Sexual harassment and sexual assault have become a key focus for the Department of Defense (DoD) within the last 2 decades. In 2004, the former Secretary of Defense, Donald Rumsfeld, ordered a review of the DoD's process for responding to and treating victims of sexual assault.1 Since then, resources have been mobilized throughout the DoD leading to the development of a shared language and programs among the branches of service. However, service members are still continuing to report experiencing sexual assaults. In fiscal year 2018, 6.2% of women and .7% of men serving in the military indicated experiencing a sexual assault.2 The DoD wants a healthy, flexible force, and to achieve this, it needs to eliminate unsafe environments within the institution and promote the mental health well-being of its team.
This article first reviews the general guidance given to the DoD on how to respond to sexual assaults and then briefly looks at each branch specifically. The Air Force, Army, Navy, and Marines will be discussed. The Coast Guard, however, will not be discussed because its reporting procedures fall under the umbrella of the Department of Homeland Security. As behavioral health providers work with military sexual trauma (MST), it is important to understand the context of the system service members are in and resources available to victims. Also, while the Defense Health Agency (DHA) transitions to taking over the military medical system it is anticipated that more care may be deferred to civilian providers in the network. It is vital for providers outside of the military system to know that there is a program in place for sexual assault prevention and response within the military and how to access these resources. For those working with veterans, knowledge of processes related to sexual assault reporting will help add context for therapy and may help shed light on additional resources. Finally, a review of clinical guidelines for treatment will also be discussed. Service members and veterans deserve the best care, and the DoD and Veterans Affairs have ensured that providers are aware of and trained on the most efficacious treatments for MST or other traumas.
Department of Defense
Through the Department of Defense Directive3 and Department of Defense Instruction (DoDI),4 the military branches were called to not only improve responses to sexual assault, but also to prevent it. These instructions lay out a template that the military branches are required to follow. This direction includes types of reports that are available, who can take a report, the medical providers who assist in the examinations, and how to refer to legal and behavioral health services. Each military branch's version will be reviewed below after a brief discussion of general DoD practices.
Throughout the DoD, victims have several venues to report an assault and two official options of reporting: unrestricted and restricted reporting. Both options connect victims to several resources, but there are differences between the two options. Unrestricted reporting is for service members who want to pursue an official investigation and potentially legal ramifications for the perpetrator. The restricted reporting option, however, allows victims to confidentially disclose details of the assault to specified parties without triggering any investigation. Victims are provided access to medical treatment, behavioral health treatment, victim advocate services, and chaplain services regardless of choosing an unrestricted or restricted report.
Service members can disclose this information to a variety of professionals, including their physician, therapist, or sexual assault representative. If they want to make an unrestricted report, and therefore press legal charges, they can talk to any of the previously mentioned people as well as their command, military police, or legal counsel.
Each medical facility throughout the DoD, including those in operational environments, have certified and trained sexual assault providers that will ensure that victims get “gender-responsive, culturally competent, and recovery-oriented” care.4 Once a referral has been made, these providers, comprising of an interdisciplinary team (eg, physicians, nurses, social workers, victim advocates) will oversee victims' medical care, coordinate available resources, and liaise with behavioral health. In addition, one of the standardized sexual assault response providers is a Sexual Assault Behavioral Health Care provider. This provider can serve as an advocate, treating provider, and/or help coordinate behavioral health care services. This position is universally found in all branches of the military. These resources are available to anyone regardless of the reporting option chosen.
People who have chosen the unrestricted option have access to resources such as potential restraining orders (ie, military restraining order), and/or expedited transfer (ie, move to a new unit and/or location) in addition to the Special Victims Counsel (ie, legal counsel) that is available to everyone.
There are multiple trained professionals within various levels of units to help facilitate any potential reports. Within the Army, there are victim advocates and Sexual Assault Response Coordinators (SARCs) attached to different units, such as at the Company level (usually comprised of 150 people) and at the Battalion level (usually comprised of over 800 people). SARCs and victim advocates at these levels are higher-ranking enlisted personnel that fill this role as an additional duty, not as their full-time job. These personnel are not in the behavioral health field, but rather serve in this role primarily as resource coordinators and advocates in addition to their regular Army job. Potential candidates for these positions undergo an extensive screening process to ensure that the appropriate personnel are assigned these sensitive duties. A SARC is the single point of contact for referrals within their unit. They ensure that victims receive quick, responsive care and understand their reporting options. They are available 24 hours a day, 7 days a week. The victim advocate also helps facilitate referrals for a victim and provides nonclinical support. In addition to assisting victims, SARCs and victim advocates are responsible for unit sexual assault and harassment education, tracking metrics, and MST prevention efforts. At the Brigade level (usually comprised of over 3,000 people), there is at least one full-time employed SARC and victim advocate.
