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Clinical Research Article

Male sex and hazardous alcohol use following military sexual assault increase suicide risk among US service members and veterans

El sexo masculino y el abuso de alcohol después de una agresión sexual en el ámbito militar aumentan el riesgo de suicidio entre los miembros y veteranos del ejército de los Estados Unidos

Rebecca K. Blaisa Psychology Department, Arizona State University, Tempe, AZ, USA;b Psychology Department, Utah State University, Logan, UT, USACorrespondence[email protected]
ORCID Iconhttps://orcid.org/0000-0002-2483-1576
ORCID Icon,
Bingyu Xua Psychology Department, Arizona State University, Tempe, AZ, USA
,
Hallie Tannahillb Psychology Department, Utah State University, Logan, UT, USA;c Wright-Patterson Medical Center, Wright-Patterson Air Force Base
&
Patrick Dulind Psychology Department, University of Alaska Anchorage, Anchorage, AK, USA
Article: 2312756 | Received 15 Sep 2023, Accepted 20 Jan 2024, Published online: 03 Apr 2024

ABSTRACT

Background: Higher alcohol use and military sexual assault (MSA) are associated with increased risk of death by suicide. Risk for death by suicide is rapidly increasing among females, who report higher rates of MSA, yet actual death by suicide and alcohol use are higher among males. It is not well understood whether higher alcohol use confers greater suicide risk in male or female service members and veterans who have experienced MSA.

Objective: To determine whether the association between alcohol misuse and suicide risk was moderated by biological sex in a sample of male and female service members (N = 400, 50% female) who reported MSA.

Method: Participants completed surveys of alcohol use and suicide risk as well as a demographic inventory. Linear regression with an interaction term was used to determine if suicide risk differed by sex and alcohol use severity after accounting for discharge status, sexual orientation, and age.

Results: Average scores on the suicide risk measure were consistent with an inpatient psychiatric sample and scores on the AUDIT-C were indicative of a probable positive screen for alcohol misuse. Suicide risk was most pronounced among males who reported higher levels of hazardous alcohol use. A sensitivity analysis examining suicide risk by sex and screening results for alcohol misuse (positive/negative) showed that men with a probable positive screen had higher suicide risk.

Discussion: The current study provides novel findings on suicide risk among survivors of military sexual violence by including both male and female survivors. Interventions to decrease suicide risk following MSA may consider alcohol reduction strategies, and optimizing these interventions in males. Engaging military culture at both the US Departments of Defense and Veterans Affairs to encourage more healthy alcohol consumption may mitigate this public health concern. Future research may consider how country of origin relates to these associations.

HIGHLIGHTS

  • Average scores for the suicide risk measure and alcohol use were high among a sample of male and female survivors of military sexual assault.

  • Suicide risk was most pronounced among males who reported higher levels of hazardous alcohol use.

  • A sensitivity analysis examining suicide risk by sex and screening results for alcohol misuse (positive/negative) showed that men with a probable positive screen had higher suicide risk.

Antecedentes: Un mayor consumo de alcohol y la agresión sexual en el ámbito militar (MSA, según sus siglas en inglés) se asocian con un mayor riesgo de muerte por suicidio. El riesgo de muerte por suicidio está aumentando rápidamente entre las mujeres, que informan de mayores tasas de MSA, sin embargo, la muerte real por suicidio y el consumo de alcohol son mayores entre los hombres. No se comprende bien si un mayor uso de alcohol confiere un mayor riesgo de suicidio en miembros y veteranos del ejército, ya sean hombres o mujeres, que han experimentado MSA.

Objetivo: Determinar si la asociación entre el abuso de alcohol y el riesgo de suicidio estaba condicionado por el sexo biológico en una muestra de miembros del ejército masculinos y femeninos (N = 400, 50% mujeres) que informaron sobre el MSA.

Método: Los participantes completaron encuestas sobre el consumo de alcohol y el riesgo de suicidio, así como un inventario demográfico. Se utilizó un modelo de regresión lineal con una interacción para determinar si el riesgo de suicidio difería según el sexo y la gravedad del consumo de alcohol, después de tener en cuenta el estado de baja, la orientación sexual y la edad.

Resultados: Las puntuaciones promedio en la medida de riesgo de suicidio fueron consistentes con una muestra psiquiátrica de pacientes hospitalizados, y las puntuaciones en el AUDIT-C indicaron una probable detección positiva de abuso de alcohol. El riesgo de suicidio fue más elevado entre los varones que declararon niveles más altos de consumo peligroso de alcohol. Un análisis de sensibilidad que examinó el riesgo de suicidio por sexo y los resultados de la detección de abuso de alcohol (positivo/negativo) mostró que los hombres con un cribado probablemente positivo tenían un mayor riesgo de suicidio.

