ‘a fag’ or [women] ‘butch’ or ‘a dyke’)”; (b) “someone saying that
men/women are not as good as women/men at your particular job or that men/women should be
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 95
prevented from having your job”; and (c) “someone mistreating, ignoring, excluding or insulting
you because of your gender.” Participants were asked how often each type of gender
discrimination happened (never, 1 time, 2–4 times, and 5+ times). All three items were combined
into one variable and dichotomized (experienced gender discrimination or not). If a participant
experienced any of the three types of gender discrimination one time, he was considered to have
experienced gender discrimination.
Assessment of stalking during military service. Stalking was assessed with four
questions based on a review of the Uniform Code of Military Justice (2006) and Loveisrespect
(2013). Questions were prefaced with an overarching statement regarding stalking experiences
while in the military. Four types of stalking were assessed: (a) “someone showing up at your
home or workplace unannounced or uninvited”; (b) “someone following you or waiting for you
at places”; (c) “someone sending you unwanted messages, emails, or phone calls”; and (d)
“someone using social media to track or follow you” (Loveisrespect, 2013; Uniform Code of
Military Justice, 2006). Participants were asked how often each type of stalking occurred (never,
1 time, 2–4 times, or 5+ times). Two or more experiences of any stalking experience constituted
stalking. For example, if participants experienced someone showing up unannounced one time
and someone using social media to track them one time, this constituted stalking. The variable
was dichotomized (experienced stalking or not).
Assessment of military sexual assault. MSA was assessed with four questions adapted
from the U.S. Department of Justice special report on rape and sexual assault victimization
among college women (Sinozich & Langton, 2014) and the Uniform Code of Military Justice
(2006). The fifth question from the original scale was removed (assessing vaginal intercourse)
due to it not being applicable to men. The questions assessed nonconsensual or unwanted sexual
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 96
contact experienced during military service with (a) a military member or civilian, (b) someone
known to the participant, or (c) a stranger. Dichotomous items were: (a) “forced touching of a
sexual nature (i.e., forced kissing, touching of private parts, groping, fondling)”; (b) “oral sex
(i.e., someone’s mouth or tongue making contact with your genitals, or your mouth or tongue
making contact with someone else’s genitals)”; (c) “anal intercourse (i.e., someone’s penis being
put in your anus”; and (d) “sexual penetration with a finger or object (i.e., someone putting their
finger or an object into your mouth, vagina, or anus).” All four items were combined and
dichotomized (experienced MSA or not). If a participant experienced any of the four types of
MSA one time, he was considered to have experienced MSA.
Assessment of probable PTSD. Probable PTSD was measured by the 20-item PTSD
Checklist for the DSM-5 (PCL-5; Blevins, Weathers, Davis, Witte, & Domino, 2015). The
measure asks participants to rate how much they were affected by exposure to a stressful event
during the prior month. For example, participants were asked how much they were bothered by
“repeated, disturbing, and unwanted memories of the stressful experience.” Participants rated
each item from 0 (not at all) to 4 (extremely). Scores range from 0 to 80, and a clinical cutoff
score of 33 was used to indicate probable PTSD (Weathers et al., 2013). In this study,
Cronbach’s alpha was .97.
Assessment of probable depression. Probable depression was measured using the 9-
item Patient Health Questionnaire (PHQ-9; Spitzer, Kroenke, & Williams, 1999). This measure
consists of items that assess how often a person had been bothered by depression symptoms
during the prior 2 weeks, such as “feeling down, depressed, or hopeless.” Participants rated each
item from 0 (not at all) to 3 (nearly every day). Scores range from 0 to 27, and a clinical cutoff
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 97
score of 10 was used to indicate probable moderate to severe depression (Kroenke, Spitzer, &
Williams, 2001). In this study, Cronbach’s alpha was .93.
Data Analysis
Descriptive statistics and logistic regression analyses were conducted in SAS 9.4. The
four types of MRST (i.e., MSH, gender discrimination, stalking, and MSA) were combined to
reflect individualized MRST experiences among male veterans. Due to this combination,
singular MRST (experiencing only one MRST) and combinations of MRST variables emerged
that accounted for individualized experiences of MRST. Subsamples smaller than 40 were not
included in the analysis due to limited power. Analyses tested differences between demographic
characteristics of those who experienced singular and combinations of MRST compared to those
who did not experience any MRST using chi-square and Fisher’s exact tests. Demographic
characteristics found to statistically differ were included in the logistic regression models. Via
two logistic regression models, i.e., one for PTSD and one for depression, the odds of
experiencing clinical levels of PTSD and depression were calculated among those who
experienced singular MRST or combinations of MRST compared to those who experienced no
MRST. In the logistic regression models, reference groups were identified via the CLASS
command in SAS. Singular MRST and combinations of MRST experiences were compared to no
MRST experience.
Results
Demographics characteristics and sexual trauma experiences of the male veterans are
presented in Table 4.1. In this sample, 39.7% of participants were 60 years old or older.
Participants were primarily White (65.5%); heterosexual (96.1%); married, had a domestic
partner, or in a long-term relationship (62.5%); and E1 to E4 with regard to rank (46.4%).
