Combating Sexual Assault

United States Air Force Scientific Advisory Board Report on Combating Sexual Assault SAB-TR-14-04 1 August 2014 DISTRIBUTION AUTHORIZED In accordance with AFI 61-204 and DODD 5230.24, Distribution Statement A, Approved for Public Release, Distribution Unlimited This report is a product of the Air Force Scientific Advisory Board (SAB) 2014 Study on Combating Sexual Assault. Statements, opinions, findings, and recommendations contained in this report are those of the SAB and do not necessarily represent the official position of the United States Air Force or the Department of Defense. United States Air Force Scientific Advisory Board Report on Combating Sexual Assault SAB-TR-14-04 1 August 2014 (This Page Intentionally Left Blank) DEPARTMENT OF THE AIR FORCE HEADQUARTERS AIR FORCE 1180 AIR FORCE PENTAGON WASHINGTON DC 20330-1180 U.S. Air Force Scientific Advisory Board 1 August 2014 MEMORANDUM FOR THE SECRETARY OF THE AIR FORCE SUBJECT: Final Report of the U.S. Air Force Scientific Advisory Board (SAB) FY14 Study on Combating Sexual Assault In response to your FY14 tasking to the Air Force Scientific Advisory Board (SAB), on behalf of the Board I am pleased to forward the attached final report of the SAB study on Combating Sexual Assault. The SAB was asked to (i) review existing research literature on the nature of sexual assault, characteristics of both perpetrators and victims, causes for perpetrator behaviors, risk factors, patterns of abuse and victim selection, patterns related to gender or ethnicity, and detection or prevention mechanisms, (ii) review existing data on sexual assault in the Air Force and compare its prevalence and nature with that in similar organizations and with its extent in the general population, (iii) identify, review, and assess existing studies on how other organizations have reduced the incidence of sexual assault to determine the efficacy of programs for prevention or remediation, (iv) provide an understanding of the time and resources needed for the Air Force to make significant progress in this area, including identifying areas likely to yield short and long term improvements, and (v) provide recommendations for data collection and future research to be led by the Air Force or DoD organizations. The SAB formed a task force to conduct information gathering and independent analyses on this topic. The Board as a whole then deliberated on information provided by the task force, which led to the findings and recommendations in this final report. This report represents the view of the Board on this topic in response to your tasking. The Air Force Scientific Advisory Board has fully endorsed the findings and recommendations in this report, and urges their appropriate consideration and adoption. Dr. Werner J.A. Dahm Chair, U.S. Air Force Scientific Advisory Board (This Page Intentionally Left Blank) Foreword For more than a decade the United States Air Force (USAF) and its varied operational elements have realized and aimed to address sexual assault as a threat to its mission operations and the order and discipline of its workforce. As a clearer picture of the extent of the threat has emerged from societal attention, external oversight, internal focus, instruments such as workplace climate surveys, incident reporting, and in general, increased collective vigilance, Air Force leadership undertook new initiatives to address the problem (e.g., creation at Headquarters Air Force of a Sexual Assault Prevention and Response Office (SAPRO)). In addition, Air Force leadership asked the Air Force Scientific Advisory Board (SAB) to examine what advice could be gleaned from current social - behavioral science literature and to look at best operational practice across government, industry, and academia. This task included information gathering to provide a current context directly from a cross section of Air Force operational elements. This report presents the findings and recommendations of the SAB’s Combating Sexual Assault (CoSA) Study in the context of the current scientific knowledge base and the operational perspectives of “what works” (or doesn’t) in the Air Force today. Both the Study and this report were organized under four themes: prevention of sexual assault, detection of assaults and perpetrators, victim reporting of assaults, and treatment for victims of assault. These four areas were examined under a concept of a “continuum of harm” that extended from the effects of workplace sexual harassment to felony sexual assault. In addition to the recommendations for each of the four themes, there emerged four “cross-cutting” recommendations for a program of continuing research, program assessment, and implementation of promising response options which can provide the Air Force with both a clearer picture of sexual assaults and progress in defeating this threat to Air Force missions and operations. The intent of this Study was not to serve as an oversight body for Air Force prevention and response to sexual assault, nor was it to question the expertise of those Air Force personnel who treat victims and investigate sexual assault crimes; rather the intent of this Study was to understand current practice which might provide new opportunities for enhancements in the Air Force near term efforts and look beyond, through the lens of the advancing science to identify research that holds promise for current and future Air Force applications. The CoSA Study Panel received briefings from across the Air Force and other elements of the Department of Defense, other US Government organizations (e.g., notably the Department of Veterans Affairs), Federally Funded Research and Development Centers, colleges and universities, private companies, and victim advocacy groups.1 This Study was the first by the SAB focused solely in the domains of social and behavioral sciences. The Study Panel included members from Academia, University Affiliated Research Centers, and Industry; a retired USAF General Officer; and advisors from the Air Force SAPRO and the Air Force Research Laboratory’s Human Effectiveness Directorate, all 1 During the final preparation of this study report, an important adjunct to the information on sexual assault in military organizations was published. The Canadian Armed Forces have completed and made public their study on this topic (Deschamps, 2015). The information in this recent Canadian study is consistent with the information, observations, and analyses of the SAB’s CoSA Study reported herein. v representing a diverse set of technical and operational backgrounds. The undersigned acknowledge the outstanding efforts put forth by the members of the Study Panel, the volunteer Executive Officers, and Air Force SAB Secretariat members, all of whom put in long hours supporting this Study. Dr. Robert E. Foster SAB CoSA Study Chair Dr. Terry L. von Thaden SAB CoSA Study Vice Chair vi Executive Summary Introduction The purpose of this Scientific Advisory Board (SAB) Study was to aid the United States Air Force Sexual Assault Prevention and Response (SAPR) program by reviewing the social, behavioral, medical scientific literature and studying new developments in the science surrounding sexual assault as well as considering applications from the cyber sciences that could be leveraged into practical solutions. Specifically, the Study was chartered to examine the multidisciplinary scientific work and data related to sexual assault in order to help “The Air Force use that work to combat the sexual assault problem.” Thus, the Study Panel had an obligation to gather data and evidence from Air Force operational elements, to consider research findings, and to consider the current state-of-SAPR practice across demographically relevant organizations outside of Air Force and well as the practice in a diverse sample of Air Force organizations. The Study was motivated both by the stated Department of Defense (DoD) goal for combating sexual assault, “A culture free of sexual assault, through an environment of prevention, education and training, response capability, victim support, reporting procedures, and appropriate accountability that enhances the safety and well-being of all persons…” (DoD Instruction (DoDI) 6495.02), and by the Air Force’s desire for addressing this problem by gaining a deeper understanding of the nature of sexual assault and its victims and perpetrators. The Study Panel asserted the vision that, “Science and research will improve military SAPR and will improve the DoD’s overall response to eliminating sexual assault as a threat to DoD personnel, missions and readiness,” thereby achieving the DoD goal. Background The Study was organized along theme areas of prevention, detection, reporting, and treatment. The Study Panel reviewed and assessed a large body of research literature across a variety of scientific disciplines including social, behavioral, medical, and cyber sciences. The insights gained through the Study’s scientific review were put into context of Air Force operations through site visits, briefings, and interviews with a host of personnel in a variety of Air Force operational elements. Importantly, professional subject matter and program experts from the Air Force’s Headquarters SAPR Office provided data and information on ongoing and planned SAPR efforts. Additionally, information was gathered from individuals and organizations that have programs, projects, and roles in combating sexual assault in United States (US) civilian life and in college settings. Uniquely, when the Study Panel was not together at a site or communicating via email, the Study Panel met as a team every two weeks via internet meetings and telephone. Analysis The framework for analysis included consideration of human behavior and organization behavior, macro- and microcultures unique to military settings (inclusive of integrated vii workplaces with military and civilian personnel), extant legal (e.g., Uniform Code of Military Justice (UCMJ)) and personnel (Equal Opportunity, or EO) policy, and implementation of SAPR programs at local levels in the Air Force structure. There were also at least four considerations that weighed on articulating both the findings and recommendations:  The unknowns of any specific individual’s ability and maturity to work and live in the macro-microcultures of the Air Force, especially relevant to the youngest members of the force,  A known and unknown population of “sexual assault victims,”  Acknowledgement that there was a continuum of harm (harassment to assault) resulting in mental health and, often, physical effects, and  A significant population of individuals coming into the Air Force likely have a prior history of abuse (physical and sexual). The results of the Study’s analyses identified (1) areas for science-informed improvement to the Air Force’s SAPR policies2 and programs in both the near and mid-term that would improve prevention, detection, reporting, and treatment options as well as (2) recommendations for key research initiatives that would further a deeper understanding of sexual assault in military settings. In addition to findings and recommendations across the four theme areas, the Study identified cross-cutting recommendations. Findings There were a number of theme-specific findings. The SAB Combating Sexual Assault in the United States Air Force Study Panel finds that: Prevention Findings  SAPR education/training is inconsistently delivered, insufficiently assessed, and lacks a deliberately planned and tracked curriculum resulting in unknown effectiveness.  First line supervisors are most crucial to sexual assault prevention but lack sufficient education to set and maintain unit culture, confront inappropriate behavior, and foster risk management in troops.  The Air Force lacks tools and specific guidance for constructing, assessing, and maintaining prevention programs tailored to their mission and demographics. Currently leadership lacks flexible options for instantiation of a culture of dignity and respect with organization specific assessment tools. Deterrence requires visible consequences and accountability; currently consequences are inconsistent and therefore not trusted. 2 During preparation of this report the Air Force updated its SAPR policy [Air Force Policy Directive 90-60, dated 2 October 2014 - Sexual Assault Prevention and Response (SAPR) Program]. The Study Panel studied this update and concludes that it is consistent with the content, findings, and recommendations as documented in this Study report. viii Detection Findings  Scientific literature on perpetrators (e.g., serial offender, partner, and opportunist), victims, and risky situations is immature.  The Air Force lacks pre-crime situation awareness for early detection of possible perpetrators, victims, and risky situations.  There are multiple opportunities for intelligence collection to detect sexual assault (e.g., improved screening, anonymous drop boxes/email, high definition video, geo-temporal heat maps, social media mining, and investigative interviewing).  There are emerging technology opportunities to improve perpetrator detection and forecasting. Reporting Findings  The continuum of sexual assault is underreported in the Air Force.  Barriers to reporting (e.g., physiological, psychological, self-blame) often lead to a time lag between the incident, reporting the incident, subsequent investigation, and victim treatment.  Constraints on reporting path hinder reports of sexual assault and the investigative process. A sexual assault report made to the supervisory chain is classified as mandatory unrestricted. The ability of the first line supervisor to assist the victim is reduced due to mandatory unrestricted reporting.  Lack of integrated and consistent data (e.g., DoD versus Department of Veterans Affairs) may mask accurate understanding (e.g., frequency, harassment-to-assault) of sexual assault. Treatment Findings  Prior history of sexual or physical assault increases the risk for being victims of sexual assault again (i.e., risk of “kindling effect”).  There are limited studies on the effectiveness of existing treatments (i.e., “outcomes”) for females; non-existent for male and lesbian-gay-bisexual (LGB) victims.  Multiple health effects of sexual assault (physical and psychological) impact performance and create attrition.  Long term health effects of sexual assault have not been studied in military contexts.  There is a lack of understanding of the effects of stigma associated with seeking treatment.  Clinicians lack standardized training for detection of victims. Cross-cutting Findings  SAPR programs are implemented variously across the Air Force and locally co-located planning and response communities including all actors in SAPR (Special Victim ix Counsel (SVC), Sexual Assault Response Coordinator (SARC), AF Office of Special Investigations (OSI), Equal Opportunity office (EO),3 Medical, Legal, Family Advocacy Program, Security Forces, etc.) should improve efficiency and effectiveness of a victim-centered program.  To assist Wing/Squadron (or equivalent) level leadership there are few, if any, with empirically validated tools for implementing culture change and assessing results.  Neither a SAPR research development, test, and evaluation resourced research program nor a sufficient research infrastructure for new initiatives addressing the full spectrum of SAPR exist in the Air Force.  There is an immediate and critical need for ongoing measurement and assessment programs to examine Air Force wide outcomes (ongoing and new), “continuous assessment process” of SAPR prevention and treatment initiatives, and addressing the male and LGB victim community. Recommendations There were both theme-specific recommendations as well as four key cross-cutting recommendations. Where appropriate, the recommendations are categorized into near term4 and mid-far term5 goals. The Air Force Scientific Advisory Board (SAB) Combating Sexual Assault (CoSA) in the United States Air Force Study Panel recommends that the Air Force should: Prevention Recommendations Near Term  Implement a pilot program to educate and empower first line supervisors to proactively develop/maintain unit culture (e.g., instantiating dignity and respect).  Initiate a SAPR strategic communications campaign including not only survivor stories but also disciplinary actions, harassment scenarios, strategies for bystanders and core value discussions.  Mandate an empirically validated assessment of all sexual assault prevention programs. Mid-Far Term  Apply research findings to improve overall education and training. Tailor training for evidence-based content, length, etc. Update and continue bystander training. Plan and coordinate training opportunities such as entry, base arrival, periodic/annual, 3 The Study Panel noted a wide variation between the Services and within Services with regard to referring to equal opportunity offices/organizations as “EEO” or “EO.” Within this report the “EO” acronym is used for consistency. 4 Near Term refers to an action that could be taken and/or an initiative that could be started within one year of the approval of the study’s recommendations. 5 Mid-Far Term refers to a time period of greater than one year. Additionally, the Study Panel considers 2-5 years to be the timeframe for any use of the phrase Mid-Term. x schoolhouse/leadership, stand-down days; consider current Career Field Education and Training Plan process as a model.  Leverage the Air Force safety culture, institutionalize a “Dignity and Respect” culture change program by engaging leadership, operations, formal, and informal systems.  Implement and assess a Social Marketing Campaign, tailored to the Air Force context.  Recruit and educate peer social influencers and peer counselors to change the Air Force culture from within. Detection Recommendations Near Term  Develop pre-crime heat maps for sexual assault by leveraging existing technology, e.g., high definition cameras, drop boxes, etc.  Develop an Air Force wide sexual assault threat picture, enabling anticipatory alerting and global pre-crime engagement.  Develop a knowledge management strategy and system to capture and appropriately share incidents (e.g., equal opportunity offices (EO), SARC, OSI data) Air Force wide to enable system wide situation understanding (e.g., to deter across-base perpetrators; to support research). Mid-Far Term  Enhance situation awareness by closing key science gaps in surveys, models and detection, including: (1) Advancing survey science and perpetrator/victim behavior models, and (2) Leveraging emerging science and technology to enhance perpetrator detection. Reporting Recommendations Near Term  Allow first line supervisors the authority to advise victims while suspending requirement for unrestricted reporting (e.g., refer to SARC, provide grace period for counseling, without requirement for mandatory unrestricted reporting). A victim should not lose ability to file restricted report based on to whom they talk.  Establish policy to minimize career disruption for victims and to minimize retaliation for victims and bystanders who report. Consider policy to allow immunity for low level collateral misconduct uncovered as a result of a sexual assault investigation.  Improve rapid coordination between victim care and investigative process (e.g., EO, SARC, and OSI).  Coordinate with Department of Veterans Affairs Disability Rating Activity Site to obtain sexual assault demographic data on active duty and retired airmen. xi Treatment Recommendations Near Term  Improve screening methods, victim identification, and understanding of long-term health effects. Conduct sexual assault screening in primary care and on the preventative health assessment. Develop clinical standards for detection of sexual assault victims. Adjust current survey platforms to capture the unmet health care needs of victims who choose not to report, and include survey items that elucidate the effects of stigma on seeking healthcare. Initiate Air Force wide longitudinal cohort study on airmen (enlisted and officers) to determine long term health effects throughout their career.  Initiate an Air Force Medical Service program to assess the effectiveness of current Air Force treatment approaches for victims. Mid Term  Initiate an Air Force Medical Service program to develop new therapeutic approaches for providing standardized holistic care to meet the physical and psychological health needs of victims.  Establish health-based return-to-duty standards for airmen recovering from sexual assault. Cross-Cutting Recommendations Near Term  Support and enable bases to develop coordinated and co-located planning and response communities including: SVC, SARC, OSI, EO, Medical, Legal, Family Advocacy Program, Security Forces, etc.  Assist Wing/Squadron (or equivalent) level leadership with empirically validated tools for implementing culture change and assessing results.  Create a SAPR research program addressing identified gaps, leveraging the current science base. Establish research infrastructure for new initiatives addressing the full spectrum of SAPR.  Charter a SAPR assessment program including: Air Force wide outcomes (ongoing and new), “continuous assessment process” of SAPR prevention and treatment initiatives, and addressing the male and LGB victim community. Conclusion The results of the Study’s analyses identified areas for science-informed improvement to the SAPR policies and programs in both the near and mid-term that would improve prevention, detection, reporting, and treatment options as well as recommendations for key research initiatives that would further a deeper understanding of sexual assault in military settings. Cross-cutting xii findings and recommendations offer advice that, in our opinion, can only be implemented through direction and leadership by the senior most civilian and military leadership in the Air Force. Based on extensive evaluation the CoSA Study Panel concludes that while the Air Force has made positive strides toward combating sexual assault, the efforts have remained localized, siloed within policies and organizations, inconsistent, and suffer from a lack of integrated enduring leadership at the Air Force’s Sexual Assault Prevention and Response command level, which has changed every two years. Air Force installations and headquarters need coordination among response, support, and investigative disciplines; and Air Force wide need proactive, integrated education and training, culture change, and deterrence. Finally, we learned that a general, Air Force-wide program probably won’t work well (i.e., need for tailoring of at least prevention and detection strategies/programs). At best the science base offering solution options for this complex social, behavioral challenge within the military is sparse. xiii (This Page Intentionally Left Blank) xiv Table of Contents Foreword …………………………………..…………………….……………..……………..…. v Executive Summary ………………….…………………………….…………….……………... vii Table of Contents …………………..……...………………..…………………..……….…..…. xv Table of Figures …………………..……...…….………………….…………..…...…….…… xvii Chapter 1: Terms of Reference, Study Scope, and Approach ....................................................... 1 1.1 Terms of Reference ............................................................................................................ 1 1.2 Study Scope ........................................................................................................................ 1 1.3 Approach ………………………………...................................................................……. 3 Chapter 2: Introduction .................................................................................................................. 7 2.1 Introduction ........................................................................................................................ 7 2.2 Overview of combatting Sexual Assault in the Air Force …………..........….........…….. 9 2.3 Background ...................................................................................................................... 10 2.4 Discussion ........................................................................................................................ 11 Chapter 3: Prevention ................................................................................................................... 17 3.1 Prevention Introduction .................................................................................................... 17 3.2 Prevention Discussion ...................................................................................................... 18 3.3 Findings ............................................................................................................................ 30 3.4 Recommendations ............................................................................................................ 31 Chapter 4: Detection .................................................................................................................... 33 4.1 Detection ........................................................................................................................... 33 4.2 Scientific Foundations ...................................................................................................... 33 4.3 Findings ............................................................................................................................ 41 4.4 Recommendations ............................................................................................................ 44 4.5 Summary .......................................................................................................................... 46 Chapter 5: Reporting .................................................................................................................... 47 5.1 Reporting .......................................................................................................................... 47 5.2 The Reporting Challenge ................................................................................................. 49 5.3 Summary of Findings........................................................................................................ 51 5.4 Recommendations ............................................................................................................ 64 xv Chapter 6: Treatment .................................................................................................................... 69 6.1 Framework: Air Force Medical Response to Health Effects of Sexual Assault .............. 69 6.2 The Process Leading to Evidence-Based Treatment ........................................................ 70 6.3 Summary of Findings ....................................................................................................... 72 6.4 Recommendations ............................................................................................................ 78 Chapter 7: Cross Cutting .............................................................................................................. 81 7.1 Introduction ...................................................................................................................... 81 7.2 Discussion ........................................................................................................................ 81 7.3 Enabling Coordinated SAPR Program (Planning and Response) Implementation ......... 81 7.4 Creating and Chartering a SAPR Program of Ongoing Research and Assessment ......... 82 Chapter 8: Findings and Recommendations Summary ............................................................... 83 8.1 Findings ............................................................................................................................ 83 8.2 Recommendations ............................................................................................................ 84 Appendix A: Survey Method Options …….……...................................................…………… 87 A.1 Treatment Survey Research ............................................................................................. 87 A.2 Survey Study Design Options ......................................................................................... 89 A.3 A Way Ahead .................................................................................................................. 92 Appendix B: Knowledge Contributions Consulted as Background …….…......…...………… 93 Appendix C: Terms of Reference …….……...……………….…..……………...………….. 101 Appendix D: Study Members ………………………….…..…..………………......…..……. 103 Appendix E: References .......................................................................................................... 105 Appendix F: Glossary ……………………………………………………..………...………. 121 Appendix G: Acronyms and Abbreviations ………………………………………...…….…. 127 Appendix H: Initial Distribution List …………………….……..………...………................. 129 xvi Table of Figures Figure 2-1 Figure 2-2 Figure 2-3 CoSA Study Continuum of Harm from Sexual Harassment to Sexual Assault ...…. 7 Identified Areas for the CoSA Study …………………………………….………. 10 Sampling of Peer Reviewed Literature ………………………………..…………. 11 Figure 3-1 Figure 3-2 Figure 3-3 Prevention Overview: Education and Training, Culture, and Deterrence …….…. 17 There are Multiple Means for Understanding and Addressing Prevention …........ 21 Summary of Research on Effective Trainer, Content, and Delivery Strategies …. 24 Figure 4-1 Military Statutes Regarding Sexual Harassment, Contact, and Assault …….…… 33 Figure 4-2 Science Regarding Perpetrator, Victim, and Situation ………………..…………. 33 Figure 4-3a Opportunities for Technology Leverage: Service-wide, Base, & Community Situation Awareness ………………………..................……………. 43 Figure 4-3b Opportunities for Technology Leverage: Cyber/Physical Surveillance …..…..…. 43 Figure 5-1 Figure 5-2 Figure 5-4 Military Statutes Regarding Sexual Harassment, Contact, and Assault …...….…. 47 Framework, Considerations, and Specific Areas of Inquiry for the Reporting Area of the CoSA Study ………....................................………………. 49 Air Force SAPRO Data and DoD-wide WGRA Survey Extrapolations on Incidents of Sexual Assault in the Air Force …………………………………. 50 Categorization of Barriers to Reporting Sexual Assault …………………………. 52 Figure 6-1 Figure 6-2 Figure 6-3 Figure 6-4 Figure 6-5 The Treatment Framework Used in the CoSA Study ……………………………. 70 The Pathways for Receiving Care Following a Sexual Assault ………………….. 71 Decision Context can be Very Personal …………....………………….…………. 72 Prior History of Sexual Abuse in Military Personnel ……………………………. 73 Results of Meta-Analysis on Psychotherapy Effectiveness ……………………… 74 Figure 5-3 Figure A-1 Survey Study Design: Two Types (Observational and Experimental) Relevant to SAPR Research ……………………..….........................……………. 88 xvii (This Page Intentionally Left Blank) xviii Chapter 1: Terms of Reference, Study Scope, and Approach 1.1 Study Terms of Reference The Air Force Scientific Advisory Board (SAB) was charged by the Secretary of the Air Force to conduct a study that would:  Review existing research literature on the nature of sexual assault, characteristics of both perpetrators and victims; causes for perpetrator behaviors; risk factors for victimization; patterns of abuse and victim selection; patterns related to victim and perpetrator demographics, including gender, ethnicity, rank, and Air Force Specialty Code; and detection or prevention mechanisms.  Review existing data on sexual assault in the United States Air Force (USAF) and compare its prevalence and nature with that in similar organizations and with its extent within the general population. Consider behavioral (e.g., prevalence of alcohol use), cultural, and organizational factors within the Air Force that may contribute to the problem or allow it to continue, or that may be leveraged to help reduce the problem. Examine other programs that have been used to create cultural and behavioral changes in the Air Force and their applicability to this problem.  Identify and review existing studies on how other organizations, groups, and companies have reduced the incidence of sexual assault to determine the efficacy of programs for prevention or remediation. Assess the validity of study findings and applicability to the Air Force problem.  Based on the above tasks, help the Air Force to identify potential abusers and defuse situations that might lead to assault by: o Enabling a better understanding of the time and resource commitment needed to make significant progress. o Identifying areas more likely to yield both short term and long term improvements, such as comparing actions affecting recruiting versus those addressing training or comparing ways to help potential victims versus means to identify potential predators. o Providing recommendations for improved data collection, relevant metrics, and further research to be led by the Sexual Assault Prevention and Response Office, other Air Force, or Department of Defense (DoD) organizations. Note: The complete Combatting Sexual Assault (CoSA) Study Terms of Reference (ToR) is provided at Appendix C of this report. 1.2 Study Scope The SAB Study Panel was organized to help with United States Air Force’s Sexual Assault Prevention and Response (SAPR) programs around the principal vision that, “Science and research will improve military SAPR and will improve the DoD’s overall response to eliminating sexual assault as a threat to DoD personnel, missions, and readiness,” thereby 1 achieving the DoD goal of, “A culture free of sexual assault, through an environment of prevention, education and training, response capability, victim support, reporting procedures, and appropriate accountability that enhances the safety and well-being of all persons,” (Office of the Secretary of Defense (OSD), DoDI 6495.02, 2013). It was agreed that the ToR for this Study met with the vision of the overall SAB, that science and research will improve military SAPR and will improve DoD’s overall response to eliminating sexual assault as a threat to DoD personnel, missions, and readiness thereby achieving the DoD goal. The Study Panel reviewed and assessed a large body of research literature across a variety of scientific disciplines including social, behavioral, medical, and cyber sciences. The insights gained through the Study’s scientific review were put into context of Air Force operations through site visits, briefings, and interviews with a host of personnel in a variety of Air Force operational elements. Additionally, information was gathered from individuals and organizations that have programs, projects, and roles in combating sexual assault in US civilian life and in college settings. Uniquely when the Study Panel was not together at a site or communicating via email, the Study Panel met as a team every two weeks via internet meetings and telephone. Given the limited resources and timing involved in this Study, the Study Panel included focus items in problem areas, solution areas, and environmental areas as objectives. In identifying the problem areas to be studied, the Study Panel focused on the continuum of harm from sexual harassment to sexual assault. This includes abusive and unwanted sexual contact; rape and assault; both male and female victims,6 and Lesbian, Gay, and Bisexual (LGB) victims.7 The Study Panel focused on four solution areas for the CoSA Study: 1. Prevention of sexual assault, 2. Perpetrator detection, 3. Incident reporting, and 4. Victim treatment (i.e., medical and psychological care). When considering the environment surrounding the sexual assault issue, the Study Panel focused on active duty Airmen,8 Reserve Airmen, and National Guard Airmen, as well as the organizational climate/culture within which they live and work. The Study Panel also determined key areas that would not be included in the Study. In the problem area, they Study Panel determined that focus groups specifically consisting of victims of sexual assault were not within the purview of this Study. First and foremost the Study Panel concluded that the mental health of survivors of sexual assault should be preserved and was best left in the hands of clinical experts. The sensitive nature of discussion and possible retraumatization of the victim disqualified this as an area for the Study. However, in the course of conducting focus groups during the Study, several victims of sexual assault self-identified to the Study Panel. The other area of consideration was the confidential nature of victim status. 6 The Study Panel is sensitive to the term “victims” and recognizes the term “survivor” may be preferable. However, an editorial decision has been made to use language contained in the Military Statutes. 7 The Study Panel recognizes the accepted terminology of Lesbian, Gay, Bisexual, and Transgender (LGBT) however made the editorial decision to use the term LGB since military service policy is not open for Transgender individuals to enlist at the time this report was compiled. 8 The term “Airmen” as used in this report refers to both male and female Air Force members. 2 In the solution area the military justice system is an integral part of identifying sexual assault perpetrators and enforcing the law to bring them to justice. Psychological treatment of sexual assault perpetrators was not included in this Study, as well as their sentencing and management in the military justice system. Also not included in solution areas of the Study were options from the Department of Veterans Affairs (DoVA) as a whole. Though the DoVA provides important and necessary care and treatment for survivors of sexual assault, it was determined to be outside the scope of the present study of active duty airmen. When considering the environment the Study Panel did not focus on the United States Air Force civilian and contractor workforce because this would broaden the investigation to a scope greater than the resources provided to this Study. The Study Panel also did not consider DoD-wide solutions though many of the findings and recommendations of this Study may be applicable DoD-wide. 1.3 Approach The Study Panel’s approach was to utilize a deep dive technique of brainstorming, investigating the science and peer reviewed literature, face to face meetings lasting three to seven days, gaining feedback from subject matter experts, performing focus groups, and conducting site visits at select military bases, universities, hospitals, etc. Members of the Study Panel held extensive internet and telephone meetings every two weeks, and were in constant near-daily contact by email throughout the study period. Prior to the Study Panel’s first face to face meeting in January 2014, the Study Panel identified a host of individuals in functional elements within the Air Force fundamentally involved with combating sexual assault. The Study Panel sought the support of these professionals in internet meetings and site visits. Specifically professional perspectives were sought to integrate and understand the problem set with research perspective, and process what was learned into a set of recommendations. Given the vision of the SAB, the Study Panel particularly focused on the scientific literature and leading research as areas to improve military SAPR. Improving SAPR will improve the USAF’s overall response to eliminating sexual assault as a threat to airmen, missions, and readiness, thereby achieving a goal of a culture of dignity and respect in the USAF. The Study Panel’s vision was to identify evidence-based, outcome oriented strategies for the prevention of sexual assault in the USAF through proactive, integrated education and training, culture change, and deterrence. Each USAF site consulted represented a unique operational perspective. Among those consulted,9 the Study Panel received information from the AF Recruiting Service, Air Force Major Commands (Air Education and Training Command, Air Mobility Command, Air Combat Command, AF Space Command, and the US Air Force Academy (USAFA)). Specifically, during each consultation, the Study Panel focused on professional perspectives such as:  AF Office of Special Investigations (OSI) Regional and Headquarters  Public Affairs 9 The Study Panel recognizes the sites selected and the panels recruited for interview may not be statistically representative across the USAF. However, the Panel considers the information gained through qualitative examination to provide insight into the SAPR issue as experienced by current airmen. 