Women at War

WOMEN AT WAR

Edited by Elspeth Cameron Ritchie, MD, MPH Chief Medical Officer Department of Behavioral Health Professor of Psychiatry, Uniformed Services University of the Health Sciences Washington, DC Anne L. Naclerio, MD, MPH Deputy Surgeon, United States Army Europe Chair, Women’s Health Task Force, Office of the Army Surgeon General Associate Professor Pediatrics, Uniformed Services University of the Health Sciences Arlington, VA

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Library of Congress Cataloging-in-Publication Data Women at war (Ritchie) Women at war / [edited by] Elspeth Cameron Ritchie and Anne L. Naclerio. p. ; cm. Includes bibliographical references. ISBN 978–0–19–934453–6 (alk. paper) I. Ritchie, Elspeth Cameron, editor. II. Naclerio, Anne L., editor. III. Title. [DNLM: 1. Military Personnel—United States. 2. Women’s Health—United States. 3. Sex Factors— United States. 4. Veterans Health—United States. 5. War—United States. WA 309 AA1] UB369 362.1086′97—dc23 2014033193

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1 3 5 7 9 8 6 4 2 Printed in the United States of America on acid-free paper Contents

Foreword ix

Contributors xi

Introduction xv

PART 1: BACKGROUND AND INTRODUCTION

1. Comparative Morbidity and Mortality of Women Serving in the US Military During a Decade of Warfare 3 Robert F. DeFraites, David W. Niebuhr, Brigilda C. Teneza, Leslie L. Clark, and Sharon L. Ludwig

2. Female Soldiers and Post-Traumatic Stress Disorder 22 Elspeth C. Ritchie, Michael R. Bell, M. Shayne Gallaway, Michael Carino, Jeffrey L. Thomas, Paul Bliese, and Sharon McBride

3. Women and War: Australia 34 Beverley Raphael, Susan Neuhaus, and Samantha Crompvoets

PART 2: WOMEN AT WAR

4. Medical Issues for Women Warriors on Deployment 49 Anne L. Naclerio

5. Reproductive Health 78 Cara J. Krulewitch vi Contents

6. Issues in the Prevention of Malaria Among Women at War 93 Remington L. Nevin

7 Women, Ships, Submarines, and the US Navy 120 Heather D. Hellwig and Paulette T. Cazares

8. Female Combat Medics 134 Charles Figley, Barbara L. Pitts, Paula Chapman, and Christine Elnitsky

9. Human Sexuality and Women in the Area of Operations 147 Amy Canuso

PART 3: WOMEN HOME FROM WAR

10. Women Home from War 157 Elizabeth C. Henderson

11. Mothers in War 178 Amy Canuso

12. Building the Framework for Successful Deployment Reunions 196 Erin Simmons

13. Traumatic Brain Injury: Implications for Women in the Military 211 Victoria Tepe and Suzanne Garcia

PART 4: PSYCHOLOGICAL ISSUES FOR ACTIVE DUTY WOMEN

14. Suicide-Related Ideation and Behaviors in Military Women 243 Marjan Ghahramanlou-Holloway, Brianne George, Jaime T. Carreno-Ponce, and Jacqueline Garrick

15. Intimate Partner Violence, Military Personnel, and Veterans 266 Glenna Tinney and Melissa E. Dichter

PART 5: THE FEMALE VETERAN EXPERIENCE

16. The Woman Veteran Experience 301 Isabel D. Ross, Natara D. Garovoy, Susan J. McCutcheon, and Jennifer L. Strauss

17. Mental Health of Women Warriors: The Power of Belonging 311 Kate McGraw Contents vii

18. The Veterans Health Administration Response to Military Sexual Trauma 321 Margret E. Bell and Susan J. McCutcheon

19. Compensation, Pension, and Other Benefits for Women Veterans with Disabilities 329 Jacqueline Garrick

Index 351

Foreword

Our nation and the military are stronger because we have embraced diversity, whether it be race, color, ethnicity, religion, or gender. This truth is reflected in the vital role that women have played throughout the history of the United States military. Since the Revolutionary War, more than 2.5 million women have served with honor and self- less dedication to the mission. Most recently, nearly 275,000 women have deployed in support of Operations Iraqi Freedom, New Dawn, and Enduring Freedom. I have seen firsthand the courageous work of these deployed women, and the value they bring to the military each and every day. Given recent policy changes, by January 2016 it is expected that all military occupations, positions, and units will be open to women, thus ensuring that they will play even larger roles in future military operations. This begs the question, what is being done to better understand and address the needs of our Servicewomen in both the garrison and deployed environments? In 2011, Army Medicine leaned forward and established the Women’s Health Task Force (WHTF) to address the unique health concerns of women serving in the military. This critical task force has introduced such initiatives as the Women’s Health Portal and new clinical treatment algorithms, and is shaping education, equipment, and care for the next generation of women in the military. While cutting-edge gender-specific healthcare and research in support of combat forces are ongoing, it is more important than ever for providers in all settings to have a full understanding of women’s medical and psychological needs during and after deployments. This book is perfectly timed to share these key insights.

ix x Foreword

While covering a wide spectrum of topics, Woman at War thoroughly explores each area in enough detail to reveal the true complexities of these issues. In particular, given our current military-wide focus on behavioral health, the authors provide critical information that will serve to better target such care to women. This book makes it clear that progress in understanding women’s issues related to war and serving in the military has been made, but that much more research on these vital topics is needed. I applaud the many authors of this book for opening up this discussion, and hope that this inspires others to continue research in these emerging fields of national importance. The more we know about the specific needs of women in the military, the more likely it is that we will be able to ensure these needs are met. This will only strengthen the contributions that women can and will continue to make in defense of our great nation. Serving to Heal . . . Honored to Serve. Patricia D. Horoho Lieutenant General, US Army The Surgeon General and Commanding General, US Army Medical Command Washington, DC Contributors

Margret E. Bell, PhD Amy Canuso, LCDR, MC USN National Military Sexual Trauma Board Certified Psychiatrist Support Team Child and Adult Psychiatrist, Mental Health Services Walter Reed National Military Department of Veterans Affairs Medical Center Boston, MA Bethesda, MD

Michael R. Bell, MD, MPH Michael Carino, DMD, MPH Commander, US Army Public Health Senior Health Systems Analyst Command Region–North Office of the Surgeon General US Army Surgeon General Consultant Falls Church, VA for Occupational and Environmental Jaime T. Carreno-Ponce, PhD Medicine Psychologist, Department of Medical Fort George G. Meade, MD and Clinical Psychology, USUHS Paul Bliese, PhD Bethesda, MD Chief, Division of Neuropsychiatry Paulette T. Cazares, MD, MPH Walter Reed Army Institute Staff Psychiatrist of Research Naval Medical Center San Diego Silver Spring, MD San Diego, CA

xi xii Contributors

Paula Chapman, PhD M. Shayne Gallaway, PhD Tampa VA Research and Education Senior Epidemiologist Foundation Behavioral & Social Health Outcomes Zephyrhills, FL Program Directorate of Epidemiology & Leslie L. Clark, PhD Disease Surveillance Armed Forces Health US Army Public Health Surveillance Center Command (Provisional) Silver Spring, MD Aberdeen Proving Ground, MD Samantha Crompvoets, BSc Suzanne Garcia, PhD Hons, PhD Associate, Booz Allen Hamilton, Inc. Australian National University McLean, VA Research Fellow ANU College of Medicine, Natara D. Garovoy, PhD, MPH Biology and Environment Women’s Counseling Center, VA Palo Canberra, Australia Alto Health Care System Women’s Mental Health, Mental Robert F. DeFraites, MD, MPH Health Services Associate Professor and Chair (Interim) Department of Veterans Affairs Department of Preventive Medicine and Palo Alto, CA Biometrics F. Edward Hebert School of Medicine Jacqueline Garrick, LCSW-C, BCETS4 Uniformed Services University of the Director, Defense Suicide Prevention Health Sciences Program Bethesda, MD Department of Defense Rosslyn, VA Melissa E. Dichter, MSW, PhD, Core Investigator Brianne George, BSC, United States VA HSR&D Center for Health Equity Air Force, MA Research and Promotion Chief, Psychological Services, Dyess Air Philadelphia, PA Force Base (AFB) Mental Health Clinic, 7th Medical Group Charles Figley, PhD Dyess AFB, TX The Paul Henry Kurzweg, MD Distinguished Chair and Marjan Ghahramanlou-Holloway, PhD Professorship Associate Professor, Department of Tulane University School of Medical and Clinical Psychology Social Work Department of Psychiatry, Uniformed Associate Dean for Research Services University of the Health and Traumatology Institute Director Sciences (USUHS) New Orleans, LA Bethesda, MD Contributors xiii

CDR Heather D. Hellwig, MS, Kate McGraw, PhD PharmD, BCPS Associate Director, Psychological Pharmacy Division Head Health Clinical Care DHCC Captain James A. Lovell Federal Defense Centers of Excellence Health Care Center Department of Defense North Chicago, IL Bethesda, MD

Elizabeth C. Henderson, MD, Anne L. Naclerio, MD, MPH FAPA CIV Chair, Women’s Health Task Force, Certified American Board of Psychiatry Office of the Army Surgeon General and Neurology Deputy Surgeon, US Army Europe Department of Deployment Health Associate Professor, Martin Army Community Hospital Department of Pediatrics Fort Benning, GA Uniformed Services University of the Cara J. Krulewitch, CNM, PhD, Health Sciences (USUHS) FACNM Bethesda, MD Director, Women’s health, Medical Susan Neuhaus, CSC MBBS, PhD, Ethics and Patient Advocacy FRACS, GAICD Department of Defense Associate Professor of Office of the Assistant Secretary of Conflict Medicine Defense (Health Affairs) University of Adelaide Falls Church, VA Former Colonel RAAMC & Appointed Sharon L. Ludwig, MD, MPH, MA member Veterans’ Health and Director of Epidemiology and Advisory Council Analysis South Australia Armed Forces Health Surveillance Remington L. Nevin, MD, MPH Center Johns Hopkins Bloomberg School of Silver Spring, MD Public Health Baltimore, MD Sharon McBride, PhD Research Psychologist David W. Niebuhr, MD, MPH Comprehensive Soldier Fitness Program Department of Preventive Medicine Washington, DC and Biometrics Uniformed Services University of the Susan J. McCutcheon, RN, EdD Health Sciences Mental Health Services Bethesda, MD Department of Veterans Affairs Washington, DC xiv Contributors

Barbara L. Pitts, MSc Brigilda C. Teneza, MD, MPH Uniformed Services University Assistant Director, Epidemiology and Bethesda, MD Analysis Division Armed Forces Health Surveillance Center Beverley Raphael, AM MBBS, MD, Silver Spring, MD FRANZCP, RFCPsych, HonMD Professor Population Mental Health Victoria Tepe, PhD and Disasters Research Portfolio Manager Disaster Response and Resilience The Geneva Foundation Research Group (DRRRG) Tacoma, Washington Medical School at University of Western Jeffrey L. Thomas, PhD Sydney Commander, US Army Medical Elspeth C. Ritchie, MD, MPH Research Unit Professor of Psychiatry Europe Walter Reed Army Institute of Uniformed Services University of the Research Health Sciences Sembach, Germany Bethesda, MD Glenna Tinney, MSW Isabel D. Ross, MD Senior Advisor, Military Advocacy Duke University Medical Center Program Durham, NC Battered Women’s Justice Project Erin Simmons, PhD Minneapolis, MN Battalion Psychologist 1st Marine Special Operations Support Battalion Camp Pendleton, CA Jennifer L. Strauss, PhD Mental Health Services, Department of Veterans Affairs Associate Professor in Psychiatry and Behavioral Sciences Duke University Medical Center Durham, NC Introduction

September 11, 2001, or 9/11, is a day burned into our collective American memory. For members of the US military, it was also the beginning of what has been over 13 years of war. Names have included the “War on Terror,” Operation Enduring Freedom (OEF; Afghanistan), Operation Iraqi Freedom (OIF; Iraq), Operation New Dawn (OND; Iraq), and the “Long War.” This latter term, the “Long War,” encapsulates the repeated deployments into combat zones in Afghanistan and Iraq, as well as the Horn of Africa and to humanitarian assistance operations (Ritchie, 2014a,b). Females have composed about 15% of the United States military for many years. The percentage is slightly lower in the recent combat environment. In Afghanistan females have averaged 8.4% of the military between 2001 and 2013. In Iraq they have averaged at 10.2% between 2003 and 2011 (US Army Medical Command, previously unpublished data) For you could say see Chapter 2 in this volume women, 9/11 and subsequent conflicts also ushered in a steadily increasing role in the US military. No longer mainly nurses, as in the Vietnam War, or primarily in support roles, as in the first Gulf War, female Service members have been in the thick of the conflicts in Iraq and Afghanistan. Technically, only recently have women officially been allowed into the military occupational specialty (MOS) of combat occupations. Combat occupations are typically the “warfighters,” including jobs like infantry, artillery, and engineers. However, it is now widely accepted that women have been in combat since long before 9/11. For example, the deployment to Somalia in 1993 started as a humanitarian assistance operation, and was transformed into a combat mission. More recently, in the “Long War,” numerous roles open to women, which are not technically combat occupations, such as military police and truckers, have been frequently involved in firefights.

xv xvi Introduction

Military women also make up a high proportion of medical personnel. Overall, medical personnel have less exposure to direct combat, but more exposure to the consequences of the casualties of war. These include not just wounded Soldiers and Marines, but enemy combatants and local casualties of bomb blasts and shootings. Many deployed women, especially mothers, anecdotally find working with injured children especially diffficult.

DEFINITIONS

For this book, we need to clarify a few definitions. First of all, the terms “mental health,” “psychological health,” and “behavioral health” are all used in the literature. “Behavioral health” in some settings is commonly used to describe both mental health and substance abuse. The Army currently uses the term “behavioral health,” while the Department of Defense uses “psychological health.” “Mental health,” “psychological health,” and “behavioral health” are used interchangeably in this volume. Another important set of definitions consists of the terms “theater,” “garrison,” “deployment,” and “re-deployment.” “Theater” means the “theater of war,” recently Iraq and Afghanistan. “Garrison” is back on the home base, whether in the United States or Germany or South Korea. “Deployment” can refer to a mission to either the war zone or to a humanitarian assistance mission. “Re-deployment” generally refers to a return to the home base, whether in the United States or to a base in Germany, Japan, or other overseas bases. This volume focuses on deployment to war, but there are many similarities to missions in other austere environments. What does “active duty” or “veteran” mean? Active duty Service members are generally considered to currently be authorized to wear the military uniform. They are in the military services, for example, the Army, Navy, Air Force, and Marines. They may be on active duty, or in the Reserves. There are many types of Reserves, including the National Guard. Most active duty military go on to become Veterans. By “Veterans” we are generally referring to those no longer on active duty. Those in the National Guard and Reserve may go back and forth between active duty and Veteran status. The term “Combat Veteran” may be used for both active duty and Veteran Service members who have served in combat. Although they are often lumped together by the civilian world, the healthcare system in the military (the military healthcare system, or MHS) is very distinct from the healthcare system in the Veterans Administration (the Veterans Health Administration, or VHA). Despite many years of effort to align the systems, they currently each have their own electronic medical record, which has only a limited ability to share information. This subject is covered in more detail in other sources (Ritchie, 2014c). Introduction xvii

These distinctions are important when reviewing the scientific literature. There is a lot of research on the psychological health needs of female Veterans, who have sought treatment in the Veterans Administration (VA). However, there is relatively very little recent data on the psychological health of active duty servicewomen. That available research will be covered in later chapters of this volume.

EMERGING ACTIVITY ON FEMALE SERVICE MEMBERS

Research and data about women in the military have had a relapsing course. After the first Gulf War there were a number of articles focusing on health issues of women deployed there. The main reasons for re-deployment to the United States were abnormal Pap smears gathered before deployment and positive pregnancy screens (Murphy et al., 1997). In the late 1990s there was a considerable amount of research, mainly covered under the loose rubric of the Defense Women’s Health Research Project (https://momrp.amedd.army.mil/dwhrp_index.html; http://www.ncbi.nlm.nih.gov/ pubmed/16313206). Issues such as the prevention of (1) urinary tract infections in the field, (2) unintended pregnancy while deployed, and (3) stress fractures in basic training were highlighted (Albright et al., 2007; Hines, 1993; Knapik et al., 2006; Lowe & Ryan-Wenger, 2003; Ryan-Wenger & Lowe, 2000; Ritchie, 2001). Then 9/11 happened, and the military embarked in the Long War. Much of the energy around women’s issues was subsumed in the need to prepare and go to war. When COL Naclerio went to Afghanistan in 2010, problems with health and hygiene were still paramount (see Chapter 4 in this volume). Recently, partly because of the repeal of the combat exclusion rule (which is covered in more detail in other places in the volume), and partly because the Long War appears to be winding down, there have been a number of activities and publications about women in combat. For example, the American Psychiatric Association has had a military track for the last four years. Female psychiatrists have been featured in the “Women at War” panels. They have related their experiences to a mixed civilian and military audience, including female psychiatrists about to be deployed. These include being a minority (about 10% in theater, as opposed to 15% in garrison) in the deployed environment, and feeling like they are in a fishbowl (Ritchie, 2013, 2014d). Under the leadership of the Uniformed Services University and the Defense Health Activity, a Women in Combat Symposium was held in April 2014. There researchers and clinicians gathered to discuss a host of related issues, including leadership, integration, optimal performance, standards to enter different jobs, and of course health issues. The results of that symposium should appear in a special issue of Military Medicine. xviii Introduction

Psychiatric Annals recently published a special issue on “Psychiatric Issues for Female Soldiers.” Several of the authors in this volume, including Tinney, Holloway, and Ritchie, published condensed versions of the book chapters from this book in that magazine (Ritchie, 2014a, 2014b; Tinney, 2014; Ghahramaniou-Holloway, 2014). Although the special issue had just appeared at the time of writing this volume, the articles have been picked up in a number of forums. So interest has resurged. We hope that this volume will further spur the knowledge of and interest in female Service members.

STATISTICS

The lack of statistics on female Service members is in contrast to the extensive scientific literature on male Service members. For example, the Mental Health Advisory Teams have focused on combat troops, which by past definition are male. The Walter Reed Army Institute of Research (WRAIR) has also concentrated on combat troops. The Millennium Study does include females, but results are just beginning to emerge (Millennium Study, 2014). VA does have data on female Veterans who access their services. However, traditionally only a small number of female Veterans go to VA. These Veterans normally have a higher rate of mental and physical illnesses, and have a lower socioeconomic status. VA studies on women have focused on military sexual assault. While this area is very important, there are many other issues that female Service members deal with. These are often focused on reproductive and genitourinary concerns. This volume will outline them in more detail. There are a few areas where there are data on active duty women, but these are scant. A notable exception, reported here for the first time, is Chapter 1 of this volume, by DeFraites et al., which nicely summarizes a vast quantity of data on deployment-related issues. Chapter 2 by Ritchie at al. outlines the known statistics on post-traumatic stress disorder (PTSD) in female Service members. Chapter 15 on intimate partner violence also has robust statistics. Because of a lack of quantitative data, some other chapters summarize either civilian data or data on male Service members, then move to extrapolate for servicewomen. A few chapters are more anecdotal, describing the experiences of being a female Sailor on ship, or a mother on deployment.

GYNECOLOGICAL ISSUES

Much of the current discussion about women in the military focuses on physical strength. Can she carry a 60 round rucksack? Can she load artillery rounds? In contrast, Introduction xix issues around reproductive and gynecological health are understudied in the recent literature on female Service members. Urinary tract infections are a major issue for women in the field. Much of the concerns that female Service members have are about bathrooms. Is the latrine—maybe used by many other Service members—clean enough to sit on? Women often restrict fluids to avoid going to the filthy or nonexistent bathrooms, and thus get UTIs or become dehydrated (Ryan-Wenger & Lowe, 2000, Ritchie, 2001; Lowe & Ryan-Wenger, 2003). Managing menses in austere conditions is another dilemma. Can I change my tampon while driving on the roads in Iraq? Should I be on oral contraception while deployed, in order to regulate menses? COL Naclerio published a report on findings from Afghanistan in 2011 (Naclerio, Stola, & TregoFlaherty, 2011). Chapters 4 and 5, by Naclerio and Krulewich, respectively, cover these issues in more details.

REPRODUCTIVE CONCERNS

Motherhood is a major issue for female Service members, who are normally in their prime reproductive years, between the ages of 20 and 40. Concerns about pregnancy, being a mother, and breastfeeding are central. If pregnant, a woman may not deploy. The different Services have different regulations as to how long after childbirth she may deploy to theater. Increasingly, breastfeeding is seen as positive. Most bases now have good lactation facilities. But it is very hard to pump breast milk while on trainings to go to war, and obviously impossible once one goes (Bell & Ritchie, 2003). Being a mother and/or wife deploying leads to all kinds of emotional issues, but also personal growth. Chapter 11 in this book by Canuso will flesh out these issues.

CONSENSUAL SEX IN THE WAR ZONE

Although sexual assault has received considerable attention, consensual sex has received much less. A taboo area seems to be the sexual desires of women who deploy. But young women—and most women who deploy are young—do have sexual desires, perhaps heightened by the daily exposure to death and close bonding in the combat zone. The literature is totally devoid on this topic (although replete with accounts of military sexual assault). What about consensual sex in the war zone? By military law it used to be forbidden, but now is permissible if fraternization rules are not broken. When young men and women are deployed together for a year, sex happens. If contraception is scarce, pregnancies also happen. In the worst cases, this results in ectopic pregnancies, resulting in xx Introduction life-threatening emergencies and expensive medical evacuations. In the “best” cases, unexpected pregnancy results in an evacuation from the war zone. Again, in the first Gulf War abnormal Pap results (from tests prior to deployment) and pregnancy were the most common reasons for female Service members to be re-deployed home. Only anecdotal information is available from providers who have served in theater (shorthand for the theater of war). In some clinics, contraception, usually condoms, are freely available. In others, they are not. There are no systematic data on availability of birth control. Another previously forbidden topic is the discussion of homosexual sex among women in the theater of war. Although now the “Don’t Ask, Don’t Tell” ban has been lifted, again there is no literature on the topic. Anecdotally, it also happens, both in garrison and while deployed.

MILITARY SEXUAL ASSAULT

Military sexual assault, on the other hand, is a highly publicized area, which is covered widely in both the scientific literature and the media. Of course, sexual assault is a major issue for both men and women. The number of reported cases has been rising. This may be partially due to better reporting. In the military, as in the civilian world, this is not a simple issue. In the military, many sexual activities are partially consensual, partially coercive. In some cases, sexual activity involves those of unequal ranks. In the garrison setting, often there is alcohol involved. If a case of sexual assault is brought to the criminal justice setting, often it is a “he-said, she said” situation (Ritchie, 1998). Obviously sexual assault leads to a myriad of mental health issues, including guilt, depression, PTSD, and substance abuse. In the small confines of a deployed unit, often everybody in the unit is aware of the situation, which can be incredibly humiliating. In many cases, it also leads to an exit from military service for both parties.

POST-TRAUMATIC STRESS DISORDER AND OTHER MENTAL HEALTH DISORDERS

PTSD is a common consequence of combat. It has been studied widely in military men after Vietnam and during these last 13 years of war. PTSD has also been widely studied in civilian women, especially after sexual assault. Far less is known about combat-related PTSD in military women since 9/11. However, the available statistics show that military women have rates of combat-related PTSD at about the same rate as men (Mental Health Advisory Teams II, Introduction xxi

2004; Joint Mental Health Advisory Teams 7, 2011). What we do not know is whether their PTSD symptoms are similar or different. Symptoms of PTSD under the old DSM-IV and new DSM-5 definitions include hypervigilance, flashbacks, numbing and avoidance, problems with sleep, somatic symptoms, depression, and irritability. For females, the symptoms may be the same as for males, but are compounded by the issues around sexual assault and guilt over leaving over children at home, described earlier. Depression, suicide, and traumatic brain injury are also common sequelae of war, covered in Chapters 13 (by Tepe and Garcia), 14 (by Ghahramanlou-Holloway et al.), and 17 (by McGraw). Substance abuse and homelessness are likewise critically important areas, but we could not find enough research for a chapter.

INFECTIOUS DISEASES

In the past five hundred years, infectious disease has been a major issue for armies in the field. Dysentery and malaria have killed many. However, in the last 20 years the risk from infectious diseases has gone down dramatically. Malaria is still an issue, especially for Special Forces and/or those deployed to Africa and Southeast Asia. Chapter 6 by Dr. Nevin outlines some rarely considered considerations for female Service members.

KILLED AND WOUNDED SERVICE MEMBERS

This volume has several chapters outlining the experiences of women after they have returned from war. They may have physical or psychological injuries. Dr. Henderson discusses psychological needs in Chapter 10, and Jackie Garrick in Chapter 19 explores the needs of wounded Service members. Again there is a weakness of existing data, but we hope to highlight the need for more research. Finding statistics on the killed and wounded broken down by gender is somewhat difficult. Here are a few snapshots of available data. As of January 2013, there were 4,365 males and 110 females killed in action (KIA) in OIF/OND. The numbers are somewhat lower for OEF: 2,122 males and 42 females (CRS). So while the risk of being killed is lower for females, due to less combat exposure, it is still substantial (Ritchie, 2014a). Statistics on wounded female Service members are not as easy to find, partly because of how the definition of wounded is made. The following statistics may be useful. As of February 2014, there were a total of about 50,000 Service members wounded in action (WIA). The vast majority of these are male and in the Army. Approximately 2.5% of Army wounded in action in Iraq are female (Pena-Collazo, 2013). As of March 2013, xxii Introduction there were 813 female Army Soldiers wounded in action, and 34,164 males (DMDC, 2013). The wounded in action numbers do not include other injuries, such as those sustained in training. The data on how injuries affect women are anecdotal, often contained in media accounts, rather than in scientific literature (Cronk, 2014). However, clearly wounded and injured women, such as those with amputations, often must deal with a new body image, new relationships with family members, and a healthcare system geared toward men.

LIMITATIONS OF THE VOLUME

This volume cannot claim to be a complete account of female Service members’ experiences in combat. We sought to gain more of an international perspective, but were not successful in gathering authors. So the experience from Australia is our lone international chapter. Additionally, we also were not successful in finding an author to present on the experience of female gay Service members, which should be an important part of the discussion.

CONCLUSION

Medical and academic volumes rely on scientific evidence, which should lead to evidence-based practice. From that standpoint, this book, Women at War, has been a difficult one to put together. This is chiefly because there has been so little recent comprehensive data on the psychological and physical health of female Service members. Nonetheless, this volume seeks (1) to gather the data that is available, (2) to add anecdotal but universal information, (3) to translate it into actionable information for clinicians, and (4) to make recommendations for future research. Female Service members are a vital part of the nation’s military, and have been heavily deployed beside their male counterparts since the Persian Gulf War in 1980. The events of 9/11 dramatically increased the operational tempo for all of the troops. It is hoped that this article will stimulate more understanding of the experiences of female Service members, women at war, in order to have the experience be a better one. We have tried to direct it toward clinicians caring for female Service members. Important take home messages for clinicians include asking about (1) whether the patient is a Service member or Veteran, (2) the patient’s overall military service, (3) the patient’s experiences in the theater of war; and (4) the positive and negative effects of that service. Introduction xxiii

Throughout, this volume offers implicit and/or explicit commentary on the lack of research data on gender issues in the military. Clearly, more targeted understanding is needed. Elspeth Cameron Ritchie

REFERENCES

Albright, T. S., Gehrich, A. P., Wright, J. Jr, Lettieri, C. F., Dunlow, S. G., & Buller J. L. (2007). Pregnancy during operation Iraqi Freedom/Operation Enduring Freedom. Military Medicine, 172(5), 511–514. Bell, M. R., & Ritchie, E. C. (2003a). Breastfeeding in the military. Part I: Information and resources provided to servicewomen. Military Medicine, 8(10), 807–812. Bell, M. R., Ritchie, E. C. (2003b). Breastfeeding in the military. Part II: Resource and policy considerations. Military Medicine, 8(10), 813–816. Cronk, T. M. Women and the wounds of war. DOD Live website. Retrieved from http://www.dodlive.mil/ index.php/2012/02/women-the-wounds-of-war (accessed February 21, 2014). DMDC statistics, quoted in Fischer, H. (2013, February 5). U.S. Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom and Operation Enduring Freedom. Congressional Research Service. Ghahramaniou-Holloway, M., Tucker, J., Neely, L. L, Carrenno-Ponce, J. T., Ryan, K., Holloway, K., & George, B. (2014). Suicide risk among military women. Psychiatric Annals, 44(4), 189–193. Hines, J. F. (1993). A comparison of clinical diagnoses among male and female soldiers deployed during the Persian Gulf War. Military Medicine, 158, 99–101. Joint Mental Health Advisory Team 7 (J-MHAT 7). (2011). Operation Enduring Freedon 2010, Afghanistan. Office of the Surgeon General United States Army Medical Command, Office of the Command Surgeon General HQ , USCENTCOM, and Office of the Command Surgeon U.S. Forces Afghanistan. Knapik, J. J., Hauret, K. G., & Jones, B. H. (2006). Primary prevention of injuries in initial entry training. In B. DeKoning (Senior Ed.), Recruit medicine: Textbook of military medicine. Washington, DC: Office of The Surgeon General, US Department of the Army and Borden Institute. Lowe, N. K., & Ryan-Wenger, N. (2003). Military women's risk factors for and symptoms of genitourinary infections during deployment, Military Medicine, 168(7), 569–574. Mental Health Advisory Team II (MHAT-II). (2004). Report from Operation Iraqi Freedom II, chartered by the Office of the U.S. Army Surgeon General. Millennium Cohort Study Team. Overview of the Millennium Cohort Study. Retrieved from http://www. millenniumcohort.org/about.php. (accessed February 21, 2014). Murphy, F., Browne, D., Mather, S., Scheele, H., & Hyams, K. C. (1997). Women in the Persian Gulf War: Implications for active duty troops and veterans. Military Medicine, 162(10), 656–660. Naclerio, A., Stola, J., & TregoFlaherty, E. (2011). The concerns of women currently serving in the Afghanistan Theater of Operations: White Paper, Kabul, Afghanistan. Health Service Support Assessment Team, ISAF Joint Command, Afghanistan. Pena-Collazo, S. (2013). Women in combat arms: A study of the global war on terror. Monograph. Command and General Staff College. Ritchie, E. C. (1998). Reactions to rape: A military forensic psychiatrist’s perspective. Military Medicine, 163(8), 505–509. Ritchie, E. C. (2001). Issues for military women in deployment. Military Medicine, 166(12), 1033–1037. Ritchie, E. C. (2014a). An overview of physical and mental issues: Women at war. Psychiatric Annals, 44(4), 182–184. Ritchie, E. C. (2014b). Health issues for female service members in the “Long War.” Psychiatric Annals, 44(4), 179–180. xxiv Introduction

Ritchie, E. C. (2014c). The DoD and VA Health Care System overview. In S. Cozza & M. Goldenberg (Eds.), Clinical manual for the care of military service members, veterans and their families, APPI, February 2014. Ritchie, E., Tuccarione, P., Vento, E. R., Soumoff, A., Martin, S. (2014d, May). Female military psychiatrists at war. Presented at the American Psychiatric Association, New York. Ritchie, E. C., Vento, E., Wolfe, C., Shippy, J., Rumayor, C., Richter, N., Henderson, E. (2013, May). Women at war. American Psychiatric Association Annual Meeting. San Francisco, CA. Ryan-Wenger, N. A., & Lowe, N. K. (2000, November–December). Military women’s perspectives on health care during deployment. Women’s Health Issues, 10(6), 333–343. http://dx.doi.org/10.1016/ S1049-3867(00)00064-5. Tinney, G. (2014). Intimate partner violence and military women. Psychiatric Annals, 44(4), 185–188. PART 1 Background and Introduction

one Comparative Morbidity and Mortality of Women Serving in the US Military During a Decade of Warfare

ROBERT F. DEFRAITES, DAVID W. NIEBUHR, BRIGILDA C. TENEZA, LESLIE L. CLARK, AND SHARON L. LUDWIG

INTRODUCTION

This chapter provides an overview of vital statistics that address health issues of men and women serving in the US military during 10 years of continuous conflict (2002–2011). This period of conflict is divided into two major campaigns: Operation Enduring Freedom (OEF; 2001 to present), which has involved counterterrorism operations in many countries, with the majority of effort focused in Afghanistan and the immediate surroundings; and Operation Iraqi Freedom (OIF; 2003–2010), which overthrew the regime of Saddam Hussein, followed by a prolonged period of stabilization in the aftermath. OIF was succeeded by Operation New Dawn (OND) on September 1, 2010, which ended on December 15, 2011. This overview reflects a public health surveillance perspective, emphasizing major trends and categories of health outcomes and issues. Detailed information on any specific problem is not covered and is beyond the scope of this chapter. Data for this overview were provided by the Defense Manpower Data Center (DMDC; https://www. dmdc.osd.mil) and the Armed Forces Health Surveillance Center (AFHSC; http:// www.afhsc.mil). DMDC’s personnel databases provide military demographic information, including dates of service and rosters of major campaigns and deployments. DMDC

3 4 Women at War maintains the Defense Casualty Analysis System (DCAS; https://www.dmdc.osd. mil/dcas/pages/main.xhtml), which includes summary data on specifically defined war casualties, described as fatalities (hostile and non-hostile) and wounded-in-action from all branches of the US military. Deaths resulting from hostile action are classified as “killed in action” or “died of wounds.” Non-hostile deaths include those determined to have been caused by accident, illness, non-battle injury, homicide, self-inflicted, or undetermined. The primary sources of data in DCAS are the casualty reporting systems of the Services. The AFHSC manages the Defense Medical Surveillance System (DMSS; Rubertone & Brundage, 2002). DMSS is a continually growing longitudinal compen- dium of health- and occupation-related data on persons who have served on active duty in the Army, Navy, Air Force, Marines, and Coast Guard. The database is most complete for the almost 10 million persons who have served in the Armed Forces since 1990 (compared to those who served before that date). The structure of the DMSS is centered on the individual Service member (using demographic data provided by DMDC). As the Service member progresses through her military career, extracts of data on her military recruit training, assignments, occupational specialty, major deployments, promotions, marital status, immunizations, hospital admissions and outpatient visits, and other health and military events are maintained. The individual record opens with data from the military accessions process and closes out with termi- nation of active service through discharge, retirement, or, rarely, death. The strength of the DMSS is its inclusion of data from disparate sources on the force over time, optimized for retrospective cohort analysis. Because it includes information on the entire population at risk, it does not suffer the selection bias of studies using hospital-based patient series for studies of military-related illness and injury. Its weaknesses include the lack of detailed health information on behavioral risk factors such as tobacco and alcohol use, exclusion of Reserve component personnel not mobilized for continual active duty service, and lack of information on Service members after discharge from military service.

WOMEN IN THE US MILITARY BEFORE 2001

Prior to the advent of the all-volunteer armed forces in the 1970s, women’s roles in the US military were limited to occupations and professions such as nursing, and women rarely served in combat-related occupations. With the establishment of the all-volunteer force in the 1970s, women were actively recruited into all branches of the US Armed Forces and were deployed in greater numbers with each subsequent military engagement. 1. Comparative Morbidity and Mortality 5

During Operation Just Cause in Panama in December 1989, 770 women were deployed (Women in Military Service Memorial; http://www.womensmemorial. org/Education/timeline.html [accessed August 5, 2013]). Over the course of the first Persian Gulf War (1990–1991), approximately 41,000 women (7% of the deployed force; GAO, 1993) were deployed. Operation Desert Shield was a tense but mostly combat-free period from August 7, 1990, through January 16, 1991, in which a rapidly deployed blocking force was augmented by much larger ground, sea, and air forces designed for offensive operations. Operation Desert Storm, which began on January 17, 1991, was marked by six weeks of air bombardment campaign, followed by a 100-hour “ground war” on February 24, 1991; it ended with a rapid withdrawal from Iraq. Most participating troops had returned to their home stations by early April 1991. Because the opposing ground forces rapidly collapsed and did not use chemical or biological weapons, combat-related casualties among the US Armed Forces were low (148; 15 were women), in contrast to pre-war estimates as high as 15,000 (Reuters/Los Angeles Times, 1990). Conversely, environmental hazards, extremely hot temperatures, oil well fires, and fear of potential chemical or biological attack were among the numerous “non-battle” health threats of concern during the military campaign. Operations in the 1990s—Operations Restore Hope (Somalia 1992–1993), Uphold Democracy (Haiti 1994–1995), Joint Endeavor (Bosnia 1995), and KFOR (Kosovo 1998)—did not involve intense or sustained combat operations, and large numbers of troops were not deployed to these areas.

CHANGING DEMOGRAPHIC PROFILE OF THE ACTIVE FORCE: FROM THE PERSIAN GULF WAR (1991) TO THE PRESENT

The demographic composition of the active component (not including the Reserve and Guard components) has changed over the intervening years between the Persian Gulf War and the current conflicts (Statistical Information Analysis Division, DMDC). Figure 1.1 shows the total number of women on active duty from 1994 to 2011. In 1990, women comprised 11% of the active component; in 2011, the percentage of women on active duty rose to 14.5%. In 1990, only 5.1% of Service members over 40 years of age were women; in 2011, this proportion had risen to 12.7%. Although the Army had the largest total number of women in 2011 (76,000) compared to other Services, the Air Force had the highest proportion of women compared to its total force (active component) at 19%, while the Marines had the lowest proportion of women at 7%. The racial composition of women in active component differed from that of men: 28% of women Service members in 2011 were African American compared with 6 Women at War

1,800,000

1,600,000

1,400,000

1,200,000 DOD Total (n) 1,000,000 DOD O cers (n) DOD Enlisted (n)

Persons 800,000 DOD Women (n) 600,000 Women O cers

400,000 Women Enlisted (n)

200,000

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Each point represents the number of persons reported to DMDC by the Services to be on active duty in September of each calendar year. In 1994 women comprised 12.4% of the force and 14.5% (16% of the o cers) in 2011. FIGURE 1.1 Officers and enlisted personnel on active duty, DoD, 1994–2011. source: Defense Manpower Data Center.

only 13% of male Service members. Non-white racial minorities comprised 45% of active component women in 2011 compared with only 28% of men. Eleven percent of the US military force deployed in support of major military conflicts in Southwest Asia from 2002 to 2011 were women (223,000 women; see Table 1.1). One-fourth of these women deployed to OEF only; 64% deployed to OIF or OND only; and 11% deployed at least once to both OEF and OIF/OND. Half of the deployed women were under 25 years of age at time of their first deployments, while 30% were over age 29. Fifteen percent were officers, with the remainder in the enlisted ranks. Service members in the US military from 2002 to 2011 served a median of 3¾ years before departure for their first deployments. Those under 25 years of age served a median of 741 days prior to their first deployments to OIF/OND or OEF. Marines served a median of 890 days prior to their first deployments, while members in the combat arms specialties (from all Service branches) deployed earlier in their careers than their counterparts, at 877 days of service (median) prior to their first deployment. Overall, women were deployed after serving about the same number of days of service (1,393 days) as men (1,365 days; AFHSC data, not shown). Women were deployed as frequently and for as long as their male counterparts in their respective branch of Service (Tables 1.2a and 1.2b). TABLE 1.1 Service Members Deploying at Least Once to the Southwest Asia Areas of Operations, US Armed Forces, 2002–2011

Women Men

Counts (%) Counts (%)

Total 223,319 (11.4%) 1,737,251 (88.6%) Component Active 160,975 (72%) 1,250,499 (72%) Reserve/Guard 62,344 (28%) 486,752 (28%) Service Army 122,963 (55%) 936,140 (54%) Navy 28,565 (13%) 205,061 (12%) Air Force 60,676 (27%) 318,008 (18%) Marine Corps 10,794 (4.8%) 274,009 (16%) Coast Guard 321 (0.1%) 4,033 (0.2%) Age <25 110,916 (50%) 855,335 (49%) 25–29 45,868 (20%) 322,212 (19%) 30+ 66,535 (30%) 559,704 (32%) Rank Enlisted 189,810 (85%) 1,513,775 (87%) Officers 33,509 (15%) 223,476 (13%) Operation OEF only 55,422 (25%) 430,750 (25%) OIF/OND only 142,927 (64%) 1,030,442 (59%) OEF & OIF/OND 24,970 (11%) 276,059 (16%)

Population: All Service (Army, Navy, Air Force, Marine Corps, and Coast Guard). All Components (Active, Reserve, and Guard). Time period: January 1, 2002–December 31, 2011. Deployment: defined as >30 days to OEF, OIF, or OND. Data Source: Defense Medical Surveillance System (DMSS), as of 30JUL13.

TABLE 1.2a Average Number of Deployments, January 1, 2002–December 31, 2011, by Service and Gender

Service Men Women

Army 1.5 1.3 Navy 1.4 1.3 Air Force 1.8 1.5 Marines 1.5 1.3 Coast Guard 1.1 1.1 8 Women at War

TABLE 1.2b Median Length (Months) of Deployments per Service Member by Service and Gender

Service Men Women

Army 10.9 10.5 Navy 5.8 5.6 Air Force 4.1 4.2 Marines 6.7 6.6 Coast Guard 7.0 7.2

The deployed women encompassed a wide range of occupational duties (Figure 1.2). The majority of deployed enlisted women were engaged in the fields of functional support and administration (30%); service, transport, and supply (16%); healthcare (9.8%); electrical and mechanical repair (7.9%); and communications and intelligence (6.7%). Key differences in military occupations among women and men were noted in combat-related jobs such as infantry, gun crew, and seamen (4.3% of women, 22% of men,) and functional support and administrative occupations (30% of women vs. 12% of men).

35.0% 30.0% 25.0% 20.0% 15.0% Females 10.0% Males

occupation, by gender 5.0% % Deployed troops in each 0.0%

All Other

Health Care Ocers Health Care Specialists

Tactical Operations Ocers CraftsworkService, and Construction Transport and Supply Infantry, GunElectronic Crew, and Equipment Seaman Repairers Functional Support and Admin. Communications and Intelligence... Other Technical andElectrical/Mechanical Allied Specialists Equip. Repairers FIGURE 1.2 Military occupational categories of Servicemen and Servicewomen deployed to Southwest Asia (OEF/OIF/OND) 2002–2011. 1. Comparative Morbidity and Mortality 9

OIF/OEF HEALTH PROFILE FOR MILITARY WOMEN

Military personnel deployed to Iraq or Afghanistan during this decade of conflict were exposed to a wide variety of health threats. Combat operations involved exposure to small arms munitions, along with shrapnel and blast forces from mortars, bombs, rockets, and improvised explosive devices (IED). Military maneuvers included operation and maintenance of heavy equipment, vehicular traffic, long-distance driving and riding, and operation and maintenance of fixed- and rotary-wing aircraft. Environmental conditions were harsh, including extremes of seasonal temperatures and suspended particulate matter in the ubiquitous dust and smoke. The region harbored a wide variety of infectious disease threats, including leishmaniasis, food- and water-borne infections, and respiratory disease agents. Operational stress was universal, reflecting the uncertainty and risks of prolonged and repeat deployments and their effects on the individual, families, and military units.

Casualties: Killed in Action (KIA), Non-Battle Deaths, and Wounded in Action (WIA)

Tables 1.3a and 1.3b reflect data on US Service members with fatal outcomes or wounded in action over the period of major conflicts. Overall, although women comprised 11.4% of the deployed force, only 2.3% of US military fatalities during these conflicts were women. These figures include 18 women killed as a result of hostile action during OEF and 61 in OIF/OND. Similar to the overall casualty profile, the majority of hostile-action casualties among women (77% in OEF and 82% of OIF/OND) were Soldiers (in the Army). Sixteen of the non-hostile fatalities in OEF and 49 cases from OIF/OND were women. Almost 1,000 women were wounded in action (WIA) during these conflicts (1.9% of the total WIA; DCAS data not shown).

TABLE 1.3a US Military (Men and Women Combined) Casualties, 2002–2011, OEF

Casualty Categories: Hostile (killed in action, died of wounds, etc.) Army Navy Marines Air Force Coast Guard Total Total Hostile Deaths 1,036 69 322 47 0 1,474 Casualty Categories: Non- Hostile (accident, illness/ injury, self-inflicted, etc.) Army Navy Marines Air Force Coast Guard Total Total Non-Hostile Deaths 249 26 60 29 0 364 Army Navy Marines Air Force Coast Guard Total Total Deaths 1,285 95 382 76 0 1,838 Army Navy Marines Air Force Coast Guard Total Total Wounded in Action 12,978 474 4,526 1,317 0 19,295 10 Women at War

TABLE 1.3b US Military (Men and Women Combined) Casualties, 2002–2011, OIF/OND

Casualty Categories: Hostile (killed in action, died of wounds, etc.) Army Navy Marines Air Force Coast Guard Total Total Hostile Deaths 2,535 63 851 29 1 3,479 Casualty Categories: Non- Hostile (accident, illness/ injury, self-inflicted, etc.) Army Navy Marines Air Force Coast Guard Total Total Non-Hostile Deaths 697 39 171 22 0 929 Army Navy Marines Air Force Coast Guard Total Total Deaths 3,232 102 1,022 51 1 4,408 Army Navy Marines Air Force Coast Guard Total Total Wounded in Action 26,608 1,087 9,246 1,627 0 38,568

Data Source: Defense Manpower Data Center.

Healthcare While Deployed

Service members afflicted with non-fatal injuries or illnesses were cared for in a deployed military healthcare system. This system provided several levels of care for the deployed force from basic first aid to definitive surgical intervention. Every military unit or base possessed some basic level of care from first responders such as enlisted medics and corpsman, with a physician or physician assistant located at a nearby aid station. More complex or severe cases were evacuated to surgical units or field hospitals. Healthcare rendered in this deployed healthcare system was recorded in the Theater Medical Data Store (TMDS; Defense Health Information Management System, http://dhims. health.mil/products/theater/tmds.aspx [accessed August 5, 2013]). A comparison of encounters coded in TMDS with those coded in non-deployed military hospitals and clinics was published in the Medical Surveillance Monthly Report (MSMR) (AFHSC, November 2011). In this analysis, in which data from men and women were combined, most of the major categories of conditions (three digit ICD-9 categories) were found to be roughly equally represented in both deployed and non-deployed settings. Some conditions that appeared to be relatively more common in the deployed setting included skin, digestive, infectious, genitourinary, and oral disorders; these were not unexpected in the harsh environmental setting of the major campaigns. Review of records of visits recorded in TMDS from both major combat operations 2002–2011 reveal a total of 3.9 million encounters coded as “disease, non-battle injury,” of which 81% were Soldiers (Army) and slightly over 20% were encounters by women. There were also almost 72,000 encounters coded as “battle injury,” of which 85% were accounted for by the Army and slightly less than 3% occurred among women. 1. Comparative Morbidity and Mortality 11

The TMDS (as well as other electronic health record systems) was not fully distributed to the combat areas for several years after the initial deployments (GAO, 2002), and remained limited to the larger medical treatment facilities at large bases for some time thereafter. Many episodes of care rendered to small combat units at remote outposts were not captured in this system and may account for some of the relative overrepresen- tation of disease and non-battle injury health encounters by women.

Medical Evacuation from the Deployed Environment

Patients with more severe illness or injury that required specialty care or prolonged convalescence were medically evacuated to military medical centers in Europe and the United States. Figure 1.3 shows the relative proportions of major categories of evacuations for men and women in 2002–2011. The top five categories for men and women combined over these years of conflict include battle injuries (17.7% of all medical evacuations), non-battle injuries (including poisoning; 14.9%), disorders of the musculoskeletal system (16.3%), mental disorders (11.6%), and signs, symptoms, and other ill-defined conditions (ICD 780–799; 10%). The first four broad categories are not surprising given the nature of military deployment, combat, and the population of otherwise healthy young adults engaged. Closer examination of the last category reveals a roughly equal contribution of ill-defined disorders from the musculoskeletal, gastrointestinal, and

25.0%

20.0%

15.0% Men Women 10.0%

5.0%

0.0% (001–139) (800–999) related) Neoplasms (140–239) (680–709) (240–279) Breast disorders (610–611) conditions (780–799) relevant V codes) Nervous system (320–389) Digestive system (520–579) Mental disorders (290–319) Circulatory system (390–459) Respiratory system (460–519) Signs, symptoms and ill-deﬁned Infectious and parasitic diseases Non-battle injury and poisoning Genitourinary system (580–629, except breast disorders ) Skin and subcutaneous tissue Congenital anomalies (740–759 ) Hematologic disorders (280–289) Endocrine, nutrition, immunity Musculoskeletal system (710–739) Other (V01-V82, except pregnancy– Pregnancy and childbirth (630–679, Battle injury (from TRAC2ES records)

ICD: International Classiﬁcation of Diseases TRAC2ES: Transportation Command (TRANSCOM) Regulating and Command & Control Evacuation System Bars represent percentage of male (blue) and female (red) patients receiving a diagnosis in the respective category. FIGURE 1.3 Medical evacuations from Southwest Asia (OEF/OIF/OND) 2002–2011, by major diagnostic code (ICD-9-CM) category and gender. 12 Women at War respiratory systems. These “ill-defined conditions” possibly represented provisional or pre-diagnostic codes used during the medical evacuation process, pending full evaluation at medical centers in Europe and the United States. These data also suggest several differences in the relative frequency of medical evacuation diagnoses between men and women. Battle injury was the single largest category of medical evacuation for men, accounting for almost one in every five, followed by musculoskeletal system disorders (16.7%), non-battle injuries (15.7%), and mental disorders (11.2%). Among women, battle injury accounted for only 2.5% of evacuations; the largest category of medical evacuations for women was mental disorders (14.9%), followed by musculoskeletal disorders and ill-defined conditions (13.9% each). These proportions cannot be translated into relative rates since the underlying populations at risk (men and women deployed) over time are not easily defined. The overall proportions shown here also do not reflect changes over time. An analysis of OIF/OND medical evacuation data (AFHSC, 2012) revealed that the proportion of evacuations in each category varied over the course of the eight years of observation; there was a continuous increase in the proportion of mental health medical evacuations (among men and women) over the entire interval and a sharp downward trend in the proportion of battle injury evacuations of men after 2007. The upward trend of mental health evacuations may reflect a combination of the cumulative negative effect of repeated deployments on the deployed force and the increased level of mental healthcare assessment and triage capabilities deployed to the combat zone in the later years of the current conflicts. The major difference in medical evacuation condition between men and women (battle injury) likely reflects the exclusion of women from combat occupational specialties; although women were not spared exposure to combat, their experience as a group may not have been as widespread or as intense as that experienced by their male counterparts.

Health Issues Upon Return From Deployment

Some deployment-related health problems may not manifest themselves until afterward and may be manifested as post-deployment encounters within the military health system (MHS). Tables 1.4a, 1.4b, 1.5a, and 1.5b, display data on encounters in the MHS (including direct and purchased or contracted care) experienced by active component men and women in 2002–2011 within 365 days (one year) of the end of deployment. These data should be interpreted with caution, however. Although these health encounters occurred following a deployment, the conditions they represent should not be interpreted as being exclusively deployment-related or caused by deployment. Some may represent unrelated new conditions, or care provided for conditions that occurred pre-deployment, but was electively deferred until after the deployment for convenience TABLE 1.4a One-Year Post-Deployment Hospitalizations, Active Component Women, 2002–2011

Major Diagnostic Category (ICD-9-CM) Counts Proportion* Rank Mental disorders 2,307 25.5% 1 Injury and poisoning 1,232 13.6% 2 Genitourinary diseases 1,152 12.7% 3 Digestive diseases 841 9.3% 4 Signs and symptoms 611 6.7% 5 Other neoplasms 607 6.7% 6 Musculoskeletal diseases 549 6.1% 7 Infectious and parasitic diseases 346 3.8% 8 Cardiovascular diseases 224 2.5% 9 Oral conditions 171 1.9% 10 Malignant neoplasm 165 1.8% 11 Skin diseases 158 1.7% 12 Respiratory disease 146 1.6% 13 Respiratory infections 100 1.1% 14 Neurologic 93 1.0% 15 Headache 86 0.9% 16

*Proportion of category over all visits, excluding pregnancy, labor, and delivery. Data Source: Defense Medical Surveillance System (DMSS).

TABLE 1.4b One-Year Post-Deployment Hospitalizations, Active Component Men, 2002–2011

Major Diagnostic Category (ICD-9-CM) Counts Proportion* Rank Injury and poisoning 19,191 28.3% 1 Mental disorders 16,911 24.9% 2 Digestive diseases 6,788 10.0% 3 Musculoskeletal diseases 6,133 9.0% 4 Signs and symptoms 4,198 6.2% 5 Cardiovascular diseases 2,462 3.6% 6 Skin diseases 2,177 3.2% 7 Respiratory disease 1,521 2.2% 8 Genitourinary diseases 1,441 2.1% 9 Infectious and parasitic diseases 1,313 1.9% 10 Respiratory infections 1,025 1.5% 11 Neurologic 913 1.3% 12 Malignant neoplasm 859 1.3% 13 Oral conditions 686 1.0% 14 Other neoplasms 447 0.7% 15 Congenital 359 0.5% 16

*Proportion of category over all visits. Data Source: Defense Medical Surveillance System (DMSS). TABLE 1.5a One-year Post-Deployment Ambulatory Visits, Active Component Women, 2002–2011

Major Diagnostic Category (ICD-9-CM) Counts Proportion* Rank

Injury and poisoning 2,09,412 17.0% 1 Mental disorders 1,85,183 15.1% 2 Musculoskeletal diseases 1,82,140 14.8% 3 Signs and symptoms 1,39,617 11.4% 4 Genitourinary diseases 9,4677 7.7% 5 Sense organ diseases 69,969 5.7% 6 Skin diseases 57,023 4.6% 7 Respiratory infections 54,582 4.4% 8 Infectious and parasitic diseases 51,875 4.2% 9 Respiratory disease 39,875 3.2% 10 Digestive diseases 33,700 2.7% 11 Headache 31,991 2.6% 12 Cardiovascular diseases 16,487 1.3% 13 Other neoplasms 15,017 1.2% 14 Neurologic 11,740 1.0% 15 Endocrine 9220 0.8% 16

*Proportion of category over all visits, excluding pregnancy, labor, and delivery. Data Source: Defense Medical Surveillance System (DMSS).

TABLE 1.5b One-Year Post-Deployment Ambulatory Visits, Active Component Men, 2002–2011

Major Diagnostic Category (ICD-9-CM) Counts Proportion* Rank Injury and poisoning 1, 517, 325 23.8% 1 Mental disorders 1,248,067 19.6% 2 Musculoskeletal diseases 9,80,590 15.4% 3 Signs and symptoms 5,99,377 9.4% 4 Sense organ diseases 4,08,580 6.4% 5 Skin diseases 2,44,430 3.8% 6 Respiratory infections 2,22,884 3.5% 7 Digestive diseases 1,75,762 2.8% 8 Infectious and parasitic diseases 1,64,493 2.6% 9 Respiratory disease 1,64,063 2.6% 10 Neurologic 1,25,423 2.0% 11 Cardiovascular diseases 1,21,099 1.9% 12 Genitourinary diseases 1,05,562 1.7% 13 Headache 89,086 1.4% 14 Other neoplasms 53,542 0.8% 15 Metabolic and immune disorders 35,407 0.6% 16

*Proportion of category over all visits. Data Source: Defense Medical Surveillance System (DMSS). 1. Comparative Morbidity and Mortality 15 or the time required for convalescence. Data available for this analysis do not permit full determination as to the likely relationship of the health encounter to the preceding deployment. Reserve component personnel are excluded from this analysis since capture of their medical encounters is limited; thus estimates of their care are likely underestimated.

Post-Deployment Inpatient Care The majority of admissions of active component women in the MHS are for care related to pregnancy, labor, and delivery (DMSS data not shown). To facilitate a comparison of deployed men and women, all admissions classified by ICD-9 codes 630–679 and 760–779 (and associated V codes) were excluded. The remaining admissions were grouped by three-digit ICD categories and were ranked in order of occurrence, with 1 being the most common. With the exclusion of obstetric admissions, men and women were admitted to hospitals for many of the same conditions in the year following return from deployment. For example, approximately one-fourth of all admissions of men and women were coded as mental disorders. Admissions for injury care and mental disorders were the top two categories for both, although mental disorders were the most common in women and injuries in men. However, almost 13% of admissions for women were for genitourinary conditions, as compared with slightly over 2% among men. Increased post-deployment genitourinary health concerns among women have been noted in past conflicts (Murphy et al., 1997) and in OIF/OEF (Klausner et al., 2009).

Post-Deployment Ambulatory Care Tables 1.5a and 1.5b show similar data focused on outpatient care, excluding prenatal visits for women. The top four most frequent categories of encounters (injury, mental disorders, musculoskeletal conditions, and signs and symptoms) were identically ranked in order of occurrence for men and women and together accounted for the majority of visits (accounting for 68% of all encounters for men and 58% for women) in the year following deployment. There were no appreciable gender differences in the patterns of encounters or condition code proportions.

Reproductive Health/Birth Rates The active duty service years coincide with the peak reproductive years in women. Long and frequent deployments and an active military operational tempo may impact childbearing in military families. Figure 1.4 shows the birth rate by age group for women in the active component who deployed at least once compared to their counterparts who did not deploy in 2002–2011. Overall, never-deployed women experienced 16 Women at War

140

120

100

60 1st time deployed Never deployed 40 Birth rate per 1,000 person -years 20

0 <20 20–29 30–39 >40All ages Age Categories

Data Source: Defense Medical Surveillance System (DMSS) as of 11/14/2013. Prepared by Armed Forces Health Surveillance Center (AFHSC) on 11/18/2013

FIGURE 1.4 Birth rate per 1,000 person-years by age among active component US military women 2002–2011, first time deployed compared to never deployed.

about 100 live births per 1,000 women years of service compared to about 70 births per 1,000 women years in the group that deployed. The highest rates were experienced by Service women in their twenties and the lowest by women in their forties in both groups. In 2011, the MSMR (AFHSC, December 2011) reported overall active component birth rates by Service branch and age for the previous decade, finding an overall birth rate of about 100 live births per 1,000 woman service years over the decade, similar to the results reported here. Figure 1.5 shows the birth rates for active component women expressed as a birth rate per 1,000 per calendar year. The women who had deployed experienced much lower birth rates in the first two years, but were similar to the rates in the never-deployed group after 2004, suggesting a delaying effect of deployment upon childbearing for women who first deployed in 2002 and 2003. In both groups the birth rate increased by approximately 5%–10% over the time period.

Traumatic Brain Injury Attributable in part to a relatively common hazard—extreme physical forces generated by explosions, or blasts, delivered by improvised explosive devices (IEDs), suicide bombers, mortars, and so on—traumatic brain injury (TBI) has presented an especially prominent source of morbidity in the recent conflicts (Okie 2005). In response to the burden of war-related TBI on the force, the Department of Defense (DoD) focused particular effort on tracking rates and patterns of TBI. Surveillance 1. Comparative Morbidity and Mortality 17

120

100

60 1st time deployed Never deployed

40 Birth rate per 1,000 person-years

0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year

Data Source: Defense Medical Surveillance System (DMSS) as of 11/14/2013. Prepared by Armed Forces Health Surveillance Center (AFHSC) on 11/18/2013.

FIGURE 1.5 Birth rate per 1,000 person-years by year among active component US military women 2002–2011, first time deployed (birth occurring within 18 months of first completed deployment) compared to never deployed. included employment of unique case definitions using a combination of ICD-9 diagnostic codes (AFHSC case definitions). Through the end of 2012, 33,108 US Service members had been diagnosed with a deployment-related TBI (diagnosed during deployment or within 30 days of returning), 94% of whom were Marines or Army personnel (AFHSC data, not shown). TBI also affected women; 1,663 cases (5% of the total) occurred among deployed women. Not surprisingly, rates of TBI were higher among ground troops (Army and Marines, 295 and 188 injuries per 10,000 person years [p yr], respectively) and among men (males in the Army 312/10,000 p yr vs. 145/10,000 p yr for Army women). As discussed previously for battle injuries, deployed women as a group may have been relatively less at risk for prolonged exposure to combat and, while not spared entirely from experiencing TBI, suffered relatively fewer than their male counterparts.

Mental Health The Armed Forces Health Surveillance Center has published several analyses related to military women’s health and deployment in the last several years. In a 2010 MSMR (Vol. 17, November 2010) analysis of mental health conditions in the US military in 2000–2009, the overall incidence of at least one mental health disorder diagnosis among active component Service members increased by about 60% over the 10 years of observation. The 18 Women at War incidence rates of mental health diagnoses for adjustment, anxiety, depressive, and personality disorders were twofold higher among women, while alcohol and substance abuse disorders were higher in men. The analysis was not limited to persons who deployed. A 2009 MSMR (Vol. 16, February 2009) analysis investigated the relationship between the nature and timing of mental health disorders before and after deploying to Iraq or Afghanistan in 2002–2008. This analysis found that active component Service members identified with PTSD or depression prior to their deployments were three times more likely to have mental disorder–related encounters after their deployments compared to those without mental health diagnoses before deploying. Approximately 14% of women deployers and 5% of male deployers had mental health disorder diagnoses before deployment. After deployment, approximately 28% of women and 21% of men received at least one mental health disorder diagnosis. For Service members with any mental health disorder before deployment, this analysis found that those diagnosed after deployment were more likely to receive the same mental health diagnosis category (such as adjustment disorder, anxiety disorder, substance abuse, PTSD, or depression) as the last encounter before deploying. In another 2009 MSMR study (Vol. 16, October 2009) study, rates of illnesses and injuries among active component women in the two years following return from deployments to OIF or OEF were compared to “expected rates” of illnesses and injuries from three reference groups within the US military. The three cohorts were same women deployers to OEF or OIF at 7–12 months prior to deployment; male Service members returning from OIF or OEF; and women Service members returning from assignment to the Republic of Korea. In general, women who returned from OIF or OEF deployments experienced higher rates of anxiety, depression, and episodic mood disorders than expected based on their pre-deployment experience, their male counterparts in OIF/OEF, and among women returning from assignments to Korea. Similarly, OIF or OEF women Veterans had higher rates of migraine headache and neck/back pain than the referent groups. There are limitations in these analyses. First, all medical conditions discussed in these analyses are from health encounters received from permanent military treatment facilities or purchased care. These medical encounters, along with other health-related information, are archived in the DMSS and are used by the MSMR in their surveillance reports. Healthcare rendered in deployed temporary treatment facilities or provided outside the military health system (such as counseling provided by chaplains) is not captured in DMSS and is not included in the analyses. Second, these analyses were restricted to the active component Service member. Service members in the Reserve or National Guard not on active duty typically receive most of their routine healthcare outside the military health system since they are usually released from active 1. Comparative Morbidity and Mortality 19 service shortly after returning from deployment. Since the majority of relevant health encounters from non-deployed Reservists and Guardsmen are therefore not captured in DMSS, they were not included in the analyses. Further, any Service member who separated from active service during the follow-up period is excluded; therefore, those with more severe injuries and illnesses that preclude continuation of active military service may be discounted in these analyses. Finally, health data in DMSS are dependent on the accuracy of health encounter coding. Medical conditions are classified in accordance with the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM). Health conditions that do not fall within the definitions of specific ICD-9 codes or are inaccurately coded by healthcare providers will receive erroneous codes, resulting in incorrect healthcare data in DMSS. Health-related information in DMSS was collected for administrative purposes and may lack the rigor and depth needed for comprehensive research investigations.

LIMITATIONS

Under-reporting or under-recognition of some medical events that may disproportion- ately affect women, such as those regarding sexual assault, for example, may result in lower rates of events in the data available for this analysis. Data were presented in terms of counts and proportions, which aspire to describe the burden of disease and injury in deployed women compared to men. Many health outcomes discussed here were not expressed in terms of risk or rates. Rates prove to be more difficult to calculate because of the need to determine the population at risk, which was continually changing owing to individual recruitment and attrition from service (and deployment) over the period of observation. Finally, the overall quality of the medical surveillance data is dependent on the accuracy, timeliness, and completeness of coding of electronic health records; thus personnel and health data are at risk for miscoding and under-reporting.

CONCLUSION

The past three decades have shown greater opportunities for women in the US military. The numbers of women who are joining the US Armed Forces are growing with each subsequent decade. As more women are deployed to major military operations and are expanding into combat-related occupations, morbidity and mortality among them are also expected to escalate. As more women join the military, adjustments will be needed in the military health system that augment women-specific health services in order to prepare them for deployment in austere environments and to address their medical needs upon return. 20 Women at War

Additional studies are needed for women-specific deployment-related diseases and injuries focusing on mental health issues and reproductive outcomes. Potential investigations include cohort studies that compare men and women on risk of disease in terms of onset of medical conditions, and healthcare utilization during and after deployment. These investigations would advance the current knowledge on gender-specific disease and injuries in relation to age, race, military occupation, and number and length of deployments.

DISCLAIMER AND ACKNOWLEDGMENTS

The opinions expressed herein are those of the author(s), and do not reflect any official policy or position of the Uniformed Services University of the Health Sciences, the Armed Forces Health Surveillance Center, the Department of Defense (DoD), or its subordinate organizations. The authors acknowledge Celia Byrne, PhD, USUHS, for her generous contributions to the key concepts and structure of this chapter.

REFERENCES

Armed Forces Health Surveillance Center (AFHSC). (2009, February). Relationships between the nature and timing of mental disorders before and after deploying to Iraq/Afghanistan, Active Component, U.S. Armed Forces, 2002–2008. Medical Surveillance Monthly Report (MSMR), 16(2), 2–6. Armed Forces Health Surveillance Center (AFHSC). (2009, October). Health of women after deployment in support of Operation Enduring Freedom/Operation Iraqi Freedom, Active Component, U.S. Armed Forces. Medical Surveillance Monthly Report (MSMR), 16(10), 2–9. Armed Forces Health Surveillance Center (AFHSC). (2010, November). Mental disorders and mental health problems, Active Component, U.S. Armed Forces, January 2000–December 2009. Medical Surveillance Monthly Report (MSMR), 17(11), 6–13. Armed Forces Health Surveillance Center (AFHSC). (2011, November). Brief report: Morbidity burdens attributable to illnesses and injuries in deployed (per Theater Medical Data Store [TMDS]) compared to nondeployed (per Defense Medical Surveillance System [DMSS]) settings, active component, U.S. Armed Forces. Medical Surveillance Monthly Report (MSMR), 18(11), 14–15. Armed Forces Health Surveillance Center (AFHSC). (2011, December). Brief report: Births, active component, U.S. Armed Forces, 2001–2010. Medical Surveillance Monthly Report (MSMR), 18(12), 16–17. Armed Forces Health Surveillance Center (AFHSC). (2012, February). Medical evacuations from Operation Iraqi Freedom/Operation New Dawn, Active and Reserve Components, U.S. Armed Forces, 2003–2011. Medical Surveillance Monthly Report (MSMR), 19(2), 18–21. Armed Forces Health Surveillance Center (AFHSC). Case definitions for data analysis and health reports. Section 13. Neurology. Retrieved from http://www.afhsc.mil/viewDocument?file=CaseDefs/ Web_13_NEUROLOGY_APR12.pdf (accessed September 23, 2013). Defense Casualty Analysis System, Defense Manpower Data Center. Retrieved from https://www. dmdc.osd.mil/dcas/pages/main.xhtml (accessed July 15, 2013). 1. Comparative Morbidity and Mortality 21

Government Accountability Office (GAO). (2002, January 24). VA and Defense health care: Progress made, but DOD continues to face Military Medical Surveillance System challenges (GAO-02-377T). Defense Medical Surveillance System (DMSS). Retrieved from http://www.afhsc.mil/dmss (accessed June 21, 2013). Government Accountability Office (GAO). (1993, July). Women in the military: Deployment in the Persian Gulf War (GAO/NSIAD-93-93). Klausner, A. P., Ibanez, D., King, A. B., Willis, D., Herrick, B., Wolfe, L., & Grob, B. M. (2009, December). The influence of psychiatric comorbidities and sexual trauma on lower urinary tract symptoms in female veterans. Journal of Urology, 182, 2785–2790. Murphy, F., Browne, D., Mather, S., Scheele, H., & Hyams, K. C. (1997, October). Women in the Persian Gulf War: Implications for active duty troops and veterans. Military Medicine, 162(10), 656–660. Okie, Susan. (2005, May 19). Traumatic brain injury in the war zone. New England Journal of Medicine, 352, 2043–2047. Reuters News Service (cited by the Los Angeles Times). (1990, September 5). Potential war casualties put at 100,000: Gulf crisis: Fewer US troops would be killed or wounded than Iraqi soldiers, military experts predict. Rubertone, M. V., & Brundage, J. F. (2002). The defense medical surveillance system and the Department of Defense serum repository: Glimpses of the future of public health surveillance. American Journal of Public Health, 92(12), 1900–1904. Statistical Information Analysis Division, Defense Manpower Data Center. https://www.dmdc.osd.mil (accessed 15 July 15, 2013). two Female Soldiers and Post-Traumatic Stress Disorder

ELSPETH C. RITCHIE, MICHAEL R. BELL, M. SHAYNE GALLAWAY, MICHAEL CARINO, JEFFREY L. THOMAS, PAUL BLIESE, AND SHARON MCBRIDE

INTRODUCTION

Approximately 2.6 million service members have deployed in support of Operation Enduring Freedom (OEF) in Afghanistan or Operation Iraqi Freedom (OIF) between 2001 and 2013. Of the deployed Soldiers, approximately 10% have been female. This chapter will focus on female Soldiers, since that is the data we have available to these authors. The other Services (Navy, Marines, and Air Force) have also deployed many women, but that deployment data is not currently available. Female Soldiers served in Vietnam and in a wide variety of roles during Desert Storm. However, compared to Iraq and Afghanistan, few female Soldiers saw significant or prolonged conflict. US Army Soldiers are officially designated as combat, combat support, or combat service support. In the Army, combat troops by law were male. These include military occupational specialties such as infantry, armor, and artillery. Combat support and combat service support troops include women. These troops include military police, signal, logistics, and medical units. Overall, currently approximately 15% of the US Army is female. The current conflicts are insurgencies without clear frontlines. Forward operating bases (FOBs) come under frequent attack by mortars and small arms. Moving from one base to another exposes individuals to risk from improvised explosive devices (IEDs) and gunfire. Thus, although technically not combat troops, most women deployed to Afghanistan or Iraq have seen combat, severe trauma, or both.

22 2. Female Soldiers and PTSD 23

There are a number of current data sources that shed light on the prevalence and incidence of post-traumatic stress disorder (PTSD) in female Soldiers. This chapter seeks to summarize those data and offer some insight on PTSD in the female Soldier today. The information is drawn from a variety of US Army data sources, but it is inter- nally very consistent. Behavioral health responses to war are clearly much broader than PTSD; they include other post-traumatic symptoms, depression, anxiety, and substance abuse, as well as positive growth. However, the PTSD data are the most clearly defined and will be used in this discussion, with other relevant mental health data introduced as needed. This chapter is not as comprehensive as we would like. It is based on available data collected for other purposes, such as evacuation from theater. However, it does present the most robust existing data that are available, and offers some insight and recommendations for future research.

BRIEF REVIEW OF THE LITERATURE

There has been little recently published research on PTSD in female Soldiers who participated in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). While there is a very extensive literature on PTSD in female civilians and Veterans, almost none focuses on female Soldiers who are still on active duty. This void exists despite a robust body of literature examining the overall effects of the wars in Afghanistan and Iraq on mental health (Hoge et al., 2005; LeardMann et al., 2009; Seal et al., 2007; Smith et al., 2008; Kessler et al., 1995; Kessler et al., 2005). In general, this latter literature either focuses on males only, or does not break out differences by gender. One prominent data source is the Millennium Cohort study team, which has reported findings for new onset self-reported symptoms or diagnosis of PTSD, and after adjusting for several factors, including occupation, determined that female Soldiers who had deployed to combat had significantly higher odds of having PTSD as compared with their male counterparts (LeardMann et al., 2009). Their findings differ from the findings in this chapter; possible reasons are discussed below. Unquestionably, there is an ample body of literature on PTSD in females. The National Comorbidity Survey has estimated that the lifetime prevalence of PTSD among adult Americans is 7.8%. Specifically, women (10.4%) are twice as likely as men (5%) to have PTSD at some point in their lives (Kessler et al., 1995). There is also a more recent study by Kessler et al. using DSM-IV criteria, which found a lifetime prevalence of 6.8% (9.7% for women, 3.6% for men) (Kessler et al., 2005). However, in general, in 24 Women at War the existing literature that focuses on PTSD in civilians, the index stressors for females are mainly sexual assault, rather than combat. Published relevant Veterans Affairs (VA) data are drawn from a VA clinical patient population, for example female Veterans who seek services in VA. A brief summary follows. Fontana and Rosenheck (1998) applied structural equation modeling to data from 327 women in a VA clinical program for PTSD. The model was chronological and broke down a woman’s life into four periods: pre-military, military, post-military, and present. The sample was predominantly composed of women who served from the end of the Korean War through the Persian Gulf War. Fifty percent of the women served in the Army. He found that both duty-related stress and sexual stress contributed significantly to PTSD, but sexual stress was more influential. Post-military social support was a highly significant effect modifier between sexual stress during military service and development of PTSD. Murdoch and Nichol (1995) conducted an anonymous survey of 191 women hospitalized from March 1992 to 1993 at the Minneapolis VA and 411 randomly selected outpatients in order to examine the impact of domestic violence and sexual harassment while in the military on mental and physical health. They found that women with a history of domestic violence in the past year or sexual harassment while in the military were more than twice as likely to report a history of anxiety or depression. Women with a history of domestic violence also had slightly increased odds of having had surgical procedures. Women who were under 50 (i.e., Vietnam era Veterans) were much more likely to report a history of domestic violence and/or sexual harassment while in the military. (Of note, deployment to a combat theater was not a predictor variable in this study, and PTSD was not an outcome variable.) Hankin et al. (1999) examined the self-reported prevalence of sexual assault experienced during military service and its association with current symptoms of depression and alcohol in a national sample of 3,632 female VA outpatients. They found that 23% of their sample reported sexual assault during their military service. Of note, the question did not specify that the sexual assault involved another service member. Among those who reported sexual assault, symptoms of current depression were three times higher, and symptoms of current alcohol abuse were two times higher. (The same comment about lack of assessment of combat deployment and PTSD applies to this study as well.) Wolfe et al. (1998) surveyed 160 women who deployed to the Persian Gulf War from Fort Devens, Massachusetts, to determine the rates and consequences of sexual harassment and assault among women in a wartime sample. She found higher proportions of sexual assault (7.3%), physical sexual harassment (33.1%), and verbal sexual 2. Female Soldiers and PTSD 25 harassment (66.2%) than are usually found in civilian and peacetime military samples. The data suggested a clear relationship between incident severity and psychological outcome. While combat was also associated with PTSD, the data illustrated a greater contribution from sexual assault and an almost equal contribution from sexual harassment. The authors noted that this may have been confounded by the relatively low intensity of combat in the Persian Gulf War. Kang and his colleagues (2005) analyzed the role of sexual assault on the risk of PTSD among Gulf War Veterans. They found that for both men and women, sexual trauma as well as combat exposure appeared to be strong risk factors for PTSD. Dobie et al. (2004) investigated whether women who screened positive for PTSD were more likely to have associated self-reported health problems and functional impairment. They mailed a survey to all women (N = 1935) who received care at VA Puget Sound Health Care System between October 1996 and January 1998. They found that 21% of the 1,259 eligible women who completed the survey screened positive for current PTSD. Having current symptoms of PTSD was associated with other self-reported mental and physical health problems and poor health-related quality of life. (The same comment about lack of assessment of combat deployment applies to this study as well.) Seal et al. (2007) studied the burden and clinical circumstances of mental health diagnoses of 103,788 OEF/OIF seen at VA healthcare facilities. Twenty-five percent had received mental health diagnoses; of those with mental health diagnoses, 56% had two or more distinct diagnoses. The median time to diagnosis was 13 days after the first VA visit, and most (about 60%) were made in primary care settings. The youngest Veterans (age 18–24) were at greatest risk for receiving mental health or PTSD diagnoses. Overall, males were slightly less likely than females to have one or more mental health diagnoses (RR 0.94, 95% confidence interval [CI]: 0.91–0.97), but slightly more likely to have a diagnosis of PTSD (1.14, 95% CI: 1.08–1.10). In past studies, Veterans in the clinical population have tended to be from a lower socioeconomic status, were less likely to be employed, and had more mental health and physical health problems compared to female Veterans who do not seek services. Thus, they are only a subset of the total female Soldier/Veteran population. In addition, in these studies of female Veterans, the source of their stressors is more often sexual assault than combat. In the most directly comparable and relevant study identified, Smith et al. and the Millennium Cohort Team (2008) were able to assess, at two points in time, self-reported symptoms of PTSD using the PCL-17 C checklist and self-report of a diagnosis of PTSD within the past three years. They evaluated self-reported symptoms of PTSD using two case definitions. One was designed to optimize sensitivity, and the other 26 Women at War optimized specificity. Logistic regression results for new onset self-reported symptoms (based on the more specific case definition) or diagnosis of PTSD were provided. After analyses were adjusted for baseline characteristics such as demographics and occupation, among others, they found a significantly higher percentage of new onset PTSD among female Soldiers (4.9%) as compared with male Soldiers (3.6%), resulting in an adjusted odds ratios of 1.7 (95% CI: 1.44–2.00). The odds ratios were similar for Air Force, Navy, Marine, and Coast Guard cohorts in the study. In a related study, LeardMann et al. (2009) reported similar, but even higher, odds of new onset PTSD among combat deployed females from all branches of service (OR 2.26, 95% CI: 1.72–2.98). They made a strong case that the strongest predictor of new onset PTSD after deployment is pre-deployment mental and physical health, not combat, gender, or sexual assault.

FINDINGS BASED ON EXISTING DATA

The Army collects a variety of data related to behavioral health. The data to be discussed in this chapter include (1) self-report anonymous surveys completed during and combat deployments that were administered by the Mental Health Advisory Teams (MHATs); (2) Post-Deployment Health Assessment (PDHA) and Re-Assessment (PDHRA) screening data; (3) other clinical data collected for all medical encounters; (4) evacuations from theater for behavioral health reasons; and (5) self-report surveys by medical personnel. The data sources will be described briefly, and then a more thorough description of the results will follow. None of these data in themselves provides a complete picture; however, taken together, they complement each other. In general, we will discuss the US Army populations between 2001 and 2009. However, it is important to note that different data sets were collected at different start dates. Officially, September 11, 2001, was the start date for some combat activities. From 2001 to 2003, the primary conflict was in Afghanistan. For some sources, data are only available since 2003, which includes the invasion of Iraq. However, few women were deployed to Afghanistan and/or other hazardous duties areas until 2003. Thus the number of female Soldiers who were potentially exposed to combat between 2001 and 2003 was small. The US Army has regularly deployed Mental Health Advisory Teams (MHATs) into Iraq and Afghanistan to collect behavioral health data using anonymous self-report surveys. There has been an annual survey in Iraq since 2003 and every other year in Afghanistan since 2005. These reports are published on the Web and are publicly available. These teams have primarily focused on Brigade Combat Teams (approximately 2. Female Soldiers and PTSD 27

2,000–4,000 Soldiers), which are combat troops, and therefore male. However, two of the MHATs (MHATs II and VI) have included enough females to provide very useful data (MHAT II, 2005). The Post-Deployment Health Assessment (PDHA) was fielded in 1998 as a result of unanswered questions about exposures to toxins in the first Gulf War. It is a clinical assessment done upon return from deployment to Iraq or Afghanistan. The Soldiers fill out a survey and then are evaluated by a primary care clinician. If needed, the Soldier is referred to behavioral health. The Post Deployment Health Re-Assessment (PDHRA) is a program developed in 2004, mandated by the Assistant Secretary for Health Affairs in March 2005, and designed to identify and address health concerns, with specific emphasis on mental health, that have emerged over time since deployment. The PDHRA is completed during the three- to six-month time period following return from deployment. The PDHA and PDHRA data are stored and managed by the Armed Forces Health Surveillance Center and other Department of Defense (DoD) systems. All of the DoD Services (Army, Navy/Marines, Air Force) now use an electronic medical record, which makes it relatively simple to search for encounters assigned ICD-9 codes noting the primary and secondary reasons for the encounter. The data on diagnoses of PTSD are based on encounters assigned an ICD-9 code (309.81) for PTSD. Diagnoses include Soldiers with diagnosed PTSD who receive treatment either on a military installation (direct care) or at a facility within the purchased care system. The number of Soldiers with a diagnosis of PTSD has risen steadily since 2001, as the wars have progressed, and extensive efforts have been made to screen for PTSD and other psychological problems, to reduce stigma, and to increase access to behavioral health care. All Services collect very specific data on medical evacuations from theater, including Iraq and Afghanistan, and can break it out by specific causes, including behavioral health and medical reasons.

MENTAL HEALTH ADVISORY TEAM DATA

The Mental Health Advisory Team (MHAT) gathers data using anonymous self-report surveys. There has been an annual survey in Iraq since 2003 and every other year in Afghanistan since 2005. Six reports (I–VI) were completed and released between 2003 and 2009. (When Iraq and Afghanistan were surveyed in the same year, the data were released in a single report.) 28 Women at War

TABLE 2.1 Gender Analysis from Support/Sustainment Sample (MHAT VI OEF), n = 605 Males, n = 117 females

No significant differences were found between males and females screening positive on the key psychological outcomes.

Males Females % % Any psychological problem 14.9 15.1 Acute stress 13.3 14.0 Depression 5.0 3.5 Anxiety 5.0 3.5 Suicidal ideation 10.6 11.1

In general, the MHAT surveys have focused on samples from Brigade Combat Teams, which are combat troops and therefore male. However, in two surveys, 2004 and 2009, enough data were collected on women to make reasonable gender comparisons on many of the metrics. When making these comparisons, it is important to note that in general women have less exposure to combat than men. Nevertheless, this does not negate the many traumatic events they have experienced, especially in caring for wounded American and Iraqi patients. During Operation Iraqi Freedom (OIF) in 2004, MHAT II surveys were collected from a total of 2,045 Soldiers deployed to Iraq and Kuwait. Of these, 1,757 were collected from male Soldiers and 288 were collected from female Soldiers. The overall percentage of Soldiers meeting the criteria for PTSD using the DSM-IV and PCL 50+ criteria (e.g., Hoge et al., 2005) was 10% for males and 11% for females. The percentage of reported symptoms for any mental health problem, as defined by PTSD, depression, and/or anxiety, was 13% for men and 12% for women. None of the above gender differences was statistically significant (Mental Health Assessment Team VI, 2009). In 2009, during Operation Enduring Freedom (OEF) in Afghanistan, the MHAT VI team conducted a sub-analysis that separated out maneuver from support and sustainment troops (see Table 2.1). In most cases, while deployed, female Soldiers work in support and sustainment units as opposed to maneuver units. Thus, a pure support and sustainment sample allows for better comparisons of female and male Soldiers because they are more likely to have been exposed to an equivalent amount of combat. In total, MHAT VI OEF surveyed 722 Soldiers (605 male and 117 female) from support and sustainment units. After controlling for level of combat exposure, rank, and time in theater, no significant differences were found between male and female Soldiers pertaining to PTSD, depression, anxiety, or a composite measure using the three screening criteria (MHAT VI). 2. Female Soldiers and PTSD 29

PTSD COMPARISON BETWEEN MALES AND FEMALES ON POST-DEPLOYMENT SURVEYS

An overall assessment of PTSD among US Army Soldiers was recently conducted by the US Army Public Health Command (Provisional), using data requested from the Defense Manpower Data Center (DMDC) and the Armed Forces Health Surveillance Center (AFHSC). Data included the deployment end states of Soldiers who deployed between 2003 and 2008, as well as self-reported PTSD screening on PDHA/PDHRA and physician-diagnosed rates of PTSD. As discussed, the PDHA is completed in conjunction with return from a deployment, and the PDHRA is completed during the three to six-month time period after return from deployment. The PDHA, which grew out of the first Gulf War, was first implemented in 1998. The PDHRA was developed in recognition that many Soldiers may deny all difficulties as they return, but might endorse them after the “honeymoon period” is over. It was initially deployed beginning in late 2004 and was fully deployed in 2005. Soldiers who completed the Post-Deployment Health Re-Assessment (PDHRA) were screened for PTSD using the following four-question tool:

Have you ever had any experience that was so frightening, horrible, or upsetting that, IN THE PAST MONTH YOU… a. Have had nightmares about it or thought about it when you did not want to? b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it? c. Were constantly on guard, watchful, or easily startled? d. Felt numb or detached from others, activities, or your surroundings?

TABLE 2.2 Number of Soldiers (US Army, All Components) Deployed (Sept 2001–Sept 2009) and Percent Diagnosed with Post-Traumatic Stress Disorder (PTSD)*

Ever Deployed** PTSD Diagnosis among Previously Deployed

n N % p-value

Male 887,180 34,822 3.9 <0.05 Female 112,891 3,407 3.0

*PTSD case defined as either two outpatient encounters on different days with ICD-9 diagnostic code (any position) of 309.81; or patient encounter with ICD-9 diagnostic code (any position) of 209.81. Incidence rate is earliest encounter with diagnosis of PTSD. **Deployment to OEF/OIF lasting longer than 30 days, beginning prior to incident PTSD diagnosis. Data Sources: Armed Forces Health Surveillance Center: Defense Medical Surveillance System, as of 08OCT2009 and Defense Manpower Data System: Contingency Tracking System, as of 31SEPT2009. 30 Women at War

Soldiers were considered to have screened positive for risk of PTSD if they self-reported two or more affirmative responses to the above questions. The prevalence of female Soldiers screening positive for PTSD on the PDHRA (range: 13%–24%) was similar to that of male Soldiers (range: 13%–23%). These numbers are based on provider diagnoses reflected in the healthcare utilization data, not the PDHA/PDHRA.

PTSD DIAGNOSES IN THE MEDICAL CARE SYSTEM

The US Army records diagnoses on patients who are seen in the direct care system as well as the purchased care system (TRICARE). Soldiers were considered to have been diagnosed with PTSD by a provider if they were assigned an ICD-9 (309.81) during two consecutive outpatient or one single inpatient medical encounter within six months of returning from deployment. From 2001 to 2013, 9.8% of the total number of troops deployed to OEF or OIF have been female. Of Soldiers deployed at least once to OIF or OEF, 8,508 female (5.06%) and 79,584 male (6.9%) Soldiers have been diagnosed with PTSD. Thus the percentage of male and female Soldiers diagnosed with PTSD who had previously been deployed to combat zones are similar, but are significantly different (p < 0.05) as a product of the tremendous power associated with the large numbers involved in the calculation of significance testing (previously unpublished data, US Army Medical Command).

BEHAVIORAL HEALTH EVACUATIONS

The U.S. Army closely tracks medical evacuations out of theater (US Transportation Regulating and Command and Control Evacuation System (TRAC2ES), including those for behavioral health (BH) reasons. Behavioral health evacuations primarily include those cases involving a severe mental health diagnosis or danger of harm to self or others, including persistent suicidal ideation. Between 2003 and 2013 the U.S. Army evacuated 8,002 Soldiers out of theater (OIF and OEF) for behavioral health reasons, including PTSD. Of these evacuations, 6,748 (85%) were male (92%) and 1,232 (15%) were female. The breakdown by gender for PTSD as the main reason for evacuation was 857 male (91%) and 85 female (9%) evacuees. This data shows that PTSD is a relatively uncommon reason for evacuation (previously unpublished data, US Amy Medical Command).

