Introduction

September 11, 2001, or 9/11, is a day burned into our collective American memory. For members of the US military, it was also the beginning of what has been over 13 years of war. Names have included the “War on Terror,” Operation Enduring Freedom (OEF; Afghanistan), Operation Iraqi Freedom (OIF; Iraq), Operation New Dawn (OND; Iraq), and the “Long War.” This latter term, the “Long War,” encapsulates the repeated deployments into combat zones in Afghanistan and Iraq, as well as the Horn of Africa and to humanitarian assistance operations (Ritchie, 2014a,b).

Females have composed about 15% of the United States military for many years. The percentage is slightly lower in the recent combat environment. In Afghanistan females have averaged 8.4% of the military between 2001 and 2013. In Iraq they have averaged at 10.2% between 2003 and 2011 (US Army Medical Command, previously unpublished data)

For you could say see Chapter 2 in this volume women, 9/11 and subsequent conflicts also ushered in a steadily increasing role in the US military. No longer mainly nurses, as in the Vietnam War, or primarily in support roles, as in the first Gulf War, female Service members have been in the thick of the conflicts in Iraq and Afghanistan.

Technically, only recently have women officially been allowed into the military occupational specialty (MOS) of combat occupations. Combat occupations are typically the “warfighters,” including jobs like infantry, artillery, and engineers. However, it is now widely accepted that women have been in combat since long before 9/11. For example, the deployment to Somalia in 1993 started as a humanitarian assistance operation, and was transformed into a combat mission. More recently, in the “Long War,” numerous roles open to women, which are not technically combat occupations, such as military police and truckers, have been frequently involved in firefights.

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

For this book, we need to clarify a few definitions. First of all, the terms “mental health,” “psychological health,” and “behavioral health” are all used in the literature. “Behavioral health” in some settings is commonly used to describe both mental health and substance abuse. The Army currently uses the term “behavioral health,” while the Department of Defense uses “psychological health.” “Mental health,” “psychological health,” and “behavioral health” are used interchangeably in this volume.

Another important set of definitions consists of the terms “theater,” “garrison,” “deployment,” and “re-deployment.” “Theater” means the “theater of war,” recently Iraq and Afghanistan. “Garrison” is back on the home base, whether in the United States or Germany or South Korea. “Deployment” can refer to a mission to either the war zone or to a humanitarian assistance mission. “Re-deployment” generally refers to a return to the home base, whether in the United States or to a base in Germany, Japan, or other overseas bases. This volume focuses on deployment to war, but there are many similarities to missions in other austere environments.

What does “active duty” or “veteran” mean? Active duty Service members are generally considered to currently be authorized to wear the military uniform. They are in the military services, for example, the Army, Navy, Air Force, and Marines. They may be on active duty, or in the Reserves. There are many types of Reserves, including the National Guard.

Most active duty military go on to become Veterans. By “Veterans” we are generally referring to those no longer on active duty. Those in the National Guard and Reserve may go back and forth between active duty and Veteran status. The term “Combat Veteran” may be used for both active duty and Veteran Service members who have served in combat.

Although they are often lumped together by the civilian world, the healthcare system in the military (the military healthcare system, or MHS) is very distinct from the healthcare system in the Veterans Administration (the Veterans Health Administration, or VHA). Despite many years of effort to align the systems, they currently each have their own electronic medical record, which has only a limited ability to share information. This subject is covered in more detail in other sources (Ritchie, 2014c).

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

Research and data about women in the military have had a relapsing course. After the first Gulf War there were a number of articles focusing on health issues of women deployed there. The main reasons for re-deployment to the United States were abnormal Pap smears gathered before deployment and positive pregnancy screens (Murphy et al., 1997).

In the late 1990s there was a considerable amount of research, mainly covered under the loose rubric of the Defense Women’s Health Research Project (https://momrp.amedd.army.mil/dwhrp_index.html; http://www.ncbi.nlm.nih.gov/pubmed/16313206). Issues such as the prevention of (1) urinary tract infections in the field, (2) unintended pregnancy while deployed, and (3) stress fractures in basic training were highlighted (Albright et al., 2007; Hines, 1993; Knapik et al., 2006; Lowe & Ryan-Wenger, 2003; Ryan-Wenger & Lowe, 2000; Ritchie, 2001).

Then 9/11 happened, and the military embarked in the Long War. Much of the energy around women’s issues was subsumed in the need to prepare and go to war. When COL Naclerio went to Afghanistan in 2010, problems with health and hygiene were still paramount (see Chapter 4 in this volume).

Recently, partly because of the repeal of the combat exclusion rule (which is covered in more detail in other places in the volume), and partly because the Long War appears to be winding down, there have been a number of activities and publications about women in combat.

