THE GENDER DIFFERENCES IN PTSD SYMPTOMATOLOGIES AND THEIR
AFFECTS ON LIFE SYSTEMS FOR RETURNING VETERANS FROM OEF / OIF
Adriana Venegas - Galvez
B.A., University of California, Santa Cruz, 2000
Stephanie McMullen - Ladd
B.A., California State University, Sacramento, 2000
PROJECT
Submitted in partial satisfaction of
the requirements for the degrees of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2011
THE GENDER DIFFERENCES IN PTSD SYMPTOMATOLOGIES AND THEIR
AFFECTS ON LIFE SYSTEMS FOR RETURNING VETERANS FROM OEF / OIF
A Project
by
Adriana Venegas - Galvez
Stephanie McMullen - Ladd
Approved by:
__________________________________, Committee Chair
Susan Talamantes Eggman, PhD, MSW
____________________________
Date
ii
Students:
Adriana Venegas - Galvez
Stephanie McMullen - Ladd
I certify that these students have met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library and
credit is to be awarded for the project.
________________ ___________, Graduate Coordinator ___________________
Teiahsha Bankhead, Ph.D., L.C.S.W.
Date
Division of Social Work
iii
Abstract
of
THE GENDER DIFFERENCES IN PTSD SYMPTOMATOLOGIES AND THEIR
AFFECTS ON LIFE SYSTEMS FOR RETURNING VETERANS FROM OEF / OIF
by
Adriana Venegas - Galvez
Stephanie McMullen - Ladd
This research project, including all data collected, was a joint endeavor between Adriana
Venegas - Galvez and Stephanie McMullen - Ladd. This exploratory and qualitative
study explored the differences in gender symptomatologies in returning veterans from the
OEF/OIF conflict that are being treated by clinicians for PTSD and examines how the
PTSD symptoms manifest in their client’s daily social and occupational functioning. The
study looked at the clinical perspectives of 28 practicing mental health professionals
treating male and female veterans of the OEF/OIF conflict through an on-line survey.
The data collected can be used to argue for the development of an improved diagnostic
tool that takes into consideration the full scope of PTSD symptoms and how they present
in different genders and contexts.
, Committee Chair
Susan Talamantes Eggman, Ph.D, MSW
____________________________
Date
iv
DEDICATION
To Gabriela, who reminded me to breathe like Buddha when it was necessary.
To my mother, Ann, my personal patron saint of social work.
- A.V.G.
To my husband, Nathan, your love, support and faith kept me going. To my amazing
stepsons, Brandon and Andrew, you are my inspiration. To my mother, Loretta, for your
grace and patience and my father, Patrick, who taught me the appreciation and privilege
of education.
– S.M.L.
Lastly this thesis is dedicated in honor and memory to
all the men and women who have served there country.
Thank You.
v
ACKNOWLEDGMENTS
We would like to acknowledge and thank all of our family, friends and fellow
students that helped and supported us through this process. Without your constant phone
calls, emails, coffee breaks and gifts of self-care, we could have never survived this
challenge that is called “thesis”. Thank you for your understanding of our absence at
many family and social events…we hope to rejoin our life again and make up for lost
time.
We would like to thank the therapist and clinicians that participated in our survey,
many who offer services to veterans pro bono. It is because of your compassion and
devotion to the men and women that serve in the United States military that we
acknowledge your efforts. To all of the men and women who have volunteered to make
the ultimate sacrifice for our nation; we honor and thank you. This research will
hopefully shed light on the many sacrifices you make, not just on the battlefield, but also
when you return home.
We would like to thank our thesis advisor, Professor Susan Talamantes Eggman,
for your faith in the two of us and all of your guidance, editing, e-mailing, and aiding us
in making this thesis a reality. You were right; it is just five papers in one.
Also to Professor Janice Gagerman whose dedication to mental health services for
veterans ignited our interest in this research. You taught us the value of clinical social
work and to always remember that as social workers we…LIVE IN AXIS IV!!
vi
I would like to thank my thesis partner, Adriana, for sharing in this
journey with me. It has been a privilege to work with you and an even greater gift to call
you my friend. Thank you to my friend, Susana: you are the social worker I hope to
become. I have learned more about theory, clinical practice and social work from you
then any book, professor or class could have taught me. Just plant the seeds. To my
husband Nathan…we survived!! Thank you for helping me get through the tough times
and never letting me quit. For handling all of the little things and for managing the big
things. To my sons Brandon and Andrew thank you for the many sacrifices you have
made to allow me to pursue this dream. I hope I have been as much of an inspiration to
you as you inspire me each and every day. I love you all so very much. ~ Steph-Mom
I would like to thank my extraordinary support of family and friends that
allowed me to succeed over the past three years, who believed in my potential and held
my hand through some of the most emotionally challenging years of my life. This thesis
is a culmination of everyone’s efforts, and not a day will go by that I will not feel an
immense sense of gratitude for those gifts. Thank you to those I had to let go of during
this time, for although you will not be standing with me at the end, you shaped the social
worker I am. To those who have left this life: I know you have watched over me from the
next. Thank you for being the guiding hands I needed on so many days. ~ Adriana
vii
TABLE OF CONTENTS
Page
Dedication ..................................................................................................................... v
Acknowledgments....................................................................................................... vi
List of Tables ................................................................................................................ x
List of Figures ............................................................................................................. xi
Chapter
1. INTRODUCTION ………………………………………………………………. 1
Statement of Collaboration ............................................................................. 3
Background of the Problem ………………………….……………………… 3
Statement of the Research Problem
………………….…………………….. 4
Purpose of the Study ....................................................................................... 5
Theoretical Framework………………………………….……………………..6
Research Questions ……………..…………………….……….……………. 7
Definition of Terms ..………………………………………………………… 7
Assumptions ................................................................................................... 8
Justification … ................……………………………….……………………. 9
Limitations .……………….…………………………….……………………. 9
Summary .. ……………….…………………………….…………………….10
2. REVIEW OF THE LITERATURE ......................................................................12
Gender Considerations ……………………………….………………………12
Co-Occurring Features ………………………………….……………………15
Risks and Barriers to Diagnosis and Veterans with PTSD ………………….. 21
Protective Factors………………………………….…………………….……28
Conclusion……………………………………..…………..…………….…... 34
3. METHODS …………………………………………….....…………………….. 36
Design ……………………………………………….……..………………. 36
Sample …………………………………………….….…………………...… 37
viii
Sample Recruitment………………………….…………………….…….….. 37
4. OUTCOMES …………………………………………………………………… 39
Overall Findings ……………………………..……………..…………….… 39
Specific Variable Results………………………….………………….…...… 41
Hypothesis Support ……………………………….…………………....…… 48
Conclusion ……… ……………………………….…………………….…… 52
5. CONCLUSIONS AND IMPLICATIONS …………………………..………… 53
Conclusions of Main Findings …..…….…..……………..……………..…… 53
Implications ……………………………………….……………………...…. 57
Limitations ….…….……………………………….……………………...… 57
Summary ………….……………………………….………………………… 60
Appendix A. Introduction Letter and Consent to Participate ……………………… 62
Appendix B. On – Line Survey …………………………………………………..….64
References ………………………………………………………………………….... 89
ix
LIST OF TABLES
Page
1.
Table 1 Female veterans’ expressions to Question #1…………………..……….41
2.
Table 2 Male veterans’ expressions to Question #1 ………………………….... 41
3.
Table 3 Female veterans’ expressions to Question #12 .……………….…….... 42
4.
Table 4 Male veterans’ expressions to Question #12 .…………….………….... 43
5.
Table 5 Female veterans’ expressions to Question #17 .……..……..……….. 43
6.
Table 6 Male veterans’ expressions to Question #17 …..……..……………….. 44
7.
Table 7 Female veterans’ expressions to Question #4 …………………………. 45
8.
Table 8 Male veterans’ expressions to Question #4 …..………………………. 45
9.
Table 9 Female veterans’ expressions to Question #8 ……………….………… 46
10.
Table 10 . Male veterans’ expressions to Question #8 .…….…………………. 46
11.
Table 11 Female veterans’ expressions to Question #15 ………………………. 47
12.
Table 12 Male veterans’ expressions to Question #15 .....………………….….. 47
x
LIST OF FIGURES
Page
1.
Figure 1 Strongly Affected/Mildly Affected Responses for Question 1 …...….. 49
2.
Figure 2 Strongly Affected/Mildly Affected Responses for Question 12 ...….... 49
3.
Figure 3 Strongly Affected/Mildly Affected Responses for Question 17 ...….... 50
4.
Figure 4 Strongly Affected/Mildly Affected Responses for Question 4 …….… 50
5.
Figure 5 Strongly Affected/Mildly Affected Responses for Question 15 .....….. 51
6.
Figure 6 Strongly Affected/Mildly Affected Responses for Question 8 ..…..…. 51
xi
1
Chapter 1
INTRODUCTION
Post Traumatic Stress Disorder (PTSD) is not a contemporary disorder; it has
been documented throughout history but labeled in many different ways. PTSD has
historically been associated with soldiers actively serving in the military, explaining
symptoms of anxiety and despondence experienced during or following combat
experience. As early as the Civil War (1861 to 1865), doctors and military commanders
recognized symptoms of PTSD and described them as “soldier’s heart” and no true
diagnosis or treatment was prescribed. During both World Wars I and II, terminology
shifted to soldiers having a diagnosis of “shell shock”. During the Vietnam War era
(1955 to 1975), doctors sought to find a better description to explain the psychological
afflictions described by soldiers, thus fashioning the term “Post-Vietnam Syndrome”
(Regalado, 2003).
Despite the overwhelming increase of soldiers describing similar symptoms, PostTraumatic Stress Disorder (PTSD) was not recognized by the American Psychiatric
Association until 1980. PTSD, an anxiety disorder that occurs following exposure to
trauma, has now become a widely recognizable diagnosis that occurs in both men and
women. Some common symptoms include; intrusive thoughts, avoidance of stimuli
associated with the trauma, numbing of general responsiveness and persistent symptoms
of increased arousal (Feczer & Bjorklund, 2009). PTSD makes no discrimination; it can
befall anyone that has been exposed to a traumatic event, regardless of race, culture or
socioeconomic status. People from many demographics experience PTSD. However, for
2
purposes of this research project, the researchers will focus on the diagnosis, effects and
treatment of PTSD in military personnel only, specifically from the Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF) deployments.
Although numerous research studies indicate women entering the military are
statistically more susceptible to PTSD than men, due to prior history of previous
traumatic events, such as previous sexual trauma (Follette, Polusny, Bechtle, & Naugle,
1996; Tolin & Foa, 2006), mental health clinicians in the military continue to diagnose
PTSD in male soldiers at a higher rate than for female soldiers (Chaumba & Bride, 2010).
One theory for this discrepancy suggests that many clinicians, still believing that only
male soldiers hold combat positions, hold fast to the idea that men are more prone to
developing PTSD. However, in today’s modern warfare, a higher number of female
soldiers participate in support roles that place them in combat zones, thereby increasing
their risk of being exposed to combat-related trauma at similar levels to those of their
male counterparts (Zinzow, Grubaugh, Monnier, Suffoletta-Maierle & Frueh, 2007).
In order to diagnosis PTSD, clinicians must use the criteria and list of symptoms
detailed in the Diagnostic and Statistical Manual of mental disorders (DSM-IV-TR)
created by the American Psychiatric Association (APA, 2000). Although the DSM-IVTR makes no distinction as to whether PTSD symptoms manifest differently in men
versus women, it is important to consider gender differences in order to create an
appropriate treatment plan. Traditional PTSD screening tools have been predominately
tested on males and do not screen for gender differences. As a result, women seeking
services are screened with tools designed to assess for symptoms commonly described by
3
males. Symptoms of PTSD in women may manifest in different areas of life not explored
in the common military PTSD screening checklist. Therefore, many women are
misdiagnosed, under-diagnosed or not diagnosed at all. This incongruence can also lead
to a deficient treatment plan that is not gender responsive. Without proper diagnostic
tools, it is difficult to fully address the personal and professional needs that women may
be struggling with because of their PTSD. It is critical to create an assessment tool that
considers these gender differences in symptomologies.
This research project proposes that PTSD symptoms will affect women and men
differently due to gender differences in PTSD system manifestations, and further
proposes that, because of the limited amount of research in gender symptomologies in
PTSD, research is indicated to create a more precise screening or assessment tool that is
more gender responsive. Such a tool would appropriately enable clinicians to create more
accurate, fluid and congruent treatment plans for both male and female soldiers suffering
from PTSD.
Statement of Collaboration
This research project, including all data collected, was a joint endeavor between
Adriana Venegas - Galvez and Stephanie McMullen - Ladd.
Background of the Problem
In the military, women have historically not been permitted to hold positions that
are considered direct combat positions. Women are allowed to hold combat support
positions in units that provide infantry, armor and artillery units with equipment,
ammunition, maintenance and other supplies in combat zones. The underlying
4
assumption for this restriction is that women will not be exposed to direct combat, and
therefore will not encounter the same psychological stresses and traumas that men face as
a result of being exposed to combat trauma.
In recent studies done by Chaumba, Bride, Feczer, and Bjorklund, a higher
percentage of male soldiers were found to have been given a diagnosis of PTSD, as
opposed to female soldiers with the same symptoms (2010). Through the use of a
random sample, researchers further found that a high percentage of women displayed
PTSD symptoms but had not received a diagnosis of PTSD. On the other hand, male
soldiers who displayed similar symptoms were 3.5 times more likely to be diagnosed
with PTSD (Chumba et al, 2010). This research helped to highlight the growing
inconsistency in access to services met by women who are returning from war
deployments, who may be suffering from the trauma exposure ultimately resulting in
PTSD symptoms.
