Women at War (Gnv64)

WOMENATWAR
WOMENATWAR
Editedby
Elspeth Cameron Ritchie, MD, MPH

Chief Medical Officer
Department of BehavioralHealth
Professor of Psychiatry, Uniformed Services
University of the Health Sciences
Washington,DC
Anne L. Naclerio, MD, MPH

Deputy Surgeon, United States Army Europe
Chair, Womens 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-PublicationData
Women at war (Ritchie)
Women at war / [edited by] Elspeth Cameron Ritchie and Anne L. Naclerio.
p. ; cm.
Includes bibliographical references.
ISBN 9780199344536 (alk. paper)
I. Ritchie, Elspeth Cameron, editor. II. Naclerio, Anne L., editor. III. Title.
[DNLM: 1. Military PersonnelUnited States. 2. Womens HealthUnited States. 3. Sex Factors
United States. 4. Veterans HealthUnited States. 5. WarUnited States. WA 309 AA1]
UB369
362.108697dc23
2014033193
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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
Robert F.DeFraites, David W.Niebuhr, Brigilda C.Teneza,
Leslie L.Clark, and Sharon L.Ludwig
2. 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
22
3. Women and War:Australia

Beverley Raphael, Susan Neuhaus, and Samantha Crompvoets
34
PART 2: WOMENATWAR
4. Medical Issues for Women Warriors on Deployment
Anne L.Naclerio
49
5. Reproductive Health
Cara J.Krulewitch
78
vi
C ontents
6. Issues in the Prevention of Malaria Among Women at War

Remington L.Nevin
93
7 Women, Ships, Submarines, and the US Navy

Heather D. Hellwig and Paulette T. Cazares
120
8. Female Combat Medics

Charles Figley, Barbara L.Pitts, Paula Chapman, and Christine Elnitsky
134
9. Human Sexuality and Women in the Area of Operations

AmyCanuso
147
PART 3: WOMEN HOME FROMWAR

10. Women Home from War
Elizabeth C.Henderson
157
11. Mothers in War

AmyCanuso
178
12. Building the Framework for Successful Deployment Reunions

Erin Simmons
196
13. Traumatic Brain Injury:Implications for Women in the Military

Victoria Tepe and SuzanneGarcia
211
PART 4: PSYCHOLOGICAL ISSUES FOR

ACTIVEDUT YWOMEN
14. Suicide-Related Ideation and Behaviors in Military Women
Marjan Ghahramanlou-Holloway, Brianne George,
Jaime T.Carreno-Ponce, and Jacqueline Garrick
243
15. Intimate Partner Violence, Military Personnel, and Veterans

Glenna Tinney and Melissa E. Dichter
266
PART 5: THE FEMALE VETER AN EXPER IENCE

16. The Woman Veteran Experience
Isabel D.Ross, Natara D.Garovoy, Susan J.McCutcheon, and
Jennifer L.Strauss
301
17. Mental Health of Women Warriors:The Power of Belonging

KateMcGraw
311
C ontents
vii
18. The Veterans Health Administration Response to

Military Sexual Trauma
Margret E.Bell and Susan J.McCutcheon
321
19. Compensation, Pension, and Other Benefits for Women

Veterans with Disabilities
Jacqueline Garrick
329
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 2.5million women have served with honor and selfless dedication to the mission. Most recently, nearly 275,000 women have deployed in
support of Operations Iraqi Freedom, New Dawn, and Enduring Freedom. Ihave seen
firsthand the courageous work of these deployed women, and the value they bring to
the military each and everyday.
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 Womens 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 Womens 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 womens medical
and psychological needs during and after deployments. This book is perfectly timed to
share these key insights.
ix
F oreword
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 towomen.
This book makes it clear that progress in understanding womens issues related to
war and serving in the military has been made, but that much more research on these
vital topics is needed. Iapplaud 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 toServe.
Patricia D.Horoho
Lieutenant General, USArmy
The Surgeon Generaland
Commanding General, US Army Medical Command
Washington,DC
Contributors
Margret E. Bell, PhD

National Military Sexual Trauma
Support Team
Mental Health Services
Department of Veterans Affairs
Boston, MA
Amy Canuso, LCDR,MCUSN

Board Certified Psychiatrist
Child and Adult Psychiatrist,
Walter Reed National Military
MedicalCenter
Bethesda,MD
Michael R. Bell, MD, MPH

Commander, US Army Public Health
Command RegionNorth
US Army Surgeon General Consultant
for Occupational and Environmental
Medicine
Fort George G.Meade,MD
Michael Carino, DMD,MPH

Senior Health Systems Analyst
Office of the Surgeon General
Falls Church,VA
Jaime T.Carreno-Ponce,PhD
Psychologist, Department of Medical
and Clinical Psychology,USUHS
Bethesda,MD
Paul Bliese, PhD

Chief, Division of Neuropsychiatry
Walter Reed Army Institute
of Research
Silver Spring,MD
Paulette T.Cazares, MD,MPH

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

PharmD, BCPS
Pharmacy Division Head
Captain James A. Lovell Federal
Health Care Center
North Chicago, IL
Kate McGraw,PhD
Associate Director, Psychological
Health Clinical Care DHCC
Defense Centers of Excellence
Bethesda,MD
Elizabeth C.Henderson, MD,

FAPACIV
Certified American Board of Psychiatry
and Neurology
Department of DeploymentHealth
Martin Army Community Hospital
Fort Benning,GA
Anne L.Naclerio, MD,MPH

Chair, Womens Health Task Force,
Office of the Army Surgeon General
Deputy Surgeon, US Army Europe
Associate Professor,
Department of Pediatrics
Health Sciences (USUHS)
Bethesda,MD
Cara J. Krulewitch, CNM, PhD,

FACNM
Director, Womens health, Medical
Ethics and Patient Advocacy
Office of the Assistant Secretary of
Defense (Health Affairs)
Falls Church, VA
Sharon L.Ludwig, MD, MPH,MA
Director of Epidemiology and
Analysis
Armed Forces Health Surveillance
Center
Silver Spring,MD
Sharon McBride, PhD
Research Psychologist
Comprehensive Soldier Fitness Program
Washington,DC
Susan J. McCutcheon, RN, EdD
Mental Health Services
Washington, DC
Susan Neuhaus, CSC MBBS, PhD,

FRACS,GAICD
Associate Professor of
Conflict Medicine
University of Adelaide
Former Colonel RAAMC & Appointed
member Veterans Health and
Advisory Council
South Australia
Remington L.Nevin, MD,MPH
Johns Hopkins Bloomberg School of
Public Health
Baltimore,MD
David W.Niebuhr, MD,MPH
Department of Preventive Medicine
and Biometrics
Health Sciences
Bethesda,MD
xiv
C ontr i butors
Barbara L.Pitts,MSc
Uniformed Services University
Bethesda,MD
Beverley Raphael, AM MBBS, MD,
FR ANZCP, RFCPsych, HonMD
Professor Population Mental Health
and Disasters
Disaster Response and Resilience
Research Group (DRRRG)
Medical School at University of Western
Sydney
Elspeth C. Ritchie, MD, MPH
Professor of Psychiatry
Health Sciences
Bethesda,MD
Isabel D.Ross,MD
Duke University MedicalCenter
Durham,NC
Erin Simmons, PhD
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 MedicalCenter
Durham,NC
Brigilda C. Teneza, MD, MPH

Assistant Director, Epidemiology and
Analysis Division Armed Forces
Health Surveillance Center
Silver Spring, MD
Victoria Tepe,PhD
Research Portfolio Manager
The Geneva Foundation
Tacoma, Washington
Jeffrey L. Thomas, PhD
Commander, US Army Medical
ResearchUnit
Europe Walter Reed Army Institute of
Research
Sembach, Germany
Glenna Tinney, MSW
Senior Advisor, Military Advocacy
Program
Battered Womens Justice Project
Minneapolis, MN
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 13years 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
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Introduct i on
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 NationalGuard.
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).
Introduct i on
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 ACTIVIT Y ONFEMALE 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 etal.,1997).
In the late 1990s there was a considerable amount of research, mainly covered
under the loose rubric of the Defense Womens 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 etal., 2007; Hines, 1993; Knapik etal., 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 womens 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 Chapter4 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.
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Introduct i on
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.
Anotable exception, reported here for the first time, is Chapter1 of this volume, by DeFraites
etal., which nicely summarizes a vast quantity of data on deployment-related issues. Chapter2
by Ritchie at al. outlines the known statistics on post-traumatic stress disorder (PTSD) in
female Service members. Chapter15 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.
Afew chapters are more anecdotal, describing the experiences of being a female Sailor
on ship, or a mother on deployment.
GYNECOLOGICALISSUES
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,
Introduct i on
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 latrinemaybe
used by many other Service membersclean 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 Ibe 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). Chapters4 and 5,
by Naclerio and Krulewich, respectively, cover these issues in more details.
REPRODUCTIVE CONCER NS
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. Chapter11 in this book by Canuso will flesh out these issues.
CONSENSUAL SEX INTHE WARZONE
Although sexual assault has received considerable attention, consensual sex has
received much less. Ataboo area seems to be the sexual desires of women who deploy.
But young womenand most women who deploy are youngdo 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
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Introduct i on
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-deployedhome.
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 Dont Ask, Dont 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-TR AUMATIC STRESS DISOR DER AND
OTHERMENTALHEALTH DISOR DERS
PTSD is a common consequence of combat. It has been studied widely in military men
after Vietnam and during these last 13years 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 since9/11.
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,
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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 Chapters13 (by Tepe and Garcia), 14 (by Ghahramanlou-Holloway etal.),
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 20years 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. Chapter6 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 Chapter10, and Jackie Garrick in Chapter19 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 availabledata.
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
Introduct i on
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
towardmen.
LIMITATIONS OFTHEVOLUME
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 nations 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 patients overall military service, (3)the
patients experiences in the theater of war; and (4)the positive and negative effects of
that service.
Introduct i on
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), 511514.
Bell, M.R., & Ritchie, E.C. (2003a). Breastfeeding in the military. Part I:Information and resources
provided to servicewomen. Military Medicine, 8(10), 807812.
Bell, M.R., Ritchie, E.C. (2003b). Breastfeeding in the military. Part II:Resource and policy considerations. Military Medicine, 8(10), 813816.
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), 189193.
Hines, J.F. (1993). A comparison of clinical diagnoses among male and female soldiers deployed during
the Persian Gulf War. Military Medicine, 158, 99101.
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), 569574.
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), 656660.
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:Astudy of the global war on terror. Monograph. Command
and General Staff College.
Ritchie, E.C. (1998). Reactions to rape:Amilitary forensic psychiatrists perspective. Military Medicine,
163(8), 505509.
Ritchie, E.C. (2001). Issues for military women in deployment. Military Medicine, 166(12), 10331037.
Ritchie, E. C. (2014a). An overview of physical and mental issues: Women at war. Psychiatric Annals,
44(4), 182184.
Ritchie, E.C. (2014b). Health issues for female service members in the Long War. Psychiatric Annals,
44(4), 179180.
xxiv
Introduct i on
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, NovemberDecember). Military womens perspectives on
health care during deployment. Womens Health Issues, 10(6), 333343. http://dx.doi.org/10.1016/
S1049-3867(00)00064-5.
Tinney, G. (2014). Intimate partner violence and military women. Psychiatric Annals, 44(4), 185188.
PA R T
Background and
Introduction
one
Comparative Morbidity and Mortality

of Women Serving inthe US Military
Duringa Decade ofWarfare
ROBERT F.DEFR AITES, DAVID W.NIEBUHR,
BR IGILDA C.TENEZA, LESLIE L.CLARK,
ANDSHARON 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 10years of continuous conflict (20022011).
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; 20032010), 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).
DMDCs personnel databases provide military demographic information,
including dates of service and rosters of major campaigns and deployments. DMDC
3
W omen at W ar
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 compendium 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 10million 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 termination 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 INTHE US MILITARY BEFORE2001
Prior to the advent of the all-volunteer armed forces in the 1970s, womens 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
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 (19901991), 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 1990sOperations Restore Hope (Somalia 19921993), Uphold
Democracy (Haiti 19941995), 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 theseareas.
CHANGING DEMOGR APHIC PROFILE OF
THE ACTIVE FORCE:FROM THEPERSIAN
GULF WAR (1991) TOTHE 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 40years 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 womenat7%.
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
W omen at W ar
1,800,000
1,600,000
1,400,000
1,200,000
Persons
DOD Total (n)

1,000,000
DOD Officers (n)

DOD Enlisted (n)
800,000
DOD Women (n)

600,000
Women Officers
400,000
Women Enlisted (n)
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
200,000
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
officers) in 2011.
FIGURE1.1 Officers and enlisted personnel on active duty, DoD, 19942011.

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% ofmen.
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
Table1.1). 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
enlistedranks.
Service members in the US military from 2002 to 2011 served a median of 3
years before departure for their first deployments. Those under 25years of age served
a median of 741days 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 877days of service (median) prior to their first deployment.
Overall, women were deployed after serving about the same number of days of service (1,393days) as men (1,365days; 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 and1.2b).
TABLE1.1 Service Members Deploying atLeast Once

tothe Southwest Asia Areas ofOperations, US Armed
Forces, 20022011
Total
Women
Men
Counts (%)
Counts (%)
223,319 (11.4%)
1,737,251 (88.6%)
160,975 (72%)
1,250,499 (72%)
62,344 (28%)
486,752 (28%)
Component
Active
Reserve/Guard
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%)
321 (0.1%)
4,033 (0.2%)
110,916 (50%)
855,335 (49%)
2529
45,868 (20%)
322,212 (19%)
30+
66,535 (30%)
559,704 (32%)
Enlisted
189,810 (85%)
1,513,775 (87%)
Officers
33,509 (15%)
223,476 (13%)
Coast Guard
Age
<25
Rank
Operation
OEF only
OIF/OND only
OEF & OIF/OND
55,422 (25%)
430,750 (25%)
142,927 (64%)
1,030,442 (59%)
24,970 (11%)
276,059 (16%)
Population:
All Service (Army, Navy, Air Force, Marine Corps, and CoastGuard).
All Components (Active, Reserve, andGuard).
Time period:January 1, 2002December 31,2011.
Deployment:defined as >30days to OEF, OIF, orOND.
Data Source:Defense Medical Surveillance System (DMSS), as of 30JUL13.
TABLE1.2a Average Number ofDeployments,

January 1, 2002December 31, 2011, byService
andGender
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
W omen at W ar
TABLE1.2b Median Length (Months) ofDeployments

per Service Member byService andGender
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
Population:
All Service (Army, Navy, Air Force, Marine Corps, and CoastGuard).
All Components (Active, Reserve, andGuard).
Time period:January 1, 2002December 31,2011.
Deployment:defined as >30days to OEF, OIF, orOND.
Data Source:Defense Medical Surveillance System (DMSS), as of 30JUL13.
The deployed women encompassed a wide range of occupational duties (Figure1.2).

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%
ofmen).
% Deployed troops in each

occupation, by gender
35.0%
30.0%
25.0%
20.0%
15.0%
Females
Males
10.0%
5.0%
er
th
O
Fu
nc
Te
c
hn
i
ca
la
lth
Ca
re
ell
In
t
d
an
H
ea
ns
tio
un
ica
m
m
Co
ig
en
ce
S
...
nd
pe
cia
El
A
t
io
ec
lli
l
ist
na
ed
tr
s
ica
lS
Sp
l/M
up
ec
po
ia
ec
lis
rt
ha
ts
an
ni
d
ca
Cr
A
l
dm
af
Eq
ts
ui
in
wo
p.
.
r
R
k
Se
e
a
pa
rv
n
d
ice
ire
Co
rs
,T
ns
ra
t
ns
ru
Ta
po
ct
ct
io
rt
ica
n
an
lO
d
pe
Su
ra
pp
tio
ly
ns
H
ea
O
ffi
lth
ce
Ca
rs
re
O
ffi
ce
rs
Al
lO
th
er
re
ep
ai
tR
en
pm
ui
Eq
on
ic
tr
ec
El
In
fa
nt
ry
,G
un
Cr
ew
,a
nd
Se
am
an
rs
0.0%
FIGURE1.2 Military occupational categories of Servicemen and Servicewomen deployed to

Southwest Asia (OEF/OIF/OND) 20022011.
OIF/OEF HEALTH PROFILE FORMILITARYWOMEN

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 militaryunits.
Casualties:Killed inAction (KIA), Non-Battle Deaths,
and Wounded inAction(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).
TABLE1.3a US Military (Men and Women Combined) Casualties,
20022011,OEF
Casualty Categories:
Hostile (killed in action,
died of wounds, etc.)
Total Hostile Deaths
Army
1,036
Navy
69
Marines
322
Air Force Coast Guard

47
Total
1,474
Casualty Categories: NonHostile (accident, illness/

injury, self-inflicted, etc.)
Total Non-Hostile Deaths
Army
249
Army
Total Deaths
1,285
Army
Total Wounded in Action 12,978
Navy
26
Navy
95
Marines
60
Marines
382
Navy
Marines
474
4,526

29

76

1,317
Total
364
Total
1,838
Total
19,295
10
W omen at W ar
TABLE1.3b US Military (Men and Women Combined) Casualties, 20022011,

OIF/OND
Casualty Categories:
Hostile (killed in action,
died of wounds, etc.)
Army
Navy
Total Hostile Deaths
2,535
63
851
29
Army
Navy
Marines
Air Force
Marines
Air Force
Coast Guard
1
Total
3,479
Casualty Categories: NonHostile (accident, illness/

injury, self-inflicted, etc.)
Total Non-Hostile Deaths
Total Deaths
Total Wounded in Action
697
39
171
22
Army
Navy
Marines
Air Force
3,232
102
1,022
51
Army
Navy
Marines
Air Force
9,246
1,627
26,608
1,087
Coast Guard Total

0
929
Coast Guard Total

1
4,408
Coast Guard Total

0
38,568
Data Source:Defense Manpower DataCenter.
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]). Acomparison 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 20022011 reveal a total of 3.9million 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.
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 overrepresentation of disease and non-battle injury health encounters bywomen.
Medical Evacuation fromthe 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 20022011.
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
780799; 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%
Men
Women
15.0%
10.0%
Breast disorders (610611)
Hematologic disorders (280289)
Other (V01-V82, except pregnancy

related)
Congenital anomalies (740759)
Nervous system (320389)
Pregnancy and childbirth (630679,

relevant V codes)
Infectious and parasitic diseases
(001139)
Endocrine, nutrition, immunity
(240279)
Neoplasms (140239)
Circulatory system (390459)
Genitourinary system (580629,

except breast disorders)
Skin and subcutaneous tissue
(680709)
Respiratory system (460519)
Digestive system (520579)
Signs, symptoms and ill-defined

conditions (780799)
Mental disorders (290319)
Musculoskeletal system (710739)
Non-battle injury and poisoning

(800999)
0.0%
Battle injury (from TRAC2ES records)
5.0%
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.
FIGURE1.3 Medical evacuations from Southwest Asia (OEF/OIF/OND) 20022011, by major

diagnostic code (ICD-9-CM) category andgender.
12
W omen at W ar
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 20022011 within 365days (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
TABLE1.4a One-Year Post-Deployment Hospitalizations, Active

Component Women, 20022011
Major Diagnostic Category (ICD-9-CM)
Counts
Proportion*
Rank
Mental disorders
Injury and poisoning
Genitourinary diseases
Digestive diseases
Signs and symptoms
Other neoplasms
Musculoskeletal diseases
Cardiovascular diseases
Oral conditions
Malignant neoplasm
Skin diseases
Respiratory disease
Respiratory infections
Neurologic
2,307
1,232
1,152
841
611
607
549
346
224
171
165
158
146
100
93
25.5%
13.6%
12.7%
9.3%
6.7%
6.7%
6.1%
3.8%
2.5%
1.9%
1.8%
1.7%
1.6%
1.1%
1.0%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
86
0.9%
16
Headache
*Proportion of category over all visits, excluding pregnancy, labor, and delivery.
Data Source:Defense Medical Surveillance System(DMSS).
TABLE1.4b One-Year Post-Deployment Hospitalizations, Active

Component Men, 20022011
Counts

Mental disorders
Digestive diseases
Signs and symptoms
Skin diseases
Respiratory disease
Neurologic
Malignant neoplasm
Oral conditions
Other neoplasms
Congenital
19,191
16,911
6,788
6,133
4,198
2,462
2,177
1,521
1,441
1,313
1,025
913
859
686
447
359
*Proportion of category over allvisits.

Proportion*
28.3%
24.9%
10.0%
9.0%
6.2%
3.6%
3.2%
2.2%
2.1%
1.9%
1.5%
1.3%
1.3%
1.0%
0.7%
0.5%
Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
TABLE1.5a One-year Post-Deployment Ambulatory Visits, Active

Component Women, 20022011
Counts
Proportion*
Rank

Mental disorders
Signs and symptoms
Sense organ diseases
Skin diseases
Respiratory disease
Digestive diseases
Headache
Other neoplasms
Neurologic
Endocrine
2,09,412
1,85,183
1,82,140
1,39,617
9,4677
69,969
57,023
54,582
51,875
39,875
33,700
31,991
16,487
15,017
11,740
9220
17.0%
15.1%
14.8%
11.4%
7.7%
5.7%
4.6%
4.4%
4.2%
3.2%
2.7%
2.6%
1.3%
1.2%
1.0%
0.8%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
*Proportion of category over all visits, excluding pregnancy, labor, and delivery.
TABLE1.5b One-Year Post-Deployment Ambulatory Visits, Active

Component Men, 20022011
Mental disorders
Signs and symptoms
Sense organ diseases
Skin diseases
Digestive diseases
Respiratory disease
Neurologic
Headache
Other neoplasms
Metabolic and immune disorders
Counts
Proportion*
Rank
1,517,325
1,248,067
9,80,590
5,99,377
4,08,580
2,44,430
2,22,884
1,75,762
1,64,493
1,64,063
1,25,423
1,21,099
1,05,562
89,086
53,542
35,407
23.8%
19.6%
15.4%
9.4%
6.4%
3.8%
3.5%
2.8%
2.6%
2.6%
2.0%
1.9%
1.7%
1.4%
0.8%
0.6%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
*Proportion of category over allvisits.

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 InpatientCare
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
630679 and 760779 (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 etal., 1997)and in
OIF/OEF (Klausner etal.,2009).
Post-Deployment AmbulatoryCare
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/BirthRates
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 20022011. Overall, never-deployed women experienced
16
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140
Birth rate per 1,000 person -years
120
100
80
60
1st time deployed
Never deployed
40
20
0
<20
2029
3039
Age Categories
>40
All ages
Data Source: Defense Medical Surveillance System (DMSS) as of 11/14/2013.

Prepared by Armed Forces Health Surveillance Center (AFHSC) on 11/18/2013
FIGURE1.4 Birth rate per 1,000 person-years by age among active component US military
women 20022011, 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 BrainInjury
Attributable in part to a relatively common hazardextreme physical forces generated by explosions, or blasts, delivered by improvised explosive devices (IEDs),
suicide bombers, mortars, and so ontraumatic 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
17
120
Birth rate per 1,000 person-years
100
80
60
1st time deployed

Never deployed
40
20
0
2002
2003
2004
2005
2006
2007
Year
2008
2009
2010
2011
Data Source: Defense Medical Surveillance System (DMSS) as of 11/14/2013.

Prepared by Armed Forces Health Surveillance Center (AFHSC) on 11/18/2013.
FIGURE1.5 Birth rate per 1,000 person-years by year among active component US military
women 20022011, first time deployed (birth occurring within 18months 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 [pyr], 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.
MentalHealth
The Armed Forces Health Surveillance Center has published several analyses related to
military womens 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 20002009,
the overall incidence of at least one mental health disorder diagnosis among active component Service members increased by about 60% over the 10years of observation. The
18
W omen at W ar
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 20022008. 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 disorderrelated 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 712months 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
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 disproportionately 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
W omen at W ar
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, 20022008. Medical Surveillance Monthly Report (MSMR), 16(2),26.
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),29.
Armed Forces Health Surveillance Center (AFHSC). (2010, November). Mental disorders and mental
health problems, Active Component, U.S. Armed Forces, January 2000December 2009. Medical
Surveillance Monthly Report (MSMR), 17(11),613.
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),1415.
Armed Forces Health Surveillance Center (AFHSC). (2011, December). Brief report: Births, active
component, U.S. Armed Forces, 20012010. Medical Surveillance Monthly Report (MSMR),
18(12),1617.
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, 20032011. Medical Surveillance Monthly Report (MSMR), 19(2),1821.
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).
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, 27852790.
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), 656660.
Okie, Susan. (2005, May 19). Traumatic brain injury in the war zone. New England Journal of Medicine,
352, 20432047.
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), 19001904.
Statistical Information Analysis Division, Defense Manpower Data Center. https://www.dmdc.osd.mil
(accessed 15 July 15,2013).
t wo
Female Soldiers and Post-Traumatic

Stress Disorder
ELSPETH C.R ITCHIE, MICHAEL R.BELL,
M. SHAYNE GALLAWAY, MICHAEL CAR INO,
JEFFREY L.THOMAS, PAUL BLIESE, AND
SHARON MCBR IDE
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, orboth.
22
2. Female Soldiers andPTSD
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 internally 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.
BR IEF REVIEW OFTHE LITER ATURE
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 etal., 2005; LeardMann etal., 2009;
Seal etal., 2007; Smith etal., 2008; Kessler etal., 1995; Kessler etal., 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 etal., 2009). Their findings differ
from the findings in this chapter; possible reasons are discussedbelow.
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 etal., 1995). There is also a more
recent study by Kessler etal. using DSM-IV criteria, which found a lifetime prevalence
of 6.8% (9.7% for women, 3.6% for men) (Kessler etal., 2005). However, in general, in
24
W omen at W ar
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 womans 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 ofPTSD.
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 etal. (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
aswell.)
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
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 GulfWar.
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 forPTSD.
Dobie etal. (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 aswell.)
Seal etal. (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 13days after the
first VA visit, and most (about 60%) were made in primary care settings. The youngest
Veterans (age 1824) 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]:0.910.97), but slightly more
likely to have a diagnosis of PTSD (1.14, 95% CI:1.081.10).
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 etal. 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
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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:1.442.00). The odds ratios were similar for Air
Force, Navy, Marine, and Coast Guard cohorts in thestudy.
In a related study, LeardMann etal. (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:1.722.98). 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 ONEXISTINGDATA
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 eachother.
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 wassmall.
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
27
2,0004,000 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
healthcare.
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 TEAMDATA
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 (IVI) 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.)
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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 etal., 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 Table2.1). 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
(MHATVI).
29
PTSD COMPAR ISON BETWEEN MALES AND

FEMALESONPOST-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 in2005.
Soldiers who completed the Post-Deployment Health Re-Assessment (PDHRA)
were screened for PTSD using the following four-questiontool:
Have you ever had any experience that was so frightening, horrible, or upsetting
that, IN THE PAST MONTHYOU
a. Have had nightmares about it or thought about it when you did not wantto?
b. Tried hard not to think about it or went out of your way to avoid situations that
remind youofit?
c. Were constantly on guard, watchful, or easily startled?
d. Felt numb or detached from others, activities, or your surroundings?
TABLE2.2 Number ofSoldiers (US Army, All Components) Deployed
(Sept2001Sept 2009)and Percent Diagnosed withPost-Traumatic
StressDisorder (PTSD)*
Ever Deployed**
PTSD Diagnosis among Previously Deployed
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 ofPTSD.
**Deployment to OEF/OIF lasting longer than 30days, 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.
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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 INTHE MEDICAL CARESYSTEM
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).
BEHAVIOR AL 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.
31
Obviously, this in marked contrast to civilian data (Kessler etal., 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
etal. (2009) discuss why poor prior mental and physical health is the strongest predictor of new onsetPTSD.
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 thepast?
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
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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
posedabove.
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, 394400.
Fontana, A., & Rosenheck, R. (1998, May). Focus on women:Duty-related and sexual stress in the etiology of PTSD among women veterans who seek treatment. Psychiatric Services, 49, 658662.
Hankin, S.S., Skinner, K.M., Sullivan, L.M., etal. (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, 601612.
Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D, etal. (2005). Combat duty in Iraq and Afghanistan,
mental health problems, and barriers to care. New England Journal of Medicine, 351,1322.
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, 191195.
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, 593602.
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), 10481060.
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, b1273b1273.
Mental Health Assessment Team II (2005). Retrieved from http://armymedicine.mil/Pages/MentalHealth-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 veterans experience with domestic violence and with
sexual harassment while in the military. Archives of Family Medicine, 4, 411418.
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, 476482.
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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:Aprospective population based US military cohort study. British Medical Journal, 336(7640), 366371.
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, 13,4057.
thr ee
Women and War:Australia

BEVERLEY R APHAEL, 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, grandmothers, daughters, and aunts. These women may have been directly or indirectly
involveddirectly 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
alongsidemen.
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 womens diverse contributions and ongoing challenges; and women in leadership.
34
3. Women at War in Australia
35
GENDEREQUIT Y
As noted in a recent review, closing the global gender gap involves levels of economic participation, education attainment, health and survival, and political empowermentall 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 mens 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. Womens
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 womens place more broadly. Men and women have valued these roles. It could be that
these roles defined mens and womens 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.
Womens 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 womans role particularly, but also one where bravery, being close
to conflict, was recognized and valued. Men and women found that these roles synchronized with their beliefs and experience of the broader Australian culture of thosetimes.
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 agentfulfilled this role with courage and exceptional
achievements. Women who were prisoners of war showed similar courage and achievement in the face of theenemy.
The progress of equity goals, through the womens 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 womens pay
equity, is still lagging behind, and womens achievement in executive or supervisory
roles, in business and politics, is often sorely challenged.
36
W omen at W ar
Womens 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 mens behavior toward women, but also, at times, womens 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 soforth.
Review:Sex Discrimination intheADF
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 womens 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 publiceye.
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
37
BOX3.1
K EY PR INCIPLES FORSUCCESS IDENTIFIED
BYTHER EV IEW
1. Strong leadership to drivereform
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, alongsidemen.
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 Morrisons 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 determinedit 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 Box3.1).
To quote from Major-General David MorrisonAM:
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
W omen at W ar
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 Ineed every one of you to support me in achieving this. The standard you walk
past is the standard you acceptthat 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 Australiathen, 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 THEHEALTH NEEDS OFAUSTR ALIAS

SERVICEWOMEN AND FEMALE VETER ANS
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
riskssuch 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
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 forlife.
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 ofAustralian Women inthe 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 womens health
agenda and are not represented in either the 1989 or 2010 National Womens 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 Australias 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 Australias defence force, their widows/widowers and dependants entitled to treatment for all medical conditions) (White
cards:Awhite Repatriation health card for specific conditions provides access to health
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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 4060kg 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 womens 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 womens health and well-being have not been adequately
researched. Services specifically tuned to womens health needs, including sexual
and reproductive health, are not well developed. As highlighted by Neuhaus and
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 womans capacity to become pregnant
and/or have potential effects on the developingfetus.
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 womens 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 etal.,2012)
Health Services
Womens 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 adaptations to womens 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 menand 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
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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 womens 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 womens 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.
AUSTR ALIAN WOMEN INWAR:UNTOLD NARR ATIVES
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 professionthe 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 WorldWarI.
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. Wearys 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, Australias first woman
to be awarded the Military Medalearned 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 Kings 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 Australias military history have
privileged male voices over womens. Womens voices have been absent or silent. In
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
20112012 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 Australias female participation in World
War II (Australian War Memorial, 20112012).
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 womens business, and in this role, war as mens business remains unchallenged. It is perhaps for this reason that few of the nontraditional narratives of womens
involvement in war have become widely recognized.
Two exceptions are the stories of Olive King, brought to light in Susanna De Vriess
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 Australias greatest war heroine. These two narratives are unique in
their femme fatale characteristicsa 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
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W omen at W ar
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
rolesestablished in just two generationshave 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 roleswife,
mother, and Soldierand 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 navet) 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 Ito the present day. Each of them
are or were women who were willing to leave behind families and friendssometimes
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 Australias Defence mandate and protect the peace
that all Australiansmen and womenhold sodear.
REFERENCES
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 ArmyAustralian
Army. [online] Retrieved from http://www.army.gov.au/Our-work/Speeches-and-transcripts/
Message-from-the-Chief-of-Army (accessed November 27,2013).
45
Australian Government, Department of Veterans Affairs. (2013). Treatment Population Statistics

Quarterly ReportMarch 2012 data extract as at 30 March 2012. [online]Retrieved from http://
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
ForceCommunity guide Phase 2, 2012. [e-book] Sydney: Australian Human Rights Commission
(pp. 1942). 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. (20112012). Nurses: from Zululand to Afghanistan. Exhibition,
December 2, 2011October 17,2012.
Commonwealth Department of Veterans Affairs. (1998). Morbidity of Vietnam veterans:AStudy of the
health of Australias 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. vvi). 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 Day2012.
De Vries, S. (2004). Heroic Australian women in war. Pymble, N.S.W.:HarperCollins.
Dennis, P., & Grey, J. (2004). The foundations of victory (pp. 198201). Canberra:Department of Defence
Army HistoryUnit.
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),
470476.
Less than 20 women seek frontline combat roles. (2013). The Sydney Morning Herald, June4.
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-ofgender-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, 369373.
Neuhaus, S., & Crompvoets, S. (2013). Australias servicewomen and female veterans:do we understand
their health needs? The Medical Journal of Australia, 199(8), 530532.
Neuhaus, S., & Mascall-Dare, S. (2013). A woman at war:The life and times of Dr Phoebe Chapple MM
(18791967), 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
W omen at W ar
Orr, R.M., Johnston, V., Coyle, J., & Pope, R. (2011). Load carriage and the female soldier. Journal of
Military and Veterans Health, 19(3),2534.
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:Areview 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., etal. (2012). Physiological employment standards IV:integration of women
in combat units physiological and medical considerations. European Journal of Applied Physiology,
Dec 14. [Epub ahead ofprint]
PA R T
WomenatWar
fou r
Medical Issues forWomen Warriors

onDeployment
ANNE L.NACLER IO
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 Womens 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 congressionally funded program, which supported over 100 intramural and 30 extramural
49
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research projects aimed at addressing the health-related needs of military women. Agap
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 etal., 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 servingsuch 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 echelons 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 maleforce.
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 womens 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
SERVICEWOMENSHEALTH
Preparation and Prevention forSuccess
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
51
FIGURE4.1 Womens bathroom in Austere enviroment.
of the nine focus areas was on womens health (Naclerio etal., 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 hadnt 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 Figure4.1they
become medical threats without the right preparation and education (Figure4.1).
The author served on the HSS assessment team as a Subject Matter Expert for Womens Health, Effects
of Deployments on Children and Families and Military Sexual Assualt and returned to serve as the first
Chair of the Womens 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.
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UrogynecologicIssues
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 etal., 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 10.5months in length (DMSS, 2013). Arecent 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 etal.,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
53
FIGURE4.2 Female Urinary Diversion Device(FUDD).
into a small opening (such as a bottle). These products are most widely used by campers, climbers, and outdoorswomen, but have not gained general acceptance across the
services (Figure4.2).
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 ofwar.
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
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name, Urinal, Female (Naclerio etal., 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 etal., 2011). These reports were very consistent with Nielsons findings
from Combat Support Hospitals in Iraq in 20052006, which reported that only
4.5% of women serving in Iraq had used the devices, and 33% had never heard of the
them (Nielson etal.,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). Areport 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 theUrogynecologicIssues
Urinary Tract Infection
The Womens 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
55
TABLE4.1 Resources Referenced, Available atthe Time ofPublication

Resources Available for Servicewomen
USAPHC Womens Health Portal
Web Link
http://phc.amedd.army.mil/topics/
healthyliving/wh/Pages/default.aspx
YouTube video on use and care of the

Female Urinary Diversion Device
https://www.youtube.com/
watch?v=JXRxjmifjO8
recently developed USAPHC Womens Health Portal. Healthcare practitioners can

refer patients to the site, or can download reference materials for patients. On the topic
of FUDDs, the Womens 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 (Table4.1).
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 (Figure4.3).
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
etal.,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 etal., 2010; Rao, Bhatt, Houghton,& Macfarlane,
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W omen at W ar
FIGURE4.3 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 13 missed days of productivity per month (Andersch &
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 etal., 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 etal.,
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 collecting, 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 ornot.
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
Nielsons 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 etal.,2011).
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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).
TABLE4.2 Goals forHormonal Contraception Therapy inServicewomen
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
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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 thering).
Or al Contr aceptivePills
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, OConnell, & 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 etal., 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 etal., 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 continuously, 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
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unintentional pregnancy (Hicks& Rome, 2010; Powell-Dunford etal, 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 etal.,
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.
TransdermalPatch
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 etal., 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 etal.,
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 etal., 2013).
Also, increased thrombotic side effects have been reported (Cole et al., 2007) which
could be exacerbated by dehydration states (Trenor etal., 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 etal., 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 etal., 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.
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VaginalRing
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. NuvaRings
extremely short shelf life (4months) 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-OnlyPills
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 endometrium when delivered by intramuscular (IM) injection every 90days (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 3months)
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 etal., 2009),
especially early on, side effect of weight gain (Christopher& Miller 2007), and delayed
return of fertility (Jain etal., 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 lessens over time and is reversible on discontinuation (Cromer etal., 2008; Kaunitz, Miller,
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Rice, Ross,& McClung, 2006). In Servicewomen who cannot take estrogens and/or
want to use this method, it should be instituted 612 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 Intr auterine 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). A90%
reduction in menstrual blood loss has been demonstrated over 12months 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).
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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 hemoglobin, 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 1844
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 1924years 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 etal.,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
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of Defense (DoD) from performing abortions except in cases of rape or incest, or risk to
the mothers life (Legal Information Institute, ND). This might account for some of the differences in rates of unintended births, as well as placing womens 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. A2010 Workplace and Gender Relations Survey of AD Members found 4.4% of
women reported unwanted sexual contact in the prior 12months (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 etal.,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 etal., 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 (Table4.3).
Fit and Function ofUniforms
Another issue raised by women to the Womens 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 etal., 2011). Like most military items, the
current and past designs were based upon male anthropometrics. One of the Womens
Health Task Forces first initiatives was to make contact with the Armys 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
65
TABLE4.3 Counseling Points forMilitary 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 environmentplanning and prevention
are the best strategy.
Menstruation is not necessary except when pregnancy isgoal.
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 36months 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 decisionbut 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 shoulder, 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 multisized 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
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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 Womens Health Assessment Team recommended that the services re-examine
these policies, however (Naclerio etal., 2011), as they conflict with the American
Academy of Pediatric policy statement (AAP, 2005), The Surgeon Generals 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 sustainable, 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 oftime.
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 CONCER NS INAN
AUSTERE ENVIRONMENT:THE ROLE OFTHE
MILITARYHEALTHSYSTEM
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
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 ofServicewomen
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 20062012, as shown in TMDS, were for urinary tract infections and
genital disordersmostly 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 members 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).
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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 etal.,2014).
These barriers were strikingly similar to those heard by the Womens 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 etal., 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 toAddressGaps

To address many of the barriers noted by Servicewomen above, the Womens 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 14years on utilizing simple methods of self-diagnosis for
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 etal., 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 thermometer, and education on the use of the kit (Ryan-Wegner etal., 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. Abroad range
of general, specialty and subspecialty providers, with varying levels of womens
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
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W omen at W ar
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
leaders 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 OFMORESTUDY

The Womens 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 womens 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 totalforce.
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).
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
committees 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 womens
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.
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REFERENCES
Albright, T.S., Gehrich, A.P., Buller, G.L.,& Davis, G.D. (2005). Acute dysuria amongst female soldiers.
Military Medicine, 170, 735738.
AHC Media. (2013). FDA approves smaller levonorgestrel intrauterine systema mini Mirena.
Contraceptive Technology Update. Retrieved from http://www.ctcfp.org/wp-content/uploads/
March-2013-Contraceptive-Technology-Update.pdf.
American Academy of Pediatrics. (2012). Policy statement. Section on breastfeeding: Breastfeeding
and the use of human milk. Pediatrics, 129(3), e827e842. Retrieved from:www.pediatrics.org/cgi/
content/full/129/3/e827
American College of Obstetricians and Gynecologists. (2006). Practice bulletin:Clinical management guidelines for obstetriciangynecologists. Number 72, vaginitis. Obstetrics& Gynecology, 107(5), 11951206.
American College of Obstetricians and Gynecologists. (2008). Depot medroxyprogesterone acetate and
bone effects. ACOG Committee Opinion Number 415. Committee on Adolescent Health Care&
Committee on Gynecologic Practice. Obstetrics& Gynecology, 112, 727730.
American College of Obstetricians and Gynecologists. (2010). Practice Bulletin Number
110:Noncontraceptive uses of hormonal contraceptives. Obstetrics& Gynecology, 110(1):206218.
doi:10.1097/AOG.0b013e3181cb50b5.
American College of Obstetricians and Gynecologists. (2014). Committee opinion no. 602: depot
medroxyprogesterone acetate and bone effects. Obstetrics & Gynecology, 123(6),13981402.
doi:10.1097/01.AOG.0000450758.95422.c8.
American College of Obstetricians and Gynecologists. (2011). Practice Bulletin Number
121: Long-acting reversible contraception: Implants and intrauterine devices. Obstetrics &
Gynecology, 118(1),184196. doi:10.1097/AOG.0b013e318227f05e.
Andersch, B.,& Milsom, I. (1982) An epidemiologic study of young women with dysmenorrhea. American
Journal of Obstetrics and Gynecology, 144(6), 655660.
Anderson, F.D, Halt, H.,& the Seasonale-301 Study Group. (2003). A multicenter, randomized study of an
extended cycle oral contraceptive. Contraception, 68, 8996. doi:10.1016/S0010-7824(03)00141-0
Andersson, K., Odlind, V.,& Rybo, G. (1994). Levonorgestrel-releasing and copper-releasing (Nova T)
IUDs during five years of use:Arandomized comparative trial. Contraception, 49,5672.
Armed Forces Health Surveillance Center. (2012). Iron deficiency anemia, Active Component, U.S.
Armed Forces, 20022011. Medical Surveillance Monthly Report, 19(7), 1721. Retrieved from
http://afhsc.army.mil/msmrpdf/2012v19no7.pdf.
Armed Forces Health Surveillance Center. (2014). Urinary tract infections during deployment, Active
Component, U.S. Armed Forces, 20082013. Medical Surveillance Monthly Report, 21(3), 25.
Retrieved from http://www.afhsc.mil/viewMSMR?file=2014/MSMR_V21_n03.pdf#Page=14.
Arowojolu, A.O., Gallo, M.F., Lopez, L.M.,& Grimes, D.A. (2012). Combined oral contraceptive pills
for treatment of acne. The Cochrane Database of Systematic Reviews, 11(7). doi:10.1002/14651858.
CD004425.pub6.
Brusch, J.L., Bavaro, M.F., Cunha, B.A.,& Tessier, J.M. (2012). Cystitis in females. Retrieved from
http://emedicine.medscape.com/article/233101-overview#a0156.
Burkman, R., Schlesselman J. J., & Zieman M. (2004). Safety concerns and health benefits associated with oral contraception. American Journal of Obstetrics and Gynecology, 190(Suppl), S5S22.
doi:10.1016/j.ajog.2004.01.061
Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (2005).
Urinary tract infections. Retrieved from http://www.cdc.gov/ncidod/dbmd/diseaseinfo/urinarytractinfectionst.htm.
Centers for Disease Control and Prevention. (2010). US medical eligibility criteria for contraceptive use.
Morbidity and Mortality Weekly Report, 59. Retrieved from http://www.cdc.gov/mmwr/preview/
mmwrhtml/rr5904a1.htm.
Charu, S., Amita, R., Sujoy, R.,& Thomas, G.A. (2012). Menstrual characteristics and prevalence and
effects of dysmenorrhea on quality of life of medical students. International Journal of Collaborative
Research on Internal Medicine& Public Health (IJCRIMPH), 4(4), 276294. Retrieved from http://
www.highbeam.com/doc/1G1-305193076.html.
73
Christopher, L.A.,& Miller, L. (2007). Women in war:Operational issues of menstruation and unintended pregnancy. Military Medicine, 172(1), 916. Retrieved from http://www.highbeam.com/
doc/1P3-1200704101.html/print.
Cole, F.A., Norman, H., Doherty, M.,& Walder, A.M. (2007) Venous thromboembolism, myocardial
infarction and stroke among transdermal contraceptive system users. Obstetrics& Gynecology, 109,
339346. Retrieved from http://www.sjsu.edu/faculty/gerstman/eks/Cole2007.pdf.
Cox, K.L. (2007). Gender and health in the military:Facts and myths. Paper presented at the 10th Annual
Force Health Protection Conference, Louisville,KY.
Cromer, B.A., Bonny, A.E., Stager, M., Lazebnik, M.D., Rome, E., Ziegler, M.A., ... Secic, M. (2008).
Bone mineral density in adolescent females using injectable or oral contraceptives:a 24-month prospective study. Fertility and Sterility, 90, 20602067. doi:10.1016/j.fertnstert.2007.10.070.
Czerwinski, B.S., Wardell, D.W., Yoder, L.H., Connelly, L.M., Ternus, M., Pitts, K.,& Kouzekanani,
K. (2001). Variations in feminine hygiene practices of military women in deployed and noncombat
environments. Military Medicine, 166(2), 152158.
Davis, A. R, Westhoff, C., OConnell, K., & Gallagher, N. (2005). Oral contraceptives for dysmenorrhea in adolescent girls:Arandomized trial. Obstetrics& Gynecology, 106, 97104. doi:10.1097/01.
AOG.0000165826.03915.65.
Defense Department Advisory Committee on Women in the Services (DACOWITS). (2011). 2011
report. Retrieved from: http://dacowits.defense.gov/Portals/48/Documents/Reports/2011/
Documents/2011/Annual Report Additional Info/DACOWITS 2011 Report (Exec Summary).
pdf.
Defense Department Advisory Committee on Women in the Services (DACOWITS). (2012). 2012
report. Retrieved from http://dacowits.defense.gov/Portals/48/Documents/Reports/2012/
Annual Report/dacowits2012report.pdf.
Defense Manpower Data Center (DMDC). (2010). Workplace and gender relations survey of active
duty members. Retrieved from http://www.sapr.mil/media/pdf/research/DMDC_2010_WGRA_
Overview_Report_of_Sexual_ Assault.pdf.
Defense Medical Surveillance System. (DMSS). Retrieved from http://www.afhsc.mil/dmss (accessed
June 21,2013).
DeNavas-Walt, C., Proctor, B.D.,& Smith, J.C. (2013). U.S. Census Bureau, current population reports,
P60-245, Income, poverty, and health insurance coverage in the United States: 2012. Washington,
DC:US Government Printing Office. www.census.gov/prod/2012pubs/p60-243.pdf.
Department of Defense. (2010). Sexual assault response and prevention report:Department of Defense fiscal
year 2009 annual report on sexual assault in the military. Retrieved from http://www.sapr.mil/index.
php/annual-reports.
Department of Defense. (2013). Department rescinds direct combat exclusion rule:Services to epand
integration of women into previously restricted occupations and units. Retrieved from http://www.
defense.gov/releases/release.aspx?releaseid=15784.
Dmitrovic, R., Kunselman, A. R., & Legro, R. S. (2012). Continuous compared with cyclic oral contraceptives for the treatment of primary dysmenorrhea:Arandomized controlled trial. Obstetrics&
Gynecology, 119(6), 11431150. doi:10.1097/AOG.0b013e318257217a.
Doherty, M.E.,& Scannell-Desch, E. (2012). Womens health and hygiene experiences during deployment to the Iraq and Afghanistan wars, 2003 through 2010. Department of Nursing, Western
Connecticut State University, Danbury, Connecticut, USA. Journal of Midwifery& Womens Health,
57(2), 172177. doi:10.1111/j.1542-2011.2011.00115.x
Edelman, A. B, Gallo, M. F., Jensen, J. T., Nichols, M. D., & Schulz, K. F., Grimes, D. A. (2006).
Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception:systematic Cochrane review of randomized controlled trials. Human Reproduction, 21(3), 573578.
doi:10.1093/humrep/dei377
Faculty of Sexual and Reproductive Health Care Clinical Effectiveness Unit. FSRH Guidance.
(2008). Progestogen-only pills. Retrieved from http://www.ffprhc.org.uk/admin/ uploads/
CEUGuidanceProgestogenOnlyPill08.pdf.
Faculty of Sexual and Reproductive Health Care Clinical Effectiveness Unit. FSRH Guidance.
(2009). Management of unscheduled bleeding in women using hormonal contraception. Royal College
74
W omen at W ar
of Obstetricians and Gynaecologists. Retrieved from http://www.rcog.org.uk/files/rcog-corp/

