Keywords

3.1 Introduction

Sexual violence – which includes experiences of sexual harassment, unwanted sexual contact, sexual coercion, and rape (Basile et al., 2014) – is a significant public health problem within the United States (Smith et al., 2018). The experience of sexual violence has wide-ranging psychological, health, and economic consequences for individuals (Rees et al., 2011; Martin et al., 2011). In fact, according to the 2011 US National Intimate Partner Sexual Violence Survey, the cost of rape is estimated to be $122,461 per victim, resulting in a population economic burden of 3.1 trillion US dollars (Peterson et al., 2017).

Attention to the prevalence and consequences of sexual violence among members of the US military has increased over the past 10 years (for reviews, see Bell et al., 2018; Castro et al., 2015; Lofgreen et al., 2017; Mondragon et al., 2015; Suris & Lind, 2008; Wood & Toppelberg, 2017). This focus is warranted, given data suggesting that 55% veteran women report sexual harassment during military service (Skinner et al., 2000), 54% of veteran women report some form of unwanted sexual contact during military service (Sadler et al., 2001), and 62% of veteran women report experiences of sexual assault at some point in their lives (Booth et al., 2011). A more recent survey conducted by RAND Corporation National Defense Research Institute (2014) among 560,000 US service members indicated that 4.9% of women and 1% of men serving in active duty experienced a prior year sexual assault. There is evidence that rates of sexual victimization among women in the military are comparable to (Black & Merrick, 2013) or higher than rates among civilian women (Bostock & Daley, 2007; Sadler et al., 2003; Schultz et al., 2006).

Whereas some risk and protective factors for sexual violence are similar for civilian and military populations, there are several unique aspects of military culture and the military environment that contribute to sexual violence among service members (Castro et al., 2015; Stander & Thomsen, 2016; Turchik & Wilson, 2010). First is the culture of military masculinity which prioritizes physical violence, subordination to others, and dominance (Belkin, 2012; Brown, 2012; Connell, 1985; Hinojosa, 2010; Hooper, 1999; Kurpius, & Lucart, 2000). As Connell (2005) notes, “violence on the largest possible scale is the purpose of the military; and no arena has been more important for the definition of hegemonic masculinity in European/American culture” (p. 213). The importance of hegemonic masculinity within military culture is particularly relevant for understanding the root causes of military sexual violence, given the strong association between adherence to traditional gender role ideology and sexual aggression in civilian populations (Murnen et al., 2002; Tharp et al., 2013). The culture of military masculinity is also rooted in power differentials between men and women in the military. For many years, women in the US military were restricted from participating in specific positions that led to promotion, including combat roles (see Katz, 1992). The emphasis on traditional masculinity in the military also communicates that women are of lesser value than men within military service (Vogt et al., 2007), which serves to justify the harassment and mistreatment of women (Barkalow & Raab, 1990; Katz et al., 2007).

As discussed by Castro et al. (2015), other aspects of military culture create an environment conducive to sexual violence. For example, because military culture values mission accomplishment and performance, leaders may dismiss allegations of sexual violence when the complainant is a low performer, or when the alleged assailant is a top performer. As a result, perpetrators of sexual aggression may deliberately target service members who they believe will not be taken seriously if they reported an assault. Military culture also values resolving conflicts “at the lowest possible level” (Castro et al., 2015; p. 5). As a result, experiences of harassment or assault may not be reported to the chain of command, especially if the harasser/assailant is senior in rank. Because leaders are also held accountable for establishing a safe environment for their unit, leaders also may “dismiss the allegations as unfounded, or convince the service member who has been harassed or assaulted not to formally report the incident” if they fear they will be held responsible for allowing an environment conducive to sexual violence to exist within their unit (Castro et al., 2015, p. 6). Finally, as noted by Castro et al. (2015), to prepare for combat, male and female service members are taught to engage in objectification. Further, aggression is a long-standing and normalized component of combat (Hunter, 2007; Neill, 2000). Whereas objectification may support mission readiness, the capacity to act with diminished empathy can also be misdirected toward other service members and may facilitate sexually aggressive behavior among individuals who feel entitled to sexual activity (Hunter, 2007). Notably, feeling entitled to sexual activity is associated with sexual aggression (Bouffard, 2010) and mediates the association between adherence to traditional masculine norms and rape-related attitudes and behaviors (Hill & Fischer, 2001).

Rates of trauma in childhood and adolescence are also higher among service members compared to civilians (Turchik & Wilson, 2010; Zinzow et al., 2007). For example, Bostock and Daley’s (2007) examination of 2018 active duty US Air Force women indicated that most initial experiences of rape (75%) as well as most of the most recent experiences of rape (56%) occurred when the service member was a civilian. Prior victimization is a well-documented predictor of subsequent victimization among service members (Suris & Lind, 2008), and it is believed that the emotional and behavioral consequences of trauma serve to increase risk for subsequent victimization (Jaffe et al., 2019). Alarmingly, women who experience sexual victimization before military service are two to five times more likely to experience revictimization during their time in service (Merrill et al., 1999; Salder et al., 2003).

At the outer layers of the social ecology, perceived acceptance of violence at the organizational level, environmental factors, and military policies also contribute to sexual violence in the military. At an organizational level, the perception that command will not hold perpetrators of sexual violence accountable for the crime (Pershing, 2003) or that victims who report will be met with social or professional retaliation (Campbell & Raja, 1999) dissuades victims from reporting and communicates to perpetrators that they will not be held accountable for sexual violence (see Groves, 2013). Data from the 2005 Service Academy Sexual Assault Survey of Cadets and Midshipmen found that both male and female cadets and midshipmen who experienced sexual victimization had negative views about the leadership’s tolerance of sexual violence. Importantly, as reported by Sadler et al. (2017), lower rates of sexual assault are reported in units where leadership is perceived to take the issue of sexual assault seriously, demonstrates a zero tolerance stance toward sexual harassment, and indicates support for service members who seek psychological care. Environmental factors – such as the frequent movement of military personnel across units and the proximity between service members within coed dormitories and barracks (see Sadler et al., 2003) – can also make it easy for perpetrators to opportunistically target service members who they believe would be unlikely to report an assault because they are either new to the unit or are preparing to leave the unit. Policies that make it difficult to report sexual violence – such as polices regarding collateral misconduct at military service academies (see Brubaker, 2009) – also foster continued violence by limiting organizational capacity to hold perpetrators accountable for their actions.

3.1.1 Purpose of the Current Chapter

The high rates of sexual violence among US military service members underscore the importance of the development of comprehensive sexual assault prevention and response efforts which attend to the unique ways that military culture cultivates violence. Whereas sexual assault prevention programs for military service members are growing, the scientific evaluation of these efforts is lacking in comparison to the scientific evaluation of sexual assault prevention programs for civilians (Gidycz et al., 2018). Efforts to advance the science of sexual assault prevention and response for the military also remain relatively siloed from other efforts to advance the health and resiliency of service members. Arguably, to have a wider-population impact, it is necessary for prevention efforts to target mechanisms that have the capacity for fostering synergistic change in multiple health outcomes (Armstead et al., 2017).