Statement of the Research Problem
Generally, clinicians must look at symptoms of PTSD in reference to what the
client is reporting and the qualifying criteria according to the DSM-IV-TR. In our study,
we looked at all possible symptoms displayed by both men and women. Additionally, we
noted any differences in symptom manifestations and the effects on Axis IV systems
associated with their personal and professional lives. In considering this wider area of
classifications, we hope to suggest a more effective assessment tool that can be used
accurately in diagnosing both male and female service members suffering from PTSD.
Due to the lack of research data on how males compare to females with PTSD in these
5
social functioning domains, speculation on gender differences must be extrapolated from
existing data (Fallon, Baca, Conforti, & Qualls, 2002).
Purpose of the Study
In a time when our military service members are fighting two separate wars in
two distinct fields of battle, it is critical that we understand how these combat situations
are affecting them and how to treat them effectively. Compared to past wars and
conflicts, there are more women serving in combat susceptible positions. It is essential to
understand whether female experiences are comparable or dissimilar to those of their
male counterparts, in order to develop gender sensitive programs (Chumba &Bride,
2010). By examining the differences in gender symptomologies and how they manifest
in all areas of a person’s life, we can anticipate the development of a better diagnostic
tool that takes into consideration the full scope of PTSD symptoms and how they present
in different cases and contexts.
The secondary purpose of this study is to convey greater awareness that women
are being exposed to combat-related trauma and not being properly diagnosed. This
inconsistency is found in the active duty military health system, the Veteran’s
Administration (VA) system and civilian healthcare systems. There is often a disconnect
within the medical establishment in the acknowledgement that women can even be
veterans of war, or a general assumption that if they are, they have not been exposed to
the traumas of war. The lack of knowledge among healthcare professionals leads them to
not take the time to properly identify women as veterans, thereby creating another barrier
6
for females in receiving proper diagnosis and treatment for their symptoms (Kaplan,
2008).
Theoretical Framework
In working with clients who have experienced trauma, it is important to take into
consideration that each individual responds to the trauma differently; therefore, a “one
size fits all” approach is not the best practice approach in treatment planning for
individuals. In this research project, we utilized a systems approach theory in examining
how the differences in gender symptomatologies affect all of the interconnecting systems
(i.e. inter-personal, social support, professional, and health) in the veteran’s life. This
theory helped to explore and illustrate the possibility of the existence of different PTSD
gender-specific symptom profiles among veterans, also examining how those symptoms
impact their lives in different ways. In taking a systems approach, we can more readily
identify areas not previously explored in symptom identification and ultimately create a
screening tool that will capture a more gender specific snapshot of symptom
manifestation. This, in turn, can help to construct a more tailored, effective treatment
plan for the individual.
Feminist theory perspective, which aims to understand gender differences and
equality, also informed this research, as the different PTSD gender symptom profiles
were examined through a feminist lens. The research focused on exposing the
differences between female veterans’ trauma exposure versus male veterans’ trauma exp,
and how those differences should be considered when developing prevention programs,
assessment tools and treatment planning for those living with PTSD. In looking at the
7
current assessment tools utilized by the military, the diagnostic questions being asked can
be interpreted as being gender biased and are therefore essentially discriminatory toward
women, as all of the different needs of women are not being incorporated or evaluated.
Even with the integration of women into more combat related military roles, the structure
of the military is very patriarchal and does not apply equality across the board. This
research aims to reduce the gap in understanding about the differences in
symptomologies between the genders, in anticipation of the development of more equal
and gender-specific treatment for PTSD, reducing this gender disparity.
Research Questions
This research intends to answer the following two research questions: (1) Is there
a difference in gender symptomatologies of PTSD for veterans returning from Operation
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)? (2) If so, does the gender
difference in how their PTSD symptoms manifest impact the different systems in their
lives disparately?
Definition of Terms
Several common terms are used throughout this research study. Some of these are
1) deployments, 2) combat related, 3) previous traumatic events, 4) military sexual
trauma, 5) OEF / OIF, 6) service members, 7) symptomologies and 8) systems.
For the purpose of this study, these researchers make the following distinctions and
definitions:
Deployments refer to any period of time in which a service member is sent overseas to an
area where combat or combat-related conflict is occurring. Deployment periods can be
8
any where from a few days, weeks, several months, and, in some cases, up to a year long
deployment.
Combat-related refers to any type of work or support roles that a service member may
have for combat mission(s).
Previous traumatic events (PTE) can include prior child abuse, domestic violence, sexual
abuse or rape, exposure to disasters or other violence, or exposure to combat related
trauma.
Military Sexual Trauma (MST) includes abuse or rape while serving in the military.
OEF /OIF are the acronyms used by the military. The acronyms represent the title of the
two current conflicts that involve the U.S. military. OEF stands for Operation Enduring
Freedom, which is the ongoing war in Afghanistan that started in 2001, shortly after the
attacks of 9/11. OIF stands for Operation Iraqi Freedom, which is the ongoing war in Iraq
that started in 2002.
Service members include all people, male or female, who are serving in one of the five
branches in the military: United States Air Force, Army, Navy, Marines or Coast Guard.
Symptomologies refers to the symptoms associated with a specific DSM-related
diagnosis.
Systems refer to the intricate areas of social spheres that individuals rely on and surround
themselves with.
Assumptions
This research project makes the assumption that all study participants are
qualified and trained in diagnosing and treating veterans who may have post traumatic
9
stress disorder symptoms, based on their clinical credentials and licensure standards.
This study assumes that female veterans are not receiving adequate diagnosis and
treatment for PTSD due to poorly designed screening and assessment tools as well as a
misconception about female veteran’s exposure to combat trauma, which are validated by
available statistics.
Justification
This research will benefit the field of social work by creating a more effective and
inclusive diagnostic tool, allowing for more appropriate treatment planning for both
female and male veterans coping with PTSD. There has been insufficient research
exploring the differences in gender symptomatologies for PTSD and how those
symptoms affect the men and women differently within the identified social systems.
Female soldiers in the military today have increased responsibilities in combat-related
roles. Additionally, there is a higher prevalence of positive screening for depression and
military sexual trauma among female soldiers. It will be important for the VA to
consider gender-specific treatments for certain mental health conditions, including PTSD
(Haskell, Gordon, Mattocks, Duggal, Eerdos, Justice, & Brandt, 2010). In order to
adequately and responsibly meet the needs of female veterans, the VA system must
expand and improve existing women’s health programs.
Limitations
This study was limited to surveying professional providers, such as mental health
clinicians that treat veterans. The study did not survey or directly involve veterans
receiving services. This study did not seek information from the participants as to
10
whether a history of additional factors such as prior sexual trauma for both the male and
female veterans and could have made the patients more susceptible to developing PTSD.
Other factors, such as the number of deployments or number of potentially traumatic
events that each veteran had been exposed to, were not taken into consideration, as the
providers were the participants of research here. The sample size for this study (N=40)
was forty therapists, and, therefore not a large enough sample to generalize for all
veterans’ providers. Additionally, this study did not conduct in person interviews with the
participating therapists, and self-report data are inherently somewhat biased. All research
data was collected through an on-line administered survey questionnaire and relied on the
honest reply of all participants responding to the survey.
Summary
PTSD is a commonly diagnosed condition for returning OEF/OIF veterans.
Although both male and female veterans are frequently diagnosed with PTSD, there is
overwhelming data suggesting that female veterans are statistically less likely to be
diagnosed with PTSD when compared to male veterans with the same symptoms, despite
being at a higher risk due to various factors. This suggests that there are women veterans
who are slipping through the cracks within the medical establishment, not receiving the
help and psychological services they need.
Understanding PTSD in female veterans’ means first considering the ways the
symptoms of PTSD manifest in their lives and comparing how those manifestations differ
from their male counterparts. This may allow clinicians to make a diagnosis that is more
11
reliable and narrow the gender bias that already exists in PTSD treatment of female
veterans.
12
Chapter 2
REVIEW OF THE LITERATURE
When examining the defining parameters of posttraumatic stress disorder in the
Iraq (OIF)/Afghanistan (OEF) populations, it is irresponsible to examine post deployment diagnoses of PTSD without addressing the existence of gender
considerations, in both medical and mental health/social work practice. Gender plays a
role in determining PTSD risk factors, protective factors, susceptibility, physiological
impact and symptomatology, as traumatic event experiences prove to be vastly different
in male and female veteran populations (Dobie et al., 2004). In analyzing the current
literature regarding posttraumatic stress disorder in the veteran populations, four common
themes arose in determining symptomatology of PTSD. These include gender, cooccurring factors, risks/barriers to diagnosis/treatment and protective factors.
Gender Considerations
The face of the U.S. military is changing. Women account for 14.3% of the US
military force and 7.7% of the veteran population, or about 1.7 million women (Kelly,
Vogt, Scheiderer, Ouimette & Daley, 2008; DOD, 2009; projections for 2007 from
VetPop; Office of the Actuary, Department of Veterans Affairs, 2004; Zinzow,
Grubaugh, Monnier, Suffoletta-Maierle & Frueh, 2007). The increase in women on the
front-line, acting in support roles and being exposed to combat, represents a major
paradigm shift between the OIF/OEF and previous U.S. wars (Sherer, 2007; CarterVisscher et al., 2010). With the increase in women veterans, it is only logical to see an
13
increase in female veterans who are presenting in medical venues with posttraumatic
stress symptoms.
As more women serve in the military and begin assuming many of the
responsibilities once only confronted by their male counterparts, it is important to
understand how their experiences are similar and different from those of male military
personnel, in order to promote gender-sensitive programs and better treatment
assessments (Chaumba & Bride, 2010). Female veterans now make up about 5.5% of
patients in Veterans Health Administration facilities and are one of the fastest growing
patient populations in the VHA (Kelly, Vogt, Scheiderer, Ouimette & Daley, 2008).
Prior to OEF/OIF, male veterans had more direct combat exposure on average than their
female counterparts. However, as the role of women in the military grows and the
implications of their roles are being studied, more information is becoming available
about sex differences in combat-related PTSD (Tolin & Foa, 2006).
In one study looking at gender differences within the diagnosis of PTSD, male
participants were more likely to express posttraumatic distress in the form of irritability,
anger or violent behavior. “Belligerent” or “aggressive” behavior might be considered a
more socially acceptable response to trauma for males, where as anxious or depressed
behavior might be considered more acceptable for females (Tolin & Foa, 2006, p. 26).
Therefore, it has been argued that the experience of a potentially traumatic event (PTE)
may exacerbate preexisting (and socially influenced) gender differences as a reaction to
environmental stresses, ultimately manifesting in PTSD symptoms. One possible
explanation for the differences in gender symptom patterns could be that certain
14
symptoms are more socially supported, encouraged and tolerated within the parameters of
both female and male gender roles (Tolin & Foa, 2006). In another study looking at the
gender differences of anger with PTSD (n=194), results showed that men scored higher
than women on the Assault, Indirect Hostility, Irritability and Verbal Hostility scales.
This confirmed theories that men with posttraumatic stress have higher scores of outward
manifestations of anger with PTSD than women (Castillo, Fallon, C'De Baca, Conforti &
Qualls, 2002). Post analysis for the Resentment and Suspicion t scores between men and
women with PTSD indicated that the sample size was adequate to detect statistically
significant differences, based on the standard deviations. Further study can be done to
determine whether these outward manifestations of anger are more likely to present upon
initial PTSD screenings with men versus women.
Although female military personnel engage in less direct combat than male
soldiers, there is an increase in women who occupy military supporting roles that expose
them to a PTE such as injury, intense environmental factors (i.e. extreme heat) and
exposure to death, threat of death and/or traumatic injuries (Chaumba & Bride, 2010).
Thus far, it appears that women are just as likely to be involved in combat when deployed
but are less likely than men to be directly exposed to traumatic events while in combat
(Zinzow, Grubaugh, Monnier, Suffoletta-Maierle & Frueh, 2007). This exposure,
however, is often unacknowledged and unrecognized by the VHA medical or mental
health community when compared with male veterans. A study conducted by Benda and
House (2003) found that 40.1 % of women compared to 62.7% of men qualified for a
PTSD diagnosis, using a random sample of veterans who had received services at a VA
15
Medical Center. A follow-up of the participant’s medical history indicated only 19.8% of
women received a PTSD diagnosis from the VA doctor versus 59.1% of men, concluding
that potentially only half of the female veterans that participated received the PTSD
treatment they needed and deserved (Chaumba & Bride, 2010). Ultimately, a PTSD
diagnosis is more likely to be given to a male veteran than a female veteran (Benda &
House, 2003; Goldzweig, Balekian, Rolon, Yano & Shekelle, 2006; Grossman et al.,
1997; Pereira, 2002; Chaumba & Bride, 2010).
In a different study looking at combat trauma and the diagnosis of PTSD in
female and male veterans, it was concluded that although both male and female veteran
participants displayed similar PTSD symptoms, the male veterans were over 3 times
more likely to be clinically diagnosed with PTSD than the women. Pereira (2002) argues
that gender bias surrounding the definitions of “combat-related trauma” is a contributing
factor to the low diagnosis rates of combat-related PTSD in female veterans, which
consequently could prevent them from receiving much needed support services (Pereira,
2002; Chaumba & Bride, 2010). Thus, female veterans are equally or less likely than
male veterans to meet criteria for PTSD (Zinzow, Grubaugh, Monnier, Suffoletta-Maierle
& Frueh, 2007). Women, it seems, are rarely identified or asked if they are veterans
while being assessed by doctors; Assumptions are made that soldiers are young males
(Kaplan, 2008).