UnscheduledBleeding23092009.pdf.
Friedl, K.E . (2005). Biomedical research on health and performance of military women:Accomplishments
of the Defense Womens Health Research Program (DWHRP). Journal of Womens Health, 14,
763802. doi:10.1089/jwh.2005.14.764.
Gierisch, J.M., Coeytaux, R.R, Urrutia, R.P., Havrilesky, L.J., Moorman, P.G., Lowery, ... Myers,
E. R. (2013). Oral contraceptive use and risk of breast, cervical, colorectal, and endometrial
cancers: A systematic review. Cancer Epidemiology Biomarkers and Prevention, 22, 19311943.
doi:10.1158/1055-9965.EPI-13-0298.
Goyal, V., Borrero, S.,& Schwarz, E.B. (2012). Unintended pregnancy and contraception among active
duty servicewomen and veterans. American Journal of Obstetrics and Gynecology, 206(6), 463469.
doi:10.1016/j.ajog.2011.11.018.
Grindlay, K.,& Grossman, D. (2013a). Unintended pregnancy among active-duty women in the US military, 2008. Obstetrics& Gynecology, 121(2 Part1), 241246. doi:10.1097/AOG.0b013e31827c616e.
Grindlay, K.,& Grossman, D. (2013b). Contraception access and use among US servicewomen during
deployment. Contraception, 87(2),162169. doi:10.1016/j.contraception.2012.09.01.
Grindlay, K., Yanow, S., Jelinska, K., Gomperts, R., & Grossman, D. (2011). Abortion restrictions in
the US military: Voices from women deployed overseas. Womens Health Issues, 21(4), 259264.
doi:10.1016/j.whi.2011.04.014.
Hack, D. (2012). Survival rates from combat wounds keep increasing [video file]. Brainline.org. Retrieved
from https://www.youtube.com/watch?v=DvPXwbj-nTA.
Hanna, J.H. (1992). An analysis of gynecological problems presenting to an evacuation hospital during
Operation Desert Storm. Military Medicine, 157, 222224.
Hawley-Bowland, C. (1995). Lady J and Freshette Complete System:Afield trial for the active duty woman
(MIPR NO:95MM5579). Fort Dedrick, MD:U.S. Army Medical Research and Materiel Command.
Hicks, C.W.& Rome, E.S. (2010). Menstrual manipulation:Options for suppressing the cycle. Cleveland
Clinic Journal of Medicine, 77(7), 445453. doi:10.3949/ccjm.77a.09128.
Holt, K., Grindlay, K., Taskier, M.,& Grossman, D. (2011). Unintended pregnancy and contraceptive use
among women in the U.S.military:Asystematic literature review. Military Medicine, 176(9),1056.
Hubacher, D. (2007) Copper intrauterine device use by nulliparous women: Review of side effects.
Contraception, 75(6 Suppl), S8S11. doi:10.1016/j.contraception.2006.12.005.
Hsia, R., & Shen, Y. C. (2011). Possible geographical barriers to trauma center access for vulnerable
patients in the United States:An analysis of urban and rural communities. Archives of Surgery, 146(1),
4652. doi:10.1001/archsurg.2010.299.
Ibis Reproductive Health. (2013). Sexual and reproductive health of women in the US military. Issue brief
1:Contraception, unintended pregnancy, and abortion. Retrieved from http://www.ibisreproductivehealth.org/pub/downloads/MilitaryBrief1_7-10-13FINAL.pdf.
Institute of Medicine. (1995). Recommendations for research on the health of military women. Committee
on Defense Womens Health Research (DWHRP). Washington, DC: National Academies Press.
Retrieved from http://www.nap.edu/openbook.php?record_id=9049&page=R1.
Institute of Medicine. (1998). Reducing stress fracture in physically active military women. Washington,
DC:The National AcademiesPress.
Jain, J., Dutton, C., Nicosia, A., Wajszczuk. C., Bode, F.R.,& Mishel, D.R. (2004). Pharmacokinetics,
ovulation suppression and return to ovulation following a lower dose subcutaneous formulation of
Depo-Provera. Contraception, 70(1):1118. doi:10.1016/j.contraception.2004.01.011.
Jamieson, D.J.,& Steege, J.F. (1996). The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and
irritable bowel syndrome in primary care practices. Obstetrics& Gynecology, 87,5558.
Jensen, J.T.,& Speroff, L. (2000). Health benefits of oral contraceptives. Obstetrics and Gynecology Clinics
of North America, 27, 705721.
Kaunitz, A.M., Miller, P.D., Rice, V.M., Ross, D.,& McClung, M.R. (2006). Bone mineral density in
women aged 2535years receiving depot medroxyprogesterone acetate:recovery following discontinuation. Contraception, 74, 9099. doi:10.1016/j.contraception.2006.03.010.
75
Kaunitz, A.M. (2000). Injectable contraception:New and existing options. Obstetrics and Gynecology
Clinics of North America, 27, 741780.
Legal Information Institute. (ND) US Code 1093. Performance of abortions:Restrictions. Retrieved
from http://www.law.cornell.edu/uscode/text/10/1093.
Lindberg, L.D. (2011). Unintended pregnancy among women in the US military. Contraception, 84(3),
249251. doi:10.1016/j.contraception.2011.01.017.
Liu, Z., Doan, Q.V., Blumenthal, P.,& Dubois, R.W. (2007). A Systematic review evaluating health-related
quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding.
Value in Health, 10(3), 183194. doi:10.1111/j.1524-4733.2007.00168.x.
Lopez, L.M., Grimes, D.A., Gallo, M.F., Stockton, L.L.,& Schulz, K.F. (2013). Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database of Systematic
Reviews. Issue 4. doi:10.1002/14651858.CD003552.pub4.
Loris, B., Tiziana, M., Ferdinando, A., Angelo, B., Almerico N.,& Giannini, A. (1996). Urinary volume,
water and recurrences in idiopathic calcium nephrolithiasis:A5-year randomized prospective study.
The Journal of Urology, 155(3), 839843.
Loudon, N.B., Foxwell, M., Potts, D. M., Guild, A. L.,& Short, R.V. (1977). Acceptability of an oral
contraceptive that reduces the frequency of menstruation:the tri-cycle pill regimen. British Medical
Journal, 2, 487490.
Lowe, N.K., Neal, J.L.,& Ryan-Wenger, N.A. (2009). Accuracy of the clinical diagnosis of vaginitis compared with a DNA probe laboratory standard. Obstetrics& Gynecology, 113(1), 8995. doi:10.1097/
AOG.0b013e3181909f63.
Lowe, N.K.,& Ryan-Wenger, N.A. (2000). A clinical test of womens self-diagnosis of genitourinary
infections. Clinical Nursing Research, 9(2), 144160. doi:10.1177/105477380000900204.
Lowe, N.K.,& Ryan-Wenger, N.A. (2003). Military womens risk factors for and symptoms of genitourinary infections during deployment. Military Medicine, 168(7), 569574.
Manski, R., Grindlay, K., Burns, B., Holt, K.,& Grossman, D. (2014) Reproductive health access among
deployed US Servicewomen:Aqualitative study. Military Medicine, 179(6), 645652. doi:10.7205/
MILMED-D-13-00302.
MEDCOM Pam 40-7-21. (2006, June 23, updated November 2011). Algorithm-Directed Troop Medical Care
(ADTMC) (pp 142161). Retrieved from http://www.vssm.org/tor/adtmc-medcom-pam-40-7-21/.
Miles, D. (2012, September 18). Deploying Soldiers test new female body armor prototype. American
Forces Press Service. Retrieved from http://www.army.mil/article/87464/.
Miller, L.,& Hughes, J.P. (2003). Continuous combination oral contraceptive pills to eliminate withdrawal bleeding:a randomized trial. Obstetrics& Gynecology, 101, 653661.
Naclerio, A.L., Stola, J., Trego L.,& Flaherty, E. (2011). The concerns of women currently serving in the
Afghanistan Theater of Operations: White paper. Health Service Support Assessment Team, IJC,
Afghanistan. Retrieved from http://www.globalsecurity.org/military/library/report/2011/
womens-concerns-afghanistan.pdf.
National Collaborating Centre for Womens and Childrens Health (UK). (2005). National Institute for
Health and Clinical Excellence (NICE) clinical guidelines, No. 30: Long-acting reversible contraception: The effective and appropriate use of long-acting reversible contraception. Retrieved from http://
www.nice.org.uk/Guidance/CG30.
Nielson, P.E., Murphy, C.S., Schultz, J., Deering, S., Troung, V., McCartin, T.,& Clemons, J.L. (2009).
Female soldiers gynecologic healthcare in Operation Iraqi Freedom:Asurvey of camps with echelon three facilities. Military Medicine, 174(11), 11921176.
Omli, R., Skotnes, L.H., Romild, U., Bakke, A., Mykletun, A.,& Kuhry, E. (2010). Pad per day usage,
urinary incontinence and urinary tract infections in nursing home residents. Age and Ageing, 39,
549554. doi:10.1093/ageing/afq082.
Paquette, S. (2011, May 11). Improved fit and performance of the IOTV for female soldiers. [Power Point
Slides]. US Army RDECOM, US Army Natick. Retrieved from http://usarmy.vo.llnwd.net/e2/c/
downloads/256744.pdf.
PASBA. Analysis of TMDS trends:20022012 by gender and CCS diagnosis category. Accessed May2014.
76
W omen at W ar
Portman, D. J., Kaunitz, A. M., Howard, B., Weiss, H., Hsieh, J., & Ricciotti, N. (2014). Efficacy and
safety of an ascending-dose, extended-regimen levonorgestrel/ethinyl estradiol combined
oral contraceptive. Contraception, 89, 299306. Retrieved from http://dx.doi.org/10.1016/j.
contraception.2014.01.013.
Powell-Dunford, N. (2003). Attitudes and knowledge about continuous oral contraceptive pill use in
military women. Military Medicine, 168, 922928.
Powell-Dunford, N., Cuda, A.S., Moore, J.L., Crago, M.S.,& Deuster, P.A. (2009). Menstrual suppression using oral contraceptives:Survey of deployed female aviation personnel. Aviation, Space, and
Environmental Medicine, 80(1), 971975. doi:10.3357/ASEM.2566.2009.
Powell-Dunford, N.C., Cuda, A.S., Moore, J.L., Crago, M.S., Kelley, A.M.,& Deuster, P.A. (2011).
Menstrual suppression for combat operations: Advantages of oral contraceptive pills. Womens
Health Issues, 21(1), 8691. doi:10.1016/j.whi.2010.08.006.2566.2009.
Pullon, S., Reinken, J.,& Sparrow, M. (1988). Prevalence of dysmenorrhoea in Wellington women. New
Zealand Medical Journal, 101(839),5254.
Rao, S., Bhatt, J., Houghton, C.,& Macfarlane, P. (2004). An improved urine collection pad method:Arandomized clinical trial. Archives of Disease in Childhood, 89, 773775. doi:10.1136/adc.2003.037770.
Ryan-Wenger, N.A.,& Lowe, N.K. (2000). Military womens perspectives on health care during deployment. Womens Health Issues, 10(6), 333343. doi:10.1016/S1049-3867(00)00064-5.
Ryan-Wenger, N. A., Neal, J. L., Jones, A. S., & Lowe, N. K. (2010). Accuracy of vaginal symptom
self-diagnosis algorithms for deployed military women. Nursing Research, 59(1), 210. doi:10.1097/
NNR.0b013e3181c3b9dd.
Seracchioli, R., Mabrouk, M., Frasc, C, etal. (2010). Long-term cyclic and continuous oral contraceptive therapy and endometrioma recurrence:Arandomized controlled trial. Fertility and Sterility, 93,
5256. doi:10.1016/j.fertnstert.2008.09.052.
Sleudel, M. R. (2012) Breastfeeding during military deployment. Nursing for Womens Health,
16(1):2025. doi:10.1016/j.fertnstert.2008.09.052.
Society of Family Planning Guideline 20092. (2010). Use of the Mirena LNG-IUS and Paragard
CuT380A intrauterine devices in nulliparous women. Contraception, 81(5), 367371. doi:10.1016/j.
Steele, N., & Yoder, L. H. (2013). Military womens urinary patterns, practices, and complications in
deployment settings. Urologic Nursing, 33(2),6171.
Stewart, F.H., Kaunitz, A.M., Laguardia, K.D., Karvois, D.L., Fisher, A.C.,& Friedman, A.J. (2005).
Extended use of transdermal norelgestromin/ethinyl estradiol: A randomized trial. Obstetrics &
Gynecology, 105(6), 13891396. doi:10.1097/01.AOG.0000160430.61799.f6.
Suhonen, S., Haukkamaa, M., Jakobsson, T., & Rauramo, I. (2004). Clinical performance
of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: A comparative study. Contraception, 69(5), 407412. doi:10.1016/j.
Sundell, G., Milsom, I.,& Andersch B. (1990). Factors influencing the prevalence and severity of dysmenorrhoea in young women. British Journal of Obstetrics and Gynecology, 97, 588594.
Tan, K.R., Magill, A.J., Parise, M.E.,& Arguin, P.M. (2011). Doxycycline for malaria chemoprophylaxis
and treatment:Report from the CDC expert meeting on malaria chemoprophylaxis. The American
Journal of Tropical Medicine and Hygiene, 84(4), 517531. doi:10.4269/ajtmh.2011.10-0285.
Thomson, B.A.,& Nielsen, P.E. (2006). Womens health care in Operation Iraqi Freedom:Asurvey of
camps with echelon Ior II facilities. Military Medicine, 171, 216219.
Trego, L. L. (2007). Military womens menstrual experiences and interest in menstrual suppression during deployment. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 36, 342347.
doi:10.1111/J.1552-6909.2007.00166.x
Trego, L.L. (2012), Prevention is the key to maintaining gynecologic health during deployment. Journal
of Obstetric, Gynecologic,& Neonatal Nursing, 41, 283292. doi:10.1111/j.1552-6909.2011.01337.x.
77
Trego, L., Wilson, C.,& Steele, N. (2010). A call to action for evidence-based military womens healthcare:Developing a womens health research agenda that addresses sex and gender in health and illness. Biological Research for Nurses, 12, 171177. doi:10.1177/1099800410375299.
Trenor, C.C., Chung, R.J., Michelson, A.D., Neufeld, E.J., Gordon C.M., Laufer, M.R.,& Emans,
J. (2011). Hormonal contraception and thrombotic risk:Amultidisciplinary approach. Pediatrics,
127(2), 347357. doi:10.1542/peds.2010-2221.
Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census
Bureaus March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic
Supplements). Retrieved from http://kff.org/other/state-indicator/total-population/.
US Army Public Health Command (USAPHC). (2010a). Summary of in-theater medical encounter data
coded for vaginal infections or menstrual disorders, U.S. Army Women, 20062008. Unpublisheddata.
US Army Public Health Command (USAPHC). (2010b). A guide to female soldier readiness (technical
guide 281). Retrieved from http://www.25idl.army.mil/PT/Guide to Female Soldier Readiness
TG281.pdf.
US Department of Health and Human Services. (2000). Office on Womens Health HHS blueprint for
action on breastfeeding. Washington, DC. Retrieved from http://www.womenshealth.gov/breastfeeding/government-in-action/blueprints-and-policy.html.
US Department of Health and Human Services. (2011a). The Surgeon Generals call to action to support breastfeeding. Washington, DC:US Department of Health and Human Services, Office of the
Surgeon General. Retrieved from http://www.surgeongeneral.gov/library/calls/breastfeeding/
calltoactiontosupportbreastfeeding.pdf.
US Department of Health and Human Services. (2011b). Healthy People 2020 maternal, infant, and
child health objectives. [updated September 29, 2011; cited October 6,2011]. Retrieved from http://
healthypeople.gov/2020/topicsobjectives2020/objectiveslist.
US Food and Drug Administration. (2007). FDA approves contraceptive for continuous use. FDA
News Release PO7-89. Retrieved from http://www.fda.gov/NewsEvents/Newsroom/
PressAnnouncements/2007/ucm108918.htm.
US Food and Drug Administration. (2010). FDA approves additional use for IUD Mirena to treat heavy menstrual bleeding in IUD users. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/
ucm184747.htm.
Van den Heuvel, M.W., van Bragt, A.J., Alnabawy, A.K.,& Kaptein, M.C. (2005). Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: The vaginal ring,
the transdermal patch and an oral contraceptive. Contraception, 72(3), 168174. doi:10.1016/j.
Wilson, C., McClung, J.P., Karl, J.P.,& Brothers, M.D. (2011) Iron status of military personnel deployed
to Afghanistan. Military Medicine, 176(12),1421.
Wilson, C.,& Nelson, J.P. (2012). Exploring the patterns, practices, and experiences of military women
who managed genitourinary symptoms in deployed settings. Journal of Obstetric, Gynecologic, &
Neonatal Nursing, 41, 293302. doi:10.1111/j.1552-6909.2012.01347.x.
World Health Organization. (2009). Medical eligibility criteria for contraceptive use (4th ed.).
Geneva: WHO. Retrieved from http://whqlibdoc.who.int/publications/2010/9789241563888_
eng.pdf?ua=1 (accessed July 12,2011).
Wright, K.P.,& Johnson, J.V. (2008). Evaluation of extended and continuous use oral contraceptives.
Journal of Therapeutics and Clinical Risk Management, 4(5), 905911. Retrieved from http://www.
ncbi.nlm.nih.gov/pmc/articles/PMC2621397/.
five
ReproductiveHealth
CAR A J.KRULEWITCH
INTRODUCTION
A large majority of active duty Servicewomen are of childbearing age. As of November
2012, among the 2.3million 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 members 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.
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5.ReproductiveHealth
79
PREGNANCY AND CONTR ACEPTION

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 1819, 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 etal. (2010) noted that some OC use might be for menstrual suppression
instead of contraception, which is supported by other studies (Powel-Dunford etal.,
2009, 2011; Trego, 2007; Powell-Dunford, Deuster, Claybaugh,& Chapin,2003).
The most recent reported estimate of unintended pregnancies among civilian
women aged 1544 was 57.2% during 20062010. The proportion was higher among
civilian women aged 2029 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,
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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 2024, and 84 per 1000 for women aged 2529 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 aboardship).
In conclusion, unintended pregnancy rates and contraceptive use in active duty
Servicewomen are similar to rates found in the civilian population and remain higher
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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 etal., 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 2020goal.
Pregnancy Outcomes
Deployment and Birth Defects

The Armed Forces Health Surveillance Center (AFHSC, 2011)reported that during
20002010 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 etal. (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 weredrawn.
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 etal., 2012; Armed Forces Health Surveillance Center [AFHSC], 2010;
Ryan etal., 2011; Conlin etal.,2012).
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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 Preventions (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 thisstudy.
In a larger study using the same methodology, Araneta etal. (2003) evaluated data
from six states that report to the CDCs 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
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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, 1.526.3, 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 etal. (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-tosevere birth defect compared to those who had not deployed (males:1.78 [1.192.66],
females:2.80 [1.266.25]). 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
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in Korea for more than 30days 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 (1.041.64) times more likely to have an infant with
birth defects, if the infant was conceived 280days or more after the exposure.
Bukowinski etal. (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 20042007 following one or both of
their parents serving in the 19901991 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 153200days, there was a 1.25 (1.051.49)
times increased risk of birth defects in children compared to active duty Service members who had been deployed 192days. This risk was not present in the group of men
who had been deployed 201485days. 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-exposedgroup.
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 etal. (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
85
pits. Two studies reported findings of a delayed association between exposure and
birth defects with fathers who had been deployed either 153200days (Bukowinski
etal., 2012)or greater than 280days (AFHSC, 2010). The birth defects in both studies were self-reported. Finally, Araneta etal. (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 20years ago, it is possible
that current exposures may not produce similar results. Alarger 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 19891992. Further research is needed to draw conclusions regarding
this exposurerisk.
Pregnancy inTheater
There are several reports that evaluated pregnancy following combat deployment
and the need for evacuation. Albright etal. (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
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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 2003April 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 giventime.
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 35,00050,000
women who have been deployed to combat zones, this translates to the potential for
5375 cases per year (Stamilio etal., 2004; Albright, etal., 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 20022011. Rivera-Alsina and Crisan (2008) and Stamillo
etal. (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
20022005 and then declined to 0.49% in 20052011. These findings were similar to
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 20years 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
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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 etal., 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.
89
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), 511514.
American College of Obstetricians and Gynecologists (ACOG). (2009, December). Committee
Opinion 450: Increasing Use of Contraceptive Implants and Intrauterine Devices To Reduce
Unintended Pregnancy. Retrieved from http://www.acog.org/~/media/Committee%20Opinions/
Committee%20on%20Gynecologic%20Practice/co450.pdf?dmc=1&ts=20130529T0357139633
American College of Obstetricians and Gynecologists (ACOG). (2012a, October). Committee Opinion
539: Adolescents and long-acting reversible contraception: implants and intrauterine devices.
Retrieved from http://www.acog.org/~/media/Committee%20Opinions/Committee%20on%20
Adolescent%20Health%20Care/co539.pdf
American College of Obstetricians and Gynecologists (ACOG). (2012b, December). Committee
Opinion 547:Health Care for Women in the Military and Women Veterans. Retrieved from http://
www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-C
are-for-Underserved-Women/Health-Care-for-Women-in-the-Military-and-Women-Veterans
American College of Obstetricians and Gynecologists (ACOG). (2013, October). Committee
Opinion 575: Exposure to Toxic Environmental Agents. Retrieved from http://www.
acog.org/Resources-A nd-Publications/Committee-Opinions/Committee-on-Health-C
are-for-Underserved-Women/Exposure-to-Toxic-Environmental-Agents
Araneta, M.R. G., Destiche, D.A., Schlangen K.M., Merz, R.D., Forrester, M.B.,& Gray, G.C. (2000).
Birth defects prevalence among infants of Persian Gulf War veterans born in Hawaii, 19891993.
Teratology, 62, 1952004.
Araneta, M. R. G., Schlangen, K. M., Edmonds, L. D., Destiche, D. A., Merz, R. D., Hobbs, C. A.,
Flood, T.J., Harris, J.A., Krishnamurti, D.& Gray, G.C. (2003, April). Prevalence of birth defects
among infants of Gulf War veterans in Arkansas, Arizona, California, Georgia, Hawaii, and Iowa,
19891993. Birth Defects Research Part A:Clinical and Molecular Teratology, 67(4), 246260.
Armed Forces Health Surveillance Center& The Naval Health Research Center. (2010). Epidemiological
studies of health outcomes among troops deployed to burn pit sites. Retrieved from http://www.afhsc.
mil/viewDocument?file=100604_FINAL_Burn_Pit_Epi_Studies.pdf.
Armed Forces Health Surveillance Center. (2011, April). Hospitalizations among members of the active
component, U.S. Armed Forces, 2010. Medical Surveillance Monthly Report (MSMR), 18(4),815.
Armed Forces Health Surveillance Center. (2012, July). Ectopic pregnancy, active component, U.S.
Armed Forces, 20022011. Medical Surveillance Monthly Report (MSMR), 19(7),1417.
Biggs, R. L., Douglas, B. H., OBoyle, A. H., & Rieg, T. S. (2009, January). The impact of pregnancy
on the individual and military organization: A postpartum active duty survey. Military Medicine,
174(1),5175.
Bucher M.A. (1999, April). The impact of pregnancy on U.S. Army readiness. Masters Thesis. Air Command
and Staff College Air University, Alabama. Au/ACSC/016/1999-04. Retrieved from www.au.af.
mil/au/awc/awcgate/acsc/99-016.pdf.
Bukowinski, A.T, DeScisciolo, C., Conlin, A.M. S., Ryan M.A. K., Sevick C.J.,& Smith, T.C. (2012).
Birth defects in infants born in 19982004 to men and women serving in the U.S.military during the
19901991 Gulf War era. Birth Defects Research (Part A), 94, 721728.
Christopher, L. A., & Miller, L. (2007). Women in war: Operation issues of menstruation and unintended pregnancy. Military Medicine, 172, 1,916.
Chung-Park, M.S. (2007). Contraceptive decision-making in military women. Nursing Science Quarterly,
20, 281287. doi:10.1177/0894318407303432.
Clark, J.B., Holt, V.L.,& Miser, F. (1998, July). Unintended pregnancy among female soldiers presenting
for prenatal care at Madigan Army Medical Center. Military Medicine, 163(7), 444448.
90
W omen at W ar
Conlin, A.M. S., DeScisciolo, C., Sevick C.J., Bukowinski, A.T, Phillips, C.J.,& Smith, T.C. (2012,
June). Birth outcomes among military personnel after exposure to documented open-air burn
pits before and during pregnancy. Journal of Occupational and Environmental Medicine, 54(6),
689697.
Conlin, A. M. S., Bukowinski, A. T., Sevick, C. J., DeScisciolo, C., & Crum-Cianflone, N. F. (2013,
March). Safety of the pandemic H1N1 influenza vaccine among pregnant U.S.military women and
their newborns. Obstetrics& Gynecology, 121(3), 511518.
Enewold, L., Brinton, L.A., McGlynn, K.A., Zahm, S.H., Potter, J.F.,& Zhu, K. (2010). Oral contraceptive use among women in the military and the general U.S.population. Journal of Womens Health,
19(5). doi:10.1089=jwh.2009.1706.
Finer, L.,& Zolna, M.R. (2011, November). Unintended pregnancy in the United States:Incidence and
disparities, 2006. Contraception 84(5):478485. doi:10.1016/j.contraception.2011.07.013.
Goyal, V., Borrero, S.,& Schwarz, B.S. (2012, June). Unintended pregnancy and contraception among
active-duty servicewomen and veterans. American Journal of Obstetrics & Gynecology, 463469.
doi:10.1016/j.ajog.2011.11.018.
Grindlay, K.,& Grossman, D. (2013, February). Unintended pregnancy among active-duty women in the
United States Military, 2008. Obstetrics& Gynecology, 121(2, part1), 241246.
Hanna, J.H. (1992) An analysis of gynecological problems presenting to an evacuation hospital during
Operation Desert Storm. Military Medicine, 157, 222224.
Harcke, H.T.,& Rooks, V.J. (2012, August). Sonographic localization and management of metallic fragments:a report of five cases. Military Medicine, 177(8), 988992.
Healthy People 2020. Family planning objectives. Retrieved from http://www.healthypeople.gov/2020/
topicsobjectives2020/objectiveslist.aspx?topicId=13.
Hines, J.F. (1993). A comparison of clinical diagnoses among male and female soldiers deployed during
the Persian Gulf War. Military Medicine, 158, 99101.
Holt K., Grindiay K., Taskier, M., & Grossman, D. (2011). Unintended pregnancy and contraceptive
use among women in the U.S. Military: A systematic literature review. Military Medicine, 176(9),
10561064.
Hourani, L., & Hilton, S. (2000). Occupational and environmental exposure correlates of adverse
live-birth outcomes among 1032 US Navy women. Journal of Occupational and Environmental
Medicine, 42, 11561165.
Jones J., Mosher, W.,& Daniels, K. (2012, October 18). Current contraceptive use in the United States,
20062010, and changes in patterns of use since 1995. National Health Statistics Report, 60,125.
Kang, H., Magee, C., Mahan, C., Lee, K., Murphy, F., MPHc, Jackson, L., & Matanoski G. (2001).
Pregnancy outcomes among U.S. Gulf War veterans:Apopulation-based survey of 30,000 veterans.
Annals of Epidemiology, 11(7), 504511.
Lindberg, L. D. (2011, September). Unintended pregnancy among women in the U.S. military.
Contraception, 84(3), 249251. doi:10.1016/j.contraception.2011.01.017.
Mosher, W.D., Martinez, G.M., Chandra, A., Abma, J.C.,& Willson, S.J. (2004). Use of contraception
and use of family planning services in the United States:19822002. Advances in Data Analysis and
Classification, 350,136.
Nelson, B.P., Melnick, E.R.,& Li, J. (2011, February). Portable ultrasound for remote environments,
Part I:Feasibility of field deployment. Journal of Emergency Medicine, 40(2), 190197.
Nielsen, P.E., Murphy, C.S., Schulz, J., Deering, S.H., Truong V., McCartin, T.,& Clemons, J.L. (2009).
Female soldiers gynecologic healthcare in operation Iraqi Freedom:Asurvey of camps with echelon
three facilities. Military Medicine, 174(11), 11721176.
Office of the Deputy Under Secretary of Defense (Military Community and Family Policy). (November,
2012). 2011 Demographics:Profile of the military community. Retrieved from http://www.militaryonesource.mil/12038/MOS/Reports/2011_Demographics_Report.pdf.
Penman, A.D., Tarver, R.S.,& Currier, M.M. (1996). No evidence of increase in birth defects and health
problems among children born to Persian Gulf War Veterans in Mississippi. Military Medicine,
161,16.
91
Powell-Dunford, N., Cuda, A.S., Moore, J.L., Crago, M.S.,& Deuster, P.A. (2009). Menstrual suppression using oral contraceptives: survey of deployed female aviation personnel. Aviation, Space and
Environmental Medicine, 80, 971975.
Powell-Dunford, N., Cuda, A. S., Moore, J. L., Crago. M. S., Kelly, A. M., & Deuster, P. A. (2011,
JanuaryFebruary). Menstrual suppression for combat operations:advantages of oral contraceptive
pills. Womens Health Issues, 21(1), 8691. http://dx.doi.org/10.1016/j.whi.2010.08.006.
Powell-Dunford, N.C., Deuster, P.A., Claybaugh, J.R.,& Chapin, M.G. (2003). Attitudes and knowledge
about continuous oral contraceptive pill use in military women. Military Medicine, 168, 922928.
Ritchie, E. C. (2001). Issues for military women in deployment: an overview. Military Medicine, 166,
10331037.
Rivera-Alsina, M.E.,& Crisan, L.S. (2008). Management of ectopic pregnancy in the military during
deployment to southwest Asia. Military Medicine, 173(1),9799.
Robbins, A.S., Chao, S.Y., Frost, L.Z., Fonseca, V.P. (2005, January). Unplanned pregnancy among
active duty servicewomen, U.S. Air Force, 2001. Military Medicine, 170(1),3843.
Ryan, M.A. K., Gumbs, G.R., Conlin, A.M. S., Sevick, C.J., Jacobson, I.G., Snell, K.J., Spooner, C.N.,
Smith T.C.,& the Department of Defense Birth and Infant Health Registry Team. (2008). Evaluation
of preterm births and birth defects in liveborn infants of US military women who received smallpox
vaccine. Birth Defects Research (Part A), 82, 533539.
Ryan, M.A. K., Jacobson, I.G., Sevick, C.J., Smith, T.C., Gumbs G.R., Conlin, A.M. S.,& United States
Department of Defense Birth and Infant Health Registry. (2011). Health outcomes among infants
born to women deployed to United States military operations during pregnancy. Birth Defects
Research (Part A), 91, 117124.
Ryan, M.A. K., Smith T.C.,& Sevick, C.J., (2008). Birth defects among infants born to women who
received anthrax vaccine in pregnancy. American Journal of Epidemiology, 168(4), 434442.
doi:10.1093/aje/kwn159.
Ryan-Wenger, N.A.,& Lowe, N.K. (2000, NovemberDecember). Military womens perspectives on
health care during deployment. Womens Health Issues, 10(6), 333343. http://dx.doi.org/10.1016/
S1049-3867(00)00064-5.
Schlagenhauf, P., Blumenthals, W.A., Suter, P., Regep, L., Vital-Durand, G., Schaerer, Boutros, M.S.,
Rhein, H.-G., & Adamcova, M. (2012, June 1). Pregnancy and fetal outcomes after exposure to
mefloquine in the pre- and periconception period and during pregnancy. Clinical Infectious Diseases,
54(10), e124e131.
Shorter, M.,& Macias, D.J. (2012, April). Portable handheld ultrasound in austere environments:Use in
the Haiti disaster. Prehospital and Disaster Medicine, 27(02), 171177.
Smoak, B.L., Writer, J.V., Keep, L.W., Cowan, J.& Chantelois, J.L. (1997). The effects of inadvertent
exposure of mefloquine chemoprophylaxis on pregnancy outcomes and infants of US Army servicewomen. Journal of Infectious Diseases, 176, 831833.
Stamilio, D.M., McReynolds, T., Endrizzi, J.,& Lyons, R.C. (2004). Diagnosis and treatment of a ruptured ectopic pregnancy in a combat support hospital during Operation Iraqi Freedom:Case report
and critique of a field-ready sonographic device. Military Medicine, 169(9), 681683.
Thomas, M.D., Thomas, P.J.,& Garland, F.C. (2001, June). Contraceptive use and attitudes toward family planning in Navy enlisted women and men. Military Medicine, 166(6), 550556.
Trego, L.L. (2007). Military womens menstrual experiences and interest in menstrual suppression during deployment. Journal of Obstetric, Gynecologic,& Neonatal Nursing, 36, 342347.
Trussell, J.,& Wynn, L.L. (2008). Reducing unintended pregnancy in the United States. Contraception,
77,15.
United States General Accounting Office. (1994, August). Operation Desert Storm:Questions remain on
possible exposure to reproductive toxicants. Washington, DC: GAO PEMD-94-30. Retrieved from
http://archive.gao.gov/t2pbat2/152284.pdf.
Uriell, Z.A.,& Burress, L. (2009, June 30). Pregnancy and parenthood in the Navy:Results of the 2008 survey.
Navy Personnel Research, Studies, and Technology, Bureau of Naval Personnel. NPRST-AB-09-3.
Retrieved from http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA503230.
92
W omen at W ar
von Sadovszky, V., Ryan-Wenger, N., Germann, S., Evans, M. &, Fortney, C. (2008). Army womens reasons for condom use and nonuse. Womens Health Issues, 18, 1740180.
Wiesen, A.R.,& Littell, C.T. (2002, March 27). Relationship between prepregnancy anthrax vaccination and pregnancy and birth outcome among US Army women. Journal of the American Medical
Association, 287(12), 15561560.
Winner, B., Peipert, J.F., Zhao, Q., Buckel, C., Madden, T., Allsworth, J.E.,& Secura, G.M. (2012, May
24). Effectiveness of long-acting reversible contraception. New England Journal of Medicine, 366(21),
19982007.
Zolna, M.,& Lindberg, L. (2012, April). Unintended pregnancy:Incidence and outcomes among young adult
unmarried women in the United States, 2001 and 2008. NewYork:Guttmacher Institute. Retrieved
from http://www.guttmacher.org/pubs/unintended-pregnancy-US-2001-2008.pdf.
six
Issues inthe Prevention ofMalaria

AmongWomenatWar
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 atwar.
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
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W omen at W ar
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 implementing 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, pharmacodynamics, 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 OFMALAR IA IN
MILITARYWOMEN
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 Imake 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). Astudy of the history of malaria in the
US Navy from World War Ithrough 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 etal., 1996)nor
case series and ecological studies (Centers for Disease Control and Prevention, 1993;
Snchez, DeFraites, Sharp,& Hanson, 1993; Wallace etal., 1996)make any mention of
malaria occurring inwomen.
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
incidencerates.
Despite these shortcomings, limited conclusions can be drawn. Overall, during the 13-year period, of 799 cases of malaria identified in these published reports,
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TABLE6.1 Published Summaries ofMalaria Cases inthe US Military,

20002012,bySex
Year
Service and
Component
Total
2000
Army Active
Male
Cases
Female
Cases
758
94.9
41
5.1
55
100
(Army Medical Surveillance
Duty
2001
Army Active
Activity, 2001)
48
92.3
7.7
35
97.2
2.8
54
98.2
1.8
55
98.2
1.8
37
92.5
7.5
117
95.9
4.1
Duty
2002
Army Active
Activity, 2002)
Duty
2003
Army Active
Activity, 2003)
Duty
2004
Army Active
Activity, 2004)
Duty
2005
Army Active
Activity, 2005)
Duty
2006
All
Reference
Activity, 2006)
Activity, 2007)
2007
All
81
94.2
5.8
(Armed Forces Health

Surveillance Center, 2008)
2008
All
81
97.6
2.4

2009
All
55
91.7
8.3

2010
All
105
92.9
7.1
2011
All
121
97.6
2.4
2012
All
35
92.1
7.9

Surveillance Center, 2012b)
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 tomales.
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 etal., 2005; Whitman etal., 2010).
With the full integration of women into such units (Steinhauer, 2013), it is reasonable
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.
STR ATEGIES INMOSQUITO 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 etal., 2005; Ledbetter, Shallow,& Hanson, 1995), complicating prevention efforts. Regular use of topical insect repellants is uncommon
(Vickery etal., 2008)and frequently occurs only in response to perceived nuisance
biting (Gambel etal., 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)
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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 properuse.
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 theseitems.
ISSUES INTHE DEVELOPMENT AND TESTING
OFANTIMALAR IALS INWOMEN
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 etal., 2012); a similar effort two decades later led to the
development of the quinine derivative mefloquine (Croft, 2007a). Clinical testing
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. HoffmanLaRoche, 1989). A subsequent US government study confirmed that 89% of subjects
in pre-licensing trials of mefloquine were male (Burke, 1996). Similarly, early militarysponsored 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 etal., 2011; Elmes, Nasveld, Kitchener, Kocisko,& Edstein, 2008;
Nasveld etal.,2010).
TOLER ANCE AND SAFET Y OF
ANTIMALAR IALSINWOMEN
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 inwomen.
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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 etal., 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 etal., 2006; Weniger, 1979), limited post-marketing studies suggest that women may experience significantly higher
serum concentrations with repeated (Binh etal., 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 etal., 2011),
the drug is generally considered reasonably well tolerated at the current recommended
daily dose of 30 mg (Magill etal., 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
etal.,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, Bjrkman, Andersson, Gustafsson, & Masimirembwa, 2003;
Louisa, Soetikno, Nafrialdi, Setiabudy,& Suyatna, 2012; Pybus etal., 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 etal., 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 etal.,
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 etal.,
2012) in the chronic treatment of rheumatologic disease (Thom, Lopes, Costa, &
Verinaud, 2013). In single dose studies, chloroquine appears not to significantly
impact the metabolism of oral contraceptives (Back etal., 1984), although effects on
the metabolism of hormonal contraceptives during long-term use cannot be ruledout.
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 etal., 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 etal.,2013).
Owing primarily to concerns of permanent staining of the developing teeth, doxycycline has traditionally been considered contraindicated at all stages of pregnancy
(Tan etal., 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 etal.,2011).
Conflicting historical guidance exists regarding use with hormonal contraceptives.
In a well-designed pharmacokinetic study, short-term use of doxycycline did not affect
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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 etal.,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, Bjrkman,& Keisu, 1991), there is generally
considered to be insufficient evidence to recommend the use of atovaquone/proguanil
during pregnancy (Irvine etal.,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 etal., 1999), the inactive prodrug proguanil
undergoes metabolism to the active form cycloguanil mostly by the cytochrome P450
(CYP) enzyme CYP2C19 (Pudney etal., 1999). While hormonal contraceptives may
significantly reduce activity of CYP2C19 (Tamminga etal., 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,
103
Ligthelm,& Goud, 1989), amnesia (MacLean, 2013; Marsepoil etal., 1993), suicide
(Croft, 2007b; Jousset etal., 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 drugs poor suitability for military use. Ablack 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 thedrug.
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 etal., 2006)and drug-mediated population heterogeneity in neuropharmacokinetics and consequent higher brain accumulation of the drug (Barraud
de Lagerie etal., 2004), serious and lasting symptoms of intoxication may occur after
only a single tablet (Grupp, Rauber,& Frscher, 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 etal., 2006), providing a parsimonious
explanation for complaints of lasting vestibular disorder and other neurological complaints associated with the drugs use (US Food and Drug Administration, 2012,2013).
Potentially as a result of sex differences in pharmacokinetics (van Riemsdijk
etal., 2004), women consistently experience a higher risk of prodromal symptoms of
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intoxication than men (Schlagenhauf et al., 1996; Schwartz, Potasman, Rotenberg,

