Posttraumatic Stress Disorder Symptoms and Gynecological-Related Distress in Trauma-Exposed Women Veterans.

As seen in Table 1 , women were, on average, 36.9 years of age; most were non-Hispanic White (62.4%). Over three-quarters (76.9%) reported sexual violence exposure. Approximately 40% met for probable PTSD based on elevated symptoms; sexual trauma survivors were overrepresented relative to non-sexual trauma survivors. Among those with available data, 68.5% endorsed MST, with 41.2% of the sample reporting experiences of both sexual harassment and assault during service. In bivariate analyses, lifetime sexual violence was linked with gynecological-related distress, but not healthcare-seeking. Specifically, sexual trauma survivors endorsed greater emotional and physical distress during pelvic exams; these women also reported greater fear of the examiner and ascribed greater importance to examiner gender. Most women had recently seen an obstetrician-gynecologist (83.2%) or received a pap smear (87.6%); this did not differ based on sexual trauma history. Total PTSD symptoms were associated with greater emotional distress (B: 0.018, 95% CI: 0.011, 0.025) and physical discomfort (B: 0.014, 95% CI: 0.007, 0.021) during gynecological care independent of lifetime history of sexual violence. Similarly, sexual trauma survivors endorsed greater emotional (B: 0.320, 95% CI: 0.149, 0.491) and physical (B: 0.276, 95% CI: 0.098, 0.455) distress during exams regardless of current trauma-related symptoms. In contrast, total PTSD symptoms—but not lifetime history of sexual trauma—was linked with greater fear (B: 0.013, 95% CI: 0.010, 0.016) during gynecological care. Interactions considering PTSD symptomatology and sexual trauma were not significant across these indicators ( Table 2 ). There was a significant interaction between PTSD symptoms and lifetime sexual violence regarding importance of examiner gender. Among those with sexual violence, the greater the PTSD symptoms, the more important the gender ( Figure 1A ); among women without this history, associations were null. Neither PTSD symptoms nor lifetime sexual violence predicted engagement in gynecological healthcare, with no significant interactions ( Table 2 ). Greater PTSD symptoms on Criterions D (B: 0.038, 95% CI 0.021, 0.054) and E (B: 0.033, 95% CI 0.021, 0.054) accounted for unique variance in emotional distress during gynecological care. Of the clusters, only Criterion D accounted for unique variance in physical discomfort (B: 0.027, 95% CI 0.011, 0.043) and in importance of examiner gender (B: 0.032, 95% CI 0.010, 0.055). Regarding fear of the examiner, Criterions D (B: 0.013, 95% CI 0.000, 0.026) and E (B: 0.024, 95% CI 0.009, 0.039) were the solely relevant clusters ( Supplemental Table 1 ). Both PTSD symptoms and MST type were linked with emotional distress during exams ( Table 3 ); relative to women without MST, women exposed to harassment only (B: 0.289, 95% CI: 0.030, 0.574) endorsed greater distress ( Figure 1B ). The association between PTSD symptoms and emotional distress during gynecological care was of a significantly greater magnitude among survivors of military-related assault (B: 0.012, 95 CI: 0.004, 0.020) than among harassment survivors and women without MST ( Supplemental Table 2 ). PTSD symptoms (B: 0.014, 95% CI: 0.008, 0.020) and MST type (harassment only, B: 0.328, 95% CI: 0.054, 0.602; assault, B: 0.323, 95% CI: 0.043, 0.578) were also linked with greater physical discomfort during pelvic exams; there were no significant interactions ( Table 3 ). While women with either MST type reported significantly greater gynecological-related physical discomfort than women without this history, analyses revealed negligible differences between the MST groups ( Supplemental Table 2 ). Regarding fear of the examiner, a significant interaction emerged ( Table 3 ; Figure 1C ). Relative to women without MST, as well as those with harassment only, women with a history of assault and reporting greater total PTSD symptoms endorsed greater fear ( Supplemental Table 2 ). There was a significant interaction between PTSD symptoms and MST regarding importance of the examiner gender ( Table 3 ). Relative to their non-MST-exposed counterparts, women with an assault history who reported greater PTSD symptom endorsed greater importance of examiner gender ( Figure 1D ). The same pattern held when comparing these women to those exposed to harassment only ( Supplemental Table 2 ). As with lifetime sexual violence, there were no significant associations with PTSD symptoms, MST, and gynecological healthcare-seeking—with one exception. Compared to women reporting harassment only MST experiences, women with assault histories were more likely to have received a recent pap smear. As seen in Supplemental Table 2 , the overall model was non-significant, and the effect size was small.