Co-Occurring Features
Many researchers speculate that if there is a cumulative effect of multiple PTE’s
across person’s lifespan, female soldiers may be at an increased their risk of developing
16
PTSD, since women are statistically more likely to experience PTE’s over a lifetime.
(Follette, Polusny, Bechtle, & Naugle, 1996; Tolin & Foa, 2006). Combat trauma,
military sexual trauma (MST) and environment-induced trauma could be the most
common types of trauma experienced by women in the military (Chaumba & Bride,
2010; Geppert & Maiers, 2009). Recent studies have also indicated that at least one third
of female veterans have child sexual abuse history (Benda, 2006; Sadler, Booth,
Mengeling & Doebbeling, 2004; Schultz, Bell, Naugle & Polusny, 2006; Suris, Lind,
Kashner, Borman, & Petty, 2004; Zinow, Grubaugh, Frueh & Magruder, 2007; Zinzow,
Grubaugh, Monnier, Suffoletta-Maierle & Frueh, 2007). One study suggests that more
than half (52-54%) of female veterans experience pre-military physical or sexual abuse
and that they are more likely than men to report pre-military trauma. Women, including
female soldiers, are often subject to unwanted sexual experiences, including forced
prostitution, rape and physical threat against reporting during deployments (King & King,
1996; McCormack, 2009). Just as women are more likely than men to be sexually
assaulted in civilian life, female veterans are also more likely than male veterans to
experience sexual assault while enlisted (Zinzow, Grubaugh, Monnier, Suffoletta-Maierle
& Frueh, 2007; Haskell et al., 2010).
Women enter the military with significant trauma histories and are exposed to
additional traumatic events during the course of military service. Statistically, sizeable
portions of women who join the military are escaping violent environments (Sadler,
Booth, Mengeling & Doebbeling, 2004; Zinzow, Grubaugh, Monnier, Suffoletta-Maierle
& Frueh, 2007). This, along with a likelihood of experiencing MST, suggests that
17
military women are at risk for cumulative trauma exposure and gender specific
occupational stress, manifesting in both mental and physical health problems (Zinzow,
Grubaugh, Monnier, Suffoletta-Maierle & Frueh, 2007).
Suris, Lind, Kashner, Borman & Petty (2004) examined the differential impact of
military, civilian adult and childhood sexual assault on the likelihood of developing
PTSD. The findings showed that women with MST history were 9 times more likely to
have PTSD; female veterans with childhood sexual assault histories were 5 times more
likely to have PTSD. In a study of civilian women deployed during Vietnam, half of the
women reported verbal or physical sexual harassment and a quarter reported forced or
threatening sexual encounters, including rape (McCormack, 2009). Although combat
injury in both men and women almost surely guaranteed a PTSD diagnosis approval,
women who were sexually assaulted during their military service and then developed
PTSD symptoms were less likely to receive a diagnosis of PTSD (Murdoch, Hodges,
Hunt, Cowper, Kressin, & O’Brien, 2003; Feczer & Bjorklund, 2009).
Although most studies indicate that women are more likely than men to develop
PTSD in response to most types of traumatic events, the findings have been somewhat
disputed (Zinzow, Grubaugh, Monnier, Suffoletta-Maierle & Frueh, 2007; Kang,
Dalager, Mahan & Ishii, 2005). Tolin and Foa (2006) proposed that women’s increased
risk for PTSD is not due to greater rates of exposure to certain types of trauma, but of
other factors, such as differences in cognitive or affective processing of traumatic events.
An increasing body of evidence is supporting the premise that patients who experience
PTSD have biological/genetic predispositions, only exasperated when coupled with a
18
previous traumatic experience (Sherer, 2007). In one study, female soldiers encountered
a 60% higher risk of any mental disorder hospitalization, double the risk of mood
disorders, 80% higher risk of adjustment disorders, 2.4 times the risk of anxiety disorder
admissions and 3.3 times the risk of PTSD (Wojcik, Akhtar, & Hassell, 2009).
PTSD is highly co-occurring with other psychiatric disorders, including
depression, social phobia, panic disorder, substance-related disorders, and other
mood/anxiety disorders (Feczer & Bjorklund, 2009; Haskell et al., 2010; Carter-Visscher
et al., 2010). PTSD with co-occurring depression is more likely in active duty soldiers
with a history of childhood trauma than in soldiers without such history; female soldiers
have higher rates of co-occurring depression than men (Gahm, Lucenko, Retzlaff &
Fukuda, 2007; Feczer & Bjorklund, 2009; Haskell et al., 2010).
One study looking at hospital admissions related to mental disorders in U.S. Army
soldiers in Iraq and Afghanistan found that in female soldiers, the risk of co-occurring
mental and adjustment disorders were doubled and the risk of mood and anxiety disorders
were tripled as compared to the male soldiers. The findings also suggested that female
soldiers were at increased risk of all mental disorders, including PTSD and attempted
suicide/self-inflicted injury disorders (Wojcik, Akhtar, & Hassell, 2009). Male
participants, however, were less likely to report internalizing disorders (e.g., anxiety or
depression) and were more likely to report externalizing disorders (e.g. conduct disorders
or substance use disorders) (Tolin & Foa, 2006; Zinzow, Grubaugh, Monnier, SuffolettaMaierle & Frueh, 2007).
19
In addition, as the experience of multiple traumas is associated with a greater risk
of PTSD in military veterans, women who experience both types of trauma are more
likely to have greater physical health care needs and manifest more complex clinical
presentations of illness than women who have simply experienced trauma by itself
(Kelly, Vogt, Scheiderer, Ouimette & Daley, 2008; Geppert & Maiers, 2009; Hajskell et
al., 2010). PTSD is associated with poor psychiatric functioning, substance abuse and
physical health problems among female veterans, while MST is linked with poor mental
and physical health as well as increased need for medical services (Zinzow, Grubaugh,
Monnier, Suffoletta-Maierle & Frueh, 2007; Kelly, Vogt, Scheiderer, Ouimette & Daley,
2008; Geppert & Maiers, 2009). A correlation was found between trauma-related sleep
disturbances and self-reported poor health. Other health issues include: chronic pain,
cardiac function, hypertension, substance abuse, smoking, obesity, irritable bowel
syndrome, fibromyalgia, chronic pelvic pain, polycystic ovary disease, asthma, cervical
cancer and stroke (Ulmer, Calhoun, Edinger, Wagner & Beckham, 2009; Zinzow,
Grubaugh, Monnier, Suffoletta-Maierle & Frueh, 2007; Dobie et al., 2004; Hughes,
Feldman & Beckham, 2006; Savas et al., 2009; Haskell et al., 2010). In one study
looking at irritable bowel syndrome and dyspepsia among women veterans, it was found
that female veterans had a high occurrence of IBS and dyspepsia symptoms, both of
which are associated with PTSD, anxiety and depression (Savas et al., 2009). Further
study could determine which physical manifestations and chronic illnesses ride gender
specific lines when co-occurring with PTSD.
20
Dobie et al. (2004) observed that female veterans who received a PTSD diagnosis
reported more psychiatric problems, substance abuse and exposure to domestic violence
in their homes (Dobie, Kivlahan, Maynard, Bush, Davis & Bradley, 2004; Chaumba &
Bride, 2010). Female veterans with substance abuse issues were more likely to report a
sexual assault. Female veterans with substance dependency were more likely to
experience MST’s during deployment and less likely to report combat-related trauma
than male substance-dependent veterans (Peirce, Kindbom, Waesche, Yuscavage &
Brooner, 2008). Further study could determine the likelihood of substance abuse
presenting symptomatology between male and female veterans when assessed for PTSD.
Female-Specific Domestic Stressors
Moral and ethical dilemmas and the lack of privacy also create emotional
stressors unique for military women that can present in practice as PTSD (ScannellDesch, 2005; McCormack, 2009). Female soldiers have often experienced hostility and
indifference from those at home, perhaps because the concept of women participating in
war violates socially perpetuated myths concerning gender roles and attitudes. Research
has demonstrated that parental separation early in life can lead to disruptions in the
mother-child attachment system, which in turn can lead to stressful and overwhelming
family situations when a military mother returns from deployment (Street, Vogt & Dutra,
2009). Power dynamics within a couple may shift upon returning home from
deployment, and often times the reintegration into the family structure proves challenging
and stressful for both genders (Leerhsen & Mabry, 1991). However, military mothers are
three times more likely to be single parents and five times more likely to be married to a
21
military spouse (who may also eligible for deployment). Military mothers are more
likely to be young, of a lower socioeconomic status, and are more likely to
divorce/remain divorced compared with other military fathers or civilian mothers (Joint
Economic Committee, 2007; Street, Vogt & Dutra, 2009).
Risks and Barriers to Diagnosis Veterans with PTSD
PTSD is not simply a series of symptoms that lead to an apparent diagnosis.
There are risks and barriers that can keep both men and women from recognizing that
they are experiencing PTSD, as well as lead to improper diagnosis from clinicians. There
is conflicting evidence that states women have higher rates of PTSD then men. The
studies that do show that women have higher rates of PTSD usually attribute that to a
history of prior traumatic events and/or prior sexual abuse or assault (Follette, Polusny,
Bechtle, & Naugle, 1996; Tolin & Foa, 2006). As was discussed earlier in this chapter it
is important to recognize that there are sex differences in PTSD symptomatology and in
order to give a proper diagnosis, it is important to understand and identify theses
differences upon initial assessment. One possible justification for the skewed diagnosis
between men and women is that gender role expectations may be supportive or tolerant of
certain symptoms in female participants and of other symptoms in male participants
(Tolin et al, 2002).
Improperly diagnosed
Research suggests that a PTSD diagnosis in more likely to be given to men
instead of women. In a recent study, it was found that 40.1% of women compared to
62.7% of men qualified for a PTSD diagnosis using a random sample of veterans who
22
received services at a Veteran’s Affairs (VA) Medical Center (Chaumba, 2010).
However, records of participants’ medical history indicated that only 19.8% of women
had received a PTSD diagnosis from the doctor versus 59.1% of the men. Men were 3.5
times more likely to be clinically diagnosed with PTSD then women (Chaumba, 2010;
Feczer et al., 2009). This significant discrepancy in misdiagnosing or lack of diagnosis is
critical in the overall treatment of female veterans returning from deployments. These
potential barriers of misdiagnosis and under diagnosis increase the risk of prolonged
suffering as well as the likelihood of suffering from PTSD in future deployments. It also
reduces the likelihood of females receiving co-occurring diagnosis such as PTSD and
substance abuse related diagnosis compared to the male service members (Zinzow et al.,
2007). Since most of the research and findings are in regards to service members that
were seen within the VA health system, it is important to take a closer look at the VA
system and their role in the improper diagnosis of female veterans.
Male dominated VA health care system
Throughout history, war has predominately been fought by men on the front lines.
Historically, women have played an active role in these war zones, mostly as nurses and
doctors, helping the injured and dying male soldiers. However, in the past decade there
has been an increase in the number of women serving in the military and working more
closely within the war zones that have been typically reserved only for their male
counterparts (Chaumba, 2010). Because the VA previously has provided care for a
largely male population, the influx of female veterans who have served in Iraq or
23
Afghanistan, with potentially different healthcare needs, raises concerns about providing
high quality care for female veterans (Haskell et al., 2010).
In a survey of female service members that were combat exposed, it was found
that participants perceived the VA is more male-oriented, and that this caused
significantly more obstruction with their use of VA services (Kelly et al., 2008). This
supports the finding that women are often over looked as veterans of war and therefore
may suffer from the same aliments as men who were in similar combat situations.
Another complication that occurs when receiving services through the VA is that women
are less likely to report prior sexual trauma as well. This is critical because it is a
predicator for increased likelihood of having PTSD. Women have reported that they
were less likely to disclose military-related sexual abuse or sexual harassment to VA
health professionals for fear of stigma and shame associated with the traumatic events
that women are most likely to experience. They are concerned about how their fellow
male service members will perceive them, and ultimately how it will affect their military
careers (Zinzow et al, 2007).
If studies show that women are more reluctant to seek services through the male
dominated VA Healthcare System, does that necessarily mean that services outside of the
VA are better equipped to handle the females returning from war? In one study it was
founded that female veterans appear less likely to use VA mental health services as
compared to male veterans. However, women have been found to use mental health
outside of the VA system at significantly higher rates (Zinzow et al, 2007). However,
even in social work settings outside of the Veteran’s Administration system, women
24
“rarely identify themselves as veterans nor do professionals often inquire about military
services,” probably due to a lack of knowledge about trauma, PTSD and treatment
options on the part of the clinician (Chaumba, 2010, p. 281). There is hope that even if
women are not seeking services within the VA health system they are seeking services
somewhere. The lack of properly identifying themselves as veterans, or that healthcare
professionals are not taking the time to identify them as veterans, creates yet another
barrier for females in receiving proper care for their symptoms. The other complication
that women face in seeking services is society’s perception of a female veteran. One
Vietnam veteran put it best regarding what can be done to increase the likelihood that a
female would be properly identified as a veteran. "Ask patients if they are soldiers," she
advised psychiatrists. "Don't assume that every soldier is young and male. There are old
ladies like me in the military" (Kaplan, 2008, p.1).
Societal view about female veterans
Hostility and indifference towards returning veterans from war has occurred in the
past, especially during the Vietnam era. There have been great strides in our society
since the Vietnam War to support the troops, even when the war itself became unpopular.
Many veterans returning home from current wars are welcomed and even seen as heroes.