Almog,& Sadetzki, 2001; van Riemsdijk etal., 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, Duchne,& 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 thedrug.
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 etal., 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 etal., 1997), clearly demonstrated an increased risk
of pregnancy loss with use of the drug (Nevin, 2012c).
SELECTING ANAPPROPR IATE ANTIMALAR IAL
FORWOMENATWAR
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 deficient (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 malarious areas for pregnancy (a relatively common occurrence) (Albright etal., 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 etal., 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
etal., 2014). As there are yet no effective alternatives to primaquine, such contraindications and interactions are likely to further complicate the prevention of relapsing
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
etal., 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 Table6.2.
The weekly dosed drug chloroquine was a favored antimalarial used both during
operations in Korea (Alving etal., 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 militarys drug of choice (Snchez etal., 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 etal., 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 etal., 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 drugs
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

most deployments
and bloodforms
Must use for 7days upon return from
deployment
Uncertain safety in pregnancy;
discontinue if pregnancy is suspected or
diagnosed
Chloroquine
Cannot be prescribed
for use in areas of
known chloroquine
resistance
Suppressive prophylaxis active against

blood formsonly
Must use for 4 weeks upon return from
deployment
Considered by some authorities safe for
use during pregnancy
Doxycycline
Cannot be used for

deployments
exceeding 3months

blood formsonly
Must use for 30days upon return from
deployment
Approved indication limits command
directed use to no more than 4months
Considered by some authorities safe
for use prior to the fourth month of
pregnancy
Mefloquine
to members of certain
eliteunits
Use restricted by DoD
policy to drug of last
resort in other units

blood formsonly
Must use for 4 weeks upon return from
deployment
Should be initiated as early as 710
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 thedrug)
Discontinuation may mandate
immediate redeployment from areas of
high malaria endemicity
Primaquine
No approved indication for prophylaxis
107
expensive antimalarial constitutes a relatively small fraction of the total cost of deployment, which by recent estimates can approach $1million 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 etal., 2011). As federal law requires that
any command-directed use of pharmaceuticals be consistent with the drugs 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 schizonts that precede blood stage infection (Schwartz, Parise, Kozarsky,& Cetron, 2003).
The causal activity of atovaquone/proguanil permits a significantly reduced 7days 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 etal., 2012),
in contrast to doxycycline, whose short half life and suppressive mechanism of action
would preclude a similar effect (Tan etal.,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
etal., 2014)for travel to areas where sensitivity has clearly re-emerged (Kublin etal.,
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 etal.,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
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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
etal., 2001)to 2% (Schlagenhauf etal., 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 drugs 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 drugs 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 etal., 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 etal., 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 thedrug.
As the prodromal symptoms of mefloquine intoxication may quickly progress
to include paranoia and confusion (Ritchie etal., 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
109
the medication despite evidence of toxicity (Nevin, 2012a). Patient counseling should
therefore be complemented by ensuring that those within the patients 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 (Strchler etal., 1990), but not all (Ritchie etal., 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 710 weekly doses
to achieve steady state and protective serum concentrations (Boudreau et al., 1993;
Whitman etal., 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
etal.,2011).
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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 etal., 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 etal., 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 etal.,2011).
CONCLUSION
As female Service members increasingly serve in military operations in forwarddeployed 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 commensurate 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.
111
REFERENCES
Aarnoudse, A.L. H.J., van Schaik, R.H. N., Dieleman, J., Molokhia, M., van Riemsdijk, M.M., Ligthelm,
R.J., ... Stricker, B.H. C. (2006). MDR1 gene polymorphisms are associated with neuropsychiatric
adverse effects of mefloquine. Clinical Pharmacology and Therapeutics, 80(4), 367374.
Abu-Qare, A.W.,& Abou-Donia, M.B. (2003). Combined exposure to DEET (N,N-diethyl-m-toluamide)
and permethrin:pharmacokinetics and toxicological effects. Journal of Toxicology and Environmental
Health. Part B, Critical Reviews, 6(1),4153.
Albright, T.S., Gehrich, A.P., Wright, J., Lettieri, C.F., Dunlow, S.G.,& Buller, J.L. (2007). Pregnancy
during Operation Iraqi Freedom/Operation Enduring Freedom. Military Medicine, 172(5), 511514.
Alving, A.S., Arnold, J.,& Robinson, D.H. (1952). Mass therapy of subclinical vivax malaria with primaquine. Journal of the American Medical Association, 149(17), 15581562.
Alving, A.S., Eichelberger, L., Craige, B., Jones, R., Whorton, C.M.,& Pullman, T.N. (1948). Studies on
the chronic toxicity of chloroquine (SN-7618). The Journal of Clinical Investigation, 27(3 Pt 2),6065.
Andrews, W., & Fitzpatrick, S. (2013, December 23). Some U.S. troops haunted by anti-malaria
drugs drastic side effects. CBS.com. Retrieved from http://www.cbsnews.com/news/
some-us-troops-haunted-by-anti-malaria-drugs-side-effects.
Aquilina, J.T. (1952). Malaria in returned veterans of the Korean War:Clinical observations. Journal of
the American Medical Association, 149(9),834.
Archer, J.S. M.,& Archer, D.F. (2002). Oral contraceptive efficacy and antibiotic interaction:Amyth
debunked. Journal of the American Academy of Dermatology, 46(6), 917923.
Armed Forces Health Surveilance Center. (2011). Prevention, policies and priorities to reduce the impact
of malaria on US Forces. Retrieved from http://afhsc.mil/viewDocument?file=Training/2011_
DOD_malaria_MeetingSynopsis.pdf.
Armed Forces Health Surveillance Center. (2007). Korea-acquired malaria, U.S. Armed Forces, January
1998October 2007. Medical Surveillance Monthly Report, 14(8),25.
Armed Forces Health Surveillance Center. (2008). Update: Malaria among U.S. military members,
2007. Medical Surveillance Monthly Report, 15(2),47.
Armed Forces Health Surveillance Center. (2009). Update:Malaria, U.S. Armed Forces, 2008. Medical
Surveillance Monthly Report, 16(1),811.
Armed Forces Health Surveillance Center. (2012a). Health of women after wartime deployments: Correlates of risk for selected medical conditions among females after initial and repeat
deployments to Afghanistan and Iraq, active component, U.S. Armed Forces. Medical Surveillance
Monthly Report, 19(7),210.
Armed Forces Health Surveillance Center. (2012b). Update:Malaria, U.S. Armed Forces, 2011. Medical
Surveillence Monthly Report, 20(1),25.
Army Medical Surveillance Activity. (1999a). Malaria, U.S. Army, 1998. Medical Surveillance Monthly
Report, 5(1),23.
Army Medical Surveillance Activity. (1999b). Malaria experience among U.S. active duty soldiers,
19971999. Medical Surveillance Monthly Report, 5(8),23.
Army Medical Surveillance Activity. (2001). Malaria among active duty U.S. soldiers, 2000. Medical
Surveillance, 7(1),23.
Army Medical Surveillance Activity. (2002). Malaria among active duty soldiers, U.S. Army, 2001.
Medical Surveillance Monthly Report, 8(3),24.
Army Medical Surveillance Activity. (2003). Malaria among active duty soldiers, U.S. Army, 2002.
Medical Surveillance Monthly Report, 9(1),25.
112
W omen at W ar
Army Medical Surveillance Activity. (2004). Malaria, U.S. Army, 2003. Medical Surveillance Monthly
Report, 10(1),68.
Report, 11(1),710.
Report, 12(1),25.
Army Medical Surveillance Activity. (2007). Update: Malaria, U.S. Armed Forces, 2006. Medical
Arthur, J.D., Shanks, G.D.,& Echeverria, P. (1990). Mefloquine prophylaxis. Lancet, 335(8695),972.
Arznei-Telegramm. (2003). [Suicidal tendency and serious dermatological reaction under Malarone].
Arznei-Telegramm, 34(8),79.
Back, D.J., Breckenridge, A.M., Grimmer, S.F., Orme, M.L.,& Purba, H.S. (1984). Pharmacokinetics
of oral contraceptive steroids following the administration of the antimalarial drugs primaquine and
chloroquine. Contraception, 30(3), 289295.
Back, D.J., Purba, H.S., Staiger, C., Orme, M.L.,& Breckenridge, A.M. (1983). Inhibition of drug metabolism by the antimalarial drugs chloroquine and primaquine in the rat. Biochemical Pharmacology,
32(2), 257263.
Baird, J. K. (2013). Suppressive chemoprophylaxis invites avoidable risk of serious illness caused by
Plasmodium vivax malaria. Travel Medicine and Infectious Disease, 11(1),6065.
Barraud de Lagerie, S., Comets, E., Gautrand, C., Fernandez, C., Auchere, D., Singlas, E., ... Gimenez,
F. (2004). Cerebral uptake of mefloquine enantiomers with and without the P-gp inhibitor elacridar
(GF1210918) in mice. British Journal of Pharmacology, 141(7), 12141222.
Beadle, C.,& Hoffman, S.L. (1993). History of malaria in the United States Naval Forces at war:World
War Ithrough the Vietnam conflict. Clinical Infectious Diseases, 16(2), 320329.
Beerahee, M. (1999). Clinical pharmacology of atovaquone and proguanil hydrochloride. Journal of
Travel Medicine, 6(Suppl 1), S13S17.
Benjamin, M. (2004, July 15). Exclusive:Army surrenders to coward GI. UPI.com. Retrieved from http://
www.upi.com/Business_News/Security-Industry/2004/07/16/Exclusive-Army-surrendersto-coward-GI/UPI-51631089996907.
Benjamin, M., & Olmsted, D. (2004, June 4). Malaria-drug diagnosis for coward GI. UPI.com.
Retrieved from http://www.upi.com/Business_News/Security-Industry/2004/06/04/Malariadrug-diagnosis-for-coward-GI/UPI-40941086385037.
Berliner, R.,& Butler, T. (1946). Summary of data on the drugs tested in man. In F. Y.Wiselogle (Ed.),
Asurvey of antimalarial drugs, 19411945. (Vol. 1, pp. 221451). Ann Arbor, MI:J. W.Edwards.
Binh, V.Q., Chinh, N.T., Thanh, N.X., Cuong, B.T., Quang, N.N., Dai, B., ... Edstein, M.D. (2009). Sex
affects the steady-state pharmacokinetics of primaquine but not doxycycline in healthy subjects. The
American Journal of Tropical Medicine and Hygiene, 81(5), 747753.
Boggild, A.K., Parise, M.E., Lewis, L.S.,& Kain, K.C. (2007). Atovaquone-proguanil:Report from the
CDC expert meeting on malaria chemoprophylaxis (II). The American Journal of Tropical Medicine
and Hygiene, 76(2), 208223.
Boudreau, E., Schuster, B., Sanchez, J., Novakowski, W., Johnson, R., Redmond, D., . . . Dausel, L.
(1993). Tolerability of prophylactic Lariam regimens. Tropical Medicine and Parasitology, 44(3),
257265.
Bradley, D. J., & Warhurst, D. C. (1995). Malaria prophylaxis: Guidelines for travellers from Britain.
Malaria Reference Laboratory of the Public Health Laboratory Service, London. British Medical
Journal, 310(6981), 709714.
Brisson, M.,& Brisson, P. (2012). Compliance with antimalaria chemoprophylaxis in a combat zone. The
American Journal of Tropical Medicine and Hygiene, 86(4), 587590.
Brookes, D.B. (1966). Chloroquine psychosis. British Medical Journal, 1(5493),983.
Burke, B.M. (1996). Tragic time-lag. New Scientist, 150(2035),51.
Centers for Disease Control and Prevention. (1993). Malaria among U.S.military personnel returning
from Somalia, 1993. Morbidity and Mortality Weekly Report, 42(27), 524526.
113
Clyde, D.F. (1981). Clinical problems associated with the use of primaquine as a tissue schizontocidal
and gametocytocidal drug. Bulletin of the World Health Organization, 59(3), 391395.
Clyde, D.F., Miller, R.M., DuPont, H.L.,& Hornick, R.B. (1971). Antimalarial effects of tetracyclines
in man. The Journal of Tropical Medicine and Hygiene, 74(11), 238242.
Coatney, G. R. (1963). Pitfalls in a discovery: The chronicle of chloroquine. The American Journal of
Tropical Medicine and Hygiene, 12, 121128.
Cobelens, F.G.,& Leentvaar-Kuijpers, A. (1997). Compliance with malaria chemoprophylaxis and preventative measures against mosquito bites among Dutch travellers. Tropical Medicine& International
Health, 2(7), 705713.
Cockrill, J. A., Von Thun, A. M., & Fukuda, M. (2012). Optimizing preventive strategies and malaria
diagnostics to reduce the impact of malaria on U.S. Military Forces. Retrieved from http://afhsc.mil/
viewDocument?file=Training/2012_DOD_malaria_MeetingSynopsis.pdf.
Croft, A.M., Baker, D.,& von Bertele, M.J. (2001). An evidence-based vector control strategy for military deployments:The British Army experience. Mdecine tropicale:revue du Corps de sant colonial,
61(1),9198.
Croft, A.M. (2007a). A lesson learnt:The rise and fall of Lariam and Halfan. Journal of the Royal Society
of Medicine, 100(4), 170174.
Croft, A.M. (2007b). Developing safe antimalaria drugs:Key lessons from mefloquine and halofantrine.
International Journal of Risk& Safety in Medicine, 19, 153161.
Dean, O.M., Data-Franco, J., Giorlando, F.,& Berk, M. (2012). Minocycline:Therapeutic potential in
psychiatry. CNS Drugs, 26(5), 391401.
Deye, G.A, Miller, R.S., Miller, L., Salas, C.J., Tosh, D., Macareo, L., ... Magill, A.J. (2012). Prolonged protection provided by a single dose of atovaquone-proguanil for the chemoprophylaxis of Plasmodium
falciparum malaria in a human challenge model. Clinical Infectious Diseases, 54(2), 232239.
Dogterom, P., van den Heuvel, M.W.,& Thomsen, T. (2005). Absence of pharmacokinetic interactions
of the combined contraceptive vaginal ring NuvaRing with oral amoxicillin or doxycycline in two
randomised trials. Clinical Pharmacokinetics, 44(4), 429438.
Dow, G., Bauman, R., Caridha, D., Cabezas, M., Du, F., Gomez-Lobo, R., . . . Cannard, K. (2006).
Mefloquine induces dose-related neurological effects in a rat model. Antimicrobial Agents and
Chemotherapy, 50(3), 10451053.
Ebringer, A., Heathcote, G., Baker, J., Waller, M., Shanks, G.D.,& Edstein, M.D. (2011). Evaluation of
the safety and tolerability of a short higher-dose primaquine regimen for presumptive anti-relapse
therapy in healthy subjects. Transactions of the Royal Society of Tropical Medicine and Hygiene,
105(10), 568573.
Elmes, N.J., Bennett, S.M., Abdalla, H., Carthew, T.L.,& Edstein, M.D. (2006). Lack of sex effect on
the pharmacokinetics of primaquine. The American Journal of Tropical Medicine and Hygiene, 74(6),
951952.
Elmes, N.J., Nasveld, P.E., Kitchener, S.J., Kocisko, D.A.,& Edstein, M.D. (2008). The efficacy and tolerability of three different regimens of tafenoquine versus primaquine for post-exposure prophylaxis
of Plasmodium vivax malaria in the Southwest Pacific. Transactions of the Royal Society of Tropical
Medicine and Hygiene, 102(11), 10951101.
Embrey, E. (2009, September 4). Policy memorandum on the use of mefloquine (Lariam) in malaria prophylaxis (HA Policy 09-017). Office of the Assistant Secretary of Defense (Health Affairs).
Eriksson, B., Bjrkman, A.,& Keisu, M. (1991). How safe is proguanil? Apost-marketing investigation of
side-effects. Scandinavian Journal of Infectious Diseases, 23(4), 489493.
F. Hoffman-La Roche. (1989, February 15). New drug application 19-591: Lariam.
F. Hoffman-La Roche. (2013a, August 7). Lariam patient monitoring card, France.
F. Hoffman-La Roche. (2013b, July). Lariam guide to healthcare professionals, Ireland.
F. Hoffman-La Roche. (2013c, July). Lariam dear doctor letter, Ireland.
F. Hoffman-La Roche. (2013d, July). Lariam product insert, Ireland.
Faulde, M.K., Uedelhoven, W.M., Malerius, M.,& Robbins, R.G. (2006). Factory-based permethrin
impregnation of uniforms:Residual activity against Aedes aegypti and Ixodes ricinus in battle dress
114
W omen at W ar
uniforms worn under field conditions, and cross-contamination during the laundering and storage
process. Military Medicine, 171(6), 472477.
Feigl, A., Feigl, D., Shem-Tov, A., Brish, M.,& Rotem, J. (1975). Congenital atrial flutter. Chest, 67(5),
618619.
Ferber, M.M. (1987). Combat exclusion laws for women in the military. GAO/T-NSAID-88-8. Washington,
DC:General Accounting Office.
Ferreira Mello, B.S., Monte, A.S., McIntyre, R.S., Soczynska, J.K., Custdio, C.S., Cordeiro, R.C., ...
Macdo, D.S. (2013). Effects of doxycycline on depressive-like behavior in mice after lipopolysaccharide (LPS) administration. Journal of Psychiatric Research, 47(10), 15211529.
Fleet, M.,& Mann, J. (2004, May 20). Militarys use of malaria drug in question. CNN.com. Retrieved
from http://www.cnn.com/2004/HEALTH/05/19/lariam.
Fontaine, F., de Sousa, G., Burcham, P. C., Duchne, P., & Rahmani, R. (2000). Role of cytochrome
P450 3A in the metabolism of mefloquine in human and animal hepatocytes. Life Sciences, 66(22),
21932212.
Gambel, J.M., Brundage, J.F., Burge, R.J., DeFraites, R.F., Smoak, B.L.,& Wirtz, R.A. (1998). Survey
of U.S. Army soldiers knowledge, attitudes, and practices regarding personal protection measures to
prevent arthropod-related diseases and nuisance bites. Military Medicine, 163(10), 695701.
Gavin, L. (1997). American women in World War 1:They also served. Niwot:University of ColoradoPress.
Gershman, M. D., Mark D. Jentes, Emily S. Johnson, Katherine J. Tan, Kathrine R. Arguin, Paul M.
Steele, . . . C. Virginia. (2014). Travel vaccines & malaria information, by country. 2014 CDC yellow
booktravelers health, Chapter 3. Retrieved from http://wwwnc.cdc.gov/travel/yellowbook/2014/
chapter-3-infectious-diseases-related-to-travel/travel-vaccines-and-malaria-information-by-country.
Good, M.I.,& Shader, R.I. (1977). Behavioral toxicity and equivocal suicide associated with chloroquine and its derivatives. The American Journal of Psychiatry, 134(7), 798601.
Grindlay, K.,& Grossman, D. (2013). Unintended pregnancy among active-duty women in the United
States military, 2008. Obstetrics and Gynecology, 121(2 Pt 1), 241246.
Grupp, D., Rauber, A.,& Frscher, W. (1994). Neuropsychiatric disturbances after malaria prophylaxis
with mefloquine. Aktuelle neurologie, 21, 134136.
Hall, W.H.,& Loomis, G.W. (1952). Vivax malaria in veterans of the Korean War:Apreliminary report
of 25 cases. The New England Journal of Medicine, 246(3),9093.
Hart, C.W.,& Naunton, R.F. (1964). The ototoxicity of chloroquine phosphate. Archives of Otolaryngology,
80, 407412.
Hellgren, U.,& Rombo, L. (2010). Alternatives for malaria prophylaxis during the first trimester of pregnancy:Our personal view. Journal of Travel Medicine, 17(2), 130132.
Hill, D.R., Baird, J.K., Parise, M.E., Lewis, L.S., Ryan, E.T.,& Magill, A.J. (2006). Primaquine:Report
from CDC expert meeting on malaria chemoprophylaxis I. The American Journal of Tropical Medicine
and Hygiene, 75(3), 402415.
Irvine, M. H., Einarson, A., & Bozzo, P. (2011). Prophylactic use of antimalarials during pregnancy.
Canadian Family Physician, 57(11), 12791281.
Jelinek, P. (2013, September 19). Elite Army units to stop taking anti-malarial drug. Army Times.
Retrieved from http://www.armytimes.com/article/20130919/NEWS/309190006/Elite-Army-u
nits-stop-taking-anti-malarial-drug.
Jousset, N., Roug-Maillart, C., Turcant, A., Guilleux, M., Le Bouil, A.,& Tracqui, A. (2010). Suicide by
skull stab wounds:Acase of drug-induced psychosis. The American Journal of Forensic Medicine and
Pathology, 31(4), 378381.
Jover, J.A., Leon, L., Pato, E., Loza, E., Rosales, Z., Matias, M.A, ... Abasolo, L. (2012). Long-term use of
antimalarial drugs in rheumatic diseases. Clinical and Experimental Rheumatology, 30(3), 380387.
Kersgard, C. M., & Hickey, P. W. (2013). Adult malaria chemoprophylaxis prescribing patterns in
the military health system from 20072011. American Journal of Tropical Medicine and Hygiene,
89(2),317325.
Kime, P. (2013, August 8). Top DoD doctor: Black-box malaria drug should be prescribed only as
last resort. Military Times. Retrieved from http://www.militarytimes.com/article/20130808/
NEWS/308080050/Top-DoD-doctor-Black-box-malaria-drug-should-prescribed-only-last-resort.
115
Koren, G., Matsui, D.,& Bailey, B. (2003). DEET-based insect repellents:Safety implications for children and pregnant and lactating women. Canadian Medical Association Journal, 169(3), 209212.
Korhonen, C., Peterson, K., Bruder, C.,& Jung, P. (2007). Self-reported adverse events associated with
antimalarial chemoprophylaxis in peace corps volunteers. American Journal of Preventive Medicine,
33(3), 194199.
Kotwal, R.S., Wenzel, R.B., Sterling, R.A., Porter, W.D., Jordan, N.N.,& Petruccelli, B.P. (2005). An
outbreak of malaria in US Army Rangers returning from Afghanistan. The Journal of the American
Medical Association, 293(2), 212216.
Kublin, J.G., Cortese, J.F., Njunju, E.M., Mukadam, R.A. G., Wirima, J.J., Kazembe, P.N., ... Plowe,
C.V. (2003). Reemergence of chloroquine-sensitive Plasmodium falciparum malaria after cessation
of chloroquine use in Malawi. The Journal of Infectious Diseases, 187(12), 18701875.
LaRocque, R.C., Rao, S.R., Lee, J., Ansdell, V., Yates, J. a, Schwartz, B.S., ... Ryan, E.T. (2012). Global
TravEpiNet:Anational consortium of clinics providing care to international travelersanalysis of
demographic characteristics, travel destinations, and pretravel healthcare of high-risk US international travelers, 2009-2011. Clinical Infectious Diseases, 54(4), 455462.
Laskas, J.M. (2004, July). The coward. Gentlemans Quarterly (pp. 106112, 159161).
Ledbetter, E., Shallow, S.,& Hanson, K.R. (1995). Malaria in Somalia:Lessons in prevention. The Journal
of the American Medical Association, 273(10), 774775.
Li, X.-Q., Bjrkman, A., Andersson, T. B., Gustafsson, L. L., & Masimirembwa, C. M. (2003).
Identification of human cytochrome P(450)s that metabolise anti-parasitic drugs and predictions of
in vivo drug hepatic clearance from in vitro data. European Journal of Clinical Pharmacology, 59(56),
429442.
Lindberg, L.D. (2011). Unintended pregnancy among women in the US military. Contraception, 84(3),
249251.
Lobel, H.O., Coyne, P.E.,& Rosenthal, P.J. (1998). Drug overdoses with antimalarial agents:Prescribing
and dispensing errors. The Journal of the American Medical Association, 280(17),1483.
Looareesuwan, S., Wilairatana, P., Chalermarut, K., Rattanapong, Y., Canfield, C. J., & Hutchinson,
D.B. (1999). Efficacy and safety of atovaquone/proguanil compared with mefloquine for treatment
of acute Plasmodium falciparum malaria in Thailand. The American Journal of Tropical Medicine and
Hygiene, 60(4), 526532.
Louisa, M., Soetikno, V., Nafrialdi, Setiabudy, R.,& Suyatna, F.D. (2012). Co-administration of ritonavir and primaquine decreases plasma concentration of primaquine:Single- and multiple-dose study
in the rats. Acta Medica Indonesiana, 44(4), 273279.
MacLean, D. S. (2013, August 8). Crazy pills. New York Times. Retrieved from http://www.nytimes.
com/2013/08/08/opinion/crazy-pills.html.
Magill, A.J.,& Smoak, B.L. (1993). Failure of mefloquine chemoprophylaxis for malaria in Somalia. The
New England Journal of Medicine, 329(16),1206.
Magill, A., Cersovsky, S.,& DeFraites, R. (2012). Special considerations for U.S. Military deployments.
2012 CDC yellow booktravelers health, Chapter8. Retrieved from http://wwwnc.cdc.gov/travel/
yellowbook/2012/chapter-8-advising-travelers-with-specific-needs/special-considerations-for-usmilitary-deployments.htm.
Magill, A.J., Forgione, M.A., Maguire, J.D.,& Fukuda, M.M. (2014). Special considerations for U.S.
Military deployments. 2014 CDC yellow booktravelers health, Chapter8. Retrieved from http://
wwwnc.cdc.gov/travel/yellowbook/2014/chapter-8-advising-travelers-with-specific-needs/
special-considerations-for-us-military-deployments.
Marsepoil, T., Petithory, J., Faucher, J.M., Ho, P., Viriot, E.,& Benaiche, F. (1993). [Encephalopathy and
memory disorders during treatments with mefloquine]. La Revue de mdecine interne, 14(8), 788791.
McGready, R., Hamilton, K. a, Simpson, J.A., Cho, T., Luxemburger, C., Edwards, R., ... Lindsay, S.W.
(2001). Safety of the insect repellent N,N-diethyl-M-toluamide (DEET) in pregnancy. The American
Journal of Tropical Medicine and Hygiene, 65(4), 285289.
McRoy, O. R. (1963). War department provisions for malaria control. In E. C. Hoff (Ed.), Preventive
medicine in World War II. Volume 6: Communicable diseases: Malaria (pp. 1159). Washington,
DC:United States Army Medical Department.
116
W omen at W ar
Meshnick, S. R., & Dobson, M. J. (2003). The history of antimalarial drugs. In P. Rosenthal (Ed.),
Antimalarial chemotherapy:Mechanisms of action, resistance, and new directions in drug discovery (pp.
1526). Totawa, NJ:HumanaPress.
Montgomery, N. (2010, April 18). Navy looks for answers after Seabee dies from malaria. Stars
and Stripes. Retrieved from http://www.stripes.com/news/navy-looks-for-answers-after-seabee-dies-from-malaria-1.101030.
Morris, T.J.,& Davis, T.P. (2000). Doxycycline-induced esophageal ulceration in the U.S. Military service. Military Medicine, 165(4), 316319.
Most, H. (1963). Clinical trials of antimalarial drugs. In J. D.Coates (Ed.), Internal medicine in World War
II. Volume II: Infectious diseases (pp. 525598). Washington, DC:Office of the US Army Surgeon
General.
Mowrey, F.H. (1963). Statistics of malaria. In J. B.Coates (Ed.), Internal medicine in World War II. Volume
II: Infectious diseases (pp. 449463). Washington, DC:Office of the US Army Surgeon General.
Mu, J.Y., Israili, Z.H.,& Dayton, P.G. (1975). Studies of the disposition and metabolism of mefloquine
HCl (WR 142,490), a quinolinemethanol antimalarial, in the rat:Limited studies with an analog,
WR 30,090. Drug Metabolism and Disposition, 3(3), 198210.
Myers, S. L. (2009, August 19). Living and fighting alongside men, and fitting in. New York Times.
Retrieved from http://www.nytimes.com/2009/08/17/us/17women.html.
Nasveld, P.E., Edstein, M.D., Reid, M., Brennan, L., Harris, I.E., Kitchener, S.J., ... Prescott, W. (2010).
Randomized, double-blind study of the safety, tolerability, and efficacy of tafenoquine versus mefloquine for malaria prophylaxis in nonimmune subjects. Antimicrobial Agents and Chemotherapy,
54(2), 792798.
National Public Radio. (2011, June 25). Among the costs of war: Billions a year in A.C.?
National Public Radio. Retrieved from http://www.npr.org/2011/06/25/137414737/
among-the-costs-of-war-20b-in-air-conditioning.
Nevin, R.L. (2010). Mefloquine prescriptions in the presence of contraindications:prevalence among
US military personnel deployed to Afghanistan, 2007. Pharmacoepidemiology and Drug Safety, 19(2),
206210.
Nevin, R.L. (2011). Mefloquine blockade of connexin 43 (Cx43) and risk of pregnancy loss. Placenta,
32(9),712.
Nevin, R.L. (2012a). Limbic encephalopathy and central vestibulopathy caused by mefloquine:Acase
report. Travel Medicine and Infectious Disease, 10(3), 144151.
Nevin, R.L. (2012b). Falling rates of malaria among U.S. Military service members in afghanistan substantiate findings of high compliance with daily chemoprophylaxis. The American Journal of Tropical
Medicine and Hygiene, 87(5), 957958.
Nevin, R. L. (2012c). Mefloquine gap junction blockade and risk of pregnancy loss. Biology of
Reproduction, 87(3),65.
Nevin, R.L. (2012d). Limitations of postmarketing surveillance in the analysis of risk of pregnancy loss
associated with maternal mefloquine exposure. Clinical Infectious Diseases, 55(8), 11671168.
Nevin, R.L.,& Caci, J.B. (2013). Letter to the editor in response to medical evacuations from Afghanistan
during Operation Enduring Freedom, active and reserve components. Medical Surveillance Monthly
Report, 20(8),24.
Newton, J.A, Schnepf, G.A., Wallace, M.R., Lobel, H.O., Kennedy, C.A.,& Oldfield, E.C. (1994).
Malaria in US Marines returning from Somalia. The Journal of the American Medical Association,
272(5), 397399.
Ollivier, L., Nevin, R. L., Darar, H. Y., Bougre, J., Saleh, M., Gidenne, S., . . . Ahmed, A. A. (2011).
Malaria in the Republic of Djibouti, 19982009. The American Journal of Tropical Medicine and
Hygiene, 85(3), 554559.
Overbosch, D., Schilthuis, H., Bienzle, U., Behrens, R. H., Kain, K. C., Clarke, P. D., . . . Chulay,
J. D. (2001). Atovaquone-proguanil versus mefloquine for malaria prophylaxis in nonimmune
travelers: Results from a randomized, double-blind study. Clinical Infectious Diseases, 33(7),
10151021.
117
Peake, J.B., Morrison, J.S., Ledgerwood, M.M.,& Gannon, S.E. (2011). The Defense Departments
enduring contributions to global health:The future of the U.S. Army and Navy Overseas Medical
Research Laboratories. Center for Strategic and International Studies. Retrieved from http://www.
smartglobalhealth.org/DoDpdf.
Peterson, A. L., Seegmiller, R. A., & Schindler, L. S. (2011). Severe neuropsychiatric reaction in a
deployed military member after prophylactic mefloquine. Case Reports in Psychiatry, 2011, 350417.
Porter, W.D. (2006). Imported malaria and conflict:50years of experience in the U.S. Military. Military
Medicine, 171(10), 925928.
Pou, S., Winter, R.W., Nilsen, A., Kelly, J.X., Li, Y., Doggett, J.S., ... Riscoe, M.K. (2012). Sontochin
as a guide to development of drugs against chloroquine resistant malaria. Antimicrobial Agents and
Chemotherapy, 56(7), 34753480.
Powell, R.D. (1978). Chemoprophylaxis and malaria in American servicemen returning from Vietnam.
The American Journal of Tropical Medicine and Hygiene, 27(1 Pt 1),15.
Pudney, M., Gutteridge, W., Zeman, A., Dickins, M.,& Woolley, J.L. (1999). Atovaquone and proguanil
hydrochloride:Areview of nonclinical studies. Journal of Travel Medicine, 6(Suppl 1), S8S12.
Pybus, B.S., Marcsisin, S.R., Jin, X., Deye, G., Sousa, J.C., Li, Q., ... Melendez, V. (2013). The metabolism of primaquine to its active metabolite is dependent on CYP 2D6. Malaria Journal, 12,212.
Pybus, B.S., Sousa, J.C., Jin, X., Ferguson, J.A., Christian, R.E., Barnhart, R., ... Melendez, V. (2012).
CYP450 phenotyping and accurate mass identification of metabolites of the 8-aminoquinoline,
anti-malarial drug primaquine. Malaria Journal, 11,259.
Rab, S.M. (1963). Two cases of chloroquine psychosis. British Medical Journal, 1(5340),1275.
Reactions Weekly. (2013). U.S. Army elite units instructed against mefloquine use. Reactions Weekly,
1471(1),2.
Reba, R.C., Barry, K.G.,& Altstatt, L.B. (1983, October). Army Drug Development Program Phase
I clinical testing annual and final report, contract DAMD17-75-C-5036 (p. 86). College Park,
MD:BioMed.
Rieckmann, K.H., Powell, R.D., McNamara, J.V, Willerson, D., Lass, L., Frischer, H.,& Carson, P.E.
(1971). Effects of tetracycline against chloroquine-resistant and chloroquine-sensitive Plasmodium
falciparum. The American Journal of Tropical Medicine and Hygiene, 20(6), 811815.
Ritchie, E.C., Block, J.,& Nevin, R.L. (2013). Psychiatric side effects of mefloquine:applications to
forensic psychiatry. Journal of the American Academy of Psychiatry and the Law, 41(2), 224235.
Robert, L.L. (2001). Malaria prevention and control in the United States military. Mdecine tropicale,
61(1),6776.
Rockwell, D. A. (1968). Psychiatric complications with chloroquine and quinacrine. The American
Journal of Psychiatry, 124(9), 12571260.
Rozman, R. S., Molek, N. A., & Koby, R. (1978). The absorption, distribution, and excretion in
mice of the antimalarial mefloquine, erythro-2,8-bis(trifluoromethyl)-alpha-(2-piperidyl)4-quinolinemethanol hydrochloride. Drug Metabolism and Disposition, 6(6), 654658.
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), 19001904.
Snchez, J.L., DeFraites, R.F., Sharp, T.W.,& Hanson, R.K. (1993). Mefloquine or doxycycline prophylaxis in U.S.troops in Somalia. Lancet, 341(8851), 10211022.
Schlagenhauf, P.,& Steffen, R. (2000). Neuropsychiatric events and travel:Do antimalarials play a role?
Journal of Travel Medicine, 7(5), 225226.
Schlagenhauf, P., Steffen, R., Lobel, H., Johnson, R., Letz, R., Tschopp, A., . . . Strchler, D. (1996).
Mefloquine tolerability during chemoprophylaxis:Focus on adverse event assessments, stereochemistry and compliance. Tropical Medicine& International Health, 1(4), 485494.
Schlagenhauf, P., Tschopp, A., Johnson, R., Nothdurft, H. D., Beck, B., Schwartz, E., . . . Steffen, R.
(2003). Tolerability of malaria chemoprophylaxis in non-immune travellers to sub-Saharan
Africa: Multicentre, randomised, double blind, four arm study. British Medical Journal,
327(7423),1078.
118
W omen at W ar
Schmidt, I.G.,& Schmidt, L.H. (1951). Neurotoxicity of the 8-aminoquinolines. III. The effects of pentaquine, isopentaquine, primaquine, and pamaquine on the central nervous system of the rhesus
monkey. Journal of Neuropathology and Experimental Neurology, 10(3), 231256.
Schoomaker, E. (2009, February 2). Memorandum. Subject: Updated guidance on the use of mefloquine for malaria prophylaxis. U.S. Army Office of the Surgeon General. Retrieved from http://www.
pdhealth.mil/downloads/DASG_Memorandum.pdf.
Schwartz, E., Parise, M., Kozarsky, P.,& Cetron, M. (2003). Delayed onset of malaria:Implications for
chemoprophylaxis in travelers. The New England Journal of Medicine, 349(16), 15101516.
Schwartz, E., Potasman, I., Rotenberg, M., Almog, S., & Sadetzki, S. (2001). Serious adverse events
of mefloquine in relation to blood level and gender. The American Journal of Tropical Medicine and
Hygiene, 65(3), 189192.
Schwartz, R.,& Tuttle, W.B. (1956). Malaria in veterans of the Korean war:Areview of 128 admissions
for malaria to a veterans hospital. The American Journal of the Medical Sciences, 232(5), 568571.
Singhi, S., Singhi, P., & Singh, M. (1979). Extrapyramidal syndrome following chloroquine therapy.
Indian Journal of Pediatrics, 46(373),5860.
Smoak, B.L., Writer, J.V, Keep, L.W., Cowan, J.,& Chantelois, J.L. (1997). The effects of inadvertent
exposure of mefloquine chemoprophylaxis on pregnancy outcomes and infants of U.S. Army servicewomen. The Journal of Infectious Diseases, 176(3), 831833.
Solano, T.L. (2011, April 28). Doxy daily maintains APS-11 Marines unit effectiveness. United States
Africa Command. Retrieved from http://www.africom.mil/Newsroom/Article/8259/doxy-da
ily-maintains-aps-11-marines-unit-effective.
Steinhauer, J. (2013, June 17). Elite units in U.S. Military to admit women. NewYork Times. Retrieved
from http://www.nytimes.com/2013/06/18/us/elite-units-in-us-military-to-admit-women.html.
Stuiver, P.C., Ligthelm, R.J.,& Goud, T.J. (1989). Acute psychosis after mefloquine. Lancet, 2(8657),282.
Strchler, D., Handschin, J., Kaiser, D., Kerr, L., Mittelholzer, M.L., Reber, R.,& Fernex, M. (1990).
Neuropsychiatric side effects of mefloquine. The New England Journal of Medicine, 322(24),
17521753.
Sudakin, D.L.,& Trevathan, W.R. (2003). DEET:Areview and update of safety and risk in the general
population. Journal of Toxicology. Clinical Toxicology, 41(6), 831839.
Tamminga, W.J., Wemer, J., Oosterhuis, B., Weiling, J., Wilffert, B., de Leij, L.F., ... Jonkman, J.H. (1999).
CYP2D6 and CYP2C19 activity in a large population of Dutch healthy volunteers:Indications for
oral contraceptive-related gender differences. European Journal of Clinical Pharmacology, 55(3),
177184.
Tan, K.R., Magill, A.J., Parise, M.E.,& Arguin, P.M. (2011). Doxycycline for malaria chemoprophylaxis
and treatment:Report from the CDC expert meeting on malaria chemoprophylaxis. The American
Journal of Tropical Medicine and Hygiene, 84(4), 517531.
Taye, A., Hadis, M., Adugna, N., Tilahun, D.,& Wirtz, R.a. (2006). Biting behavior and Plasmodium
infection rates of Anopheles arabiensis from Sille, Ethiopia. Acta tropica, 97(1),5054.
Thom, R., Lopes, S.C. P., Costa, F.T. M.,& Verinaud, L. (2013). Chloroquine:Modes of action of an
undervalued drug. Immunology Letters, 153(12),5057.
US Army. (2012, October 16). ALARACT 289. Subject: Factory treated Army combat uniforms with
permethrin.
US Army Center for Military History. (2003). The Army Nurse Corps:Acommemoration of World War II
service. Publication 72-14. Retrieved from http://www.history.army.mil/books/wwii/72-14/72-14.
HTM.
US Central Command. (2010). Mod eleven to USCENTCOM individual protection and individual/unit deployment policy. Retrieved from http://www.cpms.osd.mil/expeditionary/pdf/
MOD11-USCENTCOM-Indiv-Protection-Indiv-Unit-Deployment-Policy-Incl-Tab-A-and-B.pdf.
US Food and Drug Administration. (2012). FDA Adverse Events Reporting System (FAERS): Potential
signals of serious risks/new safety information identified by the Adverse Event Reporting System (AERS)
between AprilJune 2012. Retrieved from http://www.fda.gov/Drugs/GuidanceCompliance
RegulatoryInformation/Surveillance/AdverseDrugEffects/ucm324020.htm.
119
US Food and Drug Administration. (2013, July 29). FDA Drug Safety Communication: FDA
approves label changes for antimalarial drug mefloquine hydrochloride due to risk of serious psychiatric and nerve side effects. Retrieved from http://www.fda.gov/downloads/Drugs/DrugSafety/
UCM362232.pdf.
United Press International. (2004, September 4). Responses to UPI-CNN lariam investigation. UPI.
com. Retrieved from http://www.upi.com/Business_News/Security-Industry/2004/09/07/
Responses-to-UPI-CNN-Lariam-investigation/UPI-13621094601600.
United Press International. (2013, December 24). Report:U.S.military still using dangerous malaria
drug. UPI.com. Retrieved from http://www.upi.com/Health_News/2013/12/24/Report-U
S-military-still-using-dangerous-malaria-drug/UPI-27391387931392.
Van der Berg, J.D., Duvenage, C.S., Roskell, N.S.,& Scott, T.R. (1999). Safety and efficacy of atovaquone and proguanil hydrochloride for the prophylaxis of Plasmodium falciparum malaria in South
Africa. Clinical Therapeutics, 21(4), 741749.
Van Riemsdijk, M. M., Ditters, J. M., Sturkenboom, M. C. J. M., Tulen, J. H. M., Ligthelm, R. J.,
Overbosch, D., & Stricker, B. H. C. (2002). Neuropsychiatric events during prophylactic use of
mefloquine before travelling. European Journal of Clinical Pharmacology, 58(6), 441445.
Van Riemsdijk, M. M., Sturkenboom, M. C. J. M., Ditters, J. M., Tulen, J. H. M., Ligthelm, R. J.,
Overbosch, D.,& Stricker, B.H. (2004). Low body mass index is associated with an increased risk
of neuropsychiatric adverse events and concentration impairment in women on mefloquine. British
Journal of Clinical Pharmacology, 57(4), 506512.
Vickery, J.P., Tribble, D.R., Putnam, S.D., McGraw, T., Sanders, J.W., Armstrong, A.W.,& Riddle, M.S.
(2008). Factors associated with the use of protective measures against vector-borne diseases among
troops deployed to Iraq and Afghanistan. Military Medicine, 173(11), 10601067.
Vuic, K. D. (2010). Officer, nurse, woman: The Army Nurse Corps in Vietnam. Baltimore, MD: Johns
Hopkins UniversityPress.
Wallace, M.R., Sharp, T.W., Smoak, B., Iriye, C., Rozmajzl, P., Thornton, S.A., ... Burans, J.P. (1996).
Malaria among United States troops in Somalia. The American Journal of Medicine, 100(1),4955.
Weniger, H. (1979). Toxicity and side effects of primaquine and other 8-Aminoquinolines. WHO/MAL/79.905.
World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/65772/1/
WHO_MAL_79.905.pdf.
Whitman, T.J., Coyne, P.E., Magill, A.J., Blazes, D.L., Green, M.D., Milhous, W.K., ... Martin, G.J.
(2010). An outbreak of Plasmodium falciparum malaria in U.S. Marines deployed to Liberia. The
American Journal of Tropical Medicine And Hygiene, 83(2), 258265.
Willerson, D., Rieckmann, K.H., Carson, P.E.,& Frischer, H. (1972). Effects of minocycline against
chloroquine-resistant falciparum malaria. The American Journal of Tropical Medicine and Hygiene,
21(6), 857862.
Wiselogle, F.Y. (1946). Descriptions of the various testing procedures. In F. Y.Wiselogle (Ed.), A survey
of antimalarial drugs, 19411945 (Vol. 1, pp. 453536). Ann Arbor, MI:J. W.Edwards.
Woodson, J. (2012a, January 17). Memorandum, Subject:Service review of mefloquine prescribing practices. Office of the Assistant Secretary of Defense (Health Affairs). truth-out.org/files/Mefloquine-QAMemo-JAN-2012-(Signed).pdf
Woodson, J. (2012b, August 2). HA Policy Memorandum 12-11. Guidance memorandum on use of primaquine during primaquine shortages. Office of the Assistant Secretary of Defense (Health Affairs).
Woodson, J. (2013a, April 15). HA Policy Memorandum 13-02:Guidance on medications for prophylaxis of malaria. Office of the Assistant Secretary of Defense (Health Affairs).
Woodson, J. (2013b, August 12). Memorandum, Subject:Notification for healthcare providers of mefloquine box warning. Office of the Assistant Secretary of Defense (Health Affairs).
World Health Organization. (1989). Mefloquine:Acute neurological reactions. WHO Drug Information,
3(3),140.
Zimmerman, R.H., Lounibos, L.P., Nishimura, N., Galardo, A.K. R., Galardo, C.D.,& Arruda, M.E.
(2013). Nightly biting cycles of malaria vectors in a heterogeneous transmission area of eastern
Amazonian Brazil. Malaria Journal, 12,262.
sev en
Women, Ships, Submarines, and

theUSNavy
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 awoman.
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 ships company, or to serve on submarines. In fact, in
the Navys early years, they were not even physically onboard.
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. Womens healthcare follows and, finally, a female Navy physician will offer a first-person
account of her experiences as a ships doctor and will provide some clinical pearls.
A BR IEF HISTORY OFSHIPS ANDWOMEN
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
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7. Women, Ships, Submarines, and the USNavy
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 nations 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
in1908.
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
theshore.
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 jobs they 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.
MODER N 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
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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 nations 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 physicalspace.
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 Navys 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 puzzled by their inability to make headway into this dangerous situation. Even todayin
the midst of intensified focus, study, and scrutinysome 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 ships
crew ran the spectrum from well-intended concerns about womens health, to tangential beliefs that large numbers of women would intentionally get pregnant to avoid ship
service and deployments. A1991 a NewYork Times article highlighted this sentiment
with the headline 36 Women Pregnant Aboard a Navy Ship That Served inGulf.
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
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1993 testimony to Congress that it is a logical progression after 50years of service by

Navy women including 20years in naval aviation and 15years 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 redesign 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 USS Rushmore (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).
MEDICALCARE
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
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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 documentedhere.
As would be expected, concerns for womens 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 inmind.
Since women have been working on submarines for such a short time, data regarding womens 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 womens 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.
Womens 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 recommending rigorous pre-deployment screening due to the difficulties in the submarine
MEDEVAC process, the authors were unable to draw conclusions about these potential
womens health issues due to a lack of existingdata.
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 Navys equivalent of a physicians 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 andwomen.
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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 ships 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 Sailors 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 ships homeport.
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 thecrew.
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 ships 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).
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In personal experience, the years that I(CDR Cazares) was a GMO1 (20052007),
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 ships 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 generallymoot.
All of this practical experience mirrors a 2007 DACOWITS report, in which it was
noted that ensuring womens 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 utilize 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 deployingunit.
THE PERSONAL EXPER IENCE OFDR.CAZARES
I had little to no idea of this history when Itook my oath of office in May 2000, and
matriculated as a first-year medical student at the Uniformed Services University. By
the time Igraduated in 2004 as a Navy lieutenant, Ihad spent some time learning about
the history of women in medicine, but was still rather oblivious to the history of women
in theNavy.
1
2
AGMO is a general Medical Officer, serving in a primary care capacity for the shipscrew.
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 andolder.
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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 Iheard and learned about through my
four years of medical school, and Ididnt 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. Iwas encouraged by many on both sides:go to the Fleet,
youll love it! and just finish residency, then your training will be done. At that point
in my life, Iwas able to choose adventure freely, andIdid.
Interestingly, with the start of the war in Iraq, male GMOs were being funneled to
work with the Marine Forces, as women were not yetallowed 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 Iwas able to be freed from
the hospital and meet it. If lew 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 Ifound 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. Iworked 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 Ijoined the
crew, women had been in roles on combat ships, in one way or another, for 20years.
What Ifaced and felt was different. Iwas offered a wonderful opportunity to serve,
but there was isolation. There were five female Officers in total on the ship. As the
senior woman, Isocialized with two younger female Officers whom Ibefriended,
but had to be cautious not to cross the line and be too social. The Navy puts high
value on perception, and as the ships doctor, Itook this to heartat least through
my first of two years. (I thankfully relaxed during the second half of my duty.) Ifelt
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, Iwas able to dance in
bars at ports of call and enjoy a cigar with the CO and know Iwas on stable footing. Icompleted two deployments in two years, made wonderful friends, and saw
theworld.
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I never felt harassed on the ship or in the wardroom, and Ithankfully 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 (its still rare to find a female shipboard CO) is an
ethical, hardworking, progressive, fun person, so goes theship.
So, while Ialways felt safe carrying out my work, Iwas aware that Iwas 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,
letalone 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, Iwalked 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, Ihad a need to decorate.
I opened the main treatment door that morning, expecting to see my staffs smiling
faces, but Iwas 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 medicineno surgery consult, no ultrasound, no
CT scanner. It couldve been her ovary, or it couldve been her appendixbut there
was no way for me to know definitively. What was known was that she needed to leave
the ship that dayThanksgiving daywhen most other ships were in port (even in the
deployed setting).
Ok, lets get things up and moving, Ill talk to the Captain and let him know well
need ahelo.
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
thats exactly what is the same about them. But one thing is true, and that is that when
a medical emergency is at play, theyll move mountains to get their Sailors the help
they need. Before Iknew it, the ship was literally full-steam ahead in the direction of
an incoming helicopter. The helo ETA was to be 3 hours. Ithought, Ok, this is alright.
Ihave morphine, Ihave Phenergan for nausea and if she gets bad, Ihave 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
129
was occasionally smiling, but something wasnt smelling right to me, and as Icontinued
to watch her, Inoticed 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, Inoticed her temp was slowly climbing, the blood pressure slowly sinking, and
her pulse slowly increasing. For anyone who works in medicine, this isbad.
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? Im running to CIC to
get a move on thishelo.
CIC is military lingo for the Combat Information Center. If you want to see bells
and whistles on a naval warship, thats where they livehanging digital screens, communications in encrypted and secret forms. From Combat, its 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 Icould.
Yes sir. Its the Doc. Sir, let me repeat Ihave an urgent medevac, with worsening
vitals; Ineed you to expedite the process now. Explain? Sir, all due respect, Ihave
confirmed this case with 2 other staff physicians. Ineed a helo here now, or this
Sailor will dietoday.
Silence is a unique state, especially in the midst of an emergency.

