PART

3

Women Home from War

TEN

Women Home from War

ELIZABETH C. HENDERSON

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

This Soldier was dealing not only with the many stressors associated with deployment in general and deployment as a wife and mother, but the emotional impact of being referred for a medical board evaluation, which served to magnify these issues and added further to her emotional burden. This is an especially difficult scenario, but it reflects many of the issues that women struggle with when approaching medical separation from the military.

This chapter will discuss the processes that occur and the issues that arise during the period that follows return from deployment, with an emphasis on psychological health. Almost all of these issues and concerns are shared by men and women in the military, but gender differences are also found in the prevalence, the severity, and the manifestations of post-deployment symptoms and adjustment. Army terminology and regulations are discussed, based on the author’s experience, but the principles are shared by all branches of the military. For the sake of simplicity, the terms “Service member” and “Soldier” are both used as synonyms for “Airman,” “Marine,” “Sailor,” “Officer,” and so on.

Women now constitute 20% of new military recruits and 15% of Service members who have deployed. Of those women who have deployed, roughly 40% have participated in combat. Review of the literature does not show great gender differences in the mental health of Service members returning from deployment. Both genders are resilient, and both are also at risk for exposure to multiple potentially traumatic events while deployed. Issues encountered more commonly in women during the process of reintegration, such as military sexual trauma, may increase in visibility and prominence with increased attention to these issues as the women constitute a higher percentage of the Armed Forces.

The cycle of returning from a deployment and preparing for the next deployment in the Army is known as the ARFORGEN (Army Force Generation) process. It is “the Army’s core process for force generation,” consisting of three force “pools” that are structured to provide a steady flow of ready forces. These pools are “RESET, Train/Ready, and Available” (Army Regulation 525-29). In this chapter, the focus is on the “RESET” pool, whose activities include “[s]‌oldier-Family reintegration; block leave; unit reconstitution; changes of command; behavioral health; medical and dental readiness, reintegration; professional military education;… training tasks; and resupply.” These activities occur during “dwell” time, which is the period of time in garrison between deployments.

An important medical function during dwell time is restoring the Service member to full medical readiness and identifying those who no longer meet medical retention standards. The high tempo and long duration of recent operations have increased the importance of the efficiency and accuracy of this medical function so that units are able to obtain a suitable replacement if a Service member is not medically able to contribute to the mission. The ARFORGEN process applies to all components of the Army: Active Duty (COMPO 1) and the National Guard and Reserves (COMPO 2 and 3).

When Service members in National Guard and Reserve units demobilize, initial screening is done at the demobilization site to identify Soldiers who require continuation on orders because of significant medical problems; however, the majority return to their home unit, where the RESET process is completed, and the cycle continues. National Guard and Reserve forces are mobilized (placed on active orders) and deployed (sent overseas to an imminent harm area) at a frequency not seen in many decades. On return, these Service members also return to a job or career placed on hold, re-enter the civilian community, and may lack the psychosocial support found in garrison.

The Global War on Terror and many other recent operations are characterized by hostile activity on the part of a less organized and equipped force toward highly organized, equipped, and trained multinational forces. This type of hostile action is termed “asymmetry” and is seen in guerrilla warfare and insurgencies within an established governmental system or arising when governmental control is weak. Although this style of warfare is not new (for example, being used by the Continental Army to win the Revolutionary War), it stands in contrast to the more conventional conflict between two uniformed forces organized at the national level. In conducting this type of warfare, enemy combatants today often use unconventional tactics that are contrary to the laws of war.

These tactics result in not only injury and property destruction but incidents that are horrifying and may overwhelm psychological defenses, leading to psychological trauma. Some of these tactics include the use of women or children as shields, improvised explosive devices that cause dismemberment and bodily disintegration, suicide bombers, planting bombs inside dead people and animals, and threats to coerce the compliance of local nationals (Metz et al., 2001).

Current Army doctrine includes the concept of counterinsurgency (COIN), a combination of executing military actions to stabilize an area of operation while working within the social and political structure of the host nation to achieve strategic and political objectives (Sewell & Nagi, 2007 [US Army FM 3-24]). Attendant with this doctrine, however, is the inherent blurring of the definition of who constitutes the “enemy.” Betrayals of trust in the setting of providing active support to local nationals, building infrastructure, and making positive contributions may lead to disillusionment and demoralization. Service members may devote their energies to training or humanitarian projects, only to later realize that sometimes the local nationals who thank them for their efforts are also participating in hostile actions.

An important characteristic of the current theaters of operations is the lack of a defined rear echelon; in other words, there is no location in theater that is secure and apart from hostile activity. Every Service member, from General Officers to lower enlisted, are in a forward area and are at risk. Therefore, when “down range,” or deployed, all Service members, all the time, are at risk of harm and maintain a high degree of situational awareness. Even on well-developed forward operating bases, or FOBS, there is the risk of indirect (mortar and rocket) fire, and suicide bombers who get inside the “wire” or the perimeter of the base. Direct attack may come from local nationals who have been allowed on the base for military or police training.

