Sexual assault in the military and its impact on sexual satisfaction in women veterans: a proposed model.

Aims Sexual assault in the military (SAIM) is associated with decreased sexual satisfaction. However, mediators of this association have not been fully described.

Using a retrospective analysis of cross-sectional data collected for the national Veterans Affairs (VA) Women's Health Survey, we propose a mediator model to explain the association between SAIM and decreased sexual satisfaction among women veterans. Four mediators of the association between SAIM and decreased sexual satisfaction are tested: (1) emotional health-related quality of life, (2) physical health-related quality of life, (3) lack of a close partner, and (4) gynecological illness. These mediators were chosen to encompass independent domains potentially relevant to sexual satisfaction, including emotional, physical, and relational.

Of 3161 women (87%) who answered the sexual satisfaction question, the mean age was 45 (SD 15) years; 85% were white. Twenty-four percent reported a history of SAIM, and 39% reported sexual dissatisfaction. In age-adjusted logistic regression analyses, both SAIM and sexual dissatisfaction were strongly associated with each of the proposed mediators. However, of the four mediators, emotional health-related quality of life most strongly attenuated the association between SAIM and sexual dissatisfaction. After including all mediators, the association between SAIM and decreased sexual satisfaction was markedly attenuated.

SAIM's negative impact on sexual satisfaction in women veterans operates both directly and through its physical and mental health sequelae. Of the proposed mediators in this association, the most prominent is mental health-related quality of life; the other proposed mediators were minimally related.

Sexual satisfaction is a complex construct that incorporates multiple domains, including physical and emotional satisfaction with sexual activity and satisfaction with sexual interpersonal relationships.1–5 Sexual satisfaction is defined as “an affective response arising from one's subjective evaluation of the positive and negative dimensions associated with one's sexual relationship”6 but may incorporate both partnered sexual activity and self-stimulation.2 Although sexual satisfaction is increasingly acknowledged as an important domain of health-related quality of life7 and emotional and relational health,8 the correlates of sexual satisfaction are not well described.2 Women veterans report high rates of decreased sexual satisfaction.9,10 This may be due to the disproportionate burden of risk factors for sexual dissatisfaction found among women veterans. A history of sexual assault in the military (SAIM) is unique to women veterans and highly associated with decreased sexual satisfaction.10 SAIM may be more traumatizing than other forms of sexual violence because of assault by a close or trusted colleague, use of a weapon, or perception of inadequate response by the judicial system.11 More than half of the women who report a history of SAIM were not satisfied with their sex life, compared with 34% of women who did not report a history of SAIM.10 Sexual trauma may predispose to decreased sexual satisfaction through interference with several domains of sexual satisfaction, including emotional satisfaction, physical sexual function, including gynecological functioning, and relational and interpersonal satisfaction. SAIM is highly associated with adverse mental health consequences.12,13 Sexual assault is associated with posttraumatic stress disorder (PTSD) at higher rates than are found in victims of other types of physical violence,14,15 and military sexual trauma more strongly predicts the development of PTSD than other types of trauma.16–18 Mental health disorders are highly associated with decreased sexual functioning,11,12,19–22 which may reciprocally lower satisfaction with emotional elements of sexual life. Medical sequelae of sexual trauma include physical injuries, a greater burden of chronic somatic complaints,11,23 and decreased overall health-related quality of life.23 Increased physical illness24,25 and decreased health-related quality of life26 are likewise associated with sexual dysfunction. Satisfaction with physical aspects of sexuality may be compromised by physical illness and overall decreased health-related quality of life, which can result from sexual trauma. An extensive literature describes the adverse impact of sexual assault on gynecological and reproductive functioning. Chronic gynecological complaints are common among rape survivors,27,28 many of whom suffer vaginal and perineal tears and the late sequelae of sexually transmitted diseases (STDs).23 Sequelae of rape that may directly affect sexual satisfaction include lack of pleasure with a sexual encounter and dyspareunia.27–29 Other medically unexplained gynecological complaints that are strongly associated with sexual assault history include unexplained menstrual irregularity,27 dysmenorrhea,27 and increased hysterectomy.30 The role of medically unexplained gynecological symptoms as a potential mediator for sexual dissatisfaction has not been established. Traumatic experiences adversely affect interpersonal relations among trauma survivors,31,32 including disruption in the ability to form close partnerships. Relational factors, such as intimacy,4 marital stability and quality,33 marital satisfaction,1 and satisfaction with nonsexual aspects of a relationship,1 are associated with sexual satisfaction. Thus, trauma may mediate decreased sexual satisfaction through its effect on the relational domain of sexual satisfaction. Prior work has linked decreased emotional health, decreased physical health, including gynecological function, and disrupted interpersonal relations to both sexual trauma and sexual dissatisfaction. However, these factors have never previously been assessed for their potential mediation of the association between sexual trauma and sexual dissatisfaction. In this study, we develop and test a conceptual model to describe the association of SAIM and sexual dissatisfaction through four proposed mediators: (1) lower emotional health-related quality of life, (2) lower physical health-related quality of life, (3) gynecological problems, and (4) disruption in interpersonal relationships as measured by lack of a close partner. We use the data of Skinner et al.9–12 to examine the hypothesis that these physical and psychosocial correlates of sexual trauma mediate the association between SAIM and decreased sexual satisfaction among women veterans.