DISCUSSION

From existing available data, there appear to be minimal differences between male and female US Army Soldiers presenting and or screening positive for PTSD. 2. Female Soldiers and PTSD 31

Obviously, this in marked contrast to civilian data (Kessler et al., 2005). As noted above, studies of PTSD within female civilian or Veteran populations typically assess outcomes as a result of sexual assault and harassment. Whereas the types of exposures leading to PTSD within female Soldiers since 9/11 may be more likely to occur as a result of deployment and/or combat-related experiences. It is unclear why the results of the Millenium Cohort study differ from those reported here. It may be a result of the population including both previously deployed and non-deployed personnel. The Millennium Cohort study design also purposely oversampled female, previously deployed, and Reserve/National Guard personnel. Thus it may not be representative of the military population in general or of all deployers. Finally, there may also be some non-response bias among those who did not complete the survey at both baseline and follow-up (nearly three years), or among personnel who failed to consent to taking part in the survey at the start. In their study, LeardMann et al. (2009) discuss why poor prior mental and physical health is the strongest predictor of new onset PTSD. An acknowledged weakness of the instruments specific to this chapter are their lack of ability to discern details of deployment experience. It might be assumed that a larger percentage of males responding to the survey were exposed to combat-related trauma than female Soldiers. This assumption is based on the Army personnel assignment policy at the time the data was gathered, which restricted female from being assigned to direct combat units. Another limitation of this study, is the lack of ability to assess or correlate findings with pre-existing PTSD. The main intent of this chapter is to describe the existing data. Inevitably, the next question is, why does this confluence of recent data show different trends than in the past? The following hypotheses have been offered, but cannot currently be proved or disproved from the information available: (1) overall there is less exposure to combat among women than men, because they are not in combat arms, which leads to less PTSD; (2) female Soldiers overall form an especially hardy or resilient population; (3) the updated standardized Army training prepares all Soldiers equally for combat exposure; and (4) combat exposure is a very different exposure from exposure to sexual assault.

CONCLUSION

There are many questions this chapter cannot answer. This discussion is not able to offer any information relevant to the different presentations of PTSD in males and females, or optimal treatment strategies for the different genders. It does not distinguish between healthy and physically wounded or ill Soldiers. It cannot distinguish 32 Women at War the different stressors leading to either PTSD or other behavioral health symptoms. There are some limitations associated with the data sources utilized, including the fact that some of them were not expressly collected for the purposes of research or surveillance, but for clinical purposes. All data sources also are not capable of discerning objectively combat exposure or intensity of combat experiences, and thus there may be differential bias between males and females. Despite these limitations, this chapter adds substantial data about PTSD in female Soldiers in the US Army. Again, the data presented contrast with the data on the different populations in the civilian sector. We hope that it will stimulate other efforts to answer the hypotheses and questions posed above.

REFERENCES

Clark, J. C., Eaton, K. M., Castro, C. A., & Hoge, C. W. (2010). Combat Exposure and mental health during deployment: Does gender matter? Poster session presented at the annual meeting of the American Psychological Association, New Orleans, LA. Dobie, D. J., Kivlahan, D. R., Maynard, C., & Bush, K. R. (2004). Post traumatic stress disorder in female veterans: Association with self-reported health problems and functional impairment. Archives of Internal Medicine, 164, 394–400. Fontana, A., & Rosenheck, R. (1998, May). Focus on women: Duty-related and sexual stress in the etiol- ogy of PTSD among women veterans who seek treatment. Psychiatric Services, 49, 658–662. Hankin, S. S., Skinner, K. M., Sullivan, L. M., et al. (1999). Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military. Journal of Traumatic Stress, 12, 601–612. Hoge, C.W., Castro, C. A., Messer, S. C., McGurk, D, et al. (2005). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13–22. Kang, H., 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, 191–195. Kessler, R. C., Bergland, P., Demler, O., Jin, R.,& Walters, E. E. (2005). Lifetime prevalence and age of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602. Kessler, R. C., Sonnega, A., Bromet, H. M., & Nelson, C. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048–1060. LeardMann, C. A., Smith, T. C., Smith, B., Wells, T. S., Ryan, M. A. K., et al. (2009). Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: Prospective US military cohort study. British Medical Journal, 338, b1273–b1273. Mental Health Assessment Team II (2005). Retrieved from http://armymedicine.mil/Pages/Mental- Health-Advisory-Team-II-Information.aspx. Accessed on Nov3 2014 Mental Health Assessment Team VI (2009). Retrieved from http://www.armymedicine.army.mil/ tools/search/searchresults.cfm?col=armymed&q=mental+health+advisory+teams&start=1& num=10. Murdoch, M., & Nichol, K. L. (1995, May). Women veteran’s experience with domestic violence and with sexual harassment while in the military. Archives of Family Medicine, 4, 411–418. Seal, K. H., Bertenthal, D., Miner, C.R., Sen, S., & Marmar, C. (2007). Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167, 476–482. 2. Female Soldiers and PTSD 33

Smith, T. C., Ryan, M. A. K., Wingard, D. L., Slymen, D. J., Sallis, J. F., & Kritz-Silverstein, D. for the Millenium Cohort Team. (2008). New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: A prospective population based US military cohort study. British Medical Journal, 336(7640), 366–371. Wolfe, J., Sharkansky, E. J., Read, J. P., Dawson, R., Martin, J. A., & Ouimette, P. C. (1998). Sexual harassment and assault as predictors of PTSD symptomatology among U.S. female Persian Gulf War military personnel. Journal of Interpersonal Violence, 13, 40–57. three Women and War: Australia

BEVERLEY RAPHAEL, SUSAN NEUHAUS, AND SAMANTHA CROMPVOETS

INTRODUCTION

Australian women, like all others, have had a long association with war: as the victims of conflict themselves; as the wives and lovers of men; as mothers, grand- mothers, daughters, and aunts. These women may have been directly or indirectly involved—directly if the conflict took place where they were, or they were defending and fighting themselves to protect children, family, home. They may have served in caring and support roles, particularly as nurses, or they may have been involved in other aspects of caring for men who were wounded, angry, afraid, helpless, or dying. Australian women have participated in past as well as recent wars in these and other active roles. Their roles have progressively increased, taking them to the “front lines” of the new forms of warfare, where they participate in fields of action alongside men. These more direct roles for women have resulted from many aspects of social change, including moves to greater gender equity and the rights of women to participate in all such fields. There are several issues that emerge when considering “women at war” in this Australian context, with the focus on military operations including Vietnam, Middle East Operations, peacekeeping, Afghanistan, and present military engagements. There are important gains, as well as significant challenges. This chapter will examine a series of themes in this Australian context: the gender equity domain and its significance and development; the experiences of women in terms of their health and well-being; the evolution and success of women’s diverse contributions and ongoing challenges; and women in leadership.

34 3. Women at War in Australia 35

GENDER EQUITY

As noted in a recent review, closing the global gender gap involves levels of economic participation, education attainment, health and survival, and political empowerment—all goals that are critical but not easy to attain (Abuelaish, 2013). Deep cultural beliefs and expectations may lead to a resistance to change. Gender-related cultural issues have been very relevant in Australia, as elsewhere. War has been “men’s business,” and men have viewed this role as facing battle, fighting for their country with other men and against identified enemy men, and protecting women from the horrors, violence, death, terror, and destruction of war. The “protection” of women has been described in other cultural domains. Women’s contributions have been in support roles, particularly those of nursing and healthcare, and these “caregiver” roles have also been a core component of the Australian culture of gender and “women’s place” more broadly. Men and women have valued these roles. It could be that these roles defined men’s and women’s “places” in the world of war, as in life more broadly, and were viewed with a simplicity and clarity that was familiar and reassuring. “Equity” has been assumed to be the sameness of roles, which is not necessarily equality (Raphael, 1974). The move to greater equity has led to recognition of its rather greater complexity, challenging interpretation and adaptation for both women and men. For men, the cohesion and mateship of mutual support, shared experience, and looking after one another have also represented broader Australian cultural values. “Mateship,” or camaraderie, among men is a powerful component of identity, community, strength, and maleness. Women’s place at the “home front,” caring for children and family, has also been a strong cultural identity. The acceptability of the role of nursing was separate; military nursing was seen as a woman’s role particularly, but also one where bravery, being close to conflict, was recognized and valued. Men and women found that these roles synchro- nized with their beliefs and experience of the broader Australian culture of those times. It should be noted, however, that the exception of women “not being directly involved in combat activities” or direct offensive action against the enemy was not always fulfilled. Women in the Special Operations Executive (SOE)—for instance Nancy Wake, the Australian agent—fulfilled this role with courage and exceptional achievements. Women who were prisoners of war showed similar courage and achievement in the face of the enemy. The progress of equity goals, through the “women’s movements” to the present day, has brought for some women greater levels of equity in education, employment, political achievement, and health. However, economic achievement, in terms of women’s pay equity, is still lagging behind, and women’s achievement in executive or supervisory roles, in business and politics, is often sorely challenged. 36 Women at War

Women’s roles in the Australian Defence Forces (ADF) have, on the whole, progressed positively, but resistance and difficulties still remain. These link closely to issues in many areas of Australian culture, as well as in organizational cultures, at least covertly. Such themes have been highlighted in a number of widely publicized incidents of “unacceptable behaviors” of men toward women in the ADF. These are also, to some degree, present in other organizations and domains, not only in terms of men’s behavior toward women, but also, at times, women’s expectations and “acceptance” of such diminished status. Domestic violence, sexual harassment, and assault are part of this spectrum in Australia, as elsewhere. And sadly, this is sometimes difficult to change. It is important to recognize that the value system of the Australian Defence Force represents the society from which its members are drawn. While the ADF sets its aims to be higher than these, as could be considered appropriate, it can be difficult to sustain such goals if broader social influences operate overtly or covertly to erode such values, as exemplified, for instance with cyber-bullying, pornography, sexting, and so forth.

Review: Sex Discrimination in the ADF

In response to a number of distressing and widely publicized incidents, the Australian Human Rights Commission, under the leadership of Sexual Discrimination Commissioner Elizabeth Broderick, has carried out a review of the treatment of women at the Australian Defence Force and the Australian Defence Force Academy (ADFA). The Academy deals with Army, Navy, and Air Force cadets, 21%–22% of whom (of 1,071 cadets) currently are women. The majority of senior roles in this organization are held by men (Australian Human Rights Commission, 2011). The review was carried out using meetings, submissions, and surveys, utilizing interviews and qualitative and quantitative methodologies. The review found that while there was a significant improvement in the culture of gender compared to an earlier review, there were still major issues, such as the need for more women in leadership roles, education regarding the value of equity and diversity, gender relations, complaints processes, and provisions for women’s health and well-being. Even though many women identified their roles and experience as very positive, there was evidence of disproportionate levels of gender- and sex-related harassment and incidents of assault and abuse (Australian Human Rights Commission, 2011). These issues are also relevant for women in other organizational settings, such as colleges, though they may be less in the public eye. The recommendations of the review identified the need for the Chiefs of Services to take strong roles in promoting cultural change in gender equity, roles, and purpose; the value and importance for the future of Australian Defence Forces of equity and diversity; and the importance of women for the ADF (Australian Human Rights 3. Women at War in Australia 37

BOX 3.1 KEY PRINCIPLES FOR SUCCESS IDENTIFIED BY THE REVIEW

1. Strong leadership to drive reform 2. Diversity in leadership to increase capability 3. Increasing numbers require increasing opportunities. 4. Greater flexibility to strengthen the ADF (again, this is considered to be an area where the ADF has responded and demonstrated leadership above and beyond the rest of the community) The ADF has now enabled strategies (albeit with “special measures” temporary exemption from the Gender Discrimination Act 2012) to not only develop gender diversity as a policy but also to actually implement the changes required. 5. Gender-based harassment and violence ruin lives, divide teams, and damage capacity.

The strategies and targets proposed highlight the pathways to achieve such cultural change and its values (Australian Human Rights Commission, 2012). The review also highlighted how women valued their roles and opportunities in the ADF, and their readiness and wishes to contribute across all domains, including in the front line, where they will be able to contribute in combat directly, and to make these contributions as they do now, with competence, commitment, and courage, alongside men.

Commission, 2012). The responses of senior leaders in Defence to this review and the report have been rapid and strong, with a clear commitment to action. The strength of the leadership role from the ADF and, specifically, the head of the Army, is illustrated by Major General David Morrison’s response and commitment to positive change, as exemplified by the “e-brief” he gave to the Army (Chief of Army, 2013). This statement was passionate, clear, and determined—it went “viral,” bringing an intense, positive response by the millions who viewed it across the world, including from international Service groups. The speech made very clear that this was not just a gender issue, but a core issue of respect and tolerance, for women as well as men. It was perhaps the first time, however, that women in the ADF (or indeed elsewhere in our community) had heard such a senior leader speak with such authority and clarity about why women are important and why respect and tolerance are core values (see Box 3.1). To quote from Major-General David Morrison AM:

I have stated categorically many times that the Army has to be an inclusive organisation in which every Soldier man and woman is able to reach their full potential 38 Women at War

and is encouraged to do so. Our Service has been engaged in continuous operations since 1999 and in its longest war ever in Afghanistan, on all operations, female Soldiers and Officers have proven themselves worthy of the best traditions of the Australian Army, they are vital to us maintaining our capability now and into the future. I will be ruthless in ridding the Army of people who cannot live up to its values, and I need every one of you to support me in achieving this. “The standard you walk past is the standard you accept”—that goes for all of us, but especially those who by their rank have a leadership role. If we are a great national institution; If we care about the legacy left to us by those who have served before us; If we care about the legacy we leave to those who in turn will protect and secure Australia—then, it is up to us to make a difference! Those involved in such issues, and those specifically linked to adverse incidents have been subsequently stood down from the Defence organisation following a full enquiry. (Australian Government, Department of Defence, Army, 2013)

MEETING THE HEALTH NEEDS OF AUSTRALIA’S SERVICEWOMEN AND FEMALE VETERANS

War does not injure, maim, and harm only male participants. Australian women have been killed on ADF operations and have sustained serious injuries, including combat-related injuries. Women are also affected by the “unseen” wounds of war, including post-traumatic stress disorder (PTSD), anxiety, and depression, which may not become apparent until many years after their service (Neuhaus & Crompvoets, 2013). As the ADF expands both the number and roles of women, the profile of service-related injury and/or the health effects of service can also be expected to change. Expanded roles for women bring new physical demands, in both training and operational environments, such as those that come with wearing heavy body armor on active patrols. In addition, new operational environments may also harbor as yet unidentified risks—such as to fertility or mental health (Neuhaus & Crompvoets, 2013). There are no published data relating to health outcomes in Australian women who served in either the Boer War or World War I. During World War II, over 130 Australian Servicewomen died either overseas or in Australia. However, most collective health outcome data relates to the specific cohort of female prisoners of war, interred by the Japanese during the Pacific campaign. As with the other prisoner of war (POW) camps, living conditions for the women were extremely harsh. Women were affected by the same diseases as men: tuberculosis, dysentery, and malnutrition. Although not made to undertake hard labor, as male POWs were, the women were subjected to beatings and 3. Women at War in Australia 39 torture and threats of sexual violence. Eight Australian women died in POW camps (Nurse survivors of Japanese hell camps, 1945). The surviving POWs carried the emotional and physical scars of their internment for life. Following the Vietnam conflict, the Department of Veterans Affairs (DVA) published a landmark study reporting health outcomes of the Australian Vietnam Veteran Female Cohort. Despite the small sample size and incomplete cohort, the data suggested some gender-specific health consequences of Vietnam deployment, most notable in terms of asthma/dermatitis, depression/panic attacks, and obstetric outcomes (stillbirth/labor complications) (Commonwealth Department of Veterans Affairs, 1998). Over the last two decades, an increasing number of Australian Servicewomen have been involved in a range of peacekeeping and peace enforcement operations. The gender-specific health challenges facing this contemporary cohort have yet to be addressed.

New Generations of Australian Women in the ADF and Veterans

International research has shown that the latest generations of female veterans may face growing occupational challenges and unique threats to their physical and mental health. Female veterans are not included as a subgroup in the national women’s health agenda and are not represented in either the 1989 or 2010 National Women’s Health Policies. As a consequence, female veterans remain a largely invisible subgroup of Australian women with particular needs will their problems appropriately addressed (Neuhaus & Crompvoets, 2013). The percentage of women in the military is increasing, with women comprising 13.8% of Australia’s Defence Force, 14.6% of the US military, and 9.1% of the British Armed Forces (Crompvoets, 2012). The increasing proportion of females who are veterans of peacekeeping and peace-enforcement operations, or of war, has instigated new questions about their health and well-being needs and their use of healthcare services. Australian women have contributed to a number of Australian Defence Force (ADF) operations over the last decade, including Operations Slipper (Middle East Area of Operations), Astute (East Timor), and Anode (Solomon Islands). In 2011 women comprised 10.2% (n = 1,033) of the total personnel deployed across these three major operations (Crompvoets, 2012). Recent Department of Veterans’ Affairs (DVA) statistics indicate that 8,090 female veterans hold white/gold cards, compared with 131,826 male veterans (DVA 2013). (Gold cards: This card is issued to those veterans of Australia’s defence force, their widows/widowers and dependants entitled to treatment for all medical conditions) (White cards: A white Repatriation health card for specific conditions provides access to health 40 Women at War services for conditions accepted as related to service). These numbers only represent those who have approached DVA with accepted claims, not the wider veteran community or those with claims being processed. Post-discharge, DVA does not provide direct services, with the exception of the Veterans and Veterans Families Counselling Service (VVCS), since responsibility for Repatriation Hospitals has been transferred to state public hospital systems. DVA is rather the funder of a range of services and benefits. (In the past, DVA has not taken an active role in initiating contact with former members, but has waited for former members to contact them. Recently, however, DVA has run active campaigns for former members, and now also runs a transition program for those leaving Defence.) There can be a time lag between when veterans exit the military and when they might access DVA services or entitlements. Given that DVA has historically met the needs of a largely male client base, and little information to date has been known about the needs of female veterans, what this treatment population might look like in the future is largely unknown. The major gender-specific health issues facing contemporary Servicewomen and female veterans can be divided into three broad categories:

1. Physical standards, physiological training, and performance requirements. As indicated by Neuhaus and Crompvoets (2013), while there has been a move to “fitness for task” assessments, there are significant physiological and biomechanical demands in training and performance, and these impact differently on male and female bodies. Women are at risk of musculoskeletal injury and stress fractures (particularly when subject to military load carriage requirements, such as the 40–60 kg requirements in recent deployments to Afghanistan). Female recruits are also at risk of training-induced menstrual irregularity and subsequent osteoporosis. It is suggested that these and other physical factors, such as poorly fitting body armor, not necessarily shaped for women’s bodies, may contribute to the lasting health impacts of musculoskeletal injury, pelvic floor instability, and possibly in the longer term, incontinence (Orr, Johnston, Coyle, & Pope, 2011; Yoram, 2012). There are similar gaps in understanding the physical re-conditioning issues that confront women returning to active service after delivery or breastfeeding. 2. Sexual and reproductive health. While sexual trauma has been an issue that has recently come to the fore, the extent and nature of such trauma and the associated impacts on women’s health and well-being have not been adequately researched. Services specifically tuned to women’s health needs, including sexual and reproductive health, are not well developed. As highlighted by Neuhaus and 3. Women at War in Australia 41

Crompvoets (2013), issues such as those of contraception, menstruation regulation during deployment, and post-deployment fertility are not well addressed. Some circumstances could also contribute further to risk, for example exposure to toxic substances that could impact on a woman’s capacity to become pregnant and/or have potential effects on the developing fetus. The effects of deployment for women with dependent children need to be better understood, particularly as current data suggest that many women separate from the ADF once on maternity leave (Australian Human Rights Commission, 2012). These and potentially other issues highlight the fact that women’s health in service (ADF) environments and following deployment needs to be more specifically addressed. 3. Mental health and well-being. The actual and potential mental health issues for women in service roles need to be specifically addressed (Ferrier et al., 2010). These include the impact of traumatic exposures, such as life threat and the deaths of others, which can lead to acute or delayed onset disorders such as post-traumatic stress disorder, depression, anxiety, and panic attacks. Women may also be vulnerable if they have experienced earlier adversities, particularly abuse or neglect in childhood. Studies currently being finalized with Australian cohorts will shed further light on such mental health issues (McFarlane & Hodson, 2011; Wade et al., 2013, Dobson et al., 2013). Challenges to mental health and well-being also arise with parental roles during deployments and separation from children, with concerns and possibly vulnerabilities for mothers and dependent children. Although many mothers deploying may find their time away a positive experience, there are sequelae for the family structure that require further investigation. These issues also require special healthcare responses (McFarlane, 2009; McFarlane & Hodson, 2011; Davy et al., 2012)

Health Services

Women’s access to services attuned to their specific needs is an ongoing issue. Services have been well developed for men, but are now challenged to make specific adapta- tions to women’s health needs as veterans. It is also often difficult for women to take on the “veteran” identity, as that has been so closely linked to older male veterans; only with recent deployments has it been linked to younger men—and women. Crompvoets reported on her three-year study of female Vietnam and contemporary women veterans (Crompvoets 2012). This in-depth empirical research included women deployed to Vietnam, Rwanda, the Gulf War, Cambodia, Timor Leste, Bougainville, Solomon 42 Women at War

Islands, Iraq, and Afghanistan. She also interviewed other key stakeholders, for instance from health and counseling services. She found that while women greatly valued their roles, there were significant barriers for these women in terms of appropriate support and service resources. Barriers also included the “lack of an authentic veteran identity” (p. vi), lack of trust regarding the understanding of women’s needs and responses to these, and lack of knowledge and information about specific issues important for women such as “maternal separation, reproductive and gynaecological health, domestic violence, lesbian, transgender” (and also “military sexual trauma”). Tracking health issues over time and building appropriate prevention, early intervention, and women’s health programs to meet acute as well as delayed onset health problems are critical. As proposed by Neuhaus and Crompvoets (2013), there is the need to develop “best practice guidelines for the treatment of female veterans” (p. 531), as well as education, support, and resources for female veterans.

AUSTRALIAN WOMEN IN WAR: UNTOLD NARRATIVES

Australian women in military uniform have often had to fight not one, but two wars. They have contended with the powerful pressures and constraints of society, and they have encountered barriers in pursuing their chosen profession—the profession of arms. Thus the narrative stories of their service have not always permeated into broader society. Most Australian children know of John Kirkpatrick Simpson who, with his donkey, transported injured men up and down Shrapnel Gully to the beach and safety during the ill-fated Gallipoli campaign of World War I. Similarly, most Australians know of Sir Edward “Weary” Dunlop AC, CMG, OBE, the former Australian rugby player who was captured by the Japanese during World War II. Weary’s care for other prisoners of war in horrific circumstances, and his feats of surgery with no equipment and under the most hostile conditions, are legendary. However, few would know the stories of Phoebe Chapple MM, Australia’s first woman to be awarded the Military Medal—earned as a doctor on the Western Front in World War I. Fewer still would know of Major Josephine (Mabel) Mackerras, an entomologist with the Army Malaria Research Unit during World War II, whose work earned the citation, in an application for King’s Birthday Honours, “Few women can have made a greater contribution to the Allied war effort” (Dennis & Grey, 2004), or of Captain Carol Vaughan Evans MG, the only woman to be awarded a Medal of Gallantry under the Australian Honours system, following her service in Rwanda following the Kibheo massacre (Neuhaus & Mascall-Dare, 2013). In part, this is because the prevailing narratives of Australia’s military history have privileged male voices over women’s. Women’s voices have been absent or silent. In 3. Women at War in Australia 43 large part also, the narrative of Australian women at war has been dominated by the stories of Australian nurses. In recent years an increasing number of books, films, and other media productions have documented the role of Australian nurses in war. In 2011–2012 the Australian War Memorial exhibition entitled “Nurses: from Zululand to Afghanistan” showcased the service of these women, relating the hardships they endured and their sacrifice and bravery. The exhibition included the story of Sister Vivian Bullwinkel, who served with the Australian Army Nursing Service in the Pacific Campaign of World War II. In 1942, following the fall of Singapore, Vivian was among 65 army nurses attempting to return to Australia on the ship SS Vyner Brooke; 12 were drowned when their vessel was torpedoed and 21 were massacred after reaching Banka Island, where the Japanese ordered the nurses into the sea and shot them with machine guns from behind. Only one survived, Sister Vivian Bullwinkel. After hiding for days, she eventually gave herself up, as she had been shot and needed medical attention. After surrendering to Japanese forces, Bullwinkel was incarcerated in a POW camp for the duration of the war. Today, the story of Sister Bullwinkel and the “Paradise Road” nurses has become a resonant narrative of Australia’s female participation in World War II (Australian War Memorial, 2011–2012). Such role models from the nursing profession are important: they continue to shape the attitudes of those men and women who follow in their footsteps. But they also sit comfortably with historical roles of women. The caring professions have always been seen as “women’s business,” and in this role, “war as men’s business” remains unchal- lenged. It is perhaps for this reason that few of the nontraditional narratives of women’s involvement in war have become widely recognized. Two exceptions are the stories of Olive King, brought to light in Susanna De Vries’s book Heroic Australian Women at War (de Vries, 2004), and Nancy Wake, the so-called White Mouse. Olive King was an intrepid and determined young woman who served as a volunteer ambulance driver on the Serbian front in World War I. She drove and repaired her own ambulance, nicknamed “Ella the Elephant,” through perilous conditions, at a time when most women could not drive, far less seek adventure on a foreign battlefield. Nancy Wake was an intelligence operative in France during World War II and is arguably Australia’s greatest war heroine. These two narratives are unique in their “femme fatale” characteristics—a trait not shared by other female war service narratives.

CONCLUSION

Today, the role that women play in the military remains problematic and continues to be debated. We grapple with issues of “combat equality,” but distinctions between 44 Women at War combat and non-combat roles have become less clear. Suicide bombers, rocket attacks, and improvised explosive devices do not discriminate by gender or by role. New roles—established in just two generations—have seen women move beyond traditional nursing roles into positions as pilots, engineers, mine-clearance experts, and commanders. We now deploy not just women into war zones, but wives and mothers, and this brings new challenges in terms of the perception of female roles—wife, mother, and Soldier—and of the consequences of harm and sacrifice. Recognition of these roles has not yet entered mainstream Australian society, and female military service remains largely “invisible.” Women wearing service medals on ANZAC Day are frequently (albeit with naïveté) challenged as to their authenticity, veteran health entitlements are conflated with those of war widows, and there are few publicly recognizable female veteran role models. These factors combine to create a subtle, but nonetheless powerful, impression that female Veteran service has lesser value than male Veteran service in contemporary Australian society (Crompvoets, 2012). In addition, there are some significant assumptions around opening up direct combat roles and/or Special Forces roles for women. This is an interesting space because the drivers for this extent of reform have largely come from outside the ADF. It has been assumed that women want these roles. However, the evidence is largely to the contrary; ADF women seek acceptance and “non-exclusion” and in principle believe that women should be able to undertake these roles if they are willing and meet the standards, but very few women (even from within the ADF) have come forward to apply (Less than 20 women seek frontline combat roles, 2013). This raises issues of “pioneer roles” but probably in fact is more a reflection that many women (as indeed applies to many men) do not actually want to take on some of these roles themselves. Nevertheless, all these Servicewomen, past and present, are united by a common resolve, which crosses the generations from World War I to the present day. Each of them are or were women who were willing to leave behind families and friends—sometimes to seek adventure or to escape domestic routine, sometimes out of duty and “wanting to do their bit.” They are ordinary women, not necessarily militaristic or out to prove a point, but simply willing to put on the uniform of the Australian Defence Force and use their professional skills to support Australia’s Defence mandate and protect the peace that all Australians—men and women—hold so dear.

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Abuelaish, I. (2013). Closing the gender gap. Medical Journal of Australia, 198(4), 185. Australian Government, Department of Defence, Army. (2013). Message from the Chief of Army—Australian Army. [online] Retrieved from http://www.army.gov.au/Our-work/Speeches-and-transcripts/ Message-from-the-Chief-of-Army (accessed November 27, 2013). 3. Women at War in Australia 45

Australian Government, Department of Veterans’ Affairs. (2013). Treatment Population Statistics Quarterly Report—March 2012 data extract as at 30 March 2012. [online]Retrieved from htt p:// www.dva.gov.au/aboutDVA/Statistics/Documents/TpopMar2012.pdf (accessed November 27, 2013). Australian Human Rights Commission. (2011). Report on the review into the treatment of women at the Australian Defence Force Academy: Phase 1 of the review into the treatment of women in the Australian Defence Force. [e-book] Australian Human Rights Commission (pp. xxi-xxvi). Retrieved from Australian Human Rights Commission website. https://defencereview.humanrights.gov.au/sites/ default/files/ADFA_2011.pdf (accessed November 27, 2013). Australian Human Rights Commission. (2012). Review into the treatment of women in the Australian Defence Force. Sydney: Australian Human Rights Commission. Retrieved from http://www.humanrights.gov.au/defencereview/index.html (accessed March 3, 2013). Australian Human Rights Commission. (2012). Review into the treatment of women in the Australian Defence Force—Community guide Phase 2, 2012. [e-book] Sydney: Australian Human Rights Commission (pp. 19–42). Retrieved from Australian Human Rights Commission website. https://defencereview. humanrights.gov.au/sites/default/files/community-guide.pdf (accessed November 27, 2013). Australian War Memorial, Canberra. (2011–2012). Nurses: from Zululand to Afghanistan. Exhibition, December 2, 2011–October 17, 2012. Commonwealth Department of Veterans’ Affairs. (1998). Morbidity of Vietnam veterans: A Study of the health of Australia’s Vietnam veteran community. Volume 2: Female Vietnam Veterans Survey and community comparison outcomes. Canberra: Department of Veterans’ Affairs. Crompvoets, S. (2012). Final Report: The health and wellbeing of female Vietnam and contemporary veterans June 2012 [e-book] (pp. v–vi). Retrieved from Australian Government, Department of Veterans’ Affairs website.http://www.dva.gov.au/health_and_wellbeing/research/Documents/viet_fem_ con_report.pdf (accessed November 27, 2013). Davy CP, Lorimer M, McFarlane A, Hodson S, Crompvoet S, Lawrence-Wood E, Neuhaus SJ. (2012). Lasting effects of separation on mothers deploying to the MEAO. Presented at the South Australian Defence and Veteran Health Research Paper Day 2012. De Vries, S. (2004). Heroic Australian women in war. Pymble, N.S.W.: HarperCollins. Dennis, P., & Grey, J. (2004). The foundations of victory (pp. 198–201). Canberra: Department of Defence Army History Unit. Dobson, A., Treloar, S., Zheng, W., Anderson, R., Bredhauer, K., Kanesarajah, J., Loos, C., Pasmore, K., & Waller, M. (2013). The Middle East Area of Operations (MEAO) Health Study. The University of Queensland, Centre for Military and Veterans Health, Brisbane, Australia. (accessed August 13, 2013). Ferrier-Auerbach Erbes, C. R., Polusny, M. A., Rath, C. M., & Sponheim, S. R. (2010). Predictors of emotional distress reported by soldiers in the combat zone. Journal of Psychiatric Research, 44(7), 470–476. Less than 20 women seek frontline combat roles. (2013). The Sydney Morning Herald, June 4. Lifting of gender restrictions in the Australian Defence Force. (2013, February 1). Media release. Department of Defence. Retrieved from http://news.defence.gov.au/2013/02/01/lifting-of- gender-restrictions-in-the-australian-defence-force/ (accessed February 3, 2013). McFarlane, A., & Hodson, S. (2011). Mental health in the Australian Defence Force. Canberra: Department of Defence. McFarlane, A. C. (2009). Military deployment: the impact on children and family adjustment and the need for care. Current Opinion in Psychiatry, 22, 369–373. Neuhaus, S., & Crompvoets, S. (2013). Australia’s servicewomen and female veterans: do we understand their health needs? The Medical Journal of Australia, 199(8), 530–532. Neuhaus, S., & Mascall-Dare, S. (2013). A woman at war: The life and times of Dr Phoebe Chapple MM (1879–1967), an Australian doctor on the Western Front. Journal of Military and Veterans Health, 21(3), 40. Nurse survivors of Japanese hell camps. (1945). The Sydney Morning Herald, September 28, p. 3. 46 Women at War

Orr, R. M., Johnston, V., Coyle, J., & Pope, R. (2011). Load carriage and the female soldier. Journal of Military and Veterans Health, 19(3), 25–34. Raphael, B. (1974). The non-liberation of the liberated woman. In N. McConaghy (Ed.), Liberation movements and psychiatry. Sydney: CIBA-GEIGY. Wade, W., Fletcher, S., Howard, A., & Forbes, D. (2013). Gender differences in mental health among serving and ex-serving military personnel: A review of the literature. Australian Centre for Post-traumatic Mental Health. Retrieved from http://www.defence.gov.au/health/dmh/docs/1%20MHPWS%20 report%20-%20Front%20matter.pdf (accessed August 14, 2013). Yoram, E., Ran, Y., Daniel S., et al. (2012). Physiological employment standards IV: integration of women in combat units physiological and medical considerations. European Journal of Applied Physiology, Dec 14. [Epub ahead of print] PA R T 2 Women at War

four Medical Issues for Women Warriors on Deployment

ANNE L. NACLERIO

INTRODUCTION

Women have been serving in critical positions in war as far back as the American Revolution. On recent battlefields, although the laws have defined distinctions on where women can be functioning in the US military, the front lines have become blurred and it is impossible to distinguish “combat roles” from “combat support” roles. Women are serving at the “tip of the spear” on female engagement teams, helping US special forces gather intelligence, and they are serving on reconstruction teams interacting with indigenous populations, with transportation units moving across dangerous territory, and with logistics, police, medical, and engineering units (Naclerio, Stola, Trego, & Flaherty, 2011). In all these positions, women are serving in very austere, harsh environments with a constant threat of enemy engagement inside and outside “the wire.” The recent “lifting of the ban” of women from combat roles by the US Secretary of Defense will allow an expansion of women into jobs previously classified as “combat” (DoD, 2013). Hopefully this will remove any further artificial sense that women are not, and have not, been serving in a multitude of dangerous positions that potentially affect their physiologic and psychological health status. In fiscal year 1994, the Defense Women’s Health Research Program (DWHRP) was established to support research aimed at addressing the health-related needs of military women. The US Army Medical Research and Materiel Command managed the con- gressionally funded program, which supported over 100 intramural and 30 extramural

49 50 Women at War research projects aimed at addressing the health-related needs of military women. A gap analysis was also funded and conducted by the Institute of Medicine (IOM); the findings were published in the IOM report entitled Recommendations for Research on the Health of Military Women (Friedl, 2005; Institute of Medicine, 1995). Ongoing research is critical to ensure that the Military Health System (MHS) is properly prepared to care for its female warriors. This chapter will review the existing literature on the challenges to maintaining physical health that are unique to female warriors and will focus on what is being done and what can be done to help ameliorate existing problems. The austere environment of a theater of war presents different issues for women than men (Czerwinski et al., 2001; Doherty & Scannel-Desch, 2012; Trego, 2012), including something as simple as how and where to urinate privately and safely in the field, or how to dispose of feminine hygiene products. While these issues may sound minor, they have real second- and third-order effects on health; for many of these issues, better prevention and preparation strategies are the key. We must also ensure that the MHS in theater is equipped to handle the unique but common health conditions faced by women as far forward as women are serving—such as menstrual irregularities, pregnancy, and even the prevention and treatment of urinary tract and vaginal infections. Rarer or more serious conditions (ectopic pregnancy, suspected malignancy) unique to women would be handled like any other emergency, by movement through the ech- elons of care and out of theater as necessary. All of these are undoubtedly within the capabilities of the modern US military healthcare system. However, the military is not conventionally prepared or trained to maintain the health of women troops while deployed; rather, it is equipped for a predominantly male force. This chapter will strive to educate healthcare professionals on the specific health needs of female warriors in hopes that all providers caring for this population will be “armed and ready,” so to speak, to care for them comprehensively. It is important also for the mental healthcare professionals reading this text to be aware of the raw physical stressors faced daily by these women while serving, which can undoubtedly affect their psyche. The chapter will also explore what is already being done across the Department of Defense to improve and prevent women’s health issues in theater and will make recommendations regarding what still needs to be accomplished and where further research is needed.

CONDITIONS THAT AFFECT DEPLOYED SERVICEWOMEN’S HEALTH

Preparation and Prevention for Success

In the fall of 2011, an assessment of the theater Health Service Support (HSS) across the Combined Joint Operations Area-Afghanistan (CJOA-A) was undertaken, and one 4. Medical Issues for Women Warriors on Deployment 51

FIGURE 4.1 Women’s bathroom in Austere enviroment. of the nine focus areas was on women’s health (Naclerio et al., 2011). In December of 2011, in what would be one of the first actions by the 43rd Army Surgeon General of the United States, a Task Force was established to look further into the findings and recommendations made in their report.1 The assessment team deployed to Afghanistan and conducted interviews, town halls, and surveys of over 150 Servicewomen. Many of the women serving in enlisted positions were very young, and as noted by their more senior counterparts, many hadn’t learned even basic hygiene practices at home before coming into the Service. Now compound that with a very austere environment, where they may be away from washing facilities for their clothes or their bodies for several days at a time, hot and humid climates, and situations where they are unable to find privacy without risking their own lives and the lives of others. Several Servicewomen told the author that they served in transport companies and were often the only woman in a crew of six, working outside the wire on long transports for up to 36 hours at a time. What do you do when you need to urinate or change a tampon? When facilities are limited or as basic as the one shown in Figure 4.1—they become medical threats without the right preparation and education (Figure 4.1).

1 The author served on the HSS assessment team as a Subject Matter Expert for Women’s Health, Effects of Deployments on Children and Families and Military Sexual Assualt and returned to serve as the first Chair of the Women’s Health Task Force. The comments in this chapter include both published and unpublished findings, as well as reporting on the current status of the recommendations. 52 Women at War

Urogynecologic Issues

Urinary Tract Infections This chapter first looks closer at urination, which has been fairly well studied and reported on by other authors for almost two decades (Hawley-Bowland, 1995; Lowe & Ryan-Wegner, 2003; Nielson et al., 2009; Steele & Yoder, 2013; Trego 2012; Wilson & Nelson, 2012). The CDC reports that 25%–40% of all US women will experience a urinary tract infection (UTI) between the age of 20 and 40 (CDC, 2005). Nielson found that 47% of Army women presenting to a Combat Support Hospital in Iraq experienced at least one during their deployment (Nielson et al., 2009), which for Army women averages 10.5 months in length (DMSS, 2013). A recent analysis found that the rate of UTIs for deployed females was over 20-fold greater than for deployed males; however, in a somewhat counterintuitive finding, the incidence of UTIs during the same period was 26%–55% higher among the non-deployed than deployed females (Armed Forces Health Surveillance Center, 2014). It remains unclear how much of this difference may be due to under-reporting, self-treatment, resolution without medication, or treatment at a remote post without electronic medical record-keeping. Under-reporting is suggested by the survey results of nearly 850 Servicewomen, in which 48% reported that they had symptoms of urogynecologic infections during their deployment (Ryan-Wenger & Lowe, 2000). However, women were found to be significantly less likely to go to a provider during deployment than when at their home station (p < 0.001) (Ryan-Wenger & Lowe, 2000). Servicewomen face many issues while deployed that drive behaviors which can impact their health negatively. All Service members wear heavy protective gear as well as weapons, ammunition, and other load-bearing equipment to help keep them safe. However, for women, the gear makes it very cumbersome to urinate traditionally, as the gear has to all come off prior to being able to drop their uniform pants. Also, while on patrol, convoy, or in flight, there is often no privacy, so urinating would require disrobing in front of male teammates or potentially dismounting in hostile territory. In locations where port-a-potties are available, they have been described by women as often unclean and very tight to maneuver in with all their gear, and they are therefore often avoided (Trego, 2007). These factors drive behaviors such as withholding fluids (Albright et al., 2005). As far back as 1995, researchers recognized the benefits of devices that Servicewomen could use to void without undressing in order to prevent practices that could lead to negative health consequences (Hawley-Bowland, 1995). The female urinary diversion device (FUDD) is a commercially available, funnel-shaped device that can slip into the fly opening in military pants or flight suits to allow women to urinate standing up or 4. Medical Issues for Women Warriors on Deployment 53

FIGURE 4.2 Female Urinary Diversion Device (FUDD). into a small opening (such as a bottle). These products are most widely used by camp- ers, climbers, and outdoorswomen, but have not gained general acceptance across the services (Figure 4.2). During the 2011 HSS assessment, women reported that they were not willing to stop and dismount their vehicles to urinate, as they were frequently in hostile territory and the possibility of ambush was always a reality. Most women surveyed reported that they were not familiar with the FUDD. The lack of use of adaptive processes, such as the FUDD, in combination with maladaptive behaviors like urinary retention and water deprivation, in an austere environment with hot, humid climates and poor sanitation, puts Servicewomen at risk for UTI (Lowe & Ryan-Wegner, 2003; Steele & Yoder, 2013; Trego, 2012). Disturbingly, many women working outside the “wire” reported wearing diapers and withholding the intake of fluids to avoid the need to urinate, which reflects little improvement in the situation after over more than a decade of war. The proposed benefit of the FUDD is to decrease the need to withhold urine, purposefully dehydrate, or sacrifice their humility by disrobing or wearing diapers, thereby decreasing their risk of genitourinary irritation and infection. At the time of the assessment in 2011, the FUDD was in the US theater supply system and was available at the locations we visited; however, it was listed under a not so obvious 54 Women at War name, “Urinal, Female” (Naclerio et al., 2011), which sounds more like a hospital bedpan. But in talking to many women, the nomenclature alone was not the problem. The problem was that most of the Servicewomen encountered had never even heard of these devices, much less had ever tried to use one, or to think to ask for one (Naclerio et al., 2011). These reports were very consistent with Nielson’s findings from Combat Support Hospitals in Iraq in 2005–2006, which reported that only 4.5% of women serving in Iraq had used the devices, and 33% had never heard of the them (Nielson et al., 2009).

Vaginitis It is also not surprising that Servicewomen may suffer from vaginitis more commonly while deployed. Vaginitis is an inflammation or irritation of the vagina. It is often caused by an imbalance of the normal flora and pH, allowing an overgrowth of yeast or bacteria. Risk factors include use of antibiotics, which can upset the normal balance, douching or perfumed sprays that can cause a chemical irritation or raise the pH, and the use of estrogens and IUDs (ACOG, 2006). While vaginitis is not quite as commonly diagnosed in theater as urinary tract infection, 6.5% of women in theater between 2006 and 2008 utilized care for this condition (USAPHC, 2010a). This statistic likely under-represents the frequency that women are affected by this distracting condition, as noted by Ryan-Wegner & Lowe in 2000. Many of the risk factors discussed for UTI, such as limited opportunities for washing and the wearing of incontinence pads or briefs, may also affect the incidence of vaginitis, as well as other factors, such as the need to take antimalarial prophylaxis drugs like doxycycline (Tan, Magill, Parise, & Arguin, 2011). Researchers have also found that many Servicewomen are using estrogenic contraceptives, douching, or using feminine hygiene sprays while deployed (Lowe & Ryan-Wegner, 2003). A report in 2007 found a 3% higher utilization rate for female genitourinary encounters during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) than in garrison from 2005 to 2007 (Cox, 2007).

Addressing the Urogynecologic Issues

Urinary Tract Infection The Women’s Health Task Force (WHTF) worked with appropriate agencies to rename the FUDDs in the supply system to the more accurate description of “Female Urinary Diversion Device,” and in conjunction with US Army Public Health Command (USAPHC) has developed educational brochures, posters, and videos to educate Servicewomen on what they are and how to use them. Resources can be found on the 4. Medical Issues for Women Warriors on Deployment 55

TABLE 4.1 Resources Referenced, Available at the Time of Publication

Resources Available for Servicewomen Web Link

USAPHC Women’s Health Portal http://phc.amedd.army.mil/topics/ healthyliving/wh/Pages/default.aspx

YouTube video on use and care of the https://www.youtube.com/ Female Urinary Diversion Device watch?v=JXRxjmifjO8 recently developed USAPHC Women’s Health Portal. Healthcare practitioners can refer patients to the site, or can download reference materials for patients. On the topic of FUDDs, the Women’s Health Portal has developed a YouTube video to help teach Servicewomen on their use and care, and has created reference cards that fit into a patrol cap or pocket, which can be downloaded or ordered from their site (Table 4.1). The WHTF is also addressing changing from a “pull” to a “push” system of supply. This allows the FUDDs to be provided to Servicewomen at points in time when they may be needed (such as prior to deployments into the field or austere environments). Currently, it remains a “pull” system, so women must know to ask for them. The task force is also working to add education on the FUDD to basic and advanced military training and to leaders’ courses. Both male and female Soldiers, as well as those who lead them, need to be educated that they exist and when, why, and how they should be used in order to maintain combat power on the battlefield (or during a field exercise). As providers, we have an opportunity to ask and an obligation to educate. Providers must be familiar with the device and educate. Only then will their use become inculcated into the routine of Servicewomen (Figure 4.3). Once your patients are aware of the options that allow them to discretely urinate standing up into a bottle or behind a bush without undressing in a group of males, you can move on to talk to them about the importance of staying hydrated. Hydration is key, not only to the prevention of heat injuries, but also for the prevention of urinary tract infections (Albright, Gehrich, Buller, & Davis, 2005) and renal calculi (Loris et al., 1996).

Vaginitis Prevention efforts overlap with the urinary hygiene addressed above to avoid the need for adding additional layers of incontinence briefs, or feminine hygiene pads that can restrict airflow and even tighten the fit of garments, causing both an increase of heat and moisture and friction on the perineum. All of these have been suggested to promote the colonization of microbes and the translocation of bacteria from the perianal area to the vaginal or urethral openings (Omli et al., 2010; Rao, Bhatt, Houghton, & Macfarlane, 56 Women at War

FIGURE 4.3 US Servicewomen preparing to go outside of wire. FUDD as a routine piece of her equipment.

2004; Steele & Yoder, 2013). Additionally, Servicewomen should be counseled to avoid the use of scented products, such as feminine sprays, douches, and scented menstrual hygiene products. Such perfumed products upset the vaginal pH and balance of flora, leading to bacterial vaginosis. Another measure to advise your female Service members on is the use of unscented, alcohol-free wipes to freshen the urogenital region from front to back when out for consecutive days without access to showers or other bathing facilities. The WHTF has worked with the Army Quartermaster to ensure that these unscented, alcohol-free wipes replace the scented variety in the comfort kits offered to deploying Soldiers to prevent the upset in pH and vaginal flora that the scented varieties can cause. More research is needed to determine if uniform modifications may be helpful in promoting airflow; decreasing the amount of heat and humidity and friction in the perineal area could be beneficial in decreasing the risks of genitourinary infections in female Service members.

Menstruation

In the general population across multiple developed nations, even without the stressors of austere environment and limitations in hygiene, researchers report that 50%–90% of menstruating women suffer from dysmenorrhea, with 10% of those with pain, being severe and accounting for 1–3 missed days of productivity per month (Andersch & 4. Medical Issues for Women Warriors on Deployment 57

Milsom, 1982; Charu, Amita, Sujoy, & Thomas, 2012; Jamieson & Steege, 1996; Pullon, Reinken, & Sparrow, 1988; Sundell, Milsom, & Andersch, 1990). In a more recent study of 500 military women who had deployed to an area of combat operations, 13% reported lost duty days for menstrual-related issues (Powell-Dunford et al., 2011). In a review of 98 English-language articles, the prevalence of abnormal uterine bleeding among women of reproductive age was found to be 10%–30% (Liu, Doan, Blumenthal, & Dubois, 2007). In a survey of 397 deployed women in Iraq between August 2005 and March 2006, 35% had at least one gynecologic problem during deployment, and irregular menstrual bleeding was the most common (21%) gynecologic problem encountered (Nielson et al., 2009). Irregular menses is not surprising, considering that their bodies are undergoing physical, mental, and circadian stress during deployment. Theater Medical Data Store (TMDS) is the authoritative theater database for col- lecting, distributing, and viewing Service members’ medical information. An analysis by the Army Patient Administration Systems and Biostatistics Agency (PASBA) of TMDS data by gender and the Agency for Healthcare Research and Quality (AHRQ) Clinical Classification System (CCS) Diagnostic Categories on outpatient visits between 2006 and 2012 revealed 22,410 visits for contraceptive and procreative management, with an additional 8,583 visits for menstrual disorders (accounting for 4.4% of all visits by female Service members) (PASBA, 2014). Many of these disorders may have been preventable or at least modifiable with current hormonal therapies. Now consider having to deal with potentially preventable, painful, or irregular bleeding in an austere environment, where even privacy and the availability of feminine products may be very limited. This makes it paramount that providers caring for Servicewomen must be aware and comfortable with counseling women on options for menstrual regulation with hormonal methods during routine care visits, whether they choose to use them immediately or not. Women can use hormonal methods to either control the timing of withdrawal bleeding or to suppress withdrawal bleeding. Well-established advantages of menstrual regulation include the reduction of bleeding episodes, the control of the timing of menstruation, and decreasing the symptoms associated with the ovulatory cycle to include mood swings, breast tenderness, headaches, and dysmenorrhea. Studies of US Army women found that they were receptive to menstrual regulation, with a strong preference for amenorrhea (lack of menses) while in field environments (Powell-Dunford, 2003; Powell-Dunford, Cuda, Moore, Crago, & Deuster, 2009). In Nielson’s 2009 report, only one-third reported receiving any pre-deployment counseling on menstrual cycle control, and of those, only 13.5% were given several options for cycle regulation (Nielson et al., 2009). Our assessment in 2011 suggested that little improvement had occurred since his report (Naclerio et al., 2011). 58 Women at War

Some authors have recommend that hormonal contraception should be viewed as an essential medication to ameliorate the effects of ovulation and the menstrual cycle and to prevent the potential morbidity of a variety of conditions ranging from ovarian cysts to anemia (Christopher & Miller, 2007). Focus and education on these non-contraceptive benefits will help remove the perception that oral contraceptive pills (OCPs) are only for the prevention of pregnancy. During the Persian Gulf conflict, the belief that OCPs were only for sexual activity led many women to go off hormonal contraception “since they would not be having sex,” and the numbers of unintended pregnancies became the leading cause of evacuation of women from theater during Dessert Storm (Christopher & Miller, 2007; Hanna, 1992). Therefore it is imperative that providers caring for these women be familiar with the basic methods for menstrual cycle regulation using either oral, transdermal, or vaginal hormonal contraceptives; a levonorgestrel-releasing intrauterine device; a progestin implant; or a depot medroxyprogesterone injection (Hicks & Rome, 2010). All of these regimens should be instituted at least three to six months prior to deployment or field exercise in order to optimize desired benefits. All regimens are not equally ideal in the austere environment, emphasizing the importance of all primary care providers understanding at least the basics of menstrual cycle regulation. The following is a brief review of the advantages and disadvantages of hormonal contraception, with an emphasis on menstrual cycle regulation, that providers should consider when working with military women. This review assumes the goals listed in Table 4.2. Irrespective of method, the reduction of dysmenorrhea and menorrhagia can decrease fatigue from anemia and can improve performance/attendance, which is even more critical on the battlefield (Armed Forces Health Surveillance Center, 2012; Wilson, McClung, Karl, & Brothers, 2011). When counseling women for options for contraceptive use, providers need to cross-reference with US Medical Eligibility criteria published by the Centers for Disease Control and Prevention (CDC, 2010).

TABLE 4.2 Goals for Hormonal Contraception Therapy in Servicewomen

• Decreased cycle-associated discomforts/dysmenorrhea • Decreased bleeding/Ability to achieve amenorrhea • Positive side effect profile (improved acne, decreased mood swings, decreased breast tenderness) • Effectiveness as a contraceptive in case of planned or unplanned consensual sex, rape/ captivity • Safety of regimen • Suitability in austere environment 4. Medical Issues for Women Warriors on Deployment 59

Estrogen/Progestin Combination Therapy The following three delivery modes all contain a combination of low-dose estrogen (Ethinyl estradiol) and a progestin (levonorgestrel for continuous or extended OCPs, norelgestromin in the patch, and etonogestrel in the ring).

Oral Contraceptive Pills For young, healthy women without a contraindication to estrogen, there are many advantages to the use of OCPs, extending well beyond prevention of pregnancy and menstrual regulation (ACOG, 2010). Their use suppresses ovulation and induces endometrial atrophy and has also been shown to reduce associated benign gynecologic conditions, resulting in fewer hospitalizations because of pelvic inflammatory disease (PID), a reduction in chronic pelvic pain and endometriosis complaints (Jensen & Speroff, 2000), and reductions in dysmenorrhea and menorrhagia (Davis, Westhoff, O’Connell, & Gallagher, 2005; Dmitrovic, Kunselman, & Legro, 2012). OCPs have also been shown to decrease the long-term risk of ovarian, endometrial, and colorectal cancer, as well as osteoporosis (Burkman, Schlesselman, & Zieman, 2004; Gierisch et al., 2013; Jensen & Speroff, 2000). Studies have also suggested that long-term use can preserve fertility by delaying or reducing incidence of endometriosis (Seracchioli, Mabrouk, & Frasca, 2010), while also reducing both inflammatory and non-inflammatory acne vulgaris (Arowojolu, Gallo, Lopez, & Grimes, 2012). Prospective analysis done over three decades ago found the extended use of OCPs with withdrawal bleeding four times per year to be safe and effective (Loudon, Foxwell, Potts, Guild, & Short, 1977), and this is supported by more recent Cochrane analysis (Edelman et al., 2006) and a very recent study of over 3,700 women, which found ascending dose extended regimens to be both safe and effective (Portman et al., 2014). Amenorrhea rates in users of continuous oral contraceptives across three large studies found rates ranging from 59% and 88% by one year (Wright & Johnson, 2008). The first brand to gain FDA approval for extended use was Seasonale in 2003 (Anderson & Halt, 2003). The first product to gain FDA approval for continuous use was Lybrel in May 2007 (FDA, 2007); however, off-label use has been done safely for years before FDA approval, for a variety of conditions that are exacerbated by the ovulatory cycle (Christopher & Miller, 2007; Wright & Johnson, 2008). When used con- tinuously, OCPs are effective in inducing oligomenorrhea or amenorrhea, in over 70% of women by six months and some sooner (Miller & Hughes, 2003). In studies comparing extended and continuous dosing regimens to conventional cyclic regimens, some authors have suggested that better compliance with continuous regimens may lead to fewer missed pills, and reduced chance of ovulation and 60 Women at War unintentional pregnancy (Hicks & Rome, 2010; Powell-Dunford et al, 2011). While modern OCPs are safe for the majority of female Service members, providers should remain knowledgeable of the contraindications to estrogen use and cross-reference the eligibility requirements set forth by the World Health Organization (WHO, 2009), reviewed by the CDC (2010). The major disadvantage of this method is the requirement for daily dosing, and long-term studies suggest a slight increase in the risk of breast cancer (Gierisch et al., 2013). However, researchers have found advantages to continuous versus conventional dosing, showing twice the compliance rate and significantly less lost duty days (Powell-Dunford et al., 2011). Combination pills are readily available to deployed Servicewomen, with many forms available; they do not require special care or handling, and slight variations in the time of day taken do not have significant negative effects.

Transdermal Patch Ortho-Evra is a combination low-dose estrogen/progestin combination agent delivered transdermal that provides protection against pregnancy at similar rates to OCPs. While the patch has better compliance rates than OCPs, discontinuation rates are higher (Lopez et al., 2013). Extended use is off-label, and continuous use has not been studied. In the only extended use trial, women randomized to the 12-week extended regimen had fewer days of bleeding, while only 12% achieved amenorrhea. Spotting and unscheduled bleeding were still common, and the risk for adverse events doubled (Stewart et al., 2005). Higher serum levels of estrogens have been found with normal regimens as compared to OCPs and the vaginal ring (van den Heuvel, van Bragt, Alnabawy, & Kaptein, 2005). These higher levels may explain the increase in side effects experienced, which include breast discomfort, painful periods, nausea, and vomiting (Lopez et al., 2013). Also, increased thrombotic side effects have been reported (Cole et al., 2007) which could be exacerbated by dehydration states (Trenor et al., 2011), which are frequently encountered during deployments in austere environments for the reasons described earlier in the chapter. But most important for military Servicewomen, patch site irritation is reported in 15% of patients in a clean environment (Stewart et al., 2005) and is presumably worse in a dirty, hot, and sweaty environment. Poor adhesion is the biggest concern in the deployed environment, with 46% of Army women surveyed who were using the patch while deployed to OIF reporting patches “falling off” in the austere conditions and humid climates (Thomson & Nielson, 2006; Nielson et al., 2009). Therefore, if the Servicewoman desires this method, it is important to counsel on the need to keep extra patches and to be educated on how to replace patches mid-cycle if adhesion problems occur. Providers should also discuss the needed timeline for a transition plan if they choose to initiate its use in garrison but desire to change prior to future deployment. 4. Medical Issues for Women Warriors on Deployment 61

Vaginal Ring NuvaRing is a contraceptive ring labeled for a 21/7 cycle. The vaginal method of delivery has been shown to allow a low, continuous dosing, resulting in more stable serum concentrations as compared to the patch or OCPs, making it suitable for consideration for extended or continuous use (van den Heuvel et al., 2005). Ring users generally have fewer systemic side effects, but more vaginal irritation and discharge. NuvaRing’s extremely short shelf life (4 months) and inability to tolerate extremes of temperature limit its utility in deployment or austere environments. Servicewomen considering or using the vaginal ring should be counseled on the need for refrigeration or at least avoidance of extreme heat, making it more laborious a method for extended periods in austere locations. As with the patch, Servicewomen desiring to start this method should understand the transitioning timeline required to change to an alternative method for optimal result.

Progestin-Only Therapy The following four delivery options are all suitable for women who are unable to use estrogen or who just desire to use a progestin-only method.

Progestin-Only Pills These pills incompletely suppress ovulation, require very timely daily dosing for effectiveness, and irregular bleeding is very common (FSRH Guidance, May 2008), giving them many disadvantages for deployment (Christopher & Miller, 2007). Their advantage is for women who wish to continue to lactate.

Progestin-Only Injections: Depot Medroxyprogesterone Acetate (DMPA) Depo-Provera inhibits ovulation, thickens cervical mucous, and thins the endome- trium when delivered by intramuscular (IM) injection every 90 days (Kaunitz, 2000). Ovarian suppression and amenorrhea is about 70% at one year, taking up to two years to reach 90% of users (FSRH, 2009). While it is a convenient (dosing every 3 months) and efficacious form of birth control, it is a less ideal choice for menstrual regulation in military women due to the high rates of irregular bleeding (Nielson et al., 2009), especially early on, side effect of weight gain (Christopher & Miller 2007), and delayed return of fertility (Jain et al., 2004). Finally, the black box warning about significant bone loss when used for over two years is of particular concern in military women who are already involved in often arduous training and who already incur a higher incidence of stress fractures (IOM, 1998); however, more recent studies suggest that this risk less- ens over time and is reversible on discontinuation (Cromer et al., 2008; Kaunitz, Miller, 62 Women at War

Rice, Ross, & McClung, 2006). In Servicewomen who cannot take estrogens and/or want to use this method, it should be instituted 6–12 months before deployment to minimize bleeding, and women should be counseled appropriately on bone loss risks and bleeding side effects (ACOG, 2008, 2014).

Progestin-Only Implant There are two implantable rods available in the United States, Implanon (which is being phased out) and Nexplanon (which is replacing Implanon and is the same drug and dosing). These are very convenient forms of long-acting reversible contraception because they are good for three years at a time, providing pregnancy protection at rates similar to sterilization (CDC, 2010), without the problems of storage or missed dosing. In the deployed setting for pregnancy protection, this is an advantage. However, 78% of women continue to have regular cycles, and only 20% are amenorrheic, making this a poor choice for suppression of menses. Moreover, 50% having infrequent, frequent, or prolonged bleeding (FSRH, 2009). Their association with erratic bleeding patterns makes them a less than ideal choice for women who may deploy.

Progestin-Releasing Intrauterine System (IUS) Mirena® IUS was the first medicated (releasing levonorgestrel) intrauterine device (IUD), and it is also FDA approved for treatment of heavy menstrual bleeding in IUD users (FDA, 2010). The IUS works by inhibiting implantation and sometimes preventing fertilization; however, it does not necessarily suppress ovulation (NICE, 2005). It has many advantages, mainly five years of highly effective reversible pregnancy prevention without having to carry any supplies. The newest progestin-releasing IUD, called Skyla™, has similar effectiveness for pregnancy prevention, but is only labeled for three years (AHC, 2013). Very reliable pregnancy prevention, without any thought or supplies, may be especially important as women take on increasingly forward roles and the risk of women being taken captive increases (Christopher & Miller, 2007). A 90% reduction in menstrual blood loss has been demonstrated over 12 months of use with Mirena (FSRH Guidance, 2009), making it a good choice for menstrual suppression. While the copper IUD is not a form of hormonal contraception, we will discuss it here briefly for completeness. The copper IUD works by preventing fertilization and preventing implantation. It provides 10 years of pregnancy prevention without remembering to do anything (except to check periodically for the string) or carrying any supplies. It has no effect on ovulation and therefore no effect on ovulatory-related symptoms. Heavier bleeding and dysmenorrhea are likely. Therefore for Servicewomen desiring long-term pregnancy prevention it is highly effective; however, it is not a good option if menstrual regulation is desired (NICE, 2005). 4. Medical Issues for Women Warriors on Deployment 63

Advantages of the Levonorgestrel-releasing IUS as compared to the copper IUD were significantly lower incidence of pregnancy and PID and a significant increase in hemoglo- bin, all beneficial to our predominantly young and active military population (Andersson, Odlind, & Rybo, 1994). Initial labeling for the copper IUD in 1988 specified its intended use in women who have had at least one child; however, that language was removed when it was relabeled in 2005. While the label for the Mirena IUS still says that its intended use is for women who have had a child, the current consensus opinion of the American College of Obstetricians and Gynecologists (ACOG, 2011), Society of Family Planning (SFP, 2010), and World Health Organization (WHO, 2009), and US medical eligibility criteria for contraceptive use (CDC, 2010) support its use in nulliparous women, which is in line with current widespread practice (Hubacher, 2007; Suhonen, Haukkamaa, Jakobsson, & Rauramo, 2004). Both Mirena® and Paraguard® can be placed postpartum and are safe to use while breastfeeding (CDC, 2010). The only disadvantage of note is that at least 50% continue to ovulate, and therefore it does not provide relief from pain from ovarian cysts and other cyclic symptoms like breast tenderness and mood changes (NICE, 2005).

Unintended Pregnancy

In a recent report, based upon data from 3,745 active duty military women ages 18–44 who participated in the 2005 Department of Defense Survey of Health Related Behaviors, Lindberg (2011) describes a very high rate of unplanned pregnancy in US military women, almost double that of the general population, and the rate appears to be rising (Grindlay & Grossman, 2013a). Studies have attributed unintended pregnancies to both contraceptive failures and non-use (Goyal, Borrero, & Schwarz, 2012; Holt, Grindlay, Taskier, & Grossman, 2011). Higher rates have also been associated with younger, less educated, non-white, and married or cohabitating women (Grindlay & Grossman, 2013a). It is unclear why the rates in US Servicewomen are so much higher than their civilian counterparts. Since the military population is completely covered with health insurance, as compared to a 20% uninsured rate in the civilian female population and as high as 27% in women 19–24 years of age (DeNavas-Walt, Proctor & Smith, 2013;, CPS: Annual Social and Economic Supplements, 2013), the data suggest that something other than financial barriers to contraception is the issue. Women are still reporting going off birth control when deploying, having to change methods just before or just after arrival into theater, or experiencing access issues to continuing their method due to difficulty getting refills (Ibis Reproductive Health, 2013). These findings suggest that current policies and logistical issues may be negatively affecting health-related behaviors (Manski et al., 2014). Several recent reports also highlighted the lack of abortion services available to military women as compared to civilians. Title X U.S. Code §1093 prohibits the Department 64 Women at War of Defense (DoD) from performing abortions except in cases of rape or incest, or risk to the mother’s life (Legal Information Institute, ND). This might account for some of the differences in rates of unintended births, as well as placing women’s health and careers at risk, especially overseas, where civilian abortion options are limited or nonexistent (Grindlay, Yanow, Jelinska, Gompers, & Grossman, 2011; Ibis Reproductive Health Brief, 2013). Much like for urogenital infections, the best strategy for unintended pregnancy is prevention. Unfortunately, women in the military are also facing episodes of rape and sexual assault. A 2010 Workplace and Gender Relations Survey of AD Members found 4.4% of women reported unwanted sexual contact in the prior 12 months (DMDC, 2010) and the DoD estimates that 80% of affected Servicewomen who experience sexual assault do not report it to a military authority (DoD, 2010; Holt et al., 2011). Providers need to do better at educating Servicewomen early in their career to establish contraceptive regimens that are optimal at home station and through deployments (Powell-Dunford et al., 2011; Thomson & Nielson, 2006; Trego, 2012). Even women who do not choose to use a regimen at home station should be educated to seek counseling on alternative methods in ample time before deployments or exercises in austere environments. It is imperative that all providers caring for military Servicewomen are counseling, or referring for counseling, on the pros and cons for various methods for contraception. Providers should be familiar with the benefits of an increased role for long-acting reversible contraceptives (LARCs). LARCs are defined as means of contraception that require less than monthly dosing and therefore have lower reliance on compliance and higher efficacy for prevention of pregnancy. LARCs include the progestin-releasing IUS, the copper IUD, and progestin injection or implant. In summary, all Servicewomen, regardless of where they are in their career or deployment cycle, should be counseled by their healthcare providers on how they can be maximally prepared for what they may face if called to deploy. Preparation and prevention are the keys they need to optimize their success (Table 4.3).

Fit and Function of Uniforms

Another issue raised by women to the Women’s Health Assessment team was poorly fitting uniforms and protective gear. The individual body armor, designed primarily for male body habitus, was perceived to limit their function and cause painful chaffing and bruising over their hip area (Naclerio et al., 2011). Like most military items, the current and past designs were based upon male anthropometrics. One of the Women’s Health Task Force’s first initiatives was to make contact with the Army’s research and design team; the Task Force found that the Army had begun working on a female sizing system earlier in 2011. They had created prototypes, had conducted fit evaluations, and had begun refining them and conducting field evaluations in order to ensure that 4. Medical Issues for Women Warriors on Deployment 65

TABLE 4.3 Counseling Points for Military Servicewomen

• Even women without previous menstrual irregularities may experience issues in austere environment. • Hormonal contraception provides many advantages other than protection against pregnancy. • Menstrual cycle regulation is a broad term that includes using hormones to induce either regulation of (cyclic) withdrawal bleeding, decreased menses, or amenorrhea (no menses). • Urogenital hygiene is more difficult in the austere environment—planning and prevention are the best strategy. • Menstruation is not necessary except when pregnancy is goal. • For those already on hormonal contraception, withdrawal bleeding is not the same as menses. • Menstrual suppression is safe and many women prefer it in austere environments; however, it is best initiated 3–6 months before deployment. • Many forms of reversible contraceptive allow return of fertility shortly after discontinuation. • Many women who do not plan to have sex while deployed have unplanned encounters, usually consensual; however, you must also consider the risks of sexual assault, rape, and captivity. • Many forms of hormonal and non-hormonal contraception are available in the deployed settings with privacy protections. • The decision for menstrual regulation is a personal decision—but it should be an informed decision. the protective gear better fit female Service members. The new armored vest prototype trialed in 2012 was a dramatic improvement, allowing full range of motion at the shoul- der, improved quick release design, less bulk in the collar/yoke, darts to curve the front panel, and a much shorter torso so as to not interfere with high knee raise; because of the size options, the new design allows for smaller sized armored plates with correct fit, meaning smaller, lighter weight armor (Paquette, 2011; Miles, 2012). The new multi- sized female improved outer tactical vest (FIOTV) has been fielded to several hundred women, and 75,000 vests are scheduled for delivery by the fall of 2014. Providers should counsel patients to take the time to ensure that they receive the correct sized garments, as they remain connected with them throughout their deployments, and poorly fitted gear can add unnecessary strain to the body as well as potentially limiting function.

Lactation

Another issue women Service members face is how to handle deployment or field exercises when lactating after the birth of a child. Pregnant or postpartum Servicewomen may be concerned about how to handle this, and therefore providers 66 Women at War should be prepared to counsel and educate them on their options. Currently all services defer deployment of postpartum women for at least six months, and the Navy currently defers for one year; however, this may not apply equally to field or training exercises. The six-month postpartum deferment policies are driven by the service personnel leadership and are based on the perceived needs for manpower. The Women’s Health Assessment Team recommended that the services re-examine these policies, however (Naclerio et al., 2011), as they conflict with the American Academy of Pediatric policy statement (AAP, 2005), The Surgeon General’s Call to Action (HHS, 2011a), the goals and objectives of Healthy People 2020 (HHS, 2011b), and the HHS Blueprint for Action on Breastfeeding (HHS 2000). While continuation of lactation during a prolonged deployment is generally not sustain- able, women who are interested and committed to do so can maintain during shorter field training exercises. While there is now a single case report of a dedicated healthcare provider assigned to a fixed facility in Afghanistan being able to maintain lactation for four and a half months and even successfully send some breast milk home (Sleudel, 2012), most field environments will be conducive to an “express and dump” method that all primary care providers should be ready to discuss or refer to a lactation expert to further assistance. This can be accomplished with a simple manual method or with the assistance of a hand pump when electricity is not available. If, however, the separation is for training or a location where electricity is available, a double electric pump allows for the most effective milk expression in the least amount of time. Of note, legislative changes are currently underway in the FY15 Defense Authorization Act to ensure that Tricare, the health insurance for US Military members and their beneficiaries, provide breastfeeding support, supplies, and counseling during pregnancy and throughout the postpartum period that align with the Department of Health and Human Services’ implementation of the Patient Protection and Affordable Care Act requirement, applicable to group health plans and health insurance issuers.

FEMALE HEALTH CONCERNS IN AN AUSTERE ENVIRONMENT: THE ROLE OF THE MILITARY HEALTH SYSTEM

As policy has changed on roles available to women in the services, a frequent concern has been related to what health conditions we will see in them and whether the MHS will be equipped to handle them. The WHTF has been recognized across the MHS as 4. Medical Issues for Women Warriors on Deployment 67 a means to convene experts, make recommendations, and share best practices across the Services to ensure that the MHS is ready. The answer to the first part of the question is fairly straightforward, as women have been serving in battle for hundreds of years,and for over a decade of war, an electronic medical record has provided us the data to answer this question.

The Most Common Conditions of Servicewomen

An analysis of outpatient records from theater between 2006 and 2012 shows that the top five most common conditions that affect women are the same conditions that affect men. Four of the top five conditions are musculoskeletal complaints, likely from wearing heavy body armor, high equipment loads over time, and repeated deployments. The fifth most common condition is upper respiratory infections (PASBA, 2014). These are all conditions that the MHS is well equipped to handle and do not generally show any uniqueness by gender. When we do look a bit deeper, some differences begin to emerge. While the top five most common reasons for an outpatient visit have been the same as for men, the sixth most common reason is for management of contraceptives. In fact, if you combine visits for “contraception management” with those for “menstrual dysfunction,” which is often related to, or treated with, a hormonal contraceptive agent, this diagnostic category would move into the top five, surpassing the number for upper respiratory infections (PASBA, 2014). This does not account for visits for pregnancy or suspected pregnancy, which one could argue to be a related diagnostic category. The seventh and eighth most common diagnostic groups encountered in OIF/ OEF in 2006–2012, as shown in TMDS, were for urinary tract infections and genital disorders—mostly vaginitis (PASBA, 2014). A Force Health Protection Assessment reported a 3% higher utilization rate for female genitourinary encounters during Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) than in garrison from January 2005 to July 2007 (Cox, 2007). While none of these is a life-threatening condition, these conditions are, at a minimum, distracting from the Service member’s mission, and a UTI left untreated carries a risk of progression into a more serious pyelonephritis (Brusch, Bavaro, Cunha, & Tessier, 2012). Studies suggest that the numbers presented above for the female-specific conditions may under-represent the true prevalence of these conditions. In a survey of 841 Servicewomen, while 48% of women reported having distracting physical urogynecologic symptoms, 25% of those stated that they would not seek care (Ryan-Wegner & Lowe, 2000). 68 Women at War

Barriers and Gaps Identified

A recent, small, qualitative study of 25 women who deployed between May 2011 and January 2012 found that women reported the following barriers to seeking care: limited availability of female providers, a perception of stigma for seeking care (weak or negative consequences), logistical issues including lack of time or ability to get to a provider, a concern for lack of confidentiality, a lack of orientation to available health services, and a perception that women purposely become pregnant to avoid military service (Manski et al., 2014). These barriers were strikingly similar to those heard by the Women’s Health Assessment Team in 2011 and reported by Ryan-Wegner & Lowe over a decade earlier. They found that the most commonly cited reason was lack of confidence in the provider (15.2%), followed by embarrassment (14.6%), distrust in confidentiality (14%), preference for a female provider (8.4%), and not wanting to take time away from their mission (7.8%) (Ryan-Wegner & Lowe, 2000). Their study also suggested a lack of understanding of the healthcare system available to them, as 68% of women reported that their “provider” was a medic or corpsman (Ryan-Wegner & Lowe, 2000), which is an unprivileged, more narrowly trained, and generally young male, enlisted Soldier or Non-Commissioned Officer (NCO). While this finding makes the concerns cited above seem more understandable, it certainly highlights other issues of lack of understanding of the military healthcare system. Other concerns identified by researchers are reports of women going off hormonal contraception prior to deployment due to the policy forbidding sexual activity and a lack of pre-deployment counseling on the benefits of hormonal contraception (Ibis Reproductive Health, 2013; Manski et al., 2014), suggesting that policy changes may be needed. An online survey of almost 300 women who had deployed between 2001 and 2010 also found women reporting that they were denied access to IUDs because they did not have children, suggesting a gap in education in addition to policy (Grindlay & Grossman, 2013b; CDC, 2010). Many of the most common female-specific visits may have been preventable with early education, planning, and intervention for cycle control.

Actions Underway to Address Gaps

To address many of the barriers noted by Servicewomen above, the Women’s Health Assessment Team recommended the fielding of a self-diagnostic kit for urinary tract and vaginal infections (Naclerio et al., 2011). A significant body of evidence has accumulated over the past 14 years on utilizing simple methods of self-diagnosis for 4. Medical Issues for Women Warriors on Deployment 69 these common, non-life-threatening, but highly distractible conditions and found them to be both safe and similar to clinical diagnosis of a provider, even in military populations (Lowe & Ryan-Wegner, 2000; Lowe, Neal, & Ryan-Wegner, 2009; Ryan-Wegner et al., 2010). The kits studied include simple point of care (POC) testing items to differentiate between bacterial or yeast vaginitis and/or for UTI, an algorithm incorporating signs and symptoms and results of POC testing, a ther- mometer, and education on the use of the kit (Ryan-Wegner et al., 2010). While it is not available commercially as a kit, the WHTF has been working with the researchers, Defense Logistics Agency, and US Army Medical Material Agency, to make one available to US Servicewomen, but to date have been hindered by a myriad of regulations. In order to ensure that Servicewomen themselves are educated on basic preventative measures for urogenital hygiene (to include the use of the FUDD), menstrual regulation, and birth control options in an austere environment, basic education materials have been developed and are being approved for the addition of basic and advanced training courses for both men and women. Also in conjunction with the Public Health Command, the Female Soldier Guide to Medical Readiness, which had less than one page on contraception and nothing on hormonal control of menstruation, has been updated with expanded information and has been combined into one Warrior Readiness Guide in order to ensure that male and female Soldiers alike have the information they need to make them successful (USAPHC, 2010b). The perception by many Servicewomen that their provider is a medic or corpsman suggests that education about the healthcare system in a deployed environment also needs to be added to education materials. It is important to note that as women move farther forward on the battlefield to remote forward-operating bases, it also is more likely that the first line of care is male and that a combat medic or corpsman may be the highest level of care 24/7, with physician assistant or independent duty corpsman backup, sometimes remotely located. A review of Army medic algorithms for common gynecologic complaints reveals that the medic is not empowered to treat, but is directed to refer almost everything to a higher level of care, most often to the physician assistant (MEDCOM, 2011). In the military, physician assistants frequently serve as the first line, privileged provider for units and may be the only asset in a far forward location. A broad range of general, specialty and subspecialty providers, with varying levels of women’s healthcare training and experience, are called up to fill roles of general medical providers in the war zone. In order to standardize care provided to Servicewomen before, during, and after deployment by any type of provider, the WHTF also recommended the development of algorithms for common conditions to include 70 Women at War abnormal uterine bleeding, counseling for hormonal contraception for menstrual regulation or for birth control, and treatment of UTI and vaginitis. Development of these clinical algorithms will then be extended where appropriate to medic algorithms to ensure a standard care level in the system, irrespective of the level at which care is accessed. Finally, information on the same topics has been incorporated into pre-deployment leader’s briefs and medical threat briefs. In short, the WHTF is working to ensure that this information is woven into the core materials for all Servicewomen and leaders throughout all phases of education, much like foot care after lessons learned in Vietnam, or the importance of water discipline.

AREAS DESERVING OF MORE STUDY

The Women’s Health Research Interest Group (WHRIG) is supported by the TriService Nursing Research Program. The WHRIG consists of a core group of dedicated researchers who have been working to identify, review, and document the existing literature on military women’s health and identify gaps to help direct future research. In a literature search of medical, social, and psychological research databases from 2000 to 2010, the group has thus far identified nearly 300 peer-reviewed research articles that either address a health issue or delivery of care specific to US Servicewomen (Trego, personal communication, 2014). According to Trego (2014), of these articles, only 15% address gynecologic issues. Even fewer are specific to conditions in wartime. This suggests a gap in the literature on the identification, prevention, and treatment of gynecologic issues that arise in a conflict environment. Research efforts need to focus on identifying the health issues, including costs for transportation, treatment, and complications, that could be prevented. Building the foundation of literature will lead to evidence-based practices that are not only beneficial to women, but to the health of the total force. Women have and will continue to be an effective force multiplier for the military. They already serve in roles where only women can serve, such as gathering intelligence from women in Middle Eastern countries, where a male would not be culturally acceptable to do so. They are already highly successful members of cohesive units. The successes to date are largely because involved and responsible civilian, political, and military leaders invested energy toward ensuring their success, and that is what needs to continue. The medical community has an active role in ensuring that ongoing quality research is available to inform leaders, drive policy, and serve as the basis for our care standards (Trego, Wilson, & Steele, 2010). 4. Medical Issues for Women Warriors on Deployment 71

CONCLUSION

In 1951, the Secretary of Defense established the US Defense Department Advisory Committee on Women in the Services (DACOWITS), to provide advice and recommendations on matters and policies relating to the recruitment and retention, treatment, employment, integration, and well-being of women in the US Armed Forces. The committee’s 2011 and 2012 reports highlight successes and identify gaps in needed research and policy on both wellness and assignments (DACOWITS, 2011, 2012). Their continued diligence as an advisory body is critical to ensure that the DoD and policymakers implement the findings of the research community. Continued efforts to obtain funding and to focus research where it is most needed and to organize the growing body of data into texts like this one are critical. In our recent wars, the level of care on the battlefield is unrivaled, and the trauma care that coalition forces receive is second to none, with survival rates the highest in history, at around 95% of those reaching a care facility (Hack, 2012). Despite being in some of the most primitive and remote areas of the Earth, the availability of trauma care exceeds what US citizens receive after a car accident in the more remote and rural areas of the United States (Hsia & Shen, 2011). However, the evidence presented suggests that the care women Service members are receiving for common female conditions are left wanting. It is logical that the MHS should be most proficient in the care of the most lethal injuries; however, MHS leaders are acutely aware of the need for providers to be expert and skilled in the conditions that all Soldiers are facing. In garrison, a Service member can choose his or her provider, and there is ample access to women’s health specialty care; however, in the deployed environment, we must ensure that our primary care providers are educated in the identification, prevention, and care of commonly encountered female conditions. Recurring themes in this chapter are (1) the need for a strategy of preparation and prevention, and (2) education at all levels (Soldiers, Leaders and Health Care Providers). The ban on women in combat roles has been lifted. More women will be serving further forward on the battlefield in a wider range of positions than ever before. As the medical community who cares for them, it is our obligation to be ready to support them and to ensure that preventable and modifiable health considerations do not hinder their otherwise certain success.

DISCLAIMER

The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of Defense. 72 Women at War

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CARA J. KRULEWITCH

INTRODUCTION

A large majority of active duty Servicewomen are of childbearing age. As of November 2012, among the 2.3 million Department of Defense (DoD) active duty military personnel, 14.5% were women and 43.2% were under 26 years old. The average age for Active Duty Officers was 34.7, and the average age for enlisted personnel was 27.4. The largest proportion (46%) of female active duty military personnel are young, lower ranking enlisted personnel, with the ratio of female Officers to enlisted personnel being 1 to 4.4 (Office of the Deputy Under Secretary of Defense [Military Community and Family Policy], 2012). A female active duty Service member’s ability to balance family and work life has an impact on troop readiness and planning for deployments or other assignments, as women who are pregnant or in the early postpartum period cannot be deployed. Women who are diagnosed as pregnant in theater must be evacuated, which may affect both their career and the status of their troop, as it may be difficult to replace them (Ritchie, 2001). Bucher (1999) noted that the Persian Gulf War shed light on the impact of pregnancy on US Army readiness when there were large-scale deployments of active duty Servicewomen. Additionally, many women face physical challenges that are different from those of their male counterparts, including access to contraception, management of menstruation, and the impact of environmental exposures on reproductive outcomes. This chapter will analyze the epidemiology and research around these issues.

78 5. Reproductive Health 79

PREGNANCY AND CONTRACEPTION

Contraceptive Use and Unintended Pregnancy

Epidemiology In the United States, among civilian populations, an estimated 62% of women are currently using contraception, with the most common methods being the pill and female sterilization (Jones, Mosher, & Daniels, 2012). Holt, Grindlay, Taskier, and Grossman (2011) noted similar findings among active duty military personnel in a systematic literature review. These authors found the reported contraceptive use to be 50%–88% among active duty military women stationed in the United States and 39%–77% among active duty military women in deployed environments. Other studies had similar findings (Uriell & Burress, 2009; Goyal, Borrero, & Schwarz, 2012; Robbins, Chao, Frost, & Fonseca, 2005; Thomas, Thomas, & Garland, 2001; Clark, Holt, & Miser, 1998). Enewold et al. (2010) compared oral contraceptive (OC) use among military women (duty status not specified) included in the Military Health System Management Analysis and Reporting Tool (M2) to civilian women included in the National Health and Nutrition Examination Survey (NHANES). The authors found that military women use oral contraceptives at a higher rate compared to civilian women (34% versus 29%, p < 0.05). Although OC use was consistently higher among military women over the age of 20, in women aged 18–19, use was lower among military women (33.2% versus 40.6%). The largest difference between military women and civilians was among Hispanic women, where 32.2% of military and 19.8% of civilian women reported using OCs. Enewold et al. (2010) noted that some OC use might be for menstrual suppression instead of contraception, which is supported by other studies (Powel-Dunford et al., 2009, 2011; Trego, 2007; Powell-Dunford, Deuster, Claybaugh, & Chapin, 2003). The most recent reported estimate of unintended pregnancies among civilian women aged 15–44 was 57.2% during 2006–2010. The proportion was higher among civilian women aged 20–29 at 69%, or an estimated 105 per 1,000 women (Zolna & Lindberg, 2012; Grindlay & Grossman, 2013). Lindberg (2011) evaluated the extent of unintended pregnancy among female active duty military personnel and found similar results with 54% of pregnancies being unintended. Goyal et al. (2012) also reported similar findings of 50%–62% unintended pregnancies among active duty Servicewomen. Similar to that observed in civilian populations, studies consistently reported higher proportions of unintended pregnancy related to age. Unintended pregnancy was higher among active duty Servicewomen who were younger and lower ranking enlisted personnel, compared to Officers (Holt et al., 2011; Grindlay & Grossman, 80 Women at War

2013). Although some of these studies have suggested that unintended pregnancy may be more common among women in the military, as noted by Lindberg (2011), these studies were hampered by a range of methodological limitations. In addition, as noted above, almost half of the female active duty military personnel are under age 26. The unintended pregnancy rate among civilian women in similar age groups showed the same patterns. In 2006 the unintended pregnancy rate in the civilian population was 107 per 1000 women aged 15-44 (Finer & Zolna, 2011), 102 per 1000 women aged 20–24, and 84 per 1000 for women aged 25–29 in 2008 (Zolna & Lindberg, 2012). Regardless whether unintended pregnancy rates in Active Duty servicewomen are similar to those within the civilian population, developing a better understanding of circumstances when Active Duty women become unexpectedly pregnant provides information to inform pregnancy prevention activities in the military. Biggs, Douglas, Boyle, and Rieg (2009) conducted a survey at a military hospital with a large obstetric census, representing more than 4,000 births per year. Forty percent of women delivering at this hospital were active duty personnel. The authors felt they had captured more than 90% of all births to active duty Servicewomen in the local area because their insurance required the use of that hospital for coverage. The study included representation from members of all Services. Respondents were enrolled over a seven-month period in 2005, and 415 of 825 active duty Servicewomen who received surveys responded, producing sufficient power to make inferences about the sample. The sample was predominantly enlisted personnel (94%) with an average age of 25. Sixty percent of pregnancies were unplanned, with 35% the result of contraceptive failure, most often oral contraceptive pills. The proportion of women with an unplanned pregnancy who were single was almost twice that of women who were married (82% versus 45%, p = 0.006); 50% of single women were using no contraceptive method, and 54% became pregnant while assigned to a seagoing or deployable unit. Although 64% of women felt that pregnancy did not change their military plans, the majority planned to leave at the end of their current service obligation. Although some studies indicated that active duty Servicewomen reported they were not comfortable discussing or getting birth control from an independent duty corpsman (Ritchie, 2001; Ryan-Wenger & Lowe, 2000; Nielson et al., 2009), Uriell and Burress (2009) reported that about three-quarters of Navy enlisted personnel and two-thirds of Navy Officers stated that they would feel comfortable discussing or getting birth control from an independent duty corpsman, regardless of setting (overall, or aboard ship). In conclusion, unintended pregnancy rates and contraceptive use in active duty Servicewomen are similar to rates found in the civilian population and remain higher 5. Reproductive Health 81 than the Healthy People 2010 goal of 30% unintended pregnancies. Healthy People 2020 has set a target that 56% of all pregnancies are intended, a 10% improvement from current rates, increasing the proportion of women who consistently use contraception and decreasing the proportion of contraceptive failures. Chung-Park (2007) and others (von Sandovsky et al., 2008; Thomas, Thomas, & Garland, 2001) have evaluated contraceptive decision-making among military women; however, there is sparse information on effective training methods to promote consistent contraceptive use or the role that the physical challenges and mental stressors of deployed environments contribute to decision-making. Additional research in these areas may be the key to moving closer to the Healthy People 2020 goal.