A consequence of the asymmetric nature of recent conflicts is the potential for the Service member to fail to respond when an actual threat is a woman or a child, or to appropriately engage a threat, and then suffer moral injury, if an innocent person is killed or injured. Litz et al. (2009) note that moral injury occurs when the individual perpetrates, fails to prevent, or bears witness to “acts that transgress deeply held moral beliefs and expectations” and notes that there are emotional, psychological, spiritual, and social consequences. This may increase isolation and loneliness after separation from the military due to a feeling that others would judge or fail to understand these experiences. A routine question in a psychiatric evaluation of a returning Service member is whether or not he or she had to discharge a weapon in combat. It is not uncommon for women to answer “yes” to this question, even if performing a non-combat military occupational specialty (MOS), because of the asymmetric nature of combat in recent theaters of operation requiring women to actively participate in combat operations.

Accompanying these moral dilemmas are rules of engagement (ROEs) that specify when and whether it is appropriate to take action in a hostile engagement. These rules are based on the Law of Land Warfare (US Army FM 27-10) but are also mediated in the service of strategic objectives and political considerations. These rules serve as a guide in the short threat-action loop but also limit the range of possible responses. Service members may experience frustration when rules of engagement appear to place them at higher risk or lead to casualties, and in the modern battlefield they may struggle with the fact that they are required to follow the ROEs but the enemy is not.

“Paper thin” faith, as described by Fleming and Robichaux in Redeployed (2013), can dissolve in the aftermath of incidents that shake the Service member’s existential foundation. Some Service members recount a point at which they shut off any access to tender feelings and became cynical and unresponsive to the emotional pain of others. Some Service members struggle with the notion that a God who cared about man could permit what they have seen. One infantry Soldier said, simply, “My eyes have witnessed more than my soul can handle.”

Having been exposed to death and injury, the ambiguities of asymmetric warfare, and a culture of extreme poverty, corruption, and vicious sectarian violence, it is hard to return to a culture of comfort and means. Service members frequently have difficulty empathizing with day-to-day stresses—the routines in garrison, the washing machine breaking down, kids squabbling, the family wanting to redecorate to keep up with the neighbors, and so on. It is difficult for family members and friends to understand why, in frustration, the Service member may express the sentiment, “I wish I was back” in theater.

When deployed Service members share the common goal of executing the mission, there is mutual support and efficiency of effort. The unit becomes a cohesive support system with bonds often tighter than those with family members. The sense of meaningful team work and a goal-directed focus is a healthy characteristic of the deployed environment that may be lacking at home. Mature, empathic, and effective leadership and unit cohesion protect against the development of behavioral health symptoms (US Army, 2011; 8-J-MHAT 7-2011, p. 31).

The converse is also true. Some military units share the characteristics of a dysfunctional family or organization, especially if there are leadership problems within the command structure. Dysfunctional group behaviors may ensue, such as scapegoating, in order to maintain some degree of cohesiveness and mission focus. Sexual harassment and sexual assault are also toxic to the group process, disrupting trust, open communication, and moving the work group off task. These effects are more obvious at the level of the small working group—squad or platoon level. But higher leadership also sets the tone for the entire company or brigade.

Within a Brigade Combat Team, or even within a company, there may be marked variability in the intensity of combat exposure or exposure to other traumatic stressors. Although sharing a common mission, each smaller component—team, squad, or platoon—will go in different directions to complete the mission and may encounter intense combat activity or none at all. The small unit also serves as a natural support system. Social media and technology facilitate continuing connections over time. But the effectiveness of this natural support system is diminished when, shortly after redeployment, there are changes in command, Service members leave at the end of a contract or retire, and some receive orders to PCS, (Permanent Change of Station), sometimes from one coast to another. Some are selected for Service schools such as Airborne, Ranger, or Master Gunner, and others face some type of involuntary separation due to medical or administrative issues.

In recent years the Army has embedded behavioral health providers into Brigade Combat Teams with the intent of increasing communication with command, providing informal access to Service members, and providing a readily available source of support. This also affords behavioral health providers the opportunity to meet with small units who may have experienced more combat intensity to leverage existing bonds and encourage the continuation of healthy support around issues that no one may wish to talk about.

Even those who have not suffered psychological trauma experience redeployment (or return from deployment) as a challenge. When Dr. Caldwell, a clinical psychologist, returned from a year’s deployment, she was surprised to find that she continued to have a persistent feeling of being unsafe, especially when driving long distances or going to the concerts she missed so much while she was deployed. Loud noises made her jumpy, and she often thought about some of the more intense experiences she had in theater. But most annoying was that her mother, her fiancé, and her friends told her she had changed—and wanted her to change back. As a psychologist, she knew that her post-deployment symptoms were normal and would abate over time, but she found it hard to explain to her friends and family that what she had seen and experienced did change her—but that she was still the same in many ways. Rivers et al. surveyed US Army nurses returning from deployment to gain insight into the personal experience of coming home and reintegrating into family life and garrison responsibilities. Roughly three-quarters of the respondents were female, and all were active duty Officers in the Army Nurse Corps. Common themes that emerged included a feeling that there was a lack of command support during reintegration and that no one cared about their feelings. Superficiality of required reintegration classes and activities was another theme, described as “check the blocks.” Respondents noted a sense of feeling bombarded and disconnected, and emphasized that deployment “changes you” (Rivers et al., 2013).