Subjects We used data from the Veterans Affairs (VA) Womens' Health Project, a cross-sectional, national survey of 3632 women veterans11 that was designed to characterize the health-related quality of life of women who use VA ambulatory services. The design of this study has been described in detail elsewhere.9 Briefly, a randomly selected subset of all women veterans who had at least one outpatient VA visit between July 1, 1994, and June 30, 1995, was identified. Eligible subjects were mailed a self-administered questionnaire and returned it in a postage-paid envelope. Dependent variable Sexual satisfaction was measured using a single, face-valid, item asking: Overall how satisfied are you with your sex life? 1, very dissatisfied; 2, dissatisfied; 3, satisfied; 4, very satisfied. Responses were dichotomized into satisfied (answer 3 or 4) vs. dissatisfied (1 or 2), as described in other studies.2,7,34 The sexual satisfaction construct is deliberately broad to measure the emotional, physical, gynecological, and relational domains relevant to sexual satisfaction. Use of a single, face-valid item to measure overall sexual satisfaction has been correlated in other studies to domains of functional sexuality, including sexual interest and number of daily sexual thoughts,34 and relational and emotional factors, including family affection and partner initiation and communication.2 Independent variable Self-reported SAIM was measured by an affirmative response to the question: Did you ever have an experience where someone used force or the threat of force to have sexual relations with you against your will while you were in the military?11,12 This definition conforms to the U.S. Merit System Protection Board guidelines.12 Mediator variables We defined four potential mediators of the association between SAIM and sexual satisfaction: emotional health-related quality of life, physical health-related quality of life, gynecological illness, and absence of a close partner. Emotional health-related quality of life was measured with the mental health composite score (MCS), and physical health-related quality of life was measured with the physical health composite score (PCS) of the Short Form (SF)-36. The SF-36 is composed of eight subscales that aggregate to two higher-order clusters. Vitality, social functioning, role limitations due to emotional health, and mental health aggregate to the MCS. Physical functioning, role limitations due to physical functioning, bodily pain, and general health aggregate to the PCS. Reliability statistics for these measures exceed 80%, and validity has been established by comparison of these measures to other accepted clinical indicators for multiple disease states.35–37 In these measures, scores range from 0 to 100, with a higher score indicating a more favorable health state. Gynecological illness was a composite variable created by endorsing at least one of the following gynecological conditions: current endometriosis; vaginitis or yeast infections; abnormal, heavy, or irregular periods; chronic pelvic pain or painful periods; or a history of problems getting pregnant, hysterectomy, or abnormal Pap smears. In the construction of the composite gynecological variable, we first independently associated each age-adjusted element of the composite gynecological variable with sexual trauma and then did the same for sexual satisfaction. Each element of this composite variable was significantly (p < 0.05) and independently associated with both sexual satisfaction and sexual trauma. All the associations were in the expected direction (greater gynecological complaints among subjects endorsing sexual satisfaction and sexual trauma, respectively), suggesting each could logically be placed in the mediator pathway. Close partner was created from two survey line items. Subjects endorsed that they had a spouse or partner and subsequently that this spouse or partner was someone they “feel very close and intimate with.” This definition was chosen because these two face-valid questions incorporate necessary elements of a published definition of a close interpersonal relationship, defined as “repeated interactions over time characterized by enduring bonds, emotional attachment, personal need fulfillment and irreplaceability.”38 Covariates Covariates included self-reported age, educational status, household income, and smoking. Alcohol abuse was defined by a score of three or more on a validated five-item screening test.12 Statistical methods We compared demographic variables between sexually satisfied and dissatisfied women. We used t tests to compare continuous variables and chi-square to compare frequencies between categorical variables. An alpha ≤0.05 determined significance for all statistics. To assess the clinical significance of statistical differences, we calculated an effect size measure. The effect size is a proportion of a standard deviation (SD), defined as the absolute value of the difference between the mean scores of the satisfied vs. dissatisfied women, divided by the SD of the reference group (satisfied).39 Using previously published guidelines, an effect size of 0.20–0.40 is considered small, 0.50–0.79 is moderate, and ≥0.80 is large.40 We used logistic regression to separately model the association between each of the four proposed mediators and the exposure (SAIM), adjusting for age. We similarly modeled the association between each proposed mediator and the outcome (sexual satisfaction), adjusting for age. Lack of an independent association of any proposed mediator with either the exposure or outcome would suggest that the proposed mediator is incorrectly identified as a mediator. After determining that each of the mediators was independently associated with both SAIM and sexual satisfaction, we used a nested approach to test the proposed mediation model, fitting a sequence of logistic regression models. In nested modeling, each successive model includes significant or prespecified predictors from the previous model and adds potential predictors from the next domain. We first tested an unadjusted odds ratio (OR) for decreased sexual satisfaction, given SAIM (model 1). Next (model 2), we tested and retained all demographic and health-related variables that changed this unadjusted effect estimate by ≥10%. Next we tested four models, one for each proposed mediator. If a potential mediator reduced or eliminated the effect of SAIM on sexual satisfaction, this was consistent with our hypothesis and retained in our mediator model. If a potential mediator was either not statistically significantly associated or did not alter the effect estimate of SAIM on sexual satisfaction by at least 10% or more, it was inconsistent with our model. In our third model (model 3), we created a fully adjusted model, retaining all proposed mediators and demographic and health-related variables that were statistically significant or changed the unadjusted effect estimate by ≥10%. All statistical analyses were run using SAS version 9.1 (SAS Institute, Cary, NC).