After what seemed longer than the 30 seconds it likely was, Ihad my response, and
Iwas informed the pilot would be there sooner than we had originally expected.
At the beginning of that deployment, Iwouldve 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 fasterforget about demanding it from the Admirals representativebut
a few months at sea made this girl a little saltier than she was when she left SanDiego.
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 getall records and if you
need a translator, demand one. Ok, that should cover it, youll be alright. And she nodded the entire time, humoring me in my nervousness and my maternal physician-ness.
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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, Ithought it looked,
relatively speaking, beautiful outside. They carried the stretcher away and Iwatched
her get loaded on the helicopter. As Istood there, my pharmacy tech appeared with a
dish of the garlic-mashed potatoes he had been intermittently cooking throughout the
day for the crew. Irealized at that point Ihad no memory of when Ihad last eaten. We
exchanged Happy Thanksgivings and Idug into those potatoesand let me tell you,
they weregood.
And that was Thanksgiving. Iwas 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 ruptured. The surgery went well and she was resting comfortably.
I breathed, deeply, and yes, Icried. It was just a few tears, but Ineeded to cry. Out to
sea, theres a difference. On the ship, here, theyre not strangers; theyre one of your own
and the whole experience changed me. Care in that close environment is different from
the hospital, its 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, Ioften 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 Iserved 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
131
befriend. Idid make friends, great ones, but Ifound 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, Imissed Grand Rounds, Iwas all too happy to get my hands on a current
medical journal, and Iwas ready to advance my academic career.
Clinical Pearls (CDR Cazares)

After having navigated my tour, and subsequently trained psychiatry residents preparing for deployments, Ihave 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 docs good health and
performance on board a navalship.
1. Understand the COs 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 ships 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 inspection 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 staffs 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
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Sailors. As a combination of all of these, Ihave 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 COs 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 patients diagnosis, prognosis, 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 Sailors health. The doctor-patient relationship is critical, and should be protected at all costs.
CONCLUSION
The history of womens 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 datagrow.
We close with a remark made by a Navy woman nearly 20 years ago to The
NavyTimes:
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.
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REFERENCES
36 women pregnant aboard a Navy ship that served in Gulf. (1991, Apr 29). The NewYorkTimes.
2012. Celebrating womens history month at the U.S. Naval Academy, womens educationwomens 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 200131 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.
eigh t
Female CombatMedics
CHARLES FIGLEY, BARBAR A L.PITTS,
PAULACHAPMAN, AND CHR ISTINE 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 thanmen.
WOMEN INMILITARY 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
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8. Female CombatMedics
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 ofHonor.
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 discharging all females who had served. However, when overwhelmed by the devastation 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 Ibegan, 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 Womens 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 VietnamWar.
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
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THE ROLE OFTHE COMBATMEDIC

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 Armys 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 subpopulation 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 endurewhich include participating in combat.
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Women CombatMedics
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 Armys 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 OFCOMBATMEDICS
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
etal.,2012).
Combat MedicSample
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: E1E4 (no leadership responsibilities), and E5E9 (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 Soldiers most recent deployment, resulting in 622 total cases. Demographics are provided in Table 8.1. Of the
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TABLE8.1 Demographic Characteristics ofSample
Characteristic
Total Sample n
(%)
Male n
(%)
Female n
(%)
Grade/Rank
E1E4
331 (53.3)
269 (54.02)
60 (50.42)
E5E9
290 (46.7)
229 (45.98)
59 (49.58)
29.17 (6.50)
29.43 (6.57)
28.13 (6.18)
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)
High-school or Less
146 (23.9)
122 (24.95)
23 (19.65)
Some college
412 (67.6)
329 (67.28)
80 (68.38)
52 (8.5)
38 (7.77)
14 (11.97)
Not married
390 (63.2)
323 (65.25)
66 (55.93)
Married
227 (36.8)
172 (34.75)
52 (44.07)
Age
Mean (SD)
Race
Education
College graduate
Marital Status
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 andage.
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):ACollection 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).
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.
PsychologicalHealth
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.
Atotal score was calculated by summing all of the items. For the larger study, the measure yielded a Chronbachs 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. Atotal 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). Chronbachs alpha obtained for the larger study
sample was .95 for each of the checklists.
TABLE8.2 Combat Experiences byGender

Male
Combat Experience
Female
%
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
Seeing dead or seriously injured Americans.
194
54
46
54
Knowing someone seriously injured or killed.
218
61
46
54
90
25
190
53
24
28
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
Being in threatening situations where you were unable
158
44
16
19
Shooting or directing fire at the enemy.***
92
25
Calling in fire on the enemy.
25
between ethnic groups.***
Participating in demeaning operations.**

Improvised explosive device (IED)/booby trap exploded
near you.***
to respond because of rules of engagement.***
Engaging in hand-to-hand combat.
193
54
10
12
Clearing/searching caves or bunkers.***
72
20
Being wounded/injured.
26
173
48
30
35
238
66
51
60
Clearing/searching homes or buildings.***
Seeing ill/injured women or children whom you were

unable to help.*
Receiving incoming artillery, rocket, or mortar fire.
Being responsible for the death of US or allied personnel.
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
Had a close call/equipment shot off your body.
12
Had a buddy shot or hit who was near you.
45
13
Informed unit members/friends of a Soldiers/Marines death.
21
11
Successfully engaged the enemy.***
89
25
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 Fishers
Exact test. * p <= 0.05. ** p <= 0.01. *** p <=0.001.
141
Stigma and Barriers toCare

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. Chronbachs alphas of .84 and .79 were observed for stigma and barriers
to care, respectively. Items are available in Table8.2.
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 Fishers 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
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TABLE8.3 Combat Experiences (DRRI) byGender

Male
Female
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
304
84
60
71
52
14
15
18
Combat Experience
mines and/or booby traps.**

I or members of my unit received hostile incoming fire from small arms,
artillery, rockets, mortars, or bombs.**
I or members of my unit received friendly incoming fire
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
46
13
11
I was part of an assault on entrenched or fortified positions.*
32
I took part in an invasion that involved naval and/or land
27
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
118
33
17
20
civilians.***
I was part of a land or naval artillery unit that fired on the
enemy.
forces.*
being seriously wounded/killed.*

I personally witnessed Soldiers from enemy troops being
seriously wounded/killed.*
I was wounded or injured in combat.
16
I fired my weapon at the enemy.***
78
21
I killed or think Ikilled someone in combat.*
37
10
Note: Significant associations between gender and each combat experience were assessed using Fishers
Exact test. * p <= 0.05. ** p <= 0.01. *** p <=0.001.
differences in post-battle experiences by gender (S=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, and8.4.
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
143
TABLE8.4 Post-Battle Experiences (DRRI) byGender

Male
Female
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
Combat Experience
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
I interacted with enemy Soldiers who were taken as
136
38
14
16
155
43
20
24
259
72
52
61
prisoners of war.***
I was exposed to the sight, sound, or smell of animals
that had been wounded or killed from war-related causes.***
I took care of injured or dying people.
I was involved in removing dead bodies after battle.
68
19
16
19
146
41
26
31
137
38
30
35
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
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
109
30
30
35
I was exposed to the sight, sound, or smell of dying men and

women.
I saw enemy Soldiers after they had been severely wounded
or disfigured in combat.
disfigured.***
wounded or disfigured in combat.

I saw bodies of dead Americans or allies.
Note: Significant associations between gender and each combat experience were assessed using Fishers
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 ofWar onPsychological Well-Being
Differences in PTSD and depressive symptom severity scores were assessed using separate generalized linear regression models. The three significant measures of combat
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TABLE8.5 Stigmas and Barriers toCare byGender

Male
Female
It would harm my career.
12
Members of my unit might have less confidence in me.
24
My unit leadership might treat me differently.
119
24
31
26
I would be seen as weak.
108
22
36
30
36
I dont know where to get help.
127
25
22
18
I dont 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
Stigma
My visit would not remain confidential.

Barriers to Care
* 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 toHealthcare
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
(Table8.5).
IMPLICATIONS FORBEHAVIOR AL HEALTH PR ACTICE
WITHFEMALE COMBATMEDICS
Female medics increased exposure to combat experiences provides a unique opportunity for healthcare organizations and providers to reassess current delivery systems,
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 womens 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 incudes the cause of the behavior, not just the behavioral metric of reactions to various contexts and conditions.
REFERENCES
Bean-Mayberry, B., Yano, E.M., Washington, D., Goldzweig, C., Batuman, F., Huang, C., Miake-Lye,
I.,& Shekelle, P. (2011). Systematic review of women veterans health:Update on successes and gaps.
Womens Health Issues, 21(4S), S84S97.
146
W omen at W ar
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), 270277
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), 775784.
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, 351,1322.
Hoge, C. W., Clark, C. C., & Castro, C. A. (2007). Commentary: Women in combat and the risk of posttraumaic stress disorder. International Journal of Epidemiology, 36, 327329.
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 forPTSD.
Luz, S. & Brotherton, M. (2010). The Nightingale of Mosul: A Nurses Journey of Service, Struggle, and War.
NY: Caplan.
Mazurek& Burgess, 2006 (to be supplied shortly, along with the missing references in thetext)
Nessen, S. C., Loundbury, D. E., & Hetz, M. D. (Eds.) (2008). War Surgery in Afghanistan and Iraq: A
Series of Cases, 20032007). 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, 17371744.
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 Chairmans 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),
797806.
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 ofOperations
AMYCANUSO
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
W omen at W ar
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 realitythe scene appears more
like a fraternity housemovie.
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 ones 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 Defenses
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 womens 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. Awoman 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 theunit.
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 Iinterviewed voiced that the topic
was rarely or never discussed with their bunkmates when they were deployed.
SETTING THESCENE
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
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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 Iinterviewed explained, When Igo
to the gym in the US on base Imay be the only woman there, however, it causes little
change in the other gym goers behaviors. But, when Iwent 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 Ijust went back to teaching
the men. Inever 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 commonplace, 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, sometimesdaily.
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 Iknew 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. Ive never thought about sex this much in my life. Its like Im a teenageboy.
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 daysoff.
One woman Iinterviewed 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 tenyears.
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.
SEXUALIT Y AND WAR:WHAT BIOLOGY
DOESNTTELLUS
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 etal., 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.
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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 womens clinics, there is no way to make conclusive statements or
inferences regarding this topic, which has so little hard data todate.
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, Ilearned 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
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conflicts and/or needs. Finally, it is possible that the area is ready for scientific evaluation in order to bring this subject out into thelight.
REFERENCES
Archer, J. (2004, December). Sex differences in agression in real-world settings:Ameta-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/
T he-maternit y-militar y-How-nearly-10 0 -female-soldiers-sent-home-A fghan-frontlinegetting-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. 221226.
doi:10.1038.
Foster, G.A.,& Alviar, A. (2013, January). Military womens health while deployed:Feminine hygiene
and health in austere environments. Federal Practitioner,913.
Goldstein, Joshua S. (2001). War and Gender: How Gender Shapes the War System and Vice Versa.
Cambridge:Cambridge UniversityPress.
Gottlieb, S. (2011, January 27). Sex and war and the Dutch Army: Dont ask dont tell. Radio
Netherlands Worldwide. Retrieved on January 20, 2014, from http://www.rnw.nl/english/article/
sex-and-war-and-dutch-army--dont-ask-dont-tell.
Grindlay, K.,& Grossman, D. (2013). Unintended pregnancy among active-duty women in the United
States military, 2008. Obstetrics& Gynecology, 121(2, Part1), 241246.
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/inthenews/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:Asystemic literature review. Military Medicine, 17(9), 10561064.
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), 133148.
Rabie, N.Z.,& Magann, E.F. (2013). Unintended pregnancies among US active-duty women. Womens
Health, 9(3), 229231.
PA R T
Women Home fromWar
ten
Women Home fromWar

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 familya 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 Iraqthings she felt no one
could really understand unless they had been thereoverwhelmed her ability to drive
on. She was not sleeping, could not eat, lost 25 pounds that she couldnt 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 vertebraethe result of wearing over
100 pounds of gear day in and day out for a yearand 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 fromIraq.
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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 authors 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, andsoon.
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
Armys 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
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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 and3).
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.
ASYMMETR IC WARFARE AND COUNTER INSURGENCY
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 ofwar.
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 etal.,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
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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 etal. (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. Aroutine 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 isnot.
Paper thin faith, as described by Fleming and Robichaux in Redeployed (2013),
can dissolve in the aftermath of incidents that shake the Service members existential
foundation. Some Service members recount a point at which they shut off any access to
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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 stressesthe 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 Iwas back in
theater.
MOR ALE 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 groupsquad 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 componentteam, squad, or
platoonwill 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
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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
talkabout.
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 years 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 fianc, and her friends told her
she had changedand 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 herbut that she was still the same in many ways. Rivers etal. 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 etal.,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 Janices 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
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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 indefinitely 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 dependents 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 OFTR AINING
A critical aspect of a Service members 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 individuals response sets. While in the cycle of deploymentreset/training/
deploymentthere is further conditioning and further reinforcement, which may be
resistant to extinction (Jovanovic & Ressler,2010).
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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. APost
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 GUAR D AND RESERVEUNITS
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
etal., 2010). Difficulty with post-deployment reintegration for Service members in the
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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 etal., 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. Amarked
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 etal.,
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 etal., 2012). The expression from Iraq to the cul-de-sac has
been used to illustrate this dilemma.
R ISK FACTORS FORBEHAVIOR AL
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
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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 etal.,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 etal.,
2013). In a commentary, Hoge etal. 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 etal.,2007).
COMBAT EXPOSURE ANDGENDER
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 etal.,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 dissimilar 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
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etal., 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
thingsfrom actually firing a weapon in a lethal encounter to hearing the sound of
small arms fire while working inside thewire.
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 etal.,2012).
Drawing again from the Millennium Cohort Study, Jacobsen etal. 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 etal.,2008).
MOTHERS WHODEPLOY
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 etal.,
2013). AWhite 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 etal.,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
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of family members who dont understand why she puts her job over her responsibilities
as a mother.
LOSSES AND GR IEF FOLLOWING DEPLOYMENT AND
SEPAR ATION FROMTHE 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 ones sense of meaning
and spiritual beliefs, sometimes leading to a crisis offaith.
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
worldsometimes many years prior to what the Service member intendedmay 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 conceptualize 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
Commanderno 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
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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 withtime.
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
onbut as the end of military service nears, these symptoms overcome the Service
members 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 individuals 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 furtherstudy.
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.
DISOR DEREDEATING
Disordered eating is a problem that lacks intensive study to date in female Service
members. Astudy 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
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with PTSD, sexual trauma (particularly completed rape during military service), and
a history of childhood sexual trauma (Foreman-Hoffman etal., 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. Aprospective study of weight gain status in
civilian women with PTSD found a consistent increase in BMI following the onset of
PTSD (Kubzansky etal., 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 etal. 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 etal.,2009).
NEXT STEPS INTHE 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 20years of service develops a medical condition that does not meet medical retention standards. These standards are set out in the regulations of each branch
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 providers decision will be made in accordance with the regulations and the needs
of the Service branch.
THE WOUNDED WARR IORUNIT
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 battalions 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 Soldiers original command to obtain a replacement
for that Service members 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 Soldiers 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. Ayear-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 withaging.
Many active duty Service members remain in their assigned units while continuing
treatment and rehabilitation. The Soldiers 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
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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 units operational tempo increases, Service members may react to
these stressors in unhealthy ways, such as misconduct and substance abuse, or depressive reactions mayensue.
MEDICAL SEPAR ATIONS AND THEDISABILIT Y
EVALUATIONSYSTEM
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 20092010 and is now fully implemented Army-wide.
Entry into the iDES occurs when the Service members primary care provider determines that one condition has reached the medical retention decision point. or MRDP.
There may be other active conditions at varying stages of recovery. AVA 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 aremet.
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 electronically and are monitored by the local Medical Activity and the Soldiers command, rather
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. Astudy 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 etal., 2014). Astudy of disabled Veterans who served in the Israeli Defense Force noted that women experienced
higher levels of psychosocial distress after retirement (Koren etal., 2013). This is an
area that needs furtherstudy.
ADMINISTR ATIVE SEPAR ATIONS
There are also a number of situations that may lead the enlisted Soldiers 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 Soldiers 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, claustrophobia, 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 individualcase.
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
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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 Soldiers 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
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 etal., 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 Womens 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 harms way appear, overall, to be equally resilient, while equally sharing the psychological vulnerability that is a universal human response towar.
REFERENCES
ALARACT 007-2012. (2012). Subject: Sexual Harassment/Assault Response and Prevention
(SHARP): Program implementation guidelines. Washington, DC: Pentagon Telecommunications
Center on BehalfofDA.
Army Regulation 40-501. (2007). Standards of medical fitness:Medical Services; Headquarters Department
of the Army; 14 December 2007 with Rapid Action Revision 4 August 2011; Chapter3 and 7.www.apd.
army.mil
Army Regulation 525-29. (2011). Military operations:Army Force Generation; Headquarters Department
of the Army; 14 March 2011; Chapters17 and 10. www.apd.army.mil
Army Regulation 653-200. (2005). Active Duty Enlisted administrative separations:Personnel Separations;
Headquarters Department of the Army; 6 Jun 2005 with Rapid Action Revision 6 September 2011. www.
apd.army.mil
Benedict, H. (2010, April 27). Mothers in the military:Reconciling being a mother with being a soldier.
Blog post retrieved from https://pbs.org/pov/regardingwar/conversations/women-and-war/.
Elmasry, H., Gubata, M., Packnett, E., Niebuhr, D., & Cowan, D. (2014). Risk factors for disability retirement among active duty Air Force personnel. Military Medicine, 179,(1),510.
Fleming, B., & Robichaux, C. (2013). Redeployed:How combat veterans can fight the war within and win the
war at home (pp. 4145). Dallas, TX:FriscoHouse.
Fuerstein, M., Berkowitz, S.M., & Peck, C.A. (1997). Musculoskeletal-related disability in US Army
personnel: Prevalence, gender and military occupational specialty. Journal of Occupational &
Environmental Medicine, 39(1),6878.
Forman-Hoffman, V., Mengeling, M., Booth, B., Torner, J., & Sadler, A. (2012). Eating disorders, posttraumatic stress and sexual trauma in women veterans. Military Medicine, 177(10), 11611168.
176
W o m en at W ar
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 injuryrelated hypopituitarism: A review and
recommendations for screening combat veterans. Military Medicine, 175(8), 574580.
Hoge, C.W. (2010). Once a warrior always a warrior. Guilford, CT:LyonsPress.
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), 663675.
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), 415427.
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), 648662.
Katz, L., Cojucar, G., Davenport, C., Pedram, C., & Lindl, C. (2010). Post-deployment readjustment
inventory:reliability, validity, and gender differences. Military Psychology, 22,4166.
Kimerling, R., Street, A., Gima, K., & Smith, M. (2008). Evaluation of universasl screening for
military-related sexual trauma. Psychiatric Service, 59(6), 635640.
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:Aprospective
study of National Guard troops deployed to Iraq. Psychiatry, 76(3), 256272.
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),4451.
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,
695706.
Luxton, D., Skopp N., & Maguen, S. (2010). Gender differences in depression and PTSD symptoms following combat exposure. Depression and Anxiety, 27(11), 10271033.
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), 311316.
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), 21412148.
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 Womens Health, 22(1),918.
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:Aqualitative study. Military Medicine, 177, 14711476.
Rivers, F., Gordon, S., Speraw, S., & Reese, S. (2013). U.S. Army Nurses reintegration and homecoming
experiences after Iraq and Afghanistan. Military Medicine, 178, 166172.
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), 135145.
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 ChicagoPress.
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
12months following combat in Iraq. Archives of General Psychiatry, 67(6), 614623.
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),
797806.
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 July1976.
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.
Chapter7.1.
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MothersinWar
AMYCANUSO
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,
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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 THESOCIAL CONTEXTOF
THECHANGING LANDSCAPE OF WOMEN
INTHEMILITARY
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
pridea 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 post9/11, for the most part,
fully understood that they would deploy.
The majority of women who joined the postPersian 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 womens 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. Ifound out Iwas pregnant after Isigned up and finished my
training. Ididnt have a choice but Ireally felt it was a situation that was not only
possible, but also could be beneficial.
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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 dont think Ill 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 dont 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 toanger.
I didnt think that Iwould be sad when Ideployed away from my kid and Iwasnt,
but Idid end up angry. Angry all thetime.
You always know there is a chance you might deploy with kids, but we just decided
to do it [have children]. Ihad wanted to deploy, but now Ibegan to sort of dreadit.
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
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the clock and focus entirely on the mission without worrying about the needs of my
children or husband.
My view of deployment didnt change when Ihad my son, but my husbands did.
Now it became more family involvement and child care time forhim.
I got paid two and half times as much on deployment so it really helped usout.
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.
PREPAR ATION FORDEPLOYMENT:
HOWCLINICIANSCANHELP
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
childrens 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
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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 03years 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 03years
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 CDform.
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 15years.
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Coming Together Around Families:This is a comprehensive toolkit designed for

families and providers. It has leaflet style handouts that are promotional for
Military OneSources 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. Aclinician 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 childrens 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:
Mammas 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, Youre My Hero by Michelle Ferguson-Cohen.
Not exclusive to a mother being the parent deploying but still worthwhile and gender
neutral:
We Serve Too! AChilds Deployment Book by KathleenEdick
Love Spots by KarenPanier
You and Your Military Hero: Building Positive Thinking Skills During Your
Heros 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, womens 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
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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 nextyear?
How do you intend to discuss the deployment with yourchild?
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
mustleave?
Have you planned for sufficient time to spend with your child (without interruptions) before deployment (like a familytrip)?
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 eachother.
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 transitional 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.
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Encourage women to write often to their children in developmentally appropriate ways. Achild might really enjoy just a drawing from their mother if he or she
doesnt read, and it makes children feel special to get a piece ofmail.
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 WITHVERY 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 30years 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 branchArmy,
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 6months 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 12months 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, Table3-1#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
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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 Instruction44-102
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 (1530 minutes per 34 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 breastmilk.
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
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and advancement will be affected for a female who spends up to two hours a day away
from her post, pumpingmilk.
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 mothers ability to sustain
milk (Foster & Alviar, 2013). Plugged ducts, poor hydration, engorgement, or contaminated 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 9months. Ipumped three times
a day but at the end of that workup my milk really dropped to only a few ounces a
day. Ihad no way of getting the milk to my child so Ipumped and dumped. Ihated
to wasteit.
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 6months 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 CAREPLAN
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.
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Child-care arrangement vary from the husbands of military mothers, their childrens
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 forajob.
For example, Iinterviewed one woman whose family care plan stated that her child
would stay with the childs 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 careplan.
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 nextyear?

Do you have a family readinessplan?
Do you have a power of attorney?
Who would act as your childs 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 militarybase?
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 yourchild?
Have you discussed school or day-care provisions with the guardian?
How will your guardian have access to emergency monetaryfunds?
Who will be the temporary guardian if your assigned guardian becomesill?
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
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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 Iwas in
control and independent. Ifelt like what Idid mattered in a different way then when
Iam mom at home. Ifelt like the primary focus was my skill and Ifelt 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. Ihad this system where
Ihad something to do right after every phone call so that Iwould 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.Iam being brave and Iknow 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 mothers 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 wasaway.
My girl sometimes still brings it up. She sometimes will refer to the year that
Iwasnt 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
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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 didnt 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 womans child. That could be my child.
WHY THEAREA OFOPER ATIONS BENEFITS FROM

HAVINGMILITARY 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
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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 etal., 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. Afractured 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
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(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 ANDCOSTS
It would be nave to deny that there are negative aspects of the military deployment of
women with children. Amothers 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 units 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, etal., 2013; Bonanno etal., 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.
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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 familys story and dont 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 herchild.
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
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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
familygains.
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. Asimple questionnaire could
be used to measure resiliency and family satisfaction and would not require review of
medical documentation. In the next 10years 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, Part1:The theory. International Journal of Clinical
and Experimental Hypnosis, 59(4), 379391. 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), 807812.
Bell, M. R., & Ritchie E. C. (October 2003). Breastfeeding in the military, Part II: Information and
resources provided to servicewomen. Military Medicine, 8(10), 813817.
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:Aprospective cohort study. British Journal of Psychiatry, 200(4), 317323.
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. NewYork:Routledge.
Foster, G.A., & Alviar, A. (January, 2013). Military womens health while deployed:Feminine hygiene
and health in austere environments. Federal Practitioner,913.
Litz, B. T. (1992). Emotional numbering in combat-related posttraumatic stress disorder: A critical
review and reformation. Clinical Psychology Review, 12, 417432.
Military OneSource Website. Retrieved fromhttp://www.militaryonesource.mil/ (accessed March
1,2014).
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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 Womens Health, 22(1),918.
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? Americas 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:Apostmodern approach to analytical psychology
in practice. Psychoanalytic Dialogues, 10(3),427.
t w e lv e
Building theFramework forSuccessful

Deployment Reunions
ER IN SIMMONS
INTRODUCTION
When Ireturned 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 Ireturned. It should have worked, but it didnt, 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 theworld.
Female Service members currently make up approximately 16% of the total military force (2012 Department of Defense Demographic Report). Even given womens
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).
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12. Successful Deployment Reunions
197
I deployed from Okinawa, Japan, in September 2004, just a month after my husband and Iarrived 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 Iwould 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 couldnt communicate very often, and
which bills were in his name that Iwould have to manage. We never prepared for me
to go towar.
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. Ispent
a small fortune on eyeglasses to make sure Icould see while in the desert (the Navy
performed my PRK surgery the year after Igot back). Under my husbands guidance
Iinvested in t-shirts (skivvy shirts), underwear, sports bras, lotion, good socks, lots
of baby wipescomfort items that Ifelt Ineeded to keep myself clean and sanitary.
Later, Iwould realize that Idid 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 couldnt even imagine it.
PRE-DEPLOYMENT
Effective preparation for a couples 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
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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 familys 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 members 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 cant talk on the phone can be particularly challenging, though
much alleviated these days with Skype and webcams. A plethora of websites and organizationsUSAA, 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 fewnow 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
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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 harms 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 familys well-being, regret at missing part of her childrens 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 etal., 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 spouses and familys 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 childs adjustment
during the deployment, but also the quality of the eventual reunion (Palmer,2008).
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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 couples 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 cant 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
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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 etal., 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 couples near future. Changed financial
circumstances, such as debt accrued from house or car repairs, or simply extravagant
spendingby 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 husbands help, our attendance at
my brothers wedding, a visit with my parents, and a trip to Scotland for us and my
husbands 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 couples emotional connection to each other and to their
childrenpositive or negativewill 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 etal., 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 expectthem.
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
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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 etal., 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 havent 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
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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.
SIXRULES
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, Ihave returned time and time again to a
set of six rules that can guide couples through successful reunions. Ibegan developing
these rules after Ireturned to Okinawa after that first, unexpected deployment in 2004,
when Ifound myself a stranger in my own life. While going through my own adjustment
period, Iwas 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 Ithought about how unprepared and uncertain Iwas throughout my deployment process, and how difficult my adjustment was when Ireturned 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, Icontinue 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
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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 1AND2
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 etal., 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 didnt think Iliked them. After Itold him Idid like flowers,
he began buying them for special occasions, including my deployment homecomings.
Ihave to admit Iexpected the flowers; they were part of my fairy-tale homecoming.
If they hadnt been presentif he didnt 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
flowersI 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. Igot lucky there, so to speak, since Idid not ask
him to bring me flowers, or even suggest that Iwould like them. Doing so, however,
would have ensured that he knew what Iwanted, 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 Imay 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
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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 couples 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 couples 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.
RULE3
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
contestas
[a]game in which participants compete to see who can urinate the highest, the farthest, 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 metricsby upping the ante, as Gottman, a prominent
relationship expert, explains (Gottman & Silver, 1999, p. 103); by not accepting a partners 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 ones deployment experience was worse than his or her
spouses 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 arent, 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 etal., 2006; Bell,
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Schumm, & Gaskin working with Military OneSource, 2007). Furthermore, womens
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 unhelpful reaction.
Service members and spouses often claim any number of proofs that their experience was worsebecause 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. Irecommend to the frustrated partner to literally bite his or
her tonguethats what worked for meand 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 4AND5
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
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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. 2729) 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 wont 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, Im 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
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that may accompany the homecoming (Armstrong etal, 2006, p.177; Courage, 2013).
While each relationship will have its own rules for openness and disclosure, which ideally 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.
RULE6
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 etal. (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
contestsoccur.
CONCLUSION
After my deployment in 20042005, my husband and I created a stronger marriage
through communication, understanding, compromise, and, Ibelieve, sheer stubbornness! 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
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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 Ihave made many, many more mistakes than Ithought
Iwould, being a psychologist and being motivated to maintain my marriage as well as
my personal health. Iam able to laugh now, when Itell people, I thought Iknew better! However, Iam also able to accept that Ididnt 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 tomake.
My goal with this chapter is to provide knowledge and understandingan external resource, if you willthat 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 womens 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 etal., 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:UlyssesPress.
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.
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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:Alongitudinal study. Journal of Traumatic Stress, 27,5865.
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.
5368). NewYork: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. NewYork:Bantam.
Gottman, J. M., & Silver, N. (1999). The seven principles for making marriage work. New York: Three
RiversPress.
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),
326340.
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:NewYork.
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), S5S10.
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),
205217. 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. 3152). NewYork: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.
1627). NewYork: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, 685694.
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. 6989). NewYork:Routledge.
thirteen
Traumatic BrainInjury
Implications for Women in the Military
VICTOR IA TEPE AND SUZANNEGARCIA
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 acceleration or deceleration (jolt), rotational force, and/or exposure to explosive blast (see
Taber etal., 2006). Including injuries diagnosed in civilian inpatient and outpatient
settings, well over 3million 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 5million men, women, and children currently
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live with TBI-related cognitive, emotional, sensory, and motor disabilities (Thurman
etal., 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 etal.,2012).
Historically, women have been exposed in smaller numbers to the risks associated with military combat. More recently, womens 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 genderbased 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 (3,0005,000 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
womens health (Yano etal., 2011; Amara etal.,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 BrainInjury
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TBI is a known risk of combat and of specific high-risk military activities (e.g., parachuting; 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 DoDs 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 repeatTBI.
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 Afghanistanestimates range from 12% to
as high as 25%have sustained at least one head injury during deployment (AFHSC,
2013; Hendricks etal., 2013; Hoge etal., 2008; Okie, 2005; Schneiderman etal., 2008;
Terrio etal., 2009; Warden,2006).
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Number of Cases
60,000
50,000
40,000
30,000
20,000
10,000
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
00
20
10
20
11
20
12
19
19
97
FIGURE13.1 Head injuries diagnosed in US military personnel worldwide, 19972012, number

of cases and trend (least squares fit, R = 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
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
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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 TBI 2 is especially challenging to diagnose because there may be no visible
injury or acute neurological signs or symptoms. Symptoms such as agitation, impulsiveness, 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 etal., 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 subtlefor example, vision changes, indigestion, muscular weaknessuntil 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 neuroinflammatory sequelae that may or may not resolve quickly (Bergsneider etal., 2000; Giza &
Hovda, 2001). Some changes, such as depressed glucose metabolism, may occur even
in mildly injured, relatively asymptomatic patients (Bergsneider etal., 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. Ascore of 8 or less is classified as a severe, 912 as moderate, and 1315 asmild.
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).
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minutes, hours, days, and months after TBI, the injured brain is highly susceptible to
additional injury (Byrnes & Faden, 2007; Cernak & Noble-Haeusslein, 2010; Narayan
etal., 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 etal., 1993; Ghajar, 2000). TBI patients who experience these
conditions have an increased risk of death or disability (Chestnut et al., 1993; Chi
etal., 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 patientsincluding mTBI in military populationsto support
accurate differential diagnosis (Ghigo etal., 2005; Guerrero & Alfonso, 2010; Tanriverdi
etal., 2010; Tepe & Guerrero,2012).
Blast-InducedTBI
Most TBIs sustained by troops in Iraq and Afghanistan are attributed to blast exposure
(Galarneau etal., 2008; Warden, 2006), and symptoms of TBI are commonly observed
in blast-exposed servicemembers (Cernak etal., 1999; Okie, 2005; Trudeau etal., 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 etal., 2009; Hoffer etal.,
2013; Lawson etal., 2013; Packer etal., 2013; Tepe etal., 2013; Patterson etal.,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
217
explosive blast can cause brain concussion, contusion, and cerebral infarct due to the
formation of air emboli in blood vessels (Ling etal., 2009; Mayorga, 1997; Taber etal.,
2006). Arecent 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 etal., 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 etal., 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.
RepeatTBI
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 INWOMEN
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 etal., 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
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).
CTE is characterized by cerebral atrophy and progressive deterioration in cognition, affect, personality,
behavior, speech, neurosensory function, and motor function.
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women have a TBI incidence rate comparable to that of civilian men (Ommaya etal.,
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 etal., 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
etal.,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
(19972006). 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 2009a 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
etal.,2013).
However, the AFHSCs data evidenced a smaller (13%) difference in TBI incidence
between active duty military men and women over the four-year period (19972000)
prior to military action in Afghanistan. This suggests that some of the broader
(19972006) 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 womens incidence of TBI will likely increase as more female
servicemembers are assigned to combatroles.
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
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 asTBIs.
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
219
(a) 1.60
1.40
Rate
1.20
R2 = 0.9175
1.00
0.80
Males
Females
0.60
0.40
R2 = 0.0196
0.20
0.00
1997
1998
1999
2000
2001
2002
(b) 2.00
Rate
1.50
R2 = 0.5522
1.00
Males
Females
0.50
R2 = 0.3194
0.00
2003
2006
2009
2012
FIGURE13.2 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 (19972002, (a))
and since (20032012, (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 800804), intracranial injury (ICD-9-CM codes 850854), 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 in2003.
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 womens rate of inpatient TBI diagnoses remained relatively low and stable over the
time period 19972012. 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 Womens 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.
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).
7
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W o m en at W ar
Rate
(a)
20.00
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
R2 = 0.9212
R2
1997
1998
1999
2000
Males
Females
= 0.9279
2001
(b) 45.00
2002
R2 = 0.8222
40.00
35.00
Rate
30.00
25.00
20.00
R2 = 0.9251
15.00
Males
Females
10.00
5.00
0.00
2003
2006
2009
2012
FIGURE13.3 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 (19972002, (a))
and since (20032012, (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) in2012.
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 etal. (2000) studied a prospective cohort of men and women with moderate or
severe TBIs. Over the course of 18months after hospital discharge, women were more
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
womens outcomes after TBI; however, findings with respect to a possible interaction
between gender and age have been inconsistent. Ottochian etal. (2009) performed a
retrospective review of 1,807 severe TBI patients and found significantly higher mortality specifically for women older than 55years of age. In a study of moderate and severe
TBI, Gan etal. (2004) also found that among elderly patients (64+ years), females had
a higher mortality rate (70.4%) than males (44.7%). Farin etal. (2012) performed a retrospective analysis of severe TBI patients 6months 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 50years.
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
(20002005). In this study, the patient population was stratified to address premenopausal (1445 years), perimenopausal (4655 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
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.
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and mortality; mortality did not differ between men and women in the youngest (premenopausal) 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 (SlewaYounan 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
1660) 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 etal. (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
etal. (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 etal. (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 etal. (2011)
retrospectively studied TBI patient data (ages 1245years) 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
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 1595) 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 etal. (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 etal. (2009) reported
that although women reported higher levels of depressive, somatic, motor, memory,
stress, and cognitive symptoms within the first 6months after TBI, these differences
abated after 6months 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 etal. (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
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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 etal., 2005; Krahulik etal., 2010; Powner etal., 2006). In patients
with severe TBI, resulting hormonal deficits can persist for months or even years (Agha
etal., 2004; Benvenga etal., 2000; Bondanelli etal., 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 etal.,
2005; High etal.,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
etal., 2011). But when multivariate analyses were performed to account for blast exposure, some of these differences disappearedPTSD 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 etal., 2013). Aseparate
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 etal., 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 difficultiesincluding depression, PTSD, anxiety, substance abuse, cognitive
225
impairments, chronic pain, headaches, sleep disturbances, neurological problems, and

more severe somatosensory and vestibular symptomsmay 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 orwomen.
Can Female Endogenous Hormones Protect theBrain?
As noted previously in this chapter, some studies of TBI have observed gender differences related to womens pre- versus post-menopausal status or hormonal status
at time of injury, suggesting that endogenous female hormonesestrogen and/or
progesteronemay 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 Parkinsons disease (Dluzen & McDermott, 2000; Gillies &
McArther, 2010; Haaxma etal., 2007), Alzheimers disease (Behl & Moosmann, 2002;
Brinton, 2001), stroke (Alkayed etal., 2000; Gibson etal., 2011), and amyotrophic lateral sclerosis (ALS) (de Jong etal., 2013; Veldink etal., 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
etal., 2007; OConnor etal., 2005; Roof & Hall, 2000; Roof etal., 1993; Sarkaki etal.,
2013; Shahrokhj etal., 2010; Soustiel etal., 2005; Stein, 2008; Vagnerova etal., 2008;
Zhang etal., 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 etal., 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
etal., 1997; Singh & Su,2013).
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.
10
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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 (OConnor 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 trialstwo completed, one terminated, and one activeto 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 etal., 2010; Bazarian etal., 1999; Preiss-Farzanegan etal., 2009; Ryan &
Warden, 2003; Styrke etal., 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 etal. (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 symptomsand 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.
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 etal., 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 Alzheimers disease (Bazarian etal., 2009; Fleminger
etal., 2003; IOM, 2008; Lye & Shores, 2000; Mortimer etal., 1991; Plassman etal.,
2000; Sivanandam & Thakur, 2012) and Parkinsons disease (Bower et al., 2003;
Goldman etal., 2006; Stern etal., 1991; Veldman etal., 1998). The neuropathological markers observed in Alzheimers disease are similar to molecular changes observed
after brain injury (Magnoni & Brody, 2010)and degenerative atrophy commonly found
in temporal lobe structures of Alzheimers 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 Parkinsons 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 etal.,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
Alzheimers 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
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moderated by genotypic variables (Chen et al., 2007; Schmidt et al., 2010). Alzheimers
and Parkinsons12 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 etal., 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 Alzheimers disease and dementia if only due
to their relatively longer life expectancies (Fratiglioni etal., 1997; Hebert etal., 2001;
Kawas etal., 1997; Nelson etal., 2002; Slooter etal., 1999; Zandi etal., 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 insightsand to avoid the presumption that findings in male populations necessarily extend to all peopleresearchers 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 existand where it is found that they
do notthese findings can help to inform the development of potentially beneficial
mitigation and treatment strategies for all TBI patients. For example, it may be that
Parkinsons disease is also recognized as a primary service-connected illness for Veterans exposed to
Agent Orange and other herbicides suspected as possible causal agents.
12
229
female endogenous hormones confer at least initial advantage to women, perhaps by