Pregnancy Outcomes Deployment and Birth Defects The Armed Forces Health Surveillance Center (AFHSC, 2011) reported that during 2000–2010 there were more Service members hospitalized for labor and delivery than for any other specific condition, accounting for 58.6% of all hospitalizations of females. In March 2013, the Secretary of Defense lifted the ban on women serving in combat roles. As the number of occupational roles for active duty Servicewomen grows, the potential for environmental exposures may increase. There is sparse current research on deployment and other potential health exposures among Servicewomen and the potential effect on their pregnancy outcomes. Interest in environmental exposures and pregnancy outcome increased when the US Government Accounting Office (GAO, 1994) published a report that raised concerns that the military did not sufficiently evaluate most forms of reproductive dysfunction, including infertility and miscarriage, and that there was inconclusive evidence regarding a relationship between environmental exposures and birth defects. The report cited a study by Penman, Tarver, and Currier (1996) that evaluated birth defects among Gulf War veterans from Mississippi reserve units deployed to the Persian Gulf War. Penman et al. (1996) found no apparent increases in the rate of defects compared to the Atlanta metropolitan Congenital Defects Monitoring Program. The 1994 GAO report expressed concerns that there were methodological flaws in the study, which limited any conclusions that were drawn. Eight other studies, described below, have reported mixed findings compared to Penman et al. (1996). These studies evaluated the relationship between deployment and adverse effects on birth outcomes (Hourani & Hilton, 2000; Araneta, Destiche, Schlangen, Merz, Forrester, & Gray, 2000; Araneta et al., 2003; Kang et al., 2001; Bukowinski et al., 2012; Armed Forces Health Surveillance Center [AFHSC], 2010; Ryan et al., 2011; Conlin et al., 2012). 82 Women at War

Hourani and Hilton (2000) evaluated the relationship to self-reported exposures and adverse pregnancy outcomes among active duty Navy women who were pregnant between January and October in 1993. The authors also surveyed a comparison group of civilian beneficiaries delivering at the same hospital the following year. The authors grouped respondents by report of an adverse live-birth outcome (small for gestational age, birth defect, fetal distress prior or during delivery, birth less than 37 weeks, or birth weight less than 2,500 grams) or no adverse outcomes and compared the groups based on active duty or civilian status. They collected information on environmental exposures including radiation, heavy metals, pesticides, solvents, petroleum products, other chemicals, shipboard duty, or serving in the Persian Gulf. Active duty Servicewomen were significantly more likely to report exposures compared to civilian respondents; however, final models did not demonstrate significance between maternal exposures and adverse birth outcomes. Araneta et al. (2000) evaluated births from the Hawaii Birth Defects Program (HBDP) and Hawaii birth certificate records linked to information from the Defense Manpower Data Center (DMDC) and the Defense Enrollment Eligibility Reporting System (DEERS) to identify military status. HBDP is part of the Centers for Disease Control and Prevention’s (CDC) monitoring program and uses specific definitions for 48 major congenital anomalies that are included in the database. Military status was grouped as Gulf War veterans (GWV) and non-deployed veterans (NDV). The authors identified 17,182 infants born to military personnel (men and women) in Hawaii between 1989 and 1993, with 9,437 determined to have been conceived prior to the war and 3,717 (22%) born to GWV. Among GWV births, 202 (8.1%) had a mother who served in the military. There were 1,854 (50%) postwar conceptions among GWVs and 5,882 (44%) among NDVs. Among GWVs, there were no differences found comparing prewar conceptions to those with postwar conceptions. There were a total of 165 GWV women who conceived after the war. Among births to mothers who had served in the military, there were no statistical differences between GWV births compared to NDV births, nor were there any statistical differences in the rate of birth defects among GWV if the infant was conceived before the war compared to infants conceived after the war. Although the multiple data linkages and standardized birth defect definitions strengthen this study, the authors stress that the small number of female GWVs, along with the inability to identify stillbirths, miscarriages, or induced abortions due to anomalies, limits the generalizability of this study. In a larger study using the same methodology, Araneta et al. (2003) evaluated data from six states that report to the CDC’s birth defects monitoring system. In this case, they identified 450 GWV mothers (142 conceived prior to the war) and 3,966 NDV mothers (2007 conceived prior to the war). They found that although there was no 5. Reproductive Health 83 difference in the rates of congenital anomalies between GWV and NDV mothers for infants conceived prior to the war, there was a significant difference in the adjusted prevalence of hypospadias among sons born postwar to female GWVs compared to postwar female NDVs (RR 6.3, 1.5–26.3, p = 0.015). None of the infants was also reported to have epispadias. There were no other significant differences in the other 48 reported congenital defects. Kang et al. (2001) evaluated self-reported birth outcomes, including fetal loss and birth defects, that were included in a 16-page questionnaire sent to a large sample of Service members selected from the DMDC. Their survey methodology included stratified random sampling by gender and unit component to achieve an adequately representative sample of 15,000 GWV and 15,000 active duty Service members who were not deployed to the Gulf War. The survey oversampled for women, Reservists, and National Guardsmen. The study analyzed spontaneous abortions, stillbirths, preterm delivery, birth defects, and infant mortality. Pediatric epidemiologists evaluated the verbatim descriptions of infant birth defects to assess if the birth defect self-reports were accurate by using a 12-group sorting system. The analysis categorized a response as a birth defect only if it was determined to be “likely” and “moderate-to-severe” based upon the sorting scheme. There were 20, 917 survey respondents with 6,043 (28.9%) who had an index pregnancy during the time period. In both male and female respondents, those who had been deployed to the Gulf War were two to three times as likely to report a “moderate-to- severe” birth defect compared to those who had not deployed (males: 1.78 [1.19–2.66], females: 2.80 [1.26–6.25]). The majority reported isolated anomalies that were one or more anomalies within the same organ system. There were no significant differences for preterm birth or stillbirth. The authors noted that, although the reported spontaneous abortion rate for males was significantly increased, the rate for GWV and non-deployed Service members was still well below the expected range of 10%–15%, and may be an artifactual comparative risk. The authors evaluated the data for self-selection bias in reporting and determined that the data did not suggest this as a plausible reason for the increased reporting rate in birth defects. This population-based study demonstrated adequate power to detect differences; however, data were self-reported, and the identification of birth defects was based upon verbatim data that were categorized for evaluation. The AFHSC (2010) conducted a retrospective cohort study that included active duty, Reserve, and National Guard personnel of all Services at three USCENTCOM burn pit sites in Iraq: Joint Base Balad (JBB), Contingency Operating Base (COB) Speicher, and Camp Taji, to evaluate pregnancy outcomes following these exposures. The authors included two control groups of active component personnel, one stationed 84 Women at War in Korea for more than 30 days and one stationed in the United States during the same time. Among active duty military women who gave birth in the year following possible exposure to a burn pit area (within 5 miles), there was no significant statistical differences in the risk of preterm birth or birth defect compared to those who were not exposed. Compared to men who were not exposed, active duty Servicemen who were exposed to burn pits were 1.31 (1.04–1.64) times more likely to have an infant with birth defects, if the infant was conceived 280 days or more after the exposure. Bukowinski et al. (2012) linked birth records from Department of Defense Infant Health Registry and the Defense Manpower Data Center to identify active duty Service members who had been deployed within 3 miles of a burn pit and later had a child. The authors evaluated children born in 2004–2007 following one or both of their parents serving in the 1990–1991 Gulf War. The authors found no increased risk for birth defects among deployed active duty Servicewomen; however, among active duty Servicemen who had been deployed 153–200 days, there was a 1.25 (1.05–1.49) times increased risk of birth defects in children compared to active duty Service members who had been deployed 1–92 days. This risk was not present in the group of men who had been deployed 201–485 days. The authors note that among the 178,766 births included in the study, the majority of exposures (152,149) were paternal exposures, 19,320 were maternal exposures, and 7,297 were both parents. In addition, birth defects were identified through ICD9-CM coding, thus requiring them to be identified at birth. The gender disparity may have affected the statistical power to detect differences, and only major congenital birth defects were identified. Conlin et al. (2012) conducted a similar study using the same methodology as Bukowinski et al. (2012). They identified active duty Servicewomen who had given birth following deployment. There were 1171 women who had been deployed within a 3-mile radius of burn pits and 11,958 women who had not been exposed, but who had other deployments to Iraq or Afghanistan outside the 3-mile radius of a burn pit. The authors compared the risk of having an infant born with birth defects or preterm in relation to burn pit exposure. There were no significant differences in the rate of birth defects in the exposure group compared to the non-exposed group. In summary, there are a number of studies that have evaluated the relationship of birth defects and exposures associated with deployment, including burn pits. The studies have either conducted retrospective review of existing data registries or data obtained by self-report through mail/phone surveys. Most studies have identified no association between exposures and outcome; however, four studies identified an association. Kang et al. (2001) identified an increased risk of self-reported “moderate-to-severe” birth defects for both men and women who had been deployed to areas with burn 5. Reproductive Health 85 pits. Two studies reported findings of a delayed association between exposure and birth defects with fathers who had been deployed either 153–200 days (Bukowinski et al., 2012) or greater than 280 days (AFHSC, 2010). The birth defects in both studies were self-reported. Finally, Araneta et al. (2000) conducted a retrospective registry study and noted an association in women who had deployed with an increased risk of hypospadias. Many of the studies had small sample sizes, low response rates, or other methodological concerns that limit the ability to draw conclusions. These concerns may have affected the ability to either confirm a relationship, or may have had insufficient power to detect differences. Additionally, since data collection was 20 years ago, it is possible that current exposures may not produce similar results. A larger scale evaluation, with specific definitions of birth defects, sufficient information about exposure, and that is of sufficient size to detect differences is needed.

Vaccine or Chemoprophylaxis Exposure Since 2009, there are only a few studies that have evaluated vaccine exposure and pregnancy outcomes among Active Duty Servicewomen. Four studies (Wiesen & Littell, 2002; Conlin, Bukowinski, Sevick, DeScisciolo & Crum-Cianflone, 2013; Ryan, et al., 2008; Ryan, Smith & Sevick, 2008) evaluated vaccine exposure (anthrax, H1N1, smallpox) or chemoprophylaxis (Mefloquine) (Schlagenhauf, et al., 2012) during pregnancy and pregnancy outcomes. These studies found that neither vaccine nor chemoprophylaxis administration during the prenatal period resulted in adverse effects on pregnancy outcome, but none of these studies evaluated spontaneous abortion or early fetal loss. Smoak, Writer, Keep & Chantelois (1997) noted an increase in spontaneous abortion among women who inadvertently received Mefloquine while pregnant as they prepared to deploy for the Gulf War in 1989–1992. Further research is needed to draw conclusions regarding this exposure risk.

Pregnancy in Theater There are several reports that evaluated pregnancy following combat deployment and the need for evacuation. Albright et al. (2007) noted that in a study of one Army division in theater during the Persian Gulf War, there were 24 pregnancies out of 458 gynecologic visits. At the Eighth Evacuation Hospital, Hines (1993) found that the 26 pregnancies diagnosed accounted for 16% of the hospital evacuations and 56% of all women evacuated. In a similar study of the 312th Evacuation hospital, Hanna (1992) found that 49 of 577 gynecologic visits were for pregnancy. Hanna (1992) noted that many women stated that they had been told to stop their oral contraceptive pills as they 86 Women at War would not need them, nor would they be available. Since then, this policy has changed, and oral contraceptives are offered at pre-deployment physicals, not only for contraception, but also for menstrual suppression during deployment (Christopher & Miller, 2007; Trego, 2007; Powell-Dunford, Cuda, Crago, & Deuster, 2009). Women have access to refills through mail order and local military treatment facilities. In spite of increased contraceptive access, as discussed above, unintended pregnancies continue at a rate comparable to that for civilian women in the same age group and have an impact on theater operations. Albright et al. (2007) conducted a retrospective chart review of 1,737 gynecology visits presenting to the gynecology clinic in Camp Doha, Kuwait during August 2003–April 2004. They found that 77 (4.4%) of those visits had a positive pregnancy test. Women with positive pregnancy tests had a mean age of 27 (±7), and the most common rank was E-4. Most presented to the clinic with a complaint of amenorrhea or a desire to check for pregnancy. Three of the pregnancies were second trimester (two greater than 20 weeks), and one ectopic pregnancy was identified. Information on arrival date to theater was available for 43 of the 77 women. Among those with an arrival date, 33 had become pregnant after arrival in theater. Although pregnancy in theater can have an impact on troop readiness, these estimates are consistent with the expected rate of pregnancy in a given population. Mosher, Martinez, Chandra, Abma, and Wilson (2004) estimated that approximately 5% of women in a childbearing population would be pregnant at any given time. Ectopic pregnancy has a reported incidence of 1.5 cases per 1,000 women of reproductive age and is an obstetric emergency. It usually is asymptomatic and thus undetected until intervention is critically necessary. It is estimated that the death rate is 4 per 1,000 cases (Stamilio, McReynolds, Endrizzi, & Lyons, 2004). In the Active Component of the US Armed Forces, among the approximately 35,000–50,000 women who have been deployed to combat zones, this translates to the potential for 53–75 cases per year (Stamilio et al., 2004; Albright, et al., 2007). If ectopic pregnancy is undetected before deployment, this could present a life-threatening emergency for the Service member and may affect troop readiness. The AFHSC (2012) evaluated the incidence of ectopic pregnancy among Active Component US Armed Forces and found that among active component women younger than 49, there were 1,245 cases in 1,216 women (some women had more than one ectopic pregnancy) in 2002–2011. Rivera-Alsina and Crisan (2008) and Stamillo et al. (2004) present case reports of the challenges and successes of the treatment of ectopic pregnancy during deployment and stress the importance of available portable ultrasound machines. The annual number of ectopic pregnancies ranged from 91 to 151. The proportion of pregnancies that were ectopic remained stable at 0.70 during 2002–2005 and then declined to 0.49% in 2005–2011. These findings were similar to 5. Reproductive Health 87 rates in the civilian population. In both the active component and civilian populations, the diagnosis of ectopic pregnancy was preceded by either a diagnosis of a genital infection with chlamydia or gonococci, or pelvic inflammatory disease (PID). In summary, ectopic pregnancy is a rare and life-threatening condition. Adequate resources in theater, including portable ultrasound machines, are critical assessment tools to perform life-saving assessments in austere environments.

CONCLUSION

The participation by active duty women in military operations has expanded, and large-scale deployments to theaters of operation commenced in the Persian Gulf War. Today, women may serve in combat roles. The challenges of achieving a work-life balance are even greater than they were 20 years ago; however, the same challenges exist in the area of reproductive health. Women who choose to enlist are of similar ages to their civilian counterparts who have chosen to go to college. In these early adult years, contraception use may not be consistent, leading to higher rates of unintended pregnancy. In a college setting, this may delay graduation, but does not always require the student to leave her studies. In the military, the scenario may be quite different, and it can affect troop readiness. Women who become pregnant after deployment will need to be evacuated from theater. Complications in pregnancy that require immediate intervention, such as ectopic pregnancy, may be more difficult to diagnose and manage if far away from echelon 3 Services. Environmental exposures may affect the pregnancy outcome, or may produce delayed responses for future childbearing. Many of these issues have not been fully studied, sample sizes are small, or methodological flaws exist in the analysis, limiting conclusions that can be drawn. Additional research with greater rigor, larger sample sizes, and careful design are needed to address many of these questions. Innovative approaches to contraception education are also needed to provide necessary information on contraceptive decision-making. These findings are important for clinical providers who care for both military women and veterans. The American College of Obstetricians and Gynecologists (ACOG, 2012b) has stressed the need for healthcare providers to familiarize themselves with the unique needs of women in the military and military veterans. Although most active duty women have a primary care provider, often their primary contact with the medical system is for annual gynecologic examinations. The same is true for healthy women Reservists and veterans. Standard care for both military and veteran women should include questions about current service status; a discussion of the potential reproductive health risks due to environmental exposures during military 88 Women at War service; family planning and contraceptive considerations for deployed women, other military women, and veterans; and other potential exposures, such as vaccines or chemoprophylaxis. ACOG (2009) and others have noted that countries with higher usage of long-acting reversible contraceptive (LARC) methods such as intrauterine devices and contraceptive implants have lower rates of unintended pregnancy (Trussell & Wynn, 2008; Winner et al., 2012), and that these methods are safe in both women and adolescents (ACOG, 2012a). In addition to pregnancy prevention, hormonal contraception has been used in theater for menstrual suppression (Holt et al., 2011). Pre-deployment physicals should include discussion of the desire for menstrual suppression as well as contraception. As part of preconception planning, ACOG (2013) recommends that healthcare providers become knowledgeable about toxic environmental agents that are endemic to specific geographic areas. As discussed in this chapter, military women can be exposed to environmental agents as part of deployment or duty station. Providers should consider taking an environmental exposure history as part of an initial health history for both active duty and veteran women. Results of the exposure history can be used for teaching, counseling, and further testing if necessary. Ectopic pregnancy can be a life-threatening emergency, and when it occurs away from areas with echelon 3 or greater diagnostic capabilities, it has the potential to be deadly. Healthcare providers in deployed environments should consider portable handheld ultrasound equipment as part of the standard setup. Their utility in austere environments has been demonstrated in both military and civilian settings (Nelson, Melnick, & Li, 2011; Shorter & Macias, 2012; Harcke & Rooks, 2012). In conclusion, there are many similarities among civilian, military, and veteran women related to rates of unintended pregnancy and reproductive healthcare needs; however, there are additional unique reproductive healthcare needs that should be considered when providing or planning care to military and veteran women. Midwives, gynecologists, family practice physicians, and other healthcare providers should review and consider the ACOG Committee Opinions referenced in this chapter (ACOG 2009, 2012a, 2012b, 2013) when caring for military and veteran women.

DISCLAIMER

The views expressed by the authors in this book are their own, and do not necessarily reflect the view of the United States Government or the Department of Defense. 5. Reproductive Health 89

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Effectiveness of long-acting reversible contraception. New England Journal of Medicine, 366(21), 1998–2007. Zolna, M., & Lindberg, L. (2012, April). Unintended pregnancy: Incidence and outcomes among young adult unmarried women in the United States, 2001 and 2008. New York: Guttmacher Institute. Retrieved from http://www.guttmacher.org/pubs/unintended-pregnancy-US-2001-2008.pdf. six Issues in the Prevention of Malaria Among Women at War

REMINGTON L. NEVIN

INTRODUCTION

Service members, including women, who deploy on military operations to certain tropical and subtropical areas may be at risk of contracting malaria, a serious and potentially fatal disease. An understanding of the unique challenges faced by females in the prevention of malaria is therefore an essential component of caring for women at war. Optimal prevention of malaria in women rests on the interruption of disease transmission. As malaria is uniquely transmitted by the bite of an infected female Anopheles mosquito, prevention among women should emphasize measures intended to avoid mosquito bites. Women in deployed settings may face difficulties in the avoidance of mosquito bites; therefore, where appropriate, mosquito avoidance measures may be supplemented by the use of prophylactic antimalarial medications. In this chapter we will review considerations within the US military in both interruption of disease transmission as well as the use of prophylactic antimalarial medications, with a specific focus on the unique issues faced by female Service members. Currently deployed antimalarials, including those developed by the US military, have been tested predominantly among men, and therefore in many cases direct human safety and reproductive hazard data are not available to inform their rational use in women. However, post-marketing surveillance and animal studies provide opportunities to understand potential sex differences in their effects.

93 94 Women at War

The pharmacokinetics and pharmacologic effects of common antimalarials may vary significantly in women, potentially affecting their tolerance and safety profiles. In women, some antimalarials have been demonstrated to exhibit unique patterns of adverse events, potentially affecting compliance. Doxycycline may predispose to vaginal candidiasis. Women may experience a higher risk of neuropsychiatric symptoms from mefloquine and exhibit a higher prevalence of contraindications to its use. Although direct evidence is often lacking, information on the effects of antimalarials on fertility and risk of pregnancy loss can be derived or reasonably inferred from a combination of in vitro and animal model studies, as well as from theoretical considerations. In counseling a female military Service member deploying to a malaria endemic area, the military clinician must consider indications for and absolute and relative contraindications to causal, suppressive, and terminal prophylaxis. The military clinician must also consider the potential deleterious effects of common pharmacological interactions. Common adverse reactions must be considered and discussed with the female Service member, with particular attention to tolerability and adherence. For some women, and in some cases where risk of malaria is low or in special circumstances, mosquito avoidance measures alone may be appropriate and must be considered by the military clinician and accommodated by policy. In this chapter, the history and epidemiology of malaria in female US military populations are reviewed. Current strategies for the prevention of malaria are discussed, with an emphasis on mosquito avoidance and the potential complications in imple- menting avoidance measures in deployed settings. The chapter then discusses the history of antimalarial development in military settings, with a focus on available data on safety and tolerability in females. Information on differential pharmacokinetics, phar- macodynamics, patterns of adverse effects, and compliance is presented. This information is then used to discuss important considerations in the selection of an antimalarial or antimalarial combination appropriate for the deploying female Service member. The chapter then discusses considerations for forgoing prophylaxis in certain low-risk settings and in special circumstances, options for early diagnosis and treatment, and considerations for the medical evacuation of women in deployed settings who remain at high risk of malaria.

HISTORY AND EPIDEMIOLOGY OF MALARIA IN MILITARY WOMEN

Although malaria has been a potential threat to US military women at war since as long as women have been serving alongside men, there is surprisingly little information on the historical sex-specific epidemiology of the disease. Published reports on the 6. Issues in the Prevention of Malaria 95 role of women in World War I make no reference to malaria (Gavin, 1997). Similarly, although military historical accounts confirm that women in the World War II Army Nurse Corps were known to have contracted malaria, particularly in the Pacific Theater (US Army Center for Military History, 2003), the definitive treatise on the epidemiology of malaria in World War II excludes a specific discussion of the effects of the disease on women, and does not break down incidence figures by sex (Mowrey, 1963). During the Korean War, women were not mentioned in prominent published case studies of returned veterans with malaria (Aquilina, 1952; Hall & Loomis, 1952). The authoritative study of malaria among Korean War veterans also made no mention of disease occurring in females (Schwartz & Tuttle, 1956). A study of the history of malaria in the US Navy from World War I through the Vietnam War (Beadle & Hoffman, 1993) made no mention of malaria among women, nor did studies of imported malaria since the Korean era (Porter, 2006) or the Vietnam era (Powell, 1978). Detailed historical studies of the roles and experiences of female nurses in the Vietnam War also do not discuss malaria as a significant concern (Vuic, 2010). US Servicewomen appear to be first mentioned in the published literature during the Somalia campaign of 1993 (Smoak, Writer, Keep, Cowan, & Chantelois, 1997), though only in relation to prophylaxis and not specifically in relation to malaria risk. Neither the definitive study of malaria among US personnel (Wallace et al., 1996) nor case series and ecological studies (Centers for Disease Control and Prevention, 1993; Sánchez, DeFraites, Sharp, & Hanson, 1993; Wallace et al., 1996) make any mention of malaria occurring in women. With the advent of electronic medical records and automated medical surveillance systems (Rubertone & Brundage, 2002), by 1999 the US military had published its first annual review of malaria cases, reporting incident cases by sex. Of 61 cases of malaria in 1998 occurring among active duty US Army personnel, one occurred in a female Service member (Army Medical Surveillance Activity, 1999a). The following year, an expanded analysis of cases from 1997 to 1999 identified two of 108 malaria cases among active duty personnel occurring among females (Army Medical Surveillance Activity, 1999b). Automated surveillance permitted the routine publication of figures, summarized in Table 6.1, among both active duty US Army personnel and, in subsequent years, all US military personnel. Unfortunately, not all published analysis during the period commented specifically on women; a detailed study of 365 presumed Korea-acquired cases of malaria failed to stratify cases by sex (Armed Forces Health Surveillance Center, 2007). Additionally, these published reports do not provide incidence rates. Despite these shortcomings, limited conclusions can be drawn. Overall, during the 13-year period, of 799 cases of malaria identified in these published reports, 96 Women at War

TABLE 6.1 Published Summaries of Malaria Cases in the US Military, 2000–2012, by Sex

Service and Male Female Year Component Cases % Cases % Reference

Total 758 94.9 41 5.1

2000 Army Active 55 100 0 0 (Army Medical Surveillance Duty Activity, 2001) 2001 Army Active 48 92.3 4 7.7 (Army Medical Surveillance Duty Activity, 2002) 2002 Army Active 35 97.2 1 2.8 (Army Medical Surveillance Duty Activity, 2003) 2003 Army Active 54 98.2 1 1.8 (Army Medical Surveillance Duty Activity, 2004) 2004 Army Active 55 98.2 1 1.8 (Army Medical Surveillance Duty Activity, 2005) 2005 Army Active 37 92.5 3 7.5 (Army Medical Surveillance Duty Activity, 2006) 2006 All 117 95.9 5 4.1 (Army Medical Surveillance Activity, 2007) 2007 All 81 94.2 5 5.8 (Armed Forces Health Surveillance Center, 2008) 2008 All 81 97.6 2 2.4 (Armed Forces Health Surveillance Center, 2009) 2009 All 55 91.7 5 8.3 (Armed Forces Health Surveillance Center, 2010) 2010 All 105 92.9 8 7.1 (Armed Forces Health Surveillance Center, 2011) 2011 All 121 97.6 3 2.4 (Armed Forces Health Surveillance Center, 2012b) 2012 All 35 92.1 3 7.9 (Armed Forces Health Surveillance Center, 2013) only 41 (5.1%) were among females. Considering that approximately 10% of overseas deployments during the period were among female military members (Armed Forces Health Surveillance Center, 2012a), these figures suggest that on a population level, females are at reduced risk of malaria relative to males. The reasons for this apparent protective effect among women is unclear from these figures, but plausibly may relate to policies in place at the time precluding the large-scale assignment of women to combat units in forward-deployed areas (Ferber, 1987) where large outbreaks occurred during the period (Kotwal et al., 2005; Whitman et al., 2010). With the full integration of women into such units (Steinhauer, 2013), it is reasonable 6. Issues in the Prevention of Malaria 97 to anticipate that future risk will be more proportional by sex, underscoring the importance of emphasizing malaria prevention among female Service members during future deployments.

STRATEGIES IN MOSQUITO AVOIDANCE

In forward-deployed areas, few obvious differences should exist in the risk of mosquito exposure by sex, and prior discussions of mosquito avoidance in the military have not noted any potentially unique needs of women in this regard (Robert, 2001). Studies of compliance with recommended mosquito avoidance measures find no significant differences by sex (Cobelens & Leentvaar-Kuijpers, 1997), and there is limited information in the published literature on sex differences in the effectiveness of these strategies. While formal data are lacking, a long-sleeved and long-legged military uniform, properly worn by both sexes, should provide equal protection against mosquito bites. Among certain women, as with men, this measure should be supplemented either by the manual treatment and regular retreatment of military uniforms with an appropriate pyrethroid insecticide such as permethrin, or by the wear of factory-treated uniforms (Faulde, Uedelhoven, Malerius, & Robbins, 2006), such as those recently adopted for use by the US Army (US Army, 2012), and by the careful and regular application of topical insect repellants, such as DEET. During overnight hours, the proper use of bed nets is also essential. The doctrinal application of these measures (Gambel et al., 1998) should in theory provide nearly 100% protection against mosquito bites (Croft, Baker, & von Bertele, 2001; Robert, 2001) and hence disease transmission. Unfortunately, deviations from these ideal conditions routinely occur during deployments (Kotwal et al., 2005; Ledbetter, Shallow, & Hanson, 1995), com- plicating prevention efforts. Regular use of topical insect repellants is uncommon (Vickery et al., 2008) and frequently occurs only in response to perceived nuisance biting (Gambel et al., 1998). Frequent doffing of the military uniform, both during off-duty hours on established bases and during reprieves from active operations in forward-deployed areas, and the increasingly doctrinal wear of military physical training uniforms, which leave significant skin exposed, may place Service members at heightened risk of direct contact with Anopheles mosquitos, particularly during evening and early morning hours, when biting activity is high (Taye, Hadis, Adugna, Tilahun, & Wirtz, 2006; Zimmerman et al., 2013). Risk of exposure during these times can be minimized by the wear of physical training uniforms with long sleeves and legs and by their pre-treatment (often overlooked during deployment planning) 98 Women at War with an appropriate pyrethroid insecticide, as well as by scheduling physical training and other outdoor activities at times other than peak biting times. Similarly, while the widespread availability of air conditioning (National Public Radio, 2011) and containerized housing units (Myers, 2009) in many deployed environments has lessened the need for bed nets, in highly malaria endemic field settings their employment should be strictly enforced, and adequate training provided prior to deployment on their proper use. Among pregnant women and women at risk of pregnancy during deployment, the use of pyrethroid insecticides and DEET evokes concern (Koren, Matsui, & Bailey, 2003) for potential reproductive harm and synergistic toxicity (Abu-Qare & Abou-Donia, 2003). It is known that DEET may cross the blood placental barrier (McGready et al., 2001) and may exert neurological effects (Sudakin & Trevathan, 2003). To reduce concerns of potential fetal harm, it is therefore appropriate for deployed women at risk of pregnancy to have access to an untreated military duty uniform or physical training uniform should pregnancy be diagnosed, to wear in areas such as air-conditioned living quarters, where alternative mosquito avoidance measures can be effectively implemented, while awaiting return in accordance with policies that preclude the continued deployment of women while pregnant (Grindlay & Grossman, 2013). As rates of unintended pregnancy among military women exceed 10% annually (Grindlay & Grossman, 2013; Lindberg, 2011), and rates of pregnancy during deployment exceed 2% annually (Nevin & Caci, 2013), ensuring the availability of such untreated uniforms at clinics where pregnancy is diagnosed may aid in reducing early prenatal exposure to pyrethroids, without requiring females at risk of pregnancy to deploy with these items.

ISSUES IN THE DEVELOPMENT AND TESTING OF ANTIMALARIALS IN WOMEN

As mosquito avoidance measures alone have historically been inadequate in deployed settings in preventing significant outbreaks of disease, US military policy has long emphasized supplementing these with the command-directed use of prophylactic antimalarials (McRoy, 1963). This emphasis, together with strategic shortages of the traditional prophylactic drug quinine, has historically motivated the US military to sponsor the development and testing of synthetic antimalarial compounds (Meshnick & Dobson, 2003). Such efforts, beginning formally during World War II, led to the development of primaquine and the rediscovery of chloroquine (Coatney, 1963; Pou et al., 2012); a similar effort two decades later led to the development of the quinine derivative mefloquine (Croft, 2007a). Clinical testing 6. Issues in the Prevention of Malaria 99 in such programs has traditionally been performed predominantly among men, leaving little direct evidence of safety in women, and leaving information on pharmacokinetics and reproductive hazards to be extrapolated from studies in males or laboratory animals. Clinical drug testing during World War II was conducted primarily on two types of subjects: male prison inmates, and adult neurosyphilitic and psychiatric patients. Of five clinical testing sites employed during the effort, only one included patients of both sexes (Wiselogle, 1946). Yet owing to the sheer number of compounds tested during the war, many compounds, including chloroquine, appear to have been tested exclusively among male subjects (Berliner & Butler, 1946). In early postwar years, further testing of chloroquine (Alving et al., 1948) and primaquine also appear to have been performed almost exclusively among male subjects (Most, 1963). A continued reliance on male prisoners and military personnel as test subjects during the development of mefloquine two decades later continued this trend (Croft, 2007a). Even studies performed among US civilian volunteers exclusively enrolled men (Reba, Barry, & Altstatt, 1983), and there were no studies involving pregnant or lactating women submitted at the time of initial US licensing of the drug (F. Hoffman- LaRoche, 1989). A subsequent US government study confirmed that 89% of subjects in pre-licensing trials of mefloquine were male (Burke, 1996). Similarly, early military- sponsored trials of tetracyclines as antimalarials conducted during the same period, including trials of minocycline, tetracycline, and doxycycline, were conducted exclusively among males (Clyde, Miller, DuPont, & Hornick, 1971; Rieckmann et al., 1971; Willerson, Rieckmann, Carson, & Frischer, 1972). In contrast, early studies of more recently licensed antimalarials, such as atovaquone/proguanil, involved significant numbers of female subjects (Looareesuwan et al., 1999; Overbosch et al., 2001; van der Berg, Duvenage, Roskell, & Scott, 1999). Reassuringly, as antimalarial drug development and testing remains a US military priority (Peake, Morrison, Ledgerwood, & Gannon, 2011), recent military studies of previously licensed drugs have taken care to include significant numbers of female subjects (Ebringer et al., 2011; Elmes, Nasveld, Kitchener, Kocisko, & Edstein, 2008; Nasveld et al., 2010).

TOLERANCE AND SAFETY OF ANTIMALARIALS IN WOMEN

In additional to limited pre-marketing data, post-marketing studies have provided significant information on the tolerance and safety of currently deployed antimalarials when used in women. 100 Women at War

Primaquine

Unlike the prophylactic drugs discussed in this chapter, primaquine has traditionally been used within the US military primarily as radical cure or as presumptive treatment to prevent relapsing forms of the disease. Recently, primaquine has attracted significant interest for its potential use in prophylaxis (Hill et al., 2006), although the drug lacks a formal indication for this purpose (Magill, Forgione, Maguire, & Fukuda, 2014). Although major reviews on primaquine make no reference to differential tolerance of the drug among women (Clyde, 1981; Hill et al., 2006; Weniger, 1979), limited post-marketing studies suggest that women may experience significantly higher serum concentrations with repeated (Binh et al., 2009) but not single dose use (Elmes, Bennett, Abdalla, Carthew, & Edstein, 2006), although the clinical significance of these findings is not known. Despite evidence of potential concentration-dependent brainstem neurotoxicity (Schmidt & Schmidt, 1951), and evidence of serious adverse events requiring hospitalization in approximately 1% of women (Ebringer et al., 2011), the drug is generally considered reasonably well tolerated at the current recommended daily dose of 30 mg (Magill et al., 2014), with concerns for adverse effects traditionally focused on the possibility of a potentially fatal hemolytic anemia among those with glucose-6-phosphate dehydrogenase (G6PD) deficiency. For this reason, in routine use, the drug is generally considered contraindicated among those who have not been confirmed to have adequate levels of G6PD activity, and owing to the inability to infer fetal G6PD status, the drug is therefore contraindicated during pregnancy (Hill et al., 2006). In single dose studies, the drug appears not to significantly impact the metabolism of oral contraceptives (Back, Breckenridge, Grimmer, Orme, & Purba, 1984), but pharmacokinetic evidence exists to predict significant drug interactions (Back, Purba, Staiger, Orme, & Breckenridge, 1983), particularly within various cytochrome P450 enzyme pathways (Li, Björkman, Andersson, Gustafsson, & Masimirembwa, 2003; Louisa, Soetikno, Nafrialdi, Setiabudy, & Suyatna, 2012; Pybus et al., 2012, 2013), and no specific studies have been performed among women to rule out clinically significant interactions with hormonal contraceptives with repeated dosing, such as may occur during use as primary prophylaxis.

Chloroquine

Although considered too toxic for human use when first synthesized by the Germans (Coatney, 1963; Pou et al., 2012), chloroquine has subsequently been considered well tolerated at prophylactic doses. At high doses, chloroquine may induce visual disturbances, including difficulties in near-far accommodation and diplopia (Alving et al., 6. Issues in the Prevention of Malaria 101

1948). Idiosyncratic cases of toxicity marked by a range of symptoms, including confusion, disorientation, agitation, aggression, persecutory delusions, and hallucinations, have been reported (Brookes, 1966; Good & Shader, 1977; Rab, 1963; Rockwell, 1968). Motor and coordination symptoms have also been reported with the drug (Singhi, Singhi, & Singh, 1979). Despite rare case reports of congenital abnormalities including atrial flutter (Feigl, Feigl, Shem-Tov, Brish, & Rotem, 1975) and vestibular disorders (Hart & Naunton, 1964) associated with use during pregnancy, chloroquine has traditionally been recommended as the drug of choice for use during pregnancy in areas of chloroquine-sensitive malaria (Irvine, Einarson, & Bozzo, 2011). Although less commonly used today in the prophylaxis of malaria (LaRocque et al., 2012), chloroquine and its derivatives are increasingly used at low doses, predominantly among older women (Jover et al., 2012) in the chronic treatment of rheumatologic disease (Thomé, Lopes, Costa, & Verinaud, 2013). In single dose studies, chloroquine appears not to significantly impact the metabolism of oral contraceptives (Back et al., 1984), although effects on the metabolism of hormonal contraceptives during long-term use cannot be ruled out.

Doxycycline

Doxycycline is generally well tolerated by military Servicewomen, but carries a risk of potentially serious esophagitis (Morris & Davis, 2000), and less serious adverse events that nonetheless markedly impact tolerability, particularly complaints of vaginitis (Tan, Magill, Parise, & Arguin, 2011), and photosensitivity or sunburn, which may affect roughly a quarter of military users (Wallace et al., 1996). In randomized blinded trials, 3% of users discontinued doxycycline, but in retrospective studies of long-term field use, 20% reported discontinuation due to intolerance (Korhonen, Peterson, Bruder, & Jung, 2007). Although not traditionally considered a psychoactive compound, recent animal evidence suggests that doxycycline, as other tetracyclines (Dean, Data-Franco, Giorlando, & Berk, 2012), may also have significant behavioral effects (Ferreira Mello et al., 2013). Owing primarily to concerns of permanent staining of the developing teeth, doxycycline has traditionally been considered contraindicated at all stages of pregnancy (Tan et al., 2011). Some authorities have noted that since dentition is formed only after the first trimester, this recommendation may be too strict, and they consider doxycycline “as safe as mefloquine” for use exclusively during the first trimester (Hellgren & Rombo, 2010), or provided therapy concludes prior to the fourth month of pregnancy (Irvine et al., 2011). Conflicting historical guidance exists regarding use with hormonal contraceptives. In a well-designed pharmacokinetic study, short-term use of doxycycline did not affect 102 Women at War the metabolism of certain contraceptives (Dogterom, van den Heuvel, & Thomsen, 2005), and prior reviews have concluded that doxycycline likely has no effect on serum levels of oral contraceptives (Archer & Archer, 2002). The pharmacokinetics of doxycycline appear unaffected by sex (Binh et al., 2009).

Atovaquone/Proguanil

The combination drug atovaquone/proguanil is considered very well tolerated among US military personnel (Armed Forces Health Surveilance Center, 2011), and is increasingly considered a preferred antimalarial agent. Since its introduction in the early 2000s, it has accounted for a rising percentage of antimalarial market share (LaRocque et al., 2012). In randomized trials, adverse events, including moderate neuropsychiatric symptoms, occur significantly less often than with other drugs (Schlagenhauf et al., 2003), and overall the drug is significantly better tolerated than mefloquine (Overbosch et al., 2001). Although generally considered safe, the drug is not without risk, and serious neuropsychiatric adverse effects, while rare, have been reported (Arznei-Telegramm, 2003). Proguanil adversely affects fertility in animal studies during very early gestation, but atovaquone does not, and both proguanil and atovaquone have been found not to be teratogenic in animal studies (Pudney, Gutteridge, Zeman, Dickins, & Woolley, 1999). Despite a few reassuring observational reports, including post-marketing studies suggesting that proguanil monotherapy does not affect pregnancy outcomes (Boggild, Parise, Lewis, & Kain, 2007; Eriksson, Björkman, & Keisu, 1991), there is generally considered to be insufficient evidence to recommend the use of atovaquone/proguanil during pregnancy (Irvine et al., 2011). Similarly, there is also insufficient pharmacokinetic evidence to rule out interactions of atovaquone/proguanil with hormonal contraceptives. Although atovaquone is mostly excreted unmetabolized (Pudney et al., 1999), the inactive prodrug proguanil undergoes metabolism to the active form cycloguanil mostly by the cytochrome P450 (CYP) enzyme CYP2C19 (Pudney et al., 1999). While hormonal contraceptives may significantly reduce activity of CYP2C19 (Tamminga et al., 1999), unmetabolized proguanil may also exert synergistic effects with atovaquone (Beerahee, 1999); therefore the clinical significance of this reduced activity is unclear.

Mefloquine

Although long associated with a risk of severe and often frightening neuropsychiatric symptoms (World Health Organization, 1989), including psychosis (Stuiver, 6. Issues in the Prevention of Malaria 103

Ligthelm, & Goud, 1989), amnesia (MacLean, 2013; Marsepoil et al., 1993), suicide (Croft, 2007b; Jousset et al., 2010), and violence, skepticism within the travel and preventive medicine communities as to the causal association of the drug with many of these psychiatric symptoms (Schlagenhauf & Steffen, 2000) and reluctance within the US military to acknowledge the true frequency of psychiatric effects (Schoomaker, 2009) has until recently resulted in the drug remaining commonly used within the US military (Kersgard & Hickey, 2013; Nevin, 2012b; Solano, 2011), despite falling popularity among civilian travelers (LaRocque et al., 2012). Rising recognition that the drug has been widely misprescribed to Service members, particularly female Service members, with contraindications (Nevin, 2010), that its use has been poorly documented (Woodson, 2012a), and that the neuropsychiatric symptoms caused by mefloquine could complicate the diagnosis and management of Service members with post-traumatic stress disorder and traumatic brain injury (Magill, Cersovsky, & DeFraites, 2012) has gradually led to recognition of the drug’s poor suitability for military use. A black box warning issued for mefloquine in 2013 has further clarified that permanent neurological injury may occur with its use and that psychiatric effects may last for years after dosing (US Food and Drug Administration, 2013). Severe idiosyncratic intoxication with mefloquine is frequently preceded by subtle prodromal neuopsychiatric symptoms, which may be commonly overlooked during military operations (Nevin, 2012a; Peterson, Seegmiller, & Schindler, 2011). Many of the neuropsychiatric adverse effects caused by intoxication with mefloquine, including alterations in sleep, nightmares, anxiety, depression, and changes in behavior such as irritability, are now recognized to be prodromal symptoms of a developing limbic encephalopathy (Nevin, 2012a), and according to product labeling guidance, now mandate the immediate discontinuation of the drug. Although severe intoxication is more common with high dose rates used in treatment of malaria or in overdose (Lobel, Coyne, & Rosenthal, 1998), likely due to significant genetic (Aarnoudse et al., 2006) and drug-mediated population heterogeneity in neu- ropharmacokinetics and consequent higher brain accumulation of the drug (Barraud de Lagerie et al., 2004), serious and lasting symptoms of intoxication may occur after only a single tablet (Grupp, Rauber, & Fröscher, 1994). Although the pathophysiological mechanism of these effects remains unclear, mefloquine has been demonstrated to be neurotoxic and at physiologic concentrations to cause permanent neurological injury to the brainstems of animal models (Dow et al., 2006), providing a parsimonious explanation for complaints of lasting vestibular disorder and other neurological complaints associated with the drug’s use (US Food and Drug Administration, 2012, 2013). Potentially as a result of sex differences in pharmacokinetics (van Riemsdijk et al., 2004), women consistently experience a higher risk of prodromal symptoms of 104 Women at War intoxication than men (Schlagenhauf et al., 1996; Schwartz, Potasman, Rotenberg, Almog, & Sadetzki, 2001; van Riemsdijk et al., 2004). As with atovaquone, a significant proportion of mefloquine is excreted in unmetabolized form (Mu, Israili, & Dayton, 1975; Rozman, Molek, & Koby, 1978), although mefloquine is also metabolized by the CYP3A enzyme system (Fontaine, de Sousa, Burcham, Duchêne, & Rahmani, 2000). While formal pharmacokinetic studies are lacking, based on accumulated experience mefloquine does not appear to affect the metabolism of hormonal contraceptives, nor has contraceptive failure been attributed in published reports to use of the drug. Although prior product labeling had advised that women avoid pregnancy for three months after dosing (Nevin, 2012c), recent recommendations, presumably developed based on limited post-marketing surveillance (Nevin, 2012d), have suggested that the drug may be safely used in pregnancy (Irvine et al., 2011). However, mefloquine, as with chloroquine, crosses the blood placental barrier and may accumulate in the developing embryo and fetus (Nevin, 2012c) and in the developing trophoblast, where biological evidence suggests that it may interfere with successful embryonic implantation and placental development (Nevin, 2011). Early epidemiological evidence, including within US military cohorts (Smoak et al., 1997), clearly demonstrated an increased risk of pregnancy loss with use of the drug (Nevin, 2012c).

SELECTING AN APPROPRIATE ANTIMALARIAL FOR WOMEN AT WAR

Since the Korean War (Porter, 2006), in order to reduce the incidence of subsequent disease, US military policy has emphasized the practice of universal presumptive antirelapse treatment (PART) with primaquine among personnel who are not G6PD defi- cient (Alving, Arnold, & Robinson, 1952) upon their return from areas where relapsing malaria is prevalent. Although this policy is informally waived by reason of obvious contraindication for women evacuated or administratively redeployed from malari- ous areas for pregnancy (a relatively common occurrence) (Albright et al., 2007), such contraindications have not been explicitly articulated in recent deployment guidance (US Central Command, 2010). Similarly, recent military-wide policy on the use of primaquine (Woodson, 2012b) does not direct pregnancy testing prior to prescribing or dispensing of the drug. Recent insights into the potential for significant interactions of primaquine with antidepressants (Pybus et al., 2013) and other medications commonly used by female Service members (Nevin, 2010) have also yet to inform recommendations on the improved use of primaquine among military populations (Magill et al., 2014). As there are yet no effective alternatives to primaquine, such contraindications and interactions are likely to further complicate the prevention of relapsing 6. Issues in the Prevention of Malaria 105 disease among women returning from deployments where mosquito avoidance measures have proven ineffective. Although policies for the use of primaquine in PART have remained generally unchanged (and of questionable effectiveness) (Porter, 2006) for over six decades (Hill et al., 2006), policies and recommendations for the use of prophylactic antimalarials during deployment have evolved considerably in that time. On the basis of policies and recommendations in place as of late 2013, important limitations and considerations for the use of various antimalarial drugs in prophylaxis are summarized in Table 6.2. The weekly dosed drug chloroquine was a favored antimalarial used both during operations in Korea (Alving et al., 1952) and in Vietnam (Powell, 1978), and remains an appropriate choice for prophylaxis in areas of documented chloroquine-sensitive malaria. However, with the widespread rise of chloroquine resistance, the daily dosed drug doxycycline became the US military’s drug of choice (Sánchez et al., 1993) for operations in areas of chloroquine resistance. With the licensing of mefloquine, which had been used as an investigational new drug during US military operations in the 1980s (Arthur, Shanks, & Echeverria, 1990; Boudreau et al., 1993), doxycycline was formally replaced as the drug of choice in areas of chloroquine resistance, and mefloquine was widely adopted for overseas operations beginning in the early 1990s, including during operations in Somalia (Magill & Smoak, 1993; Newton et al., 1994). Over the next two decades, mefloquine remained a favored antimalarial within the US military, being widely used during operations in Iraq, Afghanistan, and Africa (Nevin, 2010; Ritchie, Block, & Nevin, 2013). With rising recognition of the poor tolerance and low adherence to mefloquine in deployed settings (Brisson & Brisson, 2012; Kotwal et al., 2005; Whitman et al., 2010), official policies in the US military since 2009 have prioritized the use of safer daily antimalarials (Embrey, 2009). Subsequent evidence of improved adherence with daily antimalarials (Brisson & Brisson, 2012) and ecological evidence that rates of malaria fell 70% following the implementation of these policies have further challenged conventional beliefs in the advantages of mefloquine (Nevin, 2012b). Following the drug’s black box warning, the military subsequently reiterated that mefloquine should be prescribed only as a last resort in areas of chloroquine-resistant malaria (Kime, 2013), while certain elite US military units prohibited use of the drug altogether (Jelinek, 2013; Reactions Weekly, 2013). Particularly since 2013, in areas of chloroquine-resistant malaria, the combination drug atovaquone/proguanil has been prioritized for use among deploying personnel (Woodson, 2013a), but owing to persistent concerns for its higher cost, the drug remains used relatively infrequently within the military as compared to doxycycline (Kersgard & Hickey, 2013). With increasing recognition that the cost of even this most TABLE 6.2 Policy Limitations and Considerations for the Use of Antimalarials in Command-Directed Prophylaxis Among Women in the US Military, 2013

Antimalarial Limitations Considerations

Atovaquone/ • None • Causal prophylaxis active against liver proguanil • Drug of choice for and blood forms most deployments • Must use for 7 days upon return from deployment • Uncertain safety in pregnancy; discontinue if pregnancy is suspected or diagnosed Chloroquine • Cannot be prescribed • Suppressive prophylaxis active against for use in areas of blood forms only known chloroquine • Must use for 4 weeks upon return from resistance deployment • Considered by some authorities safe for use during pregnancy Doxycycline • Cannot be used for • Suppressive prophylaxis active against deployments blood forms only exceeding 3 months • Must use for 30 days upon return from deployment • Approved indication limits command directed use to no more than 4 months • Considered by some authorities safe for use prior to the fourth month of pregnancy Mefloquine • Cannot be prescribed • Suppressive prophylaxis active against to members of certain blood forms only elite units • Must use for 4 weeks upon return from • Use restricted by DoD deployment policy to “drug of last • Should be initiated as early as 7–10 resort” in other units weeks prior to deployment to achieve steady state concentrations and to identify idiosyncratic intoxication • Must immediately discontinue medication at the onset of any neuropsychiatric reaction (may occur in one third of women prescribed the drug) • Discontinuation may mandate immediate redeployment from areas of high malaria endemicity Primaquine • Cannot be prescribed • No approved indication for prophylaxis 6. Issues in the Prevention of Malaria 107 expensive antimalarial constitutes a relatively small fraction of the total cost of deployment, which by recent estimates can approach $1 million annually (Nevin, 2012b), atovaquone/proguanil is positioned to emerge as a preferred antimalarial within the US military (Cockrill, Von Thun, & Fukuda, 2012). Apart from improved tolerability, atovaquone/proguanil has a number of distinct advantages over doxycycline when used for prophylaxis, both among female and male Service members. Unlike atovaquone/proguanil, doxycycline is indicated only for short-term use of less than four months (Tan et al., 2011). As federal law requires that any command-directed use of pharmaceuticals be consistent with the drug’s labeled indication (Magill et al., 2014), the off-label use of doxycycline for longer than four months for prevention of malaria cannot be compelled or made mandatory by military policy. Atovaquone/proguanil, which has no labeled restrictions on duration of use, in contrast to doxycycline, is also a causal prophylaxis, active against the liver stage schiz- onts that precede blood stage infection (Schwartz, Parise, Kozarsky, & Cetron, 2003). The causal activity of atovaquone/proguanil permits a significantly reduced 7 days of prophylactic therapy after leaving the malaria endemic area, in contrast to the month required of doxycycline, which suppresses only blood stage infection. Owing to the long half life of the atovaquone component, and the causal nature of its prophylactic action, limited evidence suggests that atovaquone/proguanil should also be more significantly forgiving of missed doses and subsequent multiple dosing (Deye et al., 2012), in contrast to doxycycline, whose short half life and suppressive mechanism of action would preclude a similar effect (Tan et al., 2011). Chloroquine, which remains a theoretically appropriate choice in areas of documented sensitivity, has been underutilized in recent decades for this indication. Despite the absence of significant evidence of chloroquine resistance in Iraq (Fleet & Mann, 2004), mefloquine and doxycycline were widely prescribed during early operations there (United Press International, 2004), presumably out of an abundance of caution for the remote possibility of chloroquine resistance. Some major advisory bodies also remain reluctant to recommend chloroquine (Bradley & Warhurst, 1995; Gershman et al., 2014) for travel to areas where sensitivity has clearly re-emerged (Kublin et al., 2003). Similarly, although primaquine has clear theoretical utility as a preventive medication in some settings, the lack of a formal indication for this purpose (Baird, 2013) precludes command-directed use of daily primaquine as prophylaxis in US military settings (Magill et al., 2014). Although still indicated for prophylaxis, mefloquine should be only rarely prescribed within the US military. By current policy, mefloquine is never to be mass prescribed and is to be used only among those with true contraindications or intolerance to preferred daily medications (Woodson, 2013a). As previously discussed, true 108 Women at War contraindications to either medicine are exceptionally rare, and while intolerance to doxycycline is commonly reported, atovaquone/proguanil is very well tolerated, with blinded trials reporting a rate of discontinuation due to adverse events of 1% (Overbosch et al., 2001) to 2% (Schlagenhauf et al., 2003) during prophylactic use. Under policies that restrict its use to “drug of last resort,” mefloquine should therefore be anticipated to be prescribed to fewer than one in 50 women deployed to malaria endemic areas, and any higher rate of use should prompt careful review of prescribing practices (Woodson, 2012a). In this respect, reports of continued overuse of mefloquine are problematic (United Press International, 2013) and may point either to lack of familiarity with policy or to poor command enforcement. As awareness grows of the drug’s toxicity and as senior leaders better enforce existing policy (Andrews & Fitzpatrick, 2013), such inappropriate use should further decrease or cease altogether. In addition to ensuring compliance with policy restrictions on the drug’s use, military clinicians considering prescribing mefloquine to women in those rare instances where safer daily medications are precluded must also take a number of precautions to properly comply with recent product guidance (US Food and Drug Administration, 2013). Clinicians must properly inform the female patient that any neuropsychiatric symptoms may be evidence of a potentially progressive intoxication (Ritchie et al., 2013), which mandates the immediate discontinuation of the drug (US Food and Drug Administration, 2013). Although prior to the black box warning, such symptoms were commonly attributed to other causes and were poorly appreciated as evidence of toxicity (Schlagenhauf & Steffen, 2000), vivid dreams or nightmares (F. Hoffman-La Roche, 2013a, 2013b), insomnia or other sleep disturbance (F. Hoffman-La Roche, 2013c), mild anxiety or depressive symptoms, and other potentially subtle symptoms such as personality change and irritability are reason to immediately discontinue the medication (Ritchie et al., 2013). According to recent mefloquine product guidance (F. Hoffman-La Roche, 2013d), symptoms of disturbed sleep or abnormal dreaming may each develop in greater than 10% of users, and symptoms of anxiety or depression may each develop in 1%–10% of users. In randomized controlled trials, neuropsychiatric symptoms consistent with prodromal symptoms of intoxication occurred in 29% of users, independent of sex (Overbosch et al., 2001). The significantly higher incidence of neuropsychiatric symptoms among females as compared to males (van Riemsdijk et al., 2002) would imply that the rate of expected discontinuation would be even higher, plausibly exceeding one-third of women prescribed the drug. As the prodromal symptoms of mefloquine intoxication may quickly progress to include paranoia and confusion (Ritchie et al., 2013), particularly in military settings where drug adherence has traditionally been emphasized, patients suffering from intoxication may fail to heed product insert guidance and may continue taking 6. Issues in the Prevention of Malaria 109 the medication despite evidence of toxicity (Nevin, 2012a). Patient counseling should therefore be complemented by ensuring that those within the patient’s military chain of command, particularly those in the deployed environment, are thoroughly familiar with the often subtle signs and symptoms of mefloquine intoxication, which in prior military settings have been erroneously attributed to cowardice (Benjamin & Olmsted, 2004; Benjamin, 2004; Laskas, 2004) or to malingering or factitious disorder (Nevin, 2012a). Similarly, as many (Stürchler et al., 1990), but not all (Ritchie et al., 2013), cases of mild intoxication may be identified during early use of the drug, the clinician should consider limiting initial prescribing of the drug to a small number of tablets to be taken prior to deployment, evaluating the patient regularly and carefully during this period for the development of prodromal symptoms prior to prescribing the remaining tablets for deployment. Similarly, as mefloquine can frequently take 7–10 weekly doses to achieve steady state and protective serum concentrations (Boudreau et al., 1993; Whitman et al., 2010), where deployment dates are known in advance, a long period of pre-deployment dosing with careful observation should be considered, both to improve the efficacy of the drug and to minimize the risk of unrecognized intoxication occurring during remote deployments. Owing to the high risk of discontinuation, and as noted in the product labeling, the clinician and the chain of command should be prepared for the need for the female Service member to immediately discontinue the medication (US Food and Drug Administration, 2013). Per US military policy, as the use of mefloquine as a “drug of last resort” implies that no other prophylactic medications are available to switch to (Woodson, 2013b), in areas of high malaria endemicity, this may mandate evacuation to minimize risks to the patient should mefloquine be discontinued. Although under such conditions, it may be tempting for the clinician or the chain of command to recommend continuing the use of mefloquine, the risk of serious and long-lasting psychiatric symptoms and permanent neurological effects with continued dosing (US Food and Drug Administration, 2013) make such a recommendation unwise. In limited military settings, the use of prophylactic antimalarials may be omitted in favor of emphasis on mosquito avoidance measures (Ollivier et al., 2011). This is particularly true in settings of low endemicity and minimal transmission intensity, where mosquito avoidance measures can be faithfully implemented, and where early access to definitive medical care is available. In such settings, which are in fact typical of many recent US military deployments (Woodson, 2012b), relatively rare cases of malaria may be addressed through self-referral for early diagnosis and, when necessary, empiric therapy of suspected disease with treatment doses of antimalarials (Ollivier et al., 2011). 110 Women at War

Although it has been considered heterodoxy to advocate reliance only on mosquito avoidance measures, experience teaches that non-adherence to antimalarial prophylaxis within US military populations is extremely common (Brisson & Brisson, 2012), even in areas of moderate to high endemicity (Kotwal et al., 2005; Whitman et al., 2010). Despite numerous historical episodes of widespread non-adherence, most cases of malaria that occur under such conditions are successfully managed once brought to care. Rare fatalities, while tragic and entirely preventable, would have been equally preventable with improved emphasis on mosquito avoidance measures and improved recognition of early presenting symptoms of malaria (Montgomery, 2010). Among military women in whom the risks of antimalarial prophylaxis may clinically exceed its benefits, including women at high risk of pregnancy or in whom pregnancy has been identified and who are awaiting administrative redeployment or medical evacuation (Albright et al., 2007), and women in whom intolerance or contraindications preclude the use of safer daily antimalarials, emphasizing mosquito avoidance measures and reducing barriers to early presentation for care, including education on the early symptoms of malaria, should be considered as potential options on future deployments (Ollivier et al., 2011).

CONCLUSION

As female Service members increasingly serve in military operations in forward- deployed areas, they will find themselves progressively sharing the risk of malaria traditionally experienced by their male counterparts. To accommodate the unique needs of women at war, military clinicians and public health policymakers must ensure that knowledge and practices in regard to malaria prevention are commensu- rate with the unique needs of female Service members. The insights of the present chapter emphasize the importance of flexibility in the development and implementation of malaria prevention policies, the need for a range of antimalarial medications to remain available, and the importance of careful counseling and education of the female Service member, and those in her chain of command, in relation to malaria prevention.

DISCLOSURES

Dr. Nevin has served as paid and pro bono consultant and expert witness in legal cases involving claims of antimalarial drug toxicity. 6. Issues in the Prevention of Malaria 111

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HEATHER D. HELLWIG AND PAULETTE T. CAZARES

INTRODUCTION

For centuries, and as long as men have been sailing them, seagoing vessels have been referred to as women. The sea itself has been called a woman. The United States, like many strong nations, has a long naval history. Americans chose early on to establish a navy, and actually completed its formation nine months before declaring independence. Historically and currently, a strong navy has represented strength, national unity, and a strong commitment to national defense (http:// www.history.navy.mil/history/history1.htm). Yet for many, many years, women were not permitted to serve as part of a ship’s company, or to serve on submarines. In fact, in the Navy’s early years, they were not even physically on board. This chapter will first cover a brief history of women and the Navy. Then it will discuss modern developments for women in the fleet, including their addition to the crews of submarines. Women’s healthcare follows and, finally, a female Navy physician will offer a first-person account of her experiences as a ship’s doctor and will provide some clinical pearls.

A BRIEF HISTORY OF SHIPS AND WOMEN

In the early years of the United States’ growth, the prohibition of women on ships was canonized. An early regulation from 1802 read: “He (Captain or commander) is not to

120 7. Women, Ships, Submarines, and the US Navy 121 carry any women to sea without orders from the navy office, or the commander of the squadron.” Throughout the 1800s, regulations were periodically reviewed without much interval change. By 1841 the wording was changed to require even higher, and more detailed, chain of command authority for women to embark, stating, “Women are not to be taken to sea from the United States in any vessel of the Navy without permission from the Secretary of the Navy: nor when on foreign service, without the express permission of the Commander-in-Chief of the fleet or squadron, or of the senior Officer present and then only to make a passage from one port to another.” The Naval History and Heritage Command reports that regulations of 1881 were, again, similar, stating, “Officers commanding fleets, squadrons, divisions, or ships, shall not permit women to reside on board of, or take passage in, any ship of the Navy in commission, except by special permission of the Secretary of the Navy” (http://www. history.navy.mil/faqs/faq48-3a.htm). In a century of our nation’s development, not much had changed. Despite these segregating policies, women managed to slowly advance in the workplace. In military circles, their presence especially grew in medical fields, where they were contracted for work. This was, in fact, the only capacity in which they could serve until officially serving the Armed Forces through the creation of the Nurse Corps in 1908. In 1913, as part of the war effort in support of World War I, Navy nurses served aboard the transports USS Mayflower and USS Dolphin (http://www.navygirl.org/ navywomen/navy_women_history_page.htm). After both world wars, women were relegated back to support roles, which grew over the years, but remained restricted to the shore. The irony in the restrictions for women off ships at this time is that during World War I, as well as World War II, women were called to fill industrial roles traditionally filled by men, which had been left vacant due to military service. Not only did women fill those positions, but they did so successfully. So, while women obviously were able to fill jobsthey were not previously allowed to fill in the civilian sector, this was not occurring in the military environment. Rosie the Riveter would not only have to remain marginalized to civilian industry, she would largely go home after the war was complete.

MODERN PROGRESS

It was not until the 1970s that naval roles grew substantially, with women serving in the Chaplain corps, the Reserve Officer training corps, aviation training, and finally, in 122 Women at War

1978, as part of ship commands (http://www.history.navy.mil/special%20highlights/ women/navywomen.pdf). Jimmy Carter was president, and the US Navy had just approved their 1979 budget; it included women on non-combat ships (http://www.history.navy.mil/faqs/faq48-3g.htm). Interestingly, while there were many strong leaders who worked to make this happen, there remained questions as to possible strong secondary motives for the military in including women as part of the seagoing force, as this also coincided with the end of the draft. Additionally, by that time, women had already entered the US Naval Academy, beginning in the year of the nation’s bicentennial; the first female graduates would need additional roles in which to practice the skills that their degrees conferred (US Naval Academy, 2012). Years continued to go by, however, before the Navy realized the need to fully open the ranks to women. This awareness followed the loss of highly trained Officers and enlisted to attrition, at least in part ascribed to a lack of advancement opportunities. It turns out, equality is more than the simple presence of women in a physical space. In 1984, combat logistics support ships were opened to women. These are known as supply ships, re-fuelers, and those that support the fighting Navy. It did expose and create opportunities, allowing Lieutenant Commander Darlene Iskra, in 1993, to be named the first woman to command a ship, fittingly named the USS Opportune (ARS-41) (US Naval Academy, 2012). While this was a great victory, with the promise of career advancement for women in the Navy, the sprint of women ahead was paralleled by the widening awareness of unacceptable sexual harassment and assault, a problem that persists today. So, in 1992, under Chief of Naval Operations Admiral Kelso, the Navy’s first fleet-wide training on sexual assault was established. This came at a complex time of public discussions about moving women onto combatant ships and accusations of continuing sexual assault. Seemingly unjust and abusive incidents had been happening for years during the integration of women into the fleet. In public interviews, Navy leadership appeared puz- zled by their inability to make headway into this dangerous situation. Even today—in the midst of intensified focus, study, and scrutiny—some of this “confusion” lives on in the Navy and in the military as a whole. This is the case, despite leadership now having more clearly stated, rehearsed, and impactful statements on the matter. While roles were opening, criticisms of the plan to fully integrate women into a ship’s crew ran the spectrum from well-intended concerns about women’s health, to tangen- tial beliefs that large numbers of women would intentionally get pregnant to avoid ship service and deployments. A 1991 a New York Times article highlighted this sentiment with the headline “36 Women Pregnant Aboard a Navy Ship That Served in Gulf.” Nevertheless, in 1994, after testimony from the Chief of Naval Personnel, Admiral Ronald Zlatoper, surface combat ships finally opened to women. He stated in his May 7. Women, Ships, Submarines, and the US Navy 123

1993 testimony to Congress that it is “a logical progression after 50 years of service by Navy women… including 20 years in naval aviation and 15 years at sea” (http://nation. time.com/2012/10/03/more-navy-women-joining-the-silent-service). While Congress did move forward and enable women to serve on all ships, two significant equally limiting pieces of restrictions and legislation were enacted. First, women were specifically prohibited from serving in ground combat roles. This controversial rule, known as the Combat Exclusion Law, remained in place until January 2013, when it was finally repealed in full (http://www.defense.gov/Releases/Release. aspx?ReleaseID=15784). Second, accommodations were not made for women to join submarine crews, reportedly due to the expected cost of modifying these vessels. In 2000, official guidance from the Defense Advisory Committee on Women in the Services (DACOWITS) recommended that (1) for long-term integration, the Secretary of the Navy direct rede- sign of the Virginia class (“fast-attack”) submarines to accommodate mixed-gender crews, and (2) for short-term integration, the Secretary of the Navy and Chief of Naval Operations commence with assigning women to SSBNs (“boomers”) fleet ballistic missile submarines. The Committee further recommended Congressional approval of a Department of the Navy policy change. Five years after the Navy opened the path for women to serve on combatant ships, Captain Michelle Howard became the first woman to rise to the esteemed position of Commanding Officer (CO) of a combatant vessel, the USSRushmore (LSD-37) (http://www.history.navy.mil/special%20highlights/women/navywomen.pdf). The next followed one year later: Captain Kathleen McGrath, CO of the frigate USS Jarrett. Captain Howard ultimately retired as a two-star admiral, and Captain McGrath guided her ship to the northern reaches of the Persian Gulf, where the crew hunted boats suspected of smuggling Iraqi oil in violation of United Nations sanctions (http://www. arlingtoncemetery.net/kmcgrath.htm). When it came to the submarine fleet, however, it was not until 2011 that women first began working aboard ballistic missiles subs and guided missile subs. Recently, the Navy announced that the USS Virginia and the USS Minnesota would be the first two gender-integrated fast-attack submarines by January 2015. As of this writing, 43 female Officers have been integrated into the sub force; a plan for enlisted integration is scheduled for May 2015 (Navy News Service, 2013).

MEDICAL CARE

In the midst of the political background debating allowances for women to cross the brow, there was an appropriate concern about the medical requirements necessary to 124 Women at War provide for the safe care and medical success of providers and Sailors alike. It has been difficult to independently verify the original discussions around these concerns, but some of the public data are documented here. As would be expected, concerns for women’s health would range from complex to routine, including pregnancy, annual exams (including Pap smears), medical staffing, supplies, and pharmacy requirements, as adjustments to the ship-based formulary would be debated with cost and efficacy in mind. Since women have been working on submarines for such a short time, data regarding women’s health concerns are currently lacking. In 2001, a Naval Submarine Medical Research Laboratory (NSMRL) technical report described the potential “Medical Implications of Women on Submarines.” The conclusions of the report were divided into three categories: (1) implications affecting the submarine; (2) implications affecting women’s health, and (3) research requirement recommendations. Primarily, the report concluded that since women use healthcare more than men and have a higher incidence of certain disease states (including migraine headaches and asthma), the demand for medical services while underway, as well as initial waiver requests, would increase. Another concern was the potential loss of manpower due to pregnancy. In addition, the authors recommended modifying the submarine psychiatric screen due to the differences between men and women in the types of psychiatric diseases and disorders from which they suffer. Finally, adjustment of the Authorized Medical Allowance Lists and the addition of gynecological management algorithms were deemed necessary modifications to the current medical processes. Women’s health issues brought up by the authors included osteoporosis risk due to lack of sunlight, inactivity, and increased levels of carbon dioxide; ectopic pregnancy and spontaneous abortion; and risks to the developing fetus. Other than recom- mending rigorous pre-deployment screening due to the difficulties in the submarine MEDEVAC process, the authors were unable to draw conclusions about these potential women’s health issues due to a lack of existing data. The report concluded with several recommendations regarding further research. These recommendations included bone health studies; modeling studies to determine the impact of increased healthcare utilization; risk of ectopic pregnancy, spontaneous abortion, and pregnancy on the submarine service; and assessment of additional medical staffing, fixtures, supplies, and equipment needed to ensure adequate medical care. As independent duty corpsmen (IDCs, the Navy’s equivalent of a physician’s assistant) are the primary medical providers for submarines and serve as the only medical provider available while a submarine is deployed, the authors recommended review of the year-long IDC training curriculum to ensure that these practitioners are adequately prepared for providing healthcare to both men and women. 7. Women, Ships, Submarines, and the US Navy 125

Other than osteoporosis risk due to the lack of sunlight, concerns for the care of women on a ship are similar to those of care for men. Again, most small ships (frigates, destroyers, cruisers) do not have a physician aboard, and the medical staff is generally led by an IDC. Without a family practitioner or obstetric doctor onboard, pregnant women would need to be evacuated from ship duty, and the line was drawn at 20 weeks. This meant that a woman could be retained on the ship to carry out her duties until she was 20 weeks pregnant. However, in practice, most women are removed from shipboard duty once a positive pregnancy test is confirmed, as there are multiple safety hazards onboard. Additionally, concerns for preterm labor, hemorrhage, and miscarriage were appropriate, as they could put patient and medical staff at risk, as well as potentially compromise the ship’s mission, especially during periods in which the ship is underway or deployed. Most Commanding Officers (COs) recognize this (or are encouraged by their Medical Officers to appreciate the implications), and women are typically quickly reassigned to a shore-based command at the time a pregnancy is discovered. (Of note, this is a time when a Medical Officer [doctor] can, and really must, break confidentiality to ensure that the CO is aware of the Sailor’s health status.) Once the pregnancy concludes, the Sailor can rejoin a ship-based crew after a period of convalescence. Of course, not all pregnancies occur before deployment, and for those whose tests turn positive while the ship is deployed, the Sailor is medically evacuated back to the ship’s home port. For routine health concerns on ships, policies were instituted to ensure that Pap smears occurred annually (the requirement at the time) and that they were done prior to deployment, as lab facilities on board are neither equipped nor staffed to process those samples. Additionally, even if samples could be processed (on board or at bases overseas), little could be done to manage abnormal results at that point, necessitating pre-deployment “rushes” to get these exams completed for the crew. Pharmacy requirements and formularies were another issue. Ship-based formularies are known as the Authorized Medical Allowance List, or AMAL, and requirements for such were and are determined by history, experience, and the shore-based medical chain of command. The AMAL includes all medications and treatment equipment (bandages, tubing, ACLS supplies) required by each class of ship. As such, ships were absolutely mandated to ensure that the pharmacy was stocked prior to a deployment according to the details of the AMAL. The AMAL was changed to include various forms of oral contraceptives and treatment for gynecologic infections. Additional meds could be purchased at the request of a ship’s medical department and approved by the Supply Officer and Commanding Officer. This often led to some variation in pharmacy supplies from one ship to another, and, in my experience, these were significant when it came to the issue of emergency contraception (EC). 126 Women at War

In personal experience, the years that I (CDR Cazares) was a GMO1 (2005–2007), most Medical Officers used combinations of existing OCPs when women presented to medical requesting EC. However, once Plan B2 became more widely available, it could be purchased like any other medication for the ship’s supply. An appeal was made at the time to install Plan B as part of the AMAL, but soon after, it was approved as an over-the-counter medication, and the discussion became generally moot. All of this practical experience mirrors a 2007 DACOWITS report, in which it was noted that ensuring women’s health while underway on a submarine (or, by extension, a ship) is likely largely tied to ensuring ongoing health while ashore. The report used focus groups and surveys to describe the healthcare experiences of female Service members prior to, during, and after deployment. The report also summarized participant recommendations to improve their experiences and outcomes. In order to improve the Pre-Deployment Health Assessment (PDHA) Form and review process, participants recommended adding more female-specific questions, conducting more thorough health assessments (e.g., asking about recurring medical issues such as urinary tract infections), and providing more privacy during the PDHA process. The report also recommended providing briefings on female-specific issues, improving healthcare accessibility, requiring well-woman exams, conducting mental health screenings, and improving Service members’ ability to acquire prescription medications prior to deployment. Although submariners deploy on a recurring basis for shorter periods of time than those included in these focus groups and may not uti- lize the PDHA Forms, these recommendations may be useful to incorporate in the screening and education provided before selection for submarine (or ship) duty, before an initial deployment, and then periodically while assigned to a deploying unit.

THE PERSONAL EXPERIENCE OF DR. CAZARES

I had little to no idea of this history when I took my oath of office in May 2000, and matriculated as a first-year medical student at the Uniformed Services University. By the time I graduated in 2004 as a Navy lieutenant, I had spent some time learning about the history of women in medicine, but was still rather oblivious to the history of women in the Navy.

1 A GMO is a general Medical Officer, serving in a primary care capacity for the ship’s crew. 2 Plan B is a one tablet oral form of emergency contraception, intended to prevent unwanted pregnancy by preventing ovulation, fertilization, and implantation. It was prescription only until August 2006, at which time it was approved by the FDA to be sold over the counter for women over age 18. In June 2013, it was approved for sale over the counter to women 15 and older. 7. Women, Ships, Submarines, and the US Navy 127

I completed a year of internship in San Diego and, at that time, chose not to continue to residency, but instead to “go to the Fleet.” (I actually had completed my online application for a psychiatry residency, but at the last moment, withdrew it.) Being a General Medical Officer (GMO) was something I heard and learned about through my four years of medical school, and I didn’t want to pass up the opportunity to live and work in the “real” Navy, as hospital work is not considered by most to be representative of traditional life as a Sailor. I was encouraged by many on both sides: “go to the Fleet, you’ll love it!” and “just finish residency, then your training will be done.” At that point in my life, I was able to choose adventure freely, and I did. Interestingly, with the start of the war in Iraq, male GMOs were being funneled to work with the Marine Forces, as women were not yet allowed to serve in combat those roles (even though many women subsequently did effectively fill and excel in these roles during actual combat operations). As a result, all the billets for GMOs on ships were going to women. The GMO class of 2005 was one of the largest percentage of female shipboard GMOs ever; it was something unique. My ship actually left for deployment a month before I was able to be freed from the hospital and meet it. I flew to Darwin, Australia, and completed turnover with my predecessor, a particularly unemotional appearing but very nice and organized guy. (He later became an internist.) Turnover was made to seem straightforward, but I found it nothing short of overwhelming. This was a new language, a new environment, and I was surely aware of my minority status on the ship as a woman, notably so among the Officers. I worked hard through four months of an intensely steep learning curve, and succeeded in large part due to wonderful mentorship from other medical staff. The initial difficulty is not what women in the 1980s experienced onboard, nor surely what women before them faced. When I joined the crew, women had been in roles on combat ships, in one way or another, for 20 years. What I faced and felt was different. I was offered a wonderful opportunity to serve, but there was isolation. There were five female Officers in total on the ship. As the senior woman, I socialized with two younger female Officers whom I befriended, but had to be cautious not to cross the line and be “too social.” The Navy puts high value on perception, and as the ship’s doctor, I took this to heart—at least through my first of two years. (I thankfully relaxed during the second half of my duty.) I felt tremendous pressure to live beyond reproach, and over time, I have learned that this is an incredibly intense, stressful, and ultimately unsustainable and inhumane way to live. Come the second year and second deployment, I was able to dance in bars at ports of call and enjoy a cigar with the CO and know I was on stable foot- ing. I completed two deployments in two years, made wonderful friends, and saw the world. 128 Women at War

I never felt harassed on the ship or in the wardroom, and I thankfully never experienced anything remotely resembling an assault. However, as those who have served on ships know, the entire tone, feel, and tempo of the ship is established and maintained by the Commanding Officer. If he (it’s still rare to find a female shipboard CO) is an ethical, hardworking, progressive, fun person, so goes the ship. So, while I always felt safe carrying out my work, I was aware that I was definitely in the minority. Men cringed when they needed separation physicals that required a genitourinary exam. Many had never been touched by a female doctor in their lives, let alone in their careers. Telling a chief, a senior enlisted member of the crew, that he was due for a prostate exam would almost certainly bring blank stares, and in many cases, dropped jaws and speechless moments (from the patient). Additional constraints of the shipboard environment that extend to the full crew include the technical limitations of the practice of medicine. For example, our ship was deployed during the Thanksgiving holiday in 2005. That morning, I walked down to Medical feeling excited, and anticipating a “happy” day of Nat King Cole and clinic holiday decorating. My mother had sent six boxes of decorations, and after staring at gray walls already for months by that time, I had a need to decorate. I opened the main treatment door that morning, expecting to see my staff’s smiling faces, but I was stopped, literally, by the vision of a sick patient. There was one of our enlisted, hunched over a garbage pail on the floor. It took only a preliminary abdominal and pelvic exam to know that she needed to leave the ship with a presumptive diagnosis of appendicitis. This is pure clinical medicine—no surgery consult, no ultrasound, no CT scanner. It could’ve been her ovary, or it could’ve been her appendix—but there was no way for me to know definitively. What was known was that she needed to leave the ship that day—Thanksgiving day—when most other ships were in port (even in the deployed setting). “Ok, let’s get things up and moving, I’ll talk to the Captain and let him know we’ll need a helo.” As is typical with military chains of command, or corporate environments, they all handle crisis differently. The responses are all unique, as ships and capabilities are, and that’s exactly what is the same about them. But one thing is true, and that is that when a medical emergency is at play, they’ll move mountains to get their Sailors the help they need. Before I knew it, the ship was literally full-steam ahead in the direction of an incoming helicopter. The helo ETA was to be 3 hours. I thought, “Ok, this is alright. I have morphine, I have Phenergan for nausea and if she gets bad, I have lots of fluid and plenty of antibiotics.” She understood the plan, and before long, her young-adult orange Adidas bag was packed, and her friends were hanging around Medical, chit-chatting and laughing. She 7. Women, Ships, Submarines, and the US Navy 129 was occasionally smiling, but something wasn’t smelling right to me, and as I continued to watch her, I noticed she was going from pale to paler to paler. There were two of those wirey steel wool Department of Defense issue blankets on her and she was still telling my corpsmen she was cold. We were closely monitoring her vitals, and over the last hour, I noticed her temp was slowly climbing, the blood pressure slowly sinking, and her pulse slowly increasing. For anyone who works in medicine, this is bad. I knew it was time to speed up the process. Orders were written for Tylenol, antibiotics, a second IV with fluids as fast as they could go, and, “Me? I’m running to CIC to get a move on this helo.” CIC is military lingo for the Combat Information Center. If you want to see bells and whistles on a naval warship, that’s where they live—hanging digital screens, communications in encrypted and secret forms. From Combat, it’s possible to log on to a kind of Internet chat with folks in military officialdom and “make things happen.” I excused some young Petty Officer from the main communications screen and sat down at the keyboard, typing as quickly as I could.

Yes sir. It’s the Doc. Sir, let me repeat… I have an urgent medevac, with worsening vitals; I need you to expedite the process now. Explain? Sir, all due respect, I have confirmed this case with 2 other staff physicians. I need a helo here now, or this Sailor will die today.

Silence is a unique state, especially in the midst of an emergency. After what seemed longer than the 30 seconds it likely was, I had my response, and I was informed the pilot would be there sooner than we had originally expected. At the beginning of that deployment, I would’ve never known or had the courage to waltz into Combat, sit down, turn off the big screen for privacy, and demand that a helo move faster—forget about demanding it from the Admiral’s representative—but a few months at sea made this girl a little saltier than she was when she left San Diego. At 1625 that day, my team was loading her onto a stretcher to carry her out to the flight deck. She was able to cautiously and painfully slowly walk outside, and that was enough for me; stretcher the rest of the way. I was standing on the steps above her, reviewing the mental checklist with my radiology tech, whose turn it was to travel with our medevac. As her medical escort, she would carry out all basic care from our ship to the nearest overseas hospital. “Continuous vitals, 2 IVs are in place, you have morphine and Phenergan in your bag and an ambulance will be waiting on the other end. Be sure to get all records and if you need a translator, demand one. Ok, that should cover it, you’ll be alright.” And she nodded the entire time, humoring me in my nervousness and my maternal physician-ness. 130 Women at War

There were rough seas that day and the sun was beginning to set, so other than my elevated blood pressure and that small headache above my right eye, I thought it looked, relatively speaking, beautiful outside. They carried the stretcher away and I watched her get loaded on the helicopter. As I stood there, my pharmacy tech appeared with a dish of the garlic-mashed potatoes he had been intermittently cooking throughout the day for the crew. I realized at that point I had no memory of when I had last eaten. We exchanged “Happy Thanksgivings” and I dug into those potatoes—and let me tell you, they were good. And that was Thanksgiving. I was wound up until finally, at 0040, my inbox rang with a message from my trusted radiology tech. They had arrived safely, the ambulance was at the ready, ultrasound in the ER confirmed appendicitis, and she went directly to the OR. The surgeon informed her that only a few more hours and it would have rup- tured. The surgery went well and she was resting comfortably. I breathed, deeply, and yes, I cried. It was just a few tears, but I needed to cry. Out to sea, there’s a difference. On the ship, here, they’re not strangers; they’re one of your own and the whole experience changed me. Care in that close environment is different from the hospital, it’s different from reading academic case files, and it was different from life before deployment.

• • •

I remained the senior woman on the ship for some time, until finally another female lieutenant transferred aboard. By the time we left on our second deployment in two years, I felt confident professionally. I had earned a pin that qualified me as an honorary-pseudo-Surface Warfare Officer (SWO), which basically means I was a Medical Officer who had learned enough about the ship to pass an oral board with the real SWOs. The technical knowledge helped, but gaining the confidence to speak up in a busy, male-dominated wardroom or mission-focused meeting was the most difficult. Despite my experience, I often second-guessed myself. We deployed to South America on what is often called a “cocktail cruise,” a round-the-continent tour including visits with all America-friendly Navies, this time with two smaller ships (without doctors). South America offers wonderful, culturally rich port calls, and I served as the Medical Officer for all three ships for the four months of that tour, seeing clinic and taking calls for the smaller ships when we were in port, and managing medical evacuations when necessary. (I did also get to enjoy my share of many sites.) It was a thrilling experience that taught me how much medicine can actually be practiced without fancy technology, without specialists, and without the cutting-edge practices of an academic hospital. That being said, it could be very lonely at times. The military restricts socialization in the ranks, and that left few women to 7. Women, Ships, Submarines, and the US Navy 131 befriend. I did make friends, great ones, but I found not having colleagues to discuss cases with frustrating, not for need of specialty care (I could get that if needed), but even if just to help manage the stress, intensity, and passion of it all. Further, as physicians, we are a group that self-selects to engage in lifelong learning. By the end of my two-year tour, I missed Grand Rounds, I was all too happy to get my hands on a current medical journal, and I was ready to advance my academic career.

Clinical Pearls (CDR Cazares)

After having navigated my tour, and subsequently trained psychiatry residents preparing for deployments, I have gathered a few pearls for the white coat pocket. By no means is this an exhaustive list, but they serve to protect and promote a doc’s good health and performance on board a naval ship.

1. Understand the CO’s philosophy and intent, and the deployment plan for the next one to two years. This will help profoundly in planning for spikes in needed exams (well-woman) as well as creating storage for deployment meds. When a Sailor is prescribed a routine medication, either by the ship’s physician or a specialist, each one of them requires a 6+ month supply prior to deployment. For safety, most medical departments store the majority of meds in the medical spaces, and during deployment, will administer them at manageable intervals. 2. Inspect the pharmacy, lab, and condition of medical records yourself. As a new leader on the ship, it is incumbent on the physician to be confident that inspec- tion reports match supplies, reported cleanliness, and functionality. “Trust, but verify.” 3. Sit in on interactions between junior staff and patients. This opens tremendous opportunities to understand a staff’s skill level, as well as to identify areas ripe for teaching, or for immediate correction. Properly teaching a junior staff, who almost universally want to learn, frees the physician to engage in higher level planning, thinking, supervising, and mentoring. 4. Do not engage in VIP medicine. The rank structure in the military lends itself to the idea that senior ranking members deserve or should receive care that is qualitatively different from care provided to junior ranking members. This is absolutely untrue, and in fact opens the provider to mistakes they would usually never make, and exposes the patient to substandard care. This can be secondary to nervousness on the part of the physician, or institutional structures that demand it (e.g., executive medicine wards), or the misinformed idea that Officers are less sick, engage in less risky behaviors, and drink less than enlisted 132 Women at War

Sailors. As a combination of all of these, I have witnessed good providers make unusual mistakes that are solely due to a divergence from their practiced and standardized history, physical, and laboratory examination. For example, when addressing a complaint of headaches, commanders need to be questioned about alcohol use just as much as a junior Sailor. I would argue that this can be especially poignant in the case of a female physician caring for senior enlisted and senior Officers who are men. There is an added reluctance on the part of patient and provider to engage in questions about a sexual history, alcohol use, and other behavioral patterns, even when clinically indicated. There is anxiety around urologic, rectal, or even abdominal exams. It is critical to do the same basic thing at all times. Making exams convenient (e.g., drawing blood in the CO’s stateroom versus medical) is one thing; not doing the exam is another. Finally, when treating a patient of higher rank, there is often significant intrusion from the chain of command regarding the patient’s diagnosis, progno- sis, and so on. This is understandable, but it is more than prudent for the provider assigned to the patient to politely (or directly) excuse the interested parties from e-mails, meetings, and conversations. The only people who need to know are the same who need to know about a junior Sailor’s health. The doctor-patient relationship is critical, and should be protected at all costs.

CONCLUSION

The history of women’s integration into regular shipboard life, and specifically into medical care, has covered a tremendous distance, including the recent integration of women onto submarines. There are known and unknown figures who have moved us in this direction, and we are clearly indebted to all of them. We hope to continue to learn more as experiences and data grow. We close with a remark made by a Navy woman nearly 20 years ago to The Navy Times:

I did not join the Navy to advance a social program, file subjective harassment suits, get pregnant, and accidentally carry out my assigned military mission in the process. I joined to serve my country. (http://nation.time.com/2012/10/03/more-n avy-women-joining-the-silent-service/)

We love being in the presence of women who work without question, and we serve proudly with them, onboard or ashore. 7. Women, Ships, Submarines, and the US Navy 133

REFERENCES

36 women pregnant aboard a Navy ship that served in Gulf. (1991, Apr 29). The New York Times. 2012. Celebrating women’s history month at the U.S. Naval Academy, women’s education—women’s empowerment. Retrieved from the US Naval Academy site. http://www.usna.edu/PAO/newsarticles/ images/2012.03.29-01/Womens_History_Poster.pdf. Armed Forces Surveillance Center, Medical Surveillance Monthly Report. (2013). Medical evacuations from Afghanistan during Operation Enduring Freedom, Active and Reserve Components, U.S. Armed Forces, 7 October 2001–31 December 2012 (Vol. 20, No. 6). Retrieved from http://www.afhsc.mil/ viewMSMR?file=2013/v20_n06.pdf. Commander, Submarine Forces Public Affairs. (2010, April 29). Navy policy will allow women to serve aboard submarines. Navy News Service. NNS100428-31. DACOWITS Defense Department Advisory Committee on Women in the Services. (2000).Fall Conference 2000. Retrieved from the DACOWITS website. http://dacowits.defense.gov/ ReportsMeetings/2000Fall.aspx. DACOWITS Defense Department Advisory Committee on Women in the Services. (2007). 2007 Report. Retrieved from the DACOWITS website. http://dacowits.defense.gov/Portals/48/Documents/ Reports/2007/Annual%20Report/dacowits2007report.pdf. DACOWITS Defense Department Advisory Committee on Women in the Services. (2012). 2012 Report. Retrieved from the DACOWITS website. http://dacowits.defense.gov/Portals/48/Documents/ Reports/2012/Annual%20Report/dacowits2012report.pdf. Kane, J. L., & Horn, W. G. (2001). The medical implications of women on submarines (NSMRL Technical Report #1219). Groton, CT: Naval Submarine Medical Research Laboratory. eight Female Combat Medics

CHARLES FIGLEY, BARBARA L. PITTS, PAULA CHAPMAN, AND CHRISTINE ELNITSKY

INTRODUCTION

Since the formation of the US military, women have been a valuable asset to the Army, most notably in the field of healthcare, including mental health.1 Although women comprise only 17% of active duty forces, they play a proportionately larger role in healthcare than men. As the name suggests, combat medics provide emergency (trauma) and preventative healthcare, including mental health. This chapter will review what we know about combat medics, though the focus will be on female medics. Among the research and practice literature that we will summarize are findings from of a study of combat medics we are completing at the time of this writing. Leading the chapter is a brief review of women in military medicine. The second part will focus on findings from our three-year study of combat medics and the fact that there were few differences in combat experiences or combat-related PTSD. As will be noted in the chapter, this runs counter to predictions based on civilian literature that women develop PTSD significantly more than men.