As has been reported previously, 3632 women completed questionnaires, a 58.4% response rate.11 Of these, 3181 women met inclusion criteria for our analyses, of whom 24% endorsed a history of SAIM.11 In unadjusted analyses (Table 1), respondents who reported dissatisfaction were more likely than those who reported satisfaction to be older, unmarried, more educated, and of lower household income. Respondents who reported dissatisfaction were more likely to endorse more smoking and alcohol abuse. Table 1. | | % sexually satisfieda | % sexually dissatisfieda | |---|---|---| | Variables | n = 1937 (61.3%) | n = 1244 (37.8%) | | Sexual assault in the military*** | 18 | 33 | | Demographics | || | Age, years, mean (SD)*** | 46 (16) | 43 (13) | | Marital status*** | || | Married/partnered | 45 | 33 | | Divorced/separated | 29 | 39 | | Widowed | 8 | 6 | | Never married | 19 | 21 | | Race (p = 0.11) | || | Black | 19 | 21 | | White | 75 | 72 | | Other | 6 | 7 | | Education* | || | 1–12 years | 28 | 24 | | 13+ years | 73 | 76 | | Household income** | || | <$20,000 | 40 | 44 | | $20,000 – $49,999 | 42 | 42 | | $50,000+ | 13 | 9 | | Unknown | 5 | 5 | | Health Behaviors | || | Smoking*** | || | Never | 38 | 34 | | Former | 31 | 26 | | Current | 31 | 40 | | Alcohol abuse*** | 7 | 12 | | Proposed Mediators | || | SF-36 mental health composite score (0–100), mean (SD)*** | 44.1 (12.4) | 35.1 (12.0) | | SF-36 physical health composite score (0–100), mean (SD)*** | 39.0 (12.6) | 37.0 (11.7) | | Any gynecological problem*** | 76 | 86 | | No close partner*** | 25 | 46 | Percentages may not add up to 100% because of rounding error. p < 0.001; **p < 0.01; *p < 0.05. All proposed mediators were associated with sexual dissatisfaction. The mean mental health composite score among the sexually satisfied was 44, compared with 35 among the sexually dissatisfied. The effect size for emotional health-related quality of life on sexual satisfaction was 0.73, representing a moderate clinical difference. The mean physical health composite score among the sexually satisfied was 39, compared with 37 among the sexually dissatisfied. This effect size was 0.16, a clinically inconsequential effect. A high proportion of our sample endorsed any gynecological problem. However, this was more frequent among the sexually dissatisfied (86%) than the satisfied (76%). The proportion of respondents endorsing no close partner was greater among the sexually dissatisfied (46%) versus the satisfied (25%). In Table 2, each of the proposed mediators was significantly associated with both the exposure to SAIM and the outcome of sexual dissatisfaction (all p < 0.001), and each of the associations was in the expected direction. Thus, each of the proposed mediators independently met criteria for inclusion in our adjusted final model describing the association between SAIM and sexual satisfaction. Table 2. | | Age-adjusted OR* (95% CI) | | |---|---|---| | Proposed mediator | SAIM | Sexual dissatisfaction | | SF-36 mental health composite score (per 1 SD decrease) | 1.69 (1.54, 1.85) | 2.08 (1.92, 2.27) | | SF-36 physical health composite score (per 1 SD decrease) | 1.28 (1.18, 1.41) | 1.23 (1.14, 1.33) | | Any gynecological problem | 1.98 (1.57, 2.51) | 1.77 (1.45, 2.15) | | No close partner | 1.40 (1.16, 1.68) | 2.87 (2.42, 3.41) | All p < 0.001. Table 3 shows the results of our nested logistic regression analyses to determine the association of our proposed mediators between SAIM and decreased sexual satisfaction. In model 1 (unadjusted), we found that SAIM was associated with 2.3 greater odds of decreased sexual satisfaction. After adjusting for demographics, including age, marital status, race, education, income, and the health behaviors of smoking and alcohol abuse (shown in model 2), we found modest attenuation of the association of SAIM and sexual dissatisfaction, with SAIM conferring 1.8 greater odds of decreased sexual satisfaction. Table 3. | OR* | 95% CI | | |---|---|---| | Model 1: Unadjusted | 2.26 | 1.91, 2.68 | | Model 2: Demographics and health behaviors | 1.78 | 1.42, 2.23 | | Model 2 plus SF-36 mental health composite score | 1.42 | 1.11, 1.83 | | Model 2 plus SF-36 physical health composite score | 1.76 | 1.39, 2.24 | | Model 2 plus any gynecological problem | 1.72 | 1.37, 2.16 | | Model 2 plus no close partner | 1.70 | 1.35, 2.14 | | Model 3: Model 2 plus all 4 proposed mediators | 1.32 | 1.02, 1.72 | All p < 0.05. We then created four models, adding each proposed mediator independently. Addition of the mental health composite score produced the most marked reduction in the association between SAIM and sexual dissatisfaction, reducing the OR from 1.78 to 1.42. This is a 20% change in the overall effect estimate, suggesting that emotional health-related quality of life is a substantial mediator of this association. A substantially smaller effect was found with the other proposed mediators. The addition of physical component scale to model 2 resulted in a small (1%) reduction in the increased odds of sexual dissatisfaction relative to the increased odds of sexual dissatisfaction associated with model 2 (1.78 to 1.76). Endorsing any gynecological problem decreased the OR of sexual dissatisfaction from 1.78 to 1.72, a minimal change of 3% in the effect estimate. Addition of the close partner variable also attenuated the association between SAIM and sexual dissatisfaction, reducing the OR from 1.78 to 1.70, a 4% change in the overall adjusted effect estimate. Table 4 shows the final adjusted model, with independent factors associated with sexual dissatisfaction. After controlling for demographics, health behaviors, and the proposed mediators, SAIM remained modestly associated with sexual dissatisfaction (OR 1.32, 95% CI 1.02, 1.72). The increased odds of sexual dissatisfaction associated with SAIM in the fully adjusted model dropped from 1.78 to 1.32, reflecting a clinically important 26% reduction in the effect estimate. Of note, age, marital status, race, and family income were not significantly associated with sexual satisfaction. Participants who reported lower educational attainment were less likely to report sexual dissatisfaction. Neither adverse health behavior of smoking or alcohol abuse was significantly associated with sexual dissatisfaction. Table 4. | Variable | aOR | 95% | CI | |---|---|---|---| | SAIM** | 