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 98
Participants had primarily served in the Army (53.3%), served pre-9/11 (60.8%), and had been
deployed (78.2%). Among these male veterans, 61.5% experienced MSH, 40.9% experienced
gender discrimination, 34.6% experienced stalking, and 17.0% experienced MSA while serving
in the military. Among male veterans, clinical levels of PTSD and depression were present
among 36.9% and 36.2% of participants, respectively.
Military-Related Sexual Trauma Experiences among Male Veterans
Descriptive statistics, chi-square, and Fisher’s exact analyses were conducted to identify
characteristics and significant differences between individuals with no MRST and specific
MRST experienced (Table 4.2). The majority of participants experienced at least one MRST
(67.5%). Among those who experienced MRST, 16.4% experienced only MSH; 12.7%
experienced both MSH and gender discrimination; 3.9% experienced only stalking; 4.0%
experienced both MSH and stalking; 12.4% experienced MSH, gender discrimination, and
stalking; and 14.3% experienced all four types of MRST (i.e., MSH, gender discrimination,
stalking, and MSA). Among those who experienced MRST, varying associations existed with
clinical levels of probable PTSD and depression. For example, whereas 16.4% of participants
who experienced no MRST had probable PTSD, 86.5% of participants who experienced all four
types of MRST had probable PTSD. Similarly, whereas 14.9% of participants who experienced
no MRST had probable depression, this proportion increased to 84.6% among those who
experienced all four types of MRST.
Characteristics and Associations of Military-Related Sexual Trauma Experiences
Significant demographic differences existed between participants who experienced
MRST and those who had not, including age, race/ethnicity, sexual orientation, marital status,
service branch, service era, deployment, and rank (Table 4.2). For example, in regard to age,
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 99
male veterans ages 18–39 years old were significantly more likely to experience MSH, gender
discrimination, and stalking (59.8%; χ
2
[2] = 41.41, p < .001) and all four traumas (79.0%; χ
2
[2] =
227.44, p < .001) compared to no MRST (18.5%). In regard to race/ethnicity, Latino male
veterans were significantly more likely to experience all four MRSTs (i.e. MSH, gender
discrimination, stalking, and MSA; 19.5%; χ
2
[3] = 18.51, p < .001) compared to no MRST
(9.0%). Male veterans who are gay or bisexual were significantly more likely to experience MSH
and gender discrimination (7.0%; χ
2
[1] =12.12, p < .001), MSH, gender discrimination, and
stalking (4.8%; χ
2
[1] = 5.13, p < .05), and all four MRSTs (7.7%; χ
2
[1] = 15.14, p < .001)
compared to no MRST (1.5%). Single male veterans were significantly more likely to experience
only stalking (54.7%; χ
2
[1] = 8.51, p < .01) compared to no MRST (34.3%). In regard to service
branch, male veterans who served in the Army were significantly more likely to have
experienced MSH, gender discrimination, and stalking (63.3%; p < .05) compared to no MRST
(54.9%). While those who served in the Coast Guard were significantly more likely to have
experienced all four MRSTs (10.3%; p < .001) compared to no MRST (0.5%). In regard to
service era, post-9/11 male veterans were significantly more likely to experience MSH and
gender discrimination (49.7%; χ
2
[1] = 35.29, p < .001), MSH and stalking (40.0%; χ
2
[1] = 5.73,
p < .05), MSH, gender discrimination, and stalking (66.9%; χ
2
[1] = 92.48, p < .001), and all four
MRSTs (69.7%; χ
2
[1] = 114.85, p < .001) compared to no MRST (24.9%). In regard to rank,
male veterans who served in ranks E8–E9 or W1–W5 were significantly more likely to have
experienced MSH, gender discrimination, and stalking (27.2%; χ
2
[3] = 85.09, p < .001) and
MSH, gender discrimination, stalking, and MSA (12.4%; χ
2
[3] = 20.52, p < .001) compared to
no MRST (3.2%). All significant characteristics were included as confounding variables in the
regression models.
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 100
Military-Related Sexual Trauma Experiences and Associations with PTSD
In the first regression model, race/ethnicity, sexual orientation, and service era were not
significantly associated with probable PTSD (Table 4.3). Participants aged 60 or older had lower
odds of probable PTSD compared to those aged 18–39 (OR = 0.53; 95% CI = 0.31, 0.89).
Participants who served in the Navy had lower odds of probable PTSD compared to those who
served in the Army (OR = 0.47; 95% CI = 0.31, 0.71). Participants who experienced deployment
had 1.98 the odds of probable PTSD compared to those who did not deploy (95% CI = 1.32,
2.96). With regard to rank, participants who were (a) E8–E9 or W1–W5 or (b) O1–O10 had
lower odds of probable PTSD than participants who were E1–E4 (OR = 0.51; 95% CI = 0.29,
0.90 and OR = 0.53; 95% CI = 0.33, 0.82, respectively).
In the first regression model, after adjusting for significant confounding variables, most
MRST experiences were significantly associated with probable PTSD when compared to
participants who experienced no MRST (Table 4.3). Only MSH only was not significantly
associated with probable PTSD compared to participants who experienced no MRST; all other
combinations of MRST experiences were significantly associated. For example, participants who
experienced both MSH and gender discrimination had 1.90 the odds of having probable PTSD
compared to participants who did not experience any MRST (95% CI = 1.23, 2.94). Participants
who experienced only stalking had 4.32 the odds of probable PTSD compared to participants
who did not experience any MRST (95% CI = 2.25, 8.32). The largest association of MRST with
mental health was found among participants who experienced all four types of MRST; they had
22.77 the odds of probable PTSD compared to participants who did not experience any MRST
(95% CI = 13.15, 39.42).

