Childhood Abuse and Military Experience—Important Information to Better Serve Those Who Have Served

Afifi et al1 corroborate results from a recent US study showinghigherprevalenceof childhoodabuse amongpersonswith a history of military service compared with persons who did not serve in the military.2 More importantly, Afifi and colleagues show how childhood abuse was differentially associated with suicidal risk among military and nonmilitary samples, and they explore childhood abuse in the context of deployment-related traumatic experiences among military personnel. These important findings have repercussions, from epidemiology through intervention and implementation efforts, for how scientists, health care professionals, and systems tackle the issue of understanding health outcomes, including suicide risk, among individualswhohave served in the military. The finding of a greater prevalence of childhood abuse among servicemembers supports a hypothesis that, for some individuals, enlistment in themilitary may offer an opportunity to escape childhood adversity. However, this hypothesis is admittedly difficult to test because individuals either may not choose to disclose such reasons, or, even if enlistment is to escape, they likely have concomitant positive reasons for enlisting (eg, altruism,patriotism). Theescapehypothesis has been criticized as promoting a “damaging stereotype” about military personnel. Are there alternative reasons for patterns of elevated self-reported childhood abuse emerging among military samples?Arepersonswithmilitary servicemorehonest on surveys than civilians, and thusmore prone to disclose childhood abuse? Or, as Ivany and Hoge3 suggested, could broadly defining samples by “ever served in military” or surveying current active duty personnel unfairly increase prevalenceofchildhoodabusebecause thesesamples includepeople whoeithermayhavebeendishonorablydischargedormaynot finish their service terms (presuming said people are more likely to be survivors of childhood abuse)? Themanypossible explanations notwithstanding, the fact remains that current and former military personnel report high prevalence of potentially traumatic early life abuse, and scientists and systems must take heed of this. Fromascientific standpoint, researchonmentalhealth (eg, posttraumatic stress disorder) and suicide risk among active duty personnel4 and veterans5 tends to focus on militaryincurred traumas. However, an absolute focus on servicerelated exposures does not provide a complete picture. The completepictureofanyindividualcontainspixels fromthepast; some colors fade, others wax and wane, and some burn for a lifetime. Childhood abuse has clear and consistent ramifications on adult health,6 which is why the results found by Afifi et al are so compelling. Specifically, that (1) deploymentrelatedeventswerenot significantlyassociatedwith recent suicidal ideationafter controlling for childhoodabuse, and (2) the effect sizes of childhood abuse had a greatermagnitude of association than deployment-related events with recent suicidal ideation and suicide planning. Although unable to assess temporality, deployment-related events most likely occurred after childhood abuse and, thus, are themore recent exposures. Yet, itwas childhood abuse that showed the strongerandmoreconsistentassociationswithsuicidal ideationand planning. Consequently, itmakes onewonder if some soldiers had been on a battlefield long before they ever enlisted in the military. Epidemiologic studies need to gather relevant information, such as histories of childhood abuse, that can better informus as towhich individualsmayhavepotent risk factors for poor health in general and suicide risk in particular. Froma systemsperspective, the Institute ofMedicine encourages health care systems to gather data about social determinants of health, such as exposure to violence, in electronic health records.7 However, there are at least 3 types of questions that need to be examined in collecting information from health care consumers about distal and proximal exposure to violence. First, messaging to consumers that such information is pertinent to their health andwill be handled just as sensitively as any other piece of personal health information. Second, themodality bywhich such informationwould begathered.Once consumers recognizewhyahealth care systemwouldcollect informationaboutexposuretoviolence, such aschildhoodabuse,howis that informationbestcollected from those willing to offer it (ie, self-administered questionnaire, clinical interview)? Additionally, which inventory of exposure to violence shouldbe implemented?Third, themeaningfulness of this informationmust bemade clear to health care professionals. Thismay include training abouthow this informationbears on clinical care, fostering interviewskills and referral pathways, developing specific programs to offer to survivors, and exploring potential interface across systems (ie, social services, law enforcement) to construct the architecture for a more complete patient medical home. Lastly, and on a hopeful note, Afifi et al point to the finding that, despite Canadian military personnel having greater prevalenceofchildhoodabusethantheCanadiangeneralpopulation, the associationof childhoodabusewith suicidalitywas weaker for military personnel than for the Canadian general population.1 This suggests that, rather than cast a negative Related article page 229 Opinion