Accordingly, the present chapter advances the science and practice of sexual assault prevention efforts for military service members by developing a rationale for integrated alcohol use and sexual assault prevention for service members. In this chapter, integrated alcohol use and sexual assault prevention approaches are operationalized as interventions that include active alcohol use intervention administered in combination with sexual assault prevention strategies. Toward this goal, the current chapter will first provide descriptive information on the context of sexual violence in the US military, including the prevalence of assaults among women and men, the characteristics of assaults, consequences of violence, as well as processes of disclosure, help-seeking, and reporting. Next, the chapter outlines the current science and practice of sexual assault prevention in the military, beginning with the prevention approach of the Department of Defense and ending with a review of the state of prevention science. Next, the chapter articulates the rationale for integrated alcohol and sexual assault prevention, by reviewing the rationale for addressing cross-cutting mechanisms for sexual violence and other health outcomes in prevention, as well as the scope of alcohol use in the military. Further, the chapter reviews how prevention can target various ways that alcohol use serves as a risk factor for sexual aggression, risk factor for sexual victimization, and complicating factor in bystander intervention. The chapter concludes by reviewing progress toward developing integrated alcohol use and sexual assault prevention approaches for civilian populations and exploring how these models have been adapted or developed for military populations.

3.2 The Scope of Sexual Assault Among Service Members

3.2.1 Prevalence of Sexual Violence

Sexual violence impacts all service members, regardless of gender identity. A meta-analysis of 59 studies revealed that 15.7% of military personnel and veterans indicate experiencing sexual victimization during military service, including 2.9% of men and 38.4% of women (Wilson, 2016). According to a different meta-analysis of 29 studies conducted by Hoyt et al. (2011), rates of sexual victimization at any point during military service among men range between 0.03% and 12.4% across studies. According to Hoyt et al.’s (2011) analysis of rates of military sexual trauma among men across 29 studies, experiences of sexual victimization were reported by approximately 0.09% of male service members over a year. It is important to note that the prevalence of sexual victimization during military service varies depending upon the survey sample, as well as the definition of sexual victimization utilized.

The Workplace and Gender Relations Survey of Active Duty Members is administered every 2 years across the entire active duty force (see Rock et al., 2011). The consistent administration of the survey makes it an important source of information for understanding potential changes in the rate of sexual victimization among service members over time. For example, as reported by the Defense Manpower Data Center (2012) survey note of the 2012 Workplace and Gender Relations Survey of Active Duty Military, the rates of unwanted sexual contact (which included attempted or completed sexual intercourse, as well as unwanted touching of the genitals or other sexually related parts of the body) indicated by women and men service members were 6.8% and 1.8% in 2006, 4.4% and 0.9% in 2010, and 6.1% and 1.2% in 2012, respectively. Analysis of the 2018 Workplace and Gender Relations Survey of Active Duty Members reported by the Office of People Analytics (2019) reports similar findings, finding that 6.2% of active duty women and 0.7% of active duty men experienced sexual assault in the past year. Data from the 2019 Workplace and Gender Relations Survey of Reserve Component reported in the Department of Defense Fiscal Year 2019 Annual Report on Sexual Assault in the Military also suggests that the prevalence of sexual victimization for the Reserve Component has remained the same since 2017 (Department of Defense, 2020; p. 21). Whereas the Workplace and Gender Relations Survey is conducted on behalf of the Department of Defense Sexual Assault Prevention and Response Office (SAPRO), studies administered by nongovernment contractors report similar findings. For example, data from the RAND Military Workplace Study (RMWS) among nearly 150,000 service members documented that 1 in 20 female and fewer than 1 in 100 male service members experienced past year sexual assault (Jaycox et al., 2014).

The past 10 years has also witnessed increasing attention to the needs of men who experience sexual victimization during military service (Matthews et al., 2018). There is some data to suggest that the context of sexual victimization varies among male and female service members. Notably, the Department of Defense Annual Report on Sexual Assault in the Military for Fiscal Year 2018 notes that “26 percent of men who indicated experiencing sexual assault said the offense involved hazing, and 31 percent said it involved bullying. In comparison, 11 percent of women indicated their offense involved hazing, and 18 percent said it involved bullying” (Department of Defense, 2019a; p. 11). In addition, whereas women service members identify that the perpetrator of the assault was male (92%), approximately 52% of men report the perpetrator as male, and 13% indicate that the assault was perpetrated by men and women who acted together (Department of Defense, 2019a; p. 10–11). Male service members also face gender-specific barriers in accessing social support and healthcare resources following victimization. For example, qualitative analyses among 18 male veterans who experienced military sexual trauma indicated that men often struggle with intimacy and have relationship difficulties following the experience and receive numerous negative social reactions when disclosing their experience to others (Monteith et al., 2019). Interviews with Midwestern Active Component and Reserve and National Guard servicemen, actively serving or veteran, who had returned from Iraq or Afghanistan deployments during Operation Enduring/Iraqi Freedom eras also suggest that men generally lack awareness of the occurrence of sexual assault among other men in the military and tend to hold blame and stigma toward men who experience sexual violence (Sadler et al., 2021). As Morris et al. (2014) discuss, there is a need for increased research and clinical attention to the medical and psychiatric needs of men following experiences of military sexual trauma.

3.2.2 Characteristics of Sexual Assaults

Living and working in close proximity to other service members is believed to be a risk factor for sexual harassment and assault in the military. Sexual violence involving active duty service members generally occurs in a military setting (Morral et al., 2014). According to the 2018 Workplace and Gender Relations Survey of Active Duty Members, 62% of women and 57% of men indicated that an experience of sexual assault occurred at a military installation or on a military ship (Office of People Analytics, 2019; p. vii). Further, as evidenced by Sadler et al.’ (2003) analysis of women veterans who experienced rape during military service, 51.7% of women were assaulted in the barracks, and 81.9% were assaulted while off duty.

As revealed in data from the 2018 Workplace and Gender Relations Survey of Active Duty Members, “sexual assault in the military occurs most often between junior enlisted acquaintances who are peers or near peers in rank” (Department of Defense, 2019a; p. 4). Earlier data reported by Sadler et al. (2003) also documented that 53.3% of rape victims described the perpetrator as a peer or same/similar rank. Like studies of college students (Cantor et al., 2019), perpetrators of sexual aggression tend to be identified as a “friend or an acquaintance, acting along” (Department of Defense, 2019a, p. 4). According to a national cross-sectional survey of women veterans, only 5% reported an experience of gang rape during military service (Sadler et al., 2005). Other studies indicate that most assaults experienced during military service are perpetrated by another service member, rather than a civilian (Campbell & Raja, 2005; Morral et al., 2014). Regardless of the gender of the victim, service members who experience sexual aggression most commonly identify the perpetrator as male (Department of Defense, 2019a).

Alcohol is also often involved in sexual violence among service members. As reported by Sadler et al. (2003), 26.8% of women who experienced rape while in military service reported consuming alcohol/drugs at the time of the assault, and 52.5% experienced an assault perpetrated by someone who was under the influence of alcohol/drugs at the time of the assault. These data mirror those reported by the Office of People Analytics (2019) overview report of the 2018 Workplace Gender Relations Assessment, which indicated that alcohol was involved in sexual assault among 62% of women who reported victimization and among 49% of men who reported victimization (p. vii).