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 101
Military-Related Sexual Trauma Experiences and Associations with Depression
In the second regression model, race/ethnicity, sexual orientation, and service era were
not significantly associated with probable depression (Table 4.3). Participants aged 60 or older
had lower odds of probable depression compared to participants aged 18–39 (OR = 0.29; 95% CI
= 0.17, 0.49). Participants who served in the Navy had lower odds of probable depression
compared to those who served in the Army (OR = 0.44; 95% CI = 0.27, 0.71). Participants who
experienced deployment had 1.67 the odds of probable depression compared to those who did
not deploy (95% CI = 1.11, 2.51). Participants who were E8–E9 or W1–W5 had 2.23 the odds of
probable depression compared to those who were E1–E4 (95% CI = 1.22, 4.09).
In the second regression model, most MRST experiences were significantly associated
with probable depression (Table 4.3). After adjusting for significant confounding variables (i.e.,
age, race/ethnicity, sexual orientation, marital status, service branch, service era, rank, and
deployment), participants with varying MRST experiences were compared to participants who
experienced no MRST. Only MSH only was not significantly associated with probable
depression compared to participants who experienced no MRST; all other combinations of
MRST experiences were significantly associated. Participants who experienced both MSH and
gender discrimination had 2.06 the odds of having probable depression compared to participants
who did not experience any MRST (95% CI = 1.32, 3.21). Participants who experienced only
stalking had 3.02 the odds of probable depression compared to participants who did not
experience any MRST (95% CI = 1.56, 5.84). The largest association of MRST with mental
health was found among participants who experienced all four types of MRST; they had 16.60
the odds of probable depression compared to participants who did not experience any MRST
(95% CI = 9.76, 28.22).
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 102
Discussion
Research on male military populations and MRST has focused on either one type of
MRST (Lucas, Cederbaum, et al., in progress; Morral et al., 2016; Schuyler et al., 2016) or a
combination of MSH and/or MSA (Kimerling et al., 2007; Kimerling et al., 2010; Murdoch et
al., 2007; Street et al., 2007; Street et al., 2008). No identified study has considered these four
types of MRST and how they are experienced by male veterans. As such, this study expands the
current literature (a) due to its inclusion of MSH, gender discrimination, stalking, and MSA and
(b) by providing a more concise identification of these MRST experiences. For example, the
reported rates of (1) MSH (62%) are higher than in a previous study of male veterans (11%;
Street et al., 2013) and (2) MSA (17%) are higher than in a previous study on male veterans
(12%; Schuyler et al., 2016). These higher rates supports that this study may have more
thoroughly assessed MRST experiences by asking more questions and recognizing they are most
likely present in combination with other MRST experiences.
This study highlights demographic differences by comparing male veterans who
experienced singular MRST or combinations of MRST to those who experienced no MRST. In
contrast to previous literature (Kimerling et al., 2010), these findings reveal Latino male veterans
are significantly more likely to experience all four MRSTs compared to Latino male veterans
who experienced no MRST. Similar to a previous study (Lucas, Goldbach, Kintzle, & Castro,
under review), these findings demonstrate that gay or bisexual male veterans are significantly
more likely to experience MRSTs compared to heterosexual male veterans, especially all four
types of MRST in this study. In contrast to the current literature (Kimerling, et al., 2010), the
current findings show significant rank differences, with E8–E9 or W1–W5 being significantly
more likely to experience varying singular or combinations of MRST experiences compared to
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 103
those with no MRST. It is possible that male veterans who served in ranks of E8–E9 or W1–W5
experienced more MRST due to being in the military for a longer period of time allowing for
more MRSTs to occur. Another evident addition to the literature is post-9/11 male veterans were
significantly more likely to experience MRST compared to pre-9/11 male veterans supporting
future research stratify by service era.
Similar to previous findings on military sexual trauma (Kimerling et al., 2007; Kimerling
et al., 2010; Schuyler et al., 2016), most experiences of MRST had significant associations with
both probable PTSD and depression. However, because MRST experiences were approached
differently, results provide a stronger understanding of MRST experiences and their impact on
mental health. For example, in contrast to a previous study (Street et al., 2007), this study found
MSH only was not significantly associated with mental health. However, similar to the same
previous study (Street et al., 2007), MSH and gender discrimination had a significant impact on
mental health when compared to no MRST experience. This is an important clarification,
because the previous study (Street et al., 2007) defined gender discrimination as MSH, whereas
the current study clarifies that it is the presence of both that negatively affects mental health.
Similar to a previous study (Lucas, Cederbaum, et al., in progress), experiencing only
stalking affected the mental health of male veterans. However, the previous study did not
consider other types of MRST, so this study enhances our knowledge because it shows that
experiencing only stalking can negatively affect the mental health of male veterans. By including
other types of MRST, the current study revealed that stalking in combination with other MRSTs
results in higher odds of probable PTSD and depression. It is evident the experience of stalking,
and the potential risk of harm, continues to negatively affect the mental health of male veterans.
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 104
These findings show that MRST experiences do not typically exist independent from one
another.
Although previous literature has highlighted the significant impact of MSA (Schuyler et
al., 2016), the inclusion of four MRSTs expanded what is known, showing male veterans in this
study who experienced MSA also experienced MSH, gender discrimination, and stalking. In
contrast to previous studies (Kimerling et al., 2010; Schuyler et al., 2016), combinations of
MRST, especially those that included MSA, had increased odds of experiencing clinical levels of
PTSD and depression than previously found. These findings emphasize that (1) cumulative
trauma experiences are linked to increased odds of mental health concerns, and as such, (2) it is
essential for health providers to evaluate male veterans for many types of MRST. More thorough
screeners should be implemented in health care, especially mental health, that indicate varying
types of MRST experiences to further capture the experiences of male veterans.
Limitations
Limitations to this study include possible response bias due to (1) self-selection into the
study and (2) approximately 18% of male veterans did not answer all the MRST items. Also,
because participants were from two larger cities, the responses are not generalizable to male
veterans in more isolated areas or smaller communities. Despite these limitations, this study
more fully assessed MRST experiences and provides a more nuanced understanding of MRST
experienced during military service and its association with mental health among male veterans.
This study used a community-based, nonclinical sample, highlighting the characteristics of
veterans who may not be actively seeking help and arguably providing more generalizable
findings.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 105
Conclusions
This approach to defining MRST experiences among male veterans allowed for more
concise indicators of singular and combinations of MRST experiences and their impact on
clinical levels of PTSD and depression. These findings emphasize that it is essential for health
and mental health providers to evaluate male veterans for many types of MRST to more
accurately assess and treat varying experiences of MRST that negatively affect their mental
health (Williamson, Holliday, Holder, North, & Suris, 2017). Future research among military
populations should (1) continue to individually assess MRST and (2) include combinations of
many types of MRST when analyzing their impact on mental health.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 106
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MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 112
Table 4.1. Sample Characteristics and Sexual Trauma Experiences of
Male Veterans
n (%)
Total 1,665 (100.0)
Age (n = 1,662)
18–39 559 (33.6)
40–59 443 (26.7)
60+ 660 (39.7)
Race (n = 1,661)
White (non-Hispanic) 1,088 (65.5)
Black 238 (14.3)
Latino or Hispanic 193 (11.6)
Other 142 (8.6)
Sexual orientation (n = 1,648)
Heterosexual 1,584 (96.1)
Gay, bisexual, or other 64 (3.9)
Education (n = 1,639)
Some HS, GED, HS diploma 231 (14.1)
Some college or associate degree 595 (36.3)
Bachelor’s degree 448 (27.3)
Master’s or doctoral degree 365 (22.3)
Marital status (n = 1,665)
Single, divorced, separated, or widowed 625 (37.5)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 113
Married, domestic partner, or long-term relationship 1,040 (62.5)
Service branch (n = 1,648)
Air Force 191 (11.6)
Army 879 (53.3)
Coast Guard 31 (1.9)
Marine Corps 249 (15.1)
Navy 298 (18.1)
Era (n = 1,641)
Pre-9/11 997 (60.8)
Post-9/11 644 (39.2)
Rank (n = 1,603)
E1–E4 744 (46.4)
E5–E7 496 (30.9)
E8–E9 or W1–W5 112 (7.0)
O1–O10 251 (15.7)
Deployment (n = 1,638)
Yes 1,281 (78.2)
Military sexual harassment (n = 1,443)
Yes 887 (61.5)
Gender discrimination (n = 1,444)
Yes 591 (40.9)
Stalking (n = 1,456)
Yes 504 (34.6)
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 114
Military sexual assault (n = 1,380)
Yes 234 (17.0)
Probable PTSD (n = 1,460)
Yes 538 (36.9)
Probable depression (n = 1,463)
Yes 530 (36.2)
Note. HS, high school. PTSD measured using the PCL-5 with a clinical cutoff of 33
(Weathers et al., 2013). Probable depression measured using the PHQ-9 with a
clinical cutoff of 10 (Kroenke et al., 2001).