In terms of entire installations, or Army Posts, there is a sexual assault review board, which convenes regularly. This is led by the Installation Commander or their designee. The head of the Army's Behavioral Health Department at the installation, or the Installation Director of Psychological Health, sits on this board and advises the units and their SARC's on any issues or questions that may arise as cases are being reviewed.
In the Air Force the sexual assault prevention and response teams differ somewhat in the form and position compared to the Army, while still meeting the underlying DoDI. To understand where Sexual Assault Prevention and Response (SAPR) resources are located, it is important to describe units in the Air Force. The organization within the Air Force differs from other branches of the military due to its components being divided primarily based on function. The smallest official unit is the flight, which can greatly vary in size but is unified in purpose. The next largest unit is the squadron, and above this is a group comprised of multiple squadrons. Then it is a Wing, which is comprised of separate components that make up a base structure. It is at this level that the SAPR office operates to serve the entire base.
Recently (2019), there have been changes within the Air Force according to the Air Force Instruction5 outline of the SAPR Program to meet the demands of the DoDI as well as flexing to the specific needs of the Air Force. For units within the Air Force, sexual assault prevention training is tracked and administered by unit training managers, SAPR personnel, Violence Prevention Integrators, and/or their designees. In contrast to the Army, there are no unit-embedded sexual response providers. Victim advocates and SAPR personnel are housed within the SAPR office. There is only one SAPR office required per Air Force installation. The SAPR program is headed by a nominated line officer (0–3, Captain, or above) as a career broadening opportunity or by a civilian; they are not required to be mental health providers or have specific mental health training. These officers in turn report to the Wing and higher Major Command SAPR office in terms of installation trends, statistics, and prevention initiatives.
Within the SAPR office, the person's report is handled separately from the unit. Confidentiality is maintained unless the person wishes to pursue an unrestricted report and involve command in the legal process. After identification, the victim is connected with a victim advocate, SAPR representative, and special victim's council as needed. The victim advocate and SARC would be responsible for connecting the survivor with mental health providers if this is requested.
Air Force mental health providers are separate from the sexual assault reporting process. However, they maintain a connection to the oversight of this process through the position of the Director of Psychological Health. They are the representative from the mental health component (often the mental health flight commander or clinic chief), and act as the mental health clinical consultant and outreach provider for the Wing in their respective location. The Director of Psychological Health is a mandatory member of the Case Management Group (CMG) that reviews unrestricted sexual assault reports and serves as a clinical subject matter expert and mental health consultant.
Navy and Marine Corps
Since the initial Navy Sexual Assault Program was established in 1994, the efforts to improve education, prevention, and survivor support have grown exponentially. Today's SAPR remains a commander's program, starting at the highest echelon of leadership and extending to the field and deck-plate level (all levels of the Navy).
Similar to the Army, a full-time SARC and victim advocate is assigned for every 5,000 personnel, with additional full- and part-time SARCs and victim advocate when appropriate.6 Every unit, regardless of number of personnel, has a SAPR victim advocate as a collateral duty to the person's specific job classification. In addition, a Watchstander, a duty officer specifically trained to be the first person a victim may reach out to, is available at every barracks. The Watchstander connects the victim to a SARC, victim advocate, or deployed resiliency counselor. A deployed resilience counselor is a licensed mental health clinician employed by the Fleet and Family Service Center, to be available for units at sea.
Similar to the other branches, every installation has a SAPR CMG that is chaired by the installation commander.6 This multidisciplinary team ensures the installation is meeting the requirements of the DoDI as specifically applied within their unique culture. Members of the SAPR team are carefully chosen and trained. This group executes and supervises a SAPR High Risk Response Team that ensures victim safety throughout the process with special attention paid to any threats of retaliation, ostracism, maltreatment or reprisal.
Mental or Behavioral Health Treatment
It is important that Behavioral Health providers working with the military understand applicable regulation as governed by DoDI.4 For providers working within the DoD, one of the limits to confidentiality falls under the heading of sexual assaults. If a patient reports experiencing a sexual assault, and there is no statute of limitations, then the provider must call a sexual assault reporting hotline with the patient. A full-time SARC will answer and offer the patient a multitude of services. The patient can deny all or some of the services, but the provider must call and link the patient with a SARC. This can be done on an anonymous basis. It is important for providers to be aware of the regulation that governs the limits of confidentiality, especially in regards to victims of sexual assault.
