Predictors of Moral Injury in U.S. Military Veterans: In-Service Specific Events

Background and Purpose: Moral injury refers to the emotional distress an individual experiences when their actions or behaviors conflict with deeply held values, often manifesting as guilt, shame, or betrayal. Among military veterans, moral injury remains a persistent and growing concern, as it is strongly associated with mental health conditions such as depression, post-traumatic stress disorder (PTSD), and suicidal ideation. While combat trauma has received considerable attention, research remains limited in capturing the diverse range of other in-service experiences that may lead to moral injury. This gap is critical, as veterans face a wide array of institutional and interpersonal challenges during service that may also be morally injurious. The purpose of this study was to identify specific in-service military-related events that significantly predict moral injury among veterans. specifically, which in-service experiences are most strongly associated with an increased risk of developing moral injury?

Methods: This study drew on data from the Southern California Veteran Study (Kintzle et al., 2023), which utilized a convenience sampling strategy to survey veterans residing in Los Angeles, Orange, and San Diego Counties. Between July 2022 and June 2023, a total of 3,188 veterans completed an online survey, distributed through partnerships with veteran organizations, social media platforms, and printed advertisements. After excluding incomplete and ineligible responses, the final analytic sample included 2,683 veterans. The survey took 30–60 minutes to complete, and participants received a $25 gift card as compensation. Linear regression was used to examine the direct effects of six in-service events of Combat Exposure, Sexual Harassment, Sexual Assault, Discrimination, Early Separation, and Toxin Exposure on moral injury.

Results: The analysis revealed that five of the six in-service experiences significantly predicted higher levels of moral injury. Discrimination emerged as the strongest predictor of moral injury (β = 0.39, p < 0.001), followed by early separation (β = 0.10, p < 0.001) and toxin exposure (β = 0.10, p < 0.001). These findings indicate that, independent of other variables, these events are strongly associated with elevated moral injury. While sexual assault and combat exposure had statistically significant effects, their impact was comparatively smaller. Overall, the findings suggest that veterans who did not experience discrimination, early separation, or toxin exposure reported significantly lower levels of moral injury, emphasizing the necessary future direction of considering a wider range of service-related experiences in assessing and addressing veterans' mental health outcomes.

Conclusion and Implications: This study advances the understanding of moral injury by identifying in-service events such as discrimination, early separation, and toxin exposure as significant contributors among veterans. These findings highlight the need to broaden clinical assessment and intervention beyond combat-related trauma. Recognizing and addressing these underexamined sources of distress can improve the effectiveness of moral injury intervention and inform policy changes aimed at prevention and support. Incorporating these factors into future research and program design will enable practitioners and policymakers to better meet prevent and treat the deleterious impacts of moral injury in veterans.