1.32 | 1.02 | 1.72 | | Age (per 1 year increase) | 1.00 | 0.99 | 1.01 | | Marital status | ||| | Divorced | 1.07 | 0.79 | 1.45 | | Never married | 1.22 | 0.88 | 1.68 | | Widowed | 0.97 | 0.54 | 1.73 | | Married | Ref. | — | — | | Race | ||| | Black | 1.00 | 0.75 | 1.34 | | Other | 0.88 | 0.55 | 1.40 | | White | Ref. | — | — | | Education** | ||| | Less than high school | 0.24 | 0.06 | 0.95 | | High school only | 0.59 | 0.38 | 0.92 | | Some college | 0.84 | 0.57 | 1.24 | | Completed college | Ref. | — | — | | Income | ||| | <$20,000 | 1.05 | 0.70 | 1.57 | | $20,000 – $49,999 | 1.16 | 0.80 | 1.69 | | Don't Know | 0.79 | 0.42 | 1.48 | | $50,000+ | Ref. | — | — | | Smoking | ||| | Current | 0.91 | 0.70 | 1.20 | | Former | 0.94 | 0.96 | 1.26 | | Never | Ref. | — | — | | Alcohol abuse | 1.42 | 0.95 | 2.12 | | Proposed Mediators | ||| | SF-36 mental health composite score (per 1 SDa decrease)** | 1.91 | 2.17 | 1.68 | | SF-36 physical health composite score (per 1 SDa decrease)** | 1.27 | 1.42 | 1.13 | | Any gynecological problem** | 1.39 | 1.01 | 1.90 | | No close partner** | 2.51 | 1.92 | 3.29 | p < 0.05. MCS, 1 SD = 13.0; PCS, 1 SD = 12.3. Each of the proposed mediators was independently associated with sexual dissatisfaction in the final model. A 1-SD decrement in mental health composite score was associated with 1.91 greater odds of sexual dissatisfaction and a 1-SD decrement in the physical health composite score was associated with 1.27 greater odds of sexual dissatisfaction. Endorsing a gynecological problem was associated with 1.39 greater odds, and lack of a close partner was associated with 2.51 greater odds of sexual dissatisfaction. Differences in the magnitudes of the effect estimates should be interpreted with caution in this model, which includes both measurement and categorical variables.

In a sample of over 3000 female veterans, increased mental health-related quality of life, increased physical health-related quality of life, lack of gynecological morbidity, and having a close partner largely mediate the adverse effect of SAIM on sexual satisfaction. Decreased mental health-related quality of life was the most prominent mediator in the association between SAIM and sexual dissatisfaction. The dominant mediator role of mental health-related quality of life has been suggested in studies of specific mental health conditions relevant for survivors of SAIM, such as posttraumatic stress disorder (PTSD) and depression. An association between PTSD and decreased sexual satisfaction has been directly described in male populations,19,41–43 even among those with nonsexual trauma. Among women, the link between sexual dissatisfaction and PTSD is not as well described. However, sexual dysfunction is described among female populations with PTSD,20 and sexual dissatisfaction as a manifestation of sexual dysfunction may be more prominent in survivors of sexual assault, with resultant PTSD. Avoidant behavior with respect to sexual activity and intrusive negative thoughts when attempting consensual sexual activity44 may lead to sexual dissatisfaction. Sexual assault is more strongly associated than other types of physical assault with the development of PTSD in women.13,15 Depression likely contributes to lower mental health-related quality of life after SAIM.21 Hypoactive sexual desire and anhedonia, which may manifest as decreased sexual satisfaction, are common features in depression.45 Women with a history of violence victimization are more likely than their male counterparts to manifest depression.46 The independent contributions of PTSD and depression as potential mental health-related mediators may be difficult to establish because of the high rate of cooccurrence of these psychiatric conditions among women veterans.47 Thus, emotional health-related quality of life may be an ideal measure to capture the functional impact of these disorders. Although we determined that decrements in physical health-related quality of life were statistically significant in our final adjusted model, this association showed a minimal clinical effect. Thus, our findings were concordant with the expected direction of association but not with the expected magnitude. This was unexpected because self-perceived health status has been associated with sexual satisfaction among women.48 Moreover, sexuality can be adversely affected by a variety of chronic nongynecological medical conditions,25,49,50 including respiratory disease,51 renal disease requiring chronic dialysis,52 neurological disease such as multiple sclerosis,53,54 and endocrinopathies such as diabetes mellitus55 and the metabolic syndrome,56 and has been associated with poorer self-reported health among women with heart disease.57 Thus, we anticipated that women with greater decrements in physical health-related quality of life, associated with the experience of SAIM, would report decreased sexual satisfaction. One explanation for the limited role of physical health-related quality of life as a mediator is that our sample was relatively homogeneous with respect to health status. Further, because physical health-related quality of life is less important for sexual functioning in women than in men,58 women may be less likely to report decreased sexual satisfaction due to decreased health-related quality of life. Endorsement of a gynecological problem was likewise associated with a modest increase in odds of sexual dissatisfaction. Although this finding is concordant with our expected direction of association, we anticipated a greater overall impact on our effect estimate, given the extensive literature describing the adverse and long-standing impact of sexual assault on gynecological and sexual functioning.27–29 Much of the literature on sexual functioning in survivors of sexual assault does not directly address the construct of sexual satisfaction. Thus, whereas gynecological problems may manifest as sexual dysfunction in assault survivors, this sexual dysfunction may not be reported as decreased sexual satisfaction but may be more appropriately measured as another form of sexual dysfunction, such as sexual pain disorders. Alternatively, the limited impact of gynecological problems on the association between SAIM and decreased sexual satisfaction may be explained by the relative homogeneity of our sample with respect to