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 115
Table 4.2. Participant Characteristics With and Without Singular MRST or Combinations of MRST among Male Veterans
No MRST MSH MSH, GD ST MSH, ST MSH, GD, ST MSH, GD, ST,
MSA
n (%) n (%) or χ
2
(df), p
or Fisher’s exact p
n (%) or χ
2
(df), p
or Fisher’s exact p
n (%) or χ
2
(df), p
or Fisher’s exact p
n (%) or χ
2
(df), p
or Fisher’s exact p
n (%) or χ
2
(df), p
or Fisher’s exact p
n (%) or χ
2
(df), p
or Fisher’s exact p
Total 443 (32.5) 223 (16.4) 173 (12.7) 53 (3.9) 55 (4.0) 169 (12.4) 195 (14.3)
Age 1.66 (2), .437 41.41 (2), < .001 6.45 (2), .040 8.07 (2), .018 134.34 (2), < .001 227.44 (2), < .001
18–39 82 (18.5) 42 (18.8) 64 (37.0) 13 (24.5) 19 (34.6) 101 (59.8) 154 (79.0)
40–59 113 (25.5) 47 (21.1) 60 (34.7) 20 (37.7) 13 (23.6) 53 (31.4) 32 (16.4)
60+ 248 (56.0) 134 (60.1) 49 (28.3) 20 (37.7) 23 (41.8) 15 (8.9) 9 (4.6)
Race 1.75 (3), .626 7.08 (3), .069 .005 3.04 (3), .386 7.49 (3), .058 18.51 (3), < .001
White 316 (71.3) 167 (74.9) 115 (66.5) 26 (49.1) 33 (60.0) 107 (63.3) 112 (57.4)
Black 60 (13.5) 23 (10.3) 18 (10.4) 16 (30.2) 10 (18.2) 21 (12.4) 26 (13.3)
Latino/Hispanic 40 (9.0) 18 (8.1) 20 (11.6) 7 (13.2) 7 (12.7) 22 (13.0) 38 (19.5)
Other 27 (6.1) 15 (6.7) 20 (11.6) 4 (7.6) 5 (9.1) 19 (11.2) 19 (9.7)
Sexual orientation 2.83 (1), .093 12.12 (1), < .001 .592 1.000 5.13 (1), .024 15.14 (1), < .001
Heterosexual 435 (98.4) 211 (96.4) 159 (93.0) 51 (98.1) 54 (98.2) 160 (95.2) 180 (92.3)
Gay or bisexual 7 (1.5) 8 (3.7) 12 (7.0) 1 (1.9) 1 (1.8) 8 (4.8) 15 (7.7)
Education .81 (3), .847 4.58 (3), .205 4.21 (3), .239 4.93 (3), .177 4.97 (3), .174 2.99 (3), .393
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 116
Some HS, GED,
HS diploma
53 (12.2) 26 (12.1) 31 (18.1) 7 (13.5) 10 (19.2) 21 (12.4) 15 (7.7)
Some college or
associate degree
145 (33.4) 80 (36.5) 59 (34.5) 24 (46.2) 21 (40.4) 49 (29.0) 66 (34.0)
Bachelor degree 128 (29.5) 64 (29.2) 41 (24.0) 10 (19.2) 9 (17.3) 65 (38.5) 59 (30.4)
Master’s or
doctoral degree
108 (24.9) 49 (22.4) 40 (23.4) 11 (21.2) 12 (23.1) 34 (20.1) 54 (27.8)
Marital status 1.50 (1), .221 2.87 (1), .090 8.51 (1), .004 1.21 (1), .271 .171 (1), .680 3.16 (1), .076
Single

