PART

5

The Female Veteran Experience

SIXTEEN

The Woman Veteran Experience

ISABEL D. ROSS, NATARA D. GAROVOY, SUSAN J. MCCUTCHEON, AND JENNIFER L. STRAUSS

Women are serving in today’s US military at unprecedented rates. Women comprise 15% of active military personnel, and 11.7% of Veterans of recent conflicts in Iraq and Afghanistan. Their increased presence and engagement in the US military has resulted in an equally rapidly growing population of women Veterans, projected to reach 15% of the total US Veteran population by 2035 (National Center for Veteran Analysis and Statistics, 2011). Between 2005 and 2013, the Department of Veterans Affairs (VA) witnessed a 68% increase in the number of women accessing VA healthcare; and the proportion of female VA healthcare users with mental health diagnoses more than doubled (Northeast Program Evaluation Center, 2014). Identifying and meeting the needs of this emerging population are paramount.

This chapter will review women Veterans’ mental health needs, VA mental healthcare policy and programming for women Veterans, and best practices for gender-sensitive mental healthcare.

Preliminary evidence suggests that women Veterans may differ from men in the prevalence and expression of certain mental health disorders, as well as their response to treatment. These differences may be due to biological sex differences, such as the impact of the female reproductive cycle on mental health, or social and cultural differences such as the impact of gender-related violence (e.g., intimate partner violence experienced by women, military sexual trauma [see Chapter 18 for more information on this topic]). Identification of these differences is an initial and crucial step in knowing how to best meet these women’s mental healthcare needs.

Prevalence of Mental Health Issues Among Women Veterans

Known gender differences in the prevalence of mental health conditions between men and women Veterans are largely consistent with patterns observed in the general population. For example, research consistently shows that women Veterans are more likely than Veteran men to carry a mental health diagnosis (Runnals et al., 2014). In addition, higher rates of depression and anxiety are found among women Veterans (Freedy et al., 2010; Maguen et al., 2010), whereas other mental health conditions, such as substance use disorders, are more common among male Veterans (Iverson et al., 2010; Westermeyer et al., 2009).

In contrast, while women in the general population are two to three times more likely than men to be diagnosed with post-traumatic stress disorder (PTSD), women and men Veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) have exhibited similar rates of PTSD (Freedy et al., 2010; Maguen, Ren, Bosch, Marmar, & Seal, 2010). In addition, relative to their male counterparts, women Veterans have been found to have higher rates of mental health and medical comorbidities (Banerjea, Pogach, Smelson, & Sambamoorthi, 2009; Frayne et al., 2010; Iverson et al., 2010). For example, rates of comorbid PTSD and depression are significantly higher among women Veterans then men.

These findings highlight two important points about gender difference in the prevalence of mental health disorders. The first is that the higher rates of mental health disorders and comorbidities among women Veterans who use VA health services may have treatment implications, such as the need for more intensive care. This is consistent with observed patterns of VA mental healthcare utilization, as women Veterans with mental illness are more frequent users of VA mental health services relative to their male counterparts (Frayne et al., 2012). The second, and perhaps more critical, point is the importance of not assuming that gender differences observed in non-Veteran populations generalize to the Veteran population. While a woman’s biology may be the same regardless of her occupational history, some social and cultural factors may uniquely characterize women Veterans, for example those qualities and life experiences that compel her to volunteer for military service and her experiences during and after military service. Some of these differences may in fact challenge what we believed we know about women’s mental health, as in the case of PTSD, where similar rates have been observed among male and female OEF/OIF Veterans, whereas higher rates are observed among women, as compared to men, in the general population.

On the whole, however, we have much more to learn. In the general population, women are more likely than men to be diagnosed with panic disorder, anxiety disorders, and bipolar II and eating disorders, and these differences are well established in the literature (Kessler et al., 1994; Diflorio & Jones, 2010; McLean, Asnaani, Litz, & Hofmann, 2011; Smink, van Hoeken, & Hoek, 2012). It is not currently known if rates of these disorders among the growing women Veteran population are consistent with those observed in non-Veteran women.

Biological Considerations

Biological differences between women and men can contribute to differences in mental health. Among women Veterans seeking VA healthcare, 42% are within their reproductive years (ages 18–44) and 29% are aged consistent with perimenopause (ages 45–55) (Frayne et al., 2014). Sex-specific hormonal differences and reproductive life-cycle stages, such as pregnancy and perimenopause, have known effects on mental health, and physiological hormonal transitions that occur during a woman’s life cycle may serve to increase her risk of developing a mental health disorder. In a study of women OEF/OIF Veterans, those who accessed pregnancy-related care were twice as likely as those who did not access this care to be diagnosed with depression, anxiety, PTSD, bipolar disorder, or schizophrenia (Mattocks et al., 2010).

