Psychological Harms and Treatment of Sexual Assault and Sexual Harassment in Adults: Systematic and Scoping Reviews to Inform Improved Care for Military Populations

This study documents the following three evidence reviews focused on sexual assault and sexual harassment:

• Review 1 is a systematic review focused on psychological interventions for adult victims of sexual assault or sexual harassment in military settings.
• Review 2 is a scoping review regarding barriers to and facilitators of accessing and remaining in care for adults who have experienced sexual assault or sexual harassment in military settings.
• Review 3 is a systematic review focused on associations between (1) adult victims of sexual assault and sexual harassment and (2) three mental health conditions (i.e., posttraumatic stress disorder [PTSD], depression, and substance use disorders).

Systematic reviews tend to focus on well-defined research questions with relevant study designs identified a priori, while scoping reviews tend to be broader and include a wider variety of study designs (Arksey and O'Malley, 2005). Furthermore, systematic reviews incorporate an assessment of study quality, which is not typically a component of scoping reviews. The intended outcomes of these reviews are to promote evidence-based clinical policies using the highest standards of evidence, facilitate the implementation of effective treatments to improve the care of service members, and continue to identify gaps in clinical knowledge and barriers to care.

Across the three review topics, the research team searched the following databases: PubMed/MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Campbell Collaboration Library of Systematic Reviews, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform (ICTRP). The research team also searched gray literature to identify relevant studies from January 1, 1980, through November 2020. We screened more than 10,500 citations in the title and abstract stage, followed by a full-text screening of more than 1,050 articles against the inclusion and exclusion criteria for each review topic. Sixty-seven studies met the inclusion and exclusion criteria. For the systematic reviews, we performed an in-depth critical appraisal to assess key sources of bias in prognostic studies and the quality of evidence using the Cochrane Risk of Bias in Non-Randomized Studies–of Interventions (ROBINS-I) tool (Sterne et al., 2016) for nonrandomized studies of interventions for Review 1 and the Newcastle-Ottawa Scale (NOS) for cohort and case-control studies (Wells et al., 2013) for Review 3.

This study presents our methodology, results, and conclusions (along with evidence tables) across all three reviews. For Review 1, findings showed medium to strong effects of psychotherapy interventions in reducing PTSD and depression symptoms among adult victims of sexual assault in military settings, with low to very low ranges for the quality of evidence. In Review 2, individuals who have experienced sexual assault and sexual harassment in military settings identified barriers and facilitators that affect their ability to access and remain engaged in care. These barriers include the double stigma of the experience of sexual assault and the receipt of mental health care in the military, victims' concerns about not being believed or feeling that their experiences were not serious enough to warrant receipt of care, and victims' worries about how they might be viewed by coworkers. For Review 3, there were significant associations between sexual assault and the presence of PTSD, depression, and substance use disorders, emphasizing a link between specific mental health conditions (particularly PTSD among those in military settings) and experiences of sexual assault and/or sexual harassment. However, as in Review 1, the quality of the body of evidence varies from low to very low.

In addition to these findings, this series of reviews highlights the need for higher-quality evidence (e.g., more randomized controlled trials with a “no treatment” comparator to separate the effects of studied interventions from the effects of time in the absence of treatment; more prospective longitudinal designs that follow victims both before and after the point when trauma occurs) and identifies other critical research gaps—primarily, the need to more precisely measure and capture the setting of the sexual assault or harassment, the timing of the experience in relation to symptoms and treatment seeking and outcomes, and the need for more-diverse samples.