Discusión: El presente estudio ofrece hallazgos novedosos sobre el riesgo de suicidio entre los sobrevivientes de agresión sexual en el ámbito militar al incluir tanto a sobrevivientes masculinos como femeninos. Las intervenciones para reducir el riesgo de suicidio después de una MSA podrían contemplar estrategias de reducción del consumo de alcohol y optimizar estas intervenciones en los hombres. La participación en la cultura militar en los Departamentos de Defensa y Asuntos de Veteranos de los Estados Unidos para promover un consumo más saludable de alcohol podría mitigar esta preocupación de salud pública. Investigaciones futuras podrían considerar cómo el país de origen se relaciona con estas asociaciones.

Suicide is a growing epidemic in the United States (US) military service members and veterans. Among veterans, the rate of death by suicide is nearly two times higher than that among civilians (Ramchand, Citation2021). From 2013 to 2021, the rate of death by suicide among those actively serving increased from 18.5 to 24.3 suicides per 100,000 service members (Department of Defense [DoD], Citation2022a). A small decrease in deaths by suicide was observed in 2020 (DoD, Citation2022a), but this is not yet evidence of a downward trend. Further, suicide rates among veterans also increased by 25.9% from 2005 to 2018 (US Department of Veterans Affairs [VA], Citation2018). Male service members and veterans experience particularly notable risk. In 2021, roughly 94% of deaths by suicide among service members were male (DoD, Citation2022a). In the VA, understanding risk factors for suicide has been identified as a ‘top clinical priority’ (US Department of Veterans Affairs, Citation2022). Similarly, the DoD states that ‘the health, safety, and well-being of our military community is essential … any death by suicide is a tragedy’ (DoD, Citation2019, p. 6). As such, novel studies of suicide risk are timely and critically needed to inform more pivotal areas for intervention.

Among those at particularly heightened suicide risk are survivors of military sexual trauma (MST). MST is defined as any instance of unwanted sexual attention or assault that occurred during military service. A meta-analysis on MST exposure identified a pooled prevalence rate of 38.4% in females and 3.9% in males, of which 23.6% of females and 1.9% of males reported assault exposures (military sexual assault [MSA]; Wilson, Citation2018). Sadly, these estimates likely under-represent the actual frequency of MST/MSA. Community studies observe much higher estimates (e.g. Barth et al., Citation2016; Blais, Citation2020, Citation2021), with established disclosure barriers likely accounting for these discrepancies (e.g. Andresen & Blais, Citation2019; Blais et al., Citation2018). Studies of MST/MSA and suicide risk have pooled effect sizes of .11–.14 (see meta-analysis, Livingston et al., Citation2023). In fact, research indicates that MST is more strongly correlated with suicide than combat trauma (e.g. Blais & Monteith, Citation2019), with MSA exposure conferring even higher risk than harassment-only MST exposure (e.g. Blais et al., Citation2018).

To date, many studies of suicide risk factors in military samples have focused on mental health diagnoses, such as posttraumatic stress disorder (PTSD; Rugo et al., Citation2020) and depression (LeardMann et al., Citation2013), yet recent observations of risk for death by suicide in this population highlight the role of alcohol misuse (e.g. Bryan et al., Citation2016; DoD, Citation2022a; Inoue et al., Citation2022). There is evidence that interpersonal violence, such as MST/MSA, is associated with the highest alcohol use relative to other trauma exposures, including childhood abuse or combat (i.e. Vest et al., Citation2022). Leading theories of alcohol misuse suggest individuals use alcohol to cope with traumatic exposures and their psychological sequelae (e.g. Khantzian, Citation1997; Lane et al., Citation2019). Furthermore, use of alcohol may hinder self-regulation and increase engagement in impulsive behaviours that inherently lead to a heightened risk of death by suicide (Rizk et al., Citation2021). However, a recent systematic review of the literature documented a rather mixed pattern of associations between MST and alcohol use. Some studies observed that those who experienced MST had more difficulties with problematic alcohol use whereas other studies found no association (see review, Forkus et al., Citation2021). It is possible that these mixed findings may be due to the inclusion of MST exposures that do not include assault (i.e. harassment-only MST), which is associated with less detrimental outcomes (Blais et al., Citation2018). To address this possibility, the current study focused on the association of suicide risk and alcohol use among those who reported MSA victimization.