This is not always the case for female veterans. The concept of women participating in
war violates a sacred mythology in our society that goes against what a “woman’s role”
should be, both at home as well as abroad in the military (McCormack, 2009). While our
society has made progress towards the acceptance of women in the military over recent
decades, some still do not comfortably embrace this concept. Women veteran’s
25
homecoming experiences may be impacted by the perception that women are not “real
veterans” or that they were not exposed to “real danger”. As a result, they often have a
homecoming that leaves them feeling unsupported, invalidated, or unappreciated for their
service (Street et al., 2009). This type of homecoming experience can leave these
veterans feeling even more stressed and disconnected. It can significantly impact the
probability that these female veterans will have a difficult time transitioning back to
home life and may exacerbate their PTSD symptoms. A study of Vietnam Veteran
women showed that “unsupportive homecoming receptions significantly mediated the
relationship between trauma exposure and post deployment PTSD” (Street et al., 2009, p.
692).
The discovery that individuals with lower levels of perceived social support after
a traumatic event display higher levels of PTSD has been consistent across several
studies. This consistent finding supports the evidence that women are more likely to
have PTSD as a result of not only their exposure to combat and traumatic events, but also
as a result of a lack of support when returning home (Chaumba, 2010). The social
perceptions also play a role in how both males and females’ symptoms are perceived
within society and within the healthcare system. Social expectations about gender
suggest that men are viewed as active and aggressive, whereas women are viewed as
passive and emotional. A stated previously, belligerent or aggressive behavior might be
considered a more acceptable response to trauma for men, whereas anxious or depressed
behavior might be considered more acceptable for women (Tolin et al, 2002). This may
also explain the inconsistencies within the VA Healthcare system when diagnosing
26
veterans who may be presenting with PTSD symptoms. It is critical that society breaks
through the traditional perceptions of what woman service members can do and what
they are actually experiencing in war zones in order for women to be able to properly
access mental health services when returning home after war. It would be a forward and
positive movement in our society if female veterans were valued as soldiers and
contributors to the military equal to their male counterparts.
Women are not the only ones who face social stigmas and misperceptions about
their roles in the military. Societal definitions of a male veteran can also be a barrier that
keeps men from seeking help. Frequently, men who have minor physical injuries rarely
seek medical treatment for fear that it will make them seem weak or unable to perform
their duties. If this is the case with physical injuries, then imagine what it means when
they are experiencing mental illness. Mental illness is looked down upon even more
greatly in the military then in civilian society (Castillo et al., 2002). Some perceive
mental health symptoms as an indication of weakness of character or cowardice. Many
veterans simply will not seek mental health care for their PTSD symptoms. Male
"soldiers find it hard to reconcile the way they reacted at the moment of trauma with the
way Rambo reacts in the movies” (Leerhsen et al., 1991, p. 2). They are hesitant to
concede such weakness, and even more reluctant to be labeled as having a psychiatric
disorder. They are realistically fearful of the stigma and the possible impact it may have
on their military career prospects or a military discharge less then honorable (Feczer et al,
2009). This is similar to the reasons that female veterans are unwilling to admit to
sexual trauma or harassment: there is a greater concern for how it will affect their
27
military careers then a concern for their own personal well-being. Sometimes, however,
the problem for military members is simply the disparity between their public image as
war heroes and the private feeling of having lost control of their lives (Leerhsen et al.,
1991).
Previous sexual trauma
Several research studies have shown that sexual trauma is a greater indicator for
whether or not a person is susceptible to PTSD (Follette, Polusny, Bechtle, & Naugle,
1996; Tolin & Foa, 2006). There is evidence that regardless of gender, if a person has
experienced sexual trauma, they have a higher rate of being diagnosed with PTSD. If
sexual assault, trauma or harassment is a positive predicator that a person may develop
PTSD, then it is a plausible correlation that women may be more likely than men to
experience potentially traumatic events. In which case, the higher risk of PTSD might be
an outcome of a higher risk of traumatization (Tolin et al, 2002). This is especially
concerning for women in the military because they are often not only exposed to combat
trauma, but also to military related sexual trauma.
For females in the military, there is the added work related stress that they may
experience because they must continue to live and work with their perpetrators. Militaryrelated sexual assault also affects military veterans’ careers because a substantial portion
transfer or leave the service as a result of these traumatic experiences. There is the added
risk that female survivors of abuse are less likely to attribute blame to the perpetrator and
more likely to blame themselves. Avoidance strategies for coping in already violent
environments may become habituated, which can serve to help them through the
28
traumatic event, but in the end it can hinder them from healing from the trauma (Zinzow
et al., 2007).
Among 327 women receiving treatment in a VA women’s clinical program for
stress disorders, Fontana and Rosenheck (1998) found that 93% had been exposed to
some kind of sexual stress during their military service, 63% had been sexually harassed,
and 43.1% had been sexually assaulted. While only 11.9% of the female veterans had
direct combat exposure (e.g., mortar attacks, enemy fire), 58.4% met criteria for PTSD.
Sexual stress was apparently a more toxic factor in the development of PTSD than
combat exposure and must be recognized within the VA system as such (Feczer et al.,
2009). Unlike combat, there is no sense of pride or duty fulfilled for victims of sexual
trauma (Chaumba, 2010).
Protective Factors
As with any illness or diagnosis, there are those who can experience the same
trauma and not have the same predictable outcome. It is just as important to understand
what can help reduce a veteran from being predisposed to PTSD, as much as the
predictors to developing PTSD symptoms. In many cases, there are protective factors
such as resiliency, family and friends’ support and coping mechanisms that help a person
with the transition from a traumatic event(s) to a normal life. There are also protective
factors within the military that can help reduce their vulnerability of developing PTSD.
The concept of resilience has been studied more recently as a protective factor against
PTSD in adult populations, including military personnel. It has been shown that the age
29
of the veteran, experience, length of deployment and the unit’s cohesion and training are
also protective factors for reducing PTSD.
Resiliency
Resilience is sometimes the only explanation for the difference between two
individuals who experience the same trauma, yet one thrives and continues to lead a
normal life while the other is devastated and unable to cope (Feczer et al, 2009). While
there is no doubt resilience mitigates the negative effects of exposure to extreme trauma,
its precise nature, the mechanism(s) by which it operates and the factors that promote or
optimize it are not well understood. “It is conceptualized as a trait, an adaptive process, a
positive outcome, or a characteristic set of coping behaviors” (Feczer et al, 2009, p. 282).
It is unexplainable and almost impossible to train someone to develop resiliency. For
both male and female veterans resiliency may be the only coping mechanism that they
have that can protect them from the traumas of war.
Family & Peer Support
Social support is a powerful protective factor. The protective aspect is influenced
by the capacity of an individual to accept or utilize social support when it is made
available. Common symptoms of PTSD, such as avoidance, alienation and detachment,
make it difficult for individuals to accept social supports, reducing the benefit of support
from family and friends (Friedman, 2006). In a study that looked at the different
concerns about family and home life make for service members who are deployed,
researchers found that the only significant gender differences indicated that the measure
of concerns about life and family disruptions back home during deployment were more
30
strongly associated with PTSD and depression symptoms for women than for men
(Carter-Visscher et al, 2010). Women who reported having friends and family available
to them were less likely to have symptoms of PTSD. Women felt that having someone to
depend on for assistance in times of need helped them to adjust more comfortably to
postwar life, which in turn helped to reduce the symptoms of PTSD (Chaumba, 2010). It
has also been shown that the path to recovery can be found in not only therapy, but also
in the surrounding support system that a person has. This support system includes all of
their family and friends, the ones back home, as well as their military family (Feczer et
al., 2009).
Unit Cohesion & Proper Training
It is a way of life for those in the military to feel that their fellow troops are
family. It is called unit cohesion and it is a necessary part of training in order to ensure
that a unit can perform well together, even in extreme stressful conditions. When a unit
develops this type of cohesion it forms mutual interdependence, trust, and affection; often
forged in the crucible of ongoing life-threatening combat. As a result, these units or
teams become a genuine family. The strong unit cohesion is important in creating a sense
of safety and trust with the people that you work with day in and day out, depending on
them to protect you and keep each other safe. It is especially critical for women who are
often times one of very few females in a unit. Because group cohesion, interdependence,
and mutual support are critically important within a military unit, sexual trauma is a
betrayal, a blatant breach of trust and security that can precipitate a sense of apprehension
and vulnerability. It is from this broken sense of trust that women loose that sense of unit
31
cohesion that can be a strong protective factor in helping them cope with the trauma of
war and the transitions of coming home (Friedman, 2006). The intense fellowship within
a military unit can also be a difficult one to be separated from and it can make it an even
more difficult transition for some veterans into their home family environments
(Friedman, 2006).
Training is a crucial part of preparing for combat and ensuring that service
members are prepared to handle the stresses combat. Women are often excluded from
combat training because technically they are prohibited from participating in direct
combat. As a result women may feel less prepared for deployments then the men, even
though now a days they are often in the same combat zones that their male counterparts
are. Women are also often deployed to combat zones with units that are male-dominated,
which leaves female military personnel to feel even more isolated and less social support.
This lack of a sense of support and unit cohesion puts females at an even greater risk of
PTSD and depression. It is important to examine how critical unit support and cohesion
is perceived before deployment because it can have a direct effect on a woman’s baseline
ability to function as efficiently as the men in her unit (Carter-Visscher et al., 2010).
Demographics
There are other protective factors that can help to predict a person’s ability to
handle to stress of battle that have nothing to do with training or anything that a person
can alter about themselves. Basic demographics can be a simple determining factor in
who may be more susceptible to PTSD. Age and gender are a factor in how resilient an
individual may be in a combat zone. Research has shown that being male, married, better
32
educated, of higher military rank, and being part of the Air Force contributed to better
overall physical and mental health (Wojcik et al., 2009). Whereas the opposite is true for
females who were young and separated or divorced, they had added symptoms of PTSD
(Dobie et al., 2004). In a study conducted by Wojcik et al., they found that female and
enlisted soldiers in Iraq were among the high-risk groups for almost all mental disorders.
In Afghanistan, female, enlisted, and Caucasian soldiers were among the high-risk groups
for mental disorder admissions in both Operation Iraqi Freedom (OIF) and Operation
Enduring Freedom (OEF). Comparison of genders across the same age category
suggested that it was the female soldier in her twenties who was the most vulnerable for
hospitalizations that include attempted suicide/self-inflicted injury diagnoses (Wojcik et
al., 2009). It would seem that being a single, older, married male is a protective factor
towards PTSD and other health problems. Unfortunately for young women they can be
at a much greater risk, though it is most likely due not to their age, martial status and
gender alone that puts them at risk, but more likely the lack of support and training that
the military does not provide for them.
Number of Deployments
There is not any one factor that stands alone to predict whether a person will
develop PTSD. There are however enough studies that show the more a person
experiences trauma the greater the risk they are at for PTSD. IT has been proven that the
psychological risks of exposure to trauma are proportional to the magnitude or severity
of exposure and the degree of life threat or perceived life threat. It is also directly
proportional to the length of exposure and the number of deployments that can increase
33
the likelihood of developing PTSD (Feczer et al., 2009). If this were the case then a
protective factor that would help reduce a service member’s chances of developing PTSD
would be to reduce the length of deployments and reduce the number of deployments a
person would go out on. Unfortunately, in the reality of the war(s) that the United States
is involved in, and the down sized military in which we are using to fight these wars, it is
highly unlikely that reducing any of these traumatic experiences will occur.
In today’s military multiple deployments have become the norm. Many soldiers
serve 2, 3, or even 4 tours of duty. This is a phenomenon unparalleled to any other
conflict the U.S. has been involved in. One report from the Mental Health Advisory
Team V showed an increase of PTSD symptoms from 11% to 27% from their first to
third deployments (Geppert et al., 2009). Due to the over use and abuse of our soldiers’
today clinicians are finding that there is an increase in depression and PTSD with the
increased length of deployment in male soldiers deployed. In addition, they also found
that PTSD levels increased significantly with location and duration of deployment,
increasing 1.1 percentage points for tours beyond 60 days (Wojcik et al., 2009). Women
who have higher levels of war-zone exposure are even more at risk. Women soldiers
were 7 times more likely to have current PTSD symptoms then those with less exposure,
while men with higher levels of war-zone exposure were four times likely to have current
PTSD (Chaumba, 2010). Overall it has been shown that there is an increase in
depression and PTSD with an increase in the length of deployments and that PTSD levels
increase significantly with the location and duration of deployment (Wojcik et al., 2009).
34
Coping Mechanisms
In a world where we are stretching our military and its service members so thin it
seems almost inevitable that the fall out will be much greater, and last much longer, then
just the injuries that are visible now.
How can soldiers prepare for the trauma they will
experience in combat? How do clinicians and physicians protect and heal them when
they return from deployment? One strategy is teaching and training them to utilize
effective coping skills. Immediate post trauma coping strategies have been found to
predict the subsequent onset of PTSD. Though coping strategies can be taught and used
by both men and women, it is important to note that there are gender differences in the
prevalent use of coping mechanisms. For example, female paramedics were more likely
than their male counterparts to report using the coping strategies of wishful thinking,
mental disengagement, and suppression of trauma memories. Regardless of sex, these
strategies correlated positively with the severity of PTSD symptoms (Tolin et al., 2002).
The coping mechanism most common in males is avoidance, and includes not thinking
about or delaying the processing of the trauma. Creamer, Burgess, and Pattison (1992)
found that although avoidance impairs processing in the short term, it might be an
adequate coping technique for those who use the strategy effectively. In processing
traumatic events, a clinician may help to reduce the symptoms of PTSD and possibly
even reduce the chances of a person developing PTSD in the future.