3  Wing, Group, Squadron Commanders, Company Grade Officers, Senior Noncommissioned Officers, Noncommissioned Officers (NCO), Junior Enlisted Airmen, and Cadet panels (USAFA)  Chaplain Support  Researchers o Survey Professionals o Psychologists  Sexual Assault Response Coordinator (both within the Continental United States (CONUS) and Deployed)  Victim Advocates  Sexual Assault Nurse Examiner (SANE)  Special Victim Counsel (SVC),  Judge Advocate General  Recruiting and Military Training In addition to USAF organizations, the Study Panel sought specific briefings from programs within the Office of the Secretary of Defense (OSD). These included:  Sexual Assault Prevention Response Office (SAPRO)  DoD Hotline  Defense Manpower Data Center (DMDC) o Workplace and Gender Relations Survey of Active Duty Members (WGRA)  Defense Equal Opportunity Management Institute o Local surveys at Wing and Squadron Commander level  San Antonio Military Health System Program and other briefings from the US Army to the CoSA Study Panel included those from:  US Army Medical Research and Materiel Command at Fort Detrick  US Army Sexual Harassment/Assault Response (SHARP) o US Army version of SAPRO – integrated SAPRO and Equal Opportunity (EO) Department of Veteran’s Affairs offices providing briefings to the CoSA Study Panel included:  Military Sexual Trauma Coordinator  South Texas Veterans Health Care System  Department of Veteran’s Affairs Nellis Air Force Base (AFB) 4 Each academic body consulted represented an opportunity to learn best practices and implementation program surrounding Title IX programs from leading institutions.10 Among those consulted, the Study Panel focused on large universities, small colleges, and leading programs developed for peer support to prevent sexual assault on campuses. Several corporate, non-governmental organizations, and Federally Funded Research and Development Centers representing leading edge programs, services, or bodies of information were also consulted. 10 Title IX of the United States Education Amendment of 1972, originally established to prevent sex discrimination in education, requires US colleges to take immediate action and have concrete procedures in place to handle reports of sexual violence. 5 (This Page Intentionally Left Blank) 6 Chapter 2: Introduction 2.1 Introduction The Study Panel developed a continuum of harm within which to frame the issue of sexual assault for the Air Force CoSA Study. The continuum ranges from sexual harassment, which is a form of sexual discrimination, to assault and rape. The continuum includes attitudes and beliefs, which can be considered a “grey area” concerning harassment, to the extreme injury of physical assault which is clearly a crime. The Study Panel maintains that any form of sexual harassment is an intrusion that violates the Air Force’s culture of dignity and respect. Though sexual harassment may not involve physical contact, it creates an environment that is no less psychologically harmful to the victim than that of assault. Figure 2-1 below illustrates the continuum of harm as it applies to the victim in the situation and the articles of prosecution of which the perpetrator of the harm is in violation. For the purposes of this report, the term sexual assault, unless otherwise indicated, refers to the continuum of harm from harassment to assault. Figure 2-1. CoSA Study Continuum of Harm from Sexual Harassment to Sexual Assault. Defined as a form of sex discrimination that violates Title VII of the Civil Rights Act of 1964, sexual harassment describes unwelcome and unwanted sexual advances, or other verbal or physical conduct of a sexual nature. Title VII prohibits discrimination in employment on the basis of sex, race, color, national origin, and religion, and it applies to employers with 15 or more employees, including federal, state, and local governments. Harassment can include offensive remarks about a person’s gender. For example, it is illegal to harass a female by making offensive comments about females in general. Both victim and harasser can be either female or male, and a victim and harasser can be the same gender. The law however, does not prohibit simple cases of teasing, offhand comments, or isolated incidents that are not very serious. Harassment is illegal when it becomes so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as a victim being fired, demoted, or ineligible for advancement). The harasser can be a victim’s direct supervisor, a supervisor in another area, a co-worker, or someone who is not an employee of the employer, such as a client or customer. Air Force Policy Directive 36-27 also defines the Air Force Military Equal Opportunity program that addresses Air Force core values, the Airman’s Creed, and serves as a principle in 7 the day-to-day actions of all Air Force personnel. The policy states that the Air Force will not tolerate unlawful discrimination and unlawful harassment or reprisal against individuals who engage in protected activity, and that airmen must actively make workplace professionalism a top priority and take proactive steps to prevent, correct, and eliminate unlawful discriminatory behavior. The program recognizes the unique characteristics of military service and that United States Congress has exempted military members from numerous labor and civil rights statutes applicable to civilian employees. The Military Equal Opportunity policy ensures that both the legally mandated standards and requirements for civilian employment and the military equal treatment of discrimination complaints are met at each stage of adjudication. There is also a separate and distinct military justice system applicable to members of the United States armed forces. These are set forth in Title 10 of the United States Code, Chapter 47, of the Uniform Code of Military Justice (UCMJ), which is implemented by the Manual for Courts-Martial. The purpose of the UCMJ is to promote justice, to assist in maintaining good order and discipline, to promote efficiency and effectiveness, and thereby strengthening the national security of the United States. A summarization of applicable UCMJ prosecutable offenses pertaining to the continuum of sexual assault are summarized below. Article 80 offenses:  Attempts – an act done with specific intent to commit an offense (1) The accused did a certain overt act (2) The act was done with the specific intent to commit a certain offense under the code (3) The act amounted to more than mere preparation (4) The act apparently tended to effect the commission of the intended offense Article 92 offenses:  Failure to obey order or regulation (1) Violates or fails to obey any lawful general order or regulation (2) Having knowledge of any other lawful order issued by a member of the armed forces, which it is his duty to obey, fails to obey the order (3) Derelict in the performance of his duties Article 93 offenses:  Cruelty and maltreatment (1) Person was subject to orders of accused (2) Accused was cruel toward, oppressed, or maltreated that person Article 120 offenses:  120(a) – Rape (1) Penetration (2) By force, threat of death/grievous bodily harm, drugging 8  120(b) – Sexual Assault (1) Penetration (2) By threat, harm, pretense, or when victim is asleep/impaired  120(c) – Aggravated Sexual Contact (1) Non-penetration (2) By force, threat of death/grievous bodily harm, drugging (3) With requisite intent (arouse, abuse, humiliate, etc.)  120(d) – Abusive Sexual Contact (1) Non-penetration (2) By threat, harm, pretense, or when victim is asleep/impaired (3) With requisite intent (arouse, abuse, humiliate, etc.) Article 125 offenses:  125(a) – Unnatural carnal copulation (1) Penetration, however slight (2) Act performed on child <16 (if applicable) (3) Act performed by force and without consent (if applicable) Article 133 offenses:  Actions unbecoming of an Officer (1) Person did or omitted to do certain acts (2) These acts or omissions constituted conduct unbecoming an officer Article 134 offenses:  Adultery (1) Accused wrongfully had sexual intercourse with a certain person (2) At the time, the accused or the other person was married to someone else (3) The conduct of the accused was to the prejudice of good order and discipline in the armed forces or was of a nature to bring discredit upon the armed forces 2.2 Overview of Combating Sexual Assault in the Air Force In Fiscal Year (FY) 2013 the US Air Force received 635 unrestricted reports of sexual assault and 412 restricted reports of sexual assault.11 In his focused efforts to lead the Air Force in addressing the sexual assault threat, the Chief of Staff of the Air Force contacted the SAB Chair with the request to consider what the science community could contribute to the Air Force’s efforts to combat sexual assaults. Agreeing to take on a formal SAB study effort in this domain, the resulting Terms of Reference and CoSA Study framework were organized along theme areas of prevention, detection, reporting, and treatment (Figure 2-2 below). The Study 11 Initially 488 restricted reports were filed. Of these 76 converted to unrestricted reports. 9 Panel reviewed and assessed a large body of research literature across a variety of scientific disciplines including social, behavioral, medical, and cyber sciences. The insights gained through the Study’s scientific review were put into context of Air Force operations through site visits, briefings, and interviews with a host of personnel in a variety of Air Force operational elements. Additionally, information was gathered from individuals and organizations that have programs, projects, and roles in combating sexual assault in US civilian life and in college settings. Uniquely when the Study Panel was not together at a site or communicating via email, the Study Panel met as a team every 2 weeks via internet meetings and telephone. Figure 2-2. Identified Areas for the CoSA Study. 2.3 Background The Study Panel recognizes the ongoing efforts of the Air Force to deal with the sexual assault issue. Since the original 2005 DoD Directive (DoDD 6495.01) the Air Force SAPR has installed numerous programs at major commands and installations. Recent SAPR initiatives include:12  Air Force leadership recognizes sexual assault problem importance and began to address  Reinforcement of “culture of dignity and respect”  Service-wide health and welfare inspections  Airman’s “Bill of Rights”  “Every Airman Counts” initiative  OSD-driven SAPRO initiative to review alcohol policies  Special Victims Counsel (personal legal victim representation)  Basic Military Training (BMT) program changes  Provision of additional SARCs  SAPR Stand Down Day  Revision of SAPR policy guidance and training curriculum In addition to considering the ongoing Air Force efforts, the Study Panel received information on and interacted with program officials in the Office of the Secretary of Defense’s 12 This list is not exhaustive. 10 SAPR Office. Additionally and to the extent possible, information from the Army’s and Navy’s efforts was sought and considered. 2.4 Discussion The Study Panel employed a multidisciplinary approach to a review of the literature and latest research. The Study Panel consulted multiple specializations including medical sciences, criminology, victimology, psychology, neuroscience, sociology, psychiatry, violence, security, military studies, human factors, cybercrime, and sexual behavior, to name but a few. Figure 2-3. Sampling of Peer Reviewed Literature. 2.4.1 Understanding Sexual Assault Through the Lens of Safety Culture The battle to eliminate sexual harassment to sexual assault must have constant and continual commitment; this includes everyone from enlisted to officer, contractor to civilian. To move toward the goal of eliminating sexual assault in the Air Force, one must change the culture wherein this behavior occurs. At each base visit the Study Panel listened to stories of an Air Force culture where harassment had been tolerated as a way of fitting in or as part of the onboarding unit strategy. This culture would be pushed farther and become more typical, often leading to the blurred lines between what is sexual harassment and what is sexual assault. Leadership at each base recognized the importance of setting the tone for the Air Force culture of dignity and respect, wherein harassment and assault are not tolerated. However, there was concern, and at times confusion, on how to do so. Schein (2010) describes organizational culture as a, “pattern of shared basic assumptions that the group has learned as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.” Culture represents the values, beliefs, and behaviors that people 11 share; it can bind groups together and provide cues and clues for behavior in certain situations. When these values represent negative characteristics of culture that are normalized and interspersed with what it means to be an airman or part of a team, changing entrenched cultural beliefs can be daunting. Leadership at each base and throughout the Air Force is clearly dedicated to building and sustaining a culture of dignity and respect, however the Study Panel found that the understanding of how to implement cultural change in regard to sexual harassment and sexual assault in the Air Force is not as clear. The Study Panel suggests that understanding culture and focusing on change becomes more tractable when the effort can be focused by leveraging the concept of safety culture. Safety culture has been defined as the enduring value and priority placed on worker and public safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety; act to preserve, enhance and communicate safety concerns; strive to actively learn, adapt and modify (both individual and organizational) behavior based on lessons learned from mistakes; and be honored (or held accountable) in a manner consistent with these values (Wiegmann, et al., 2001; von Thaden & Gibbons, 2008). Two principles within a safety culture are to identify safety problems before they result in an undesirable event and to share information so it is appropriately meaningful to everyone in an organization (von Thaden, 2013). 2.4.2 Key Indicators of Safety Culture Key indicators of safety culture include Organizational Commitment to Safety, Operations Interactions, Formal Safety Indicators, and Informal Safety Indicators. These indicators are correlated with professional ethics and perceptual behaviors. There is no single element of importance, but rather an integrated relationship between the cultural aspects of safety at an organization that demonstrates the strengths in its alignment and continually seeks ways to address discrepancies and close safety gaps. The following describes these indicators (von Thaden & Gibbons, 2008): 2.4.2.1 Organizational Commitment Organizational commitment to safety refers to the degree to which leadership prioritizes safety in decision-making and allocates adequate resources to safety management. In particular, this represents the attitudes and values expressed in words and actions by leadership. This reflects the commitment to safety at the top levels of the organization, the fundamentals of rules and regulations, such as training requirements, manuals and procedures, and the coordination of activity within and between teams/units, and the priority given to safety in the allocation of resources (e.g., equipment, personnel) even when they are beyond what is required by regulations (e.g., such as providing advanced technology when basic technology is all that is required). 2.4.2.2 Operations Interactions Operations interactions is reflected in working relationships with middle management, supervisors, and other support personnel, who take into account involvement in and concern for safety on their part. This entails the priority given to safety and the regard for the actual risks. This also refers to the degree to which those directly involved in supporting work, the 12 supervision, and/or the training of personnel are actually committed to safety and reinforce the safety values espoused by leadership. 2.4.2.3 Formal Safety Formal safety indicators refer to organizationally instantiated procedures and systems for reporting and addressing safety hazards. It is not enough for an organization to have a system to collect event data; it must be a system that encourages reporting. Concerns center on the accessibility, familiarity, and actual use of the reporting system. Is the system used as per its intent, do personnel feel safe using it, and do they, in fact, use it? There is also a necessary timely and appropriate response and feedback to reported information, and dissemination of this information to other personnel who are not directly involved. Once data is captured, it should be analyzed and shared on a routine basis so that safety lessons may be learned throughout the organization. Persons in formal safety roles should also be perceived as effective and responsive. Do they actively exchange information and promote best practices? Do safety personnel systematically track data trends in an effort to reduce or eliminate emerging problem areas? 2.4.2.4 Informal Safety In contrast to formal safety indicators, informal safety indicators refer to the unwritten rules pertaining to behavior, including rewards and punishments for safe and unsafe actions and the manner in which such rewards and punishments are instituted justly and fairly. Specifically, informal safety indicators include such factors as accountability, authority (empowerment), and professionalism. Are personnel consistently and appropriately held accountable, or blamed, for hazardous behavior? Is there a competent investigation of events that identifies systemic deficiencies? Concerns center on justice and preferential treatment. As front line personnel represent the eyes and the ears of the organization, they are well suited to propose solutions that may prove effective in curtailing improper behaviors or processes. They should also be empowered to intervene in barring improper behaviors. Professionalism and the ethical standards of the peer culture group norms set the stage for implementing and committing to safe, consistent behavior. 2.4.3 Safety Behaviors and Perceptions of Risk Safety culture is expected to predict both safety behaviors among personnel and their perceptions of risk (Cooper & Phillips, 2004; Rundmo, 2000). Knowing which safety factors are most strongly related to outcomes indicates the relative importance of each factor in how the culture is shaped and suggests directions in which to focus improvement efforts (von Thaden & Gibbons, 2008). There are many different ways in which safety outcomes might be assessed. Lee & Harrison (2000) identified personnel’s negative attitudes as significantly associated with the likelihood of an accident, or in the case of sexual assault, harm. Neal & Griffin (2006) verified the latent effects of this same concept between safety climate and accident rates demonstrating that group safety climate shapes individual safety motivation, which in turn influences individual safety behavior, and thus accident (harm) rates. Perceptions of risk (harm) reflect the experiences and expectations of personnel on the front lines who have the most opportunity to observe their own and others’ behavior. Through understanding personnel’s perceptions of the prevalence of harmful behaviors, such as deviations from dignity and respect 13 standards, and the attitudes personnel have toward such deviations, an organization can address the attitude for the priority or disregard of dignity and respect displayed in certain circumstances. Major, intentional behavior disregarding dignity and respect in the Air Force is most likely infrequent, and personnel are unlikely to report such behaviors. It is behaviors seen as minor that reflect more common (and perhaps more accepted) deviations which nonetheless breach appropriateness and can result in undesired harassment. Understanding the patterns of these behaviors allows a measure of safety climate and thus the importance of personal action to be related to the overall safety culture of an organization. It is important to address personnel’s beliefs about the likelihood of negative behaviors in the organizational as a whole. They constitute a global evaluation of personnel’s assessments of the overall safety level. This allows the assessment of the factors personnel perceive as out of their control and in the hands of “the Air Force” itself (i.e., the demonstrated leadership climate). 2.4.4 High Reliability Organization A tenet of safety culture is the theory of the High Reliability Organization. According to Weick & Sutcliffe (2007) there are five key characteristics of a High Reliability Organization: 1. Preoccupation with Failure. Attention to detail is focused on errors and near-misses, learning from them and determining how to prevent their future repeat rather than simply reacting to incidents. Finding and fixing problems is everyone’s responsibility and is encouraged and supported by leadership. 2. Commitment to Resilience. Breaches will happen that cannot be predicted; mistakes will be made, and individuals will get into trouble. To minimize harm, resilient organizations quickly identify issues and have structures in place to immediately respond, improvising when the need arises. 3. Reluctance to Simplify Interpretations. Constantly asking “why” and inviting others with diverse experience to express their opinions. The idea is to avoid thinking about potential failure as a single, simple cause and to leverage other’s objective observations; to question areas that need questioning. 4. Sensitivity to Operations. An ongoing concern with the rooting out the unexpected. Features include finding anomalies, closing loopholes in processes where there is potential for individual harm, empowering individuals to speak up, paying attention to the frontline, and maintaining situational awareness. 5. Deference to Expertise. Finding and using expertise for a given problem at a given time. Recognizing that those closest to the frontlines may be the individuals with the most knowledge relevant to the issue, and empowering them to make decisions. When critical issues arise this allows organization to prevent and respond to problems effectively and results in swifter mitigation of harm. In High Reliability Organizations, senior leaders conduct frequent walk-arounds to reinforce safety behaviors. In so doing, they find and readily fix safety issues. They also conduct frequent operational briefings to study prior failures and anticipate areas of vulnerability to predict and diminish areas of risk or harm. 14 2.4.5 Safety Culture Opportunities and Key Implementation Questions The Study Panel determined that understanding prevention, detection, reporting, and treatment as they relate to the overall safety culture surrounding sexual assault provides the best opportunity to develop tractable methods to confront the issue. Key questions for the Air Force with respect to implementation of safety culture are:  Organizational. What are the leaders’ messages from above? Leadership talks the talk, but do they walk the walk? Have programs and policies been fully developed and put in place to proactively halt sexual harassment/assault in the Air Force? Does the Air Force go above and beyond what is legally required?  Operational. What is the working climate set and enforced by first line supervisors? Do airmen know how to report events? Do airmen feel threatened when they report inappropriate behavior? Are airmen afraid to report inappropriate behavior?  Formal. How well are the systems and processes that have been put in place utilized (i.e., the SARC, legal, medical)? How often is training conducted? Is the training effective? What formal protection mechanisms exist?  Informal. What are the peer influences? Are some offenders given preferential treatment? Are airmen empowered to speak up? Do airmen trust the system will truly help them? At each base visited by the Study Panel, the leadership discussed a culture of dignity and respect. This concept, and various approaches to institute the culture, are ubiquitous in the places visited. There is a growing effort to make sexual assault training additive and more coordinated throughout the Air Force. It is apparent that Air Force leadership desires to adhere to a culture of dignity and respect given the emphasis on sexual assault prevention and the work led by the SAPRO, especially in areas reflective of victim’s advocates and counsel. However, cross-cutting organizational solutions to ensure that prevention and response are integrated and collaborative are evolving to meet the challenge. Examples of early initiatives for integration and collaborations include programs at Air Force Academy and in the US Army at its SHARP Centers. 15 (This Page Intentionally Left Blank) 16 Chapter 3: Prevention 3.1 Prevention Introduction The Study Panel viewed prevention as an essential area for the Air Force to address in order to combat sexual assault. Fundamentally, if an assault is prevented, then there is no need for reporting or treatment. Conversely, if military members are not motivated to report and rarely report, it is the equivalent of a “green light” for perpetrators within that culture; such a culture aids and encourages perpetrators due to lack of consequences. As shown in Figure 3-1 below, the Study Panel recommends three primary areas to understand existing prevention work in the Air Force and to consider for how to make progress: education and training, culture, and deterrence. The overlap shown between these aspects of prevention reflects their interdependence. For example, training can help to change culture and to deter assault via informing members of consequences; a respectful and aware culture in which bystanders step in to avert risky situations is a deterrent to sexual assault. The assessment of all three areas is essential, and was highlighted to the Study Panel repeatedly during visits to Air Force bases as a particular need. The ability to understand how well interventions in all of these areas affect outcomes of interest to the Air Force, such as culture assessments, trust in the system to hold people accountable, and training effectiveness, must be considered and designed into each intervention (American College Heath Association, 2008). Education and Training: Culture: Safety culture, just culture, dignity and respect Life cycle of training from entry through down days Deterrence: Consequences, Accountability Assessment Figure 3-1. Prevention Overview: Education and Training, Culture, and Deterrence. Note: These are are key elements considered to improve prevention of sexual assault. Assessment of success in each area was identified as a critical need. 17 Prevention of sexual violence has come to be seen as a public health issue in the United States; the term Primary Prevention is used to denote the need to create safe environments where the conditions that might lead to sexual violence are curbed by a spectrum of prevention efforts, rather than from any single action or intervention. The National Sexual Violence Resource Center’s report on the spectrum of prevention (Davis, et al., 2006) characterizes the spectrum via the following six levels: 1. Strengthening individual knowledge and skills. Enhancing an individual’s capability of preventing violence and promoting safety. 2. Promoting community education. Reaching groups of people with information and resources to prevent violence and promote safety. 3. Educating providers. Informing providers who will transmit skills and knowledge to others and model positive norms. 4. Fostering coalitions and networks. Bringing together groups and individuals for broader goals and greater impact. 5. Changing organizational practices. Adopting regulations and shaping norms to prevent violence and improve safety. 6. Influencing policies and legislations. Enacting laws and policies that support healthy community norms and a violence-free society. Education, culture, and deterrence are interwoven across this spectrum from individual education to the policy and legislation level. The Study Panel has focused on these three areas as specific avenues of progress that can help shape social norms toward primary prevention in the Air Force, but we include the spectrum of prevention since it captures a well-known and comprehensive framework for making progress in sexual assault prevention. 3.2 Prevention Discussion 3.2.1 Site Visit Results Informing Prevention Findings The Study Panel’s site visits provided an in-depth view of how some bases have significantly changed policy toward prevention of harassment and assault, and how others are struggling with these issues, including the fact that first-term airmen reporting for duty have a significantly different expectation of organizational and supervisor behavior than in the past. At the Study Panel’s site visit to Joint Base San Antonio (JBSA), briefers and small group sessions provided an in-depth understanding of how Lackland AFB has changed procedures and policy in the wake of the BMT sexual assault investigation. With the understanding that both familiarity across ranks and harassment are precursors to sexual assault, current practice at BMT has changed in the following ways:  Trainees spend approximately 6 hours with the SARC to learn a range of topics to arm them with an understanding of what behavior, when encountered, is beyond the boundaries of appropriateness in the Air Force, including expectations of military professional behavior, stories/understanding of what constitutes sexual harassment and/or assault, “grooming” behavior, and more.  Military training instructors, once given almost absolute control over trainees and their 18 learning environment, are more limited in control and subject to oversight.  Chaplains can freely enter the training area and are made available for confidential discussions.  Trainees are each assigned a wingman, and held accountable to a rule that no basic trainee will go anywhere alone.  Trainees have access to an anonymous drop box in which they can submit reports of inappropriate behavior, to highlight inappropriate behavior before an assault occurs. Learning from the JBSA visit set the stage for Study Panel site visits to Nellis AFB, the Air Force Academy, and Joint Base Lewis McChord (JBLM). At Nellis and JBLM, a key issue highighted was the need for the SAPROs and units with first-term airmen to understand how new airmen are currently being trained in BMT, in order to better leverage this learning and understand their perspective. Across all visits, a picture emerged of the particular vulnerability of the youngest military members. The risk factors specific to this population include the prevalence of alcohol in the culture, cultural norms carried over from environments, homes, or situations prior to entering the Air Force, immaturity, poor decision making, and other factors relating to being new to the Air Force and new to independent adulthood. Vulnerability of our youngest members is consistent with the Air Force SAPR’s data13 on age of victims (Leard-Mann, et al., 2013; Galbreath, 2013), broader national research on victim age (Kruttschnitt, et al., 2014; Leard-Mann, et al., 2013), and University/College sexual assault data (Koss & Dinero, 1988). The fall of one’s freshman year in college has been dubbed the “red zone” for assault risk, as it is for the newest airmen who struggle to align a lifetime of experience with expectations of their new environment, sometimes among mixed messages from various Air Force sources. When airmen or officers arrive at their first operational unit, the Air Force culture that they are led to expect from their introductory training experience may not be the culture they find. The Air Force, like any other very large, distributed, multi-mission organization, is comprised of multiple micro-cultures that evolve over time and can be difficult to change. During the Study Panel’s interviews with panels of Commanders, Senior and Mid-Level NCOs, First-line Supervisors, Cadets, SARCs, and other groups, a broad range of cultural attitudes and practices were evident. A flying squadron will have different mores than a maintenance squadron, which will be different from security police units, from Headquarters units, and from Acquisition organizations. The panels comprising supervisors of airmen in their first few years of Air Force service described risky behavior, vulnerabilities, and organizational culture that indicated the Air Force could make significant progress in prevention if training, education, culture, and deterrence interventions were targeted at these groups. Attitudes and practices of these supervisors, who are typically young and inexperienced managers, reflected a lack of understanding and education regarding how to set a unit culture of dignity and respect, even though they understood that it was important. If young supervisors were provided the educational exposure that is given to college students who become peer counselors for sexual assault victims, their awareness, perspective, and intervention skills might be significantly enhanced. 13 According to Air Force SAPRO data (averaged across 2008-2012) 72% of victims from unrestricted reports were age 24 and younger, and 72% of victims were E-1 through E-4 in rank (Grosso, 2014). 19 3.2.2 First Line Supervisors and Harassment Culture During site visits the Study Panel learned that first line supervisors of our youngest airmen typically transition from being a peer to a position of supervisory responsibility, often changing from the position of a buddy to a position of authority among the same airmen with whom they have been close friends. These first line supervisors must set the appropriate unit culture and maintain cohesiveness in circumstances of sexual harassment. Their prevention of, response to, and action against unit sexual harassment may help change the environmental tone of not only their own unit, but the units their people eventually lead. First line supervisors interact with airmen on a daily basis and need to model expected behaviors as well as confront inappropriate behaviors. They must learn to sense risk and anticipate, rather than react to, harmful events. Through them, a culture of bystander intervention and community responsibility can be developed and reinforced. It is mindfulness (Weick, 1988) on behalf of the first line supervisor that can allow them to predict what events might occur in the next 24-hour period and make real-time adjustments to keep their airmen safe. As an example of unit cohesiveness versus harassment, the Study Panel listened to an account from a senior NCO discussing how language influenced subordinate NCOs. A lone female worked among a unit of males with a habit of making unwelcome derogatory female jokes, a common behavior in the unit. To promote unit cohesiveness, the female felt obligated to participate to demonstrate she was part of the unit, even though the behavior was harassing. She stated, “You go along to get along. You have to show them you’re not bothered, you know, put up or shut up. But no one puts up, no one wants to be ‘that guy.’” It was during the discussion with the Study Panel that she came to the self-realization regarding the harm of her own language and that her behavior had an influence on subordinate NCOs that she needed to change. Even seemingly lewd comments toward others by one person in a work environment can be a predatory behavior in terms of “testing the waters.” If nothing is done to curtail this type of language, then the behavior continues unchecked and possibly leads to an escalated situation. This has been documented time and again in reports and documentary studies of military and civilian sexual assault. This underscores the importance of the ability of leadership at all levels to identify this harassing type of behavior, understand why it is unacceptable, and live and communicate what is acceptable as they lead in their organization. However, the Study Panel finds leadership at all levels may not quite understand this connection between promoting unit cohesiveness and an atmosphere of absolute zero tolerance toward unseemly language and actions. Leaders have been observed allowing sexually harassing behavior because it occurs in informal instances (e.g., the locker room, maintenance hangar, barracks) and is not recognized as negative or pervasive. Because there is no physical injury, it is seem as, “no harm, no foul.” However, the extent of harm caused by these offenses has an effect on morale, safety, welfare, and discipline. It is the culture of “go along to get along” that sets the stage for this pervasive offender-victim relationship and learned helplessness. The graphic in Figure 3-2 below represents this aspect of young, new Air Force member risk and its implications for prevention. 20 Figure 3-2. There are Multiple Means for Understanding and Addressing Prevention. Note: Risks specific to the newest and youngest airmen include unit cultures with permissive environments, perpetrators who focus on young, vulnerable members; young members’ supervisors having a lack of education and motivation for active prevention, and risky behavior that is prevalent among youth. 3.2.3 Education and Training 3.2.3.1 Existing Sexual Assault Prevention and Response Education and Training The Air Force conducts extensive sexual assault prevention and response training throughout the career of an airman, with varying messages.14 Each training session provided should ideally build on and enhance previous content. The Air Force SAPRO training lead, with whom the Study Panel met, is making efforts to address consistency and coherence of these multiple training sessions, but the Study Panel’s assessment is that this effort may require more resources than are currently allocated. The Panel heard from airmen in the field who felt overwhelmed with too much education and training as well as media coverage on this issue. Other members reported knowing peers who don’t believe that sexual assault is a problem. The Air Force SAPRO is attempting to address this oversaturation by appointing motivated SARCs and developing innovative, thought-provoking training covering the continuum of harm (starting with sexual harassment) that is targeted to Air Force specific audiences. However, the Air Force is a resource-constrained environment; hence, some feedback about training provided to the 14 In general, education provides the theory and understanding behind a topic; training is meant to teach the learner to take action, whether or not the full theory is understood. SAPR topics are generally provided to Air Force groups as short-term training courses. Education is exemplified by courses provided to personnel who elect to become victim advocates or peer counselors. 21 Study Panel indicated that trainers may be assigned as an additional duty and may not have the education nor the motivation to engage trainees in meaningful discussion. Methods of SAPR training have evolved. Training has traditionally been delivered via PowerPoint presentation, with little opportunity for trainees to discuss or interact with the presenter or each other. In the 2010 timeframe, the Air Force initiated Bystander Intervention Training (BIT). BIT was developed by outside subject matter experts using adult learning theory, and included specific modules for males, females, and for leadership. This training, emphasizing community responsibility for creating safe environments and intervening in precarious situations, involved discussion-based training in small groups. The approach received strong positive response based on feedback evidence. The program initially planned to formally measure baseline attitude, prevalence, and other metrics, but the assessment element was later cancelled and never obtained. The Air Force was the first service to use bystander training as an approach to prevention, though it is a commonly used and well-researched means for prevention in the civilian community as evidenced by research studies indicating BIT is effective (see Banyard, et al., 2007). The formal BIT was discontinued in 2012 when the Air Force sought another team to develop and provide SAPR training, but bystander-based approaches and methods continue to be applied in some SAPR training programs. Annual SAPR training is required throughout the Air Force for every airman and civilian who supervises military members. Additionally, the Air Force has established SAPR “stand down days” twice a year, during which all members receive a SAPRO-directed training curriculum. Recently, the Air Force SAPRO has redeveloped the eight-day course for SARCs and full-time SAPR Victim Advocates (SVA); that course includes a pre-course and post-course assessment. The Study Panel was concerned that deployed environments might be riskier than CONUS environments with respect to sexual assault. According to deployed SARC personnel the Study Panel interviewed, airmen receive additional SAPR training and information regarding what to expect in a deployed environment both prior to deployments and in pre-deployment training. Enroute to the deployment airmen are provided additional information regarding sexual assault prevention and response, and once in country they are introduced to the SARC and SVAs during newcomers’ orientation. Airmen also meet with the SARC during out-processing. Some airmen reported that pre-deployment training involving male victim scenarios in a predominantly male environment (such as deployments) made the audience uncomfortable, but had an important effect of raising awareness about male victims. Millennium Cohort data indicate that females who deploy and work in combat, report significantly increased odds (>2x incidence) of harassment and assault. The Deployed SARCs the Study Panel interviewed indicated the following:  Deployed environments may be hyper-masculine.  Assailant may be in the same unit as the victim, and may be armed and threatening.  Personnel are less likely to report in theater; they often bury issue until returning stateside.  Victim who reports is moved to location with services (e.g., Kandahar; Article 32 hearing is done at subject’s home station). 