gynecological complaints. A substantial majority of both sexually satisfied and dissatisfied subjects endorsed any gynecological problem, suggesting that all women veterans may be at high risk for gynecological complaints. This finding deserves further study. Not only having a close partner but having a long-standing stable partner is protective of sexual functioning.24 Given the adverse impact of trauma on interpersonal relationships,31 we anticipated that our close partner variable would be an important mediator of the association between SAIM and decreased sexual satisfaction. The minimal independent contribution of this variable to the association suggests that although it functions as an intermediary, the adverse mental health-related quality of life is the predominant mediator. Of note, we found no independent effect of marital status after controlling for having a close partner. Lack of a close partner was more strongly associated with sexual dissatisfaction in our model than was marital status. This suggests that the stability of interpersonal relationships, rather than partner availability, more strongly affects sexual satisfaction in this population, a finding reported in other work.59 Our findings with respect to educational status were surprising. Lower education in our cohort was correlated with increased sexual satisfaction. Prior work has described increased interest in sex and decreased painful sex with higher educational attainment.58 In international samples,5,60 higher educational attainment was correlated with greater sexual satisfaction, possibly due to more permissive sexual attitudes. Conversely, among Finnish women,5 higher educational attainment was associated with female orgasmic dysfunction. The study of orgasmic dysfunction as a possible mediator of decreased sexual satisfaction was beyond the scope of this work but presents a target for future research. The remaining sociodemographic variables were not significant in our final model, suggesting limited independent contribution of these to sexual satisfaction in a model that includes mental health-related quality of life. Our work has several important strengths. Sexual satisfaction, an important dimension of health-related quality of life, has been minimally studied in women veterans, and further research on this topic may improve care for a growing population of women veterans. Although prior studies have described an association between sexual trauma and sexual dissatisfaction, our study extends this line of inquiry by proposing and testing mediators of this association. An important limitation of our study is that our data are cross-sectional. Thus, causality cannot be established, and the directionality of association can only be inferred. Some directions of associations proposed in our mediator model may logically be reversed. For example, sexual dissatisfaction may lead to a lower emotional health-related quality of life or may impact the ability to form close partnerships instead of the converse. This cannot be tested in cross-sectional data, which preclude the establishment of temporal associations. Additionally, the data were collected by self-report; thus, the medical conditions and other histories collected cannot be verified. Further, we did not collect data on satisfaction with sexual frequency. Relational and physical aspects of sexual satisfaction may logically be compromised by partner unavailability. Further, women voluntarily abstaining from either partnered or unpartnered sexual activity may report high sexual satisfaction. The VA Women's Health Project did not collect data on premilitary sexual violence, including childhood sexual abuse, or ongoing interpersonal violence, including intimate partner violence (IPV). Thus, a potentially unmeasured confounder in these associations is nonmilitary violence. Sexual revictimization is common, affecting approximately two thirds of rape victims, and there is evidence that the adverse health effects of multiple victimizations are cumulative.61 Thus, among subjects with a history of multiple victimizations, premilitary or ongoing interpersonal violence may account for these findings. We cannot adequately assess the relative contribution of antidepressant medication on sexual satisfaction in these data. Antidepressant medications, especially selective serotonin reuptake inhibitor (SSRI) antidepressants, contribute to sexual dysfunction in women.62 Given the burden of psychiatric illness in this population, it is possible that a large proportion of these women were prescribed antidepressant medications. Some women may have experienced adverse sexual side effects of SSRI medication and were dissatisfied because of this. Regardless, among women who are appropriately treated for psychiatric illnesses that have resulted from trauma, the association between SAIM, and decreased sexual satisfaction may be attenuated due to improved emotional health-related quality of life. Finally, the sexual satisfaction construct is based on a single, face-valid question designed to capture all domains of sexual satisfaction. A single, face-valid question to measure overall sexual satisfaction has been related previously to functional, relational, and emotional aspects of sexuality.2,34 A multiple-question, psychometrically validated instrument designed to capture operationally different domains of sexual satisfaction was not available in these data. Indeed, the study of sexuality is often problematic because studies that enroll subjects willing to answer detailed multiquestion surveys addressing sexual issues may not represent the population under study.63 Conversely, surveys designed to measure a broad range of topics, such as the one reported here, may be more representative of the study population but provide limited ability to elaborate details of the domains of sexual constructs. Future research should establish if the proposed mediators impact more strongly on operationally distinct domains of sexual satisfaction. After controlling for mediators, a modest but significant association between SAIM and decreased sexual satisfaction remained. This suggests that the four proposed mediators do not fully describe the association between SAIM and sexual dissatisfaction. Elaboration of additional mediators presents an important target for further research.

