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Mental Health Issues of Women Deployed to Iraq and Afghanistan

Published:December 26, 2012DOI:https://doi.org/10.1016/j.apnu.2012.10.005
      The number of women serving in the military and deployed to active-duty is unprecedented in the history of the United States. When women became a permanent sector of the U.S. Armed Services in 1948, their involvement was restricted to comprise only 2% of the military population; today women constitute approximately 14.5% of the 1.4 million active component and 18% of the 850,000 reserve component. Yet, little attention has been paid to the mental health needs of women military members. This review article highlights the history of women in the military and then focuses on the impact of combat exposure and injuries, military sexual trauma, alcohol use, and family separations which are associated with PTSD, depression, suicide, difficulty with reintegration, and homelessness.
      THROUGHOUT THE UNITED States' history women have proudly served their country in the Military Services, but the extent of their integration into the armed forces has dramatically changed through the years. The number of women entering the Military Services of the United States has steadily increased over the last several decades with women making up a much greater share of the military services than at any time in American history. Today, women constitute approximately 14.5% of the 1.4 million active component military personnel (full-time Army, Navy, Air Force Marines, and Coast Guard) and 18% of the 850,000 reserve component or the part-time members of the National Guard and Reserve forces (

      Office of Under Secretary of Defense Personnel and Readiness, (2012). Report to congress on the Review of Laws, Policies and Regulations Restricting the Service of Female Members in the U.S. Armed Forces. Department of Defense. Retrieved from http://www.defense.gov/news/WISR_Report_to_Congress.pdf

      ,
      • U.S. Department of Veterans Affairs, Women Veterans Task Force
      Strategies for serving our women veterans, author.
      May 1). In contrast, the total number of women in the military in 1950 was just 2%.
      The Army, Navy, Air Force, and Marine Corps services are organized within the U.S. Department of Defense (DOD); the Coast Guard is housed in the U.S. Department of Homeland Security. This distinction becomes important when discussing military population statistics because the DOD reports on the Army, Navy, Air Force, Marine Corps data, their reserve components and the National Guard; whereas Homeland Security reports the active and reserve Coast Guard data. Within the Department of Defense, 37% of women serve in the Army, the largest active duty branch of the military, 31% in the Air Force, 25% in the Navy; 7% in the Marine Corps (
      • U.S. Department of Veterans Affairs, Women Veterans Task Force
      Strategies for serving our women veterans, author.
      May 1). It is expected that the population of women veterans will increase at an average rate of about 11,000 women per year for the next 20 years. Currently they comprise 8% of the veteran population and are less likely to have served in a war zone than men (15% of women veterans versus 35% of men veterans), but by 2035 their number is expected to increase to 15% with much greater combat exposure (
      • National Center for Veterans Analysis and Statistics
      ,

      Patten, E., & Parker, K. (2011). Women in the U.S. Military: Growing Share, Distinctive Profile. Retrieved from www.pewsocialtrends.org/files/2011/12/22/women-in-the-u-s-military-growing-share-distinctive-profile/.

      ).
      The experiences of women in the military services have been largely overlooked in favor of focusing on men, a much larger force. As more women warriors return from active duty in Iraq and Afghanistan, their deployment struggles and their mental health challenges are becoming more visible. We are learning that the impact of deployment on their mental health may not be evident immediately upon return, but may emerge 3 to 12 months following deployment (
      • Kline A.
      • Falca-Dodson M.
      • Sussner B.
      • Ciccone D.S.
      • Changler H.
      • Callahan L.
      • Losonczy M.
      Effects of repeated deployment to Iraq and Afghanistan on the health of New Jersey Army National Guard troops: Implications for military readiness.
      ). The following review traces the history of women in the U.S. military and highlights current research on the mental health issues of women deployed to Iraq and Afghanistan.