22  Saturation of SARC phone numbers and SAPR messages.  SARCs pre-brief and debrief deploying members. When the Study Panel discussed deployment prevalence with panels of airmen, including Guard and Reserve component members, the overall picture presented was one of boredom leading to flirting, sometimes in an overly aggressive manner, and a perceived high level of marital infidelity. Several members felt that this environment was problematic, and that the Air Force should take steps to address the issue of sexual misadventure during deployment. 3.2.3.2 Opportunities for Improvement Although events such as Sexual Assault Awareness Month strive to ensure that airmen are reminded of the importance of prevention and response to sexual assault, members in the field indicated they were dissatisfied with many aspects of training. Base personnel who provide local training noted the lack of input opportunity regarding content and delivery of these training day/week events. Some populations the Study Panel surveyed felt that the training can make them feel as if they are covert rapists. Others indicated that the amount of training had reached saturation. They also indicated that materials for training for these events might be provided earlier in order for them to properly prepare their presentations and training. Striking a balance between consistency and coherence of training curriculum on the one hand, and providing flexibility for local commanders and SARCs to tailor material for what is known about local vulnerabilities on the other, is a challenge that needs to be addressed. Airmen who had never been assaulted nor known someone involved in a sexual assault case failed to see the need for so much time and effort to be devoted to SAPR training. Others who were aware of the issues felt that part of the problem is the population segments who say there is no problem. How to educate and inform members who firmly believe no problem exists is tricky. The Air Force can learn a great deal from approaches taken at some colleges and universities in the United States to create a culture where the dominant social norm is to respect others and to proactively avert risky situations. For example, at Bowdoin College the Title IX coordinator used her student group networks to identify social influencers, either formal or informal (i.e., lacrosse team captains and those whom students naturally like and emulate), and skillfully recruited them to receive extra education to act as student leaders in setting the culture. 3.2.3.3 Science Regarding SAPR Education and Training The Study Panel found a rich literature of research reporting on sexual assault prevention and response training effectiveness, summarized in Figure 3-3 below. The challenge to interpret this research lay in the inconsistencies. Many research studies cited effectiveness of a particular intervention, yet meta-analyses of these studies yielded inconclusive results. The Study Panel’s approach was to examine both research reports and meta-analyses, to the extent possible, and report on findings that are most relevant to the organizational size and diversity of the Air Force. 23 Figure 3-3. Summary of Research on Effective Trainer, Content, and Delivery Strategies. Research on the effectiveness of sexual assault prevention and response education and training provides insight into a range of topics, including how to optimize the facilitator or participant characteristics and the content of instruction. Keep in mind that not all recommendations are intended for every training session; the Air Force should employ a range of methods and approaches across different training and educational opportunities. The Study Panel concluded that the training is most effective when the trainer(s) are motivated and knowledgable (Schewe, 2007; Anderson & Whiston, 2005), regardless of gender and pairing. Airmen receiving training provided by someone who is not invested in the subject matter is not an effective use of time. Studies also show:  Male/Female teams of educators: In a statewide assessment of 29 high school age programs, Schewe (2004) reported that pairing a male and a female educator yielded a larger effect on students than male- or female-only educators. This is a finding that is disputed across researchers, and is one that has resource implications.  Many experts in this field make their living as professional presenters; the Air Force and other Services have hired professional presenters in the past. Anderson & Whiston’s extensive meta-analysis (2005) found that professional presenters yielded the greatest effect on all outcomes examined (separate meta-analyses were conducted on seven separate outcomes: rape attitudes, rape empathy, rape-related attitudes, rape knowledge, behavioral intentions, rape awareness behaviors, and incidence of sexual assault).  If peer facilitators are used, they must be well-trained in order to achieve outcomes desired (Anderson & Whiston, 2005). 24 Research further supports content and delivery strategies that include providing training as early as possible, even in middle school, because the youngest are the most vulnerable (Schewe, 2007). Specific programs that research has proven to be effective include bystander training (Schewe, 2007; Anderson & Whiston, 2005; Banyard, et al., 2007; Vukotich, 2013), and Safe Dates programs (Foshee, et al., 2004). Given the overwhelming empirical and content evidence provided about bystander intervention training and its success in both Air Force and other military settings, reviving this training is a recommendation of the Study Panel. The literature highlights that proven effective content of sexual assault prevention and response training includes addressing rape myths, and teaching self-defense skills, communications, boundary setting, and risk-reduction methods (Schewe, 2007). As for length of time per training period, research is mixed. One set of findings concludes that using an instruction format of shorter, repeated sessions is among the most effective training strategies (Schewe, 2007; Anderson & Whiston, 2005). However, a major finding also indicates that a longer amount of time spent being exposed to the material results in better outcomes (Anderson & Whiston, 2005). Furthermore, training is more effective if the content is in the language of the receipient (Potter & Stapleton, 2012) tailored to the age and culture of the audience (Schewe, 2007; Anderson & Whiston, 2005). Tailoring to age and culture is particularly difficult in the Air Force setting because of the various age groups and microcultures that may make up the audience at any given base or wing. A finding echoed during site visits is that training content is more effective when males are treated as allies and not as rapists (Potter & Moynihan, 2011). Moreover, to reach the audience, evidence indicates that the tone or content of the training cannot be accusatory; males will tune out if it is accusatory, and a single gender audience may be more responsive to the training (Schewe, 2007; Brecklin & Forde, 2000). 3.2.4 Culture Work takes place within a culture and a context. Air Force leadership from wing commanders through the Chief of Staff of the Air Force have embraced the importance of culture in combating sexual assault. Research on workplace culture is vast, and it shows indisputably that establishing and maintaining cultural norms of mutual support and intolerance for the spectrum of assault-related behaviors can be effective. Cultural change can be brought about through both through education and training, but must be emphasized through everyday pervasive messages in the work environment. Section 2.4 of this report describes how the Air Force safety culture concept can be used as a model for cultural change and maintenance with respect to sexual assault. Two other key elements are the research in colleges and universities, as well as in military settings, on “bystander” methods for propagating culture, including the use of social influencers to help set the culture from within. 3.2.4.1 Existing Air Force Culture At every site visit location, Commanders emphasized the importance of implementing a culture of dignity and respect to the Study Panel. Commanders also indicated the challenges of trying to undertake culture change without having clear guidance, tools, and experience in implementing culture change, as well as difficulties in knowing how to measure the effects of any cultural change implementation. 25 The Chief of Staff of the Air Force has emphasized the importance of culture in leadership conferences with commanders. Beginning with health/wellness inspections, an Air Force change in culture has been underway over the past 8-10 years. However, as mentioned earlier, the Air Force does not have one culture. Each unit is subject to legacy cultural norms, and is hampered by the frequent turnover of leadership/personnel whose successful change efforts can be overcome by new leadership. During base visits the Study Panel came to understand the scope and magnitude of challenges associated with ensuring each unit’s leadership, and especially their first line supervisors, are equipped to set and maintain a culture that is hostile to sexual assault. 3.2.4.2 Opportunities for Improvement If each Air Force member feels responsibility for combating sexual assault, cultures shift in important ways: members will actively chide others for language and action that is unwanted, and will act to steer people and situations away from leaning toward harassment or assault. Ingraining this responsibility in all members is what a successful bystander culture attempts to achieve; it is essentially a safety culture that extends to physical and psychological safety of members. The Air Force has an opportunity to revive and refine University and other well-known bystander approaches along with known approaches for creating a safety culture, in order to create and maintain a culture in which every member feels responsible for noticing problems and taking action to prevent assault. The Study Panel also observed that airmen interpreted bystander training to mean that they should directly confront people whose behavior is inappropriate. Open confrontation can be difficult and daunting, especially when rank or social disparities are involved. Applying an oblique, subtle ‘distraction’ approach seen in universities is an opportunity for improvement. 3.2.4.3 Science on Culture in Sexual Assault Prevention What guidance can be found to help the Air Force as a whole implement a culture of resilience with respect to sexual assault? The Social Norms approach to changing public health behaviors was introduced in 1986 by H. Wesley Perkins and Akan Berkowitz in their research on student alcohol use patterns. They discovered that college students regularly overestimated the extent to which their peers drank alcohol, and that these over-estimates were related to how much individuals drank. Essentially, students tended to follow an erroneous “norm” that “everybody drinks, so I will, too.” In a shift away from previous prevention efforts that focused on health education, Perkins & Berkowitz proposed that prevention efforts provide students with accurate information on peer drinking attitudes and behavior. In other words, if students are presented an accurate norm (e.g., most students do not drink heavily), they will decrease their drinking behavior to adhere to the “new” norm. In at least seven studies conducted in the 1990’s and early 2000’s, the social norm approach was found to successfully alter alcohol use and abuse on college campus populations (e.g., Glider, et al., 2001; Haines & Barker, 2003). According to Berkowitz (2004, 2010), the social norms approach relies upon peer influence, which can have more impact on young people than personality, family, and cultural factors. Essentially, the approach is based upon the difference between the perceived norms (what individuals think their friends do) with the actual norms (what their peers think or do). This gap is referred to as the “misperception of the norm.” The goal of an intervention program 26 is to close this gap by presenting correct information about peer group norms in a manner that is accepted by the population. The first step of the intervention is to survey students’ perceived and actual norms. The second step is to choose the normative message that will correct the misperceptions. Next, the presentation of the message and delivery approach are designed to suit the characteristics of the campus. The actual campaign can be accomplished by a social marketing campaign (e.g., putting up posters around campus), teaching modules that extend through a semester, a series of workshops, and interactive scenarios in student programs. The final step is to evaluate the effectiveness of the message. While most of the research on social norms has focused on college student drinking behavior, the approach can essentially be applied to any behavior that presents a public health problem. Berkowitz (2004, 2010) cites the successful use of social norm interventions to increase seat belt use and reduce drinking while driving and cigarette use. One of the most interesting applications has been the use of social norms to change attitudes and behaviors related to sexuality and sexual assault reducing sexual assault. Berkowitz (2004, 2010) cites evidence that men’s misperception of peer attitudes related to sexual assault is related to sexual assault behavior. Berkowitz (2010) cites several studies as evidence for the proposed link between misperception of the peer norms and a rape supportive climate. A strong case for using the social norms “correction” approach to counter this link between peer attitudes and sexual violence is offered by Fabiano, et al. (2003). These authors found that college men under-estimated the importance that most men and women place on consent and willingness of most men to intervene against sexual aggression. They also discovered that men’s personal adherence to only consensual sexual activity and their willingness to act as women’s allies were strongly influenced by their perceptions of other men’s and women’s norms. The authors of this study argue that accurate normative data which counters the misperception of rape-supportive environments can be a critical part of comprehensive campus programs to motivate men to become women’s social justice allies in prevention sexual violence. Berkowitz (2010) cites a small number of studies as evidence for the effectiveness of the Social Norms approach to sexual assault prevention. Bruce (2002) conducted a campaign at a university to change men’s intimate behavior toward women. Initial data collection indicated that men had positive attitudinal and behavioral norms toward interacting with women. A poster campaign was created to make the campus aware of these positive norms. The three messages developed were: 1. Three out of four men think it is NOT ok to pressure a date to drink alcohol in order to increase the chances of having sex with her. 2. Most men believe that talking about sex doesn’t ruin the romance of the moment. 3. Nine out of ten men stop the first time their date says “no” to sexual activity. Data collected after the campaign revealed a significant increase in the percentage of men who indicated that they “stop the first time a day says no to sexual activity.” White, et al. (2003), designed an intervention to correct male and female college students’ misperceptions of sexual consent on a campus that had a population of deaf and hard-of-hearing students. The general campaign had no effect on this sub-population. However, 27 a second media campaign that was designed to address the needs, culture, and communication styles of the deaf and hard-of-hearing was significantly related to a reduction in sexual assault. More recently, Kilmartin, et al. (2008) conducted a social norms intervention to correct college men’s sexist attitudes and beliefs about rape. The intervention was introduced in small group discussions with male college students. The intervention, which involved an experimental group and control groups, was causally related to decreases in men’s agreement with rape myths. The experimental group also showed somewhat smaller decreases in sexist attitudes and their level of comfort with other men’s sexism. Hillenbrand-Gunn, et al. (2010) used the social norms approach along with other strategies in a study to change acceptance of rape myths and willingness to engage in rape prevention among high school students. The campaign involved giving three workshops which provided “norms correction” feedback to the boys on these topics. The study, which involved experimental and control groups, revealed a significant decrease in misperception of peer’s acceptance of rape myths as well as a decrease in personal attitudes that were conducive to rape. These changes were still evident at a one month follow up. Berkowitz (2010) cites several studies in which men’s negative attitudes toward women were altered with the social norms approach. Moran and Berkowitz (2007) developed a high school social norms campaign the promoted the “do’s” of healthy dating relationships. At a two-year follow-up, boys reported more accurate perceptions of other boys’ discomfort when boys “talked trash” about girls. These more accurate perceptions were related to an increase in the number of boys who took action when they heard trash talking against girls. Not all efforts succeeded. Scholly, et al. (2005) conducted a study in which messages about risky sexual activities were disseminated through multiple campuses in a social media marketing campaign. The campaign failed to have an effect, possibly due to the short length of the campaign and insufficient tailoring of the media specific for the campus culture. In conclusion, the Social Norms approach has promise as a prevention effort for sexual assault in school populations. There exists a small body of experimental evidence that “norm correction” can reduce rape myth acceptance and, in at least one study, the level of sexual assault. Other studies show that the introduction of correct social norms can reduce boys’ disrespectful behavior toward girls, and sexist attitudes. Although the Social Norms approach has not been specifically evaluated with a military population, its success with college student populations may potentially transfer to troops in the same age group. Given the lack of effective, evidence-based prevention strategies for sexual assault (DeGue et al., 2012, p. 1216), the availability of the Social Norms approach should not be overlooked. In fact, DeGue, et al. (2012, p. 1213) states that addressing social norms that allow sexual violence to flourish is necessary to reduce perpetration of sexual violence. Berkowitz (2004, 2010) suggests that the Social Norms approach can be easily combined with and boost the effectiveness of other approaches in a multi-dimensional campaign. One program that could easily be combined with the Social Norms approach is the Bystander Intervention program developed by Banyard, et al. (2004) in which participants are taught to notice and intervene in situations that could lead to sexual assault. The Social Norms approach could be integrated as a strategy for “correcting” misperceptions of norms related to sexual assault in bystander education programs. 28 3.2.5 Deterrence The Study Panel has framed the third major Prevention element, Deterrence, to capture how perpetrator consequences could more effectively deter sexual assault. When military sexual assault is described in the media, often the percentage of cases which are successfully prosecuted is highlighted. These statistics present a view of an environment in which perpetrators can and do get away with sexual assault. As discussed, environments where sexual harassment is allowed to go unchecked often have a higher incidence of sexual assault, 600% more likely according to Sadler, et al. (2003). This research has been reinforced in Air Force briefings. Air Force harassment policy15states that harassment is usually addressed at the lowest level of command. The Study Panel learned that claims of harassment are typically dispatched with a verbal reprimand and may not be reported to EO at all. In the 2013 Congressional hearings, both General Welsh (Air Force Chief of Staff) and General Rice (Commander, Air Education and Training Command) acknowledged that Air Force commanders have discretion in deciding whether to include episodes of sexual harassment on the service records of Air Force personnel. They said it was possible for people to be transferred from one base to another without any record of instances of sexual harassment noted in their personnel files. Though the Air Force promotes a zero tolerance policy for sexual assault, this policy does not appear to be consistently enforced throughout the Air Force, especially where claims of sexual harassment are heard. Instituting and following through with consequences and punishment for sexual harassment in the workplace is an important step in changing the culture and gaining and maintaining trust among airmen. Leadership, even at the lowest level, plays an important part in minimizing and abolishing sexual harassment in the work environment. Sexually harassing behaviors need to rise to a punishable level by cultivating a climate intolerant of sexual harassment. This can be done by leaders (at all levels) walking through the work areas and taking action toward a harassing environment (e.g., lewd pictures, gender derogatory language, etc.). Immediate and thorough follow through communicates to all of those in the unit that harassing behavior will not be tolerated. The Air Force’s Health and Wellness checks of all work environments began this process. Broken Windows theory, much of which centers around why New York City had a huge drop in crime rates under Mayor Giuliani’s leadership, captures the essence of how environment and consequences has been shown to reduce criminal behavior (Corman & Mocan, 2002). The original work was captured by Wilson & Kelling (1982). Although various research has since questioned the basic relationship between community disorder and crime, the theory holds that, for example, cars are much more likely to be vandalized in neighborhoods of abandoned buildings with broken windows, due to the perception of lack of lawfulness and consequences in the area. New York began to clean up graffiti and to arrest people who jump turnstiles to show that the environment is not permissive of crime. Likewise, predators who send test signals in the form of mildly harassing behaviors, and who are not checked, would continue to test the boundaries regarding whether they are in a “permissive environment16” for sexual assault. David Lisak’s extensive work on environmental “green lights” for sexual predators exemplifies how deterrence can be achieved by presenting environmental barriers and consequences to assault. 15 In Air Force Instruction 36-2706, Equal Opportunity Program Military and Civilian. 16 Permissive environment in the literature on sexual assault/violence connotes an environment permissive to the spectrum of these behaviors, rather than referring to the DoD’s official definition of permissive environment, which refers to an operational environment in a host country. 29 Consistent with such an approach, deterrence requires that the Air Force must dispel perceptions that people can engage in the continuum from harassment to assault with impunity. The Air Force should develop transparency in the accountability process for infractions of the UCMJ on the continuum of harm for sexual assault. Developing and publicizing a logic tree, describing penalties associated with sexual assault-related infractions, is needed to create transparency toward greater deterrence. Further, the Air Force should explain and publicize evidentiary facts surrounding judgments in sexual assault offenses to reduce misperceptions of injustice and demonstrate consistent enforcement of UCMJ Articles related to sexual assault. Explaining the facts surrounding Letters of Reprimand, rank reduction, discharge, and imprisonment protocols for each case will serve to educate airmen about the judicial system while also serving as a deterrent mechanism. 3.3 Findings The Study Panel developed four findings in the area of prevention. 3.3.1 The Air Force SAPR Education and Training is Inconsistently Delivered, Insufficiently Assessed (Measured), and Lacks a Deliberately Planned and Tracked Curriculum, Resulting in Unknown Effectiveness The content of SAPR training and education programs vary throughout the Air Force; airmen are trained but the content of training differs. Air Force SAPR training is not currently coordinated across the life cycle of members’ careers. This lack of coordination makes it difficult to determine the effectiveness of the extensive, ongoing SAPR training that is taking place across the Air Force. Details on the existing Air Force SAPR education and training programs are described in Section 3.2.3. 3.3.2 First Line Supervisors are the Most Crucial to Sexual Assault Prevention but They Lack Sufficient Education to Set and Maintain Unit Culture, Confront Inappropriate Behavior, and Foster Risk Management in Their Subordinates First-level supervisors interact with airmen on a daily basis and need to model expected behaviors as well as confront inappropriate behaviors. They must learn to sense risk and anticipate, rather than react to, harmful events. Through them, a culture of bystander intervention and community responsibility can be developed and reinforced. An in-depth discussion on this finding can be found in Section 3.2.1. 3.3.3 The Air Force Lacks Tools and Specific Guidance for Constructing, Assessing, and Maintaining Prevention Programs Tailored to Their Mission and Demographic Status (e.g., Providing Leadership with Flexible Options for Implementing a Culture of Dignity and Respect with Organization-Specific Assessment Tools) Although commanders understand the importance of improving culture, and have tools for assessing climate, the “dignity and respect” concept and how to create it, given a mission set and populations at hand, are not well-defined. See Section 3.2.4 for this finding’s detailed rationale. 30 3.3.4 Deterrence Requires Visible Consequences and Accountability; Currently Consequences for Sexual Assault Incidences are Inconsistent While this may be due to individual fact-based outcomes, such inconsistency in turn causes airmen to distrust the system. See Section 3.2.5 for this finding’s rationale. 3.4 Recommendations The CoSA Study Panel recommends three actions in the near term: 3.4.1 Implement a Pilot Program to Educate and Empower First Line Supervisors to Proactively Develop and Maintain a Unit Culture of Dignity and Respect First line supervisors of first term and non-supervisory personnel oversee the youngest most vulnerable population of airmen and junior officers. Although a culture of dignity and respect is encouraged in the Air Force, leaders at every level lack the education and specific guidance on how to go about creating and assessing such a culture. Airmen who are newly promoted supervisors of their former peers face pressure from many sides to continue the current culture in place; they often lack the maturity and education about sexual assault topics as well as mentorship to propagate change. The Study Panel talked with, and reviewed programs from, Colleges and Universities who cultivate peer leaders to participate in programs requiring them to take educational courses. These courses, similar to what the Air Force Academy requires of their student peer counselors, result in significant shifting of perspective and understanding. Requiring first line supervisors to understand the entire spectrum of behaviors leading to assault, and providing them with practice in both confronting insidious behavior and successfully handling reporting situations, would accomplish several goals. It would enable a generation of airmen to seed cultural change, and would provide partnership to senior leaders who lack firsthand views into operational micro-cultures. It would also enable messages provided by SAPR training to gain traction and reinforcement by individuals with influence in the lives of the Air Force’s youngest, most vulnerable airmen. 3.4.2 Initiate a SAPR Strategic Communications Campaign Including not only Survivor Stories but also Disciplinary Actions, Harassment Scenarios, Strategies for Bystanders, Social Norms Strategies, and Core value Discussions This recommendation is aimed at more effective story-based training, based on both empirical findings and on the critiques of SAPR training we heard during site visits. Survivor stories have impact, and combat the common reaction to perceived over-training for members who do not have any exposure to the problem itself. These stories illustrate opportunities for bystanders to intervene along the spectrum of harm, and provide a personal connection to the problem space. Perceptions that perpetrators are never brought to justice were repeatedly cited during the Study Panel’s visits with member panels; publicizing examples to the contrary, while explaining how justice can be successfully achieved, may help. The research on use of narratives in safety and health communications is not definitive; most reported research does not include control groups or alternative treatments, but using concrete messages—those that are “descriptive, specific, explicit, precise, definite, and imaginable” are found to be more effective than “abstract” messages (Ricketts, 2007). Communicating explicitly about Air Force member stories, while protecting identities, can have great impact to remove the fog of uncertainty, doubt, 31 and victim-blaming that clouds current situations. Since airmen felt that head-on confrontation was expected bystander behavior, communicating examples of other types of bystander actions, i.e., exemplifying the distracting behavior that can successfully prevent an assault, can help bystanders see more subtle means for intervening. 3.4.3 Mandate Empirically Prevention Programs Validated Assessment of All Sexual Assault The Study Panel found that lack of assessment cripples the Air Force’s ability to make progress. Using the number of assaults reported is challenging when many members do not report until they are re-assigned and feel safely removed from their previous situation. The wellreceived Bystander Intervention training originally planned an assessment component, but that element was never implemented. At the base and unit level, commanders do not know how to assess whether their own culture change initiatives are having an effect. There is extensive expertise and resources available to provide guidance on assessment of interventions. Making use of these resources to plan for assessment in the early phases of an intervention is necessary for the Air Force to know which interventions to continue and which to curtail. In the mid to far term, there were two broad recommendations: 3.4.4 Apply Research Findings to Improve Overall Education and Training This recommendation includes tailoring training for evidence-based content, length, and other factors cited earlier in Section 3.2.3; updating and continuing Bystander Intervention training; and planning and coordinating training opportunities throughout an airman’s career (e.g., entry, base arrival, periodic/annual, school house, leadership, stand-down days). The Air Force might consider the current Career Field Education and Training Plan process as a model. 3.4.5 Leveraging the Air Force Safety Culture, Institutionalize a “Dignity and Respect” Culture Change Program by Engaging Leadership, Operations, Formal and Informal Systems The Study Panel found that among Air Force units visited, many have been mired in a traditional culture that accepts behavior along the spectrum of harm to various degrees. Leaders and literature agree that culture change is a primary means for improving this situation, and yet how to accomplish culture change is not clearly understood by many Air Force leaders. The Study Panel has evaluated how some Colleges and Universities have significantly shifted student language and behavior to attack the spectrum of harm, and has also examined safety culture process and outcomes. Further, the Air Force should implement and assess a Social Marketing Campaign, tailored to the Air Force context, and recruit/educate peer social influencers and peer counselors to change culture from within. 32 Chapter 4: Detection 4.1 Detection An essential aspect of preventing sexual assault is the early, accurate, and comprehensive detection of potential perpetrators, victims, and risky situations. Figure 4-1 below illustrates the main actors involved in sexual assault including the victim, perpetrator and the situation in which the assault occurs. Sexual assault often involves a spectrum of harm, including sexual harassment which is prosecutable under UCMJ Article 92 (equal opportunity law driven) as well as Article 134 (good order and discipline), abusive or aggravated sexual contact which falls under Article 120c and d and sexual assault or rape (Article 125 and 120a and b). Figure 4-1. Military Statutes Regarding Sexual Harassment, Contact, and Assault. The Study Panel believes the Air Force should embrace a vision to move left of crime to not only provide early warning but to forecast risk and to act to shape the risk of sexual assault out of the Air Force. This section first reviews the scientific basis for detection, identifies findings, and articulates recommendations. 4.2 Scientific Foundations Figure 4-2. Science Regarding Perpetrator, Victim, and Situation. To explain key observations from the scientific literature, the crime of sexual assault was considered from three perspectives: the perpetrator, the victim, and the situation in which the 33 crime occurs. Figure 4-2 above summarizes key elements of the current state of the science in terms of sexual assault knowledge along these three dimensions, which are described in turn. 4.2.1 Perpetrator Although every sexual assault is a unique event, research has revealed features that are predictive of the perpetrator, the victim, and the situation in which the assault occurs. The question of who perpetrates sexual assault was first studied by researchers who examined the characteristics of incarcerated rapists (Armentrout & Hauer, 1978). From this research emerged the view that sexual assault of females is typically perpetrated by a maladjusted stranger in a surprise attack involving weapons. The “stranger rape” scenario was expanded by the “acquaintance or date rape” view offered by Koss and colleagues (Koss & Dinero, 1988) who revealed that most sexual assaults of females on college campuses were committed by males who they knew. In this time period “marital rape” of females by males in co-habiting and marital relationships was documented (Martin, et al., 2007). A sprinkling of studies discovered that males can commit both stranger rape and date rape of other males (e.g., Myers, 1989) and that small percentages of females can commit date rape (e.g., Struckman-Johnson, 1988). In recent years, researchers have found that date rapists include a psychologically-abnormal male “serial predator” (Lisak & Miller, 2002), as well as psychologically-normal college males who engage in “opportunistic” sexual assault along with rowdy party behavior (Abbey, et al., 2012; Hall, et al., 2006; Logan-Greene & Davis, 2011). An example of a predator behavior would be active targeting, grooming, and tracking potential victims. Unfortunately, lacking an enterprise wide database of perpetrators across bases, commanders, and supervisors are unaware of existing perpetrators and unable to intervene. Current understanding is that males and females, as individuals or in groups of mixed genders, may commit sexual assault against an individual who is known or unknown. This recognition is exemplified in the results of the Department of Defense’s 2012 Workplace and Gender Relations Survey of Active Duty Members (WGRA , 2012) administered to 108,478 troops to four branches of the military (DMDC, 2013). Of 22,792 members responding, 6.1% of the females and 1.2% of the males reported at least one experience of unwanted sexual contact in the past year since joining the military. When describing the one sexual assault situation with the most impact, female victims cited the perpetrator as a military person (57% or more), DoD/Service civilian (5%), spouse or significant other (7%), local community member (8%), and stranger (10%). For male victims, the reported perpetrators were a military person (52% or more), DoD/Service civilian (13%), spouse or significant other (13%), community member (9%), and stranger (13%). For female victims, the majority of perpetrators were male (94%), followed by female (1%), and both male and female (5%). The gender of perpetrators for male victims was not reportable in the 2012 survey. The DoD’s WGRA survey provides valuable information about who perpetrates sexual assault against military members, but it cannot explain the “why” of these actions. Potential answers may be found in the social science research literature. A group of researchers from the Centers for Disease Control (CDC) (Tharp, et al., 2013) performed a meta-analysis of 191 published studies of risk factors that significantly related to the perpetration of adolescent and adult sexual violence. Note that a risk factor is not a proven cause of sexual assault but is a characteristic associated with those who commit sexual assault. Based on the Tharp, et al. review of research through 2008 and other more recent or relevant studies, perpetrator motives 34 can be categorized as background experiences, sexual behaviors, personality traits, attitudes and beliefs, and relationships. The risk factors with the strongest research support are summarized in the following sections. 4.2.1.1 Background of Child Abuse, Parental Conflict, and Delinquency The literature suggests that boys who are traumatized in childhood by abusive experiences are more likely to perpetrate sexual assault as adults in comparison to boys who do not share these experiences. There is consistent evidence that these experiences include childhood emotional abuse (DeGue & DiLillo, 2004; Krahe, et al., 2001) and physical abuse (Lyndon, et al., 2007; Merrill, Thomsen, Gold, et al., 2001; Merrill, Thomsen, Sinclair, et al., 2001). There is some support that childhood sexual abuse may be related to adolescent and adult sexual assault perpetration (Casey, et al., 2009), especially for incarcerated male populations (Burton, et al., 2002). Being exposed to significant parental conflict and violence as a child is related to boys’ perpetration of sexual assault as an adult (Dean & Malamuth, 1997; Sears, et al., 2007; White & Smith, 2004). Delinquency during adolescence has been associated with sexual violence among adjudicated offenders (those who have been brought into the criminal justice system for some type of offense) (Lee, et al., 2002) and among samples of males living in college and community settings (Abbey & McAuslan, 2004; Casey, et al., 2009; Malamuth, et al., 1995). 4.2.1.2 Sexual Behaviors: Age of First Perpetration, Past Perpetration, Victimization, Multiple Partners, Impersonal Sex, and Biology Sexual assault by males is most likely perpetrated after age 13 and through young adulthood due to a convergence of developmental changes, sexual motivation, and opportunity (Becker, et al., 1986). A study of over 4,000 adult male sex offenders indicated that repeat offenses for rapists was highest in years 18 to 24 and then steadily decreased with age (Hanson, 2002). One of the best predictors of sexual violence among college, community, and military samples is past perpetration of sexual assault (Hall, et al., 2006; Loh & Gidycz, 2006; Malamuth, et al., 1995; White & Smith, 2004). In a study of 1,146 newly enlisted male navy personnel, (McWhorter, et al., 2009) revealed that 11% of the males had engaged in an attempted or completed rape before entering the Navy. These males were nearly ten times more likely than other males in the study to commit sexual assault during their first year of military service. There is also some evidence that being a victim of adolescent or adult sexual assault is related to perpetration of sexual assault by college males (Menard, et al., 2003). Having multiple sexual partners is associated with perpetration of adult sexual assault according to numerous studies of college, community, and military males (Byers & Eno, 1991; DeGue & Dilillo, 2004; Malamuth, et al., 1995; Merrill, Thomsen, Gold, et al., 2001; Merrill, Thomsen, Sinclair, et al., 2001) Early initiation of sex is also related to later perpetration of sexual assault (Abbey & McAuslan, 2004). Holding favorable attitudes toward casual or impersonal sex is one of the stronger predictors of sexual violence in the literature (Abbey, et al., 2006; Logan-Green & Davis, 2011; Malamuth, et al., 1995; Mouilso & Calhoun, 2013). Sexual motivation, as in having a higher sex drive or sex as a goal for dating, is predictive of sexual coercion by adjudicated sex offenders (Cortoni & Marshall, 2001) and college males (Craig, et al., 1989). Discovery of biologically-based motives to sexually assault is an emerging science (Singh, et al., 2014). For example, criminality is now known to have a genetic basis and may be 35 inherited in family lines (Baschetti, 2008; Frisell, et al., 2011). Furthermore, Cantor (2012) has found evidence that distinctive brain structures are related to the motivation to have sex with children. 