When Janice arrived in theater, she joined a medical detachment that had already deployed as a group three months earlier. She was called up from the PROFIS list (the Professional Filler List). This is a list of various medical professionals who are assigned to a fixed military treatment facility in the United States, and in Janice’s case, she replaced a nurse who had to return early from deployment due to a knee injury. Janice is a basically shy individual who does not make friends quickly, and she felt like an outsider. Her deployment was for six months, and during that time she did not hear anything from her coworkers back home. She was located in a fairly isolated area and dealt not only with US casualties but also cared for a number of local nationals, including children. She did not note any mental health issues on post-deployment screenings because she had heard (inaccurately) that this would cause her to have to wait indefinitely to go on post-deployment leave. Six months later she was taken to the Emergency Room by her coworkers on the Pediatric Ward after a military dependent’s child was admitted with burns. She was unable to stop crying. Following brief treatment for depressive symptoms and her feelings of guilt and grief over not being able to “save” the children she saw while deployed, many of whom suffered severe burns, she was able to recoup her healthy coping skills and returned to full duty. But she remained disappointed in her coworkers and command, who welcomed her back as though she had just been on vacation.

Family members may not be able to understand that the returning Service member will not be the same person who deployed. This “new normal” reflects the profound experience of living for months in an active area of operation and being exposed to poverty, death, and destruction. It is hard to become distressed about things the family is concerned about that seem to be mundane or trivial. This difficulty reconnecting is one of many phenomena that Service members experience that are similar to traumatic stress symptoms but that lack the functional impairment and global distress of a traumatic stress disorder. Symptoms, especially in proximity to a traumatic experience or early after redeployment, do not constitute a syndrome or disorder. Reassurance and psychological first aid can be useful, and Service members are often able to enlist natural support systems to help them to readjust.

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

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

The duration of a typical infantry deployment during Operations Iraqi Freedom and Enduring Freedom is a year, for line units and support and sustainment units. During this time Service members are usually granted one two-week block of “mid-cycle” leave. At the time of redeployment the Service member completes a Post Deployment Health Assessment (PDHA) questionnaire that is reviewed by a medical provider to identify any need for further assessment or specialty consultation. Service members who are found to be in good health are released for a block of time for leave with family. A Post Deployment Health Re-assessment (PDHRA) is completed within three to six months after the Service member redeploys.

It is not uncommon for symptoms to appear on the PDHRA that were not noted on the initial PDHA. Although there may be confounding factors, such as minimizing symptoms on the PDHA to avoid possible medical hold and delay of leave, a gradual increase in symptoms over time, with the full spectrum of traumatic stress symptoms appearing months after redeployment, is often observed in those who go on to develop post-traumatic stress disorder (PTSD) or depressive disorders.

Thomas et al. found that severity of traumatic stress and depressive symptoms and associated functional impairment increased between three and twelve months following redeployment. He also noted higher symptom severity in several measures among National Guard Soldiers when compared to their Active Duty counterparts. (Thomas et al., 2010). Difficulty with post-deployment reintegration for Service members in the National Guard and Reserve is noted in other studies, with some reports showing more difficulty for these components compared to active duty, and some showing less, for reasons that remain unclear. Milliken et al., in a review of over 88,000 responses to the PDHA and PDHRA, found that rates of symptoms on surveys immediately after redeployment greatly underestimate the prevalence of symptoms and distress. A marked difference in symptom severity between active duty and Guard/Reserve respondents was also noted, even though measures of overall mental health risk and exposure to potentially traumatic events occurred at similar rates in both groups (Milliken et al., 2009). It has also been noted that many Service members in the National Guard and Reserves do not seek treatment.

Pfeiffer et al. proposed an outreach approach using organized peer support in National Guard units. Soldiers in these components may face problems with access to care for a number of reasons. In addition to the negative stigma about seeking behavioral health care, they face the additional challenge of going back to the civilian workplace, and they do not have the daily presence of an active military unit to serve as a source of support (Pfeiffer et al., 2012). The expression “from Iraq to the cul-de-sac” has been used to illustrate this dilemma.

The duration and intensity of combat exposure and the number of deployments have consistently been found to correlate with the prevalence and severity of mental health symptoms following deployment. The Mental Health Advisory Teams, including the most recent J-MHAT 7 (Joint Mental Health Advisory Team 2011), identify the following as risk factors for the development of behavioral health symptoms: intensity of direct exposure to combat, cumulative exposure to combat, deployment length, and number of deployments. Operational stressors, such as relationship problems at home, being separated from family, problems with supplies, living conditions, sleep, and lack of personal space and time, also contribute to behavioral health complaints in theater and following redeployment.

Review of data on over 300,000 OIF/OEF Veterans who had made at least one visit to a Veterans Administration (VA) facility between 2002 and 2008 confirmed the finding that increased combat exposure is a risk factor for both genders for the development of PTSD. Older age was a risk factor for PTSD and depression in women but not men (Maguen, Luxton, Skopp, & Madden, 2011). Katz et al., in the course of examining the reliability and validity of a Post-Deployment Readjustment Inventory, also noted some gender differences. There was no apparent difference between men and women in exposure to combat activities, being injured, or in overall adjustment and incidence of symptoms. However, the nature of the deployment stressors did differ in one aspect. Military sexual trauma (MST) was reported significantly more often by women than men, whereas men reported witnessing others being injured or killed significantly more often than women. Respondents with MST, as a subgroup, also reported more symptoms and more difficulty with readjustment (Katz et al., 2010).