Conclusion
Research has shown the different factors that cause a person to be more
susceptible to experiencing PTSD as a result of a traumatic event. In examining the
35
literature it was found that for females a history of past sexual abuse and/or multiple
traumatic experiences makes a woman more likely to develop PTSD (Tolin et al., 2006).
For males, a history of substance abuse and prolonged exposure to war zone conditions
are risk factors that make men more predisposed to developing PTSD (Kelly et al., 2006).
Gender plays a role in determining PTSD risk factors, protective factors, susceptibility,
physiological impact and symptomatology, as traumatic event experiences prove to be
vastly different in male and female veteran populations (Dobie et al., 2004). In analyzing
the current literature regarding posttraumatic stress disorder in the veteran populations,
four common themes arose in determining symptomatology of PTSD. These include
gender, co-occurring factors, risks/barriers to diagnosis/treatment and protective factors.
An area that the literature seemed to be deficient was the way gender differences in the
PTSD symptoms affected the social and environmental systems surrounding returning
war veterans. It is crucial that we examine the symptomatology differences in relations
to these systems in order to improve treatment for both men and women veterans and
identify possible gaps in diagnostic analysis. Understanding these differences will also
facilitate advancements in the preventive programs that train both male and females
soldiers how to cope with the mental causalities of war.
36
Chapter 3
METHODS
This research project will examine the differences in gender symptomatologies of
posttraumatic stress disorder (PTSD) by examining social/occupational functioning
within the perimeters of the PTSD Checklist (military version), which already used by the
military to determine PTSD. The data collected will be used to argue for the
development of a better diagnostic tool that takes into consideration the full scope of
PTSD symptoms and how they present in different cases and contexts. The secondary
purpose of this study is to convey greater awareness that women are being exposed to
combat-related trauma and not being properly diagnosed.
Design
The researchers used a quantitative research approach and employed a descriptive
research design through the use of an on-line administered survey via surveymonkey.com
sent to mental heath professional’s personal email address. Research subjects completed
an on-line survey through the use of an on-line medium called survey monkey. Subjects
were asked to read a cover letter prior to beginning the survey (see attached example).
This cover letter acted as their informed consent. This explained the purpose of the
research and requested authorization for their participation in this project. Researchers
did not receive or store any copies of written consent forms from the research subjects.
Subjects were asked to complete an on-line consent prior to completing the survey
through an online medium. The use of an on-line medium also ensured the protection
and anonymity of the subject’s identity, as the researcher did not have the name of the
37
participants. The survey itself included “I agree” and “I do not agree” buttons on the
website for participants to click their choice of whether or not they consented to
participate. By clicking on the link and beginning the survey, subjects agreed to
participate in the study. Subjects were informed that they have the option of exiting the
survey at any time and in doing so their data was eliminated.
Sample
Research subjects were licensed and license-eligible therapists who provided
mental health services for returning OEF/OIF veterans. As previously stated, research
subjects completed an on-line survey that is 34 questions, asking them to select all
possible answers that apply for each gender and symptom. This made the questions
qualitative. The risk to subjects was minimal and may have been consistent with the
stress in recalling patient situations.
Sample Recruitment
Research subject participation was voluntary; no inducements were offered.
Research subjects were not representing their places of employment, therefore they were
asked to use their private e-mail accounts, not their work e-mails, in order to bypass
agency compliance concerns. The researchers contacted between approximately 300
eligible therapists who provided mental health services to OEF/OIF veterans. The
researchers hoped to achieve a goal of between 30-40 participants to submit a completed
survey. The researchers recruited therapists from a public list of mental health
professionals posted by TriCare Insurance, who provided medical insurance benefits to
38
the military. The researchers contacted therapists via email or telephone to see if they are
interested in participating in our survey.
The survey was composed of primarily minimal or no – risk questions about their
expert observations regarding the symptomatologies of their military veteran client’s who
were deployed to forward location in both combat and combat supporting roles in the
OEF and OIF conflicts. This research study was minimal risk because of the low level
of disclosure and minimal because the questions were centered around the subject’s
professional life with no disclosure of personal aspects. The questions on the survey
were consistent with the stress in recalling patient situations.
Subjects’ rights to privacy and safety were protected through a secure
transmission from survey monkey. Each question on the online survey included the
option “n/a” if they preferred not to respond or if the respondent wanted to skip a
question for any reason. The identity of participants was kept unknown and therefore
confidential. The data was also kept confidential through online sources (described in
detail below). These researchers stored the data on a home computer, which can only be
accessed via password known only the researchers. The computer was also kept in a
locked room. Once the research is completed, the researchers will destroy the data
completely from the computer using a data-wiping program called DBAN.
The Protocol for the Protection of Human Subjects was submitted and approved
by the Division of Social Work and was found to pose minimal risk. Respondents were
advised to contact mental health services connected to their own personal insurance in the
event that participating in the survey causes psychological stress.
39
Chapter 4
OUTCOMES
The primary purpose of this study was to examine and compare PTSD
symptomatology expression within the realm of Axis IV in female and male veterans of
the OIF/OEF conflict. Specifically, this study explores the how male and female
expressions of Axis IV symptomatology explain the under diagnosing of women with
PTSD. The study examined data from 27 online surveys collected from study participants
that had previously been identified as persons who were 1) social workers/licensed
clinical social workers, marriage and family therapists, doctors, psychologists and clinical
psychologists, and 2) have experience providing services for OIF/OEF veterans. The
survey included thirty-nine questions and asked participants to select all possible answers
that apply for each gender and symptom. Questions were adapted from the PTSD Check
List – Military Version (PCL-M), which is in the public domain.
Overall Findings
Study participants were asked to provide demographic information regarding
gender, current and past active military service, education and years of experience
working with the veteran mental health population. Study finding showed that 30% of
participants were male and 70% were female. 3.7% of participants were currently
serving in active duty, while 96.3% were not. 22.2% of participants had previous active
service, 74.1% did not have previous active service and 3.7% did not respond to question.
Of the 27 participants 44.4% identified as MSW/LCSW, 25.9% identified as
MFT/LMFT, 18.5% identified as PhD, 3.7% identified as PsyD and 7.4 % identified MD.
40
Of those surveyed, 11.1% had worked with this population for 0-4 years, 18.5% had
worked with this population for 4-8 years, 22.2% had worked with this population for 812 years and 48.1% had worked with this population for 12 or more years. Participants
were asked to consider both male and female OEF/OIF veterans that they had treated
within the past 8 years for mental health services, generalize their experiences by gender
and rate their symptom expression as a Likert Scale ranging from “Not Affected”,
“Mildly Affected”, “Strongly Affected” or “N/A” in the following subcategories: 1)
Job/occupation (J), 2) Children (C), 3) Spouse/partner (SP), 4) Daily home life (DHL), 5)
Social interactions/activities (SIA), 6) Sexual activity/function (SAF), 7) Military
functioning (MF), 8) School/educational pursuits (SEP), 9) Faith/worship expression
(FEW), 10) Housing (H), 11) Finances (F), 12) Legal/criminal problems (LCP), and 13)
Substance abuse/dependency (SAD). These expressions are reflections of psycho/social
functioning, reflected in the Axis IV of the DSM-IV.
The first 17 questions asked participants to relate their experiences to male clients
and the second 17 questions asked them to relate their experience to female clients, for a
total of 442 variables. The data was then analyzed using SPSS software. The researchers
conducted a frequency analysis of the aforementioned variables in order to compare male
and female sub categorical expression. After analyzing the female frequencies, the
researchers were able to determine the three checklist questions that statistically “strongly
affected” women in all areas of the subcategories the most, and determine those that
affected them the least. These six frequencies were then compared to their male
counterpart questions in the same category.
41
Specific Variable Results
The following questions were found to have the strongest effect on females
(highest affect averages), with the following frequency data to support this, and male
responses below to compare:
Question #1 - Which areas of social functioning are affected in patients/clients who have
repeated, disturbing memories, thoughts, or images of a stressful military experience?
Table 1
Female veterans’ expressions to Question #1.
Not
Affected
J
0.00%
C
0.00%
SP
0.00%
DHL 0.00%
SIA 11.10%
SAF 0.00%
MF
0.00%
SEP 0.00%
FWE 11.10%
H
11.10%
F
11.10%
LCP 11.10%
SAD 0.00%
Mildly
Affected
10.00%
0.00%
0.00%
20.00%
0.00%
11.10%
11.10%
22.20%
11.10%
22.20%
22.20%
11.10%
11.10%
Strongly
Affected
50.00%
50.00%
50.00%
50.00%
55.60%
44.40%
55.60%
33.30%
22.20%
22.20%
33.30%
22.20%
44.40%
N/A
40.00%
50.00%
50.00%
30.00%
33.30%
44.40%
33.30%
44.40%
55.60%
44.40%
33.30%
55.60%
44.40%
Note: Average affect of 52.70%
Table 2
Male veterans’ expressions to Question #1
J
C
Not
Affected
6.70%
6.70%
Mildly
Affected
20.00%
26.70%
Strongly
Affected
66.70%
53.30%
N/A
6.70%
13.30%
42
SP
DHL
SIA
SAF
MF
SEP
FEW
H
F
LCP
SAD
0.00%
0.00%
0.00%
13.30%
0.00%
0.00%
13.30%
20.00%
0.00%
6.70%
0.00%
0.00%
13.30%
20.00%
13.30%
40.00%
26.70%
46.70%
26.70%
33.30%
33.30%
26.70%
93.30%
86.70%
73.30%
60.00%
20.00%
46.70%
13.30%
33.30%
46.70%
20.00%
66.70%
6.70%
0.00%
6.70%
13.30%
40.00%
26.70%
26.70%
20.00%
20.00%
40.00%
6.70%
Question #12 - Which areas of social functioning are affected in patients/clients who feel
as if their futures will somehow be cut short?
Table 3
Female veterans’ expressions to Question #12
Not
Affected
J
0.00%
C
0.00%
SP
0.00%
DHL 0.00%
SIA 0.00%
SAF 0.00%
MF
0.00%
SEP 0.00%
FWE 11.10%
H
22.20%
F
22.20%
LCP 11.10%
SAD 11.10%
Mildly
Affected
11.10%
0.00%
0.00%
0.00%
11.10%
0.00%
11.10%
11.10%
11.10%
22.20%
11.10%
33.30%
11.10%
Strongly
Affected
44.40%
55.60%
55.60%
55.60%
44.40%
55.60%
44.40%
55.60%
33.30%
22.20%
33.30%
0.00%
33.30%
N/A
44.40%
44.40%
44.40%
44.40%
44.40%
44.40%
44.40%
33.30%
44.40%
33.30%
33.30%
55.60%
44.40%
43
Note: Average affect of 51.2%
Table 4
Male veterans’ expressions to Question #12
J
C
SP
DHL
SIA
SAF
MF
SEP
FWE
H
F
LCP
SAD
Not
Affected
7.70%
7.70%
0.00%
0.00%
0.00%
7.70%
7.70%
7.70%
15.40%
23.10%
15.40%
0.00%
0.00%
Mildly
Affected
15.40%
23.10%
7.70%
7.70%
15.40%
23.10%
23.10%
15.40%
0.00%
7.70%
7.70%
30.80%
7.70%
Strongly
Affected
53.80%
53.80%
69.20%
61.50%
61.50%
38.50%
23.10%
38.50%
38.50%
30.80%
46.20%
15.40%
69.20%
N/A
23.10%
15.40%
23.10%
30.80%
23.10%
30.80%
46.20%
38.50%
46.20%
38.50%
30.80%
53.80%
23.10%
Question #17 - Which areas of social functioning are affected in patients/clients who feel
jumpy or easily startled?
Table 5
Female veterans’ expressions to Question #17
Not
Affected
J
0.00%
C
0.00%
SP
0.00%
DHL 0.00%
SIA 0.00%
SAF 0.00%
MF
0.00%
SEP 0.00%
Mildly
Affected
11.10%
0.00%
0.00%
11.10%
0.00%
25.00%
12.50%
25.00%
Strongly
Affected
44.40%
55.60%
55.60%
55.60%
66.70%
37.50%
50.00%
37.50%
N/A
44.40%
44.40%
44.40%
33.30%
33.30%
37.50%
37.50%
37.50%
44
FWE
H
F
LCP
SAD
12.50%
25.00%
25.00%
0.00%
0.00%
37.50%
25.00%
37.50%
37.50%
25.00%
12.50%
12.50%
0.00%
12.50%
37.50%
37.50%
37.50%
37.50%
50.00%
37.50%
Note: average affect of 55.7%
Table 6
Male veterans’ expressions to Question #17
J
C
SP
DHL
SIA
SAF
MF
SEP
FWE
H
F
LCP
SAD
Not
Affected
7.70%
0.00%
7.70%
0.00%
0.00%
38.50%
7.70%
7.70%
23.10%
30.80%
38.50%
7.70%
7.70%
Mildly
Affected
46.20%
46.20%
30.80%
30.80%
30.80%
23.10%
23.10%
38.50%
30.80%
30.80%
23.10%
38.50%
23.10%
Strongly
Affected
46.20%
38.50%
53.80%
69.20%
61.50%
30.80%
23.10%
30.80%
0.00%
7.70%
7.70%
0.00%
38.50%
N/A
0.00%
15.40%
7.70%
0.00%
7.70%
7.70%
46.20%
23.10%
46.20%
30.80%
30.80%
30.80%
30.80%
The following questions were found to have the least effect on females (lowest
affect averages), with the following frequency data to support this:
Question #4 - Which areas of social functioning are affected in patients/clients who feel
very upset when something reminds them of a stressful military experience?