4.2.1.3 Personality Traits: Psychopathic Empathy, Callousness, Narcissism, and Impulsivity Research on incarcerated rapists who are likely to have committed “stranger rape” has consistently revealed patterns of psychopathology (Armentrout & Hauer, 1978; Aromaki, et al., 2002). However, an increasing number of studies show that sub-groups of males who commit acquaintance sexual assault on campuses and in communities can be distinguished by abnormal personality traits. These traits include psychopathy related to low empathy and callous affect (Abbey, et al., 2012) and willingness to manipulate people (Gray-Little & Hersh, 1998). Narcissism (feelings of entitlement and willingness to exploit others) has been found to correlate with perpetration of sexual violence (Abbey, et al., 2012; Mouilso & Calhoun, 2012; Zeigler-Hill, et al., 2013), as well as impulsivity (Mouilso & Calhoun, et al., 2013; White, et al., 2008). 4.2.1.4 Beliefs and Attitudes: Rape Myth Acceptance, Hostile Sexism, Sexual Adversity, Traditional Gender Attitudes, Hypermasculinity, and Acceptance of Violence One of the best predictors of sexual assault perpetration by college and community males is rape myth acceptance — for example holding beliefs that females who dress sexily or drink want to be raped, or that females lie about being raped (Abbey, et al., 2008; Bohner, et al., 2005; DeGue & DiLillo, 2004; Suarez & Gadalla, 2010). Hostile sexism (anger and suspiciousness directed toward females) and beliefs that sexual relationships are adversarial and exploitative are strong predictors of sexual violence among samples of males living on campus or in community settings (Abbey & McAuslan, 2004; DeGue & DiLitto, 2004; Gray-Little & Hersh, 1998; LoganGreen & Davis, 2011; Malamuth, et al., 1995). Beliefs that females and males should fulfill traditional gender role traits and behaviors consistently correlate with sexual perpetration by males in college and community samples (Berkowitz, 1992; Forbes, et al., 2004; Loh, et al., 2005). Hypermasculinity (placing an exaggerated value on traditional masculine traits with elements of negativity toward feminine traits) is sometimes associated with sexual violence in college and community samples (Malamuth, et al., 1995; Mosher & Anderson, 1986; White, et al., 2008) and adjudicated offenders (Zakireh, et al., 2008). Finally, attitudes that violence or sexual violence are acceptable is predictive of sexual assault perpetration (Sears, et al., 2007; Abbey & McAuslan, 2004). 4.2.1.5 Relationship: Communication and Conflict Poor communication between partners (Jewkes, et al., 2006) and misperception of cues of a partner’s sexual intent and consent (Abbey, et al., 1998) are associated with sexual aggression in a limited number of studies. Persons who use verbal and physical aggression to resolve relationship disputes and who emotionally abuse their partners show higher levels of sexual assault perpetration (Loh & Gidycz, 2006; Ozer, et al., 2004). 36 4.2.1.6 Characteristics of Female Perpetrators of Sexual Assault There is very limited research on female perpetrators who engage in sexual assault against males or other females. In studies of college student populations, risk factors for females who are sexually coercive against males include child/adolescent sexual abuse (Anderson, 1998; Craig-Shea, 1998; Krahe, Waizenhofer, et al., 2003), being previously sexually victimized as an adult (Russell & Oswald, 2001), having adversarial beliefs about sexual relationships and hostility toward males (Anderson, 1998; Craig-Shea, 1998: Hines, 2007; Russell & Oswald, 2001), having high levels of sexual activity and early initiation of sex (Anderson, et al., 2005; Krahe, Waizenhofer, et al., 2003), peer pressure to have sex (Krahe, Scheinberger-Olwig, et al., 2003), being motivated by sex as a goal (Craig-Shea, 1998), and misreading communication of sexual intent (Krahe, Scheinberger-Olwig, et al., 2003). In a multilevel, multinational study of university students, Hines (2007) found that higher levels of status for females within the country was related to higher levels of forced sex against males. 4.2.1.7 Characteristics of Perpetrators of Sexual Harassment Researchers have found that individuals who engage in sexual assault may also engage in sexual harassment, a behavior related to unwelcome sexual conduct in the workplace (Bartling & Eisenman, 1993). According to Pryor & Whalen (1997), the proclivity to sexually harass is influenced by four factors: sexual exploitation, miscommunication related to sexual attractiveness, hostility toward females or misogyny, and hostile attitudes toward gay/lesbian bisexual individuals. Bartling & Eisenman (1993) found that a proclivity toward committing sexual harassment among college males and females students was related to high adversarial sexual beliefs, acceptance of rape myths, anti-feminist attitudes, low empathy for others, and willingness to sexually exploit a subordinate at work. For males, likelihood to rape was predictive of their proclivity to engage in sexual harassment. Lucero, et al. (2006) discovered that sexual harassers in actual case studies often had a history of aggressive behaviors. They tended to repeat the same type of harassing behaviors and increased the severity of their behavior over time, despite punishment for past infractions. 4.2.2 Victim Just as understanding the various characteristics of perpetrators is essential, so too is understanding characteristics of victims of sexual assault. There have been extensive reviews mainly focused on female victims and male perpetrators; however, there is a paucity of research examining other victims, such as males, or LGB individuals. Common characteristics, in particular, gender, age, marital status and prior sexual abuse, have surfaced and have been shown to be statistically significant in studies that compare victims of sexual assault to non-victims (Elliot, et al., 2004, Dardis, Kelley, et al., 2013). Victims tend to be female and younger in age, ranging from adolescent to early adulthood. They also tend to be single (never married), divorced, or widowed, and have experienced prior sexual abuse as a child (Dardis, Edwards, et al., 2013; Elliot, et al., 2004). Other factors that were examined, but were not found to be significant, were race/ethnicity, education, and employment status. Due to the recent spotlight on sexual assaults in the military, researchers have conducted comprehensive reviews of the military domain (Sadler, et al., 2003; Turchik & Wilson, 2010). Similar characteristics of victims in the military compared to the general population surfaced, more specifically, age, prior abuse, and marital status of the victim. Specifically, victims of 37 sexual assault tend to be younger (i.e., late adolescence and early adulthood), single or divorced, and have experienced abuse in childhood. The following sections outline characteristics of victims that significantly relate to having experienced sexual assault while in the military. It is important to note that the characteristics discussed below are not predictive or causal of having experienced sexual assault, but are associated with those known to have been victims of sexual assault. 4.2.2.1 The Military Domain A large cross-sectional study done by Sadler, et al. (2003) focused on female veterans from all branches of service comparing victims of rape to those who were not raped. The researchers conducted a logistical regression on various predictors, outlined as risk factors, to determine their significance in relation to the outcome of rape or no rape. The risk factors were split into four different categories: enlistment, military violence, workplace environment, and off-duty on-base environment; however, in this section, only the enlistment category will be discussed. The remaining categories will be discussed in Section 4.2.3, which focuses on situational factors. Sadler, et al.’s findings substantiate findings from outside the military (i.e., the general population). Victims of rape enlisted at 19 years of age or younger (Odds ratio [OR]=1.97, p<.05), experienced childhood physical abuse (OR=1.88, p<.05), and or childhood sexual abuse (OR=2.38, p<.01). An additional factor that was significantly related to the rape outcome was rape prior to entering the military (OR=2.57, p<.01). Other predictors that were analyzed, but were found to be non-significant (p>.05) included domestic violence prior to joining the military and enlisting to escape an abusive home life (although escaping an abusive home life approached significance, OR=1.69, p=.054). Turchik & Wilson’s (2010) review of the literature revealed common characteristics of victims of sexual assault as well. They found that prior sexual abuse before entering the military ranged from 15.1% to 49% for females across the services (i.e., Army, Navy, and Air Force), and 1.5% to 22.5% for males across the services; however, it is difficult to compare rates across services because various methodologies were used when collecting information. Lastly, marital status was a common characteristic among sexual assault victims who typically were single or recently divorced. 4.2.2.2 Under-Represented Groups The previous studies examine only females as victims and did not discuss sexual orientation. The literature shows that females are not the only victims of sexual assault. While other groups have been victimized (e.g., males, lesbian, gay, and bisexual), they are understudied, which limits knowledge about these victims. However, a few studies provided some enlightenment regarding these under-represented groups. For example, Mattocks, et al. (2013) examined a group of female veterans comparing those that identified as Lesbian or Bisexual (LB) to females who identified as heterosexual in relation to Military Sexual Trauma. Mattocks, et al. (2012, 2013) found that the LB veterans compared to heterosexual veterans were significantly more likely to have experienced prior abuse by an adult before the age of 13 (46% and 26%, respectively, p<.05). Also, the LB group compared to the heterosexual group was significantly more likely to have had prior sexual 38 contact without consent before the age of 18 (34% and 17%, respectively, p=.01). Furthermore, LB veterans were significantly more likely to have experienced force or threat for sexual contact during their military service compared to their heterosexual counterparts (31% and 13%, respectively, p<.001). LB veterans and heterosexual veterans received equivalent levels of combat trauma exposure and uninvited sexual attention during military service. McLean (2013) reviewed male victims of sexual assault and found similar characteristics to female victims. Primarily age (adolescence to young adult) and marital status were common; however, other factors associated with the rape were different. For example, males were more likely to experience digital or object penetration, whereas, females experienced penile penetration. Also, males experienced more injuries in the anal area as compared to females. Males were also more likely to be raped by more than one perpetrator (i.e., gang-raped) compared to females whose rapes typically involved one perpetrator (Elliot, et al., 2004). It is very important to note that the literature is nascent regarding male, lesbian, gay, and bisexual victims. Because of the lack of research in this area, victim characteristics are not fully understood in the following areas; the reaction to a sexual assault, the decision to report a sexual assault and the response to treatment for a sexual assault among males, lesbian, gay, and bisexual individuals. 4.2.3 Situation In addition to understanding the perpetrator and victim, knowledge of the circumstances surrounding the assault is necessary. Social environmental factors such as time and location, presence of others, precipitating activities such as the use of alcohol and drugs, and the climate created by social norms and attitudes can potentially contribute to an incident of sexual assault. The situational characteristics that have been determined by research to be associated with sexual assault are described in the following sections: 4.2.3.1 Independence from Parental Home There is evidence that young people who separate from their parental household and move to a new location enter a stage of vulnerability to sexual assault. A study by Buddie & Testa (2005) found that sexual assault rates were approximately the same for females who moved to a college environment and those who moved to a new place in the community, suggesting that it is the move to independent living away from parents that is associated with risk of sexual assault. Similarly, Sadler, et al. (2003) found that females who joined the military at a young age of 19 or younger had higher odds of being raped in their later military service. 4.2.3.2 Location and Time of Day According to O’Sullivan, et al. (1998), most sexual assaults occurring among male and female college students take place late in the evening in either the victim’s or perpetrator’s room or apartment. Sadler, et al. (2003) found that 71% of female rape victims were assaulted on base: 51% were assaulted between 6 p.m. and midnight while off duty, and 18% were assaulted during these hours while on duty. Similar results were found in the 2012 WGRA survey: 70% of military members who reported unwanted sexual contact were assaulted at a military installation. Incidents took place during the work day/duty hours for 41% of the females and 49% of the males, indicating that at least half of the incidents took place after work day/duty hours (DMDC, 2013). 39 4.2.3.3 Alcohol Use Alcohol use, by the victim, the perpetrator, or both, has been found to be a major risk factor in sexual assault situations (Tharp, et al., 2013). It is theorized that alcohol facilitates aggression by impairing higher order cognitive processes involved in the perception of cues and the regulation of behavior (Lisco, et al., 2012). Alcohol also affects perceptions and expectations about the sexual intent of others (Abbey, et al., 2012). Alcohol use has been directly implicated in sexual assaults by males reported in college and community samples (Abbey & McAuslan, 2004; Parkhill & Abbey, 2008, Lisco, et al., 2012; White, et al., 2008), among sex offenders (Aromaki & Lindman, 2001), in same-gender pairings (Strike, et al., 2001) and among military personnel (Merrill, Thomsen, Gold, et al., 2001; Merrill, Thomsen, Sinclair, et al., 2001). In a survey of female veterans (Sadler, et al., 2003), more than a quarter of the victims and over half of assailants were reportedly under the influence of alcohol or drugs at the time of the rape. According to the 2012 WGRA survey of unwanted sexual contact among military members, 47% of female victims and 19% of male victims indicated that they or the offender had been drinking alcohol before the incident (DMDC, 2013). 4.2.3.4 Peer Influence and Norms Perpetration of sexual assault by young males in high school, college, and community samples has been found to be influenced by peers who hold rape supportive attitudes or have engaged in sexual assault (e.g., Abbey, et al., 2007; DeKeseredy & Kelly, 1995; Sears, et al., 2007.) According to Strang & Peterson (2013), perpetration of verbal sexual coercion and rape by a community sample of young males was related to the degree that they perceived that their close friends accepted or approved of sexually aggressive behaviors. Peer pressure to be sexually active has been associated with sexual assault in several studies (Abbey, et al., 2006; Krahe, et al., 2003). Some studies have found a relationship between perpetration of sexual assault and being a member of “high risk” all-male fraternities and sports teams who are party-prone (Humphrey & Kahn, 2000). 4.2.3.5 Sexual Harassment Sexual harassment has been defined as engaging in unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when submission to such conduct affects conditions of employment or creates a hostile or offensive environment (Equal Employment Opportunity Commission, 1980). High levels of sexual harassment directed toward females have been found in military environments (Buchanan, et al., 2008). A national survey of female veterans by Sadler et al. (2003) found that being exposed to a hostile work environment in the military was related to a six-fold increase in the odds of being raped. In the 2012 WGRA study (DMDC 2013), b0% of the females and 19% of the males who reported unwanted sexual contact indicated that the offender sexually harassed them before or after the incident (DMDC, 2013). 40 4.2.3.6 Military Culture and Environment The military environment has unique characteristics that can potentially increase the risk of sexual assault (Hunter, 2007; Sadler, et al., 2003; Turchik & Wilson, 2010). These include the following 4 characteristics: 1. New Service Member Environment. Turchik & Wilson (2010) cite a 2004 DoD report that discusses the multiple risk factors for new servicemen: youthful age, recent independence from parental care, peer pressure, close quarters, limited privacy, new relationships, and access to alcohol. This combination of factors may produce situations rife for sexual assault of inexperienced young females and males. 2. Barracks Housing. Sadler, et al. (2003) found that sleeping in cross-gender housing did not in itself lead to higher levels of rape reported by female veterans. However, having observed heterosexual or homosexual behavior in sleeping quarters was related to significantly higher odds of being raped. 3. Culture of Hypermasculinity and Obedience. Turchik & Wilson (2010) note that the male-dominated environment of the military is often perceived as reinforcing stereotypic sex role attitudes, sexism, and hypermasculine values and behaviors among its male members. As discussed earlier in this report on perpetrator characteristics, high levels of these attitudes and beliefs are considered risk factors for sexual assault (Malamuth et al., 1995). The obedience to authority and high group cohesiveness required of military members may serve to entrench these attitudinal norms and make change difficult (Hunter, 2007; Morris, 1996). 4. Lower Status of Females. It has been argued that the lower proportion of females in the military, the lack of females in leadership positions, and the segregation of females in non-combat roles creates a power differential between males and females (Turchik & Wilson, 2010). The higher status of males and the status of females as a minority group may establish conditions that are conducive to sexual victimization (Henry, et al., 2004; Mazur, 2007). 4.3 Findings From observations of the literature and interaction with multiple Air Force organizations emerge four key findings, detailed below in turn:  The scientific literature on perpetrators (e.g., serial offender, partner, and opportunist), victims, and risky situations is immature.  The Air Force lacks pre-crime situation awareness for early detection of possible perpetrators, victims, and risky situations.  There exist multiple opportunities for intelligence collection to detect sexual assault (e.g., improved screening, anonymous drop boxes/email, HD video, geo-temporal heat maps, social media mining, investigative interviewing).  There are emerging technology opportunities to improve perpetrator detection or forecasting. 41 4.3.1 Scientific Literature on Perpetrators (e.g., Serial Offender, Partner, and Opportunist), Victims, and Risky Situations is Immature As detailed in the previous section, the Study Panel found that the scientific literature is still emergent regarding the personality, attitudinal and behavioral models of perpetrators and victims. Perpetrators come in multiple forms (e.g., individual serial offender, situational opportunist, or assault or rape in an existing relationship). In part because of underreporting, incomplete reporting, and restricted reporting, perpetrator understanding remains limited with individual cases being discovered and analyzed on a regular basis. This suggests a degree of caution and humility regarding the ability to automatically detect perpetrators as their attitudes and behaviors are not fully understood yet. Accordingly, the Study Panel’s first finding is that the scientific literature on perpetrators (e.g., serial offender, partner, and opportunist), victims, and risky situations is immature. The lack of research is most acute for male victim and LGB populations. Research continues to reveal increasingly informed and nuanced models of perpetrators, victims, and risky situations. 4.3.2 Air Force Lacks Pre-crime Situation Awareness for Early Detection of Possible Perpetrators, Victims, and Risky Situations The Study Panel’s second finding is that the Air Force lacks pre-crime situational awareness for early detection of possible perpetrators, victims, and risky situations. As illustrated in Figure 4-1, sexual assault involves a spectrum of harm from harassment to contact to assault. Furthermore, an environment of dignity and respect is critical to prevention and deterrence. One study (Sadler, et al., 2003) reported that a hostile work environment increases by orders of magnitude the likelihood of sexual assault; and the WGRA study links harassment and assault. Unfortunately, the Air Force has relatively few current means of early detection, however, many opportunities exist to remedy this situation. 4.3.3 Multiple Opportunities for Intelligence Collection to Detect Sexual Assault The Study Panel’s third finding is that there are multiple opportunities for intelligence collection to detect sexual assault. The Study Panel observed multiple instances on Air Force installations of both electronic and physical intelligence collection that demonstrated effective detection in the field. For example, Joint Base San Antonio (JBSA)/Lackland AFB has worked with the Force Protection Program out of Hanscom AFB to deploy high definition cameras in common areas and high frequency assault areas to enable perpetrator identification. Cadets at USAFA noted to the Study Panel that they thought a similar application would be beneficial at the USAFA. Also at Joint Base San Antonio/Lackland BMT, simple anonymous drop boxes have been installed to facilitate basic trainees’ reporting. The OSI at Peterson AFB employs cyber/social media surveillance to detect cyber indicators of sexual assault. While not performing digital fusion, the Joint Base Lewis-McCord SHARP Center is exploring human “data fusion” to attack and destroy the predator environment. The Study Panel noted that civilian law enforcement units (e.g., Ashland-Oregon Police) have pioneered “investigative interviewing” to rapidly discover information and relationships to help solve crimes. More generally, there are a number of human sensor collection opportunities (e.g., survivor reporting, bystander reporting and/or intervention, third parties, routine medical examinations, family services) that could enhance the resiliency and speed of detection. 42 Perpetrators have certain personality and attitudinal characteristics which could be useful during accessions to improve screening out potentially dangerous perpetrators. More generally, there is insufficient detection of perpetrators across the airmen career cycle, from screening of recruits (e.g., for prior sexual abuse/crime), within basic and technical training, during active and reserve duty, and during post separation treatment. For example, in the latter category, cases of abuse and assault arise even post separation (e.g., 50% of military members seek treatment through the Veteran’s Administration to avoid the stigma associated with sexual assault). 4.3.4 Emerging Technology Opportunities to Improve Perpetrator Detection or Forecasting The Study Panel’s fourth and final finding is there are emerging technology opportunities to improve perpetrator detection and forecasting. As illustrated in Figure 4-3 below, there are a number of opportunities to leverage state of the art technologies. Figures 4-3(a) and 4-3(b). Opportunities for Technology Leverage. Several commercial startups have emerged to address detection of sexual assault17. For instance, cyber surveillance is possible with emerging tools such as those used by the National Center for Missing and Exploited Children that employ a deep hash algorithm and vision forensics to detect illicit files (e.g., child pornography, terrorism) and the associated activity of “bad actors” on enterprise networks, providing alerts and forensics reports for investigators and law enforcement. Furthermore, at least one company has developed an enterprise-wide behavioral data monitoring system to reliably detect distress, attitude, and intent in human communication and movement by continuous collection and interpretation of non-verbal, behavioral, and social signals underlying telephone conversations, video chats, and smartphone behaviors. These and other physical monitoring tools such as motion detectors could be adapted to sexual assault monitoring, piloted and assessed for their ability to enhance base situational awareness of sexual assault as well as other crimes. In addition, a number of municipal police departments such as in Santa Cruz, California, have used heat maps to track the location and timing of various types of crimes to anticipate where to deploy interventions, achieving quantitative benefits. Other technologies developed in the Air Force for intelligence, 17 Commercial technology examples provided for illustrative purposes only. Neither the Study Panel nor the USAF endorse specific commercial technologies. 43 surveillance, and reconnaissance such as data and information fusion and heat maps could be applied to enhance Air Force wide global situational awareness, ultimately leading to sexual assault crime forecasting and prevention. In addition to these near term opportunities to leverage technologies, the Study Panel identified a number of promising medium to long term technologies. Research continues to improve survey instruments to reduce high false positives in personality/behavior screening. In other important research, OSD’s Rapid Technology Office is developing a 90 minute, $100 DNA (Deoxyribonucleic Acid) analyzer that would provide significant benefit to timely resolution of sexual assault crime scene investigations. Finally, research in the largest sexual clinic in Canada is examining detailed functional magnetic imaging of brains of pedophiles (Cantor, 2012). While only in its infancy, this research promises future biomarker tests for early detection and prevention of childhood sexual abuse, including better understanding of adverse childhood events affecting the hippocampus, anti-sociality reflected in the prefrontal cortex, and pedophilia associated with, among other areas, networks in the fronto-occipital fasciculus and arcuate fasciculus. 4.4 Recommendations Given the above findings, the Study Panel recommends that the Air Force adopt a strategic vision of moving left of crime and provide proactive capabilities for early detection of sexual assault. This can be achieved through specific actions in the near term and in the mid to far term. Near Term  Develop pre-crime heat maps for sexual assault by leveraging existing technology, e.g., high definition cameras, drop boxes.  Develop an Air Force wide sexual assault threat picture, enabling anticipatory alerting and global pre-crime engagement.  Develop a knowledge management strategy and system to capture and appropriately share incidents (e.g., EO, SARC, OSI data) Air Force-wide to enable system wide situation understanding (e.g., to deter across-base perpetrators; to support research). Mid-Far Term  Enhance situation awareness by closing key science gaps in surveys, models and detection, including: o Advancing survey science and perpetrator/victim behavior models. o Leverage emerging science and technology to enhance perpetrator detection. 4.4.1 Develop Pre-crime Heat Maps for Sexual Assault by Leveraging Existing Technology (e.g., High Definition Cameras, Drop Boxes) In the near term the Study Panel recommends three major actions. First, the Study Panel recommends the Air Force enhance base level cyber and physical situation awareness by developing pre-crime heat maps for sexual assault by leveraging existing technology. This recommendation can be advanced in concrete ways as described in the findings above, such as: 44  Improving screening for recruits (e.g., careful measurement of personality, attitudes, and behaviors),  Improving physical surveillance by deploying high definition cameras in common areas and high frequency assault areas,  Installing anonymous physical and digital drop boxes, piloting COTS-enabled cyber surveillance (e.g., CyberMerlin, Cogito), and  Increasing human sensing and investigative interviewing by law enforcement to enhance the resiliency and speed of detection of perpetrators. 4.4.2 Develop Air Force Wide Sexual Assault Threat Picture, Enabling Anticipatory Alerting and Global Pre-Crime Engagement Second, the Study Panel recommends moving beyond base level situational awareness to develop a dynamic Air Force wide sexual assault threat picture across global bases to enable anticipatory alerting and global, pre-crime engagement. This recommendation can be achieved largely through the application of existing off the shelf technology. 4.4.3 Develop a Knowledge Management Strategy and System to Capture and Appropriately Share Incidents (e.g., EO, SARC, OSI Data) Air Force-Wide to Enable System-Wide Situation Understanding (e.g., to Deter Across-Base Perpetrators; to Support Research) Third, the Air Force should develop a knowledge management strategy and system to capture and appropriately share incidents (e.g., EO, SARC, OSI data) Air Force-wide to enable system wide situation understanding (e.g., to deter across-base perpetrators; to support research). The Air Force should leverage its considerable institutional competence to create service wide tracking and alerting capabilities to ensure perpetrators are not allowed to enact crimes across the enterprise and to shape crime out of the force. Of course, these efforts must be pursued in a lawful manner, with full sensitivity to relevant statutes, notably Title 50 (National Intelligence), Title 18 (Law Enforcement), and Title 32 (National Guard), and protection of privacy. Accordingly this effort will require key contributions from the OSI and law enforcement communities. 4.4.4 Enhance Situation Awareness by Closing Key Science Gaps in Surveys, Models, and Detection Finally, in the mid to far term the Air Force should enhance situational awareness by closing key science gaps in surveys, models and detection. This should include advancing underlying science including survey science and perpetrator/victim behavior models. In addition the Air Force should leverage emerging science and technology to enhance perpetrator detection. This can include efforts such as the OSD Rapid DNA testing program as well as closely tracking and leveraging neuroscience efforts to provide earlier and more accurate perpetrator detection. 45 4.5 Summary While there remains much to be learned about perpetrators, victims, and risky situations, there is already a significant body of literature, technology, and operational insights that support action by the Air Force to combat the crime of sexual assault. More importantly, rigorous application of detection methods can not only help move the Air Force left of crime, but if successful can enhance reporting, prevention, and deterrence to enable the more rapid establishment and sustainment of a pervasive climate of dignity and respect. 46 Chapter 5: Reporting A key aspect in sexual assault prevention, perpetrator detection, victim treatment, and organizational response is timely, actionable reporting. Reporting is defined as a process to identify and provide services to victims of sexual assault. It is an avenue to identify sexual assault crimes across the spectrum, including sexual harassment, to collect information, identify systemic deficiencies, and identify the perpetrators and bring them to justice. This section will review the reporting challenges, reporting science, and the components of, and barriers to, reporting. 5.1 Reporting As seen earlier (Page 7), Figure 5-1 below illustrates the continuum of harm to the victim of inappropriate sexual contact in the military. This includes sexual harassment which is prosecutable under Article 92 (equal opportunity law) of the UCMJ as well as Article 134 (good order and discipline), abusive or aggregated sexual contact (Article 120c and d), and sexual assault or rape (Articles 125 and 120a and b). While each of these statutes represents a classification of harm, each statute is subject to interpretation by the courts and evidentiary proof. Figure 5-1. Military Statutes Regarding Sexual Harassment, Contact, and Assault. Under SAPR Policy, airmen have two reporting options through the Air Force when treatment services for sexual assault are sought: unrestricted reporting or restricted reporting. Unrestricted reporting results in both command and law enforcement notification. While sexual assault incidents reported to command activate both victims’ services and law enforcement actions, some airmen may desire only healthcare and advocacy services and do not want command or law enforcement involved. Therefore, restricted reporting (also referred to as confidential reporting), allows a victim of sexual assault to access healthcare (both medical and psychological), advocacy, and legal counsel without notifying command or law enforcement; thus no investigation is initiated. Regardless of reporting method, the first priority is to treat victims with dignity and respect, and to provide medical treatment, mental health counseling, and advocacy services. A victimized airman also has the right to use civilian authorities, agencies, or healthcare. 47 To file a restricted report, an airman must use one of the following reporting avenues:18  Sexual Assault Response Coordinator  SAPR Victim Advocate  Military healthcare provider or personnel. Filing a confidential restricted report allows the airman to maintain control over the release and management of their personal information, and may give the airman needed recovery time and space for personal reasons. Restricted reporting is intended to empower victims of sexual assault to seek relevant information and support to make more informed decisions about participating in a criminal investigation. Even if the airman chooses not to pursue an official investigation, the commander receives the anonymous report within 24 hours, which in turn, gives commanders a clearer picture of the sexual violence within their command and enhances a commander’s ability to provide a safe environment that contributes to well-being and mission readiness. An airman may file a restricted report and later convert to an unrestricted report. Though a restricted report identifies the existence of an incident, it does not allow for the investigation of the incident nor the collection of evidence that could potentially prevent another assault. When an airman reports a sexual assault to law enforcement or anyone in their chain of command, the report is automatically considered an unrestricted report and must be investigated by the OSI. A commander must immediately report all assertions of sexual assault to investigators and has no authority or control over the investigation. If a bystander reports suspicion of a sexual assault, the report is mandatorily considered an unrestricted report. According to information the Study Panel learned on site visits and from a recent survey, reporting channels are broadly publicized throughout the military, and are discussed in numerous sexual assault briefings. However, it is not clear that many airmen, in particular junior enlistees, sufficiently understand their options for reporting sexual assault. As discussed earlier, this may be due to tuning-out during training. Most concerning is that nearly one half of junior enlisted personnel surveyed this year mistakenly believe they can make a restricted report to someone in their chain of command (Farris, et al., 2013). Figure 5-2 below summarizes the framework, considerations, and specific areas of inquiry for the reporting area of the CoSA Study. Along the reporting spectrum, sexual harassment/assault is reported or not reported, and there may be a time lag (sometimes years) from the point in which the assault occurs to the point in which it is reported. Air Force data indicates 95% of the reports of sexual assault occurred six months, or longer, prior to reporting. Confusion of what and where to report add to the complexities, and sexual victimization reports may be mishandled, especially at the harassment end of the spectrum. DoDI 6495.02 directs that when an unrestricted report of sexual assault is made, the order of response is: (1) Stabilization of the victim (e.g., medical treatment) and (2) OSI notification. Yet the OSI reports that in the majority of cases, the victim may have already given numerous statements to untrained investigators before OSI is called in to begin an investigation (e.g., to a SARC, to a SANE, to MPs, or SVC). While the intent is well-meaning, such interactions delay the investigation, allow interview evidence to deteriorate, and place the OSI at a disadvantage. On the other hand, 18 While Chaplains and Special Victims Counsel have confidentiality privilege, they cannot accept a Restricted Report from a victim of sexual assault. 48 numerous unfounded cases have been opened wherein the facts surrounding the report have been disproven, the acts were consensual, or the victims have been uncooperative, yet the OSI is not allowed to administratively end the investigation. These reports may occlude sexual assault data integrity and falsely inflate annual rates. Figure 5-2. Framework, Considerations, and Specific Areas of Inquiry for the Reporting Area of the CoSA Study. 5.2 The Reporting Challenge In Figure 5-3 (below) an iceberg metaphor is used to illustrate a view of sexual assault in the Air Force. The numbers on the tip of the iceberg above the waterline represent the hard data based on reporting mechanisms. Although the tip of the iceberg represents official reports received through the Air Force, it cannot be known if the number represents reports from occurrences during the current fiscal year. In other words, an airman may report an assault from a prior year and the report is counted as part of the current year’s total. The number just below the waterline represents a statistically derived estimate from the 2012 DoD WGRA survey. The WGRA estimated 2,469 cases of unwanted sexual contact; the Air Force maintains that during that time period there were 3,529 incidents of sexual assault.19 At the bottom there are any possible number of assaults that are unknown except for the fact that active duty airmen are being seen by non-DoD entities for treatment of issues surrounding sexual assault. The WGRA 19 The FY12 Air Force estimate of sexual assault incidents includes criminal acts of touching, grabbing, and fondling up to and including penetration (Grosso, 2014). 49 survey serves as an indicator of the prevalence of unwanted sexual contact but cannot accurately determine occurrences of sexual assault due to its methodology and differing definitions. It does however, provide an overview of the population. The Study Panel determined that while the number of restricted and unrestricted reports rose between FY 2012 and FY 2013, there is no way to definitively assert whether the increase in reports indicates a higher degree of trust in the system, an increase in the crime, or both. Similarly, in years where the number of reports may decrease, it cannot be determined if the decrease is due to lack of trust in the system, or fewer assaults. Additionally, due to a variety of barriers, there is no way to determine or extrapolate the broader number of sexual assault crimes that are never reported. Figure 5-3. Air Force SAPRO Data and DoD-wide WGRA Survey Extrapolations on Incidents of Sexual Assault in the Air Force. (Note: The number displayed on the left is the Fiscal 2013 USAF Active Duty end strength. Information gathered during the CoSA Study strongly suggests that the total number of sexual assault victims in the Air Force is largely unknown, and, like the bulk of an ice berg, hidden from direct viewing.) If one examines individuals from the numbers above from their health and treatment options, some key considerations for a SAPR program become clear – lack of reporting prevents victims from receiving treatment, could set the stage for additional crimes, and allows perpetrators to go unpunished. In a safety reporting system the ultimate goal of reporting events is to report happenings before they become full blown crimes. Other than the victim, the community at large bears responsibility to report events. As noted in earlier parts of this report, bystander reporting is one such opportunity in the larger community. Ultimately, to make progress in reporting sexual assault events, airmen must trust the reporting system, feel confident that submitted reports will be acted upon, and be compelled to understand event reporting as a shared community responsibility. 