      History of women in the U.S. military services

      Women became a permanent part of the military with the passage of the Armed Services Integration Act of 1948 but were restricted to comprise only 2% of the military population. When conscription ended in 1973 and the military transitioned to an All Volunteer Force (AVF), more women were actively recruited; thus opportunities for them to serve in the military labor force rapidly increased (
      • National Center for Veterans Analysis and Statistics
      ).
      By the end of the 20th century, significant changes in policy led to further integration of women into the military as the number and diversity of military occupations expanded. In the early 1990s, women service members became more visible as 41,000 women were deployed in support of the Gulf War. In 1992, the Defense Authorization Act rescinded the policy that had prevented women from flying combat aircraft and 2 years later the policy which excluded women from serving on combatant ships in the Navy was repealed. However, in 1994 after examining the role of women soldiers in the Gulf War, the Department of Defense created the Direct Ground Combat Definition and Assignment Rule (DGCDAR) which governs the service of female members of the military services. The DGCDAR contained a combat exclusion policy that prohibited women from participating in the most dangerous of combat jobs: armor, infantry and special operations (
      • National Center for Veterans Analysis and Statistics
      ,

      Office of Under Secretary of Defense Personnel and Readiness, (2012). Report to congress on the Review of Laws, Policies and Regulations Restricting the Service of Female Members in the U.S. Armed Forces. Department of Defense. Retrieved from http://www.defense.gov/news/WISR_Report_to_Congress.pdf

      ,

      Parrish, K. (2012). DOD Opens More Jobs, Assignments to Military Women. American Forces Press Service. Retrieved from http://www.defense.gov/news/newsarticle.aspx?id=67130.

      ,

      Tan, M. (2012). Women in combat: Army to open 14K jobs, 6 MOSs. Marine Corps Times, Retrieved from http://www.marinecorpstimes.com/news/2012/05/army-to-open-14000-jobs-6-mos-women-in-combat-050212/.

      ,

      Women in Military Service for America Memorial Foundation, Inc. Statistics on Women in the Military. November, 2011. Retrieved from http://www.womensmemorial.org/PDFs/StatsonWIM.pdf.

      ). Under this rule, women could not be assigned to units below brigade level whose primary mission was to engage in direct ground combat (

      Baldor, L. (2012). Military Women to Serve Closer to Front Lines, According to Pentagon Report. Huffington Post, Retrieved from http://www.huffingtonpost.com/2012/02/09/military-women_n_1266038.html.

      ,

      Office of Under Secretary of Defense Personnel and Readiness, (2012). Report to congress on the Review of Laws, Policies and Regulations Restricting the Service of Female Members in the U.S. Armed Forces. Department of Defense. Retrieved from http://www.defense.gov/news/WISR_Report_to_Congress.pdf

      ).
      When the tragic event of the September 11, 2001 attacks occurred, the United States was catapulted into Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq (2001–2010). On Sept 1, 2010, a new term, Operation New Dawn (OND) was introduced to represent the transition from the U.S. military combat operations in Iraq to supporting the Iraqi Security Forces, the government and people of Iraq. More than 11% of the forces deployed in these wars were women who engaged in combat-related assignments alongside their male counterparts. Although women were excluded from direct land combat, they occupied support jobs which often placed them in combat situations (
      • National Center for Veterans Analysis and Statistics
      ). Since the 1990s when the Department of Defense began to change its policies related to women serving in combat-related roles, the number of women in combat zones has increased from 7 to 24% (

      Patten, E., & Parker, K. (2011). Women in the U.S. Military: Growing Share, Distinctive Profile. Retrieved from www.pewsocialtrends.org/files/2011/12/22/women-in-the-u-s-military-growing-share-distinctive-profile/.

      ). Over 200,000 women have been deployed in Iraq and Afghanistan with more than 140 casualties and over 1000 injured (

      Defense Casualty Analysis System (DCAS), 2012. U.S. military casualty conflicts reports. Retrieved from https://www.dmdc.osd.mil/dcas/pages/main.xhtml on June 29, 2012.

      ).
      In today's military services the occupational roles of women soldiers tend to be heavily concentrated in administrative and medical positions. In 2008, 41% of the women officers and 16% of enlisted women held medical positions while 30% were in administrative roles (
      • National Center for Veterans Analysis and Statistics
      ). Data show that 44% of the enlisted women and 13% of the women officers have been deployed two or more times (
      • National Center for Veterans Analysis and Statistics
      ,

      Tan, M. (2012). Women in combat: Army to open 14K jobs, 6 MOSs. Marine Corps Times, Retrieved from http://www.marinecorpstimes.com/news/2012/05/army-to-open-14000-jobs-6-mos-women-in-combat-050212/.

      ).
      In 2012 the Department of Defense revised the military policy by amending the DGCDAR to open more job opportunities for women in the military. The Army is opening an additional 13,139 combat-related jobs to women in six military occupational specialties such as field artillery radar operators and tank mechanics (

      Parrish, K. (2012). DOD Opens More Jobs, Assignments to Military Women. American Forces Press Service. Retrieved from http://www.defense.gov/news/newsarticle.aspx?id=67130.