A detailed examination of variables related to the expression of traumatic stress symptoms in a New Jersey National Guard Unit found that gender was a significant but weak predictor of traumatic stress symptoms following deployment (Kline et al., 2013). In a commentary, Hoge et al. note that unlike the epidemiologic data for civilians, where depression and PTSD are more prevalent among women, gender differences are not found following deployment. The degree of combat exposure, rather than gender, is the primary risk factor for both genders for the development of traumatic stress syndromes (Hoge et al., 2007).

Review of gender differences in combat exposure, operational stress, and subsequent behavioral health symptoms reflects the consensus that women were already serving in positions that, although not defined as “combat arms,” nonetheless were in the thick of the action. Combat medics, truck drivers, petroleum supply specialists, and vehicle mechanics are some examples. Now that women are eligible for combat specialties, it is heartening to note that gender has not been consistently shown to be a predictive factor for the development of traumatic stress symptoms, depression, or impairment in functioning (Vogt et al., 2011).

Studies looking at gender effects, combat exposure, and diagnosis vary in the details of their findings, some of which are contradictory to a minor extent, but two issues relevant to post-deployment assessment and treatment are consistent and are not dissimilar from the findings on all male samples: intensity of combat exposure tends to result in higher levels of traumatic stress symptoms, as well as increased difficulties with depressive symptoms and substance abuse. Most also agree that roughly 50% of women deployed in the service of OIF or OEF were directly exposed to combat even though not having a combat arms occupational specialty.

One study of over 6,697 male and 554 female Soldiers found no gender differences in PTSD symptoms, more depression in females, and more alcohol abuse in males. MST was noted more often in females. (Maguen, Luxton, Skopp, & Madden, 2011). In a cohort of similar size and percentage of males versus females, combat exposure was more likely to result in symptoms of traumatic stress or depression in females (Luxton et al., 2010). These surveys are useful, but the data analyzed may suffer from lack of specificity. Soldiers will confirm that exposure to combat can mean very different things—from actually firing a weapon in a lethal encounter to hearing the sound of small arms fire while working “inside the wire.”

Data from the Millennium Cohort Study were used to study the mental health risks associated with deployment in over 17,000 women. The positive association between combat exposure and symptoms of PTSD was confirmed. But no significant association was found with other mental health conditions and combat. In contrast to the MHAT reports, multiple deployments, duration of deployment, and length of dwell time did not show a significant association with any mental health outcomes. Data from this cohort also revealed that disrupted sleep, past mental health symptoms, smoking, and problem drinking correlated with mental health symptoms for women during deployment (Seelig et al., 2012).

Drawing again from the Millennium Cohort Study, Jacobsen et al. found that combat exposure during deployment was associated with increased prevalence of misuse of alcohol by both men and women, with men being more likely to binge drink and have associated negative consequences. Combat exposure, combined with a previous substance use disorder or mental health diagnosis, also increased the risk of alcohol abuse following redeployment for both genders (Jacobsen et al., 2008).

There are other areas of concern for women returning from deployment that need further study. Women in the Millennium Cohort who deployed after childbirth and who experienced combat were at increased risk for maternal depression after coming home, and the determining variable, again, appeared to be exposure to combat (Nguyen et al., 2013). A White Paper discussing research and areas of concern for deployed women noted grief, guilt, sadness, and depression in mothers separated from their infants, and recommended that post-partum deferment of deployment be extended to one year in all branches (Naclerio et al., 2011).

Mothers who deploy may be viewed as uncaring or negligent, rather than serving selflessly and patriotically. Guilt and concern about the welfare of older children and teenagers can be a distracting influence in theater, and the length of deployments may wear on those left behind with child-care duties (Benedict 2010; Scott 2010). It is more culturally acceptable for men to go to war. Dealing with the absence of a father, husband, or brother who deploys is seen as a patriotic sacrifice on the part of those left behind on the home front. But a woman may face resentment and confusion on the part of family members who don’t understand why she puts her job over her responsibilities as a mother.

Men and women alike experience many losses in the course of deployment and when ending a term of service. Grieving the loss of comrades killed in action, and losses of family members who may have died while the Service member was deployed, add additional complexity to the task of reintegration. Service members may have missed important milestones for their children and achievements like a graduation. For mobilized Reservists and National Guard Soldiers, career opportunities may have been missed. There may be the loss of physical integrity and ability due to the wear and tear caused by heavy protective equipment and other hazards in an austere environment, and the Service member may have sustained injuries. Relationships may dissolve while the Service member is deployed, leaving the Service member without a support system at home. And exposure to war and its attendant evils may affect one’s sense of meaning and spiritual beliefs, sometimes leading to a crisis of faith.

For some, joining the military at a young age provided support, direction, and meaning. Joining the Army “family” may have served as a corrective emotional experience that helped to address childhood family dysfunction. Entering the civilian world—sometimes many years prior to what the Service member intended—may be a bewildering task. The Army requires Soldiers to participate in classes and workshops addressing educational benefits, VA system, and job-seeking skills prior to separation or retirement. And the Department of Defense initiated a program in collaboration with a mental health managed care organization to provide phone support from a licensed behavioral health provider that can continue after “clearing post” and provide coaching and resources for re-establishing behavioral health care. But because many Service members enter military service at a young age, it can be difficult to conceptualize how one might fit into a civilian working environment, especially in the profession of Combat Arms. One senior Non-Commissioned Officer (NCO) with multiple deployments quipped, “I keep looking in the classifieds for an opening for a ‘Tank Commander’—no luck.” With some discussion, he realized that his leadership skills, his experience as a team member, and his experience with executing a mission from beginning to end have great value in the civilian workforce.