50 5.3 Summary of Findings This section provides a summary of Study Panel findings as well as from a review of the scientific literature and SAB Study Panel’s interactions (site visits, interviews, and briefings) with Air Force personnel. Six broad findings will be discussed.  The continuum of sexual assault is underreported in the Air Force.  Barriers to reporting (e. g. physiological, psychological, self-blame) often lead to a time lag between the incident, reporting the incident, subsequent investigation, and victim treatment.  Constraints on reporting path hinder reports of sexual assault and the investigative process o Sexual assault report made to supervisory chain is mandatory unrestricted. o Ability of the first line supervisor to assist the victim is reduced due to mandatory unrestricted reporting. o Lack of integrated and consistent data (e.g., DoD versus DoVA) may mask accurate understanding (e.g., frequency, harassment-to-assault) of sexual assault. 5.3.1 The Continuum of Sexual Assault is Underreported in the Air Force In general, individuals fail to report crimes but research has revealed that sexual victimization in particular is largely unreported (Tjaden & Thoennes, 2000). The National Crime Victimization Survey has consistently shown that sexual assaults are the most widely underreported violent crimes. The 2012 National Crime Victimization Survey results revealed that only 28.2% of these crimes were reported to the police. Research has shown that only 25% of all incidents of victimization against college students are reported to authorities. Reporting is even lower when other forms of sexual victimization are included. In a national study, Fisher and Cullen (1999) discovered that nearly all (97.7%) unwanted sexual contacts were not reported to police. Studies have also discovered that the demographic characteristics of victims are related to the likelihood of reporting, older females are more likely to report sexual victimization to police than are younger victims (Gartner & Macmillan, 1995). As noted in the Prevention section of this report, the youngest enlistees in the military are the ones at highest risk for sexual assault. Clearly, failure to report sexual assault is not just a problem in the military; it is one of the most under-reported crimes in society (Bostock & Daley, 2007; National Research Council, 2013). However, the military is uniquely transparent, and its members held accountable to a higher standard of behavior than the civilian community. As stated above, although the numbers of restricted and unrestricted reports rose between FY 2012 and FY 2013, there is currently no statistically valid way to determine whether the increase indicates a higher degree of trust in the system, or an increase in the crime of sexual assault or both. As illustrated in Figure 5-3, the Study Panel found that currently there is also no way to extrapolate the numbers of personnel who do not report via SARCs or surveys. This “Tip of the Iceberg” knowledge leads to a discussion of the scientific underpinnings of why most sexual assault victims fail to report. 51 5.3.2 Barriers to Reporting (e.g. Physiological, Psychological, Self Blame) often Lead to a Time Lag between the Incident, Reporting the Incident, Subsequent Investigation, and Victim Treatment Systemic Vulnerability and Consequences of Reporting Complexities. The Study Panel identified areas that both complicate the reporting process as well as leave the system vulnerable due to lack of reporting. The identified areas include: barriers to reporting, victim forced choice, reporting time lag, and bystander reporting issues. Each of these areas impacts Air Force ability to accurately track and effectively deal with sexual assaults. The Study Panel focused on three primary categories that comprise barriers to sexual assault reporting: psychological issues, physiological issues, and self-blame. Many of the underlying issues in these three areas are interrelated and overlapping. Most sexual assault victims do not report, resulting in:  Preclusion of perpetrator justice; limited effectiveness of criminal justice system, detection and prevention of crime  Restricts likelihood victims will have access to treatment and AF ability to understand magnitude of the problem for planning and policy decisions  Failure to address certain types of crime or particular crime dense areas Barriers to reporting: Psychological Issues Mission mentality, Compartmentalization Physiological Issues Impaired cognitive processing Self-Blame Alcohol use, drugs Hyper masculine culture Diminished awareness incapacitation Others will negatively judge, betrayal Fear of retaliation Stress Not believed Shame, stigma Cognitive dissonance Fear add’l victimization from familiar perpetrator Career disruption Trauma, injury Following orders Male victim stigma Prior abuse history LBG vulnerability Did not resist Perception of lack of justice Figure 5-4. Categorization of Barriers to Reporting Sexual Assault. 5.3.2.1 Psychological Issues Mission Mentality, Compartmentalization. From the time airmen enter the Air Force, they are trained that the mission comes first. Reporting sexual assault can be seen as disrupting the mission as opposed to accomplishing the mission. Studies and interviews have revealed that airmen will often fail to report sexual assault, favoring instead to compartmentalize the traumatic event and focus on the effort to “get the job done.” Failing to report is not seen by the airman as an action that could potentially harm the mission due to performance issues and possible trauma associated with sexual assault. This is especially relevant in the deployed and temporary duty (TDY) atmosphere, where airmen may elect to wait to report the incident when they arrive back 52 home. In doing so, the time lag in reporting can decrease the chance of collecting factual evidence to successfully prosecute the case. Hyper Masculine, Obedient Military Culture. As noted earlier, the male-dominated military environment often reinforces stereotypic gender role attitudes, sexism, and hypermasculine values and behaviors among its male members. The military culture lauds masculine traits and behaviors. The obedience to authority and high group cohesiveness is required of military members for mission readiness. This hypermasculine influence not only promotes the culture of military “brotherhood,” it also exaggerates negative group traits that promote bystanders, wherein airmen will not report their brother’s bad behavior, and indeed it may be a culturally accepted behavior (Hillman, 2009). These characteristics are also associated with the commitment and non-reporting of gang, or sequential, rape (Woodhams, 2013). It also leads numerous males to believe it is a sign of weakness to report having been sexually harassed or assaulted (Fiebert & Tucci, 1998; Davies, 2002; Burrowes & Horvath, 2013). Fear of Retaliation. The Study Panel found that fear of retaliation has a large impact on reporting. Depending on the circumstances of the assault, especially underage drinking and incapacitation, or the status of the perpetrator (i.e., either as a star performer or a member of the chain of command), a victim or bystander may feel too threatened to report an assault. This may be especially prevalent where there is a hostile work environment or a culturally accepted atmosphere of sexual harassment. Junior airmen and women feel particularly threatened in these circumstances, citing factors surrounding career disruption, Letters of Reprimand, collateral misconduct punishment, physical retaliation, harassment, or separation from the service. Reports can also result in revictimization (e.g., repeated questioning, general population knowledge, proximity of perpetrator, hostile unit during investigation). Shame, Stigma. A victim may experience shame and vulnerability stemming from sexual assault (Baker, 1999; Hazelwood & Burgess, 2008; Weiss, 2010). Victims also report shame and embarrassment during the questioning and physical examination after a report has been made, or an unwillingness to report due to not wishing to expose their shame in court. Additionally, after reporting, victims and bystanders may fear they will be singled out by peers and superiors as “that person” who reported a fellow airman or ruined unit cohesion. With that stigma comes ostracism from their peer group or organization. Studies suggest victims are unlikely to report a co-worker/peer (Livingston, 1982; Loy & Stewart, 1984). Male Victim Stigma. The scientific literature on male victimization and trauma is scant, in part, due to the reluctance of males to report. Male victims may not report due to a fear of ridicule for not being able to deter or fight the attack or unwanted sexual contact (McLean, 2013). Rock, et al. (2010) report survey results that 85% of military men who reported experiencing unwanted sexual contact, did not report it to authorities; 43% of these men related they did not want anyone to know about the unwanted sexual contact. Others (36%) feared the report would not stay confidential, while 27% feared retaliation. As noted earlier, males are more likely to be assaulted by more than one perpetrator (Elliott, et al., 2004; Stermac, et al., 2004). Males are also more likely to experience feelings of shame, humiliation, guilt, and embarrassment stemming from a sexual assault (Calderwood, 1987; Fiebert & Tucci, 1998; Davies & Rogers, 2006; Willis, 2008). Kakhnovets & Holohan (2007) note that military males in particular reinforce masculine stereotypes such as “men should be able to fight back and protect themselves” and “only homosexual men are raped.” These thoughts decrease the likelihood a male victim will report having been sexually assaulted. 53 LGB Vulnerability. The lesbian, gay, and bi-sexual communities are more vulnerable to issues such as prejudice and discrimination. Johnson, et al. (2015) discusses the implications of the repeal of the Don’t Ask Don’t Tell20 policy on the LGB community as bringing a potential spike in sexual-orientation-based harassment and victimization. Under Don’t Ask Don’t Tell and prior bans on homosexuality in the military, the programs led to an atmosphere in the military that condoned anti-gay harassment and violence (National Defense Research Institute, 2010; Shilts, 1994). Lehavot & Simpson (2013) describe LB females in the military in particular as experiencing higher instances of persecution, bullying, anti-gay jokes, and humiliation during their time in military service. They describe “corrective rapes,” a term used for a hate crime wherein the individual is raped because of their perceived sexual or gender orientation. The intended consequence of the rape is to “correct” their orientation and make them behave more like their gender stereotype. This crime has not been studied or addressed extensively in the military, nor has the pervasiveness of anti-gay hostility such as the prevalence of Air Force cultural norms represented in rituals and songs deriding females and “queers.” The Study Panel also found a disturbing lack of scientific study on harassment and sexual assault of LGB in the military. Career Disruption. In an effort to protect sexual assault victims, units may choose to reassign or even re-locate victims or bystanders who report. Victims/bystanders may see this as punishment, particularly if they are satisfied with their current jobs, or locations. This makes reporting an unattractive alternative, and in fact further victimizes the reporter. Airmen also cited the fear of other types of career disruption (aside from relocation), such as letters of reprimand, as a reason not to report. Populations particularly vulnerable to this are those in the training environment, where disruption in training could result in the need to repeat the training process, thus losing status. Other areas reported to the Study Panel include those positions, especially occupied by women or minorities, who cite being overlooked for promotions. Airmen report not being seen as a team player or being seen as unable to cope with the hyper masculine military environment, and thus may be overlooked for career enhancing assignments. For victims, this also includes fear of being categorized in mental health records with a psychological disorder, loss of security clearance, and thus classified as not mission ready. UCMJ Code 513(d), military rules of evidence, negates the mental health provider confidentiality privilege for numerous reasons such as mission readiness or harm to others. However, this privilege may also be revoked due to exception 513(d)(8), which states that any statement made by a patient to a mental health provider may be used in court when it is constitutionally required. Perception of Lack of Justice. Due to a number of factors, the military justice system, the investigative system, and the chain of command can be perceived as either unable or not inclined to bring justice to sexual assault victims. In cases of harassment especially, Estrich (1991) notes that the legal system has consistently declared that female behavior implies harassment was welcome, did not occur, or could not have been as bad as suggested. If these instruments of justice are perceived as ineffectual, the victim may determine it’s not worth the risk to report harassment or assault (Legrand, 1973, Bond & Mosher, 1986; Herman, 1988; Torrey, 1990; Orenstein, 1997; Garrison, 1999; Clay-Warner & Burt, 2005; Orenstein, 2007; Hillman, 2009; Stemple, 2009). 20 Don’t Ask, Don’t Tell Repeal Act of 2010, Public Law No. 111-321, 124 Stat. 3515 (2010). 54 The military justice process, including administrative separations and Article 15, carries differing punishments for offenses as cases vary. Each case must be reviewed individually, although general deterrence is a factor considered. The Manual for Courts-Martial directs Commanders to dispose of criminal allegations in a timely manner at the lowest appropriate level of disposition - Commanders may: (1) Take no action; (2) Take adverse administrative action, such as counseling, admonition or warning, reprimand, extra military instruction, or withholding of privileges; (3) Impose nonjudicial punishment under Article 15, UCMJ; (4) Forward the case to a higher level or return it to a subordinate commander; or (5) Prefer charges initiating the court-martial process and forward the charges and case file (with a recommendation as to disposition) to a superior commander who has authority to convene a court-martial. Per the Rules for Courts-Martials, before making a disposition decision commanders must consider the following factors:21 A. The nature of and circumstances surrounding the offense and the extent of the harm caused by the offense, including the offense’s effect on morale, health, safety, welfare, and discipline; B. When applicable, the views of the victim as to disposition; C. Existence of jurisdiction over the accused and the offense; D. Availability and admissibility of evidence; E. The willingness of the victim or others to testify; F. Cooperation of the accused in the apprehension or conviction of others; G. Possible improper motives or biases of the person(s) making the allegation(s); H. Availability and likelihood of prosecution of the same or similar and related charges against the accused by another jurisdiction; I. Appropriateness of the authorized punishment to the particular accused or offense; and J. Other likely issues. There are numerous cases that lack substantial factual evidence (unsubstantiated or unfounded) and are either not pursued (investigation dropped by victim), are dismissed by a judge or panel, or result in acquittal of the defendant. Reporters and non-reporters alike have remarked that there appears to be a lack of consistency in sentencing sexual assault crimes. It is important to note that military judges are not the sole sentencing authority in sexual assault cases, whereas most states have a judge as the sole sentencing authority. If the accused decides 21 Note: The Rules for Courts-Martials are contained in the Manual for Courts-Martial. See Rules for Courts-Martials rule 306(b). Paragraph letters are taken directly from the current (2012) Manual for Courts-Martial. The 2014 National Defense Authorization Act removed consideration of “the character and military service of the accused” (which was the original letter “J”) which had been another factor. 55 to be sentenced by a council or panel (including enlisted panel), there may be a lighter sentence or a harsher sentence than would be carried out by a judge. As for sentencing, the government may present extenuating and mitigating evidence which would include impact on the victim and on the unit. The defense may present matters in extenuation (e.g., good service record, mental health issues, etc.) even though consideration of "the character and military service of the accused" may not be used by a commander making a disposition decision. Airmen discussed with the Study Panel that when they read sexual assault narratives from annual report data, a number of cases that involve alcohol have different outcomes. Article 120 clearly discusses incapacitation. If the Air Force espouses a zero tolerance policy, why are the punishment outcomes different? The Study Panel determined this difference is due to evidence. When a commander prefers charges forward, there is existing evidence, however it may later be determined insufficient at a court martial. It is perceived that physical trauma appears to hold up as evidence better in court than psychological trauma. Sexual assault, other than forcible rape, has most certainly resulted in psychological trauma, but may not be perceived as such a high impact crime at courts martial. While inconsistencies in the law are outside the realm of this study on scientific approaches, the Study Panel identifies these issues as adding to the perception of inconsistent or lack of justice for a victim of sexual assault. When rulings are not summarized and explained there appears to be a lack of transparency in sentencing that reinforces the perception of a lack of explicit justice, and a tolerance for sexual assault crimes other than penetrative. There are also retained myths and cultural misconceptions surrounding the perception of a lack of justice and reluctance to report sexual assault. One of these retained myths is that answering positively to Question 21 on the Standard Form 86 Questionnaire for National Security Positions has hurt chances at receiving a security clearance.22 Though the instructions for answering this item have recently been revised to state: “Victims of sexual assault who have consulted with the health care professional regarding an emotional or mental health condition during this period strictly in relation to the sexual assault are instructed to answer ‘No.’” (US Office of Personnel Management, 2013). However, mental health records are subject to examination for security clearance and airmen convey they do not want to risk unfavorable review from categorization of a psychological disorder in their mental health records due to treatment for sexual assault. Even if they answer, “No,” airmen believe their mental health records that document counseling for sexual assault will result in a negative clearance review, thus the decline to seek help. 5.3.2.2 Physiological Issues Impaired Cognitive Processing. Individuals with a past history of abuse or trauma may have developed ineffective means to balance their human urges, as a coping strategy. Even those individuals experiencing a new trauma may also experience a difficulty in recalling (strategically) important memories related to the event, known as dissociative amnesia (Berntsen & Rubin, 2014). Although they function well in actuality, they may become confused with unclear or unreal thoughts and thus become reluctant to report sexual assault for fear they are 22 Now currently Question 21 on the SF 86 asks if in the last seven years an individual has consulted a health care professional regarding an emotional or mental health condition or if they were similarly hospitalized. There are currently exemptions for this question. 56 mistaken (Burgess, et al., 1995). Some medications, such as those used to treat pain, anxiety, nausea, insomnia, depression, and anxiety, or those used in sedation, may produce hallucinations or an impaired or amnesiac state due to their effect on the neurotransmitters of the brain (e.g., benzodiazepines, ketamine, scopolamine). Individuals with past histories of abuse or who are using these medications may question whether an assault did indeed take place. Diminished Awareness/Incapacitation. There are circumstances in which a victim or bystander may have diminished awareness of an assault due to a distorted state of awareness. This can involve areas such as inebriation/incapacitation, prescription medication, being in a drugged state, injury or head trauma, excessive fatigue, or being asleep. The victim or bystander may be unable to accurately recall details, and in many cases to question the actual events, or reason that they will not be believed. Stress/Fear. Threats, or perceived threats, of harm trigger the fight-flight-or-freeze response of the autonomic nervous system. This floods the noradrenergic system and activates the opioid system that can cause amnesia or poor information encoding into memory. Due to this response, victims may have trouble accurately recalling information after an assault, or question the circumstances (Dahl, 1999). Chronic exposure to stress, such as prolonged harassment, also affects a victim’s ability to accurately recall details (Berntsen & Rubin, 2014). Cognitive Dissonance. According to Festinger (1957) dissonance is a psychological conflict resulting from incongruous beliefs and attitudes held simultaneously. Elkin & Leippe (1986) discuss that dissonance creates a stressful physiological arousal state, but attitude change sustains rather than reduces the arousal. It is suggested that if dissonance is a drive state, drive reduction typically may be accomplished through gradual cognitive change or forgetting. In order to reduce the discomfort of dissonance, one may try to forget, reduce, or rationalize the importance of the dissonance. In the case of sexual assault, victims may feel the need to maintain their self-identity both privately and outwardly. Leippe & Eisenstadt (1994) describe the extent that dissonance involves a threat to self-image, the magnitude of dissonance will be heightened both by the choice in engaging in an attitude-discrepant act and personal responsibility for its foreseeable negative outcomes. As an example, a victim may rationalize based on faith in another’s behavior, rather than evidence to the contrary: “We were both drinking, and it was a misunderstanding,” “I tell myself to forget about it,” “S/he didn’t mean to hurt me,” or “I must have led [my superior] on because s/he is concerned about my wellbeing.” Kelly (1988) notes some sexual assault victims rationalize they are at fault simply because they were born women or dressed provocatively. Cognitive dissonance also applies to the sexual harassment end of the spectrum, “Disparaging talk about or actions toward women from males in my unit doesn’t bother me because I’m one of the boys.” Research has further demonstrated that sexist behaviors that occur under the guise of normal activity are often reduced in their importance to maintain cognitive consonance. Victims persuade themselves a transgression is alright due to perceived authority, honesty, physical attractiveness, and likeability. Most people think of rape as a sudden, violent attack by a stranger in a deserted, public place, after which the victim is expected to provide evidence of the attack and of active resistance (Williams, 1984). When an individual experiences a situation that does not conform to the stereotypical concept of rape, they may be reluctant to report the incident. Trauma, Injury. For example, forceful motion, head injury, or a loss of consciousness (for less than 30 minutes) can cause a temporary loss of mental function. The individual may 57 develop cognitive problems such as difficulty thinking, memory problems, attention deficits, mood swings, and frustration. The person may also experience amnesia around the time of the injury. These symptoms can be delayed days or weeks after experiencing the trauma, while the person may appear normal to the untrained eye. This is particularly important for cases of male on male sexual assault where the assault tends to be more violent in order to subdue and incapacitate the victim. Trauma however, can also be inflicted psychologically. Psychological trauma affects morale, health, safety, welfare, and discipline. The extent of psychological trauma experienced from a non-penetrative-forceful sexual assault is not well studied or understood. 5.3.2.3 Self-Blame Victims may blame themselves for being in a situation whereby an assault has occurred, or for the circumstances surrounding the assault. Factors in the spectrum of self-blame or incrimination that lead to a reluctance to report are discussed below. Alcohol Use, Drugs. As discussed in the Prevention section of this study, alcohol and certain drugs affect perceptions and expectancies about the sexual intent of others and may cloud judgment (e.g., Abbey et al., 2012). This circumstance can lead victims to blame themselves for an assault, or question if an assault occurred at all, and thus choose not to report (Franklin, 2010). The Study Panel heard numerous accounts of alcohol use/abuse among airmen, and alcohol is recognized in the military as a contributing factor in the majority of reported sexual assault cases (Foster, 2013). In fact, victim inebriation is also a contributing factor in numerous cases where the victim will ultimately drop the charges. Others will Negatively Judge, Betrayal. Victims who blame themselves may fear they will be negatively judged or that they are betraying their peers or units by reporting. Additionally, the victim may feel betrayed by those they trusted or the system they trusted, and choose not to report. The Study Panel heard numerous reports regarding units where harassment is accepted and seen as part of the unit culture. Unit commanders have made it clear that those who do not appreciate the environment will not advance. Airmen report “going along to get along” in order to be seen as “one of the boys.” Not Believed/Lack of Trust. In light of the complexities of sexual assault, and the fact that many sexual assault victims are younger and lower ranking, victims may not view themselves as credible in the eyes of those in the chain of command or other reporting venues. Additionally, the circumstances surrounding the assault and the victim’s response may lead the victim to doubt they will be believed. This is particularly applicable to threats from a superior or in the eyes of a cadet (Snyder, et al., 2012). Fear of Additional Victimization from Familiar Perpetrator. If the victim is assaulted by a member of their unit or someone in their chain of command, the concern for additional victimization may prevent them from reporting. Research has shown that 61% of victims who did not report sexual assault had some prior contact or substantial contact with the perpetrator prior to the assault (Feldman-Summers & Norris, 1984). Further, they cite evidence that victims who show no injuries and/or report that the perpetrator was an acquaintance are substantially less likely to be believed than those victims with injuries who did not know the perpetrator. Many victims of sexual assault recognize that naming an acquaintance and having no physical injuries is likely to arouse suspicion and the victim may feel they will be treated indifferently or not 58 believed. This in turn leads them to fear additional reprisals or attacks from the perpetrator. Women victimized by known assailants are less likely to file a criminal report than those who do not know their assailants (Jones, et al., 2009). The Study Panel learned this fear has also been voiced about victimization when a sexual assault case reaches trial, it is also well known in the literature regarding victim blaming in court (Legrand, 1973, Bond & Mosher, 1986; Torrey, 1990; Garrison, 1999; Orenstein, 2007). A clear message is sent to the victim when the First Sergeant up through the chain of command sit on the side of the defense and testify for the accused. As voiced by one airman, “Why would I report when I know, even if I make it to trial, I’m ostracized by my unit and will not receive their support?” Following Orders. The intimidation a victim may feel toward command staff often results in non-reporting. In cases relayed to the Study Panel, perpetrators have been in positions of authority to command a victim’s presence and they felt they had no choice but follow the order otherwise. Harassment, assault, or hazing were known to, or committed by, a commanding officer. Victims have relayed that if they want respect they will follow orders, to do otherwise indicates disrespect for the chain of command. Prior Abuse History. The WGRA shows that 30% of women and 6% of men victims are themselves victims of prior abuse. This history may lead the victim to assume responsibility for the assault, and not report. Those who have suffered past trauma are more likely to believe that nothing will be done (Fitzgerald, et al., 1995), or may suffer from post-traumatic stressors that comprise an acute reaction to the current trauma (Morris & Rao, 2013). Did Not Resist. For a variety of reasons (e.g., alcohol, drugs (recreational or date rape), fear, self-preservation, unable to overpower the perpetrator(s), etc.), numerous victims may not physically resist the assault. When this is the case, the victim may conclude they themselves are to blame, regardless of the circumstance or trauma associated with the assault. Fear of Collateral Misconduct Punishment. As has been noted, sexual assault can happen in conjunction with alcohol, drug use, or other illicit/unapproved activity, such as being absent past curfew. When this is the case, and the victim has engaged in unauthorized behavior punishable under the UCMJ, such as underage drinking, the victim may choose not to report to avoid punishment for the collateral offense. The Air Force does not routinely grant immunity for minor collateral misconduct for the fear that this could facilitate fabricated sexual assault claims and detract from good order and discipline. Numerous sexual assault cases that have been dismissed by the Court due to lack of substantiating evidence have resulted in collateral misconduct charges against the victim. This has led to a perception that the military justice system is biased toward punishing the victim and allowing the perpetrator to go free. 5.3.2.4. Victim Forced Choice Following a sexual assault, the victim has three basic reporting options. They can make an unrestricted report, they can make a restricted report, or they can choose not to report through Air Force channels. Each of these choices has its own set of consequences. Additionally, victims who choose to report may elect to delay reporting, sometimes for years after the assault. The following discusses the results of forcing a victim to choose between restricted and unrestricted reporting. 59 Too Traumatized. Following a sexual assault, the range of obstacles facing victims include mental and physical trauma. A victim may be too traumatized to consider the ramifications of reporting choice. When victims choose to report, they must decide whether they want to make a restricted or unrestricted report. The degree of trauma they experience impacts whether they recognize a crime has been committed, when they may choose to report, and then an immediate decision to choose restricted or unrestricted reporting (depending on how the incident is reported) that they may wish to change later. In the case of a restricted report, a later decision to make the report unrestricted has consequences discussed below. In the case of a decision (or forced choice due to misunderstanding the reporting path) to make an unrestricted report, there is no option to later restrict the report. This can further add to victim trauma. Unaware of Consequences of Reports to Supervisory Chain. A victim’s communication with another person (e.g., roommate, friend, family member) does not, in and of itself, prevent the victim from later electing to make a restricted report. However, if the person to whom the victim confides information (e.g., roommate, friend, family member) is in the victim’s officer and non-commissioned officer chain of command or DoD law enforcement, there can be no restricted report. Airmen are trained from the day they come into the Air Force to trust in the chain of command. Routinely the first line supervisor is the initial entry point for many of the problems airmen encounter. In the case of sexual assault, reporting, or even discussion of the sexual assault with this first line supervisor, First Sergeant, or Commander chain-of-command automatically defaults to an unrestricted report. Airmen who are accustomed to discussing problems with these supervisors may approach their chain of command without thinking through the fact that this discussion will result in an unrestricted report despite their desires. This not only impacts the victim, but other airmen in the unit who may see this as a betrayal, and could affect their decision to approach their chain of command with a similar problem. This is also problematic for the supervisor who must immediately cease a personal confidential relationship built on trust, and file an unrestricted report, even when this may go against the victim’s wishes to file a restricted report. Leads Some to Seek Help Outside DoD. The requirement for a victim to choose between restricted or unrestricted reporting, despite trying to deal with the facts and trauma of the assault, can lead them to seek help outside the chain of command and the DoD itself. Most airmen discuss fear of career damage or retaliation as reasons for seeking help outside of the military. When this happens, the victim may receive delayed, disrupted, or no treatment. Treatment outside the DoD system also impacts investigation, sexual assault tracking, and can result in perceived poor performance by supervisors of victims needing time off for treatment outside the system. Knowing that airmen may be reluctant to disclose, one avenue the DoD has pursued to encourage victims to seek crisis counseling is through contracting the Rape, Abuse & Incest National Network DoD Safe Helpline which provides confidential crisis support services for the DoD community through their website, telephone, text, or application. 5.3.3 Constraints on the Reporting Path Hinder Reports of Sexual Assault and the Investigative/Justice Process 5.3.3.1 Reporting Time Lag As discussed above, there are many reasons for delayed reporting. This can be a reporting time lag between a sexual assault and initial report, and/or between the initial report 60 and investigative statement. This time lag is a significant obstacle to ensuring adequate victim treatment, as well as an obstacle to criminal investigation and bringing perpetrators to justice. Below is a discussion of delayed reporting. Confusion of What or How to Report (EO, SARC, OSI). Many sexual harassment reports are handled through the lowest supervisory level or through the Equal Opportunity office (EO), yet the OSI related that the National Defense Authorization Act for Fiscal Year 2013 directs that sexual harassment reports should be investigated as federal crimes. Conflicting policies present a conundrum for the reporter as to who, or where, to report. There is also fear to report what may constitute possible hijinks that could be dealt with through peer training (e.g., snapping a towel at someone in the locker room) and what constitutes a federal crime that must be reported. The Study Panel learned that when sexual assaults are reported, more often than not, there is a significant delay contacting the OSI. As a result, a victim may make numerous, repeated reports to untrained investigators. Without specially trained techniques for conducting a proper Cognitive Interview, well-meaning but untrained investigators may lead or confuse the victim, thus planting false suggestions into their memory, in turn making it more difficult for the OSI to uncover the factual story. When an airman files an unrestricted report the first duty is to provide medical care. At this point, according to policy, the OSI should be brought in to the investigation to collect factual/forensic evidence, and will offer to bring in the Special Victim Counsel (SVC). However, more often than not, victims are directly offered the services of the SVC. Once the SVC is engaged all dialogue must proceed through the SVC, even the OSI investigative interview or OSI requests for items such as a medical report. This undue command influence can impede factual evidence collection and hold up the investigation. It has also been treated as an adversarial encounter when the SVC acts as an Ad Hoc Defense Counsel and advises the victim not to cooperate. Restricted Reports are not Investigated, Physical Evidence is not Collected. When victims file restricted reports a criminal investigation does not commence. Physical or factual evidence (witness statements, security footage, etc.) may not be collected. If a victim subsequently converts to an unrestricted report, the delay in collecting evidence may lead to a lack of evidence which complicates investigations and convictions and can lead to further feelings of betrayal or lack of trust in the system. Evidence Deteriorates. The longer the time lag in reporting, the more physical and factual evidence deteriorates. Depending upon the degree of deterioration, this can complicate the investigation and impact bringing the perpetrator to justice. As a result, the investigation may be unable to substantiate a valid claim. Compromised Memory. Time lag in reporting can compromise the victim’s ability to accurately process episodic memory. The longer the time from the actual crime to filing the report can change a victim’s memory of the facts, the timing, the situation, and who might have witnessed the crime. The compromised memory, complicated by additional stress induced by the trauma and multiple other factors, impacts the ability to effectively investigate the crime. Multiple Victim Statements. As time passes between the crime and the report, the victim may make several statements. This has several consequences. First, the victim may become 61 “re-victimized” by having to relive the crime multiple times. As the trauma and stress of the situation play out, statements may change and add additional confusion to an investigation. The Air Force SAPRO estimates that on average, a victim tells their story seventeen times during the course of filing an unrestricted report (Galbreath, 2013). Victim answers to questions may change from one to the next based on the context of whom the victim is answering, the kind of questions asked, the tone of the interviewer, and the impact of trauma on victim semantics. Prevents Substantiation. The deterioration of evidence and compromised memory induced by reporting time lag may prevent substantiation of the sexual assault. The time lag itself may reduce the credibility of the report. Incident Location May Not be Where Incident is Reported. Statistics show that in many cases, sexual assaults are not reported at the location they occur. Whether the crime occurs while TDY, or while in the AOR (Area of Responsibility), many airmen choose to wait until they return to home base to report (Leard-Mann, et al., 2013). In some cases, crimes are not reported until the next assignment or many years after the event. This time lag prevents the ability to investigate, to identify perpetrators, and to ensure victims receive appropriate treatment. The assault may be attributed on one AFB, when in fact it was merely reported there and occurred somewhere else. Can Impact Sexual Assault Tracking. Delayed reporting may lead to inaccurate reflection of annual sexual assault rates in the Defense Sexual Assault Incident Database (e.g., data from an assault committed in prior years will count as data reported in the current year). This tracking includes not only the statistical tracking, but any information regarding the location of the perpetrator, which could help in prevention and detection, as well as bringing the perpetrator to justice. Lack of Bystander Intervention Adversely Impacts Prevention, Detection, and Treatment, Third Party Non-involvement (Bystander Intervention, Bystander Fear of Retribution). Current Air Force Instructions do not specifically outline bystander responsibilities, nor consequences for failure to meet these guidelines. Harnessing the power of the bystander in terms of required reporting or engagement is a rich environment for further exploration. Required bystander engagement and reporting responsibilities motivated by attendant consequences, as well as taking care of Wingmen, provide a wider set of opportunities to detect, prevent, and report sexual assault crimes and should be an area of research. For example, how does one perceive consent? From a reporting perspective and from a by-stander perspective, this is a critical issue and most likely a major reason for bystander nonintervention. Removing obstacles and developing better methods for bystander reporting will prove important toward placing appropriate guidelines. Easily accessible anonymous drop boxes or anonymous digital drop boxes are a good idea for close campuses such as in the basic training environment or at the USAFA, but may not work at larger facilities. 