This is a secondary cross-sectional analysis of the Longitudinal Investigation of Gender, Health, and Trauma (LIGHT) study, an ongoing, mail-based survey designed to examine the impact of trauma exposure and community violence on veterans’ mental and reproductive health. Veterans ages 18–50 years were identified using the VA/DoD Identity Repository, a database of all separated servicemembers. Using this repository, 28,000 veterans were randomly selected to participate; aligned with LIGHT’s aims, women and those living in high-crime areas were oversampled. Approximately one-third of those identified had non-deliverable mailing addresses, resulting in 17,178 reachable veterans. Using a modified Dillman approach, 19 veterans were mailed an initial study invitation letter and fact sheet, LIGHT survey, opt-out postcard, and $5 pre-incentive. A total of 3,544 veterans completed the baseline survey (20.6% response rate; 50.9% women), forming the primary LIGHT sample. Veterans were paid $20 per survey, and procedures were approved by the VA Boston Healthcare System’s Institutional Review Board; see elsewhere for more. 20 For this study, the analytic sample included trauma-exposed cisgender women with complete data on lifetime sexual violence and PTSD symptoms at baseline ( n =1,185). All other data—including sociodemographic information—were also drawn from LIGHT’s baseline wave, which was collected from September 2018 to July 2019. Women completed an adapted Life Events Checklist (LEC-5), 21 which assessed exposure to traumatic events across different developmental periods. We included six checklist exposures, as consistent with DSM-5 ’s Criterion A: serious accident, violent death, captivity, community violence, sexual assault, and physical assault. On a separate measure, women reported unwanted sexual experiences and/or physical violence in an intimate relationship. 22 Women also completed the Deployment Risk and Resilience Inventory-2 (DRRI-2), 23 nine items of which captured combat-related events (e.g., exposed to incoming fire, saw civilians severely wounded or disfigured) consistent with Criterion A trauma exposure. Using the information collated across these measures, we created an indicator to denote whether women did or did not endorse lifetime sexual violence. Women who endorsed any sexual violence—including assault and/or rape by an intimate or non-intimate partner—were coded as having a lifetime history of sexual trauma, whereas women who reported exposure to non-sexual traumas only (e.g., physical assault, combat) were classified as having no sexual violence history. This indicator was then used as the moderator variable in the primary analyses examining whether associations between PTSD symptoms and gynecological-related factors depended on lifetime history of sexual trauma. Women completed the PTSD Checklist-5 (PCL-5) 24 to assess posttraumatic stress symptomatology as anchored to their self-identified worst event. Women reported how bothered they were by each of the 20 PTSD symptoms over the past month with responses rated from 0 ( not at all ) to 4 ( extremely ); responses were summed to create a total PTSD symptom severity score. Internal consistency was high (α = .969). We additionally considered PTSD as a unitary construct, with scores ≥33 considered as indicative of probable PTSD based on elevated symptoms, 25 as well as created sum scores to represent total symptomatology across DSM-5’s symptom clusters: re-experiencing (Criterion B), avoidance (Criterion C), negative cognitions/mood (Criterion D), and hyperarousal (Criterion E). Four structured-item questions assessed gynecological-related distress: “Do you experience emotional distress during pelvic exams?”; “Do you experience physical discomfort during pelvic exams?”; “Are you afraid of the examiner?”; and “How much does it matter to you if the doctor is male or female?” Responses for each question were coded on a 5-point Likert scale ranging from 1 ( not at all ) to 5 ( extremely ). These questions were developed for LIGHT by a VHA gynecologist based on her clinical experience and are similar to scales used in other research on exam-related psychological distress, 10 including among women veterans. 11 , 12 , 18 Because items captured different components of gynecological-related distress, each were treated as individual indicators in analyses. Women also reported on two binary behavioral indicators of gynecological healthcare-seeking: “Did you see an OB/GYN or gynecologist during the past three years?” and “During the past three years, have you had a Pap smear?” These two indicators were also analyzed separately. Across all gynecological-related questions, response rates varied slightly, with missingness ranging from 1.9 to 3.7%. A subsample ( n =1,159) had available data on the DRRI-2’s Sexual Harassment Scale, which is comprised of eight items assessing sexual harassment (e.g., “made crude and offensive sexual remarks directed at me, either publicly or privately”) and assault (e.g., “physically forced me to have sex”) during military service. Women indicated the frequency with which they experienced each of these on a scale from 0 ( never ) to 3 ( many times ). Because not all MST experiences fit within the definition of Criterion A trauma exposure (i.e., sexual harassment may or may not implicate direct sexual violence), we then categorized women based on their endorsed MST types, as is consistent with previous research examining differential effects of diverse MST experiences on mental health. 