Women veterans are exposed at high rates to sexual trauma, which adversely impacts sexual satisfaction, an important aspect of health-related quality of life. Much of the adverse impact of SAIM on sexual satisfaction in women veterans is explained by decrements in emotional health-related quality of life. The Department of Defense reported that 1620 service members were victims of SAIM during fiscal year 2007.64 As the population of women veterans increases in both the VA and the community, the burden of SAIM may become more evident. Healthcare providers treating survivors of SAIM should focus on treatable sequelae of this adverse life event, including mental health consequences. Providers who recognize adverse mental health disorders in SAIM survivors should screen patients for adverse sexual effects in all domains of sexual satisfaction: emotional, physical including gynecological, and relational. In addition to primary prevention of SAIM, efforts to both screen for and then appropriately treat the sequelae of SAIM may improve patient satisfaction and overall well-being of women veterans. Acknowledgments Data collection for the VA Women's Health Project (Katherine Skinner, PI, deceased) was supported by VA HSR&D SDR 93–101. We gratefully honor the memory of Dr. Skinner and her contributions to the health of women veterans by continuing her research. J.S.M.-H. was supported by a Department of Veterans Affairs Special Fellowship in the Health Issues of Women Veterans while this research was performed. J.M.L. was supported by National Institute on Drug Abuse K23 DA016665. A.S. was supported by a Department of Veterans Affairs Clinical Sciences R&D Merit Review. The conclusions are those of the authors and do not necessarily reflect the opinions of the Department of Veterans Affairs or the National Institute on Drug Abuse. Preliminary results of this work were presented at the Society of General Internal Medicine 30th Annual Meeting, Toronto, Ontario, Canada, on April 26, 2007. Disclosure Statement The authors have no conflicts of interest to report.

- 1.Young M. Denny G. Young T, et al. Sexual satisfaction among married women age 50 and older. Psychol Rep. 2000;86:1107–1122. doi: 10.2466/pr0.2000.86.3c.1107. [DOI] [PubMed] [Google Scholar] - 2.Bridges SK. Lease SH. Ellison CR. Predicting sexual satisfaction in women: Implications for counselor education and training. J Couns Dev. 2004;82:158–166. [Google Scholar] - 3.Byers ES. MacNeil S. Further validation of the interpersonal exchange model of sexual satisfaction. J Sex Marital Ther. 2006;32:53–69. doi: 10.1080/00926230500232917. [DOI] [PubMed] [Google Scholar] - 4.Haning RV. O'Keefe SL. Randall EJ, et al. Intimacy, orgasm likelihood, and conflict predict sexual satisfaction in heterosexual male and female respondents. J Sex Marital Ther. 2007;33:93–113. doi: 10.1080/00926230601098449. [DOI] [PubMed] [Google Scholar] - 5.Haavio-Mannila E. Kontula O. Correlates of increased sexual satisfaction. Arch Sex Behav. 1997;26:399–419. doi: 10.1023/a:1024591318836. [DOI] [PubMed] [Google Scholar] - 6.Lawrence K. Byers E. Sexual satisfaction in heterosexual long-term relationships: The interpersonal exchange model of sexual satisfaction. Pers Relatsh. 2005;195;2:267–285. [Google Scholar] - 7.Hays J. Ockene JK. Brunner RL, et al. Effects of estrogen plus progestin on health-related quality of life. N Engl J Med. 2003;348:1839–1854. doi: 10.1056/NEJMoa030311. [DOI] [PubMed] [Google Scholar] - 8.Rosen RC. Bachmann GA. Sexual well-being, happiness, and satisfaction, in women: The case for a new conceptual paradigm. J Sex Marital Ther. 2008;34:291–297. doi: 10.1080/00926230802096234. [DOI] [PubMed] [Google Scholar] - 9.Skinner KM. Furey J. The focus on women veterans who use Veterans Administration health care: The Veterans Administration Women's Health Project. Mil Med. 1998;163:761–766. [PubMed] [Google Scholar] - 10.Skinner KM. Kressin NR. Frayne S, et al. The prevalence of military sexual assault among female Veterans' Administration outpatients. J Interpers Violence. 2000;15:291–310. [Google Scholar] - 11.Frayne SM. Skinner KM. Sullivan LM, et al. Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military. J Womens Health Gend Based Med. 1999;8:835–845. doi: 10.1089/152460999319156. [DOI] [PubMed] [Google Scholar] - 12.Hankin CS. Skinner KM. Sullivan LM. Miller DR. Frayne S. Tripp TJ. Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military. J Trauma Stress. 1999;12:601–612. doi: 10.1023/A:1024760900213. [DOI] [PubMed] [Google Scholar] - 13.Faravelli C. Giugni A. Salvatori S. Ricca V. Psychopathology after rape. Am J Psychiatry. 2004;161:1483–1485. doi: 10.1176/appi.ajp.161.8.1483. [DOI] [PubMed] [Google Scholar] - 14.Kang H. Dalager N. Mahan C. Ishii E. The role of sexual assault on the risk of PTSD among Gulf War veterans. Ann Epidemiol. 2005;15:191–195. doi: 10.1016/j.annepidem.2004.05.009. [DOI] [PubMed] [Google Scholar] - 15.McFarlane J. Malecha A. Watson K, et al. Intimate partner sexual assault against women: Frequency, health consequences, and treatment outcomes. Obstet Gynecol. 