Research Paper On Ptsd And The Iraq War Controversy

Abstract

Despite the marked expansion of roles for women in the US military over the last decade, whether differences by gender exist in regard to the development of mental health conditions postdeployment is unclear. This comprehensive review of the literature (2001–2012) examined whether US servicewomen were more likely than men to experience post-traumatic stress disorder (PTSD) after returning from deployments to the Iraq and Afghanistan conflicts. Findings from 18 studies from 8 unique study populations were reviewed. Seven studies found that women had a higher risk for screening positive for PTSD compared with men, including prospectively designed studies that evaluated new-onset PTSD among members from all service branches. Although results from studies with Veterans Affairs samples found women at decreased risk in 4 analyses, these studies used the same source databases, were conducted in treatment-seeking populations, and were mostly unable to account for combat experience. Seven studies detected no differences by gender. In summary, women appeared to have a moderately higher risk for postdeployment PTSD, although there was a lack of consensus among the studies, and even those with the most rigorous methods were not designed specifically to evaluate potential gender differences. Given the limitations of the published literature, further research should use longitudinal study designs and comprehensive evaluations of deployment experiences while adjusting for predeployment factors to confirm that gender differences exist with regard to postdeployment PTSD.

deployment, gender, health outcomes, military, Operation Enduring Freedom; Operation Iraqi Freedom; post-traumatic stress disorder, women

INTRODUCTION

Women in the military

Women have experienced markedly expanding roles in military service over the past decade. They have swiftly transitioned from roles of “support” (e.g., nursing, food services, and clerical work) to those mirroring their male counterparts. During the first Gulf War in the early 1990s, women served as military police officers and pilots as well as on board combat ships (1). Although the Department of Defense policy until 2013 prohibited women from serving in “any unit below brigade level whose primary mission is to engage in direct ground combat” (2, p. 4) (3), hence barring service in combat infantry or special operations, the blurring of the front lines of war in Iraq and Afghanistan has led to a sizable number of women encountering combat situations.

Not only have the roles of women changed, but their numbers on active duty service have also markedly increased. Since 1973 when the United States ended conscription and established an all-volunteer force, the number of enlisted women has increased from 2% to 14%, with commissioned officers increasing from 4% to 16%. As of 2011, 214,098 women were serving on active duty, representing one-seventh (14.6%) of the active Armed Forces (Table 1) (4). In addition, 72,790 women serve in the Reserves and National Guards. The Army has the largest absolute number of women, while the Air Force has the highest proportion of female service members (Table 1).

Table 1.

Number of Women Serving on Military Active Duty, as of September 30, 2011a

Service Branch Total Service Size, no. Women
No. 
Army 565,463 76,694 13.6 
Marine Corps 201,157 13,677 6.8 
Navy 325,123 53,385 16.4 
Air Force 333,370 63,552 19.1 
Coast Guard 43,251 6,790 14.5 
 Total 1,468,364 214,098 14.6 
Service Branch Total Service Size, no. Women
No. 
Army 565,463 76,694 13.6 
Marine Corps 201,157 13,677 6.8 
Navy 325,123 53,385 16.4 
Air Force 333,370 63,552 19.1 
Coast Guard 43,251 6,790 14.5 
 Total 1,468,364 214,098 14.6 

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The number of women deployers has also rapidly increased, representing approximately 10% of military personnel deployed in support of the conflicts in Iraq and Afghanistan, the largest percentage in the country's history (5). Between October 1, 2001, and December 31, 2010, a total of 154,548 women in the active component of the US military deployed to Iraq and Afghanistan, with 31% deploying 2 or more times and 7% deploying at least 3 times (6).

Women returning from the Iraq and Afghanistan conflicts have reported more exposure to traumatic events than during any past war, with data showing that 9% of Army women deployers witnessed a killing and 31% were exposed to death (7). In addition to women's expanding role on the warfront, their roles in the military at large have grown: Over 92% of specialties are currently open to women, and nearly an identical proportion of women are officers compared with men (approximately 16%) (2). In short, never before in US military history have the roles of women in the Armed Forces been more similar to those of men.

With the expansion of the roles and numbers of women in the military, concern has arisen regarding the health of women, especially following deployment. Mental health disorders have become the “signature wounds” of the Iraq and Afghanistan conflicts, with markedly increased rates among returning service members (8–10). Although there has been a surge in concerns about mental disorders (e.g., post-traumatic stress disorder (PTSD)) among women veterans, few data have focused specifically on women deployers (11) or have compared mental health outcomes among women and men who recently deployed to the military operations in Iraq and Afghanistan. Given the large number of women service members and veterans, it is imperative to identify potential gender differences in postdeployment mental health outcomes. This paper summarizes the existing published data regarding the development of PTSD among women service members during the recent conflicts and discusses gaps in the existing literature.