WOMEN IN MILITARY MEDICINE

While most policies have limited the integration of women in the US military, when needed, women have participated in some fashion in every major US war and have proven to be a necessary part of military medicine. Recent policy changes have brought women closer to combat than ever before, making it even more important to examine

134 8. Female Combat Medics 135 gender differences in the roles that women play in the war zone and the impact that their experiences have on mental health. As early as the Revolutionary War, women served as nurses, providing front-line trauma care to wounded American Soldiers. During the Civil War, 6,000 female nurses were recruited by the Union Army to serve in field hospitals and on the hospital ship Red Rover. Dr. Mary Walker, a combat surgeon during the Civil War, was the first female physician in the US Army and in 1866 became the only woman in US history to receive the Medal of Honor. Despite their heroic contributions to the US military, when the Civil War ended the Army reverted to an all-male force, assigning men to nursing duties and dis- charging all females who had served. However, when overwhelmed by the devasta- tion caused by typhoid, malaria, and yellow fever during the Spanish-American War, the Army again looked to women for their assistance. Dr. Anita Newcomb McGee, a surgeon and director of the Daughters of the American Revolution, suggested to the Army Surgeon General that qualified female nurses be hired under her selection and guidance. Soon after, 1,500 civilian nurses were assigned to Army hospitals on the mainland, abroad, and on the hospital ship Relief. Dr. McGee was appointed as Acting Assistant Surgeon General and was asked to help create a permanent corps of Army nurses. In 1901, Congress established the Army Nurse Corps. Nurses under this establishment held full military status, but were considered military auxiliary, meaning that they had no military rank or benefits. When World War I began, the Army Nurse Corps was well prepared, increasing its numbers from 4,100 to 21,460 to serve at base and evacuation hospitals, on transport ships, on hospital trains, and at mobile surgical hospitals across Europe. The Army Nurse Corps was again asked to increase its numbers during World War II, when more than 60,000 nurses served at locations across the United States and abroad. Despite the contributions made by women in combat theaters during World War II and the Women’s Armed Services Integration Act of 1948, which initiated full integration of all branches of the US military, women were largely excluded from the Korean War. Their role during this time was to fill the US positions of men who had been sent abroad. This policy carried into the beginning of the Vietnam War. The Persian Gulf War was a major turning point for the integration of female troops (Patten & Parker, 2011). This war marked the first time that females were in operational units in a combat zone. Wars in Iraq and Afghanistan saw similar roles for women. Although restricted from combat-specific positions, they were often attached to operational units in support positions, and often were required to engage in firefights and other combat situations from which they were previously sheltered 136 Women at War

THE ROLE OF THE COMBAT MEDIC

Combat medics are an integral part of any mission (Nessen, Loundbury, & Hetz, 2008; Combs, 2012). Combat medics are one of the largest Military Occupational Specialty (MOS) within the Army, second only to the Infantry (Bond, 2005). Thus, medics are an integral part of the Army’s combat mission and serve in maneuvering or sustainment units and military treatment facilities (MTF) as well as clinics. While medics serving with sustainment units or in MTFs or clinics provide medical support to logistics and personnel services units required to maintain combat operations, those serving in maneuvering units are more likely to directly engage the enemy in combat (Chapman et al., 2012). This chapter focuses specifically on US Army combat medics and will present the results of a recently concluded, three-year study of medics deployed with maneuvering units between 2009 and 2011, particularly deploying with Brigade Combat Teams (BCTs). The US Army relies heavily upon the combat medics during war (Nessen et al., 2008). Army medics receive training in tactical casualty combat care (TC3) for treating Soldiers directly on the battlefield. During warfare, they deploy with other Soldiers on the front lines, where they provide frontline trauma care, often in the heat of battle, with limited resources, and under enormous stress. They are considered a special sub- population due to their dual role of both warfighter and healthcare provider, carefully balancing the emotional burden associated with the responsibility of maintaining the health and well-being of all Soldiers, while facing the potentially life-threatening traumas of war experienced by most Soldiers. Due to their limited numbers and increased rotation on patrols/missions, medics are likely to report more combat experiences than other Soldiers deployed outside operating bases (Chapman et al., 2012).<1> This is an important insight, as combat is considered a primary risk factor for post-traumatic stress disorder (PTSD) and comorbid psychopathologies, such as depression. Because combat medics provide front-line trauma care, with limited resources, they endure enormous stress, but enjoy considerable respect among the Soldiers under their care. In modern warfare, they must be able to transition from a Soldier role to a medic role quickly and decisively, in accordance with the tactical situation. They must not only understand the nature of war, but also the nature of war-related injuries and the implications for medical procedures that will be effective given the tactical environment, current location, resources available, and capabilities (Mazurek and Burgess, 2006). Thus, combat medics are required to cope not only with the emotional burden associated with the responsibility of maintaining the health and well-being of all Soldiers, but also with the potentially life-threatening situations of war that all Soldiers must endure—which include participating in combat. 8. Female Combat Medics 137

Women Combat Medics

Though not always given the title of medic, women have functioned as medics since at least World War II (Luz & Brotherton, 2010). Until very recently, female medics were attached to support units, such as aviation companies. However, the Army’s initiation of modular brigades during Operation Enduring Freedom (OEF) brought female medics into maneuvering units like never before (Thibeault, 2012). Female medics from modular brigades performed tasks such as running a battalion aid station, providing tactical medical support, and even supporting combat logistics patrols, route-clearing missions, and security and reconnaissance missions. Female medics have been especially useful in providing healthcare to the local women and children, who otherwise would have gone untreated due to differences in the cultural climate of Muslim countries, where they believe that females cannot have contact with males, even for medical care, without the presence of a male family member. Women have proven to be a vital part of the mission in Afghanistan as part of Operation Enduring Freedom (OEF), and they continue to prove themselves essential to military medicine (Thibeault, 2012).

THE CURRENT STUDY OF COMBAT MEDICS

The authors are completing a three-year longitudinal study on behavioral health among US Army Combat Medics. Complete sampling techniques, data collection, and sample descriptive characteristics for the larger study are available elsewhere (Chapman et al., 2012).

Combat Medic Sample

Participation was open to all European and Fort Hood, Texas, US Army combat medics, and consisted of 799 medics. All participants were enlisted Soldiers, in one of two groups: E1–E4 (no leadership responsibilities), and E5–E9 (Non-Commissioned Officers). Those under the age of 18 and those with combat-related physical injuries requiring overnight hospitalization were excluded. The main study excluded Soldiers with combat-related physical injuries requiring overnight hospitalization during their most recent deployment due to (a) the high correlation of physical injury and mental health issues, and (b) time out of theater. Eligible participants attended a briefing where they were informed about the study, and written informed consent was obtained. Cases for the current study were drawn from the Soldier’s most recent deployment, resulting in 622 total cases. Demographics are provided in Table 8.1. Of the 138 Women at War

TABLE 8.1 Demographic Characteristics of Sample

Total Sample n Male n Female n Characteristic (%) (%) (%)

Grade/Rank E1–E4 331 (53.3) 269 (54.02) 60 (50.42) E5–E9 290 (46.7) 229 (45.98) 59 (49.58) Age Mean (SD) 29.17 (6.50) 29.43 (6.57) 28.13 (6.18) Race White 421 (68.9) 347 (70.53) 71 (61.74) Black 95 (15.5) 68 (13.82) 26 (22.61) Other 95 (15.6) 77 (15.65) 18 (15.65) Education High-school or Less 146 (23.9) 122 (24.95) 23 (19.65) Some college 412 (67.6) 329 (67.28) 80 (68.38) College graduate 52 (8.5) 38 (7.77) 14 (11.97) Marital Status Not married 390 (63.2) 323 (65.25) 66 (55.93) Married 227 (36.8) 172 (34.75) 52 (44.07)

622 combat medics, 81% were males (499) and 19% were females (119). The sample appears to be consistent with combat medics throughout the US Army, with fewer females than males at both junior and senior enlistment ranks. The same contained more females who are African American (22.61% vs. 13.82%) and fewer females with high school education or less (19.65% vs. 24.95%) but more college graduates (11.97% vs. 7.77%). More female combat medics were married (44.07% vs. 34.75%). There were generally no differences, however, between females and males in terms of rank distribution and age.

Measures Validated measures used in larger military population health samples were utilized in the current study and originated from the previous Mental Health Advisory Team (MHAT) studies of the US Army and the Manual for the Deployment Risk and Resilience Inventory (DRRI): A Collection of Measures for Studying Deployment-Related Experiences of Military Veterans; sychometric properties for the MHAT measures are provided elsewhere (King, King, & Vogt (2003). For the current study, participants responded to a survey questionnaire containing demographic items and measures of combat experiences, psychological health, and perceived stigma and barriers to care (Hoge, Castro, Messer, McGurk, Cotting, & Koffman, 2004). 8. Female Combat Medics 139

Combat Experiences and Exposures Deployment experiences were characterized by several variables. The Combat Experiences Scale (MHAT) was used to assess a wide variety of potential warfare events. The measure consists of 35 items and is used in the MHAT-V.<37> Each item is dichotomized into 0 (= never experienced) and 1 (= experienced at least once). Items are summed to obtain a total score, with higher scores indicative of more combat experience. In addition to the MHAT combat experiences scale, experiences of combat were also measured with the Combat Experiences Scale (CES) from the DRRI. This 15-item scale was designed to measure exposure to stereotypical warfare experiences such as firing a weapon, being fired on (by enemy or friendly troops), witnessing injury and death, and going on special missions or patrols that involve such experiences. Items are dichotomous (0 = no; 1 = yes). Items are summed to obtain a total score, with higher scores indicative of more combat exposure. Alpha reliability is reported as .85. The experiences related to the aftermath of battle were measured with the Post-Battle Experiences Scale from the DRRI. The scale was designed to measure exposure to the consequences of combat. The 15 items are dichotomous, (0 = no; 1 = yes). Items are summed to obtain a total score, with higher scores indicative of more post-battle experiences. Alpha reliability is reported as .89.

Psychological Health The nine-item Patient Health Questionnaire (PHQ-9) (Spitzer, Kroenke & Williams, 1999) was utilized to screen for major depressive symptoms. Instructions were to indicate how bothersome each symptom had been in the past two weeks using a 4-point scale. Responses were not at all, several days, more than half the days, or nearly every day. A total score was calculated by summing all of the items. For the larger study, the measure yielded a Chronbach’s alpha of .88. Post-traumatic stress symptoms were measured with the PTSD CheckList (PCL) (Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL is a 17-item self-report rating scale designed by the Department of Veterans Affairs’ National Center for PTSD to evaluate PTSD symptom categories. Two versions of the PCL were utilized, although the differences are slight. The PCL-M is a military version and questions refer to “a stressful military experience.” Respondents indicated how bothered they had been in the past month, utilizing a 5-point scale ranging from not at all to extremely. A total score was calculated by summing all of the items, with higher scores indicative of more severe symptomotology. The psychometric properties of this measure are well-established in the literature (Hoge, Castro, Messer, McGurk, Cotting, & Koffman, 2004). Chronbach’s alpha obtained for the larger study sample was .95 for each of the checklists. TABLE 8.2 Combat Experiences by Gender

Male Female

Combat Experience f % f %

Being attacked or ambushed.*** 202 56 30 35 Seeing destroyed homes and villages.*** 227 63 30 35 Receiving small arms fire.*** 184 51 24 28 Seeing dead bodies or human remains. 235 65 46 54 Handling or uncovering human remains. 153 43 36 42 Witnessing an accident that resulted in serious injury or death. 138 38 28 33 Witnessing violence within the local population or 159 44 20 24 between ethnic groups.*** Seeing dead or seriously injured Americans. 194 54 46 54 Knowing someone seriously injured or killed. 218 61 46 54 Participating in demeaning operations.** 90 25 8 9 Improvised explosive device (IED)/booby trap exploded 190 53 24 28 near you.*** Working in areas that were mined or had IEDs.*** 256 71 36 42 Having hostile reactions from civilians.** 207 57 34 40 Disarming civilians.*** 123 34 4 5 Being in threatening situations where you were unable 158 44 16 19 to respond because of rules of engagement.*** Shooting or directing fire at the enemy.*** 92 25 8 9 Calling in fire on the enemy. 25 7 2 2 Engaging in hand-to-hand combat. 9 3 1 1 Clearing/searching homes or buildings.*** 193 54 10 12 Clearing/searching caves or bunkers.*** 72 20 3 4 Being wounded/injured. 26 7 7 8 Seeing ill/injured women or children whom you were 173 48 30 35 unable to help.* Receiving incoming artillery, rocket, or mortar fire. 238 66 51 60 Being responsible for the death of US or allied personnel. 1 0 1 1 Having a member of your own unit become a casualty.* 183 51 32 38 Had a close call/dud landed near you. 128 36 26 31 Had a close call. 17 5 1 1 Had a close call/equipment shot off your body. 12 3 2 2 Had a buddy shot or hit who was near you. 45 13 5 6 Informed unit members/friends of a Soldier’s/Marine’s death. 21 6 9 11 Successfully engaged the enemy.*** 89 25 4 5 Encountered grateful civilians. 275 76 59 69 Provided aid to the wounded. 282 78 65 76 Saved the life of a Soldier/Marine or civilian. 143 40 35 41

Note: Significant associations between gender and each combat experience were assessed using Fisher’s Exact test. * p <= 0.05. ** p <= 0.01. *** p <= 0.001. 8. Female Combat Medics 141

Stigma and Barriers to Care Perceived stigma and barriers to care were measured with five items, each originally developed by Hoge and colleagues. Participants rated concerns that might affect the decision to receive mental health services. Responses ranged from strongly disagree to strongly agree. A positive response was considered an endorsement of either agree or strongly agree. Chronbach’s alphas of .84 and .79 were observed for stigma and barriers to care, respectively. Items are available in Table 8.2.

Statistical Analysis Analyses were performed using Statical Analytic System (SAS) and were conducted with list-wise deletion of missing data. Combat experiences from the MHAT and the DRRI and the Deployment Concerns were approximately normally distributed, so gender differences were assessed with the two independent samples t-test. The Post-Battle Experiences Scale was not normal and was therefore analyzed using the two independent-sample Wilcoxon Rank Sum tests. Proportions were calculated for each item of the combat experience and exposures scales and were tested using exact Fisher’s test. Due to lack of normality, generalized linear models were utilized to assess possible differences in PTSD and depression symptom severity scores, after controlling for combat experiences and exposures. Collinearity issues were assessed for the combat experiences and exposures scale using the condition index in SAS. Using a general rule of thumb of 30, none of the combat experiences or exposures was removed from the model. For PTSD, the procedure involved a gamma distribution and its canonical link function. Depression symptom severity scores were rescaled by adding “1” to each score so that the log link function could be utilized. (Note: Rescaling was required because there were some “0” responses and the log of 0 is infinity.) Finally, gender differences in stigma and barrier items were each assessed with logistic regression, controlling for combat experiences.

RESULTS

Combat Experiences, Exposures, and Concerns

Significant differences were found in total number of MHAT combat experiences by gender (t (441) = 4.46, p < .001), with group variances assumed to be equal. Males had a higher total number of combat experiences (M = 13.97, SD = 7.74) compared to the females (M = 9.88, SD = 6.88). Significant differences were also found in the total number of DRRI combat experiences by gender (t (446) = 4.46, p < .001), with group variances assumed equal. Males had a higher total number of combat experiences (M = 5.17, SD = 3.04) compared to females (M = 3.55, SD = 2.87). Significant 142 Women at War

TABLE 8.3 Combat Experiences (DRRI) by Gender

Male Female

Combat Experience f % f %

I went on combat patrols or missions.*** 316 87 60 71 I or members of my unit encountered land or water 213 59 33 39 mines and/or booby traps.** I or members of my unit received hostile incoming fire from small arms, 304 84 60 71 artillery, rockets, mortars, or bombs.** I or members of my unit received “friendly” incoming fire 52 14 15 18 from small arms, artillery, rockets, mortars, or bombs. I was in a vehicle that was under fire.** 151 42 22 26 I or members of my unit were attacked by terrorists or 248 68 35 41 civilians.*** I was part of a land or naval artillery unit that fired on the 46 13 9 11 enemy. I was part of an assault on entrenched or fortified positions.* 32 9 2 2 I took part in an invasion that involved naval and/or land 27 7 1 1 forces.* My unit engaged in a battle in which it suffered casualties. 112 31 18 21 I personally witnessed someone from my unit or an ally unit 127 35 19 22 being seriously wounded/killed.* I personally witnessed Soldiers from enemy troops being 118 33 17 20 seriously wounded/killed.* I was wounded or injured in combat. 16 4 6 7 I fired my weapon at the enemy.*** 78 21 3 4 I killed or think I killed someone in combat.* 37 10 2 2

Note: Significant associations between gender and each combat experience were assessed using Fisher’s Exact test. * p <= 0.05. ** p <= 0.01. *** p <= 0.001.

differences in post-battle experiences by genderS ( = 15343, p < .001) were found. Males had a higher post-battle experience mean rank sum (233.03) compared to females (180.51). Finally, a t-test revealed no significant difference in deployment concerns by gender (t (345) = 0.06, p = .951). Information concerning frequencies, proportions, and differences for each experience by gender can be found in Tables 8.2, 8.3, and 8.4.

DISCUSSION

Female medics currently participate in patrols and convoys so that they can assist with the medical care and briefing of Afghan women. This will increase significantly 8. Female Combat Medics 143

TABLE 8.4 Post-Battle Experiences (DRRI) by Gender

Male Female

Combat Experience f % f %

I observed homes or villages that had been destroyed.** 205 57 33 39 I saw refugees who had lost their homes and belongings 101 28 19 22 as a result of battle. I saw people begging for food. 241 67 47 55 I or my unit took prisoners of war.*** 155 43 8 9 I interacted with enemy Soldiers who were taken as 136 38 14 16 prisoners of war.*** I was exposed to the sight, sound, or smell of animals 155 43 20 24 that had been wounded or killed from war-related causes.*** I took care of injured or dying people. 259 72 52 61 I was involved in removing dead bodies after battle. 68 19 16 19 I was exposed to the sight, sound, or smell of dying men and 146 41 26 31 women. I saw enemy Soldiers after they had been severely wounded 137 38 30 35 or disfigured in combat. I saw bodies of dead enemy Soldiers.** 131 36 17 20 I saw civilians after they had been severely wounded or 185 51 26 31 disfigured.*** I saw the bodies of dead civilians.* 135 38 21 25 I saw Americans or allies after they had been severely 171 48 34 40 wounded or disfigured in combat. I saw bodies of dead Americans or allies. 109 30 30 35

Note: Significant associations between gender and each combat experience were assessed using Fisher’s Exact test. * p<= 0.05. ** p<= 0.01. *** p<= 0.001. due to the 2013 policy change that rescinds the Direct Combat Exclusion Rule (US Department of Defense, January 24, 2013). Therefore, it appears that differences in combat experience and exposure may be more a result of the ability of women, until recently, to lawfully be involved in direct combat, such as foot patrols. With the new change in policy, more and more women will likely be involved in direct combat, just as the men. Therefore, it will be necessary to revisit this issue in the future.

Impact of War on Psychological Well-Being

Differences in PTSD and depressive symptom severity scores were assessed using separate generalized linear regression models. The three significant measures of combat 144 Women at War

TABLE 8.5 Stigmas and Barriers to Care by Gender

Male Female

f % f %

Stigma It would harm my career. 12 2 5 4 Members of my unit might have less confidence in me. 24 5 5 4 My unit leadership might treat me differently. 119 24 31 26 I would be seen as weak. 108 22 36 30 My visit would not remain confidential. 36 7 6 5 Barriers to Care I don’t know where to get help. 127 25 22 18 I don’t have adequate transportation. 159 32 38 32 It is difficult to schedule an appointment. 181 36 48 40 There would be difficulty getting time off for treatment. 158 32 39 33 My leaders discourage the use of mental health services. 121 24 26 22

* p <= 0.05. ** p <= 0.01. *** p <= 0.001.

experiences and exposures above were each entered as covariates. The model was significant for PTSD symptom severity scores. However, gender was not significant in the model. Similarly, the model for depressive symptom severity scores was significant. However, again, gender was not significant in the model. Thus, the results indicate that after accounting for any differences in combat experiences and exposures, male and female combat medics do not differ on PTSD or depression symptom severity scores.

Stigma and Barriers to Healthcare

Two separate logistic regressions were utilized to assess possible differences in stigma and barrier endorsement by gender. The previous significant measures of combat experiences and exposures were entered as covariates. While both models for stigma and barriers were significant, gender was not a significant predictor of stigma or barriers (Table 8.5).

IMPLICATIONS FOR BEHAVIORAL HEALTH PRACTICE WITH FEMALE COMBAT MEDICS

Female medics’ increased exposure to combat experiences provides a unique opportunity for healthcare organizations and providers to reassess current delivery systems, 8. Female Combat Medics 145 processes, and interventions. These findings are not new and are consistent with other reports (Vogt, Vaughn, Glickman, Schultz, Drainoni, Elwy, & Eisen, 2011; Hoge, Clark, & Castro, 2007). The increase in the number of women in the military is reshaping the military population and healthcare systems. While the research in Military/Veteran women’s health has been largely observational and is now shifting from a descriptive to an analytical focus examining determinants of care or health (Bean-Mayberry et al., 2011), more is now known about barriers and utilization of services (Elnitsky et al., 2013). This information should lead healthcare organizations to remove the barriers, reorganize care to meet the needs of women Soldiers and Veterans, and better inform potential interdisciplinary interventions to co-manage mental health care and general preventive healthcare.

CONCLUSION

The findings cited above underscore the need for healthcare providers to be aware of the potential for gender differences. Specifically, it is important to repeatedly assess individual patients returning from deployment for exposure to a full range of traumatic combat experiences since exposure dosages will vary by gender. Both healthcare organizations and providers should be attentive to evolving research to fill gaps in our current understanding of post-deployment readjustment among combat medics and other returnees/families and in quality interventions to address mental conditions. As military women take their place alongside men in combat and studies show repeatedly that women are not at risk for combat-related stress injuries compared to men, studies of female combat medics are important indicators. It is even more important today that the growing problem of sexual assault and harassment within the military must be stopped and prevented.

DISCLOSURE STATEMENT

We choose to use the term “mental” rather than “behavioral” because the former incu- des the cause of the behavior, not just the behavioral metric of reactions to various contexts and conditions.

REFERENCES

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Bond, C. (Ed.) (2005). Combat Medic Field Reference. Boston: Jones and Bartlett. Chapman, P. L., Baker, M., Cabrera, D., Varela-Mayer, C., Elnitsky, C., Figley, C., Thurman, R. M., & Mayer, P. (2012) Mental Health and Stigma and Barriers to Care: Key Findings from U.S. Army Combat Medics Deployed with Line Units. Military Medicine, 177(3), 270–277 Combs, J. (2012). Mercy warriors: Saving lives under fire. Trafford.com (books on demand). Elnitsky, C., Chapman, P., Thurman, R., Pitts, B., Figley, C. R., & Unwin, B. (2013). Gender differences in combat medic mental health services, barriers, and stigma. Military Medicine, 178(7), 775–784. Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13–22. Hoge, C. W., Clark, C. C., & Castro, C. A. (2007). Commentary: Women in combat and the risk of post- traumaic stress disorder. International Journal of Epidemiology, 36, 327–329. King, D. W., King, L. A., & Vogt, D. S. (2003). Manual for the Deployment Risk and Resilience Inventory (DRRI): A collection of measures for studying deployment-related experiences of military veterans. Boston, MA: National Center for PTSD. Luz, S. & Brotherton, M. (2010). The Nightingale of Mosul: A Nurse’s Journey of Service, Struggle, and War. NY: Caplan. Mazurek & Burgess, 2006 (to be supplied shortly, along with the missing references in the text) Nessen, S. C., Loundbury, D. E., & Hetz, M. D. (Eds.) (2008). War Surgery in Afghanistan and Iraq: A Series of Cases, 2003–2007). San Antonio: Walter Reed US Army Medical Center Borden Institute. Spitzer, R. L., Kroenke, K., & Williams, J. B. W., Patient Health Questionnaire Study Group. (1999). Validity and utility of a self-report version of PRIME-MD: The PHQ Primary Care Study. Journal of the American Medical Association, 282, 1737–1744. Thibeault, P. (2012). My Journey as a Combat Medic: From Desert Storm to Operation Enduring Freedom. PDF e-book: Osprey Publishing. (ISBN: 17820000909) US Department of Defense (2013). The Chairman’s Women in Service Review Info Memo, 9 January. Accessed November 10, 2014 at: http://www.defense.gov/news/WISRImplementationPlanMemo. pdf Vogt, D., Vaughn, R., Glickman, M. E., Schultz, M., Drainoni, M., Elwy, R., & Eisen, S. (2011). Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF Veterans. Journal of Abnormal Psychology, 120(4), 797–806. Weathers, F. W., Litz, B. T., Herman, J. A., Huska, J. A., Keane, T. M. (1993). The PTSD checklist (PCL): Reliability, validity and diagnostic utility. Paper presented at the 9th Annual Conference of the ISTSS, San Antonio, CA. nine Human Sexuality and Women in the Area of Operations

AMY CANUSO

INTRODUCTION

The content of this chapter is intended to begin a dialogue about the normal and expected sexual experiences of women in the military on deployment and in the war zone. It is a highly charged topic that may be very difficult for some to broach openly. However, if not addressed, unfortunate outcomes, such as pregnancy requiring evacuation, potentially life-threatening ectopic pregnancies, and sexually transmitted diseases, may result. This is not a discussion on sexual assault, although sexual assault in the military continues to be often considered as an epidemic. At the time of this writing, Senators McCaskill and Gillibrand continue to revise and champion a bill before the US Senate that would keep commands from overturning sexual assault convictions, require a civilian impartial review, and mandate dishonorable discharges for military members convicted of sexual assault. The fact that so many active duty women have experienced sexual assault while serving in the US military continues to make the topic of consensual human sexual activity at war awkward, problematic, and even taboo. It is in no way the intent of this chapter to compare sexual assault with the topic of female sexuality for active duty women. The two may be considered completely separate topics for this discussion. However, human sexuality and sexual responsiveness remain important to the understanding of the cumulative psychological and emotional human experience of

147 148 Women at War our active duty Service members. Clinicians should explore the topic of sexuality with women prior to deployment, and post-deployment. This topic merits discussion to ensure both cognitive and medical preparation of the active duty woman who deploys in service of her country, along with the possible processing of experiences after her deployment. This is the end of the introduction. The idea of consensual sexual relationships in the area of operations has produced a vivid landscape for many books and screenplays. Visualize the story of a young nurse who falls in love with the Soldier she cares for; or one might remember the MASH series and the somewhat ruckus, clandestine encounters between doctors and nurses, with a laugh track keeping the story light and far from reality—the scene appears more like a fraternity house movie. We have very little knowledge of the actual amount of consensual sexual activity that is occurring during deployments between military members because very little research is done on that topic. In the recent past, all sexual activity between two Service members during deployment was forbidden. However, in 2008 the lift on the ban for sexual activity between unmarried active duty members of the US Armed Services deployed, and between unmarried and of the same rank, was lifted (Brown, 2008). In 2010 the US Department of Defense added emergency contraception to its list of contraceptive options that “typically” are available at medical facilities, and theoretically includes the medical facilities in the area of operations. Even though there may be an official direction, the Commanding Officer of an individual unit may have the option of putting forth his or her own ban on sexual activity, either as explicit order or by “strongly discouraging” sexual activities. Some Commanding Officers report that such relationships can deteriorate unit cohesion and can be problematic. So even if one is in a consensual relationship with an unmarried person of one’s same rank, one may either be banned from engaging in sexual activity or may opt not to, fearing unit reprimand. Very little of this subject matter is known in the open because there is very little that is recorded or researched regarding the consensual sexual activity between active duty members. Few are willing to come forward and speak openly. Somehow, though, pregnancies and sexually transmitted diseases (STDs) continue to occur; divorces and perhaps even marriages have resulted from sexual relationships during an overseas deployment. What we do know is that active duty women on deployments do get pregnant and do contract sexually transmitted infections. Studies indicate that as many 12% of deployed women had an unplanned pregnancy during deployment in 2008 (Holt, Grindlay, Taskeir, & Grossman, 2011; Grindlay & Grossman, 2013). Another study indicates that 13.2% of active duty women who visited a military-run gynecological clinic in Iraq between 9. Human Sexuality 149

2007 and 2008 had complaints of vaginal infections that included sexually transmitted infections (Foster & Alviar, January 2013). From these studies and others, there have been reports that women were not offered or were not able to continue contraception when they were deployed, either due to the military not having the supply or a belief that sex does not happen in the war zone. Women reported that the subject of contraception was not discussed with them prior to deployment by their primary care provider, illustrating the need for clinicians to be cognizant of this subject matter with their active duty female patients. The above indicates that there is a disparity between the Department of Defense’s stance on providing contraception to women during deployment, the military stance on consensual sexual relationships with active duty members during deployment, and the outcomes that military women have unplanned pregnancies and contact sexually transmitted infections during deployment. It may be that women are afraid to ask for contraception or STD prevention, as it may indicate that they are promiscuous or that they are violating orders or policy (Rabie & Magann, 2013). Being in the area of operations amplifies inherent sexual feelings in many different ways. Active duty women may find themselves in a difficult “Catch 22” of suppressing and/or denying natural feelings due to personal, cultural, or unit scrutiny. The dissonance of subconscious versus conscious desires, fears, moral judgments, anxiety, and emotional discord should be considered when addressing mental health wellness with women who have served in the US military. Somewhat mixed messages continue to be conveyed regarding women’s sexuality and cultural norms. For example, in the deployed setting, women are removed from the area of operations because of pregnancy; however, a male who is treated for an STD does not get sent home for engaging in sexual behavior. A woman who is then aerovaced out of the area when her command learns she is pregnant may often face the judgment of her unit (and herself) for leaving the mission; leaving the mission for any reason is often a source of guilt, and even shame, for military members who place a great deal of value in remaining part of the unit. Even the topic of masturbation seems to be skewed in favor of males (Gottlieb, 2011) (Jones, 2013). Many men describe that in their unit there was a unspoken agreement for needed privacy during deployments, “taking turns being the last person out [of] the tent or hygiene tent.” However, the women I interviewed voiced that the topic was rarely or never discussed with their bunkmates when they were deployed.

SETTING THE SCENE

The area of operations during OIF and OEF was and remains (in OEF) a primal environment. There is a heightened sense of danger, a sense of lawlessness, and often there 150 Women at War is the reality of combat operations that may shorten life. There is a significantly skewed ratio of men to women, of about ten to one, but it is not necessarily more than the general population of the unit itself back in garrison. For instance, most units deploy with roughly the same percentage of women who are part of the unit in garrison. Most women interviewed for this writing describe that there is far more focus on the difference in ratio between men and women during deployment than when stateside. One woman I interviewed explained, “When I go to the gym in the US on base I may be the only woman there, however, it causes little change in the other gym goers behaviors. But, when I went to the weights area of the forward operating base [most bases have some form of exercise equipment] my presence there seemed to make everyone stop and stare.” One enlisted man I knew reported to me that that just seeing a woman when deployed was like seeing something rare. He describes a day during his deployment when he was giving an instructions course to a number of other young men when a young woman walked by in workout gear on her way to the hygiene tents. “We all just stopped and stared at her for almost a full 30 seconds. Then I just went back to teaching the men. I never would have done that stateside.” One woman told me that it seemed to her that sexual issues came up more in her casual conversations with other women. Discussing how another active duty member looked in the gym, or discussing the attractiveness of a movie celebrity, was com- monplace, but she never would have been comfortable with such subject matter in the United States, perceiving it to be unprofessional. One can hypothesize as to the reasons that there may be an increase of perceived sexual consciousness among active duty members who are deployed. First, the area of operations is a constant reminder to many of life and death in the area of operations. Whether one is on a mission outside the wire or tending to incoming medevaced injuries in the hospital, it is common to see grave injuries and amputations, and to see death, sometimes daily. There is the obvious geographic separation from partners, and so there is the absence of familiar companionship for the monogamous, and the absence of available partners for the others. There is also the conscious awareness of abstaining, which may add a heightened sense of “wanting what cannot be had.” Many deployed personnel will cite that there is an increased sense of purpose; daily distractions and mundane, non-essential tasks are replaced by the goal-directed focus of the military mission. One woman I knew reported that having this sense of importance was empowering and liberating for her. She described that she felt stronger, like she was “living for the first time,” and that it caused her to experience her sexuality more overtly. “I’ve never thought about sex this much in my life. It’s like I’m a teenage boy.” 9. Human Sexuality 151

Deployed active duty personnel may find that they are confined to the area of a small forward operating base; on a larger operating base, they may only navigate between a small workspace, a small gym, a chow hall, a galley or other eating facility, and their living spaces. Restricted areas and restricted mobility force an increased awareness on small human interactions, subtle subtexts, and picking up small expressions. The environment lends to long hours with the same people, sometimes 12-hour days (or longer), and no days off. One woman I interviewed stated that she became attracted to a colleague and had to work closely with him long hours every day. She reported to me that even though she loved her husband and had no desire to engage in an affair, she felt that there was nowhere for her to escape from looking at this man. Her suppression took on an obsessive-compulsive quality, and she began pulling at her eyelashes and biting her nails again for the first time in ten years. It is also known by those who have deployed that there may be lots of downtime between the rushes of combat activity. Such downtime is time for the mind to wander, and with limited distractions one may find that the mind wanders toward thoughts of a sexual content. Finally, there is also the unconscious (and perhaps conscious) awareness that the area of operations, while dangerous, has many phallic representations.

SEXUALITY AND WAR: WHAT BIOLOGY DOESN’T TELL US

Historically there have been connections between war and aggression and sexuality in humans. Centuries of accounts of women (and men) being sexually assaulted by warring captors, conquerers, military occupiers, security in refugee camps, returning victors, or liberating troops have noted these connections, which have been universal in war. Biology, sociology, and historical studies have weighed in on the topic, and a simple literature search reveals years of studies on the connection on how exposure to combat may facilitate the aggression-enhanced properties of sexuality. Many studies, though, are exclusively male-centric, are based on only male animal models, or are exclusively the act of sexual aggression, or deviant psychopathology in the male, which, for the purpose of this writing, is meant to be separate from female sexuality in the deployment setting (Archer, 2004), (Dayu et al., 2011). Such evaluations and endeavors essentially discredit (1) the perspective of female sexuality, and (2) the subjective meaning of sexuality. In order to fully appreciate the subject of female sexuality in the area of operations, a new model of evaluating the ways that women view and experience sexuality is needed, which may be as diverse as those of men, and likely are as difficult to measure qualitatively and quantatively. 152 Women at War

One study indicates that the individuals’ meaning of sexuality is more important than the question of the sexual act itself. Libby and Strauss found that in student subjects the connection between sexual activity and violence and aggression behavior was more evident in individuals who viewed sexual activity as a dominating and exploitive act. The inverse was found with individuals who viewed sexual activity as a warm and affectionate act (Libby & Straus, 1980). History also can give us some clues regarding the consensual sexual behaviors of women in wartime, though there is no precedence for active duty women who are embedded in US military units. In his book Gender and War: How the War System Shapes Gender and Vice Versa, Joshua Goldstein writes of the consensual and common interactions between European civilian women and American troops during World War II, as well as the “Victory Girls” of the United States who were consensual in showing their appreciation through sexual relations with returning Veterans (Goldstein, 2001). However, the line between consensual and coercive for women of history is thin and relatively uncertain. Similarly, based only on reports of women active duty members’ visits to military women’s clinics, there is no way to make conclusive statements or inferences regarding this topic, which has so little hard data to date. Based on observations from this author and those women interviewed, it appears as though the US military is alone in its approach of expecting celibacy by military direction and denying the reality that sexual relations will occur between Service members. When visiting the Danish and British Battalion health clinics, I learned of the public health campaign for safe sexual encounters, even in the area of operations. They had free distribution of STD protection and birth control. There were posters in the halls of the hospital that encouraged safe sexual practices, and one entire clinic was devoted to sexual health. This effort occurred despite the British ban on sexual activity while deployed (Crossley, 2014).

CONCLUSION

Clinicians may be reluctant to speak with patients regarding sexuality during deployment, and patients may be reluctant to speak of this topic, which may be embarrassing, incriminating, and/or shameful. However, this dialogue could have great therapeutic value. Recently, many psychological health and resiliency programs have recognized the ways that good sexual health is part of full-person wellness, so it is important to be cognizant of how this vital part of our human experience (and lack of) contributes to the psychological experience of deployment. It is also important to explore how sexuality, perceived inappropriate feelings, and interactions represent deeper psychological 9. Human Sexuality 153 conflicts and/or needs. Finally, it is possible that the area is ready for scientific evaluation in order to bring this subject out into the light.

REFERENCES

Archer, J. (2004, December). Sex differences in agression in real-world settings: A meta-analytic review. Review of General Psychology, 8(4). doi:10.1037/1089-2680.8.4.291. Bureau of Medicine and Surgery Public Website for Navy Medicine, page for Policies on Contraception. Retrieved on March 2, 2014, from http://www.med.navy.mil/bumed/womenshealth/Pages/contraception.aspx. Brown, D. (2008, May 15). Ban on sex for soldiers in Afghanistan lifted… sort of. Stars and Stripes. Retrieved from http://www.military.com/features/0,15240,167950,00.html. Crossley, L. (2014, February 15). The maternity military: How nearly 100 female soldiers have been sent home from the Afghan front line after getting pregnant.Daily MailOnline. Retrieved on March 1, 2014, from http://www.dailymail.co.uk/news/article-2560032/ The-maternity-military-How-nearly-100-female-soldiers-sent-home-Afghan-frontline- getting-pregnant.html. Dayu, L, Boyle, M. Dollar, P, Hyosang, L, Lein, E., Peronal, P., & Anderson, D. (2011, February). Functional identification of an aggression locus in the mouse Hyptothalmus. Nature. 221–226. doi:10.1038. Foster, G. A., & Alviar, A. (2013, January). Military women’s health while deployed: Feminine hygiene and health in austere environments. Federal Practitioner, 9–13. Goldstein, Joshua S. (2001). War and Gender: How Gender Shapes the War System and Vice Versa. Cambridge: Cambridge University Press. Gottlieb, S. (2011, January 27). Sex and war and the Dutch Army: Don’t ask don’t tell. Radio Netherlands Worldwide. Retrieved on January 20, 2014, from http://www.rnw.nl/english/article/ sex-and-war-and-dutch-army-–-’don’t-ask-don’t-tell’. Grindlay, K., & Grossman, D. (2013). Unintended pregnancy among active-duty women in the United States military, 2008. Obstetrics & Gynecology, 121(2, Part 1), 241–246. Back up your Birth Control Day: US military expands access. Media Center of Public Website of Guttmacher Institute. Retrieved on March 1, 2014, from http://www.guttmacher.org/media/inthe- news/2010/03/22/index.html?utm_source=feedburner&utm_medium=feed&utm_campaign=F eed:+Guttmacher+(New+from+the+Guttmacher+Institute). Holt, K., Grindlay, K., Taskeir, M., & Grossman, D. (2011). Unintended pregnancy and contraception use among women in the US military: A systemic literature review. Military Medicine, 17(9), 1056–1064. Jones, B. (2013, October 8). US military cracks down on troop masturbation in Afghanistan. BusinessInsider. Retrieved on January 3, 2014, from http://www.businessinsider.com/ military-cracking-down-on-masturbation-in-afghanistan-2013-10. Libby, R., Straus, M. (1980, April) Make love not war? Sex, sexual meanings, and violence in a sample of university students. Archives of Sexual Behavior, 9(2), 133–148. Rabie, N. Z., & Magann, E. F. (2013). Unintended pregnancies among US active-duty women. Women’s Health, 9(3), 229–231.

PART 3 Women Home from War

ten Women Home from War

ELIZABETH C. HENDERSON

INTRODUCTION

When Staff Sergeant (SSG) Perry became aware that the pain and muscle spasms she developed while deployed might lead to the end of her military career, her normal mental toughness began to unravel. She came from a military family—a father who retired as a command sergeant major in the Army, a brother in the Marines, and a sister who lost her life in Iraq, not far from where SSG Perry was assigned as a member of an Army Military Police unit. The grief of losing her sister, who was her closest friend, the bewildering process of resuming the role of “Mom” to a recalcitrant three-year-old, and the heavy weight of the things she saw and experienced in Iraq—things she felt no one could really understand unless they had been there—overwhelmed her ability to “drive on.” She was not sleeping, could not eat, lost 25 pounds that she couldn’t spare, and began feeling as though she had no place anymore in this world. Treatment did help, but between the damage to her feet and cervical vertebrae—the result of wearing over 100 pounds of gear day in and day out for a year—and her persistent depressive symptoms, her primary care provider determined that she would be referred to the Medical Evaluation Board for evaluation. While this meant that she would no longer have to face wrenching separation from her daughter, reading the words “medically unacceptable” and “failing retention standards” on the narrative summary of her medical board felt like betrayal and abandonment. And it echoed the sharp, lingering pain of learning that her ex-husband would not or could not wait for her to return from Iraq.

157 158 Women at War

This Soldier was dealing not only with the many stressors associated with deployment in general and deployment as a wife and mother, but the emotional impact of being referred for a medical board evaluation, which served to magnify these issues and added further to her emotional burden. This is an especially difficult scenario, but it reflects many of the issues that women struggle with when approaching medical separation from the military. This chapter will discuss the processes that occur and the issues that arise during the period that follows return from deployment, with an emphasis on psychological health. Almost all of these issues and concerns are shared by men and women in the military, but gender differences are also found in the prevalence, the severity, and the manifestations of post-deployment symptoms and adjustment. Army terminology and regulations are discussed, based on the author’s experience, but the principles are shared by all branches of the military. For the sake of simplicity, the terms “Service member” and “Soldier” are both used as synonyms for “Airman,” “Marine,” “Sailor,” “Officer,” and so on. Women now constitute 20% of new military recruits and 15% of Service members who have deployed. Of those women who have deployed, roughly 40% have participated in combat. Review of the literature does not show great gender differences in the mental health of Service members returning from deployment. Both genders are resilient, and both are also at risk for exposure to multiple potentially traumatic events while deployed. Issues encountered more commonly in women during the process of reintegration, such as military sexual trauma, may increase in visibility and prominence with increased attention to these issues as the women constitute a higher percentage of the Armed Forces.

THE ARFORGEN PROCESS

The cycle of returning from a deployment and preparing for the next deployment in the Army is known as the ARFORGEN (Army Force Generation) process. It is “the Army’s core process for force generation,” consisting of three force “pools” that are structured to provide a steady flow of ready forces. These pools are “RESET, Train/ Ready, and Available” (Army Regulation 525-29). In this chapter, the focus is on the “RESET” pool, whose activities include “[s]‌oldier-Family reintegration; block leave; unit reconstitution; changes of command; behavioral health; medical and dental readiness, reintegration; professional military education;… training tasks; and resupply.” These activities occur during “dwell” time, which is the period of time in garrison between deployments. An important medical function during dwell time is restoring the Service member to full medical readiness and identifying those who no longer meet medical retention 10. Women Home from War 159 standards. The high tempo and long duration of recent operations have increased the importance of the efficiency and accuracy of this medical function so that units are able to obtain a suitable replacement if a Service member is not medically able to contribute to the mission. The ARFORGEN process applies to all components of the Army: Active Duty (COMPO 1) and the National Guard and Reserves (COMPO 2 and 3). When Service members in National Guard and Reserve units demobilize, initial screening is done at the demobilization site to identify Soldiers who require continuation on orders because of significant medical problems; however, the majority return to their home unit, where the RESET process is completed, and the cycle continues. National Guard and Reserve forces are mobilized (placed on active orders) and deployed (sent overseas to an imminent harm area) at a frequency not seen in many decades. On return, these Service members also return to a job or career placed on hold, re-enter the civilian community, and may lack the psychosocial support found in garrison.

ASYMMETRIC WARFARE AND COUNTERINSURGENCY

The Global War on Terror and many other recent operations are characterized by hostile activity on the part of a less organized and equipped force toward highly organized, equipped, and trained multinational forces. This type of hostile action is termed “asymmetry” and is seen in guerrilla warfare and insurgencies within an established governmental system or arising when governmental control is weak. Although this style of warfare is not new (for example, being used by the Continental Army to win the Revolutionary War), it stands in contrast to the more conventional conflict between two uniformed forces organized at the national level. In conducting this type of warfare, enemy combatants today often use unconventional tactics that are contrary to the laws of war. These tactics result in not only injury and property destruction but incidents that are horrifying and may overwhelm psychological defenses, leading to psychological trauma. Some of these tactics include the use of women or children as shields, improvised explosive devices that cause dismemberment and bodily disintegration, suicide bombers, planting bombs inside dead people and animals, and threats to coerce the compliance of local nationals (Metz et al., 2001). Current Army doctrine includes the concept of counterinsurgency (COIN), a combination of executing military actions to stabilize an area of operation while working within the social and political structure of the host nation to achieve strategic and political objectives (Sewell & Nagi, 2007 [US Army FM 3-24]). Attendant with this doctrine, however, is the inherent blurring of the definition of who constitutes the 160 Women at War

“enemy.” Betrayals of trust in the setting of providing active support to local nationals, building infrastructure, and making positive contributions may lead to disillusionment and demoralization. Service members may devote their energies to training or humanitarian projects, only to later realize that sometimes the local nationals who thank them for their efforts are also participating in hostile actions. An important characteristic of the current theaters of operations is the lack of a defined rear echelon; in other words, there is no location in theater that is secure and apart from hostile activity. Every Service member, from General Officers to lower enlisted, are in a forward area and are at risk. Therefore, when “down range,” or deployed, all Service members, all the time, are at risk of harm and maintain a high degree of situational awareness. Even on well-developed forward operating bases, or FOBS, there is the risk of indirect (mortar and rocket) fire, and suicide bombers who get inside the “wire” or the perimeter of the base. Direct attack may come from local nationals who have been allowed on the base for military or police training. A consequence of the asymmetric nature of recent conflicts is the potential for the Service member to fail to respond when an actual threat is a woman or a child, or to appropriately engage a threat, and then suffer moral injury, if an innocent person is killed or injured. Litz et al. (2009) note that moral injury occurs when the individual perpetrates, fails to prevent, or bears witness to “acts that transgress deeply held moral beliefs and expectations” and notes that there are emotional, psychological, spiritual, and social consequences. This may increase isolation and loneliness after separation from the military due to a feeling that others would judge or fail to understand these experiences. A routine question in a psychiatric evaluation of a returning Service member is whether or not he or she had to discharge a weapon in combat. It is not uncommon for women to answer “yes” to this question, even if performing a non-combat military occupational specialty (MOS), because of the asymmetric nature of combat in recent theaters of operation requiring women to actively participate in combat operations. Accompanying these moral dilemmas are rules of engagement (ROEs) that specify when and whether it is appropriate to take action in a hostile engagement. These rules are based on the Law of Land Warfare (US Army FM 27-10) but are also mediated in the service of strategic objectives and political considerations. These rules serve as a guide in the short threat-action loop but also limit the range of possible responses. Service members may experience frustration when rules of engagement appear to place them at higher risk or lead to casualties, and in the modern battlefield they may struggle with the fact that they are required to follow the ROEs but the enemy is not. “Paper thin” faith, as described by Fleming and Robichaux in Redeployed (2013), can dissolve in the aftermath of incidents that shake the Service member’s existential foundation. Some Service members recount a point at which they shut off any access to 10. Women Home from War 161 tender feelings and became cynical and unresponsive to the emotional pain of others. Some Service members struggle with the notion that a God who cared about man could permit what they have seen. One infantry Soldier said, simply, “My eyes have witnessed more than my soul can handle.” Having been exposed to death and injury, the ambiguities of asymmetric warfare, and a culture of extreme poverty, corruption, and vicious sectarian violence, it is hard to return to a culture of comfort and means. Service members frequently have difficulty empathizing with day-to-day stresses—the routines in garrison, the washing machine breaking down, kids squabbling, the family wanting to redecorate to keep up with the neighbors, and so on. It is difficult for family members and friends to understand why, in frustration, the Service member may express the sentiment, “I wish I was back” in theater.

MORALE AND LEADERSHIP

When deployed Service members share the common goal of executing the mission, there is mutual support and efficiency of effort. The unit becomes a cohesive support system with bonds often tighter than those with family members. The sense of meaningful team work and a goal-directed focus is a healthy characteristic of the deployed environment that may be lacking at home. Mature, empathic, and effective leadership and unit cohesion protect against the development of behavioral health symptoms (US Army, 2011; 8-J-MHAT 7-2011, p. 31). The converse is also true. Some military units share the characteristics of a dysfunctional family or organization, especially if there are leadership problems within the command structure. Dysfunctional group behaviors may ensue, such as scapegoating, in order to maintain some degree of cohesiveness and mission focus. Sexual harassment and sexual assault are also toxic to the group process, disrupting trust, open communication, and moving the work group off task. These effects are more obvious at the level of the small working group—squad or platoon level. But higher leadership also sets the tone for the entire company or brigade. Within a Brigade Combat Team, or even within a company, there may be marked variability in the intensity of combat exposure or exposure to other traumatic stressors. Although sharing a common mission, each smaller component—team, squad, or platoon—will go in different directions to complete the mission and may encounter intense combat activity or none at all. The small unit also serves as a natural support system. Social media and technology facilitate continuing connections over time. But the effectiveness of this natural support system is diminished when, shortly after redeployment, there are changes in command, Service members leave at the end of a 162 Women at War contract or retire, and some receive orders to PCS, (Permanent Change of Station), sometimes from one coast to another. Some are selected for Service schools such as Airborne, Ranger, or Master Gunner, and others face some type of involuntary separation due to medical or administrative issues. In recent years the Army has embedded behavioral health providers into Brigade Combat Teams with the intent of increasing communication with command, providing informal access to Service members, and providing a readily available source of support. This also affords behavioral health providers the opportunity to meet with small units who may have experienced more combat intensity to leverage existing bonds and encourage the continuation of healthy support around issues that no one may wish to talk about. Even those who have not suffered psychological trauma experience redeployment (or return from deployment) as a challenge. When Dr. Caldwell, a clinical psychologist, returned from a year’s deployment, she was surprised to find that she continued to have a persistent feeling of being unsafe, especially when driving long distances or going to the concerts she missed so much while she was deployed. Loud noises made her jumpy, and she often thought about some of the more intense experiences she had in theater. But most annoying was that her mother, her fiancé, and her friends told her she had changed—and wanted her to change back. As a psychologist, she knew that her post-deployment symptoms were normal and would abate over time, but she found it hard to explain to her friends and family that what she had seen and experienced did change her—but that she was still the same in many ways. Rivers et al. surveyed US Army nurses returning from deployment to gain insight into the personal experience of coming home and reintegrating into family life and garrison responsibilities. Roughly three-quarters of the respondents were female, and all were active duty Officers in the Army Nurse Corps. Common themes that emerged included a feeling that there was a lack of command support during reintegration and that no one cared about their feelings. Superficiality of required reintegration classes and activities was another theme, described as “check the blocks.” Respondents noted a sense of feeling bombarded and disconnected, and emphasized that deployment “changes you” (Rivers et al., 2013). When Janice arrived in theater, she joined a medical detachment that had already deployed as a group three months earlier. She was called up from the PROFIS list (the Professional Filler List). This is a list of various medical professionals who are assigned to a fixed military treatment facility in the United States, and in Janice’s case, she replaced a nurse who had to return early from deployment due to a knee injury. Janice is a basically shy individual who does not make friends quickly, and she felt like an outsider. Her deployment was for six months, and during that time she did not hear anything from her coworkers back home. She was located in a fairly isolated area and 10. Women Home from War 163 dealt not only with US casualties but also cared for a number of local nationals, including children. She did not note any mental health issues on post-deployment screenings because she had heard (inaccurately) that this would cause her to have to wait indefi- nitely to go on post-deployment leave. Six months later she was taken to the Emergency Room by her coworkers on the Pediatric Ward after a military dependent’s child was admitted with burns. She was unable to stop crying. Following brief treatment for depressive symptoms and her feelings of guilt and grief over not being able to “save” the children she saw while deployed, many of whom suffered severe burns, she was able to recoup her healthy coping skills and returned to full duty. But she remained disappointed in her coworkers and command, who welcomed her back as though she had just been on vacation. Family members may not be able to understand that the returning Service member will not be the same person who deployed. This “new normal” reflects the profound experience of living for months in an active area of operation and being exposed to poverty, death, and destruction. It is hard to become distressed about things the family is concerned about that seem to be mundane or trivial. This difficulty reconnecting is one of many phenomena that Service members experience that are similar to traumatic stress symptoms but that lack the functional impairment and global distress of a traumatic stress disorder. Symptoms, especially in proximity to a traumatic experience or early after redeployment, do not constitute a syndrome or disorder. Reassurance and psychological first aid can be useful, and Service members are often able to enlist natural support systems to help them to readjust.

THE EFFECTS OF TRAINING

A critical aspect of a Service member’s initial and continued training is the over-rehearsal of combat skills. Regardless of MOS, all Soldiers are expected to be able to carry and fire a personal weapon and evade direct and indirect fire. Over-learned skills and “muscle memory” allow the Service member to act quickly and effectively in high arousal and high threat situations. The Service member is, in essence, conditioned to maintain a high level of alertness and threat recognition and to react quickly and accurately, without having to engage in reasoning to place a threat in context, weigh alternative courses of action, and make a benefit-risk decision on the appropriate response. Threats are followed by action, conditioned by training, and analysis follows. Once over-learned, it takes time for this conditioning to be unlearned, or at least to allow for more flexibility in the individual’s response sets. While in the cycle of deployment—reset/training/ deployment—there is further conditioning and further reinforcement, which may be resistant to extinction (Jovanovic & Ressler, 2010). 164 Women at War

Grossman and Christensen in On Combat (2008) and Charles Hoge in Once a Warrior Always a Warrior (2010) discuss the process by which the brain responds to threat and extreme stress and the nature of the emotions that are associated with situations of intense fear and lethal actions. Anger is an activating mechanism that allows the individual to overcome potentially paralyzing fear and to survive. But the combination of “threat-action” conditioning with fear experienced as anger, and the irritability that is the result of hyperarousal and exhaustion, leads the Service member to respond inappropriately to triggers or potential threats after coming home. These reactions can be confusing and threatening to the Service member, who may feel a need to remain in control in order to remain vigilant and safe. And it is also confusing and disruptive to relationships. Irritability, especially when combined with overuse of alcohol, can prevent healthy reconnection and may lead to domestic violence, estrangement, or divorce.

REDEPLOYMENT SCREENING

The duration of a typical infantry deployment during Operations Iraqi Freedom and Enduring Freedom is a year, for line units and support and sustainment units. During this time Service members are usually granted one two-week block of “mid-cycle” leave. At the time of redeployment the Service member completes a Post Deployment Health Assessment (PDHA) questionnaire that is reviewed by a medical provider to identify any need for further assessment or specialty consultation. Service members who are found to be in good health are released for a block of time for leave with family. A Post Deployment Health Re-assessment (PDHRA) is completed within three to six months after the Service member redeploys. It is not uncommon for symptoms to appear on the PDHRA that were not noted on the initial PDHA. Although there may be confounding factors, such as minimizing symptoms on the PDHA to avoid possible medical hold and delay of leave, a gradual increase in symptoms over time, with the full spectrum of traumatic stress symptoms appearing months after redeployment, is often observed in those who go on to develop post-traumatic stress disorder (PTSD) or depressive disorders.

NATIONAL GUARD AND RESERVE UNITS

Thomas et al. found that severity of traumatic stress and depressive symptoms and associated functional impairment increased between three and twelve months following redeployment. He also noted higher symptom severity in several measures among National Guard Soldiers when compared to their Active Duty counterparts. (Thomas et al., 2010). Difficulty with post-deployment reintegration for Service members in the 10. Women Home from War 165

National Guard and Reserve is noted in other studies, with some reports showing more difficulty for these components compared to active duty, and some showing less, for reasons that remain unclear. Milliken et al., in a review of over 88,000 responses to the PDHA and PDHRA, found that rates of symptoms on surveys immediately after redeployment greatly underestimate the prevalence of symptoms and distress. A marked difference in symptom severity between active duty and Guard/Reserve respondents was also noted, even though measures of overall mental health risk and exposure to potentially traumatic events occurred at similar rates in both groups (Milliken et al., 2009). It has also been noted that many Service members in the National Guard and Reserves do not seek treatment. Pfeiffer et al. proposed an outreach approach using organized peer support in National Guard units. Soldiers in these components may face problems with access to care for a number of reasons. In addition to the negative stigma about seeking behavioral health care, they face the additional challenge of going back to the civilian workplace, and they do not have the daily presence of an active military unit to serve as a source of support (Pfeiffer et al., 2012). The expression “from Iraq to the cul-de-sac” has been used to illustrate this dilemma.

RISK FACTORS FOR BEHAVIORAL HEALTH SYMPTOMS

The duration and intensity of combat exposure and the number of deployments have consistently been found to correlate with the prevalence and severity of mental health symptoms following deployment. The Mental Health Advisory Teams, including the most recent J-MHAT 7 (Joint Mental Health Advisory Team 2011), identify the following as risk factors for the development of behavioral health symptoms: intensity of direct exposure to combat, cumulative exposure to combat, deployment length, and number of deployments. Operational stressors, such as relationship problems at home, being separated from family, problems with supplies, living conditions, sleep, and lack of personal space and time, also contribute to behavioral health complaints in theater and following redeployment. Review of data on over 300,000 OIF/OEF Veterans who had made at least one visit to a Veterans Administration (VA) facility between 2002 and 2008 confirmed the finding that increased combat exposure is a risk factor for both genders for the development of PTSD. Older age was a risk factor for PTSD and depression in women but not men (Maguen, Luxton, Skopp, & Madden, 2011). Katz et al., in the course of examining the reliability and validity of a Post-Deployment Readjustment Inventory, also noted some gender differences. There was no apparent difference between men and women 166 Women at War in exposure to combat activities, being injured, or in overall adjustment and incidence of symptoms. However, the nature of the deployment stressors did differ in one aspect. Military sexual trauma (MST) was reported significantly more often by women than men, whereas men reported witnessing others being injured or killed significantly more often than women. Respondents with MST, as a subgroup, also reported more symptoms and more difficulty with readjustment (Katz et al., 2010). A detailed examination of variables related to the expression of traumatic stress symptoms in a New Jersey National Guard Unit found that gender was a significant but weak predictor of traumatic stress symptoms following deployment (Kline et al., 2013). In a commentary, Hoge et al. note that unlike the epidemiologic data for civilians, where depression and PTSD are more prevalent among women, gender differences are not found following deployment. The degree of combat exposure, rather than gender, is the primary risk factor for both genders for the development of traumatic stress syndromes (Hoge et al., 2007).

COMBAT EXPOSURE AND GENDER

Review of gender differences in combat exposure, operational stress, and subsequent behavioral health symptoms reflects the consensus that women were already serving in positions that, although not defined as “combat arms,” nonetheless were in the thick of the action. Combat medics, truck drivers, petroleum supply specialists, and vehicle mechanics are some examples. Now that women are eligible for combat specialties, it is heartening to note that gender has not been consistently shown to be a predictive factor for the development of traumatic stress symptoms, depression, or impairment in functioning (Vogt et al., 2011). Studies looking at gender effects, combat exposure, and diagnosis vary in the details of their findings, some of which are contradictory to a minor extent, but two issues relevant to post-deployment assessment and treatment are consistent and are not dis- similar from the findings on all male samples: intensity of combat exposure tends to result in higher levels of traumatic stress symptoms, as well as increased difficulties with depressive symptoms and substance abuse. Most also agree that roughly 50% of women deployed in the service of OIF or OEF were directly exposed to combat even though not having a combat arms occupational specialty. One study of over 6,697 male and 554 female Soldiers found no gender differences in PTSD symptoms, more depression in females, and more alcohol abuse in males. MST was noted more often in females. (Maguen, Luxton, Skopp, & Madden, 2011). In a cohort of similar size and percentage of males versus females, combat exposure was more likely to result in symptoms of traumatic stress or depression in females (Luxton 10. Women Home from War 167 et al., 2010). These surveys are useful, but the data analyzed may suffer from lack of specificity. Soldiers will confirm that exposure to combat can mean very different things—from actually firing a weapon in a lethal encounter to hearing the sound of small arms fire while working “inside the wire.” Data from the Millennium Cohort Study were used to study the mental health risks associated with deployment in over 17,000 women. The positive association between combat exposure and symptoms of PTSD was confirmed. But no significant association was found with other mental health conditions and combat. In contrast to the MHAT reports, multiple deployments, duration of deployment, and length of dwell time did not show a significant association with any mental health outcomes. Data from this cohort also revealed that disrupted sleep, past mental health symptoms, smoking, and problem drinking correlated with mental health symptoms for women during deployment (Seelig et al., 2012). Drawing again from the Millennium Cohort Study, Jacobsen et al. found that combat exposure during deployment was associated with increased prevalence of misuse of alcohol by both men and women, with men being more likely to binge drink and have associated negative consequences. Combat exposure, combined with a previous substance use disorder or mental health diagnosis, also increased the risk of alcohol abuse following redeployment for both genders (Jacobsen et al., 2008).

MOTHERS WHO DEPLOY

There are other areas of concern for women returning from deployment that need further study. Women in the Millennium Cohort who deployed after childbirth and who experienced combat were at increased risk for maternal depression after coming home, and the determining variable, again, appeared to be exposure to combat (Nguyen et al., 2013). A White Paper discussing research and areas of concern for deployed women noted grief, guilt, sadness, and depression in mothers separated from their infants, and recommended that post-partum deferment of deployment be extended to one year in all branches (Naclerio et al., 2011). Mothers who deploy may be viewed as uncaring or negligent, rather than serving selflessly and patriotically. Guilt and concern about the welfare of older children and teenagers can be a distracting influence in theater, and the length of deployments may wear on those left behind with child-care duties (Benedict 2010; Scott 2010). It is more culturally acceptable for men to go to war. Dealing with the absence of a father, husband, or brother who deploys is seen as a patriotic sacrifice on the part of those left behind on the home front. But a woman may face resentment and confusion on the part 168 Women at War of family members who don’t understand why she puts her job over her responsibilities as a mother.

LOSSES AND GRIEF FOLLOWING DEPLOYMENT AND SEPARATION FROM THE MILITARY

Men and women alike experience many losses in the course of deployment and when ending a term of service. Grieving the loss of comrades killed in action, and losses of family members who may have died while the Service member was deployed, add additional complexity to the task of reintegration. Service members may have missed important milestones for their children and achievements like a graduation. For mobilized Reservists and National Guard Soldiers, career opportunities may have been missed. There may be the loss of physical integrity and ability due to the wear and tear caused by heavy protective equipment and other hazards in an austere environment, and the Service member may have sustained injuries. Relationships may dissolve while the Service member is deployed, leaving the Service member without a support system at home. And exposure to war and its attendant evils may affect one’s sense of meaning and spiritual beliefs, sometimes leading to a crisis of faith. For some, joining the military at a young age provided support, direction, and meaning. Joining the Army “family” may have served as a corrective emotional experience that helped to address childhood family dysfunction. Entering the civilian world—sometimes many years prior to what the Service member intended—may be a bewildering task. The Army requires Soldiers to participate in classes and workshops addressing educational benefits, VA system, and job-seeking skills prior to separation or retirement. And the Department of Defense initiated a program in collaboration with a mental health managed care organization to provide phone support from a licensed behavioral health provider that can continue after “clearing post” and provide coaching and resources for re-establishing behavioral health care. But because many Service members enter military service at a young age, it can be difficult to conceptu- alize how one might fit into a civilian working environment, especially in the profession of Combat Arms. One senior Non-Commissioned Officer (NCO) with multiple deployments quipped, “I keep looking in the classifieds for an opening for a ‘Tank Commander’—no luck.” With some discussion, he realized that his leadership skills, his experience as a team member, and his experience with executing a mission from beginning to end have great value in the civilian workforce. It is important to note that continued grief, unhappy feelings, worry, and anxiety about the future are normal reactions and are appropriate to the circumstances. Behavioral health providers can provide support, encouragement, and a sounding 10. Women Home from War 169 board. Assigning a diagnosis to these feelings is not helpful. Just as it is normal, as illustrated above, to experience distressing feelings on return from deployment, leaving military service may also elicit unpleasant feelings. An important role of the military behavioral health provider is to be able to identify normal emotional reactions and distinguish these from pathological processes. This includes providing reassurance that normal feelings will resolve with time. On the other hand, the stress of separation from the military may be accompanied by the onset of significant behavioral health symptoms. For Service members who have avoided treatment and have suppressed traumatic memories, the process of leaving the military may trigger the emergence of the symptoms of PTSD. Senior NCOs approaching retirement, for example, may experience an increase in irritability, disrupted sleep, problems with closeness in their primary relationships, and an increase in hypervigilance. The late emergence of these symptoms is not typical of a delayed onset of PTSD. In this situation the Service member has been experiencing symptoms and “driving on”—but as the end of military service nears, these symptoms overcome the Service member’s will to suppress and not acknowledge them. In disability cases, this may draw skepticism on the part of disability examiners, who may take the position that symptoms are faked or exaggerated in order to get a higher rating. But the symptoms are very real and are beyond the individual’s control in most cases. One might speculate that the long length of the operations in Iraq and Afghanistan and the need for repeated deployments with little downtime may make this phenomenon more common. The answer, however, awaits further study. Depressive reactions may also occur, for example, when the Service member does not have emotional attachments outside the military. Many young adults with limited parental support choose to join the military. Through the process of training, the Service member becomes a valued member of the military “family.” Because the military also maintains some degree of control over the lives of Service members, the tasks of leaving home and becoming an independent adult may be delayed for these Service members, and these issues may emerge at the time of separation from military service. These emotional reactions may be more pronounced if separation from military service is involuntary, either for medical, administrative, or disciplinary reasons.

DISORDERED EATING

Disordered eating is a problem that lacks intensive study to date in female Service members. A study of women enrolled in two VA medical centers in the Midwest found that one in six reported a lifetime history of disordered eating. Associations were found 170 Women at War with PTSD, sexual trauma (particularly completed rape during military service), and a history of childhood sexual trauma (Foreman-Hoffman et al., 2012). As is noted in other occupations that require athletic fitness and control of body weight, the pressure to maintain weight within prescribed parameters as a condition of continued service also contributes to the complexity of the problem. Although association does not confer causation, stress alone can contribute to weight gain and emotional eating, and many of the medications used to treat PTSD and depression are associated with weight gain. A prospective study of weight gain status in civilian women with PTSD found a consistent increase in BMI following the onset of PTSD (Kubzansky et al., 2014). Another area of potential concern in women Veterans who have been exposed to blast injury in theater is that pituitary injury may result in impaired growth hormone regulation and hypogonadism, endocrine factors that can also contribute to weight gain (Guerrero & Alfonso, 2010). Studies of occupations with a high rate of eating disorders, such as dancers, gymnasts, and models, consistently identify a requirement to maintain weight within specific guidelines as a risk factor for the development of disordered eating. The authors of VA study recommend routine screening for eating disorders. In another examination of Millennium Cohort Study data, Jacobson et al. did not find an association between deployment and disordered eating. The study did find, however, an association between combat-related traumatic events and disordered eating. Other significant variables noted were a past history of a mental health diagnosis and being placed on a diet for weight loss (Jacobsen et al., 2009).

NEXT STEPS IN THE RESET PROCESS

After block leave is over, and unit members have left for military schools, permanent change of station, new command, or re-classing to another occupational specialty, the unit begins the process of preparing for the next deployment. Immediately following deployment, symptoms of “normal” combat and operational stress tend to diminish, although some never completely recede. There is a subgroup, however, that will continue with active or worsening symptoms and associated functional impairment. It is at this point that medical providers are responsible for determining what conditions are treatable and thus will allow the Service member to continue in service, and what conditions may cause the Service member to fail retention standards. Providers are often faced with tough decisions when a Service member who planned to retire after 20 years of service develops a medical condition that does not meet medical retention standards. These standards are set out in the regulations of each branch 10. Women Home from War 171 of military service (Army Regulation 40-501). If possible, the Service member may be able to “re-class” to another specialty or may be accepted to COAD (Continue on Active Duty) following examination by the Physical Evaluation Board. But ultimately the provider’s decision will be made in accordance with the regulations and the needs of the Service branch.

THE WOUNDED WARRIOR UNIT

Each branch has a component dedicated to the treatment and rehabilitation of warriors who are injured or who become ill in the course of a mobilization or deployment. Wounded Warrior programs with similar goals are found in the Navy, Marines, Air Force, and Army, where this component is referred to as Warrior Transition, with bat- talions at each post. The Warrior Transition Unit (WTU) in the Army provides the Soldier with a unit assignment where the mission focus is on treatment and rehabilitation without distraction in order to return to full duty if possible, or referral to a Medical Evaluation Board to determine if there are conditions that do not meet retention standards. The WTU also enables the Soldier’s original command to obtain a replacement for that Service member’s position and to continue to train and prepare for the next deployment. Reserve or National Guard Soldiers who are demobilizing are assessed to see if they can be medically cleared for release from active duty and can continue treatment at home, or if there is a need for treatment that would warrant continuation on active duty and assignment to the Warrior Transition Unit. In this case the Soldier’s active duty orders are extended pending the outcome of medical treatment and further evaluation. Although allowing for treatment and stabilization of medical conditions, continuation on active orders may be a hardship for the Service member. A year-long mobilization, for example, can stretch into a two- to three-year absence from home if there are conditions serious enough to continue to require treatment or that lead to referral for a Medical Board evaluation. On the other hand, it provides the Service member with financial support and medical care during the rehabilitative period. These COMPO 2 and 3 Soldiers are older than the average active duty Soldier, and many also require treatment of conditions such as hypertension, heart disease, osteoarthritis, and other chronic disorders associated with aging. Many active duty Service members remain in their assigned units while continuing treatment and rehabilitation. The Soldier’s profile is modified to specify what duty limitations and restrictions are warranted and whether these are temporary and expected to improve or are permanent. The demands of OIF/OED/OND filled the Warrior Transition Units to the limit, and as a result, Service members who are medically unable 172 Women at War to perform may remain in their original positions. This in turn may result in feelings of resentment when others have to pick up the duties that the Soldier is unable to perform. The unit “family” gets off task, and dysfunctional group behaviors may emerge. Behavioral health conditions that lead to duty limitations may be especially likely to result in a sense of alienation from the unit. The Service member may feel “broken,” or as though he or she is resented or no longer belongs, adding to the difficulty of coping with post-deployment reintegration or transition to civilian life. When the situation is prolonged and the unit’s operational tempo increases, Service members may react to these stressors in unhealthy ways, such as misconduct and substance abuse, or depressive reactions may ensue.

MEDICAL SEPARATIONS AND THE DISABILITY EVALUATION SYSTEM

Before the increase in the size of the fighting force over the last decade, and the increase in the number of Service members with disqualifying medical and psychiatric conditions, Service members received treatment while on active duty until their health reached a point of stability. Then, if one or more conditions still did not meet retention standards, the Soldier was referred to the Medical Evaluation Board for further evaluation and entry into the military disability evaluation system. Recent revisions to the disability determination process have increased the efficiency and have decreased the processing time for medical separations. By integrating VA function of providing a Service connection rating with the military function of determining fitness for duty, duplications in the process are eliminated and Service members can remain on active duty while VA rating is completed, with the ultimate goal of sealing the benefits gap between the Army and VA system. The Integrated Disability Evaluation System (iDES) was piloted in 2009–2010 and is now fully implemented Army-wide. Entry into the iDES occurs when the Service member’s primary care provider deter- mines that one condition has reached the “medical retention decision point.” or MRDP. There may be other active conditions at varying stages of recovery. A VA Compensation and Pension examination follows, and once completed is reviewed, along with other treatment records, to determine, for each claimed or referred condition, if medical retention standards are met. An important aspect of this is the “e-Profile.” This process of monitoring readiness and managing medical profiles (lists of duty limitations) continues to evolve, with the emphasis on maintaining the fighting force. Medical profiles are now entered electroni- cally and are monitored by the local Medical Activity and the Soldier’s command, rather 10. Women Home from War 173 than being completed by hand and potentially getting lost when the Soldier moves from one post to another or following a change in command. Some gender differences are noted in the rates of disability and types of disabling conditions, but overall the differences are not extreme. For example, women are more prone to musculoskeletal injuries that lead to disability retirement (Fuerstein et al., 1997). A study of disability retirement in the Air Force found that female gender increased the relative risk of disability retirement, but when stratified by deployment history, this difference diminished. A study of Air Force disability retirement found that gender increased the relative risk of disability retirement, but when stratified by deployment history, this difference diminished (Elmasry et al., 2014). A study of disabled Veterans who served in the Israeli Defense Force noted that women experienced higher levels of psychosocial distress after retirement (Koren et al., 2013). This is an area that needs further study.

ADMINISTRATIVE SEPARATIONS

There are also a number of situations that may lead the enlisted Soldier’s command to initiate an involuntary separation of an administrative nature for “Convenience of the Government.” The details of the types and nature of these separations are detailed in Army Regulations and are different for enlisted Service members and Officers (AR 635-200). For example, the Soldier’s commander can recommend administrative separation if initial accession was defective, when parental obligations interfere with military duty, for personality disorders that do not respond to corrective measures, and for “other designated physical or mental conditions,” including chronic seasickness, claus- trophobia, sleepwalking, and others. Included in this regulation is separation for “failure to adapt” to military life, or “adjustment disorder.” Separations due to inadequate performance, failure to meet weight and tape standards, and relapse following rehabilitation for alcohol dependence are also found in this regulation, as is the process for separation due to various types of misconduct. At the present time, Soldiers who have deployed must obtain a behavioral health screen for PTSD and traumatic brain injury (TBI) before certain administrative separations can be approved. If PTSD or TBI or another significant psychiatric disorder is found (with the exception of substance use disorders) and it is determined that the condition does not meet retention standards, then disposition “through medical channels” is recommended, and a General Officer makes a decision as to which type of separation is appropriate in that individual case. There are gender differences observed in the types and frequency of administrative separations, but little formal research is found on the nature of these differences 174 Women at War and their significance. Because of the differences in the absolute numbers of male and female Soldiers on active duty in the Army, it is difficult to say, for example, that separations for “adjustment disorder” or “patterns of misconduct” are more prevalent among one group or the other simply by casual observation. Larger numbers would likely be needed to obtain an effect size that allowed for reliable conclusions. Differences in coping strategies, such as the degree to which the individual internalizes or externalizes stress or dysphoria, have been noted and may have an impact on the risk for disciplinary separation.

CONCLUSION

Women continue to contribute to the mission of the US military in a variety of roles, with duties in increasingly forward areas requiring proficiency in combat skills. As a group, women who deploy are resilient and do not appear to be at higher risk than their male counterparts for the development of psychological disorders due to deployment. There are some differences noted in the types of stressors encountered, with military sexual trauma having pervasive toxic effects on the Soldier’s well-being and effectiveness. As women enter the profession of combat arms, the challenge is preserving military effectiveness while making changes to tactics, techniques, and procedures that allow for optimal utilization of women in combat operations. Addressing the psychological needs of both men and women during the process of reintegration continues to evolve. Embedding teams of behavioral health providers into the medical support units of the Brigade Combat Teams allows for more individual consideration when the teams redeploy, as to which units may require more intensive evaluation and intervention, and allows for more optimal use of the natural support system of the small unit while its membership is still intact. Behavioral health providers can also identify and intervene when group dysfunction is identified at the company and platoon level. With the development over time of familiarity and trust between the troops and the behavioral health providers, there is an opportunity, following deployment, to continue the process of traumatic event management (TEM) and to interact at the smaller unit level when dysfunction is identified, encouraging a return to task orientation and promoting the use of healthier coping skills. Although this ideal may remain elusive, embedded teams are a step in the right direction. Military sexual trauma is well established as a serious risk factor for the development of psychiatric symptoms in both genders, with the incidence being much higher in women. All branches of the Service strongly discourage sexual harassment and are making improvement in policies to raise awareness and to encourage reporting and investigation without fear of retaliation (ALARACT 007-2012). Review of the efficacy 10. Women Home from War 175 of routine screening for military sexual trauma in a large sample of VA patients of both genders revealed marked discrepancy in the rates of positive screens, with positive responses for women at 19.5% and for men at 1.25%. The study recommended routine screening to allow for early detection of MST and further development of evidence-based intervention for positive screens (Kimerling et al., 2008). Since there is also evidence to support an increase in sexually aggressive behavior in combat settings, the addition of sensitive screening measures to routine post-deployment evaluations seems prudent. To mitigate the psychological stress of deployment, the Women’s Health Assessment Team, in a report on concerns of women serving in Afghanistan in 2011, also made a number of policy recommendations such as increasing postpartum deployment deferment to a year in all branches, and encouraging the development of community based peer support (Naclerio, 2011). Providers who are charged with evaluating Service members returning from a combat deployment, assisting with the challenges of reintegration, and monitoring readiness should be sensitive to potential differences between women and men in their coping strategies and their emotional needs. At the same time, it is important to recognize that women and men in harm’s way appear, overall, to be equally resilient, while equally sharing the psychological vulnerability that is a universal human response to war.

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Grossman, D., & Christensen, L.W. (2008). On combat: The psychology and physiology of deadly conflict in peace and war (3rd ed.). Warrior Science Publication. Guerrero, A. F., & Alfonso, A. (2010). Traumatic brain injury–related hypopituitarism: A review and recommendations for screening combat veterans. Military Medicine, 175(8), 574–580. Hoge, C. W. (2010). Once a warrior always a warrior. Guilford, CT: Lyons Press. Jacobsen, I., Ryan M., Hooper, T., Smith, T., Amoroso, P., Boyko, E., Gasckstetter, G., Wells, T., & Bell, N. (2008). Alcohol use and alcohol related problems before and after military combat deployment. Journal of the American Medical Association, 300(6), 663–675. Jacobsen, I., Smith, T., Smith, B., Keel, P., Amoroso, P., Wells, T., Bathalon, G., Boyko, E., & Ryan, M. (2009). Disordered eating and weight changes after deployment: longitudinal assessment of a large US military cohort. American Journal of Epidemiology, 169,(4), 415–427. Jovanovic, T., & Ressler, K. (2010). How the neurocircuitry and genetic of fear inhibition may inform our understanding of PTSD. American Journal of Psychiatry 167(6), 648–662. Katz, L., Cojucar, G., Davenport, C., Pedram, C., & Lindl, C. (2010). Post-deployment readjustment inventory: reliability, validity, and gender differences. Military Psychology, 22, 41–66. Kimerling, R., Street, A., Gima, K., & Smith, M. (2008). Evaluation of universasl screening for military-related sexual trauma. Psychiatric Service, 59(6), 635–640. Kline, A., Ciccone, D., Weiner, M., Interian, A., St Hill, L., Falca-Dodson, M., Black, C., & Losonczy, M. (2013). Gender differences in the risk and protective factors associated with PTSD: A prospective study of National Guard troops deployed to Iraq. Psychiatry, 76(3), 256–272. Koren, E., Bergman, Y., & Katz, M. (2013). Disability during military service in Israel: raising awareness of gender differences. Journal of Gender Studies (online), Taylor and Francis Online. doi:10:2080/0 9589236.2013.820132. Kubansky, L., Bordelois, P., Hee, J., Roberts, A., Cerda, M., Bluestone, N., & Koenen, K. (2014). The weight of traumatic stress: A prospective study of posttraumatic stress disorder symptoms and weight status in women. Journal of the American Medical Association Psychiatry, 7(1), 44–51. Litz, B., Stein, N., Delaney, E., Lebowitz, L., Nash, W., & Silva, C. (2009). Moral Injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706. Luxton, D., Skopp N., & Maguen, S. (2010). Gender differences in depression and PTSD symptoms following combat exposure. Depression and Anxiety, 27(11), 1027–1033. Metz, S., & Johnson, D. (2001, January). Asymmetry and US military strategy: Definition, background, and strategic concepts. Strategic Studies Institute, US Army War College. Maguen, S., Luxton, D., Skopp, N., & Madden, E. (2011). Gender differences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan. Journal of Psychiatric Research, 46(3), 311–316. Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2009). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association, 298(18), 2141–2148. Naclero, A., Stola J., Trego, L., & Flaherty, E., Health Service Support Assessment Team, IJC, Afghanistan. (2011). The concerns of women currently serving in the Afghanistan theater of operations: White paper. San Antonio, TX: US Army Medical Department. Nguyen, S., Leardmann, C, Conlin, A., Slymen, D., Hooper, T., & Smith, T. (2013). Is military deployment a risk factor for maternal depression? Journal of Women’s Health, 22(1), 9–18. Pfeiffer, P, Blow A., Miller, E., Forman, J., Dalack, G., & Valenstein, M. (2012). Peers and peer-based interventions in supporting reintegration and mental health among National Guard Soldiers: A qualitative study. Military Medicine, 177, 1471–1476. Rivers, F., Gordon, S., Speraw, S., & Reese, S. (2013). U.S. Army Nurses’ reintegration and homecoming experiences after Iraq and Afghanistan. Military Medicine, 178, 166–172. Seelig, A., Jacobsen I., Smith, B., Hooper, T., Gackstetter, G., Ryan, M., Wells, T., Wadsworth, S., & Smith, T. (2012). Prospective evaluation of mental health and deployment experience among women in the military. American Journal of Epidemiology, 176(2), 135–145. 10. Women Home from War 177

Scott, J., (2010, April 13). Mothers in the military: punishing mother who serve. Blog post retrieved from https://pbs.org/pov/regardingwar/conversations/women-and-war/. Sewell, S., Nagi, J. (2007). The U.S. Army/Marine Corps Counterinsurgency Field Manual: U.S. Army Field Manual 3-24; Marine Corps Warfighting Publication No. 3-33-5/with Forewords by General David Petraeus and Lt General James F Amos. Chicago: University of Chicago Press. Thomas, J., Wilk, J., Riviere, L., McGurk, D., Castro, C., & Hoge, C. (2010). Prevealence of mental health problems and functional impairment among active component and National Guard Soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry, 67(6), 614–623. Vogt, D., Vaughn, R., Glickman, M., Schultz, M., Drainoni, M., Elwy, R., & Eisen, S. (2011). Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF veterans. Journal of Abnormal Psychology, 120(4), 797–806. U.S. Army Field Manual FM 27-10: The Law of Land Warfare; Department of the Army, Washington 25, D.C. 18 July 1956 with Change 1, 15 July 1976. U.S. Army, Office of the Surgeon General and Office of the Command Surgeon HQ , USCENTCOM and Office of the Command Surgeon US Forces Afghanistan (USFOR-A). (2011, February 22). Joint Mental Health Advisory Team 7 (J-MHAT-7) Operation Enduring Freedom 2010 Afghanistan. Chapter 7.1. eleven Mothers in War

AMY CANUSO

INTRODUCTION

The purpose of this chapter is to introduce clinicians to topics that may be the focus of clinical attention and to highlight the unique issues that women with children face when they deploy in the United States military. The military is becoming more inclusive to women in leadership and combat operations; thus the number of women with children who deploy in the operational setting continues to increase. This chapter will educate clinicians on the resources available to military mothers. It will discuss the ways that clinicians can advocate for Servicewomen with infants by educating commands on the various military instructions which ensure that women have adequate bonding time and opportunity to breastfeed. Mental health clinicians and medical providers alike will be able to discuss with mothers who are about to deploy, and their children, how cognitive preparations can help them to maintain a sense of family stability and proficiency in their work while they are deployed. This chapter will explore the ways that mental health providers and other clinicians can stress to military Servicewomen that the deployment experience can be strengthening to their family, and to themselves, offering many resiliency-building attributes. Clinicians with this knowledge can assist women in their personal and family readiness, and can begin to set the stage for healthy processing of the deployment experience. The changes in the way that women and mothers have deployed with the military may be attributed to the changing structure of the military itself. The military continues to integrate women in non-medical military occupations, no longer limiting them to the “male supporting roles” (Defense Manpower Data Center via Military OneSource,

178 11. Mothers in War 179

2012). Similarly, the traditional family structure is changing. There are a growing number of female primary breadwinners, single breadwinner income with stay-at-home fathers, families in the military who are dual active duty (both mother and father being active duty), and single mothers in military service (Defense Manpower Data Center via Military OneSource, 2012). With these changes in the demographics of family structure, there will continue to be more women who have children in deployable positions.

UNDERSTANDING THE SOCIAL CONTEXT OF THE CHANGING LANDSCAPE OF WOMEN IN THE MILITARY

The majority of “Generation X” women who entered military service (as well as those who are younger) do not view women who deploy in service of their country as a novel phenomenon. Women in the military often see their deployments with generational pride—a period in history when more women are actively integrated into military roles (other than as nurses) (Patten & Parker, 2011). There is very little research that has exclusively tracked the attitudes and expectations of military mothers in this age group; however, it is the experience of this author and other professional women interviewed for this writing that most women who entered the military post–9/11, for the most part, fully understood that they would deploy. The majority of women who joined the post–Persian Gulf War military entered their service commitment without children. Most women interviewed for this chapter did not initially appreciate that they had to choose between motherhood and career, or motherhood and service to country. The current cohort of women in military service grew up in the era that followed the women’s movement of the 1960s and 1970s; for the most part, they believed that women could (and should) “bring home the bacon” as well as “fry it up in a pan” (as most of that generation saw on an Enjoli cologne commercial, which became iconic). This faction of women grew up after Title IX; thus they were more apt to participate in school athletics, and to feel that they could perform physically in rigorous military training, which led to a desire to pursue the military lifestyle of activity and physical readiness. While women with children were becoming more successful in the civilian sector, as police officers, pilots, managers, and scientists, it seemed logical that there would be similar trend in the military sector (US Department of Commerce, US Census Bureau, 2013).

“I was a single mom. I found out I was pregnant after I signed up and finished my training. I didn’t have a choice but I really felt it was a situation that was not only possible, but also could be beneficial.” 180 Women at War

Women in the military are less likely to marry then their male counterparts. Women who do get married frequently marry an active duty partner after basic training and military educational training (specialty schools or specialty training) (Defense Manpower Data Center via Military OneSource, 2012). For new families and single mothers, the resources of the military social support Services, the steady paycheck and housing, the free healthcare and generous maternity leave can be favorable.

“I was married when I joined; however, I did not think I would have children. I thought I would serve my time and get out of the military but I just never did.”

“I knew I would deploy so I timed it to when I could go early after the baby was born. I don’t think I’ll stay in though, I would not want to do another deployment with my kids older.”

For many military women with children, deployment orders can be a conflicting situation. They may want to deploy because the mission is the result of months, sometimes years, of training and preparation. Women whom I interviewed explained that they were honored to be able to be among the fighting forces serving their country. However, the reality is that when they leave their children, there may be significant cognitive dissonance. Unfortunately, most women don’t fully appreciate the ambivalence until they have both a child and deployment orders in hand at the same time. Reactions may range from sadness and denial to anger.

“I didn’t think that I would be sad when I deployed away from my kid and I wasn’t, but I did end up angry. Angry all the time.”

“You always know there is a chance you might deploy with kids, but we just decided to do it [have children]. I had wanted to deploy, but now I began to sort of dread it.”

There are women with children who enjoy deployment time as much as any person without a child. Many women find the deployment very satisfying, both professionally and personally (Patten & Parker, 2011). It is an opportunity to serve the United States. It is an opportunity to provide for their family monetarily. It is an opportunity to gain precious job experience.