2005;105:99–108. doi: 10.1097/01.AOG.0000146641.98665.b6. [DOI] [PubMed] [Google Scholar] - 16.Suris A. Lind L. Kashner TM. Borman PD. Petty F. Sexual assault in women veterans: An examination of PTSD risk, health care utilization, and cost of care. Psychosom Med. 2004;66:749–756. doi: 10.1097/01.psy.0000138117.58559.7b. [DOI] [PubMed] [Google Scholar] - 17.Yaeger D. Himmelfarb N. Cammack A. Mintz J. DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. J Gen Intern Med. 2006;21S:S65–69. doi: 10.1111/j.1525-1497.2006.00377.x. [DOI] [PMC free article] [PubMed] [Google Scholar] - 18.Fontana A. Rosenheck R. Duty-related and sexual stress in the etiology of PTSD among women veterans who seek treatment. Psychiatr Serv. 1998;49:658–662. doi: 10.1176/ps.49.5.658. [DOI] [PubMed] [Google Scholar] - 19.Cosgrove DJ. Gordon Z. Bernie JE, et al. Sexual dysfunction in combat veterans with post-traumatic stress disorder. Urology. 2002;60:881–884. doi: 10.1016/s0090-4295(02)01899-x. [DOI] [PubMed] [Google Scholar] - 20.Letourneau EJ. Resnick HS. Kilpatrick DS. Best E. Comorbidity of sexual problems and posttraumatic stress disorder in female crime victims. Behav Ther. 1996;27:321–336. [Google Scholar] - 21.Baldwin DS. Depression and sexual dysfunction. Br Med Bull. 2001;57:81–99. doi: 10.1093/bmb/57.1.81. [DOI] [PubMed] [Google Scholar] - 22.Bartlik B. Kocsis JH. Legere R. Villaluz J. Kossoy A. Gelenberg AJ. Sexual dysfunction secondary to depressive disorders. J Gend Specif Med. 1999;2:52–60. [PubMed] [Google Scholar] - 23.Sadler AG. Booth BM. Nielson D. Doebbeling BN. Health-related consequences of physical and sexual violence: Women in the military. Obstet Gynecol. 2000;96:473–480. doi: 10.1016/s0029-7844(00)00919-4. [DOI] [PubMed] [Google Scholar] - 24.Laumann EO. Nicolosi A. Glasser DB, et al. Sexual problems among women and men aged 40–80 years: Prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res. 2005;17:39–57. doi: 10.1038/sj.ijir.3901250. [DOI] [PubMed] [Google Scholar] - 25.Wilmoth MC. Sexuality: A critical component of quality of life in chronic disease. Nurs Clin North Am. 2007;42:507–514. doi: 10.1016/j.cnur.2007.08.008. [DOI] [PubMed] [Google Scholar] - 26.Lewis RW. Fugl-Meyer KS. Bosch R, et al. Epidemiology/risk factors of sexual dysfunction. J Sex Med. 2004;1:35–39. doi: 10.1111/j.1743-6109.2004.10106.x. [DOI] [PubMed] [Google Scholar] - 27.Golding JM. Sexual assault history and women's reproductive and sexual health. Psychol Women Q. 1996;20:101–121. doi: 10.1111/j.1471-6402.1996.tb00667.x. [DOI] [PubMed] [Google Scholar] - 28.Campbell R. Lichty LF. Sturza M. Raja S. Gynecological health impact of sexual assault. Res Nurs Health. 2006;29:399–413. doi: 10.1002/nur.20155. [DOI] [PubMed] [Google Scholar] - 29.Letourneau EJ. Holmes M. Chasedunn-Roark J. Gynecologic health consequences to victims of interpersonal violence. Womens Health Issues. 1999;9:115–120. doi: 10.1016/s1049-3867(98)00031-0. [DOI] [PubMed] [Google Scholar] - 30.Reiter RC. Gambone JC. Demographic and historic variables in women with idiopathic chronic pelvic pain. Obstet Gynecol. 1990;75:428–432. [PubMed] [Google Scholar] - 31.Goff BSN. Crow JR. Reisbig AMJ. Hamilton S. The impact of individual trauma symptoms of deployed soldiers on relationship satisfaction. J Fam Psychol. 2007;21:344–353. doi: 10.1037/0893-3200.21.3.344. [DOI] [PubMed] [Google Scholar] - 32.Walker LEA. Battered woman syndrome: Empirical findings. Ann NY Acad Sci. 2006;1087:142–157. doi: 10.1196/annals.1385.023. [DOI] [PubMed] [Google Scholar] - 33.Yeh HC. Lorenz FO. Wickrama KA, et al. Relationships among sexual satisfaction, marital quality, and marital instability at midlife. J Fam Psychol. 2006;20:339–343. doi: 10.1037/0893-3200.20.2.339. [DOI] [PubMed] [Google Scholar] - 34.Davison SL. Bell RJ. LaChina M, et al. Sexual function in well women: Stratification by sexual satisfaction, hormone use, and menopause status. J Sex Med. 2008;5:1214–1222. doi: 10.1111/j.1743-6109.2008.00780.x. [DOI] [PubMed] [Google Scholar] - 35.McHorney CA. Ware JE., Jr Lu JF, et al. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32:40–66. doi: 10.1097/00005650-199401000-00004. [DOI] [PubMed] [Google Scholar] - 36.McHorney CA. Ware JE., Jr Raczek AE. The MOS 36-item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31:247–263. doi: 10.1097/00005650-199303000-00006. [DOI] [PubMed] [Google Scholar] - 37.Ware JE., Jr Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473–483. [PubMed] [Google Scholar] - 38.Guerrero LK. Andersen PA. Afifi WA. Close encounters: Communication in Relationships. 2nd. Sage Publications; Thousand Oaks, CA: 2007. [Google Scholar] - 39.Kaboli PJ. Doebbeling BN. Saag KG. Rosenthal GE. Use of complementary and alternative medicine by older patients with arthritis: A population-based study. Arthritis Rheum. 