3.2.3 Consequences of Sexual Violence

The consequences of sexual violence among military service members include a range of individual psychological and health aftereffects (Street & Stafford, 2002). As reported by Zinzow et al. (2008), women veterans with a history of sexual victimization demonstrate greater psychological impairment in comparison to those reporting other forms of trauma. The effects of sexual victimization in the military are also exacerbated when individuals report victimization at other times during the lifespan (Creech & Orchowski, 2016; Suris et al., 2007).

There is a strong association between sexual victimization during military service and the severity of post-traumatic stress disorder (PTSD; Maguen et al., 2012; Schry et al., 2015; Rosellini et al., 2017a; Sexton et al., 2017). For example, in a sample of women veterans seeking primary care at the VA, Creech and Orchowski (2016) found that PTSD symptoms were positively associated with the number of time periods a woman experienced sexual victimization via force (i.e., childhood, adult premilitary, during military service, after military service), as well as the total number of lifetime experiences of sexual victimization via force. Notably, sexual victimization during military service is also associated with greater PTSD risk compared to victimization at other times in the lifespan (Suris et al., 2004).

Experiencing sexual victimization during military service is also associated with heavy drinking as well as alcohol problems (Fillo et al., 2018; Seelig et al., 2017). Importantly, numerous studies indicate a positive association between alcohol use and PTSD among service members (Davis et al., 2003; Kelley et al., 2013; Maguen et al., 2010, 2012). A study of OEF/OIF veterans found that while combat exposure in and of itself did not increase the risk for alcohol misuse, PTSD symptoms and depression doubled the risk for alcohol misuse (Jakupcak et al., 2010). The self-medication hypothesis posits that individuals use alcohol following sexual victimization to alleviate the negative psychological effects of the trauma (Khantzian, 1997), and studies of military veterans indicate that service members report self-medicating with alcohol to cope with PTSD symptoms (Bremner et al., 1996). Other explanations of the positive association between alcohol use and PTSD have also been proposed, including the negative reinforcement model (Baker et al., 2004), the mutual maintenance model (Kaysen et al., 2011), and the high-risk susceptibility hypothesis (Chilcoat & Breslau, 1998).

Individuals who experience sexual victimization during military service also report other psychological aftereffects, including depression (Maguen et al., 2012; Schry et al., 2015; Sexton et al., 2017), as well as suicidal ideation and suicide mortality (Blais & Monteith, 2018; Kimerling et al., 2016). For example, analysis of Army STARRS data suggests that women who experience a sexual assault during active duty service have increased odds of attempted suicide (Rosellini et al., 2017a).

Sexual victimization during military service is also associated with several physiological consequences. According to Sadler et al.’s (2000) analysis of a cross-sectional telephone survey of 558 women veterans, women who reported experiences of rape during military service were more likely to report chronic health problems, as well as use of prescription medicine for psychological concerns. Other health concerns reported by survivors of sexual victimization during military service include gynecological symptoms leading to hysterectomy (Ryan et al., 2016), as well as the occurrence of eating disorders (Breland et al., 2018).

In addition to psychological, health, and occupational concerns, some researchers are also now examining the extent to which sexual victimization among service members leads to moral injury (Stein et al., 2012). When sexual violence occurs in the context of one’s workplace or community, individuals can also experience institutional betrayal, feeling like the organization/institution meant to protect them failed in their responsibility (Smith & Freyd, 2013, 2014). Thus, because sexual victimization during military service often involves betrayal by other service members as well as military leadership, a growing number of studies document experiences of institutional betrayal among service members who experience sexual victimization (Andresen et al., 2019; Holliday & Monteith, 2019; Monteith et al., 2016, 2021).

3.2.4 Disclosure, Help-Seeking, and Reporting

Relatively few studies have examined the process of disclosing experiences of sexual victimization that occur during military service. According to qualitative research among 20 women veterans conducted by Dardis et al. (2018), which included a sample of women who disclosed experiences of military sexual victimization, 87% told informal sources (i.e., family or friends), 70% told military personnel, and 52% told medical personnel. Further, although many veterans are screened for experiences of sexual victimization during military service, 25% of veterans report not disclosing their true status as experiencing sexual victimization during service (Blais et al., 2018). Importantly, when disclosing experiences of sexual victimization during military service, 50% of women report experiencing at least one negative reaction from others, including retaliation. The negative impact of unhelpful reactions to sexual assault disclosure among civilians is well documented (Dworkin et al., 2019), and emerging research with men who experience sexual victimization during military service also highlight the negative impact of unhelpful responses to disclosure on the process of recovery (Monteith et al., 2019).

The Department of Defense allows for restricted reporting, which provides for confidential reporting without the triggering of an investigation, as well as unrestricted reporting, which facilitates the opening of a criminal investigation. Studies of servicewomen experiencing sexual assault while in the military suggest that approximately 25% formally report the experience (Mengeling et al., 2014). Further, the 2018 Department of Defense Annual Report on Sexual Assault in the Military notes that “in Fiscal Year 2018, 6053 Service members made a report of sexual assault for an incident that occurred during military service, which equates to about a 30 percent reporting rate” (Department of Defense, 2019a, p. 4).

There are numerous reasons why most assaults among service members go unreported. According to Sadler et al. (2005), barriers to reporting sexual victimization during military service include lack of knowledge on how to report (33%), the belief that rape was to be expected during military service (19%), the individual who would take the report was the perpetrator of the assault (25%) or a friend of the perpetrator (33%), feelings of shame about reporting (77%), worry that reporting would have a negative career impact (78%), the belief that reporting would not lead to anything beneficial being done (70%), fear of being blamed for the assault (60%), and worry that reporting would make things worse (79%). There is also a strong emphasis on psychological resiliency among military service members (Meredith et al., 2011), as well as maintenance of unit cohesion (Siebold, 2007). As a result, individuals who experience sexual violence during military service may be reluctant to bring reports of sexual violence forward, believing that seeking help to cope with stress is a sign of weakness (Hoge et al., 2004) or that doing so would betray their unit (Burns et al., 2014). Notably, despite these barriers, there is evidence that reports of sexual victimization have increased over time. Specifically, “the number of reported sexual assaults involving military service members more than doubled from about 2800 reports in fiscal year 2007 to about 6100 reports in fiscal year 2014” (Government Accountability Office, 2015, p. 1). Whereas sexual violence undoubtedly remains underreported, the increase in reporting may reflect greater confidence in the Department of Defense’s ability to respond to the needs of victims.

Problematically, rates of help-seeking are relatively low among service members who experience sexual victimization. For example, research among women veterans suggested that following experiences of rape during military service, approximately one-third of women reported seeking medical attention, and one-fifth reported seeking psychological support (Sadler et al., 2005). Further, research by Zinzow et al. (2008) found that only 38% of military personnel with a history of sexual victimization seen within a VA primary care setting sought psychological care in the past year (Zinzow et al., 2008). Help-seeking among male service members following sexual victimization may be even less common. For example, in one study reported by Burgess et al. (2016), none of the men who experienced sexual victimization during military service sought emotional support from a counselor or therapist, in comparison to 53% of women service members who experienced sexual victimization.