152 (34.3) 66 (29.6) 72 (41.6) 29 (54.7) 23 (41.8) 55 (32.0) 53 (27.2)
Married

291 (65.7) 157 (70.4) 101 (58.4) 24 (45.3) 32 (58.2) 114 (67.5) 142 (72.8)
Service branch .352 .739 .471 .366 .038 < .001
Air Force 52 (11.7) 27 (12.1) 19 (10.4) 10 (18.9) 6 (10.9) 9 (5.3) 30 (15.4)
Army 243 (54.9) 113 (50.7) 90 (52.0) 25 (47.2) 28 (50.9) 107 (63.3) 101 (51.8)
Coast Guard 2 (0.5) 4 (1.8) 2 (1.2) 0 (0.0) 1 (1.8) 0 (0.0) 20 (10.3)
Marine Corps 66 (14.9) 31 (13.9) 28 (16.2) 10 (18.9) 6 (10.9) 31 (18.3) 25 (12.8)
Navy 80 (18.1) 48 (21.5) 35 (20.2) 8 (15.1) 14 (25.5) 22 (13.0) 19 (9.7)
Service Era .04 (1), .850 35.29 (1), < .001 .292 (1), .589 5.73 (1), .017 92.48 (1), < .001 114.85 (1), < .001
Pre-9/11 332 (75.1) 166 (74.4) 87 (50.3) 38 (71.7) 33 (60.0) 56 (33.1) 59 (30.3)
Post-9/11 110 (24.9) 57 (25.6) 86 (49.7) 15 (28.3) 22 (40.0) 113 (66.9) 136 (69.7)
Rank 5.66 (3), .129 7.81 (3), .050 < .001 .374 85.09 (3), < .001 20.52 (3), < .001
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 117
E1–E4 218 (49.4) 95 (43.0) 77 (44.8) 28 (52.8) 26 (47.3) 54 (32.0) 84 (43.5)
E5–E7 120 (27.2) 80 (36.2) 62 (36.1) 18 (34.0) 20 (36.4) 49 (29.0) 49 (25.39)
E8–E9/W1–W5 14 (3.2) 6 (2.7) 9 (5.2) 2 (3.8) 2 (3.6) 46 (27.2) 24 (12.4)
O1–O10 89 (20.2) 40 (18.1) 24 (14.0) 5 (9.4) 7 (12.7) 20 (11.8) 36 (18.7)
Deployment 1.37 (1), .242 14.00 (1), < .001 1.55 (1), .213 .72 (1), .396 23.11 (1), < .001 22.14 (1), < .001
Yes 319 (72.3) 170 (76.6) 86 (49.7) 34 (64.2) 42 (77.8) 153 (90.5) 174 (89.2)
Note. Figures in bold are statistically significant. Subgroups not included due to small sample sizes: GD only (n = 13); GD and ST (n = 1); MSA only (n = 2);
MSH and MSA (n = 10); GD and MSA (n = 1); MSH, GD, and MSA (n = 18); MSH, ST, and MSA (n = 7); and GD, ST, and MSA (n = 1). MRST, military-
related sexual trauma; MSH, military sexual harassment; GD, gender discrimination; ST, stalking; MSA, military sexual assault; HS, high school; Single, Single,
divorced, separated, or widowed; Married, Married, domestic partner, or long-term relationship. PTSD measured using the PCL-5 with a clinical cutoff of 33
(Weathers et al., 2013). Depression measured using the PHQ-9 with a clinical cutoff of 10 (Kroenke et al., 2001).