reducing edema in the immediate aftermath of TBI (OConnor etal., 2006; Roof etal.,
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 etal., 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).
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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 womens biological, psychological,
and social needs after TBI (Harris etal., 2012). The authors called for increased advocacy and a national strategy to promote health and quality of life for women and girls
afterTBI.
National research initiatives can yield significant return on investment, as did the
Defense Womens 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 womens 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 womens
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, womens 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 clearest 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.,
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 whoserve.
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
(Womens 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 womens and Veterans health.
REFERENCES
Agha, A., Rogers, B., Sherlock, M., etal. (2004). Anterior pituitary dysfunction in survivors of traumatic
brain injury. Journal of Clinical Endocrinology and Metabolism, 89(10), 49294936.
Alkayed, N. J., Murphy, S. J., Traystman, R. J., Hum, P. D., & Miller, V. M. (2000). Neuroprotective
effects of female gonadal steroids in reproductively senescent female rats. Stroke, 31(1), 161168.
Amara, J., Iverson, K.M., Krengel, M., Pogoda, T.K., & Hendricks, A. (2014). Anticipating the traumatic
brain injury-related health care needs of women veterans after the Department of Defense change in
combat assignment policy. Womens Health Issues, 24(2), e171176.
Armed Forces Health Surveillance Center. (August 2007). Traumatic brain injury among members of
active components, U.S. Armed Forces, 19972006. Medical Surveillance Monthly Report, 14(5),26.
Armed Forces Health Surveillance Center. (July 2012). Health of women after wartime deployments: Correlates of risk for selected medical conditions among females after initial and repeat
deployments to Afghanistan and Iraq, Active Component, U.S. Armed Forces. Medical Surveillance
Monthly Report, 19(7),210.
Armed Forces Health Surveillance Center. (March, 2013). External causes of traumatic brain
injury, 20002011. Medical Surveillance Monthly Report, 20(3), 914. http://www.afhsc.mil/
viewMSMR?file=2013/v20_n03.pdf Accessed June 25,2013.
Assistant Secretary of Defense Health Affairs Memorandum. (October 1, 2007). Traumatic brain
injury: Definition and reporting. Retrieved from http://www.health.mil/libraries/HA_Policies_
and_Guidelines/07-030.pdf (accessed May2013).
Baugh C., Stamm J., Riley D., etal. (2012). Chronic traumatic encephalopathy:Neurodegeneration following repetitive concussive and subconcussive brain trauma. Brain Imaging and Behavior, 6(2),
244254.
Bay, E., Sikorskii, A., & Saint-Arnault, D. (2009). Sex differences in depressive symptoms and their
correlates after mild-to-moderate traumatic brain injury. Journal of Neuroscience Nursing, 41(6),
298309.
Baxter, D., Sharp, D.J., Feeney, C., Papadopoulou, D., Ham, T.E., Jilka, S., Hellyer, P.J., Patel, M.C.,
Bennett, A.N., Mistlin, A., McGilloway, E., Midwinter, M. & Goldstone, A.P. (2013). Pituitary dysfunction after blast traumatic brain injury:The UK BIOSAP study. Ann Neurol, 74(4), 527536.
232
W o m en at W ar
Bazarian, J.J., Blyth, B., Mookerjee, S., He, H., & McDermott, M.P. (2010). Sex differences in outcome
after mild traumatic brain injury. Journal of Neurotrauma, 27(3), 527539.
Bazarian, J.J., Cernak, I., Noble-Haeusslein, L., Potolicchio, S., & Temkin, N. (2009). Long-term neurologic outcomes after traumatic brain injury. Journal of Head Trauma Rehabilitation, 24(6), 439451.
Bazarian, J.J., Wong, T., Harris, M., Leahey, N., Mookerjee, S., & Dombovy, M. (1999). Epidemiology
and predictors of post-concussive syndrome after minor head injury in an emergency population.
Brain Injury, 13(3), 173189.
Behl, C., & Moosmann, B. (2002). Antioxidant neuroprotection in Alzheimers disease as preventative
and therapeutic approach. Free Radical Biology and Medicine, 33(2), 182191.
Bell, K.R., & Pepping, M. (2001). Women and traumatic brain injury. Physical Medicine and Rehabilitation
Clinics of North America, 12(1), 169182.
Benvenga, S., Campenni, A., Ruggeri, R.M., & Trimarchi, F. (2000). Clinical review 113:Hypopituitarism
secondary to head trauma. Journal of Clinical Endocrinology and Metabolism, 85(4), 13531361.
Bergsneider M., Hovda, D.A., Lee, S.M., etal. (2000). Dissociation of cerebral glucose metabolism and
level of consciousness during the period of metabolic depression following human traumatic brain
injury. Journal of Neurotrauma, 17, 389401.
Berry, C., Ley, E.J., Tillou, A., Cryer, G., etal. (2009). The effect of gender on patients with moderate to
severe head injuries. Journal of Trauma, 67(5), 950953.
Bigler, E.D., Anderson, C.V., & Blatter, D.D. (2002). Temporal lobe morphology in normal aging and
traumatic brain injury. American Journal of Neuroradiology, 23(2), 255266.
Bigler, E.D., & Maxwell, W.L. (2011). Neuroimaging and neuropathology of TBI. NeuroRehabilitation,
28(2),6374.
Binder, L.M. (1986). Persisting symptoms after mild head injury:Areview of the post concussive syndrome. Journal of Clinical and Experimental Neuropsychology, 8, 323346.
Boake, C., McCauley, S.R., Levin, H.S., Pedroza, C., Contant, C.F., etal. (2005). Diagnostic criteria for
postconcussional syndrome after mild to moderate traumatic brain injury. Journal of Neuropsychiatry
and Clinical Neurosciences, 17, 350356.
Bondanelli, M., De Marinis, L., Ambrosio, M.R., etal. (2004). Occurrence of pituitary dysfunction following traumatic brain injury. Journal of Neurotrauma, 21, 68596.
Bower, J.H., Maraganore, D.M., Peterson, B.J., McDonnell, S.K., Ahlskog, J.E., & Rocca, W.A. (2003).
Head trauma preceding PD:Acase-control study. Neurology, 60(10), 16101615.
Brenner, L.A., Vanderploeg, R.D., & Terrio, H. (2009). Assessment and diagnosis of mild traumatic
brain injury, posttraumatic stress disorder, and other polytrauma conditions:Burden of adversity
hypothesis. Rehabilitation Psychology, 54(3), 239246.
Brinton, R. D. (2001). Cellular and molecular mechanisms of estrogen regulation of memory function and neuroprotection against Alzheimers disease: Recent insights and remaining challenges.
Learning and Memory, 8, 121133.
Broshek, D.K., Kaushik, T., Freeman, J.R., Erlanger, D., etal. (2005). Sex differences in outcome following sports-related concussion. Journal of Neurosurgury, 102(5), 856863.
Bryan, C. J. & Clemans, T. A. (2013). Repetitive traumatic brain injury, psychological symptoms, and
suicide risk in a clinical sample of deployed military personnel. JAMA Psychiatry, 70(7), 686691.
Byrnes, K.A., & Faden, A.I. (2007). Roll of cell cycle proteins in CNS injury. Neurochemical Research,
32(10), 17991807.
Campbell., R., Greeson, M. R., Bybee, D., & Raja, S. (2008). The co-occurrence of childhood sexual
abuse, adult sexual assault, intimate partner violence, and sexual harassment:Ameditational model
of posttraumatic stress disorder and physical health outcomes. Journal of Consulting and Clinical
Psychology, 76(2), 194207.
Cernak, I., & Noble-Haeusslein, L.J. (2010). Traumatic brain injury:An overview of pathobiology
with emphasis on military populations. Journal of Cerebral Blood Flow & Metabolism, 30(2),
255266.
Cernak, I., Savic, J., & Ignjatovic, D. (1999). Blast injury from explosive munitions. Journal of Trauma,
47, 96103.
233
Cernak, I., Wang, Z., Jiang, J., Bian, X., & Savic, J. (2001). Ultrastructural and functional characteristics
of blast injury-induced neurotrauma. Journal of Trauma, 50, 695706.
Chen, H., Richard, M., Sandler, D.P., Umbach, D.M., & Kamel, F. (2007). Head injury and amyotrophic
lateral sclerosis. American Journal of Epidemiology, 166, 810816.
Chestnut, R.M., Marshall, L.F., Klauber, M.R., Blunt, B.A., Baldwin, N., Eisenberg, H.M., Jane, J.A.,
Marmarou, A., & Foulkes, M.A. (1993). The role of secondary brain injury in determining outcome
from severe head injury. Journal of Trauma, 34(2), 216222.
Colvin, A.C., Mullen, J., Lovell, M.R., West, R.V., Collins, M.W., & Groh, M. (2009). The role of concussion history and gender in recovery from soccer-related concussion. American Journal of Sports
Medicine, 37(9), 16991704.
Coronado, V., McGuire, L., Sarmiento, K., etal. (2012). Trends in traumatic brain injury in the U.S.and
the public health response:19952009. Journal of Safety Research, 43(4), 299307.
Corrigan, J.D., Wolfe, M., Mysiw, W.J., Jackson, R.D., & Bogner, J.A. (2003). Early identification of
mild traumatic brain injury in female victims of domestic violence. American Journal of Obstetrics &
Gynecology, 188(5), S71S76.
Covassin, T. & Bay, E. (2012). Are there gender differences in cognitive function, chronic stress, and
neurobehavioral symptons after mild-to-moderate traumatic brain injury? (Review) Journal of
Neuroscience Nursing, 44(3), 124133.
Cutler, S.M., Cekic, M., Miller, D.M., Wali, B., etal. (2007). Progesterone improves acute recovery after
traumatic brain injjury in the aged rat. Journal of Neurotrauma, 24(9), 14751486.
DACOWITS. (2009). Defense Advisory Committee on Women in the Services 2009 Report. Washington, DC.
Retrieved from http://dacowits.defense.gov/Portals/48/Documents/Reports/2009/Annual%20
Report/dacowits2009report.pdf (accessed November 16,2013).
DCOE. (2010). Traumatic brain injury and effects of altitude:An analysis of the literature. Retrieved from
http://hprc-online.org/environment/files/tbi-and-the-effects-of-altitude-pdf (accessed September
13,2013).
de Jong, S., Huisman, M., Sutedja, N., van der Kooi, A., etal. (2013). Endogenous female reproductive
hormones and the risk of amytrophic lateral sclerosis. Journal of Neurology, 260(2), 507512.
Dick, R.W. (2009). Is there a gender difference in concussion incidence and outcomes? British Journal of
Sports Medicine, 43, i46i50.
Dluzen, D. E. & McDermott, J. L. (2000). Gender differences in neurotoxicity of the nigrostriatal
dopaminergic system: Implications for Parkinsons disease. Journal of Gender Specific Medicine,
3(6),3642.
DoD Worldwide Numbers for TBI. Defense and Veterans Brain Injury Center. Retrieved from http://www.
dvbic.org/dod-worldwide-numbers-tbi (accessed April2013).
Englander, J., Bushnik, T., Oggins, J., & Katznelson, L. (2010). Fatigue after traumatic brain
injury:Association with neuroendocrine, sleep, depression, and other factors. Brain Injury, 24(1),
13791388.
Farace, E. & Alves, W.M. (2000). Do women fare worse:Ametaanalysis of gender differences in traumatic brain injury outcome. Journal of Neurosurgury, 93(4), 539545.
Farin, A., Deutsch, R., Biegon, A., & Marshall, L.F. (2012). Sex-related differences in patients with severe
head injury:Greater susceptibility to brain swelling in female patients 50years of age and younger.
Journal of Neurosurgery, 116(6),3236.
Faul, M., Xu, L., Wald, M., & Coronado, V. (2010). Traumatic brain injury in the United States:Emergency
department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and
Prevention, National Center for Injury Prevention and Control.
Fisher, H. (2013, February 5). U.S. military casualty statistics: Operation New Dawn, Operation Iraqi
Freedom, and Operation Enduring Freedom. Washington, DC: Congressional Research Service,
RS22452.
Fleminger, S., Oliver, D.L., Lovestone, S., Rabe-Hesketh, S., & Giora, A. (2003). Head injury as a risk
factor for Alzheimers disease:The evidence 10years on; a partial replication. Journal of Neurology,
Neurosurgery, and Psychiatry, 74(7), 857862.
234
W o m en at W ar
Fratiglioni, L., Viitanen, M., von Strauss, E., Tontodonati,V., etal. (1997).Very old women at highest risk
of dementia and Alzheimers disease. Neurology, 48(1), 132138.
Friedl, K.E . (2005). Biomedical research on health and performance of military women:Accomplishments
of the Defense Womens Health Research Program (DWHRP). Journal of Womens Health, 14(9),
764802.
Galarneau, M.R., Woodruff, S.I., Dye, J.L., etal. (2008). Traumatic brain injury during Operation Iraqi
Freedom:Findings from the United States navy-Marine Corps Combat Trauma Registry. Journal of
Neurosurgury, 108, 950957.
Gan, B. K., Lim, J. H., & Ng, I. H. (2004). Outcome of moderate and severe traumatic brain injury
amongst the elderly in Singapore. Annals of the Academy of Medicine, Singapore, 33,6367.
Gatson, J.W., Liu, M.M., Abdelfattah, K., Wigginton, J.G., etal. (2012). Estrone is neuroprotective in
rats after traumatic brain injury. Journal of Neurotrauma, 29(12), 22092219.
Gavett, B.E., Stern, R.A., Cantu, R.C., Nowinski, C.J., & McKee, A.C. (2010). Mild traumatic brain
injury:Arisk factor for neurodegeneration. Alzheimers Research & Therapy,2,18.
Gerberich, S.G., Gibson, R.W., Fife, D., Mandel, J.S., etal. (1997). Effects of brain injury on college
academic performance. Neuroepidemiology, 16(1),114.
Ghajar, J. (2000). Traumatic brain injury. The Lancet, 356(9233), 923929.
Ghigo, E., Masel, B., Aimaretti, G., Leon-Carrion, J., etal. (2005). Consensus guidelines on screening for
hypopituitarism following traumatic brain injury. Brain Injury, 19(9), 711724.
Gibson, C.L., Coomber, B., & Murphy, S.P. (2011). Progesterone is neuroprotective following cerebral
ischaemia in reproductively ageing female mice. Brain, 134(7), 21252133.
Gillies, G. E., & McArthur, S. (2010). Independent influences of sex steroids of systemic and central
origin in a rat model of Parkinsons disease:Acontribution to sex-specific neuroprotection by estrogens. Hormones and Behavior, 57(1),2334.
Giza, C. C., & Hovda, D. A. (2001). The neurometabolic cascade of concussion. Journal of Athletic
Training, 36, 228235.
Goldman, S.M., Tanner, C.M., Oakes, D., Bhudhikanok, G.S., Gupta, A., & Langston, J.W. (2006).
Head injury and Parkinsons disease risk in twins. Annals of Neurology, 60(1),6572.
Goldstein, L.E., Fisher, A.M., Tagge, C.A., Zhang, X.L., etal. (2012). Chronic traumatic encephalopathy in blast-exposed military veterans and a blast neurotrauma mouse model. Science Translational
Medicine, 4(134),1.
Gouin, J.-P., & Kiecolt-Glaser, J.K. (2011). The impact of psychological stress on wound healing:Methods
and mechanisms. Immunology and Allergy Clinics of North America, 31(1),8193.
Groswasser, Z., Cohen, M., & Keren, O. (1998). Female TBI patients recover better than males. Brain
Injury, 12, 805808.
Guerrero, A.F., & Alfonso, A. (2010). Traumatic brain injury-related hypopituitarism:Areview and recommendations for screening combat veterans. Military Medicine, 175 (8), 574580.
Guskiewicz, K., McCrea, M., Marshall, S., et al. (2003). Cumulative effects associated with recurrent concussion in collegiate football players: The NCAA Concussion Study. JAMA, 290(19),
25492555.
Haaxma, C.A., Bloem, B.R., Borm, G.F., Oyen, W.J. G., etal. (2007). Gender differences in Parkinsons
disease. Journal of Neurology, Neurosurgery & Psychiatry, 78, 819824.
Hall, E.D., Gibson, T.R., & Pavel, K.M. (2005). Lack of a gender difference in post-traumatic neurodegeneration in the mouse controlled cortical impact injury model. Journal of Neurotrauma, 22(6),
669679.
Harris, O.A. (2013). Gender and the effects of polytrauma:Aretrospective cohort comparative analysis.
Findings presented at the Symposium on Women Veterans Employment:Skills Matter, August 29,
2013, in Washington, DC. Retrieved from http://www.dol.gov/vets/womenveterans/Gender_and_
the_effects_of_polytrauma.pdf (accessed May 12,2014).
Harris, J. E., Colantonio, A.,Bushnik, T., Constantinidou, F., et al. (2012). Advancing the health and
quality-of-life of girls and women after traumatic brain injury:Workshop summary and recommendations. Brain Injury, 26(2), 177182.
235
Hebert, L.E., Scherr, P.A., McCann, J.J., Beckett, L.A., & Evans, D.A. (2001). Is the risk of developing Alzheimers disease greater for women than for men? American Journal of Epidemiology, 153(2),
132136.
Hendricks, A.M., Amara, J., Baker, E., Charns, M.P., etal. (2013). Screening for mild traumatic brain
injury in OEF-OIF deployed US military: An empirical assessment of VHAs experience. Brain
Injury, 27(2), 125134.
Hendricks, A. Krengel, M., Iverson, K.M., Kimerling, R., Tun, C., Amara, J., & Lew, H. (2012). Estimating
the costs of care. In J. Vasterling, R. Bryant, & T. Keane (Eds.), PTSD and mild traumatic brain injury
(pp. 260281). NewYork:GuilfordPress.
High, W. M., Briones-Galano, M., Clark, J. A., Gilkison, C., et al. (2010). Effect of growth hormone
replacement therapy on cognition after traumatic brain injury. Journal of Neurotrauma, 27(9),
15651575.
Hoffer, M.E., Balaban, C., Nicholas, R., Marcus, D., etal. (2013). Neurosensory sequelae of mild traumatic brain injury. Psychiatric Annals, 43(7), 318323.
Hoge, C.W., McGurk, D., Thomas, J.L., Cox, A.L., Engel, C.C., & Castro, C.A. (2008). Mild traumatic brain injury in U. S. soldiers returning from Iraq. New England Journal of Medicine, 358,
453463.
Institute of Medicine. (2005). Amyotrophic lateral sclerosis in veterans:Review of the scientific literature.
Washington, DC: The National Academies Press. Retrieved from http://books.nap.edu/catalog.
php?record_id=11757 (accessed July 20,2013).
Institute of Medicine. (2008). Gulf War and health: Volume 7: Long-term consequences of traumatic brain
injury. Washington, DC: The National Academies Press. Retrieved from http://books.nap.edu/
openbook.php?record_id=12436 (accessed November 16,2013).
Iverson, K.M., Hendricks, A.M., Kimerling, R., Krengel, M., Meterko, M., Stolzmann, K.L., Baker, E.,
Pogoda, T.K., Vasterling, J.J., & Lew, H.L. (2011). Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related traumatic brain injury:Agender comparison. Womens Health Issues, 21(4 Suppl), S210S217.
Iverson, K.M., King, M.W., Resick, P.A., Gerber, M.R., etal. (2013). Clinical utility of an intimate
partner violence screening tool for female VHA patients. Journal of General Internal Medicine, 28,
12881293.
Iverson, K.M., Mercado, R., Carpenter, S.L., & Street, A.E. (2013). Intimate partner violence among
women veterans: Previous interpersonal violence as a risk factor. Journal of Traumatic Stress,
26,15.
Ivins, B. J. (2010). Hospitalization associated with traumatic brain injury in the active duty US
Army:2000-2006. Neurorehabilitation, 26(3), 199212.
Ivins, B. J., Schwab, K. A., Warden, D., Harvey, S., Hoilien, M., Powell, J., Johnson, E. W., & Salazar,
A.M. (2003). Traumatic brain injury in U.S. Army paratroopers:prevalence and character. Journal
of Trauma-Injury Infection & Critical Care, 55(4), 617621.
Ivins, B. J., Schwab, K. A., Baker, G., & Warden, D. L. (2006). Hospital admissions associated with
traumatic brain injury in the US army during peacetime:1990s trends. Neuroepidemiology, 27(3),
154163.
Jack, C.R., Petersen, R.C., Xu, Y., OBrien, P.C., Smith, G.E., Ivnik, R.J., Tangalos, E.G., & Kokmen,
E. (1998). Rate of medial temporal lobe atrophy in typical aging and Alzheimers disease. Neurology,
51(4), 993999.
Jensen, O.K. & Nielsen, F.F. (1990). The influence of sex and pre-traumatic headache on the incidence
and severity of headache after head injury. Cephalalgia, 10, 285293.
Jobst, K. A., Smith, A. D., Szatmari, M., Esiri, M. M., Jaskowski, A., Hindley, N., McDonald, B., &
Molyneux, A.J. (1994). Rapidly progressing atrophy of medial temporal lobe in Alzheimers disease.
The Lancet, 343(8901), 829830.
Kashluba, S., Hanks, R., Casey, J., & Mills, S. (2008). Neuropsychologic and functional outcome
after complicated mild traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 89,
904911.
236
W o m en at W ar
Kawas, C., Resnick,S., Morrison, A., Brookmeyer, R., et al. (1997). A prospective study of estrogen
replacement therapy and the risk of developing Alzheimers disease: The Baltimore longitudinal
study of aging. Neurology, 48(6), 15171521.
Kim, E., Lauterbach, E., Reeve, A., Arciniegas, D., etal. (2007). Neuropsychiatric complications of traumatic brain injury:Acritical review of the literature (a report by the ANPA Committee on Research).
Journal of Neuropsychiatry and Clinical Neurosciences, 19, 106127.
Kirkness, C.J., Burr, R.L., Mitchell, P.H., & Newell, D.W. (2004). Is there a sex difference in the course
following traumatic brain injury? Biological Research for Nursing, 5, 299310.
Kontos, A.P., Kotwal, R.S., Elbin, R.J., Lutz, R.H., etal. (2013). Residual effects of combat-related mild
traumatic brain injury. Journal of Neurotrauma, 30(8), 680686.
Krahulik, D., Zapletalova, J., Frysak, Z., & Vaverka, M. (2010). Dysfunction of hypothalamic-hypophysial
axis after traumatic brain injury in adults. Journal of Neurosurgery, 113(3), 581584.
Kraus, J.F, Peek-Asa, C., & McArthur, D. (2000). The independent effect of gender on outcomes following traumatic brain injury:Apreliminary investigation. Neurosurgical Focus,8,e5.
Kwako, L.E., Glass, N., Campbell, J., Melvin, K.C., etal. (2011). Traumatic brain injury in intimate
partner violence:Acritical review of outcomes and mechanisms. Trauma, Violence & Abuse, 12(3),
115126.
Landre, N., Poppe, C. J., Davis, N., Schmaus, B., & Hobbs, S. E. (2006). Cognitive functioning and
postconcussive symptoms in trauma patients with and without mild TBI. Archives of Clinical
Neuropsychology, 21(4), 255273.
Lawson, B.D., Rupert, A.H., & Kelley, A.M. (2013). Mental disorders comorbid with vestibular pathology. Psychiatric Annals, 43(7), 324327.
Leddy, J.J., Sandhu, J.G., Baker, J.G., Sodhi, V.S., & Willer, B. (2012). Rehabilitation of concussion and
post concussion syndrome. Sports Health:AMultidisciplinary Approach., 4 (2) 147154.
Leitgeb, J., Mauritz, W., Brazinova, A., Janciak, I., etal. (2011). Effects of gender on outcomes after traumatic brain injury. Journal of TraumaInjury, Infection and Critical Care, 71(6), 16201626.
Levin, H., Mattis, S., Ruff, R., et al. (1987). Neurobehavioral outcome following minor head
injury:Athree-center study. Journal of Neurosurgery, 66, 234243.
Ling, G., Bandak, F., Armonda, R., Grant, G., & Ecklund, J. (2009). Explosive blast neurotrauma. Journal
of Neurotrauma, 26(6), 815825.
Lye, T.C., & Shores, E.A. (2000). Traumatic brain injury as a risk factor for Alzheimers disease:Areview.
Neuropsychology Review, 10(2), 115129.
Ma, J., Huang, S., Qin, S., & You, C. (2012, October 17). Progesterone for acute traumatic brain injury.
Cochrane Database of Systematic Reviews, published online. Retrieved from http://onlinelibrary.
wiley.com/doi/10.1002/14651858.CD008409.pub3/abstract (accessed December 1,2013).
MacGregor, A.J., Dougherty, A.L., Morrison, R.H., Quinn, K.H., & Galarneau, M.R. (2011). Repeated
concussion among U.S.military personnel during Operation Iraqi Freedom. Journal of Rehabilition
Research and Development, 48(10), 12691278.
Magnoni, S., & Brody, D. L. (2010). New perspectives on amyloid-beta dynamics after acute brain
injury: Moving between experimental approaches and studies in the human brain. Archives of
Neurology, 67(9), 10681073.
Maguen, S., Madden, E., Lau, K.M., & Seal, K. (2012). The impact of head injury mechanism on mental
health symptoms in veterans:Do number and type of exposures matter? Journal of Traumatic Stress,
25(1),39.
Mayorga, M.A. (1997). The pathology of primary blast overpressure injury. Toxicology, 121(1),1728.
McCullagh, S., Oucherlony, D., Protzner, A., etal. (2001). Prediction of neuropsychiatric outcome following mild trauma brain injury: An examination of the Glasgow Coma Scale. Brain Injury, 15,
489497.
McKee, A., Cantu, R., Nowinski, C., et al. (2009). Chronic traumatic encephalopathy in athletes: Progressive tauopathy following repetitive head injury. Journal of Neuropathology and
Experimental Neurology, 68(7),709735.
237
Meares, S., Shores, E.A., Taylor, A.J., Batchelor, J., Bryant, R.A., etal. (2008). Mild traumatic brain
injury does not predict acute postconcussion syndrome. Journal of Neurology, Neurosurgery &
Psychiatry, 79(3), 300306.
Miller, K.J., Ivins, B.J., & Schwab, K.A. (2013). Self-reported mild TBI and postconcussive symptoms in
a peacetime active duty military population:Effect of multiple TBI history versus single mild TBI.
Journal of Head Trauma Rehabilitation, 28(1),3138.
Moore, D.W., Ashman, T.A., Cantor, J.B., Krinick, R.J., & Spielman, L.A. (2010). Does gender influence cognitive outcome after traumatic brain injury? Neuropsychological Rehabilitation, 20(3),
340354.
Mortimer, J.A., van Duijn, C.M., Chandra, V., Fratiglioni, L., Graves, A.B., Heyman, A., Jorm, A.F., etal.
(1991). Head trauma as a risk factor for Alzheimers disease:Acollaborative re-analysis of case-control
studies. EURODEM Risk Factors Research Group. International Journal of Epidemiology, 20(Suppl
2), S28S35.
Moser, R., Schatz, P., & Jordan, B. (2005). Prolonged effects of concussion in high school athletes.
Neurosurgery, 57(2), 300306.
Murdoch, M. & Nichol, K. L. (1995). Women veterans experiences with domestic violence and with
sexual harassment while in the military. Archives of Family Medicine, 4(5), 411418.
Mushkudiani, N.A., Engel, D.C., & Steverberg, E.W. (2007). Prognostic value of demographic characteristics in traumatic brain injury:Results from the IMPACT study. Journal of Neurotrauma, 24(2), 259269.
Nampiaparampil, D. E. (2008). Prevalence of chronic pain after traumatic brain injury: A systematic
review. JAMA, 300(6), 711719.
Narayan, R.K., Kishore, P.R. S., Becker, D.P., Ward, J.D., Enas, G.G., Greenberg, R.P., Young, H.F.
(1982). Intracranial pressure:to monitor or not to monitor? Areview of our experience with severe
head injury. Journal of Neurosurgery, 56(5), 650659.
Nelson, H.D., Humphrey, L.L., Nygren, P., Teutsch, S.M., & Allan, J.D. (2002). Postmenopausal hormone replacement therapy:Scientific review. JAMA, 288(7), 872881.
OConnor, C.A., Cernak, I., & Vink, R. (2005). Both estrogen and progesterone attenuate edema formation following diffuse brain injury in rats. Brain Research, 1062(12), 171174.
OConnor, C.A., Cernak, I., & Vink, R. (2006). The temporal profile of edema formation differs between
male and female rats following diffuse traumatic brain injury. Acta Neurochirurgica Supplementa, 96,
121124.
Okie, S. (2005). Traumatic brain injury in the war zone. The New England Journal of Medicine, 352,
20432047.
Ommaya, A.K., Dannenberg, A.L., & Salazar, A.M. (1996). Causation, incidence, and costs of traumatic
brain injury in the U.S.military medical system. Journal of Trauma, 40(2), 211217.
Ottochian, M., Salim, A., Berry, C., Chan, L.S., etal. (2009). Severe traumatic brain injury:Is there a
gender difference in mortality? American Journal of Surgery, 197(2), 155158.
Packer, M., Hammill, T., Nelson, J., Miller, J., et al. (2013). Integrated care for multisensory injury.
Psychiatric Annals, 43(7), 334337.
Patterson, T.J., Brennan, M.B., & Schobitz, R.P. (2013). Concurrent and co-located early intervention
for concussion and acute stress reaction. Psychiatric Annals, 43(7), 313317.
Plassman, B.L., Havlik, R.J., Steffens, D.C., Helms, M.J., Newman, T.N., Drosdick, D., Phillips, C.,
etal. (2000). Documented head injury in early adulthood and risk of Alzheimers disease and other
dementias. Neurology, 55(8), 11581166.
Pogoda, T.K., Hendricks, A.M., Iverson, K.M., Stolzmann, K.L., etal. (2012). Multisensory impairment
reported by veterans with and without mild traumatic brain injury history. Journal of Rehabilitation
Research & Development, 49(7), 971984.
Ponsford, J., Willmott, C., Rothwell, A., etal. (2000). Factors influencing outcome following mild traumatic brain injury in adults. Journal of the International Neuropsychological Society. 6, 568579.
Powner, D.J., Boccalandro, C., Alp, M.S., & Vollmer, D.G. (2006). Endocrine failure after traumatic
brain injury in adults. Neurocritical Care, 5,6170.
238
W o m en at W ar
Preiss-Farzanegan, S.J., Chapman, B., Wong, T.M., Wu, J., & Bazarian, J.J. (2009). The relationship
between gender and postconcussion symptoms after sport-related mild traumatic brain injury.
Physical Medicine &Rehabilitation, 1(3), 245253.
Ratcliff, J.J., Greenspan, A., Goldstein, F.C., Stringer, A.Y., etal. (2007). Gender and traumatic brain
injury:Do the sexes fare differently? Brain Injury, 21(10), 10231030.
Renner, C., Hummelsheim, H., Kopczak, A., Steube, D., etal. (2012). The influence of gender on the initial severity, course, and outcome of traumatic brain injury. Brain Injury, 26(11), 13601371.
Roof, R.L., & Hall, E.D. (2000). Gender differences in acute CNS trauma and stroke:Neuroprotective
effects of estrogen and progesterone. Journal of Neurotrauma, 17(5), 367388.
Roof, R.cL., Duvdevani, R., & Stein, D.cG. (1993). Gender influences outcome of brain
injury:Progesterone plays a protective role. Brain Research, 607(12), 333336.
Roof, R.L., Hoffman, S.W., & Stein, D.G. (1997). Progesterone protects against lipid peroxidation following traumatic brain injury in rats. Molecular and Chemical Neuropathology, 31(1),111.
Ryan, L., & Warden, D. (2003). Post concussion syndrome. International Review of Psychiatry, 15,
310316.
Sadler, A.G., Booth, B.M., Mengeling, M.A., & Doebbeling, B.N. (2004). Life span and repeated violence against women during military service: Effects on health status and outpatient utilization.
Journal of Womens Health, 13(7), 799811.
Salcido, R., & Costich, J.F. (1992). Recurrent traumatic brain injury. Brain Injury, 6(3), 293298.
Sarkaki, A.R., Khaksari Haddad, M., Soltari, Z., Shahrokhj, N., & Mahmoodi, M. (2013). Time- and
dose-dependent neuroprotective effects of sex steroid hormones on inflammatory cytokines after a
traumatic brain injury. Journal of Neurotrauma, 30(1),4754.
Schmidt, S., Kwee, L.C., Allen, K.D., & Oddone, E.Z. (2010). Association of ALS with head injury, cigarette smoking and APOE genotypes. Journal of Neurological Sciences, 291,2229.
Schneiderman, A.L., Braver, E.R., & Kang, H.K. (2008). Understanding sequelae of injury mechanisms
and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan:Persistent
postconcussive symptoms and posttraumatic stress disorder American Journal of Epidemiology,
167(12), 14461452.
Shahrokhj, N., Khaksari, M., Soltani, Z., Mahmoodi, M., & Nakhaee, N. (2010). Effect of sex steroid hormones on brain edema, intracranial pressure, and neurologic outcomes after traumatic brain injury.
Canadian Journal of Physiology & Pharmacology, 88(4), 414421.
Shively, S. B. & Perl, D. (2012). Traumatic brain injury, shell shock, and posttraumatic stress disorder
in the military past, present, and future. Journal of Head Trauma Rehabilitation, 27(3), 234239.
Singh, M., & Su, C. (2013). Progesterone and neuroprotection. Hormones and Behavior, 63(2), 284290.
Sivanandam, T.M., & Thakur, M.K. (2012). Traumatic brain injury:Arisk factor for Alzheimers disease.
Neuroscience and Biobehavioral Reviews, 36(5), 13761381.
Slewa-Younan, S., Green, A.M., Baguley, I.J., Gurka, J.A., & Marosszeky, J.E. (2004). Sex differences in
injury severity and outcome measures after traumatic brain injury. Archives of Physical Medicine and
Rehabilitation, 85(3), 376379.
Slewa-Younan, S., van den Berg, S., Baguley, I.J., Nott, M., & Cameron, I.D. (2008). Towards an understanding of sex differences in functional outcome following moderate to severe traumatic brain
injury:Asystematic review. Journal of Neurology, Neurosurgery & Psychiatry, 79(11), 11971201.
Slooter, A.J. C., Bronzova, J., Witteman, J.C. M.,Van Broeckhoven, C., etal. (1999). Estrogen use and
early onset Alzheimers disease: A population-based study. Journal of Neurology, Neurosurgery &
Psychiatry, 67, 779781.
Soutsitel, J.F., Palzur, E., Nevo, O., Thaler, I., & Vlodavsky, E. (2005). Neuroprotective anti-apoptosis
effect of estrogens in traumatic brain injury. Journal of Neurotrauma, 22(3), 345352.
Stein, D.G. (2008). Progesterone exerts neuroprotective effects after brain injury. Brain Research Reviews,
57(2), 386397.
Stein, D.G. (2013). A clinical/translational perspective:Can a developmental hormone play a role in the
treatment of traumatic brain injury? Hormones and Behavior, 63(2), 291300.
239
Stein, D.G. & Hoffman, S.W. (2003). Estrogen and progesterone as neuroprotective agents in the treatment of acute brain injuries. Developmental Neurorehabilitation, 6(1),1322.
Stern, M., Dulaney, E., Gruber, S.B., Golbe, L., Bergen, M., Hurtig, H., Gollomp, S., & Stolley, P. (1991).
The epidemiology of Parkinsons disease:Acase-control study of young-onset and old-onset patients.
Archives of Neurology, 48(9), 903907.
Stoica, B.A., & Faden, A.I. (2010). Cell death mechanisms and modulation in traumatic brain injury.
Neurotherapeutics, 7(1),312.
Styrke, J., Soika, P., Bjornstig, U., Bylund, P.-O., & Stalnacke, B-M. (2013). Sex differences in symptoms,
disability, and life satisfaction three years after mild traumatic brain injury: A population based
cohort study. Journal of Rehabilitation Medicine, 45(8), 749757.
Taber, K.H., Warden, D.L., & Hurley, R.A. (2006). Blast-related traumatic brain injury:What is known?
Journal of Neuropsychiatry and Clinical Neurosciences, 18, 141145.
Tanriverdi, F., Unluhizarci, K., & Kelestimur, F. (2010). Pituitary function in subjects with mild traumatic brain injury: A review of literature and proposal of a screening strategy. Pituitary, 13(2),
146153.
Taylor, C.A., Saint-Hilaire, M.H., Cupples, L.A., Thomas, C.A., Burchard, A.E., Feldman, R.G.,&
Myers, R. H. (1999). Environmental, medical, and family history risk factors for Parkinsons
disease: A New England-based case control study. American Journal of Medical Genetics, 88(6),
742749.
Tepe, V., Cernich, A., & Kelly, J. (2013). Polytraumatic TBI: Perspectives from military medicine.
Psychiatric Annals, 43(7), 308312.
Tepe, V., & Guerrero, A. (2012). Endocrine disturbances following TBI. In J. Tsao (Ed.), Traumatic
brain injury:Aclinicians guide to diagnosis, management, and rehabilitation. London; New York:
Springer.
Terrio, H., Bremner, L. A., Ivins, B. J., Cho, J. M., et al. (2009). Traumatic brain injury screening:Preliminary findings in a U.S. Army brigade combat team. Journal of Head Trauma Rehabilitation,
24(1),1423.
Trudeau, D.L., Anderson, J., Hansen, L.M., Shagalov, D.N., etal. (1998). Findings of mild traumatic brain
injury in combat veterans with PTSD and a history of blast concussion. Journal of Neuropsychiatry
and Clinical Neurosciences, 10, 308313.
Thurman, D., Alverson, C., Dunn, K., Guerrero, J., & Sniezek, J. (1999). Traumatic brain injury in
the United States: A public health perspective. Journal of Head Trauma Rehabilitation, 14(6),
602615.
VA/DoD. (2009). Clinical practice guideline for management of concussion/mild traumatic brain injury
2009 (pp. 1112). Washington, DC. Retrieved from http://www.healthquality.va.gov/mtbi/concussion_mtbi_full_1_0.pdf (accessed January 26,2014).
Vagnerova, K., Koerner, I.P., & Hurn, P.D. (2008). Gender and the injured brain. Anesthesia & Analgesia,
107(1), 201214.
Veldink, J.H., Bar, P.R., Joosten, E.A. J., Otten, M., Wokke, J.H. J., & van den Berg, L.H. (2003). Sexual
differences in onset of disease and response to exercise in a transgenic model of ALS. Neuromuscular
Disorders, 13(8), 737743.
Veldman, B.A., Wijn, A.M., Knoers, N., Praamstra, P., & Horstink, M.W. (1998). Genetic and environmental risk factors in Parkinsons disease. Clinical Neurology & Neurosurgery, 100(1),1526.
Wall, S., Williams, W., Cartwright-Hatton, S., etal. (2006). Neuropsychological dysfunction following
repeat concussion in jockeys. Journal of Neurology, Neurosurgery & Psychiatry, 77, 518520.
Warden, D. (2006). Military TBI during the Iraq and Afghanistan wars. The Journal of Head Trauma
Rehabilitation, 21, 398402.
Weiner, M.W., Friedl, K.E., Pacifico, A., Chapmand, J.C., Jaffee, M.S., etal. (2013). Military risk factors
for Alzheimers disease. Alzheimers & Dementia, 9, 445451.
Weisskopf, M.G., OReilly, E.J., McCullough, M.L., Calle, E.E., Thun, M.J., Cudkowicz, M., & Ascherio,
A. (2005). Prospective study of military service and mortality from ALS. Neurology, 64,3237.
240
W o m en at W ar
Whiteneck, G., Brooks, C.A., Mellick, D., Harrison-Felix, C., etal. (2004). Population-based estimates
of outcomes after hospitalization for traumatic brain injury in Colorado. Archives of Physical Medicine
and Rehabilitation, 85(4 Supp 2), S73S81.
Wright, D.W., Kellermann, A.L., Hertzberg, V.S., Clark, P.L., etal. (2007). ProTECT:Arandomized
clinical trial of progesterone for acute traumatic brain injury. Annals of Emergency Medicine, 49(4),
391402.
Wunderle, K., Hoeger, K. M., Wasserman, E., & Bazarian, J. J. (2014). Menstrual phase as predictor
of outcome after mild traumatic brain injury in women. Journal of Head Trauma Rehabilitation,
29(5),E18.
Xiao, G., Wei, J., Yan, W., Wang, W., & Lu, Z. (2008). Improved outcomes from the administration of
progesterone for patients with acute severe traumatic brain injury:a randomized controlled trial.
Critical Care, 12(2),R61.
Yano, E.M., Bastian, L.A., Bean-Mayberry, B., Eisen, S., etal. (2011). Using research to transform care
for women veterans:Advancing the research agenda and enhancing research-clinical partnerships.
Womens Health Issues, 21(4), S73S83.
Yeung, J.H. H, Mikocka-Walus, A.A., Cameron, P.A., Poon, W.S., etal. (2011). Protection from traumatic brain injury in hormonally active women vs men of a similar age:Aretrospective international
study. Archives of Surgery, 146(4), 436442.
Zandi, P. P., Carlson, M. C., Plassman, B. L., Welsh-Bohmer, K. A., et al. (2002). Hormone replacement therapy and incidence of Alzheimer disease in older women:The Cache County study. JAMA,
288(17), 21232129.
Zhang, D., Hu, Y., Sun, Q., Zhao, J., etal. (2013). Inhibition of transforming growth factor beta-activated
kinase 1 confers neuroprotection after traumatic brain injury in rats. Neuroscience (238), 209217.
PA R T
Psychological Issues for

Active DutyWomen
fou rt een
Suicide-Related Ideation and

BehaviorsinMilitaryWomen
MARJAN GHAHR AMANLOU-HOLLOWAY,
BR IANNE GEORGE,
JAIME T.CARRENO-PONCE, AND
JACQUELINE GARR ICK
INTRODUCTION
Beginning with Deborah Samson, who in 1776 enlisted under the name Robert
Shurtliffin order to fight for the United States in the Revolutionary War, women have
been an important part of our nations 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 anddying.
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 12months, to the following top six life events:(1)being away from
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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 19902004 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 militarywomen.
SUICIDE-RELATED THOUGHTS AND BEHAVIORS
National Data onWomen
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 1524
years, the third leading cause of death in women aged 2534 years, and the fourth
leading cause of death in women aged 3544 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 2564 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 20082009. Approximately 1.2million 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 4.6million adult women, reflecting 3.9% of the US adult female population, had suicidal thoughts in the pastyear.
Department ofDefense (DoD) Data onMilitaryWomen
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., 20082011) 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 suicidethis 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.
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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. Agreater 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 inSuicide-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% weremen.
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 etal., 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 womenindicating 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 etal.,2012).
China is a notable exception, where women outnumber men in suicide deaths (WHO,2013).
Age adjusted
3
Age adjusted.
4
Age adjusted.
1
2
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 exacerbation 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 etal., 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 64years 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 militarywomen.
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 todie.
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R ISK FACTORS FORSUICIDE AMONGWOMEN