3.3 Science and Practice of Sexual Assault Prevention Within the Military

3.3.1 Sexual Assault Prevention Strategy

Several publications put forward by the US Department of Defense document strategies to protect the readiness of the force through prevention of sexual violence among service members and timely victim’s assistance and advocacy. For example, in the Fiscal Year 2008 Department of Defense Report on Sexual Assault in the Military, Secretary of Defense Robert Gates identifies four priorities for advancing sexual assault prevention and response, including (1) reducing the stigma surrounding reporting sexual assault, (2) ensuring commander training and accountability, (3) ensuring investigator training, and resourcing, and (4) ensuring prosecutor training (Department of Defense, 2008, p. 29–30). Over time, the scope of recommendations for advancing military sexual assault prevention and efforts has grown. For example, the Department of Defense 2019–2023 Prevention Plan of Action (PPoA) highlights the importance of advancing military sexual violence through investing in the engagement of leadership, development of the prevention workforce, enhancing collaborative relationships with experts in the field, prevention-specific policy, development of data systems to ensure institutional accountability, strengthening of prevention-related policy, implementation of a comprehensive prevention approach, and commitment to quality implementation and outcome evaluation (Department of Defense, 2019b).

3.3.2 State of Prevention Science

Despite over a decade of guidance guiding Department of Defense sexual assault prevention efforts, there are relatively few rigorous evaluations of sexual assault prevention programs specific to military populations (Gedney et al., 2018; Gidycz et al., 2018; Orchowski et al., 2018a). For example, a 2018 systematic review completed by Orchowski and her colleagues (2018a) documented only six published outcome studies of sexual assault prevention programs for service members. There are also gaps in the understanding of rigor of existing program evaluations of sexual assault prevention programs for military personnel. When Orchowski et al. (2018a) as well as Gidycz et al. (2018) published their reviews, no existing studies of sexual assault prevention on military posts had assessed whether the program was associated with decreases in rates of either sexual victimization or sexual victimization among program participants. More recently, Griffin et al.’ (2021) evaluation of the Cadet Personal Skills (CHIPS) program among cadets at the US Air Force Academy documented that the program was associated with decreases in unwanted sexual contact in comparison to the control group.

Whereas the reasons why scientific evaluations of sexual assault prevention programs for service members lack assessments of sexual violence outcomes among participants are unclear, advancing the science of sexual assault prevention for military service members will require that evaluations include robust assessments of behavioral outcomes (see Gidycz et al., 2011a, b). To ensure that participants can report sensitive information honestly, without fear of the information being linked to their identity in any way, researchers completing evaluations of sexual assault prevention programs for college students have utilized self-generated codes to match anonymous participant surveys across pre- and posttest assessments (Orchowski et al., 2008; Gidycz et al., 2011a). Similar approaches can also be implemented when evaluating the efficacy of sexual assault prevention approaches for military populations.

The types of sexual assault prevention efforts that have sustained evaluation for service members are wide-ranging and include individual-level interventions, efforts to engage bystanders in changing community norms, as well as social marketing campaigns. For example, one sexual assault prevention program for male service members was tested among men at a US military installation in Germany (Foubert & Masin, 2012). The intervention includes a workshop for men, which addresses rape myths and aims to foster empathy. Because a pre- and posttest designs were utilized (with no follow-up period), no data are available as to whether the program decreased rates of sexual aggression among participants. The Sexual Assault Victim Intervention (SAVI) program has also been evaluated among US service members (Kelley et al., 2005). SAVI includes 3 h of prevention training and 3 hours of content focused on advocacy; however, there are no data available as to whether the program impacts rates of sexual violence among service members. The Bringing in the Bystander program has also sustained evaluation among US Army Europe (USAREUR) personnel (Potter & Moynihan, 2011). Compared to the control group, soldiers who participated in the program were more likely to engage bystander action when faced with situations that posed a risk for sexual violence (Potter & Moynihan, 2011). Finally, a social marketing campaign entitled Know Your Power has also sustained evaluation among service members at USAREUR posts (Potter & Stapleton, 2012). Findings indicated that USAREUR soldiers who were exposed to the campaign were more likely to intervene to address risky sexual assault situations compared to those who were not exposed to the images (Potter & Stapleton, 2012).

To date, one study has examined the preliminary efficacy of resistance training (i.e., self-defense) for women veterans with a history of PTSD and military sexual trauma. Specifically, in a small-scale pilot study to evaluate Taking Charge (David et al., 2006), women demonstrated significant reductions in PTSD and depression, as well as increases in self-defense self-efficacy at posttest. This research is notable considering research in civilian samples suggesting that unwanted sexual and social advances most often stop because of women’s verbal and physical resistance, but few advances stopped because of bystander intervention (Orchowski et al., 2021). Although no published evaluations of risk reduction and resistance education training for military service members exist, sexual assault risk reduction and resistance education interventions with civilian populations document reductions in rates of sexual victimization over short-term (Orchowski et al., 2008) as well as longer-term follow-up periods (Senn et al., 2015, 2017).

Research on the efficacy of sexual assault prevention approaches for young adults within US military academies is also limited (Rosenstein et al., 2018). As noted earlier, a recent publication documents the efficacy of the Cadet Personal Skills (CHIPS) program among cadets at the US Air Force Academy, which is a curriculum designed to change social norms and bystander intervention behavior to address sexual violence, increase knowledge and skills relating to sexual consent, educate cadets on the association between alcohol use and sexual assault, increase interpersonal skills, and foster self-regulation (Griffin et al., 2021). The 7.5-h intervention is administered in groups of 15–20 cadets. As documented by Griffin et al. (2021), at posttest intervention participants were less likely to report unwanted sexual contact in comparison to the control group, after accounting for baseline unwanted sexual contact, alcohol use, and gender. The assessment was limited, however, by not including an assessment of whether the program also reduced perpetration of sexual aggression among program participants. Thus, while military service academies are active in developing and implementing sexual assault prevention approaches (see Caslen et al., 2015), additional research which incorporates assessments of behavioral outcomes is urgently warranted.

3.4 Envisioning Integrated Alcohol and Sexual Assault Prevention Approaches for the Military

The current chapter operationalizes integrated alcohol use and sexual assault prevention as interventions that include active intervention components addressing alcohol use, as well as active strategies for sexual assault prevention. To be considered an integrated intervention for alcohol use and sexual assault, the intervention must address both health concerns in a manner that recognizes the intersection between alcohol use and sexual assault. Through this lens, offering two standalone interventions – one addressing alcohol use and one addressing violence – would not be considered an integrated intervention, as such an approach fails to address the intersections between alcohol use and violence.

Whereas alcohol use and sexual assault are recognized among civilian and military populations as critical public health issues, sexual assault prevention and response programs often fail to recognize how alcohol use and sexual violence intersect (i.e., Lund & Thomas, 2015). Some sexual assault prevention programs do indeed include some mention of the role of alcohol as a risk factor for violence (i.e., through the incorporation of content, or scenarios that depict alcohol-related victimization). However, such information alone – without incorporation of alcohol use intervention – is likely to be insufficient to foster robust change in personal alcohol use patterns. As will be reviewed below, there are few sexual assault prevention approaches which include active alcohol intervention, or active alcohol use prevention strategies (see Orchowski et al., 2017, 2018b; Gilmore et al., 2015, 2018a, b; Creech et al., 2021).