2001;45:398–403. doi: 10.1002/1529-0131(200108)45:43.0.CO;2-I. [DOI] [PubMed] [Google Scholar] - 40.Cohen J. Statistical power analysis for the behavioral sciences. 2nd. Hillsdale, NJ: L. Erlbaum; 1988. [Google Scholar] - 41.Kaplan PM. Post-traumatic stress syndrome and sexual dysfunction. J Sex Marital Ther. 1989;15:74–77. doi: 10.1080/00926238908412849. [DOI] [PubMed] [Google Scholar] - 42.Kotler M. Cohen H. Aizenberg D, et al. Sexual dysfunction in male posttraumatic stress disorder patients. Psychother Psychosom. 2000;69:309–315. doi: 10.1159/000012413. [DOI] [PubMed] [Google Scholar] - 43.Letourneau EJ. Schewe PA. Frueh BC. Preliminary evaluation of sexual problems in combat veterans with PTSD. J Trauma Stress. 1997;10:125–132. doi: 10.1023/a:1024868632543. [DOI] [PubMed] [Google Scholar] - 44.van Berlo W. Ensink B. Problems with sexuality after sexual assault. Annu Rev Sex Res. 2000;11:235–257. [PubMed] [Google Scholar] - 45.Dobkin RD. Leiblum SR. Rosen RC. Menza M. Marin H. Depression and sexual functioning in minority women: Current status and future directions. J Sex Marital Ther. 2006;32:23–36. doi: 10.1080/00926230500229251. [DOI] [PubMed] [Google Scholar] - 46.Porcerelli JH. Cogan R. West PP, et al. Violent victimization of women and men: Physical and psychiatric symptoms. J Am Board Fam Med. 2003;16:32–39. doi: 10.3122/jabfm.16.1.32. [DOI] [PubMed] [Google Scholar] - 47.Frayne SM. Seaver MR. Loveland S, et al. Burden of medical illness in women with depression and posttraumatic stress disorder. Arch Intern Med. 2004;164:1306–1312. doi: 10.1001/archinte.164.12.1306. [DOI] [PubMed] [Google Scholar] - 48.Walfisch S. Maoz B. Antonovsky H. Sexual satisfaction among middle-aged couples: Correlation with frequency of intercourse and health status. Maturitas. 1984;6:285–296. doi: 10.1016/0378-5122(84)90045-8. [DOI] [PubMed] [Google Scholar] - 49.Kralik D. Koch T. Telford K. Constructions of sexuality for midlife women living with chronic illness. J Adv Nurs. 2001;35:180–187. doi: 10.1046/j.1365-2648.2001.01835.x. [DOI] [PubMed] [Google Scholar] - 50.McInnes RA. Chronic illness and sexuality. Med J Aust. 2003;179:263–266. doi: 10.5694/j.1326-5377.2003.tb05535.x. [DOI] [PubMed] [Google Scholar] - 51.Goodell TT. Sexuality in chronic lung disease. Nurs Clin North Am. 2007;42:631–638. doi: 10.1016/j.cnur.2007.08.003. [DOI] [PubMed] [Google Scholar] - 52.Coelho-Marques FZ. Wagner MB. Poli de Figueiredo CE. d'Avila DO. Quality of life and sexuality in chronic dialysis female patients. Int J Impot Res. 2006;18:539–543. doi: 10.1038/sj.ijir.3901470. [DOI] [PubMed] [Google Scholar] - 53.Salonia A. Munarriz RM. Naspro R, et al. Women's sexual dysfunction: A pathophysiological review. BJU Int. 2004;93:1156–1164. doi: 10.1111/j.1464-410X.2004.04796.x. [DOI] [PubMed] [Google Scholar] - 54.Koch T. Kralik D. Eastwood S. Constructions of sexuality for women living with multiple sclerosis. J Adv Nurs. 2002;39:137–145. doi: 10.1046/j.1365-2648.2002.02253.x. [DOI] [PubMed] [Google Scholar] - 55.Salonia A. Lanzi R. Scavini M, et al. Sexual function and endocrine profile in fertile women with type 1 diabetes. Diabetes Care. 2006;29:312–316. doi: 10.2337/diacare.29.02.06.dc05-1067. [DOI] [PubMed] [Google Scholar] - 56.Esposito N. Women with a history of sexual assault. Health care visits can be reminders of a sexual assault. Am J Nurs. 2006;106:69–71. doi: 10.1097/00000446-200603000-00033. [DOI] [PubMed] [Google Scholar] - 57.Addis IB. Ireland CC. Vittinghoff E. Lin F. Stuenkel CA. Hulley S. Sexual activity and function in postmenopausal women with heart disease. Obstet Gynecol. 2005;106:121–127. doi: 10.1097/01.AOG.0000165276.85777.fb. [DOI] [PubMed] [Google Scholar] - 58.Laumann EO. Paik A. Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA. 1999;281:537–544. doi: 10.1001/jama.281.6.537. [DOI] [PubMed] [Google Scholar] - 59.Laumann EO. Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: A network explanation. Sex Transm Dis. 1999;26:250–261. doi: 10.1097/00007435-199905000-00003. [DOI] [PubMed] [Google Scholar] - 60.Barrientos JE. Paez D. Psychosocial variables of sexual satisfaction in Chile. J Sex Marital Ther. 2006;32:351–368. doi: 10.1080/00926230600834695. [DOI] [PubMed] [Google Scholar] - 61.Classen CC. Palesh OG. Aggarwal R. Sexual revictimization: A review of the empirical literature. Trauma Violence Abuse. 2005;6:103–129. doi: 10.1177/1524838005275087. [DOI] [PubMed] [Google Scholar] - 62.Hensley PL. Nurnberg HG. SSRI sexual dysfunction: A female perspective. J Sex Marital Ther. 2002;28 (Suppl 1):143–153. doi: 10.1080/00926230252851267. [DOI] [PubMed] [Google Scholar] - 63.Hayes R. Dennerstein L. The impact of aging on sexual function and sexual dysfunction in women: A review of population-based studies. J Sex Med. 2005;2:317–330. doi: 10.1111/j.1743-6109.2005.20356.x. [DOI] [PubMed] [Google Scholar] - 64.Department of Defense, Sexual Assault Prevention and Response Office. FY07 Report on sexual assault in the military. United States Department of Defense; 2008. [Google Scholar]