Reproductive mental health issues can also affect treatment decisions. Providers must consider contraception counseling and pregnancy testing, as well as risk benefit counseling, before prescribing medication that is potentially teratogenic (i.e., agents that can interfere with normal fetal development and can result in birth defects). Simultaneously, there are risks to antidepressant use during pregnancy, yet untreated mental health disorders may also have adverse effects on the patient, her baby, and her family (e.g., increased risk for pre-term birth among depressed pregnant women) (Grote et al., 2010). With up to 20% of pregnant women in the general population experiencing mood or anxiety disorders during pregnancy and 10%–15% experiencing postpartum depression (Marcus et al., 2003), there is a clear need for women Veterans’ providers to be well informed of the impact of biological differences on mental health and to be competent in reproductive mental health issues.

Social and Cultural Considerations

It is equally important to consider the influence of social and cultural factors on women’s mental health. Gender differences in social resources and socioeconomic status (SES) are well known, and research indicates that SES is a key factor in determining the psychological health of women (American Psychological Association, 2013). For example, women Veterans are more likely than male Veterans to be unmarried (Maguen, Ren, Bosch, Marmar, & Seal, 2010; National Center for Veterans Analysis and Statistics, 2013). Veteran women are also more likely to divorce and remain divorced when compared to male Veterans and age-matched civilian women (Adler-Baeder, Pittman, & Taylor, 2005; National Center for Veterans Analysis and Statistics, 2013). Among VA users receiving PTSD treatment, women report fewer interpersonal and economic resources than men (Fontana, Rosenheck, & Desai, 2010). We do not yet know precisely how these differences affect the mental health of women Veterans, but we can imagine that the effects could be challenging.

Socioeconomic differences also extend to and within the homeless population. While there are more homeless Veteran men than women, women are increasingly identified as a group that is at high risk for homelessness. As compared to homeless male Veterans, homeless women Veterans are younger and have higher rates of unemployment and mental illness (Byrne, Montgomery, & Dichter, 2013). These trends are consistent with previous studies that have compared homeless women and men in the general population. In the general homeless population, women have been found to be younger, more often members of a minority group, less likely to have a substance use disorder, and more likely to have symptoms of major depression. One pivotal difference between homeless men and women noted is that, unlike men, most women are also of childbearing age and have young children in their custody, suggesting that there may be different origins as well as a need for different solutions (e.g., housing for women, and housing for women and children) to mitigate risk for homelessness and to provide related services for homeless men and women (Culhane & Metraux, 1999; North & Smith, 1993). Further, in the general population, gender-based violence (i.e., domestic and sexual violence) are the leading causes of homelessness for women and families, and 20%–50% of all homeless women and children become homeless as a direct result of domestic violence (Zorza, 1991). Among homeless Veterans who receive VA health services, 39.7% of women and 3.3% of men have experienced military sexual trauma (Pavao et al., 2013).

Social and cultural differences are also pronounced when examining gender differences in PTSD. For example, the context in which Servicemen and Servicewomen experience the same combat theater during deployment may differ (Street, Vogt, & Dutra, 2009; Vogt et al., 2011). Women are less likely than men to be exposed to intense combat (Street et al., 2013), but more likely to experience other deployment-related stressors, including sexual assault, sexual harassment, general harassment, and a lack of unit support (Murdoch, Pryor, Polusny, & Gacksetter, 2007; Street, Gradus, Stafford, & Kelly, 2007; Vogt, Pless, King, L.A., & King, D.W., 2005). As support from fellow military personnel has been shown to improve resiliency among those exposed to military-related stressors (Bliese, 2006; Griffith &Vaitkus, 1999), gender differences in unit support may also influence mental health outcomes. Data from previous eras demonstrate that post-deployment stressors, such as an unsupportive homecoming atmosphere, mediate the relationship between deployment-related trauma and negative mental health outcomes for male Veterans (Johnson et al., 1997). Women Veterans are the gender minority within the Veteran population. Like any minority group, these women may have greater difficulty connecting with other Veterans in their community. In addition, the public does not always recognize or remember that women can be Veterans. Women Veterans are less likely than men to be recognized for their military service and therefore may feel less supported within their home communities. This experience may be particularly salient for National Guard and Reservists who return to home to civilian communities, rather than a military base, as well as for those who return to more isolated rural areas. Further, while the effects of post-deployment stressors have not been fully researched in women Veterans, it would not be difficult to imagine how stressors such as readjusting to a primary caregiver role, marital transitions, and attempting to navigate healthcare resources—responsibilities that often carry gender role expectations—could also create unique readjustment challenges for women Veterans.