Integrated alcohol and sexual assault prevention approaches have the potential to attend to multiple risk and protective factors across the social ecology. As discussed in the Centers for Disease Control and Prevention’s Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence, there are numerous risk and protective factors across the individual, interpersonal, community, and societal levels of the social ecology that can be targeted as a part of efforts to reduce sexual violence (Wilkins et al., 2014). An integrated approach to alcohol intervention and sexual assault prevention can also be universal, selective, or indicated in nature. While all types of prevention are necessary for preventing the occurrence of sexual harassment and assault, true primary prevention of sexual violence requires population-based strategies which foster environmental, systems-level, and policy-based changes and actions that “get to the left of violence” and stop it from initially occurring (Wilkins et al., 2018). A recent publication of the Division of Violence Prevention at the Centers for Disease Control and Prevention (2016) highlights the importance of developing intervention approaches with the potential for cross-cutting impact on multiple health outcomes. Further, public health strategies for violence prevention are shifting toward addressing risk and protective factors at the community and societal levels of the social ecology, which are likely to have a synergistic and broad-scale impact preventing multiple types of violence simultaneously (Armstead et al., 2017).

A case for integrated alcohol use and sexual assault prevention can be made when recognizing that rigid adherence to traditional gender role norms is a social-level factor that intersects with problematic alcohol use (Iwamoto et al., 2011; Mullen et al., 2007; Wilkinson & Wilkinson, 2020) as well as sexual aggression (Armstead et al., 2018; Tharp et al., 2013). There are also numerous ways that alcohol use and violence intersect in some constructions of masculinity, such that alcohol-related violence is conceptualized among some men to demonstrate dominance and control in relationships with women (Peralta et al., 2010). Given the disproportionate representation of women in the US military (Patten & Parker, 2011) and historical emphasis on traditional masculine norms within the military, prevention approaches that target the ways in which adherence to traditional masculine norms intersects with health outcomes may be especially relevant for military populations.

Problematic alcohol use is also a concern in and of itself within the military. In an analysis of survey data collected by the Centers for Disease Control and Prevention from over 27,000 individuals across 25 different industries, the Delphi Behavioral Health Group found that military service members consumed alcohol an average of 130 days per year, ranking the military as the professional with the highest rate of alcohol use in the United States (Delphi Behavioral Health Group, 2021). Survey data suggest that the prevalence of heavy drinking among military service members from 1980 to 2005 was estimated to be 15 to 20% (Bray & Hourani, 2007). Young adults in military service are also more likely than their same-age civilian peers to engage in heavy alcohol use (Ames & Cunradi, 2004). For these reasons, alcohol is an important health outcome to address in military populations. As articulated in the sections that follow, alcohol use is also an important risk factor for sexual aggression and sexual victimization and a complicating factor in bystander intervention, which has important implications for prevention.

3.4.1 Alcohol Use and Sexual Aggression

Research among civilian and military samples suggests that alcohol use is positively associated with sexual aggression perpetration. For example, sexually aggressive men report greater daily alcohol use (Borowsky et al., 1997), heavy drinking (Neal & Fromme, 2007), and alcohol problems (Abbey et al., 2006) compared to non-sexually aggressive men. Further, data from the Historical Administrative Data System of the Army STARRS indicates that severe emotional-substance problems precede perpetration of nonfamily sexual assault among service members (Rosellini et al., 2017b). This is not to say that men who perpetrate sexual aggression are under the influence of alcohol each time they perpetrate. Rather, research by Parkhill and Abbey (2008) examining a sample of civilian men found that 47.8% perpetrated only when sober, 26.8% perpetrated only when drinking, and 25.4% perpetrated both when sober and when drinking alcohol. Thus, the way in which alcohol intersects with sexual aggression is multifaceted and may be related to a complex interplay of individual, interpersonal, and situational drivers.

The Integrated Model of Sexual Assault is a multicomponent model of sexual aggression which highlights individual, interpersonal, situational/environmental, and community influences as important considerations on men’s proclivity to perpetrate sexual aggression (Berkowitz, 1994, 2003). As discussed by Berkowitz (2003), a perpetrator’s attitudes, early experiences, and perception of peer norms interact to facilitate sexual aggression, where situational or environmental drivers – such as alcohol use – can serve as “releasers” for the expression of sexual aggression. The Integrated Model of Sexual Assault also places a high emphasis on the role of misperceptions of peer support for sexual aggression (Lynch et al., 2004; Bohner et al., 2006; Dardis et al., 2016), which foster engagement in sexual aggression by pressuring men to engage in coercive behavior and inhibiting bystander intervention by suppressing men’s discomfort with other men’s inappropriate behavior (Berkowitz, 2003). Given the high emphasis on perceived norms embedded within the theoretical framework of the Integrated Model of Sexual Assault, sexual assault prevention programs grounded in the approach often include the provision of normative feedback (Gidycz et al., 2011a, b), an intervention approach which is also common in alcohol intervention (Larimer & Cronce, 2007; Scott-Sheldon et al., 2014).

Alcohol increases risk for sexual aggression in several potential ways. First, the myopic and psychological effects of alcohol (Steele & Josephs, 1990) interact with personal beliefs and situational factors to facilitate sexual aggression. Specifically, drinking decreases an individual’s ability to appraise cues in their environment (Sayette, 1993), reduces the capacity to make decisions (Curtin & Fairchild, 2003), and lowers levels and individuals’ overall level of tension and anxiety (Greeley & Oei, 1999). These myopic cognitive effects and disinhibiting psychological effects can increase proclivity for sexual aggression by increasing the likelihood that an individual fails to attend to or disregards a partner’s refusal of sexual activity (Abbey et al. 2004). Notably, there is strong research to document that when intoxicated, individuals are apt to misinterpret signs of sexual interest (George & Stoner, 2000; Parkhill & Abbey, 2008), which is positively associated with perpetration of sexual aggression (Bridges & McGrail, 1989; Muehlenhard & Linton, 1987). An individual’s expectancies or beliefs about how alcohol use will influence their behavior (Goldman et al., 1999) are also relevant to sexual aggression. Specifically, individuals who believe that alcohol use increases sexuality, aggression, and liquid courage may consume alcohol, intentionally or unintentionally, to facilitate engaging in uninhibited or aggressive behavior (George & Stoner, 2000; Tedor et al., 2018). Misperceptions regarding peer approval for aggression when intoxicated may serve to normalize sexually aggressive behavior or foster a sense that they can mitigate culpability for acting aggressively by “blaming it on the alcohol” (Hochstetler et al., 2014). Shared associations between alcohol use and other personality factors which are associated with rape proclivity may also contribute to the association between alcohol use and sexual aggression (Abbey, 2008). For example, individuals with antisocial traits or high levels of impulsivity are likely to consume alcohol as well as engage in sexual aggression (Lansford et al., 2003; Moffitt et al., 2002). Taken together, these studies highlight the importance of addressing alcohol use as one part of a constellation of factors that increase risk for sexual aggression. Given that alcohol use is one of the many risk factors for sexual aggression suggests that standalone alcohol intervention may be insufficient to reduce proclivity for sexual aggression. Sexual assault prevention programs that fail to include active alcohol intervention may also be lacking attention to the range of influences that increase proclivity to rape.