For example, the American Psychiatric Association has had a military track for the last four years. Female psychiatrists have been featured in the “Women at War” panels. They have related their experiences to a mixed civilian and military audience, including female psychiatrists about to be deployed. These include being a minority (about 10% in theater, as opposed to 15% in garrison) in the deployed environment, and feeling like they are in a fishbowl (Ritchie, 2013, 2014d).

Under the leadership of the Uniformed Services University and the Defense Health Activity, a Women in Combat Symposium was held in April 2014. There researchers and clinicians gathered to discuss a host of related issues, including leadership, integration, optimal performance, standards to enter different jobs, and of course health issues. The results of that symposium should appear in a special issue of Military Medicine.

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

So interest has resurged. We hope that this volume will further spur the knowledge of and interest in female Service members.

The lack of statistics on female Service members is in contrast to the extensive scientific literature on male Service members. For example, the Mental Health Advisory Teams have focused on combat troops, which by past definition are male. The Walter Reed Army Institute of Research (WRAIR) has also concentrated on combat troops. The Millennium Study does include females, but results are just beginning to emerge (Millennium Study, 2014).

VA does have data on female Veterans who access their services. However, traditionally only a small number of female Veterans go to VA. These Veterans normally have a higher rate of mental and physical illnesses, and have a lower socioeconomic status.

VA studies on women have focused on military sexual assault. While this area is very important, there are many other issues that female Service members deal with. These are often focused on reproductive and genitourinary concerns. This volume will outline them in more detail.

There are a few areas where there are data on active duty women, but these are scant. A notable exception, reported here for the first time, is Chapter 1 of this volume, by DeFraites et al., which nicely summarizes a vast quantity of data on deployment-related issues. Chapter 2 by Ritchie at al. outlines the known statistics on post-traumatic stress disorder (PTSD) in female Service members. Chapter 15 on intimate partner violence also has robust statistics.

Because of a lack of quantitative data, some other chapters summarize either civilian data or data on male Service members, then move to extrapolate for servicewomen. A few chapters are more anecdotal, describing the experiences of being a female Sailor on ship, or a mother on deployment.

Much of the current discussion about women in the military focuses on physical strength. Can she carry a 60 round rucksack? Can she load artillery rounds? In contrast, issues around reproductive and gynecological health are understudied in the recent literature on female Service members.

Urinary tract infections are a major issue for women in the field. Much of the concerns that female Service members have are about bathrooms. Is the latrine—maybe used by many other Service members—clean enough to sit on? Women often restrict fluids to avoid going to the filthy or nonexistent bathrooms, and thus get UTIs or become dehydrated (Ryan-Wenger & Lowe, 2000, Ritchie, 2001; Lowe & Ryan-Wenger, 2003).

Managing menses in austere conditions is another dilemma. Can I change my tampon while driving on the roads in Iraq? Should I be on oral contraception while deployed, in order to regulate menses? COL Naclerio published a report on findings from Afghanistan in 2011 (Naclerio, Stola, & TregoFlaherty, 2011). Chapters 4 and 5, by Naclerio and Krulewich, respectively, cover these issues in more details.

Motherhood is a major issue for female Service members, who are normally in their prime reproductive years, between the ages of 20 and 40. Concerns about pregnancy, being a mother, and breastfeeding are central.

If pregnant, a woman may not deploy. The different Services have different regulations as to how long after childbirth she may deploy to theater.

Increasingly, breastfeeding is seen as positive. Most bases now have good lactation facilities. But it is very hard to pump breast milk while on trainings to go to war, and obviously impossible once one goes (Bell & Ritchie, 2003).

Being a mother and/or wife deploying leads to all kinds of emotional issues, but also personal growth. Chapter 11 in this book by Canuso will flesh out these issues.

Although sexual assault has received considerable attention, consensual sex has received much less. A taboo area seems to be the sexual desires of women who deploy. But young women—and most women who deploy are young—do have sexual desires, perhaps heightened by the daily exposure to death and close bonding in the combat zone. The literature is totally devoid on this topic (although replete with accounts of military sexual assault).

What about consensual sex in the war zone? By military law it used to be forbidden, but now is permissible if fraternization rules are not broken. When young men and women are deployed together for a year, sex happens. If contraception is scarce, pregnancies also happen. In the worst cases, this results in ectopic pregnancies, resulting in life-threatening emergencies and expensive medical evacuations. In the “best” cases, unexpected pregnancy results in an evacuation from the war zone. Again, in the first Gulf War abnormal Pap results (from tests prior to deployment) and pregnancy were the most common reasons for female Service members to be re-deployed home.

Only anecdotal information is available from providers who have served in theater (shorthand for the theater of war). In some clinics, contraception, usually condoms, are freely available. In others, they are not. There are no systematic data on availability of birth control.