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 118
Table 4.3. Singular MRST, Combinations of MRST, Probable PTSD, and Probable Depression
among Male Veterans
Model 1 Model 2
Probable PTSD Probable Depression
OR 95% CI OR 95% CI
Singular MRST and Combinations of MRST
No MRST (n = 443; Ref) 1 1
MSH only (n = 223) 1.09 0.69, 1.71 1.17 0.73, 1.88
MSH and GD (n = 173) 1.90 1.23, 2.94 2.06 1.32, 3.21
Stalking only (n = 53) 4.32 2.25, 8.32 3.02 1.56, 5.84
MSH and stalking (n = 55) 3.77 2.00, 7.08 3.27 1.68, 6.39
MSH, GD, and stalking (n = 169) 3.92 2.50, 6.16 4.57 2.88, 7.26
MSH, GD, stalking, and MSA (n = 195) 22.77 13.15, 39.42 16.60 9.76, 28.22
Age
18–39 (n = 559; Ref) 1 1
40–59 (n = 443) 1.26 0.84, 1.89 0.82 0.55, 1.23
60+ (n = 660) 0.53 0.31, 0.89 0.29 0.17, 0.49
Race/ethnicity
White (n = 1,088; Ref) 1 1
Black (n = 238) 1.45 0.94, 2.24 1.32 0.85, 2.05
Latino (n = 193) 0.72 0.46, 1.14 0.97 0.62, 1.52
Other (n = 142) 1.16 0.71, 1.90 0.94 0.57, 1.54
Sexual orientation
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 119
Heterosexual (n = 1,584; Ref) 1 1
Gay or bisexual (n = 64) 1.05 0.51, 2.17 0.79 0.38, 1.63
Marital status
Single (n = 62; Ref) 1 1
Married (n = 1,040) 0.83 0.60, 1.14 0.78 0.56, 1.07
Service branch
Army (n = 879; Ref) 1 1
Air Force (n = 191) 0.69 0.43, 1.12 0.75 0.46, 5.39
Coast Guard (n = 31) 1.78 0.55, 5.73 1.72 0.55, 5.39
Marine Corps (n = 249) 0.81 0.58, 1.22 0.67 0.44, 1.02
Navy (n = 298) 0.47 0.31, 0.71 0.44 0.27, 0.71
Service Era
Pre 9/11 (n = 997; Ref) 1 1
Post 9/11 (n = 644) 1.35 0.90, 2.03 1.25 0.83, 1.88
Rank
E1–E4 (n = 744; Ref) 1 1
E5–E7 (n = 496) 0.95 0.68, 1.33 0.93 0.66, 1.31
E8–E9 or W1–W5 (n = 112) 0.51 0.29, 0.90 2.23 1.22, 4.09
O1–O10 (n = 251) 0.53 0.33, 0.82 0.44 0.38, 1.63
Deployment
No deployment (n = 357; Ref) 1 1
Deployment (n = 1,281) 1.98 1.32, 2.96 1.67 1.11, 2.51
Adjusted R
2
.392 .442
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 120
Note. Figures in bold statistically significant at p < .05. PTSD measured using the PCL-5 with a clinical cutoff of 33
(Weathers et al., 2013). Probable depression measured using the PHQ-9 with a clinical cutoff of 10 (Kroenke et al.,
2001). OR, odds ratio; CI, confidence interval; MRST, military-related sexual trauma; MSH, military sexual
harassment; GD, gender discrimination; MSA, military sexual assault; Single, single, divorced, separated, or
widowed; Married, married, domestic partner, long-term relationship.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 121
Chapter Five: Conclusions, Future Directions, and Recommendations
The goal of this dissertation was to expand military sexual trauma, the study of military
sexual harassment (MSH) and military sexual assault (MSA) within the U.S. Department of
Defense (Kimerling, Gima, Smith, Street, & Frayne, 2007), by including multiple assessment
items of not only MSH and MSA, but highlighting the necessity to include gender discrimination
and stalking as sexual traumas. Within this dissertation MSH, gender discrimination, stalking,
and MSA are referred to as military-related sexual trauma (MRST). Assessing each MRST
individually allowed for (1) stalking to be evaluated and identified as an MRST in manuscript 1
and (2) combinations of MRST to be evaluated to better understand how they cumulatively affect
the mental health of female and male veterans. The framework for this dissertation used trauma
theory (Bloom, 1999) with the application of cumulative trauma in Manuscripts 2 and 3, as
cumulative trauma is known to indicate an increased likelihood of mental health concerns
(Turner & Lloyd, 1995). Evaluating MRST from a cumulative trauma perspective allowed for
further understanding of how combinations of MRST are experienced and associated with PTSD
and depression among female and male veterans.
Major Findings
This dissertation highlights the need for gender discrimination and stalking to be included
with MSH and MSA. Further, MRSTs should be individually assessed with more than one
screening item. This dissertation provided further information on (1) stalking, (2) combinations
of MRST, and (3) associations with PTSD and depression among female and male veterans.
Manuscript 1
As very little is known about stalking among veterans (Clancy et al., 2006; Dardis,
Amoroso, & Iverson, 2016; Dardis, Shipherd, & Iverson, 2016), findings from Manuscript 1
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 122
provide new information on types of stalking experienced while in the military, characteristics
associated with stalking, and stalking associations with mental health among female and male
veterans. As the previous literature on female veterans has focused on lifetime stalking when a
form of intimate partner violence (IPV; Dardis, Amoroso, et al., 2016), this study adds to the
literature by highlighting stalking experiences (regardless of IPV) while in the military. By
identifying characteristics of those who experienced stalking the findings support sexual
minority female veterans are more likely to experience stalking than heterosexual female
veterans (Dardis, Shipherd, et al., 2016), but add that sexual minority female veterans were also
significantly more likely to experience stalking than sexual minority male veterans. Previous
literature has not highlighted what type of stalking has been experienced by male veterans or
associations with mental health (Clancy et al., 2006), and the current findings provide more
detailed information about types of stalking, characteristics of men who experienced stalking,
and associations with mental health. For stalking in the military to be addressed, we must first
know that it exists and how it is happening. Now that (1) types of stalking are known and (2)
stalking has been found to negatively affect the mental health of female and male veterans, it
should be included in clinical assessments and future research with MSH, gender discrimination,
and MSA.
Manuscript 2
Findings from Manuscript 2 expand on lessons from Manuscript 1, indicating how
stalking is experienced in combination with MSH, gender discrimination, and MSA among
female veterans. Due to its more complete assessment of MRST experiences, the current study
captured higher overall reported rates of MSH and gender discrimination than previously
reported (Street, Gradus, Stafford, & Kelly, 2007). In contrast to the current literature (Street,
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 123
Stafford, Mahan, & Hendricks, 2008), current findings indicate that the presence of MSH and