It is important to note that continued grief, unhappy feelings, worry, and anxiety about the future are normal reactions and are appropriate to the circumstances. Behavioral health providers can provide support, encouragement, and a sounding board. Assigning a diagnosis to these feelings is not helpful. Just as it is normal, as illustrated above, to experience distressing feelings on return from deployment, leaving military service may also elicit unpleasant feelings. An important role of the military behavioral health provider is to be able to identify normal emotional reactions and distinguish these from pathological processes. This includes providing reassurance that normal feelings will resolve with time.

On the other hand, the stress of separation from the military may be accompanied by the onset of significant behavioral health symptoms. For Service members who have avoided treatment and have suppressed traumatic memories, the process of leaving the military may trigger the emergence of the symptoms of PTSD. Senior NCOs approaching retirement, for example, may experience an increase in irritability, disrupted sleep, problems with closeness in their primary relationships, and an increase in hypervigilance. The late emergence of these symptoms is not typical of a delayed onset of PTSD. In this situation the Service member has been experiencing symptoms and “driving on”—but as the end of military service nears, these symptoms overcome the Service member’s will to suppress and not acknowledge them. In disability cases, this may draw skepticism on the part of disability examiners, who may take the position that symptoms are faked or exaggerated in order to get a higher rating. But the symptoms are very real and are beyond the individual’s control in most cases. One might speculate that the long length of the operations in Iraq and Afghanistan and the need for repeated deployments with little downtime may make this phenomenon more common. The answer, however, awaits further study.

Depressive reactions may also occur, for example, when the Service member does not have emotional attachments outside the military. Many young adults with limited parental support choose to join the military. Through the process of training, the Service member becomes a valued member of the military “family.” Because the military also maintains some degree of control over the lives of Service members, the tasks of leaving home and becoming an independent adult may be delayed for these Service members, and these issues may emerge at the time of separation from military service. These emotional reactions may be more pronounced if separation from military service is involuntary, either for medical, administrative, or disciplinary reasons.

Disordered eating is a problem that lacks intensive study to date in female Service members. A study of women enrolled in two VA medical centers in the Midwest found that one in six reported a lifetime history of disordered eating. Associations were found with PTSD, sexual trauma (particularly completed rape during military service), and a history of childhood sexual trauma (Foreman-Hoffman et al., 2012). As is noted in other occupations that require athletic fitness and control of body weight, the pressure to maintain weight within prescribed parameters as a condition of continued service also contributes to the complexity of the problem.

Although association does not confer causation, stress alone can contribute to weight gain and emotional eating, and many of the medications used to treat PTSD and depression are associated with weight gain. A prospective study of weight gain status in civilian women with PTSD found a consistent increase in BMI following the onset of PTSD (Kubzansky et al., 2014). Another area of potential concern in women Veterans who have been exposed to blast injury in theater is that pituitary injury may result in impaired growth hormone regulation and hypogonadism, endocrine factors that can also contribute to weight gain (Guerrero & Alfonso, 2010). Studies of occupations with a high rate of eating disorders, such as dancers, gymnasts, and models, consistently identify a requirement to maintain weight within specific guidelines as a risk factor for the development of disordered eating.

The authors of VA study recommend routine screening for eating disorders. In another examination of Millennium Cohort Study data, Jacobson et al. did not find an association between deployment and disordered eating. The study did find, however, an association between combat-related traumatic events and disordered eating. Other significant variables noted were a past history of a mental health diagnosis and being placed on a diet for weight loss (Jacobsen et al., 2009).

After block leave is over, and unit members have left for military schools, permanent change of station, new command, or re-classing to another occupational specialty, the unit begins the process of preparing for the next deployment. Immediately following deployment, symptoms of “normal” combat and operational stress tend to diminish, although some never completely recede. There is a subgroup, however, that will continue with active or worsening symptoms and associated functional impairment. It is at this point that medical providers are responsible for determining what conditions are treatable and thus will allow the Service member to continue in service, and what conditions may cause the Service member to fail retention standards.

Providers are often faced with tough decisions when a Service member who planned to retire after 20 years of service develops a medical condition that does not meet medical retention standards. These standards are set out in the regulations of each branch of military service (Army Regulation 40-501). If possible, the Service member may be able to “re-class” to another specialty or may be accepted to COAD (Continue on Active Duty) following examination by the Physical Evaluation Board. But ultimately the provider’s decision will be made in accordance with the regulations and the needs of the Service branch.

Each branch has a component dedicated to the treatment and rehabilitation of warriors who are injured or who become ill in the course of a mobilization or deployment. Wounded Warrior programs with similar goals are found in the Navy, Marines, Air Force, and Army, where this component is referred to as Warrior Transition, with battalions at each post. The Warrior Transition Unit (WTU) in the Army provides the Soldier with a unit assignment where the mission focus is on treatment and rehabilitation without distraction in order to return to full duty if possible, or referral to a Medical Evaluation Board to determine if there are conditions that do not meet retention standards. The WTU also enables the Soldier’s original command to obtain a replacement for that Service member’s position and to continue to train and prepare for the next deployment.