3.4.2 Alcohol Use and Sexual Victimization

Numerous studies also document a positive association between alcohol use and sexual victimization (see other chapters in this volume for further discussion). Studies of civilians as well as military samples suggest that women who report sexual victimization are more likely than non-victimized women to report heavy drinking and alcohol problems (Benson et al., 2007; Booth et al., 2011; Merrill et al., 1999; Windle, 1994). As Farris and Hepner (2014) report, rates of heavy alcohol use are positively associated with rates of sexual victimization across branches of the military. Individuals who experience sexual assault are likely to abuse alcohol to mitigate post-assault distress (Kaysen et al., 2006; Miranda et al., 2002; Ullman & Najdowski, 2009; Ullman et al., 2006), which increases risk for revictimization (Messman-Moore et al., 2009; Testa et al., 2000). One prospective study of civilians documented that women with a history of sexual victimization who reported heavy drinking habits were ten times more likely to experience revictimization compared to women with a history of victimization who identified as light or nondrinkers (Gidycz et al., 2007). These data underscore the importance of reducing the role of alcohol use as a potential risk for sexual victimization and revictimization.

There are ways in which alcohol increases risk for sexual victimization. Alcohol consumption interferes with the ability to evaluate high-risk situations (Fromme et al., 1999), including those that pose a risk for sexual assault (Testa et al., 2000). Numerous studies suggest that alcohol use makes it difficult for an individual to recognize that a situation poses a risk for victimization (Abbey et al., 2003; Abbey et al., 2006; Davis et al., 2004; Davis et al., 2009). Individuals who consume alcohol attend to a restricted range of information in social situations and can take longer to comprehend, synthesize, and respond to signals (Lannutti & Monahan, 2004). As a result of the myopic effects of alcohol (Steele & Josephs, 1990; Taylor & Chermack, 1993), the most prominent cues in an environment are heightened when drinking, which may turn women’s attention away from risk cues (Davis et al., 2007). Alcohol consumption is associated with reductions in tension and anxiety (Greeley & Oei, 1999), which can decrease the ability to appraise stress-related cues (Sayette, 1993). Studies of civilian women suggest that individuals report that they are less likely to be attuned to whether a dating situation is unsafe when drinking (Norris et al., 1996, 1999). Decision-making in sexual situations tends to be generally less self-protective when individuals consume alcohol (Abbey et al., 2005; George et al., 2009). Therefore, even if women notice risk in dating situations, alcohol consumption may decrease the likelihood women respond to risk self-protectively (Stoner et al., 2007). Alcohol use can also make it difficult to physically fight back against an attacker (Harrington & Leitenberg, 1994; McCauley & Calhoun, 2008). Alcohol use in bar and party settings also increases women’s exposure to potential perpetrators, who may opportunistically target women who are drinking (Parks & Zetes-Zanatta, 1999; Testa & Parks, 1996). Perpetrators of sexual assault also report tactical use of alcohol to decrease a woman’s ability to resist an unwanted sexual advance (Kanin, 1985). Taken together, these data suggest that approaches that include alcohol intervention may be especially relevant for reducing victimization among populations who engage in heavy drinking, given that such activities increase risk for alcohol-related sexual assault (Farris & Hepner, 2014; Testa & Livingston, 2009).

Scholars argue in regard to both military populations (Farris & Hepner, 2014) and college women (Testa & Livingston, 2009) that reducing heavy episodic drinking can potentially lead to reduced rates of sexual victimization, especially rates of sexual assault that occurs when the victim is incapacitated. However, as discussed by Testa and Livingston (2018), “in general, women’s alcohol use has rarely been addressed as a primary intervention target and in general, there seems to be a reluctance to even talk about the role of alcohol, out of a concern that this is victim-blaming or deflects blame from the perpetrator” (p. 148–149). Yet, as the authors articulate, “it would be foolish and unethical to ignore the fact that women’s heavy episodic drinking (HED) plays a significant role in sexual victimization vulnerability out of an outsized concern that it is victim-blaming to do so” (Testa & Livingston, 2018; pp. 158).

To address the concern that talking about the intersection of sexual victimization and alcohol use conveys victim blame, it is essential that integrated prevention approaches convey that nothing an individual does – including drinking alcohol – fosters culpability for sexual victimization. Responsibility for sexual violence rests solely with perpetrators of sexual aggression, and their decision to take advantage is under the influence of alcohol, or who is incapacitated as a result of drinking. Indeed, ensuring that responsibility is clearly and solely placed on perpetrators of violence is at the heart of feminist sexual assault risk reduction programs (Orchowski & Gidycz, 2018). There is also ample evidence to suggest that risk reduction interventions serve to empower victims to more appropriately allocate blame for sexual assault onto perpetrators (Gidycz et al., 2006). Women who experience sexual assault after engaging in a risk reduction program also report lower levels of self-blame compared to women who do not receive such training (Gidycz et al., 2015). Ensuring that outcome evaluations of prevention programs include assessment of self- and perpetrator-blaming among participants following the intervention is one strategy for ensuring that programs continue to be well-received by participants with histories of victimization and that participants who experience victimization following an intervention allocate responsibility to the perpetrator.

3.4.3 Alcohol Use and Bystander Intervention

In addition to considering the role of alcohol as a risk for perpetration and victimization, there is growing attention to how alcohol use intersects with an individual’s ability to intervene to address risk for sexual violence in social settings. Although individuals who engage in heavy drinking are likely to be present in environments where there are opportunities to intervene to address risk for sexual violence (Haikalis et al., 2018; Oesterle et al., 2018), there is also evidence that individuals also often fail to intervene when they are in bar settings (Graham et al., 2014). As discussed in a conceptual review by Leone et al. (2018), there is reason to believe that alcohol use can interfere with each step that a bystander must take to address a potential risk for sexual violence, including (1) noticing risk; (2) labeling the situation as problematic; (3) taking responsibility for addressing the situation; and (4) possessing the skills to intervene. Pugh et al. (2016) also report that bystanders experience more barriers to intervention when a victim is intoxicated.

Whereas research addressing the intersection between alcohol use and bystander intervention is still relatively sparse, several quantitative and qualitative studies provide insight into ways that alcohol could influence each of the steps in bystander intervention. Qualitative research presented by Oesterle et al. (2018) found that although college men perceived themselves to be more likely to have the “liquid courage” to intervene, they might be at risk to intervene using more aggressive strategies when intoxicated. Research from alcohol administration studies is mixed. Further, a laboratory study involving an alcohol consumption task among participants found that whereas intoxication influenced participants’ ability to notice an event, and perceive greater risk/need for intervention, alcohol did not influence participants’ engagement in the later steps of the bystander intervention model (Ham et al., 2019). A different pattern of results was reported by Leone and Parrott (2019b), who documented in a laboratory-based alcohol administration study that alcohol intoxication was associated with decreased likelihood and intervention among men who reported intentions to help. Differences in the study sample and approach to measuring bystander intervention across these studies may in part be responsible for these variations in findings, and additional research is needed to elucidate the mechanisms through which acute intoxication influences bystander behavior in real-world contexts. To date, findings from one field study found that participant intoxication decreased the accuracy of recalling a situation in a hypothetical sexual assault scenario, as well as assessment of risk in the scenario and need for intervention, but was not associated with ratings or one’s personal responsibility to intervene, choice of strategy to intervene, or confidence in intervening (Melkonian et al., 2020).