5.3.4 Sexual Assault Reports Made to Supervisory Chain are Mandatorily Classified as Unrestricted As seen during site visits, the mandatory classification of “unrestricted” to a sexual assault report made to the supervisory chain of command, can create a deterrent to reporting. The many psychological and physiological issues that exist following a sexual assault crime may 62 make the first decision a victim makes, whether to file a restricted or unrestricted report, one they might not make if there were greater latitude in reporting to their supervisory chain. Airmen have discussed confusion in how to report. While they are aware of reporting options, they are not necessarily well aware of the consequences. This is not a result of lack of training, but tuning out. Airmen note that sexual assault training is frequent and begins to fall on deaf ears. Airmen who have been forced into filing an unrestricted report, against their wishes, have been known to decline to participate in the subsequent investigation resulting in unsubstantiated cases or cases that are substantiated but the parties refuse to move forward with prosecution. These cases may be actual crimes, or they may consist of reports made by witnesses who misunderstood what was perceived as an assault. These reports (founded, unfounded, substantiated, unsubstantiated) are Titled and kept in the Defense Sexual Assault Incident Database. Retaining and recoding these reports allows the OSI to follow trend information on suspected perpetrators. 5.3.5 The Ability of the First Line Supervisor to Assist the Victim is Reduced Due to Mandatory Unrestricted Reporting The Air Force routinely conditions airmen to trust their first line supervisor to be the first person they confide in regardless of the issue for which they may need consultation. Due to the requirement that a report made to anyone in the supervisory chain automatically becomes unrestricted, the hands of the first line supervisor are tied in advising or interacting with the victim. More importantly this critical link in the chain may never know the crime took place, sees performance or other problems, but cannot link these problems with the trauma. Supervisors relayed how they can see comorbid behaviors developing in some airmen (e.g., use of alcohol, reporting late, not obeying commands). In attempts to counsel and help the airman they must gain trust. If it is revealed that the airman suffered a sexual assault, the discussion with someone in their supervisory chain of command must immediately end and the mandatory reporting process must begin. A supervisor cannot offer a victim the choice of restricted treatment. Supervisors relayed to the Study Panel that this erodes trust. An airman may come to a supervisor for guidance on what to do after a sexual assault and the supervisor must immediately stop the conversation and become an officer who needs to make an official unrestricted sexual assault report. While the Study Panel feels it is the duty of a supervisor to report an assault and does not suggest this requirement be overturned in any way, the current practice does not allow the supervisor to counsel the victim regarding their choice of reporting avenues. 5.3.6 Lack of Integrated and Consistent Data (e.g., DoD vs DoVA) May Mask Accurate Understanding (e.g., Frequency, Harassment to Assault) of Sexual Assault When it is reported, sexual harassment is mainly reported through EO channels and sexual assault is reported through chain of command or SARC channels. There is no venue locally or at the Air Force level that aggregates this information. This can allow perpetrators to be masked as they may in some cases victimize airmen both as harassers and assaulters, but are not easily recognized during investigation or otherwise due to dual/non-integrated reporting chains. 63 The Study Panel learned of numerous cases of reports in the system that cannot be retracted (nor should they be fully retracted for data and tracking purposes). These unrestricted reports mandatorily must open an investigation, even when the apparent victim does not wish to go forward. A victim may have confided to a superior, thus starting the mandatory unrestricted report process. In turn, the victim feels forced into an investigation in which they do not wish to cooperate. In these circumstances, the victim does not wish to go forward with prosecution and may drop the case. There have also been cases where bystanders have reported a suspected assault, when the events in question were actually misunderstood (e.g., husband groping wife in driveway, people seen drinking at a bar and “hooking up” when it was, in reality, consensual, etc.). These reports are filed into the system and cannot be retracted. These reports appear in terms of reporting annual frequency, but in terms of content, they do not constitute active reports. The Study Panel determined that retracting these reports may compromise the system. There may be unfounded reports in the system that are filed due to a misunderstanding; however, there may also be cases where a perpetrator moves from base to base claiming their actions constitute a misunderstanding. Recoding this data allows information from opened cases to be kept aside from the founded, substantiated cases for more accurate statistical calculation of assault rates. This critical finding undergirds the resolution of the sexual assault problem. Without this data, in an integrated and consistent format, commanders at the unit level all the way up to Headquarters USAF cannot identify key indicators, such as: (1) predators moving from unit to unit undetected, (2) units with a hostile work environment, and (3) those with a high sexual assault rate. An integrated data base that allows access by commanders at all levels regarding personnel in their units is a key link in solving the sexual assault problem from the bottom up. It is also important to note that any report of sexual assault is accepted into the system. This means that reports from assaults that occurred years prior, or occurred when an airman was TDY can skew data interpretation of when and where an assault occurred. 5.4 Recommendations All recommendations for reporting sexual assault can be handled in the near term. These recommendations include:  Allow first line supervisor authority to advise victim while suspending requirement for unrestricted reporting (e.g., refer to SARC, provide grace period for counseling, without requirement for mandatory unrestricted reporting). o Victim should not lose ability to file restricted report based on to whom they talk.  Establish policy to minimize career disruption for victims and to minimize retaliation for victims and bystanders who report. o Consider policy to allow immunity for low level collateral misconduct uncovered as a result of a sexual assault investigation.  Improve rapid coordination between victim care and investigative process (e.g., EO, SARC, and OSI).  Coordinate with DoVA Disability Rating Activity Site to obtain sexual assault demographic data on active duty and retired airmen. 64 5.4.1 Allow the First Line Supervisor the Authority to Advise the Victim While Suspending the Requirement for Unrestricted Reporting (e.g., Refer to SARC, Provide Grace Period for Counseling, Without Mandatory Unrestricted Reporting) Victims Should Not Lose Their Ability to File a Restricted Report Based on to Whom They Talk As a policy issue, grant first line supervisor (e.g., first shirt) the authority to counsel the victim while suspending requirement for unrestricted reporting (e.g., privacy privilege). Rather, the default should be restricted reporting (e.g., refer to SARC, provide grace period for counseling, without requirement for mandatory unrestricted reporting). Suspending the unrestricted reporting requirement allows the first line supervisor to ensure the victim gets appropriate treatment while exploring all options available to the victim. Further, the supervisor and chain of command are still bound to maintain confidentiality. This is in keeping with existing responsibilities and capabilities for first line supervisors to assist their subordinates. Despite psychological and physiological trauma, or the litany of reasons discussed previously, the victim should have the ability to file restricted regardless of to whom they report the crime. The goal is to reduce confusion and prevent a delay in care/treatment from occurring, if possible, thereby preventing extra unnecessary suffering, and increasing airman performance and subsequent mission readiness. Research should also be conducted to ensure that victims of sexual assault get the care they need. This may mean developing a different mechanism for reporting sexual assaults outside of the chain of command. While a sensitive issue, the current reporting system has not been definitively proven to work. Because an estimated 80-90% of sexual assaults are unreported, and in some cases years have passed before the victim gets care, there is a critical need to explore other reporting avenues. As an example, the DoVA and Military One Source are used by many airmen as a venue to report sexual assault. Given that we know these resources are already being used, research should be conducted to evaluate the effectiveness of these options for the airman as an official avenue to receive care for sexual assault. Having multiple channels to report that are easily accessible is useful, as long as they serve a unique purpose and airmen don't end up with too many channels which could further confuse the victim. 5.4.2 The Air Force Should Establish Policy to Minimize Career Disruptions for Victims and to Minimize Retaliation for Victims and Bystanders Who Report The Air Force Should Consider Policy to Allow Immunity for Low-Level Collateral Misconduct Uncovered as a Result of Sexual Assault Investigation This is fundamental to realizing any improvement to reporting. This can be done through better coordination of education, training, and public relations campaigns to empower victims and compel bystanders to report, as well as assure victim safety and care; thus eliminating reporting stigma (culture change) and developing trust. Developing a logic tree/organizational justice accountability algorithm to create transparency in penalty or Zero Tolerance guidelines for specific offenses can eliminate perceptions of favoritism, help reduce fear of retaliation for reporting, and increase trust that the 65 justice system works. Include a prominent role for the OSI in public relations campaign materials from the SAPRO to assure airmen of the OSI cooperation and commitment to justice. While current Air Force Instructions allow commanders to balance collateral misconduct, explicit guidance that takes away low level collateral misconduct punishment allowing commanders to deal with the greater crime has significant potential to improve reporting both by victims and bystanders. For example, an underage airman may have been intoxicated at the time they were the victim of a sexual assault. Alcohol abuse/conduct issues impede reporting of sexual assault. The Air Force should consider research into amnesty policies for lesser infractions uncovered as a result of a sexual assault investigation, such as those utilized in universities, to encourage felony reporting. 5.4.3 Improve Rapid Coordination Between Victim Care and Investigative Process (e.g., EO, SARC, and OSI) The fourth recommendation is required to provide an integrated picture and demonstrate results that both assist the victim and help to bring the perpetrator to justice. Time lag introduces a variety of issues that impact appropriate victim treatment and impede investigative efforts. These issues constitute major barriers to reporting that can be alleviated by simply following proper protocols or changing mandatory restricted/unrestricted reporting protocols to allow the OSI the opportunity for immediate contact with a victim outside of the (unrestricted) reporting requirements. If policy cannot be changed, it is important for an investigation to proceed in a systematic and appropriate manner so that accurate information pertaining to the case can be carried forward to the next level. Therefore, the Air Force should integrate the response to the victim for rapid resolution and improved coordination between victim care and the investigative process (e.g., EO, SARC, and OSI). Improved coordination between the SARC and the OSI can quickly bring in the OSI, who are trained in proper cognitive interview techniques to elicit victim statements. This enhanced coordination between the SARC and the OSI to handle the detailed account of the assault and reduce the frequency of victim statements, can minimize the delay in a post assault investigative interview to reduce memory encoding inaccuracy and ultimately preserve evidence. This ultimately provides better service and care to the victim, and reduces the numerous times they must narrate their statement. The Air Force should recognize in policy that trauma may compromise a victim’s statement in initial or subsequent interviews, reflecting possible inaccuracy in victim’s statements (dissociative amnesia). Recognizing this may help reduce the chance of a perceived adversarial encounter and ensure the investigative process does not inhibit the victim. 5.4.4 Coordinate with Disability Rating Activity Site (D-RAS) to Obtain Sexual Assault Demographics Data on Active Duty and Retired Airmen A recurring finding was that various organizations in the Department of Veterans Administration were being used by active duty sexual assault victims who chose not to use the DoD’s SAPR options. To gain a deeper understanding of the cohort of victims, the Study Panel recommends that the SAPRO seek access to and begin to analyze relevant DoVA data sources. The Veteran’s Benefits Administration determines disability ratings for all serviceconnected conditions, even the ones that would not result in a finding of “unfit for continued military service.” The DoVA’s Disability Rating Activity Site is used to evaluate a Service 66 member’s referred and claimed conditions. Presently, through Presidential executive action, active duty airmen are rated as part of a pilot program, in addition to retired airmen. As it pertains to the Presidential action to improve the transition between DoD and DoVA care, and to combat homelessness and lack of healthcare for all combat veterans, active duty airmen transitioning from military service are rated through the DoVA and kept as active duty until DoVA care begins. The only exception to having been deployed is Military Sexual Trauma. Claim files are reviewed by the Ratings Veterans Service Representative, with specific raters assigned to sexual assault cases. As it stands, current active duty airmen have sexual assault claims entered into D-RAS with the appropriate, clearly documented history. The spectrum of sexual assault can be determined based on the percentage the rater assigns with the associated benefits granted. Given this, the Veteran’s Benefits Administration houses data on how many airmen are service connected for sexual assault. Therefore, the Air Force should coordinate with the DoVA to run D-RAS data of how many active duty and retired airmen have filed for military sexual trauma, what is the breakdown between males and females, and what percentage are they rated? This data will provide a more accurate picture of airmen who experienced sexual assault in the Service. 67 (This Page Intentionally Left Blank) 68 Chapter 6: Treatment 6.1 Framework: Air Force Medical Response to Health Effects of Sexual Assault23 DoD’s SAPR policy (DoDI 6495.02) obligates all DoD Components to provide effective health care to the victims of mental and physical trauma across the spectrum of sexual assault.24 We specifically adopted a spectrum approach for treatment in recognition that sexual harassment can be just as debilitating as rape, although rarely acknowledge in DoD and service policy and law. To provide that care for Air Force personnel, the Air Force’s medical system has a variety of health care providers including physicians, nurses, psychologists, and social workers. All of the professional providers utilize one or more of the evidence-based practice methods relevant for stress disorders attendant to sexual assault. Additionally the Military Health System mandates that the treatment of sexual assault victims adhere to national practice standards.25 Figure 6-1 below provides the treatment framework used in the CoSA Study. This framework illustrates that the health threat, health consequences, the victims/patients, and medical treatment response must all be considered. The health threat of sexual assault can range from the psychological to the physical resulting from the continuum of harm from sexual harassment to unwanted sexual contact and rape. Included in this spectrum are the social, environmental, and organizational components all of which can impact the health and recovery of the victim/patient. Importantly, these components are not independent, but are overlapping and co-occurring, with multiple threats occurring simultaneously. Thus, approaches to eliminating and reducing the health threat must be comprehensive and holistic. The health consequences of sexual assault might include physical and psychological injury, emotional suffering, performance decrements, and separation from the service (Suris & Lind, 2008; Norman, et al., 2006). While the psychological and physical injuries that result from sexual assault are well recognized (The White House, 2014), less appreciated and understood are the disruptions in performance that might also result from harm experienced on any level of the continuum of sexual assault, ultimately resulting in the airman leaving the military. Changes in work performance might reflect an airman who has been harassed or sexually assaulted, for example, yet has not reported the incident. Leaders, however, are likely to attribute poor work performance to a lack of motivation and dedication, when in fact, the airman’s poor performance, accompanied with psychological and emotional issues, is likely due to sexual assault. Thus, the trauma from sexual assault often results in the airman leaving the Service. 23 Scientific literature citations for those knowledge contributions that were consulted as background and which became foundational to the observations leading to the findings and recommendations are listed in Appendix B of this report. 24 Perpetrators of sexual assault certainly have mental/behavioral health issues that require medical treatment. However, as noted previously, this study did not investigate perpetrator treatment. 25 During finalization of this report, a very relevant review article appeared in the journal Current Psychiatry Reports (Castro, et al., 2015). The review provides both a rich bibliography and options for medical considerations for the health effects of sexual assault in military settings. 69 Figure 6-1. The Treatment Framework Used in the CoSA Study. Any airman can become a victim of sexual assault, both male and female. Because there are heterosexual males, as well as LGB victims that need treatment following sexual assault, no assumptions are made regarding the effectiveness of these treatments for these other diverse groups. Indeed, in the absence of strong clinical findings showing these treatments to be effective, a key recommendation is to validate these therapies in these groups, who are especially high risk for becoming victims of sexual trauma. The standard Post Traumatic Stress Disorder (PTSD) therapies used for sexual assault victims include Prolonged Exposure Therapy (PE), Cognitive Behavior Therapy, and Eye-Movement Desensitization and Reprocessing (EMDR). These therapies have been shown to be effective in treating female victims of rape, with important limitations that will be discussed below (Tolin & Foa, 2006; Katz, et al., 2008). A final insight from the treatment perspective is that information derived from sexual assault patients and their treatment can inform the considerations and options for the Air Force’s overall SAPR programs but especially those for prevention, detection, and reporting of sexual assault. Indeed, any new SAPR program and/or research initiatives in the area of treatment should include study aims and study trial arms that seek to inform the prevention program, at a minimum. 6.2 The Processes Leading to Evidence-Based Treatment Figure 6-2 below is a simplified diagram of the pathways for receiving care following a sexual assault: the formal SAPR reporting path (solid lines) and the informal, alternative path for a victim to seek help (dotted line). Briefly, many recruits enter the Air Force with a history of psychological and/or physical abuse, including sexual assault (Merrill, et al., 1999), many 70 who have never reported the assault or received treatment or care for the assault, thus placing them at increased risk for being re-victimized (Risser, et al., 2006; Sandberg, et al., 1999; Turchik & Wilson, 2010). If an airman is assaulted, they can either report the assault through the restricted or unrestricted reporting routes or not report the assault. Reporting the assault will involve the SARC, SVA, and, possibly, a peer counselor who can assist the victim in receiving care and support to recover from the assault. If the airman chooses not to report the assault then they must determine what care they need and seek that care without the assistance of the SARC, SVA and peer counselor. Unfortunately, how these airmen fare regardless of which path they take is unknown, and represents a major data gap in efforts to combat sexual assault and mitigate trauma for victim members of the Air Force. Figure 6-2. The Pathways for Receiving Care Following a Sexual Assault. (Note: Solid lines = formal SAPR reporting path. Dotted lines = informal, alternative path.) By way of illustration, a victim of physical sexual assault may enter the system via a medical emergency facility where a physician and/or a Sexual Assault Nurse Examiner is the airman’s first contact with the SAPR process. SAPR policy directs the medical provider to engage the SARC as soon as practical. During this Study’s various discussions with personnel at Air Force installations, and with therapists treating victims of sexual assault within and outside the military, the Study Panel confirmed that many victims of sexual assault avoid the formal DoD reporting and care process, thereby avoiding the SARC and SVA. It is also important to appreciate the very personal decisions that must be made by the airman who has been sexually assaulted, before seeking treatment. Figure 6-3 below provides a graphic depiction of the context for this consideration. If an airman seeks immediate care following a sexual assault, current treatments are more likely to be effective than if treatment is 71 delayed. However, in the case of sexual assault, seeking care/treatment following a sexual assault is often delayed by weeks or months, and often years. There is no doubt that delaying care/treatment leads to a worsening of symptoms, performance decrements, and ultimately attrition from the service. However, as noted earlier in the Reporting section, there are many barriers and obstacles to reporting a sexual assault (DMDC, 2013). Key barriers include psychological stigma (including personal shame), concerns over the impact of reporting a sexual assault on their military career, and fears of being rejected by their peer group within the Air Force. Figure 6-3. Decision Context can be Very Personal. Note: A pre-military service history of sexual trauma as well as personal decisions on seeking care after military sexual trauma have multiple behavioral effects and effects on definitive treatment options. Regardless of the path chosen in seeking treatment, the consequences of a sexual assault are an unpredictable performance deficit that has implications for both military personnel readiness for duty and military unit readiness. This is an area of research deserving of significant and immediate scientific enquiry. The development of effective policies and strategies to reduce barriers to seeking care following a sexual assault should be immediately undertaken. Rigorous scientific studies to determine the immediate and long-term effects of sexual assault on military performance (including attrition) should be undertaken. The effectiveness of current treatments of sexual assault in reducing the physical and psychological suffering, preventing performance decrements, and reducing military attrition should commence at once. 6.3 Summary of Findings from the Science Literature, SAB Study Panel Site Visits, Interviews, and Briefings Using the background presented in Sections 6.1 and 6.2, this section will elaborate on six broad findings from the Study Panel’s interactions with a myriad of Air Force personnel (e.g., SAPR providers, victims, management, and leadership) and those six findings provide the core insights for the Study’s recommendations (see Section 6.4).  Prior history of sexual or physical assault increases risk for being victims of sexual assault again, i.e., risk of “kindling effect” (Schumm, et al., 2005).  Limited studies on effectiveness of existing treatments (i.e., “outcomes”) for females; non-existent for male and LGB victims. 72  Multiple health effects of sexual assault (physical and psychological) impact performance and create attrition.  Long term health effects of sexual assault have not been studied in military contexts.  Lack of understanding of the effects of stigma associated with seeking treatment.  Clinicians lack standardized training for detection of victims. Before elaborating about the broad findings above, it is important to elaborate on the context of consideration in Figure 6-3 and focus on the left and right ends of that process figure. These provide two context setting concerns for the Military Health System’s response. PERCENT Prior History of Sexual Abuse 28-33 30 12-18 6 MIL U.S. Pop MALES MIL U.S. Pop FEMALES Individuals with prior history of sexual abuse are 3 - 5x more likely to be revictimized Figure 6-4. Prior History of Sexual Abuse in Military Personnel. (Note: From DMDC, 2013). Trauma History. Figure 6-4 above illustrates an unfortunate fact that many new military members may have had a prior history of sexual abuse. The scope of the numbers of individuals affected that is relevant to the military’s response is 6% for males and 30% for females (DMDC, 2013). It is known from these data that these individuals are three to five times more likely to experience sexual assault again (Sadler, et al., 2003). How the military should respond to both the reality of new members having prior sexual abuse and to the risk that these individuals will be re-victimized needs both to be researched and to be acknowledged with treatment policy and procedures.26 26 The CoSA Study Panel was encouraged to learn that the Air Force SAPRO was initiating a treatment protocol for new recruit victims of prior abuse at Lackland AFB and during new recruit training with follow-up at least through early technical training. Assuming this is fully funded/resourced, it is a good example of an initiative that should have a hypothesis-based research aspect that is separately funded by Defense Health Research, Development, Test, and Evaluation (RDT&E) Program. 73 Patient Response to Treatment. The second context is the data on how well victims of sexual assault respond to the current standard therapies. Figure 6-5 below shows the results of a recent meta-analysis on psychotherapy effectiveness (Bradley, et al., 2005). The data illustrate that more than 50% of all patients (i.e., dropouts plus nonresponders) do not have their sexual assault PTSD effectively treated. These data have clear implications for both the need for new research on better treatments and on the need for a better and deeper understanding of military readiness implications of sexual assault. Figure 6-5. Results of Meta-Analysis on Psychotherapy Effectiveness. (Source: Bradley, et al., 2005). Within these contexts, the remainder of this section will elaborate on the “Treatment Findings” and extend to a deeper consideration of the current state-of-science and state-ofmedical practice. 6.3.1 Health Effects of Sexual Assault Psychological Health. The health effects of victims of sexual assault have been well described. Posttraumatic stress disorder, depression, and eating disorders are among the major psychological injuries resulting from being sexually assaulted (Campbell, et al., 2009). It has been estimated that upwards of 80% of females sexually assaulted will suffer from PTSD, with 70-80% suffering from depression, and 30-40% having an eating disorder. The psychological harm resulting from being sexually assaulted can result in significant and prolonged performance decrements, ultimately resulting in the service member being separated from military service (Sadler, et al., 2004). Physical Health. In addition to psychological injuries, sexual assault can also result in significant medical health issues that might also impair performance (Sadler, et al., 2004). The physical health issues resulting from being sexually assaulted might include becoming infected 74 with a sexually transmitted disease, to enduring a wide variety of non-specific physical health complaints such as headache, nausea, stomach ache, cramps, back and joint pain, and fatigue (Elliott, et al., 2004). These non-specific physical health injuries are often referred to as Medically Unexplained Physical Symptoms (MUPS) (Norman, et al., 2006). Mental Distress. Many victims of sexual assault will suffer in silence. As discussed earlier, most victims of sexual assault will not report the incident to officials. It is estimated that 80-90% of victims of sexual assault will never file a restricted or unrestricted report. Further, many victims of sexual assault will not even tell a friend about the crime until months or years later. Keeping silent about being sexually assaulted can create extreme distress, resulting in guilt and second guessing. Unwanted Pregnancy. It is estimated that approximately 5-8% of sexual assaults that occur in the civilian population result in an unwanted pregnancy. For a variety of reasons it is unknown how many unwanted pregnancies result from sexual assault in the military. However, it has been reported that over one half (54%) of all pregnancies amongst female service members are unwanted (Duberstein, 2011). Suicide/Suicidality. Victims of sexual assault are at increased risk of dying from suicide, and for suicidality (Saladin, et al., 2003; Noll, et al., 2003). It has been estimated that being a victim of sexual assault increases the risk of incidence of death by suicide by four-fold. It should be appreciated, however, that this probably represents an underestimate given the low reporting rates of sexual assault; thus, resulting in lack of documentation/confirmation of the crime. Re-victimization. The single, largest predictor of the potential to become a victim of sexual assault is having a prior history of being physically or sexually assaulted (Simmel, et al., 2012). It has been estimated that upwards of 50% of all sexual assault victims will be re-victimized. Often, victims of sexual assault have not received adequate care for the initial assault, nor do they receive immediate care for subsequent assaults. 6.3.2 Treatment and Clinical Issues and Knowledge Gaps Treatment of Male Victims. Effective psychological therapies exist for treating female victims of sexual assault. For PTSD, these psychotherapies include prolonged exposure therapy, cognitive processing therapy (CPT) and EMDR (Bradley, et al., 2005). In careful clinical trials, upwards of 80-85% of female victims of sexual assault respond favorably to one of these treatments if they remain in the treatment protocol (Bradley, et al., 2005). Unfortunately the effectiveness of these treatments do not approach these levels outside of the research venue. For depression and eating disorders, cognitive behavior therapies are used. Indeed, all of these therapies were developed and validated to specifically treat females who were sexually assaulted. Group therapeutic approaches have also been developed and implemented for female sexual assault victims. Unfortunately, there have been no studies assessing the effectiveness of these therapies for male victims of sexual assault (Morris, et al., 2014). And only recently have group therapies for male sexual assault victims been established (Hoyt, et al., 2012). Non-DoD Medical Care. It is clear that many victims of sexual assault do not access medical care through the DoD SAPR process. DoVA patient data (Castro, et al., 2014) indicate significant delays in victims of sexual assault receiving care and/or treatment. According to the DoVA, many female and male victims don’t receive any medical care for a sexual assault that occurred while they were on active duty until they leave military service (numerous interviews). 75 Further, many active duty victims of sexual assault seek medical care outside of the DoD medical health system. The DoVA, military one source, and a private health care provider appear to be the main alternative sources of care (see Figure 6-2) for active duty service members who are victims of sexual assault. Stigma of Seeking Treatment. As previously discussed, the barriers and obstacles to reporting a sexual assault are considerable (DMDC, 2013). It takes a great deal of courage to overcome the fear that many victims describe to report a sexual assault. Yet oftentimes victims themselves are viewed as maligners, not good team members, and/or trouble makers by fellow airmen and the immediate supervisory chain. Clinician Training. Given the wide range of psychological and physical symptoms associated with sexual assault and given the reluctance of sexual assault victims to report being sexually assaulted, it is critical that clinicians, especially primary care providers and mental health care providers, are aware of the health effects of sexual assault. However, standardized training for clinicians is not provided nor required for the detection of sexual assault, especially in those cases when the airmen presents with non-specific health care complaints (i.e., MUPS). 6.3.3 Improving Health Outcomes through Research Effectiveness Outcomes. While PE, CPT, and EMDR are established clinical psychological treatments for treating PTSD resulting from sexual assault, there have been no effectiveness studies to determine which therapy is most effective in a military population (Rau, et al., 2011). Further, 20-25% of female victims of sexual assault are unresponsive to existing psychological treatments, with no studies having been conducted to assess the effectiveness of these therapies with male sexual assault victims (Rau, et al., 2010). Innovative Therapies/Holistic Models of Care. There are currently no new therapeutic approaches to treating sexual assault being explored. Sexual assault results in numerous and known psychological and physical health needs, yet the Study Panel learned that there are no efforts underway anywhere within the DoD Military Health System to research, develop, validate and standardize a holistic approach to meet the physical and psychological health care needs of sexual assault victims on any part of the continuum. Return-to-Duty Standards. There are no validated return-to-duty standards for airmen being treated for sexual assault. Currently, each return-to-duty determination is made on a caseby-case basis by the health care provider using subjective, clinical judgment, which may vary from installation to installation, and vary from one clinician to another. Not having clear, validated guidelines for when a sexual assault victim can return to full duty can result in other members and leaders assuming the assaulted airmen are malingering (Sadler, et al., 2004). DoD Survey Content. The current DoD and Air Force surveys do not attempt to capture unmet health care needs of victims of sexual assault who do not report their sexual assault, either restricted or unrestricted. While the survey asks if the individual is a victim of sexual assault, none of these surveys ask airmen who have been sexually assaulted (yet chose not to formally report their assault) about their mental health status, or where or if they received health care. Additionally, these surveys have not attempted to capture the impact that sexual assault has on the airmen’s performance and intention to remain in the Air Force. 76 6.3.4 Knowledge from Treatment Can be Used to Improve Prevention, Detection, and Reporting From the numerous interviews that the Study Panel conducted, it is clear that many airmen and leaders do not understand the magnitude of the physical and psychological injuries that can result from being a victim of sexual assault. The likelihood of a victim developing psychological and/or physical health issues following sexual assault is almost certain. This knowledge needs to be incorporated into the Air Force’s SAPR training in order to increase understanding and compassion for the assaulted airman and increase awareness of the suffering this crime produces across the continuum of harm. Airmen and leaders need to be educated that it is typical for victims of sexual assault not to report being assaulted for months or even years after the assault occurs. These delays in reporting do not indicate that the assault didn’t occur, nor do they indicate that the assaulted airman is in anyway responsible for the assault. Delays in reporting a sexual assault occur for a variety of reasons, including fear, embarrassment, distrust, and anger. Leaders and fellow airmen should not be concerned about the reasons for the delay in reporting the crime. Rather, regardless of when a sexual assault occurs, once a sexual assault has been reported, leaders and fellow airmen need to focus on ensuring the assaulted airman receives the care and support needed to fully recover. Many airmen and leaders fail to appreciate how being sexually assaulted can impact an airman’s performance. The psychological and physical injuries resulting from being sexually assaulted can have profound effects on job performance. The impact of sexual assault on job performance can be sudden, occurring immediately after the sexual assault; or gradual, with job performance deteriorating over a period of time. Leaders at all levels need to be aware that sudden or gradual decrements in job performance may be indicative of psychological or physical distress resulting from sexual assault. Some supervisors believe that claims of sexual assault are excuses to cover for poor performance. While approximately 8% of sexual assault claims are determined to be false reports (DMDC, 2013), the vast majority of sexual assault reports are valid, and should not be lumped with false reports. This latter point needs to be emphasized in Air Force sexual assault training. Airmen need to be aware that recovering from sexual assault can take time, months to years, to fully recover. Treatments for the various psychological and physical harm resultant of sexual assault may last from several months to years. For instance, while the treatment for PTSD resulting from sexual assault can be delivered in approximately 10-12 sessions over three to four months, recovering from the mistrust and betrayal can take years. Leaders and supervisors need to provide a supportive work environment to ensure that every airman receives the support they need to fully recover, with specific tools and practice to mitigate social stigma (e.g., preventing microculture impressions that the airmen is a “malingerer” or “just playing the system”). As noted earlier in the section, sexual assault is associated with increased risk for suicide (Saladin, et al., 2003; Noll, et al., 2003). Suicidal ideation, such as thinking about suicide and making a plan to die by suicide, has been shown to be higher in sexual assault victims. Risk factors associated with sexual assault need to be incorporated into the Air Force’s suicide prevention training. Further, screening and assessments for sexual assault should be conducted in airmen who are suicidal. An integrated holistic approach to caring for an airmen who is suicidal and who has been sexually assaulted needs to be developed and implemented following 77 the DoVA/DoD clinical practice guidelines for the treatment of PTSD (if appropriate) and suicide. It has been estimated that upwards of 20% of female airmen and 6% of male airmen have been physically or sexually assaulted prior to entering the Air Force, indicative of and not unlike the general problem of sexual assault crimes in the United States (DMDC, 2013). It is likely these pre-Air Force sexual assaults were not reported, nor did the victim receive care or treatment for the sexual assault. Further, victims of sexual assault are more likely to become victims of sexual assault in the future. Thus, it is critical that all new recruits, both male and female, are screened for any unmet physical and psychological health needs from past sexual assault. Appropriate interventions (i.e., care and treatment, as well as prevention) need to be provided. Treatment interventions should be focused on addressing the unmet psychological and physical health needs of the recruit. Prevention efforts should focus on preventing the airmen from becoming re-victimized and sexually assaulted in the future. These interventions should be provided prior to the airmen reporting to their first duty station. Convincing evidence (Ullman, 2007) is emerging that when victims of sexual assault are treated with dignity and respect following a report of sexual assault, their recovery is quicker from both the physical and psychological injuries, while maintaining positive views of the organization. In contrast, when airmen are treated with mistrust and skepticism, their recovery is delayed, frequently resulting in the airman leaving the military. Thus, it is important to educate and train airman, supervisors, leaders, and all personnel in the role they play in the healing process of airmen who report sexual assault. The behaviors of these individuals should be monitored to ensure dignity and respect is shown to every airman who reports sexual assault. The Study Panel is confident that processes to ensure personal accountability can be developed and implemented to demonstrate the Air Force’s commitment to ensuring reports of sexual assault are free of retaliation and recrimination. 