Finally, as a behavioral health care provider working with the military community, there are Veterans Affairs/DoD guidelines for the treatment of posttraumatic stress disorder (PTSD).7 The guidelines address medication, individual and group therapy, prevention strategies, as well as treatment of PTSD with comorbid diagnoses. One of the first steps is the recommendation to use individual trauma-focused psychotherapy over sole pharmacotherapy. Trauma-focused therapies with the strongest evidence from clinical trials are prolonged exposure, cognitive-processing therapy, and eye movement desensitization and reprocessing. The DoD has worked to ensure that behavioral health providers operating in this system have support and training in these therapies. The guidelines then discuss medications or other treatment options if first-line therapies are not working or if patients are not ready for evidenced-based trauma-focused treatments listed above. Throughout the military and DoD, there are multiple levels of care. If the need is too great for outpatient individual therapy, intensive work is available. Large hospitals have intensive outpatient programs (IOPs) where patients are seen daily for group therapy with at least one or two individual sessions a week. There are some tracks within IOPs that only focus on trauma and provide a condensed version of an evidenced-based trauma treatment within 6 to 8 weeks. For more severe mental health difficulties requiring residential treatment, patients can be referred to programs within the TRICARE network, the military health insurance system.
Defense Health Agency
Now that the Defense Health Agency (DHA) is taking over medical care, there are some questions about what the medical system will look like and how these changes may impact treatment. The sexual assault preventive initiatives will remain command programs following DoD instructions, which allow the services to fill in the gaps using their own discretion. However, the care for service members within the medical system, including the medical treatment of sexual assault victims, will now fall under a universal system and protocol. Upcoming changes to the medical system bring questions about the future. It is currently unknown if DHA will allow for differences in structure and coordination of care as is the current practice. Perhaps the DHA transition will allow for more communication between branches and ease the facilitation of treatment among them. One noticeable difference with DHA already is the transition away from active duty health care providers. This could result in more of the care for sexual assault victims occurring in the civilian-purchased care network rather than in military treatment facilities. This transition will create other changes as providers in the civilian network will likely not be as familiar with DoD policies, nor would they have the direct link to Command, which is currently available within the military treatment facility. Although challenges will likely exist with the DHA transition, there is no indication that the DoD will discontinue prioritizing efforts to reduce sexual assault and properly support victims.
The military has been focusing on improving sexual assault prevention, reporting, and response over the past 20 years. The onset of the #MeToo movement ( https://metoomvmt.org/) has shown that there is so much work yet to be done in reporting sexual assaults, treating, and protecting its victims. Fortunately, the military is aggressively working on preventing sexual assaults and ensuring the highest quality of care for survivors. One of the current best practices within the DoD is done on the treatment side where behavioral health teams regularly meet to discuss high need cases. This ensures that the multidisciplinary team is synchronized with all members of the team working toward the same goals. These meetings help ensure that all needed resources are being used, and nothing is missed. In addition, there is one Sexual Assault Behavioral Health Provider who is embedded in the clinic and can act as a consultant for the generalist behavioral health providers on resources and reporting features. Finally, another best practice in the DoD system, is the availability of widespread, free training on evidenced-based treatments for PTSD, depression, and anxiety. This is an invaluable asset for providers as training allows providers to stay abreast on the most up-to-date research, allowing for patients to receive the best care.
Other best practices are done on the command side. All data on sexual assault reports are being tracked anonymously to assess for trends. This allows for command teams to make potentially needed interventions. In terms of prevention, the training that is offered throughout the DoD has evolved over time to now focus on systemic cultural changes. Discussions on how assault can happen regardless of gender identity are being held as well as conversations focused on preventing people from perpetrating assault by ensuring that consent is discussed and conveyed on many levels.
Regarding areas of improvement, one thing stands out for the DoD. In particular, the power differential is visible and ever present in the DoD as rank is a tangible factor. Diffusing power differential will be a key preventive factor and help to facilitate reporting.
Finally, with the transition to DHA, there is a movement toward standardization of medical care throughout the services. This may further the development of a universal language and processes that may help victims and those who support them navigate a large, complex system. Hopefully, this transition will allow for the response to and treatment of sexual assault victims in a fluid and effective manner that is consistent with the victim's wishes and evidenced-based clinical practices.