      ). The Army, Navy and Marines will open 1186 select positions at the battalion level in specialties that are already open to women who will continue to be banned from serving in the infantry and special operations forces (

      Baldor, L. (2012). Military Women to Serve Closer to Front Lines, According to Pentagon Report. Huffington Post, Retrieved from http://www.huffingtonpost.com/2012/02/09/military-women_n_1266038.html.

      ).

      Military services active and reserve components

      Almost half of the service members who have served in Iraq or Afghanistan are reservists (National Guard and Reserve members). Women comprise 15.5% of National Guard and 19.5% of Reserve forces (

      U.S. Department of Defense. (2009). Report to the White House Council on Women and Girls. Retrieved from http://www.defense.gov/pubs/pdfs/DoD_WHC_on_Women_and_Girls_Report_personal_info_redacted_C82A.pdf.

      )
      These statistics do not include the Coast Guard Active or Coast Guard Reserve.
      (see Table 1, Table 2). By 2007 over 575,000 National Guard and reserve members had been mobilized representing slightly more than 44% of the U.S. force deployed to Iraq and Afghanistan (
      • Defense Science Board
      ).
      Table 1Number of Women Serving in Active Component.
      BranchWomenTotal% women
      Army76,694565,46313.6
      Marine Corps13,677201,1576.8
      Navy53,385325,12316.4
      Air Force63,552333,37019.1
      Coast Guard679043,25115.7
      Total214,0981,468,36414.6
      Table 2Number of Women Serving in Reserve Component.
      BranchWomenTotal% women
      Army Reserve62,473288,68621.6
      Marine Corps Reserve5704100,4535.7
      Navy Reserve20,549103,01519.9
      Air Force Reserve28,462106,81426.6
      Coast Guard Reserve1592952616.7
      Army National Guard53,290365,16614.6
      Air National Guard19,500105,68518.5
      Total191,5711,079,34517.7
      Note. Adapted from the

      Women in Military Service for America Memorial Foundation, Inc. Statistics on Women in the Military. November, 2011. Retrieved from http://www.womensmemorial.org/PDFs/StatsonWIM.pdf.