Reserve or National Guard Soldiers who are demobilizing are assessed to see if they can be medically cleared for release from active duty and can continue treatment at home, or if there is a need for treatment that would warrant continuation on active duty and assignment to the Warrior Transition Unit. In this case the Soldier’s active duty orders are extended pending the outcome of medical treatment and further evaluation. Although allowing for treatment and stabilization of medical conditions, continuation on active orders may be a hardship for the Service member. A year-long mobilization, for example, can stretch into a two- to three-year absence from home if there are conditions serious enough to continue to require treatment or that lead to referral for a Medical Board evaluation. On the other hand, it provides the Service member with financial support and medical care during the rehabilitative period. These COMPO 2 and 3 Soldiers are older than the average active duty Soldier, and many also require treatment of conditions such as hypertension, heart disease, osteoarthritis, and other chronic disorders associated with aging.

Many active duty Service members remain in their assigned units while continuing treatment and rehabilitation. The Soldier’s profile is modified to specify what duty limitations and restrictions are warranted and whether these are temporary and expected to improve or are permanent. The demands of OIF/OED/OND filled the Warrior Transition Units to the limit, and as a result, Service members who are medically unable to perform may remain in their original positions. This in turn may result in feelings of resentment when others have to pick up the duties that the Soldier is unable to perform. The unit “family” gets off task, and dysfunctional group behaviors may emerge. Behavioral health conditions that lead to duty limitations may be especially likely to result in a sense of alienation from the unit. The Service member may feel “broken,” or as though he or she is resented or no longer belongs, adding to the difficulty of coping with post-deployment reintegration or transition to civilian life. When the situation is prolonged and the unit’s operational tempo increases, Service members may react to these stressors in unhealthy ways, such as misconduct and substance abuse, or depressive reactions may ensue.

Before the increase in the size of the fighting force over the last decade, and the increase in the number of Service members with disqualifying medical and psychiatric conditions, Service members received treatment while on active duty until their health reached a point of stability. Then, if one or more conditions still did not meet retention standards, the Soldier was referred to the Medical Evaluation Board for further evaluation and entry into the military disability evaluation system.

Recent revisions to the disability determination process have increased the efficiency and have decreased the processing time for medical separations. By integrating VA function of providing a Service connection rating with the military function of determining fitness for duty, duplications in the process are eliminated and Service members can remain on active duty while VA rating is completed, with the ultimate goal of sealing the benefits gap between the Army and VA system. The Integrated Disability Evaluation System (iDES) was piloted in 2009–2010 and is now fully implemented Army-wide.

Entry into the iDES occurs when the Service member’s primary care provider determines that one condition has reached the “medical retention decision point.” or MRDP. There may be other active conditions at varying stages of recovery. A VA Compensation and Pension examination follows, and once completed is reviewed, along with other treatment records, to determine, for each claimed or referred condition, if medical retention standards are met.

An important aspect of this is the “e-Profile.” This process of monitoring readiness and managing medical profiles (lists of duty limitations) continues to evolve, with the emphasis on maintaining the fighting force. Medical profiles are now entered electronically and are monitored by the local Medical Activity and the Soldier’s command, rather than being completed by hand and potentially getting lost when the Soldier moves from one post to another or following a change in command.

Some gender differences are noted in the rates of disability and types of disabling conditions, but overall the differences are not extreme. For example, women are more prone to musculoskeletal injuries that lead to disability retirement (Fuerstein et al., 1997). A study of disability retirement in the Air Force found that female gender increased the relative risk of disability retirement, but when stratified by deployment history, this difference diminished. A study of Air Force disability retirement found that gender increased the relative risk of disability retirement, but when stratified by deployment history, this difference diminished (Elmasry et al., 2014). A study of disabled Veterans who served in the Israeli Defense Force noted that women experienced higher levels of psychosocial distress after retirement (Koren et al., 2013). This is an area that needs further study.

There are also a number of situations that may lead the enlisted Soldier’s command to initiate an involuntary separation of an administrative nature for “Convenience of the Government.” The details of the types and nature of these separations are detailed in Army Regulations and are different for enlisted Service members and Officers (AR 635-200). For example, the Soldier’s commander can recommend administrative separation if initial accession was defective, when parental obligations interfere with military duty, for personality disorders that do not respond to corrective measures, and for “other designated physical or mental conditions,” including chronic seasickness, claustrophobia, sleepwalking, and others.

Included in this regulation is separation for “failure to adapt” to military life, or “adjustment disorder.” Separations due to inadequate performance, failure to meet weight and tape standards, and relapse following rehabilitation for alcohol dependence are also found in this regulation, as is the process for separation due to various types of misconduct. At the present time, Soldiers who have deployed must obtain a behavioral health screen for PTSD and traumatic brain injury (TBI) before certain administrative separations can be approved. If PTSD or TBI or another significant psychiatric disorder is found (with the exception of substance use disorders) and it is determined that the condition does not meet retention standards, then disposition “through medical channels” is recommended, and a General Officer makes a decision as to which type of separation is appropriate in that individual case.

There are gender differences observed in the types and frequency of administrative separations, but little formal research is found on the nature of these differences and their significance. Because of the differences in the absolute numbers of male and female Soldiers on active duty in the Army, it is difficult to say, for example, that separations for “adjustment disorder” or “patterns of misconduct” are more prevalent among one group or the other simply by casual observation. Larger numbers would likely be needed to obtain an effect size that allowed for reliable conclusions. Differences in coping strategies, such as the degree to which the individual internalizes or externalizes stress or dysphoria, have been noted and may have an impact on the risk for disciplinary separation.