45
Table 7
Female veterans’ expressions to Question #4
Not
Affected
J
0.00%
C
0.00%
SP
0.00%
DHL 0.00%
SIA 0.00%
SAF 0.00%
MF
0.00%
SEP 0.00%
FWE 10.00%
H
10.00%
F
10.00%
LCP 0.00%
SAD 0.00%
Mildly
Affected
22.20%
0.00%
0.00%
11.10%
0.00%
11.10%
11.10%
22.20%
30.00%
20.00%
30.00%
22.20%
0.00%
Strongly
Affected
44.40%
44.40%
44.40%
44.40%
66.70%
33.30%
33.30%
33.30%
0.00%
10.00%
10.00%
11.10%
44.00%
N/A
33.30%
55.60%
55.60%
44.40%
33.30%
55.60%
55.60%
44.40%
60.00%
60.00%
50.00%
66.70%
55.60%
Note: Average affect of 46.1%
Table 8
Male veterans’ expressions to Question #4
J
C
SP
DHL
SIA
SAF
MF
SEP
FWE
H
F
LCP
Not
Affected
7.70%
15.40%
0.00%
0.00%
7.70%
15.40%
7.70%
7.70%
23.10%
23.10%
15.40%
7.70%
Mildly
Affected
23.10%
38.50%
38.50%
38.50%
30.80%
38.50%
23.10%
38.50%
30.80%
30.80%
38.50%
7.70%
Strongly
Affected
61.50%
38.50%
53.80%
61.50%
53.80%
30.80%
23.10%
30.80%
7.70%
15.40%
23.10%
38.50%
N/A
7.70%
7.70%
7.70%
0.00%
7.70%
15.40%
46.20%
22.10%
38.50%
30.80%
23.10%
46.20%
46
SAD
0.00%
15.40%
61.50%
23.10%
Question #8 - Which areas of social functioning are affected in patients/clients who have
trouble remembering important parts of a stressful military experience?
Table 9
Female veterans’ expressions to Question #8
Not
Affected
J
11.10%
C
22.20%
SP
0.00%
DHL 0.00%
SIA 0.00%
SAF 0.00%
MF
11.00%
SEP 22.20%
FWE 33.30%
H
44.40%
F
33.30%
LCP 22.20%
SAD 11.10%
Mildly
Affected
33.30%
33.30%
55.60%
55.60%
55.60%
55.60%
0.00%
33.30%
22.20%
11.10%
22.20%
22.20%
55.60%
Strongly
Affected
22.20%
0.00%
0.00%
0.00%
0.00%
0.00%
44.40%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
N/A
33.30%
44.40%
44.40%
44.40%
44.40%
44.40%
44.40%
44.40%
44.40%
44.40%
44.40%
55.60%
33.30%
Note : Average affect of 40.1%
Table 10
Male veterans’ expressions to Question #8
J
C
SP
DHL
SIA
SAF
Not
Affected
7.70%
7.70%
7.70%
7.70%
7.70%
7.70%
Mildly
Affected
38.50%
46.20%
30.80%
38.50%
46.20%
53.80%
Strongly
Affected
23.10%
15.40%
30.80%
23.10%
15.40%
7.70%
N/A
30.80%
30.80%
30.80%
30.80%
30.80%
30.80%
47
MF
SEP
FWE
H
F
LCP
SAD
7.70%
23.10%
15.40%
30.80%
30.80%
15.40%
7.70%
23.10%
23.10%
38.40%
23.10%
23.10%
23.10%
38.50%
23.10%
15.40%
0.00%
7.70%
15.40%
7.70%
23.10%
46.20%
38.40%
46.20%
38.50%
30.80%
53.80%
30.80%
Question #15 - Which areas of social functioning are affected in patients/clients who
have difficulty concentrating?
Table 11
Female veterans’ expressions to Question #15
Not
Affected
J
0.00%
C
0.00%
SP
0.00%
DHL 0.00%
SIA 0.00%
SAF 0.00%
MF
0.00%
SEP 0.00%
FWE 33.30%
H
22.20%
F
22.20%
LCP 11.10%
SAD 11.10%
Mildly
Affected
11.10%
44.40%
11.10%
11.10%
33.30%
33.30%
0.00%
11.10%
22.20%
11.10%
11.10%
33.30%
33.30%
Strongly
Affected
44.40%
22.20%
44.40%
44.40%
22.20%
22.20%
55.60%
44.40%
0.00%
33.30%
22.20%
0.00%
11.10%
N/A
44.40%
33.30%
44.40%
44.40%
44.40%
44.40%
44.40%
44.40%
44.40%
33.30%
44.40%
55.60%
44.40%
Note: Average affect of 48.6%
Table 12
Male veterans’ expressions to Question 15
J
Not
Affected
7.70%
Mildly
Affected
23.10%
Strongly
Affected
69.20%
N/A
0.00%
48
C
SP
DHL
SIA
SAF
MF
SEP
FWE
H
F
LCP
SAD
15.40%
7.70%
0.00%
7.70%
15.40%
0.00%
7.70%
30.80%
23.10%
7.70%
7.70%
0.00%
46.20%
46.20%
38.50%
46.20%
53.80%
23.10%
15.40%
30.80%
38.50%
23.10%
38.50%
38.50%
23.10%
38.50%
46.20%
38.50%
15.40%
30.80%
53.80%
0.00%
7.70%
38.50%
0.00%
30.80%
15.40%
7.70%
15.40%
7.70%
15.40%
46.20%
23.10%
38.50%
30.80%
30.80%
53.80%
30.80%
Hypothesis Support
The researchers hypothesized that the gap in PTSD diagnosing and services for
female veterans may be the result of a gender biased diagnostic tool, and that social and
environmental factors affected by PTSD could be different for men and women.
Consequently, these differences could skew a clinician’s determination of a formalized
diagnosis of PTSD. Preliminary results analyzing the three highest and lowest affecting
questions show evidence to suggest that female and male veterans may indeed express
some symptoms in different areas of their social functioning and expresses them to
different degrees.
49
Figures 1-6 show the most significantly affected symptoms reported by clinicians in
reference to female veterans. Male-reported symptoms, however, may appear much more
strongly perceived by clinicians due to their outward manifestation, and therefore female
symptoms may appear less apparent to a diagnosing clinician.
Figure 1. Strongly Affected/Mildly Affected responses for Question 1
Figure 2. Strongly Affected/Mildly Affected responses for Question 12
50
Figure 3. Strongly Affected/Mildly Affected responses for Question 17
Figure 4. Strongly Affected/Mildly Affected responses for Question 4
51
Figure 5. Strongly Affected/Mildly Affected responses for Question 15
Figure 6, however, demonstrates that some symptom expression in male and
female veterans bears no measurably significant difference.
Figure 6. Strongly Affected/Mildly Affected responses for Question 8
52
Conclusion
Data suggests that gender may be a factor as to how the outward manifestations of
PTSD symptoms display in men and women, specifically how those symptoms affect
psycho/social functioning. In most cases, men appeared to present more strongly in their
prospective environments, and may suggest that the more subtle displays of women could
be overlooked or even dismissed if the norm is projected as being visibly evident.
53
Chapter 5
CONCLUSIONS AND IMPLICATIONS
The purpose of this exploratory study was to examine differences in PTSD
symptoms displayed by both men and women and the variation in symptom
manifestations within the Axis IV systems associated with their personal and professional
lives. In considering this wider area of classifications, we hoped to suggest a more
effective assessment tool that can provide a more accurate diagnosis for both male and
female service members suffering from PTSD. The secondary purpose of this study is to
convey greater awareness that women are being exposed to combat-related trauma and
not being properly diagnosed. The research study collected twenty-seven on-line surveys
from study participants who, based on their clinical credentials and licensure standards,
were qualified and trained in diagnosing and treating veterans who may have post
traumatic stress disorder symptoms. The results of those surveys were summarized in the
preceding chapter. This chapter will highlight the data findings as well as discuss whether
the findings support the need for a gender responsive assessment tool in order to properly
diagnose female veterans and the implications within the field of social work.
Conclusions of Main Findings
The outcomes generated from the surveys produced findings that suggest that the
PTSD symptoms of 1) repeated, disturbing memories, thoughts, or images of a stressful
military experience, 2) feeling as if their futures will somehow be cut short, and 3)
feeling jumpy or easily startled were the symptoms most affected as reported by
clinicians in reference to female veterans within the Axis IV psycho-social-emotional
54
systems. Reversely responses regarding the symptoms of 1) feeling very upset when
something reminds them of a stressful military experience, and 2) having difficulty
concentrating were the least significantly affected symptoms reported by clinicians in
reference to female veterans within their Axis IV psycho-social-emotional systems. In
most cases these symptoms had a greater affect on the male veterans’ psycho-socialemotional systems. The exception to these results was in regards to the symptom of
having trouble remembering important parts of a stressful military experience. In this
instance the symptom expression in male and female veterans bears no measurable
significant difference. In both the highly affected and less affected data sets the male’s
percentages were significantly higher than women’s in almost every system that men
reported being mostly affected or mildly affected by. This supports the hypothesis that
males express their symptoms more intensely then female veterans and may support the
explanation for the under-diagnosis or misdiagnosis of PTSD for female veterans. These
results also suggest that the male-reported symptoms may be more strongly perceived by
clinicians due to their outward manifestation, whereas female symptoms may appear less
apparent to a diagnosing clinician.
As mentioned in Chapter 2, the empirical research supports the presumption that
it is important to recognize that there are gender differences in PTSD symptomatologies
and in order to give a proper diagnosis, it is important to understand and identify these
differences upon initial assessment. One possible justification for the skewed diagnosis
between men and women is that gender role expectations may be more supportive or
tolerant of certain symptoms in female participants and of other symptoms in male
55
participants (Tolin et al, 2002). These findings support our initial hypothesis that female
veterans PTSD symptoms are expressed differently than their male counterparts. The
data indicated that female veteran’s symptoms tend to have a greater affect on their social
and emotional relationships and less on negative coping mechanisms such as substance
abuse and /or criminal and legal problems. Figure 1 in the preceding chapter showed that
an average of 50% or greater, of female veterans were strongly or mildly affected by the
PTSD symptom of having repeated, disturbing memories, thoughts, or images of a
stressful military experience. Figure 1 further illustrates that the highest impacted areas
for female veterans were primarily the interpersonal and familial systems. Reversely the
areas that had the lowest percentage of being affected for females were the social and
emotional systems consisting of occupational and environmental stressors. Alternatively,
these were consistently the areas that male veterans had higher levels of being affected by
the PTSD symptoms. The figures also show that even in the environmental areas that
females did have the highest percentages of being affected in comparison to other
symptoms of PTSD, the male veterans usually had an even higher percentage for these
symptoms then the then the females. Due to clinicians often seeing male veterans as
having a more highly elevated and pronounced expression of these PTSD symptoms
compared to female veterans, the clinicians may be down playing female symptoms and
under diagnosing PTSD.
As discussed in Chapter 2 in a study looking at the gender differences of anger
with PTSD, results showed that men scored higher than women on the Assault, Indirect
Hostility, Irritability and Verbal Hostility scales. This confirmed theories that men with
56
posttraumatic stress have higher scores of outward manifestations of anger with PTSD
than women (Castillo et al, 2002). Our preliminary data analysis suggests that males
express their PTSD symptoms more often in the in the areas of substance abuse, sexual
activity and function and increase in problems with criminal and legal problems. Often
more outwardly these manifestations of anger are expressed symptoms and are likely to
be seen as problematic or high-risk behaviors. Due to the severity of the expression of
these symptoms many therapist may have quicker intervention responses. Whereas with
female veterans, their symptoms frequently affect their interpersonal and familial
systems, and may illicit a less urgent intervention response since their PTSD symptoms
are not perceived as an impairment or risk of imminent harm to themselves or others.
These results suggest a possible explanation as to why females are often misdiagnosed or
under diagnosed. It can be inferred that from the data that since the female symptom
expression is not as overt as their male counterparts, females PTSD symptoms may be
under-diagnosed as PTSD and instead diagnosed as having anxiety disorders, depression
or adjustment disorders. Their [female veterans] symptomatologies may be perceived as
more manageable and not worth reporting, whereas as the males factors, such as
problems related to their sexual activity or substance abuse have a greater impact on their
ability to function or cope, and are therefore less manageable and more often reported.
Furthermore, as discussed in Chapter 2, prior research gives one possible explanation for
the differences in gender symptom patterns that the fact that certain symptoms are more
socially supported, encouraged and tolerated within the parameters of both female and
male gender roles (Tolin & Foa, 2006). Based on these findings, further research should
57
be done to determine whether these outward manifestations of anger are more likely to
present upon initial PTSD screenings with men versus women.
Implications
This research project results suggest that PTSD symptoms may affect women and
men differently due to gender differences in PTSD system manifestations within the Axis
IV systems. The research furthermore indicates the need to create a more precise
screening or assessment tool that is more gender responsive. Such a tool would
appropriately enable clinicians to create more accurate, fluid and congruent treatment
plans for both male and female soldiers suffering from PTSD.
The implications for future research based on the current findings show the need
to explore the differences in actual symptoms expressed by both male and female
veterans. There are also disparities in understanding the variations in how these
symptoms are expressed within each Axis IV system. Future research could examine any
one of the 442 variables superficially examined by the researchers in regards to the
psychosocial systems affected and the corresponding symptom expression given by male
and female participants, in an attempt to understand the causality for these differences
between the genders. For instance in the six questions referenced in the previous chapter
the participants reported that the PTSD symptoms had a greater affect on substance abuse
was more prevalent in male veterans then in female veterans.