In further understanding the association between suicide and alcohol use in the context of MSA exposure, it is critical to understand how biological sex influences this association. Whereas rate of death by suicide is higher among males (DoD, Citation2019), females’ rate of death by suicide is increasing faster than males’ (Department of Veteran Affairs, Citation2019). Additionally, females have higher rates of exposure to MST/MSA relative to males (Blais et al., Citation2023; Kimerling et al., Citation2016; Tannahill et al., Citation2023), yet males report more severe forms of MST (Morral et al., Citation2015). Males are also more likely to engage in problematic drinking (e.g. Vest et al., Citation2018), suggesting a dynamic interplay among suicide risk, biological sex, and alcohol among MST survivors. Notably, studies highlight that males reporting PTSD, a common diagnosis following MST (e.g. Kimerling et al., Citation2007), were more likely to report problematic drinking or have a co-occurring substance use disorder (see review, Jones & Fear, Citation2011; Walter et al., Citation2022). Moreover, relative to females, males reporting a history of MST had 70% greater alcohol consumption and 86% higher heavy drinking episodes, as well as 45% greater problem alcohol use scores (Fillo et al., Citation2023). Collectively, such findings suggest that the association of alcohol use with suicide risk following MSA would be highest among males.

To further clarify these associations, the current study builds on the existing literature on suicide risk by examining how alcohol use and sex interact to increase suicide risk in a sample of MSA survivors. We hypothesized that suicide risk would be highest as alcohol use increased, particularly among males. We covaried for discharge status, as studies show that separation from the military is associated with changes in drinking patterns (e.g. Porter et al., Citation2020). We also covaried for age (Ravindran et al., Citation2020) and sexual orientation (Blosnich et al., Citation2012; Schuyler et al., Citation2020), as these have been associated with suicide risk, MST/MSA, and/or alcohol misuse in military samples.

1. Method

1.1. Participants and procedure

Data for this current analysis were drawn from a parent study that was developed to understand the associations of MSA, posttraumatic cognitions, PTSD, and biological sex (Tannahill et al., Citation2023). That investigation did not examine alcohol use or suicide risk. Participants were 400 service members/veterans who reported history of MST that involved assault (see Section 1.2 Measures below). Participants who met study inclusion criteria were recruited via Qualtrics, Inc. panels in 2021 (Qualtrics Panels, Citation2017). Qualtrics, Inc. solicited survey participation via email invitations to individuals who served in the military in the post-9/11 era, reported history of MST that involved assault, and were aged 18 years or older. Screening questions for MST are included in Measures, below. We intentionally sought to recruit 200 males and 200 females to ensure adequate power to examine sex differences. To limit possible fraudulent responses, we used four military validation questions (Tannahill & Blais, Citationforthcoming). Questions included military facts that are known characteristics to service members/veterans but not to civilians. Incorrect responses to any of these validation items led to automatic discontinuation, resulting in likelihood of only 0.16% to answer four questions correctly by chance. If participants passed the military service validation checks, they were provided with an electronic Letter of Information and indicated their informed consent. Out of the 1,953 participants who initiated the survey, 400 (20.48%) met all study inclusion criteria and passed the validation checks. In order to ensure anonymity, participants were compensated directly by Qualtrics, Inc panels, with recruitment and compensation costs totalling $20/participant. This study was approved by the Institutional Review Boards at Utah State University and Arizona State University.

The average age of our sample was 35.89 (SD = 5.65; range = 19–59). Around half of the sample were discharged from service (n = 184; 46%), and the remaining sample were current service members (n = 216; 54%). The majority (n = 398; 99.5%) identified as cisgender and reported at least two assaults during their military service. The majority (n = 340; 88%) also reported exposure to sexual violence (assault, attempted assault) prior to military service. Most of the participants identified as married (n = 346; 86.5%), White (n = 289; 72.3%), heterosexual (n = 361; 90.3%), and reported service in the Army (n = 296; 74%). Half of the sample (n = 209; 52.25%) reported their rank was in the Officer class.

1.2. Measures

Demographics. A demographic inventory was used to assess participant sex and gender characteristics (cisgender, gender nonconforming, transgender, two-spirit, other), sexual orientation (straight/heterosexual, sexual minority), age, race (Alaska Native/Native American, Black/African American, Latinx/Hispanic, White/Caucasian, other), military branch (Air Force, Army, Coast Guard, Marine Corps, Navy), military rank (enlisted, officer), and discharge status (veteran, active). For the current study, sex was identified as sex assigned at birth.