      , www.womensmemorial.org.
      The deployed active and reserve components (National Guard and Reserve) receive similar training and serve side by side, but their stresses are very different (
      • Lane M.E.
      • Hourani L.L.
      • Bray R.M.
      • Williams J.
      Prevalence of perceived stress and mental health indicators among reserve-component and active-duty military personnel.
      ). Up until activation or deployment, reservists typically participate in one weekend per month of training and attend a 2 week training session yearly. Even though reservists are likely to be older and have higher levels of education than their active-duty counterparts, they are more likely to be found in the lower military pay grades (
      • Lane M.E.
      • Hourani L.L.
      • Bray R.M.
      • Williams J.
      Prevalence of perceived stress and mental health indicators among reserve-component and active-duty military personnel.
      ). When activated, reservists must rapidly arrange for an extended leave of absence from their civilian jobs and family/community responsibilities. Unlike the active component military community which provides support to members and their families, reservists' communities are widely dispersed and ill prepared to provide the needed support to families during deployment and re-integration. Upon return, reservists must readjust to civilian life and often do not have the time or resources to participate in reintegration programs. Since access to free military health care only lasts 6 months after deployment, the reservists are trying to purchase health care or initiate care at a veterans' administration facility at a very difficult post-deployment period. Additionally, research consistently indicates that stress increases in both the active component and reservists as multiple deployments increase (
      • Kline A.
      • Falca-Dodson M.
      • Sussner B.
      • Ciccone D.S.
      • Changler H.
      • Callahan L.
      • Losonczy M.
      Effects of repeated deployment to Iraq and Afghanistan on the health of New Jersey Army National Guard troops: Implications for military readiness.
      ).
      While we understand that the military backgrounds are different for the active and reserve components, we do not yet have a complete picture of differences in mental health issues. Several studies suggest that deployment impacts the mental health of the service members of the reserve component more than the active component (
      • Lane M.E.
      • Hourani L.L.
      • Bray R.M.
      • Williams J.
      Prevalence of perceived stress and mental health indicators among reserve-component and active-duty military personnel.
      ,
      • Milliken C.S.
      • Auchterlonie J.L.
      • Hoge C.W.
      Longitudinal assessment on mental health problems among active and reserve component soldiers returning from the Iraq war.
      ,
      • Thomas J.L.
      • Wilk J.E.
      • Riviere L.A.
      • McGurk D.
      • Castro C.A.
      • Hoge C.W.
      Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq.
      ). Lane et al. found that OEF/OIF reservists have significantly higher rates of anxiety, depression, PTSD, suicidal ideation and suicide attempts than their active component counterparts. In a population-based study (N=88,235), the Milliken group found that 42.4% of reserve component soldiers required mental health services compared to 20.3% of active component (
      • Milliken C.S.
      • Auchterlonie J.L.
      • Hoge C.W.
      Longitudinal assessment on mental health problems among active and reserve component soldiers returning from the Iraq war.
      ). In another study (N=18,305) the rates of PTSD or depression for active component (23.2%) and National Guard (31%) members with some impairment or serious functional impairment (8.5–14%) were similar following combat in Iraq at 3 months post-deployment, but at 12 months, prevalence of PTSD in the National Guard increased dramatically to 30.5% compared to 20.7% in the active component (
      • Thomas J.L.
      • Wilk J.E.
      • Riviere L.A.
      • McGurk D.
      • Castro C.A.
      • Hoge C.W.
      Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq.
      ).
      On the other hand, active component members report higher levels of stress while carrying out military duties than the reservists, but lower rates of mental health care utilization. Using an anonymous survey to 10,386 active component and National Guard soldiers at 3 and 12 months after deployment,
      • Kim P.Y.
      • Thomas J.L.
      • Wilk J.E.
      • Castro C.A.
      • Hoge C.W.
      Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat.
      found a higher proportion of active component soldiers compared to National Guard members reporting at least one mental health problem at 3 (45 versus 33%) and 12 months (44 versus 35%), whereas National Guard soldiers reported higher rates of mental health service utilization (
      • Kim P.Y.
      • Thomas J.L.
      • Wilk J.E.
      • Castro C.A.
      • Hoge C.W.
      Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat.
      ). One of the explanations for the active component's lower rates of mental health service utilization is the stigma attached to having a mental health problem. For active component soldiers, jeopardizing promotion opportunities, being ostracized by peers, and being re-assigned to less responsible jobs are real fears that contribute to an unwillingness to seek mental health care. In addition to the stigma associated with mental health problems, there are other barriers to receiving care. Active component soldiers report that they have difficulty scheduling appointments and getting time off work; whereas National Guard soldiers report the cost of mental health care as a barrier (
      • Kim P.Y.
      • Thomas J.L.
      • Wilk J.E.
      • Castro C.A.
      • Hoge C.W.
      Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat.
      ).

      The reality of deployment

      While women are restricted from serving in ground combat, they are attached to ground combat troops that serve with Ranger and Special Forces units, serve on submarines, and fly attack helicopters (

      U.S. Department of Veterans Affairs. (2012). VA Research Currents. Retrieved from www.research.va.gov/currents/feb12/feb12-02.cfm.

      Feb.). They also serve as military police (MPs) who provide convoy and unit security, control traffic, and enforce military regulations including search for IEDs (improvised explosive devices) (
      • Mattocks K.M.
      • Haskell S.G.
      • Krebs E.E.
      • Justice A.C.
      • Yano E.M.
      • Brandt C.
      Women at war: Understanding how women veterans cope with combat and military sexual trauma.
      ). Women are sustaining injuries similar to their male counterparts, both in severity and complexity (

      U.S. Department of Veterans Affairs. (2012). VA Research Currents. Retrieved from www.research.va.gov/currents/feb12/feb12-02.cfm.