Demographic Factors
In a representative cross-national study of 84,850 adults, female sex, younger age
(1834 years), lower educational attainment, being unmarried, and the presence
of a mental disorder served as the strongest risk factors for suicidal behaviorsand
these factors appeared to be universal across 17 participating countries (Nock etal.,
2008). In a cohort study of 87,257 women and 70,570 men (aged 1589) receiving services through a health maintenance organization (HMO), the following factors were
found to be significantly associated with suicide attempts in women:age 1524years,
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 1524years, 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 etal., 2008; Brent, Baugher,
Bridge, Chen, & Chiappetta, 1999; Brown, Cohen, Johnson, & Smailes, 1999; Felitti
etal., 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% [20.647.1]).
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
249
of childhood sexual abuse, adulthood sexual assault, adulthood physical assault, and
pregnancy loss (Cox etal.,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 etal., 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 etal., 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 assaultmany 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
ones career (Zinzow etal., 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).
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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 etal., 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 traumaticevent.
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 1544 indicates that the most common precipitating circumstances associated with female suicides across 16 US states
(20032007) 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 providedbelow.
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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% [5.0819.14]) and women (OR 5.00, CI 95% [3.197.83]) 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 ChildLoss

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 behavioras increases in
depression, anxiety, and substance use disorders are experienced as well (Furgusson,
Horwood, & Ridder,2006).
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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). Arecent study (Medical Surveillance Monthly Report,
2011) on alcohol-related diagnoses for US Armed Forces in 20012010 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
etal., 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
forsuicide.
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
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 etal., 2008). Women with eating disorders have shown considerable risk for
suicide-related behaviors (Franko etal.,2004).
Personality Disorders
The co-occurrence of personality disorders contributes a greater risk of suicide, independent of Axis Idiagnoses, among both civilian men and women (Schneider etal.,
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 etal., 2006). Specifically, borderline personality disorder (BPD) poses significant increased risk for suicide in women;
however, younger age (35years) 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 andwomen.
History ofSuicide 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 etal.,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 attemptrelated hospitalization is noteworthy among
female Veterans. Aretrospective cohort study on Veterans who had received inpatient
care after a suicide attempt, during 19931998, at US Veterans Affairs facilities has
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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 etal.,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 suicidethat 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;
VanOrden, Witte, Gordon, Bender, & Joiner,2008).
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PROTECTIVE FACTORS FORSUICIDE AMONGWOMEN

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 overrepresentation 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 ones 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.
GENER AL RECOMMENDATIONS FORBEHAVIOR AL
HEALTHPROVIDERS 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
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settings. Based on the information presented in this chapter on suicide-related thoughts

and behaviors among womenparticularly women who serve our nationthe 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 womenfor 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 members 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 patients 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,
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 Lines (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 patients 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 malingeringthis
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
militaryand 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
VAs Womens 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
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predictive of VA utilization (Vogt etal., 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 militarywomen.
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. Aretrospective 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 etal.,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 womens 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)
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 understudiedarea.
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
nations military history. As the nature of womens 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.
REFERENCES
Afifi, T.O., Enns, M.W., Cox, B.J., Asmundson, G.J. G., Stein, M.B., & Sareen, J. (2008). Population
attributable fractions of psychiatric disorders and suicidal ideation and attempts associated with
adverse childhood events in the general population. The American Journal of Public Health, 98,
946952.
260
W omen at W ar
Air Force Medical Operations Agency. (2013). Air Force guide for suicide risk assessment, management, and
treatment. San Antonio,TX.
Appleby, L. (1991). Suicide during pregnancy and in the first postnatal year. British Medical Journal, 302,
137140.
Appleby, L., Mortensen, P., & Faragher, E. (1998). Suicide and the causes of mortality after postpartum
psychiatric admission. British Journal of Psychiatry, 173, 209211.
Appolonio, K.K., & Fingerhut, R. (2008). Postpartum depression in a military sample. Military Medicine,
173(11), 10851091.
Baca-Garcia, E., Diaz-Sastre, C., Ceverino, A., Perez-Rodriguez, M. M., Navarro-Jimenez, R.,
Lopez-Castroman, J., ... Oquendo, M. (2010). Suicide attempts among women during low estradiol/
low progesterone states. Journal of Psychiatric Research, 44, 209214.
Barbee, A. P., Cunningham, M. R., Winstead, B. A., Derlega, V. J., Gulley, M. R., Yankeelov, P. A., &
Druen, P.B. (1993). Effects of gender role expectations on the social support process. Journal of Social
Issues, 49(3), 175190.
Barlas, F.M., Higgins, W.B., Pflieger, J.C., & Diecker, K. (2013, February). 2011 Department of Defense
health related behaviors survey of active duty military personnel. Retrieved from http://www.murray.
senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-d
uty-survey-report.pdf.
Beautrais, A. (2006). Women and suicidal behaviors. Crisis, 27(4), 153156.
Bell, N.S., Harford, T.C., Amoroso, P.J., Hollander, I.E., & Kay, A.B. (2010). Prior health care utilization patterns and suicide among US Army Soldiers. Suicide and Life-Threatening Behavior, 40(4),
407415.
Bernert, R. A., & Joiner, T. E. (2007). Sleep disturbances and suicide risk: A review of the literature.
Neuropsychiatric Disease and Treatment, 3, 735743.
Bhugra, D., & Desai, M. (2002). Attempted suicide in South Asian women. Advances in Psychiatric
Treatment, 8(6), 418423.
Blank, K. (2008). Women in the military:Overcoming challenges [Online]. Substance Abuse and Mental
Health Services Administration. Retrieved from http://www.samhsa.gov/samhsanewsletter/volume_16_number_6/womeninmilitary.aspx (accessed September 1,2010).
Borowsky, I.W., Ireland, M., & Resnick, M.D. (2001). Adolescent suicide attempts:Risks and protectors.
Pediatrics, 107, 485493.
Boyd, M.A., Bradshaw, W., & Robinson, M. (2013). Mental health issues of women deployed to Iraq and
Afghanistan. Archives of Psychiatric Nursing, 27(1),1022.
Bray, R.M., Fairbank, J.A., & Marsden, M.E. (1999). Stress and substance use among military women
and men. American Journal of Drug and Alcohol Abuse, 25(2), 239256.
Brent, D.A., Baugher, M., Bridge, J., Chen, T., & Chiappetta, L. (1999). Age- and sex-related risk factors for adolescent suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 38,
14971505.
Breslau, N., & Anthony, J.C. (2007). An epidemiological study of urban young adults. Journal of Abnormal
Psychology, 116(3), 607611.
Brown, J., Cohen, P., Johnson, J.G., & Smailes, E.M. (1999). Childhood abuse and neglect:Specificity of
effects on adolescent and young adult depression and suicidality. Journal of the American Academy of
Child and Adolescent Psychiatry, 38, 14901496.
Bryan, C.J., Cukrowicz, K.C., West, C.L., & Morrow, C.E. (2010). Combat experience and the acquired
capability for suicide. Journal of Clinical Psychology, 66(10), 10441056.
Burns, S.M., & Mahalik, J.R. (2011). Suicide and dominant masculinity norms among current and former United States military servicemen. Professional Psychology, 42, 347353.
Canetto, S.S., & Lester, D. (1995). Women and suicidal behavior:Issues and dilemmas. In S. S.Canetto
& D. Lester (Eds.), Women and suicidal behavior (pp. 38). NewYork:Springer.
Carlton, J.R., Manos, G.H., & Van Slyke, J.A. (2005). Anxiety and abnormal eating behaviors associated
with cyclical readiness testing in a naval hospital active duty population. Military Medicine, 170(8),
663667.
261
Cassels, C. (2009). APA 2009:Young women veterans at high risk for suicide. Retrieved from http://www.
medscape.com/viewarticle/703424 (accessed June 17,2010).
Center for Substance Abuse Treatment. Substance abuse and suicide prevention: Evidence and
implicationsA white paper. DHHS Pub. No. SMA-08-4352. Rockville, MD:Substance Abuse and
Mental Health Services Administration,2008.
Centers for Disease Control and Prevention (CDC). (2013). National Center for Injury Prevention and
Control, WISQARS leading causes of death reports, national and regional, 19992010 [online].
Retrieved from http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html (accessed November
10,2013).
Centers for Disease Control and Prevention (CDC). (2011). Suicidal thoughts and behaviors among
adults aged 18 yearsUnited States, 20082009. The Morbidity and Mortality Weekly Report,
60(13),122.
Cheng, J.K. Y., Fancher, T.L., Ratanasen, M., Conner, K.R., Duberstein, P.R., Sue, S., & Takeuchi, D.
(2010). Lifetime suicidal ideation and suicide attempts in Asian Americans. Asian American Journal
of Psychology, 1(1),1830.
Chioqueta, A., & Stiles, T.C. (2007). The relationship between psychological buffers, hopelessness, and
suicidal ideation: Identification of protective factors. Crisis: The Journal of Crisis Intervention and
Suicide Prevention, 28(2),6773.
Cougle, J.R., Keough M.E., Riccardi, C.J., & Sachs-Ericsson, N. (2009). Anxiety disorders and suicidality in the National Comorbidity Survey-Replication. Journal of Psychiatric Research, 43, 825829.
Cougle, J.R., Resnick, H., & Kilpatrick, D.G. (2009). PTSD, depression, and their comorbidity in relation to suicidality: Cross-sectional and prospective analyses of a national probability sample of
women. Depression and Anxiety, 26, 11511157.
Cox, D.W., Ghahramanlou-Holloway, M., Szeto, E., Greene, F., Engel, C., Wynn, G., ... & Grammer, G.
(2011). Gender difference in documented trauma histories:Inpatients admitted to a military psychiatric unit for suicide-related thoughts or behaviors. Journal of Nervous and Mental Disease, 199,
183190.
Dansak, D. A. (1998). Childhood abuse and parental disorders reported by Navy outpatient mental
health patients. Military Medicine, 163(8), 510514.
Do, T., Hu, Z., Otto, J., & Rohrbeck, P. (2013). Depression and suicidality during the postpartum period
after first time deliveries, active component service women and dependent spouses, U.S. Armed
Forces, 20072012. Medical Surveillance Monthly Report, 20(9),27.
Dube, S.R., Anda, R.F., Felitti, V.J., Chapman, D.P., Williamson, D.F. & Giles, W.H. (2001). Childhood
abuse, household dysfunction, and the risk of attempted suicide throughout the life span. Journal of
the American Medical Association, 286(24), 30893096.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A., Edwards, V., ... & Marks, J. (1998).
Relationship of childhood abuse and household dysfunction to many of the leading causes of death
in adults:The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine,
14(4), 245258.
Fergusson, D.M., Horwood, L.J., & Ridder, E.M. (2006). Abortion in young women and subsequent
mental health. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 47(1),1624.
Fontana, A., & Rosenheck, R. (2006). Treatment of female veterans with posttraumatic stress disorder:The role of comfort in a predominantly male environment. Psychiatric Quarterly, 77(1),5567.
Franko, D. L., Keel, P. K., Dorer, D. J., Blais, M. A., Delinsky, S. S., Eddy, K. T., . . . & Herzog, D. B.
(2004). What predicts suicide attempts in women with eating disorders? Psychological Medicine,
34(5), 843853.
Freeman, L., & Bond, A. (1992). Americas first woman warrior, the courage of Deborah Sampson.
NewYork:ParagonHouse.
Fridner, A., Belkic, K., Marini, M., Minicci, D., Pavan, L., & Schenck-Gustafsson, K. (2009). Survey
on recent suicidal ideation among female university hospital physicians in Sweden and Italy
(the HOUPE study): Cross-sectional associations with work stressors. Gender Medicine, 6(1),
314328.
262
W omen at W ar
Gianakos, I. (2002). Predictors of coping with work stress:The influences of sex, gender role, social desirability, and locus of control. Sex Roles, 46(56), 149158.
Goldacre, M., Seagroatt, V. & Hawton, K. (1993). Suicide after discharge from psychiatric inpatient care.
The Lancet, 342(8866), 283286.
Gomberg, E.S. L. (1989). Suicide risk among women with alcohol problems. American Journal of Public
Health, 79(10), 13631365.
Gutierrez, P.M., Brenner, L.A., Rings, J.A., Devore, M.D., Kelly, P.J., Staves, P.J., ... Kaplan, M.S.
(2013). A qualitative description of female veterans deployment-related experiences and potential
suicide risk factors. Journal of Clinical Psychology, 69(9), 923935.
Hankin, C.S., Skinner, K.M., Sullivan, L.M., Miller, D.R., Frayne, S., & Tripp, T.J. (1999). Prevalence
of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing
sexual assault while in the military. Journal of Trauma Stress, 12(4), 601612.
Harlow, L. L., Newcomb, M. D., & Bentler, P. M. (1986). Depression, self-derogation, substance use,
and suicide ideation:Lack of purpose in life as a mediational factor. Journal of Clinical Psychology,
42(1),521.
Hawton, K. & Fagg, J. (1988). Suicide and other causes of death following attempted suicide. British
Journal of Psychiatry, 152, 259266.
Hirsch, J.K., Duberstein, P.R., & Untzer, J. (2009). Chronic medical problems and distressful thoughts
of suicide in primary care patients:Mitigating role of happiness. International Journal of Geriatric
Hourani, L.L., Yuan, H., & Bray, R.M. (2003). Psychosocial and health correlates of types of traumatic
event exposure among U.S.military personnel. Military Medicine, 168(9), 736743.
Hovey, J.D., & King, C.A. (1996). Acculturative stress, depression, and suicidal ideation among immigrant and second-generation Latino adolescents. Journal of the American Academy of Child Adolescent
Jacobson, I.G., Ryan, M.A., Hooper, T.I., Smith, T.C., Amoroso, P.J., Boyko, E.J., ... & Bell, N.S.
(2008). Alcohol use and alcohol-related problems before and after military combat deployment.
Journal of American Medical Association, 300(6), 663675.
Jobes, D.A. (2006). Managing suicidal risk:Acollaborative approach. NewYork:Guilford.
Johnson, H., & Thompson, A. (2008). The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture:Areview. Clinical Psychology
Review, 28(1),3647.
Joiner, T.E., Jr. (2005). Why people die by suicide. Cambridge, MA:Harvard UniversityPress.
Kaplan, M.S., McFarland, B.H., & Huguet, N. (2009). Characteristics of adult male and female firearm
suicide decedents:Findings from the National Violent Death Reporting System. Injury Prevention,
15, 322327.
Karch, D., Crosby, A., & Simon, T. (2006). Toxicology testing and result for suicide victims13 States,
2004. Morbidity and Mortality Weekly Report, 55, 12451248.
Katz, L.S., Bloor, L.E., Cojucar, G., & Draper, T. (2007). Women who served in Iraq seeking mental
health services: Relationships between military sexual trauma, symptoms, and readjustment.
Psychological Services, 4(4), 239249.
Kelley, A., Goldston, D.B., Brunstetter, R., Daniel, S., Ievers, C., & Reboussin, D.M. (1996). First-time
suicide attempters, repeat attempters, and previous attempters on an adolescent inpatient psychiatry
unit. Journal of the American Academy of Child & Adolescent Psychiatry, 35(5), 631639.
Kingree, J. B., Thompson, M. P., & Kaslow, N. J. (1999). Risk factors for suicide attempts among
low-income women with a history of alcohol problems. Addictive Behaviors, 24, 583587.
Koller, G., Preuss, U.W., Bottlender, M., Wenzel, K., & Soyka, M. (2002). Impulsivity and aggression as
predictors of suicide attempts in alcoholics. European Archives of Psychiatry and Clinical Neuroscience,
252(4), 155160.
Krakow, B., Artar, A., Warner, T. D., Melendrez, D., Johnston, L., Hollifield, M., . . . & Koss, M.
(2000). Sleep disorder, depression, and suicidality in female sexual assault survivors. Crisis, 21,
163170.
263
Kress, A. M., Peterson, M. R., & Hartzell, M. C. (2006). Association between obesity and depressive symptoms among U.S.military active duty service personnel, 2002. Journal of Psychosomatic
Research, 60(3), 263271.
Langhinrichsen-Rohling, J., Snarr, J.D., Slep, A.M. S., Heyman, R.E., Foran, H.M., & United States Air
Force Family Advocacy Program. (2011). Risk for suicidal ideation in the US Air Force:An ecological perspective. Journal of Consulting and Clinical Psychology, 79(5), 600612.
Lauder, T.D., & Campbell, C.S. (2001). Abnormal eating behaviors in female reserve officer training
corps cadets. Military Medicine, 166(3), 264268.
Legleye, S., Beck, F., Peretti-Watel, P., Chau, N., & Firdion, J.M. (2010). Suicidal ideation among young
French adults:Association with occupation, family, sexual activity, personal background and drug
use. Journal of Affective Disorders, 123(13), 108115.
Lewinsohn, P.M., Rohde, P. & Seeley, J.R. (1994). Psychosocial risk factors for future adolescent suicide
attempts. Journal of Consulting and Clinical Psychology, 62(2), 297305.
Luxton, D.D., Osenbach, J.E., Reger, M., Smolenski, D.J., Skopp, N.A., Bush, N., & Gahm, G.A. (2012).
DoDSER Department of Defense suicide event report calendar year 2011 annual report. National Center
for Telehealth and Technology (T2), Defense Centers of Excellence for Psychological Health &
Traumatic Brain Injury (DCoE).
Martin, L., Rosen, L.N., Durand, D.B., Knudson, K.H., & Stretch, R.H. (2000). Psychological and physical health effects of sexual assaults and nonsexual traumas among male and female United States
Army soldiers. Behavior Modification, 26(1),2333.
McCarthy, J.F., Valenstein, M., Kim, H.M., Ilgen, M., Zivin, K., & Blow, F.C. (2009). Suicide mortality among patients receiving care in the Veterans Health Administration Health System. American
Journal of Epidemiology, 169(8), 10331038.
Mahon, M.J., Tobin, J.P., Cusack, D.A., Kelleher, C., & Malone, K.M. (2005). Suicide among regular-duty
military personnel:Aretrospective case-control study of occupation-specific risk factors for workplace suicide. American Journal of Psychiatry, 162(9), 16881696.
Mann, J.J., Waternaux, C., Haas, G.L., & Malone, K.M. (1999). Toward a clinical model of suicidal
behavior in psychiatric patients. American Journal of Psychiatry, 156, 181189.
Maris, T. M., Berman, A. L., & Silverman, M. M. (2000). Comprehensive textbook of suicidology.
NewYork:Guilford.
McNulty, P.A. (2001). Prevalence and contributing factors of eating disorder behaviors in active duty
service women in the Army, Navy, Air Force, and Marines. Military Medicine, 166(1),5358.
Medical Surveillance Monthly Report. (2011, October). Alcohol-related diagnoses, active component,
U.S. Armed Forces, 20012010. MSMR, 18(10),913.
Molnar, B.E., Berkman, L.F., & Buka, S.L. (2001). Psychopathology, childhood sexual abuse and other
childhood adversities: Relative links to subsequent suicidal behaviour in the US. Psychological
Medicine, 31(6), 965977.
Murdoch, M., Pryor, J. B., Polusny, M. A., & Gackstetter, G. D. (2007). Functioning and psychiatric
symptoms among military men and women exposed to sexual stressors. Military Medicine, 172(7),
718725.
Murphy, G.E. (1998). Why women are less likely than men to commit suicide. Comprehensive Psychiatry,
39(4), 165175.
Nock, M.K, Borges, G., Bromet, E.J., Cha, C.B., Kessler, R.C., & Lee, S. (2008). Suicide and suicidal
behavior. Epidemiologic Reviews, 30, 133154.
Nunnink, S.E., Goldwaser, G., Heppner, P.S., Pittman, J.O. E., Nievergelt, C.M., & Baker, D.G. (2010).
Female veterans of the OEF/OIF conflict:Concordance of PTSD symptoms and substance misuse.
Addictive Behaviors, 35, 655659.
Oquendo, M. A., Bongiovi-Garcia, M. E., Galfalvy, H., Goldberg, P. H., Grunebaum, M. F., Burke,
A.K., & Mann, J.J. (2007). Sex differences in clinical predictors of suicidal acts after major depression:Aprospective study. American Journal of Psychiatry, 164, 134141.
Ortega, L.A. G., & Karch, D. (2010). Precipitating circumstances of suicide among women of reproductive age in 16 U.S. States, 20032007. Journal of Womens Health, 19(1),57.
264
W omen at W ar
Owens, G. P., Herrera, C. J., & Whitesell, A. A. (2009). A preliminary investigation of mental health
needs and barriers to mental health care for female veterans of Iraq and Afghanistan. Traumatology,
15(2),3137.
Pereira, A. (2002). Combat trauma and the diagnosis of post-traumatic stress disorder in female and male
veterans. Military Medicine, 167(1),2327.
Pfeffer, C.R., Klerman, G.L., Hurt, S.W., Kakuma, T., Peskin, J.R., & Siefker, C.A. (1996). Suicidal
children grow up:Rates and psychosocial risk factors for suicide attempts during follow-up. Journal
of the American Academy of Child and Adolescent Psychiatry, 32, 106113.
Posner, K., Brent, D., Lucas, C., Gould, M., Stanley, B., Brown, G., . . . & Mann, J. (2006). Columbia
Suicide-Severity Rating Scale (C-SSRS). NewYork:NewYork State Psychiatric Institute.
Qin, P. (2011). The impact of psychiatric illness on suicide:Differences by diagnosis of disorders and by
sex and age of subjects. Journal of Psychiatric Research, 45(11), 14451452.
Qin, P., Agerbo, E. & Mortensen, P.B. (2003). Suicide risk in relation to socioeconomic, demographic,
psychiatric, and familial factors:Aregister-based study of all suicides in Denmark, 19811997. The
American Journal of Psychiatry, 160(4), 765772.
Ritchie, E.C., Keppler, W.C., & Rothberg, J.M. (2003). Suicidal admissions in the United States military. Military Medicine, 168(3), 177181
Rowan, A. B., & Campise, R. L. (2006). A multisite study of air force outpatient behavioral health
treatment-seeking patterns and career impact. Military Medicine, 171(11), 11231127.
Rowe, J.L., Conwell, Y., Schulberg, H.C., & Bruce, M.L. (2006). Social support and suicidal ideation in
older adults using home healthcare services. American Journal of Geriatric Psychiatry, 14(9), 758766.
Sadler, A.G., Booth, B.M., Cook, B.L., & Doebbeling, B.N. (2003). Factors associated with womens risk
of rape in the military environment. American Journal of Industrial Medicine, 43, 262273.
Sareen, J., Cox, B.J., Stein, M.B., Afifi, T.O., Fleet, C., & Asmundson, G.J. (2007). Physical and mental
comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large
community sample. Psychosomatic Medicine, 69(3), 242248.
Schneider, B., Wetterling, T., Sargk, D., Schneider, F., Schnabel, A., Maurer, K. & Fritze, J. (2006). Axis
Idisorders and personality disorders as risk factors for suicide. European Archives of Psychiatry and
Clinical Neuroscience, 256(1),1727.
Sher, L., Oquendo, M.A., & Mann, J.J. (2001). Risk of suicide in mood disorders. Clinical Neuroscience
Research, 1(5), 337344.
Sher, L. (2006). Alcoholism and suicidal behavior:Aclinical overview. Acta Psychiatrica Scandinavica,
113(1),1322.
Simmons, C.A. (2007). Speculation as to why women get PTSD more often than men. Women and
Therapy, 30,8598.
Stanley, B., & Brown, G. (2008). Safety plan treatment manual to reduce suicide risk: Veteran version.
Retrieved from www.mentalhealth.va.gov/College/docs/VA_Safety_planning_manual.doc
(accessed September 1,2010).
Stanley, B., & Brown, G. (2012). Safety Planning Intervention:Abrief intervention to mitigate suicide
risk. Cognitive and Behavioral Practice, 19(2), 256264.
Street, A.E., Gradus, J.L., Stafford, J., & Kelly, K. (2007). Gender differences in experiences of sexual
harassment:Data from a male-dominated environment. Journal of Consulting and Clinical Psychology,
75(3), 464474.
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, 685694.
Susanszky, E., Hajnal, A., & Kopp, M. (2011). Sleep disturbances and nightmares as risk factors for suicidal behavior among men and women. Psychiatria Hungarica, 26(4), 250257.
Tolin, D.F., & Foa, E.B. (2006). Sex differences in trauma and posttraumatic stress disorder:Aquantitative review of 25years of research. Psychological Bulletin, 132(6), 959992.
Van Orden, K.A., Witte, T.K., Gordon, K.H., Bender, T.W., & Joiner, T.E. (2008). Suicidal desire and
the capability for suicide:Tests of the interpersonal-psychological theory of suicidal behavior among
adults. Journal of Consulting and Clinical Psychology, 76,7283.
265
Violanti, J. M. (2004). Predictors of police suicide ideation. Suicide and life-threatening behavior, 4,
277283.
Vogt, D.S., Bergeron, A., Salgado, D., Daley, J., Ouimette, P., & Wolfe, J. (2006). Barriers to Veterans
Health Administration care in a nationally representative sample of women veterans. Journal of
General Internal Medicine, 21, S19S25.
Wiener, J., Richmond, T.S., Conigliaro, J., & Wiebe, D.J. (2011). Military veteran mortality following a
survived suicide attempt. BMC Public Health, 11,374.
Wimer, D.J., & Levant, R.F. (2011). The relationship of masculinity and help-seeking style with the academic help-seeking behavior of college men. Journal of Mens Studies, 19, 256274.
Women in the Military Service for America Memorial. (2013, November 11). Statistics on women in the
military. Retrieved from http://www.womensmemorial.org/Press/stats.html.
World Health Organization (WHO). (2013). Suicide prevention (SUPRE). Retrieved from http://www.
who.int/mental_health/prevention/suicide/suicideprevent/en/.
Yamane, G.K., & Butler, J.L. (2009). Suicide burden in the U.S. Air Force:19902004. Military Medicine,
174(10), 10191023.
Zhang, J., Mckeown, R.E., Hussey, J.R., Thompson, S.J. & Woods, J.R. (2005). Gender differences in
risk factors for attempted suicide among young adults:Findings from the third national health and
nutrition examination survey. Annals of Epidemiology, 15(2), 167174.
Zinzow, H. M., Grubaugh, A. L., Monnier, J., Suffoletta-Maierle, S., & Frueh, B. C. (2007). Trauma
among female veterans:Acritical review. Trauma Violence Abuse, 8(4), 384400.
fifteen
Intimate Partner Violence, Military

Personnel, and Veterans
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 asmale.
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. Anumber of researchers and the Military Services began to use the term intimate partner
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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 abusers 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 overtime.
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 ANDFACTS
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 etal., 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 femicides are homicide-suicides (Roehl, OSullivan, Webster, & Campbell, 2005, p.13).
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IPV is not a gender-neutral phenomenon. Although some women are violent in

intimate relationships, womens 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 theabuse.
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. Avictim who
stays in the relationship is constantly evaluating and trying to determine the best and
safest time toleave.
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
etal.,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
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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 dutywomen.
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 1829, while only about
29% of the civilian sample fell into this age range. Definitions were aligned to closely
match DoD definitions.
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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 dutymen.
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 dutymen.
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 dutymen.
A deployment history appears to impact active duty womens 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 Preventions 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.
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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 dont want the abuser to go tojail.
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. Aprimary 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 forhelp.
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 ones 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 abusers acts of violence and abuse to
his employer. Fear of negative career consequences is the primary barrier to reporting
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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 forMary.
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 that any involvement by military response
systems will blemish the Service members (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.
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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 members 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 theirlives.
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 abusers 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 doesnt drop
the charges. They may threaten to get a divorce and take the children. Sometimes they play
on the victims 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
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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 doesnt believe her. It may be that
the abusers 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 helpher.
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 manyshe must like it or she wouldnt 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 protecther.
The initial system response can have a huge impact on a victims subsequent actions.
Abad response can significantly increase danger to the victim and her children and
ensure she will not report again. Agood response can send a message to the victim and
the perpetrator that these actions are unacceptable and that someonecares.
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 Womens Justice Project. Safety at Home:Intimate
Partner Violence, Military Personnel, and Veterans (an e-learning course). 2013, module 1. http://
elearning.bwjp.org/safety/index.php.
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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 withCoercive 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 victims 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 victims 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
perpetrators 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 victims 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 perpetrators control. Sometimes victims of IPV with coercive control dont 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 hasended.
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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 hitting 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 arguments 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.
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Intimate Partner Violence Related toMental Illness, Substance

Abuse, or BrainInjury
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
etal., 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 partners freedom due to PTSD-related hypervigilance) may be
resolved through PTSD treatment. However, coercive controlling violence may not be
resolved with PTSD treatmentalone.
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
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negatively affect a victims 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 etal., 2011; Hoge etal., 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 betrue.
R ISK, DANGER, ANDSAFET Y
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.171181; Kropp, 2008, pp.202220). 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 motivation for treatment; attitudes that support violence toward women (Kropp & Hart,
This section has been adapted from the Battered Womens Justice Project, Safety at Home: Intimate
Partner Violence, Military Personnel, and Veterans (an e-learning course), 2013, module 2. http://
elearning.bwjp.org/safety/index.php
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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.6374; Weisz, Tolman, & Saunders 2000, pp.7590). 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; stepchild in the home; and obsessively jealous and controlling behavior (Campbell,1995).
Risk and Danger and theMilitary
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 29years (Greenfeld etal., 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 etal., 2012). If the partner has deployed to a combat zone, a victim may wonder if the partners violence is a
symptom of combat-related conditions such as PTSD or other co-occurring conditions
like depression or substanceabuse.
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 comings 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
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populations, the presence of so many risk factors is important to note and to assess for
when working with military-related victims ofIPV.
Other Considerations inRisk 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 individuals 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 ofIPV.
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 victims 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.
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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 victims 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 gethelp.
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 andTrauma
Given that the impacts of trauma on an individuals health and well-being can build
up over time, it is important to recognize trauma exposure over a persons lifetime.
The US Department of Health and Human Services Substance Abuse and Mental
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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 individuals 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 experiencedboth.
Trauma Prior toEntering theMilitary
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,
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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 inthe Military
Many women also experience trauma while in the military. Sometimes the trauma is
combat related, and sometimes it is not. Over 2.5million 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/shorttemper
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Agitation, irritation, annoyance

Jumpy and easily startled
Avoiding people andplaces
Increased drinking, smoking, druguse
Mistrust
Over-controlling or overprotective
(National Center for PTSD, A Guide for Families of Military Members; National
Center for PTSD, AGuide for Military Personnel).
In the 2008 study, Invisible Wounds of WarPsychological 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 Universitys 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).
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, Volume2).
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-OCCURR ING 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
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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
dutywomen?
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 overallrisk.
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 persons 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 etal., 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 etal., 2006). IPV victims often experience multiple types of trauma. IPV and childhood trauma increase a womans 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 persons
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 conf lict and problems.
In addition, the health and mental health sequelae of trauma can negatively affect
a persons functioning in all areas of life, which can lead to further relationship problems. Health and mental health symptoms can also interfere with a persons ability to
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 victims 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 persons 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, Womens Bureau,2011).
WOMEN VETER ANS ANDIPV
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.
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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 etal., 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 etal., 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
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.
TR AUMA-INFOR MED APPROACH TOADVOCACY
ANDINTERVENTION
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
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trauma and the impact it has on the lives of consumers receiving services. All programming must be viewed through a traumalens.
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 couples 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 persons life circumstances and strategic to survival.
Viewing trauma as a defining and organizing experience at the core of the individuals
identifyrather 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 whats wrong with
them: Always ask about a persons experiences, which focuses on the trauma,
instead of asking what is wrong with them, which focuses on individual pathology.
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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 members and Veterans
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 longlasting. 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 faceor realistically fearnegative 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
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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 perseverancethese 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.
REFERENCES
Battered Womens Justice Project. (2013). Safety at home:Intimate Partner Violence, Military Personnel,
and Veterans (an e-learning course). Retrieved from http://elearning.bwjp.org/safety/index.php.
Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, M.T., ... Stevens, M.R.
(2011). The National Intimate Partner and Sexual Violence Survey: 2010 summary report. National
Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Division
of Violence Prevention. Atlanta, GA:National Center for Injury Prevention and Control, Centers
for Disease Control and Prevention. Retrieved from http://www.cdc.gov/violenceprevention/pub/
nisvspubs.html (accessed May 18,2013).
Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, M.T., ... Stevens, M.R.
(n.d.). National Intimate Partner and Sexual Violence Survey:Fact sheet. CDC National Center for
Injury Prevention, Division of Violence Prevention. Atlanta, GA:Centers for Disease Control and
Prevention. Retrieved from http://www.cdc.gov/violenceprevention/pdf/nisvs_factsheet-a.pdf
(accessed June2013).
Black, M.C., & Merrick, M.T. (2013). Prevalence of intimate partner violence, sexual violence, and stalking among
active duty women and wives of active duty mencomparisons with women in the U.S.general population,
2010. CDC National Center for Injury Prevention and Control, Division of Violence Prevention. Atlanta,
GA:Centers for Disease Control and Prevention. Retrieved from http://www.sapr.mil/public/docs/
research/2010_National_Intimate_Partner_and_Sexual_Violence_Survey-Technical_Report.pdf.
293
Blosnich, J.R., Dichter, M.E., Cerulli, C., Batten, S.V., & Bossarte, R.M. (2014). Disparities in adverse
childhood experiences among individuals with a history of military service. JAMA Psychaiatry, 71,
10411048.
Booth-Kewley, S., Larson, G.E., & Ryan, M.A. (2002, September). Predictors of Navy attrition:I.Analysis
of 1-year attrition. Military Medicine, 169(9), 760769.
Caliber Associates. (1996). The final report of the Study of Spousal Abuse in the Armed Forces. Washington,
DC:Department of Defense.
Campbell, J.C. (1995). Assessing dangerousness. Newbury Park:Sage Publications.
Caralis, P.V., & Musialowski, R. (1997, November). Womens experiences with domestic violence and
their attitudes and expectations regarding medical care of abuse victims. Southern Medical Journal,
90(11), 10751080.
Carlson, K.F., Dobscha, S.K., Greer, N., Kehle, S.M., MacDonald, R., Meis, L.A., ... Wilt, T.J. (2011,
April). Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic
stress disorder:Asystematic review of the evidence. Journal of Head Trauma Rehabilitation, 26(2),
103115. Retrieved from http://www.nursingcenter.com/pdf.asp?AID=1140782.
Catalano, S.M. (2012, January 2). Intimate partner violence, 19932010. US Department of Justice, Office
of Justice Programs, Bureau of Justice Statistics. Washington, DC:Office of Justice Programs, US
Department of Justice. Retrieved from www.bjs.gov/index.cfm?ty=pbdetail&iid=4536 (accessed
May 18,2013).
Cloitre, M., Stolbach, B.C., Herman, J.L., van der Kolk, B., Pynoos, R., Wang, J., & Petkova, E. (2009,
October). A developmental approach to complex PTSD:Childhood and adult cumulative trauma
as predictors of symptom complexity. Journal of Traumatic Stress, 22(5), 399408. Retrieved from
http://www.traumacenter.org/products/JTS_Oct_09_Cloitre_et_al.pdf.
Coker, A.L., Smith, P.H., Thompson, M.P., McKeown, R.E., Bethea, L., & Davis, K.E. (2002, June).
Social support protects against the negative effects of partner violence on mental health. Journal of
Womens Health & Gender-Based Medicine, 11(5), 465476. Retrieved from http://uknowledge.uky.
edu/cgi/viewcontent.cgi?article=1114&context=crvaw_facpub&sei-redir=1&referer=http%3A%2
F%2Fwww.google.com%2Furl%3Fsa%3Dt%26rct%3Dj%26q%3Dsocial%2520support%2520prot
ects%2520against%2520the%2520negative%2520effects%2520of%2520partner%.
Coker, A.L., Watkins, K.W., Smith, P.H., & Brandt, H.M. (2003, September). Social support reduces the
impact of partner violence on health:Application of structural equation models. Preventive Medicine,
37(3), 259267.
Department of Defense, Family Advocacy Program. (2013). Child abuse and domestic abuse data trends
from FY01 to FY12. Department of Defense. Retrieved from http://www.bwjp.org/files/bwjp/files/
FAP_FY12_Final_Data.pdf.
Department of Defense, Sexual Assault Prevention and Response. (2013). Department of
Defense annual report on sexual assault in the military fiscal year 2012: Volume 1. Washington,
DC: Department of Defense. Retrieved from http://www.sapr.mil/media/pdf/reports/
FY12_DoD_SAPRO_Annual_Report_on_Sexual_Assault-VOLUME_ONE.pdf.
Department of Defense, Sexual Assault Prevention and Response. (2013). Department of Defense
annual report on sexual assault in the military fiscal year 2012: Volume 2. Washington,
DC: Department of Defense. Retrieved from http://www.sapr.mil/public/docs/reports/
FY12_DoD_SAPRO_Annual_Report_on_Sexual_Assault-VOLUME_TWO.pdf.
Dichter, M.E. (2013). Intersection between family violence exposure and military service:Impacts on
health, well-being, health care, and help-seeking. APHA 141st Annual Meeting & Exposition (unpublished research). Boston:American Public Health Association.
Dichter, M. E., Cerulli, C., & Bossarte, R. M. (2011, JulyAugust). Intimate partner violence victimization among women veterans and associated heart health risks. Womens Health Issues, 21(4),
S190S194. doi:10.1016/j.whi2011.04.008.
Dichter, M.E., & Marcus, S.C. (2013, October). Intimate partner violence victimization among women
veterans: Health, healthcare serve use, and opportunities for intervention. Military Behaviorial
Health, 1, 107113.
294
W omen at W ar
Dichter, M.E., Marcus, S.C., Wagner, C. & Bonomi, A.E. (2014). Associations between psychological, physical, and sexual intiamte partner vioelnce and health outcomes among women veteran VA
patients. Social Work in Mental Health, 12, 411428.
Dubovsky, S. (2011, December 30). Who will become violent? New insights in psychiatric research. Journal
Watch Psychiatry. Retrieved from http://psychiatry.jwatch.org/cgi/content/full/2011/1230/7
Dutton, D. G., & Kropp, P. R. (2000, April). A review of domestic violence risk. Trauma, Violence, &
Abuse(1), 171181.
Dutton, M.A., & Goodman, L.A. (2005). Coercion in intimate partner violence:Toward a new conceptualization. Sex Roles:AJournal of Research, 52(1112), 743756. doi:10.1007/s1199-005-4196-6.
Gerlock, A.A. (2004, June). Domestic violence and post-traumatic stress disorder severity for participants of a domestic violence rehabilitation program. Military Medicine, 169(6), 470474.
Gerlock, A. (2013, January 22). Women veterans and trauma. Webinar. Battered Womens Justice Project.
Retrieved from http://www.bwjp.org/webinar_recordings_military.aspx.
Goodman, L.A., Dutton, M.A., & Bennett, L. (2000, January). Predicting repeat abuse among arrested
batterers:Use of the danger assessment scale in the criminal justice system. Journal of Interpersonal
Violence, 15(1), 6374. doi:10.1177/088626000015001005.
Goodman, L., Dutton, M.A., Vankos, N., & Weinfurt, K. (2005, March). Womens resources and use
of strategies as risk and protective factors for reabuse over time. Violence Against Women, 11(3),
311336. doi:10.1177/1077801204273297.
Greendlinger, R., & Spadoni, P. (2010). Engaging veterans and families to enhance service delivery:Atool
kit for community-based organizations. Newton, MA:The National Center on Family Homelessness.
Retrieved from http://www.familyhomelessness.org/media/174.pdf.
Greenfeld, L.A., Rand, M.R., Klaus, P.A., Perkins, C.A., Ringel, C., Warchol, G., ... Fox, J.A. (1998).
Violence by intimates. Office of Justice Programs, Bureau of Justice Statistics. Washington, DC:US
Department of Justice. Retrieved from http://bjs.gov/content/pub/pdf/vi.pdf.
Hamilton, A. B., Poza, I., & Washington, D. L. (2011, JulyAugust). Homelessness and trauma go
hand-in-hand: Pathways to homelessness among women veterans. Womens Health Issues, 21,
S203S209. doi:10.1016/j.whi.2011.04.005.
Harris, M., & Fallot, R.D. (Eds.). (2001). Using trauma to design service systems:New directions for mental
health services. San Francisco:Jossey-Bass.
Herman, J.L. (1997). Trauma and recovery. NewYork:BasicBooks.
Hoge, C.W., McGurk, D., Thomas, J.L., Cox, A.L., Engel, C.C., & Castro, C.A. (2008, January 31). Mild
traumatic brain injury in U.S. soldiers returning from Iraq. The New England Journal of Medicine,
358(5), 453463. Retrieved from http://www.nejm.org/doi/pdf/10.1056/NEJMoa072972.
ICF International. (2012). 2011 demographics:Profile of the military community. Washington, DC:Office
of the Deputy Under Secretary of Defense (Military Community and Family Policy). Retrieved from
http://www.militaryonesource.mil/12038/MOS/Reports/2011_Demographics_Report.pdf.
Iverson, K.M., King, M., Resick, P., Gerber, M.R., Kimerling, R., & Vogt, D. (2013, July 4). Clinical utility of an intimate partner violence screening tool for female VA patients. Journal of General Internal
Medicine, 28, 12881293.
Iverson, K.M., Monson, C.M., & Street, A.E. (2012). Dual combat and sexual trauma during military
service. In M. Duckworth, & V. Follette (Eds.), Retraumatization:Assessment, treatment, and prevention (pp. 253281). NewYork:Routledge.
Jacobson, I.G., Ryan, M.A., Hooper, T.I., SMtih, T.C., Amoroso, P.J., Boyko, E., ... Bell, N.S. (2008,
August 13). Alcohol use and alcohol-related problems before and after miltary combat deployment.
Journal of the American Medical Association, 300(6), 663675. doi:10.1001/jama.300.6.663.
Johnson, K. M., Bradley, K. A., Bush, K., Gardella, C., Dobie, D. J., & Laya, M. B. (2006, March 1).
Frequency of mastalgia among women veterans:Association with psychiatric conditions and unexplained pain syndromes. Journal of General Internal Medicine, 21(Suppl 3), S70S75.
Joyal, C. C., Dubreucq, J.-L., Gendron, C., & Millaud, F. (2007). Major mental disorders and violence:Acritical update. Current Psychiatry Reviews, 3(1), 3350. Retrieved from http://www.benthamscience.com/cpsr/sample/cpsr3-1/D0005SR.pdf.
295
Karch, D.L., Logan, J., & Patel, N. (2011, August 26). Surveillance for violent deathsNational violent death
reporting system, 16 states, 2008. CDC National Center for Injury Prevention and Control, Division
of Violence Prevention. Atlanta, GA:Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6010a1.htm.
Kropp, P.R. (2008, March). Intimate partner violence risk assessment and management. Violence and
Victims, 23(2), 202220.
Kropp, P.R., & Hart, S.D. (2000). The Spousal Assault Risk Assessment (SARA) guide:Reliability and
validity in adult male offenders. Law and Human Behavior, 24(1), 101118.
Larson, G. E., Booth-Kewley, S., & Ryan, M. A. (2002, September). Predictors of Navy attrition: II.
Ademonstration of potential usefulness for screening. Military Medicine, 167(9), 770776.
LeardMann, C.A., Pietrucha, A., Magruder, K.M., Smith, B., Murdoch, M., Jacobson, I.G., ... SMith,
T. C. & Millenium Cohort Study Team. (2013). Combat deployment is associated with sexual
harassment or sexual assault in a large, female military cohort. Womens Health Issues, 23, e215e223.
Lynch, S.M., DeHart, D.D., Delknap, J., & Green, B.L. (2012). Womens pathways to jail:The roles and intersections of serious mental illness and trauma. Washington, DC:US Department of Justice, Bureau of Justice
Assistance. Retrieved Presented at the 17th Annual International Conference on Violence, Abuse and
Trauma. Retrieved from https://www.bja.gov/Publications/Women_Pathways_to_ Jail.pdf.
MacManus, D., Dean, K., Al Bakir, M., Iversen, A.C., Hull, L., Fahy, T., ... Fear, N.T. (2012, August).
Violent behaviour in UK military personnel returning home after deployment. Psychological
Medicine, 42(8), 16631673. doi:10.1017/S0033291711002327.
Maguen, S., Lexton, D.D., Skopp, N.A., & Madden, E. (2012, March). Gender differences in traumatic
experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan. Journal
of Psychiatric Research, 46, 311316. doi:10.1016/j.jpsychires.2011.11.007.
McCarroll, J. E., Castro, S., Nelson, E. M., Fan, Z., Evans, P. K., & Rivera, A. (2008, September).
Characteristics of domestic violence incidents reported at the scene by volunteer victim advocates.
Military Medicine, 173(9), 865870.
Merrill, L.L. (2001, July). Trauma symptomatology among female U.S. Navy recruits. Military Medicine,
166(7), 621624.
Merrill, L.L., Newell, C.E., Milner, J.S., Koss, M.P., Hervig, L.K., Gold, S.R., ... Thornton, S.R. (1998,
April). Prevalence of premilitary adult sexual victimization and aggression in a Navy recruit sample.
Military Medicine, 163(4), 209212.
Merrill, L.L., Newell, C.E., Thomsen, C.J., Gold, S.R., Milner, J.S., Koss, M.P., & Rosswork, S.G.
(1999, April). Childhood abuse and sexual revictimization in a female Navy recruit sample. Journal
of Traumatic Stress, 12(2), 211225.
Merrill, L.L., Stander, V.A., Thomsen, C.J., Crouch, J.L., & Milner, J.S. (2004, June). Childhood exposure to family violence and attrition in the Navy. Military Medicine, 169(6), 465469.
Merrill, L.L., Thomsen, C.J., Gold, S.R., & Milner, J.S. (2001, April). Childhood abuse and premilitary
sexual assault in male navy recruits. Journal of Consulting and Clinical Psychology, 69(2), 252261.
Merrill, L.L., Thomsen, C.J., Sinclair, B.B., Gold, S.R., & Milner, J.S. (2001, December). Predicting
the impact of child sexual abuse on women:The role of abuse severity, parental support, and coping
strategies. Journal of Consulting and Clinical Psychology, 69(6), 9921006.
National Center for PTSD, US Department of Veterans Affairs. (2010, September). Returning from the
war zone:Aguide for families of military members. Retrieved from http://www.ptsd.va.gov/public/
reintegration/returning_from_the_war_zone_guides.asp (accessed June 15,2013).
National Center for PTSD, US Department of Veterans Affairs. (2010, September). Returning from the
war zone: A guide for military personnel. Retrieved from http://www.ptsd.va.gov/public/reintegration/returning_from_the_war_zone_guides.asp (accessed June 28,2013).
Newport, F. (2012, November 12). In U.S., 24% of men, 2% of women are veterans. Retrieved from http://
www.gallup.com/poll/158729/men-women-veterans.aspx.
Olson, C.B., Stander, V.A., & Merrill, L.L. (2004, January). The influence of survey confidentiality and
construct measurement in estimating rates of childhood vitimization among Navy recruits. Military
Pyschology, 16(1), 5369. doi:10.1207/s15327876mp1601_4.
296
W omen at W ar
Orcutt, H.K., King, L.A., & King, D.W. (2003, August). Male-perpetrated violence among vietnam
veteran couples: relationships with veterans early life characteristics, trauma history, and PTSD
symptomatology. Journal of Traumatic Stress, 16(4), 381390. Retrieved from http://www.niu.
edu/~horcutt/publications/orcutt%20jts%202003%20nvvrs.pdf.
Pence, E., & Lizdas, K. (1998). The Duluth safety and accountability audit:Aguide to assessing institutional
response to domestic violence. Duluth:Minnesota Program Development.
RAND Center for Military Health Policy Research. (2008). Invisible wounds of war:Psychological and
cognitive injuries, their consequences, and services to assist recovery, T. Tanielian & L. H.Jaycox (Eds.).
Santa Monica, CA:RAND Corporation. Retrieved from http://www.rand.org/content/dam/rand/
pubs/monographs/2008/RAND_MG720.pdf (accessed June 23,2013).
Roehl, J., & Guertin, K. (2000). Intimate partner violence:The current use of risk assessments in sentencing offenders, S. Talarico (Ed.). Justice System Journal, 21(2), 171198.
Roehl, J., OSullivan, C., Webster, D., & Campbell, J. (2005). Intimate Partner Violence Risk Assessment
Validation Study (NIJ 2000WTVX0011), final report: March 28, 2005. National Criminal Justice
Reference Service. Retrieved from https://www.ncjrs.gov/pdffiles1/nij/grants/209731.pdf.
Rosen, L.N., & Martin, L. (1996a, November). Childhood antecedents of psychological adaptation to
military life. Military Medicine, 161(11), 665668.
Rosen, L.N., & Martin, L. (1996b, December). Impact of childhood abuse history on psychological symptoms among male and female soldiers in the U.S. Army. Child Abuse & Neglect, 20(12), 11491160.
doi:10.1016/S0145-2134(96)00112-3.
Rosen, L.N., & Martin, L. (1996c, June). The measurement of childhood trauma among male and female
soldiers in the U.S. Army. Military Medicine, 161(6), 342345.
Rosen, L.N., & Martin, L. (1998a, January 1). Childhood maltreatment history as a risk factor for sexual
harassment among U.S. Army soldiers. Violence and Victims, 13(3), 269286.
Rosen, L. N., & Martin, L. (1998b, March). Long-term effects of childhood maltreatment history on
gender-related personality characteristics. Child Abuse & Neglect, 22(3), 197211.
Saakvitne, K.W., Gamble, S., Pearlman, L.A., & Lev, B.T. (1999). Risk connection:Atraining curriculum
for working with survivors of childhood abuse. Baltimore, MD:SidranPress.
Sadler, A.G., Booth, B.M., Mengeling, M.A., & Doebbeling, B.N. (2004, September). Life span and
repeated violence against women during military service: Effects on health status and outpatient
utilization. Journal of Womens Health, 13(7), 799811. doi:10.1089/jwh.2004.13.799.
Santen, D. (2010, December 1). OHSU-PSU research identifies hidden epidemic: Suicide
rate among young women veterans more than twice that of civilians. Retrieved from
ht t p://w w w.pd x .edu/new s/oh su-psu-resea rch-ident i f ies-h idden- epidem ic-su ic ide-r
ate-among-young-women-veterans-more-twice (accesed June 23,2013).
Sayers, S.L., Farrow, V.A., Ross, J., & Oslin, D.W. (2009, February 18). Family problems among recently
returned military veterans referred for a mental health evaluation. Journal of Clinical Psyschiatry, 70,
163170. Retrieved from http://www.psychiatrist.com.
Smikle, C.B., Fiedler, E., Sorem, K.A., Spencer, D.K., & Satin, A.J. (1996, March). The impact of sexual
abuse on job attrition in military recruits. Militrary Medicine, 161(3), 146148.
Sonkin, D. (1997). Domestic violence:Perpetrator assessment manual. Sausalito:Daniel Sonkin,Ph.D.
Stander, V. A., Olson, C. B., & Merrill, L. L. (2002, April). Self-definition as a survivor of childhood
sexual abuse among navy recruits. Journal of Consulting and Clinical Psychology, 70(2), 369377.
Street, A. E., Gradus, J. L., Giasson, H. L., Vogt, D., & Resick, P. A. (2013, July). Gender differences
among veterans deployed in support of the wars in Afghanistan and Iraq. Journal of General Internal
Medicine, 28(Suppl 2), 556562. doi:10.1007/s11606-013-2333-4.
Street, A.E., Vogt, D., & Dutra, L. (2009, December). A new generation of women veterans:Stressors
faced by women deployed to Iraq and Afghanistan. Clinical Psychology Review, 29(8), 685694.
doi:10.1016/j.cpr.2009.08.007.
Taylor, L. R. (2002, March 1). The home front. Retrieved from http://www.govexec.com/
magazine/2002/03/the-home-front/11093/.
297
The Violence Policy Center. (2012). When men murder women: An analysis of 2010 homicide data.
Washington, DC: The Violence Policy Center. Retrieved from http://www.vpc.org/studies/
wmmw2012.pdf.
Tolin, D.F., & Foa, E.B. (2006, November). Sex differences in trauma and posttraumatic stress disorder:Aquantitative review of 25years of research. Psychological Bulletin, 132(6), 959992.
Ulrich, Y. C., Cain, K. C., Sugg, N. K., Rivara, F. P., Rubanowice, D. M., & Thompson, R. S. (2003,
January). Medical care utilization patterns in women with diagnosed domestic violence. American
Journal of Preventive Medicine, 24(1), 915. doi:10.1016/S0749-3797(02)00577-9.
US Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration. (2012, December 10). Trauma definition:Part one:Defining trauma. Retrieved from
http://www.samhsa.gov/traumajustice/traumadefinition/definition.aspx (accessed June 23,2013).
US Department of Justice, Federal Bureau of Investigation. (n.d.). Uniform crime reporting program
data:Supplementary homicide reports, 2010. Washington, DC:US Department of Justice.
US Department of Labor, Womens Bureau. (2011). Trauma-informed care for women veterans experiencing
homelessness:Aguide for service providers. Washington, DC:US Department of Labor. Retrieved from
http://www.dol.gov/wb/trauma/WBTraumaGuide2011.pdf.
US Department of Veterans Affairs, Women Veterans Task Force. (2012). Strategies for serving our women
veterans. Washington, DC:US Department of Veterans Affairs. Retrieved from http://www.va.gov/
opa/publications/draft_2012_women-veterans_strategicplan.pdf.
USA Today. (2013, January 25). A decade of war proved womens mettle for combat. Retrieved from http://
www.usatoday.com/story/news/nation/2013/01/25/women-combat-ref lects-reality/1864195/
(accessed June 23,2013).
Washington, D.L., Kleimann, S., Michelini, A.N., Kleimann, K.M., & Canning, M. (2007, August).
Women veterans perceptions and decision-making about Veterans Affairs health care. Military
Medicine, 172(8), 812817.
Washington, D.L., Yano, E.M., Simon, B., & Sun, S. (2006). To use or not to use. Journal of General
Internal Medicine, 21(Suppl 3), S11S18.
Weisz, A. N., Tolman, R. M., & Saunders, D. G. (2000). Assessing the risk of severe domestic violence: The importance of survivors predictions. Journal of Interpersonal Violence, 15(1), 7590.
doi:10.1177/088626000015001006.
Zinzow, H. M., Grubaugh, A. L., Monnier, J., Suffoletta-Maierle, S., & Freuh, B. C. (2007, October).
Trauma among female veterans:Acritical review. Trauma, Violence & Abuse, 8(4), 384400.
PA R T
The Female Veteran