Women continue to contribute to the mission of the US military in a variety of roles, with duties in increasingly forward areas requiring proficiency in combat skills. As a group, women who deploy are resilient and do not appear to be at higher risk than their male counterparts for the development of psychological disorders due to deployment. There are some differences noted in the types of stressors encountered, with military sexual trauma having pervasive toxic effects on the Soldier’s well-being and effectiveness. As women enter the profession of combat arms, the challenge is preserving military effectiveness while making changes to tactics, techniques, and procedures that allow for optimal utilization of women in combat operations.

Addressing the psychological needs of both men and women during the process of reintegration continues to evolve. Embedding teams of behavioral health providers into the medical support units of the Brigade Combat Teams allows for more individual consideration when the teams redeploy, as to which units may require more intensive evaluation and intervention, and allows for more optimal use of the natural support system of the small unit while its membership is still intact. Behavioral health providers can also identify and intervene when group dysfunction is identified at the company and platoon level. With the development over time of familiarity and trust between the troops and the behavioral health providers, there is an opportunity, following deployment, to continue the process of traumatic event management (TEM) and to interact at the smaller unit level when dysfunction is identified, encouraging a return to task orientation and promoting the use of healthier coping skills. Although this ideal may remain elusive, embedded teams are a step in the right direction.

Military sexual trauma is well established as a serious risk factor for the development of psychiatric symptoms in both genders, with the incidence being much higher in women. All branches of the Service strongly discourage sexual harassment and are making improvement in policies to raise awareness and to encourage reporting and investigation without fear of retaliation (ALARACT 007-2012). Review of the efficacy of routine screening for military sexual trauma in a large sample of VA patients of both genders revealed marked discrepancy in the rates of positive screens, with positive responses for women at 19.5% and for men at 1.25%. The study recommended routine screening to allow for early detection of MST and further development of evidence-based intervention for positive screens (Kimerling et al., 2008). Since there is also evidence to support an increase in sexually aggressive behavior in combat settings, the addition of sensitive screening measures to routine post-deployment evaluations seems prudent.

To mitigate the psychological stress of deployment, the Women’s Health Assessment Team, in a report on concerns of women serving in Afghanistan in 2011, also made a number of policy recommendations such as increasing postpartum deployment deferment to a year in all branches, and encouraging the development of community based peer support (Naclerio, 2011).

Providers who are charged with evaluating Service members returning from a combat deployment, assisting with the challenges of reintegration, and monitoring readiness should be sensitive to potential differences between women and men in their coping strategies and their emotional needs. At the same time, it is important to recognize that women and men in harm’s way appear, overall, to be equally resilient, while equally sharing the psychological vulnerability that is a universal human response to war.

ALARACT 007-2012. (2012). Subject: Sexual Harassment/Assault Response and Prevention (SHARP): Program implementation guidelines. Washington, DC: Pentagon Telecommunications Center on Behalf of DA.

Army Regulation 40-501. (2007). Standards of medical fitness: Medical Services; Headquarters Department of the Army; 14 December 2007 with Rapid Action Revision 4 August 2011; Chapter 3 and 7. www.apd.army.mil

Army Regulation 525-29. (2011). Military operations: Army Force Generation; Headquarters Department of the Army; 14 March 2011; Chapters 1–7 and 10. www.apd.army.mil

Army Regulation 653-200. (2005). Active Duty Enlisted administrative separations: Personnel Separations; Headquarters Department of the Army; 6 Jun 2005 with Rapid Action Revision 6 September 2011. www.apd.army.mil

Benedict, H. (2010, April 27). Mothers in the military: Reconciling being a mother with being a soldier. Blog post retrieved from https://pbs.org/pov/regardingwar/conversations/women-and-war/.

Elmasry, H., Gubata, M., Packnett, E., Niebuhr, D., & Cowan, D. (2014). Risk factors for disability retirement among active duty Air Force personnel. Military Medicine, 179,(1), 5–10.

Fleming, B., & Robichaux, C. (2013). Redeployed: How combat veterans can fight the war within and win the war at home (pp. 41–45). Dallas, TX: Frisco House.

Fuerstein, M., Berkowitz, S. M., & Peck, C. A. (1997). Musculoskeletal-related disability in US Army personnel: Prevalence, gender and military occupational specialty. Journal of Occupational & Environmental Medicine, 39(1), 68–78.

Forman-Hoffman, V., Mengeling, M., Booth, B., Torner, J., & Sadler, A. (2012). Eating disorders, posttraumatic stress and sexual trauma in women veterans. Military Medicine, 177(10), 1161–1168.

Grossman, D., & Christensen, L.W. (2008). On combat: The psychology and physiology of deadly conflict in peace and war (3rd ed.). Warrior Science Publication.

Guerrero, A. F., & Alfonso, A. (2010). Traumatic brain injury–related hypopituitarism: A review and recommendations for screening combat veterans. Military Medicine, 175(8), 574–580.

Hoge, C. W. (2010). Once a warrior always a warrior. Guilford, CT: Lyons Press.