26 This resulted in three, mutually exclusive classifications: no MST, harassment only, or assault with or without harassment. This variable was used as the three-level moderator in analyses considering whether associations between PTSD symptoms and gynecological-related distress depended on MST exposure. Women reported their age, race/ethnicity, income, education, and military branch; there was some missing data across these variables (0.3–2.7%). First, to investigate whether strength of the associations between PTSD symptomatology and the gynecological indicators varied based on lifetime sexual violence history, we conducted six regression-based moderation models in PROCESS v4.2 for SPSS. We employed effect coding in order to allow for discussion of main effects of both PTSD symptoms and lifetime sexual violence. Second, we conducted simultaneous linear regression models to explore whether certain PTSD symptom clusters accounted for a greater proportion of variance in gynecological-related distress relative to the other clusters; analyses were agnostic to PTSD diagnosis. As these symptom clusters are known to be highly intercorrelated, we examined the variance inflation factors of models and confirmed that none exceeded 10. 27 Third, we replicated our initial six models in PROCESS with MST history, rather than lifetime sexual violence, as the moderator. Due to the three-level nature of the MST variable, we used dummy coding to test simple effects for each MST group. Age, minoritized racial and ethnic identity (operationalized as non-Hispanic White versus person of color), and income were included as covariates across models, given relevance of these sociodemographic factors to gynecological healthcare. 28 , 29 Missing data was minimal, ranging from 5.9 to 7.6% across adjusted models, and thus addressed with listwise deletion.

In this national sample of trauma-exposed women veterans, PTSD symptoms were associated with numerous indicators of adverse gynecological experiences—including emotional distress, physical discomfort, and fear of the examiner—regardless of lifetime history of sexual violence. Sexual violence was also independently linked with some, but not all, of these indicators, similar to what has been observed in prior research. 9 , 10 The fact that PTSD symptoms operated over and above lifetime history of sexual violence and, in some cases, was more relevant than this exposure suggests that the mental health consequences of trauma likely compound gynecological-related distress. De-composing PTSD into its symptom clusters revealed that Criterions D and E were of particular importance, with Criterion D as the most consistently relevant. Greater Criterion D symptomatology—reflecting habitual negative mood and thinking patterns following trauma—captured unique variance in all distress indicators, and Criterion E symptoms—comprised of fear-based physiological symptoms, such as hypervigilance—was relevant to emotional distress and fear. Considering MST, rather than lifetime history of sexual violence, revealed a slightly different pattern of findings, with this form of sexual trauma frequently interacting with posttraumatic stress to contribute to gynecological-related distress. Prior research has focused on PTSD and gynecological-related factors in sexual violence survivors only, 11 , 12 even though PTSD symptoms can onset following any traumatic event. We extend this by examining PTSD dimensionally—both as a total symptom severity score and across its symptom clusters—in survivors of both sexual and non-sexual trauma. The fact that we observed main effects of PTSD symptoms over and above sexual violence history suggests that trauma-related symptoms—rather than the precipitating traumatic event itself—may be more a more proximal and relevant indicator with regards to gynecological-related distress. Moreover, only one other study, conducted using DSM-IV-TR ’s three PTSD symptom clusters, has examined PTSD symptom clusters and gynecological-related distress, and findings in that sample of sexual trauma survivors converged on hyperarousal. 18 Here, we found both hyperarousal and negative cognitions and mood to be of particular relevance. The specificity of these clusters suggests that pelvic exams may represent an over-generalized perception of threat that is uncircumscribed to prior sexual trauma. Further, the lack of observed significance of re-experiencing symptoms—which has remained largely unchanged through different DSM iterations and is typically distinct to the index event—further support that gynecological-related distress does not appear to be exclusive to a particular trauma type. Importantly, effect sizes were small, and results are exploratory. No other research has examined the role of MST—a common, often traumatic experience among women veterans—in psychosocial experiences of gynecological care. We found evidence that this military-specific trauma type functioned slightly differently than did lifetime sexual violence. Specifically, associations between PTSD symptoms and emotional distress during gynecological care depended on MST type, with assault-exposed women as particularly impacted. However, as was the case with lifetime sexual violence, MST-exposed women who experienced assault and reported greater PTSD symptoms also endorsed greater importance of examiner gender. Minor observed differences across lifetime and military-specific sexual trauma may be due, in part, to the fact that MST involves institutional betrayal, in addition to the interpersonal betrayal implicit in all forms of sexual trauma. As medical providers represent larger institutions, MST survivors may be at particular risk for experiencing distress in healthcare settings, especially during vulnerable and sensitive procedures such as pelvic exams. In our study, neither sexual violence—occurring across the lifespan or during military service, specifically—nor PTSD symptoms negatively impacted receipt of gynecological care, which is consistent with prior work. 30 , 31 Indeed, most women in this trauma-exposed sample had received a pap smear within the past three years, as aligned with national guidelines for cervical cancer screening for reproductive-aged individuals. 