Experience
sixteen
The Woman Veteran Experience

ISABEL D.ROSS, NATAR A D.GAROVOY,
SUSANJ.MCCUTCHEON, AND
JENNIFERL.STR AUSS
INTRODUCTION
Women are serving in todays 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 VETER ANS MENTAL HEALTHNEEDS

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 Chapter18 for more information
on this topic]). Identification of these differences is an initial and crucial step in knowing how to best meet these womens mental healthcareneeds.
Prevalence ofMental 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 etal., 2014). In addition, higher rates of depression and anxiety are found among women Veterans (Freedy
etal., 2010; Maguen etal., 2010), whereas other mental health conditions, such as substance use disorders, are more common among male Veterans (Iverson et al., 2010;
Westermeyer etal.,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 etal., 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 etal., 2010; Iverson
et al., 2010). For example, rates of comorbid PTSD and depression are significantly
higher among women Veterans thenmen.
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 etal., 2012). The second, and perhaps more critical, point
is the importance of not assuming that gender differences observed in non-Veteran
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populations generalize to the Veteran population. While a womans 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 womens 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 etal., 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-Veteranwomen.
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 1844) and 29% are aged consistent with perimenopause (ages 4555)
(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 womans 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 etal.,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 etal., 2003), there is a clear need for women Veterans
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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 womens
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 precisely 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 etal.,2013).
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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 etal., 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 etal., 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 resourcesresponsibilities that often carry gender role expectationscould also create unique readjustment challenges for women
Veterans.
Current VA Mental Healthcare Policy and
ProgrammingforWomen
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 womens safety, privacy, dignity, and respect.
This includes providing separate and secure sleeping and bathroom arrangements for
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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 womens
treatment teams, and many of these programs serve as national resources for all women
Veterans. Examples of such VA programing include specialized womens 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 PR ACTICES FORGENDER-SENSITIVE
MENTALHEALTHCARE
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. Adefinition of
gender-sensitive mental healthcare that specified measurable organizational features
and processes for the needs of VA was developed (Strauss etal., 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 womens unique treatment needs; and innovation of creative options and settings for subgroups of women, especially when caseloads of women are small (Strauss
etal., 2014). These tenets of gender sensitivity guide VAs current approach to womens
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
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co-located mental health providers in womens 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 womens 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 patients 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 VAs 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 in2014.
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 womens 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
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to best address these differences, that includes comprehensiveness of services, choice

of treatment modality, competency of providers to address womens unique treatment
needs, and innovation as needed to meet womens 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.
REFERENCES
Adler-Baeder, F., Pittman, J. F., & Taylor, L. (2005). The prevalence of marital transitions in military
families. Journal of Divorce and Remarriage, 44, 91106.
American Psychological Association. (2013). Fact sheet: Women and socioeconomic status. Retrieved
from https://www.apa.org/pi/ses/resources/publications/factsheet-women.aspx (accessed January
30,2014).
Banerjea, R., Pogach, L., Smelson, D., & Sambamoorthi, U. (2009). Mental illness and substance use
disorders among women veterans with diabetes. Womens Health Issues, 19(6), 446456.
Bliese, P. (2006). Social climates: Drivers of soldier well-being and resilience. In A. B. Adler, C.
A.Castro,& T. W.Britt (Eds.), Military life:The psychology of serving in peace and combat: Volume 2:
Operational stress (pp. 213234). Westport, CT:Praeger Security International.
Byrne, T., Montgomery, A.E., & Dichter, M.E. (2013). Homelessness among female veterans:Asystematic review of the literature. Women & Health, 53(6), 572596.
Culhane, D.P., & Metraux, S. (1999). Assessing relative risk for homeless shelter usage in NewYork City
and Philadelphia. Population Research and Policy Review, 18(3), 219236.
Department of Veterans Affairs. (2008). VHA Handbook 1160.01:Uniform mental health services in VA
Medical Centers and Clinics. Washington, DC: Department of Veterans Affairs, Veterans Health
Administration.
Diflorio, A., & Jones, I. (2010). Is sex important? Gender differences in bipolar disorder. International
Review of Psychiatry, 22(5):437452.
Federal Partners Committee on Women and Trauma. (September, 2013). Trauma-informed
approaches:Federal activities and initiatives. Retrived from:http://www.nasmhpd.org/Publications/
Women_and_Trauma.aspx
Fontana, A., Rosenheck, R., & Desai, R. (2010). Female veterans of Iraq and Afghanistan seeking care
from VA specialized PTSD programs:Comparison with male veterans and female war zone veterans
of previous eras. Journal of Womens Health, 19(4), 751757.
Frayne, S., Chiu, V., Igbal, S., Berg, E., Laungani, K., Cronkite, R., etal. (2010). Medical care needs of
returning veterans with PTSD:Their other burden. Journal of General Internal Medicine, 26(1),3339.
Frayne, S.M., Phibbs, C.S., Saechao, F., Maisel, N.C., Friedman, S.A., Finlay, Haskell S. (February 2014).
Sourcebook: Women Veterans in the Veterans Health Administration. Volume 3. Sociodemographics,
Utilization, Costs of Care, and Health Profile. Womens Health Evaluation Initiative, Womens Health
Services, Veterans Health Administration, Department of Veterans Affairs.
Freedy, J.R., Magruder, K.M., Mainous, A.G., Frueh, B.C., Geesey, M.E., & Carnemolla, M. (2010).
Gender differences in traumatic event exposure and mental health among veteran primary care
patients. Journal of General Internal Medicine, 175(10), 750758.
Grote, N.K., Bridge, J.A., Gavin, A.R., Melville, J.L., Iyengar, S., & Katon, W.J. (2010). A meta-analysis
of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine
growth restriction. Archives of General Psychiatry, 67, 10121024.
309
Griffith, J., & Vaitkus, M. (1999). Relating cohesion to stress, strain, disintegration, and performance:An
organizing framework. Military Psychology, 11(1),2755.
Iverson, K., Hendricks, A., Kimerling, R., Krengle, M., Stokzmann, M., Baker, E., etal. (2010). Psychiatric
diagnoses and risk of suicide in veterans. Archives of General Psychiatry, 67(11), 11521158.
Johnson, D.R., Lubin, H., Rosenheck, R., Fontana, A., Southwick, S., & Charney, D. (1997). The impact
of the homecoming reception on the developmen of posttraumatic stress disorder:The West Haven
Homecoming Stress Scale (WHHSS). Journal of Traumatic Stress, 10(2), 259277.
Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., etal. (1994). Lifetime
and 12-month prevalence of DSM-III-R psychiatric disorders in the United States:Results from the
National Comorbidity Study. Archives of General Psychiatry, 51,819.
Landes, S.J., Burton, J.R., King, K.M., & Sullivan, B.F. (2013). Womens preference of therapist based
on sex of therapist and presenting problem:An analog study. Counseling Psychology Quarterly, 26,
330342.
Maguen, S., Ren, L., Bosch, J., Marmar, J., & Seal, K. (2010). Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in Veterans Affairs health care. American Journal
f Public Health, 100(12), 24502456.
Mattocks, K., Skanderson, M., Goulet, J., Brandt, C., Womack, J., Krebs, E., et al. (2010). Pregnancy
and mental health among women veterans returning from Iraq and Afghanistan. Journal of Womens
Health, 19(12), 21592166.
Marcus, S.M., Flynn, H.A., Blow, F.C., & Barry, K.L. (2003). Depressive symptoms among pregnant
women screened in obstetrics settings. Journal of Womens Health, 12(4), 373380.
McLean, A., & Litz, H. (2011). Gender differences in anxiety disorders:Prevalence, course of illness,
comorbidity and burden of illness. Journal of Psychiatric Research, 45(8), 10271035.
Murdoch, M., Pryor, J. B., Polusny, M. A., & Gackstetter, G. D. (2007). Functioning and psychiatric
symptoms among military men and women exposed to sexual stressors. Military Medicine, 172(7),
718725.
National Center for Veterans Analysis and Statistics. (2011). Americas women veterans: Military service history and VA benefit utilization statistics. National Center for Veteran Analysis and Statistics,
Department of Veterans Affairs, Washington,DC.
National Center for Veterans Analysis and Statistics. (2013). Profile of veterans: 2011; data from the
American Community Survey. Washington, DC:National Center for Veteran Analysis and Statistics,
Department of Veterans Affairs.
North, C.S., & Smith, E.M. (1993). A comparison of homeless men and women:Different populations,
different needs. Community Mental Health Journal, 29(5), 423431.
Northeast Program Evaluation Center, Office of Mental Health Operations, Department of Veterans
Affairs. (2014). 2012 National mental health fact sheet on women Veterans (NEPEC-MHFS13-2).
Pavao, J., Turchik, J.A., Hyun, J.K., Karpenko, J., Saweikis, M., McCutcheon, S., Kane, V., & Kimerling,
R. (2013). Military sexual trauma among homeless veterans. Journal of General Internal Medicine,
28(Suppl 2):536541.
Runnals, J.J., Garovoy, N., McCutcheon, S.J., Robbins, A.T., Mann-Wrobel, M., Ventimiglia, A. (2014).
Mid-Atlantic Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC)
Women Veterans Workgroup, Strauss, J.L. Systematic review of gender differences in mental health
and unique needs of women Veterans. Womens Health Issues, 24(5), 485502.
Smink, F.R., van Hoeken, D., Hoek, H.W. (2012). Epidemiology of eating disorders:Incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4) 406414.
Strauss, J.L., Oishi, S., Garovoy, N., Hyun, J., Canelo, I., McCutcheon, S.J. (2014). Research partnership
to conduct a national survey of gender-sensitive mental health care for women Veterans. Abstract
presented at the National VA HSR&D Conference on Enhancing Partnerships for Research and
Care of Women Veterans, WashingtonDC.
Street, A.E., Gradus, J.L., Giasson, H.L., Vogt, D., & Resick, P. (2013). Gender differences among veterans deployed in support of the wars in Afghanistan and Iraq. Journal of General Internal Medicine,
28(Suppl 2), S556S562.
310
W omen at W ar
Street, A.E., Gradus, J.L., Stafford, J., & Kelly, K. (2007). Gender differences in experiences of sexual
harassment:Data from a male-dominated environment. Journal of Consulting and Clinical Psychology,
75(3), 464474.
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(8), 685694.
Vogt, D., Pless, A.P., King, L.A., & King, D.W. (2005). Deployment stressors, gender, and mental health
outcomes among Gulf War IVeterans. Journal of Traumatic Stress, 18 (3), 272284.
Vogt, D., Vaughn, R., Glickman, M.E., Schultz, M., Drainoni, M., Elwy, R., & Eisen, S. (2011). Gender
nationally representative sample of U.S. OEF/OIF Veterans. Journal of Abnormal Psychology, 120(4),
797806.
Westermeyer, J., Canive, J., Thuras, P., Thompson, J., Crosby, E., & Garrard, J., (2009). A comparison of
substance use disorder severity and course in American Indian male and female veterans. American
Journal of Addictions, 18(1),8792.
Zorza J. (1991). Woman battering:Amajor cause of homelessness. Clearinghouse Review, 25, 421427.
sev ent een
Mental Health ofWomen Warriors:The

Power ofBelonging
K ATEMCGR AW
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 ones 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 thesame.
STUDIES OFSERVICE-RELATED MENTALHEALTH
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
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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 occupies 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
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in a category that reflects subjects active duty experience, rather than the subjects 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 etal. 2011; Batuman etal.,
2011; McGraw etal., 2013; Runnals, etal., 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
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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 etal.
(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 malepeers.
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/
OIFera 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 subjects reports of perceived threats (for example, fear
for ones 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
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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, etal. (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 aswell.
OSTR ACISM
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 fieldsor, as in the military, are breaking into previously closed combat
positions currently held by malesmay suddenly find themselves part of a social group
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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. Robinsons 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 doesnt 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 groupa need that appears
to be innate and critical to our survival as a species. The ambiguity that often accompanies acts of social omission is typically unsettling, and tends to disrupt both the individual targets 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 individuals
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 deliberately 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
ostracisms profound impact on the body andmind.
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
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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 individuals
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 individuals reaction of social ostracism to an individuals 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 minds experience of ostracism and the bodys experience of physical pain
to a central pain mechanism, which is visible on magnetic resonance imaging (MRI)
studies (Eisenberger and Lieberman, 2004; Wesslemann etal., 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 observers 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 etal. (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 teams 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
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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 Dewalls 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 dont 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
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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 thanmales?
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
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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), S84S97.
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), 931937.
Eisenberg, N., & Lieberman, M. (2004). Why rejection hurts:Acommon neural alarm system for physical and social pain. Trends in Cognitive Science, 8(7), 294300.
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., OReilly, 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. Womens HealthIssues, 24(5), 485502.
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,
391403.
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), 819831.
Vogt, D., Vaughn, R., Glickman, M.E., Schultz, M., Drainoni, M.L., Elwy, R., & Eisen, S. (2011). Gender
nationally representative sample of U.S. OEF/OIF veterans. Journal of Abnormal Psychology, 120(4),
797806.
Wesselmann, E., Williams, K., Hales, A. (2013). Vicarious ostracism. Frontiers of Human Neuroscience,
7,153.
Williams, K., & Jarvis, B. (2006). Cyberball:Aprogram for use in research on ostracism and interpersonal acceptance. Behavior Research Methods, Instruments, and Computers, 38, 174180.
Williams, K., & Nida, S. (2011). Ostracism:Consequences and coping. Current Directions in Psychological
Science, 20(2),71.
eigh t een
The Veterans Health Administration

Response toMilitary SexualTrauma
MARGRET E.BELL AND
SUSANJ.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. Akey
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 VAs authorization to include treatment not only of
mental health conditions secondary to a Veterans 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.
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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 20years 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 womans 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, shes felt jumpy
and on edge all the time, and chronically worries that shes 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 beating 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, Jonass 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 circumscribed his life. Finally, 10years following his discharge, his wife threatened to leave
18. Military SexualTrauma
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 willhe 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 persons 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 individuals 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
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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, etal.,2013).
VETER ANS HEALTH ADMINISTR ATION RESPONSE
Although MST has also been the subject of much attention from the Veterans
Benefits Administration (VBA), which administers VAs disability compensation
and other related benefits, in this chapter we focus on VAs 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 VHAs 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 shed 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 VHAs 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 ofMST.
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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 Veterans 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
VHAs MST-related policies more generally, which eliminate many potential barriers to accessing care. For example, all care related to a Veterans 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-relatedcare.
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
VHAs 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.
VHAs 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.
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Staff Education
In 2006, program responsibility for MST was transitioned from VHAs national
Womens 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 MSTrelated discussion forums.
Also prominent among VHAs 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 Veterans 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
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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 toCare
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.
VHAs 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 VHAs 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 VAs MST-related services to Service members leaving active duty and otherwise
ensure a seamless transition to VAcare.
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, aboutMST.
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
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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 experiencedMST.
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, 21602166.
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., etal. (2013). Military sexual trauma among homeless Veterans. Journal of General Internal Medicine, 28(Suppl 2), S536S541.
Nineteen
Compensation, Pension, and Other Benefits

for Women Veterans with Disabilities
JACQUELINE GARR ICK
INTRODUCTION
American women have stood alongside the nations 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 courageouswilling 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 SpanishAmerican War in 1901. However, there are a multitude of examples of womens 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 subsidence, sustenance, formal appointment, and pension. These benefits were outgrowths of
the attitudes that informed remuneration policies as women went from patriotic volunteerism, 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
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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 militarywomen.
Although not in uniform, 20,000 female patriots during the Revolutionary War
(17751783) provided their states 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 Armys 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 connected1 medical conditions.
1
S ervice 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 asmen.
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 veterans pension many years later, but only after a long bureaucratic
battle. Sally St. Clair also dressed in mens 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 noncommissioned 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
10years 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 Marys. 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
With the passage of the US Constitution.
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that was half that of the monthly allotment paid to soldiers plus a one time clothing
allowance3 (US Army Womens MuseumFt. 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
clothing allowance is still afforded to some service connected veterans whose disability causes wear
A
and tear on clothes, such as with prosthetic devices or skin creams from the Department of Veterans
Affairs and is paid annually.
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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 toduty.
Women who worked around and aboard ships also suffered injuries or drowned by
falling through hatches or between ships. Diseases, such as smallpox, measles, pneumonia, 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 workersusually from religious orders or a higher socioeconomic
classrefused 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
5
Hopkins, who had used her fortune to establish confederate hospitals, died in poverty.
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.
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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
workersgiving 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 Presidents Commission on Veterans 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 womens 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. Awitness statement is
still considered evidence by todays VA standards, and veterans are encouraged to find
former battle buddies or family members who can attest to their injuries and manifestation 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).
idows were also given a pension, so nurses were not allowed to double dip, and thus had to apply for
W
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.
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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 behaviorsmoking, 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 theArmy.
During the period after the Civil War, with so many Union veterans in Congress,
veterans 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 veterans pension. She remained undiscovered as Cashier until
aged and hospitalized in a veterans 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 veterans 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
Presidents Commission on Veterans 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 rankthey 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
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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 workmens 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 individuals 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 thehome.
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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 veterans
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 Womens 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 Womens Reserve, the Coast Guard Womens 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 Iwomen. 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
As of 2014, VA has 57 Veterans Benefits Administration Regional Offices.
A s 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 in1977.
7
8
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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 WAACsfor 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
soldiersalong 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 Womens 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 100,000significantly
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
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%. Acomplete 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 mildat0%.
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 Servicemens
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 10years, 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 counterpartsmaking 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
dutyand among them were 280,000 women. The US Armed Forces needed to downsize 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
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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 wars 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 thisday.
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 Presidents
Commission on Veterans Pension. Overall, the Commission found that [e]x isting 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 Presidents Commission on Veterans 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 Presidents Commission on Veterans 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
Presidents Commission on Veterans 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
ccording to the Veterans Disability Benefits Commission, there were 103,284 wounded warriors durA
ing the Korean Conflict.
11
DACOWITS continues to make policy and program recommendations to the DoD in2014.
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, werewomen.
10
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those of male Service members, including the opening of flag officer rankAna 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 tothem.
Mostly because of the Bradley Commissions 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 intermittentbasis.
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
communitythe 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
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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 womens 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
14
Public Law 102-585.

ST is a term used by the VA to describe a set of experiences. It is not a diagnosis contained in the
M
DSM, nor is it a criminal code under the justice system.
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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). Adiagnosis by a VA or other medical doctor is required as evidence for
a service-connected disability, which further impacts these womens ability to receive
VA compensation or access to other programs.
According to the VA as of 2013, there were almost 22million 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
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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 veterans 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
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. A10% 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 10years 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
W omen at W ar
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. Ajoint VA/DoD Disability Evaluation
System (DES) has been designed to expedite the process between medically discharging 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
arning capacity was calculated by taking the ratio of earned income and adding VA Service Connection
E
Compensation.
347
filing VA disability compensation claims and offer other social support. There are specialized programs that assist women veterans, such as the Service Womens 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 postRevolutionary 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 betterment. 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 ones 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
18
See www.deploymentpsych.org/military-culture.
Aformer Army helicopter pilot who lost both legs in Iraq in2004.
348
W omen at W ar
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 camelater.
REFERENCES
Ackerknecht, E. (1982). A Short History of Medicine. Baltimore:The Johns Hopkins UniversityPress.
Bellafaire, J. (2006). History highlights: Women veterans and the WWII GI Bill of Rights. Arlington,
VA:Women in Military Service for America Memorial Foundation.
Bellafair, J. (2009). The Womens Army Corps:Acommemoration of World War II service. Arlington, VA:US
Army Center of Military History.
Blankenship, N. (2008, March). Fighting for causes at home and abroad, 17751918. VFW Magazine
Special Publicaiton:Women at War From the Revolutionary War to the Present, pp.56.
Brooks, R. B. (2013, February 21). The History of Massachusetts. Retrieved November 30, 2014,
from The Role of Women in the Revolutionary War: http://historyofmassachusetts.org/
the-roles-of-women-in-the-revolutionary-war/
Carter, J. (2011, April). A phenomenological study of female military servicemembers adjustment to traumatic amputation. Retrieved from http://search.proquest.com/docview/755042696.
Christensen, E, J. M. (2007). Final report of the Veterans Disability Benefits Commission:Compensation,
survey results, and selected topics. Alexandria:CNA Corporation.
Veterans Administration. (1949). Claims information bulletin IB 8-25. Washington, DC: Veterans
Administration.
Department of Defense. (2014). U.S. Casualty Status. Arlington, VA:Department of Defense.
Department of Veterans Affairs. (2001). 2001 National Survey of Veterans. Washington, DC:Department
of Veterans Affairs.
Department of Veterans Affairs. (2006). VA history in brief. Washington, DC:Department of Veterans
Affairs.
Department of Veterans Affairs. (2011). Americas women veterans:Military service history and VA benefits
utilization. Washington, DC:Department of Veterans Affairs.
Department of Veterans Affairs. (2012, September). Disability compensation: Military sexual trauma.
Retrieved from www.benefits.va.gov/BENEFITS/factsheets/serviceconnectedMST.pdf.
Department of Veterans Affairs. (2013). Federal benefits for veterans, dependents, and survivors.
Washington, DC:Department of Veterans Affairs.
Evans, E. N. (2004). Out of the shadows: African American women and the military. Social Work
Today,26.
Ferguson, H. (2013, July 21). The roles women played in the War of 1812. Retrieved from http://umbrigade.
tripod.com/articles/women.html.
Fischer, H. (2013). U.S.military casualty statistics:Operation New Dawn, Operation Iraqi Freedom, and
Operation Eduring Freedom. Washington, DC:Congressional Research Service.
Flanagan, D. (1996, Summer). The heroine of Manmouth. Women in the Military a New Breed,p.13.
Frayne, S., K. S. (1999). Medical profile of women veterans administration outpatients who report a history of sexual assault occurring while in the military. Journal of Womens Health and Gender Based
Medicine, 835845.
Klein, R. (2005). Women veterans: Past, present and future. Washington, DC: Department of Veterans
Affairs.
Krowl, M.A. (2006). Women of the Civil War. Petaluma:Pomegranate Communications.
National Center for Veterans Analysis and Statistics. (2011). Americas women veterans:Military service
history and VA benefits utilization statistics. Washington, DC:Department of Veterans Affairs.
Resch, J. (1999). Suffering soldier:Revolutionary War veterans, moral sentiment and political culture in the
early republic. Amherst:University of MassachusettsPress.
349
Ridgeway, J.D. (2013). Recovering an institutional memory:The origins of the modern veterans benefits
system from 1914 to 1958. Veterans Law Review,155.
Schultz, J.E. (2004). Women at the front:Hospital workers in Civil War America. Chapel Hill:University
of North CarolinaPress.
Straubing, H. E. (1993). In Hospital and Camp: The Civil War Through the Eyes of Doctors and Nurses.
Mechanisburg:StackpoleBooks.
The Presidents Commission on Veterans Pensions. (1956). Veterans benefits in the United States:Areport
to the President. Washington, DC:The WhiteHouse.
United States Code Section 1720D. (n.d.).
US Army Womens MuseumFt. Lee, VA. (n.d.). Retrieved November 30, 2014, from Margaret Corbin
and Mary Ludwig Hayes McCauley:Revolutionary War (17751783):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 designatedpage

Abma, J.C.,86
abortion, 6364, 82, 83, 85, 124,251
acclimation to separation from families, 188190
administrative separations, 173174
Afghanistan
combat unit participation,135
female deployments,22
HSS CJOAA-A assessment,5051
IED dangers,345
limited female PTSD data,23
mefloquine antimalarial use,105
TBIs, 216, 218, 224,226
use of female combat medics, 137,142
AFHSC. See Armed Forces Health
SurveillanceCenter
Afifi, T.O.,248
Africa, xv, xxi,105
African Americans
combat medic role, 138,138
suicide attempts,246
2002-2011 deployment data,56
women service data,343
Agency for Healthcare Research and Quality
(AHRQ ),57
AirForce
breastfeeding provisions, 185,186
child-care separation provision,186
disability retirement study,173
electronic medical records,27
female population data,5
head injury rates, trends, 219,220

median length of deployments,8
post-childbirth deployment restriction,185
PTSD prevalence,26
sexual abuse data,282
Southwest Asia deployment data,7
suicide ideation data, 244, 254,256
2002-2011, casualties,9,10
2002-2011, deployment data,7
Women Air Force Service Pilots,337
Wounded Warrior program,171
Air Force Nurse Corps,339
Albright, T.S.,85,86
alcohol abuse/misuse, 4, 18, 24, 164, 167, 212,
229, 252, 268,277
Alzheimers disease, 227228
ambulatory care visits, post-deployment,14,15
amenorrhea (lack of menses), 57, 58, 59, 60, 61,
65, 86,338
American College of Obstetricians and
Gynecologists, 63,8788
American Congress of Rehabilitation
Medicine,230
American Indian/Alaskan Natives, suicide
rates,245
American Legion,346
American Psychiatric Association,xvii
amyotrophic lateral sclerosis (ALS), 227228
anemia, hemolytic,100
Anopheles mosquito,93,97
351
352
Index
Answer the Call campaign (MST Support

Team),328
antibiotics, 54, 128129
antidepressant medication, 104, 227,303
antimalarial medications
adherence issues, 105,110
adverse effects/contraindications, 54, 100101,
102103, 108110
atovaquone/proguanil, 102, 104, 105, 107108
chloroquine, 9899, 100101, 104, 105,
106t,107
development, testing issues,9899
gender-based reaction differences,9394
mefloquine, 85, 94, 98, 99, 101105, 102104,
106, 107109
neuropsychiatric reactions, 94, 102103,
106,108
pharmacokinetic/pharmacologic effects,94
policy limitations, usage considerations,106
primaquine, 100, 104105, 106,107
selection considerations, 104110
anxiety disorder, 18, 224, 251,303
Araneta, M.R. G.,8283
ARFORGEN (Army Force Generation) process,
158159
Armed Forces Health Surveillance Center
(AFHSC),3
analysis limitations,1819
birth defects, retrospective cohort
study,8384
management of DMSS,4
pregnancy hospitalization data,81
PTSD post-deployment survey,29
TBI incidence review,218
2009, mental health analysis,18
2010, mental health analysis,1718
Army
child-care separation without pay
provision,185
Civil War Union nurses,135
combat exposure training,3132
combat medics, 136138
counterinsurgency doctrine, 159160
educational benefits, classes and
workshops,168
embedded behavioral health providers,162
female population data,5,22
hospitalization/long-term care benefits,336
IPV data,283
Law of Land Warfare (FM 27-10),160
malaria cases,95,96
medical evacuations,30
mosquito avoidance strategy,9798
non-hostile deaths,9
Office of Army Nurses,332
PDHRA program, 26, 27, 2930, 164165
pregnancies during Gulf War,86
psychological health assessments,313
PTSD data, 24, 26, 27,29,30
Southwest Asia deployment,7
TBI data, 17, 218, 219, 220,230
2002-2011, casualties, 9,10,10
uniform sizing system,6465
UTI data,52
Warrior Transition Unit,171
Womens Army Auxiliary Corps, 337338
Womens Army Corps,338
Army Knowledge Online (AKO), 186,198
Army Nurse Corps (ANC), 95, 135, 162,335
Army Nurses Pension Act (1892),334
Army Patient Administration Systems and
Biostatistics Agency (PASBA),57
asymmetric warfare and counterinsurgency,
159161
atovaquone/proguanil (antimalarial
combination), 102, 104, 105, 106, 107108
atrial flutter,101
austere environments
bathroom issues, 50, 51,53,55
common conditions,67
constant threat of engagement,49
contraception issues,61,67
identified barriers and gaps,6870
menses management concerns, xix, 51,56,65
pre-deployment preparation, 19, 64,197
urogenital hygiene concerns,65
water deprivation concerns,53
Australia,3444
domestic violencein,36
gender-related cultural issues,3436
history of women in wars,34
untold narratives of women in war,4243
Australian Army Nursing Service,43
Australian Defence Force Academy (ADFA),36
Australian Defence Forces(ADF)
access to services challenges,4142
combat-related deaths, injuries,38
Index
DVA, post-discharge study,3940

gender diversity strategies,37
gender-specific health challenges,
3839,4041
growing occupational challenges,39,41
growth of womens contributions,3940
reluctance to take pioneer roles,44
sex discrimination in,3638
Australian Human Rights Commission,
3637,37,41
Australian Vietnam Veteran Female Cohort,
health outcomes study,39
Australian War Memorial exhibition,43
Authorized Medical Allowance Lists (AMAL, for
ships), 124,125
Authorized Medical Allowance Lists (for
submarines),124
aviation training,121
avoidant personality disorder,253
Baca-Garcia, E.,247
bacterial vaginosis,56
ballistic missile submarines,123
basic training, xvii, 180,282
bathrooms
absence of,xix
in austere environments, 50, 51,53,55
hygienic concerns, xix,52
segregated arrangements, 305306
battering, 266, 275. See also intimate partner
violence
Battle of Manmouth,331
Bay, E.,223
BCTs. See Brigade CombatTeams
Beautrais, A.,258
behavioral health providers (clinicians)
breastfeeding resources for,186
contraception discussions,149
embedding of, 162, 168169, 174,256
malaria prevention role, 108,110
preparation for deploying mothers, 181185,
186, 188,193
sexuality guidance, 148,152
suicide-related recommendations for, 255259
therapeutic tools for,193
Women in Combat Symposium,xvii
Behavioral Risk Factor Surveillance Survey
(CDC),270
benefits programs. See disability and pension
programs
Biggs, R.L.,80
birth defects, deployment-related,8185
353
blast-induced TBI, 212213, 216217

Blueprint for Action on Breastfeeding (HHS),66
Boer War,38
borderline personality disorder (BPD),253
Boyle, B.H.,80
Bradley, Omar,340
Bradley Commission, 340341
brainstem neurotoxicity, of primaquine,100
Bray, R.M.,250
breastfeeding provisions, xix, 185, 186187
Brigade Combat Teams (BCTs), 2627, 28, 136,
161162,174
Broderick, Elizabeth,36
Broshek, D.K.,223
Bukowinski, A.T.,84
Bullwinkel, Vivian,43
Bureau of War Risk Insurance,336
burn pit exposure, birth defect studies,8485
Call to Action (US Surgeon General),66
Camp Pendleton, California,197
Camp Taji, Iraq burn pit site,84
Campbell, Jacquelyn,279
Caralis, P.V.,288
Carter, Jimmy,122
Cashier, Albert, 335. See also Hodgers, Jeannie
Cazares, Paulette T., 126132
Center for Deployment Psychology,347
Centers for Disease Control and Prevention
(CDC),52
Behavioral Risk Factor Surveillance
Survey,270
birth defect monitoring program,82
injury-/violence-related statistics, 244245
intimate partner violence data,268
traumatic brain injury data, 211212
cerebral infarct,217
cervicitis,338
Chandra,A.,86
Chantelois, J.L.,85
Chaplain corps, 121,185
Chapple, Phoebe,42
child loss, and suicide ideation,251
child-care issues, 167, 185188,204
children of mothers whodeploy
books for,183
clinician role in preparation, 181185
conflict/guilt of mothers, xxi, 167,180
family activities for, 184185
family care plans, 187188, 192,198
feelings of pride for mother,189
guilt of mothers, xxi,167
354
Index
children of mothers whodeploy (Cont.)

health/well-being concerns,41
very young children, 185187
childrens books about deploying mothers,
183,184
chlamydia,87
chloroquine (antimalarial), 9899, 100101, 104,
105, 106,107
chloroquine-resistant malaria,105
Chung-Park, M.S.,81
CivilWar
female nurses, 135, 332, 333,335
impact of female service,334
MST during,343
support services,332
Union troops disability benefits,336
women enlistments as men,334
CJOA-A. See Combined Joint Operations
Area-Afghanistan
Clinical Classification System (CCS) Diagnostic
Categories (AHRQ ),57
clinicians. See behavioral health providers
(clinicians)
closed-head injuries,216
Cluster B personality disorders,253
Cluster C personality disorders,253
CNA Corporation, disability study, 345346
COAD (Continue on Active Duty),171
CoastGuard
PTSD prevalence,26
Soutwest Asia deployment,7
2002-2011, casualties,9,10
Coast Guard Womens Reserve,337
cognitive framing techniques,193
colorectal cancer,59
Columbia Suicide Severity Rating Scale
(C-SSRS),256
Combat Exclusion Law,123
Combat Experiences Scale (CES, DRRI),139
Combat Information Center (CIC),129
combat logistics support ships,122
combat medics, 134145. See also US Army
Combat Medics, longitudinalstudy
Army Nurse Corps, 95, 135, 162,335
behavioral health practice implications,
144145
Navy Nurse Corps, 121,335