“I thought it was almost easier being deployed in Afghanistan then trying to balance between work and home-life Stateside. When deployed, I could work around 11. Mothers in War 181

the clock and focus entirely on the mission without worrying about the needs of my children or husband.”

“My view of deployment didn’t change when I had my son, but my husband’s did. Now it became more family involvement and child care time for him.”

“I got paid two and half times as much on deployment so it really helped us out.”

For the mental health provider, it is important to appreciate the diverse presentations and experiences that a woman with children may have before and during deployment. The ability to focus on inherent healthy defenses and positive cognitive framing of the situation can be used therapeutically to strengthen baseline resiliency.

PREPARATION FOR DEPLOYMENT: HOW CLINICIANS CAN HELP

Family therapists and family readiness specialists agree that it is necessary to designate a period of family preparation when any family member is deploying. This is beneficial for the family and also for the active duty parent. While it may be tempting for parents to not want to distress their children, it is imperative to recognize that the motive for not telling children may be unconscious avoidance of the parent. When a mother understands that her child is mentally prepared and that all caregiving needs are secure, she can better focus on the needs of the mission. There are multiple resources to assist a mother in explaining the separation of deployment to their children in a developmentally appropriate manner. There are numerous children’s books that feature stories of children whose parent is deployed and that discuss the feelings that children and parents feel in the pre- and post-deployment stages. In these books, characters find ways of resolving their conflict when a parent is away in military service. Many books are even specific to children whose mothers are deploying. For example, Sesame Street has produced a DVD that has been helpful to many families (Sesame Street Workshop, 2006). Other tools for families include journals, “mommy dolls” videos, and numerous cognitive tokens (such as filling a jar with small candies to number the days Mommy will be deployed and then eating one a day until the return). It is a commonly understood phenomenon that at times Service Members can be overwhelmed with the amount of social services that are available and may not know which would be the most beneficial.

“I became so obsessed with learning about every resource book, video and craft possible that I nearly collapsed. I needed to be sure that my kids did not miss THE 182 Women at War

book/video/class/toy that was going to ensure that my kids did not forget about me and did not suffer an emotional scar.”

“I must say that when Elmo spoke about this topic I was really starting to feel a bit comforted.”

Resources are widely available through military social service programs, such as Fleet and Family Services, and family support programs, and they are often free. Clinicians should be aware that such resources could be helpful to women with children who deploy, and they should be familiar with resources so that clinically relevant and therapeutically sound resources can be recommended. The following is a list of helpful materials that clinicians can keep on hand. All are readily available through Military One Source (www.militaryonesource.mil) and are free of charge.

• Home Again by Dorinda Silver Williams: This is a lovely illustrated book for children ages 0–3 years that helps children and parents with some of the issues of reunification after deployment. • Over There by Dorinda Silver Williams: This is a book for children ages 0–3 years that introduces the concept of a parent deploying. There is a Mommy version and a Daddy version. • Over There: This is a downloadable MP3 recording of Dr. Heidi Kraft discussing some of the challenges and the benefits of mothers who have deployed. It is also available for order in CD form. • Military Youth Coping With Separation: When a Family Member Deploys: This is a video that can be downloaded or ordered on DVD. It is designed specifically for older children and adolescents to help them understand and prepare for the social and emotional changes in the household when a parent deploys. It was designed by military pediatricians. • Mr. Poe and Friend Discuss Family Reunion After Deployment: An animated carton designed for young children and school-aged children to discuss the return of parents and reunification. It also features real children and their active duty parents who discuss how they got through deployment and reunification in their families. This video focuses on positive family strengthening aspects of deployment. • Sesame Street Talk Listen Connect: Deployment Homecoming Change: From the writers and directors of Sesame Street, this video features familiar Sesame Street characters as they talk about the changes and feelings they have when their parents deploy. This is a bilingual DVD, which also has some supplemental materials for parents to act as “a conversation starters” to discuss deployment with their kids. This is appropriate for children ages 1–5 years. 11. Mothers in War 183

• Coming Together Around Families: This is a comprehensive “toolkit” designed for “families and providers.” It has leaflet style handouts that are promotional for Military OneSource’s other programs and articles, which are found the Military OneSource website (http://www.militaryonesource.mil). It includes the Over There books and the Sesame Street DVD. It is not age specific.

While OneSource has very useful tools, they limit the amount that one person can order. A clinician may want to have multiple resources on hand, however. OneSource representatives report that they would rather clinicians refer to the website so that military members can log in themselves to order. Clinicians can log in with families while in session to ensure that the resource can be utilized. There are a number of children’s books specifically about mothers deploying that can be bought at bookstores or procured from city or military base libraries. The following is a list of some readily available titles that are exclusive to the subject of military mothers who deploy:

• Mamma’s Boots by Sandra Miller Linhart, illustrated by Tahana Marie Desmond • Love, Lizzie: Letters to a Military Mom by Lisa Tucker McElroy, illustrated by Diane Paterson • My Mommy Wears Combat Boots by Sharron G McBride • Mommy, You’re My Hero by Michelle Ferguson-Cohen.

Not exclusive to a mother being the parent deploying but still worthwhile and gender neutral:

• We Serve Too! A Child’s Deployment Book by Kathleen Edick • Love Spots by Karen Panier • You and Your Military Hero: Building Positive Thinking Skills During Your Hero’s Deployment by Sara Jensen-Fritz, Paula Jones-Johnson, and Thea L. Zitzow.

The military healthcare provider is in a key position to assist women in preparing their families and themselves for an upcoming deployment and separation. Mental health providers, women’s health practitioners, pediatricians, and general medical providers can use pre-deployment health visits, well women visits, and well child visits to explore the level of preparedness with women who are in deployable positions. This should be part of an ongoing wellness screen because it is not unheard of to have spontaneous deployments or “hot fills,” which can mean as little time as two weeks to 184 Women at War prepare for deployment. Clinicians may consider the following questions to discuss with patients and clients in preparation for deployment:

• Is there a chance you will deploy in the next year? • How do you intend to discuss the deployment with your child? • Have you allowed sufficient time for your child to process fears and questions? (an opportunity to discuss the importance of not waiting to tell children about the deployment) • What resources have you utilized to help your child understand why you must leave? • Have you planned for sufficient time to spend with your child (without interrup- tions) before deployment (like a family trip)? • Have you investigated the ways you will be able to communicate with your children? (Skype is often unavailable) • How do you hope that this deployment will help you and your family? (an opportunity to put focus on the value of deployment and how the family may benefit).

Such questions are meant to begin the discussion and facilitate the opportunity to assist the mother in the arduous and sometimes overwhelming preparations for deployment and separation. Questions should be discussed, with answers derived by the clinician and the mother in a therapeutic manner, again with resources readily available. It may be that the mother about to deploy needs a meaningful act to sublimate her anxiety and fear of separation. Clinicians can suggest the following activities that families can do together to facilitate discussion and bonding.

• Consider a memory box with some special items, pictures, meaningful tokens, and a special letter that the child can look at when he or she misses mommy. This box can be made together, or a mother could make one for her child and the child could make one for the mother; then they could share the experience of giving a gift to each other. • Create a jelly bean jar: a jar is filled with jelly beans (or other candy) that has enough pieces in the bowl for each day that mommy is gone. One piece gets eaten every day until mommy returns. • Consider a mommy doll (https://www.daddydolls.com/); this can act as a tran- sitional object for a child while the mother is deployed. • Suggest that books are read and recorded in front of the laptop (in photo booth type application or similar program). This allows children to see their mother read them a story, thus maintaining a part of the nighttime routine. 11. Mothers in War 185

• Encourage women to write often to their children in developmentally appropriate ways. A child might really enjoy just a drawing from their mother if he or she doesn’t read, and it makes children feel special to get a piece of mail. • USO offers a reading program for kids through the chaplain services at most overseas bases (http://www.uso.org/united-through-reading.aspx). This, again, is an opportunity for the child to have a special connection, a special gift, that comes just for them from their mother. • Caregivers can keep a journal in the kitchen and write down the date and just a line about something humorous or significant the child did or said that day. After a few pages are filled out, the pages can be sent to the parent as a letter.

NEW MOTHERS WITH VERY YOUNG CHILDREN

It is not uncommon for women in the military to deploy when their children are very young, given that 65.7% of military members are less than 30 years of age and 44.0% of the members of the Armed Forces who have deployed have children (Department of Defense, 2010; Defense Manpower Data Center via Military OneSource, 2012). Each branch has a slightly different direction regarding the deferment period before a postpartum active duty member must return to her deployable status. Each branch—Army, Navy, Air Force, US Coast Guard, and US Marine Corps (USMC)—has some provision to allow women in the deferment period to continue military service and training while breastfeeding their children. The Air Force, the US Army, the Coast Guard, and the USMC prohibit deployment for 6 months following childbirth. The US Navy has a 12-month deferment from deployment after childbirth. The Air Force also supplies a recommendation to commands to wait a full 12 months after birth before the active duty member deploys; however, there is no guarantee that the command will follow the recommendation, especially when resources and manpower are limited. The US Coast Guard has a one-time opportunity for men and women, Officer and enlisted, to be separated without pay from their service obligation for child-care needs. After two years there is a return to previous pay grade and benefits are restored. The respective directions are as follows:

• Army AR 614-30 Deployment, Table 3-1 #33 Available on Internet at http://www.apd.army.mil/pdffiles/r614_30.pdf • Marine Corps Order 5000.12E (Revised by MARADMIN 358/07) Available on the Internet at http://www.marines.mil/Portals/59/Publications/ MCO%205000.12E%20W%20CH%201-2.pdf 186 Women at War

• Navy OPNAVINST 6000.1C Available on the Internet at http://doni.daps.dla.mil/Directives/06000%20 Medical%20and%20Dental%20Services/06-00%20General%20Medical%20 and%20Dental%20Support%20Services/6000.1C.PDF • Air Force Instruction 44-102 Available on the Internet at http://www.unitedstatesairman.com/AFI44-102_ 20_medical%20care%20management-1.pdf • Coast Guard COMDTINST M1000.6A Available on the Internet at http://isddc.dot.gov/OLPFiles/USCG/010564.pdf.

Most branches also have a provision in place for returning to service and being able to sustain breastfeeding. The US Army is the only branch with no clear guidelines; however, there is a formatted template letter that women can give to commands asking accommodations for breast-pumping needs, which is available with CAC access on Army Knowledge Online. In the readiness manual for female Soldiers there is a section on supporting breastfeeding after return to work. An excellent resource that clinicians can provide to women is the website www.breastfeedingincombatboots.com, which has a link to all military policies, military manuals, and sample letters provided in a very concise and user-friendly format (forgoing the need for CAC cards and time-consuming Internet searches) (Roche-Paul, 2014). The US Air Force and the Coast Guard have in their written directions the specific requirement of a private space for breast pumping when mothers return from maternity leave. The US Air Force written direction requires specific time allotments (15–30 minutes per 3–4 hours) to allow women time away from their duties. The Navy and the USMC written directions even state that the room provided for mothers who use breast pumps must be private, and with running water (the Navy even requires refrigeration). Times allotted are not specified in the Navy direction or the USMC direction. This “unspecified” time allotment for breastfeeding can be extremely problematic. Most women find out soon after delivery that breast milk is produced in response to demand, so minimal breaks that are relatively short through the day result in a dwindling supply of breast milk.

“With my first baby I was so worried about being away from my job and I only produced milk for about 4 months. If I my breasts felt full, like I needed to pump, I just waited until it was 4 hours from my last pump. With my second baby I stopped worrying about what my command thought and pumped often for at least 40 minutes. My supervisor never complained. I sustained feeding for nearly 10 months.”

The ability to be away from the needs of the job varies, depending on the job and the command. Furthermore, there is the unspoken future ramification of how promotion 11. Mothers in War 187 and advancement will be affected for a female who spends up to two hours a day away from her post, pumping milk. While the ability to breastfeed is no doubt better for baby and for mother, the limitations to time spent breastfeeding and the conditions under which a mother is pumping (such as unclean spaces, or no running water) can affect the mother’s ability to sustain milk (Foster & Alviar, 2013). Plugged ducts, poor hydration, engorgement, or contami- nated milk product due to lack of cleaning and refrigeration are some of the unfavorable outcomes that may result from limitations to pumping and inappropriate accommodations (Bell & Ritchie, 2003).

“I was in the field for two weeks when my child was 9 months. I pumped three times a day but at the end of that workup my milk really dropped to only a few ounces a day. I had no way of getting the milk to my child so I ‘pumped and dumped.’ I hated to waste it.”

Neither the Army, Navy, USMC, US Coast Guard, or US Air Force allot for the deferment of training exercises, special trainings (TAD), special schools, or field training. It is plausible that 6 months postpartum, an active duty women may be expected to go to operational, pre-deployment workups, possibly being in the field training for days or weeks. As illustrated above, in addition to compromising the amount of milk produced and its usability, this interrupts the bonding process that is known to occur during breastfeeding, and may result in the child switching preference for bottle feeding over breastfeeding. Clinicians can assist new mothers in the military by providing education and information from the above military directions.

THE FAMILY CARE PLAN

A family care plan is a mandatory document that all Service Members with children must submit to their commands. This document is considered an essential part of operational readiness. It is devised to pre-plan for child-care arrangements when a parent deploys or could be deployable. There are roughly 20,000 couples in which both husband and wife are in military service, and 30,000 single military mothers. Forty-eight percent of married women in the military are married to a man who is also in the military, but only 7% of men are married to an active duty female (Defense Manpower Data Center via Military OneSource, 2012). It is important to understand that the family care plan is not choosing a babysitter or a preschool. The mother will be deployed for months, conceivably even over a year. 188 Women at War

Child-care arrangement vary from the husbands of military mothers, their children’s fathers with whom the mother is not married, grandparents, aunts and uncles, and, in some cases, family friends. The family care plan can be especially stressful for single mothers (Ritchie, 2001 December). Women may find that they have problems with the consistency and reliability of family care plans before and during deployment. It is impossible to predict unforeseen complications in care, such as when a grandparent becomes sick, a caretaker has legal problems, or a father relocates for a job. For example, I interviewed one woman whose family care plan stated that her child would stay with the child’s biological father, whom she had divorced two years earlier. This father developed a drug habit and became increasingly unreliable and difficult to contact. She asked to return from deployment to ensure the safety of her child and was legally charged by her command for not having a proper family care plan. Women with children have much more to prepare for when they are about to deploy or go underway than merely having their backpacks or sea bags fully “squared away.” Clinicians can assist mothers in the military by being supportive as they navigate mother-specific challenges in deployment preparation. Clinicians may consider the following questions to discuss with patients and clients in preparation for deployment:

• Is there a chance you will deploy in the next year? • Do you have a family readiness plan? • Do you have a power of attorney? • Who would act as your child’s guardian if you deploy? • Will your child need to move to a different location to be with the guardian? Would this move entail that the family will be outside travel to a military base? • Does your guardian have reliable transportation? Reliable income? • Does your guardian have legal problems? Substance abuse problems? • Have you discussed how your guardian will discipline your child and set boundaries with your child? • Have you discussed school or day-care provisions with the guardian? • How will your guardian have access to emergency monetary funds? • Who will be the temporary guardian if your assigned guardian becomes ill?

WHILE DEPLOYED

Many military women who are mothers find that they can, somewhat, acclimate to the separation from their children during deployment. Once a unit is “boots on the ground,” the emotions of missing and longing for children, or even the feelings of guilt 11. Mothers in War 189 because a mother has left a child during deployment, are often replaced by the urgency of the mission.

“For the first time since before being married and before children, it felt like I was in control and independent. I felt like what I did mattered in a different way then when I am mom at home. I felt like the primary focus was my skill and I felt like my work was important.”

It may only be during phone conversations, letters, or Skype sessions that women really begin to experience the full emotional weight of missing their children. There are some very helpful tools, such as cognitive reframing or simple behavioral planning, that can assist to ensure that the duty member remains effective occupationally if she begins to have mood or anxiety symptoms.

“I tried to avoid thinking of [my child] most of the time. I had this system where I had something to do right after every phone call so that I would not retreat to my tent and start crying.”

Besides the positive feelings of competence that mothers have when they are deployed, they may find to their surprise that their families also are experiencing a sort of satisfaction that comes with mastery of task: “Mommy is doing her part for the country and so am I. I am being brave and I know Mommy will come back soon.” This can be an opportunity to allow children to build self-confidence in a shared, family endeavor, and even start to develop healthy autonomy. Mothers describe that upon their return from deployment, children recall with pride their mother’s service to their country: “Veterans day is special because Mommy is a Veteran.” Some describe that their child connects seeing people in need on the news with the work that their mother did when she was away.

“My girl sometimes still brings it up. She sometimes will refer to the year that I wasn’t there as ‘the year you were helping to keep America and us safe.’ ”

The unique perspective of motherhood can be both helpful and also a challenge. Deployed mothers, whether in healthcare support, supply support, or directly in the line or wing units, report improved patience with the younger active duty population with whom they interact. Being a mother inherently has a way of helping a woman recognize that every person has a mother somewhere, and there becomes almost a surrogate nature to interactions with younger Service Members. Mothers describe having 190 Women at War an ability to mitigate the needs and demands of their mission with an ability to also be supportive and sometimes even diplomatic. This ultimately can be beneficial for the mission. Women describe being able to keep peace in the military unit by using the skills of keeping peace in a family unit.

“Once I had children I noticed I didn’t want to strangle my young guys when they did something foolish. Before I may have really laid into them.”

“I always took the time to talk to the young Service members, just ask them how they were doing. I explained that I had two kids, and if one of my kids was serving in Afghanistan I would want someone to check in with them and make sure they were doing okay, tell them their mom was proud of them. Even the biggest toughest Soldier seemed to soften up a little.”

A specific challenge to many mothers who deploy can be when their mission requires that they come in contact with local children. This was the case for many women deployed in the Middle East during OIF and OEF, and for women who deploy on humanitarian missions, such as Haiti and Tsunami relief missions. Healthcare workers in military treatment centers, as well as women integrated into line or support units who travel beyond the wire in operations, can often be in contact with local children. It is not uncommon to see sick or injured children. Women in healthcare positions often treat children injured from military operations. In places like Afghanistan, injured children brought to US or NATO treatment facilities for medical care are not accompanied by women; they are escorted by a male family member or the village elder. This contributes to the level of emotional distress the child may experience when injured. While the sight of severely harmed, frightened, sometimes badly burned, or even deceased children can be traumatizing for anyone, many mothers who deploy say it is particularly difficult.

“It was not that we were reduced to ineffective puddles on the floor, however it did color our interactions with the patients and the families. It was almost as though there was an extra sensitivity or a commonality we had with this child. This was another woman’s child. That could be my child.”

WHY THE AREA OF OPERATIONS BENEFITS FROM HAVING MILITARY MOTHERS

In the area of operations, there are profound differences in the male and female ratio. One source reports states that there were nearly 300,000 women deployed in support 11. Mothers in War 191 of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) between September 2001 and February 28, 2013, making up approximately 11% of the fighting and supportive force (Burrelli, 2012). Mental health workers interacting with women who deploy are in a unique position of not only helping to build resiliency in the mother and her family in the pre-deployment stage, but also, in theory, focusing and highlighting inherent resiliency traits in the active duty member to help her potentiate her leadership capabilities. Many mental health experts have examined how the experience of deployment and exposure to trauma may be defined in psychodynamic theory as a “disconnect from self or shattering of the “self” (or ego). When active duty members, men and women alike, are separated from the familiarity of their homes, families, and normal environment and social structure, it is not uncommon to have a regression to more primitive defense mechanisms (Figley & Nash, 2007; Litz, 1992; Arreed et al., 2011). For example, when an active duty member is in the United States, doing his or her job, that person may suppress anxiety and anger over everyday stressors while at work for social appropriateness. When that active duty member goes home at night, he or she releases frustration in the safety of the home (with distance from the given stressor). During deployment, that same active duty member now finds that there is no acceptable place to discharge emotion and no way to gain distance from the stressor. Thus the secure “self” becomes compromised, and the active duty member may experience frustration, anger, and/or anxiety. The conceptualization of “self” that many active duty members have in military service is that they are strong, untouchable, and able to withstand. This is a fundamental teaching to every military recruit. It is embraced by all branches in the military in all Corps and Services. A fractured self-concept is more vulnerable to doubt, insecurity, and fear. Such “chinks in the armor” of the self (ego) may become more pronounced with exposure to trauma. Women who return from deployments with positive and healthy experiences describe that using the lessons they have learned as mothers can be helpful in navigating the stressors of a tour of duty. Denial, suppression, depression, and anxiety are common when challenged with separation from their children while deployed. One therapeutic approach for women is to embrace the “mother” in them and to pursue sublimation. Women who describe the ability to take the fear and sadness they feel from being separated from family and refocus the frustration in a positive way in their work (such as maintaining focus on the greater good of the unit, and accepting that separation is temporary) describe less emotional conflict. It is possible that supportive interactions by mothers (and even women who in any way identify with the representative human archetype “Mother” or “Sage”) have therapeutic potential to enhance ego strength 192 Women at War

(Young-Eisendrath, 2000; Wilson, 2007). As anecdotally reported above, a woman who is a mother may have a conscious or unconscious desire to sublimate the energy of longing for her child. This surrogate capacity may shape psychological processing of the trauma associated with combat. Trauma exposure and the development of a psychological stress reaction may be mitigated or lessened when the innate resiliency (balanced sense of self) is strengthened. The representational “mother figure” assists with the processing of fear, sense of loss, lack of trust, and the fundamental feeling of helplessness and separation. This is in no way to suggest that the area of operations benefits from the presence of women to “soften the trauma of war.” However, figures that are reminiscent of the inherent unconscious representations of safety and security and trust may act to balance the idea of “self” and may foster pre-existing resiliency. Likewise, for mothers who are deployed and who are enduring their own grief and guilt of not being with their own children, the interactions may have a reciprocal therapeutic capacity, through the sublimation of the mothers’ desire. This technique in reciprocal therapeutic interaction is a positive alternative for women who may feel the need to suppress their natural drive to nurture, or to comfort, because they fear them to be inappropriate or unfavorable in the environment of military service. This theory is based on anecdotal observations of women who verbalized successful and favorable experiences during OEF. There is no known research to support the theory, and so it remains a much needed area for continued research and the development of appropriate metrics.

WEIGHING BENEFITS AND COSTS

It would be naïve to deny that there are negative aspects of the military deployment of women with children. A mother’s separation from her children for extended periods can be particularly critical during specific early child developmental periods and can impair the relational connection or bond between mother and child. There is always the chance that the marriage may be strained and that there may be unsettled damage to the family unit’s cohesion. For single mothers who implement the family care plan, there is a potential for abuse or neglect of children while the mother is deployed. No mother would willingly want to leave a child in an unsafe or unprotected situation, but unforeseen circumstances have resulted in tragic outcomes. Thus there is a risk of post-combat symptomatology that may affect parenting ability (Nguyen, et al., 2013; Bonanno et al., 2012). However, this potential exists for fathers who deploy as well, not only mothers. This continues to be an area that lacks data. There is a need for a long-term, evidence-based evaluation of how families fare after a parent deploys, examining both the negative and positive aspects. 11. Mothers in War 193

I suggest that there is also a therapeutic benefit that likely cannot be quantified to having women with children in deployment areas. Women who deploy in service to their country are able to significantly contribute to the family household income. Most Service members know the financial incentive of service and deployment, not only in building savings, but also later in utilizing the GI bill. For a single mother, this economic advantage could potentially outweigh the costs of separation from a child, particularly if there is stable family or community support to ensure the safety of her child in her absence. There can be a therapeutic advantage to stressing pride in the family member, the family sacrifice, growth in autonomy, and the effort that all in the family put forth. Though separations can be difficult, there is also a potential for the strengthening of family bonds.

“I have a special place for the letters my family and I wrote to each other. I cherish them as part of our family’s story and don’t take for granted the time I now spend with my kids.”

CONCLUSION

Every active duty military member who deploys will face challenges, as well as gaining some rewards, when she serves her country overseas. This is true for all parents, whether mother or father. Clinicians who provide care for the military population can assist active duty mothers by including deployment planning and family preparation as part of the ongoing treatment plan and treatment goals. Clinicians should be educated regarding the resources and military instructions pertaining to mothers who deploy and serve with the United States military. They should have tools and materials readily available in their clinic or should be able to offer in-office demonstrations of navigation to online sites, because it is a common clinical complaint that military social and family support networks are resource rich but utilization poor (Department of Defense, 2010). Clinicians can include positive cognitive framing techniques as a therapeutic tool to build a strong, stable mindset, and to encourage that the entire family, together, work toward viewing the deployment as an opportunity to grow. Clinicians for active duty mothers have a unique position of working with military leadership to challenge the flawed notion that mothers cannot be productive workers in the military or effective members of the unit, and they can champion for the accessions needed so that a mother can do her duty without compromising her ability to provide for her child. The numbers of women, and also women who are mothers, in military operations are rising. This chapter reflects some experiences of the women interviewed in preparation for this writing; however, at this time there is very little evidence-based data to 194 Women at War support conclusive statements. Future research should focus on family outcomes to examine the challenges that both mothers and children face and the benefits that the family gains. It is known that women Veterans experience many of the same challenges that male Veterans do (Patten & Parker, 2011). It would be helpful to evaluate if the children of women who deploy experience more health concerns. A review of medical documentation from specific families and of women who deployed may be a way to gauge overall family well-being as the OEF mission is slowing. A simple questionnaire could be used to measure resiliency and family satisfaction and would not require review of medical documentation. In the next 10 years there will be a cohort of children who have had mothers deployed and are now reaching their own adulthood. This prospective approach may invalidate entrenched views of the way our society regards mothers who deploy in service to their country.

REFERENCES

Barabasz, A. F., Barabasz, M., & Watkins, J. G. (2011). Single-session manualized Ego State Therapy (EST) for combat stress injury, PTSD, and ASD, Part 1: The theory.International Journal of Clinical and Experimental Hypnosis, 59(4), 379–391. doi:10.1080/00207144.2011.595349 Bell, M. R., & Ritchie, E. C. (October 2003). Breastfeeding in the military, Part I: Information and resources provided to servicewomen. Military Medicine, 8(10), 807–812. Bell, M. R., & Ritchie E. C. (October 2003). Breastfeeding in the military, Part II: Information and resources provided to servicewomen. Military Medicine, 8(10), 813–817. Bonanno, G. A., Mancini, A. D., Horton, J. L., Powell, T. M., LeardMann, C. A., Boyko, E. J., Well, T. S., Hooper, T. I., Gackstetter, G. D., & Smith, T. C., for the Millennium Cohort Study Team. (2012, April). Trajectories of trauma symptoms and resilience in deployed U.S. military service members: A prospective cohort study. British Journal of Psychiatry, 200(4), 317–323. Burrellli, D. (April, 2012). Woman in combat: Issues for Congress. Congressional Research Service. Retrieved from http://www.fas.org/sgp/crs/natsec/R42075.pdf (accessed February 23, 2014). Defense Manpower Data Center. (2012). 2012 Demographics: Profile of the military community. Retrieved online from Office of the Deputy Secretary of Defense (Military Community and Family Policy), under contract with ICF International website. Retrieved fromhttp://www.militaryonesource. mil/12038/MOS/Reports/2012_Demographics_Report.pdf (accessed March 20, 2014). Department of Defense. (October, 2012). Report on the impact of deployment of members of the armed forces on their dependent children. Report to the Senate and House Committees on Armed Services. Retrieved from http://www.militaryonesource.mil/12038/MOS/Reports/Report_to_Congress_ on_Impact_of_Deployment_on_Military_Children.pdf (accessed March 1, 2014). Figley, C. R., & Nash, W. P. (2007). Combat stress, theory research and management. New York: Routledge. Foster, G. A., & Alviar, A. (January, 2013). Military women’s health while deployed: Feminine hygiene and health in austere environments. Federal Practitioner, 9–13. Litz, B. T. (1992). Emotional numbering in combat-related posttraumatic stress disorder: A critical review and reformation. Clinical Psychology Review, 12, 417–432. Military OneSource Website. Retrieved fromhttp://www.militaryonesource.mil/ (accessed March 1, 2014). 11. Mothers in War 195

Nguyen, S., LeardMann, C. A., Smith, B., Conlin, A. M. S., Slymen, D. J., Hooper, T. I., Ryan, M. A. K., & Smith, T. C., for the Millennium Cohort Study Team. (2013, January). Is military deployment a risk factor for maternal depression? Journal of Women’s Health, 22(1), 9–18. Patten, E., & Parker, K. (2011, December 22). Women in the US military: Growing share, distinct profile. Pew Research Social and Demographic Trends. Retrieved from http://www.pewsocialtrends. org/2011/12/22/women-in-the-u-s-military-growing-share-distinctive-profile/3/ (accessed March 20, 2014). Ritchie, E. C. (2001 December). Issues for military women in deployment: An overview. Military Medicine, 166(12), 1033. Roche-Paul, R. (2014). Breastfeeding in combat boots. Retrieved from http://breastfeedingincombatboots.com (accessed September 3, 2013). Sesame Street Workshop. (2006). Talk, Listen Connect, DVD. Retrieved from www.sesameworkshop. org/tlc. US Department of Commerce, US Census Bureau. (2013). How do we know? America’s changing labor force. Retrieved from http://www.census.gov/how/infographics/acs_infographic_eeo.html (accessed March 10, 2014). Wilson, J. P. (2007). The lens of culture: Theoretical and conceptual perspectives in the assessment of psychological trauma and ptsd. Springer. http://link.springer.com/chapter/10.1007/978-0-387-70990-1_1# Young-Eisendrath, P. (2000). Self and transcendence: A postmodern approach to analytical psychology in practice. Psychoanalytic Dialogues, 10(3), 427. twelve Building the Framework for Successful Deployment Reunions

ERIN SIMMONS

INTRODUCTION

When I returned from Fallujah, Iraq, in March 2005, my husband did his best to sweep me off my feet. It should have worked. He brought me flowers. He arranged a two-week vacation at an Okinawan resort. He cooked my favorite food. He even kept in touch with my colleagues at the Naval Hospital on my behalf, and had them at the airport to greet me when I returned. It should have worked, but it didn’t, and for a year after the deployment, we fought for happiness and for our marriage in a struggle that is going on in hundreds of thousands of couples throughout the world. Female Service members currently make up approximately 16% of the total military force (2012 Department of Defense Demographic Report). Even given women’s historically lesser, but growing, role in combat theaters, of the over two million Service members who have deployed to Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), over 11% of them are female (as of 2009 data; Mulhull, 2009; Wilmot, 2013). Interestingly, female Service members, particularly enlisted females, have been found to be at higher risk for divorce than males, and are also more likely to be married to another Service member (Karney & Crown, 2007; Street, Bogt, & Dutra, 2009), which means potentially more deployments, more separations, and simply more complications in their relationships. Despite these numbers, relatively little research has been done regarding the marital relationships of female Service members (Wilmot, 2013).

196 12. Successful Deployment Reunions 197

I deployed from Okinawa, Japan, in September 2004, just a month after my husband and I arrived on the island. We had none of our household goods, no established relationships for social support, no knowledge of the island, and no notice that this was going to happen. When we had discussed our plans and expectations for coming to Okinawa, they included frequent travel to exotic countries, sampling Japanese restaurants and theater, and playing the tourist on sightseeing trips around the island. We expected that my husband, a Marine stationed with 3rd Marine Division, would deploy, and we had discussed what I would do while he was gone. We planned for what actions to take if something happened to him, ways to stay in touch and be optimistic even if we couldn’t communicate very often, and which bills were in his name that I would have to manage. We never prepared for me to go to war. In the single week I had to prepare, I was torn between excitement and anxiety. Like many women early in the “Long War” (referring to the Global War on Terror; Graham & White, 2006), particularly Navy psychologists, I was not trained to be “downrange,” or to be serving in a combat theater in an austere environment. I spent a small fortune on eyeglasses to make sure I could see while in the desert (the Navy performed my PRK surgery the year after I got back). Under my husband’s guidance I invested in t-shirts (“skivvy” shirts), underwear, sports bras, lotion, good socks, lots of baby wipes—comfort items that I felt I needed to keep myself clean and sanitary. Later, I would realize that I did not bring anything to keep myself feeling feminine, and my mother and mother-in-law helped by sending me colored underwear and fragrant body lotion. My husband shared his wealth of knowledge about living in the field, which helped alleviate my worry about being unprepared, and he flooded me with helpful ideas for staying safe and healthy. We also planned for the eventuality of him deploying while I was still away: who would watch the cats, how could we set up the bill payments automatically, who would check on our apartment. I deployed from Camp Pendleton, California with 1st Medical Battalion, part of what the Marine Corps then called 1st Force Service Support Group (FSSG), and what is now called 1st Marine Logistics Group (MLG). When I left Okinawa on the plane that would take me to California, I realized I couldn’t even imagine it.

PRE-DEPLOYMENT

Effective preparation for a couple’s reunion has to start before the deployment, with the expectation that the unexpected will occur. Research reviewed in a 2007 Rand study suggests that deployments and military stress do not cause marital stress, but 198 Women at War rather exacerbate pre-existing conditions in the marriage or the environment (Karney & Crown, 2007). The authors of this study emphasize the importance of preparation when they refer to researchers who have compared a deployment, in some ways, to the life-altering event of having a child: “those who expect the new child to be stressful do better than the relationships of those who fail to anticipate that their lives will change significantly” (Karney & Crown, 2007, p. 54). To that end, preparation for deployment includes financial, legal, logistical, social, emotional, medical, and in some cases developmental issues. Preparatory discussions should involve the Service member, the spouse, children, and any “supportive adults” (Armstrong, Best, & Domenici, 2006) who will assume responsibility for the family’s affairs during the deployment cycle. Throughout the remainder of this chapter, the deployed partner will be referred to as the Service member, while the partner at home will be called the spouse. Getting the bills paid is merely the start of financial issues, which include whether or not to deregister or sell a vehicle, whether a spouse will start or stop working, and whether child care is started, stopped, or taken over by the spouse or other family member. Legal powers of attorney must be generated and wills signed. “Family care plans,” or the equivalent, must be filed with a Service member’s unit to ensure that a certain course of action is followed should something happen to the other parent or caregiver. Logistical concerns include care for pets and possessions, the need for storage, the feasibility of the family staying in their location or returning to the location of other family members, as well as what technology will best enable the family to keep in touch. When and how often to communicate can be planned in advance, with the understanding that plans may change depending on circumstances. Maintaining communication with small children who can’t talk on the phone can be particularly challenging, though much alleviated these days with Skype and webcams. A plethora of websites and organizations—USAA, Army and Navy Knowledge Online (AKO and NKO, respectively), the Real Warriors Campaign, Navy and Marine Corps Public Health Center (NMCPHC), to name just a few—now provide deployment checklists to ensure that these issues are addressed, and suggestions for how best to do so. Socially, there are three main tasks to be accomplished: saying goodbye to family and friends, and creating an “emotional armament” to cope with being away from them (Rabb & Rasmussen, 2013, p. 41); building support for the spouse and family who remain behind; and establishing trust and rapport with the deploying unit. Female friends can be “essential” for the social and mental well-being of female Service members, as female Service members may be isolated on deployment with few female or supportive companions (Courage, 2013, p. 59; Street et al., 2009). As a case in point, during my 2008 deployment to Ramadi, Iraq, I lived and worked in a compound that 12. Successful Deployment Reunions 199 housed four Marine Corps and Army Commands. I was one of three females, and the only female Officer in the entire compound. I negotiated with the male commanders for shower times for the three of us, when we locked ourselves in the shower trailer, and we put signs up on the bathroom trailer (the “head”) to the remind the men that the trailer was coed. Family members, who may have traveled with Service members to duty stations far from their home of origin and have limited connections to friends, neighbors, or other families in the unit, may also experience a sense of isolation. This can be especially true for Reserve families, or families new to the military or to the deploying unit, because of lack of knowledge and established social connections that are taken for granted by established personnel (Karney & Crown, 2007; Palmer, 2008; Rabb & Rasmussen, 2013). Family and community support are equally essential when the Service member is in harm’s way, for emotional encouragement, as well as material aid, such as picking up children or helping with financial difficulties (Courage, 2013). Emotionally, the Service member must balance a myriad of emotions. She might feel excitement for the deployment, sadness at leaving her family, worry for her safety and her family’s well-being, regret at missing part of her children’s development (i.e., “parenting stress”; Palmer, 2008), and concern for a spouse who suddenly has to pick up the slack. A deploying mother must deal with the stress of figuring out how to be a “mother from afar” (Street et al., 2009). Service members must come to terms with the knowledge that they will miss birthdays, weddings, graduations, and other important milestones and life events. Spouses, too, may experience their own mixed emotions, including shock, disbelief, increased emotional distance, anticipatory fear or grief, and anger at those in the unit not deploying (see Palmer, 2008, for a summary of research). Medical needs must also be evaluated and care established, particularly if the spouse is new to the military and is not familiar with the Military Health System and available resources. Children need to be registered in the Defense Enrollment Eligibility Reporting System (DEERS; the military database used for Service members and their dependents to register for healthcare benefits), and their educational and developmental needs planned for. Decisions must be made about how to explain to children of various ages why their mother is going away for an extended period of time. Many websites and organizations also exist to help with this process, including the Courage to Care campaign, Strategic Outreach to Families of All Reservists, Military OneSource, Zero to Three, and Afterdeployment.org. The spouse’s and family’s support of the child and each other, and their confidence in a positive outcome, during the pre-deployment phase not only contributes to the extent of a child’s adjustment during the deployment, but also the quality of the eventual reunion (Palmer, 2008). 200 Women at War

DEPLOYMENT

By the time many people leave for deployment, they are relieved that the planning and preparation stages are over and they can begin focusing on the work that has taken them from home. Preparation for reunion continues during the deployment as status updates on current events, children, family, pets, finances, and the household become important facets of a couple’s communication. Communication itself, not always readily available when new areas of operation are established, is vital to the eventual reunion, as long as the communication is positive and effective (Karney & Crown, 2007; Palmer, 2008). If phone or Internet connections are unavailable, letters remain a good way to stay emotionally connected with a spouse and children, even if to letters can’t be sent immediately. Events such as birthdays, anniversaries, and meaningful holidays can be important to mark in some way when feasible, depending on the couple. For example, in late 2004, following the successful completion of Operation Phantom Fury in Fallujah, we were again able to fly the US flag without fear it would be shot down or blown up. We were able to provide flags to be flown for the day, which would then be returned to us to take home, with a certificate of authenticity. I flew a flag for my husband on his thirtieth birthday outside the Fallujah medical center. Though I did not give the flag or certificate to him until I returned three months later, the act of commemorating his birthday in such a way made me feel closer to him. Emotional closeness and maintaining contact is thought to increase the resiliency of the relationship and lead to more successful reunions (see Palmer, 2008, for a summary of research.) Communication is a double-edged sword, however, particularly as technology has improved. Talking or Skyping every day is now frequently possible, and can be an easy way for couples to stay in touch. However, with more extensive contact come the risks of relationship problems being carried over to deployment, with negative news, problems at home or on deployment, and disappointed expectations becoming the frequent topics of conversation (Street et al., 2009). Such negative interactions and the feelings that accompany them can reflect poor adjustment of the marriage to stress (i.e., the stress of deployment) and can erode the quality and function of the relationship (Gottman & Silver, 1999; Karney & Crown, 2007). It is important for couples to remember that both of them are experiencing hardship, regardless of the length or intensity of the deployment. During the deployment, specific preparations for homecoming should also be discussed and solidified. These preparations are essential to maximize the chances of a positive reunion experience. Again, these preparations may be financial, logistical, social, emotional, medical, or developmental. First and foremost, the question must be asked: What is expected from each partner? Answers may range from a big party the night of homecoming to seclusion in the home for a week. Does the Service member 12. Successful Deployment Reunions 201 want to talk about the deployment or not during the first few days? Will children be present to meet the Service member, or will they be at home waiting for her? Realistic expectations can prevent many of the negative events that can accompany the reunion (Armstrong et al., 2006; Karney & Crown, 2007). The financial situation, including costs of a vacation, party, or a trip to visit extended family, should be discussed. Finances are usually improved by the Hazardous Duty and Family Separation pay gained during combat deployments, and the disposition of this money can be an important issue in the couple’s near future. Changed financial circumstances, such as debt accrued from house or car repairs, or simply extravagant spending—by either partner (another risk of better Internet connectivity)—should not be kept secret. The logistics of plans for travel, vacation, social engagements, and hosting visitors will be affected by this information. These plans can be worked out in advance to minimize the stress during the emotional time of homecoming. While in Ramadi, I was able to completely plan, with my husband’s help, our attendance at my brother’s wedding, a visit with my parents, and a trip to Scotland for us and my husband’s parents, which turned into a successful and rewarding post-deployment vacation. Social and extended family interaction should be discussed in advance so that both partners are on the same page about how social each partner wants to be after the separation. Friends and family can be contacted prior to the homecoming to explain the plans and to minimize the immediate phone calls asking when the couple is visiting. Most important, the couple’s emotional connection to each other and to their children—positive or negative—will be thrown into high gear, particularly after a first deployment, and even more so when that deployment was unexpected or particularly hazardous. This emotional connection can be volatile at such a time, and the adjustment to being home and being together often takes more time than couples expect (see Armstrong et al., 2006; Moore & Kennedy, 2011). Preparation for immediate plans can prevent conflicts over little things. Preparation for how and what to communicate to children keeps parents working together, rather than being opposed, and also addresses the developmental needs of the children. Advanced warning of changes or problems can prevent disappointment and surprise, which can cause negative feelings within the family at a time they least expect them.

POST-DEPLOYMENT

“Prior planning prevents poor performance” is a common expression in military culture, referring to the importance of planning before acting. Prior planning in the case of deployment reunions is the scaffolding that provides structure, direction, and support 202 Women at War for the homecoming and continued relationship. Added to this scaffolding are varying degrees of internal and external support structures, as well as “relationship resources,” or beneficial qualities of the relationship itself (Karney & Crown, 2007, p. 22; see also Cigrang et al., 2014; Palmer, 2008). Externally, factors that can bolster incomplete scaffolding, and ultimately reunion success, include social and community supporters of the couple and the individual, family involvement, financial stability, unit support and military programs, and societal appreciation, as well as a rewarding deployment experience. In the absence of some of these factors, a strong scaffolding will likely hold, but may be weakened. A weakened scaffolding will be more dependent on factors internal to the couple, such as quality of communication before the deployment, age and maturity of the couple and each partner, realism of expectations toward each other as well as the deployment and the homecoming, and the relative health of the family unit, including the children (Karney & Crown, 2007; Palmer, 2008). Should internal factors be lacking, external factors can likewise support the weakened structure to some extent. Furthermore, strong planning and consistent work toward the goal of reunion can supplement missing or problematic internal factors. However, a reunion with weakened scaffolding due to any reason is often more difficult and fraught with conflict. Karney and Crown (2007) remark, “Spouses who possess personal strengths and those who live in supportive, resource-rich environments should generally experience more positive outcomes” (p. 18). Preparation must also contend with external and internal stressors that may impair reunion success. For instance, existing unit or social support may be less effective for male spouses who feel isolated from their civilian male peers and out of place among their fellow spouses, who are usually female. Male spouses may also experience a kind of identity crisis for not adhering to the typical values associated with a male in American society. This crisis may “erode their satisfaction with the relationship” (Karney & Crown, 2007, p. 41) or may cause them to take out negative feelings on servicemember (Wilmot, 2013). In addition, exposure to combat or operational trauma can result in unexpected individual changes to the Service member, which might include physical or psychological injury, and which may affect her ability to function in the relationship or in her daily life without more extensive help from a spouse than either partner planned for. Research has shown that psychological trauma has a strong relationship with poor deployment reunions (Cigrang et al., 2014). The Defense Advisory Committee on Women in the Services also listed in their 2012 report several health concerns that occur at a higher rate in women who have deployed, compared to women who haven’t deployed and to men who have deployed, including sexual assault; migraines; disorders of the back and neck; anxiety, depression, and other mental disorders; upper respiratory illness; and pregnancy and fertility-related conditions, as well 12. Successful Deployment Reunions 203 as routine medical treatments that may have been deferred during deployment (also see Murdoch, Bradley, Mather, Klein, Turner, & Yano, 2006). Finally, Karney and Crown (2007) point out that, regardless of the stress of deployment, it is possible that military service in general attracts or promotes certain risk factors in individuals and their relationships, such as youth, younger marriages, proneness to violent behavior, and history of psychiatric disorders or “neurotic behavior” that can negatively impact relationships. These researchers state, “There is no consistent evidence that the normal, expected demands of military service lead to higher rates of marital dissolution in military couples” (p. 66). Therefore, the internal and external factors, both beneficial and risky, including those offered by the individuals themselves, must be addressed in order to successfully navigate the stress caused by deployment. It is important to realize that “addressed” does not necessarily mean “fixed.” It simply means that known and expected problems are much easier to prepare for and cope with than unidentified or denied issues.

SIX RULES

In the course of my own life, working as an active duty psychologist, being a deployed wife, and being the wife of a deployed Marine, I have returned time and time again to a set of six “rules” that can guide couples through successful reunions. I began developing these rules after I returned to Okinawa after that first, unexpected deployment in 2004, when I found myself a stranger in my own life. While going through my own adjustment period, I was asked to conduct Return and Reunion briefs to spouses waiting for their Service members to return, as well as to the returning Service members. Some of the rules were developed as I thought about how unprepared and uncertain I was throughout my deployment process, and how difficult my adjustment was when I returned to my husband. Some were developed through listening to other Service members and spouses in crisis, and learning the common threads that ran through their conflicts. Throughout the last decade of working with thousands of military members and their families at war, I continue to reference these rules as a foundation upon which to build successful deployment reunions. These rules generally focus on strategies that can improve communication and mutual understanding in all relationships, but that reflect particular aspects of relationship functioning that have been shown to affect military marriages in particular. For instance, typical “guidelines for effective communication,” including problem-solving, listening, and compromise, are not always valued in military culture in the same way that they are valued by civilians (Karney & Crown, 2007, p. 29). Furthermore, Karney and Crown point out that female Service members tend to marry later than their civilian 204 Women at War counterparts, resulting in “younger” marriages that have fewer resources internal to the marriage to contribute to the relationship scaffolding. In addition, the frequent separations that are “normal” to a military couple, particularly a dual military couple, limit the availability of each partner for productive interactions that bolster the relationship and that counter negative events such as emotional distance or chronic negativity (see Gottman, Swanson, & Swanson, 2002).

RULES 1 AND 2

Rule 1 is to beware the fairy tale, while Rule 2 is to create only reasonable expectations of each other and of external factors. It is natural for human beings to create expectations of events and people. This practice is what allows us to look forward to things, as well as to prepare for disappointment. However, when our expectations are not accurate, the ways we act, think, and feel after we realize our mistake can be damaging to ourselves and our loved ones (see Armstrong et al., 2006; Military OneSource; Moore & Kennedy, 2011; Real Warriors regarding managing expectations of deployment reunions). The intense feelings associated with a deployment homecoming tend to deepen our emotional attachment to our expectations, whether or not they have a logical basis. For instance, my husband never got me flowers in the beginning of our relationship because he didn’t think I liked them. After I told him I did like flowers, he began buying them for special occasions, including my deployment homecomings. I have to admit I expected the flowers; they were part of my fairy-tale homecoming. If they hadn’t been present—if he didn’t have time, or the store he planned to go to was closed, or if any one of a dozen other events had prevented him from bringing flowers—I would have been disappointed. That disappointment, on top of my sleep deprivation, my desire for a shower after the week-long trip, and my excitement to see him after so long, would have been significantly more damaging than if he had simply not bought me flowers on my birthday. I got lucky there, so to speak, since I did not ask him to bring me flowers, or even suggest that I would like them. Doing so, however, would have ensured that he knew what I wanted, and hopefully would have prevented negative emotions that might have hurt my homecoming. Coming home from his deployments, my husband always asks me to pick him up in his truck, so he can drive it home. Such an easy request, but I may not have thought of it otherwise. Expectations may be formed about anything: from celebrating special days to getting house repairs done, from child-care practices to managing the finances, and from changing your personal appearance (hair color, new clothes) to homecoming plans. Realistic expectations, however, regardless of the extent of the stress or hardship, can enhance resiliency and relationship health (Karney & Crown, 2007). Moore and 12. Successful Deployment Reunions 205

Kennedy (2011, p. 10) suggest “practicing what you plan to say and do” prior to the homecoming, in order to minimize the damage of unrealistic expectations. Particularly vulnerable are the aspects of a couple’s life on which they tend to disagree. For instance, compromises in food choices or spending practices that a couple created prior to the deployment may have drifted during the separation. This may have happened without a great deal of conscious thought on the part of either spouse, who may have simply returned to doing what came naturally without periodic reinforcement from his or her partner. It is a safe bet that not all of a couple’s expectations will be met the way they want, as in a fairy-tale reunion, but it is much more likely that things may turn out as expected if these expectations are communicated in advance.

RULE 3

The expression “pissing contest” is typically reserved for men trying to impress each other or other observers with their exploits or skills. Wikipedia defines “pissing contest” as

[a]‌ game in which participants compete to see who can urinate the highest, the far- thest, or the most accurately.… Since the 1940s the term has been used as a slang idiomatic phrase describing contests that are “futile or purposeless,” especially if waged in a “conspicuously aggressive manner.”

This never-ending game of trying to outdo a companion using subjectively important but realistically meaningless metrics—by “upping the ante,” as Gottman, a prominent relationship expert, explains (Gottman & Silver, 1999, p. 103); by not accepting a partner’s emotional reality (p. 149); or by trying always to be “right” (p. 150)—is a common but maladaptive occurrence in relationships having difficulties. With difficult and complex experiences such as deployments, this game can become more hurtful and damaging than it might be in other circumstances. Therefore, avoiding the “pissing contest,” or curtailing the urge to claim that one’s deployment experience was worse than his or her spouse’s is Rule 3 of deployment reunions. Claims or accusatory complaints of hardship can trigger the strong emotions discussed in Rules 1 and 2, such as the desire for things to be “perfect,” disappointment that they aren’t, guilt at not having done everything possible to make them “perfect,” and fear that this failure will cause long-term hurt in the relationship. In addition, other intense emotions may be present, such as relief that the deployment is over, worry about the next deployment, concern about how the homecoming is going, even anger at how well the other partner has done being on his or her own (Armstrong et al., 2006; Bell, 206 Women at War

Schumm, & Gaskin working with Military OneSource, 2007). Furthermore, women’s combat (or other trauma) experiences are sometimes doubted by employers, family, and even fellow deployers (Wilmot, 2013), which creates residual negative feelings that are easily triggered by a challenge to their personal experience. Finally, either partner may still be emotionally reeling from difficult experiences that he or she lived through during the separation, whether or not the other knows about those experiences. All of these emotions can create “buttons,” or emotional “tripwires” (Goleman, 2009), that can be inadvertently pressed by an unsuspecting partner to create a stormy and unhelp- ful reaction. Service members and spouses often claim any number of “proofs” that their experience was worse—because of the danger of being in combat, or because of the worry while staying at home; because of the physical hardship of an austere environment, or because of the logistical challenges of being a single parent. However, these claims usually only serve to stir up emotions that have not yet been communicated, processed, and resolved, which results in hostility, hurt, and/or resentment between spouses. These negative emotions weaken the internal scaffolding of the relationship, and increase the risk that the relationship will fail. It only takes one person to exercise his or her “emotional intelligence” (Goleman, 2009) and stop the “pissing contest” by accepting that his or her partner did indeed have a difficult experience, regardless of how hard his or her own might have been. I recommend to the frustrated partner to literally bite his or her tongue—that’s what worked for me—and remember that there will be a chance to share his or her own trials if he or she exercises patience and acceptance. It may be a challenge, but it is not a competition.

RULES 4 AND 5

Whether the communication is about difficult deployment experiences or planning a post-deployment vacation, communication only really happens when one says what he or she really wants to say when the other person is listening. This means creating or maintaining a supportive “encouraging… atmosphere” (Gottman & Silver, 1999, p. 245), and avoiding overwhelming or “flooding” (p. 34) the other person. The choice of when and how to say something can be just as important, or more so, than deciding what to say. Rule 4 is to consider the timing of what is going to be said before it is actually said. At least one partner will usually have a lot to say after an extended separation, particularly if the communication on the deployment was erratic, or there were unexpected hardships. Sometimes, people just want to resume what they think of as their “normal lives” as soon as possible. This may involve presenting “honey-do” lists, discussing major changes to the home, or planning tuition costs for going back to school. These 12. Successful Deployment Reunions 207 types of communications might be initiated by either partner, and are almost always ineffective if presented during the initial homecoming period (see Bell, Schumm, & Gaskin working with Military OneSource, 2007). Equally ineffective are complaints or criticisms (criticisms are rarely beneficial in relationships; Gottman & Silver, 1999, pp. 27–29) made about the spouse or the household at this time. Keep in mind the fatigue, stress, hunger, and joy to be home that are likely present in the Service member, and the fatigue, stress, relief, and excitement that are likely present in the spouse. Notwithstanding other potential factors at play, such as existing relationship problems, external stressors, or negative expectations, these emotions alone tend to prevent people from listening or hearing any complicated thoughts or plans in the moment. Rule 5 addresses particular questions of the Service member that tend to be dubbed by combat Veterans as the “stupid” or the “dumb” questions (Armstrong et al., 2006, p. 166). Popular media is full of examples and some quite explicit and sometimes humorous portrayals of these questions (for examples, search for “stupid questions” on Military.com). These questions tend to require special consideration of timing and context before being asked. The “stupid questions” often include references to traumatic events, particularly killing other human beings (i.e., “Did you kill anyone?”); events that the Service member feels she should share exclusively with her deployed unit or that won’t be understood by non-deployers (i.e., “What was it like getting blown up all the time?”); or events of which she is not proud or feels guilty (i.e., “Where were you when Sgt. So-and-so got hurt?”). Even saying “Thank you” to a Service member who does not feel like she contributed significantly to the mission could result in an unexpectedly negative response. Other questions may simply not elicit a useful or desired response. For instance, the question, “How was it?” is so general, it may elicit the typical response when asking a preteen how school was (i.e., “Fine”). The question, “Are you glad to be home?” may result in confusion or disappointment when the Service member replies, “No,” or, “I’m not sure yet.” Often, the rewarding experiences of a deployment (e.g., pride, camaraderie, self-confidence; Scurfield & Platoni, 2013) or the complexities involved in coming home result in feelings of regret for being back, instead of the happiness that is expected. These feelings are normal. Questions that elicit negative memories or emotions, or bland or confusing responses, have the potential to cause significant bad feelings for one or both partners and to disrupt the reunion process. They also increase the emotional or intellectual distance the Service member may already be feeling (Armstrong et al., 2006). It is also important for Service members to realize that spouses may ask or not ask questions out of a desire to be understanding and supportive, but may not know the best time or method for doing this. Talking to “supportive adults” can be extremely valuable for Service members, and helps to alleviate the isolation and adjustment problems 208 Women at War that may accompany the homecoming (Armstrong et al, 2006, p. 177; Courage, 2013). While each relationship will have its own rules for openness and disclosure, which ide- ally should be discussed prior to the homecoming as part of the preparation process, couples are encouraged to use planning and thoughtfulness when discussing difficult or emotional topics and when asking or answering these questions. It is helpful to communicate in advance whether or not questions are expected or desired.

RULE 6

Rule 6 is meant to remind Service members and spouses alike that the family members at home keep the home functioning and the children fed while Service members fight for the right to do both. Sincere thanks and appreciation, in both directions, are appropriate and are usually welcomed (if done with good timing). It can be easy for Service members to feel entitled to this appreciation because of the challenges and hardship of the deployment experience. Society has come full circle from the infamous disdain in which many returning Vietnam Veterans were held when they returned, and our American culture now reinforces the need to recognize the accomplishment, patriotism, and service of men and women in uniform. However, it can be just as easy, and no less valued, for spouses and family members to expect credit for providing emotional and material support for a Service member while running a household in her absence. The thanks that are due, and how those thanks are demonstrated, can be part of the homecoming planning, and should certainly be considered by each partner as they prepare for reunion. Armstrong et al. (2006) point out that communication overall can be improved by simply asking the spouse how their experience was while the Service member was away. These positive additions to the homecoming process reinforce the existing scaffolding, strengthen parts that were weakened by separation and hardship, and can ensure that essential mutual value, respect, and “fondness” (Gottman & Silver, 1999, Chapter 4) remain part of the relationship, even when the inevitable “pissing contests” occur.

CONCLUSION

After my deployment in 2004–2005, my husband and I created a stronger marriage through communication, understanding, compromise, and, I believe, sheer stubborn- ness! We were not prepared in advance, and we had only the most rudimentary scaffolding in place in our relationship at a time when it seemed that everything changed at once, from the simple fact of being apart, to having just moved to another country. Our internal and external resources were both weakened, and, though our internal 12. Successful Deployment Reunions 209 resources proved strong enough to heal the relationship in the long run, the friends made in Okinawa and the counseling sessions we attended at Marine Corps Community Services were needed for external support. My next deployment took place in 2008, and my husband deployed to Afghanistan in 2009 and 2011. Each deployment had its own challenges, for each of us, and I have made many, many more mistakes than I thought I would, being a psychologist and being motivated to maintain my marriage as well as my personal health. I am able to laugh now, when I tell people, “I thought I knew better!” However, I am also able to accept that I didn’t know better, had to bite my tongue, and had to learn. We did not have the same problems after later deployments that we had during and after our first, thanks to the knowledge we gained, and the preparations we learned to make. My goal with this chapter is to provide knowledge and understanding—an external resource, if you will—that I have gained in my 12 years as a Navy psychologist, my 13 years as a Marine Corps wife, and my experiences on both sides of the deployment cycle. Though this chapter is part of a book geared toward women’s experiences, I hope readers will be able to apply its contents to either spouse or partner, male or female, at any phase of the deployment cycle. I hope also that this chapter provides reinforcement to go find those external resources at times when help is needed. Additional tips and resources are listed in Courage After Fire (Armstrong et al., 2006) and Wheels Down (Moore & Kennedy, 2011), in addition to the websites and organizations listed earlier in this chapter. Research has still not determined definitively how and why deployments can deteriorate relationships; however, there is widespread agreement that external support, individual risk factors, health and maturity of the relationship, and preparedness to deploy are very important to the process (Cigrang et al., 2014; Karney & Crown, 2007). Though fairy tales are generally unrealistic, planning, scaffolding, understanding, and preparing can make relationship reunions into rewarding, fulfilling, and positive events.

DISCLAIMER

The views expressed in the this chapter are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.

REFERENCES

Armstrong, K., Best, S., & Domenici, P. (2006). Courage After Fire. Berkeley, CA: Ulysses Press. Bell, D. B., Schumm, W. R., & Gaskin, T. A. (2007). Returning to family life after deployment.Military OneSource. Retrieved from http://dhl.dhhq.health.mil/Product/RetrieveFile?prodId=234. 210 Women at War

Cigrang, J. A., Talcott, G. W., Tatum, J., Baker, M., Cassidy, D., Sonnek, S., Snyder, D. K., Balderrama-Durbin, C., Heyman, R. E., & Smith Slep, A. M. (2014). Impact of combat deployment on psychological and relationship health: A longitudinal study. Journal of Traumatic Stress, 27, 58–65. Courage, C. (2013). Army National Guard warriors: A part-time job becomes a full-time life. In R. M. Scurfield & K. T. Platoni (Eds.), War trauma and its wake: Expanding the circle of healing (pp. 53–68). New York: Routledge. Defense Advisory Committee on Women in the Services. (2012)Report . Retrieved from http://dacowits. defense.gov/Portals/48/Documents/Reports/2012/Annual%20Report/dacowits2012report.pdf Goleman, D. (2009). Emotional intelligence: 10th Anniversary Edition. New York: Bantam. Gottman, J. M., & Silver, N. (1999). The seven principles for making marriage work. New York: Three Rivers Press. Gottman J., Swanson, C., & Swanson, K. (2002). A general systems theory of marriage: Nonlinear difference equation modeling of marital interaction. Personality and Social Psychology Review, 6(4), 326–340. Graham, B., & White, J. (2006). Abizaid credited with popularizing the term “Long War.” Washington Post. Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2006/02/02/ AR2006020202242.html. Karney, B. R., & Crown, J. S. (2007). Families under stress: An assessment of data, theory, and research on marriage and divorce in the military. Santa Monica, CA: RAND Corporation. Moore, B. A., & Kennedy, C. H. (2011). Wheels down: Adjusting to life after deployment. Washington, DC: American Psychological Association. Mulhull, E. (2009, October). Women warriors: Supporting she who has “borne the battle.” (Issue Report). Iraq and Afghanistan Veterans of America: New York. Murdoch, M., Bradley, A., Mather, S. H., Klein, R. E., Turner, C. L., & Yano, E. M. (2006). Women and war: What physicians should know. Journal of General Internal Medicine, 21(Suppl 3), S5–S10. doi:10.1111/j.1525-1497.2006.00368.x. Palmer, C. (2008). A theory of risk and resilience factors in military families. Military Psychology, 20(3), 205–217. doi:10.1080/08995600802118858. Office of the Deputy Assistant Secretary of Defense (Military Community and Family Policy). (2012). 2012 Demographics: Profile of the military community (Department of Defense Demographic Report). Retrieved from http://www.militaryonesource.mil/12038/MOS/Reports/2012_Demographics_ Report.pdf. Rabb, D., & Rasmussen, C. (2013) Citizen/warriors: Challenges facing U.S. Army Reserve soldiers and their families. In R. M. Scurfield & K. T. Platoni (Eds.), War trauma and its wake: Expanding the circle of healing (pp. 31–52). New York: Routledge. Scurfield, R. M., & Platoni, K. T. (2013). Myths and realities about war, its impact, and healing. In R. M. Scurfield & K. T. Platoni (Eds.), War trauma and its wake: Expanding the circle of healing (pp. 16–27). New York: Routledge. Street, A. E., Vogt, D., & Dutra, L. (2009). A new generation of women veterans: Stressors faced by women deployed to Iraq and Afghanistan. Clinical Psychology Review, 29, 685–694. Wilmot, M. (2013). Women warriors: From making milestones in the military to community reintegration. In R. M. Scurfield & K. T. Platoni (Eds.), War trauma and its wake: Expanding the circle of healing (pp. 69–89). New York: Routledge. thirteen Traumatic Brain Injury

Implications for Women in the Military

VICTORIA TEPE AND SUZANNE GARCIA

INTRODUCTION

The purpose of this chapter is to consider military traumatic brain injury (TBI) as it relates to women and to military women in particular. Unfortunately, the research in this area is limited, inconsistent, and sometimes contradictory across an assortment of studies whose questions and methodologies differ with respect to mechanisms of injury, injury severity, age groups, independent variables, and outcome measures. Few military medical studies have specifically considered the effects of TBI on women. There is a pressing need for prospective research, especially for studies that consider injury processes and outcomes for women who sustain mild TBI, repeat TBI, non-impact, and blast-induced TBI. TBI is a complex cascade of injury processes that begin with the disruption of normal brain function due to blunt impact, penetration by a foreign body, sudden accel- eration or deceleration (jolt), rotational force, and/or exposure to explosive blast (see Taber et al., 2006). Including injuries diagnosed in civilian inpatient and outpatient settings, well over 3 million individuals are diagnosed with non-fatal traumatic brain injuries (TBIs) each year in the United States, usually due to motor vehicle accidents, falls, or violence (Coronado et al., 2012; Faul et al., 2010). The Centers for Disease Control (CDC) estimate that more than 5 million men, women, and children currently

211 212 Women at War live with TBI-related cognitive, emotional, sensory, and motor disabilities (Thurman et al., 1999). Though often invisible, chronic disabilities associated with TBI and mild TBI (mTBI) nonetheless can exert profound and lasting adverse effects on the lives, work, and relationships of those afflicted. In particular, military Veterans who report a history of head injury are also more likely to screen positive for post-traumatic stress disorder (PTSD), depression, and alcohol misuse (Maguen et al., 2012). Historically, women have been exposed in smaller numbers to the risks associated with military combat. More recently, women’s exposure to combat-related injury has increased. In 1993, the US military finally lifted a 45-year ban that had previously prevented women from flying fighter jets and bombers in combat environments. The following year, the Department of Defense (DoD) and the US Army narrowed gender- based exclusion to apply only to direct ground combat units; women were prohibited from infantry, artillery, armor, combat engineer, and special operation units below the level of brigade (3,000–5,000 members). That more specific exclusion then became difficult if not impossible to apply effectively during the recent wars in Afghanistan and Iraq, where women have accounted for approximately 10% of all US servicemembers deployed, sometimes multiple times (AFHSC, 2012), sometimes temporarily “attached” (versus assigned) to combat units. In these conflicts, enemy tactics and weaponry have blurred the distinction between combat and non-combat environments on the ground. As a result, many women deployed to these conflicts have been exposed to hostile action. A 2009 report by the Defense Advisory Committee on Women in the Services (DACOWITS) explored the combat experiences of military women deployed to Afghanistan and Iraq. Most of the DACOWITS study participants reported that deployed female servicemembers had in fact been involved in combat functions and/or had been exposed to hostile fire (e.g., on convoys, as drivers, as participants in search teams) (DACOWITS, 2009). Not surprisingly, the number of women Veterans who need service-connected healthcare has also increased, prompting the Department of Veterans Affairs (VA) to adapt its services and accelerate research in critical areas of women’s health (Yano et al., 2011; Amara et al., 2014). In January 2013, the Chairman of the Joint Chiefs sent a letter to Defense Secretary Leon Panetta, suggesting that “the time has come to rescind the direct combat exclusion rule for women and to eliminate all unnecessary gender-based barriers to service.” Two weeks later, on January 24, 2013, the combat exclusion policy was finally lifted. As combat jobs and direct combat unit assignments now become available to female servicemembers, so too will all associated risks, including TBI. 13. Traumatic Brain Injury 213

TBI is a known risk of combat and of specific high-risk military activities (e.g., para- chuting; see Ivins et al., 2003). Due to the high prevalence of blast-related injuries among military Veterans since US military actions began in Afghanistan (2001) and Iraq (2003), blast-related TBI has gained attention as the “signature injury” of modern military service (Shively & Perl, 2012). The associated medical, individual, and societal costs are recognized as significant. A recent overview of related costs in the military Veteran population emphasized the combined impact of costs directly associated with treatment (inpatient, outpatient, uninsured services), programmatic/educational support, and a variety of indirect and intangible costs, including absence from employment, delayed or poorly coordinated care, emotional/behavioral sequelae (e.g., depression, substance abuse), and intangible burdens (e.g., stigma) borne by patients and their families (Hendricks et al., 2012). The DoD has invested heavily in research to study the prevalence and outcomes of TBI, to identify its biological markers and opportunities for early intervention, to improve patient outcomes, and to better understand the relationship between TBI and degenerative brain disease, including the effects of exposure to multiple head injuries. Unfortunately, questions concerning how TBI might specifically affect female servicemembers have not yet captured attention as a knowledge gap to be addressed by military medicine. Missing from the DoD’s otherwise determined effort to address the problem of service-related TBI is a concentrated effort to explore TBI as it occurs in women warfighters whose response, recovery, and reintegration trajectories could inform the development of injury mitigation and treatment strategies for all servicemembers, Veterans, their families, and civilians. The purpose of this chapter is to review current findings with respect to TBI in women, and to emphasize the need for additional research to inform the care and treatment of those who serve. We begin with an overview of TBI as pertains to the military environment more generally, recognizing specific challenges associated with mTBI, secondary injury processes, blast exposure, and repeat TBI.

TBI AND MILITARY SERVICE

Since the year 2000, nearly half a million head injuries have been diagnosed among members of the US Armed Forces (Figure 13.1). Although most military TBIs occur in non-deployed settings, studies published since 2001 indicate that a significant number of US servicemembers deployed to Iraq or Afghanistan—estimates range from 12% to as high as 25%—have sustained at least one head injury during deployment (AFHSC, 2013; Hendricks et al., 2013; Hoge et al., 2008; Okie, 2005; Schneiderman et al., 2008; Terrio et al., 2009; Warden, 2006). 214 Women at War

60,000 50,000 40,000 30,000

umber of Cases 20,000 N 10,000 0

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2000 2010 2011 2012 FIGURE 13.1 Head injuries diagnosed in US military personnel worldwide, 1997–2012, number of cases and trend (least squares fit, R² = 0.9402). Combined inpatient and outpatient diagnoses include skull fracture (ICD-9 800-804), intracranial injury (ICD-9 850-854), and unspecified head injury (ICD-9 989.01) sustained in combat and non-combat settings (e.g., includes vehicular accidents, military training, falls). Data source: Defense Medical Surveillance System (Dmss); Www. Afhsc.Mil/Aboutdmed.

Diagnosis

The DoD defines TBI as a structural injury and/or physiological disruption of brain function indicated by the onset or worsening of at least one of the following clinical signs at or immediately after injury:

■ Any period of loss of or a decreased level of consciousness; ■ Any loss of memory for events immediately before or after the injury; ■ Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.); ■ Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/ plegia, sensory loss, aphasia, etc.) that may or may not be transient; ■ Intracranial lesion.

The severity of initial TBI may be assessed as mild, moderate, or severe. Military physicians classify head injury as mTBI when structural imaging is normal, loss of consciousness is less than 30 minutes, alteration of consciousness is less than 24 hours, or post-traumatic amnesia is less than one day. If a patient meets criteria in more than one category of severity, a higher level of severity is assigned (Assistant Secretary of Defense Health Affairs Memorandum, October 1, 2007; VA/DoD Clinical Practice Guideline, 2009).1

1 The US military medical approach to TBI severity classification is generally consistent with use of the well-known Glasgow Coma Scale (GCS) and with similar criteria set forth by various professional medical organizations, including the CDC. In each case, there is an essential recognition that TBI usually involves at least a temporary alteration of mental status (confusion, daze, disorientation, amnesia, or loss of consciousness). The Glasgow Coma Scale (GCS) is used to assess the depth and duration of 13. Traumatic Brain Injury 215

Although most (82%) military TBIs are classified as mild, these injuries are by no means insignificant. Even as most mTBI patients will recover well within several weeks after injury, without medical treatment, approximately 40% of mTBI patients experience symptoms that persist beyond 3 months after injury, and as many as one-third go on to develop more persistent physical, cognitive, or emotional symptoms (Kashluba et al., 2008; Levin et al., 1987; McCullagh et al., 2001; Ponsford et al., 2000). Military personnel with mTBI are more likely to be discharged for behavioral causes such as alcoholism, drug use, and criminal activity (Ommaya et al., 1996). Mild TBI2 is especially challenging to diagnose because there may be no visible injury or acute neurological signs or symptoms. Symptoms such as agitation, impulsive- ness, or emotional lability are easily overlooked or are mistaken as transient emotional reaction to other physical injuries, fear of medical intervention, sudden helplessness, or psychological or mood disorder. TBI also increases the risk for psychiatric disturbances such as depression and stress-related disorder (Kim et al., 2007). Other common TBI comorbidities and sequelae include neurosensory (vision, hearing) and vestibular (balance) injuries, chronic pain, and hormonal dysfunction. Individuals who sustain TBI/ mTBI may appear to recover well initially, only to deteriorate later due to undetected neurovascular injuries. Symptoms of delayed deterioration may be subtle—for example, vision changes, indigestion, muscular weakness—until their underlying cause (e.g., compression due to blood vessel rupture) becomes life-threatening.

Secondary Injury Processes

The injury process that follows initial trauma to the brain involves a complex cascade of secondary adverse biochemical events, metabolic processes, and neuroinflamma- tory sequelae that may or may not resolve quickly (Bergsneider et al., 2000; Giza & Hovda, 2001). Some changes, such as depressed glucose metabolism, may occur even in mildly injured, relatively asymptomatic patients (Bergsneider et al., 2000; Giza & Hovda, 2001). Potentially serious effects of these injury processes include intra-cranial bleeding/hemorrhage; infection; cerebral swelling (edema); low blood pressure (hypotension), reduced blood supply (ischemia), and inadequate oxygen (hypoxia); fluid accumulation (hydrocephalus); elevated intra-cranial pressure (ICP); and displacement of neural tissue due to compression (brain herniation). Within the first few

impaired consciousness based on eye-opening, motor, and verbal responses. A score of 8 or less is classified as a severe, 9–12 as moderate, and 13–15 as mild. 2 The terms mTBI and concussion overlap, but are not necessarily always interchangeable. The Brain Injury Association of American (BIAA) views concussion and mTBI along a continuum, with Grade 3 concussion and mTBI overlapping (http://www.biausa.org/mild-brain-injury.htm). 216 Women at War minutes, hours, days, and months after TBI, the injured brain is highly susceptible to additional injury (Byrnes & Faden, 2007; Cernak & Noble-Haeusslein, 2010; Narayan et al., 1982; Stoica & Faden, 2010). The most common causes of secondary injury are hypoxia and/or hypotension, which are estimated to occur in 30%–50% of head-injured patients before they reach the hospital (Chestnut et al., 1993; Ghajar, 2000). TBI patients who experience these conditions have an increased risk of death or disability (Chestnut et al., 1993; Chi et al., 2006; Ghajar, 2000). Therefore, it is critical to avoid circumstances that may tend to aggravate or accelerate secondary injury processes. This is a particular concern in military operational settings, where brain injured servicemembers may be exposed to physiologically demanding environmental factors such as extreme climates and high altitude (DCOE, 2010). The hypothalamus and anterior pituitary gland are especially vulnerable to TBI due to their fragile blood supply at the base of the brain. The anterior pituitary gland is an especially common site of TBI-related injury. Anterior pituitary hormones stimulate the release of product substances from other target glands and organs throughout the body. Damage resulting from vascular insult, strain and/or shear, compression, swelling, necrosis, hemorrhage, or laceration can cause abnormally reduced secretion of one or more pituitary hormones (hypopituitarism). These abnormalities affect 20%–40% of TBI patients across all levels of severity. Numerous authors have emphasized the need for routine screening of TBI patients—including mTBI in military populations—to support accurate differential diagnosis (Ghigo et al., 2005; Guerrero & Alfonso, 2010; Tanriverdi et al., 2010; Tepe & Guerrero, 2012).

Blast-Induced TBI

Most TBIs sustained by troops in Iraq and Afghanistan are attributed to blast exposure (Galarneau et al., 2008; Warden, 2006), and symptoms of TBI are commonly observed in blast-exposed servicemembers (Cernak et al., 1999; Okie, 2005; Trudeau et al., 1998; Warden, 2006). TBI is especially complicated when it is due to the force of explosive blast, a scenario that commonly also involves injuries to multiple other body structures, organs, and systems (also known as polytrauma). Resulting diagnostic and treatment challenges are most complicated for closed-head injuries of this type, presenting in combination with multiple other physical (e.g., neurosensory), life-threatening (e.g., limb loss), and/or psychological injuries (e.g., PTSD) (Brenner et al., 2009; Hoffer et al., 2013; Lawson et al., 2013; Packer et al., 2013; Tepe et al., 2013; Patterson et al., 2013). The precise pathophysiological mechanisms and effects of blast-related TBI are not yet well characterized, but it is known that rapid pressure shifts emanating from an 13. Traumatic Brain Injury 217 explosive blast can cause brain concussion, contusion, and cerebral infarct due to the formation of air emboli in blood vessels (Ling et al., 2009; Mayorga, 1997; Taber et al., 2006). A recent study of British Soldiers found an increased prevalence of anterior pituitary dysfunction among solders with moderate to severe blast-related TBI (vs. civilian moderate to severe non-blast TBI) (Baxter et al., 2013). However, it is not known specifically how blast overpressure affects endocrine system structures in particular. It is sometimes difficult to differentiate the initial symptoms of blast-induced TBI (especially mTBI) from those of anxiety and stress. Clinical and experimental findings have shown that blast-related neurotrauma is associated with biochemical changes and cognitive impairment (Cernak et al., 2001). However, these effects may or may not be immediately clinically evident, and subtle symptoms can be overlooked when medical attention is necessarily focused on other more obvious or urgent injuries.

Repeat TBI

Repeat TBI is a known risk in the military environment, especially among deployed personnel exposed repeatedly to blast within relatively short time intervals (Kontos et al., 2013; MacGregor et al., 2011). Previous head injury is a known risk factor for future head injury3 and there is a growing body of evidence to show that multiple head traumas lead to cumulative adverse impact (Guskiewicz et al., 2003; Moser et al., 2005; Wall et al., 2006). Repeat TBI has been linked to slower functional recovery, increased likelihood of depression, development of chronic traumatic encephalopathy (CTE)4, and increased risk of suicide in head-injured athletes and blast-exposed military Veterans (Baugh et al., 2012; Bryan & Clemans, 2013; Gavett et al., 2010; Goldstein et al., 2012; McKee et al., 2009).

TBI IN WOMEN

Incidence

In general, TBI and TBI-related deaths occur more often among men than among women for every age group and cause (Bell & Pepping, 2001; Coronado et al., 2012; Faul et al., 2010). However, women serving in the military are at relatively greater risk for TBI than their civilian female counterparts; even during peacetime, military

3 Among civilians with TBI, the risk of a second TBI is approximately three times, and of a third TBI approximately eight times, that of those who have never sustained a TBI (Salcido & Costich, 1992). 4 CTE is characterized by cerebral atrophy and progressive deterioration in cognition, affect, personality, behavior, speech, neurosensory function, and motor function. 218 Women at War women have a TBI incidence rate comparable to that of civilian men (Ommaya et al., 1996). Among female Veterans of the Iraq and Afghanistan wars, 12.7% later seeking care through VA have screened positive for TBI or reported a prior TBI diagnosis (Iverson et al., 2011). As women gain greater access to the full spectrum of military occupational roles and opportunities, their training and operational exposure to head injuries will also increase. Anticipating increased utilization of Veterans’ health services by female military Veterans, researchers observing trends in VA medical services have advocated for more integrated medical and mental healthcare provision to address female military Veterans’ myriad healthcare needs, including TBI (Amara et al., 2014). In 2007, the Armed Forces Health Surveillance Center (AFHSC, 2007) examined the incidence of TBI in active duty military personnel over a 10-year period (1997–2006). During this period, which included servicemembers injured while on active duty before and after September 2001, a total of 110,392 servicemembers were seen at fixed military medical facilities for injuries indicative of TBI (skull fracture, intracranial injury, and unspecified head injury). Female servicemembers accounted for approximately 12% (N = 13,546) of that total. Incidence rates were found to be 21% higher among military men than women over the 10-year period of surveillance.5 Similarly, in a study of combat Veterans deployed to Afghanistan or Iraq and screened for TBI by VA between 2007 and 2009—a population sample that was predominantly male (87.5%)—the rate of positive TBI screening for women was less than half that for men (10.7% and 23.1%, respectively) (Hendricks et al., 2013). However, the AFHSC’s data evidenced a smaller (13%) difference in TBI incidence between active duty military men and women over the four-year period (1997–2000) prior to military action in Afghanistan. This suggests that some of the broader (1997–2006) reported differences may be due specifically to combat-related risks and exposures associated with the conflicts in Afghanistan and Iraq. Among active duty Army personnel, a substantial increase in the incidence of TBI-related hospitalizations between 2000 and 2006 included a 60-fold increase in TBIs attributed to weapons (Ivins, 2010). Military women’s incidence of TBI will likely increase as more female servicemembers are assigned to combat roles. To explore service-related TBI trends over time and by gender, we queried the Defense Medical Epidemiology Database (DMED).6 We designed this data search to

5 Note that the reported differences may not account for TBIs related to blast exposure, which frequently present as other symptoms, in combination with other injuries, and so may not be initially coded as TBIs. 6 Available to all researchers who wish to query aggregate military medical data contained in the Defense Medical Surveillance System (DMSS), the Defense Medical Epidemiology Database (DMED) was 13. Traumatic Brain Injury 219

(a) 1.60 1.40 1.20 R2 = 0.9175 1.00

ate 0.80 R Males 0.60 Females 0.40 R2 = 0.0196 0.20 0.00 1997 1998 1999 2000 2001 2002

(b) 2.00

1.50 R2 = 0.5522

ate 1.00 Males R Females 0.50 R2 = 0.3194 0.00 2003 2006 2009 2012 FIGURE 13.2 Inpatient diagnoses expressed as head injury rates and trends for male and female US. military personnel (Army, Navy, Air Force, and Marines) during years prior to (1997–2002, (a)) and since (2003–2012, (b)) the beginning of the Iraq War. Rates are calculated as number of cases per 1,000 persons per year (person-years) for members of each population. include primary diagnoses coded as skull fracture (ICD-9-CM7 codes 800–804), intracranial injury (ICD-9-CM codes 850–854), and unspecified head injury (ICD-9-CM code 959.01). Findings are presented for inpatient/hospitalized (Figure 13.2) and outpatient/ ambulatory cases (Figure 13.3), depicting injury rates in the years before and since the beginning of the Iraq War in 2003. Generally, diagnoses derived from inpatient (hospitalized) settings can be inferred to represent moderate-to-severe TBIs. Figure 13.2 illustrates a notable increase in the rate of inpatient TBI diagnoses among male members of the US military between the years 1997 and 2002, followed by a more gradual reduction since 2003. By comparison, military women’s rate of inpatient TBI diagnoses remained relatively low and stable over the time period 1997–2012. However, it should be noted that in absolute numbers, these data represent 2,259 women who have sustained serious, potentially life-threatening head injuries during the course of their military service.8

originally supported by the Defense Women’s Health Research Program to evaluate the health of active duty servicemembers, with particular emphasis on women. DMED provides access to summarized medical event data gathered from the military Services and DoD worldwide. 7 The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is a standardized system of codes used by physicians and hospitals to classify disease and injury diagnoses. 8 For the purpose of context, we note that fewer (1,715) Service members have suffered partial or major limb loss related to their military service in Iraq or Afghanistan (total injuries documented to December 2012; Fisher, 2013). 220 Women at War

(a) 20.00 2 18.00 R = 0.9212 16.00 14.00 12.00 Males

ate 10.00 Females

R 2 8.00 R = 0.9279 6.00 4.00 2.00 0.00 1997 1998 1999 2000 2001 2002

(b) 45.00 2 40.00 R = 0.8222 35.00 30.00 25.00

ate Males R 20.00 2 Females 15.00 R = 0.9251 10.00 5.00 0.00 2003 2006 2009 2012 FIGURE 13.3 Outpatient diagnoses expressed as head injury rates and trends for male and female US military personnel (Army, Navy, Air Force, and Marines) during years prior to (1997–2002, (a)) and since (2003–2012, (b)) the beginning of the Iraq War. Rates are calculated as number of cases per 1,000 persons per year (person-years) for members of each population.

While the rate of hospitalizations for TBI among male servicemembers has tended to decrease since 2003, the rate of outpatient diagnoses has increased dramatically for both male and female servicemembers since 1997 (Figure 13.3). Outpatient diagnoses in outpatient/ambulatory care settings likely represent more common, less severe mTBIs/concussion. Among military women specifically, the rate of outpatient diagnoses of head injury has nearly quadrupled, increasing from 5.57 in 1997 (1,079 diagnoses) to 21.20 in 2012 (4,300 diagnoses) in 2012.

Medical Outcomes

Owing to differences in research methodology, patient demographics, injury severities, and outcome variables of interest in studies published to date, it is difficult to reach summary conclusions about gender as it may relate to the medical outcomes of TBI. However, a number of studies have suggested that women who sustain TBI suffer more severe adverse effects and/or poorer medical outcomes than their male counterparts. Krause et al. (2000) studied a prospective cohort of men and women with moderate or severe TBIs. Over the course of 18 months after hospital discharge, women were more 13. Traumatic Brain Injury 221 likely than men to suffer poor outcomes, including severe disability, vegetative state, or death. Age and/or pre- versus post-menopausal status may play a contributing role in women’s outcomes after TBI; however, findings with respect to a possible interaction between gender and age have been inconsistent. Ottochian et al. (2009) performed a retrospective review of 1,807 severe TBI patients and found significantly higher mortality specifically for women older than 55 years of age. In a study of moderate and severe TBI, Gan et al. (2004) also found that among elderly patients (64+ years), females had a higher mortality rate (70.4%) than males (44.7%). Farin et al. (2012) performed a retrospective analysis of severe TBI patients 6 months after injury and found that female patients had a significantly higher frequency of brain swelling and intracranial hypertension; however, differences in this study were most pronounced in female patients younger than 50 years. Kirkness et al. (2004) examined the interaction of sex and age effects on functional outcome9 in patients 3 and 6 months after admission to a level 1 trauma center, and found that women 30 years or older had significantly poorer functional outcome than men or younger women. Whiteneck et al. (2004) conducted follow-up interviews with 1591 individuals who had previously been hospitalized with moderate or severe TBI. At 1 year after injury, negative outcomes (persistent physical symptoms, requiring assistance with cognitive activities, social and occupational difficulties, reduced quality of life) were reported more frequently by those who were female, older, and had sustained more severe injuries. However, among patients with less severe (mTBI) injuries, Ponsford et al. (2008) identified a subgroup (24%) of patients who suffered persistent symptoms and significant life disruption at 3 months post-injury; members of this subgroup were more likely to be young (students) and female, and to have a history of prior head injury, neuro/psychiatric symptoms, or TBI as the result of a motor vehicular accident. By contrast, other studies have reported that women with TBI show better outcomes than their male counterparts. To address the possible interaction of gender and menopausal status on TBI mortality, Berry et al. (2009) performed a retrospective review of 72,294 moderate to severe TBI patient data from the National Trauma Database (2000–2005). In this study, the patient population was stratified to address premeno- pausal (14–45 years), perimenopausal (46–55 years), and postmenopausal (55+ years) subgroups. Compared to their male counterparts, women in the perimenopausal and postmenopausal subgroups actually showed a reduced risk of post-injury complications

9 The Extended Glasgow Outcome Scale (GOSE) and the Functional Status Examination (FSE) are often used to evaluate level of disability, recovery, and change in everyday life activities post-injury. Together, they include consideration of physical, social, and psychological status. 222 Women at War and mortality; mortality did not differ between men and women in the youngest (pre- menopausal) subgroup. Other studies have found better TBI outcomes in women (vs. men) based on post-rehabilitative evaluation of work capacity (Grosswasser et al., 1998) and cognitive recovery (attention/working memory and language; Ratcliff et al., 2007). However, a review of 13 studies where gender was examined as a possible factor in functional outcome concluded that women do not fare better than men after moderate to severe TBI, and pointed to the need for additional prospective research with attention to factors including age, injury severity, and hormonal status at the time of injury (Slewa- Younan et al., 2008). Hormonal status at the time of injury may be an important factor that has been largely overlooked for its potential to distort otherwise well-controlled comparisons between male and female patient cohorts. In one study of 144 women (ages 16–60) with mTBI, quality of life and neurological outcomes 1 month after injury were associated with menstrual cycle phase at the time of injury. Specifically, the outcomes of women who were injured during the luteal phase of their menstrual cycle (high progesterone) were significantly worse than those of women injured during the follicular phase of their cycle or women taking oral contraceptives (Wunderle et al., 2014). Some investigators have looked for gender differences in TBI outcome and found none at all. For example, Leitgeb et al. (2011) prospectively studied 6-month outcomes of 863 moderate and severe TBI patients and found no significant differences in mortality or unfavorable outcome for men versus women. In another prospective study, Renner et al. (2012) followed 427 TBI patients from acute care through rehabilitation and found no effect of gender on clinical course, pituitary dysfunction, or patient outcome. Some retrospective studies have also failed to find differences. Mushkudiani et al. (2007) found no gender or gender/age interaction in a retrospective study of 8,720 moderate and severe TBI patients’ 6-month outcomes. Slewa-Younan et al. (2004) examined the effect of patient gender on outcome after TBI, excluding patients who had a history of previous head injury or psychiatric disturbance. No significant differences were found for post-rehabilitation outcome measures between men and women. Yeung et al. (2011) retrospectively studied TBI patient data (ages 12–45 years) from two trauma registries (Hong Kong, Australia) to identify possible effects of gender on brain edema and mortality. No significant sex differences were found in mortality; data derived from one registry (Hong Kong) pointed to an association between female sex and brain edema, but no such association was apparent based on data from the other registry (Australia).