MST Screening Questions. The initial screen for MST that involved sexual assault included the question, ‘When you were in the military, did someone ever have sexual contact with you against your will or when you were unable to say no (for example, after being forced or threatened, or to avoid other consequences)?’ An affirmative response resulted in continuation in the survey. A negative response would be prompted with the question, ‘When you were in the military, did someone try to have sexual contact with you against your will or when you were unable to say no?’ We included the latter question due to DSM-5 criteria (American Psychiatric Association, Citation2013) that states both actual and threatened traumatic events meet criteria for an index event. An affirmative response to this question resulted in continuation in the survey; a negative response terminated participation. Secondary validation of MST history that included sexual assault was with the Sexual Experiences Survey – Short Form Victimization (SES-SFV; Koss et al., Citation2006). The SES-SFV is a 10-item self-report questionnaire that assesses participants’ history of unwanted sexual experiences. The survey was modified for participants to answer about experiences that occurred during their military service. All participants indicated at least one form of MST involving sexual assault on both MST screeners.

Suicide risk. Suicide risk was assessed with the Suicide Behaviors Questionnaire-Revised (SBQ-R; Osman et al., Citation2001). The SBQ-R is a 4-item self-report questionnaire that assesses lifetime suicidal ideation and suicide attempts, the frequency of suicidal ideation over the past 12 months, threats of making a suicide attempt, and self-report likelihood of suicidal behaviours in the future. Total scores can be calculated by summing up the four items, ranging from 3 to 18, with higher scores indicating greater suicide risk. The SBQ-R shows excellent psychometric properties in military samples (i.e. Gutierrez et al., Citation2019). Internal consistency of SBQ-R in the current sample was adequate (Cronbach’s α = .81).

Alcohol use. The U.S.-Alcohol Use Disorder Identification Test – Consumption (Bush et al., Citation1998) was used to examine alcohol use. The AUDIT-C is a three-item inventory that measures problematic alcohol use. Scores range from 0 to 12 with higher scores indicating greater alcohol misuse. Scores of 3 and 4 indicate consumption that is above the recommended limits for females and males, respectively. Scores at or above 3 and 4 indicate a probable positive screen for alcohol misuse. In the current study, severity (linear) and a positive screen for alcohol misuse (positive/negative) were used. Internal consistency of the AUDIT-C in the current sample was adequate (Cronbach’s α = .83).

1.3. Analytic plan

Participant characteristics were assessed using descriptive statistics. A series of analyses of variance (ANOVA), correlations (t-test, Pearson’s r), and chi-square tests were conducted to assess bivariate associations between sex (male/female), suicide risk, and alcohol use, as well as covariates. A linear regression with an interaction term was conducted to examine whether sex moderated the relation of alcohol consumption and suicide risk. Covariates of the study outcome, suicide risk, included age, discharge status (service member, veteran), and sexual minority status. Missing data were excluded using listwise deletion. All statistical analyses were conducted using IBM SPSS Statistics v27 (IBM, Citation2020).

2. Results

Descriptive Characteristics. The average score on the SBQ-R was 7.81 (SD = 4.28). This is higher than the cutoff score of 7 to classify suicide risk in the adult general population, and close to the cutoff score of 8 for adult inpatients (Osman et al., Citation2001). Scores on the AUDIT-C demonstrated high risk for hazardous drinking in both men and women. Eighty-three percent (n = 332) had a positive screening result, of which 50.30% (n = 167) were males. Given the average scores and percent of positive screens observed, we refer to drinking as ‘hazardous drinking’ in the following analyses. See full demographic statistics in .

Table 1. Study variable comparisons, stratified by sex.

Bivariate Associations. Bivariate associations can be found in and . Males reported significantly higher scores on AUDIT-C compared to females, but there were no differences in severity of suicide risk between males and females. Males were significantly more likely to be current service members compared to female participants. There were no sex differences in age or sexual orientation (covariates; see ). Overall, suicide risk was positively correlated with alcohol use with a medium-to-large effect size. Suicide risk was higher among those who were actively serving. Alcohol use was higher among those actively serving and those who identified as heterosexual (see ).

Table 2. Intercorrelations among study variables of interest and covariates.