gender discrimination did not affect mental health among female veterans. In addition, female
veterans were more likely to experience more than one MRST during their military service. As
previous literature tends to focus on one MRST, such as stalking (Dardis, Shipherd, et al., 2016)
or MSA (Schuyler, Kintzle, Lucas, Moore, & Castro, 2016), this study highlights female
veterans who experienced stalking or MSA were also highly likely to have experienced MSH
and gender discrimination (cumulative trauma). These findings support the need to individually
assess for MSH, gender discrimination, stalking, and MSA to correctly identify sexual traumas,
cumulative trauma, and provide appropriate treatment among female veterans.
Manuscript 3
Findings from Manuscript 3 echo many of the key findings in Manuscript 2, but with
respect to MRST experiences and associations with mental health among male veterans. The
inclusion of the four MRST experiences again allowed for a more nuanced identification of
varying MRST experiences. For example, male veterans reported higher rates of MSH and MSA
than previously reported (Schuyler et al., 2016; Street, Gradus, Giasson, Vogt, & Resick, 2013).
Once MRSTs were individually assessed they were then combined to examine singular MRST
(experienced only one MRST), combinations of MRST, and associations with mental health. For
example, this study found the singular MRST of experiencing only MSH (and no other MRST)
was not significantly associated with PTSD or depression. However, similar to Manuscript 1, the
singular MRST of experiencing only stalking had negative mental health outcomes. These
findings exemplify why it is important to combine MRSTs to highlight associations with mental
health.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 124
In contrast to female veterans in Manuscript 2, male veterans who experienced both MSH
and gender discrimination were found to have negative mental health outcomes. It is possible the
experiences of MSH and gender discrimination had negative mental health outcomes for male
veterans (and not female veterans) as the MSH and gender discrimination were experienced in a
hyper-masculine environment that places emphasis on masculine ideals and dominance (Castro,
Kintzle, Schuyler, Lucas, & Warren, 2015). It is possible that the experiences of MSH and
gender discrimination were in direct contrast to this emphasis and has had a lasting negative
affect on male veterans. In a separate finding, evaluating stalking in combination with MSH,
gender discrimination, and MSA resulted in higher odds of both probable PTSD and depression
than stalking evaluated not in combination with other MRSTs as in Manuscript 1. Finally,
expanding what is known about MSA, by combining it with MSH, gender discrimination, and
stalking, showed male veterans who experienced MSA (1) were likely to have experienced
MSH, gender discrimination, and stalking (i.e. cumulative trauma) and (2) had higher odds of
PTSD and depression than previously found in the literature (Schuyler et al., 2016). Unless
MRST experiences are individually assessed and then evaluated in combination, we are not able
to clearly define which MRSTs are affecting the mental health of male veterans.
Limitations and Future Research
Limitations of these studies include possible response bias due to self-selection into the
study. Because the participants in these studies were from two larger cities (Chicago and San
Francisco), responses are not generalizable to veterans who may be more isolated or in smaller
communities. Additionally, the overall sample size of female veterans did not allow for testing of
other combinations of MRST categories. This same approach applied to a larger sample of
female veterans may yield more combinations of MRST experiences that may explicate more
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 125
combinations of MRST experiences and their impact on mental health in this population. These
studies also used a nonclinical sample, highlighting the characteristics of veterans who are not
necessarily actively seeking help and thus, potentially providing more generalizable findings.
Future research should continue to draw from communities of veterans to provide findings that
are not driven by a help-seeking population.
Implications and Recommendations
Findings from this dissertation indicate critical approaches to fully assessing veterans
who have experienced MRST. They exemplify that female and male veterans who experience
one MRST experience tend to experience other types of MRST. As such, while fully assessing
for more MRSTs in clinical settings may be seen as time consuming, at a minimum, it is highly
recommended that when a veteran indicates any type of MRST all other MRSTs be individually
assessed. Also, while experiencing both MSH and gender discrimination were found to not
negatively affect the mental health among female veterans it is important to continue to assess
for these MRSTs among female and male veterans for three reasons. First, female veterans who
experienced stalking or MSA also experienced MSH and gender discrimination and due to the
cumulative trauma had higher odds of probable PTSD and depression than found in Manuscript 1
on stalking and a previous study on MSA (Schuyler et al., 2016). Second, male veterans who
experienced MSH and gender discrimination did have significant negative outcomes for mental
health. Third, a universal screening for female and male veterans would be most useful and
therefore, should assess for known indicators of PTSD and depression among female and male
veterans. Finally, as these studies set the foundation for evaluating combinations of MRST
experiences, to further delineate the negative mental health outcomes future studies should focus
MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 126
on how the co-morbidity of PTSD and depression (Campbell et al., 2007) is present for those
who experienced MSH, gender discrimination, stalking, and MSA.
Although this dissertation focused on veterans, it explored MRST experienced while in
the military. With added knowledge of MRSTs occurring during military service, it would be
beneficial to further assess MRSTs not only among veterans, but also among active-duty service
members, reservists, and guardsmen. Furthermore, it is likely that current military personnel are
also experiencing more than one type of MRST. Therefore, similar approaches to assessing
MRST and evaluating MRST associations with mental health should be conducted in female and
male active-duty, reserve, and guard populations.