      , Feb.).
      In a qualitative study of OEF/OIF service members, 19 women identified three categories of stressful military experiences—combat-related experiences, military sexual trauma, and separation from family (
      • Mattocks K.M.
      • Haskell S.G.
      • Krebs E.E.
      • Justice A.C.
      • Yano E.M.
      • Brandt C.
      Women at war: Understanding how women veterans cope with combat and military sexual trauma.
      ). The results of this study are consistent with other studies that indicate, for women, combat stress, military sexual trauma and family separation are major stressors that contribute separately and significantly to the development of PTSD (
      • Dutra L.
      • Gubbs K.
      • Greene C.
      • Trego L.L.
      • McCartin T.L.
      • Kloezeman K.
      • Morland L.
      Women at war: Implications for mental health.
      ,
      • Fontana A.
      • Rosenheck R.
      Focus on women; Duty-related and sexual stress in the etiology of PTSD among women veterans who seek treatment.
      ,
      • Skopp N.A.
      • Reger M.A.
      • Reger G.M.
      • Mishkind M.C.
      • Raskind M.
      • Gahm G.A.
      The role of intimate relationships, appraisals of military service, and gender on the development of posttraumatic stress symptoms following Iraq deployment.
      ). One female officer described deployment to Iraq as a constant fear of victimization by male military members. For example, restroom and showers can be located 50 to 200 yards away from the living quarters making a nighttime trip to the latrine a fearful trek. In addition to the everyday stress of living in a combat and sexually threatening environment, deployed women faced uniquely female decisions such as whether to suppress their menstrual periods with contraceptives or continue menstruating under conditions of primitive to non-existent bathroom facilities with no privacy to manage their hygiene needs (
      • Doherty M.D.
      • Scannell-Desch E.
      Women's health and hygiene experiences during deployment to the Iraq and Afghanistan Wars, 2003 through 2010.
      ).

      Combat-Related Experiences

      There are no unwounded OEF/OIF/OND service members. Battlefield lines are not linear. There is no clearly defined front line or area to the rear in which combat support operations could be performed in a safe environment. Attacks occur without warning, battle lines shift, and everyone is vulnerable to the enemy (

      Baldor, L. (2012). Military Women to Serve Closer to Front Lines, According to Pentagon Report. Huffington Post, Retrieved from http://www.huffingtonpost.com/2012/02/09/military-women_n_1266038.html.

      ,

      Parrish, K. (2012). DOD Opens More Jobs, Assignments to Military Women. American Forces Press Service. Retrieved from http://www.defense.gov/news/newsarticle.aspx?id=67130.

      ,

      Tan, M. (2012). Women in combat: Army to open 14K jobs, 6 MOSs. Marine Corps Times, Retrieved from http://www.marinecorpstimes.com/news/2012/05/army-to-open-14000-jobs-6-mos-women-in-combat-050212/.

      ). Distinction between the combat (i.e., engaging an enemy with weapons) and combat exposure (i.e., being exposed to combat while serving in supportive occupational roles such as mechanics, pilots, military police, health care personnel) is blurred. Any time a service member steps out of a safe zone, he or she must be in full combat gear which weighs as much as 75 lb. The environment is physically harsh with temperatures reaching over 110°. The enemy wears no uniform, can strike without warning and can be a woman or child.
      There are multiple traumatic events that contribute to mental health morbidity including multi-casualty incidents (suicide bombers) IEDs, ambushes, seeing the aftermath of battle, handling human remains, friendly fire, witnessing or being involved in excessive violence, witnessing death or injury of close friend, death and injury of women and children, feeling helpless to defend or counter-attack, being unable to protect/save another service member, killing at close range, and killing civilians and avoidable casualties or deaths. Combat exposure is a strong predictor of post-deployment depression and PTSD symptoms in women (
      • Luxton D.D.
      • Skopp N.A.
      • Maguen S.
      Gender differences in depression and PTSD symptoms following combat exposure.
      ).
      In a study of 115 Gulf War and OEF/OIF women veterans using healthcare services at a VA postdeployment clinic, more than a quarter of the women reported combat exposure (
      • Hassija C.M.
      • Jakupcak M.
      • Maguen S.
      • Shipherd J.C.
      The influence of combat and interpersonal trauma on PTSD, depression, and alcohol misuse in U.S. Gulf War and OEF/OIF women veterans.
      ). Dutra et al. (2011) interviewed active duty women (N=54) within 3 months of returning from deployment to Iraq and found approximately three-fourths reported combat exposure.
      • Maguen S.
      • Luxton D.D.
      • Skopp N.A.
      • Madden E.
      Gender differences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan.
      investigated gender differences in traumatic experiences and mental health in active duty soldiers redeployed to Iraq and Afghanistan (N=7251; 6697 men and 554 women). Combat exposure was defined as being wounded or injured, seeing bodies of dead soldiers or civilians, personally witnessing anyone being killed and killing another person. Even though more men than women reported combat exposures, investigators found that 31% of the women reported exposure to death, 9% reported witnessing killing, 7% reported injury in the war zone, and 4% reported killing in war. Sustaining injuries was more strongly associated with PTSD symptoms for women who were also more susceptible to depression than men. Being injured, exposure to death, witnessing killing, and military sexual trauma were each significantly associated with depression symptoms. Men were more susceptible to hazardous alcohol use which was also associated with exposure to death, witnessing killing, and killing (
      • Maguen S.
      • Luxton D.D.
      • Skopp N.A.
      • Madden E.
      Gender differences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan.
      ).
      In a similar study in the United Kingdom, combat exposure was assessed on 13 specific experiences of military personnel (n=432 women; n=4554 men) and categorized according to risk to self, trauma to others, and appraisal of deployment (
      • Woodhead C.
      • Wessely S.
      • Jones N.
      • Fear N.T.
      • Hatch S.L.
      Impact of exposure to combat during deployment to Iraq and Afghanistan on mental health by gender.
      ). For both genders, combat experiences were associated with symptoms of PTSD and symptoms of common mental disorders, but not with alcohol use. Women reported greater symptoms of mental disorders and men reported greater hazardous alcohol use.