Moderating Effect of Sex. The model of suicide risk regressed on alcohol use, sex, and their interaction, after accounting for covariates, was significant and explained 19.50% variance in suicide risk (F[6,392] = 15.82, p < .001; see ). Higher alcohol use was significantly associated with higher suicide risk (b = 0.44, SEb = 0.09, t(392) = 5.04, p < .001). Male sex was significantly associated with lower suicide risk (b = −1.75, SEb = 0.72, t(392) = −1.99, p = .05), and the regression parameter for the interaction term suggested that there is a significant interaction between alcohol use and sex (b = 0.25, SEb = 0.12, t(392) = 2.04, p = .04). Simple slopes analysis demonstrated that when sex was male, the simple slope between alcohol use and suicide risk was 0.68 (SE = 0.09). When sex was female, the simple slope between alcohol use and suicide risk was 0.44 (SE = 0.09). In other words, the positive association between alcohol use and suicide risk was significantly stronger among males than females (see ). Covariates were unrelated to suicide risk in adjusted models.

Figure 1. Probe of moderation model of alcohol use and sex on suicide risk.

Figure 1. Probe of moderation model of alcohol use and sex on suicide risk.

Table 3. Suicide risk regressed on alcohol use and sex.

Given the different cut-off scores for a probable positive screen for alcohol misuse for males and females, we next ran a sensitivity analysis where males and females were dichotomously coded as having a positive or negative screen for alcohol misuse. Those who had a positive screen were coded 1 according to their sex-specific cut-off and those with a negative screen were coded 0. The model of suicide risk regressed on alcohol use screening results, sex, and their interaction, after accounting for covariates, was significant and explained 11.75% variance in suicide risk (F[6,393] = 8.72, p < .001; see ). A positive screen for alcohol misuse was significantly associated with higher suicide risk (b = 2.19, SEb = 0.76, t(393) = 2.87, p < .004). Male sex was marginally significantly associated with lower suicide risk (b = −1.94, SEb = 1.00, t(3923) = −1.94, p = .052), and the regression parameter for the interaction term suggested that there was a significant interaction between alcohol misuse screening results and sex (b = 2.59, SEb = 1.09, t(3923) = 2.37, p = .02). Simple slopes analysis demonstrated that when sex was male, the simple slope between alcohol misuse screening results and suicide risk was 4.78 (SE = 0.78). When sex was female, the simple slope between alcohol use and suicide risk was 2.19 (SE = 0.76). Similar to the previous model, the positive association between alcohol misuse and suicide risk was significantly stronger among males than females (see ). Covariates were unrelated to suicide risk in adjusted models after accounting for alcohol use and sex.

Figure 2. Suicide risk stratified by sex and hazardous drinking, with 95% confidence interval error bars.

Figure 2. Suicide risk stratified by sex and hazardous drinking, with 95% confidence interval error bars.

3. Discussion

The purpose of the current study was to extend the literature on suicide risk among MST survivors by focusing on the interaction of alcohol misuse and sex. Notably, this study addresses a literature gap identified in the Independent Review Commission on Sexual Assault in the Military (DoD, Citation2022b) report, which called for additional research on service member well-being that focuses on specific traumas such as MST. This also relates to the current efforts of the Suicide Prevention and Response Independent Review Committee, which is tasked with understanding the growing rate of suicide in the military (Iwamasa et al., Citation2023; US Congress, Citation2022). Our results indicate that alcohol use is a serious concern among military service members and veterans who have experienced MSA. Notably, the mean level of drinking in our sample was indicative of a probable positive screen for alcohol misuse. Such elevated scores in a traumatized sample are not necessarily surprising; however, the magnitude of scores observed was unexpected. Correspondingly, addressing hazardous alcohol use in this population is an urgent priority, particularly given that alcohol can lower inhibitions and facilitate engagement in risky behaviours, including the use of lethal means. Health care practitioners who treat members of this group should routinely query for problematic alcohol use and be prepared to promptly provide psychoeducation and referrals to addiction assessment and treatment.

We observed that suicide risk was highest among male survivors of MST who reported higher alcohol use. Our findings build on the literature demonstrating males’ heightened risk for death by suicide (DoD, Citation2022a) and that their high levels of alcohol consumption may contribute to their potential for suicide (Bray et al., Citation2013; Gutierrez et al., Citation2006). Among men, a diagnosis of alcohol misuse is also associated with increased risk of death by suicide (e.g. Chung et al., Citation2022; Qin, Citation2011). Given the magnitude of heavy drinking observed in the current sample, results collectively show how detrimental alcohol use can be on males. To our knowledge, we are the first to report such findings on the association of how sex relates to the association of suicide risk and alcohol use among members of the US military who have experienced sexual violence. It is possible that increased alcohol use is a form of coping for those who have survived MSA, and would be consistent with several theories of alcohol use, including the self-medication hypothesis (Khantzian, Citation1997). Additional research would strengthen this line of inquiry by understanding the role and timing of alcohol use following MST or MSA.