6.4 Recommendations Notwithstanding the suggestions for new activities and initiatives articulated in the previous section, the Study Panel developed four formal recommendations to improve the treatment aspects of the Air Force’s SAPR. Three recommendations are for near term actions (begin execution within 6 months to 1 year), and one is for the mid-term (begin planning now with actions to begin no later than 2 years) completion envisioned for the 3-5 year time frame. 6.4.1 Initiate Improvements to DoD Treatment Access, Processes, Procedures, and Policy (Near Term) Following a sexual assault, the primary focus must be on ensuring that the health care needs of the victim are met. In the context of health care ethics, gathering evidence of the crime for a possible subsequent conviction is secondary to the health and wellbeing of the victim. Currently, airmen are only encouraged to seek care through the SAPR reporting process. However, the Study Panel discovered that many airmen receive health care for sexual assaults outside the Military Health System, while many more don’t receive health care for months or years after the sexual assault. Accessing health care following a sexual assault can be delinked from the SAPR reporting process. To build trust, it is suggested that alternatives to accessing healthcare should be widely publicized instead of via formal and informal military social 78 networks, including disseminating this information as part of the EO and Air Force sexual assault prevention training. Treating victims of sexual assault requires specialized training. The mental health skills necessary to treat victims27 of sexual assault requires training in specific psychotherapies; and unique knowledge in the treatment of the physical injuries that can result from sexual assault are necessary, in particular the treatment of medically unexplained physical symptoms (MUPs). Moreover, given the nature of the crime, male and female airmen who have been victims of sexual assault generally require same-gender providers. The Air Force, however, does not have a mechanism in place to ensure that victims of sexual assault will be treated by health care providers with experience in the treatment and care of victims of sexual assault. Nor does the Air Force ensure that the providers available to treat and/or care for victims of sexual assault consist of both genders. The Air Force should assess the expertise needed for every rank-andfile medical provider and should mandate that sufficient expertise is available for treating female and male airmen who have been victims of sexual assault. The DoD estimates that nearly 80% of sexual assaults go unreported (DMDC, 2013). It is also unknown how many victims of sexual assault never receive care or treatment for their physical or psychological injuries or how long after the assault before they receive care. In many cases, it was discovered that victims of sexual assault do not receive care until they leave the military. The Air Force is required to conduct annual physical and psychological health screenings for every airman (i.e., the Periodic Health Assessment). Using information from the DoVA’s medical screening process, the Air Force should revise its annual health assessment to include a screen for sexual assault. In addition, the Air Force should mandate that primary health care providers conduct routine screens of airmen for sexual assault (both male and female), especially when an individual presents with non-specific health complaints. The Air Force should ensure that all health care providers are trained in the administration of the sexual assault screen, and how to appropriately respond when airmen have been identified needing care. 6.4.2 Establish a Research Agenda for Improved Treatments and Outcomes (Mid-Term) It is generally known that 20-30% of sexual assault victims do not fully recover following physical or psychological treatment. Yet surprisingly, there are no studies underway within the DoD to identify more effective treatments for either the psychological or physical injuries that result from sexual assault. Given the broad spectrum of injuries resulting from sexual assault, for instance PTSD, depression, eating disorders and suicidality in the psychological health domain; and chronic non-localized pain, fatigue, headaches and sleeping difficulties in the physical health domain, a comprehensive research program will be required. In particular, such a research program should focus on identifying effective treatments for non-responders to current treatments for sexual assault. The Air Force is engaged in treating victims of sexual assault, primarily female victims, using evidence-based treatment protocols for PTSD. However, the Air Force does not conduct 27 The age, sex, and racial demographics of sexual assault victims are complex and will determine the scope of medical provider training. For example, expertise in adolescent health may be a prerequisite for many providers who treat sexual assault victims, but, the Study Panel learned that Air Force health care providers who have professional fellowship experience in adolescent health are few. 79 routine health outcome studies that could provide a wealth of information regarding the effectiveness of the current PTSD therapies in treating victims of sexual assault. The Air Force should conduct a broad range of health outcome studies to: determine effectiveness of sexual assault treatments for male airmen; determine which treatment approach is most effective in treating sexual assault within the Air Force demographic; and establish return-to-duty criteria following sexual assault. Such studies would enable the Air Force to determine which approaches to the treatment of sexual assault for airmen are the most effective, and where specific improvements in the care and treatment of victims of sexual assault can be targeted. As noted previously, victims of sexual assault may present with a wide range of physical and psychological injuries, however, the nature and extent of these injuries is poorly understood. Thus, it is challenging to develop a holistic approach to the care and treatment of sexual assault victims. The Air Force is in a unique position to provide a leading role in enhancing the medical science understanding of the injury profile of victims of sexual assault by conducting comprehensive physical and psychological assessments of victims of sexual assault receiving care with the military health system. The Air Force should determine what psychological and physical health injuries present in victims of sexual assault. It is generally accepted that sexual harassment can have a devastating impact on the psychological and physical health of the victim. However, because sexual harassment doesn’t involve physical contact, it is typically viewed as less harmful. To some extent this view is understandable, but not always correct. In most cases, sexual assault occurs in work environments were sexual harassment is tolerated or condoned, either explicitly or implicitly. The Air Force has worked diligently to decrease sexual harassment in the work place, yet it still exists. Thus, determining the impact that sexual harassment has on the health and performance of the airman is critical for assessing the readiness of the force. It is recommended that the Air Force define the impact that sexual harassment can have on performance and health. The Air Force and the DoD conduct numerous surveys on the topic of sexual assault. Yet, none of the surveys employed inquire about the unmet health care needs of those airmen who have been sexually assaulted yet didn’t report the incident. Health questions are only asked of those airmen who reported the incident. Given the vast majority of sexual assault victims don’t report, it remains unknown how many of these victims never receive care and/or treatment and how many still require care and/treatment. Nor is it known where these airmen might be receiving care/treatment if they received it, and whether they felt the care/treatment was adequate. The Air Force needs to re-define survey methods/content to determine the unmet health care needs for those airmen who reported the sexual assault, as well as those who did not. Suggestions/examples for a pathway to this end are provided in Appendix A of this report. 80 Chapter 7: Cross Cutting 7.1 Introduction In gathering information about sexual assault prevention and response across the themes of prevention, detection, reporting, and treatment, there emerged several recurrent findings that would be best addressed under the label “cross-cutting.” The general characteristic of these findings is that the issue needs an integrated Air Force corporate response with direction and oversight from the most senior level of Air Force leadership. Additionally, these findings and recommendations were developed in the context of what was learned about efforts in other DoD elements as well as previous analyses of US Federal programs targeted at sexual assault prevention and response. 7.2 Discussion During its visits and interviews the Study Panel consistently asked several questions about: (1) Knowledge and implementation of Air Force specific SAPR programs, (2) The need for updated information on the extent of the sexual assault threat, and (3) The general knowledge of US Federal mandates regarding SAPR. Integrating the answers to these general questions and the findings from the four themes, there emerged three cross-cutting findings about program integration, continuous program assessments, and the need for ongoing social/behavioral research. 7.3 Enabling Coordinated SAPR Program (Planning and Response) Implementation Universally the Study Panel observed a dedicated commitment to SAPR at all of the operational sites that were visited or heard from. Unfortunately the various organizations and offices that have a role in SAPR have policy, corporate, and local barriers to a fully coordinated SAPR effort. While the visit to the Army’s SHARP offices at JBLM illustrated an initial instantiation effort by a DoD Component for a fully coordinated and co-located SAPR effort, even there the staff identified challenges when considering that at least six or more independent policies and associated implementation structures had to be coordinated. For the Air Force, the challenge of coordinating and co-locating the local planning and response communities encompasses at least 7 entities (SVC, SARC, OSI, EO, Medical, Legal, Family Advocacy Program, and Security Forces). Additionally, and if pilot programs for local implementation of coordination and co-location are attempted, it was clear that Wing/Squadron (or equivalent) level leadership need empirically validated tools for implementing the programs and responses that are targeted at culture change, and for assessing the results. 81 7.4 Creating and Chartering a SAPR Program of Ongoing Research and Assessment During the timeframe of this Study, the Air Force largely relied on DoD managed assessment surveys and meta-analyses tasked to a Federally Funded Research and Development Center (e.g., RAND Corp). There was neither the infrastructure nor formal Research, Development, Test, and Evaluation (RDT&E) program funding specific for SAPR in the Air Force corporate laboratory (Air Force Research Laboratory). And, at best, the Army, Navy, and DoD Agencies have minimal infrastructure that the Air Force might be able to rely on. In as much as across all four themes there was a plethora of gaps (science, operations research, policy research) identified and this area of social/behavioral research would need to be specific to Air Force culture, personnel, and organizations, it is strongly recommended that the Air Force create a SAPR research program with establishment of relevant research infrastructure for new initiatives addressing the full spectrum of SAPR. While a research program can result in new options for SAPR, both new initiatives and existing programs require knowledge of “what works” in “which settings” with “what personnel and organizations.” This knowledge is only gained via ongoing and targeted assessment with adequate systems of measurement for ongoing policy and programs. Thus the Study Panel recommends that Air Force charter a SAPR assessment program with at least three initial components: (1) Air Force wide outcomes (ongoing and new); (2) “Continuous assessment process” of SAPR prevention and treatment initiatives, and (3) Addressing the male and LGB victim community. 82 Chapter 8: Findings and Recommendations Summary 8.1 Findings There were a number of theme-specific findings. The SAB Combating Sexual Assault in the United States Air Force Study Panel finds that: 8.1.1 Prevention Findings SAPR education/training is inconsistently delivered, insufficiently assessed, and lacks a deliberately planned and tracked curriculum resulting in unknown effectiveness. First line supervisors are most crucial to sexual assault prevention but lack sufficient education to set and maintain unit culture, confront inappropriate behavior, and foster risk management in troops. The Air Force lacks tools and specific guidance for constructing, assessing, and maintaining prevention programs tailored to their mission and demographics. Currently leadership lacks flexible options for instantiation of a culture of dignity and respect with organization specific assessment tools. Deterrence requires visible consequences and accountability; currently consequences are inconsistent and therefore not trusted. 8.1.2 Detection Findings Scientific literature on perpetrators (e.g., serial offender, partner, and opportunist), victims, and risky situations is immature. The Air Force lacks pre-crime situation awareness for early detection of possible perpetrators, victims, and risky situations. There are multiple opportunities for intelligence collection to detect sexual assault (e.g., improved screening, anonymous drop boxes/email, high definition video, geo-temporal heat maps, social media mining, and investigative interviewing). There are emerging technology opportunities to improve perpetrator detection or forecasting. 8.1.3 Reporting Findings The continuum of sexual assault is underreported in the Air Force. Barriers to reporting (e. g. physiological, psychological, self-blame) often lead to a time lag between the incident, reporting the incident, subsequent investigation, and victim treatment. Constraints on reporting path hinder reports of sexual assault and the investigative process. A sexual assault report made to the supervisory chain is classified as mandatory unrestricted. The ability of the first line supervisor to assist the victim is reduced due to mandatory unrestricted reporting. 83 Lack of integrated and consistent data (e.g., DoD versus DoVA) may mask accurate understanding (e.g., frequency, harassment-to-assault) of sexual assault. 8.1.4 Treatment Findings Prior history of sexual or physical assault increases the risk for being victims of sexual assault again, i.e., risk of “kindling effect.” There are limited studies on the effectiveness of existing treatments (i.e., “outcomes”) for females; non-existent for male and LGB victims. Multiple health effects of sexual assault (physical and psychological) impact performance and create attrition. Long term health effects of sexual assault have not been studied in military contexts. There is a lack of understanding of the effects of stigma associated with seeking treatment. Clinicians lack standardized training for detection of victims. 8.2 Recommendations There were both theme-specific recommendations as well as three key cross-cutting recommendations. Where appropriate, the recommendations are categorized into near term and mid-far term goals. The SAB Combating Sexual Assault in the United States Air Force Study Panel recommends that the Air Force should: 8.2.1 Prevention Recommendations 8.2.1.1 Near Term Implement a pilot program to educate and empower first line supervisors to proactively develop/maintain unit culture (e.g., instantiating dignity and respect). Initiate a SAPR strategic communications campaign including not only survivor stories but also disciplinary actions, harassment scenarios, strategies for bystanders, social norms strategies, and core value discussions. Mandate an empirically validated assessment of all sexual assault prevention programs. 8.2.1.2 Mid-Far Term Apply research findings to improve overall education and training. Tailor training for evidence-based content, length, etc. Update and continue bystander training. Plan and coordinate training opportunities such as entry, base arrival, periodic/annual, schoolhouse/leadership, stand-down days; consider current Career Field Education and Training Plan process as a model. Leverage the Air Force safety culture, institutionalize a “Dignity and Respect” culture change program by engaging leadership, operations, formal and informal systems. Implement and assess a Social Marketing Campaign, tailored to the Air Force context. 84 Recruit and educate peer social influencers and peer counselors to change the Air Force culture from within. 8.2.2 Detection Recommendations 8.2.2.1 Near Term Develop pre-crime heat maps for sexual assault by leveraging existing technology, e.g., high definition cameras, drop boxes, etc. Develop an Air Force wide sexual assault threat picture, enabling anticipatory alerting and global pre-crime engagement. Develop a knowledge management strategy and system to capture and appropriately share incidents (e.g., EO, SARC, OSI data) Air Force wide to enable system wide situation understanding (e.g., to deter across-base perpetrators; to support research). . 8.2.2.2 Mid-Far Term Enhance situation awareness by closing key science gaps in surveys, models and detection, including: advancing survey science and perpetrator/victim behavior models, and leverage emerging science and technology to enhance perpetrator detection. 8.2.3 Reporting Recommendations 8.2.3.1 Near Term Allow first line supervisors the authority to advise victims while suspending requirement for unrestricted reporting (e.g., refer to SARC, provide grace period for counseling, without requirement for mandatory unrestricted reporting). A victim should not lose ability to file restricted report based on to whom they talk. Establish policy to minimize career disruption for victims and to minimize retaliation for victims and bystanders who report. Consider policy to allow immunity for low level collateral misconduct uncovered as a result of a sexual assault investigation. Improve rapid coordination between victim care and investigative process (e.g., EO, SARC, and OSI). Coordinate with DoVA Disability Rating Activity Site to obtain sexual assault demographic data on active duty and retired airmen. 8.2.4 Treatment Recommendations 8.2.4.1 Near Term Improve screening methods, victim identification, and understanding of long-term health effects. Conduct sexual assault screening in primary care and on the preventative health assessment. Develop clinical standards for detection of sexual assault victims. Adjust current survey platforms to capture the unmet health care needs of victims who choose not to report, and 85 include survey items that elucidate the effects of stigma on seeking healthcare. Initiate Air Force wide longitudinal cohort study on airmen (enlisted and officers) to determine long term health effects throughout their career. Initiate an Air Force Medical Service program to assess the effectiveness of current Air Force treatment approaches for victims. 8.2.4.2 Mid Term Initiate an Air Force Medical Service program to develop new therapeutic approaches for providing standardized holistic care to meet the physical and psychological health needs of victims. Establish health-based return-to-duty standards for airmen recovering from sexual assault. 8.2.5 Cross-Cutting Recommendations 8.2.5.1 Near Term Support and enable bases to develop coordinated and co-located planning and response communities including: SVC, SARC, OSI, EO, Medical, Legal, Family Advocacy Program, Security Forces, etc. Assist Wing/Squadron (or equivalent) level leadership with empirically validated tools for implementing culture change and assessing results. Create a SAPR research program addressing identified gaps, leveraging the current science base. Establish research infrastructure for new initiatives addressing the full spectrum of SAPR. Charter a SAPR assessment program including: Air Force wide outcomes (ongoing and new), “continuous assessment process” of SAPR prevention and treatment initiatives, and addressing the male and LGB victim community. 86 Appendix A: Survey Study Design A.1 Treatment Survey Research Currently, the Air Force Sexual Assault Prevention and Response (SAPR) policy, programs, processes, and procedures rely on a single type of survey study design “observational cross-sectional surveys” which cannot robustly contribute to knowledge necessary for advancing prevention, detection, reporting, and treatment efforts. Additionally, neither of the cross-sectional surveys used, WGRA (Workplace and Gender Relations Assessment) and Defense Equal Opportunity Management Institute Organizational Climate Survey (DEOCS), are specifically designed to achieve a deep understanding of the variables contributing to USAF sexual assault incidents, nor is there any survey based research that can test the long term effectiveness of prevention, detection, or treatment programs. This chapter describes the various types of survey methods and what they are best used for. Examples of how the methods can be applied to the SAPR domain are provided. Various social, behavioral and population study designs have different purposes and provide information of different quality. The purposes of this type of research for United States Air Force (USAF) SAPR can include: (1) Describing the prevalence and demographic profiles of sexual assault, (2) Identifying the effects of a prior exposure to assault (in all forms), (3) Sexual assault prevalence as a function of organizational variables, (4) Describing the prevalence of health problems of sexual assault victims; (5) Identifying causes of health problems (etiological research), (6) Evaluating the effects of prevention programs, and (7) Evaluating therapies. The USAF SAPR has only employed “observational-cross sectional surveys” to address sexual assaults within the Air Force (note the red box in Figure A-1 below). Sole reliance on this type of study design offers little hope of achieving the detailed understanding of sexual assaults in such a complex organization as the Air Force to identify the root causes of sexual assault necessary for identifying possible solutions. Further, the cross-sectional survey methodology is completely insufficient for examining the effectiveness of prevention efforts (including detection and reporting) or improvement in patient-centered treatments. Figure A-1 contains a brief overview of general research study designs illustrating alternative research options for achieving “evidence-based SAPR” for the Air Force. 87 Figure A-1. Survey Study Design: Relevant to SAPR Research. Two Types (Observational and Experimental) Currently the USAF SAPR programs utilize only the WGRA and DEOCS cross-sectional surveys to gain very general situational awareness of sexual assault at the USAF-level (WGRA) and at the unit-level (DEOCS utilizes as a “unit climate” survey). While somewhat useful for SAPR purposes there are four key problems with these survey platforms: (1) WGRA and DEOCS survey strategy and core content are designed to generate information on generic personnel policy issues (WGRA) or general unit climate (DEOCS) with SAPR only lately being added. (2) Neither the WGRA nor the DEOCS survey platforms are under the control of USAF although Air Force can influence the survey questions for both and, in administering DEOCS, can chose some SAPR-related questions to be included. (3) Neither survey platform can provide information on causal sequences or details on incidence rates. (4) Neither approach examines longitudinal trends linked to SAPR program interventions. In the light of scientific evidence that surveys can be key to SAPR options and to respond to several Recommendations of the CoSA Study, the USAF should end the reliance on the single study type for assisting SAPR and should take action beginning in 2015 to utilize more robust observational and experimental study platforms. A comprehensive research strategy focused on sexual assault prevention and reporting should be developed, funded, and executed that provides a strong scientific base for the understanding and prevention of sexual assault within the USAF. Besides being an ethical and responsibility obligation to the Nation, its families that provide military members and to the Air Force as a critical national security institution, this research investment can be, at minimum, cost neutral and, at best, readiness positive to the USAF looking across a 2-10 year horizon—assuming that these studies begin to focus and assist 88 SAPR programs in reducing/eliminating sexual assaults which have a significant annual cost and readiness burden to the Air Force. There is no reason that within 18 months, a robust series of intervention studies could be developed and executed. A model research program within the Defense Health Research, Development, Test, and Evaluation (RDT&E) Program with expert, experienced researchers and program managers exists – the “Millennium Cohort Study.”28 While the Department of Defense (DoD) possesses the necessary research infrastructure and competencies to conduct “cohort” and other study types, the USAF lacks the necessary assets to do so. To quickly implement this recommendation, the USAF may have to rely on such expertise as resides within the US Army Medical Research and Materiel Command and Naval Health Research Center-San Diego (the designers and managers of DoD’s ongoing “Millennium Cohort Study”). For the intervention studies, screening, assessment, training interventions and improved treatments, it may be that extramural performers will have to be sought. A.2 Survey Study Design Options A.2.1 Background In observational studies, the researcher observes and systematically collects information, but does not try to change the people being observed. In an observational study there is no intervention. Examples of SAPR observational studies would include: 1. A survey of drinking habits among new airmen; a researcher who joins a social group to study their lifestyle (note, as long as the researcher does not try to change their behavior, it is an observational study). 2. Taking blood samples to measure blood alcohol levels during Monday morning briefings (this does intervene to take the blood, but the researcher is not trying to change the blood alcohol level: it's just a measurement). In an experimental studies, by contrast, the researcher intervenes to change something (e.g., gives some persons alcohol) and then observes what happens to, for example, the group dynamics in a social situation. Examples of this in the SAPR domain might include: 1. Plying a maintenance operator with beer to see whether verbal bantering changes from humor to abusive. 2. Training one group in bystander intervention and comparing its behavior to a group without training in real life social situations where alcohol is introduced by the researcher as a behavior modifying variable. For experimental studies in a domain where a crime is the dependent variable (i.e., the SAPR domain of sexual assault), it is highly unlikely that the research would be approved for a host of moral, ethical and DoD policy reasons. Thus, observational studies are the only practical and feasible option for research on sexual assault as a crime. However, when an area such as treatment of victims of sexual assault is considered, experimental studies are indeed feasible. What follows is a further elaboration and description of observation and experimental studies. 28 Executed by staff at the Naval Health Research Center-San Diego under the Military Health System RDT&E Joint Program Committee 5 (JPC-5) for Military Operational Medicine. 89 A.2.2 Observational Studies and Designs Currently all DoD Components utilize observational studies to provide information to the SAPR programs so they can assess how well the programs are functioning and possibly provide ideas for improving the programs. The primary study platforms are the WGRA and the DEOCS surveys. This study methodology is primarily used for the purpose of collecting descriptive information – “Is the incidence of sexual assault rising or falling?” However, observational studies can be designed to answer more detailed questions on cause and on various prevention, detection, and reporting strategies, for example: What are contributing social factors to sexual assault in the normal Air Force work/social environments? There are many types of observational studies but three main types can be considered to improve Air Force SAPR, one of which (surveys) is currently utilized: A.2.2.1 Cross-Sectional Surveys Cross-Sectional Surveys are the current default research option for DoD and Air Force SAPR. Example research question: What is the prevalence of sexual assault in this community? Here, you draw a random sample of people and enquire about their history of sexual assault. As long as the sample is random and representative of the population you can determine prevalence rates of sexual assault in the community. This approach will also allow for the identification of risk factors associated with sexual assault, such as alcohol consumption. However, a risk factor is NOT a causal factor. For a causal linked to be established between the causal event and the outcome, the causal event must be both necessary and sufficient to produce the predicted outcome. In the case of alcohol use and sexual assault, while alcohol use is frequently present during sexual assaults, it is not always present; and more importantly, there a far more instances of alcohol use in the absence of sexual assault. So, eliminating alcohol use will not necessarily lead to the elimination of sexual assault because alcohol use is not causing the sexual assault. A.2.2.2 Cohort, or “Longitudinal,” or “Prospective” Studies These are like surveys, but extend over time. This allows you to study changes and to establish the time-sequence in which things occur. Therefore, you can use this approach to establish causality. For example, you could assess the sexual assault history of all new Air Force recruits at accession and then conduct similar assessments throughout their military career. Such a study might focus on when the sexual assault occurred and how their military performance/career intentions were affected. For example, did the assault occur early in the airman’s career, when they arrived at a new duty location, when they were getting ready to move to another duty location, duty temporary duty, while deployed, etc., and how did their career intentions and performance change as a function of the sexual assault. The important factor here is that identifiable information that can allow same airmen to be assessed over time will be necessary. Currently, all of the Air Force’s and DoD efforts have focused on anonymous data collection efforts. A.2.2.3 The “Case-Control” Study This is more practical, but suffers from other disadvantages. It is a “retrospective” study. This means that (like a detective) you begin at the end, with the sexual assault, and then work 90 backwards, to hunt for possible causes. Example, you could identify a group of patients with Post Traumatic Stress Disorder (PTSD) (these would be the cases in “case-control”). Then identify a control group who do not have PTSD.29 Then, collect information on their previous use of alcohol, dating pattern, sexting on cell phones, dating back as far as you can manage. Again, you might be able to collect "exposure" information from phone bills. The hypothesis would be that phone sexting would be significantly higher in the assaulted group than the control group; after collecting the data you can test how well the data fit this hypothesis using a statistical test. The advantages are that a case-control study can be done faster and more cheaply than a cohort study. However, it may be difficult to collect the information you require on past exposures, and there may be other ways in which the cases and controls differ, not just the cell phone use, which could also be a causative factor in the assault. Sometimes you also have difficulty in being sure which came first: the assault or the exposure (the Law of Retrospection: “You cannot tell which way the train went by looking at the track”). Note that with a case-control design you cannot calculate incidence of sexual assault (because the cases already had an assault when you began) and this weakens the analysis. Nor can you calculate prevalence, because it was part of the study design how many cases and how many controls were used, and this determined the apparent prevalence in the study. Instead of the relative risk, you have to use a calculation called an “odds ratio” to estimate the association between phone use and sexual assault. But, because case-control studies are much more practical for studying the causes of many chronic diseases, they are used very commonly. Whether this study method can be robustly applied to sexual assault is an open question. A.2.3 Experimental Studies In the context of SAPR, experimental studies are difficult at best due to legal, moral and ethical concerns. It is conceivable that experimental studies on some aspects of SAPR can be designed and conducted, such as studying the effectiveness of various mental health therapies in male compared to female victims of rape. In general, there are two types of experimental study that should be considered: (1) Randomized control trials and (2) Quasi-experimental studies. A.2.3.1 “Randomized Controlled Trial (RCT)” or “Randomized Clinical Trial” The RCT is the mainstay of experimental medical studies, it is normally used in testing new treatments (and drugs etc). Specific applications in the SAPR domain would be to study the effectiveness of Prolonged Exposure Therapy, Cognitive Processing Therapy, and Eye-Movement Desensitization and Reprocessing in a male victim population or the same therapies for victims with pre-military exposure to assault. Generally the process involves:  A sample of patients with the condition, and who meet other selection criteria, are randomly allocated to receive either the experimental treatment, or the control treatment (commonly the standard treatment for the condition).  Occasionally, a placebo or sham treatment will be used in the control group, but where there is already an accepted treatment, it is unlikely to be ethical to use a placebo. 29 Technical detail: In fact, great care is needed in choosing the control group: Should patients with other types of medical complaints, or healthy people, or both be selected? 91  The experimental and control groups are then followed for a set time, and relevant measurements are taken to indicate the results (or “outcomes”) in each group. A.2.3.2 Quasi-Experimental Designs Finally, there is a category of studies that falls between observational and true experimental studies; they are called “quasi-experimental studies.” In these, there is an intervention, but it is often not completely planned by the person doing the research. An example would be a study of the effects of removing punishment for underage drinking on the sexual assault reporting rates: is there an increase reporting rate? This is an observational study, but there was also an intervention, although it was not the experimenter who decided when and how the change would occur and to whom it would be applied, so this is a “quasi-experiment.” Typically, random allocation is not involved. In the literature one may come across “matched” and “unmatched” case-control studies. A problem with case-control studies is that the cases and controls may differ on a number factors, including characteristics (such as age, or sex, or wealth) that you are not considering as potential causes. To ensure greater comparability between the two groups, and thereby avoid confounding, the controls could be matched for sex and age to the cases. A.3 A Way Ahead With the various survey options in mind and in the context of CoSA Study recommendations in the body of this report, a way ahead to leverage the best aspects of survey methods follows: Develop a broad research portfolio so that USAF SAPR program initiatives will be evidenced-based thereby enabling the USAF to achieve its goal of eliminating sexual assault. If the urgency of improving surveys for Air Force SAPR is present, efforts could begin immediately. Within six months, Air Force-focused cohort studies focused on sexual assault could be initiated. The minimum up front resource investment would be $10-20 million (M) in Year 1 with a recurring cost of $1-2 M per study per annum. The sole source of funding need not be DoD’s Major Force Program 6 (RDT&E). The following is the minimum set of studies that would begin to build the necessary comprehensive research program (including observational and experimental studies) to move Air Force SAPR forward:  Pivotal: An “USAF SAPR Longitudinal Cohort Study 2015” with two clear and separate arms, one for enlisted airmen and one for officers.  Effective screens/assessments for the early identification of airmen who have been sexually assaulted.  Improved individual and group treatments for airmen who have been sexually, especially for those resistant to current treatments.  Validated sexual assault prevention and reporting training, especially preventions targeted at root causes of sexual assaults.  Validated crime prevention efforts such as Bystander training.  A “USAF Perpetrator Case Control Study.” 92 Appendix B: Knowledge Contributions Consulted as Background Note: Scientific literature citations in the first two paragraphs of Section 6.1 of this final report are those knowledge contributions that were consulted as background and which became foundational to the observations leading to the findings and recommendations. The references are classified as follows: 1. 2. 3. 4. 5. 6. 7. General health effects Guidelines informing treatment Specific treatment programs Relevant to prevention Relevant to detection Relevant to reporting Cross cutting Classification Full Literature Citation 1 Bell, M., & Reardon, A. (2011). Experiences of sexual harassment and sexual assault in the military among OEF/OIF veterans: Implications for health care providers. Social Work in Health Care, 50(1), 34-50. 1 Braswell, H., & Kushner, H. (2012). Suicide, social integration, and masculinity in the U.S. military. Social Science & Medicine, 74(4), 530-536. 1 Canetto, S., & Cleary, A. (2012). Men, masculinities and suicidal behavior. Social Science & Medicine, 74(4), 461-465. 1 Creech, S., & Borsari, B. (2014). Alcohol use, military sexual trauma, expectancies, and coping skills in women veterans presenting to primary care. Addictive Behavior, 39(2), 379-85. 1 Davis, T., & Wood, P. (1999). Substance abuse and sexual trauma in a female veteran population. Journal of Substance Abuse Treatment, 16(2) 123-127. 1 Edwards, V., Freyd, J., Dube, S., Anda, R., & Felitti, V. (2012). Health outcomes by closeness of sexual abuse perpetrator: A test of betrayal trauma theory. Journal of Aggression, Maltreatment & Trauma, 21(2), 133-148. 