MRST AMONG VETERANS AND ASSOCIATIONS WITH MENTAL HEALTH 127
References
Bloom, S. L. (1999). Trauma theory abbreviated. Retrieved from
http://www.dhs.vic.gov.au/__data/assets/pdf_file/0005/587966/trauma_theory_abbreviate
d_sandra_bloom.pdf
Campbell, D. G., Felker, B. L., Liu, C., Yano, E. M., Kirchner, J. E., Chan, D., Rubenstein, L.
V., & Chaney, E. F. (2007). Prevalence of depression-PTSD comorbidity: Implications
for clinical practice guidelines and primary care-based interventions. Journal of General
Internal Medicine, 22(6), 711-718. doi:10.1007/s11606-006-0101-4
Castro, C. A., Kintzle, S., Schuyler, A. C., Lucas, C. L., & Warner, C. H. (2015). Sexual assault
in the military. Current Psychiatry Reports, 17(54), 1-13.
doi:10.1007/s11920-015-0596-7
Clancy, C. P., Graybeal, A., Tompson, W. P., Badgett, K. S., Feldman, M. E., Calhoun, P. S., …
Beckham, J. C. (2006). Lifetime trauma exposure in veterans with military-related
posttraumatic stress disorder: Association with current symptomatology. Journal of
Clinical Psychiatry, 67, 1346–1353. doi:10.4088/JCP.v67n0904
Dardis, C. M., Amoroso, T., & Iverson, K. M. (2016). Intimate partner stalking: Contributions to
PTSD symptomatology among a national sample of women veterans. Psychological
Trauma: Theory, Research, Practice, and Policy. Advance online publication.
doi:10.1037/tra0000171
Dardis, C. M., Shipherd, J. C., & Iverson, K. M. (2016). Intimate partner violence among women
veterans by sexual orientation. Women & Health. Advanced online publication.
doi:10.1080/03630242.2016.1202884
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Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. (2007). The Veterans Health
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Schuyler, A. C., Kintzle, S., Lucas, C. L., Moore, H., & Castro, C. A. (2016). Military sexual
assault (MSA) among veterans in Southern California: Associations with physical health,
psychological health, and risk behaviors. Traumatology. Advanced online publication.
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Asset Metadata

Creator Lucas, Carrie L. (author)

Core Title An examination of sexual harassment, gender discrimination, stalking, and sexual assault among female and male veterans and associations with PTSD and depression

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 07/21/2017

Defense Date 06/07/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Depression,military-related sexual trauma,OAI-PMH Harvest,PTSD,veterans

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Castro, Carl A. (committee chair), Cederbaum, Julie A. (committee member), John, Richard S. (committee member)

Creator Email careleigh38@yahoo.com,carriell@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-409446

Unique identifier UC11264522

Identifier etd-LucasCarri-5585.pdf (filename),usctheses-c40-409446 (legacy record id)

Legacy Identifier etd-LucasCarri-5585.pdf

Dmrecord 409446

Document Type Dissertation

Rights Lucas, Carrie L.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

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