Limitations
This study was limited to only surveying professional providers, such as mental
health clinicians that treat veterans. The researchers were unable to directly survey male
58
and female veterans receiving mental health services for PTSD diagnosis. As a result of
not being able to interview the veterans themselves we were unable to find out if they had
been exposed to direct combat trauma, combat –at all. Prior to OEF/OIF, male veterans
had more direct combat exposure on average than their female counterparts. However,
as the role of women in the military grows and the implications of their roles are being
studied, more information is becoming available about gender differences in combatrelated PTSD (Tolin & Foa, 2006). We also did not account for how often or how many
times the veterans had been forward deployed to a combat zone. Thus far, it appears that
women are just as likely to be involved in combat when deployed but are less likely than
men to be directly exposed to traumatic events while in combat (Zinzow et al 2007).
There are also other risk factors that can increase a veteran’s predisposition to
PTSD. The survey did not include questions to assess any history of suicidal ideation or
previous mental health diagnosis. PTSD is highly co-occurring with other psychiatric
disorders, including depression, social phobia, panic disorder, substance-related
disorders, and other mood/anxiety disorders (Feczer et al, 2009; Haskell et al., 2010;
Carter-Visscher et al., 2010). The research survey did not differentiate if the PTSD
symptoms were as a result of just combat trauma or if there was a history of other past
trauma experiences (i.e. sexual trauma, prior childhood abuse and military sexual
trauma). Several research studies have shown that sexual trauma is a greater indicator for
whether or not a person is susceptible to PTSD (Follette et al, 1996; Tolin et al, 2006).
There is evidence that regardless of gender, if a person has experienced sexual trauma,
they have a higher rate of being diagnosed with PTSD.
59
The research is also limited because of the lack of participation in taking the
survey. The survey was emailed out to over 300 qualified professionals and the snowball
method of data collection was utilized in that the email encouraged the participants to
forward the email on to other possible qualified participants. In the time line given only
thirty-seven participants responded and completed the on-line survey. There were also a
greater number of surveys that were completed regarding just the male veterans then fully
completed surveys for both male and female veterans. The assumption that is inferred
from this difference is that the therapists work primarily with male veterans versus both
male and female veterans. This discrepancy in a larger percentage of male veterans
receiving treatment as opposed to female veterans may be due to several factors as
previously discussed in the empirical research in Chapter 2.
In one study it was found that female veterans appear less likely to use VA mental
health services as compared to male veterans. However, women have been found to use
mental health outside of the VA system at significantly higher rates (Zinzow et al, 2007).
Despite seeking services in social work settings outside of the Veteran’s Administration
system, women “rarely identify themselves as veterans nor do professionals often inquire
about military services,” probably due to a lack of knowledge about trauma, PTSD and
treatment options on the part of the clinician (Chaumba, 2010, p. 281). If this research
could have been expanded then a larger and more in-depth analysis of the data collected
may have been able to show a stronger association between the differences in PTSD
symptomatologies and how they affect male and females Axis IV systems differently.
Due to time constraints, we chose to focus on the six most significant primary data sets.
60
Summary
Traditional PTSD screening tools have been predominately tested on males and
do not screen for gender differences. As a result, women seeking services are screened
with tools designed to assess for symptoms commonly described by males. This
incongruence can also lead to a deficient treatment plan that is not gender responsive.
The research demonstrates that symptoms of PTSD in women manifest in different areas
of life not explored in the common military PTSD screening checklist. Therefore, many
women are misdiagnosed, under-diagnosed or not diagnosed at all properly for PTSD.
Without proper diagnostic tools, it is difficult to fully address the personal and
professional needs that women may be struggling with as a result of their PTSD. It is
critical to create an assessment tool that considers these gender differences in
symptomatologies.
61
APPENDICES
62
APPENDIX A
Introduction Letter and Consent to Participate
Dear Participants:
The following information will be used to determine better strategies for identifying and
understanding PTSD symptom manifestations in female and male OEF/OIF veterans in
relation to their social functioning within different life systems (Axis IV). It will take
approximately 10-15 min to complete. Please generalize you answers in order to
represent most patients/clients you work with.
Thank you for participating in following questionnaire on Clinical Perspectives on
Gender Differences in Social Functioning and Symptomatology for OEF/OIF Veterans
with PTSD. Your participation in research will assist in investigating the relationship
these gender differences and how those symptoms affect the different life systems in
which veterans live and participate. The researcher(s) anticipates the data collected will
assist in advocating for additional assessment tools and programs designed with these
possible gender difference taken into consideration.
Please read through the following states regarding your participation. Your signature and
initials will indicate you have read and are in agreement with the terms and conditions of
this study. If you have any questions about this research, you may contact Adriana
Galvez at (916) 889-6694 or via e-mail at arglvz@gmail.com or contact Stephanie Ladd
at (707) 208- 7959 or via email at stephmcmullen@yahoo.com. You may also contact the
Faculty Advisor for this project, Dr. Susan Eggman at (916) 278-7181 or via e-mail at
eggmans@csus.edu.
Please feel free to print this page as record of your participation and future reference.
Thank you for your participation!
63
Consent to Participate
I agree to take part in this research study about gender differences in PTSD
symptomatologies conducted by Adriana Galvez and Stephanie Ladd, students in the
Social Work Graduate program at California State University, Sacramento. I understand
I will be asked to complete an on-line survey that will inquire as to my understanding of
symptoms of clients I have previously worked with.
I understand that the questionnaire may bring up positive or negative feelings
surrounding my work and the clients that I work with. In the event that participating in
this survey triggers any psychological stress, I agree to seek mental health support
through my individual insurance provider or other related mental health support system.
I understand that my participation is voluntary and I can refuse to participate at any time.
I understand I will receive no monetary compensation for my participation. I understand
that the surveys will be anonymous and will not be shared with other participants but will
be analyzed and used in the findings of this research project.
I understand the findings will be reported in aggregate so that no personal information
may be traced back to me.
Do you accept the terms of this agreement?
To continue, please click "I Accept" below and "Next".
If you decline to continue, please click the
"Exit Survey" button located on the upper right hand of the screen.
Thank you!
2. Consent for Participation
o n "I Accept."
64
APPENDIX B
On – Line Survey
Part 1
Please identify the following demographic information.
1. Please identify your gender:
o Male
o Female
o Other
2. Are you currently serving in any branch of the US military?
o Yes
o No
3. Have you ever previously served in any branch of the U.S. military?
o Yes
o No
4. What is your training in the field of mental health?
o MSW/LCSW
o MFT/LMFT
o PhD.
o PsyD.
o M.D.
o Paraprofessional
o Other
5. How many years of experience do you have working in the field of mental health?
3. Part I0-4 yrs
o 4-8 yrs
o 8-12 yrs
o 12+ yrs
65
Part II
For Part II, please consider male OEF/OIF veterans that you have treated within the past
8 years for mental health services. Below is an adapted version of the PTSD Checklist –
Military Version. Overall, please generalize your experiences with male OEF/OIF
veterans and rate their symptom expression in the following subcategories:
1. Which areas of social functioning are affected in patients/clients who have
repeated, disturbing memories, thoughts, or images of a stressful military
experience?
4. Part II
Not Affected
Mildly
Strongly
N/A
Affected
Affected
Job/occupation
o
o
o
o
Children
o
o
o
o
Spouse/partner
o
o
o
o
Daily home life
o
o
o
o
Social
o
o
o
o
Interactions/Activities
o
o
o
o
Sexual
o
o
o
o
activity/function
Military functioning
o
o
o
o
School/educational
o
o
o
o
pursuits
Faith/worship
o
o
o
o
expression
Housing
o
o
o
o
Finances
o
o
o
o
Legal/Criminal
o
o
o
o
Problems
Substance
o
o
o
o
Abuse/Dependency
o
o
o
o
2. Which areas of social functioning are affected in patients/clients who have
repeated, disturbing dreams of a stressful military experience from the past?
Not Affected
Job/occupation
o
Mildly
Affected
Strongly
Affected
o
o
N/A
o
66
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3. Which areas of social functioning are affected in patients/clients who Suddenly
begin acting or feeling as if a stressful military experience were happening again (as
if they were reliving it)?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
67
Finances
o
o
o
o
Legal/Criminal
o
o
o
o
Problems
Substance
o
o
o
o
Abuse/Dependency
o
o
o
o
Clinical Perspectives on Gender Differences in Social Functioning and
4. Which areas of social functioning are affected in patients/clients who feel very
upset when something reminds them of a stressful military experience?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
5. Which areas of social functioning are affected in patients/clients who have
physical reactions (e.g., heart pounding, trouble breathing or sweating) when
something reminds them of a stressful military experience?
Not Affected
Job/occupation
Children
o
o
Mildly
Affected
Strongly
Affected
o
o
o
o
N/A
o
o
68
Spouse/partner
o
o
o
o
Daily home life
o
o
o
o
Social
o
o
o
o
Interactions/Activities
o
o
o
o
Sexual
o
o
o
o
activity/function
Military functioning
o
o
o
o
School/educational
o
o
o
o
pursuits
Faith/worship
o
o
o
o
expression
Housing
o
o
o
o
Finances
o
o
o
o
Legal/Criminal
o
o
o
o
Problems
Substance
o
o
o
o
Abuse/Dependency
o
o
o
o
Clinical Perspectives on Gender Differences in Social Functioning and
6. Which areas of social functioning are affected in patients/clients who avoid
thinking about or talking about a stressful military experience or avoid having
feelings related to it:
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
69
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
7. Which areas of social functioning are affected in patients/clients who avoid
activities or situations because they remind them of stressful military experiences:
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
8. Which areas of social functioning are affected in patients/clients who have trouble
remembering important parts of a stressful military experience?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
o
o
o
o
Mildly
Affected
Strongly
Affected
o
o
o
o
o
o
o
o
N/A
o
o
o
o
70
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
9. Which areas of social functioning are affected in patients/clients who have a loss
of interest in things that they used to enjoy?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
71
Abuse/Dependency
o
o
o
o
Gender Differences in Social Functioning and
10. Which areas of social functioning are affected in patients/clients who feel distant
or cut off from other people within the following areas:
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
11. Which areas of social functioning are affected in patients/clients who seem to feel
emotionally numb or are unable to have loving feelings for those close to them:
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
o
o
o
o
o
o
o
Mildly
Affected
Strongly
Affected
o
o
o
o
o
o
o
o
o
o
o
o
o
o
N/A
o
o
o
o
o
o
o
72
activity/function
Military functioning
o
o
o
o
School/educational
o
o
o
o
pursuits
Faith/worship
o
o
o
o
expression
Housing
o
o
o
o
Finances
o
o
o
o
Legal/Criminal
o
o
o
o
Problems
Substance
o
o
o
o
Abuse/Dependency
o
o
o
o
n Social Functioning and
12. Which areas of social functioning are affected in patients/clients who feel as if
their futures will somehow be cut short?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
73
13. Which areas of social functioning are affected in patients/clients having trouble
falling or staying asleep:
Not Affected
Mildly
Affected
Strongly
Affected
N/A
Job/occupation
o
o
o
o
Children
o
o
o
o
Spouse/partner
o
o
o
o
Daily home life
o
o
o
o
Social
o
o
o
o
Interactions/Activities
o
o
o
o
Sexual
o
o
o
o
activity/function
Military functioning
o
o
o
o
School/educational
o
o
o
o
pursuits
Faith/worship
o
o
o
o
expression
Housing
o
o
o
o
Finances
o
o
o
o
Legal/Criminal
o
o
o
o
Problems
Substance
o
o
o
o
Abuse/Dependency
o
o
o
o
Perspectives on Gender Differences in Social Functioning and
14. Which areas of social functioning are affected in patients/clients who feel
irritable or have angry outbursts?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
74
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
15. Which areas of social functioning are affected in patients/clients who have
difficulty concentrating?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
16. Which areas of social functioning are affected in patients/clients who become
super alert or watchful on guard?
75
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
17. Which areas of social functioning are affected in patients/clients who feel jumpy
or easily startled?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
76
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
77
For Part III, please consider female OEF/OIF veterans that you have treated within the
past 8 years for mental health services. Below is an adapted version of the PTSD
Checklist – Military Version. Overall, please generalize your experiences with female
OEF/OIF veterans and rate their symptom expression in the following subcategories:
1. Which areas of social functioning are affected in patients/clients who have
repeated, disturbing memories, thoughts, or images of a stressful military
experience?
5. Part III
C
Not Affected
Mildly
Strongly
N/A
Affected
Affected
Job/occupation
o
o
o
o
Children
o
o
o
o
Spouse/partner
o
o
o
o
Daily home life
o
o
o
o
Social
o
o
o
o
Interactions/Activities
o
o
o
o
Sexual
o
o
o
o
activity/function
Military functioning
o
o
o
o
School/educational
o
o
o
o
pursuits
Faith/worship
o
o
o
o
expression
Housing
o
o
o
o
Finances
o
o
o
o
Legal/Criminal
o
o
o
o
Problems
Substance
o
o
o
o
Abuse/Dependency
o
o
o
o
2. Which areas of social functioning are affected in patients/clients who have
repeated, disturbing dreams of a stressful military?
Not Affected
Job/occupation
Children
Spouse/partner
o
o
o
Mildly
Affected
Strongly
Affected
o
o
o
o
o
o
N/A
o
o
o
78
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3. Which areas of social functioning are affected in patients/clients who suddenly
begin acting or feeling as if a stressful military experience were happening again (as
if they were reliving it)?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
79
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
Clinical Perspectives on Gender Differences in Social Functioning and
4. Which areas of social functioning are affected in patients/clients who feel very
upset when of a stressful military experience?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
5. Which areas of social functioning are affected in patients/clients who have
physical reactions (e.g., heart pounding, trouble breathing or sweating) when
something reminds them of a stressful military experience?