Revolutionary/Civil Wars,135
roles of,136
World War II,135
Combat Support Hospitals (Iraq),52,54
Combined Joint Operations Area-Afghanistan
(CJOA-A),5051
Coming Together Around Families (toolkit for
families),183
communication
couples overexposure issues,200
dysfunctional behaviors,161
with family during deployment, 184, 198,200
guidelines for effectiveness, 303304
intimate partner violence issues,276
ostracism of a team member,316
pre-deployment challenges, 197, 198, 202,206
reunion preparation and rules, 200201,
204208
role of embedded behavioral health
providers,162
compensation programs. See disability and
pension programs
Computer/Electronic Accommodations Program
(CAP),346
concussions, 217, 223, 226,229
confidentiality, distrustin,68
Congressional Black Caucus,343
Conlin, A.M.S.,84
consensual sex in the warzone
coercive sex vs., xx,152
contraception issues, 58,149
as counseling point,65
Danish/British strategies,152
lifting of ban, xix,148
Consolidation Act (1873),333
Continental Army, 159, 330331
Contingency Operating Base (COB) Speicher,
Iraq burn pit site,8384
contraception/contraceptiveuse
austere environment concerns,67
availability variability,xx
copper intrauterine device,64
counseling points for servicewomen,65
estrogen/progestin,59
goals for hormonal contraception,58
limited predeployment counseling,149
long-acting reversible contraceptives,64,88
oral contraceptive pills, 58, 5960,79
Plan B, emergency contraception, 126,148
progestin-only implant,58,62
progestin-only injection, 58,6162
Index
progestin-only pill,61
progestin-releasing intrauterine system,
6263,64
related genitourinary issues,54
transdermal patch,58,60
2006-2012 data,57
vaginal ring,60,61
counterinsurgency (COIN) doctrine, 159160
Covassin, T.,223
Crisan, L.S.,86
Crompvoets, S.,4042
cultural considerations for women veterans,
304305
Currier, M.M.,81
cyberbullying,36
cytochrome P450 enzyme pathways,100
DACOWITS. See Defense Advisory Committee
on Women in the Services
Danger Assessment Scale (DAD),279
Daughters of the American Revolution,135
De Vries, Susanna,43
DEET, topical insect repellant,97,98
Defense Advisory Committee on Women in the
Services (DACOWITS), 123, 212,340
Defense Authorization Act (FY 2015),60
Defense Casualty Analysis System (DCAS),4
Defense Enrollment Eligibility Reporting System
(DEERS),82
Defense Health Activity,xvii
Defense Logistics Agency,69
Defense Manpower Data Center (DMDC), 34,
29, 82,83,84
Defense Medical Epidemiology Database
(DMED), 218219
Defense Medical Surveillance System (DMSS),4
Defense Womens Health Research Program
(DWHRP), xvii,49
goals of,230
Defensive Manpower Data Center (DMDC),34
demographic profile of the active force, 1991 to
the present
combat casualties, by type,9,10
healthcare while deployed,1011
median lengths, by service, gender,8
occupational categories,8
officers/enlisted personnel, active duty,6
racial composition, male vs. female,56
2002-2011, by gender,7
2002-2011, medical evacuations, Southwest
Asia, 11,1112
2002-2011, Southwest Asia,6,7
355
Department of Defense(DoD)
abortion restriction rule,6364
antimalarial prophylaxis guidelines,106t
combat-related gender-based rules,212
Computer/Electronic Accommodations
Program,346
Family Advocacy Program, 267,269
Health Related Behaviors Survey, 63, 243,247
Infant Health Registry,84
IPV data,269
mental health assessments,313
sexual assault data,64
sexual harassment policy,249
suicide data for military women, 245246
suicide prevention efforts, 258259
TBI definition, 214215
TBI tracking, xvixvii,213
use of electronic medical records,27
wounded, ill, injured (WII) data,344
Department of Veterans Affairs (DVA,
Australia),3940
deployment preparation for mothers, 181185
Deployment Risk and Resilience Inventory
(DDRI),314
Depo-Provera (progestin-only injection),6162
depression
antimalarial side effect, 103,104
Australian servicewomen, 38,39,41
behavioral issues from,172
combat-related risk,136
domestic violence and,24
eating disorders and,252
IPV and, 274, 275, 278,279
MHAT survey data, 28,28t
mothers who deploy and, 167,191
PHQ-0 assessment,136
post-concussion syndrome and,226
postpartum depression, 251,256
PTSD comorbidity, 18, 224,247
severity assessment, 143144,164
SSG Perry, example,157
substance abuse and,252
suicide ideation and, 244, 247, 249, 250, 251,
253, 254,279
TBI association, 212, 213, 215, 217, 223, 227,
229,284
wartime commonality,xxi
women veterans, 302, 303,304
Desmond, Tahana Marie,183
Dewall, C.,317
Diagnostic and Statistical Manual of Mental
Disorders (DSM), xxi, 23, 28,351
356
Index
diapers,53
Dick, R.W.,223
digestive system disorders, 10, 11, 13, 14, 215,
288,344
Direct Combat Exclusion Rule, 143,212
disability and pension programs, 329348
Army Nurses Pension Act,334
Bradley Commission report, 340341
Civil War, womens service, 332333, 332335
evaluation system, 172173
GI Bill, 193, 339, 341,345
McCauley, Mary, example,331
MST compensation, treatment expansion,
342343,344
1923, hospitalization, long-term care
benefits,336
PTSD treatment expansion, 342,344
Public Law 877 (1945),339
Revolutionary War Pension Act,330
Sampson, Deborah, example, 330331
Servicemens Readjustment Act,339
St. Clair, Sally, example,331
Transition Assistance Programs,346
VA/DoD Disability Evaluation System,346
VASRD rating schedule, 336337, 340,
341,344
VR&E programs,345
War Risk Insurance Acts,336
Disabled American Veterans,346
divorce, 148, 164, 188, 196, 248, 273, 278,282
Dix, Dorothea, 332,347
DMSS. See Defense Medical SurveillanceSystem
Dobie, D.J.,25
DoD Military Equal Opportunity (MEO)
Program,249
DoD Suicide Event Report (DoDSER),
245246,259
DoD Suicide Prevention Office (DSPO),245
domestic abuse. See intimate partner violence
domestic assault. See intimate partner violence
domestic violence. See intimate partner violence
Douglas, B.H.,80
doxycycline (antimalarial)
contraindications, 54, 94, 101102
military sponsored trials,99
usage considerations,106
DRRI. See Deployment Risk and Resilience
Inventory
drug use/abuse, 215, 244, 246, 247,252
Duckworth, Tammy, 347348
Dunlop, Sir Edward Weary,42
DVA. See Department of Veterans Affairs

(DVA, Australia)
dysentery, xxi, 38,330
dysfunctional group behaviors, 161,172
dysmenorrhea, 5657,58
eating disorders, 169170, 252253,303
Economic Validation of the Rating Schedule
(ECVARS, VA study),341
ectopic pregnancies, xixxx, 50, 8687, 124,147
Edick, Kathleen,183
Edmonds, Sarah (aka Franklin Thompson),335
electronic medical records
limited sharing ability,xvi
malaria case review,95
monitoring of, 172173
simplicity of searches,27
under-reporting issues,52
embarrassment, 68, 152,271
embedding of behavioral health providers, 162,
168169, 174,256
emergency contraception (EC), 125, 126,148
endometrial cancer,59
endometriosis,59
Enewold,L.,79
epidemiology
of contraceptive use,7981
Defense Medical Epidemiology Database,
218219
of malaria in military women, 9497,96
of unintended pregnancy,7981
estrogen/progestin, hormonal
contraception,59,60
Ethinyl estradiol (low-dose estrogen),59
Evans, Carol Vaughan,42
Evans, Estella Norwood,343
Family Advocacy Program (FAP), 267,269
Farin, A.,221
FBI, Supplementary Homicide Report,267
female endogenous hormones and TBI, 225226
female improved outer tactical vest (FIOTV),65
female prisoners of war (POW), 3839,338
female provider preference,68
Female Urinary Diversion Device (FUDD),
5255, 53,56,69
Ferguson-Cohen, Michelle,183
fertility, post-deployment,41
Finer,L.,80
First Pennsylvania Artillery,331
1st Force Support Group (FSG),197
Index
357
1st Marine Logistics Group (MLG),197

Fleming, B., 160161
fluid intake, withholdingof,53
Fontana,A.,24
forward operating bases (FOBs),22
functional magnetic resonance imaging (fMRI)
studies,318
Hourani, L., 82,250

Howard, Michelle,123
HSS. See Health Service Support
human sexuality. See sexuality in areas of
operation
Hussein, Saddam,3
hypertension, 171, 221, 284, 343,345
Gan, B.K.,221
gear, protective, urination difficulties,52
Gender and War:How the War System Shapes
Gender and Vice Versa (Goldstein),152
gender-integrated submarines,123
General Medical Officer (GMO),127
Generation X women,179
genital infections,87
genitourinary conditions. See
urogynecologicissues
Gerberich, S.G., 222223
GI Bill, 193, 339, 341,345
Gillibrand, Kirsten,147
Global War on Terror, xv, 159,197
glucose-6-phosphate dehydrogenase (G6PD)
deficiency,100
Goldstein, Jonathan,152
Goyal,V.,79
guided missile submarines,123
guidelines for effective communication, 303304
Gutierrez, P.M.,254
gynecological issues. See urogynecologicissues
IDCs. See independent duty corpsmen

ill-defined disorders, 2002-2011 data, 11,1112
Implanon (progestin-only implant),62
improvised explosive devices (IEDs), 9, 1617,
22,345
incontinence/incontinence pads,40,54
independent duty corpsmen (IDCs),124
Infant Health Registry (DoD),84
infectious diseases,xxi
injury-/violence-related statistics (CDC), 244245
insecticide risk factors,97,98
Institute of Medicine (IOM),50
Integrated Disability Evaluation System
(IDES),172
International Classification of Diseases,
9th revision, Clinical Modification
(ICD-9-CM),10,19
intimate partner violence (IPV), 24, 266292
in Australia,36
barriers for victims, 42,268
causes,164
with coercive control,275
contextual analysis, 274278
co-occurring problems, 285287
Danger Assessment Scale,279
FAP report data, 269,274
Jennifer, victim example, 272273
Mary, victim example,272
mental illness and, 277278
military sexual trauma and, 268270, 278,
280283, 285286, 288,291
myths/facts about, 267268
NISVS study findings, 269270
previous terminology, 266267
psychological risk factors,254
PTSD association, 268, 277, 279,286
resistive violence,276
risk assessments, 279280
risk factors, 278279
safety planning,281
situational IPV,276
statistics, 268270
substance abuse and, 268, 277279, 281282,
286287
Hall, E.D.,223
Hankin, S.S.,24
Hanna, J.H.,8586
Hawaii Birth Defects Program (HBDP),8282
Hays, Ana Mae,340
Health People 2020 (HHS),66,81
Health Related Behaviors Survey of Active Duty
Military Personnel (DoD), 63, 243,247
Health Service Support (HSS), 5051,53,66
heart disease,171
hemolytic anemia,100
Heroic Australian Women at War (De Vries),43
Hilton,S.,82
Hines, J.F.,85
Hodgers, Jeannie (aka Albert Cashier),335
Hoge, C.W.,166
Home Again (Silver Williams),182
homelessness,xxi
hormonal contraceptives, 58,5859
hospital ships,135
hostile deaths, 2002-2011 data,9,10
358
Index
intimate partner violence (IPV) (cont.)

suicide ideation and, 248, 267, 274, 278,
279,284
TBI and, 278,279
trauma and, 271, 279, 281285
trauma-informed care for, 290291
VA data, 288289,291
victim behavior, 271274
women veterans and, 270, 284, 286,
287289,291
women vs. men, 229,268
intracranial injury, 214t, 218,219
Invisible Wounds of War-Psychological and
Cognitive Injuries, Their Consequences,
and Services to Assist Recovery study
(RAND),284
Iraq
burn pit site survey,8384
Combat Support Hospitals,52,54
combat unit participation,135
female deployments,22
GMOs in,127
gynecological issues data, 57, 148149
IED dangers,345
limited female PTSD data,23
mefloquine antimalarial use,105
MHAT surveys, 28, 313314
TBIs, 216, 218, 224,226
UTI incident data,52
Iraq and Afghanistan Veterans of America,346
Iskra, Darlene,122
Israeli Defence Force, study of disabled
veterans,173
Jarvis, B., 316317
jelly bean jar,184
Jensen-Fritz, Sara,183
Joint Base Balad (JBB), Iraq burn pit site,83
Jones-Johnson, Paula,183
journaling by families,185
Kang, H.,25,83
Keep, L.W.,85
Kelso, Frank,122
Kessler, R.C.,23
killed in action(KIA)
2002-2011 data, 9,9,10
2013 data,xxi
King, Olive,43
Kirkness, C.J.,221
Korean War, 24, 95, 104, 135, 340,343
Kraft, Heidi,182
Krakow, B.,251
Kraus, J.,220
Kuwait, MHAT II surveys,28
lactation, xix,6566
latrines. See bathrooms
Law of Land Warfare (US Army FM 27-10),160
LBQT (lesbian, bisexual, queer, transgender),
42,280
LeardMann, C.A.,26,31
Leitgeb, 236,222
letter-writing,185
levonorgestrel contraceptive devices, 58,
59,6263
Libby, R.,152
Lindberg, L.D.,79,80
logistics units,22
long-acting reversible contraceptives
(LARCs),64,88
Love, Lizzie:Letters to a Military Mom
(Tucker McElroy),183
Love Spots (Panier),183
Lowe, N.K.,68
Lybrel (oral contraceptive),59
Mackerras, Josephine (Mabel),42
magnetic resonance imaging (MRI) studies,
317318
malaria, 93110. See also antimalarial
medications
Africa/Southeast Asia risk factor,xxi
Anopheles contact risks, 93,9798
antimalarial development, testing
issues,9899
chloroquine-resistant malaria,105
history/epidemiology,9497
insecticide risk factors,97,98
mosquito avoidance strategy, 93,9798
predeployment counseling,94
2000-2012, case summaries,96
wartime assistance of women,135
WW II, Army Malaria Research Unit,42
malnutrition, 38,338
Mammas Boots (Miller Linhart),183
Manual for the Deployment Risk and Resilience
Inventory (DRRI):ACollection of Measures
for Studying Deployment-Related Experiences
of Military Veterans, 138, 139, 141, 142,
143,314
MarineCorps
breastfeeding provisions,185
Index

female overseas deployment data,343
proportion of women,5
psychological health assessments,313
PTSD data,26,27
sexual harassment risk factors,285
TBI data,17
2002-2011, casualties,9,10
women Reserves unit,335
Marine Corps Womens Reserve,337
Martinez, G.M.,86
masturbation,149
McBride, Sharron G.,183
McCaskill, Claire,147
McCauley, Mary Ludwig Hays,331
McCauley, William,331
McGee, Anita Newcomb,135
MEDEVAC process on ships, 124,129
medical care on ships, 123126
Cazares clinical pearls, 131132
Cazares personal experience, 126131
NSMRL report,124
osteoporosis risk factors,125
PDHA Form modifications,126
pharmacy/formulary requirements, 125,131
pregnancy concerns, 124,125
medical evacuations
for behavioral health issues,26,30
categories, 11,1112
for malaria, 94,110
for pregnancy, xixxx, 58, 8586,147
tracking of data,27,30
Medical Evaluation Board, 157, 171,172
Medical Implications of Women on Submarines
(NSMRL),124
medical outcomes from TBI, 220222
medical separations, 172173
Medical Surveillance Monthly Report (MSMR),10
mefloquine (antimalarial), 85, 94, 98, 99,
101105, 106, 107109
memory box,184
menopause/perimenopause, 303, 338,345
menstruation/menstrual disorders,5658
amenorrhea, 57, 58, 59, 60, 61, 65, 86,338
austere environment management, xix,41,57
counseling points for servicewomen,65
359
cycle regulation choices,58

dysmenorrhea,5657
irregularities, management,40,50
limited predeployment counseling,57
lost duty days,57
menorrhagia,58
2006-2012 data,57
mental health, 311320
behavioral risk factors, 165166,167
challenges for women,41
combat-related sexuality issues,149
DDRI assessment,314
impact of sexual assault,xx
IPV and, 271, 274, 278280, 283287,292
medical evacuations due to,12,30
mothers in war issues, 178, 181, 183,191
MST, outpatient services,324
ostracism issues, 315319
phone support services,168
service-related studies, 311315
stigmas/barriers to seeking help, 141,144t
suicide ideation and, 249250, 253, 257259
TBI and, 218,224
2002-2011 data, 11,11,12
2010 MSMR analysis,1719
VA facilities diagnoses,25
women veterans issues, 302303
Mental Health Advisory Teams
(MHATs)
behavioral risk factors guidelines,165
combat experiences studies, 139,141
combat troops focus,xviii
mental health assessments, 313314
PTSD findings, xxxxi, 2628,28
Mental Health Services (MHS) program,326
metritis,338
mild TBI (mTBI), 212217, 220223, 226227
Military Crisis Lines (800 number),257
Military Health System(MHS)
admissions data, active component
women,15
funding of MST Support Team,326
lethal injury preparedness,71
OCPs use comparison,79
ongoing research, preparation, 50, 6667,71
post-deployment encounters data,13,14
VA comparison, xvi,50
Military Medicine journal,xvii
Military OneSource (website), 178179, 180,
183,185
military police,22
360
Index
military sexual trauma(MST)

Answer the Call campaign,328
in Brigade Combat Teams,161
career impact,249
compensation, treatment expansion, 342343
definition,323
epidemic levels,147
IPV and, 268270, 278, 280283, 285286,
288,291
Kirsten, example, 322323
mental health consequences, xx,xxi
MHS program educational initiative, 326327
National Comorbidity survey findings,2324
Naval fleet-wide training,122
outpatient mental health services for,324
outreach to veterans, 327328
Persian Gulf War data,2425
in POW camps,3839
as PTSD risk factor, 2425,26
risk factors for post-deployment,174
self-reporting data,24
staff education programs, 326327
suicide ideation and,247
treatment services expansion,342
2010 Gender Relations Survey,64
under-reportingof,19
VA data,285
VA response to, 321328
veterans access to care for, 327328
veterans screening programs, 323325
Military Youth Coping With Separation:When a
Family Member Deploys (DVD),182
Millennium Cohort Study findings
eating disorders,170
mothers who deploy,167
oversampling of females,31
PTSD, 23, 2526,167
sexual assaults,285
Millennium Study (2014),xviii
Miller Linhart, Sandra,183
minocycline,99
Mirena IUS (intrauterine system),6263
Mommy, Youre My Hero (Ferguson-Cohen),
183
mommy doll,184
mood disorders. See anxiety disorder; depression;
panic disorders; suicide-related ideation and
behaviors
Moore, D.W.,223
morale and leadership, 161163
Morrison, David,3738
Mosher, W.D.,86
mosquito avoidance strategy, for malaria,

93,9798
mothers in war, 167168, 178194
acclimation to separation, 188190
benefits to area of operations, 189192
benefits to mothers, post-deployment,192
challenges in deployment,190
child-care issues, 167, 185188,204
clinician assessment questions,184
conflict/guilt in leaving children, xxi, 167,180
materials for clinicians, 182183
new moms with very young children, 185187
ongoing wellness screening, 183184
predeployment, family activities, 184185
predeployment, preparations, 181185,188
self-concept issues, 191192
social context, 179181
weighing costs vs. benefits, 192193
mothers who deploy, 167168
Mr. Poe and Friend Discuss Family Reunion After
Deployment (aminated cartoon),182
MST Resource Homepage (VA),326
MST. See military sexualtrauma
Murdoch,M.,24
musculoskeletal system disorders, 11, 11,
15,40,67
Mushkudiani, N.A.,222
Musialowski, R.,288
My Mommy Wears Combat Boots (McBride),183
National Center for PTSD (Department of
Veterans Affairs),139
National Comorbidity Survey,2324
National Guard and Reserves
ARFORGEN process applicability to,8384
counseling services eligibility,342
GI Bill eligibility,341
healthcare eligibility,1819
IPV data, 268269
Millennium Cohort study sampling,31
psychological health assessment, 314315
release from duty assessment,171
reproductive health survey inclusion,8384
traumatic stress/depression data, 164165,166
VA services eligibility,346
National Health and Nutrition Examination
Survey (NHANES),79
National Intimate Partner and Sexual Violence
Survey (NISVS), 268, 269270
National Resource Directory,346
National Survey of Veterans (2001),343
Index
National Trauma Database,221

National Vietnam Veterans Readjustment Study
(NVVRS),341
NATO treatment facilities,190
Naval History and Heritage Command,121
Naval Submarine Medical Research Laboratory
(NSMRL),124
Navy
birth control data,80
female service on ships, 121132
history of malaria study,95
IPV data,283
postpartum deployment deferment,66
pregnancy outcomes evaluation,82
preparations for deployment,197
PTSD data,26,27
reunion preparations, 197198,209
2002-2011, casualties,9,10
women Reserves unit,335
Navy and Marine Corps Public Health Center
(NMCPHC),198
Navy Knowledge Online (NKO),198
Navy Nurse Corps (NNC), 121,335
The Navy Times,132
Neuhaus, S.,4042
neurobehavioral outcomes from TBI, 222225
neurocognitive rehabilitation,227
neurodegenerative disease and TBI, 227228
neuropsychiatric reactions, to antimalarials, 94,
102103, 106,108
New Jersey National Guard Unit,166
Nexplanon (progestin-only implant),62
Nichol, K.L.,24
Nida, S.,317
Nielson, P.E.,52,57
nightmares, 29, 103, 108, 251,283
9/11 terrorist attack, xv,xvii
non-battle injuries, 2002-2011 data, 11,11,12
non-blast TBI,217
non-Hispanic Whites, suicide rates,245
non-hostile deaths, 4,9,10
NSMRL. See Naval Submarine Medical Research
Laboratory
361
NurseCorps
Army Nurse Corps, 95, 135, 162,335
Navy Nurse Corps, 121,335
Nurses:from Zululand to Afghanistan
(Australian War Memorial exhibition),43
NuvaRing (vaginal ring),61
OBoyle, A.H.,80
Office of Army Nurses,332
oophoritis,338
Operation Anode (Solomon Islands),39
Operation Astute (East Timor),39
Operation Desert Shield (1990-1991),5
Operation Desert Storm (1991),5,22
Operation Enduring Freedom(OEF)
female combat levels,250
female death data,283
female deployment data, 6, 22, 191,196
female genitourinary encounters,67
female support data,191
health profile, military women,919
mental health assessments, 313,315
MHAT VI survey findings,28
post-deployment Warrior Transition Units,
171172
PTSD risk factors, 25, 28, 30,303
total female deployment data,344
2002-2011, KIA/WIA data, 9,9,10
2002-2011 medical evacuation data,11,12
2009, MSMR post-deployment study,18
use of female combat medics,137
Operation Iraqi Freedom (OIF), ix,xv,3
female combat levels,250
female death data,283
female deployment data, 6, 22, 191,196
female genitourinary encounters,67
female support data,191
health profile, military women,919
mental health assessments, 313,315
MHAT II survey findings,28
171172
PTSD risk factors, 25, 28, 30,303
transdermal contraceptive patch issues,60
2002-2011, KIA/WIA data, 9,9,10
2002-2011 medical evacuation data,11
2009, MSMR post-deployment study,18
urinary tract infections data,67
Operation Joint Endeavor (Bosnia, 1995),5
Operation Just Cause (Panama),5
362
Index
Operation KFOR (Kosovo, 1998),5

Operation New Dawn (OND),ix,xv
171172
2002-2011, KIA/WIA data, 9,9,10
2002-2011 deployment data,6
2002-2011 medical evacuation data,11,12
Operation Restore Hope (Somalia, 1992-1993),
5, 95,105
Operation Slipper (Middle East Area of
Operations),39
Operation Uphold Democracy (Haiti,
19941995),5
oral contraceptive pills (OCPs), 58, 5960,79
oral disorders,10
Ortho-Evra (transdermal contraceptive
patch),60
osteoporosis, 59,125
ostracism issues, 315319
Ottochian, M.,221
ovary-related health issues, 59, 338339
Over There (Silver Williams),182
Over There book (Silver Williams),182
Over There MP3 recording (Kraft),182
pain, physical, 317318
pain, social, 317319
Panetta, Leon,212
panic disorders, 247, 251,303
Panier, Karen,183
Parkinsons disease, 225, 227228
PART (practice of universal presumptive
antirelapse treatment), 104,105
Paterson, Diane,183
Patient Administration Systems and Biostatistics
Agency (PASBA, Army),57
Patient Health Questionnaire (PHQ-9),139
Patient Protection and Affordable Care Act,66
pelvic floor instability,40
pelvic inflammatory disease (PID),59,87
Penman, A.D.,81
pension programs. See disability and pension
programs
perimenopause,303
Permanent Change of Station (PCS) orders, 162,
170,244
permethrin,97
Persian Gulf War (1990-1991),xv
abnormal pap results,xx
birth defects among veterans, 81,8283
female deployment data,5
onset of combat unit participation,135

pregnancy data,78
PTSD data,24
sexual harassment rates, consequences,2425
unintended pregnancy data,58,85
womens leadership on ships,123
persistent post-concussion syndrome (PPCS),
226227
personality disorders, 18, 173, 253,278
PHQ-9. See Patient Health Questionnaire
physical sexual harassment,2425
physical standards, challenges for women,40
physiological training, challenges for women,40
Plan B emergency contraception,126
point-of-care (POC) testing kit,69
polytraumatic injuries, 216, 224225, 226227,
229,231
Ponsford, J.,221
pornography,36
port-a-potties. See bathrooms
Post Deployment Health Assessment (PDHA),
26, 27, 2930, 126, 164165
Post-Battle Experiences Scale (DRRI), 139,141
post-concussion syndrome (PCS), 226227
post-deployment health issues
(20022011),1219
ambulatory visits, one-year,14,15
hospitalizations, one-year,13
inpatient care,15
mental health,1719
reproductive health/birth rates, 1516,17
traumatic brain injury,1617
Post-Deployment Health Re-Assessment
(PDHRA), 26, 27, 2930, 164165
postpartum depression,251
posttraumatic stress disorder (PTSD),2232
associated mental/physical health issues,25
Australian servicewomen,38
behavioral health evacuations,30
combat-related association, xxxxi,167
eating disorder association,170
female vs. male prevalence, 2324,25
findings on existing data,2627
IPV association, 268, 277, 279,286
MHAT findings, xxxxi, 2628,28
Millennium Cohort study findings, 23,2526
MSMR, 2009 analysis,18
National Comorbidity survey findings,2324
nightmare symptom,251
PDHA/PDHRA surveys, finding,2930
post-deployment, male vs. female surveys,
29,2930
Index
post-deployment screening,173
PTSD CheckList (PCL),139
as risk factor from sexual assault,2425
sexual assault and,xx
suicide-ideation association, 247, 249,251
symptom severity scores, 143144
TBI comorbidity, 212,227
Vietnam War data, 341342
practice of universal presumptive antirelapse
treatment (PART),104
Pre-Deployment Health Assessment (PDHA),126
Pre-Deployment Health Re-Assessment
(PDHRA),126
pregnancy. See also contraception/contraceptive use;
reproductive health; unintended pregnancy
antidepressant risk factors,303
chloroquine risk factors,101
contraception prevention choices,58
deployment and birth defects,8185
ectopic pregnancies, xixxx, 50, 8687,
124,147
IPV during,279
medical evacuations for, xixxx, 58, 8586,147
mefloquine risk factors,85
post-deployment data,15,17
postpartum deployment recommendation,175
PTSD and,303
submarine service concerns, 124,125
suicide ideation and,251
women veterans issues,303
preparation/prevention for success,5051
Presidents Commission on Veterans Pension
(1956),334
prisoners of war (POW). See female
prisonersofwar
progestin-only implant,62
progestin-only injections (depot
medroxyprogesterone acetate),6162
progestin-only pills,61
progestin-releasing intrauterine system (IUS),
6263,64
protective factors against suicide-related
ideation,255
Psychiatric Annals journal,xviii
PTSD CheckList (PCL),139
Public Law 877 (1945),339
Purple Heart awards,338
pyrethroid insecticide,9798
race-based suicide statistics,245
RAND Center for Military Health Policy
Research,284
363
rape, 58, 6364, 65, 170, 267, 268,285

reading program for children,185
Real Warriors Campaign,198
Recommendations for Research on the Health of
Military Women (IOM),50
Red Rover hospital ship (Civil War),135
Redeployed (Fleming and Robichaux), 160161
redeployment screening, 158159, 164. See also
ARFORGEN (Army Force Generation)
process
Relief hospital ships,135
Renner, C.,222
repeat TBI,217
reproductive health, xix, 4041,7888
contraceptive use, unintended
pregnancy,7981
deployment and birth defects,8185
post-deployment data,1516
pregnancy in theater,8587
sexually transmitted diseases, 148, 149,152
vaccine/chemoprophylaxis exposure,85
Reproductive Mental Health Steering
Committee,307
Reserve Officer training corps,121
RESET, Train/Ready and Available process,
158159, 163, 170171
resistive violence,276
returning from deployment, 157175. See also
reunion preparations; reunionrules
behavioral health risk factors, 165166
combat exposure issues, 166167
disordered eating issues, 169170
effects of training,163
family integration issues, 158159
loss and grief issues, 168169
Medical Evaluation Board, 157, 171,172
medical separations, 172173
mothers who deploy, 167168
National Guard/Reserve Units, 164165
PCS orders, 162, 170,244
redeployment screening, 158159,164
RESET process, 158159, 163,
170171
Staff Sergeant Perry, example,
157158
triggering of PTSD issues,169
Wounded Warrior programs, 171172
reunion preparations
deployment phase, 200201
post-deployment phase, 201203
pre-deployment phase, 197199
364
Index
reunionrules
beware the fairy tale, 204205
consider the timing, 206207
create only reasonable expectations, 204205
no dumb/stupid questions, 207208
pissing contest avoidance, 205206
two-way sincere thanks, appreciation,208
Revolutionary War, ix, 135, 243,330
Revolutionary War Pension Act,330
rheumatologic disease,101
Rieg, T.S.,80
Rivera-Alsina, M.E.,86
Robichaux, C., 160161
Robinson, S.,316
Rogers, Edith Nourse,337
Rosenheck, R., 24,257
Rosie the Riveter,121
Ryan-Wegner, N.A.,68
safety planning, for intimate partner violence,281
Safety Planning Intervention guide (VA),257
salpingitis,338
Sampson, Deborah (aka Robert Shurtliff),
330331
Samson, Deborah,243
Seal, K.H.,25
Seasonale (oral contraceptive),59
secondary injury processes, from TBI, 215216
Secretary of the Navy, 121,123
self-concept issues,191
self-diagnostic kit recommendation,6869
Service Womens Action Network (SWAN),
346347
Servicemens Readjustment Act (1944),339
Sesame Street, materials for families, 181,
182183
Sesame Street Talk Listen Connect:Deployment
Homecoming Change (video/DVD),182
sexting,36
sexual assault and harassment. See military
sexualtrauma
sexuality in areas of operation, xixxx, 58, 65,
147153, 148149, 152. See also consensual
sex in the warzone
sexually transmitted diseases (STDs), 148,
149,152
ships and women. See also medical care on ships;
submarine service
Authorized Medical Allowance Lists, 124,125
Cazares personal experience, 126132
DACOWITS report,123
IDC leadership, 124,125
MEDEVAC process, 124,129

pharmacy requirements,125
post-1970s history, 121123
pre-1970s history, 120121
Pre-Deployment Health Re-Assessment,126
pregnancy concerns, 124,125
sexual assault training,122
Shurtliff, Robert, 330331. See also Sampson,
Deborah
signal units,22
signature injuries. See posttraumatic stress
disorder; traumatic braininjury
Simpson, John Kirkpatrick,42
Sisters of Charity,332
situational intimate partner violence,276
skin conditions,10
skull fracture, 214t, 218,219t
Skype, 184, 189,198
sleep problems, 108, 169, 273,288
Slewa-Younan, S.,222
Smoak, B.L.,85
smoking problems,167
social anxiety, 247,251
social considerations for women veterans,
304305
social context of women in the military, 179181
social media,161
social networks, 288,292
social pain, 317319
Society of Family Planning (SFP),63
Somalia campaign. See Operation RestoreHope
Southeast Asia, malaria issues,xxi
Southwest Asia deployment data, 6, 7,8,11
Spanish-American War, 135, 329,335
Special Forces, malaria issues,xxi
Special Operations Executive (SOE),
Australia,35
Stamillo, D.M.,86
Strauss, M.,152
stress fractures,xvii
submarine service
limited service opportunities, 120,123
osteoporosis risk factors,125
2001, NSMRL report,124
2011, onset of gender-integration,123
Substance Abuse and Mental Health Services
Administration (HHS), 281282
substance use/abuse, xvi, xx, 18, 23, 166, 172173,
252, 268, 271, 277279, 281282, 286287,
302. See also alcohol abuse/misuse; drug
use/abuse
suicide bombers, 16, 44, 159,160
Index
Suicide Status Form (SSF),256

suicide-related ideation and behaviors, xxi,
243259
anxiety/mood disorders and,251
assessment/screening for,256
associated psychiatric conditions,247
CDC/national data on women, 244245
child loss and,251
demographic factors,248
depression and, 244, 247, 249, 250, 251, 253,
254,279
DoD Suicide Event Report, 245246,259
eating disorders and, 252253
gender differences, 246247
history of multiple attempts, 253254
IPV and, 248, 267, 274, 278, 279,284
as mefloquine side effect,103
military women risk rate,244
military-related factors, 249250
occupational/interpersonal factors,254
personality disorders and,253
pregnancy, postpartum depression, and,251
protective factors,255
psychiatric factors,250
PTSD association, 247, 249,251
recommendations for professionals, 255259
substance use disorders and,252
trauma-related factors, 248249
treatment modalities, 248,255
Supplementary Homicide Report (FBI),267
surface combat ships, 122123
Surface Warfare Officer (SWO),130
Tarver, R.S.,81
TBI. See traumatic braininjury
tetracycline, 99,101
Theater Medical Data Store (TMDS), 1011,57
Thompson, Franklin,335
transdermal patch,58,60
Transition Assistance Programs (TAP),346
trauma. See also military sexualtrauma
combat-related, 31, 202, 283285
IPV and, 271, 279, 281285
of mothers in war, 191192
pre-military service experiences, 282283
psychological trauma,159
suicidal ideation and, 243, 248250,255
treatment by combat medics, 134,136
trauma care, 71,136
traumatic brain injury (TBI), xxi, 211231
blast-induced TBI, 212213, 216217
causes/description, 211, 214215
365
CDC data, 211212

combat-related risk factors, 212213
concussions, 217, 223, 226,229
deployment screening for,173
depression association, 212, 213, 215, 217, 223,
227, 229,284
diagnosis, 214216, 219, 220, 224227,
229230
female endogenous hormones and, 225226
hospitalizations, 218, 220, 227,230
ICD-9-CM codes,219
incidence in women, 217220
intimate partner violence and,278
IPV association, 278,279
medical outcomes, 220222
mefloquine conflicts with,103
mild TBI, 212217, 220223, 226227
mortality, male vs. female,217
neurobehavioral outcomes, 222225
neurodegenerative disease and, 227228
non-blast TBI,217
post-concussion syndrome, 226227
post-deployment data,1617
PTSD comorbidity, 212,227
repeat TBI,217
secondary injury processes, 215216
treatment strategies,227
traumatic event management (TEM),174
Trego, L.L.,70
Tricare, military health insurance,66
Truman, Harry,339
tuberculosis, 38,336
Tucker McElroy, Lisa,183
typhoid,135
under-reporting of medical issues,
19,52,54
Uniformed Services University, xvii,126
uniforms, fit/function issues,6465
unintended pregnancy
deployment rates, 63,148
epidemiological data,7981
lack of abortion services,6364
1990s research,xvii
Persian Gulf conflict data,58
prevention strategies,64
rapes/sexual assaults, and,64
reasons,63
2005 DoD survey data,63
United States Code, Title 38,344
upper respiratory infections,67
Uriell, Z.A.,80
366
Index
urinary tract infections (UTIs). See also female

urinary diversiondevice
bathroom issues,xix
CDC incident data,52
1990s, research data,xvii
prevention measures,5455
resources,55
risk factors,5354
urogynecologicissues
amenorrhea, 57, 58, 59, 60, 61, 65, 86,338
bacterial vaginosis,56
cervicitis, metritis, oophoritis, salpingitis,338
endometriosis,59
genital infections,87
genitourinary conditions,10,15
in Iraq, 57, 148149
need for prevention education,69
1945 VASRD report,338
ovary-related health issues, 58, 59, 338339
pelvic inflammatory disease,59
sex-specific hormonal differences,303
ship on-board medical supplies,125
submarine service modifications,124
under-reporting,52
urinary tract infections, xvii, xix, 5254,
5255, 67,126
uterine-related health issues, 338339
VA healthcare benefits,345
vaginitis, 54, 55, 67, 70, 101,338
US Army Combat Medics, longitudinalstudy
combat experiences, exposures,139
combat experiences by gender, 140,142
combat medic sample, 137139
demographics of sample,138
experiences, exposures, concerns, 141142
measures,138
post-battle experiences by gender,143
psychological health,139
statistical analysis,141
stigma/barriers to care,141
US Army Medical Material Agency,69
US Army Medical Research and Material
Command,4950
US Army Public Health Command (USAPHC),
29,5455
US Christian Commission, 332,333
US Defense Department Advisory
Committee onWomen in the Services
(DACOWITS),71
US Department of Health and Human Services
(HHS), 66, 281282
US Department of Justice (DOJ),267
US Department of Veterans Affairs. See Veterans

Administration(VA)
US Government Accounting Office (GAO),81
US Naval Academy,122
US Record and Pension Division,333
US Sanitary Commission, 332,333
US Secretary of Defense,71
US Senate,147
USO reading program for kids,185
USS Dolphin,121
USS Jarrett,123
USS Mayflower,121
USS Minnesota,123
USS Opportune,122
USS Rushmore,123
USS Virginia,123
uterine-related health issues, 338339
UTIs. See urinary tract infections
VA Community of Practice intranet website,326
VA Palo Alto Polytrauma System of Care clinics,
224225
VA Puget Sound Health Care System,25
vaccine/chemoprophylaxis exposure,85
VA/DoD Disability Evaluation System,346
vaginal candidiasis,94
vaginal hormonal contraceptives,58
vaginal ring,60,61
vaginitis, 54, 5556, 67, 70, 101,338
VASRD. See Veterans Administration Schedule
for Rating Disabilities
Vaughn, R.,315
verbal sexual harassment,2425
vestibular disorders and rehabilitation, 101,227
veterans. See women veterans
Veterans Administration (VA), xvi,xvii
combat exposure data,165
disability determination role,172
eating disorder recommendations, 169170
ECVARS study,341
female veteran totals,343
IPV data, 288289,291
mental health assessments,313
mental health problems data,284
mental healthcare policy for women veterans,
305306
military sexual trauma data, 175,285
non-service related healthcare eligibility,330
Palo Alto Polytrauma System of Care clinics,
224225
PTSD data, 24, 25, 165,257
Puget Sound Health Care System,25
Index
response to military sexual trauma, 321328

Safety Planning Intervention guide, 257258
sexual trauma screening,175
TBI screening data, 214, 218, 224225
Womens Stress Disorders Treatment
Team,257
Veterans Administration Schedule for Rating
Disabilities (VASRD), 336337, 340,
341,344
Veterans and Veterans Families Counseling
Service (VVCS, Australia),40
Veterans Benefits Administration (VBA), 324,
342,344
Veterans Brain Trust (Congressional Black
Caucus),343
Veterans Disability Benefits Commission
(VDBC), 344, 345346
Veterans Health Administration (VHA). See
Veterans Administration(VA)
Veterans of Foreign Wars,346
victims of intimate partner violence (IPV),
266281, 285291
Vietnam syndrome,341
VietnamWar
Australian servicewomen health outcomes
study,39
chloroquine antimalarial use,105
female voluntary service, 340341
gender specific health consequences,39
post-deployment NVVRS survey,341
PTSD data, 341342
roles of female soldiers,22
Virginia class (fast attack) submarines,123
visual disturbances, from chloroquine,100
Vocational Rehabilitation and Employment
(VR&E),345
Vogt, D., 314,315
vulvovaginitis,338
Wake, Nancy,35
Walker, Mary,135
Walter Reed Army Institute of Research
(WRAIR),xviii
War of 1812,331
War Risk Insurance Acts (1914, 1917),336
Warrior Transition Unit (WTU, Army),171
Washburn, Delilah, 344345
Washington, George,331
We Serve, Too! AChilds Deployment Book
(Edick),183
webcams,198
Whiteneck, G.,221
367
Williams, Dorinda Silver,182

Williams, K., 316317
Willson, S.J.,86
Women Accepted for Voluntary Emergency
Service (WAVES),337
Women Air Force Service Pilots (WASP),337
Women Armed Services Integration Act
(1948),339
Women at War panels,xvii
Women in Combat Symposium (2014),xvii
women veterans, 301308
best practices for mental healthcare, 306307
biological considerations, 303304
Crompvoets health services study,4142
IPV and, 270, 284, 286, 287289,291
long-term blast injury concerns,170
mental health needs, 302303
MST screening program, 323325
OIF/OEF service, headaches,18
prevalence of mental health issues, 302303
Service Womens Action Network, 346347
service-connected healthcare needs,212
sexual trauma carryover,285
social/cultural considerations, 304305
VA mental healthcare policy for, 305306
Womens Armed Services Integration Act
(1948),135
Womens Army Auxiliary Corps (WAAC),
337338
Womens Army Corps (WAC),338
Womens Central Relief Association,332
Womens Health Assessment Team, 66,
6869,175
Womens Health Portal (USAPHC), ix,55,55
Womens Health Research Interest Group
(WHRIG),70
Womens Health Task Force(WHTF)
FUDD supplies,54,55
self-diagnosis kits development,6870
sharing of best practices,6667
2001 establishmentof,ix
uniform design initiative,6465
vaginitis prevention strategy,56
Womens Stress Disorders Treatment Team
(VA),257
Workplace and Gender Relations Survey
(2010),64
World Health Organization(WHO)
on contraceptive use eligibility,63
estrogen use guidelines,60
multinational suicide-ideation survey,246
World WarI,121
368
WorldWarII
Army Nurse Corps service,135
Australian servicewomen deaths,38
consensual sexual interactions,152
female deaths,338
female service data,337
malaria/Army Nurse Corps,95
ship restrictions,121
use of female combat medics,137
wounded in action(WIA)
2002-2011 data, 9,9,10
2014 data, xxixxii
Wounded Warrior programs, 171, 346347
Writer, J.V.,85
Index
yellow fever,135
You and Your Military Hero:Building Positive
Thinking Skills During Your Heros
Deployment ( Jensen-Fritz, Jones-Johnson,
Zitzow),183
YouTube video, use/care of FUDD,55
Yuan, H.,250
Zitzow, Thea L., 183,249
Zlatoper, Ronald, 122123
Zolna, M.R., 80

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Women at War (Gnv64)

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WOMENATWAR

Elspeth Cameron Ritchie, MD, MPH

Anne L. Naclerio, MD, MPH

Oxford University Press 2015

PART 1: BACKGROUND AND INTRODUCTION

2. Female Soldiers and Post-Traumatic Stress Disorder

3. Women and War:Australia

6. Issues in the Prevention of Malaria Among Women at War

7 Women, Ships, Submarines, and the US Navy

8. Female Combat Medics

9. Human Sexuality and Women in the Area of Operations

PART 3: WOMEN HOME FROMWAR

11. Mothers in War

12. Building the Framework for Successful Deployment Reunions

13. Traumatic Brain Injury:Implications for Women in the Military

PART 4: PSYCHOLOGICAL ISSUES FOR

15. Intimate Partner Violence, Military Personnel, and Veterans

PART 5: THE FEMALE VETER AN EXPER IENCE

17. Mental Health of Women Warriors:The Power of Belonging

18. The Veterans Health Administration Response to

19. Compensation, Pension, and Other Benefits for Women

Margret E. Bell, PhD

Amy Canuso, LCDR,MCUSN

Michael R. Bell, MD, MPH

Michael Carino, DMD,MPH

Paul Bliese, PhD

Paulette T.Cazares, MD,MPH

CDR Heather D. Hellwig, MS,

Elizabeth C.Henderson, MD,

Anne L.Naclerio, MD,MPH

Cara J. Krulewitch, CNM, PhD,

Susan Neuhaus, CSC MBBS, PhD,

Brigilda C. Teneza, MD, MPH

Military women also make up a high proportion of medical personnel. Overall,

Psychiatric Annals recently published a special issue on Psychiatric Issues for

life-threatening emergencies and expensive medical evacuations. In the best cases,

Comparative Morbidity and Mortality

maintains the Defense Casualty Analysis System (DCAS; https://www.dmdc.osd.

1. Comparative Morbidity and Mortality

DOD Total (n)

DOD Officers (n)

DOD Women (n)

Women Enlisted (n)

FIGURE1.1 Officers and enlisted personnel on active duty, DoD, 19942011.

TABLE1.1 Service Members Deploying atLeast Once

TABLE1.2a Average Number ofDeployments,

TABLE1.2b Median Length (Months) ofDeployments

The deployed women encompassed a wide range of occupational duties (Figure1.2).

% Deployed troops in each

FIGURE1.2 Military occupational categories of Servicemen and Servicewomen deployed to

1. Comparative Morbidity and Mortality

OIF/OEF HEALTH PROFILE FORMILITARYWOMEN

Air Force Coast Guard

Casualty Categories: NonHostile (accident, illness/

Total Wounded in Action 12,978

Air Force Coast Guard

Air Force Coast Guard

Air Force Coast Guard

TABLE1.3b US Military (Men and Women Combined) Casualties, 20022011,

Total Hostile Deaths

Casualty Categories: NonHostile (accident, illness/

Coast Guard Total

Coast Guard Total

Coast Guard Total