Jacobsen, I., Ryan M., Hooper, T., Smith, T., Amoroso, P., Boyko, E., Gasckstetter, G., Wells, T., & Bell, N. (2008). Alcohol use and alcohol related problems before and after military combat deployment. Journal of the American Medical Association, 300(6), 663–675.

Jacobsen, I., Smith, T., Smith, B., Keel, P., Amoroso, P., Wells, T., Bathalon, G., Boyko, E., & Ryan, M. (2009). Disordered eating and weight changes after deployment: longitudinal assessment of a large US military cohort. American Journal of Epidemiology, 169,(4), 415–427.

Jovanovic, T., & Ressler, K. (2010). How the neurocircuitry and genetic of fear inhibition may inform our understanding of PTSD. American Journal of Psychiatry 167(6), 648–662.

Katz, L., Cojucar, G., Davenport, C., Pedram, C., & Lindl, C. (2010). Post-deployment readjustment inventory: reliability, validity, and gender differences. Military Psychology, 22, 41–66.

Kimerling, R., Street, A., Gima, K., & Smith, M. (2008). Evaluation of universasl screening for military-related sexual trauma. Psychiatric Service, 59(6), 635–640.

Kline, A., Ciccone, D., Weiner, M., Interian, A., St Hill, L., Falca-Dodson, M., Black, C., & Losonczy, M. (2013). Gender differences in the risk and protective factors associated with PTSD: A prospective study of National Guard troops deployed to Iraq. Psychiatry, 76(3), 256–272.

Koren, E., Bergman, Y., & Katz, M. (2013). Disability during military service in Israel: raising awareness of gender differences. Journal of Gender Studies (online), Taylor and Francis Online. doi:10:2080/09589236.2013.820132.

Kubansky, L., Bordelois, P., Hee, J., Roberts, A., Cerda, M., Bluestone, N., & Koenen, K. (2014). The weight of traumatic stress: A prospective study of posttraumatic stress disorder symptoms and weight status in women. Journal of the American Medical Association Psychiatry, 7(1), 44–51.

Litz, B., Stein, N., Delaney, E., Lebowitz, L., Nash, W., & Silva, C. (2009). Moral Injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706.

Luxton, D., Skopp N., & Maguen, S. (2010). Gender differences in depression and PTSD symptoms following combat exposure. Depression and Anxiety, 27(11), 1027–1033.

Metz, S., & Johnson, D. (2001, January). Asymmetry and US military strategy: Definition, background, and strategic concepts. Strategic Studies Institute, US Army War College.

Maguen, S., Luxton, D., Skopp, N., & Madden, E. (2011). Gender differences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan. Journal of Psychiatric Research, 46(3), 311–316.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2009). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association, 298(18), 2141–2148.

Naclero, A., Stola J., Trego, L., & Flaherty, E., Health Service Support Assessment Team, IJC, Afghanistan. (2011). The concerns of women currently serving in the Afghanistan theater of operations: White paper. San Antonio, TX: US Army Medical Department.

Nguyen, S., Leardmann, C, Conlin, A., Slymen, D., Hooper, T., & Smith, T. (2013). Is military deployment a risk factor for maternal depression? Journal of Women’s Health, 22(1), 9–18.

Pfeiffer, P, Blow A., Miller, E., Forman, J., Dalack, G., & Valenstein, M. (2012). Peers and peer-based interventions in supporting reintegration and mental health among National Guard Soldiers: A qualitative study. Military Medicine, 177, 1471–1476.

Rivers, F., Gordon, S., Speraw, S., & Reese, S. (2013). U.S. Army Nurses’ reintegration and homecoming experiences after Iraq and Afghanistan. Military Medicine, 178, 166–172.

Seelig, A., Jacobsen I., Smith, B., Hooper, T., Gackstetter, G., Ryan, M., Wells, T., Wadsworth, S., & Smith, T. (2012). Prospective evaluation of mental health and deployment experience among women in the military. American Journal of Epidemiology, 176(2), 135–145.

Scott, J., (2010, April 13). Mothers in the military: punishing mother who serve. Blog post retrieved from https://pbs.org/pov/regardingwar/conversations/women-and-war/.

Sewell, S., Nagi, J. (2007). The U.S. Army/Marine Corps Counterinsurgency Field Manual: U.S. Army Field Manual 3-24; Marine Corps Warfighting Publication No. 3-33-5/with Forewords by General David Petraeus and Lt General James F Amos. Chicago: University of Chicago Press.

Thomas, J., Wilk, J., Riviere, L., McGurk, D., Castro, C., & Hoge, C. (2010). Prevealence of mental health problems and functional impairment among active component and National Guard Soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry, 67(6), 614–623.

Vogt, D., Vaughn, R., Glickman, M., Schultz, M., Drainoni, M., Elwy, R., & Eisen, S. (2011). Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF veterans. Journal of Abnormal Psychology, 120(4), 797–806.

U.S. Army Field Manual FM 27-10: The Law of Land Warfare; Department of the Army, Washington 25, D.C. 18 July 1956 with Change 1, 15 July 1976.

U.S. Army, Office of the Surgeon General and Office of the Command Surgeon HQ, USCENTCOM and Office of the Command Surgeon US Forces Afghanistan (USFOR-A). (2011, February 22). Joint Mental Health Advisory Team 7 (J-MHAT-7) Operation Enduring Freedom 2010 Afghanistan. Chapter 7.1.