Context

In the general adult US population, the overall prevalence rate of PTSD is 5–10%, with women having an approximate 2-fold higher prevalence compared with men (12–14). Similarly, studies examining military populations prior to the recent conflicts in Iraq and Afghanistan showed higher baseline prevalence rates of mental health disorders among women (15). In a study utilizing the Millennium Cohort data, 76,476 service members (including 20,424 women) were evaluated by using a validated survey instrument, the PTSD Checklist Civilian Version (PCL-C), and found that women had higher rates of predeployment PTSD (3.2% vs. 2.2%; adjusted odds ratio (AOR) = 1.4, 95% confidence interval (CI): 1.2, 1.5) (15). This review will examine potential gender differences in PTSD after deployment to the recent conflicts in Iraq and Afghanistan. Evaluation of studies examining new-onset PTSD, which show the likelihood of developing the outcome among a group of individuals that were outcome free at baseline, is critical to understanding gender differences because women have higher baseline rates of PTSD in both general and military populations.

Regarding PTSD in a specific subpopulation (e.g., women), the rate may be elevated because the group is more vulnerable, more likely to report symptoms or be diagnosed with the condition, or more likely to experience traumatic events that lead to the outcome. Some data in the civilian sector suggest that the higher risk of PTSD among women in the general population may be due to females being more vulnerable to developing PTSD after specific traumatic events (14), rather than due to differing number or type of traumatic events. In the military settings, some of the risk factors for postdeployment PTSD mirror those in the general population, while others are specific to military experiences, such as combat experiences, longer deployments, in-theater injury including traumatic brain injury, being part of the ground troops, and lack of unit support (6–8, 11, 16–36). Whether women are specifically more vulnerable to combat-related traumatic experiences and hence more likely to develop postdeployment PTSD in relation to the recent conflicts is currently unclear.

Reasons for potential gender differences in postdeployment PTSD

There are several factors that may impact the rates of PTSD among women serving in the military. Although women were not authorized to serve in combat infantry roles before 2013 (3) and men typically report more combat experiences during deployments, women nonetheless report a substantial level of combat-related events. For example, a study showed that firefights were experienced by 36% of female deployers (vs. 47% of male deployers) and shooting the enemy among 7% (vs. 15%). This study also found that women were more likely to experience some traumatic events than men, such as handling of human remains (38% vs. 29%) (9), likely because of the large proportion of women in health-care specialties.

There may be gender differences in trauma appraisals and perception (37), with lower levels of exposure creating similar perceived stress among women (38). For example, women are more likely to have a history of specific traumatic events (e.g., childhood sexual abuse and intimate partner violence), which may alter their perception and increase their vulnerability for PTSD after military-related events (18, 25, 35, 39–41). Further, information processing may differ by gender, with men being more likely to externalize stress (leading to higher rates of substance use issues), while women internalize stress, raising the possibility of mental health disorders (42).

In addition to combat-related experiences, women are at higher risk for sexual trauma during deployments (7, 18). Studies have shown that approximately 15% of returning female deployers reported military-related sexual trauma (MST) compared with <1% of male deployers (43). MST increases the risk for PTSD among both men and women, with a stronger effect size among women; whether this is due to increased vulnerability in women or differences in MST intensity or number of events is currently unknown (43). Finally, because women remain the minority gender (approximate 85:15 ratio) in the military, they may have lower factual or perceived deployment preparedness and access to social support during and after deployments.

Although there are many hypothetical reasons that could impact a woman's vulnerability to deployment and combat-related experiences, a review of the literature is needed to determine if gender differences in the development of PTSD exist among service members returning from the recent conflicts to inform veteran health care.

MATERIALS AND METHODS

We conducted a search of the published literature (including Medline, PubMed, Embase, and PsychInfo) using the terms “woman”, “women”, “female”, or “gender”; “deploy”, “military”, “military personnel”, or “armed forces”; and “PTSD”, “post-traumatic stress disorder”, or “posttraumatic stress disorder” for articles published in the English language between September 2001 and August 2012. We also utilized references of articles to identify additional studies. All studies that provided information on postdeployment PTSD stratified by gender during the recent conflicts in Iraq and Afghanistan were included. Studies that did not directly compare the outcome of PTSD by gender, unpublished data, and data collected prior to the initiation of the recent conflicts were not considered. Data collected from each study included the study design, deployment years, number of men and women service members evaluated, study location, measure utilized to define PTSD, rates of PTSD by gender, and assessment of predictors (specifically combat) of PTSD by gender. All papers were reviewed by 2 researchers (N. C-C., I. J.). Although a meta-analysis was considered, the feasibility of this approach was limited given the large heterogeneity of the study designs and methodologies. Also, the outcome of PTSD was not measured consistently across studies, since different instruments were used and the way in which the outcome was examined (dichotomous vs. continuous) varied greatly. Therefore, a descriptive review of the literature was conducted. Results from studies with prospective designs that examined new-onset outcomes were given more consideration compared with smaller studies using retrospective or cross-sectional designs when making final conclusions from the review. Publications about prior conflicts, such as Vietnam or the first Gulf War, were not considered, as studies regarding gender differences during these conflicts were sparse (38, 44, 45).