To reduce suicide risk in military service members, it may be critical to focus prevention efforts on encouraging more healthy drinking habits, and consider the effects of sex in delivering these interventions. More rigorous interventions will be needed given that a recent meta-analysis reviewing brief alcohol interventions in military samples were largely ineffective (see Doherty et al., Citation2017). That said, there is emerging evidence that screening, brief interventions, and referrals to treatment did reduce alcohol misuse among active-duty service members (Reed et al., Citation2023), but these results did not explore any changes in suicide risk. Thus, interventions may be most effective if they include both a brief intervention and referral to additional care. In 2017, instituting alcohol control policies including an alcohol tax was associated with lower suicide deaths, but these efforts have not been tested in a US sample (Lange et al., Citation2023). This line of inquiry would be strengthened by additional studies that explored how suicide risk changes as alcohol use decreases.

Though the association of alcohol use and suicide risk was higher among males, this is not to say that preventing problematic alcohol use in females will not be helpful. As observed in the current study, drinking scores for both men and women were high and increased suicide risk in both sexes was observed, suggesting that interventions to reduce problematic alcohol use are needed for males and females. In the context of suicide risk factors, it is possible that other factors among females elevate risks. Future studies could take a more comprehensive approach to understanding risk for suicide across sex.

It is worth noting that this sample was comprised of service members and veterans who were recruited during the COVID-19 pandemic (Tannahill et al., Citation2023). Research shows that suicide risk during the pandemic increased among those reporting problematic alcohol use (Nichter et al., Citation2021). The average level of alcohol consumption in the current sample was deemed severe according to the average score (Babor et al., Citation2016). It was not our intent to recruit a problematic drinking sample, but the timeframe of data collection and inclusion of only those that experienced MST that includes assault may explain our sample composition in the absence of purposeful sampling. The field may benefit from a replication study using a sample that was not recruited during the pandemic.

Interestingly, no differences in suicide risk were observed between those that were currently serving and those that have separated from military service. Such results suggest that suicide reduction interventions to decrease problematic drinking following MST should leverage efforts at both the DoD and the VA. Importantly, these prevention efforts should fully engage military culture and not simply rely on targeting specific individuals. Notably, identifying parts of military culture that promote unhealthy alcohol use is one potential avenue to make larger scale changes. While targeting individuals may be somewhat helpful, others have argued suicide interventions are most beneficial when they look at systematic factors (e.g. Bryan, Citation2021).

There are limitations in the current study that should be considered when interpreting our findings. We used an anonymous self-report survey and it is possible the suicide risk and rate of alcohol use was not accurately reported. Whereas we attempted to collect data from those who were currently or previously serving, it is possible the validation checks did not filter out non-military service members. Future studies may also consider using a variety of measures that assess degrees of suicide risk. Associations may differ between alcohol use, sex, and ideation and alcohol use, sex, and risk for attempt. The measure used in the current study did not allow us to test these differences without compromising the reliability of our outcome measure. Data collection was cross-sectional, so causal inferences cannot be inferred. The sample was limited to those who have served in these most recent conflicts. The sample was notably homogenous in terms of gender identity. Indeed, extant literature shows that identities other than cisgender are at heightened risk for sexual victimization and more profound mental health outcomes (e.g. Schuyler et al., Citation2020).

A future area of inquiry that would largely grow this area of literature is to examine these associations in countries outside of the US. The US has an all-volunteer force, making it notably different than other countries (e.g. Israel, Switzerland). At the same time, some of these countries limit service to males, making this type of study impossible. That said, it would be of great benefit to understand similarities and differences across cultures. Other countries that have high rates of MSA may not experience heightened problems with suicide or problematic drinking or have interventions that prevent MSA from occurring or mitigate the negative effects of MSA. We hope this study will serve as a springboard for additional studies.

Notwithstanding these limitations, the current study suggests a need to facilitate more healthy drinking habits among survivors of assault MST given their heightened risk for suicide, and such efforts may consider a stronger focus in males. Future research in this area would grow this line of inquiry by including studies that measure change over time and how results differ as a function of trauma exposure type.

Acknowledgements

We thank the men and women service members and veterans for participating in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability

Data are not publicly available but syntax and output can be made available by request to the first author.

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