28 While encouraging that PTSD is not related to avoidance of important preventative healthcare, there was still significant distress associated with receiving such care among the trauma survivors in this study. Thus, routine screening for posttraumatic stress symptoms may be clinically indicated in medical settings. The Primary Care PTSD Screen is a short, validated screener 32 that may be used to identify individuals who may experience more gynecological-related distress. Once identified, these women could be directed to or offered specific, trauma-informed interventions (e.g., self-insertion of the speculum, choosing gender of examiner) during their gynecological visits. 33 Further, attending to Criterion D and E symptoms may be particularly pertinent foci, and clinicians in gynecological care settings could consider brief interventions that may target these. For example, gynecologists could consider leading women through relaxation strategies prior to an exam, and open discussions of women’s fears and beliefs about gynecological care may also reduce arousal and distress. This study is characterized by several strengths. We utilize a large, national sample of veterans, unlike prior research that has relied on small, clinical or convenience samples of VHA users; as such, we minimize some of the selection bias inherent in studying individuals already engaging with the healthcare system and increase generalizability to a broader array of veterans. This is particularly important given evidence that women veterans are more likely to engage with non-VHA providers for healthcare than are their men counterparts. 34 Our assessments capture lifetime exposure to a wide range of traumatic events, which enabled us to examine trauma-exposed women with and without a history of sexual violence; we also assess PTSD as agnostic to diagnostic status. These methods increase our confidence in the role of PTSD symptoms in gynecological-related distress above and beyond specific trauma exposures. Despite these strengths, there are also important methodological limitations. The cross-sectional design precludes determinations of both temporality and causality, particularly given that gynecological healthcare-seeking variables assessed behaviors from the prior three years. Additionally, the gynecological-related distress measures were from a non-validated questionnaire that was created for this study, thereby limiting utilization of potentially more advanced analytic approaches; however, this structured-item questionnaire is similar to what has been used in prior research on psychosocial experiences of gynecological care, 11 , 12 , 18 and no standardized measures of this construct yet exist. 10 It is also important to note LIGHT’s relatively low response rate (20.6%), though this is consistent with rates in other epidemiological surveys of veterans (which approximate 20–30%), 35 who constitute an understudied population that faces unique barriers in recruitment and retention in mail-based surveys (e.g., geographic mobility). Finally, as LIGHT was not designed specifically to examine gynecological-related health, we are limited by available data. We do not know the specific reasons why women may have been pursuing gynecological services, nor do we know whether or not they had gynecological conditions characterized by vulvovaginal pain and sensitivity (e.g., provoked vulvodynia, endometriosis)—the presence of which may interact with PTSD symptoms to influence gynecological-related distress and experiences. Future research should aim to include more comprehensive assessments of women’s gynecological health in order to account for potential confounders or moderators of these associations. Such work could also be conducted in civilian samples, as extant research on traumatic stress and gynecological-related distress has primarily focused on veterans—potentially due to higher rates of PTSD in this subgroup. Future research could also adopt a longitudinal design and consider mechanisms by which trauma exposure and PTSD symptomatology precipitates distress during gynecological care. In sum, PTSD symptomatology—which can develop following any trauma exposure—may be an important clinical target in ameliorating distress during gynecological healthcare among women veterans, and symptoms related to negative cognitions and mood and hyperarousal may be particularly relevant. In contrast to non-military-specific sexual violence, MST, particularly assault, may especially compound the effects of PTSD on gynecological-related distress in this population. Findings emphasize attending to potential gynecological-related distress among all trauma-exposed women, particularly those exhibiting PTSD symptoms, and support the need for trauma-informed reproductive healthcare.