RESULTS

Although a large number of articles on PTSD have been published in the last decade, few focused specifically on gender differences in postdeployment PTSD in association with the recent conflicts in Iraq and Afghanistan (Figure 1; Table 2) (1, 7, 16, 17, 19–22, 46–55). Studies were categorized by service branch and active duty versus veteran status, given the differences in military experiences by branch and various methods of data collection (e.g., active duty studies typically enrolled random military samples, whereas veteran studies mainly included those seeking Veterans Administration (VA) care). Further, articles using the same or similar data sources for their study populations were grouped together.

Table 2.

Summary of Published Studies on Mental Health Outcomes Among OIF/OEF Deployers by Gender, 2001–2012

First Author, Year (Reference No.) Study Design Years of Deployment Study Population, no.
Setting Outcome Measure PTSD by Gender Combat Experience, yes/no and measure Limitations 
Total Men Women 
Army
Skopp, 2011 (19)aRetrospective cohort 2006–2008 2,896 2,708 188 Army—large installation Screening database with pre- (45–120 days) and post- (90–180 days) deployment surveys;
PTSD by PC-PTSD screen 
Increased odds of nearly 2.5 times among women Yes. 4 yes or no questions about CE (e.g., becoming wounded or injured), summed for total score Retrospective design, PTSD symptoms may be underreported on PDHA screen, and limited generalizability to other service branches or Reserve/Guard 
Luxton, 2010 (1)aRetrospective cohort 2006–2009 6,943 6,427 516 Army—large installation Screening database with pre- (45–120 days) and post- (90–180 days) deployment surveys;
PTSD by PC-PTSD screen 
Similar rates of PTSD symptoms and scores by gender. Higher levels of combat were more strongly associated with PTSD in women Yes. 4 yes or no questions about CE (e.g., becoming wounded or injured), summed for total score Retrospective design, no adjustment for vulnerability factors including prior trauma, and limited generalizability to other service branches or Reserve/Guard 
Maguen, 2012 (7)aRetrospective cohort 2006–2009 7,251 6,697 554 Army—large medical treatment facility Pre- and post- (90–180 days) deployment surveys;
PTSD by PC-PTSD screen 
No gender differences Yes. 4 yes or no questions about CE (e.g., becoming wounded or injured), summed for total score Retrospective design, limited generalizability to other service branches or Reserve/Guard 
Lapierre, 2007 (16) Cross-sectional 2004–2005 4,089 3,826 263 Army reintegration training program Survey after 12-month deployment to Iraq or Afghanistan;
PTSD was detected by using the SPTSS 
No gender differences CE not measured Cross-sectional design, potential for selection bias, no clinical confirmations of disease, limited generalizability to other service branches or Reserve/Guard 
Wojcik, 2009 (46) Retrospective study 2001–2004 473,964 419,358 54,606 Army personnel admitted by using data from the Standard Inpatient Data Record Hospital-associated ICD-9 codes Increased among women CE not measured Retrospective design, no adjustment for combat experience or predeployment factors, use of medical records identifies only those seeking care, limited generalizability to other service branches or Reserve/Guard 
All Service Branches
Smith, 2008 (21)bProspective cohort 2001–2006 50,128 36,279 13,849 Millennium Cohort Survey Survey at baseline and 3 years, categorized by deployment status between 2 surveys; PTSD by PCL-C Increased among women with odds of 1.7–2.0 Yes. At least 1 affirmative response to any of 5 items (e.g., witnessing dead soldiers or civilians; dichotomous variable used Combat experiences may not have occurred during deployment, no clinical confirmation of symptoms 
LeardMann, 2009 (50)bProspective cohort 2001–2006 5,410 4,544 866 Millennium Cohort Survey Surveys at baseline and 3 years, includes only combat deployers; PTSD by PCL-C Increased among women with >2-fold higher odds Yes. Combat deployer population created using method from Smith paper (21). Combat severity measured as exposure to 1 item, 2 items, or 3 or more items Combat experiences may not have occurred during deployment, no clinical confirmation of symptoms 
Eisen, 2012 (48)cCross-sectional 2007–2008 596 253 343 All service branches Survey within 1 year after return among veterans of all services; PTSD by military version of PTSD Checklist No gender differences CE not measured Cross-sectional design, no adjustment for predeployment factors, small sample size, no clinical confirmation of symptoms 
Vogt, 2011 (49)cCross-sectional 2007–2008 592 (random sample of 2,000 OIF/OEF personnel; 592 completed survey)