Not Affected
Job/occupation
Children
o
o
Mildly
Affected
Strongly
Affected
o
o
o
o
N/A
o
o
80
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
6. Which areas of social functioning are affected in patients/clients who avoid
thinking about or talking about a stressful military experience or avoid having
feelings related to it:
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
81
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
7. Which areas of social functioning are affected in patients/clients who avoid
activities or situations because they remind them of a stressful military experiences:
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
8. Which areas of social functioning are affected in patients/clients who have trouble
remembering important parts of a stressful military experience?
Not Affected
Job/occupation
Children
Spouse/partner
o
o
o
Mildly
Affected
Strongly
Affected
o
o
o
o
o
o
N/A
o
o
o
82
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
9. Which areas of social functioning are affected in patients/clients who have a loss
of interest in things that they used to enjoy?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
83
Substance
o
o
o
o
Abuse/Dependency
o
o
o
o
Clinical Perspectives on Gender Differences in Social Functioning and
10. Which areas of social functioning are affected in patients/clients who feel distant
or cut off from other people within the following areas:
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
11. Which areas of social functioning are affected in patients/clients who seem to feel
emotionally numb or are unable to have loving feelings for those close to them:
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
o
o
o
o
o
o
Mildly
Affected
Strongly
Affected
o
o
o
o
o
o
o
o
o
o
o
o
N/A
o
o
o
o
o
o
84
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
12. Which areas of social functioning are affected in patients/clients who feel as if
their futures will somehow be cut short?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
85
13. Which areas of social functioning are affected in patients/clients having trouble
falling or staying asleep:
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
14. Which areas of social functioning are affected in patients/clients who feel
irritable or have angry outbursts?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
86
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
15. Which areas of social functioning are affected in patients/clients who have
difficulty concentrating?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
16. Which areas of social functioning are affected in patients/clients who become
super alert or watchful on guard?
87
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
17. Which areas of social functioning are affected in patients/clients who feel jumpy
or easily started?
Not Affected
Job/occupation
Children
Spouse/partner
Daily home life
Social
Interactions/Activities
Sexual
activity/function
Military functioning
School/educational
pursuits
Faith/worship
Mildly
Affected
Strongly
Affected
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
88
expression
Housing
Finances
Legal/Criminal
Problems
Substance
Abuse/Dependency
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
89
REFERENCES
Benda, B. & House, H. (2003). Does PTSD differ according to gender among military
veterans? Journal of Family Social Work, 7(1), 15-34.
Benda, B. (2006). Survival analyses and social support and trauma among homeless male
and female veterans who abuse substances. American Journal of
Orthopsychiatry, 76, 70-79.
Carter-Visscher, R. , Polusny, M. , Murdoch, M. , Thuras, P. , Erbes, C. , et al. (2010).
Predeployment gender differences in stressors and mental health among U.S.
National Guard troops poised for Operation Iraqi Freedom deployment. Journal
of Traumatic Stress, 23(1), 78-85.
Castillo, D. , Fallon, S. , C'De Baca, J. , Conforti, K. , & Qualls, C. (2002). Anger in
PTSD: General psychiatric and gender differences on the BDHI. Journal of Loss
& Trauma, 7(2), 119-128.
Chaumba, J. , & Bride, B. (2010). Trauma experiences and posttraumatic stress disorder
among women in the United States military. Social Work in Mental Health, 8(3),
280-303.
Choudhary, C. , & O'Carroll, R. (2007). Left hand preference is related to posttraumatic
stress disorder. Journal of Traumatic Stress, 20(3), 365-369.
Department of Defense (2009). Active duty military personnel by rank and grade:
September 2009 (women only). 2009. Retrieved August 28, 2010, from the
Department of Defense:
http://siadapp.dmdc.osd.mil/personnel/MILITARY/rg0909f.pdf
90
Dobie, D. , Kivlahan, D. , Maynard, C. , Bush, K. , Davis, T. , et al. (2004). Posttraumatic
stress disorder in female veterans: Association with self-reported health problems
and functional impairment. Archives of Internal Medicine, 164(4), 394-400.
Feinstein, A. , & Sinyor, M. (2009). Women war correspondents: They are different in so
many ways. Nieman Reports, 63(4), 24-25.
Feczer, D. , & Bjorklund, P. (2009). Forever changed: Posttraumatic stress disorder in
female military veterans, a case report. Perspectives in Psychiatric Care, 45(4),
278-291.
Felmingham, K. , Williams, L. , Kemp, A. , Liddell, B. , Falconer, E. , et al. (2010).
Neural responses to masked fear faces: Sex differences and trauma exposure in
posttraumatic stress disorder. Journal of Abnormal Psychology, 119(1), 241-247.
Follette, V. , Polusny, M. , Bechtle, A. , & Naugle, A. (1996). Cumulative trauma: The
impact of child sexual abuse, adult sexual assault, and spouse abuse. Journal of
Traumatic Stress, 9(1), 25-35.
Friedman, M. (2006). Posttraumatic stress disorder among military returnees from
Afghanistan and Iraq. American Journal of Psychiatry, 163(4), 586-593.
Gahm, G.A., Lucenko, B.A., Retzlaff, P., & Fukuda, S. (2007). Relative impact of
adverse events and screened symptoms of posttraumatic stress disorder and
depression among active duty soldiers seeking mental health care. Journal of
Clinical Psychology, 63(3), 199-211.
Geppert, C. , & Maiers, A. (2009). From war to home: Psychiatric emergencies of
returning veterans. Psychiatric Times, 26(10), 1-7.
91
Goldzweig, C.L., Balekian, T.M., Rolon, C., Yano, E.M., & Shekelle, P.G. (2006). The
state of women veterans’ health research. Journal of General Internal Medicine,
21(3), 82-92.
Grossman, L.S., Willer, J.K., Stovall, J.G., McRae, S.G., Maxwell, S. & Nelson, R.
(1997). Under diagnosis of PTSD and substance use disorders in hospitalized
female veterans. Psychiatric Services, 48(3), 393-395.
Haskell, S. , Gordon, K. , Mattocks, K. , Duggal, M. , Erdos, J. , et al. (2010). Gender
differences in rates of depression, PTSD, pain, obesity, and military sexual trauma
among Connecticut war veterans of Iraq and Afghanistan. Journal of Women's
Health (15409996), 19(2), 267-271.
Hughes, J. , Feldman, M. , & Beckham, J. (2006). Posttraumatic stress disorder is
associated with attenuated baroreceptor sensitivity among female, but not male,
smokers. Biological Psychology, 71(3), 296-302.
Jakupcak, M. , Conybeare, D. , Phelps, L. , Hunt, S. , Holmes, H. , et al. (2007). Anger,
hostility, and aggression among Iraq and Afghanistan war veterans reporting
PTSD and sub threshold PTSD. Journal of Traumatic Stress, 20(6), 945-954.
Joint Economic Committee (2007). Helping military moms balance family and longer
deployments. Washington, DC: Author.
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(3), 191-195.
Kaplan, A. (2008). Untreated vets: A "gathering storm" of PTSD/depression. Psychiatric
Times, 25(12), 12-13.
92
Katz, L. , Cojucar, G. , Davenport, C. , Pedram, C. , & Lindl, C. (2010). Post-deployment
readjustment inventory: Reliability, validity, and gender differences. Military
Psychology, 22(1), 41-56.
Kelly, M. , Vogt, D. , Scheiderer, E. , Ouimette, P. , Daley, J. (2008). Effects of military
trauma exposure on women veterans' use and perceptions of veterans’ health
administration care. JGIM: Journal of General Internal Medicine, 23(6), 741-747.
King, D. , & King, L. (1996). Prewar factors in combat-related posttraumatic stress
disorder: Structural equation modeling with... Journal of Consulting & Clinical
Psychology, 64(3), 520-531.
Leerhsen, C. , & Mabry, M. (1991). The second battleground. Newsweek, 117(18), 60-61.
Lunney, C. , & Schnurr, P. (2007). Domains of quality of life and symptoms in male
veterans treated for posttraumatic stress disorder. Journal of Traumatic Stress,
20(6), 955-964.
McCormack, L. (2009). Civilian women at war: Psychological impact decades after the
Vietnam War. Journal of Loss & Trauma, 14(6), 447-458.
Murdoch, M., Hodges, J., Hunt, C. Cowper, D., Kressin, N., & O’Brien, N. (2003).
Gender differences in service connection for PTSD. Medical Care, 41(8), 950961.
Nunnink, S. , Goldwaser, G. , Heppner, P. , Pittman, J. , Nievergelt, C. , et al. (2010).
Female veterans of the OEF / OIF conflict: Concordance of PTSD symptoms and
substance misuse. Addictive Behaviors, 35(7), 655-659.
93
Office of the Actuary, Department of Veterans Affairs (2004). VetPop2004 Version 1.0.
Retrieved August 28, 2010, from http://www.va.gov/vetdata/
Peirce, J. , Kindbom, K. , Waesche, M. , Yuscavage, A. , & Brooner, R. (2008).
Posttraumatic stress disorder, gender, and problem profiles in substance
dependent patients. Substance Use & Misuse, 43(5), 596-611.
Pereira, A. (2002). Combat trauma and the diagnosis of post-traumatic stress disorder in
female and male veterans. Military Medicine, 167(1), 23-27.
Regalado, A. (2003). The war inside the mind. Wall Street Journal - Eastern Edition,
241(69), B1--1.
Sadler, A.G., Booth, B.M., Cook, B.L., & Doebbeling, B.N. (2003). Factors associated
with women’s risk of rape in the military environment. American Journal of
Industrial Medicine, 43, 262-273.
Savas, L. , White, D. , Wieman, M. , Daci, K. , Fitzgerald, S. , et al. (2009). Irritable
bowel syndrome and dyspepsia among women veterans: Prevalence and
association with psychological distress. Alimentary Pharmacology &
Therapeutics, 29(1), 115-125.
Scannell-Desch, E. (2005). Lessons learned and advice from Vietnam War nurses: A
qualitative study. Journal of Advanced Nursing, 49(6), 600-607.
Schultz, J.R., Bell, K.M., Naugle, A.E. & Polusny, M.A. (2006). Child sexual abuse and
adulthood sexual assault among military veteran and civilian women. Military
Medicine, 171, 723-728.
94
Sherer, R. (2007). VA statistics show large number of vets with psychiatric diagnoses.
Psychiatric Times, 24(6), 1-8.
Spoont, M. , Sayer, N. , Friedemann-Sanchez, G. , Parker, L. , Murdoch, M. , et al.
(2009). From trauma to PTSD: Beliefs about sensations, symptoms, and mental
illness. Qualitative Health Research, 19(10), 1456-1465.
Stein, M. , Hanna, C. , Vaerum, V. , & Koverola, C. (1999). Memory functioning in adult
women traumatized by childhood sexual abuse. Journal of Traumatic Stress,
12(3), 527-534.
Street, A. , 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), 685-694.
Suris, A., Lind, L., Kashner, T.M, Borman, P.D., & Petty, F. (2004). Sexual assault in
women veterans: An examination of PTSD risk, health care utilization, and cost
of care. Psychosomatic Medicine, 66(5), 749-756.
Tolin, D., & Foa, E. (2006). Sex Differences in Trauma and Posttraumatic Stress
Disorder: A Quantitative Review of 25 Years of Research. Psychological Bulletin,
132(6), 959-992. doi:10.1037/0033-2909.132.6.959.
Ulmer, C. , Calhoun, P. , Edinger, J. , Wagner, H. , & Beckham, J. (2009). Sleep
disturbance and baroreceptor sensitivity in women with posttraumatic stress
disorder. Journal of Traumatic Stress, 22(6), 643-647.
Vasterling, J. , Proctor, S. , Friedman, M. , Hoge, C. , Heeren, T. , et al. (2010). PTSD
symptom increases in Iraq-deployed soldiers: Comparison with nondeployed
95
soldiers and associations with baseline symptoms, deployment experiences, and
post deployment stress. Journal of Traumatic Stress, 23(1), 41-51.
Vishnevsky, T. , Cann, A. , Calhoun, L. , Tedeschi, R. , & Demakis, G. (2010). Gender
differences in self-reported posttraumatic growth: A meta-analysis. Psychology of
Women Quarterly, 34(1), 110-120.
Vogt, D. , Stone, E. , Salgado, D. , King, L. , King, D. , et al. (2001). Gender awareness
among veterans’ administration health-care workers: Existing strengths and
areas.... Women & Health, 34(4), 65-83.
Vythilingam, M. , Luckenbaugh, D. , Lam, T. , Morgan, C. , Lipschitz, D. , et al. (2005).
Smaller head of the hippocampus in gulf war-related posttraumatic stress
disorder. Psychiatry Research: Neuroimaging Section, 139(2), 89-99.
Wakefield, P. (2008). PTSD doubly disabling for female vets. Human Rights: Journal of
the Section of Individual Rights & Responsibilities, 35(2), 19.
Wojcik, B. , Akhtar, F. , & Hassell, L. (2009). Hospital admissions related to mental
disorders in U.S. Army soldiers in Iraq and Afghanistan. Military Medicine,
174(10), 1010-1018.
Zinzow, H. , Grubaugh, A. , Monnier, J. , Suffoletta-Maierle, S. , & Frueh, B. (2007).
Trauma among female veterans: A critical review. Trauma, Violence & Abuse,
8(4), 384-400.
Zinzow, H.M., Grubaugh, A.L, Frueh, B.C, & Magruder, K.M. (2007). Sexual assault
among veterans seen in Veterans Affairs primary care clinics: A multisite study.
Psychiatry Research. in press.
96