Although studies report that engaging in heavy episodic drinking is associated with a lower likelihood of engaging in bystander intervention to address risk for sexual assault among men (Fleming & Wiersma-Mosley, 2015), there is also reason to believe that underlying beliefs relating to sexual aggression may influence both alcohol use and likelihood to intervene. For example, Orchowski et al. (2016) found that men who engaged in heavy drinking are less likely to engage in proactive bystander intervention, and this association was mediated by men’s endorsement of peer approval of sexual aggression, their own comfort with sexism, and engagement in coercive sexual behavior. Other studies among community men also point to the importance of adherence to masculine norms among heavy drinking men as a contributing factor to bystander intervention. Specifically, Leone and Parrott’s (2019a) analysis of survey responses from 148 men between the ages of 21 and 30 revealed that among heavy drinking men, but not non-heavy drinkers, avoidance of stereotypical feminine activities was negatively associated with engaging in bystander intervention to help friends. Because all of the aforementioned research addressing alcohol use and bystander intervention is among civilian samples, research is needed to examine the extent to which these findings generalize to service members. There is also a question of what populations are best to target with integrated interventions that address alcohol use and bystander intervention. Arguably, integrated alcohol and sexual assault interventions which focus especially on bystander intervention may be particularly relevant for individuals who frequent bar and party environments, where risk for violence is likely to occur (Oesterle et al., 2018).

3.5 An Overview of Integrated Approaches

3.5.1 Interventions for College Populations

Integrated alcohol and sexual assault prevention programs for military populations can draw from lessons learned developing, piloting, and evaluating prevention approaches for college students. To date, several integrated interventions exist for different target audiences, including women, men, and all college students at large. These intervention approaches are outlined below.

3.5.1.1 Approaches for Women

Through funding from the NIAAA (R01 AA014514), Testa et al. (2010) examined the efficacy of using parent-based intervention to reduce alcohol-involved sexual victimization for first year college women. The parent-based intervention (PBI) was designed to increase alcohol-specific communication between mothers and daughters, as well as general communication. The study examined four conditions: alcohol-based PBI, enhanced alcohol and sexual victimization PBI, a control condition, and an unmeasured control condition. Both the alcohol PBI and the enhanced PBI were associated with a lower incidence of incapacitated rate among first year college women in comparison to the control condition. The researchers note that “intervention effects were relatively modest, and we did not observe a direct effect of the intervention on college [heavy episodic drinking]. Likewise, the enhanced intervention did not increase daughters’ sexual assertiveness or reduce sexual victimization relative to the alcohol-only intervention” (Testa et al., 2010; p. 316). Because PBI must be delivered from mother to daughter, the potency of the intervention is variable, and the information must be relayed between mothers and daughters in a way that can be readily perceived and acted upon. Researchers also have little control over the fidelity, intensity, and style through which individuals convey the PBI to others. Thus, Testa et al. (2010) note that “the impact of PBI is likely to be more modest relative to more intensive or investigator-delivered interventions” (p. 317).

Gilmore and her colleagues (2015) also received funding through NIAAA to evaluate the efficacy of a web-based combined alcohol use and sexual assault risk reduction program for college women who engaged in heavy episodic drinking. This intervention is grounded in the Assess, Acknowledge, and Act (AAA) model of sexual assault risk reduction and resistance education (Rozee & Koss, 2001). The web-based intervention provides women with personalized feedback on alcohol use as well as self-protective strategies for sexual victimization and includes sexual assault risk reduction strategies. This intervention was effective over a 3-month follow-up at reducing heavy episodic drinking and victimization among women with more severe sexual assault histories (Gilmore et al., 2015). The sexual assault risk reduction content of the intervention was also associated with decreased alcohol-related blackouts as well as incapacitation, whereas the combined alcohol use and sexual assault risk reduction program reduced alcohol-induced blackouts (Gilmore et al., 2018a, b). These findings document the potential for brief web-based integrated alcohol and sexual assault prevention programs to show effects on both alcohol use and sexual assault outcomes.

Although the approach would not meet the proposed operational definition of an integrated alcohol and sexual assault prevention program, it is worth noting that several studies have examined whether reducing drinking alone is sufficient to reduce risk for sexual victimization among college women. Clinton-Sherrod et al. (2011) found that motivational interviewing, personalized normative feedback, and a combination of both were associated with reduced reports of sexual activity when women were “too intoxicated to prevent it.” Because the reduction in incapacitated sexual assault was not mediated through reductions in alcohol use, it is possible that women were at reduced vulnerability to sexual assault as result of enhanced ability to recognize risk for victimization. Brahms et al. (2011) found that Brief Alcohol Screening and Intervention in College Students (BASICS) intervention was equally effective among college women with and without a history of sexual victimization. The effects of the intervention on sexual assault were not examined. Taken together, these studies suggest that standalone alcohol interventions may be effective in reducing alcohol use for women with and without a history of victimization, but reductions in alcohol use may not be sufficient to reduce victimization risk.

There are a few broad conclusions that can be drawn from the aforementioned research. First, integrated approaches for alcohol and sexual assault prevention among college women are limited, focusing to date on first year college women and heavy drinking college women. Second, as integrated interventions are developed, attention should be paid to whether interventions are effective among survivors of sexual victimization. Whereas some studies demonstrate reductions in women with a history of victimization (Gilmore et al., 2015), other research shows that interventions are ineffective in reducing drinking among women with a history of sexual victimization (Clinton-Sherrod et al., 2011). There is also a lack of data to address the assumption that interventions that include active alcohol intervention could directly or indirectly imply that victims are to blame for assaults that involve voluntary consumption of alcohol use. Future studies which incorporate measures of self-blame among participants who participate in interventions can help to ensure that interventions have no iatrogenic effects for survivors, or individuals who experience victimization following program participation.

3.5.1.2 Interventions for Men

Through a treatment development grant from NIAAA (R34 AA020852), Orchowski and her colleagues designed and tested an in-person intervention to reduce perpetration of sexual aggression among college men who report heavy drinking (Orchowski et al., 2018b). The intervention included an individually administered brief motivational intervention (BMI) with a personalized feedback report (PFR) addressing alcohol use, alcohol use in sexual situations, alcohol-related sexual consequences, consent, and bystander intervention. The BMI with PFR was followed by a sexual assault prevention workshop grounded in social norms intervention and bystander intervention that shows evidence for reductions in sexual aggression perpetration among college men (Gidycz et al., 2011b). For this integrated intervention, the workshop was revised to address the intersection of alcohol use and sexual aggression more rigorously. Preliminary findings suggest that the in-person approach is feasible, acceptable, and promising to facilitate change in attitudes relating to violence and foster safer alcohol use consumption (Orchowski et al., 2018b).