Neurobehavioral Outcomes

There is evidence to suggest that after TBI, women tend to experience more significant cognitive and neurobehavioral symptoms. Gerberich et al. (1997) examined the 13. Traumatic Brain Injury 223 academic performance of undergraduate students previously hospitalized for brain injuries (versus other injuries) and found a significant adverse effect of TBI on grade point average only for female students. A meta-analysis of eight studies concluded that TBI neurobehavioral outcomes were worse in women (vs. men) for most of 20 measured outcomes, including memory, headaches, dizziness, fatigue, irritability, anxiety, and depression (Farace & Aleves, 2000). In a patient sample (ages 15–95) with no history of psychiatric illness, Fann et al. (2004) found that women were at relatively greater risk for developing psychiatric problems subsequent to TBI. Studies of concussion in sports have also found gender differences in post-concussive symptoms reported by athletes. Among soccer players with history of concussion, female players reported a significantly higher number of discrete neurobehavioral symptoms than their male counterparts (Colvin et al., 2009). Broshek et al. (2005) observed increased cognitive impairment and more post-concussive symptoms among female athletes. Dick (2009) reviewed multiple studies published over a 10-year period and concluded that female athletes are at relatively greater risk for concussion and adverse neuropsychological outcomes than their male counterparts. However, findings from other studies suggest that gender differences in the severity of cognitive and neurobehavioral symptoms post-TBI may be isolated, limited, and/or temporary. Covassin and Bay (2012) studied mild to moderate TBI patients recruited from outpatient rehabilitation centers and compared men and women for their performance on a variety of cognitive tasks, neurobehavioral symptoms, and chronic stress measures. The authors found that women performed worse than men only in the domain of verbal memory. In another study comparing men and women on multiple measures of cognitive function (processing speed, executive functioning, and memory), Moore et al. (2010) observed that women with mTBI scored better than men on a test of visual memory and found no other gender differences in cognitive outcome. Comparing men and women after mild or moderate TBI, Bay et al. (2009) reported that although women reported higher levels of depressive, somatic, motor, memory, stress, and cognitive symptoms within the first 6 months after TBI, these differences abated after 6 months post-injury. We cannot assume that gender differences that have been observed in some civilian research settings necessarily extend or straightforwardly apply to military settings and military populations. It may be that men and women differ in medical and/or behavioral response to some types of brain injury but not others. In an animal model study of TBI, Hall et al. (2005) suggested that gender differences post-TBI may be linked to the timing of post-traumatic neurodegeneration, which tends to occur more quickly after focal (vs. diffuse) injury and thus could limit the potentially beneficial neuroprotective effects of female endogenous hormones. While military personnel are certainly 224 Women at War vulnerable to both types of TBI, the risk of diffuse brain injuries is more pronounced in relation to blast exposure. It is also important to consider that the emergence of behavioral symptoms post-TBI may indicate pituitary abnormality, which affects 20%–40% of TBI patients across all levels of severity. Findings published over a decade of research in this area indicate that 20%–30% of adult TBI patients will develop a disorder involving at least one endocrine function (Ghigo et al., 2005; Krahulik et al., 2010; Powner et al., 2006). In patients with severe TBI, resulting hormonal deficits can persist for months or even years (Agha et al., 2004; Benvenga et al., 2000; Bondanelli et al., 2004). Early symptoms of neuroendocrine dysfunction might include fatigue, impaired cognition, and mood disturbance, which are easily mistaken for symptoms of primary injury (TBI) or psychiatric comorbidity. Left untreated, these abnormalities can compromise recovery, outcome, overall health, and mental health. For TBI patients with hypopituitarism, pituitary hormone replacement therapy can help to mitigate cognitive impairment (Ghigo et al., 2005; High et al., 2010). Military personnel face unique physical and cultural stressors that may contribute to psychiatric comorbidities often associated with TBI. In a study of 12,605 Iraq and Afghanistan war Veterans who were evaluated as having deployment-related TBI, men and women were compared for the presence of psychiatric diagnoses and for the severity of self-reported neurobehavioral symptoms. PTSD was found to be the most common comorbid psychiatric condition for both genders. Initially, women were found more likely than men to be diagnosed with depression, anxiety, or PTSD with comorbid depression, and less likely to have a PTSD diagnosis without depression (Iverson et al., 2011). But when multivariate analyses were performed to account for blast exposure, some of these differences disappeared—PTSD diagnosis was no longer less likely for women, and women were no more likely to be diagnosed with non-PTSD anxiety disorder. Instead, women were found more likely to report severe somatosensory, cognitive, and vestibular symptoms. A subsequent study of 2,348 Veterans of Iraq and Afghanistan suggested strong associations between TBI and physical and mental health symptoms for men and women alike, independent of PTSD. TBI was linked to all reported health symptoms in women and to anxiety and physical health in men (Iverson et al., 2013). A separate study of 13,746 Veterans found that multiple factors were predictive of multisensory (auditory, visual, vestibular) impairment, including a history of deployment-related mTBI, PTSD, depression, older age, lower rank, and being female (Pogoda et al., 2012). Findings from a retrospective cohort analysis of women (N = 60) treated in VA Palo Alto Polytrauma System of Care clinics since 2006 suggested that numerous neurobehavioral difficulties—including depression, PTSD, anxiety, substance abuse, cognitive 13. Traumatic Brain Injury 225 impairments, chronic pain, headaches, sleep disturbances, neurological problems, and more severe somatosensory and vestibular symptoms—may be especially common among female Veterans with a diagnosis of TBI (Harris, 2013). The relationship between neurotrauma and psychiatric disorder is neither clear nor predictable. Neurobehavioral symptoms can and do occur in both men and women. Thus far, the research literature is largely silent on the question of what, if any, physiological, familial, and/or sociocultural factors might influence the emergence of psychiatric disorder after TBI in men or women.

Can Female Endogenous Hormones Protect the Brain?

As noted previously in this chapter, some studies of TBI have observed gender differences related to women’s pre- versus post-menopausal status or hormonal status at time of injury, suggesting that endogenous female hormones—estrogen and/or progesterone—may play a role in determining the extent, recovery, and/or outcome of TBI. The potential neuroprotective effects of female endogenous hormones have also been noted in studies of Parkinson’s disease (Dluzen & McDermott, 2000; Gillies & McArther, 2010; Haaxma et al., 2007), Alzheimer’s disease (Behl & Moosmann, 2002; Brinton, 2001), stroke (Alkayed et al., 2000; Gibson et al., 2011), and amyotrophic lateral sclerosis (ALS) (de Jong et al., 2013; Veldink et al., 2003). The apparent neuroprotective effects of these hormones can be attributed to a variety of mechanisms by which they may act to mitigate neurodegenerative processes associated with brain disease and injury. Although the precise underlying mechanisms of hormonal neuroprotection have not been fully specified, in general it appears that estrogen and progesterone can diminish adverse disease/injury processes and act to promote brain cell survival by exerting one or more antioxidant, anti-inflammatory, and anti-apoptotic effects (Cutler et al., 2007; O’Connor et al., 2005; Roof & Hall, 2000; Roof et al., 1993; Sarkaki et al., 2013; Shahrokhj et al., 2010; Soustiel et al., 2005; Stein, 2008; Vagnerova et al., 2008; Zhang et al., 2013). One recent study also linked estrogen (estrone) to a key cell growth factor (brain-derived neurotrophic factor, BDNF) implicated in cell survival and repair (Gatson et al., 2012). It is believed that progesterone acts to stabilize and protect cell membranes against lipid peroxidation, which otherwise contributes to the breakdown of the blood-brain barrier10 and related degeneration of neural tissue after TBI (Roof et al., 1997; Singh & Su, 2013).

10 Composed of highly specialized endothelial cells, the blood-brain barrier protects the brain from potentially injurious blood-borne substances and hormonal fluctuations that could cause uncontrolled brain activity. 226 Women at War

A compelling body of preclinical research has demonstrated beneficial effects of treatment with exogenous estrogen and/or progestins,11 leading to improved TBI outcomes, including reduced cerebral edema and intracranial pressure (O’Connor et al., 2005; Stein, 2013; Stein & Hoffman, 2003). Observations from a very limited number of human studies performed to date also suggest that progesterone administration may lead to improved TBI outcome (Ma et al., 2012; Wright et al., 2007; Xiao et al., 2008). The National Institute of Neurological Diseases and Stroke has funded additional clinical trials—two completed, one terminated, and one active—to determine if progesterone can be used safely and effectively to reduce brain swelling and damage after brain injury (Clinicaltrials.gov identifiers NCT00048646, NCT01143064, NCT00822900, and NCT01809639).

Post-Concussion Syndrome

When physical, cognitive, and/or emotional symptoms of mTBI or concussion become persistent or chronic, patients are sometimes diagnosed as suffering from persistent post-concussion syndrome (PPCS or PCS). Their persistent symptoms may include headaches, dizziness, sleep disturbance, depressed mood, anxiety, irritability, fatigue, and cognitive difficulties (attention, memory, conceptual and abstract thinking). Some studies have observed PCS to be more common or more pronounced in women (Bazarian et al., 2010; Bazarian et al., 1999; Preiss-Farzanegan et al., 2009; Ryan & Warden, 2003; Styrke et al., 2013). However, it is not known whether reported differences reflect underlying differences in physiologic susceptibility, contributing history of prior or comorbid injuries or ailments, greater willingness to seek medical care (e.g., due to resulting strain on family relationships), or other factors. For example, in a study of military personnel with histories of mTBI related to service in Iraq or Afghanistan, Schneiderman et al. (2008) found that the strongest predictor of PCS was PTSD; after controlling for a higher prevalence of PTSD among female subjects, the prevalence of PCS was comparable for male and female Veterans. It is also important to note here that while some 10% of head injury patients develop persistent post-concussive symptoms—and a history of prior or multiple head injuries is a possible risk factor for post-concussive symptoms (Miller et al., 2013)—development of PCS is not specific to head injury. To the contrary, patients who have no history of head injury whatsoever, but who have suffered other physical injuries, psychological trauma, or polytrauma may also experience symptoms of

11 Synthetic progesterone. 13. Traumatic Brain Injury 227

PCS (Binder, 1976; Boake et al., 2005; Landre et al., 2006; Meares et al., 2008). The available evidence suggests that PCS may be due to combined effects of injury-related neuropathology as well as pre- and post-morbid psychological and physiological factors (Ryan & Warden, 2003). Because neither its underlying mechanisms nor its predictors are well understood, PCS remains a somewhat controversial diagnosis. Differential diagnosis may be all but impossible for individuals who suffer with comorbid PTSD, as is often seen among military TBI patients. There is no specific treatment for PCS per se. Treatment is largely symptom-based as needed to address specific symptoms and difficulties (e.g., psychological intervention, antidepressant therapy, neurocognitive rehabilitation, vestibular rehabilitation, controlled exercise) (Leddy et al., 2012). Effective management can thus be time-consuming and cumbersome, particularly when strategies employed to mitigate one symptom area (e.g., vestibular therapy) introduce additional stress, fatigue, or worsening of another (e.g., headaches, depression). Regardless of cause or diagnostic characterization, those who suffer persistent symptoms in the aftermath of head injury are often forced to change many aspects of how they conduct their daily lives as individuals and as family members.

TBI and Neurodegenerative Disease

A comprehensive analysis of military and non-military risk factors for neurodegenerative disease is beyond the scope of this chapter, but it is relevant here to recognize that a growing body of research suggests a link between TBI and later development of neurodegenerative diseases such as Alzheimer’s disease (Bazarian et al., 2009; Fleminger et al., 2003; IOM, 2008; Lye & Shores, 2000; Mortimer et al., 1991; Plassman et al., 2000; Sivanandam & Thakur, 2012) and Parkinson’s disease (Bower et al., 2003; Goldman et al., 2006; Stern et al., 1991; Veldman et al., 1998). The neuropathologi- cal markers observed in Alzheimer’s disease are similar to molecular changes observed after brain injury (Magnoni & Brody, 2010) and degenerative atrophy commonly found in temporal lobe structures of Alzheimer’s patients has also been observed in patients with TBI (Bigler et al., 2002; Bigler & Maxwell, 2011; Jack et al., 1998; Jobst et al., 1994). The association between TBI and Parkinson’s disease may vary with severity of TBI, most evident in the case of moderate or severe TBI, but may play a role in cases of mTBI involving loss of consciousness (Taylor et al., 1999). A retrospective analysis of World War II Veterans found that hospitalization for head injury during military service was associated with greater risk of developing Alzheimer’s disease later in life (Plassman et al., 2000). A history of multiple head injuries may also be a risk factor for amyotrophic lateral sclerosis (ALS), perhaps 228 Women at War moderated by genotypic variables (Chen et al., 2007; Schmidt et al., 2010). Alzheimer’s and Parkinson’s12 diseases are now considered secondary service-connected illnesses for Veterans who also have service-connected moderate or severe TBI. VA also recognizes ALS as a service-connected disease based on evidence that military personnel have an increased risk of developing ALS (IOM, 2005; Weisskopf et al., 2005). These findings present potentially serious concerns for the long-term health of all individuals exposed to TBI(s) while in military service (Weiner et al., 2013). Although there is no evidence yet to suggest that the relationship between head injury and neurodegenerative disease might differentially affect women in particular, women face an already elevated risk of developing Alzheimer’s disease and dementia if only due to their relatively longer life expectancies (Fratiglioni et al., 1997; Hebert et al., 2001; Kawas et al., 1997; Nelson et al., 2002; Slooter et al., 1999; Zandi et al., 2002). This raises the possibility that women may be susceptible to associated risks over a longer period of time, perhaps with more likely or more prolonged consequences.

CONCLUSION

Studies of TBI in women have differed with respect to their research objectives, designs, methodologies, and findings. A great deal of additional research is needed to address possible interactions of TBI with common psychiatric comorbidities, blast-related TBI, multiple injury scenarios, repeat head traumas, and chronic and neurodegenerative effects of TBI. These problems pose pressing challenges to military and civilian medicine alike. Although civilians are not commonly exposed to dangers such as explosive blast, such scenarios unfortunately can and do occur in civilian settings. In this context of injury and others, knowledge gained from military medicine lends value to civilian medicine generally. With respect to TBI in particular, the military setting provides a unique opportunity to identify factors that may serve to reduce individual vulnerability, improve individual resilience, and promote effective recovery from TBI. To capture potentially valuable insights—and to avoid the presumption that findings in male populations necessarily extend to all people—researchers who study TBI should seek opportunities to include appropriately sized samples of men and women to support adequately powered comparisons and analyses of differences and similarities. Where it is found that gender differences exist—and where it is found that they do not—these findings can help to inform the development of potentially beneficial mitigation and treatment strategies for all TBI patients. For example, it may be that

12 Parkinson’s disease is also recognized as a primary service-connected illness for Veterans exposed to Agent Orange and other herbicides suspected as possible causal agents. 13. Traumatic Brain Injury 229 female endogenous hormones confer at least initial advantage to women, perhaps by reducing edema in the immediate aftermath of TBI (O’Connor et al., 2006; Roof et al., 1993). These and other findings make a compelling case for the use of hormone therapy as potentially beneficial to both men and women in the early acute phase of TBI. However, much of the data are drawn from animal models, and it is not yet known whether findings are applicable to all injury types and severities. A great deal more research is needed to disentangle multiple independent and interactive variables, their relationships to TBI in general, their relevance to military populations and settings, and to what extent they may influence women in particular. Concentrated, prospective studies are also needed to address the underlying bases and significance of observed gender differences with respect to other factors (e.g., age) and how these might inform the care and treatment of injuries sustained in military operational settings. Research in this area should recognize the additional complexity of cases involving psychiatric comorbidities (depression, anxiety) and/or polytraumatic injuries, which are especially common in military medical settings. In addition, women are more likely than men to have experienced gender-related harassment, sexual assault, and/or incidents of domestic violence that may have involved prior undiagnosed concussion. Although it is not yet clear specifically how and to what extent prior psychological and/or physical trauma might influence subsequent TBI recovery and outcome, it is generally understood that stress exerts an adverse effect on physical wound repair, lends itself to harmful behavior such as alcohol and tobacco use, and discourages healthy behavior such as exercise that can aid and promote healing (Gouin & Kiecolt-Glaser, 2011). In relation to TBI, women are also more likely to suffer from chronic pain, headaches, and sleep disorders (Englander et al., 2010; Jensen & Nielsen, 1990; Nampiaparampil, 2008), which can complicate diagnosis and treatment, slow recovery, and compromise functional outcome. The current available research literature barely speaks to the question of gender differences in the incidence or impact of recurrent/repeated TBI. There is a need to know if factors such as gender, age, and medical history influence vulnerability or resilience to the effects of TBI in general, and to repeat TBI in particular. While it would not be surprising to observe a relatively lower incidence of repeat TBIs in women who have been less frequently exposed to combat and contact sports, the incidence of prior head injury may also be underestimated among women exposed to criminal assault and/or intimate partner violence (Corrigan et al., 2003; Kwako et al., 2011). This is a particular concern for women in the military who, relative to their civilian counterparts, face an elevated risk of exposure to intimate partner violence, sexual assault, and associated health problems (Campbell et al., 2008; Iverson et al., 2013; Iverson, Mercado, et al., 2013; Murdoch & Nichol, 1995; Sadler et al., 2004). 230 Women at War

Attendees of the American Congress of Rehabilitation Medicine in 2010 held a workshop to specifically consider unique health issues experienced by girls and women who sustain TBI, and to identify related gaps in research, education, and policy. Their findings emphasized the scarcity of systematic research concerning both short-term and long-term outcomes of TBI in women, as well as the lack of clinical guidelines to inform the care and treatment of women’s biological, psychological, and social needs after TBI (Harris et al., 2012). The authors called for increased advocacy and a national strategy to promote health and quality of life for women and girls after TBI. National research initiatives can yield significant return on investment, as did the Defense Women’s Health Research Program (DWHRP) established by Congress in 1994, when women gained access to more military jobs, including some combat roles. The objective of the DWHRP was to accelerate research in key areas of women’s health and performance and to “bring protection of the health and performance of military women on a par with men, after more than a century of research based solely on males” (Friedl, 2005). The investment yielded more than 200 published studies supporting significant new knowledge, applications, and policy enhancement in key areas of concern, including physical training and exercise, nutrition, dehydration, military equipment design, medical surveillance, and susceptibility to some injuries. However, DWHRP objectives were prioritized to address research problems that were unique to military women, especially prevalent among military women, or related to military women’s ability to perform their mission responsibilities. It is understandable that TBI was not recognized as a problem of unique relevance to, or prevalence among, military women at the time. Women were still excluded from ground combat assignments and, during the 1990s, there was in fact a marked decrease in TBI-related hospitalization of active duty US Army personnel (by the late 1990s, Army TBI hospitalization rates were actually lower than civilian rates; Ivins et al., 2006). Two decades later, women’s mission responsibilities (and resulting risks) have changed and are expanding to include combat assignments. This raises the need to focus attention on combat injuries that are neither unique to women nor uniquely prevalent among women, but rather may affect military women in unique ways. The improved understanding of such differences may be beneficial to military men as well. Targeted investment is needed for the scientific study of injury scenarios that until now have received little or no attention for their possible immediate or long-term effects on military women. It is important that TBI be diagnosed and treated with the clear- est possible understanding and recognition of injury type, severity, and potential physiological and endocrinologic, psychological, and behavioral comorbidities and sequelae. Likewise, it is important to understand what specific injury scenarios (e.g., 13. Traumatic Brain Injury 231 blast exposure, polytrauma) may or may not affect women differently, and why. This is an opportunity to advance medical scientific knowledge generally, to achieve new insights, and to promote better health outcomes for all who serve.

DISCLAIMER AND ACKNOWLEDGMENTS

The views expressed in this article are those of the authors and do not reflect official policy or position of the Department of Defense, the US Government, or institutional affiliations listed.

We extend our thanks to Colonel (Ret.) Karl Friedl, Ph.D., for his thoughtful suggestions and comments to an earlier draft of this chapter; and to Dr. Katherine Iverson (Women’s Health Sciences Division, National Center for PTSD) and Dr. Jomana Amara (Defense Resources Management Institute, Naval Postgraduate School) for their helpful insights and research contributions to women’s and Veterans’ health.

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fourteen Suicide-Related Ideation and Behaviors in Military Women

MARJAN GHAHRAMANLOU-HOLLOWAY, BRIANNE GEORGE, JAIME T. CARRENO-PONCE, AND JACQUELINE GARRICK

INTRODUCTION

Beginning with Deborah Samson, who in 1776 enlisted under the name “Robert Shurtliff” in order to fight for the United States in the Revolutionary War, women have been an important part of our nation’s military history (Freeman & Bond, 1992). There are approximately 214,098 active duty women serving in the US military (comprising 14.6% of all branches), with an additional 118,781 in the Reserve and 470,851 in the National Guard (Women in the Military Service for America Memorial, 2013). Military service, while challenging and rewarding for many, may expose the individual to a number of physical (e.g., sleep deprivation, injury), psychological (e.g., anticipation about deployment, trauma exposure), and psychosocial stressors (e.g., relationship and/or parenting issues)—all of which can serve as risk indicators for thoughts about death and dying. Many of the stressors associated with military service may affect women differently than men. Moreover, military women, as compared to their military male and female civilian counterparts, may face additional unique stressors. Results of the 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel (Barlas, Higgins, Pflieger, & Diecker, 2013) indicate that military women attribute “a lot” or “some” stress, over the past 12 months, to the following top six life events: (1) being away from

243 244 Women at War family and friends (46.6%); (2) change in work load (45.5%); (3) responsibilities and family/personal responsibilities (38.0%); (4) having to undergo a permanent change of station (37.1%); (5) problems with coworkers (32.4%); and (6) being deployed (30.3%). In recent years, increasing attention has been paid to the psychological stressors most relevant to military women, yet there continues to be a lack of general dissemination of clinical observations and research on suicide-related ideation and behaviors among military women. Military women, compared with their civilian counterparts, have a threefold increased risk for suicide (Cassels, 2009). An analysis of 1990–2004 suicide mortality rates among military women in the US Air Force indicates that both enlisted and Officer women have higher suicide deaths compared to their general population counterparts (Yamane & Butler, 2009). This risk continues after military discharge, as female veterans are 79% more likely to die by suicide than civilian women (Cassels, 2009; McCarthy et al., 2009). I believe this is of those who attempt suicide, not 79% of the population. One explanation for the higher observed rates of suicide in military women is related to their access, familiarity, and use of firearms as compared to their civilian counterparts, who may choose other methods such as drug overdose (Cassels, 2009). Factors that are significantly associated with firearm use in women include the following: “being older, married, white and a veteran; residing in areas with higher rates of firearm availability; having an acute crisis; having experienced the death of a relative or friend; being depressed; and having relationship problems” (Kaplan, McFarland, & Huguet, 2009, p. 322). The aims of this chapter are twofold: (1) to educate military and civilian mental health providers on the important public health problem of suicide-related ideation and behaviors among military women; and (2) to provide a series of recommendations on assessment, management, and treatment of suicide-related ideation and behaviors among military women.

SUICIDE-RELATED THOUGHTS AND BEHAVIORS

National Data on Women

The Centers for Disease Control and Prevention (CDC) maintain national injury- and violence-related statistics. The most current 2010 national fatal injury report (CDC, 2013) indicates that suicide is the second leading cause of death in women aged 15–24 years, the third leading cause of death in women aged 25–34 years, and the fourth leading cause of death in women aged 35–44 years. In 2010, a total of 8,087 women died of suicide in the United States (age-adjusted rate of 4.99 per 100,000). Female suicides account for approximately 21% of all national suicides. Poisoning (37%), firearms (30%), and suffocation (24%) are the three most common methods of suicide for 14. Suicide-Related Ideation and Behaviors 245 women. In terms of race, the highest 2010 suicide rates for women aged 25–64 years were among non-Hispanic Whites (8.98 per 100,000), followed by American Indian/ Alaskan Natives (8.36 per 100,000). An interesting fact is that suicides occur at a higher rate than homicides (i.e., 5.15 crude rate versus 2.22 per 100,000) for women of all ages when homicide gets most of the media attention. A recent CDC report (2011) presents national data on suicidal thoughts and behaviors among adults over the age of 18 for 2008–2009. Approximately 1.2 million adult women, reflecting 1.0% of the US adult female population made suicide plans in the past year; nearly 616,000 adult women, reflecting 0.5% of the US adult female population, made a suicide attempt in the past year. An estimated 4.6 million adult women, reflecting 3.9% of the US adult female population, had suicidal thoughts in the past year.

Department of Defense (DoD) Data on Military Women

Currently, the DoD Suicide Event Report (DoDSER; Luxton et al., 2012) is a standardized suicide surveillance effort implemented among all military branches of service. Overall, a total of 52 military women have been reported as having died by suicide between 2008 and 2011. While the total number of suicides for these four recent years (i.e., 2008–2011) has been reported, the DoDSER reports do not provide an estimated annual rate of suicide for military women. Authors of the report indicate that a relatively small count of military women who die of suicide each year results in stability issues in rate estimations. There is statistical merit to the practice of not calculating rates when incidents of mortality are less than 20 per year (as is the case with suicide in military women). Rates, incorporating events with such low frequencies, risk dramatic changes in the statistically derived rate of suicide from year to year with minimal changes to the actual number of female suicides. The DoDSER for calendar year 2011 shows that approximately 16 military women died by suicide—this count reflects 5.32% of all suicides during the year. The 2011 overall demographics indicate that 14.86% of DoD Service members were women during the same calendar year. In general, given the small counts of suicides among military women, there is also no basis for making any conclusions about the observed “suicide by service” percentages. The DoD Suicide Prevention Office (DSPO) has provided the following additional information on 2011 suicides among military women based on the DoDSER collected information. Approximately two out of every five military women who died by suicide were under the age of 25, Caucasian, and married. All were enlisted Service members at the time of death. About a third used a non-military issued gun, about half were diagnosed with a mood disorder, and approximately 87% did not have a history of deployment. 246 Women at War

In the 2011 DoDSER, women accounted for 26.5% of suicide attempts in the military. The DoDSER purposely does not provide rates of suicide attempts, as the Services have implemented different standards for including an attempt in the DoDSER, and attempts may be underreported, making the consistency of attempt rates questionable. In this case, three out of every five military women who attempted suicide were under the age of 25 and Caucasian, half were married, and 73% were junior enlisted. Almost 75% of the attempts were made by drug overdose. Failed relationships were reported in 50% of the suicide attempt cases. Approximately 75% of the women did not have a history of deployment. A greater proportion of women who attempted suicide were African American (29% female, 15% male) and had a history of physical (32% female, 18% male), emotional (35% female, 18% male), and/or sexual abuse (42% female, 9% male).

Sex Differences in Suicide-Related Thoughts and Behaviors

Sex differences in suicide deaths have been well documented in the general civilian population, with men dying four times more frequently1 than women (Beautrais, 2006). Of the 38,364 (12.08 per 100,000)2 suicide deaths among American adults in 2010, approximately 30,277 (19.95 per 100,000)3 were men, while only about 8,087 (4.99 per 100,000)4 were women (CDC, 2013). Suicide deaths in the US military also show a higher proportion of male suicides than female. Of the 301 US military suicide deaths in 2010, 94.7% were men. In terms of suicide attempts and sex differences, women attempt suicide with three times greater frequency (CDC, 2013). In the World Health Organization (WHO) multinational survey (Nock et al., 2008), for those individuals who reported ideation, women had a significantly higher conditional probability of (1) making a future attempt, (2) making an attempt without a lifetime plan, or (3) making an attempt with a lifetime plan. Suicide attempts in the military present a slightly different picture in terms of sex differences. Nearly a quarter (26.5%) of 935 DoD 2011 documented suicide attempts were made by women—indicating that for every military female suicide attempt, there were three military male suicide attempts. One should keep in mind, however, that women comprise only 14.6% of the military (Luxton et al., 2012).

1 China is a notable exception, where women outnumber men in suicide deaths (WHO, 2013). 2 Age adjusted 3 Age adjusted. 4 Age adjusted. 14. Suicide-Related Ideation and Behaviors 247

Finally, in terms of suicidal thoughts, among the adults in the United States who endorse suicide ideation, 3.8 million are men (3.5% of all US men) but 4.6 million (3.9%) are women (CDC, 2011). Systematic tracking of suicide ideation among military personnel is not currently occurring within the DoD. However, the 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel (Barlas, Higgins, Pflieger, & Diecker, 2013) shows that 13.4% of military women, compared with 11.8% of military men perceived a higher sex-related stress due to suicide ideation since joining the military. Moreover, while we do not have much information about sex differences in suicidal thoughts for military women versus men, the civilian literature provides a helpful starting point for identifying potential sex differences in the onset, sustainment, and exac- erbation of suicidal thoughts. The civilian literature indicates that females are more likely than males to experience suicidal thoughts as a way of coping with feelings of depression (Harlow, Newcomb, & Bentler, 1986). Psychiatric diagnoses that are most predictive of suicide ideation in women include post-traumatic stress disorder (PTSD), social anxiety, generalized anxiety, and panic disorders (Cougle, Keough, Riccardi, & Sachs-Ericcson, 2009). For women with PTSD, a greater prevalence of suicide ideation is noted with comorbid depression (Cougle, Resnick, & Kilpatrick, 2009). Additionally, a history of forced sexual intercourse, illegal drug use (other than cannabis), and exposure to violence are recognized as risk factors for suicide ideation in women specifically (Legleye et al., 2010). Women who are younger, who experience perceived workplace harassment, who are working with inadequate resources, and who experience professional burnout are also at risk for suicide ideation (Fridner et al., 2009). Psychiatric disorders, sexual harassment or abuse, and work-related stresses may all present similar risk factors for female Service members and may represent unique risk factors for this military subgroup. Finally, men and women in the general population appear to differ in the trajectory from suicide ideation to suicide attempts. Baca-Garcia and colleagues (2010) found that the occurrence of suicide ideation without subsequent attempts was higher in women than in men. More specifically, Caucasian women between 18 and 64 years of age had the highest comparative risk of suicide ideation without a subsequent attempt when compared to other groups. However, there continues to be a lack of knowledge about whether these research findings correspond to the experiences of military women. In the sections below, a brief review of risk and protective factors for suicide, pertaining to civilian and military women, is presented. While the scope of the scientific literature on military women and suicide risk is limited, the information presented here provides a solid foundation for best understanding the types of life experiences that may predispose women to develop a wish to die. 248 Women at War

RISK FACTORS FOR SUICIDE AMONG WOMEN

Demographic Factors

In a representative cross-national study of 84,850 adults, female sex, younger age (18–34 years), lower educational attainment, being unmarried, and the presence of a mental disorder served as the strongest risk factors for suicidal behaviors—and these factors appeared to be universal across 17 participating countries (Nock et al., 2008). In a cohort study of 87,257 women and 70,570 men (aged 15–89) receiving services through a health maintenance organization (HMO), the following factors were found to be significantly associated with suicide attempts in women: age 15–24 years, Caucasian race, 12th grade or less education, history of emotional problems, and history of family problems. The following factors were found to be significantly associated with suicide deaths in women: age 15–24 years, Asian race, Caucasian race, being separated/divorced, prior inpatient hospitalization for suicide attempt, and history of emotional problems.

Trauma-Related Factors

General Population Adverse childhood experiences, including neglect, parental divorce/separation, witnessing domestic violence, sexual and/or physical abuse, and other traumatic events significantly impact suicide-related risk in adulthood (Afifi et al., 2008; Brent, Baugher, Bridge, Chen, & Chiappetta, 1999; Brown, Cohen, Johnson, & Smailes, 1999; Felitti et al., 1998). Risk of at least one suicide attempt among adults with a history of adverse childhood experiences increases two to five times compared with adults without such history (Dube et al., 2001); further, the odds of ever making a suicide attempt increases sharply for those with seven or more adverse childhood experiences (adjusted OR = 31.1, CI 95% [20.6–47.1]). In terms of sex differences, Afifi and colleagues (2008) found that for men, physical abuse and witnessing domestic violence in childhood were associated with suicide ideation in adulthood, while childhood physical and sexual abuse were associated with a suicide attempt in adulthood. On the other hand, for women, childhood sexual and physical abuse were associated with suicide ideation in adulthood, while any experience of adverse childhood experience was associated with a suicide attempt in adulthood. In addition, military women who receive psychiatric care for suicide-related thoughts and behaviors have demonstrated a significantly higher likelihood of documented histories 14. Suicide-Related Ideation and Behaviors 249 of childhood sexual abuse, adulthood sexual assault, adulthood physical assault, and pregnancy loss (Cox et al., 2011).

Military

A recent review by Zinzow and colleagues (2007) provides necessary information for mental health practitioners in regard to trauma for military women. This review indicates that military women (1) have higher rates of lifetime trauma than civilian women; (2) have higher rates of childhood trauma than civilian women (and that these traumas may be more severe); and (3) are at a higher risk for “cumulative trauma exposure” due to increased rates of trauma prior to military service and subsequent increased risk for trauma exposure during military service (Zinzow et al., 2007). Military women, compared to their male counterparts, are more likely to have survived multiple types of abuse during childhood (Dansak, 1998). Some implications of these higher trauma exposure rates include higher rates of anxiety, particularly PTSD, depression, medical and psychological service utilization, and psychological as well as physical health problems (Murdoch, Pryor, Polusny, Anderson, & Gackstetter, 2007; Zinzow et al., 2007), which can all serve as important indicators for suicide risk for women in uniform. In addition, Zinzow and colleagues note that military women have increased rates of adult sexual assault—many of these events are “in-service” assaults (victim and assailant are both Service members). Military sexual assault survivors may have to continue to live and work with the perpetrator, particularly if on a deployment, and the survivor may have unique stigma concerns regarding how reporting the crime will affect one’s career (Zinzow et al., 2007). One study found that almost half of the women in their sample experienced sexual and/or physical assault during their military service, and that these women were more likely to have subsequent physical or emotional health problems (Sadler, Booth, Cook, & Doebbeling, 2003). The DoD has a zero tolerance policy for sexual harassment of military members, as established by DoD Directive 1350.2, DoD Military Equal Opportunity (MEO) Program. This directive provides clear policy for how violations should be handled and what services should be available to victims. Despite these efforts, sexual harassment continues to occur and can cause significant psychological effects. Military women have been found to be the victims of sexual harassment with greater frequency than military men, as in the civilian population, and both women and men who experience this harassment have been found to endorse more negative mental health symptoms and higher scores on a depression measure (Murdoch, Pryor, Polusny, Anderson, & Gackstetter, 2007; Street, Gradus, Stafford, & Kelley, 2007). 250 Women at War

In addition, compared to their civilian counterparts, military women are at higher risk of being exposed to traumas resulting from combat, natural disasters, and major accidents (Zinzow et al., 2007). There may also be sex differences in exposure and reaction to these types of traumas within the military. Hourani, Yuan, and Bray (2003) describe the most prevalent trauma for men as witnessing major accidents, and for women, as witnessing a major disaster. Military men are at risk for more physical symptoms of stress related to their trauma exposures, whereas military women have twice the risk for developing mental health problems following exposure to a traumatic event. While minimal research exists on sex differences in combat exposure and reactions to combat for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans, two solid reviews have made significant contributions to the literature (Boyd, Bradshaw, & Robinson, 2013; Street, Vogt, & Dutra, 2009). Street and colleagues (2009) show that although male Service members are more likely to be exposed to combat, approximately 12% of women deployed to OIF and OEF have experienced “moderate levels of combat,” and that a far greater percentage (around 40%) of women have reported coming under mortar or artillery fire. There is also some evidence that combat-related PTSD may be underdiagnosed in female Veterans, though this finding is in need of further exploration with Veterans of the current conflicts (Pereira, 2002). Finally, women have often been observed as having higher rates of PTSD following trauma exposure in a variety of populations, including victims of sexual assault, combat Veterans, and civilians exposed to war and torture (Tolin & Foa, 2006; Johnson & Thompson, 2008). In fact, women have rates of PTSD that are twice as high as men, PTSD tends to last longer in women than in men, and the symptoms tend to result in poorer health among women versus men (Simmons, 2007). In addition, this effect has been shown even after controlling for type of trauma (Breslau & Anthony, 2007; Tolin & Foa, 2006). PTSD has been shown to be associated with suicide attempts even after adjusting for sociodemographic, mental disorders, and severity of physical disorders (Sareen, Cox, Stein, Afifi, Fleet, & Asmundson, 2007).

Psychiatric Factors (Summarizing General Population and Military Literature)

A review of 4,203 suicides among women aged 15–44 indicates that the most common precipitating circumstances associated with female suicides across 16 US states (2003–2007) are a current mental health problem (60%), having been treated for a mental health problem (54%), current depressed mood (44%), and past/current intimate partner relational problems (36%) (Ortega & Karch, 2010). A more detailed description of a number of psychiatric factors, identified as contributors to suicide risk, is provided below. 14. Suicide-Related Ideation and Behaviors 251

Anxiety and Mood Disorders PTSD and panic disorder are predictive of suicide risk among men, whereas PTSD and panic disorder, along with social anxiety disorder and generalized anxiety disorder, are predictive of suicide risk among women (Cougle, Keough, Riccardi, & Sachs-Ericcson, 2009). The diagnosis of major depressive disorder places both men (OR = 9.86, CI 95% [5.08–19.14]) and women (OR 5.00, CI 95% [3.19–7.83]) at greater risk for suicide attempts (Zhang, Mckeown, Hussey, Thompson, & Woods, 2005). Nightmares, a symptom of PTSD that negatively impacts the quality of sleep, have been associated with increased risk of suicide (Bernert & Joiner, 2007). Among individuals with a recent suicide attempt, frequent nightmares were associated with an increased risk for a subsequent attempt among men (3.9 times) and women (1.7 times) and a significant increase in suicide ideation for both men (3.0 times) and women (1.6 times) (Susansky, Hajnal, & Kopp, 2011). Krakow and colleagues (2000) examined sleep disturbance among female sexual assault survivors who had PTSD and found that women who had greater levels of suicide ideation had signs of breathing-related sleep disorders.

Pregnancy, Postpartum Depression, and/or Child Loss Pregnancy creates unique challenges for military women. Appolonio and Fingerhut (2008), based on their review of the literature, highlight unique stressors for military women during pregnancy. These stressors include working longer hours and later into their pregnancies, receiving less support, facing an ongoing struggle to balance work and family demands, and experiencing stigma about reporting issues resulting from pregnancy or new motherhood. Rates of postpartum depression in active duty military samples are roughly equivalent to rates in civilian populations, though these authors note that military women may have more barriers to care, including less awareness, less education, and increased stigma. In a recent study (Do, Hu, Otto, & Rohrbeck, 2013), 9.9% of all active duty military women who delivered a baby were diagnosed with postpartum depression during the one-year postpartum. Military women with postpartum depression compared with those without, after adjusting for various covariates, had 42.2 times the odds of being diagnosed with suicidality in the postpartum period (Do, Hu, Otto, & Rohrbeck, 2013). Notably, postpartum psychosis increases the risk of suicide among civilian women by 7-fold during the first year after childbirth and 17-fold over the next several years (Appleby, 1991; Appleby, Mortensen, & Faragher, 1998). Finally, women in the general population who experience abortion as a traumatic life event have also shown to be at risk for suicide ideation and behavior—as increases in depression, anxiety, and substance use disorders are experienced as well (Furgusson, Horwood, & Ridder, 2006). 252 Women at War

Substance Use Disorders When compared to military men, women have been found to be similar in their use of drugs, but have reported lower rates of alcohol consumption than men (Bray, Fairbank, & Marsden, 1999). A recent study (Medical Surveillance Monthly Report, 2011) on alcohol-related diagnoses for US Armed Forces in 2001–2010 indicates that military women had a rate of 9.1% (compared with 14.5% in military men) for acute cases of alcohol related disorders and a rate of 6.5% (compared with 10.7% in military men) for chronic cases of alcohol-related disorders. The association between alcohol-related disorders and suicide outside the military has been well established since the 1980s (Center for Substance Abuse Treatment, 2008). Younger women with alcohol-related problems are twice as likely to attempt suicide, compared with older women (Gomberg, 1989)—therefore, young military women with an alcohol-related disorder should be considered as a high-risk group for suicide ideation and/or behaviors. Female Veteran outpatients with a history of military sexual assault, compared to those without, are found to have higher rates of alcohol abuse and depression (Hankin et al., 1999). Higher rates of alcohol and drug use subsequently predict having a PTSD diagnosis (Nunnink et al., 2010), which, as noted earlier, is yet another risk factor for suicide. As stated above, substance-use disorders are often noted among individuals who have suicide-related thoughts and behaviors, with alcohol involved in approximately one-third of all suicide deaths in the general population (Karch, Crosby, & Simon, 2006). Alcohol or drug abuse conveys over a six times greater risk of suicide attempts (Molnar, Berkman, & Buka, 2001), and the link between impulsivity, substance abuse, and suicide has been widely noted in risk literature for suicide (Koller, Preuss, Bottlender, Wenzel, & Soyka, 2002; Mann, Waternaux, Haas, & Malone, 1999; Sher, Oquendo, & Mann, 2001; Sher, 2006).

Eating Disorders Requirements to maintain fitness standards per service regulations, which include measurement of body composition, may pose a unique challenge to military women at risk for disordered eating. Though subject to the same types of standards as military men, military women, compared to their male counterparts, have reported higher levels of body dissatisfaction and report higher depressive symptoms associated with their weight (Carlton, Manos, & VanSltyke, 2005; Kress, Peterson, & Hartzell, 2006). Military women also show significantly higher rates of eating disorder, not otherwise specified, than civilian women, perhaps as a result of the pressure to attain and maintain fitness and weight standards in the military (McNulty, 2001). Military women who express a higher drive for thinness and greater body dissatisfaction are at a greater risk 14. Suicide-Related Ideation and Behaviors 253 for developing an eating disorder (Lauder & Campbell, 2001). Additionally, women exposed to combat may be at particular risk for disordered eating. Military women who experienced combat versus those who did not were 1.8 times more likely to develop new disordered eating and 2.4 times more likely to lose a large amount of weight (Jacobson et al., 2008). Women with eating disorders have shown considerable risk for suicide-related behaviors (Franko et al., 2004).

Personality Disorders The co-occurrence of personality disorders contributes a greater risk of suicide, independent of Axis I diagnoses, among both civilian men and women (Schneider et al., 2006). Cluster B personality disorders (i.e., dramatic) are independent predictors of suicide death in women, while cluster C personality disorders (i.e., avoidant) are independent predictors of suicide death in men (Schneider et al., 2006). Specifically, borderline personality disorder (BPD) poses significant increased risk for suicide in women; however, younger age (≤35 years) and BPD together are associated with increased suicide risk for both men and women (Qin, 2011). The potential increased suicide risk that these disorders present to military personnel has yet to be formally evaluated. Studies identifying such links may be particularly challenging in a population where personality disorders are likely underdiagnosed in both men and women.

History of Suicide Attempt Individuals with multiple suicide attempts are at the greatest risk of eventual death by suicide (Hawton & Fagg, 1988; Kelley, Goldston, Brunstetter, Daniel, Ievers, & Reboussin, 1996; Pfeffer, Klerman, Hurt, Kakuma, Peskin, & Siefker, 1996). For individuals discharged from inpatient psychiatric hospitalization, the first month following hospitalization is the period of greatest risk for suicide death (Goldacre, Seagroatt, & Hawton, 1993), and current suicide ideation, along with depression, conveys increased risk of repeated suicide attempts (Lewinsohn, Rohde, & Seeley, 1994). For women with a history of suicide attempt(s), there is a six times greater risk of suicide attempt. Among women, suicide ideation, greater suicide attempt lethality, hostility, fewer reasons for living, borderline personality disorder, and nicotine use increase suicide attempt risk beyond the impact of prior attempt (Oquendo et al., 2007). For military members, mental health hospitalizations have been associated with risk of suicide following discharge, especially if the Service member has a history of injury or alcohol use (Bell, Harford, Amoroso, Hollander, & Kay, 2010). The risk for suicide subsequent to a suicide attempt–related hospitalization is noteworthy among female Veterans. A retrospective cohort study on Veterans who had received inpatient care after a suicide attempt, during 1993–1998, at US Veterans Affairs facilities has 254 Women at War shown that suicide is the leading cause of mortality (accounting for 25%) among the sample of female Veterans (Weiner, Richmond, Conigliaro, & Wiebe, 2011).

Occupational- and Interpersonal-Related Factors

Unemployment is a predictor of suicide risk for men; however, this has not been consistently identified as a risk factor for women (Qin, Agerbo, & Mortensen, 2003) and is not directly applicable to military women, who are obviously employed. What is important to understand here is that while men have an increased risk for suicide attempts when unemployed, women display the higher risk when faced with workplace problems. Factors predictive of suicide ideation in women facing occupational difficulties include younger age, perceived workplace harassment, working with inadequate resources, and occupational burnout (Fridner et al., 2009). Professional risk factors are salient in understanding military-related suicide risk. Occupational and work dissatisfaction among military members play a role in suicide-related behaviors. For men in the US Air Force (USAF), for instance, dissatisfaction with USAF life in general is significantly associated with suicide ideation, while differences in satisfaction with work relationships are associated with suicide ideation among USAF women (Langhinrichsen-Rohling, Snarr, Slep, Heyman, Foran, & United States Air Force Family Advocacy Program, 2011). Additional military-related occupational risk factors include access to firearms and exposure to workplace trauma (Mahon, Tobin, Cusack, Kelleher, & Malone, 2005; Violanti, 2004). The workplace problems experienced by women may be linked to another risk factor for suicide—that is, interpersonal problems. For women, dealing with interpersonal crises or loss of any significant relationship conveys an increased risk of ideation and attempts; this risk has been seen for women across their life span and independently of their culture (Bhugra & Desai, 2002; Cheng et al., 2010; Kingree, Thompson, & Kaslow, 1999). Furthermore, women who are victims of domestic violence that has involved physical injuries are at elevated risk for anxiety, depression, and suicide ideation (Fergusson, Horwood, & Ridder, 2006). Most recently, Gutierrez and colleagues (2013) have presented qualitative findings on female Veterans’ deployment-related experiences. Having a sense of failed belongingness, burdensomeness, and acquired capability for suicide were observed as themes emerging from the interviews conducted with these women. These factors have been presented as a contemporary model for suicide risk (Joiner, 2005) and have been consistently supported in the scientific literature as serving as risk indicators for suicide (Bryan, Cukrowicz, West, & Morrow, 2010; Van Orden, Witte, Gordon, Bender, & Joiner, 2008). 14. Suicide-Related Ideation and Behaviors 255

PROTECTIVE FACTORS FOR SUICIDE AMONG WOMEN

Suicide risk may be attenuated by the presence of protective factors, which may be social, psychiatric, and/or health related. On a positive note, women are seen as generally more emotionally expressive and open to seeking help, as well as identifying and using more social supports than men (Barbee, Cunningham, Winstead, Derlaga, Yankeelov & Druen, 1993; Gianakos, 2002; Maris, Berman, & Silverman, 2000). During times of emotional distress, men are less likely to express a need for help and may avoid their problems or use unhealthy coping strategies (e.g., alcohol) in an attempt to reduce their distress (Gianakos, 2002; Wimer & Levant, 2011). Greater distress levels and lower expressiveness among men have been tied to negative coping responses associated with the perceived threat to their masculinity (Burns & Mahalik, 2011). The general stigma and avoidance related to help seeking in the military is not surprising, given the over- representation of men in service (85%) and the masculine normative behaviors associated with military service (Burns & Mihalik, 2011). In addition, positive family relationships, a sense of familial connection, and social support (Borowsky, Ireland & Resnick, 2001; Hovey & King, 1996) serve as socially protective factors for suicide. Perceived social support appears to lessen and protect against suicide ideation (Chioqueta & Stiles, 2007; Hovey, 1999). Satisfaction in personal relationships and a sense of usefulness to one’s family and friends are also associated with lower suicide ideation risk (Rowe, Conwell, Schulberg, & Bruce, 2006). For female physicians, meetings to discuss stressful workplace situations result in a lower risk of suicide ideation (Fridner et al., 2009). For individuals with chronic medical problems, risk for thoughts of suicide may be mitigated by feelings of happiness despite the medical conditions (Hirsch, Duberstein, & Unutzer, 2009). Unit cohesion and support from military leaders in the unit could play a crucial role for military members surviving a trauma; both unit cohesion and leader support are significantly associated with fewer health problems for soldiers exposed to trauma, both sexual and non-sexual in nature (Martin, Rosen, Durant, Knudson, & Stretch, 2000). Overall, social support and healthy interpersonal relationships appear to attenuate suicide ideation for both men and women.

GENERAL RECOMMENDATIONS FOR BEHAVIORAL HEALTH PROVIDERS AND RESEARCHERS

A foundation of knowledge of the unique life experiences and health-related challenges of military women is essential in order to provide optimal evidence-based interventions and to advance the science of sex differences and suicide within DoD and civilian 256 Women at War settings. Based on the information presented in this chapter on suicide-related thoughts and behaviors among women—particularly women who serve our nation—the following practice and research recommendations are provided for behavioral health providers and scientists:

1. Conduct a suicide risk screening and assessment at every intake session using psychometrically sound measures such as the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2006) or the Suicide Status Form (SSF; Jobes, 2006), which is a collaborative assessment, treatment-planning, and documentation source for interviewing a patient about suicide-related risk and protective factors. The SSF has been used for many years within the US Air Force and is currently mandated for usage with at-risk patients based on the new Air Force Guide for Suicide Risk Assessment, Management, and Treatment (2013). The C-SSRS has a current military version (available for free at http://www.cssrs. columbia.edu/) that you may find extremely helpful. Do not assume that since military women are not demonstrating suicide deaths at a similar rate to their male counterparts that they are not at risk for suicide-related ideation and behaviors. Pay close attention to specific risk indicators for suicide ideation and behaviors among military women—for instance, traumatic life events, psychiatric problems, history of self-injurious behaviors with and without intention to die, postpartum depression, relational and/or occupational problems. Allow for sufficient time to best understand the specific biopsychosocial stressors that may place your female military patient at risk for suicidal thoughts and subsequent behaviors. 2. Consider the fact that military women, in general, have greater knowledge about weapons and are significantly more likely than their civilian counterparts to have ready access to lethal means such as firearms. For military women at risk for suicide, ensure that you have a discussion about availability to lethal means and address the removal of and/or restriction of access to such means and the conditions under which the lethal means would be returned to the individual. Depending on the imminence of the suicide threat, you are encouraged to consider collaborative work with family members, trusted peers, military police, and/or the Service member’s command to ensure safety. 3. Collaborate with the patient to prepare an individualized, hierarchically arranged, written list of coping strategies (i.e., a safety plan) to implement in future distressing circumstances. Discuss thoroughly the patient’s prior experiences, specifically, cognitions, emotions, and/or behaviors that precipitate self-injury at times of crises. Make sure that the safety plan, at the very least, 14. Suicide-Related Ideation and Behaviors 257

contains contact information for the provider, the on-call provider (if available), the local 24-hour emergency department, and at least one reliable suicide hotline number, as well as information on how to best limit access to lethal means. Contact information for Military Crisis Line’s (1-800-273-TALK [8255] or 00800-1273-TALK [8255] in Europe, 24 hours a day, 7 days a week) suicide crisis hotline must be provided, along with name and address of the nearest Emergency Department. Check on the patient’s willingness to follow the safety plan and help problem-solve perceived obstacles in implementation. Refer to the Safety Planning Intervention guide provided by VA (http://www.mentalhealth. va.gov/docs/VA_Safety_planning_manual.pdf) for constructing safety plans (Stanley & Brown, 2008, 2012). 4. Remain mindful of the stigma, harassment, and possible ridicule within the military environment that many military women may experience because of how their suicide-related behaviors may be perceived by others. Within the military, suicide-related behaviors may be perceived and labeled as malingering—this may be more pronounced for women. “Women are still seen as weak, whiny, hormonal, and incapable” (Blank, 2008, p. 19), and such negative perceptions may lead to a minimization or dismissal of their symptoms. Therefore, work collaboratively with your female military patient in order to assist her to overcome organizational, cultural, and/or interpersonal challenges within the military—and thus to feel empowered about her skills, work functions, and overall contributions. 5. Remember that perceived barriers to care may play an important role concerning the timely delivery of mental health treatment to military women. Owens and colleagues (2009) report that over 40% of female Veterans studied reported needing psychological services but not utilizing these services, most often citing long waiting periods and prior bad experiences within VA healthcare system. Of the women who sought treatment from a non-VA mental health provider, most indicated feeling some stigma going to the local VA, and/or not feeling “welcome” there. Fontana and Rosenheck (2006) studied women admitted to VA’s Women’s Stress Disorders Treatment Team for treatment of their PTSD and found comfort to be a potential important factor in treatment adherence. The women generally reported feeling “somewhat comfortable” from the start of their treatment, and for those for whom this was their first contact with VA, comfort increased as exposure to treatment increased. For these women, level of comfort showed some associations with treatment compliance, though only slightly associated with outcomes. In another recent study, “ease of use” of the facility, as well as variables such as physician sensitivity and logistics of care, was 258 Women at War

predictive of VA utilization (Vogt et al., 2006). Stigma concerns, as well as the importance of comfort and sensitivity, should therefore be a focus of particular attention for providers who work with military women. 6. Provide psychoeducation to your female patients about career-related implications associated with seeking psychological care on a voluntary preventative basis versus those associated with seeking psychological care when mandated by command. A retrospective chart review (Rowan & Campise, 2006) was conducted using 1,068 cases of active duty USAF Service members seen in eight USAF behavioral health clinics during a one-year period. The investigators reported that self-referred USAF personnel, as compared with commander-mandated members, were less likely to have their confidentiality broken and to experience career-impacting recommendations. Of course, certain medical and psychiatric conditions may have significant impact on Service members’ careers, leading to administrative separation. Providers may face the difficult decision of determining the fitness and suitability of military women who have a history of suicide thoughts and behaviors. However, openly discussing concerns about career-related implications of seeking mental healthcare may help your female military patients understand that mental healthcare does not lead to separation from the military, but that this outcome may occur if their psychiatric symptoms have exacerbated, requiring further evaluation of their fitness for duty. Similarly, suicide-related thoughts and behaviors that result in hospitalization do not warrant a mandatory separation from military service. In a previous study of military members hospitalized for suicide-related reasons, nearly half the sample were returned to full duty status (Ritchie et al., 2003). 7. Promote and engage in research studies that advance our understanding of the unique needs of military women who experience suicide-related ideation and/or behaviors. Beautrais (2006, p. 153) writes the following: “One reason for the lack of investment in female suicidal behavior may be that there has been a tendency to view suicidal behavior in women as manipulative and nonserious (despite evidence of intent, lethality, and hospitalization), to describe their attempts as ‘unsuccessful,’ ‘failed,’ or attention-seeking, and generally to imply that women’s suicidal behavior is inept or incompetent (Canetto & Lester, 1995; Murphy, 1998).” Given the relatively low number of military women who die by suicide, some may argue that DoD resources should primarily be focused on preventing male suicides. However, military women, while underrepresented in the suicide death statistics, are expected to be overrepresented in the suicide ideation and attempt categories. DoD suicide prevention efforts and population-level surveillance cannot solely focus on suicide deaths (fatal events) and must consider ideation and attempts (non-fatal events) 14. Suicide-Related Ideation and Behaviors 259

as other important areas for inquiry and prevention. Since the positions that military women hold are just as impacting on unit readiness as are those of their male counterparts. 8. When preparing scientific presentations, publications, and/or reports, conduct statistical analyses and present your findings on sex-related differences pertaining to suicide-related ideation and behaviors among military women. As repeatedly noted, this is an area of research inquiry that has not received much attention and is in desperate need for growth. It would be very helpful for DoD reports such as the DoDSER to provide a summary section on findings specifically pertaining to military women, so that the important discoveries pertaining to these individuals are not simply lost in the numbers. Funding of studies on suicide-related thoughts and behaviors among military women would also contribute to the advancement of science in this important understudied area.

CONCLUSION

This chapter has provided an overview of suicide-related ideation and behaviors among military women and a series of recommendations for behavioral healthcare providers and scientists. From recruits to Veterans, women are expanding their ranks in our nation’s military history. As the nature of women’s involvement in the military evolves, providers across various DoD, VA, and civilian healthcare settings have an increasing responsibility to recognize, understand, and respond to the psychological issues these women encounter. While efforts to address behavioral healthcare needs of military Service members as a whole have been outstanding, there is still a great deal of mental health research disparity in relation to issues pertaining to military women. Providers, researchers, and policymakers within the DoD are strongly encouraged to pay closer attention to the unique needs of this subgroup.

DISCLAIMER

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of Defense.

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GLENNA TINNEY AND MELISSA E. DICHTER

INTRODUCTION

This chapter will focus on intimate partner violence (IPV) as it relates to military women and women Veterans. First, we will provide general information about violence in intimate relationships and then will discuss IPV in the military and Veteran populations. It is important to clarify the terms used throughout the chapter. Although the authors acknowledge that there are women who use violence in intimate heterosexual and same-sex relationships, the majority of IPV victims are women abused by male partners. From 1994 to 2010, four out of five victims of IPV were women (Catalano, 2012). Therefore, this chapter will focus on male violence against women in intimate relationships and will generally refer to “victims” as female and “abusers” as male. In the 1970s, advocates began to use the term “battering” to describe the experience of many women who were entering shelters when fleeing violent relationships. Battering described an ongoing pattern of coercion, intimidation, isolation, and emotional abuse in an intimate relationship, reinforced by the use and threat of physical and/or sexual violence. The terms “domestic violence,” “domestic assault,” and “domestic abuse” gradually replaced “battering,” especially in statutory language. However, in many jurisdictions, these terms include acts committed by any cohabitant or family member, as well as acts of resistance committed by an abused woman against her abuser. A number of researchers and the Military Services began to use the term “intimate partner

266 15. Intimate Partner Violence 267 violence,” which has the advantage of excluding violence outside of adult intimate or romantic relationships, while including same-sex relationships. We will use the term “intimate partner violence” or “IPV” throughout this chapter. IPV generally involves physical and/or sexual violence at least once, if not on an ongoing basis. When there has been physical and/or sexual violence in an intimate relationship, the abuser’s behavior continually reminds the victim that violence is always a possibility, and she is afraid of the abuser. The goal is to exercise control over the victim, using tactics such as physical force, sexual coercion or violence, financial control, psychological or emotional coercion, isolation, and medical control or manipulation. IPV includes behaviors that frighten, intimidate, terrorize, manipulate, hurt, humiliate, blame, injure, or wound someone. There is often an ongoing pattern of coercive control in the relationship, resulting in entrapment of the victim so that her world narrows more and more over time. The Department of Defense (DoD) Family Advocacy Program (FAP) uses the terms “domestic abuse” and “domestic violence” to describe this same range of abusive behaviors. The Department of Veterans Affairs (VA) is subject to statutory terminology in the jurisdiction where the VA facility is located.

IPV MYTHS AND FACTS

There are many myths about IPV that allow people to minimize the widespread incidence and danger of IPV. These myths create problems for both military and civilian victims as they decide whether to report and seek help. Here, we provide some information to counter some of the common myths about IPV. IPV is not a rare event. A national survey found that more than one in three women (35.6%) in the United States has experienced rape, physical violence, and/or stalking by an intimate partner in her lifetime (Black et al., 2011). IPV is a serious health concern and can be lethal. In 2010, 1,800 females were murdered by males in single victim/single offender incidents that were submitted to the Federal Bureau of Investigation for its Supplementary Homicide Report. Ninety-four percent were murdered by males they knew (US Department of Justice, Federal Bureau of Investigation, p. 6). The US Department of Justice (DOJ) has found that women are far more likely to be the victims of violent crimes committed by intimate partners than are men, especially when a weapon is involved. Moreover, women are much more likely to be victimized at home than in any other place (The Violence Policy Center, 2012, p. 4). It is not uncommon for an IPV offender to commit suicide after killing the victim and sometimes children and other family members and/or bystanders. Significantly, 27%–32% of intimate partner femi- cides are homicide-suicides (Roehl, O’Sullivan, Webster, & Campbell, 2005, p. 13). 268 Women at War

IPV is not a gender-neutral phenomenon. Although some women are violent in intimate relationships, women’s violence is often in response to abuse perpetrated against them. It might be self-defense, and it might be a result of many years of abuse. Women are more likely than men to experience IPV and more likely to suffer negative consequences of IPV. While there may be many cases of IPV that involve the use of drugs/alcohol, substance use does not cause IPV. The use of drugs/alcohol is often an excuse for the abuse. Many abusers do not use alcohol/drugs, and there are many men who abuse drugs/alcohol who are not abusive. An IPV offender chooses to use violence to control his partner, and abstaining from alcohol/drugs will not necessarily stop the abuse. Counseling for drug or alcohol problems will not stop the abuse without other intervention. The abuser alone is responsible for his violent/abusive behavior. Regardless of any dyadic or family dynamics that contribute to tension in the relationship or family, the victim and children are not responsible for the abuse. It is possible for there to be one incident of IPV that never occurs again, but this is not common. It is more common for there to be an ongoing pattern of abuse, which often involves coercive control. Most victims do not report IPV the first time it happens. By the time they report, there have usually been multiple incidents, often with escalating violence. IPV victims face many barriers to leaving abusive relationships; staying in the relationships does not indicate that the victims enjoy or accept the abuse. Actually, many victims leave an average of six to eight times before leaving for good. Risk and danger increase when a victim tries to separate from her abuser, so victims who leave their abusers are at higher risk for domestic homicide than those who stay. Either staying or leaving the abusive relationship poses risks to safety. A victim who stays in the relationship is constantly evaluating and trying to determine the best and safest time to leave.

STATISTICS

According to the Centers for Disease Control and Prevention (CDC) 2010 National Intimate Partner and Sexual Violence Survey (NISVS), women experience high rates of severe IPV, rape and stalking, and long-term chronic disease and other health impacts, such as post-traumatic stress disorder (PTSD) symptoms. One in four women has been the victim of severe physical violence by an intimate partner. One in five has been raped in her lifetime, and one in seven has been stalked (Black et al., 2011). How does this compare to statistics in the DoD? Women currently make up nearly 15% of the active duty military force and 18% of the reserve component, which includes 15. Intimate Partner Violence 269 members of the Reserves and National Guard (ICF International, 2012). The DoD Family Advocacy Program (FAP) collects statistics on domestic abuse and IPV from the Services annually, including only cases reported to FAP for the active duty military force, so they do not include statistics for the Coast Guard, Reserves, and National Guard. In fiscal year (FY) 2012, there were 18,671 reports of spouse abuse. Less than half of the 18,671 reports (8,345) met criteria to be substantiated and entered into the Central Registry, a database kept by each of the Services. In addition, in 2012, there were 909 reports of IPV (violence between non-married intimate partners) that met criteria to be entered into the Central Registry (Department of Defense, Family Advocacy Program, 2013). In domestic abuse cases that met criteria, the abuser may have been an active duty member or a civilian family member: 67% of the abusers were male; 61% of the abusers were active duty; 67% of the abusers were in the E-4 to E-6 pay grades; 85% of the reports were for physical abuse; 49% of the domestic abuse victims were active duty; 42% of the victims were between 18 and 24 years old; and 46% of the victims were between 25 and 35 years old (Department of Defense, Family Advocacy Program, 2013). Unfortunately, the FAP data do not break out how many of the victims or abusers were active duty women. The FY 2012 FAP domestic abuse data report 17 domestic abuse fatalities. Six of the victims and ten of the abusers were previously reported to FAP. Eighty-eight percent of the abusers were male, and 71% were active duty (Department of Defense, Family Advocacy Program, 2013). Is it possible to compare the DoD FAP statistics to civilian IPV statistics, or would that be comparing apples to oranges? Civilian studies have found that there is as much as five times more IPV in the military than in the civilian population (Taylor, 2002). However, there have always been questions about whether these studies controlled for variables specific to the military population. In 2010 for the first time, the DoD, CDC, and DOJ collaborated to include two random samples from the military in the NISVS (Black & Merrick, 2013). The samples included active duty women and wives of active duty men from all Service branches. This survey is the first time that data have been collected that will allow for a comparison of military and civilian rates of IPV, sexual violence, and stalking. The NISVS civilian sample was 9,000 women, and the military sample was 2,836 women (1,408 active duty women and 1,428 wives). The military sample does not include intimate partners who are not married. Statistical controls were applied for age and marital differences to decrease the probability of distorting the survey results. The majority of the military sample was ages 18–29, while only about 29% of the civilian sample fell into this age range. Definitions were aligned to closely match DoD definitions. 270 Women at War

The following are key survey findings:

• The risk of contact sexual violence for military and civilian women is the same, after controlling for age and marital status differences between these groups. With few exceptions, the past year and lifetime prevalence (occurrence) of IPV, sexual violence, and stalking in the civilian and military populations are quite similar, with no statistically significant differences. The lifetime prevalence was 40% for the civilian sample, 36% for active duty women, and 33% for wives of active duty men. • Active duty women were significantly less likely than civilian women to indicate that they experienced IPV in the three years prior to the survey. The lifetime prevalence of physical violence was 36% for the civilian sample, 28% for active duty women, and 27% for wives of active duty men. The lifetime prevalence for psychological aggression was 57% for the civilian sample, 54% for active duty women, and 49% for wives of active duty men. • Active duty women were less likely to report stalking than civilian women. The lifetime prevalence of stalking by any perpetrator was 1 in 5 for the civilian sample, 1 in 9 for active duty women, and 1 in 7 for wives of active duty men. • A deployment history appears to impact active duty women’s experience of IPV and sexual violence. Active duty women with a deployment history had higher rates of IPV and sexual violence than women without a deployment history. These differences appeared in the past three-year and lifetime prevalence rates but were not present in the past-year prevalence rates. This suggests that IPV and sexual violence are problems that may develop over time for active duty women who have deployed.

Although the NISVS study found decreased rates of IPV among active duty women compared to civilian women, analysis of data from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance Survey found higher rates of lifetime IPV (measured as actual or threatened physical violence or unwanted sex from an intimate partner) among women who had served in the military compared with women who had not served in the military (33% vs. 25%). The higher rate of victimization among women Veterans remained when controlling for age, race, income, and education (Dichter, Cerulli, & Bossarte, 2011). Research has found that women experience IPV before, during, and after military service (Dichter, unpublished research, 2013) indicating that women Veterans may experience higher rates of IPV after leaving military service. 15. Intimate Partner Violence 271

UNDERSTANDING VICTIM BEHAVIOR

Most IPV victims, both military and civilian, do not report to the police or seek help from domestic violence programs. They first try to handle the situation themselves, using a variety of strategies. They often love their partner and want the abuse to stop, but often don’t want the abuser to go to jail. Victims may turn to informal support networks such as family, friends, and neighbors. If that is not successful, they may reach out to medical providers, faith communities, and employers or schools. Many abusive behaviors do not fall into the range of criminal conduct, so often it is only after the violence has escalated in frequency and severity, or perhaps the abuser has also started abusing the children, that victims seek help from the police and courts as well as domestic violence shelters and counselors/ therapists. The primary reasons that victims report to the police are to stop the violence and to receive protection. There are many reasons that IPV victims do not report to the police or seek help outside their informal support networks. Many of these apply to both military and civilian victims. A primary reason is fear of increased violence and reprisal from the abuser. There are often financial concerns, especially if the abuser has not allowed the victim to work outside the home, go to school, or maintain a career. There may be reluctance to become involved with the police and courts that stems from prior bad experiences and/ or expectations of negative experiences, which may be particularly prominent among people of color and immigrant populations who have historically had a troubled relationship with the legal system. Some victims are ashamed or embarrassed to tell anyone, or they fear no one will believe them. They may have had previous bad experiences when trying to seek help from systems other than the police as well. They may be afraid that child protective services will take their children away, especially if they have trauma histories and mental health or substance abuse issues themselves. Each time a victim is not believed, is blamed for the abuse, is treated as a criminal, or is not appropriately assisted, this experience reinforces the abuse and control and makes victims less safe and less likely to reach out for help. Women in the military have additional reasons for not reporting. Military life and cultural norms present unique challenges for IPV victims in need of help. Unlike in the civilian world, where clear boundaries exist between one’s employer and the intervening doctor, judge, social worker, and advocate, the military system is, for the most part, seamless. Imagine if in the civilian world that calling a local shelter or confiding in your doctor automatically prompted notification of the abuser’s acts of violence and abuse to his employer. Fear of negative career consequences is the primary barrier to reporting 272 Women at War

IPV in the military (Caliber Associates, 1996). Consider Mary, an active duty Sailor, who is in an intimate relationship with John, who is also an active duty Sailor, and they are stationed on the same ship. There has been escalating violence in their relationship in which Mary is the victim. On one occasion, she fights back, which results in an injury to John. Mary is disciplined for this incident and is administratively separated from the Navy. In this case, the fear of negative career consequences became a reality for Mary. Women whose abusive partners also serve in the military may fear that if the abuse is reported, the Service member abuser may be passed over for promotion or lose his job, which would also mean loss of benefits. For many, the military provides relatively stable job security and the availability of a broad range of services and benefits, including housing assistance, day care, child and youth services, healthcare, food shopping at reduced prices, educational assistance for Service members and spouses, the opportunity to travel, and other formal support services. These are highly valued benefits for many young families. Because of the potential loss of these services and benefits, IPV can affect the livelihoods of Service members much more readily than it does for civilians. In addition, active duty victims may fear being perceived by their command as “weak” and unsuitable for career advancement; military women have reported being denied promotion for not initially reporting violence from an abusive partner when the command learned of it later. This fear is based on reality given the necessary command focus on mission readiness, good order and discipline, and fitness for duty. Therefore, many active duty IPV victims fear that it is just not acceptable to report the abuse. Moreover, both victims and offenders fear thatany involvement by military response systems will blemish the Service member’s (whether victim or perpetrator) career, even if the allegations are not substantiated. Frequently, IPV victims experience a conflict of loyalty to self versus loyalty to the relationship or the partner. This conflict is not unique to military-related victims. In many cases, the victim has strong emotional attachment to the abuser and a desire to remain in the relationship but wants the abuse to stop. This emotional battle often causes victims to sacrifice their own safety to keep the relationship intact. This battle can be even stronger if the victim is in a relationship with a military member or Veteran who has combat-related physical and/or psychological injuries. The victim may be in a caretaker role and therefore feel obligated to stay to help the partner and feel that leaving would be abandonment. This was the case for Jennifer, who has been married to Tim for five years. He deployed to the war zone multiple times. Each time he returned, Jennifer noted changes in him. Although he was abusive prior to deployment, his abusive behavior escalated, with the violence increasing in frequency and severity. Tim is experiencing symptoms of PTSD and has used alcohol to deal with the symptoms. 15. Intimate Partner Violence 273

Jennifer has become increasingly afraid of Tim, but she feels that she has to stay to support him and try to convince him to get help. She feels she owes this to him after all he has experienced. The constant mobility and geographic relocation of military families can isolate victims by cutting them off from family and support systems. The frequent moving of Service members and their families, sometimes to locations with unfamiliar cultures, increases the isolation and dependence on the abusive partner. During a Service member’s deployment to a war zone, spouses/partners and family members experience many different feelings, including fear, worry, loneliness, and pride. They eagerly await the safe return of the Service member. Although reunion should be a happy time, it can also be an unexpectedly stressful time for many Service members and their spouses/partners. The Service member and spouse/partner have different experiences during the deployment. Both change. This is exacerbated if both deployed to a war zone. It can take time to rebuild intimacy and adjust to changes in roles and responsibilities. This may result in unanticipated challenges. Each Service member reacts differently to his or her experience in a combat zone, but for most, these experiences affect them and their relationships for a long time; for some, the impact lasts for the rest of their lives. It is not easy to transition back to a “civilian” mindset after being in full military and survival mode during the time in the war zone. All Service members will need time to readjust after being in a war zone. Many will experience common stress reactions, such as sleep problems, bad dreams, irritability, anger, flashbacks, substance misuse and abuse, and agitation as a part of normal readjustment. Anger and aggression are common war-zone stress reactions. Even minor incidents can lead to overreactions. These reactions can have a negative effect on relationships and, for some, can increase the risk of violent and abusive behavior, especially if abusive behavior existed prior to deployment to the war zone (National Center for PTSD, US Department of Veterans Affairs, 2010). Recantation, dropping charges, or at least regretting making a report are major issues in IPV cases whether the victims are military or civilian. Professionals who work with IPV victims find this behavior very frustrating and often become judgmental and even angry. Sometimes a victim recants or drops the charges based on the abuser’s behavior. Some abusers continue to use coercive control and threats to influence the victim to drop the charges or recant. They may threaten to hurt her worse or even kill her if she doesn’t drop the charges. They may threaten to get a divorce and take the children. Sometimes they play on the victim’s fear of losing her children by making reports to child protective services that she is an unfit mother. The abuser may withdraw financial support, placing her and the children at risk for homelessness. They use the court system to continue their abusive and 274 Women at War controlling behavior by alleging that she was violent, filing for protection orders, or trying to get custody of the children. They may also use more subtle and manipulative tactics, such as saying how lonely and depressed they are and how much they miss her and the children. They may threaten to commit suicide or threaten to kill her and then commit suicide. Sometimes victims recant or drop charges because the systems that are in place to protect them and hold the perpetrators accountable fail them. For military victims, it may be a commander who is not supportive, blames the victim, or doesn’t believe her. It may be that the abuser’s commander colludes with the abuser and takes no action to protect the victim or hold the abuser responsible for his behavior. Law enforcement may arrest the victim and treat her as if she were the perpetrator when she was defending herself. Child protective service or FAP workers may hold the victim responsible for the child abuse inflicted by the abuser or because she did not protect the children and may threaten to place her children in foster care. The community-based domestic violence program may not have space in the shelter or may reject the victim because she has mental health or substance issues. FAP staff may not be supportive or may side with the abuser, especially if the victim does not behave as they think she should. She may be angry or hysterical and vent her anger everywhere, including toward those trying to help her. When a victim recants, drops the charges, or chooses to remain in the relationship with the abuser, it is much more complicated than the simplistic explanation heard from many—she must like it or she wouldn’t stay. Leaving an abusive relationship is often very dangerous. IPV victims are the ones who can best assess the level of danger that their abuser poses. Tina, the wife of an Army major, believed him when he told her that if she ever tried to leave him that he would hunt her down and kill her. Tina knew that he had personal weapons and knew how to use them. He had threatened her with guns on previous occasions, so she knew that the situation was dangerous. She was uncertain that anyone or any protection order could protect her. The initial system response can have a huge impact on a victim’s subsequent actions. A bad response can significantly increase danger to the victim and her children and ensure she will not report again. A good response can send a message to the victim and the perpetrator that these actions are unacceptable and that someone cares.

CONTEXTUAL ANALYSIS

Anyone who works with IPV victims knows that all IPV victims do not have the same experience.1 Each incident is different because it occurs within a larger context, so it is

1 This section has been adapted from the Battered Women’s Justice Project. Safety at Home: Intimate Partner Violence, Military Personnel, and Veterans (an e-learning course). 2013, module 1. htt p:// elearning.bwjp.org/safety/index.php. 15. Intimate Partner Violence 275 important to determine the context in which the violence is embedded. This involves looking deeper than the current incident to the history of abuse and violence in the relationship. The goal is to determine the intent of the violence for the perpetrator and the meaning and effect of the violence for the victim. Identifying the context of the violence is instrumental in determining appropriate intervention for both the victim and perpetrator. This chapter focuses on four contexts in which IPV takes place that have significant implications for risk and danger assessment, safety planning, and intervention. Military-related IPV cases are found in all of these contexts.

Intimate Partner Violence with Coercive Control

The first context is IPV with coercive control, which is equivalent to “battering,” a term used since the 1970s. Coercive control includes threats of negative consequences for noncompliance, punishing when necessary, monitoring of the victim’s behavior through surveillance, and attempts to wear down resistance (Dutton & Goodman, 2005). The violence is embedded in a larger pattern of coercive control that permeates all aspects of the relationship and is intended to maintain long-term control over the partner through intimidation and threats of violence. IPV with coercive control has major effects on all aspects of a victim’s life. There are physical injuries and increased likelihood of severe injury or death as the violence increases in frequency and severity. There are stress-related health problems as well as psychological issues such as fear, anxiety, depression, and post-traumatic stress. The perpetrator’s control of where a victim goes and when results in disruption of school or job performance, which creates economic dependence or entrapment. The combination of all of these effects can erode the victim’s ability to confront the violence and take action to protect herself and her children. Despite sustained efforts to undermine them, most victims of IPV with coercive control take action to protect themselves and their children, and many do leave the relationships. Especially in cases of IPV with coercive control, a perpetrator is likely to react to attempts to separate with an escalation of violence, stalking, and controlling tactics because separation represents a loss of the perpetrator’s control. Sometimes victims of IPV with coercive control don’t experience a physical attack until they threaten or attempt to separate from their partners. Many perpetrators of IPV with coercive control continue their abusive and controlling tactics post-separation. They often engage practitioners in the very system in place to protect victims to perpetuate this ongoing pattern of coercive control and harassment. For example, they call the police and obtain protection orders against the victim, and use the court system to complicate parenting and custody arrangements, maintaining a connection to the victim for years after the relationship has ended. 276 Women at War

Resistive Violence

Resistive violence is largely the response of female partners to IPV with coercive control directed against them by their male partners. Resistive violence is part of a broader strategy used by victims to stop or contain the abuse they have experienced over time. Violence may be used to stand up to the abuse, to retaliate, to defend herself or others, or to pre-empt further attacks. The intent of resistive violence is generally not to dominate. The violence is often minor and ineffectual and typically has little impact on their partners’ behavior, nor does it result in the same level of fear or intimidation. Resistive violence can, however, result in serious injury or death to either partner. Perpetrators of IPV may escalate their use of violence following resistive violence by the partner, and those who use resistive violence may be vulnerable to arrest and possible conviction, which creates an array of possible negative consequences, including temporary or permanent loss of custody of her children, employment, and freedom. Suzanne is married to an active duty Marine. There has been ongoing physical abuse for the entire marriage. Recently, he has started hit- ting the children. In the most recent incident, Mark, her husband, was strangling her. She picked up a knife and cut him on the arm. He called the police. Suzanne was arrested as the perpetrator because there were no signs of injury to her from the strangulation. Mark obtained a temporary protection order in which he was awarded temporary custody of their two children. Suzanne is now faced with criminal charges for domestic violence at the same time that she is fighting for custody of the children.

Situational Intimate Partner Violence

Situational IPV is violence in the absence of an ongoing pattern of coercive control in the relationship. The intent of the violence is not to establish dominance over the partner and is not in response to being abused. The violence often occurs during argu- ments about an ongoing unresolved issue in the relationship such as jealousy, infidelity, finances, childrearing, communication deficits, and so on. Although the incident may have been frightening, victims report that the violence was not typical in their relationship and that they are not afraid of their partners. While severe violence occurs at a lower rate in situational IPV than it does in IPV with coercive control, it can still be dangerous and potentially lethal. 15. Intimate Partner Violence 277

Intimate Partner Violence Related to Mental Illness, Substance Abuse, or Brain Injury

Most people with mental illness do not commit violent acts, including IPV. In fact, IPV is an intentional act to obtain a desired result in an intimate relationship. Most IPV perpetrators do not have diagnosed mental illness. More commonly, mental illness, substance abuse, or brain injuries can be co-occurring conditions in perpetrators of all forms of IPV. This emphasizes the need for careful assessment to determine if these conditions are part of the context in which the IPV is embedded so that interventions can effectively address both the factors related to the increased risk of violence associated with the co-occurring conditions and the conditions themselves. One article that reviewed research over a 15-year period identified the risk factors for psychiatric violence as history of violence; noncompliance with pharmacological and outpatient treatment; substance abuse; violent ideation or fantasies; acute persecutory delusions with negative affect; and brain lesions (Joyal, Dubreucq, Gendron, & Millaud, 2007). Evidence has been mounting over time that co-occurring substance abuse is a major factor increasing the risk of committing violence in people with psychiatric disorders (Dubovsky, 2011). However, how these factors interact or are mitigated by protective factors is still unknown. A relationship between combat-related PTSD and IPV perpetration has been found consistently in research studies (Gerlock, 2004; Orcutt, King, & King 2003; Sayers et al., 2009). Some PTSD symptoms may lead to acts of IPV. The challenge is to determine if the symptoms are stand-alone PTSD symptoms, or if the behaviors are IPV tactics that reflect a history of ongoing abuse and violence in intimate relationships. Violent behavior that occurs due to manifestations of PTSD symptoms (e.g., using violence against a partner in a heightened state of arousal in response to a triggering incident; controlling a partner’s freedom due to PTSD-related hypervigilance) may be resolved through PTSD treatment. However, coercive controlling violence may not be resolved with PTSD treatment alone. It is not uncommon for Service members and Veterans to increase their use of alcohol and drugs during and after a war-zone deployment. Substances can be used to self-medicate to relax, fall asleep, or avoid thinking about war-zone experiences. Substance abuse is often present in IPV incidents in both the military and civilian populations. People with substance use disorders can present with symptoms of irritability, aggression, and impulsivity. However, this behavior is generally not directed only at an intimate partner or family members. Both the victim and the perpetrator may be under the influence of alcohol and/or drugs at the time of the IPV incident. This can 278 Women at War negatively affect a victim’s safety by interfering with her ability to assess danger and protect herself. Exhibiting aggressive behavior after a moderate to severe traumatic brain injury (TBI) is common and is generally seen within the first year after the injury. This aggression may also be associated with other conditions, such as a major depression and pre-injury substance abuse (Carlson et al., 2011; Hoge et al., 2008). However, this aggression is usually diffuse, occurring in many settings and not directed specifically at an intimate partner. The bottom line is that thorough assessment is necessary to determine if there is a history of coercive control and abusive behavior in the relationship, in order to rule out IPV with coercive control before deciding that the IPV is due to mental illness, substance abuse, or brain injury. Many people believe that when active duty military personnel or Veterans who have deployed to a combat zone engage in IPV after their return that the IPV is “caused” by the combat zone experience or by co-occurring combat-related conditions such as PTSD, TBI, substance abuse, and/or depression, and so on. Therefore, they assume that the IPV is embedded in the larger context of mental illness, substance abuse, or brain injury. This may or may not be true.

RISK, DANGER, AND SAFETY

Risk Factors

Regardless of the context, all IPV can be dangerous.2 There is general consensus in the research literature identifying risk factors that help predict continuing and escalating violence (Dutton & Kropp, 2000, pp. 171–181; Kropp, 2008, pp. 202–220). Risk factors include a history of violent behavior toward family members (including children), acquaintances, and strangers; a history of physical, sexual, or emotional abuse toward intimate partners; use of or threats with a weapon; threats of suicide; estrangement, recent separation, or divorce; frequent use of drugs or alcohol; antisocial attitudes and behaviors and affiliation with antisocial peers; presence of other life stressors, including employment/financial problems or recent loss; a history of being a witness or victim of family violence in childhood; mental health problems and/or a personality disorder (i.e., antisocial, dependent, borderline traits); resistance to change and lack of moti- vation for treatment; attitudes that support violence toward women (Kropp & Hart,

2 This section has been adapted from the Battered Women’s Justice Project, Safety at Home: Intimate Partner Violence, Military Personnel, and Veterans (an e-learning course), 2013, module 2. htt p:// elearning.bwjp.org/safety/index.php 15. Intimate Partner Violence 279

2000; Pence & Lizdas, 1998; Roehl & Guertin, 2000; Sonkin, 1997). Dr. Jacquelyn Campbell (Assessing Dangerousness, 1995) developed the Danger Assessment Scale (DAS) using known risk markers for lethal violence; studies have also shown the DAS to be predictive of re-assault in the short term (Goodman, Dutton, & Bennett, 2000, pp. 63–74; Weisz, Tolman, & Saunders 2000, pp. 75–90). In addition to the risk markers listed above, the DAS includes the following factors: access to a gun(s) in the house; strangulation or attempted strangulation; violence during pregnancy; forced sex; step- child in the home; and obsessively jealous and controlling behavior (Campbell, 1995).

Risk and Danger and the Military

Many of the risk factors for IPV are the same in both the military and civilian populations. However, there are some additional considerations for the military population. The military population is generally young and concentrated in the ages at highest risk for IPV: 18 to 29 years (Greenfeld et al., 1998). Constant mobility and geographic separation isolate victims by sometimes creating physical distance from family and familiar support systems. In addition, deployments and reintegration create unique stresses for military families, as does combat exposure. Recent research has shown a link between combat and trauma and increased violence at home, often directed at intimate partners (MacManus et al., 2012). If the partner has deployed to a combat zone, a victim may wonder if the partner’s violence is a symptom of combat-related conditions such as PTSD or other co-occurring conditions like depression or substance abuse. Evidence of PTSD, depression, and suicidal talk is a dangerous combination for Service members, Veterans, and their partners. It should raise a red flag when IPV is accompanied by these co-occurring conditions in not only the military and Veteran populations but the civilian population as well. Military personnel and Veterans often have access to personal firearms. After deployment to a war zone where a firearm may be the difference between life and death, access to firearms often becomes more important than it was previously. As already discussed, military personnel and Veterans often self-medicate with alcohol and/or drugs to deal with combat stress, PTSD symptoms, TBI, and depression. Since many military personnel have had multiple deployments to war zones, there have been multiple separations and reunifications. These com- ings and goings can create stress and exacerbate existing problems in a relationship, such as obsessive jealousy and infidelity. Access to weapons, substance abuse, perpetrator mental health issues, and a pattern of estrangement, separations, and reunions are risk markers for lethal IPV (Karch, Logan, & Patel, 2011). Although there is currently no research data that show a higher rate of lethal IPV in the military and Veteran 280 Women at War populations, the presence of so many risk factors is important to note and to assess for when working with military-related victims of IPV.

Other Considerations in Risk Assessment

Risk assessment is an ongoing process, not a one-time event. There should be a continuous process of risk management in every IPV case. Some victims downplay risk and signs of danger, but victims are the best source of information relative to risk and danger in their situations. The goal is to identify life-threatening violence and serious risk to victims and their children. Some of the most dangerous cases are those in which there has been no intervention. It is also important to remember that intervention can compromise safety. There can be unintended consequences for all interventions. There is often an expectation that a victim will leave the perpetrator, but it is critical to keep in mind that separating from an abuser can be very dangerous for the victim. The perpetrator may feel that he has a right to reclaim his authority by any means, which can mean an escalation in the frequency and severity of the violence. Cultural and demographic factors play a major role in the dynamics of IPV and create another layer of risks for victims from minority communities and people of color, whether they are military or civilian. They may be afraid of the police or may have a strained relationship, so they would not feel comfortable calling law enforcement when there is an IPV incident. There may be immigration status and language barriers that interfere with their ability to seek or obtain help. Religious and class issues may be part of the larger context in which the victim must function and make decisions. Women with female partners or who identify as lesbian, bisexual, queer, or transgender may also face stigma, discrimination, or lack of recognition and support. Abusers may also exploit an individual’s vulnerabilities due to discrimination, legal status, language proficiency, or physical or mental limitations. All interveners must be aware of and sensitive to cultural issues with all victims of IPV. In summary, when assessing for risk and danger in IPV situations in both the military and civilian populations, it is important to be mindful of the variety of risk factors and vulnerabilities at the individual, interpersonal, and sociocultural levels, as well as the unintended consequences of institutional intervention. In assessing for risk, it is critical to identify and validate a victim’s own sense of risk, even in the absence of objective factors, and also to recognize that perceptions of risk may also be muted by the impacts of trauma (e.g., dissociation, emotional numbing) and entrapment within the relationship. 15. Intimate Partner Violence 281

Safety Planning

A discussion of risk and danger is not complete without addressing safety planning as well. Safety is the freedom from continued physical, sexual, and emotional harm, coercion, and threats. Safety planning is not a static, one-time event. It is a dynamic, evolving process that adjusts to changing risks and circumstances of each victim. It is different for active duty victims than for civilian victims and different depending on whether the victim is staying in the relationship with the perpetrator or leaving. Many things must be considered when developing a safety plan with an IPV victim, whether she is military or civilian. It is important to pay attention to a victim’s fears and concerns, that is, deployments and returns, new duty stations, and her perception of her situation and the risks and dangers she identifies. Whether there are personal weapons in the home is critical information for safety planning since it has such a significant impact on the dangerousness of the situation. It is important to provide key contact information for resources on the military installation and in the community near the installation. If a victim is choosing to leave the abuser, she needs to take key documents such as ID cards, passports, banking information, insurance information, and so on. It is important to discuss the pros and cons of, and process for, obtaining military and/or civilian protection orders. Some victims, both military and civilian, are not ready to leave the abuser. Safety planning in this situation is more about harm reduction, which focuses on helping the victim identify strategies for minimizing further abuse and options for seeking safety when necessary. Safety planning in this situation includes providing possible referral resources for the abuser and discussing how the victim might safely approach the abuser to encourage him to get help. Active duty IPV victims do not have the freedom to leave at any time they choose, so safety planning must include a discussion of whether or not she wants her command to know about the abuse and become involved. Any action she takes that affects her ability to do her job affects the command and accomplishment of the mission. She must be mission ready at all times. As discussed earlier, active duty IPV victims are often concerned that if their command becomes aware of the abuse, there might be negative consequences for their military careers. This must be a part of the discussion during safety planning.