Another previously forbidden topic is the discussion of homosexual sex among women in the theater of war. Although now the “Don’t Ask, Don’t Tell” ban has been lifted, again there is no literature on the topic. Anecdotally, it also happens, both in garrison and while deployed.

Military sexual assault, on the other hand, is a highly publicized area, which is covered widely in both the scientific literature and the media. Of course, sexual assault is a major issue for both men and women. The number of reported cases has been rising. This may be partially due to better reporting.

In the military, as in the civilian world, this is not a simple issue. In the military, many sexual activities are partially consensual, partially coercive. In some cases, sexual activity involves those of unequal ranks. In the garrison setting, often there is alcohol involved. If a case of sexual assault is brought to the criminal justice setting, often it is a “he-said, she said” situation (Ritchie, 1998).

Obviously sexual assault leads to a myriad of mental health issues, including guilt, depression, PTSD, and substance abuse. In the small confines of a deployed unit, often everybody in the unit is aware of the situation, which can be incredibly humiliating. In many cases, it also leads to an exit from military service for both parties.

PTSD is a common consequence of combat. It has been studied widely in military men after Vietnam and during these last 13 years of war. PTSD has also been widely studied in civilian women, especially after sexual assault. Far less is known about combat-related PTSD in military women since 9/11.

However, the available statistics show that military women have rates of combat-related PTSD at about the same rate as men (Mental Health Advisory Teams II, 2004; Joint Mental Health Advisory Teams 7, 2011). What we do not know is whether their PTSD symptoms are similar or different.

Symptoms of PTSD under the old DSM-IV and new DSM-5 definitions include hypervigilance, flashbacks, numbing and avoidance, problems with sleep, somatic symptoms, depression, and irritability. For females, the symptoms may be the same as for males, but are compounded by the issues around sexual assault and guilt over leaving over children at home, described earlier.

Depression, suicide, and traumatic brain injury are also common sequelae of war, covered in Chapters 13 (by Tepe and Garcia), 14 (by Ghahramanlou-Holloway et al.), and 17 (by McGraw). Substance abuse and homelessness are likewise critically important areas, but we could not find enough research for a chapter.

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

This volume has several chapters outlining the experiences of women after they have returned from war. They may have physical or psychological injuries. Dr. Henderson discusses psychological needs in Chapter 10, and Jackie Garrick in Chapter 19 explores the needs of wounded Service members. Again there is a weakness of existing data, but we hope to highlight the need for more research.

Finding statistics on the killed and wounded broken down by gender is somewhat difficult. Here are a few snapshots of available data.

As of January 2013, there were 4,365 males and 110 females killed in action (KIA) in OIF/OND. The numbers are somewhat lower for OEF: 2,122 males and 42 females (CRS). So while the risk of being killed is lower for females, due to less combat exposure, it is still substantial (Ritchie, 2014a).

Statistics on wounded female Service members are not as easy to find, partly because of how the definition of wounded is made. The following statistics may be useful. As of February 2014, there were a total of about 50,000 Service members wounded in action (WIA). The vast majority of these are male and in the Army. Approximately 2.5% of Army wounded in action in Iraq are female (Pena-Collazo, 2013). As of March 2013, there were 813 female Army Soldiers wounded in action, and 34,164 males (DMDC, 2013). The wounded in action numbers do not include other injuries, such as those sustained in training.

The data on how injuries affect women are anecdotal, often contained in media accounts, rather than in scientific literature (Cronk, 2014). However, clearly wounded and injured women, such as those with amputations, often must deal with a new body image, new relationships with family members, and a healthcare system geared toward men.

This volume cannot claim to be a complete account of female Service members’ experiences in combat. We sought to gain more of an international perspective, but were not successful in gathering authors. So the experience from Australia is our lone international chapter.

Additionally, we also were not successful in finding an author to present on the experience of female gay Service members, which should be an important part of the discussion.

Medical and academic volumes rely on scientific evidence, which should lead to evidence-based practice. From that standpoint, this book, Women at War, has been a difficult one to put together. This is chiefly because there has been so little recent comprehensive data on the psychological and physical health of female Service members.

Nonetheless, this volume seeks (1) to gather the data that is available, (2) to add anecdotal but universal information, (3) to translate it into actionable information for clinicians, and (4) to make recommendations for future research.

Female Service members are a vital part of the nation’s military, and have been heavily deployed beside their male counterparts since the Persian Gulf War in 1980. The events of 9/11 dramatically increased the operational tempo for all of the troops.

It is hoped that this article will stimulate more understanding of the experiences of female Service members, women at war, in order to have the experience be a better one. We have tried to direct it toward clinicians caring for female Service members.

Important take home messages for clinicians include asking about (1) whether the patient is a Service member or Veteran, (2) the patient’s overall military service, (3) the patient’s experiences in the theater of war; and (4) the positive and negative effects of that service.

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

Elspeth Cameron Ritchie

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