Current VA Mental Healthcare Policy and Programming for Women

VA has taken active steps to meet the unique mental healthcare needs of the emerging population of women Veterans. Current VA policy specifically addresses gender-related concerns and requires that mental health services be provided in a manner that recognizes gender-specific issues as important components of care (Department of Veterans Affairs, 2008). All VA healthcare facilities are required to provide treatment environments that can accommodate and support women’s safety, privacy, dignity, and respect. This includes providing separate and secure sleeping and bathroom arrangements for residential treatment facilities (Department of Veterans Affairs, 2008). To accommodate women Veterans who do not feel comfortable in mixed-gender treatment settings, many VA facilities have women-only programs or have established specialized women’s treatment teams, and many of these programs serve as national resources for all women Veterans. Examples of such VA programing include specialized women’s mental health outpatient clinics, women-only residential treatment programs, and comprehensive primary care clinics for women that incorporate mental health services. In addition, as part of meeting gender-specific needs, VA policy strongly encourages all healthcare facilities to provide Veterans the option of a consultation from a same- or opposite-sex provider.

The proportion of women Veterans seeking VA mental healthcare is rapidly growing, yet women Veterans remain a significant gender minority among VA users. As such, these women may face unique challenges navigating a healthcare system that predominantly serves men. To meet this challenge, in 2012 VA surveyed mental health leadership at every medical center within VA healthcare system to determine the availability of gender-sensitive mental healthcare for women Veterans. A definition of gender-sensitive mental healthcare that specified measurable organizational features and processes for the needs of VA was developed (Strauss et al., 2014): Gender-sensitive mental healthcare refers to services that attend to gender differences in the prevalence and expression of mental health disorders and treatment responses, as well as the influence of biological, social, and cultural factors on mental health. The key components of gender-sensitive mental healthcare identified through this effort include the following: comprehensiveness of mental health services, including a full continuum of service availability for women in general mental health, specialty mental health, and residential/inpatient programming in a range of treatment settings; choice of treatment modality (e.g., mixed-gender or women-only service options); competency of providers to address women’s unique treatment needs; and innovation of creative options and settings for subgroups of women, especially when caseloads of women are small (Strauss et al., 2014). These tenets of gender sensitivity guide VA’s current approach to women’s mental health programming.

Findings from the 2011 survey indicate that women Veterans have access to general and specialty outpatient treatment options at all VA healthcare systems. In addition to standard treatment options available to all Veterans, additional treatment options for women Veterans are achieved through various organizational efforts, including co-located mental health providers in women’s comprehensive health clinics and providing women-only groups or individual therapy to women. However, in keeping with a patient-centered approach to care, VA does not promote one model of women’s mental healthcare as universally appropriate, or gender-sensitive. This approach recognizes that some women Veterans may benefit from single-gender treatment environments, to foster their sense of safety, ability to address gender-related concerns, and strong peer and social support. On the other hand, some Veterans may benefit from mixed-gender treatment environments, which can help to challenge patients’ assumptions and can offer a therapeutic environment in which to confront fears and misperceptions about the opposite sex. Thus, the individual patient’s clinical needs and treatment preferences inform which setting is most appropriate. This approach also recognizes the importance of offering choice, flexibility, and options of care for all Veterans.

Another example of VA’s commitment to gender-sensitive mental healthcare is the establishment of the Reproductive Mental Health Steering Committee in 2012. Reproductive mental health issues require complex treatment decisions and knowledge of pharmacologic and behavioral intervention choices, such as consideration of maternal and fetal benefits and risks in medication management among pregnant women. In response to this need for competence, the Reproductive Mental Health Steering Committee developed a training curriculum for VA mental health providers and began to disseminate the curriculum nationally in 2014.

Similarly, to address the needs of the subgroup of women Veterans who have experienced high rates of childhood and adult trauma exposure, VA has adopted a trauma-informed care model (Federal Partners Committee on Women and Trauma, 2013). This treatment model includes actively considering the role of violence and trauma in women’s lives, establishing collaborative and empowering working relationships, and designing services to anticipate stressors that may remind Veterans of past traumas and to address them as a part of treatment, if they arise (Harris & Fallot, 2001).

This chapter provides information for clinical practice, policy, and systems-level organization, with the goal of identifying and serving the unique mental healthcare needs of women Veterans. We have presented known gender differences in the prevalence of certain mental health conditions between men and women Veterans, such as higher rates of depression and mental and physical comorbidities among women. We have also described gender differences in biological, social, and cultural factors that influence mental health, such as reproductive health needs and gender disparities in economic resources. We have also proposed a definition of gender-sensitive mental healthcare to best address these differences, that includes comprehensiveness of services, choice of treatment modality, competency of providers to address women’s unique treatment needs, and innovation as needed to meet women’s mental healthcare needs in unique systems of care, such as VA. A tremendous amount of work has already been done to provide and improve gender-sensitive care for women Veterans. We look forward with interest to future collaborative efforts among researchers, clinicians, administrators, policymakers, and the Veterans they serve, to continue to optimize treatment outcomes for this very important emerging population.

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