Military Women and Trauma

Given that the impacts of trauma on an individual’s health and well-being can build up over time, it is important to recognize trauma exposure over a person’s lifetime. The US Department of Health and Human Services Substance Abuse and Mental 282 Women at War

Health Services Administration (Trauma Definition: Part One: Defining Trauma, 2012) defines individual trauma as follows:

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.

This definition focuses on the event and circumstances surrounding the event, the experience of the individual, and the effects of the experience on the individual. Many women in the military have experienced individual trauma at some point in their lifetimes. For some, the trauma occurred prior to entering the military, and for others the trauma occurred while in the military. Some have experienced both.

Trauma Prior to Entering the Military

Research has found that women in the military and female Veterans have experienced higher rates of childhood abuse and neglect, partner violence, and adulthood sexual assault than the civilian population (Zinzow, Grubaugh, Monnier, Suffoletta-Maierle, & Freuh, 2007). Disparities in adverse childhood experiences have been found among individuals with military service history. Results from 11 states found that women who had served in the military (active duty or Veteran women) reported higher rates of multiple adverse childhood experiences, including: household alcohol abuse, physical abuse, exposure to domestic violence, emotional abuse, and sexual abuse in childhood, compared with women who had not served in the military. There were no differences between military/ non-military women on reports of other adverse childhood experiences: household mental illness, parental separation or divorce, household drug use, incarcerated household member, made to touch another sexually, forced to have sex (Blosnich, Dichter, Cerulli, Batten, & Bossarte, 2014). Escape from intimate or family violence may be an impetus for women joining the military (Sadler, Booth, Mengeling, & Doebbeling, 2004). The Military Services have conducted research with active duty military personnel to determine the extent of trauma experienced prior to entering the military and how this affects success in the military and retention. The Air Force conducted a study of 28,918 recruits entering basic training from October 1991 to September 1992, including one adverse childhood experience question, “I believe I have been sexually abused.” They found that 15.1% of the women and 1.5% of the men reported past sexual abuse; attrition from military service was 1.6 times more likely among women reporting sexual abuse than those not reporting sexual abuse (Smikle, Fiedler, Sorem, Spencer, & Satin, 15. Intimate Partner Violence 283

1996). The Army included several adverse childhood experience questions in a survey of 1,072 men and 305 women Soldiers from combat support and service support units at three major Army posts. They found that 56% of men and 66% of women Soldiers reported a history of any form of abuse in childhood; 50% of men and 48% of women reported a history of child physical abuse; 17% of men and 51% of women reported a history of child sexual abuse; and 11% of men and 34% of women reported a history of both physical and sexual abuse in childhood (Rosen & Martin, 1996a, 1996b, 1996c, 1998a, 1998b). In a survey of Navy recruits (5,969 men and 5,226 women), more than two-thirds of the women reported past abuse, 50% reported coercive sexual experiences, and more than 27% reported having been raped; rates of abuse were higher among women than men, and childhood trauma was associated with poor mental health and early attrition from military service (Merrill et al., 2004; Merrill, Thomsen, et al., 2001; Merrill, 2001; Merrill et al., 2001; Merrill, Newell, et al., 1999; Merrill, Newell, Milner, et al., 1998; Olson, Stander, & Merrill, 2004; Stander, Olson, & Merrill, 2002). Other studies have also found associations between childhood abuse and poor mental/behavioral health and early attrition from the military among Navy personnel (Booth-Kewley, Larson, & Ryan, 2002; Larson, Booth-Kewley, & Ryan, 2002). The research conducted by the Military Services shows that adverse childhood experience histories are common in young adults joining the US military. In addition, assessing such a history is challenging and depends greatly on methodology and specific questions asked. The research also shows that adverse childhood experience histories are consistently related to early attrition, but the relationship to later military performance is unclear.

Trauma in the Military

Many women also experience trauma while in the military. Sometimes the trauma is combat related, and sometimes it is not. Over 2.5 million people have served in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) in Afghanistan. More than 280,000 of these are women, and 152 of them have died. Women have experienced unprecedented combat exposure during OIF and OEF (USA Today, 2013). Many people, both men and women, who return from a combat zone experience varying degrees of combat stress that may include many of the following symptoms:

• Sleep disturbance • Bad dreams/nightmares • Anger/short temper 284 Women at War

• Agitation, irritation, annoyance • Jumpy and easily startled • Avoiding people and places • Increased drinking, smoking, drug use • Mistrust • Over-controlling or overprotective

(National Center for PTSD, A Guide for Families of Military Members; National Center for PTSD, A Guide for Military Personnel). In the 2008 study, Invisible Wounds of War—Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, the RAND Center for Military Health Policy Research (2008) estimated that 300,000 Service members returning from OIF and OEF had PTSD or major depression. The study also estimated that 320,000 had experienced a TBI. The study found that many had co-occurring disorders, and only about 50% had sought help at that time. The RAND study did not separate out statistics for women OIF and OEF Veterans. However, some researchers have explored gender differences in Veterans’ experiences, stressors, and trauma (Maguen, Lexton, Skopp, & Madden, 2012; Street, Vogt, & Dutra, 2009; Street, Gradus, Giasson, Vogt, & Resick, 2013). There is some evidence that levels of combat exposure for women deployed to OIF and OEF are not that different from the men who deployed. Forty-five percent of women compared to 50% of men in a national sample reported some combat exposure (Jacobson et al., 2008). Broader literature indicates that women are at higher risk for mental health problems following a variety of traumatic events (Tolin & Foa, 2006). However, this literature is based primarily on non-combat traumas; combat trauma samples from prior cohorts show that the effect is smaller when limited to combat trauma samples. Since the RAND study was published, there have been many other estimates of the incidence of PTSD in OIF and OEF Veterans that go as high as 35%. The VA reports that a higher proportion of female Veterans (22%) are diagnosed with mental health problems than male Veterans. The VA says that studies show that 31% of women Veterans have both medical and mental health conditions compared with 24% of male Veterans. The most common diagnoses among women Veterans seeking care are PTSD, hypertension, depression, high cholesterol, low back pain, gynecologic problems, and diabetes (US Department of Veterans Affairs, Women Veterans Task Force, 2012). Portland State University’s School of Community Health conducted the first general-population analysis of suicide risk among female Veterans. They looked at suicide data from 2004– 2007 in 16 states. The study found that women Veteran suicide rates are three times higher than non-Veteran women (Santen, 2010). 15. Intimate Partner Violence 285

Not all trauma in the military is related to combat. Although women in the military are less likely to be exposed to direct combat than men, they are more likely to be exposed to sexual harassment and sexual assault. Sexual assault is unfortunately an all-too-common trauma for women serving in the military. Sexual harassment and assault occur everywhere the military is located, including in war zones. In fiscal year 2012, the DoD reports that there were a total of 3,374 reports of sexual assault involving Service members as victims or subjects, an increase from the 3,192 reports received in fiscal year 2011 (Department of Defense, Sexual Assault Prevention and Response, 2013, Volume 1). These reports involved offenses ranging from abusive sexual contact to rape. In addition, the DoD reports that there were 26,000 incidents of unwanted sexual contact in fiscal year 2012, a 35% jump from fiscal year 2010 (Department of Defense, Sexual Assault Prevention and Response, 2013, Volume 2). One in five women Veterans who use the VA for healthcare screen positive for “military sexual trauma” (MST), a VA term that includes incidents of sexual harassment as well as sexual assault. In one study, 23% of female users of VA healthcare reported experiencing at least one sexual assault while in the military. Women who enter the military at younger ages and those of enlisted rank appear to be at increased risk for MST. Women who have had sexual assaults prior to military service report higher incidences of MST (US Department of Veterans Affairs, Women Veterans Task Force, 2012). New Department of Veterans Affairs’ research found that in anonymous surveys of female Service members who deployed to Iraq and Afghanistan, about half report being sexually harassed. Nearly one in four report that they were sexually assaulted. This suggests a far higher prevalence of sexual misconduct against women in war zones than is reflected by complaints gathered by the various service branches (Iverson, Monson, & Street, 2012). The Millennium Cohort Study found that military women who had served between 2001 and 2004, and who had been in direct combat, were 2.5 times more likely to say they had been sexually assaulted during those years than female Service members who had never been to war. The study reported that, in addition to having been deployed with combat experience, other risk factors for sexual harassment and sexual assault included “younger age, recent separation or divorce, service in the Marine Corps, positive screen for a baseline mental health condition, moderate/severe life stress, and prior sexual stressor experiences” (LeardMann et al., 2013).

IPV AND CO-OCCURRING PROBLEMS

As reported earlier in this chapter, the NISVS found that active duty women had a decreased risk of IPV, contact sexual violence, and stalking compared to the general population. However, active duty women who deployed at some point in the three 286 Women at War years prior to the survey had a significantly increased risk of IPV victimization and contact sexual violence (Black & Merrick, 2013). There are logical questions that are not answered by the survey: What are the protective factors that decrease the risk for active duty women in general? And what aspects of deployment increase risk for active duty women? Perhaps part of the answer to why deployment to a war zone and reintegration increases risk of IPV and contact sexual violence lies in the cumulative effect of trauma over a lifetime. As reported earlier in this chapter, the research done by the Military Services on people entering the active duty force found that many had trauma histories prior to entering the military. Many of these people enter the military to escape a negative and possibly unsafe family and/or community environment. It is likely that most have not received any type of treatment for the trauma, so they bring the physical and mental effects of the trauma into the military environment. The military provides stable employment, secure housing, and access to medical care and other support services. Perhaps these are protective factors that contribute to the decrease in the overall risk. However, many active duty women experience additional trauma while in the military. Whether it is IPV, sexual victimization, or combat trauma, there is a cumulative effect on a person’s physical, mental, and spiritual well-being. The outcome is a complex symptom presentation that can include PTSD, depression, substance abuse, and other health and mental health conditions (Cloitre et al., 2009). One study found that women Veterans with “frequent” breast pain were more likely to have a trauma history to include IPV victimization, have a diagnosis of PTSD, depression, panic, alcohol misuse, and other medical problems (Johnson et al., 2006). IPV victims often experience multiple types of trauma. IPV and childhood trauma increase a woman’s risk for substance abuse, major mental illness, and incarceration later in life (Lynch, DeHart, Delknap, & Green, 2012). It is easy to see how this entire constellation of trauma history and co-occurring problems can increase the risk of IPV for active duty women following deployment to a war zone. Return from a war zone and reintegration into the person’s life do not go smoothly for everyone. Exposure to combat changes a person, and things have changed for the partner as well during the deployment. Separations can exacerbate any pre-existing problems in relationships, including jealousy and suspicion of infidelity, which are risk factors for IPV (McCarroll et al., 2008). Therefore, reunions with intimate partners can be stressful, with increased conflict and problems. In addition, the health and mental health sequelae of trauma can negatively affect a person’s functioning in all areas of life, which can lead to further relationship problems. Health and mental health symptoms can also interfere with a person’s ability to 15. Intimate Partner Violence 287 work. Active duty Service members, both men and women, are often hesitant to seek help for mental health problems for fear it will negatively affect their careers. Many self-medicate using alcohol and/or drugs, which can lead to additional problems in all areas of their lives. In relationships in which IPV is present, substance abuse can interfere with the victim’s ability to accurately assess danger and to take action to maximize safety. Trauma can also affect the ability to access services. Some will not reach out to get help in order to avoid any experience that might trigger their trauma symptoms, especially if they have been re-victimized by the system when attempting to seek help. Victims are reluctant to reach out when their trust has been betrayed. People who have experienced ongoing trauma may view the world and other people as not safe. Trauma also affects how a person comes across to law enforcement, advocates, court personnel, and treatment providers, and so on. Although each person’s response to trauma is different, there are stereotypes of “good” and “bad” victims. If an IPV victim does not behave as others think she should behave, the system (military and civilian) response may be negative, which increases the probability that she will not reach out again. Individuals who have experienced trauma may appear hysterical or hypervigilant, may be numb to the experience, may dissociate from the reality of the experience, and may fail to remember critical elements of the experience. These are all typical psychological responses to trauma that may appear irrational or may be unexpected to those not familiar with trauma response. For some, the combination of these co-occurring problems and obstacles to seeking and obtaining help begins a downward spiral that can result in separation from the military, unemployment, unhealthy substance use, and homelessness. Homelessness and unhealthy substance use increase risk of further victimization of all types, and places women in jeopardy of involvement with the criminal justice system (U.S. Department of Labor, Women’s Bureau, 2011).

WOMEN VETERANS AND IPV

Women Veterans have served in the military in the past but now live as civilians in society. Their experiences with IPV are similar to those of women serving on active duty or women with no military service. The same considerations of military service stressors and experiences apply to women Veterans and active duty women, although Veterans are no longer under military command and subject to military rules. Women Veterans may experience IPV after their service in the military. Women Veterans are a unique population given their military histories, their current civilian status, and their access to VA and Veteran-specific services and supports. 288 Women at War

As with active duty military and civilian women, research has identified physical, mental, and social health conditions associated with IPV experience among women Veterans. Research on female Veterans receiving VA healthcare has found the experience of IPV victimization to be associated with higher rates of mood disorders, PTSD, alcohol or drug dependence, smoking, chronic pain, sleep problems, infectious diseases, digestive system disorders, and lower overall self-rated health (Dichter, Marcus, Wagner, & Bonomi, 2014; Dichter & Marcus, 2013; Iverson et al., 2013). Additionally, IPV experience has been found to serve as a pathway into poverty and homelessness among women Veterans (Hamilton, Poza, & Washington, 2011). Perhaps because of the increased health burden associated with IPV, women who have experienced IPV typically use healthcare services at higher rates than women who have not experienced IPV (Ulrich et al., 2003). Caralis and Musialowski (1997) found that 40% of women Veteran patients at a VA medical center reported experiencing emotional or physical IPV. In a face-to-face survey, 86% of women Veterans under the age of 65 receiving care at a VA medical center reported lifetime psychological, physical, or sexual IPV; 39% reported IPV victimization in the past year (Dichter, 2013). In a mail survey, Iverson and colleagues (2013) found that 29% of female Veterans Health Administration (VHA) enrollees who had a recent intimate relationship reported past-year physical, sexual, or severe psychological violence. Women are a minority population both in the military and as Veterans. Approximately 10% of Veterans currently are women, and only 2% of women in the United States are Veterans (Newport, 2012). As a minority group, women Veterans may experience stereotyping, stigma, and isolation. Others may erroneously assume that women who have served in the military have a strength or toughness that protects them against victimization, or that women Veterans do not need support to help them escape or heal from violence. Having trained within a military culture emphasizing strength, discipline, and unit cohesion, women Veterans may feel that they need to embody, or portray, invulnerability to victimization and/or help-seeking. Social networks and social support are important in helping women, both Veterans and non-Veterans, seek protection from further violence and heal from the wounds of past violence (Coker et al., 2002; Coker et al., 2003; Goodman et al., 2005). However, women Veterans may have had limited opportunities to build and maintain support networks, especially with other women Veterans, given high mobility among women who have served in the military and a relatively small and dispersed population of women Veterans. Women Veterans may also not know where to seek formal help; they may lack strong social and community networks due to frequent moving and may perceive that the VA is not available to them or friendly to them. Lack of knowledge about VA eligibility and services and perceptions of poor care for women serve as barriers 15. Intimate Partner Violence 289 to women Veterans’ use of VA services (Washington et al., 2006; Washington et al., 2007). Although the VA has historically focused on serving male Veterans, the female population is growing rapidly in the VA, and VA clinical services have expanded to provide comprehensive, gender-specific, and gender-sensitive high-quality care to women Veterans. Through a network of large medical centers and smaller community-based clinics, the VA offers integrated and comprehensive healthcare with primary and specialty medical care in inpatient, outpatient, and emergency settings, as well as mental and behavioral healthcare and social services. Through the VA, IPV survivors can access a variety of services to address needs related to their experiences of violence, including medical and mental healthcare, trauma-informed therapies, and links to supportive social work services for housing, employment, and domestic violence counseling. Women Veterans have the benefit of access to both community-based civilian services that may be more specialized in addressing IPV-related needs (e.g., navigating the criminal and civil legal systems and social services such as shelter and advocacy), as well as VA-based services that may be more sensitized to the particular needs of women Veterans and may be able to link patients to care both within and outside the VA.

TRAUMA-INFORMED APPROACH TO ADVOCACY AND INTERVENTION

People who have experienced multiple traumas do not view and experience the world in the same way as those who have not experienced trauma. Therefore, services need to be tailored to their needs. Understanding the intersection between trauma and IPV can affect how the military and civilian systems respond to military-related IPV victims. Without a trauma framework, services can be re-traumatizing. Without an understanding of IPV dynamics, services may place a victim at risk for further violence. Understanding the intersection of trauma and IPV victimization can improve the response and can decrease risk. It is critical for both military and civilian systems, programs, and providers to incorporate a trauma-informed approach to advocacy and intervention for active duty women and women Veteran IPV victims. The primary focus of a trauma-informed approach is safety. This approach gives the victim a voice and provides choices. Services are flexible, individualized, culturally competent, gender responsive, promote respect and dignity, are based on best practices, and reflect the centrality of trauma in the lives of people. Maxine Harris (Harris & Fallot, 2001) describes a trauma-informed service system as “a human services or health care system whose primary mission is altered by virtue of knowledge about 290 Women at War trauma and the impact it has on the lives of consumers receiving services.” All programming must be viewed through a trauma lens. Trauma-informed care is important at the system, organizational, and program levels. It informs all levels (and settings) of care and includes the following principles (Gerlock, 2013; Saakvitne, Gamble, Pearlman, & Lev, 1999):

• Safety as a priority (physical and psychological): Ensuring physical safety and privacy by never asking questions about abuse in front of someone not identified as safe. This would include during couple’s therapy, in the presence of children, when seeking corroboration from a partner or family member, or from an abuser for collateral information. It includes being respectful, using professional translators when needed, and discussing any limits to confidentiality. • Understanding clients and their experiences in context (across the life span, cultures, and societies): Moving past cultural stereotypes, offering gender responsive services, leveraging the healing value of traditional cultural connections, recognizing and addressing historical trauma, and building on what the client has to offer, rather than responding to perceived deficits. • Genuine collaboration between provider and consumer: Attending to the potential for re-injury, being in tune to the power dynamics in the relationship, and understanding the importance of respect, choice, and control. Interveners need to tolerate strong emotional reactions to include fear and anger, to be comfortable with uncertainty and not being able to fix everything, and to be aware of their own responses. • Emphasis on skill building and acquisition rather than symptom management: Use trauma-specific interventions and be aware of the limitations of traditional interventions when the person is still a victim. Interveners must be nonjudgmental and creative when working with IPV victims who choose to remain in relationships with their abusers. • Understanding symptoms as an attempt to cope: Be aware that what appears as maladaptive (e.g., “borderline” characteristics and behaviors) may be very adaptive to the person’s life circumstances and strategic to survival. • Viewing trauma as a defining and organizing experience at the core of the individual’s identify—rather than a discrete event: Know that chronic, prolonged trauma can create a personality forged by survival. • Focusing on “what happened” to the person rather than “what’s wrong” with them: Always ask about a person’s experiences, which focuses on the trauma, instead of asking what is wrong with them, which focuses on individual pathology. 15. Intimate Partner Violence 291

Military service also affects how one views the world, and the military culture has its own view of violence and trauma. Therefore, in addition to a trauma-informed lens, people working with military-related IPV victims must understand the military culture. Greendlinger and Spadoni (2010) defined the following components of military cultural competence:

• General military knowledge (e.g., language, acronyms, branches of service, rules/ regulations, processes) • Ongoing information-gathering regarding the experiences of military Service members (in-person interviews, focus groups, and online tools and resources offering a perspective on military service, combat, and the experiences of specific populations, including women Veterans) • An understanding of the military culture among and across branches of service • An understanding of the VA system (processes, benefits, services, eligibility) • Knowledge of how the military culture impacts a Service member’s and Veteran’s worldview.

Trauma-informed services are designed to treat the actual sequelae of sexual and/ or physical abuse trauma. They are based on the belief that “recovery can only happen with persuasion rather than coercion, ideas rather than force, mutuality rather than authoritarian control” (Herman, 1997).

CONCLUSION

IPV is common, serious, pervasive, and often criminal. The impacts of IPV can be severe (including debilitating mental and physical injuries, as well as death) and long- lasting. Women who experience violence from an intimate partner often experience ongoing assaults, threats, and loss of freedom and independence due to violence. Although resources, including medical, legal, and social services, exist to support women who have experienced violence to both seek safety from further violence and heal from past violence, many women experience barriers to accessing such services. Women actively seek safety and protection, for themselves and their children, in a variety of ways. Women may face—or realistically fear—negative consequences as a result of help-seeking, and those consequences may include further violence. Sometimes, women find the only safe avenue for self-protection is seeking safety within the context of the relationship, as leaving the relationship can be a trigger for increased violence. Women who are serving in the US military, or who have served in the past, experience the same forms of and consequences from IPV as their civilian/non-Veteran 292 Women at War counterparts, with the exception that active duty women face a greater threat to their military careers. However, military/Veteran women also face unique experiences, concerns, barriers, and resources. Military/Veteran women may have multiple trauma exposures, including trauma experienced in childhood and in combat, in addition to IPV, which can exacerbate problems resulting from trauma exposure. Women serving in the military may be or feel constrained by their medical, mental health, social, and legal services being tied in with their employment and career advancement as well as, potentially, that of their partners. Deployments can create additional barriers to seeking protection and healing from violence. Veteran women may be disconnected from their communities, creating a barrier to seeking help from formal resources and more informal social networks. Women who have served in the military may also be hampered by stereotypes, stigma, minority status, and cultural norms associated with military service, including a warrior mentality that emphasizes stoicism, hierarchy, and masculine traits. These cultural norms have been identified as barriers to help-seeking, particularly for mental health and social health concerns. At the same time, women who serve in the military have resourcefulness, resilience, and perseverance—these are the characteristics that have led them to succeed in joining and serving in the military. When addressing IPV experienced by military or Veteran women, it is critical that we consider not only the full context of IPV and the risks and consequences and associated conditions that any woman may experience related to IPV, but also the unique circumstances faced by women who are serving, or who have served, in the military.

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PART 5 The Female Veteran Experience

sixteen The Woman Veteran Experience

ISABEL D. ROSS, NATARA D. GAROVOY, SUSAN J. MCCUTCHEON, AND JENNIFER L. STRAUSS

INTRODUCTION

Women are serving in today’s US military at unprecedented rates. Women comprise 15% of active military personnel, and 11.7% of Veterans of recent conflicts in Iraq and Afghanistan. Their increased presence and engagement in the US military has resulted in an equally rapidly growing population of women Veterans, projected to reach 15% of the total US Veteran population by 2035 (National Center for Veteran Analysis and Statistics, 2011). Between 2005 and 2013, the Department of Veterans Affairs (VA) witnessed a 68% increase in the number of women accessing VA healthcare; and the proportion of female VA healthcare users with mental health diagnoses more than doubled (Northeast Program Evaluation Center, 2014). Identifying and meeting the needs of this emerging population are paramount. This chapter will review women Veterans’ mental health needs, VA mental healthcare policy and programming for women Veterans, and best practices for gender-sensitive mental healthcare.

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WOMEN VETERANS’ MENTAL HEALTH NEEDS

Preliminary evidence suggests that women Veterans may differ from men in the prevalence and expression of certain mental health disorders, as well as their response to treatment. These differences may be due to biological sex differences, such as the impact of the female reproductive cycle on mental health, or social and cultural differences such as the impact of gender-related violence (e.g., intimate partner violence experienced by women, military sexual trauma [see Chapter 18 for more information on this topic]). Identification of these differences is an initial and crucial step in knowing how to best meet these women’s mental healthcare needs.

Prevalence of Mental Health Issues Among Women Veterans

Known gender differences in the prevalence of mental health conditions between men and women Veterans are largely consistent with patterns observed in the general population. For example, research consistently shows that women Veterans are more likely than Veteran men to carry a mental health diagnosis (Runnals et al., 2014). In addition, higher rates of depression and anxiety are found among women Veterans (Freedy et al., 2010; Maguen et al., 2010), whereas other mental health conditions, such as substance use disorders, are more common among male Veterans (Iverson et al., 2010; Westermeyer et al., 2009). In contrast, while women in the general population are two to three times more likely than men to be diagnosed with post-traumatic stress disorder (PTSD), women and men Veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) have exhibited similar rates of PTSD (Freedy et al., 2010; Maguen, Ren, Bosch, Marmar, & Seal, 2010). In addition, relative to their male counterparts, women Veterans have been found to have higher rates of mental health and medical comorbidities (Banerjea, Pogach, Smelson, & Sambamoorthi, 2009; Frayne et al., 2010; Iverson et al., 2010). For example, rates of comorbid PTSD and depression are significantly higher among women Veterans then men. These findings highlight two important points about gender difference in the prevalence of mental health disorders. The first is that the higher rates of mental health disorders and comorbidities among women Veterans who use VA health services may have treatment implications, such as the need for more intensive care. This is consistent with observed patterns of VA mental healthcare utilization, as women Veterans with mental illness are more frequent users of VA mental health services relative to their male counterparts (Frayne et al., 2012). The second, and perhaps more critical, point is the importance of not assuming that gender differences observed in non-Veteran 16. The Woman Veteran Experience 303 populations generalize to the Veteran population. While a woman’s biology may be the same regardless of her occupational history, some social and cultural factors may uniquely characterize women Veterans, for example those qualities and life experiences that compel her to volunteer for military service and her experiences during and after military service. Some of these differences may in fact challenge what we believed we know about women’s mental health, as in the case of PTSD, where similar rates have been observed among male and female OEF/OIF Veterans, whereas higher rates are observed among women, as compared to men, in the general population. On the whole, however, we have much more to learn. In the general population, women are more likely than men to be diagnosed with panic disorder, anxiety disorders, and bipolar II and eating disorders, and these differences are well established in the literature (Kessler et al., 1994; Diflorio & Jones, 2010; McLean, Asnaani, Litz, & Hofmann, 2011; Smink, van Hoeken, & Hoek, 2012). It is not currently known if rates of these disorders among the growing women Veteran population are consistent with those observed in non-Veteran women.

Biological Considerations

Biological differences between women and men can contribute to differences in mental health. Among women Veterans seeking VA healthcare, 42% are within their reproductive years (ages 18–44) and 29% are aged consistent with perimenopause (ages 45–55) (Frayne et al., 2014). Sex-specific hormonal differences and reproductive life-cycle stages, such as pregnancy and perimenopause, have known effects on mental health, and physiological hormonal transitions that occur during a woman’s life cycle may serve to increase her risk of developing a mental health disorder. In a study of women OEF/OIF Veterans, those who accessed pregnancy-related care were twice as likely as those who did not access this care to be diagnosed with depression, anxiety, PTSD, bipolar disorder, or schizophrenia (Mattocks et al., 2010). Reproductive mental health issues can also affect treatment decisions. Providers must consider contraception counseling and pregnancy testing, as well as risk benefit counseling, before prescribing medication that is potentially teratogenic (i.e., agents that can interfere with normal fetal development and can result in birth defects). Simultaneously, there are risks to antidepressant use during pregnancy, yet untreated mental health disorders may also have adverse effects on the patient, her baby, and her family (e.g., increased risk for pre-term birth among depressed pregnant women) (Grote et al., 2010). With up to 20% of pregnant women in the general population experiencing mood or anxiety disorders during pregnancy and 10%–15% experiencing postpartum depression (Marcus et al., 2003), there is a clear need for women Veterans’ 304 Women at War providers to be well informed of the impact of biological differences on mental health and to be competent in reproductive mental health issues.

Social and Cultural Considerations

It is equally important to consider the influence of social and cultural factors on women’s mental health. Gender differences in social resources and socioeconomic status (SES) are well known, and research indicates that SES is a key factor in determining the psychological health of women (American Psychological Association, 2013). For example, women Veterans are more likely than male Veterans to be unmarried (Maguen, Ren, Bosch, Marmar, & Seal, 2010; National Center for Veterans Analysis and Statistics, 2013). Veteran women are also more likely to divorce and remain divorced when compared to male Veterans and age-matched civilian women (Adler-Baeder, Pittman, & Taylor, 2005; National Center for Veterans Analysis and Statistics, 2013). Among VA users receiving PTSD treatment, women report fewer interpersonal and economic resources than men (Fontana, Rosenheck, & Desai, 2010). We do not yet know pre- cisely how these differences affect the mental health of women Veterans, but we can imagine that the effects could be challenging. Socioeconomic differences also extend to and within the homeless population. While there are more homeless Veteran men than women, women are increasingly identified as a group that is at high risk for homelessness. As compared to homeless male Veterans, homeless women Veterans are younger and have higher rates of unemployment and mental illness (Byrne, Montgomery, & Dichter, 2013). These trends are consistent with previous studies that have compared homeless women and men in the general population. In the general homeless population, women have been found to be younger, more often members of a minority group, less likely to have a substance use disorder, and more likely to have symptoms of major depression. One pivotal difference between homeless men and women noted is that, unlike men, most women are also of childbearing age and have young children in their custody, suggesting that there may be different origins as well as a need for different solutions (e.g., housing for women, and housing for women and children) to mitigate risk for homelessness and to provide related services for homeless men and women (Culhane & Metraux, 1999; North & Smith, 1993). Further, in the general population, gender-based violence (i.e., domestic and sexual violence) are the leading causes of homelessness for women and families, and 20%–50% of all homeless women and children become homeless as a direct result of domestic violence (Zorza, 1991). Among homeless Veterans who receive VA health services, 39.7% of women and 3.3% of men have experienced military sexual trauma (Pavao et al., 2013). 16. The Woman Veteran Experience 305

Social and cultural differences are also pronounced when examining gender differences in PTSD. For example, the context in which Servicemen and Servicewomen experience the same combat theater during deployment may differ (Street, Vogt, & Dutra, 2009; Vogt et al., 2011). Women are less likely than men to be exposed to intense combat (Street et al., 2013), but more likely to experience other deployment-related stressors, including sexual assault, sexual harassment, general harassment, and a lack of unit support (Murdoch, Pryor, Polusny, & Gacksetter, 2007; Street, Gradus, Stafford, & Kelly, 2007; Vogt, Pless, King, L.A., & King, D.W., 2005). As support from fellow military personnel has been shown to improve resiliency among those exposed to military-related stressors (Bliese, 2006; Griffith &Vaitkus, 1999), gender differences in unit support may also influence mental health outcomes. Data from previous eras demonstrate that post-deployment stressors, such as an unsupportive homecoming atmosphere, mediate the relationship between deployment-related trauma and negative mental health outcomes for male Veterans (Johnson et al., 1997). Women Veterans are the gender minority within the Veteran population. Like any minority group, these women may have greater difficulty connecting with other Veterans in their community. In addition, the public does not always recognize or remember that women can be Veterans. Women Veterans are less likely than men to be recognized for their military service and therefore may feel less supported within their home communities. This experience may be particularly salient for National Guard and Reservists who return to home to civilian communities, rather than a military base, as well as for those who return to more isolated rural areas. Further, while the effects of post-deployment stressors have not been fully researched in women Veterans, it would not be difficult to imagine how stressors such as readjusting to a primary caregiver role, marital transitions, and attempting to navigate healthcare resources—responsibilities that often carry gender role expectations—could also create unique readjustment challenges for women Veterans.

Current VA Mental Healthcare Policy and Programming for Women

VA has taken active steps to meet the unique mental healthcare needs of the emerging population of women Veterans. Current VA policy specifically addresses gender-related concerns and requires that mental health services be provided in a manner that recognizes gender-specific issues as important components of care (Department of Veterans Affairs, 2008). All VA healthcare facilities are required to provide treatment environments that can accommodate and support women’s safety, privacy, dignity, and respect. This includes providing separate and secure sleeping and bathroom arrangements for 306 Women at War residential treatment facilities (Department of Veterans Affairs, 2008). To accommodate women Veterans who do not feel comfortable in mixed-gender treatment settings, many VA facilities have women-only programs or have established specialized women’s treatment teams, and many of these programs serve as national resources for all women Veterans. Examples of such VA programing include specialized women’s mental health outpatient clinics, women-only residential treatment programs, and comprehensive primary care clinics for women that incorporate mental health services. In addition, as part of meeting gender-specific needs, VA policy strongly encourages all healthcare facilities to provide Veterans the option of a consultation from a same- or opposite-sex provider.

BEST PRACTICES FOR GENDER-SENSITIVE MENTAL HEALTHCARE

The proportion of women Veterans seeking VA mental healthcare is rapidly growing, yet women Veterans remain a significant gender minority among VA users. As such, these women may face unique challenges navigating a healthcare system that predominantly serves men. To meet this challenge, in 2012 VA surveyed mental health leadership at every medical center within VA healthcare system to determine the availability of gender-sensitive mental healthcare for women Veterans. A definition of gender-sensitive mental healthcare that specified measurable organizational features and processes for the needs of VA was developed (Strauss et al., 2014): Gender-sensitive mental healthcare refers to services that attend to gender differences in the prevalence and expression of mental health disorders and treatment responses, as well as the influence of biological, social, and cultural factors on mental health. The key components of gender-sensitive mental healthcare identified through this effort include the following: comprehensiveness of mental health services, including a full continuum of service availability for women in general mental health, specialty mental health, and residential/inpatient programming in a range of treatment settings; choice of treatment modality (e.g., mixed-gender or women-only service options); competency of providers to address women’s unique treatment needs; and innovation of creative options and settings for subgroups of women, especially when caseloads of women are small (Strauss et al., 2014). These tenets of gender sensitivity guide VA’s current approach to women’s mental health programming. Findings from the 2011 survey indicate that women Veterans have access to general and specialty outpatient treatment options at all VA healthcare systems. In addition to standard treatment options available to all Veterans, additional treatment options for women Veterans are achieved through various organizational efforts, including 16. The Woman Veteran Experience 307 co-located mental health providers in women’s comprehensive health clinics and providing women-only groups or individual therapy to women. However, in keeping with a patient-centered approach to care, VA does not promote one model of women’s mental healthcare as universally appropriate, or gender-sensitive. This approach recognizes that some women Veterans may benefit from single-gender treatment environments, to foster their sense of safety, ability to address gender-related concerns, and strong peer and social support. On the other hand, some Veterans may benefit from mixed-gender treatment environments, which can help to challenge patients’ assumptions and can offer a therapeutic environment in which to confront fears and misperceptions about the opposite sex. Thus, the individual patient’s clinical needs and treatment preferences inform which setting is most appropriate. This approach also recognizes the importance of offering choice, flexibility, and options of care for all Veterans. Another example of VA’s commitment to gender-sensitive mental healthcare is the establishment of the Reproductive Mental Health Steering Committee in 2012. Reproductive mental health issues require complex treatment decisions and knowledge of pharmacologic and behavioral intervention choices, such as consideration of maternal and fetal benefits and risks in medication management among pregnant women. In response to this need for competence, the Reproductive Mental Health Steering Committee developed a training curriculum for VA mental health providers and began to disseminate the curriculum nationally in 2014. Similarly, to address the needs of the subgroup of women Veterans who have experienced high rates of childhood and adult trauma exposure, VA has adopted a trauma-informed care model (Federal Partners Committee on Women and Trauma, 2013). This treatment model includes actively considering the role of violence and trauma in women’s lives, establishing collaborative and empowering working relationships, and designing services to anticipate stressors that may remind Veterans of past traumas and to address them as a part of treatment, if they arise (Harris & Fallot, 2001).

CONCLUSION

This chapter provides information for clinical practice, policy, and systems-level organization, with the goal of identifying and serving the unique mental healthcare needs of women Veterans. We have presented known gender differences in the prevalence of certain mental health conditions between men and women Veterans, such as higher rates of depression and mental and physical comorbidities among women. We have also described gender differences in biological, social, and cultural factors that influence mental health, such as reproductive health needs and gender disparities in economic resources. We have also proposed a definition of gender-sensitive mental healthcare 308 Women at War to best address these differences, that includescomprehensiveness of services, choice of treatment modality, competency of providers to address women’s unique treatment needs, and innovation as needed to meet women’s mental healthcare needs in unique systems of care, such as VA. A tremendous amount of work has already been done to provide and improve gender-sensitive care for women Veterans. We look forward with interest to future collaborative efforts among researchers, clinicians, administrators, policymakers, and the Veterans they serve, to continue to optimize treatment outcomes for this very important emerging population.

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KATE MCGRAW

INTRODUCTION

There is no doubt that the experience of combat, the challenges of war and hostile conflict, and the psychological impacts of these events on combatants of both genders are profound and unforgettable. Many of the experiences of combat can lead to profound shifts in life perspective, unresolved moral and ethical conflicts surrounding actions taken or not taken in the heat of battle, and a re-examination of one’s values, priorities, and goals in life. Some warriors who have had combat exposure may develop mild and brief physical or psychological symptoms related to their experiences, while others may go on to develop severe and lasting symptoms that require professional intervention in order for the warrior to return to healthy functioning. While the experience of war will have permanent impact on all participants, little is known about whether the psychological impacts of these combat experiences may vary based on gender, and if they do, exactly how and why they are not the same.

STUDIES OF SERVICE-RELATED MENTAL HEALTH

There are some studies in the current literature where findings seem to suggest that there may be salient factors that influence post-deployment psychological health. Some of these factors may be related to the reported amount, type, or quality of social support perceived by the warrior. The relationship between psychological health and reports of

311 312 Women at War social support appears to vary by gender. These findings raise further questions related to warrior gender, psychological health, and the power of belonging to a group. Is the psychological health of women warriors strengthened or weakened by the amount and type of social support they experience, and if so, is their psychological health influenced by social support factors in ways that are different from male warriors? What about social support in the immediate and larger military work environments? Does the presence or absence of social support for a female in her unit or theater of operations have a different impact on her psychological health than on that of her male peers in similar circumstances? Currently, there are several significant limitations and barriers in the field that create challenges when looking for gender-related differences in psychological health among warriors. The most obvious challenge to understanding potential gender differences in the psychological impact of combat on military members is the lack of a large enough sample population upon which to draw any valid statistical inference. Because the current sample size of female combat participants is so limited, findings in the extant literature cannot be reliably generalized to all relevant military populations. Recent changes to combat exclusion law will create larger populations to sample from, and will provide new opportunities to study questions about potential gender differences. Another challenge when studying potential gender differences in the psychological impact of combat is related to the lack of standard constructs in the literature that define sample populations in such a way as to draw easy comparisons among studies. This absence of common understanding related to the terms that researchers used when describing study populations in turn makes it difficult to generalize results of one study of a defined sample population to a larger, more general population. For example, the current literature uses the terms “Veteran” and “Active Duty” in a way that tends to mix subjects of different categories within some studies, and also appears to conflate constructs within other studies. One study that examines the mental health outcomes of a group of females who are no longer on active duty may report findings that are representative of what subjects report they experienced retrospectively. That study may define the construct of the subject as “Veteran” and label the role the subject occu- pies at the time data is collected for the study, rather than use the label of the role the subjects occupied when the events they report actually had occurred (“Active Duty”). These individuals may at the time of the study be receiving care in the Veterans Health Administration system as Veterans, and yet may be recalling experiences that occurred while on active duty combat several months or years prior. This category of subjects may be labeled “Veterans” in one study, yet in another study researchers may label this same category of subjects “Active Duty.” This may occur because the second group of researchers perceive the content of the retrospective report of study data as belonging 17. Mental Health of Women Warriors 313 in a category that reflects subjects’ active duty experience, rather than the subject’s status at the time the report is made by the subject. In this scenario, even if the statistical outcomes of these two studies with different perspective constructs were the same, the field would have limited ability to conduct comparisons across like-sample populations and subjects, due to the absence of standard constructs and methodologies. These types of challenges are widespread in the relevant body of literature. As a result, we are currently limited in our ability to draw reasonable conclusions about psychological health similarities and differences among combat warriors based on gender. Some research studies do provide us with important pieces of the puzzle and contribute to our understanding of mental health gender differences in specific military or Veteran sample populations, but most of these studies need to be expanded, further refined, or replicated. There are a few systematic literature reviews that evaluate existing literature, identify and summarize common themes, gaps, and findings, and make recommendations related to future directions in current research. These systematic reviews, including one recently conducted by Department of Defense (DoD) and Department of Veterans Affairs (VA) scientists, help us to better understand the breadth and scope of research findings related to the psychological challenges women face while on active duty, in Veteran status, and while in combat or deployment situations or recollecting those experiences (Bean-Mayberry et al. 2011; Batuman et al., 2011; McGraw et al., 2013; Runnals, et al., 2014). These reviews also underscore that current findings on gender differences in the prevalence of mental health conditions are inconclusive and disparate. There is an ongoing assessment effort in the Department of Defense that periodically collects data related to psychological health in the combat environment from Army and Marines Service members who are deployed in theater. Since 2003 the Military Health Advisory Team (MHAT) has consisted of teams of 6 to 12 subject matter experts who visit deployed Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) combat locations and conduct surveys and interviews related to the psychological heath of deployed Service members. One important goal of the MHAT is to assess the quality of available resources for those who are struggling with mental health issues while deployed, and to recommend courses of action for improvement to quality of care and access to care for those warriors in theater. While the opportunity to capture meaningful real-time gender differences related to feedback from combat operational military members on these issues while deployed is significant, few MHAT reports have focused on, analyzed, or included gender-based findings. For example, the MHAT II in 2005 reported no significant differences in the rates of mental health problems between male and female Soldiers deployed to Iraq. The 2006 MHAT IV also reported no differences between the rates of positive screening among 314 Women at War male and female Soldiers for anxiety, depression, or acute stress. However, careful analysis of the reported MHAT data indicated that in situations where combat exposure experiences were reported as “low,” female Soldiers were more likely to screen positive for a mental health condition than male Soldiers. Further, in situations where combat exposure experiences were reported as “medium,” no gender differences were noted; the females who reported combat exposure experiences as “high” were reported as too small a group to analyze. Finally, the MHAT V in 2008 reported that ratings of unit morale appear to be influenced by gender, as females reported they perceived lower unit morale than males. No further data were discussed in MHAT V to help us understand what factors played a role in the reported perception of females that unit morale was low. There is a great opportunity for the DoD to use the MHAT in the future to help us shape what data we collect in order to learn more about gender-related psychological health differences of those Service members deployed to combat environments. Another key finding about gender-related psychological health differences in the combat environment that merits further exploration relates to the work of Vogt et al. (2008). Their team examined nine scales of the Deployment Risk and Resilience Inventory (DRRI) and found that female Service members in this study reported less exposure to combat and the aftermath of combat exposure, felt less prepared for the rigors of battle, perceived a higher sense of threat, and reported mental health issues at higher rates than their male counterparts. This was a retrospective study and as such was not designed for prospective predictive statistical analyses; thus no conclusions can be drawn about why study females reported higher rates of mental health issues, or perceived a higher sense of threat in a combat environment than their male peers. Some other studies suggest that the psychological health of women who experience combat or deploy into combat operations may be impacted by specific salient factors that differ from factors that have significant impact on the psychological health of men in the same environments. For example, Vogt et al. (2011) studied the relationship between pre-deployment factors and post-deployment mental health among OEF/ OIF–era Veterans, as compared to prior result published in Vietnam-era cohorts. Their research team surveyed 579 subjects, who were identified by a Service-stratified randomized sample of OEF/OIF Veterans. Their study sample contained 48.3% active duty, 24.6% Reserve, and 27.1% National Guard subjects, and was oversampled for females; it found an association across genders related to concerns about relationship disruption and posttraumatic stress disorder (PTSD) symptoms. This association appeared to be mediated by the subject’s reports of perceived threats (for example, fear for one’s physical safety and being in a war zone) during his or her deployment. The research team additionally noted that female Veterans who reported greater relationship disruption concerns also were more likely to endorse that they experienced less 17. Mental Health of Women Warriors 315 post-deployment social support, and found what appeared to be a stronger relationship between self-reported poor social support and post-traumatic symptoms among female Veterans, when compared to male Veterans. These findings suggest that social support factors may play a unique and perhaps different role in the psychological health of female combat Veterans as compared to male combat Veterans. Vogt, Vaughn, et al. (2011) used a national stratified random sample of 2,000 OEF/ OIF Service members (50% active duty, 25% National Guard, 25% Reserve) in their study of gender differences in combat-related stressors and the impact of those stressors on psychological health, and ensured that at least 50% of the 595 subjects were females in each study subgroup, based on a power analysis. Results supported previous findings, which indicated that social support appears to be a significant factor in the psychological health of female Service members who had deployed. This team found that females reported slightly higher levels of previous life stressors and sexual harassment during deployment than their male peers, while males versus females reported higher rates of combat-related stressors, such as combat exposure, exposure to the aftermath of battle, and perceived threat. Both males and females in this study reported similar levels of post-deployment post-traumatic stress and mental health symptoms. As compared to their male peers, females did not report elevated post-deployment mental health risks associated with combat-related stressors. Study authors concluded that female Veterans relative to male Veterans of recent conflicts seem to have experienced similar levels of most aspects of combat exposure, and do not appear to demonstrate greater risk for mental health difficulties related to combat exposure. Conclusions of this study, and attempts to generalize the findings, should be interpreted keeping in mind that subjects reported symptoms within one year after their deployment. This limitation means that subject retrospective reports of the psychological health impact of their combat experiences, if made more than one year after their deployment, may differ based on the amount of time elapsed since their deployment or other intervening factors, and these potentially different outcomes may vary by gender as well.

OSTRACISM

As there appears to be a relationship between the reported pre- and post-deployment social support of female combat warriors and their psychological health, as compared to the reported experiences of their male peers, perhaps the amount of social support that females may or may not find in their military workplace environment might also play a critical role in their psychological health. Women who are working in primarily male career fields—or, as in the military, are breaking into previously closed combat positions currently held by males—may suddenly find themselves part of a social group 316 Women at War that has difficulty fully accepting or integrating females. This experience can be painful for the unaccepted female, as well as the unit members who witness or participate in the social exclusion behavior. This lack of acceptance, or silent setting aside of the female from her group, can have a negative impact on the mental health of not only the individual who is excluded, but also on those members of the unit who either actively exclude her, or those who simply observe her exclusion. The negative impact of this type of behavior may intensify during periods of high stress, such as in combat or deployed locations. The act of exclusion of an individual from a group, through omission, is called ostracism. There is a growing body of literature of the impact of ostracism on the organizational health of the work environment, and on the physical and psychological health of involved individuals. In order to study situations in which one person is excluded from a social connection with another, especially in the workplace, Robinson et al. (2013) developed a theoretical model. Robinson’s team identified many forms of ostracism in the work environment, to include “linguistic” (which involves exclusion of the target individual from group discussion by use of terms or language that the group understands, but the target doesn’t understand); “missing action” (which includes failure by the group to invite the target to attend social events that the rest of the group is invited to); and “organizational shunning” (whereby a target is eliminated or prevented from participation in group activities due to existing or newly created institutional or organizational policy or practice). Their study emphasized that deliberate acts of omission related to exclusion of an individual from a group can have a significantly negative impact on an individual, because of our fundamental need to belong to a group—a need that appears to be innate and critical to our survival as a species. The ambiguity that often accompa- nies acts of social omission is typically unsettling, and tends to disrupt both the individual target’s ability to function, as well as the overall functioning of the group. Acts of ostracism can be “purposeful” (to bring about deliberate harm) or “non-purposeful” (harm may result but was not the original intention), and the impact of the act appears to vary according to the intensity of the behaviors, as well as the targeted individual’s perception of the meaning of the acts of ostracism. Ostracism can produce long-term psychological and physical consequences, in addition to those pragmatic and logistic consequences that arise when a group delib- erately leaves a team member out of a critical communication, which may result in a complete communication breakdown and serious degradation of the mission. Several recent studies of the psychological and physical consequences of ostracism illustrate ostracism’s profound impact on the body and mind. Williams and Jarvis (2006) developed a computer game to study the psychological impact of ostracism on an individual. Their computer game was designed to simulate 17. Mental Health of Women Warriors 317 a social exchange that would trigger the sense of ostracism that occurs when an individual believes that he or she has been excluded by a group. The subjects participated in a pretend game of catch (tossing an object to one another on the computer), with online “confederates” (these confederates were not real people, but the subject believed they were). The subjects were then suddenly excluded from the game (experimental intervention). After the act of ostracism, subjects were asked about their thoughts and feelings related to the game. Responses from the subjects then led the researchers to conclude that social exclusion, even by strangers, can negatively impact an individual’s need to belong to a social group, as well as his or her self-esteem, sense of control, and belief of a meaningful existence. Williams and Jarvis and their team went on to identify the stages that a target is likely to go through in order to fully process their experience of social exclusion. Their computer ostracism simulation is now widely used in studies related to the growing body of research on ostracism. Williams and Nida (2011) also compared the individual’s reaction of social ostracism to an individual’s experience of actual physical pain, which reflects an important direction for expanded research on the impact of ostracism. There are recent studies that links the mind’s experience of ostracism and the body’s experience of physical pain to a central pain mechanism, which is visible on magnetic resonance imaging (MRI) studies (Eisenberger and Lieberman, 2004; Wesslemann et al., 2003). In fact, the experience of ostracism appears to initiate activity in the dorsal anterior cingulate cortex and the anterior insula, the same areas of the brain that show evidence when a subject experiences physical pain. Further, for those observers who watch a target being ostracized by others, they found evidence that the vicarious experience of the observer appears to activate those same regions of the observer’s brain (dorsal anterior cingulate cortex and the anterior insula), as well as the temporal parietal junction and insula. This brain area activation occurred whether or not the individual target was a person known to the observer. Finally, Dewall et al. (2010) conducted two experiments in an attempt to show that there are similar behavioral and underlying central neural mechanisms that may overlap when comparing the behavioral and biological evidence of the experience of physical pain, to the behavioral and biological evidence of the psychological pain of social rejection and ostracism. In the team’s first experiment, 62 patients were given either 1,000 mg of acetaminophen or a placebo twice daily for three weeks, and were assessed using the “Hurt Feelings Scale,” which is a measurement tool that has been accepted by psychologists as a valid instrument to examine the construct of social pain. Hurt feelings, as measured by this self-report scale, and social pain, as reported by the subjects, appeared to decrease during the time of study for those who took the acetaminophen, while no 318 Women at War change was observed in subjects who took the placebo. Levels of positive emotions reported by both groups appeared to remain stable during this same time period, with no significant changes observed in either group related to positive emotions. Subjects in this study were also administered functional magnetic resonance imaging (fMRI) to measure their brain activity. Researchers found that subjects who took acetaminophen appeared to have reduced neural responses to social rejection in the same brain regions previously associated with distress caused by social pain, and also in those same regions associated with the affective component of physical pain (the dorsal anterior cingulate cortex, and anterior insula). These results suggest that acetaminophen use may decrease perception or recognition of social pain over time, through an unknown mechanism that impacts the experience of those emotions associated with social pain. Results also suggest that social pain perhaps shares some central pain mechanism pathway with physical pain, and that they each influence one another. In Dewall’s second experiment, 25 healthy volunteers took 2,000 milligrams daily of either acetaminophen or a placebo. After three weeks, subjects participated in the computer ostracism simulation game, which was rigged to create feelings of social rejection. Functional magnetic resonance imaging (fMRI) used while playing the game suggested that acetaminophen appeared to reduce neural responses to social rejection in those brain regions previously associated both with the distress of social pain and the affective component of physical pain (the dorsal anterior cingulate cortex and anterior insula). In other words, the parts of the brain associated with physical pain were activated in the subjects who received the placebo when they were rejected, while those same parts of the brain displayed significantly less activity in the subjects who were similarly rejected, but who received the acetaminophen. Thus, acetaminophen appeared to reduce both the behavioral and the neural responses that appear to be associated with the pain of social rejection. These experiments, and the expanding literature on this topic, continue to demonstrate existing neural overlaps between social and physical pain, and their interactive influences. This brings us to important questions for further study: If research findings indicate that female warriors may respond differently from a psychological health standpoint to the presence or absence of social support in their life, and evidence also suggests that ostracism impacts both psychological and physical health, how will female warriors respond to ostracism in their units? If female warriors don’t feel socially included as welcome members as they integrate and deploy alongside their mostly male combat group colleagues, does this lack of inclusion and subsequent diminishment of their sense of belonging to the team impact their sense of safety, their perception of unit morale, and their psychological and physical health? In combat circumstances the individual is heavily dependent for survival upon his or her group. Are female warriors 17. Mental Health of Women Warriors 319 more vigilant or responsive to the presence or absence of social acceptance or ostracism within their unit than their male counterparts? If so, could this potential difference lead to more negative psychological health outcomes in female warriors than in males within units where ostracism is intense or pervasive? Or is this not entirely a gender-related difference, and are there other factors that play a significant role? Is it more about how ostracism impacts any individual in a military unit under combat conditions? Do male warriors who are ostracized from their unit have similar psychological health outcomes as compared to their female warrior buddies? Do female warriors experience more social rejection in their unit than males?

CONCLUSION

Clearly, further research in the area of psychological health of women warriors is needed. Researchers should work to agree to minimize differences in data collection methods, as well as constructs of study concepts and subject population definitions, in order to optimize cross-study comparisons. Disparities in the types of screening or survey methods and questions used, differences in the actual amount of time subjects are exposed to combat, or the mixture of subjects from different roles into one study are all potential variables that are likely to influence study outcomes and the reliability of findings. Lack of clarity and consistency in these areas across studies results in both obvious and subtle impacts on the interpretation of findings, limits how confident we are in our ability to generalize results from a given study to a larger population, and reduces our ability to compare findings across studies. More longitudinal and prospective studies are needed to further explore those social and occupational factors that influence the psychological health of female warriors. Future studies should include as study variables those known significant factors from existing literature that have already been shown to influence psychological health outcomes of combat females, as well as be informed by relevant studies in other parallel lines of research in other fields. This will allow scientists to better integrate dynamic theories that tend to emerge in separate but related areas of study on similar topics, and will help us better understand how physical and psychological mechanisms may relate to one another. Additional studies will also help inform combat performance enhancement and organizational health, which are heavily dependent on the psychological health of leaders and individual members, as well as dependent on the way the team functions together as a group. Finally, future research on the unique psychological health needs of our women warriors will ensure that high-quality psychological health services are tailored to the needs of the individual Service member, will help the military health system develop effective psychological health prevention efforts, and will 320 Women at War inform high-quality evidence-based care for warriors of both genders who may develop psychological health conditions after combat.

REFERENCES

Batuman, F., Bean-Mayberry, B., Goldzweig, C., Huang, C., Miake-Lye, I., Washington, D., Yano, E., Zephyrin, L., & Shekelle, P. (2011, May). Health effects of military service on women veterans. Evidence-based synthesis program. Washington, DC: Department of Veterans Affairs. Bean-Mayberry, B., Yano, E., Washington, D., Goldzweig, C., Batuman, F., Huang, C., Miake-Lye, I., & Shekelle, P. G. (2011). Systematic review of women veterans’ health: Update on successes and gaps. Womens Health Issues, 21(4 Suppl), S84–S97. Dewall, C., Macdonald, G., Webster, G., Masten, C., Baumeister, R., Powell, C., Combs, D., Schurtz, D., Stillman, T., Tice, D., & Eisenberger, N. (2010). Acetaminophen reduces social pain: Behavioral and neural evidence. Psychological Science, 21(7), 931–937. Eisenberg, N., & Lieberman, M. (2004). Why rejection hurts: A common neural alarm system for physical and social pain. Trends in Cognitive Science, 8(7), 294–300. McGraw, K., Strauss, J., Liebenguth, D., Runnals, J., Mann-Wrobel, M., Garovoy, N., Ventimiglia, A., McCutcheon, S. (2013, June 26). VA/DoD Integrated mental health strategy summary, strategic action #28: Summary report of a systematic literature review: Female mental health needs and military sexual trauma, assault, and harassment among military service members and veterans of both genders. Prepared for Health Executive Council Psychological Health/Traumatic Brain Injury Work Group. Washington, DC. Robinson, S., O’Reilly, J., & Wang W. (2013). Invisible at work: An integrated model of workplace ostracism. Journal of Management, 39, 203. Runnals, J., Garovoy, N., McCutcheon, S., Robbins, A., Mann-Wrobel, M., Ventimiglia, A. (2014). Mid-Atlantic Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC) Women Veterans Workgroup, Strauss, J. Systematic review of genderdifferences in mental health and unique needs of women Veterans. Women’s Health Issues, 24(5), 485–502. Vogt, D., Proctor, S., King, D., King, L., Vasterling, J. (2008). Validation of scales from the deployment risk and resiliency inventory in a sample of operation Iraqi freedom veterans. Assessment, 15, 391–403. Vogt, D., Smith, B., Elwy, R., Martin, J., Schultz, M., Drainoni, M. L., & Eisen, S. (2011). Predeployment, deployment, and postdeployment risk factors for posttraumatic stress symptomatology in female and male OEF/OIF veterans. Journal Abnormal Psychology, 120(4), 819–831. Vogt, D., Vaughn, R., Glickman, M. E., Schultz, M., Drainoni, M. L., Elwy, R., & Eisen, S. (2011). Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF veterans. Journal of Abnormal Psychology, 120(4), 797–806. Wesselmann, E., Williams, K., Hales, A. (2013). Vicarious ostracism. Frontiers of Human Neuroscience, 7, 153. Williams, K., & Jarvis, B. (2006). Cyberball: A program for use in research on ostracism and interpersonal acceptance. Behavior Research Methods, Instruments, and Computers, 38, 174–180. Williams, K., & Nida, S. (2011). Ostracism: Consequences and coping. Current Directions in Psychological Science, 20(2), 71. eighteen The Veterans Health Administration Response to Military Sexual Trauma

MARGRET E. BELL AND SUSAN J. MCCUTCHEON

INTRODUCTION

The Department of Veterans Affairs’ (VA) mandate to address the issue of sexual assault and sexual harassment during military service dates to 1992, when legislation was first passed authorizing the Veterans Health Administration (VHA) to establish “counseling” services for women Veterans who had experienced “physical assault of a sexual nature, battery of a sexual nature, or sexual harassment” while on active duty. A key impetus for this legislation was a series of Congressional hearings held earlier in the year in which female Veterans described experiences of sexual assault and harassment during their military service and provided emotional testimony about how these experiences had impacted their lives. One major concern raised during the hearings was the difficulty that these and other Veterans encountered in finding healthcare services to assist them in their recovery. Later legislation expanded VA’s authorization to include treatment not only of mental health conditions secondary to a Veteran’s experiences of what came to be called “military sexual trauma,” or MST, but also physical health conditions. Services were also authorized for men who had experienced MST; the definition of MST was expanded to include experiences while on active duty for training (for example, boot camp) and inactive duty training (for example, weekend drill); and some of the initial restrictions on eligibility and duration of treatment were removed.

321 322 Women at War

As we will detail in this chapter, Veterans who need help in recovering from experiences of MST encounter a very different landscape in 2014 than they did 20 years ago. Nonetheless, stories from those original hearings in 1992 serve as a poignant reminder of the crucial role that VHA plays in assisting both female and male Veterans who have experienced MST. After reviewing background information about definitions, prevalence, and associated conditions among VHA users, this chapter will provide an overview of the MST-related treatment services available through VHA, as well as its extensive staff education, Veteran outreach, and access to care efforts.

BACKGROUND

During her deployment to Iraq, Kristen prided herself on her ability to keep up with the guys and told herself that all the jokes about her sleeping around, laughing requests for her to perform sexual acts on others, and comments about her body were just part of being “one of the gang.” One night, her Commanding Officer (CO) called her into his office and ordered her to stand watch in the hallway while he met with another female Service member. Kristen could hear him make sexual advances to the woman, and then heard the woman’s verbal and physical attempts to resist, but felt unable to intervene when she eventually heard her CO force the woman to have sex with him. Afterward, her CO dismissed her without any comment about what had happened in his office. However, in the days to come, he would make offhand remarks to Kristen about how he might need to “schedule a night meeting” with her in his office. Since then, she’s felt jumpy and on edge all the time, and chronically worries that she’s in danger. She also has had difficulty trusting others, meaning that she has few close relationships and struggles with significant symptoms of depression. Knowing that a friend received treatment at VA for problems related to MST, Kristen called her local facility after her discharge and asked to speak to the MST Coordinator to learn more about services available. Jonas was leaving a club one night when he was suddenly surrounded by a group of men. One of them threw a blanket over his head while the others began kicking and beat- ing him. Although he collapsed to the ground in pain, one of the men jerked his body upward and forced him to perform oral sex on him. In the days and months following the assault, Jonas’s work performance declined, he began isolating himself from others, and he was disciplined several times for aggressive behavior. Out of shame and fear of how others might react to hearing about the sexual assault, he came up with various excuses to explain away his behavior. Since leaving the service he has had a hard time keeping a job, and symptoms of post-traumatic stress disorder (PTSD) and depression have greatly cir- cumscribed his life. Finally, 10 years following his discharge, his wife threatened to leave 18. Military Sexual Trauma 323

him because of his drinking and behavior at home. Because of this pressure, Jonas went to VA for help. At his first visit, his healthcare provider screened him for MST; Jonas sat quietly after hearing the question, but eventually nodded his head “yes.” The provider and Jonas talked further about how his experience of MST might be contributing to his current difficulties, and discussed what services might best help him in his recovery.

“Military sexual trauma,” or MST, is the term used by VA to refer to experiences of sexual assault or repeated, threatening sexual harassment that a Veteran experienced during his or her military service. The definition used by VA comes from federal law (Title 38 U.S. Code 1720D) and is “psychological trauma, which in the judgment of a VA mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty, active duty for training, or inactive duty training.” Sexual harassment is further defined as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.” MST includes any sexual activity during military service in which a Service member is involved against his or her will—he or she may have been pressured into sexual activities (for example, with threats of negative consequences for refusing to be sexually cooperative or with implied better treatment in exchange for sex), may have been unable to consent to sexual activities (for example, when intoxicated), or may have been physically forced into sexual activities. Other experiences that fall into the category of MST include unwanted sexual touching or grabbing; threatening, offensive remarks about a person’s body or sexual activities; and threatening and unwelcome sexual advances. The identity or characteristics of the perpetrator, whether the Service member was on or off duty at the time, and whether he or she was on or off base at the time do not matter. If these experiences occurred during an individual’s military service, they are considered by VA to be MST. In 2000, VA established a universal screening program in which every Veteran seen for healthcare is asked whether he or she experienced MST. National data from this program reveal that about 1 in 4 women and 1 in 100 men respond “yes,” that they experienced MST, when screened by their VA provider (Military Sexual Trauma Support Team, 2013). Although rates of MST are higher among women, because there are so many more men than women in the military, there are actually significant numbers of both women and men seen in VA who have experienced MST. For example, among Veterans seen for VA healthcare in fiscal year 2012, 72,497 women and 55,491 men reported experiencing MST (Military Sexual Trauma Support Team, 2013). MST is an experience, not a diagnosis or a mental health condition, and as with other forms of trauma, there are a variety of reactions that Veterans can have in response 324 Women at War to MST. Among Veterans seen in VA, the mental health diagnoses most frequently associated with MST are PTSD, depression and other mood disorders, and substance use disorders. Veterans who have experienced MST also often commonly experience physical health problems secondary to their experiences of MST (Kimerling, Gima, Smith, Street, & Frayne, 2007) and/or difficulties with issues like homelessness (Pavao, Turchik, Hyun, Karpenko, Saweikis, McCutcheon, et al., 2013).

VETERANS HEALTH ADMINISTRATION RESPONSE

Although MST has also been the subject of much attention from the Veterans Benefits Administration (VBA), which administers VA’s disability compensation and other related benefits, in this chapter we focus on VA’s MST-related initiatives and policies specific to healthcare services. This is the domain of the Veterans Health Administration (VHA).

Screening and Treatment Services

Kristen and Jonas both decided to participate in VHA’s outpatient mental health services to help with their recovery. Kristen quickly established a strong working relationship with her therapist, and was able to discuss how her experiences of MST had affected her beliefs about others, herself, and the world. She pushed herself to join some local community groups in order to meet other people with similar interests, and over time, she began to expand her network of friends and her engagement in activities that were meaningful to her. She eventually discontinued individual therapy, but continued to participate in group therapy at VA to assist her in applying the skills she’d developed in individual therapy. After being sober for a year, Jonas decided he was ready to confront his memories of MST, but he felt afraid he would “ fall apart” if he did so. His therapist and he agreed that it would helpful for him to participate in one of VHA’s residential treatment programs, and to engage in this trauma-processing work while he had the support and structure of the residential environment. After some time spent learning additional coping strategies that he could draw upon to manage emotional distress, Jonas completed 12 sessions of Cognitive Processing Therapy and experienced a significant reduction in his symptoms of PTSD. He returned home and resumed outpatient mental health treatment to help him consolidate his gains from his time in the residential program. He also decided to begin physical therapy to improve the strength in his left knee, which had been injured during the physical violence involved in his experience of MST. 18. Military Sexual Trauma 325

Recognizing that many survivors of sexual trauma do not disclose their experiences unless asked directly, it is national policy that VA healthcare providers ask every Veteran whether he or she experienced MST. This is an important way of ensuring not only that healthcare providers know to adapt their care to be sensitive to a given Veteran’s history of sexual trauma, but also that Veterans know about the services available to them. This effort to streamline access to services is visible in VHA’s MST-related policies more generally, which eliminate many potential barriers to accessing care. For example, all care related to a Veteran’s experiences of MST is provided free of charge. This includes care for both mental and physical health conditions, whether provided via outpatient, inpatient, residential, or pharmaceutical modalities. To receive this free treatment, Veterans do not need to have reported the incident(s) when they happened or have other documentation that they occurred; they also do not need to be service connected (that is, have a VA disability rating). There are no length of service requirements, meaning that some Veterans may be able to receive this benefit even if they are not eligible for other VA care. Pre-military trauma and pre-existing conditions do not impact eligibility for MST-related care. Further reducing potential barriers to care, MST-related services are available at every VA healthcare facility, and every facility has a designated MST Coordinator who serves as a point person for MST-related issues and who can assist Veterans in accessing care. Typically, MST-related care for physical health conditions is provided through VHA’s general and specialty medical clinics. There is more variability in how facilities have outpatient MST-related mental health services organized, with some facilities providing this care through identified “MST clinics” and others providing it in a more distributed fashion, integrating services into General Mental Health, PTSD, and other clinics. Community-based Vet Centers, which provide counseling services in a non-hospital environment, also have specialized MST-related services available. Complementing these outpatient services, VA has mental health residential rehabilitation and treatment programs and inpatient mental health programs to assist Veterans who need more intense treatment or support. Some of these programs focus specifically on MST or have specialized MST tracks. VHA’s MST-related mental health services are designed to meet Veterans where they are in their recovery from MST, whether that is focusing on strategies for coping with emotions and memories or, for Veterans who are ready, actually talking about their MST experiences in depth. This is consistent with national VHA policy that mental health services be provided in a Veteran-centric, recovery-oriented manner. Similarly, Veterans are welcome to ask to meet with a provider of a certain gender, if they think this would facilitate their engagement in treatment. 326 Women at War

Staff Education

In 2006, program responsibility for MST was transitioned from VHA’s national Women’s Health program office to its Mental Health Services (MHS) program office, in recognition that both women and men experience MST. That same year, MHS funded a national MST Support Team. Among its responsibilities, the Team is specifically charged with coordinating and expanding national MST-related education and training, as well as providing resources, technical assistance, and consultation to promote best practices in treatment and clinical programming. For example, the Team hosts monthly continuing education calls on MST-related topics that are open to all VA staff and are available online afterward; there are typically upward of 190 attendees on these calls. Since 2007, the MST Support Team has hosted an annual conference focused on MST-related program development. It also maintains the MST Resource Homepage, a VA intranet Community of Practice website where VA staff can access MST-related resources and materials and participate in MST- related discussion forums. Also prominent among VHA’s educational initiatives related to MST is the mandatory training requirement for mental health and primary care providers. Since 2012, all mental health providers are required to either complete a web-based training that provides a comprehensive review of issues relevant to provision of mental healthcare to MST survivors or pass a knowledge assessment that demonstrates significant pre-existing expertise in mental health issues related to MST. Primary care providers must complete a web-based training that reviews a range of issues including health conditions associated with MST, screening sensitively for MST, how MST can affect a Veteran’s experience of healthcare, how to appropriately adapt care to address the needs of MST survivors, and VA documentation requirements. In addition to this mandatory training requirement for mental health and primary care providers, MST Support Team training initiatives have also targeted chaplains, Veterans Crisis Line staff, clerks and telephone operators, staff charged with assisting newly discharged Veterans, and other groups to ensure that all staff have the knowledge they need to provide sensitive, informed assistance to Veterans who have experienced MST. The Team has also sought to have information about MST included in non-MST-specific training initiatives such as Mental Health Services’ national rollouts of empirically-based psychotherapies. Many of the conditions targeted by these rollouts are strongly associated with MST, meaning that these national rollout initiatives have been an important means of expanding MST survivors’ access to cutting-edge treatments. Furthermore, several of these treatments were originally developed in the 18. Military Sexual Trauma 327 treatment of sexual assault survivors and have a particularly strong research base with this population. Complementing these national offerings, at a local level, MST Coordinators and others host grand rounds and other educational presentations, distribute informational materials, provide clinical consultation, and engage in other training activities.

Veteran Outreach and Access to Care

Equally important to ensuring that specialized services are available and that staff are knowledgeable about Veterans’ MST-specific needs is ensuring that Veterans are aware of and able to access services. VHA’s universal screening program noted earlier is one important means of disseminating information and connecting Veterans with appropriate services. The MST Support Team also has developed national outreach posters, handouts, and educational documents for Veterans, has secured inclusion of information about MST on relevant va.gov websites, and has developed an MST-specific website (www.mentalhealth. va.gov/msthome.asp). MST is also one of the topics included in VHA’s innovative “Make the Connection” (www.maketheconnection.net) website, which features videos of Veterans sharing their stories of recovery from mental health difficulties. VHA has also worked closely with the Department of Defense to disseminate information about VA’s MST-related services to Service members leaving active duty and otherwise ensure a seamless transition to VA care. At a local level, MST Coordinators engage in a range of efforts to raise awareness of MST-related services, including disseminating outreach materials throughout their facility, participating in community events, connecting with local military installations and community organizations, and integrating information about MST into facility outreach efforts more generally. Although these outreach efforts occur throughout the year, MST Coordinators also often capitalize on Sexual Assault Awareness Month (SAAM) as an opportunity to raise general awareness, among both Veterans and staff, about MST. In addition to these outreach efforts, facility MST Coordinators are charged with addressing systems issues that might create barriers to care; they also directly assist, as needed, individual Veterans in accessing services. Recognizing that frontline staff often also play a key role in Veterans’ ability to access care, the MST Support Team has developed an “Answer the Call” campaign to verify that Veterans calling VA medical centers with MST-related questions can reach the facility MST Coordinator. As part of this campaign, members of the Team conduct test calls to VA medical centers to confirm that telephone operators and clinic clerks are familiar with the terms “military 328 Women at War sexual trauma” and “MST,” are readily able to identify and direct callers to the MST coordinator, and are sensitive to Veterans’ privacy concerns. The campaign provides an excellent platform for MST Coordinators to provide education about their role to a wide range of staff and to raise awareness about some of the unique barriers to care faced by Veterans who have experienced MST.

CONCLUSION

Many Veterans show incredible resilience after experiences of trauma, including after experiences of MST. Not all will need or want treatment, but it is crucial that there are easily accessible, specialized services available for those who do. VHA has helped ensure this is the case, by establishing treatment services with expansive eligibility, and widespread staff education and extensive Veteran outreach and access to care initiatives. Together, these efforts have created a comprehensive network of programs to ensure that all Veterans have access to specialized, tailored care to assist them in their recovery from MST.

REFERENCES

Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. (2007). The Veterans Health Administra tion and military sexual trauma. American Journal of Public Health, 97, 2160–2166. Military Sexual Trauma Support Team. (2013). Military Sexual Trauma (MST) Screening Report, fiscal year 2012. Washington, DC: Department of Veterans Affairs, Office of Patient Care Services, Mental Health Services. Pavao, J., Turchik, J. A., Hyun, J. K., Karpenko, J., Saweikis, M., McCutcheon, S., et al. (2013). Military sexual trauma among homeless Veterans. Journal of General Internal Medicine, 28(Suppl 2), S536–S541. Nineteen Compensation, Pension, and Other Benefits for Women Veterans with Disabilities

JACQUELINE GARRICK

INTRODUCTION

American women have stood alongside the nation’s men from the moment the first woman stepped ashore at Plymouth. As a union was formed and defended, they have endured the same hardships and deprivations as their male countrymen. Women were equally patriotic and courageous—willing to risk life and limb for the creation and preservation of the United States. Women sometimes disguised themselves as men to join the Army since females were prohibited from military service until the Spanish- American War in 1901. However, there are a multitude of examples of women’s service that pre-date their entitlement to actual military service. The work these women performed was at times recognized at the state and federal level with various approaches to benefits and compensation based on the cultural and political will conforming to the era. Compensation and benefits were provided in various forms that included subsid- ence, sustenance, formal appointment, and pension. These benefits were outgrowths of the attitudes that informed remuneration policies as women went from patriotic volun- teerism, religious charity, and civilian employment to actual military service. The procession of patriotic women in service to this nation has been a constant; the recognition of a grateful nation however has undergone a sea change from generation to generation. The way in which we value this service has directly impacted the way in which we compensate women for their disabilities. Women to this day do not

329 330 Women at War always recognize themselves as veterans, so they do not apply for the same benefits at the same rate as men. Furthermore, the clinicians that evaluate and treat them do not always understand or appreciate the circumstances of military women. Although not in uniform, 20,000 female patriots during the Revolutionary War (1775–1783) provided their state’s militia and the Continental Army with support that they could not have done without. As the period of Enlightenment spread across Europe, the philosophies of medicine experienced progress in the 18th century, which also informed medical care during the Revolutionary War. As medicine moved away from a soul-saving engagement to addressing sanitary conditions, prevention, and mental health, armies and navies were a primary focus for reducing the spread of diseases, such as scurvy and typhus (Ackerknecht, 1982). As the importance of personal hygine and sanitation became better understood, the role of women in facilitating and performing these functions grew with public health acceptance. Performing activities that were considered appropriate for housewives, Revolutionary War women delivered food and supplies, cooked meals, spun and sewed clothes and blankets, washed laundry, spied on the enemy, couriered messages, and nursed the injured and the ill without compensation. Males who performed similar roles were considered professional merchants and service providers, and therefore were compensated until General Washington directed that the Continental Army Medical Corps establish a system for nursing in 1777 that had one matron supervising 10 nurses. The matrons were paid 50 cents a day plus a food ration and the nurses were paid 25 cents a day plus a food ration (Brooks, 2013). Historian John Resch documents the trials and tribulations of the Revolutionary War minutemen and Continental Army soldiers. He describes battlefield deaths, wounds and infections, along with putrid sanitary conditions within the camps and improper clothing for harsh winters and long marches, which caused illnesses, such as dysentery and typhoid, to run rampant. He goes on to describe veterans with troubled minds, physical disabilities, and pauperism (Resch, 1999). Thirty-five years after the Continental Army’s disband and amid much controversy, Congress passed the 1818 Revolutionary War Pension Act, which finally recognized the reduced quality of life for those veterans who were suffering from injuries and illness that had resulted from their military service. Initially, the law required a means test so that only destitute Revolutionary War Veterans were eligible, but two years later that provision was repealed (Resch, 1999). Means testing is in effect today when determining eligibility for Department of Veterans Affairs (VA) healthcare eligibility for non-service con- nected1 medical conditions.

1 Service connection is the process by which a veteran applies for and is granted a disability compensation award from the Department of Veterans Affairs. 19. Women Veterans with Disabilities 331

Although Resch documents well the service and conditions of the men, he rarely notes the impact that the Revolutionary War had on its daughters. However, it would stand to reason that if wives, sisters, daughters, and other women were following the troops, then these women also got hurt, sick, and died without recognition or compensation, since the 1818 pension only applied to the men who actually wore a uniform. Even under circumstances when women impersonated men and fought valiantly, they were not afforded the same level of benefits or recognition as men. Such was the case of Deborah Sampson, who joined the 4th Massachusetts Regiment as Robert Shurtliff and was wounded by a musket ball to her thigh and a deep cut to her forehead in 1782. Treatment at that time did not expose her gender, but she became ill a year later and was discovered, thus prompting her immediate discharge from the Army. She was awarded a veteran’s pension many years later, but only after a long bureaucratic battle. Sally St. Clair also dressed in men’s clothing. Her gender was discovered only when she was killed in 1779 at the Battle of Savannah (Blankenship, 2008). Although the federal government did not recognize these women, there were occasions when the states stepped up to support their heroines. In the legendary accounting of “Molly Pitcher” (a nickname given to many women carrying water to thirsty soldiers), the actual Mary Ludwig Hays McCauley followed her husband, William, into the Battle of Manmouth with the First Pennsylvania Artillery, along with 400 other women (Blankenship, 2008). As was customary, they carried pitchers of water onto the battlefield to cool the cannons and the ramrods and hydrate the men, which in the summer of 1778 was essential since temperatures were very high. When William collapsed from heat stroke, Mary took his place at the cannon and fought on until the battle ended. Impressed with her valor and fortitude, General George Washington granted her non- commissioned officer (NCO) status in the Continental Army. From then on, she was known as Sergeant Molly. Although she was not eligible under the 17892 or the 1818 pension provisions authorized by the Continental Congress, in 1822 the Pennsylvania legislature awarded her an annual pension of $40, which she collected until her death 10 years later (Flanagan, 1996). She was buried with military honors. The Pennsylvania legislature previously had granted pension to another female heroine whose story is similar to Mary’s. In 1776, during a battle against the Hessians at Fort Washington, John Corbin was killed in action, at which time his wife, Margaret, assumed his position at the cannon until she was badly wounded in the arm. In 1779, Margaret was the first woman in the United States to be awarded a military pension. Pennsylvania granted her a stipend of $30 and Congress later granted her a pension

2 With the passage of the US Constitution. 332 Women at War that was half that of the monthly allotment paid to soldiers plus a one time clothing allowance3 (US Army Women’s Museum—Ft. Lee, VA). The War of 1812 again saw wives following their husbands to military camps. Perhaps to avoid the masses of women and children who were at camp during the Revolutionary War, some Army regiments instituted a lottery for enlisted soldiers’ wives so that only six could be in camp per 100 soldiers. These women took care of their own families and an entire unit (Ferguson, 2013). As the only benefit afforded these women, they were able to stay up to six months after their husbands died to give them time to grieve and make arrangements to return home. If she wanted to remain with the Army camp, she had to marry another soldier, which sometimes happened multiple times. Although war widows were already afforded pensions based on previous legislation from the Revolutionary Era, women opted to do this to ensure their protection and financial security (Women During the War, 2013). Women during the Civil War served in many of the same capacities as in previous generations of war, providing laundry, cooking, and nursing support. These domestic activities were seen as being in the purview of women and a necessary support function to conserve the strengh of the fighting forces. By 1863, the Union was more organized in its approach to recruiting and retaining women into voluntary and professional positions. Servitude varied between Northern and Southern women, as well as the inclusion of free women of color and former female slaves. Although women were motivated by various factors ranging from patriotic beliefs, religious callings, widowhood, or indigence, remuneration for appointments played a key role in filling these crucial support positions. So, although women were not recruited to join the military, they were given appointments as civilian military personnel. Amid much confusion, spreading disease, and a paucity of male medical personnel, organizations formed, such as the US Sanitary Commission, Sisters of Charity, US Christian Commission, and Womens Central Relief Association, that unified the local aid societies, which assisted in the recruitment and placement of women in military hospitals and camps to care for and feed the troops (Straubing, 1993). Well known for her reformation work with prisons and asylums, Dorothea Dix was appointed as superintendent in 1861 by the Army Surgeon General to establish the Office of Army Nurses and to create guidelines for selecting, appointing, and compensating Union Army nurses (Schultz, 2004). She established a pay scale based on the nature of the work and experience of the worker. Women of distinction and affluence often chose to support the wounded and ill through charity work and volunteered their nursing skills, whereas widows and poorer white and black women sought compensation for their work.

3 A clothing allowance is still afforded to some service connected veterans whose disability causes wear and tear on clothes, such as with prosthetic devices or skin creams from the Department of Veterans Affairs and is paid annually. 19. Women Veterans with Disabilities 333

Nuns were also recruited to care for the worst of the wounded and ill, especially those with highly contagious diseases. There were serious divisions of class labor between nursing, cooking, and laundering, which was the most physically taxing job, but the least paid, so often performed by the lowest class of white women or former slaves. Nurses often experienced combat on the battlefield, as they lived in tents among the troops, ate with them, suffered the same hardships, and treated them on the battlefield. They dragged wounded soldiers back to their amulances, which they were deputized to drive (Schultz, 2004). Many of these nurses where shot or hit by shrapenel. Juliet Hopkins4 (shot twice in the leg), Annie Etheridge5 (shot in the hand), and Elmina Spencer (shot in thelower back) are examples of wounded nurses who, once recovered, returned to duty. Women who worked around and aboard ships also suffered injuries or drowned by falling through hatches or between ships. Diseases, such as smallpox, measles, pneu- monia, erysipelas, flu, diarrhea, consumption, and typhoid were still the most common causes of disability and death for these women, as they was for the men, but women were not compensated for these injuries or illnesses. Some of the nurses benefited from the Consolidation Act of 1873, which, along with revising pension to be based on disability rather than rank, created the aid and attendance program that authorized eligible disabled veterans to pay a nurse or maid (Department of Veterans Affairs, 2006). Former military nurses and other service providers were then able to continue using their skills in paid employment, serving disabled veterans. In 1890, the US Record and Pension Division estimated that 21,208 women (10% were black) were paid as Union nurses throughout the Civil War. White Union nurses were paid 40 cents per day and a ration, which amounted to about $12 per month. Black nurses made about $2 less a month. Cooks and laundressesses were paid $6–$10 per month. The Sanitary and Christian Commission paid their workers slightly more than the Army. Unpaid workers—usually from religious orders or a higher socioeconomic class—refused pay and often cited their convictions as reward enough. They also used their social status to argue with surgeons and hospital administrators for better conditions and treatment of the wounded and ill soldiers and the staff that cared for them. However, nurses’ pay was often delayed or never received since the paymaster had difficulties keeping track of all of the pay tables and allowances for the women. There was also a system that paid contracted hospital workers in places, such as in New Orleans, where Southern women were hired to nurse Union troops. Superindenant Dix often

4 Hopkins, who had used her fortune to establish confederate hospitals, died in poverty. 5 Etheridge was the only woman who served in the field for four years with the 2nd Michigan Infantry, but never received pay. She was awarded the Kearney Cross for bravery and later worked for the US Patent Office at the Department of Treasury. 334 Women at War heard protests from women about their wages and appeals that tied competency to compensation. Nurses and surgeons often had to advocate for pay and benefits for workers—giving rise to an appreciation for nursing as a profession and the women who performed the work, which had not previously been recognized or documented (Schultz, 2004). This public voice contributed to overcoming the stigma (and questioning of their virtue) that many women felt when first offering to join the war effort and paved the way for women to travel alone and work alongside men who were not their relatives. Nurses as veterans would again become activists as they fought for pension and other social reforms in the years following the war. Since so many former Union officers went to Congress, the women found among them those who would listen to their cause, understood what they had endured, and found ways to officially recognize and validate their role in military service. Female service during the Civil War changed many of the other social conventions by which nineteenth-century women lived, but the greatest recognition for the equal role of women to soldiers came with the passage of the Army Nurses Pension Act of 1892, which provided a $12 a month pension to nurses who could prove service and need. At the time, the Union Forces were receving pension under a General Law system. Compensation was based on rank and degree of disability; thus compensation ranged from $8 a month to $30 (The President’s Commission on Veteran’s Pension, 1956). Thirty years after the war, payroll, marriage certificates,6 and testimonials from fellow hospital staff workers, administratiors, surgeons, and patients became significant for women in their ability to prove service to the Pension Bureau, which processed 2,448 women’s claims for almost the next half century (Schultz, 2004). However, those who had volunteered, women of color, and those unable to secure witnesses had a great deal of difficulty proving their claims to the Pension Bureau. A witness statement is still considered evidence by today’s VA standards, and veterans are encouraged to find former battle buddies or family members who can attest to their injuries and manifesta- tion of symptoms when filing a claim for benefits. Altough the Confederacy did establish a hospital system and women were employed, there is less accurate accounting of Confederate women and the work that they did, since their work was often conducted in their homes or churches and they were less likely to be compensated for their services. However, those who were compensated were done so at a highter rate than Union workers. Confederate wages for women ranged from $25 to $40 a month (Schultz, 2004).