93 1 Farris, C., Miller, L., & Keller, K. (2014, January). The scientific literature and recent RAND research on sexual assault. Briefing presented to the CoSA Study Panel of the AF SAB at the SAB Winter Board meeting in Crystal City VA. 1 Goldsmith, R., Freyd, J., DePrince, A. (2012). Betrayal trauma: Associations with psychological and physical symptoms in young adults. Journal of Interpersonal Violence, 27,(3), 547-567. 1 Han Kang, Dalager, N., Mahan, C., & Ishii, E. (2005). The role of sexual assault on the risk of PTSD among Gulf War veterans. Annals of Epidemiology, 15(3) 191-195. 1 Harrell, M., Castaneda, L., Adelson, M., Gaillot, S., Lynch, C., & Pomeroy, A. (2009). A compendium of sexual assault research. Santa Monica, CA: RAND National Defense Research Institute. 1 Hyun, J., Kimmerling, R., Cronkite, R., McCutcheon, S., & Frayne, S. (2012). Organizational factors associated with screening for military sexual trauma. Women’s Health Issues, 22(2), e209-e215. 1 Kaehler, A., & Freyd, J. (2009). Borderline personality characteristics: A betrayal trauma approach. Psychological Trauma: Theory, Research, Practice, and Policy, 1(4), 261-268. 1 Kaehler, L. & Freyd, J. (2012). Betrayal trauma and borderline personality characteristics: Gender differences. Psychological Trauma: Theory, Research, Practice, and Policy, 4(4), 379-385. 1 Kulkarnia, M., Portera, K., & Rauch, S. (2012). Anger, dissociation, and PTSD among male veterans entering into PTSD treatment. Journal of Anxiety Disorders, 26(2), 271-278. 1 Maguen, S., Cohen, B., Li Ren, Bosch, J., Kimerling, R., & Seal, K. (2012). Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder. Women’s Health Issues, 22(1), e61-e66. 1 Maremmani, I., Dell’Osso, L., Rovai, L., Arduino, G., Giovanni, A., Schiavi, E., Perugi, G., Akiskal, K., & Akiskal, H. (2010). Temperamental traits of women applying for a type of job that has been characterized historically by male identity: The military career as case study. Journal of Affective Disorders, 130(1-2), 275-279. 1 Martin, C., Cromer, L., DePrince, A., & Freyd, J. (2013). The role of cumulative trauma, betrayal, and appraisals in understanding trauma symptomatology. Psychological Trauma: Theory, Research, Practice, and 94 Policy, 5(2), 110-118. 1 Mattiko, M., Rae Olmsted, K., Brown, J., & Bray, R. (2011). Alcohol use and negative consequences among active duty military personnel. Addictive Behaviors, 36(6), 608-614. 1 Peterson, Z., Voller, E., Polusny, M., & Murdoch, M. (2011). Prevalence and consequences of adult sexual assault of men: Review of empirical findings and state of the literature. Clinical Psychology Review, 31(1), 1-24. 1 Platt, M., & Freyd, J. (2012). Trauma and negative underlying assumptions in feelings of shame: An exploratory study. Psychological Trauma: Theory, Research, Practice, and Policy, 4(4), 370-378. 1 Rentoul, L., & Appleboom, N. (1997). Understanding the psychological impact of rape and serious sexual assault of men: A literature review. Journal of Psychiatric and Mental Health Nursing, 4(4), 267-274. 1 Sadler, A. (2012). Combat, sexual assault, and post-traumatic stress in OIF/OEF military women. Iowa City, IA: Iowa City VA Medical Center. 1 Sadler, A., Booth, B., Nielson, D., & Doebbeling, B. (2000). Health-related consequences of physical and sexual violence: Women in the military. Obstetrics and Gynecology, 96(3), 473-480. 1 Sexual violence and conflict – War’s other victims: The scale of an unspeakable horror. (2006, December 8). The Economist [On-line]. Available: http://www.economist.com/node/10253410 1 Smith, C. & Freyd, J. (2013). Dangerous safe havens: Institutional betrayal exacerbates sexual trauma. Journal of Traumatic Stress, 26(1), 119-124. 1 Steiger, D., Chattopadhyay, M., Rao, M., Green, E., Nemeckay, K., & Yen, E. (2010). Findings from the 2010 prevalence/incidence survey of sexual assault in the Air Force: Final report. Washington, DC: Gallup Government. 1 Surís, A., & Lind, L. (2008). Military sexual trauma a review of prevalence and associated health consequences in veterans. Trauma, Violence, & Abuse, 9(4), 250-269. 1 Tarrasch, R., Lurie, O., Yanovich, R., & Moran, D. (2011). Psychological aspects of the integration of women into combat roles. Personality and Individual Differences, 50(2), 305-309. 95 1 Valerie, A., Stander, V. A., Merrill, L. L, Thomsen, C. J. Crouch, J. L., & Milner, J. S. (2008.) Premilitary adult sexual assault victimization and perpetration in a Navy recruit sample. Journal Interpersonal Violence, 23(11):1636-1653. 1 Williams, I., & Bernstein, K. (2011). Military sexual trauma among U.S. female veterans. Archives of Psychiatric Nursing, 25(2), 138-147. 1 Zinzow, H., Grubaugh, A., Frueh, B., & Magruder, K. (2008). Sexual assault, mental health, and service use among male and female veterans seen in Veterans Affairs primary care clinics: A multi-site study. Psychiatry Research, 159, 226-236. 2 Botello, S. (2014). Southwest Texas regional advisory council sexual assault and abuse response Team: Regional guidelines for adult (> 18 years of age) sexual assault patient. Briefing presented to the CoSA Study Panel of the AF SAB at a Study Panel meeting in San Antonio, TX. 2 Lehavot, K., & Simpson, T. L. (2013). Incorporating lesbian and bisexual women into women veterans’ health priorities. Journal of General Internal Medicine, 28(2), 609-614. 2 American Academy of Nursing. (2014, January 7). Nursing academy supports sexual assault nurse examiner provision in National Defense Authorization Act (press release). Washington, DC: Author. 2 Office of the Director of National Intelligence. (2013, April 5). Director of National Intelligence issues new security clearance guidance: Guidance will support victims of sexual assault who have consulted with a health care professional (ODNI News Release 05-13). Washington, DC: Author. 2 Pavliscsak, H. (2014). mCare: Leveraging a mobile health application to manage TBI, PTS and mental behavioral health among wounded warriors. Briefing presented to the CoSA Study Panel of the AF SAB at the SAB Winter Board meeting in Crystal City VA. 2 Sexual assault forensic examinations in the military. (2014). Sexual assault forensic examinations in the military. DoD Issue Paper. (Unattributed issue paper on Boxer Amendment provided to the CoSA Study Panel of the AF SAB.) 3 Bruce, S. (2002). The “A Man” campaign: Marketing social norms to men to prevent sexual assault. The Report on Social Norms: Working Paper #5, Little Falls, NJ: PaperClip Communications. 3 Campbell, R., Patterson, D., & Lichty, L. (2005). The effectiveness of sexual assault nurse examiner (SANE) programs: A review of psychological, medical, legal, and community outcomes. Trauma, Violence, 96 & Abuse, 6(4), 313-329. 3 Castillo, D. (2004). Systematic outpatient treatment of sexual trauma in women: Application of cognitive and behavioral protocols. Cognitive and Behavioral Practice, 11, 352-365. 3 Coxell, A., King, M., Mezey, G., & Gordon, D. (1999). Lifetime prevalence, characteristics, and associated problems of non-consensual sex in men: Cross sectional survey. BMJ, 338, 846-850. 3 Kimerling, R., Pavao, J., Valdez, C., Mark, H., Hyun, J., & Saweikis, M. (2011). Military sexual trauma and patient perceptions of Veteran Health Administration health care quality. Women’s Health Issues, 21(4), (Suppl.), S145-S151. 3 Rowan, A., & Campise, R. (2006). A multisite study of Air Force outpatient behavioral health treatment-seeking patterns and career impact. Military Medicine, 171(11), 1123-1127. 3 Rundell, J. (2006). Demographics of and diagnoses in Operation Enduring Freedom and Operation Iraqi Freedom personnel who were psychiatrically evacuated from the theater of operations. General Hospital Psychiatry, 28, 352-356. 3 Scholly, K., Katz, A., Gascoigne, J., & Holk, P. (2005). Using social norms theory to explain perceptions and sexual health behaviors of undergraduate college students: An exploratory study. Journal of American College Health, 53(4), 159-166. 5 Craig-Shea, M. (1998). When the tables are turned: Verbal sexual coercion among college women. In P. B. Anderson and C. J. Struckman-Johnson (Eds.) Sexually Aggressive Women: Current perspectives and controversies (pp. 94-104). New York: Guilford. 5 Marcus, R. (2013, October 24). Missing the point on binge drinking. The Washington Post [On-line]. Available: https://www.washingtonpost. com/opinions/ruth-marcus-missing-the-point-on-binge-drinking/2013/10/24/ 56c8a70a-3ce0-11e3-a94f-b58017bfee6c_ story.html 5 Martin, E. K., Taft, C. T., & Resick, P. A. (2007). A review of marital rape. Aggression and Violent Behavior, 12, 329-347. 5 Epifano, A. (2012, October 17). An account of sexual assault at Amherst College. The Amherst Student, 142(6). 5 Faris, R., & Felmlee, D. (2014). Casualties of social combat: School networks of peer victimization and their consequences. American 97 Sociological Review, 79(2), 228-257. 5 Franklin, C. (2010). Physically forced, alcohol-induced, and verbally coerced sexual victimization: Assessing risk factors among university women. Journal of Criminal Justice, 38(2), 149-159. 5 Hanna, J. (2011, December 13). W&L’s bystander programs educate to prevent violence, alcohol abuse [On-line]. Available: http://news.blogs.wlu.edu/2011/12/13/wls-bystander-programs-educate-toprevent-violence-alcohol-abuse/ 5 Harlem, G. (2009, August 6). Unjust and ineffective. America has pioneered the harsh punishment of sex offenders. Does it work? The Economist [On-line]. Available: http://www.economist.com/node/ 14165460 5 Hillenbrand-Gunn, T. L., Heppner, M. J. (2010). Men as allies: The efficacy of high school rape prevention interventions. Journal of Counseling and Development, 88(1), 43-51. 5 Katz, J., & Moore, J. (2013). Bystander education training for campus sexual assault prevention: An initial meta-analysis. Violence and Victims, 28(6), 1054-1067. 5 Kelley, M., Schwerin, M., Farrar, K., & Lane, M. (2005). An evaluation of a sexual assault prevention and advocacy program for U.S. Navy personnel. Military Medicine, 170(4), 320-326. 5 Moynihan, M., Banyard, V., Arnold, J., Eckstein, R., & Stapleton, J. (2011). Sisterhood may be powerful for reducing sexual and intimate partner violence: An evaluation of the bringing in the bystander in-person program with sorority members. Violence Against Women, 17(6), 703-719. 5 National Public Radio. (2013, April 17). Why vaguely defining bullying can be a problem (Interview Transcript, On-line). Available: http://www.npr. org/2013/04/17/177558210/why-vaguely-defining-bullying-can-be-aproblem 5 Rau, T. J., Merrill, L. L., McWhorter, S. K., Stander, V. A., Thomsen, C. J., Dyslin, C. W., & Milner, J. S. (2010). Evaluation of a sexual assault education/prevention program for male US Navy personnel. Military Medicine, 175(6), 429-434. 5 Rau, T. J., Merrill, L. L., McWhorter, S. K., Stander, V. A., Thomsen, C. J., Dyslin, C. W., & Milner, J. S. (2011). Evaluation of a sexual assault education/prevention program for female US Navy personnel. Military Medicine, 176(10), 1178-1183. 98 5 Ricketts, M. (2007). The use of narratives in safety and health communication (Doctoral Dissertation, Kansas State University). Available: http://krex.k-state.edu/dspace/handle/ 2097/416 5 Rudis, J. (n.d.). True or false: Women get drunker than men [On-line]. Available: http://health.cvs.com/GetContent.aspx?token=f75979d3-9c7c4b16-af56-3e122a3f19e3&chunkiid=157010 5 Sexual assault: A co-complaint. (2013, December 4). The Amherst Student, 143(12), [On-line]. Available: http://amherststudent.amherst.edu/?q= article/2013/12/04/sexual-assault-co-complaint 5 Slotboom, A-M., Hendriks, J., & Verbruggen, J. (2011). Contrasting adolescent female and male sexual aggression: A self-report study on prevalence and predictors of sexual aggression. Journal of Sexual Aggression, 17(1), 15-33. 5 Spring SAPR stand down day--Identifying offenders. (n.d.) Briefing slides provided to the CoSA Study Panel of the AF Scientific Advisory Board. 5 Student-on-Student Sexual Assault Centers of Gravity. (2013, November). Student-on-student sexual assault centers of gravity. Briefing slides provided to the CoSA Study Panel of the AF SAB. 5 Yoffe, E. (2013, October 15). College women: Stop getting drunk (It’s closely associated with sexual assault. And yet we’re reluctant to tell women to stop doing it.). Slate [On-line]. Available: http://www.slate. com/articles/double_x/doublex/2013/10/sexual_assault_and_drinking_ teach_ women_the_connection.html 6 White, J., & Smith, P. (2004). Sexual assault perpetration and reperpetration: From adolescence to youth adulthood. Criminal Justice and Behavior, 31, 182. 6 White, J., McMullikn, D., Swartout, K., Sechrist, S., & Gollehon, A. (2008). Violence in intimate relationships: A conceptual and empirical examination of sexual and physical aggression. Children and Youth Services Review, 30, 338-351. 6 Widman, L., & McNulty, J. (2010). Sexual narcissism and the perpetration of sexual aggression. Archives of Sexual Behavior, 39(4), 926-939. 7 Yeater, E., Lenberg, K., & Bryan, A. (2012). Predictors of sexual aggression among male juvenile offenders. Journal of Interpersonal Violence, 27(7), 1242-1258. 8 Government Accountability Office. (2010, February). Military personnel: 99 Additional actions are needed to strengthen DOD’s and the Coast Guard’s sexual assault prevention and response programs (GAO-10-215). Washington, DC: Author. 8 LeGrand, C. (1973). Rape and rape laws: Sexism in society and law. California Law Review, 61(3), 919-941. 100 Appendix C: Terms of Reference USAF Scientific Advisory Board Combating Sexual Assault Background All those who dedicate themselves to serve the Nation as members of the US Air Force deserve to be treated with respect and dignity. Sexual assault, in any form, is a crime that violates the bond of trust the Air Force owes its personnel. This study will focus on reviewing the scientific work done in this area and helping the Air Force use that work to combat the sexual assault problem. Charter This study will:  Review existing research literature on the nature of sexual assault, characteristics of both perpetrators and victims; causes for perpetrator behaviors; risk factors for victimization; patterns of abuse and victim selection; patterns related to victim and perpetrator demographics, including gender, ethnicity, rank, and Air Force Specialty Code; and detection or prevention mechanisms.  Review existing data on sexual assault in the Air Force and compare its prevalence and nature with that in similar organizations and with its extent within the general population. Consider behavioral (e.g., prevalence of alcohol use), cultural, and organizational factors within the Air Force that may contribute to the problem or allow it to continue, or that may be leveraged to help reduce the problem. Examine other programs that have been used to create cultural and behavioral changes in the Air Force and their applicability to this problem.  Identify and review existing studies on how other organizations, groups, and companies have reduced the incidence of sexual assault to determine the efficacy of programs for prevention or remediation. Assess the validity of study findings and applicability to the Air Force problem.  Based on the above tasks, help the Air Force to identify potential abusers and defuse situations that might lead to assault by: o Enabling a better understanding of the time and resource commitment needed to make significant progress. o Identifying areas more likely to yield both short term and long term improvements, such as comparing actions affecting recruiting versus those addressing training or comparing ways to help potential victims versus means to identify potential predators. 101 o Providing recommendations for improved data collection, relevant metrics, and further research to be led by the Sexual Assault Prevention and Response Office, other Air Force, or DoD organizations. Study Products Briefing to SAF/OS & AF/CC in June 2014. Publish report in August 2014. 102 Appendix D: Study Members Study Leadership Study Chair: Dr. Robert Foster, SAB Member Study Vice Chair: Dr. Terry von Thaden, SAB Member Study Members Dr. Carl Castro, SAB Consultant Dr. Cynthia Dominguez, SAB Member Lieutenant General Terry Gabreski, USAF (Ret), SAB Consultant Dr. Mark Maybury, SAB Member Dr. Lisa Schenck, SAB Consultant Dr. Cynthia Struckman-Johnson, SAB Consultant General Officer Participants Office of the Vice Chief of Staff, USAF:  Major General Margaret H. Woodward, USAF, Director, Director (2013-2014), Air Force Sexual Assault Prevention and Response Office (SAPRO)  Major General Gina M. Grosso, USAF, Director (2014-2015), Air Force Sexual Assault Prevention and Response Office (SAPRO)  General Officer Participants’ Representative: Lieutenant Colonel Rachel E. Foster, USAF, SAPRO Government Participant Dr. Stephanie D. Swindler, Human Effectiveness Directorate, AF Research Laboratory Study Support Lieutenant Colonel Derek M. Lincoln, USAF Major Jennifer L. Dahms, USAFR Major Harris J. Hall, USAFR Major Todd S. Hill, USAFR Major Georgette A. Trezvant, USAFR Mr. William M. Quinn 103 (This Page Intentionally Left Blank) 104 Appendix E: CoSA Study References This reference list provides citations for the sources referenced within this report. Many were provided by outside organizations/individuals who briefed or otherwise informed the Study Panel. Most were contributed by the Panel members themselves during the course of discovery and research. In general, many of the materials provided as background information or as briefings during various fact finding trips or meetings undertaken by the CoSA Study Panel members are not available for distribution beyond the Air Force Scientific Advisory Board as they contain proprietary, copyrighted, and/or For Official Use Only (FOUO) information. Notes:  The references are listed by author(s) and date (if no date then “n.d.”). If no author is cited in the body of the document then the document is ordered by its title.  The author(s) cited below reflect the persons(s) or organization cited within the document. In the case of briefings actually presented to the CoSA Study Panel the cited author(s) may not be the individual(s) who actually briefed the Panel. Abbey, A., McAuslan, P., & Ross, L. T. (1998). Sexual assault perpetration by college men: The role of alcohol, misperception of sexual intent, and sexual beliefs and experiences. Journal of Social and Clinical Psychology, 17(2), 167-195. Abbey, A. (2002). Alcohol-related sexual assault: A common problem among college students. Journal of Studies on Alcohol, 14, (Suppl., 118-122). Abbey, A., & McAuslan, P. (2004). A longitudinal examination of male college students’ perpetration of sexual assault. Journal of Consulting and Clinical Psychology, 72(5), 747-756. 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Individual beliefs, attitudes and victimization histories of male juvenile sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 20(3), 323-351. Zeigler-Hill, V., Enjaian, B., & Essa, L. (2013). The role of narcissistic personality features in sexual aggression. Journal of Social and Clinical Psychology, 32(2), 186-199. 119 (This Page Intentionally Left Blank) 120 Appendix F: Glossary Air Force Specialty Code – AFSC is an alphanumeric code used by the United States Air Force to identify an Air Force Specialty (AFS) applicable to officers or enlisted personnel. The AFSC is similar to the Military Occupational Specialty (MOS) used by the United States Army or Ratings used by the United States Navy. AFSC is sometimes used as shorthand for “required specific skill sets” or “job description” or “position description.” Cognitive Dissonance – Conflicting attitudes, beliefs, or behaviors. Thoughts/ideas that conflict with one another and result in an unpleasant motivating state. For example: “I smoke cigarettes.” And “Cigarettes cause lung cancer.” Corrective Rape – A rape hate crime practiced to: (1) force females to conform to gender stereotypes or (2) “cure” homosexuals (male or female) of their homosexuality and convert them to heterosexuality. The term has evolved to include the rape of any lesbian, gay, bisexual, transsexual, intersexual, asexual, or queer person to get them to “behave” the way heterosexuals behave. It is used against people who do not conform to perceived social norms of gender identity. The goal is to punish “abnormal” behavior and reinforce societal norms. A violent action of supposedly “teaching” those who deviate from society's patriarchal norm a lesson. Geo-Temporal Heat Maps – A dynamic visualization tool used to represent “hot spot” entities on a map for various protocol such as where a crime has been committed, areas of low lighting, or places alcohol is served. Hostile Sexism – A belief system that regards women as inferior to men, assigns women to traditional and subordinate roles, considers women as sexual objects, and believes that women are ultimately interested in dominating and controlling men. Hostile sexists tend to support traditional gender role arrangements (e.g., wife as mother and homemaker, husband as wage earner) and tend to be openly derogatory of feminist ideals (Blaine, 2013). Hypermasculinity – Placing an exaggerated value on traditional masculine traits with elements of negativity toward feminine traits. Hypermasculine behavior may be partially explained by the creation of social stereotypes, such as when individuals overemphasize their own gender characteristics. Males may strive for the development of a more muscular appearance or think that a beard makes them more masculine. Body hair, strength, aggression, and outward appearance are expressed as male traits. The ascribed male behavior is thought to focus on strength and assertiveness. Males are more often associated with violence and killing than are females. For instance, boys are taught to be aggressive and are rewarded for such behavior, whereas girls learn more nurturing roles. Investigative Interviewing – Techniques used by trained specialists when gathering factual information from a victim. Kindling Effect – A stressful event following a stressful event that had resulted in a first depressive episode, which is likely to become a second depressive episode. Further 121 stressful events or depressive episodes may develop into a phenomenon researchers have called the "kindling effect," or “kindling-sensitization hypothesis.” Initial depressive episodes make the individual more prone to developing future episodes of depression. This is likened to the use of kindling wood to spark the flames of a fire. Misogyny – Dislike of, contempt for, or ingrained prejudice against females. Program 6 – Within the Department of Defense various broad categories of program spending are divided into “Major Force Programs” or MFPs. An MFP is an aggregation of Service and other component budget program elements that contain the resources required to achieve an objective or plan. It also reflects the fiscal year time-phasing of mission objectives to be accomplished and the means proposed for their accomplishment. All DoD funding resides in one of eleven MFPs. For example, “Major Force Program 6” refers to the DoD’s Research and Development budget. Other examples include Program 1 (Strategic Forces), Program 2 (General Purpose Forces), Program 8 (Training, Medical, and Other General Personnel Activities), and Program 11 (Special Operations Forces). Narcissism – Extreme selfishness, with a grandiose view of one's own talents and a craving for admiration, as characterizing a personality type. As a personality disorder, narcissism involves arrogant behavior, a lack of empathy for others, and a need for admiration; all of which must be consistently evident at work and in relationships. People who are narcissistic are frequently described as cocky, self-centered, manipulative, and demanding. Narcissists may concentrate on unlikely personal outcomes (e.g., fame) and may be convinced that they deserve special treatment. Odds Ratio – In statistics, the odds ratio is a way to quantify how strongly the presence or absence of property A is associated with the presence or absence of property B in a given population. Program 6 – Within the Department of Defense various broad categories of program spending are divided into “Major Force Programs” or MFPs. An MFP is an aggregation of Service and other component budget program elements that contain the resources required to achieve an objective or plan. It also reflects the fiscal year time-phasing of mission objectives to be accomplished and the means proposed for their accomplishment. All DoD funding resides in one of eleven MFPs. For example, “Major Force Program 6” refers to the DoD’s Research and Development budget. Other examples include Program 1 (Strategic Forces), Program 2 (General Purpose Forces), Program 8 (Training, Medical, and Other General Personnel Activities), and Program 11 (Special Operations Forces). Rape – A criminal offense defined in most states as forcible sexual relations with a person against that person's will. Rape is the commission of unlawful sexual intercourse or unlawful sexual intrusion. Rape Myth(s) – Beliefs that rape victims are somehow responsible for their victimization and relieve the perpetrator from responsibility. These widely held, culture-based beliefs may place blame on rape victims, excuse the actions of perpetrators, or blur the lines between rape and consensual sex. While extended to victims of both genders, it is mainly associated with females who are raped by males. Virtually all rape myths share a common theme — it is a victim’s fault for being raped — the offenders (i.e., rapists) are innocent. 122 Endorsers of rape myths are likely to say things like, “she should not have been drinking so much.” “Myths” that women are “asking for it” or are actually sexually aroused by force are common in US culture. The “no means maybe” mentality confuses both genders, and perpetuates rape myths. Research shows that endorsement/acceptance of the notion that women are responsible for rape contributes to the prevalence of rape. Studies show that rape myths are related to, or more prevalent in, a patriarchal social system where men are expected to be strong and powerful, and women are expected to be inferior and weak. The “boys will be boys” mentality is a classic example of how culture encourages boys to be rough and domineering, while it asks girls to be subdued and passive. A brief summary of widely circulated female rape myths is provided below:  Women must really want to be raped because any woman could really get away if she wanted to.  Women “ask for it” by the way they dress or the places they go.  Women never really mean “no.”  Women are not really harmed by rape.  Women lie about rape following a regretful night of consensual sex.  Women enjoy or are sexually aroused by rape. There are common phrases illustrating the endorsement of female rape myths:  “She wears her skirts way too short – she was asking for something bad to happen.”  “Everyone knows that is the wrong place to go – what did she think would happen?”  “She lied about it.” Rape myths about male victims of sexual assault are similar to those of female victims in that men are held responsible for their victimization by either a male or female perpetrator. In addition, male rape myths imply that a man cannot be seriously harmed by an act of sexual assault. Some male rape myths identified in the literature include:  It is impossible for a man to be raped by another man (or woman).  Most men who are raped by a man are somewhat to blame for not escaping or fighting the man (or woman) off.  Most men who are raped by a man (or woman) are not very upset by the incident.  Most men who are raped by a man (or woman) don’t need counseling after the incident.  A big strong man can’t be raped by another man (or woman).  Safe Date Programs – Safe Dates is a school-based prevention program for middle and high school students designed to stop or prevent the initiation of dating violence victimization and perpetration, including the psychological, physical, and sexual abuse that may occur between youths involved in a dating relationship. The program goals are to change adolescent norms on dating violence and gender-roles, improve conflict resolution skills for dating relationships, promote victims’ and perpetrators’ beliefs in the 123 need for help and awareness of community resources for dating violence, encourage helpseeking by victims and perpetrators, and develop peer help-giving skills. Because dating violence is often tied to substance abuse, Safe Dates may also be used with drug and alcohol prevention and general violence prevention programs. The Safe Dates program includes a curriculum with nine 50-minute sessions, one 45-minute play to be performed by students, and a poster contest. The sessions include:  1. Defining Caring Relationships. Students are introduced to Safe Dates and discuss how they wish to be treated in dating relationships.  2. Defining Dating Abuse. Discussing scenarios and statistics, students clearly define dating abuse.  3. Why Do People Abuse? Students identify the causes and consequences of dating abuse through large- and small-group scenario discussions.  4. How to Help Friends. Students learn why it is difficult to leave abusive relationships and how to help an abused friend through a decision-making exercise and dramatic reading.  5. Helping Friends. Students use stories and role-playing to practice skills for helping abused friends or for confronting abusing friends.  6. Overcoming Gender Stereotypes. Students learn about gender stereotypes and how they affect dating relationships through a writing exercise, scenarios, and small-group discussions.  7. Equal Power Through Communication. Students learn the eight skills for effective communication and practice them in role-plays.  8. How We Feel, How We Deal. Students learn effective ways to recognize and handle anger through a diary and a discussion of “hot buttons,” so that anger does not lead to abusive behavior.  9. Preventing Sexual Assault. Students learn about sexual assault and how to prevent it through a quiz, a caucus, and a panel of peers. Sexual Assault – A summarization of applicable Uniform Code of Military Justice prosecutable offenses pertaining to the continuum of sexual assault are summarized below. Article 80 offenses:  Attempts – an act done with specific intent to commit an offense o The accused did a certain overt act o The act was done with the specific intent to commit a certain offense under the code o The act amounted to more than mere preparation o The act apparently tended to effect the commission of the intended offense Article 92 Offenses:  Failure to obey order or regulation o Violates or fails to obey any lawful general order or regulation 124 o Having knowledge of any other lawful order issued by a member of the armed forces, which it is his duty to obey, fails to obey the order o Derelict in the performance of his duties Article 93 Offenses:  Cruelty and maltreatment o Person was subject to orders of accused o Accused was cruel toward, oppressed, or maltreated that person Article 120 Offenses:  120(a) – Rape o Penetration o By force, threat of death/grievous bodily harm, drugging  120(b) – Sexual Assault o Penetration o By threat, harm, pretense, or when victim is asleep/impaired  120(c) – Aggravated Sexual Contact o Non-penetration o By force, threat of death/grievous bodily harm, drugging o With requisite intent (arouse, abuse, humiliate, etc.)  120(d) – Abusive Sexual Contact o Non-penetration o By threat, harm, pretense, or when victim is asleep/impaired o With requisite intent (arouse, abuse, humiliate, etc.) Article 125 Offenses:  125(a) – Unnatural carnal copulation  Penetration, however slight  Act performed on child <16  Act performed by force and without consent Article 133 Offenses:  Actions unbecoming of an Officer o Person did or omitted to do certain acts o These acts or omissions constituted conduct unbecoming an officer Article 134 Offenses:  Adultery o Accused wrongfully had sexual intercourse with a certain person o At the time, the accused or the other person was married to someone else 125 o The conduct of the accused was to the prejudice of good order and discipline in the armed forces or was of a nature to bring discredit upon the armed forces. Sexual Harassment – Defined as a form of sex discrimination that violates Title VII of the Civil Rights Act of 1964, sexual harassment describes unwelcome and unwanted sexual advances, or other verbal or physical conduct of a sexual nature. Social Media Mining – The process of representing, analyzing, and extracting data from social media accounts. Title IX Programs – As part of the Education Amendments of 1972, Title IX prohibits discrimination in education on the basis of gender. Title IX covers all levels and areas of education, including athletics and vocational/technical education. Title IX has helped females and males benefit from more equitable treatment and attain more equitable outcomes. 126 Appendix G: Acronyms and Abbreviations AF AFSC ART BIT BMT CONUS CPT DEOCS DMDC DNA DoD DoDI DoVA DSAID D-RAS EMDR EO FY HQ JBLM JBSA LB LGB LGBT MEO MIL MUPS OR OSD OSI PE POP PTSD RDT&E Air Force Air Force Specialty Code Article Bystander Intervention Training Basic Military Training Continental United States Cognitive Processing Therapy Defense Equal Opportunity Management Institute Organizational Climate Survey Defense Manpower Data Center Deoxyribonucleic Acid Department of Defense Department of Defense Instruction Department of Veteran’s Affairs/Veteran’s Administration Defense Sexual Assault Incident Database Disability Rating Activity Site Eye-Movement Desensitization and Reprocessing (therapy) Equal Opportunity Fiscal Year Headquarters Joint Base Lewis McChord Joint Base San Antonio Lesbian, Bisexual Lesbian, Gay, Bisexual Lesbian, Gay, Bisexual, Transgender Military Equal Opportunity Military Medically Unexplained Physical Symptoms Odds Ratio Office of the Secretary of Defense Office of Special Investigations Prolonged Exposure Therapy Population Post Traumatic Stress Disorder Research, Development, Test, and Evaluation 127 SAB SAPR SAPRO SARC SANE SHARP SVA SVC TDY UCMJ USAF WGRA Scientific Advisory Board Sexual Assault Prevention and Response Sexual Assault Prevention Response Office Sexual Assault Response Coordinator Sexual Assault Nurse Examiner Sexual Harassment Assault Response and Prevention Special Victim Advocate Special Victim Counsel Temporary Duty Uniform Code of Military Justice United States Air Force Workplace and Gender Relations Survey of Active Duty Personnel 128 Appendix H: Initial Distribution List Air Force Leadership SAF/OS – Secretary of the Air Force AF/CC – Chief of Staff of the Air Force SAF/US – Under Secretary of the Air Force AF/CV – Vice Chief of Staff of the Air Force Air Force Secretariat and Air Staff SAF/AQ – Assistant Secretary (Acquisition)  Military Director of the Scientific Advisory Board  SAF/AQR – Science, Technology, & Engineering Directorate SAF/MR – Assistant Secretary (Manpower and Reserve Affairs) AF/CVA – Assistant Vice Chief of Staff AF/RE – Chief of the Air Force Reserve AF/SB – Military Director of the Scientific Advisory Board AF/ST – Chief Scientist of the Air Force AF/TE – Directorate of Test and Evaluation AF/A1 – Deputy Chief of Staff for Manpower, Personnel, and Services AF/A2 – Deputy Chief of Staff for Intelligence, Surveillance, and Reconnaissance AF/A3 – Deputy Chief of Staff for Operations, Plans, and Requirements AF/A4/7 – Deputy Chief of Staff for Logistics, Installations, and Mission Support AF/A5/8 – Deputy Chief of Staff for Strategic Plans and Programs AF/A9 – Director of Studies and Analyses, Assessments, and Lessons Learned AF/A10 – Deputy Chief of Staff for Strategic Deterrence and Nuclear Integration NGB/CF – Chief of the Air National Guard Air Force Major Commands Air Combat Command Air Education and Training Command Air Force Global Strike Command Air Force Materiel Command Air Force Reserve Command Air Force Space Command Air Force Special Operations Command Air Mobility Command Pacific Air Forces US Air Forces Europe 129 Other Air Force Elements Air University  Air War College  Air Command and Staff College  School of Advanced Air and Space Studies AF Research Laboratory  AFRL/CC – Commander  AFRL/CZ – Chief Technologist  AFRL/RH – Human Effectiveness Directorate  AFOSR – AF Office of Scientific Research Combatant and Regional Commands US Africa Command US Central Command US European Command US Northern Command US Pacific Command US Southern Command US Special Operations Command US Strategic Command US Transportation Command Other DoD and Service Advisory Boards Army Science Board Defense Policy Board Defense Science Board Naval Research Advisory Committee Executive Office of the President National Security Council Office of Science and Technology Policy Office of the Secretary of Defense and Defense Agencies Department of Defense Sexual Assault Prevention and Response Office Under Secretary of Defense (Acquisition, Technology, and Logistics) Under Secretary of Defense (Personnel and Readiness) Under Secretary of Defense (Policy) Defense Equal Opportunity Management Institute (DEOMI) National Defense University (NDU)  NDU Institute for National Strategic Studies Office of Cost Assessment and Program Evaluation (CAPE) 130 Other Military Services US Army Center for the Army Profession and Ethic US Army Office of Sexual Harassment/Assault Response and Prevention US Army School of Advanced Military Studies US Army Training and Doctrine Command Department of Navy Sexual Assault Prevention and Response Office US Marine Corps Sexual Assault Prevention and Response Office National Guard Bureau Sexual Assault Prevention and Response Office US Coast Guard Office of Work-Life Programs (SAPR Program Coordinator) Joint Chiefs of Staff Chairman, Joint Chiefs of Staff Vice Chairman, Joint Chiefs of Staff Joint Chiefs of Staff, Director for Manpower and Personnel (J-1) Joint Chiefs of Staff, Director for Intelligence (J-2) Joint Chiefs of Staff, Director for Operations (J-3) Joint Chiefs of Staff, Director for Logistics (J-4) Joint Chiefs of Staff, Director for Strategic Plans and Policy (J-5) Joint Chiefs of Staff, Director for Joint Force Development (J-7) Joint Chiefs of Staff, Director for Force Structure, Resources, and Assessment (J-8) Libraries and Data Repositories Air Force Institute of Technology Library Air University Library Defense Technical Information Center Library of Congress National Defense University Library Pentagon Library US Air Force Academy Library US Army Command and General Staff College US Army War College US Marine Corps Command and Staff College US Military Academy Library US Naval Academy Library US Naval War College 131 (This Page Intentionally Left Blank) 132 Form Approved OMB No. 0704-0188 REPORT DOCUMENTATION PAGE Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and manipulating the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget Paperwork Reduction Project (0704-0188), Washington, DC 20503. 1. AGENCY USE ONLY (Leave Blank) 2. REPORT DATE 3. REPORT TYPE AND DATES COVERED 1 August 2014 Final, January 2014 – August 2014 4. TITLE AND SUBTITLE 5. FUNDING NUMBERS Combating Sexual Assault 6. AUTHORS: Dr. Robert Foster (Study Chair), Dr. Terry von Thaden (Study Vice Chair), Dr. Carl Castro, Dr. Cynthia Dominguez, Lt Gen Terry Gabreski, USAF (Ret), Dr. Mark Maybury, Dr. Lisa Schenck, Dr. Cynthia Struckman-Johnson 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION REPORT NUMBER SAF/AQB 1060 AF PENTAGON RM 5E815 WASHINGTON, DC 20330-1060 SAB-TR-14-04 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSORING/MONITORING AGENCY REPORT NUMBER 11. SUPPLEMENTARY NOTES 12a. DISTRIBUTION/AVAILABILITY STATEMENT 12b. DISTRIBUTION CODE Approved for Public Release, Distribution Unlimited A ABSTRACT The CoSA Study was chartered to examine the multidisciplinary scientific work and data related to sexual assault in order to help “the Air Force use that work to combat the sexual assault problem.” The Study was motivated by the stated DoD goal for combating sexual assault and by the Air Force’s desire for addressing this problem by gaining a deeper understanding of the nature of sexual assault and its victims and perpetrators. The Study was organized along four theme areas: prevention, detection, reporting, and treatment. The Study Panel reviewed a large body of research literature across a variety of scientific disciplines. The results of the study’s analyses identified (1) areas for science-informed improvement to the Air Force’s Sexual Assault Prevention and Response (SAPR) policies and programs in both the near and mid-term that would improve prevention, detection, reporting and treatment options and (2) recommendations for key research initiatives that would further a deeper understanding of sexual assault in military settings. There were several theme-specific recommendations as well as three key cross-cutting recommendations. . 15. NUMBER OF PAGES 14. SUBJECT TERMS Sexual Assault, Sexual Assault Prevention and Response, SAPR, Rape, Equal Opportunity, Lesbian Gay and Bisexual, LGB, Uniform Code of Military Justice, UCMJ 17. SECURITY CLASSIFICATION OF REPORT Unclassified 18. SECURITY CLASSIFICATION OF THIS PAGE Unclassified 19. SECURITY CLASSIFICATION OF ABSTRACT Unclassified 133 154 16. PRICE CODE 20. LIMITATION OF ABSTRACT Public Release (This LAST Page Intentionally Left Blank) 134