3.5.1.3 Interventions for Men and Women

Researchers have also received funding from NIAAA to develop and evaluate an integrated web-based alcohol and sexual assault prevention program for college students which integrates the programs developed by Orchowski et al. (2018b) and Gilmore et al. (2015) into an integrated web-based approach for all students (R34AA025691: Gilmore, PI). The alcohol and sexual assault prevention program (+ change) includes personalized normative feedback addressing alcohol use and its intersection with sexual aggression, sexual victimization, as well as bystander intervention. The web-based intervention approach addresses concerns relating to the feasibility of implementing single-gender approaches for men and women and is also unique in its inclusion of content tailored to sexual and gender minorities. Results from an open pilot trial of the intervention suggest that the intervention has high feasibility, acceptability, and utility among college students (Gilmore et al., 2020).

There is also increasing attention to whether protective behavioral skills (PBS) to reduce alcohol-related harms may protect against sexual victimization (see Scaglione et al., 2015). For example, greater engagement in protective behavioral skills is negatively associated with sexual victimization (Neilson et al., 2018). Currently, an intervention development study is underway through the support of NIAAA funding to pilot an integrated PBS intervention for alcohol use, sexual risk, and sexual assault among college students (Napper et al., 2018; Napper & Kenney, 2018). The Sex Positive Lifestyles: Addressing Alcohol & Sexual Health [SPLASH] Intervention is tri-pronged, targeting alcohol use, risky sexual behavior, and bystander behavior to address both alcohol-related and sexual assault-related risks. The intervention includes live, interactive group-based normative feedback designed to reduce discrepancies between perceived and actual norms addressing alcohol use and sexual risk. The intervention addresses the intersection between alcohol use and sexual risk, providing skills training to increase sex- and alcohol-related protective behaviors. The intervention also includes bystander intervention training to increase protective action.

It is also important to note that other interventions for men and women reference the intersection of alcohol use and sexual violence, but do not incorporate evidence-based alcohol intervention. For example, using pre-, post-, and follow-up assessments, Zinzow and her colleagues (2018) evaluated an intervention that included an education program designed to address knowledge, attitudes, and bystander intervention relating to alcohol use as well as sexual assault. Although content addressing the intersection of alcohol use and sexual violence is woven across the intervention, the publication does not describe specific intervention strategies designed to reduce participant drinking, making it unclear whether the approach fits the proposed definition of an integrated intervention. Notably, whereas the 70-minute educational intervention had an impact on rape myth acceptance, program participants did not maintain gains in alcohol risk reduction strategies over time.

3.5.2 Programs for Service Members

Two studies are underway which seek to adapt the integrated alcohol use and sexual assault prevention approaches for college students for utilization in military samples. In 2014, Orchowski and her colleagues received funding from the Department of Defense Congressionally Directed Medical Research Programs (PT140100) to revise the promising integrated alcohol and sexual assault prevention program for heavy drinking college men (Orchowski et al., 2018b) for use among male soldiers who report at-risk alcohol use. This research has resulted in a standardized protocol to provide personalized normative feedback to reduce alcohol use and sexual assault among male service members who engage in at-risk alcohol use. Findings of the open trial found that soldiers were receptive to the intervention content, with most soldiers reporting that the intervention met their needs (Orchowski et al., 2017). Given the tendency for soldiers to move frequently, challenges emerged in maintaining enrollment in an in-person intervention which was administered over multiple time points.

Orchowski, Gilmore, and Walters (joint PIs) have also received funding from the Department of Defense Congressionally Directed Medical Research Programs to adapt the web-based alcohol and sexual assault prevention approach for college men and women described above (Gilmore et al., 2020) for use among sailors. In addition to active alcohol intervention, the intervention also addresses the intersection of alcohol use with sexual perpetration, sexual victimization, and bystander intervention. The treatment development study now underway utilizes a normative survey as well as a series of iterative qualitative intervention development activities to refine the web-based alcohol and sexual assault prevention to meet the needs of sailors (Orchowski et al., 2020a, b). With an eye toward eventual implementation and dissemination, the study also engages a military advisory board to guide the intervention structure and content.

3.5.3 Interventions Among Veterans

One study has examined intervention approaches for preventing sexual revictimization among women veterans who experienced sexual victimization during military service by concurrently targeting alcohol use. Specifically, Creech et al. (2021) report on the preliminary efficacy of Safe and Health Experiences (SHE), a computerized intervention to reduce hazardous drinking, intimate partner violence, and PTSD among women veterans with a history of sexual victimization. The study was funded by the Congressionally Directed Medical Research Program and included an open pilot trial, as well as a small, randomized pilot trial. The findings of the open pilot trial were promising. Women were satisfied with the program and reported reductions in hazardous drinking, intimate partner violence, as well as PTSD over a 4-month follow-up. Given the high rates of revictimization among survivors of sexual violence, intervention approaches that address the consequences of sexual trauma and concomitantly seek to reduce risk for future harm are an important component of victims’ assistance.

3.6 Summary and Future Directions

This chapter sought to articulate the need, rationale, and status of integrated alcohol and sexual assault prevention for military personnel. Integrated approaches to alcohol and sexual assault prevention are growing among civilian populations and, given the high rates of alcohol use in military settings, represent an emerging and relevant focus for military populations as well. To date, a limited number of integrated alcohol use and sexual assault prevention programs exist for military populations, representing a significant gap in prevention science. Alcohol intervention researchers have worked for decades to hone effective alcohol intervention strategies, and sexual assault prevention scientists and practitioners would benefit from “reaching across the aisle” to foster collaborations outside of what can often be a siloed discipline.

To increase the cross-cutting impacts of prevention efforts on multiple behavioral outcomes among service members, integrated interventions should draw from best practices in prevention. As delineated by Nation et al. (2003), prevention approaches should be comprehensive in nature, address peer influences, implement varied teaching methods, be of sufficient dosage, maintain grounding in sound theory, promote strong or positive relationships, be appropriately timed, be socioculturally relevant, incorporate outcome evaluations, and be administered by well-trained staff. Integrated alcohol and sexual assault prevention programs should also be viewed as one of the many necessary strategies for reducing risk of sexual violence in the military and be implemented in conjunction with other efforts to change cultural norms and bolster victim services. As articulated in the Department of Defense, 2014–2016 Sexual Assault Prevention Strategy, “due to the complex nature of the problem, it is important to conduct a number of interventions (actions) that span multiple levels to achieve the greatest, lasting impact” (Department of Defense, 2014; p. 8). Environmental interventions focused on policies that restrict access to alcohol and lead to decreased consumption may also reduce risk for sexual victimization (Farris & Hepner, 2014; Testa & Livingston, 2018).

As prevention scientists work to develop integrated alcohol and sexual assault prevention approaches for both military and civilian audiences, it will also be necessary to grapple with the questions of who should be targeted with such approaches. There is also the consideration of what intervention approach is likely to be most salient. Addressing the shared association between traditional gender role adherence, alcohol use, and sexual aggression appears to be a promising strategy for targeting the array of factors that influence proclivity to rape. Given that perceived peer norms play a significant role in both personal alcohol use and sexual aggression, the adoption of a social norms approach to target both health concerns may have a synergistic effect. Regardless of the approach taken, there is likely to little downside to developing prevention programs which have the potential for cross-cutting effects on multiple psychological and health outcomes.