Sexual violence—referring to unwanted sexual contact, including but not limited to assault and/or rape—is common among, and disproportionately affects, women veterans. 1 , 2 The gynecological sequalae of sexual trauma can be wide-ranging, including consequences such as increased risk for cervical cancer, 3 , 4 adverse obstetric outcomes, 5 and pelvic floor dysfunction. 6 Experiencing sexual violence is also associated with psychological sequalae; this trauma type is a particularly potent predictor of posttraumatic stress disorder (PTSD), 7 the sentinel stress-related psychopathology and a diagnosis overrepresented among women veterans. 8 Recently, two systematic reviews identified that sexual violence history is also linked with elevated distress during gynecological exams in both veteran and civilian women 9 , 10 —an association which may contribute to delayed healthcare-seeking and adverse reproductive health. Sexual violence survivors may be particularly vulnerable to adverse experiences during gynecological healthcare. Indeed, these visits frequently involve genital examinations, which may evoke reminders of and parallel prior sexually traumatic experiences. Not surprisingly, most research examining psychological distress during gynecological healthcare has focused on survivors of sexual violence, 9 , 10 thereby limiting our understanding of how other trauma-exposed individuals experience reproductive healthcare. However, research considering PTSD in women veterans with histories of sexual violence has found this psychopathology to account for gynecological-related distress above and beyond sexual trauma exposure, 11 , 12 suggesting a primary role of posttraumatic stress. In contrast, another small study in women veterans with sexual violence histories supported no association between PTSD and gynecological-related anxiety, 13 with the authors instead attributing observed distress to the sexual trauma experiences. Discrepancies regarding the importance of PTSD are likely due, in part, to methodological limitations across studies, including sole reliance on small convenience cohorts ( Ns range = 31–49) recruited from the Veterans Health Administration (VHA) 11 – 13 and a lack of appropriate comparison groups (e.g., sampling trauma-exposed women without a history of sexual violence). Consequently, less is known about PTSD and gynecological-related factors in survivors of non-sexual trauma. As PTSD can develop following any Criterion A traumatic event, PTSD symptoms—versus sexual trauma exposure in and of itself—may be a more proximal target that contributes to gynecological healthcare experiences. Current Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ) criteria consider PTSD according to four symptom clusters: re-experiencing (e.g., intrusive trauma-related thoughts and memories), avoidance (e.g., avoiding internal and external trauma-related reminders), negative cognitions and mood (e.g., chronic negative emotions, self-blame), and hyperarousal (e.g., hypervigilance, sleep and concentration problems), with a select number of symptoms of certain frequency and intensity required for diagnosis. 14 However, PTSD is highly clinically heterogenous, 15 , 16 and subthreshold presentations are also linked with distress and impairment. 17 Moreover, research has demonstrated differential associations between specific PTSD symptoms and health indicators, including in one study of women veterans, where hyperarousal symptoms were particularly relevant to gynecological-related distress. 18 Notably, this sample was restricted to sexual violence survivors. In this study, we examined whether associations between PTSD symptoms and gynecological-related distress and healthcare-seeking depended on whether trauma-exposed women veterans endorsed lifetime sexual violence. Specifically, we were interested in whether PTSD symptoms in survivors of non-sexual trauma (e.g., combat, physical assault) would be linked with these gynecological-related factors at similar magnitudes as compared to trauma-exposed women with sexual trauma histories. To address this, we leveraged data from a national sample of trauma-exposed women veterans engaged in a longitudinal survey study. We hypothesized that women with a history of sexual violence would exhibit greater distress during gynecological healthcare and be more likely to delay gynecological visits relative to trauma-exposed women without sexual trauma. For exploratory purposes, we also investigated whether certain PTSD symptoms—operationalized according to DSM-5 ’s symptom clusters—particularly accounted for gynecological-related distress. Finally, given the population, we considered whether military sexual trauma (MST)—defined as sexual harassment or assault experienced during service—functioned similarly as lifetime sexual violence in the PTSD symptoms—gynecological-related factors link.