6 Widows were also given a pension, so nurses were not allowed to “double dip,” and thus had to apply for one or the other pension. When rates changed for one and not the other, women would opt for the higher paying pension and re-file claims. 19. Women Veterans with Disabilities 335

As daring as the female nurses and other caregivers were, another group of women exemplified even greater bravery by secretly enlisting as men during the Civil War. For the same reasons they became nurses, they became soldiers: patriotism, closeness to male relatives, and poverty. There are approximately 250 known women who disguised themselves to enlist under an assumed male name, wore bulky military uniforms, and engaged in unlady-like behavior—smoking, drinking, and swearing (Krowl, 2006). The lackluster enlistment physical allowed these women to join, and the poor quality of medical care often allowed them to continue serving, even after being wounded, without being discovered. Pregnancy was often the game changer. Those who died in battle or from disease were buried under their assumed identities. However, if discovered, they were thrown out of the Army. During the period after the Civil War, with so many Union veterans in Congress, veteran’s benefits for Union servicemembers were lucrative. Yet, as veterans, these undercover female soldiers were not given the same recognition as the men, with a few exceptions. For example, Jeannie Hodgers as Albert Cashier served honorably until discharge and received a veteran’s pension. She remained undiscovered as Cashier until aged and hospitalized in a veteran’s hospital, when she was discovered by the medical staff after a fall in 1911. Although the issue was controversial, she was allowed to keep her benefits. In another case, Sarah Edmonds, who served as Franklin Thompson, deserted. The charges were later overturned and she was able to secure a veteran’s pension with the support of her male compatriots. The Spanish-American War saw little movement in the expansion of veterans’ benefits. In fact, the only changes came in 1918, which allowed for non-service connected pension for those destitute. In 1920, there was an expansion of disability pension. In 1922, pension was authorized for surviving dependents, and then pension for Spanish-American War veterans themselves was enacted in 1938 (The President’s Commission on Veteran’s Pension, 1956). However, in 1901, during the Spanish-American War, with an epidemic of typhoid spreading through the forces, Congress created the Army Nurse Corps (ANC), but did not authorize women to carry rank—they were given the title “nurse,” (Department of Veterans Affairs, 2011). Furthermore, they were not compensated at nearly the same rates as male soldiers. The Navy followed suit in 1908 with the Navy Nurse Corps. About 1,500 women served, and more than 20 became casualties from the exposures they encountered while performing their duties. The fight that Civil War nurses had faced for recognition and the long delays of their benefits did not keep another generation of women from answering the call of duty when the United States entered into World War I. With a stringent physical examination required for entrance into the military, women no longer could disguise themselves as 336 Women at War men to join. So, more than 3,500 women joined the ANC and another 18,000 joined the Reserves. In 1917, the Navy and Marine Corps opened recruitment for women to join its Reserves. They filled additional administrative and logistics roles and served in the United States (mostly in the Washington, DC, area) and abroad. In all, 34,000 women served during World War I. While serving overseas, 101 nurses died from exposure to combat and mustard gas, three were wounded, and 134 nurses, along with 51 female Navy yeomen, died at home from illnesses incurred while serving. An additional 300 women were sworn into the Army as volunteers to man switchboards in France. Many of these female Army contractors, like their sisters in previous wars, did so without any benefits, had to obtain their own food and shelter, and were not entitled to the same legal or medical care as the military (Bellafair, 2009). The uniformed women were not authorized the same benefits as those afforded to men, whether on active duty or as veterans. However, in 1923, Congress did extend veterans’ hospitalization benefits and long-term care in veterans’ homes to the Army and Navy women Service members, but did not include the voluntary telephone operators until 1979 (Blankenship, 2008). The lessons learned by Congress after the political patronage and the institutional disorganization associated with compensating Civil War disability benefits (for Union troops only) and in anticipation of war in Europe culminated in the passage of an amendment to the War Risk Insurance Act of 1914. This added responsibility for adjudicating benefits for Service members (along with ships and cargo) to the responsibilities of the Bureau of War Risk Insurance (Ridgeway, 2013). Congress knew it needed a better way to remunerate returning disabled veterans, so the first compensatory rating schedule, established for measuring the degree of loss or loss of use of a body part, was introduced in 1921, based on requirements outlined in the War Risk Insurance Act of 1917. Already used in some European countries and Canada, the rating schedule was based on a workmen’s compensation model since it tied level of disability to loss of earnings capacity in a civilian occupation (Veterans Disability Benefits Commission, 2007). Only male veterans were eligible. In 1925, the rating schedule was modified to accommodate the notion that a disability should be rated based on the individual’s similar occupation at the time of enlistment (Veterans Disability Benefits Commission, 2007). This meant that each veteran would be judged in accordance to the skills and abilities that he had when he joined the military and the rating schedule recognized the unique needs of individual veterans based on their previous occupation. So, for example, a carpenter who lost an arm would not be rated in the same light as a lawyer with the same level of impairment since the impact to their careers would be different. Since the work that women performed for the military was considered on par with housework, it was not valued in the same way as the occupations of men outside the home. 19. Women Veterans with Disabilities 337

With the backdrop of the Great Depression, the Economy Act, Bonus Army marches, a tuberculosis epidemic, and the drum beats of war sounding again in Europe, the Veterans’ Bureau was instituted and 54 regional offices7 opened, while the veteran’s hospital system expanded to 91 facilities8 (Veterans Disability Benefits Commission, 2007). In order to manage the influx of claims and systematically provide assistance, the 73rd Congress published the United States Veterans’ Administration Schedule for Rating Disabilities (VASRD) on March 20, 1933. This rating schedule would see two additional revisions; five levels of disability impairment were added, and the average man concept of the 1921 rating schedule was restored, since rating cases on such a subjective level as the 1925 schedule required was too challenging for adjudicators at the Veterans’ Bureau. The 1933 rating schedule for the first time included codes for gynecological conditions as women were becoming integrated into the military rolls. Among these were ratings for uterus displacement, in degrees of mild, moderate, severe, complete prolapsed through vulva, and loss of; panhysterectomy; loss of both ovaries; mammary loss of unilateral, bilateral, and unilateral with extensive muscle loss, and bilateral with extensive muscle loss (Veterans Administration, March 20, 1933). This revision of benefits for military women fueled their interests to serve in expanding military capacities beyond nursing. As early as 1940, Congress was already preparing for the next war and created new insurance programs for Service members and veterans, while it also instituted the first peacetime draft (Department of Veterans Affairs, 2006). At about the same time, the notion of the Women’s Army Auxiliary Corps (WAAC) was being hatched by Congresswoman Edith Nourse Rogers to support the Army with a non-combant workforce, similar to the jobs women were holding in the civilain business world. By 1942, the Navy had created the Women Accepted for Volunteer Emergency Service (WAVES) and the Marine Corps Women’s Reserve, the Coast Guard Women’s Reserve, and the Women Air Force Service Pilots (WASP9). In total, over 350,000 women served in the military during World War II (Klein, 2005). According to a historical account of the WAACs by the US Army Center of Military History, Congresswoman Rogers advocated for women to have equal pay, pension, and disability benefits, which had been denied to World War I women. The Army finally agreed to provide 150,000 WAACs with “food, uniforms, living quarter, pay, and medical care” (Bellafair, 2009). The first WAAC director, Oveta Culp Hobby, served in the

7 As of 2014, VA has 57 Veterans Benefits Administration Regional Offices. 8 As of 2014, VA has 153 VA Medical Centers, about 800 Community Based Outpatient Clinics (CBOC), and over 300 Vet Centers. 9 WASPs were given veteran status in 1977. 338 Women at War rank of major with first, second, and third officers (equal to lieutenants and captains), while all of the enlisted were auxiliaries. Although these were great concessions at the time, there were still many inequities. Women could not command men and were not equally compensated, nor were they eligible for wartime legal protections, overseas pay, life insurance, or veterans’ benefits or treatment. If they became pregnant, they were discharged (Bellafair, 2009). But women (including many black women) flocked in droves to become WAACs—for many of the same patriotic and familial reasons as had motivated previous generations. It was not long before they were assigned to missions overseas and were exposed to the same hardships, accidents, and war as other soldiers—along with the same questioning of their virtue that Civil War nurses had endured. The prejudices and stigma against them among civilian men and women on the home front fed a political debate over the role of women in the military. Yet, the Army needed them, and by mid-1943, the Women’s Army Corps (WAC) was authorized by Congress so that women serving with the Army could now serve in the Army and were afforded rank, benefits, and the same wartime protections as the regular forces. As the roles and assignements of the women increased worldwide, new health challenges emerged related to psychological issues as a result of the tedious work and social isolation instilled to protect their virtue. Illnesses, such as respitory diseases, malaria, and skin conditions, occurred because of improper uniforms that did not protect against environmental conditions, exhaustion from the hours worked, and malnutrition since supplies were inadequte. WACs were medically evacuated 267 per 100,000—significantly higher than the rate for men, who were better supplied and clothed. WACs sustained injuries from bombings and 16 of them recieved the Purple Heart for combat-related injuries (Bellafair, 2009). Eleven of the Navy nurses were captured in the Phillipines and held as prisoners of war (POWs) (National Center for Veterans Analysis and Statistics, 2011). There were 68 Army POW nurses as well. Over 540 women died during World War II; 16 were killed by enemy fire (Blankenship, 2008). In 1945, with World War II ending and veterans returning stateside in droves, the Veterans Administration (VA) amended the 1933 VASRD to primarily account for the organ system injuries and illness suffered by over 670,000 wounded Service members (Veterans Disability Benefits Commission, 2007). The 1945 edition provided extensive guidance on rating gynecological conditions. It did not allow for conditions related to menopause, amenorrhea, pregnancy, or complicated childbirth, except for some surgical complications or other treatment resulting in disability or otherwise attributable to the unusual circumstances of service. Congenital malformations and conditions resultant from misconduct (equally for both genders), such as syphilis or gonorrhea, were not ratable. The excision of the uterus, ovaries, and related body systems prior 19. Women Veterans with Disabilities 339 to natural menopause were considered disabling conditions. Gynecological conditions considered ratable were vulvovaginitis, vaginitis, cervicitis, metritis, salpingitis, and oophoritis. These conditions were rated as severe (30%), moderate (10%), or mild (0%). Complete removal of the uterus and both ovaries was rated at 100% for the first six months and 50% thereafter. Uterus removal, including corpus, was rated 100% for three months and 30% thereafter. Complete removal of both ovaries and artificial menopause was rated 100% for six months and 30% thereafter. Removal of one ovary with or without partial removal of the other was rated at 10%. Complete atrophy of both ovaries was rated at 20%. A complete prolapsed uterus was rated at 50%, or 30% if incomplete. Severe uterus displacement was rated at 30%, moderate at 10%, and mild at 0%. Surgical complications from a pregnancy were rated as severe with rectocele or cystocele at 50%, at moderate with relaxation of the perineum at 10%, or mild at 0%. Although service-connected and disability benefits were being extended to World War II women veterans, they were still not fully equal under the law. For example, the 80th Congress did not allow women to claim a husband as a dependent for the purposes of applying for additional compensation under the otherwise allowable provision for wives within Public Law 877 dated December 19, 1945 (Claims, 1949). To reintegrate Service members into civilian life, Congress passed the Servicemen’s Readjustment Act of 1944, which included women. This vast benefit covered everything from mustering-out pay, home and business loans, education, and VA medical coverage. Four out of five veterans used their GI Bill, and within 10 years, they were socially and economically better off than their non-veteran counterparts (Veterans Disability Benefits Commission, 2007). Among these successful veterans were 64,728 female veterans, who used their GI Bill to attend college at a greater rate than the men. Women veterans enrolled in college at a rate of 19.5%, while male enrollment was 15% of those eligible (Bellafaire, 2006). It could be argued that the aptitude for these women was greater since they had served in military positions, such as administration, communication, logistics, and medical fields that gave them the skills necessary for college. In addition, with colleges under pressure to register veterans, women veterans were more likely to be accepted into college programs than their non-veteran female counterparts—making advanced degrees more limited and competitive among American women in general. At the end of World War II, 12 million Service members were discharged from active duty—and among them were 280,000 women. The US Armed Forces needed to down- size over the next few years, but the need to keep a vital force was obvious to President Truman. So, he signed the Women Armed Services Integration Act of 1948, capping at 2% the number of women who could permanently be in the military (National Center for Veterans Analysis and Statistics, 2011). However, just two years after the integration 340 Women at War of women into the military, there were only 22,000 women left on active duty (a third were medical professionals) as the Korean Conflict escalated in 1950. But, they were among the first group of American troops to deploy. By the war’s end, almost 120,000 women would serve, including the newly formed Air Force Nurse Corps, which would medically evacuate 350,000 wounded,10 ill, or injured patients (National Center for Veterans Analysis and Statistics, 2011). To focus more on the recruitment and retention of women, the Department of Defense (DoD) created the Department Advisory Committee on Women in the Services (DACOWITS)11 in 1951, which makes recommendations to improve the benefits and services available to women in the US Armed Forces to this day. In the years following the Korean War, the focus on veterans’ benefits and the success of the VA were documented by Omar Bradley, the Chairman of the President’s Commission on Veterans’ Pension. Overall, the Commission found that “[e]‌xisting veterans’ benefit programs on the whole are working well and are being soundly administered. Veterans as a group are better off economically than nonveterans. . . . The present practice of assisting the veteran in his immediate readjustment to civilian life is much more effective” (The President’s Commission on Veteran’s Pension, 1956). However, the Commission found that there were inconsistencies with the VASRD and made recommendations to align the progression of ratings from degrees of disability to more accurately reflect loss of earnings capacity and mortality, especially for the more totally disabled. The Commission further advocated for a system that was much more holistic in its approach (The President’s Commission on Veteran’s Pension, 1956). The Bradley Commission report, although very comprehensive and respected in its time, did not provide discussion on the present or future issues of female veterans. Categories of veterans were examined by period of service, disability, age, and family status, but not gender. The one notation in the Bradley Commission report that related to women was that of the 2,076,026 veterans receiving service-connected disability compensation as of June 30, 1955, 1,631 or .1% of the total were doing so for gynecological conditions12 (The President’s Commission on Veteran’s Pension, 1956). So, as DoD began to change its focus on including women in the military under programs such as DACOWITS, the VA was still not providing them the same level of recognition and services. Throughout the Vietnam War, the military would continue to expand the roles for women and the level of compensation that they were entitled to, making them equal to

10 According to the Veterans Disability Benefits Commission, there were 103,284 wounded warriors during the Korean Conflict. 11 DACOWITS continues to make policy and program recommendations to the DoD in 2014. 12 Since the report did not break out disabilities by gender, it is unknown how many of those receiving service-connected disability for other conditions, such as medical or psychiatric, were women. 19. Women Veterans with Disabilities 341 those of male Service members, including the opening of flag officer rank—Ana Mae Hays became the first woman brigadier general in 1970. Congress also lifted the 2% cap in 1967, so that more women could join. Although still with limitations, women voluntarily served during the Vietnam War since they were not conscripted. During the war, approximately 250,000 women served, 7,500 in theater, with the majority of these (6,200) as nurses treating the wounded (Blankenship, 2008). To assist disabled Vietnam veterans, Congress expanded the GI Bill programs in 1966 and increased life insurance coverage. It expanded eligibility for Reservists and National Guard members and academy students. Women veterans also benefited from these expansions, and more VA benefits were made available to them. Mostly because of the Bradley Commission’s earlier recommendations, by 1961, the VA updated the VASRD, primarily to modernize the terminology being applied to psychiatric conditions in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM). By 1971, the VA would make 15 revisions to the VASRD. But, in the late 1960s, Congress asked the VA to ensure that the VASRD was meeting the needs of disabled veterans, since a great deal of criticism was focused on its outdated loss of earnings approach (based on a physical labor construct) and advances in medicine that it did not account for. The 1971 VA study, entitled “Economic Validation of the Rating Schedule” (ECVARS), incorporated several recommendations based on organizational reviews and interviews with 485,000 veterans, none of whom were women (Veterans Administration, 1971). ECVARS made recommendations to change ratings and rates of compensation within the VASRD. The VA made the proposed changes, but after much political controversy among Congress and the Veteran Service Organizations, the 1973 VASRD was not adopted, and the 1945 edition of the VA Rating Schedule remained (Veterans Disability Benefits Commission, 2007). This is the same VASRD construct in effect in 2014, with regulatory changes having been made on an intermittent basis. With the addition of posttraumatic stress disorder (PTSD) to the DSM in 1980, VA began to refocus its efforts on “Vietnam syndrome” and “war neurosis” disabilities. In 1984, Congress required the VA under Public Law 98-160 to engage in an independent study of PTSD and other readjustment problems among the Vietnam veteran community—the National Vietnam Veterans Readjustment Study (NVVRS) was created. Vietnam veterans were provided a five-hour survey that included an oversampling of disabled, black, Hispanic, and female veterans (with civilian control groups). The NVVRS found that 15.2% of males and 8.5% of females who served in Vietnam had PTSD, with a lifetime prevalence of PTSD being 30.9% for males and 26.9% for females. Comparisons of current and lifetime rates found that 49.2% of the males and 31.6% of the females who ever had PTSD still had it (Veterans Administration, 1984). The rates of PTSD among female Vietnam veterans created new awareness of the challenges 342 Women at War facing them that differed from their male counterparts. Further analysis showed that these women veterans were more likely to be older and better educated than their male counterparts (given that most of the women were nurses or other professionals during service), and that the onset of their PTSD resulted more from the medical traumas they witnessed and the sexual assaults that they suffered. However, in the early 1980s, the Government Accountability Office (GAO) issued reports that documented the lack of VA data on women veterans, as well as the concern that those who identified as veterans (since many did not) and used the VA did not feel safe at medical facilities (nor did women feel that the facilities did a good job at accommodating their needs). There was also a lack of information regarding the benefits and services available to women veterans. The NVVRS began to inform the VA regarding the types of programs that it needed specifically to compensate and treat women from their disability perspective. The VA developed its “Women Are Veterans Too” campaign to help increase awareness of available benefits and services and increase women’s utilization of VA resources. Nevertheless, problems persist today with women not identifying themselves as veterans and not thinking that they are entitled to the same benefits as male veterans. By the 1990s women were averaging over 10% of the force, and when the Gulf War struck, 400,000 women deployed. In 1992, the National Defense Authorization Act repealed the exclusion that kept women from flying combat missions, and in 1994 the combat exclusion that kept women off warships was also lifted (National Center for Veterans Analysis and Statistics, 2011). With the additional roles and responsibilities came additional risks, and more and more women have been involved in training accidents, have been exposed to safety hazards, have experienced unwanted sexual contact, and have endured dangerous deployments, which have led to increases in disabilities among women veterans. In 1992,13 Congress expanded counseling and treatment services for military sexual trauma (MST14) within the VA healthcare system to all active duty or National Guard or Reserves who were active duty for training, regardless of eligibility for VA healthcare. The law requires the VA to provide medical care and psychological counseling to overcome trauma resulting from “a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment,” further defined as “repeated, unsolicited, verbal or physical contact of a sexual nature, which is threatening in character” (38 U.S. Code Section 1720D). The VA will also provide compensation for a PTSD diagnosis resulting from MST. The Veterans Benefits Administration (VBA) requires evidence from DoD

13 Public Law 102-585. 14 MST is a term used by the VA to describe a set of experiences. It is not a diagnosis contained in the DSM, nor is it a criminal code under the justice system. 19. Women Veterans with Disabilities 343 documentation, law enforcement, medical personnel, family, friends, peers, or a chaplain related to any witnessing or performance issues related to the trauma (Department of Veterans Affairs, 2012). MST compensation is applied for in the same way as benefits for any other disability. However, the challenge in obtaining these benefits results from the level of dificulty veterans have in producing the required evidence that the VA needs to rate a claim. Since most victims do not report the crime while on active duty because of the stigma and negative career impacts (real or precieved) (Frayne, 1999), it is usually many years later that they will seek compensation, and the ability to produce evidence is lost (a situation similiar to that of the Civil War nurses who needed to find witnesses willing to file affidavits testifying to their experience and resulting symptoms). Since it is often difficult to produce this level of evidence, clinicians conducting disability exams need to be aware and sensitive to the nature of MST when narrating those cases and to record as much of an oral history as possible. The 2001 National Survey of Veterans found female veterans to be younger than their male counterparts, more likely to have college degrees, and a higher percentage classified themselves as Black. Women surveyed were also more likely to seek care for chronic pain issues and arthritis than men, who sought care more often for high blood pressure. However, men and women were equally as likely to seek care for eye or vision problems (Department of Veterans Affairs, 2001). Women veterans are more likely to seek healthcare at younger ages. The top three diagnostic categories for which the VA treated female veterans in 2004 were hypertension, depression, and hyperlipidemia. In a special report on the work of the Congressional Black Caucus, Veterans’ Brain Trust, Estella Norwood Evans reported that African American women represent the largest group of minority women serving in the military at 30.8% (while only 12% of the US population), which means that they serve in a greater percentage than their African American male counterparts. However, these women were more likely to come from and endure poverty, even while on active duty. Additionally, they were more likely to suffer unwanted sexual contact and hazing, but had less access to adequate VA services, which also resulted in the misdiagnosis of physical or psychiatric disorders (Evans, 2004). A diagnosis by a VA or other medical doctor is required as evidence for a service-connected disability, which further impacts these women’s ability to receive VA compensation or access to other programs. According to the VA as of 2013, there were almost 22 million American veterans, dating back to the early part of the twentieth century. Among that population were 1,692,398 female veterans. They represent about 8% of the total veteran population. But in the current US Armed Forces, women have grown to be 15% of active duty forces, which means that there are 121,700 serving female soldiers, sailors, airman, and Marines. Among that population in 2013, there were 7,200 females on deployment 344 Women at War overseas. Therefore, the female segment of the veteran population will grow to about 15% as well by 2035, while the overall veteran population will decrease with the passing of World War II and Korean War veterans. Since September 11, 2001, women have engaged in more combat support roles, which will increase following the 2013 rescinding of the ban on women serving in combat units and occupations. The numbers of female troops being exposed to the hardships of military life, combat, and disease will increase. More than 220,000 women have served in Operation New Dawn (OND), Operating Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF). As of January 14, 2014, the DoD casualty report notes that there were 51,802 wounded, ill, and injured (WII) Service members and 6,791 deaths (Department of Defense, 2014) with 1,715 combat zone amputees (Fischer, 2013). A 2010 study notes that of the deployed female Service member population, there were over 120 deaths, 620 injuries, and over 20 amputations. Although these women faced the same challenges of adjusting to an amputation as would others, these women noted that a positive recovery could be attributed to their military attitude and training, social support, and finding a sense of purpose and meaning as a result of their service (Carter, 2011). In general, when rating disabilities, the VBA today follows the statutes outlined in Title 38 of the United States Code and the 38 Code of Federal Regulations, which delineates procedures for rating conditions and adjudicating claims made by veterans and their families. In 2007, the Veterans Disability Benefits Commission (VDBC) observed that the VASRD outlines 14 body systems that encapsulate 700 diagnostic codes. The overarching body systems include the musculoskeletal, visual, auditory, respiratory, cardiovascular, digestive, genitourinary, hemic and lymphatic, skin, endocrine, neurological and convulsive, dental and oral disorders, mental disorders, and gynecological and breast disorders. The VASRD rates disabilities on a zero to 100% scale in 10-degree declinations, and computes additive disabilities with a combined rating formula based on the remaining level of function. In order for a claim to be adjudicated in favor of the veteran, there must be three crucial pieces of evidence: (1) proof that the condition was incurred or aggravated by military service, (2) a current diagnosis, and (3) a nexus between the two. Clinicians are crucial to the evidence-building process. Treatment notes and exams need to identify the military circumstances that led to a diagnosis and the continuous impact that the condition is having on the veteran’s quality of life. This sensitivity is particularly important in the clinical environment with female veterans as patients since they have a harder time identifying their military service as even eligible for VA benefits, and then have an even greater challenge producing evidence of events, such as MST or combat-related PTSD. Over the years, female veterans have testified at several Congressional hearings on not understanding the 19. Women Veterans with Disabilities 345

VA system and its applicability to them or not being believed when they reported their traumas or injuries to clinicians who were uneducated on the roles that women play in the military. According to Delilah Washburn, “Because females are officially excluded from ‘combat roles’ in the military,15 women veterans have a greater burden of proof in establishing the link between PTSD and combat. . . . Because there is no clear front line on the ground in Iraq and Afghanistan, female service members are exposed to direct fire, Improvised Explosive Devices (IEDs), and constant threats from insurgents without the benefit of the awards and decorations to prove it” (Washburn, 2009). In 2011, there were 3,354,741 veterans receiving a service-connected disability from the VA (US Department of Veterans Affairs, Veterans Benefits Administration, 2011). Gulf War era veterans were over 1.2 million of that population, in which the female demographic continues to grow. In 2011, 217,038 veterans began receiving disability compensation; women were 16,546 of that population. A 10% disability rating was the most common for both genders. While 305,510 males were awarded 100%, only 17,860 women saw that level of an award by the VA (US Department of Veterans Affairs, Veterans Benefits Administration, 2011). The top 10 most common disabilities for all veterans were (in descending order) tinnitus, hearing loss, PTSD, scars, diabetes, back strain, knee range of motion limitations, hypertension, traumatic arthritis, and knee impairment. Within the gynecological body system, uterus removal was the most common disability with 14,779 cases, followed by removal of uterus and both ovaries with 13,296 cases, and then benign growths within the reproductive system or mammary glands in 7,683 cases. Women are most likely to be service connected today for PTSD, lower back pain, and migraines (US Department of Veterans Affairs, Veterans Benefits Administration, 2011). If eligible for VA medical care, then they are entitled to all primary and specialty care services, residential treatment, and gynecological and reproductive health services, which include contraception, menopause management, and cancer screenings through Pap smears and mammography. Civilian-provided maternity care and a week of newborn care are covered by the VA, along with limited infertility evaluation and treatment (Department of Veterans Affairs, 2013). Women veterans are likely to partake in Vocational Rehabilitation and Employment (VR&E), which assists disabled veterans in obtaining an education and entering the workforce and assists those who cannot work with independent living skills. VR&E is available for 10 years post military discharge, and most veterans are eligible with a 10% disability rating. Women comprised 20% of the participation rate within the VR&E program. Additionally, over 80% of women use their GI Bill benefits, and 12% continue on to advanced degrees (Department of Veterans Affairs, 2011).

15 The removal of this ban should change the ability of women to prove combat experiences. 346 Women at War

In studies conducted for the VDBC, the CNA Corporation found that “as the degree of disability increased, generally overall health declined,” with mental disabilities impacting physical health more than the converse. Furthermore, when comparing disabled male veterans to their non-disabled counterparts, there was a slight loss in earning capacity16 below parity, but for female veterans it was slightly above parity (Eric Christensen, 2007). Disabled women veterans were less likely than their non-disabled veteran counterparts to be employed across their life span and across levels of disability (10%–100%). They were also less likely to be employed in comparision to the general population group. Therefore, without VA compensation, disabled female veterans would fare worse than other non-disabled comparison groups (Eric Christensen, 2007). Women in general earned less than men across all spectrums. Ultimately, the CNA found that the greater impacts of disability were associated with younger age at onset and mental versus physical disabilities, not necessarily gender. In addition to all of the benefits and services available through the VA, the Department of Defense offers programs to facilitate maintaining those on active duty and in the National Guard and Reserves through its Medical Treatment Facilities and its Tricare network. The Transition Assistance Programs (TAP) helps Service members access the VA and prepare for civilian life. A joint VA/DoD Disability Evaluation System (DES) has been designed to expedite the process between medically discharg- ing from the Services and filing a VA disability claim. For those not being medically discharged from the Services, they can still file a VA claim through a Benefits Delivery at Discharge (BDD) process. Benefits information is available through an eBenefits portal; if, after separation, a veteran still wants to file a claim, it can be done online through the www.va.gov website. The DoD Computer/Electronic Accommodations Program (CAP) provides assistive technologies to individuals with disabilities who want to continue in government employment. Additional info can be found at www. cap.mil to assist those with impaired vision or hearing, dexterity loss, cognitive impairments, and other communication deficits. Besides the government programs, there are a multitude of community service programs and resources dedicated to assisting veterans in overcoming the adversity that disability brings. There are over 15,000 sources listed on the National Resource Directory (www.nrd.org) dedicated to connecting wounded warriors and their families with federal, state, local government, and nonprofit organizations. The Veteran Service Organizations (i.e., the American Legion, Disabled American Veterans, Veterans of Foreign Wars, Iraq and Afghanistan Veterans of America, etc.) assist veterans with

16 Earning capacity was calculated by taking the ratio of earned income and adding VA Service Connection Compensation. 19. Women Veterans with Disabilities 347 filing VA disability compensation claims and offer other social support. There are specialized programs that assist women veterans, such as the Service Women’s Action Network (SWAN), which provides legal support for VA claims and appeals. The Wounded Warrior Project has also instituted summits for women designed to build their resilience while recovering from disabling injuries and illnesses.

CONCLUSION

In general, recognition and compensation for military service have been a point of great debate from generation to generation. Societal beliefs that military service was a duty of every American and did not warrant compensation changed as early as post–Revolutionary War, as veterans aged and suffered more deficits than their non-veteran peers. Military service has always had a physical, psychological, economic, or social impact on those who served and their families. For some, it was to their bet- terment. They learned resilience and how to overcome adversity with a positive attitude and the continued use of military skills; however, as studies have demonstrated over time, even limited disability will have an effect on one’s quality of life. For the subset of women who served this nation, that service has been the subject of much debate as well. The value that society places on the roles and functions that military women can undertake remains controversial. The way in which women were awarded or compensated for their service was very much based on the values of their era. Clinicians today need to assess their own beliefs about the military and women in uniform before evaluating or treating this population. Military cultural competency training is recommended, such as that offered by the Center for Deployment Psychology.17 Each time a generation of women stepped up to serve, they added to the national understanding of the capabilities that women had, and benefits and services to support Service women were added to the federal benefits package. It was not until after the Vietnam era that women were given full and equal benefits to their male counterparts, but it took an array of advisory committees, Congressional hearings, and government reports to document their needs and the inadequacies of the support available to them to make it happen. Often the benefits available to military widows precipitated the debate on benefits offered to military Service women. Over the ages, women veterans were their own best advocates as they took leadership positions and made the political changes necessary. From Molly Pitcher to Dorothea Dix and her nurses to Congresswoman Tammy Duckworth,18 the first disabled female veteran to

17 See www.deploymentpsych.org/military-culture. 18 A former Army helicopter pilot who lost both legs in Iraq in 2004. 348 Women at War serve in the US House of Representatives, women have not let adversity, disability, or political opinion stand in the way of their service. Remuneration, compensation, and other benefits came later.

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Ridgeway, J. D. (2013). Recovering an institutional memory: The origins of the modern veterans benefits system from 1914 to 1958. Veterans Law Review, 1–55. Schultz, J. E. (2004). Women at the front: Hospital workers in Civil War America. Chapel Hill: University of North Carolina Press. Straubing, H. E. (1993). In Hospital and Camp: The Civil War Through the Eyes of Doctors and Nurses. Mechanisburg: Stackpole Books. The President’s Commission on Veterans’ Pensions. (1956).Veterans’ benefits in the United States: A report to the President. Washington, DC: The White House. United States Code Section 1720D. (n.d.). US Army Womens Museum—Ft. Lee, VA. (n.d.). Retrieved November 30, 2014, from Margaret Corbin and Mary Ludwig Hayes McCauley: Revolutionary War (1775–1783): http://www.awm.lee.army. mil/research_pages/margaret_corbin.htm US Department of Veterans Affairs, Veterans Benefits Administration. (2011).Annual benefits report fiscal year 2011. Washington, DC: Department of Veterans Affairs. Veterans Administration. (1933, March 20). The United States Veterans’ Administration schedule for rating disabilities: Under the Authority of Public, No. 2, 73 Congress. Washington, DC: Government Printing Office. Veterans Administration. (1945). Schedule for rating disabilities: 1945 edition. Washington, DC: US Government Printing Office. Veterans Administration. (1971). Economic validation of the rating schedule. Washington, DC: Office of the Administrator of Veterans Affairs. Veterans Administration. (1984). National Vietnam Veterans Readjustment Study. Washington, DC: Veterans Administration. Veterans Disability Benefits Commission. (2007).Honoring the call to duty: Veterans’ disability benefits in the 21st century. Washington, DC: Department of Veterans Affairs. Women during the war. (2013, July 21). Retrieved from http://war1812.tripod.com/women.html.

Index

Italicized page numbers represent figures, tables, or boxes, on the designated page

Abma, J. C., 86 head injury rates, trends, 219, 220 abortion, 63–64, 82, 83, 85, 124, 251 median length of deployments, 8 acclimation to separation from families, 188–190 post-childbirth deployment restriction, 185 administrative separations, 173–174 PTSD prevalence, 26 Afghanistan sexual abuse data, 282 combat unit participation, 135 Southwest Asia deployment data, 7 female deployments, 22 suicide ideation data, 244, 254, 256 HSS CJOAA-A assessment, 50–51 2002-2011, casualties, 9, 10 IED dangers, 345 2002-2011, deployment data, 7 limited female PTSD data, 23 Women Air Force Service Pilots, 337 mefloquine antimalarial use, 105 Wounded Warrior program, 171 TBIs, 216, 218, 224, 226 Air Force Nurse Corps, 339 use of female combat medics, 137, 142 Albright, T. S., 85, 86 AFHSC. See Armed Forces Health alcohol abuse/misuse, 4, 18, 24, 164, 167, 212, Surveillance Center 229, 252, 268, 277 Afifi, T. O., 248 Alzheimer’s disease, 227–228 Africa, xv, xxi, 105 ambulatory care visits, post-deployment, 14, 15 African Americans amenorrhea (lack of menses), 57, 58, 59, 60, 61, combat medic role, 138, 138 65, 86, 338 suicide attempts, 246 American College of Obstetricians and 2002-2011 deployment data, 5–6 Gynecologists, 63, 87–88 women service data, 343 American Congress of Rehabilitation Agency for Healthcare Research and Quality Medicine, 230 (AHRQ), 57 American Indian/Alaskan Natives, suicide Air Force rates, 245 breastfeeding provisions, 185, 186 American Legion, 346 child-care separation provision, 186 American Psychiatric Association, xvii disability retirement study, 173 amyotrophic lateral sclerosis (ALS), 227–228 electronic medical records, 27 anemia, hemolytic, 100 female population data, 5 Anopheles mosquito, 93, 97

351 352 Index

Answer the Call campaign (MST Support IPV data, 283 Team), 328 Law of Land Warfare (FM 27-10), 160 antibiotics, 54, 128–129 malaria cases, 95, 96 antidepressant medication, 104, 227, 303 median length of deployments, 8 antimalarial medications medical evacuations, 30 adherence issues, 105, 110 mosquito avoidance strategy, 97–98 adverse effects/contraindications, 54, 100–101, non-hostile deaths, 9 102–103, 108–110 Office of Army Nurses, 332 atovaquone/proguanil, 102, 104, 105, 107–108 PDHRA program, 26, 27, 29–30, 164–165 chloroquine, 98–99, 100–101, 104, 105, post-childbirth deployment restriction, 185 106t, 107 pregnancies during Gulf War, 86 development, testing issues, 98–99 psychological health assessments, 313 gender-based reaction differences, 93–94 PTSD data, 24, 26, 27, 29, 30 mefloquine, 85, 94, 98, 99, 101–105, 102–104, Southwest Asia deployment, 7 106, 107–109 TBI data, 17, 218, 219, 220, 230 neuropsychiatric reactions, 94, 102–103, 2002-2011, casualties, 9, 10, 10 106, 108 2002-2011, deployment data, 7 pharmacokinetic/pharmacologic effects, 94 uniform sizing system, 64–65 policy limitations, usage considerations, 106 UTI data, 52 primaquine, 100, 104–105, 106, 107 Warrior Transition Unit, 171 selection considerations, 104–110 Women’s Army Auxiliary Corps, 337–338 anxiety disorder, 18, 224, 251, 303 Women’s Army Corps, 338 Araneta, M. R. G., 82–83 Army Knowledge Online (AKO), 186, 198 ARFORGEN (Army Force Generation) process, Army Nurse Corps (ANC), 95, 135, 162, 335 158–159 Army Nurses Pension Act (1892), 334 Armed Forces Health Surveillance Center Army Patient Administration Systems and (AFHSC), 3 Biostatistics Agency (PASBA), 57 analysis limitations, 18–19 asymmetric warfare and counterinsurgency, birth defects, retrospective cohort 159–161 study, 83–84 atovaquone/proguanil (antimalarial management of DMSS, 4 combination), 102, 104, 105, 106, 107–108 pregnancy hospitalization data, 81 atrial flutter, 101 PTSD post-deployment survey, 29 austere environments TBI incidence review, 218 bathroom issues, 50, 51, 53, 55 2009, mental health analysis, 18 common conditions, 67 2010, mental health analysis, 17–18 constant threat of engagement, 49 Army contraception issues, 61, 67 administrative separations, 173–174 identified barriers and gaps, 68–70 breastfeeding provisions, 185, 186 menses management concerns, xix, 51, 56, 65 child-care separation without pay pre-deployment preparation, 19, 64, 197 provision, 185 urogenital hygiene concerns, 65 Civil War Union nurses, 135 water deprivation concerns, 53 combat exposure training, 31–32 Australia, 34–44 combat medics, 136–138 domestic violence in, 36 counterinsurgency doctrine, 159–160 gender-related cultural issues, 34–36 educational benefits, classes and history of women in wars, 34 workshops, 168 untold narratives of women in war, 42–43 electronic medical records, 27 Australian Army Nursing Service, 43 embedded behavioral health providers, 162 Australian Defence Force Academy (ADFA), 36 female population data, 5, 22 Australian Defence Forces (ADF) head injury rates, trends, 219, 220 access to services challenges, 41–42 hospitalization/long-term care benefits, 336 combat-related deaths, injuries, 38 Index 353

DVA, post-discharge study, 39–40 blast-induced TBI, 212–213, 216–217 gender diversity strategies, 37 Blueprint for Action on Breastfeeding (HHS), 66 gender-specific health challenges, Boer War, 38 38–39, 40–41 borderline personality disorder (BPD), 253 growing occupational challenges, 39, 41 Boyle, B. H., 80 growth of women’s contributions, 39–40 Bradley, Omar, 340 reluctance to take “pioneer roles,” 44 Bradley Commission, 340–341 sex discrimination in, 36–38 brainstem neurotoxicity, of primaquine, 100 Australian Human Rights Commission, Bray, R. M., 250 36–37, 37, 41 breastfeeding provisions, xix, 185, 186–187 Australian Vietnam Veteran Female Cohort, Brigade Combat Teams (BCTs), 26–27, 28, 136, health outcomes study, 39 161–162, 174 Australian War Memorial exhibition, 43 Broderick, Elizabeth, 36 Authorized Medical Allowance Lists (AMAL, for Broshek, D. K., 223 ships), 124, 125 Bukowinski, A. T., 84 Authorized Medical Allowance Lists (for Bullwinkel, Vivian, 43 submarines), 124 Bureau of War Risk Insurance, 336 aviation training, 121 burn pit exposure, birth defect studies, 84–85 avoidant personality disorder, 253 Call to Action (US Surgeon General), 66 Baca-Garcia, E., 247 Camp Pendleton, California, 197 bacterial vaginosis, 56 Camp Taji, Iraq burn pit site, 84 ballistic missile submarines, 123 Campbell, Jacquelyn, 279 basic training, xvii, 180, 282 Caralis, P. V., 288 bathrooms Carter, Jimmy, 122 absence of, xix Cashier, Albert, 335. See also Hodgers, Jeannie in austere environments, 50, 51, 53, 55 Cazares, Paulette T., 126–132 hygienic concerns, xix, 52 Center for Deployment Psychology, 347 segregated arrangements, 305–306 Centers for Disease Control and Prevention battering, 266, 275.See also intimate partner (CDC), 52 violence Behavioral Risk Factor Surveillance Battle of Manmouth, 331 Survey, 270 Bay, E., 223 birth defect monitoring program, 82 BCTs. See Brigade Combat Teams injury-/violence-related statistics, 244–245 Beautrais, A., 258 intimate partner violence data, 268 behavioral health providers (clinicians) traumatic brain injury data, 211–212 breastfeeding resources for, 186 cerebral infarct, 217 contraception discussions, 149 cervicitis, 338 embedding of, 162, 168–169, 174, 256 Chandra, A., 86 malaria prevention role, 108, 110 Chantelois, J. L., 85 preparation for deploying mothers, 181–185, Chaplain corps, 121, 185 186, 188, 193 Chapple, Phoebe, 42 sexuality guidance, 148, 152 child loss, and suicide ideation, 251 suicide-related recommendations for, 255–259 child-care issues, 167, 185–188, 204 therapeutic tools for, 193 children of mothers who deploy Women in Combat Symposium, xvii books for, 183 Behavioral Risk Factor Surveillance Survey clinician role in preparation, 181–185 (CDC), 270 conflict/guilt of mothers, xxi, 167, 180 benefits programs.See disability and pension family activities for, 184–185 programs family care plans, 187–188, 192, 198 Biggs, R. L., 80 feelings of pride for mother, 189 birth defects, deployment-related, 81–85 guilt of mothers, xxi, 167 354 Index children of mothers who deploy (Cont.) Navy Nurse Corps, 121, 335 health/well-being concerns, 41 Revolutionary/Civil Wars, 135 very young children, 185–187 roles of, 136 children’s books about deploying mothers, World War II, 135 183, 184 Combat Support Hospitals (Iraq), 52, 54 chlamydia, 87 Combined Joint Operations Area-Afghanistan chloroquine (antimalarial), 98–99, 100–101, 104, (CJOA-A), 50–51 105, 106, 107 Coming Together Around Families (toolkit for chloroquine-resistant malaria, 105 families), 183 Chung-Park, M. S., 81 communication Civil War couples’ overexposure issues, 200 female nurses, 135, 332, 333, 335 dysfunctional behaviors, 161 impact of female service, 334 with family during deployment, 184, 198, 200 MST during, 343 guidelines for effectiveness, 303–304 support services, 332 intimate partner violence issues, 276 Union troops disability benefits, 336 ostracism of a team member, 316 women enlistments as men, 334 pre-deployment challenges, 197, 198, 202, 206 CJOA-A. See Combined Joint Operations reunion preparation and rules, 200–201, Area-Afghanistan 204–208 Clinical Classification System (CCS) Diagnostic role of embedded behavioral health Categories (AHRQ), 57 providers, 162 clinicians. See behavioral health providers compensation programs. See disability and (clinicians) pension programs closed-head injuries, 216 Computer/Electronic Accommodations Program Cluster B personality disorders, 253 (CAP), 346 Cluster C personality disorders, 253 concussions, 217, 223, 226, 229 CNA Corporation, disability study, 345–346 confidentiality, distrust in, 68 COAD (Continue on Active Duty), 171 Congressional Black Caucus, 343 Coast Guard Conlin, A. M. S., 84 breastfeeding provisions, 185, 186 consensual sex in the war zone child-care separation provision, 186 coercive sex vs., xx, 152 median length of deployments, 8 contraception issues, 58, 149 post-childbirth deployment restriction, 185 as counseling point, 65 PTSD prevalence, 26 Danish/British strategies, 152 Soutwest Asia deployment, 7 lifting of ban, xix, 148 2002-2011, casualties, 9, 10 Consolidation Act (1873), 333 2002-2011, deployment data, 7 Continental Army, 159, 330–331 Coast Guard Women’s Reserve, 337 Contingency Operating Base (COB) Speicher, cognitive framing techniques, 193 Iraq burn pit site, 83–84 colorectal cancer, 59 contraception/contraceptive use Columbia Suicide Severity Rating Scale austere environment concerns, 67 (C-SSRS), 256 availability variability, xx Combat Exclusion Law, 123 copper intrauterine device, 64 Combat Experiences Scale (CES, DRRI), 139 counseling points for servicewomen, 65 Combat Information Center (CIC), 129 estrogen/progestin, 59 combat logistics support ships, 122 goals for hormonal contraception, 58 combat medics, 134–145. See also US Army limited predeployment counseling, 149 Combat Medics, longitudinal study long-acting reversible contraceptives, 64, 88 Air Force Nurse Corps, 339 oral contraceptive pills, 58, 59–60, 79 Army Nurse Corps, 95, 135, 162, 335 Plan B, emergency contraception, 126, 148 behavioral health practice implications, progestin-only implant, 58, 62 144–145 progestin-only injection, 58, 61–62 Index 355

progestin-only pill, 61 Department of Defense (DoD) progestin-releasing intrauterine system, abortion restriction rule, 63–64 62–63, 64 antimalarial prophylaxis guidelines, 106t related genitourinary issues, 54 combat-related gender-based rules, 212 transdermal patch, 58, 60 Computer/Electronic Accommodations 2006-2012 data, 57 Program, 346 vaginal ring, 60, 61 Family Advocacy Program, 267, 269 counterinsurgency (COIN) doctrine, 159–160 Health Related Behaviors Survey, 63, 243, 247 Covassin, T., 223 Infant Health Registry, 84 Crisan, L. S., 86 IPV data, 269 Crompvoets, S., 40–42 mental health assessments, 313 cultural considerations for women veterans, sexual assault data, 64 304–305 sexual harassment policy, 249 Currier, M. M., 81 suicide data for military women, 245–246 cyberbullying, 36 suicide prevention efforts, 258–259 cytochrome P450 enzyme pathways, 100 TBI definition, 214–215 TBI tracking, xvi–xvii, 213 DACOWITS. See Defense Advisory Committee use of electronic medical records, 27 on Women in the Services wounded, ill, injured (WII) data, 344 Danger Assessment Scale (DAD), 279 Department of Veterans’ Affairs (DVA, Daughters of the American Revolution, 135 Australia), 39–40 De Vries, Susanna, 43 deployment preparation for mothers, 181–185 DEET, topical insect repellant, 97, 98 Deployment Risk and Resilience Inventory Defense Advisory Committee on Women in the (DDRI), 314 Services (DACOWITS), 123, 212, 340 Depo-Provera (progestin-only injection), 61–62 Defense Authorization Act (FY 2015), 60 depression Defense Casualty Analysis System (DCAS), 4 antimalarial side effect, 103, 104 Defense Enrollment Eligibility Reporting System Australian servicewomen, 38, 39, 41 (DEERS), 82 behavioral issues from, 172 Defense Health Activity, xvii combat-related risk, 136 Defense Logistics Agency, 69 domestic violence and, 24 Defense Manpower Data Center (DMDC), 3–4, eating disorders and, 252 29, 82, 83, 84 IPV and, 274, 275, 278, 279 Defense Medical Epidemiology Database MHAT survey data, 28, 28t (DMED), 218–219 mothers who deploy and, 167, 191 Defense Medical Surveillance System (DMSS), 4 PHQ-0 assessment, 136 Defense Women’s Health Research Program post-concussion syndrome and, 226 (DWHRP), xvii, 49 postpartum depression, 251, 256 goals of, 230 PTSD comorbidity, 18, 224, 247 Defensive Manpower Data Center (DMDC), 3–4 severity assessment, 143–144, 164 demographic profile of the active force, 1991 to SSG Perry, example, 157 the present substance abuse and, 252 combat casualties, by type, 9, 10 suicide ideation and, 244, 247, 249, 250, 251, healthcare while deployed, 10–11 253, 254, 279 median lengths, by service, gender, 8 TBI association, 212, 213, 215, 217, 223, 227, occupational categories, 8 229, 284 officers/enlisted personnel, active duty, 6 wartime commonality, xxi racial composition, male vs. female, 5–6 women veterans, 302, 303, 304 2002-2011, by gender, 7 Desmond, Tahana Marie, 183 2002-2011, medical evacuations, Southwest Dewall, C., 317 Asia, 11, 11–12 Diagnostic and Statistical Manual of Mental 2002-2011, Southwest Asia, 6, 7 Disorders (DSM), xxi, 23, 28, 351 356 Index diapers, 53 DVA. See Department of Veterans’ Affairs Dick, R. W., 223 (DVA, Australia) digestive system disorders, 10, 11, 13, 14, 215, dysentery, xxi, 38, 330 288, 344 dysfunctional group behaviors, 161, 172 Direct Combat Exclusion Rule, 143, 212 dysmenorrhea, 56–57, 58 disability and pension programs, 329–348 Army Nurses Pension Act, 334 eating disorders, 169–170, 252–253, 303 Bradley Commission report, 340–341 “Economic Validation of the Rating Schedule” Civil War, women’s service, 332–333, 332–335 (ECVARS, VA study), 341 CNA Corporation, disability study, 345–346 ectopic pregnancies, xix–xx, 50, 86–87, 124, 147 evaluation system, 172–173 Edick, Kathleen, 183 GI Bill, 193, 339, 341, 345 Edmonds, Sarah (aka Franklin Thompson), 335 McCauley, Mary, example, 331 electronic medical records MST compensation, treatment expansion, limited sharing ability, xvi 342–343, 344 malaria case review, 95 1923, hospitalization, long-term care monitoring of, 172–173 benefits, 336 simplicity of searches, 27 PTSD treatment expansion, 342, 344 under-reporting issues, 52 Public Law 877 (1945), 339 embarrassment, 68, 152, 271 Revolutionary War Pension Act, 330 embedding of behavioral health providers, 162, Sampson, Deborah, example, 330–331 168–169, 174, 256 Servicemen’s Readjustment Act, 339 emergency contraception (EC), 125, 126, 148 St. Clair, Sally, example, 331 endometrial cancer, 59 Transition Assistance Programs, 346 endometriosis, 59 VA/DoD Disability Evaluation System, 346 Enewold, L., 79 VASRD rating schedule, 336–337, 340, epidemiology 341, 344 of contraceptive use, 79–81 VR&E programs, 345 Defense Medical Epidemiology Database, War Risk Insurance Acts, 336 218–219 Disabled American Veterans, 346 of malaria in military women, 94–97, 96 divorce, 148, 164, 188, 196, 248, 273, 278, 282 of unintended pregnancy, 79–81 Dix, Dorothea, 332, 347 estrogen/progestin, hormonal DMSS. See Defense Medical Surveillance System contraception, 59, 60 Dobie, D. J., 25 Ethinyl estradiol (low-dose estrogen), 59 DoD Military Equal Opportunity (MEO) Evans, Carol Vaughan, 42 Program, 249 Evans, Estella Norwood, 343 DoD Suicide Event Report (DoDSER), 245–246, 259 Family Advocacy Program (FAP), 267, 269 DoD Suicide Prevention Office (DSPO), 245 family care plans, 187–188, 192, 198 domestic abuse. See intimate partner violence Farin, A., 221 domestic assault. See intimate partner violence FBI, Supplementary Homicide Report, 267 domestic violence. See intimate partner violence female endogenous hormones and TBI, 225–226 Douglas, B. H., 80 female improved outer tactical vest (FIOTV), 65 doxycycline (antimalarial) female prisoners of war (POW), 38–39, 338 contraindications, 54, 94, 101–102 female provider preference, 68 military sponsored trials, 99 Female Urinary Diversion Device (FUDD), usage considerations, 106 52–55, 53, 56, 69 DRRI. See Deployment Risk and Resilience Ferguson-Cohen, Michelle, 183 Inventory fertility, post-deployment, 41 drug use/abuse, 215, 244, 246, 247, 252 Finer, L., 80 Duckworth, Tammy, 347–348 First Pennsylvania Artillery, 331 Dunlop, Sir Edward “Weary,” 42 1st Force Support Group (FSG), 197 Index 357

1st Marine Logistics Group (MLG), 197 Hourani, L., 82, 250 Fleming, B., 160–161 Howard, Michelle, 123 fluid intake, withholding of, 53 HSS. See Health Service Support Fontana, A., 24 human sexuality. See sexuality in areas of forward operating bases (FOBs), 22 operation functional magnetic resonance imaging (fMRI) Hussein, Saddam, 3 studies, 318 hypertension, 171, 221, 284, 343, 345

Gan, B. K., 221 IDCs. See independent duty corpsmen gear, protective, urination difficulties, 52 ill-defined disorders, 2002-2011 data,11 , 11–12 Gender and War: How the War System Shapes Implanon (progestin-only implant), 62 Gender and Vice Versa (Goldstein), 152 improvised explosive devices (IEDs), 9, 16–17, gender-integrated submarines, 123 22, 345 General Medical Officer (GMO), 127 incontinence/incontinence pads, 40, 54 Generation X women, 179 independent duty corpsmen (IDCs), 124 genital infections, 87 Infant Health Registry (DoD), 84 genitourinary conditions. See infectious diseases, xxi urogynecologic issues injury-/violence-related statistics (CDC), 244–245 Gerberich, S. G., 222–223 insecticide risk factors, 97, 98 GI Bill, 193, 339, 341, 345 Institute of Medicine (IOM), 50 Gillibrand, Kirsten, 147 Integrated Disability Evaluation System Global War on Terror, xv, 159, 197 (IDES), 172 glucose-6-phosphate dehydrogenase (G6PD) International Classification of Diseases, deficiency, 100 9th revision, Clinical Modification Goldstein, Jonathan, 152 (ICD-9-CM), 10, 19 Goyal, V., 79 intimate partner violence (IPV), 24, 266–292 guided missile submarines, 123 in Australia, 36 guidelines for effective communication, 303–304 barriers for victims, 42, 268 Gutierrez, P. M., 254 causes, 164 gynecological issues. See urogynecologic issues with coercive control, 275 contextual analysis, 274–278 Hall, E. D., 223 co-occurring problems, 285–287 Hankin, S. S., 24 Danger Assessment Scale, 279 Hanna, J. H., 85–86 FAP report data, 269, 274 Hawaii Birth Defects Program (HBDP), 8282 Jennifer, victim example, 272–273 Hays, Ana Mae, 340 Mary, victim example, 272 Health People 2020 (HHS), 66, 81 mental illness and, 277–278 Health Related Behaviors Survey of Active Duty military sexual trauma and, 268–270, 278, Military Personnel (DoD), 63, 243, 247 280–283, 285–286, 288, 291 Health Service Support (HSS), 50–51, 53, 66 myths/facts about, 267–268 heart disease, 171 NISVS study findings, 269–270 hemolytic anemia, 100 previous terminology, 266–267 Heroic Australian Women at War (De Vries), 43 psychological risk factors, 254 Hilton, S., 82 PTSD association, 268, 277, 279, 286 Hines, J. F., 85 resistive violence, 276 Hodgers, Jeannie (aka Albert Cashier), 335 risk assessments, 279–280 Hoge, C. W., 166 risk factors, 278–279 Home Again (Silver Williams), 182 safety planning, 281 homelessness, xxi situational IPV, 276 hormonal contraceptives, 58, 58–59 statistics, 268–270 hospital ships, 135 substance abuse and, 268, 277–279, 281–282, hostile deaths, 2002-2011 data, 9, 10 286–287 358 Index intimate partner violence (IPV) (cont.) Krakow, B., 251 suicide ideation and, 248, 267, 274, 278, Kraus, J., 220 279, 284 Kuwait, MHAT II surveys, 28 TBI and, 278, 279 trauma and, 271, 279, 281–285 lactation, xix, 65–66 trauma-informed care for, 290–291 latrines. See bathrooms VA data, 288–289, 291 Law of Land Warfare (US Army FM 27-10), 160 victim behavior, 271–274 LBQT (lesbian, bisexual, queer, transgender), women veterans and, 270, 284, 286, 42, 280 287–289, 291 LeardMann, C. A., 26, 31 women vs. men, 229, 268 Leitgeb, 236, 222 intracranial injury, 214t, 218, 219 letter-writing, 185 Invisible Wounds of War-Psychological and levonorgestrel contraceptive devices, 58, Cognitive Injuries, Their Consequences, 59, 62–63 and Services to Assist Recovery study Libby, R., 152 (RAND), 284 Lindberg, L. D., 79, 80 Iraq logistics units, 22 burn pit site survey, 83–84 long-acting reversible contraceptives Combat Support Hospitals, 52, 54 (LARCs), 64, 88 combat unit participation, 135 Love, Lizzie: Letters to a Military Mom female deployments, 22 (Tucker McElroy), 183 GMOs in, 127 Love Spots (Panier), 183 gynecological issues data, 57, 148–149 Lowe, N. K., 68 IED dangers, 345 Lybrel (oral contraceptive), 59 limited female PTSD data, 23 mefloquine antimalarial use, 105 Mackerras, Josephine (Mabel), 42 MHAT surveys, 28, 313–314 magnetic resonance imaging (MRI) studies, TBIs, 216, 218, 224, 226 317–318 UTI incident data, 52 malaria, 93–110. See also antimalarial Iraq and Afghanistan Veterans of America, 346 medications Iskra, Darlene, 122 Africa/Southeast Asia risk factor, xxi Israeli Defence Force, study of disabled Anopheles contact risks, 93, 97–98 veterans, 173 antimalarial development, testing issues, 98–99 Jarvis, B., 316–317 chloroquine-resistant malaria, 105 jelly bean jar, 184 history/epidemiology, 94–97 Jensen-Fritz, Sara, 183 insecticide risk factors, 97, 98 Joint Base Balad (JBB), Iraq burn pit site, 83 mosquito avoidance strategy, 93, 97–98 Jones-Johnson, Paula, 183 predeployment counseling, 94 journaling by families, 185 2000-2012, case summaries, 96 wartime assistance of women, 135 Kang, H., 25, 83 WW II, Army Malaria Research Unit, 42 Keep, L. W., 85 malnutrition, 38, 338 Kelso, Frank, 122 Mamma’s Boots (Miller Linhart), 183 Kessler, R. C., 23 Manual for the Deployment Risk and Resilience killed in action (KIA) Inventory (DRRI): A Collection of Measures 2002-2011 data, 9, 9, 10 for Studying Deployment-Related Experiences 2013 data, xxi of Military Veterans, 138, 139, 141, 142, King, Olive, 43 143, 314 Kirkness, C. J., 221 Marine Corps Korean War, 24, 95, 104, 135, 340, 343 breastfeeding provisions, 185 Kraft, Heidi, 182 child-care separation provision, 185 Index 359

electronic medical records, 27 cycle regulation choices, 58 female overseas deployment data, 343 dysmenorrhea, 56–57 head injury rates, trends, 219, 220 irregularities, management, 40, 50 median length of deployments, 8 limited predeployment counseling, 57 post-childbirth deployment restriction, 185 lost duty days, 57 proportion of women, 5 menorrhagia, 58 psychological health assessments, 313 2006-2012 data, 57 PTSD data, 26, 27 mental health, 311–320 sexual harassment risk factors, 285 behavioral risk factors, 165–166, 167 Soutwest Asia deployment, 7 challenges for women, 41 TBI data, 17 CNA Corporation, disability study, 345–346 2002-2011, casualties, 9, 10 combat-related sexuality issues, 149 2002-2011, deployment data, 7 DDRI assessment, 314 women Reserves unit, 335 impact of sexual assault, xx Wounded Warrior program, 171 IPV and, 271, 274, 278–280, 283–287, 292 Marine Corps Women’s Reserve, 337 medical evacuations due to, 12, 30 Martinez, G. M., 86 mothers in war issues, 178, 181, 183, 191 masturbation, 149 MST, outpatient services, 324 McBride, Sharron G., 183 ostracism issues, 315–319 McCaskill, Claire, 147 phone support services, 168 McCauley, Mary Ludwig Hays, 331 service-related studies, 311–315 McCauley, William, 331 stigmas/barriers to seeking help, 141, 144t McGee, Anita Newcomb, 135 suicide ideation and, 249–250, 253, 257–259 MEDEVAC process on ships, 124, 129 TBI and, 218, 224 medical care on ships, 123–126 2002-2011 data, 11, 11, 12 Cazares’ clinical pearls, 131–132 2010 MSMR analysis, 17–19 Cazares’ personal experience, 126–131 VA facilities diagnoses, 25 NSMRL report, 124 women veterans’ issues, 302–303 osteoporosis risk factors, 125 Mental Health Advisory Teams PDHA Form modifications, 126 (MHATs) pharmacy/formulary requirements, 125, 131 behavioral risk factors guidelines, 165 pregnancy concerns, 124, 125 combat experiences studies, 139, 141 medical evacuations combat troops focus, xviii for behavioral health issues, 26, 30 mental health assessments, 313–314 categories, 11, 11–12 PTSD findings, xx–xxi, 26–28, 28 for malaria, 94, 110 Mental Health Services (MHS) program, 326 for pregnancy, xix–xx, 58, 85–86, 147 metritis, 338 tracking of data, 27, 30 mild TBI (mTBI), 212–217, 220–223, 226–227 Medical Evaluation Board, 157, 171, 172 Military Crisis Lines (800 number), 257 “Medical Implications of Women on Submarines” Military Health System (MHS) (NSMRL), 124 admissions data, active component medical outcomes from TBI, 220–222 women, 15 medical separations, 172–173 funding of MST Support Team, 326 Medical Surveillance Monthly Report (MSMR), 10 lethal injury preparedness, 71 mefloquine (antimalarial), 85, 94, 98, 99, OCP’s use comparison, 79 101–105, 106, 107–109 ongoing research, preparation, 50, 66–67, 71 memory box, 184 post-deployment encounters data, 13, 14 menopause/perimenopause, 303, 338, 345 VA comparison, xvi, 50 menstruation/menstrual disorders, 56–58 Military Medicine journal, xvii amenorrhea, 57, 58, 59, 60, 61, 65, 86, 338 Military OneSource (website), 178–179, 180, austere environment management, xix, 41, 57 183, 185 counseling points for servicewomen, 65 military police, 22 360 Index military sexual trauma (MST) mosquito avoidance strategy, for malaria, Answer the Call campaign, 328 93, 97–98 in Brigade Combat Teams, 161 mothers in war, 167–168, 178–194 career impact, 249 acclimation to separation, 188–190 compensation, treatment expansion, 342–343 benefits to area of operations, 189–192 definition, 323 benefits to mothers, post-deployment, 192 epidemic levels, 147 challenges in deployment, 190 IPV and, 268–270, 278, 280–283, 285–286, child-care issues, 167, 185–188, 204 288, 291 clinician assessment questions, 184 Kirsten, example, 322–323 conflict/guilt in leaving children, xxi, 167, 180 mental health consequences, xx, xxi family care plans, 187–188, 192, 198 MHS program educational initiative, 326–327 materials for clinicians, 182–183 National Comorbidity survey findings, 23–24 new moms with very young children, 185–187 Naval fleet-wide training, 122 ongoing wellness screening, 183–184 outpatient mental health services for, 324 predeployment, family activities, 184–185 outreach to veterans, 327–328 predeployment, preparations, 181–185, 188 Persian Gulf War data, 24–25 self-concept issues, 191–192 in POW camps, 38–39 social context, 179–181 as PTSD risk factor, 24–25, 26 weighing costs vs. benefits, 192–193 risk factors for post-deployment, 174 mothers who deploy, 167–168 self-reporting data, 24 Mr. Poe and Friend Discuss Family Reunion After staff education programs, 326–327 Deployment (aminated cartoon), 182 suicide ideation and, 247 MST Resource Homepage (VA), 326 treatment services expansion, 342 MST. See military sexual trauma 2010 Gender Relations Survey, 64 Murdoch, M., 24 under-reporting of, 19 musculoskeletal system disorders, 11, 11, VA data, 285 15, 40, 67 VA response to, 321–328 Mushkudiani, N. A., 222 veterans’ access to care for, 327–328 Musialowski, R., 288 veterans’ screening programs, 323–325 My Mommy Wears Combat Boots (McBride), 183 Military Youth Coping With Separation: When a Family Member Deploys (DVD), 182 National Center for PTSD (Department of Millennium Cohort Study findings Veterans Affairs), 139 eating disorders, 170 National Comorbidity Survey, 23–24 mothers who deploy, 167 National Guard and Reserves oversampling of females, 31 ARFORGEN process applicability to, 83–84 PTSD, 23, 25–26, 167 counseling services eligibility, 342 sexual assaults, 285 GI Bill eligibility, 341 Millennium Study (2014), xviii healthcare eligibility, 18–19 Miller Linhart, Sandra, 183 IPV data, 268–269 minocycline, 99 Millennium Cohort study sampling, 31 Mirena® IUS (intrauterine system), 62–63 psychological health assessment, 314–315 Mommy, You’re My Hero (Ferguson-Cohen), release from duty assessment, 171 183 reproductive health survey inclusion, 83–84 mommy doll, 184 traumatic stress/depression data, 164–165, 166 mood disorders. See anxiety disorder; depression; VA services eligibility, 346 panic disorders; suicide-related ideation and National Health and Nutrition Examination behaviors Survey (NHANES), 79 Moore, D. W., 223 National Intimate Partner and Sexual Violence morale and leadership, 161–163 Survey (NISVS), 268, 269–270 Morrison, David, 37–38 National Resource Directory, 346 Mosher, W. D., 86 National Survey of Veterans (2001), 343 Index 361

National Trauma Database, 221 Nurse Corps National Vietnam Veterans Readjustment Study Air Force Nurse Corps, 339 (NVVRS), 341 Army Nurse Corps, 95, 135, 162, 335 NATO treatment facilities, 190 Navy Nurse Corps, 121, 335 Naval History and Heritage Command, 121 “Nurses: from Zululand to Afghanistan” Naval Submarine Medical Research Laboratory (Australian War Memorial exhibition), 43 (NSMRL), 124 NuvaRing (vaginal ring), 61 Navy birth control data, 80 O’Boyle, A. H., 80 breastfeeding provisions, 185, 186 Office of Army Nurses, 332 child-care separation provision, 186 oophoritis, 338 electronic medical records, 27 Operation Anode (Solomon Islands), 39 female service on ships, 121–132 Operation Astute (East Timor), 39 head injury rates, trends, 219, 220 Operation Desert Shield (1990-1991), 5 history of malaria study, 95 Operation Desert Storm (1991), 5, 22 IPV data, 283 Operation Enduring Freedom (OEF) median length of deployments, 8 female combat levels, 250 post-childbirth deployment restriction, 185 female death data, 283 postpartum deployment deferment, 66 female deployment data, 6, 22, 191, 196 pregnancy outcomes evaluation, 82 female genitourinary encounters, 67 preparations for deployment, 197 female support data, 191 PTSD data, 26, 27 health profile, military women, 9–19 reunion preparations, 197–198, 209 mental health assessments, 313, 315 Soutwest Asia deployment, 7 MHAT VI survey findings, 28 2002-2011, casualties, 9, 10 post-deployment Warrior Transition Units, 2002-2011, deployment data, 7 171–172 women Reserves unit, 335 PTSD risk factors, 25, 28, 30, 303 Wounded Warrior program, 171 total female deployment data, 344 Navy and Marine Corps Public Health Center 2002-2011, KIA/WIA data, 9, 9, 10 (NMCPHC), 198 2002-2011 medical evacuation data, 11, 12 Navy Knowledge Online (NKO), 198 2009, MSMR post-deployment study, 18 Navy Nurse Corps (NNC), 121, 335 use of female combat medics, 137 The Navy Times, 132 Operation Iraqi Freedom (OIF), ix, xv, 3 Neuhaus, S., 40–42 female combat levels, 250 neurobehavioral outcomes from TBI, 222–225 female death data, 283 neurocognitive rehabilitation, 227 female deployment data, 6, 22, 191, 196 neurodegenerative disease and TBI, 227–228 female genitourinary encounters, 67 neuropsychiatric reactions, to antimalarials, 94, female support data, 191 102–103, 106, 108 health profile, military women, 9–19 New Jersey National Guard Unit, 166 mental health assessments, 313, 315 Nexplanon (progestin-only implant), 62 MHAT II survey findings, 28 Nichol, K. L., 24 post-deployment Warrior Transition Units, Nida, S., 317 171–172 Nielson, P. E., 52, 57 PTSD risk factors, 25, 28, 30, 303 nightmares, 29, 103, 108, 251, 283 total female deployment data, 344 9/11 terrorist attack, xv, xvii transdermal contraceptive patch issues, 60 non-battle injuries, 2002-2011 data, 11, 11, 12 2002-2011, KIA/WIA data, 9, 9, 10 non-blast TBI, 217 2002-2011 medical evacuation data, 11 non-Hispanic Whites, suicide rates, 245 2009, MSMR post-deployment study, 18 non-hostile deaths, 4, 9, 10 urinary tract infections data, 67 NSMRL. See Naval Submarine Medical Research Operation Joint Endeavor (Bosnia, 1995), 5 Laboratory Operation Just Cause (Panama), 5 362 Index

Operation KFOR (Kosovo, 1998), 5 onset of combat unit participation, 135 Operation New Dawn (OND), ix, xv pregnancy data, 78 post-deployment Warrior Transition Units, PTSD data, 24 171–172 sexual harassment rates, consequences, 24–25 total female deployment data, 344 unintended pregnancy data, 58, 85 2002-2011, KIA/WIA data, 9, 9, 10 women’s leadership on ships, 123 2002-2011 deployment data, 6 persistent post-concussion syndrome (PPCS), 2002-2011 medical evacuation data, 11, 12 226–227 Operation Restore Hope (Somalia, 1992-1993), personality disorders, 18, 173, 253, 278 5, 95, 105 PHQ-9. See Patient Health Questionnaire Operation Slipper (Middle East Area of physical sexual harassment, 24–25 Operations), 39 physical standards, challenges for women, 40 Operation Uphold Democracy (Haiti, physiological training, challenges for women, 40 1994–1995), 5 Plan B emergency contraception, 126 oral contraceptive pills (OCPs), 58, 59–60, 79 point-of-care (POC) testing kit, 69 oral disorders, 10 polytraumatic injuries, 216, 224–225, 226–227, Ortho-Evra (transdermal contraceptive 229, 231 patch), 60 Ponsford, J., 221 osteoporosis, 59, 125 pornography, 36 ostracism issues, 315–319 port-a-potties. See bathrooms Ottochian, M., 221 Post Deployment Health Assessment (PDHA), ovary-related health issues, 59, 338–339 26, 27, 29–30, 126, 164–165 Over There (Silver Williams), 182 Post-Battle Experiences Scale (DRRI), 139, 141 Over There book (Silver Williams), 182 post-concussion syndrome (PCS), 226–227 Over There MP3 recording (Kraft), 182 post-deployment health issues (2002–2011), 12–19 pain, physical, 317–318 ambulatory visits, one-year, 14, 15 pain, social, 317–319 hospitalizations, one-year, 13 Panetta, Leon, 212 inpatient care, 15 panic disorders, 247, 251, 303 mental health, 17–19 Panier, Karen, 183 reproductive health/birth rates, 15–16, 17 Parkinson’s disease, 225, 227–228 traumatic brain injury, 16–17 PART (practice of universal presumptive Post-Deployment Health Re-Assessment antirelapse treatment), 104, 105 (PDHRA), 26, 27, 29–30, 164–165 Paterson, Diane, 183 postpartum depression, 251 Patient Administration Systems and Biostatistics posttraumatic stress disorder (PTSD), 22–32 Agency (PASBA, Army), 57 associated mental/physical health issues, 25 Patient Health Questionnaire (PHQ-9), 139 Australian servicewomen, 38 Patient Protection and Affordable Care Act, 66 behavioral health evacuations, 30 pelvic floor instability, 40 combat-related association, xx–xxi, 167 pelvic inflammatory disease (PID), 59, 87 eating disorder association, 170 Penman, A. D., 81 female vs. male prevalence, 23–24, 25 pension programs. See disability and pension findings on existing data, 26–27 programs IPV association, 268, 277, 279, 286 perimenopause, 303 MHAT findings, xx–xxi, 26–28, 28 Permanent Change of Station (PCS) orders, 162, Millennium Cohort study findings, 23, 25–26 170, 244 MSMR, 2009 analysis, 18 permethrin, 97 National Comorbidity survey findings, 23–24 Persian Gulf War (1990-1991), xv nightmare symptom, 251 abnormal pap results, xx PDHA/PDHRA surveys, finding, 29–30 birth defects among veterans, 81, 82–83 post-deployment, male vs. female surveys, female deployment data, 5 29, 29–30 Index 363

post-deployment screening, 173 rape, 58, 63–64, 65, 170, 267, 268, 285 PTSD CheckList (PCL), 139 reading program for children, 185 as risk factor from sexual assault, 24–25 Real Warriors Campaign, 198 sexual assault and, xx Recommendations for Research on the Health of suicide-ideation association, 247, 249, 251 Military Women (IOM), 50 symptom severity scores, 143–144 Red Rover hospital ship (Civil War), 135 TBI comorbidity, 212, 227 Redeployed (Fleming and Robichaux), 160–161 Vietnam War data, 341–342 redeployment screening, 158–159, 164. See also practice of universal presumptive antirelapse ARFORGEN (Army Force Generation) treatment (PART), 104 process Pre-Deployment Health Assessment (PDHA), 126 Relief hospital ships, 135 Pre-Deployment Health Re-Assessment Renner, C., 222 (PDHRA), 126 repeat TBI, 217 pregnancy. See also contraception/contraceptive use; reproductive health, xix, 40–41, 78–88 reproductive health; unintended pregnancy contraceptive use, unintended antidepressant risk factors, 303 pregnancy, 79–81 chloroquine risk factors, 101 deployment and birth defects, 81–85 contraception prevention choices, 58 post-deployment data, 15–16 deployment and birth defects, 81–85 pregnancy in theater, 85–87 ectopic pregnancies, xix–xx, 50, 86–87, sexually transmitted diseases, 148, 149, 152 124, 147 vaccine/chemoprophylaxis exposure, 85 IPV during, 279 Reproductive Mental Health Steering medical evacuations for, xix–xx, 58, 85–86, 147 Committee, 307 mefloquine risk factors, 85 Reserve Officer training corps, 121 post-deployment data, 15, 17 RESET, Train/Ready and Available process, postpartum deployment recommendation, 175 158–159, 163, 170–171 PTSD and, 303 resistive violence, 276 submarine service concerns, 124, 125 returning from deployment, 157–175. See also suicide ideation and, 251 reunion preparations; reunion rules women veterans’ issues, 303 administrative separations, 173–174 preparation/prevention for success, 50–51 behavioral health risk factors, 165–166 President’s Commission on Veteran’s Pension combat exposure issues, 166–167 (1956), 334 disordered eating issues, 169–170 prisoners of war (POW). See female effects of training, 163 prisoners of war family integration issues, 158–159 progestin-only implant, 62 loss and grief issues, 168–169 progestin-only injections (depot Medical Evaluation Board, 157, 171, 172 medroxyprogesterone acetate), 61–62 medical separations, 172–173 progestin-only pills, 61 mothers who deploy, 167–168 progestin-releasing intrauterine system (IUS), National Guard/Reserve Units, 164–165 62–63, 64 PCS orders, 162, 170, 244 protective factors against suicide-related redeployment screening, 158–159, 164 ideation, 255 RESET process, 158–159, 163, Psychiatric Annals journal, xviii 170–171 PTSD CheckList (PCL), 139 Staff Sergeant Perry, example, Public Law 877 (1945), 339 157–158 Purple Heart awards, 338 triggering of PTSD issues, 169 pyrethroid insecticide, 97–98 Wounded Warrior programs, 171–172 reunion preparations race-based suicide statistics, 245 deployment phase, 200–201 RAND Center for Military Health Policy post-deployment phase, 201–203 Research, 284 pre-deployment phase, 197–199 364 Index reunion rules MEDEVAC process, 124, 129 beware the fairy tale, 204–205 pharmacy requirements, 125 consider the timing, 206–207 post-1970s history, 121–123 create only reasonable expectations, 204–205 pre-1970s history, 120–121 no dumb/stupid questions, 207–208 Pre-Deployment Health Re-Assessment, 126 pissing contest avoidance, 205–206 pregnancy concerns, 124, 125 two-way sincere thanks, appreciation, 208 sexual assault training, 122 Revolutionary War, ix, 135, 243, 330 Shurtliff, Robert, 330–331. See also Sampson, Revolutionary War Pension Act, 330 Deborah rheumatologic disease, 101 signal units, 22 Rieg, T. S., 80 signature injuries. See posttraumatic stress Rivera-Alsina, M. E., 86 disorder; traumatic brain injury Robichaux, C., 160–161 Simpson, John Kirkpatrick, 42 Robinson, S., 316 Sisters of Charity, 332 Rogers, Edith Nourse, 337 situational intimate partner violence, 276 Rosenheck, R., 24, 257 skin conditions, 10 Rosie the Riveter, 121 skull fracture, 214t, 218, 219t Ryan-Wegner, N. A., 68 Skype, 184, 189, 198 sleep problems, 108, 169, 273, 288 safety planning, for intimate partner violence, 281 Slewa-Younan, S., 222 Safety Planning Intervention guide (VA), 257 Smoak, B. L., 85 salpingitis, 338 smoking problems, 167 Sampson, Deborah (aka Robert Shurtliff), social anxiety, 247, 251 330–331 social considerations for women veterans, Samson, Deborah, 243 304–305 Seal, K. H., 25 social context of women in the military, 179–181 Seasonale (oral contraceptive), 59 social media, 161 secondary injury processes, from TBI, 215–216 social networks, 288, 292 Secretary of the Navy, 121, 123 social pain, 317–319 self-concept issues, 191 Society of Family Planning (SFP), 63 self-diagnostic kit recommendation, 68–69 Somalia campaign. See Operation Restore Hope Service Women’s Action Network (SWAN), Southeast Asia, malaria issues, xxi 346–347 Southwest Asia deployment data, 6, 7, 8, 11 Servicemen’s Readjustment Act (1944), 339 Spanish-American War, 135, 329, 335 Sesame Street, materials for families, 181, Special Forces, malaria issues, xxi 182–183 Special Operations Executive (SOE), Sesame Street Talk Listen Connect: Deployment Australia, 35 Homecoming Change (video/DVD), 182 Stamillo, D. M., 86 sexting, 36 Strauss, M., 152 sexual assault and harassment. See military stress fractures, xvii sexual trauma submarine service sexuality in areas of operation, xix–xx, 58, 65, limited service opportunities, 120, 123 147–153, 148–149, 152. See also consensual osteoporosis risk factors, 125 sex in the war zone 2001, NSMRL report, 124 sexually transmitted diseases (STDs), 148, 2011, onset of gender-integration, 123 149, 152 Substance Abuse and Mental Health Services ships and women. See also medical care on ships; Administration (HHS), 281–282 submarine service substance use/abuse, xvi, xx, 18, 23, 166, 172–173, Authorized Medical Allowance Lists, 124, 125 252, 268, 271, 277–279, 281–282, 286–287, Cazares’ personal experience, 126–132 302. See also alcohol abuse/misuse; drug DACOWITS report, 123 use/abuse IDC leadership, 124, 125 suicide bombers, 16, 44, 159, 160 Index 365

Suicide Status Form (SSF), 256 CDC data, 211–212 suicide-related ideation and behaviors, xxi, combat-related risk factors, 212–213 243–259 concussions, 217, 223, 226, 229 anxiety/mood disorders and, 251 deployment screening for, 173 assessment/screening for, 256 depression association, 212, 213, 215, 217, 223, associated psychiatric conditions, 247 227, 229, 284 CDC/national data on women, 244–245 diagnosis, 214–216, 219, 220, 224–227, child loss and, 251 229–230 demographic factors, 248 female endogenous hormones and, 225–226 depression and, 244, 247, 249, 250, 251, 253, hospitalizations, 218, 220, 227, 230 254, 279 ICD-9-CM codes, 219 DoD Suicide Event Report, 245–246, 259 incidence in women, 217–220 eating disorders and, 252–253 intimate partner violence and, 278 gender differences, 246–247 IPV association, 278, 279 history of multiple attempts, 253–254 medical outcomes, 220–222 IPV and, 248, 267, 274, 278, 279, 284 mefloquine conflicts with, 103 as mefloquine side effect, 103 mild TBI, 212–217, 220–223, 226–227 military women risk rate, 244 mortality, male vs. female, 217 military-related factors, 249–250 neurobehavioral outcomes, 222–225 occupational/interpersonal factors, 254 neurodegenerative disease and, 227–228 personality disorders and, 253 non-blast TBI, 217 pregnancy, postpartum depression, and, 251 post-concussion syndrome, 226–227 protective factors, 255 post-deployment data, 16–17 psychiatric factors, 250 PTSD comorbidity, 212, 227 PTSD association, 247, 249, 251 repeat TBI, 217 recommendations for professionals, 255–259 secondary injury processes, 215–216 substance use disorders and, 252 treatment strategies, 227 trauma-related factors, 248–249 traumatic event management (TEM), 174 treatment modalities, 248, 255 Trego, L. L., 70 Supplementary Homicide Report (FBI), 267 Tricare, military health insurance, 66 surface combat ships, 122–123 Truman, Harry, 339 Surface Warfare Officer (SWO), 130 tuberculosis, 38, 336 Tucker McElroy, Lisa, 183 Tarver, R. S., 81 typhoid, 135 TBI. See traumatic brain injury tetracycline, 99, 101 under-reporting of medical issues, Theater Medical Data Store (TMDS), 10–11, 57 19, 52, 54 Thompson, Franklin, 335 Uniformed Services University, xvii, 126 transdermal patch, 58, 60 uniforms, fit/function issues, 64–65 Transition Assistance Programs (TAP), 346 unintended pregnancy trauma. See also military sexual trauma deployment rates, 63, 148 combat-related, 31, 202, 283–285 epidemiological data, 79–81 IPV and, 271, 279, 281–285 lack of abortion services, 63–64 of mothers in war, 191–192 1990s research, xvii pre-military service experiences, 282–283 Persian Gulf conflict data, 58 psychological trauma, 159 prevention strategies, 64 suicidal ideation and, 243, 248–250, 255 rapes/sexual assaults, and, 64 treatment by combat medics, 134, 136 reasons, 63 trauma care, 71, 136 2005 DoD survey data, 63 traumatic brain injury (TBI), xxi, 211–231 United States Code, Title 38, 344 blast-induced TBI, 212–213, 216–217 upper respiratory infections, 67 causes/description, 211, 214–215 Uriell, Z. A., 80 366 Index urinary tract infections (UTIs). See also female US Department of Veterans Affairs.See Veterans urinary diversion device Administration (VA) bathroom issues, xix US Government Accounting Office (GAO), 81 CDC incident data, 52 US Naval Academy, 122 1990s, research data, xvii US Record and Pension Division, 333 prevention measures, 54–55 US Sanitary Commission, 332, 333 resources, 55 US Secretary of Defense, 71 risk factors, 53–54 US Senate, 147 urogynecologic issues USO reading program for kids, 185 amenorrhea, 57, 58, 59, 60, 61, 65, 86, 338 USS Dolphin, 121 bacterial vaginosis, 56 USS Jarrett, 123 cervicitis, metritis, oophoritis, salpingitis, 338 USS Mayflower, 121 endometriosis, 59 USS Minnesota, 123 genital infections, 87 USS Opportune, 122 genitourinary conditions, 10, 15 USS Rushmore, 123 in Iraq, 57, 148–149 USS Virginia, 123 need for prevention education, 69 uterine-related health issues, 338–339 1945 VASRD report, 338 UTIs. See urinary tract infections ovary-related health issues, 58, 59, 338–339 pelvic inflammatory disease, 59 VA Community of Practice intranet website, 326 sex-specific hormonal differences, 303 VA Palo Alto Polytrauma System of Care clinics, ship on-board medical supplies, 125 224–225 submarine service modifications, 124 VA Puget Sound Health Care System, 25 under-reporting, 52 vaccine/chemoprophylaxis exposure, 85 urinary tract infections, xvii, xix, 52–54, VA/DoD Disability Evaluation System, 346 52–55, 67, 126 vaginal candidiasis, 94 uterine-related health issues, 338–339 vaginal hormonal contraceptives, 58 VA healthcare benefits, 345 vaginal ring, 60, 61 vaginitis, 54, 55, 67, 70, 101, 338 vaginitis, 54, 55–56, 67, 70, 101, 338 US Army Combat Medics, longitudinal study VASRD. See Veterans’ Administration Schedule combat experiences, exposures, 139 for Rating Disabilities combat experiences by gender, 140, 142 Vaughn, R., 315 combat medic sample, 137–139 verbal sexual harassment, 24–25 demographics of sample, 138 vestibular disorders and rehabilitation, 101, 227 experiences, exposures, concerns, 141–142 veterans. See women veterans measures, 138 Veterans Administration (VA), xvi, xvii post-battle experiences by gender, 143 combat exposure data, 165 psychological health, 139 disability determination role, 172 statistical analysis, 141 eating disorder recommendations, 169–170 stigma/barriers to care, 141 ECVARS study, 341 US Army Medical Material Agency, 69 female veteran totals, 343 US Army Medical Research and Material IPV data, 288–289, 291 Command, 49–50 mental health assessments, 313 US Army Public Health Command (USAPHC), mental health problems data, 284 29, 54–55 mental healthcare policy for women veterans, US Christian Commission, 332, 333 305–306 US Defense Department Advisory military sexual trauma data, 175, 285 Committee on Women in the Services non-service related healthcare eligibility, 330 (DACOWITS), 71 Palo Alto Polytrauma System of Care clinics, US Department of Health and Human Services 224–225 (HHS), 66, 281–282 PTSD data, 24, 25, 165, 257 US Department of Justice (DOJ), 267 Puget Sound Health Care System, 25 Index 367

response to military sexual trauma, 321–328 Williams, Dorinda Silver, 182 Safety Planning Intervention guide, 257–258 Williams, K., 316–317 sexual trauma screening, 175 Willson, S. J., 86 TBI screening data, 214, 218, 224–225 Women Accepted for Voluntary Emergency Women’s Stress Disorders Treatment Service (WAVES), 337 Team, 257 Women Air Force Service Pilots (WASP), 337 Veterans’ Administration Schedule for Rating Women Armed Services Integration Act Disabilities (VASRD), 336–337, 340, (1948), 339 341, 344 “Women at War” panels, xvii Veterans and Veterans Families Counseling Women in Combat Symposium (2014), xvii Service (VVCS, Australia), 40 women veterans, 301–308 Veterans Benefits Administration (VBA), 324, best practices for mental healthcare, 306–307 342, 344 biological considerations, 303–304 Veterans’ Brain Trust (Congressional Black Crompvoet’s health services study, 41–42 Caucus), 343 IPV and, 270, 284, 286, 287–289, 291 Veterans Disability Benefits Commission long-term blast injury concerns, 170 (VDBC), 344, 345–346 mental health needs, 302–303 Veterans Health Administration (VHA). See MST screening program, 323–325 Veterans Administration (VA) OIF/OEF service, headaches, 18 Veterans of Foreign Wars, 346 prevalence of mental health issues, 302–303 victims of intimate partner violence (IPV), Service Women’s Action Network, 346–347 266–281, 285–291 service-connected healthcare needs, 212 Vietnam syndrome, 341 sexual trauma carryover, 285 Vietnam War social/cultural considerations, 304–305 Australian servicewomen health outcomes VA mental healthcare policy for, 305–306 study, 39 Women’s Armed Services Integration Act chloroquine antimalarial use, 105 (1948), 135 female voluntary service, 340–341 Women’s Army Auxiliary Corps (WAAC), gender specific health consequences, 39 337–338 post-deployment NVVRS survey, 341 Women’s Army Corps (WAC), 338 PTSD data, 341–342 Women’s Central Relief Association, 332 roles of female soldiers, 22 Women’s Health Assessment Team, 66, Virginia class (“fast attack”) submarines, 123 68–69, 175 visual disturbances, from chloroquine, 100 Women’s Health Portal (USAPHC), ix, 55, 55 Vocational Rehabilitation and Employment Women’s Health Research Interest Group (VR&E), 345 (WHRIG), 70 Vogt, D., 314, 315 Women’s Health Task Force (WHTF) vulvovaginitis, 338 FUDD supplies, 54, 55 self-diagnosis kits development, 68–70 Wake, Nancy, 35 sharing of best practices, 66–67 Walker, Mary, 135 2001 establishment of, ix Walter Reed Army Institute of Research uniform design initiative, 64–65 (WRAIR), xviii vaginitis prevention strategy, 56 War of 1812, 331 Women’s Stress Disorders Treatment Team War Risk Insurance Acts (1914, 1917), 336 (VA), 257 Warrior Transition Unit (WTU, Army), 171 Workplace and Gender Relations Survey Washburn, Delilah, 344–345 (2010), 64 Washington, George, 331 World Health Organization (WHO) We Serve, Too! A Child’s Deployment Book on contraceptive use eligibility, 63 (Edick), 183 estrogen use guidelines, 60 webcams, 198 multinational suicide-ideation survey, 246 Whiteneck, G., 221 World War I, 121 368 Index

World War II yellow fever, 135 Army Nurse Corps service, 135 You and Your Military Hero: Building Positive Australian servicewomen deaths, 38 Thinking Skills During Your Hero’s consensual sexual interactions, 152 Deployment (Jensen-Fritz, Jones-Johnson, female deaths, 338 Zitzow), 183 female service data, 337 YouTube video, use/care of FUDD, 55 malaria/Army Nurse Corps, 95 Yuan, H., 250 ship restrictions, 121 use of female combat medics, 137 Zitzow, Thea L., 183, 249 wounded in action (WIA) Zlatoper, Ronald, 122–123 2002-2011 data, 9, 9, 10 Zolna, M. R., 80 2014 data, xxi–xxii Wounded Warrior programs, 171, 346–347 Writer, J. V., 85