exposed to different types of stressors in considerably different social contexts. This heterogeneity constitutes yet another challenge for evaluation discussed in more detail in Chapter 5.
Military sexual assault (sexual assault experienced while in military service5) is an additional traumatic stressor that affects military personnel, and subsequently, is identified as an exposure leading to PTSD in some, generally female, veterans. There is evidence that military sexual assault makes PTSD more likely than sexual assault occurring before or after military service (Himmelfarb et al., 2006; Yaeger et al., 2006), and potentiates the risk of developing PTSD from combat exposure (Himmelfarb et al., 2006; Kang et al., 2005)..
One of the major challenges of diagnosing and treating PTSD is the stigma associated with it and mental illness in general. Stigma may have a profoundly negative effect on individual self-esteem, care-seeking behaviors, and social interaction (Department of Health and Human Services, 1999; Sartorius, 2002). In the military context, where self-reliance and inner strength are highly valued, mental illness may be considered a sign of weakness or a reason for shame, leading people to deny their illnesses or, once diagnosed, to avoid seeking care. Data on this issue in the veteran population are limited, but a 2003 study of several thousand current members of the Army and Marine Corps before and after deployment explored mental health status, interest in receiving care, and health care service utilization (Hoge et al., 2004). The study’s findings were striking, highlighting several common themes, including the role of perceived stigma as a barrier to accessing services, perception of stigma and damage to one’s military career, and other negative views of what suffering from a mental health condition and seeking care for it would mean for one’s future in the military (Hoge et al., 2004). As a result of stigma, only 23–40 percent of those in need of mental health services actually seek care (Hoge et al., 2004).
Treatments available for PTSD include a variety of pharmacologic and psychotherapeutic modalities, and they are provided in diverse settings. For veterans, a considerable proportion receive services at both inpatient and outpatient VA facilities. The general population receives services in community clinics (some may specialize in specific types of trauma), from