252 340 All service branches Survey within 1 year after return among veterans from all services; PTSD by military version of PTSD Checklist No gender differences Yes. 15-item scale used with a modified 5-point Likert scale response format. Sum score created Cross-sectional design, small sample size, no clinical confirmation of symptoms 
US National Guard
Riviere, 2011 (51) Cross-sectional with 2 time points 2005–2007, 3 and 12 months after deployment 2,539 at 3 months 2,409 130 US National Guard soldiers from 2 brigades PTSD assessed by PTSD Checklist (DSM-IV criteria plus 50 points) Increased among females at 3 months, but no gender difference at 12 months Yes. Sum of 28 CE items Small sample, National Guard only. May not represent all military personnel. No predeployment baseline data available, no clinical confirmation of symptoms 
1,495 at 12 months 1,407 88 
Veterans Administration
Maguen, 2010 (17)dRetrospective 2002–2008 329,049 288,348 40,701 VA First health-care visit after deployment to a VA facility (2002–2008). Utilized ICD-9 codes Decreased among women CE not measured Retrospective design, no adjustment for important behavioral factors because of record abstraction, limited generalizability to veterans not seeking VA care or currently serving personnel 
Haskell, 2011 (47)dRetrospective 2001–2007 163,812 144,562 19,250 VA Health-care visit in first year and required 2 outpatient or inpatient visits with ICD-9 codes for a given condition Decreased among women CE not measured Retrospective design, no adjustment for important behavioral factors because of record abstraction, limited generalizability to veterans not seeking VA care or currently serving personnel 
Haskell, 2010 (52)eRetrospective 2001–2006 1,229 1,032 197 VA Connecticut Electronic medical records, including vital signs package and progress notes Decreased among women CE not measured Small sample of users of the VA health-care system in Connecticut—may not be generalizable to personnel who are not seeking care 
Seal, 2009 (22)dRetrospective 2002–2008 289,328 254,904 34,424 VA First health-care visit after deployment to a VA facility (2002–2008). Utilized ICD-9 codes No gender differences Proxies for CE were measured, including being of enlisted rank, in the Army, and being deployed more than once Retrospective design, no adjustment for important behavioral factors because of record abstraction, limited generalizability to veterans not seeking VA care or currently serving personnel 
Seal, 2007 (53)dRetrospective 2001–2005 103,788 90,136 13,652 VA Inpatient and outpatient mental health visits. Utilized ICD-9 codes Decreased among females CE not measured Retrospective design, no adjustment for important behavioral factors because of record abstraction, limited generalizability to veterans not seeking VA care or currently serving personnel 
Baker, 2009 (54)eCross-sectional 2006 339 302 37 OIF/OEF veterans and reservists enrolled for care at San Diego VA PTSD by the Davidson Trauma Scale (endorsement of trauma exposure and a score of at least 40) No gender differences Yes. Combat Exposure Scale Small sample, not necessarily representative of all veterans. Treatment-seeking sample 
Non-US Military
Woodhead, 2012 (20) Prospective cohort 2003–2007 4,986 4,554 432 United Kingdom Survey of a representative sample of all 3 service branches;
PTSD by PCL-C 
Increased among women at lower levels of risk Yes. 13-item scale to items on a 5-point scale. Responses summed and scored. May not be generalizable to US service members, no clinical confirmation of symptoms 
Rona, 2007 (55) Cross-sectional 2003 2,539 1,593 946 United Kingdom PTSD by PCL-C No statistically significant gender differences Yes. Combat role (combat, combat support, other) and 3 items on personal exposure (e.g., small-arms fire) Small sample, cross-sectional design. Focused only on 1 year of deployments to the Iraq war, may not represent trends of disease from entire war period, and no clinical confirmation of symptoms 
First Author, Year (Reference No.) Study Design Years of Deployment Study Population, no.
Setting Outcome Measure PTSD by Gender Combat Experience, yes/no and measure Limitations 
Total Men Women 
Army
Skopp, 2011 (19)aRetrospective cohort 2006–2008 2,896 2,708 188 Army—large installation Screening database with pre- (45–120 days) and post- (90–180 days) deployment surveys;
PTSD by PC-PTSD screen 
Increased odds of nearly 2.5 times among women Yes. 4 yes or no questions about CE (e.g., becoming wounded or injured), summed for total score Retrospective design, PTSD symptoms may be underreported on PDHA screen, and limited generalizability to other service branches or Reserve/Guard 
Luxton, 2010 (1)aRetrospective cohort 2006–2009 6,943 6,427 516 Army—large installation Screening database with pre- (45–120 days) and post- (90–180 days) deployment surveys;
PTSD by PC-PTSD screen 

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