      Military Sexual Trauma

      Military sexual trauma refers to sexual harassment and sexual assault that occurs in the military environment and is highly associated with mental health disorders including PTSD, depression, anxiety disorders, and substance use (
      • Maguen D.
      • Cohen B.
      • Ren L.
      • Bosch J.
      • Kimerling R.
      • Seal K.
      Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder.
      ,
      • Street A.
      • Stafford J.
      Military sexual trauma: Issues in caring for veterans.
      ). Sexual assault ranges from inappropriate sexual jokes or flirtation, to pressure for sexual favors, to completed forcible rape. The victimization process is complicated and the victim's response is dependent on multitude of factors such as previous trauma history, appraisal of the traumatic event, and the quality of their support systems following the trauma. In the enclosed military environment, victims work and live with perpetrators who are often peers or supervisors who make career decisions. Military sexual trauma is highly associated with posttraumatic stress disorder and other co-morbidities such as depression, alcohol abuse, impaired health status, and chronic health problems (
      • Ferdinand L.G.
      • Kelly U.A.
      • Skelton K.
      • Stephens K.J.
      • Bradley F.
      An evolving integrative treatment program for military sexual trauma (MST) and one veteran's experience.
      ,
      • Kelly U.A.
      • Skelton K.
      • Patel M.
      • Bradley F.
      More than military sexual trauma: Interpersonal violence, PTSD, and mental health in women veterans.
      ,
      • Suris A.
      • Lind L.
      Military sexual trauma: A review of prevalence and associated health consequences in veterans.
      ,
      • Williams I.
      • Bernstein K.
      Military sexual trauma among U.S. female veterans.
      ).
      According to the Department of Defense, there were 3192 reports of sexual assault involving service members as victims during fiscal year 2011 (

      U.S. Department of Defense. (2012). Department of Defense Annual Report on Sexual Assault in the Military: Fiscal Year 2011. Department of Defense Sexual Assault Prevention and Response. April 12, 2011. Retrieved from http://www.sapr.mil/media/pdf/reports/Department_of_Defense_Fiscal_Year_2011_Annual_Report_on_Sexual_Assault_in_the_Military.pdf.

      ). Anecdotal reports indicate that MST is severely under reported with at least half of all sexual assaults go unreported and that the sexual victimization is epidemic (

      Mulhall, E. (2009). Supporting she ‘who has borne the battle’. Women Warriors. Iraq and Afghanistan Veterans of America, Retrieved from http://media.iava.org/IAVA_WomensReport_2009.pdf.

      ). In the
      • Dutra L.
      • Gubbs K.
      • Greene C.
      • Trego L.L.
      • McCartin T.L.
      • Kloezeman K.
      • Morland L.
      Women at war: Implications for mental health.
      study, over half of the sample (n=54) reported exposure to military sexual harassment ranging from gossip or rumors being spread about their sex life to threats of retaliation for not being sexually cooperative. In a study comparing the gender differences in military sexual trauma and mental health diagnoses (N=356; 22% females), the rates of psychiatric disorders were 30% PTSD, 20% major depressive disorder, 6% substance abuse or dependence and 10% for the presence of other Axis I psychiatric disorders. In those who screened positively for PTSD, MST was reported in 31% of women and 1% of men.

      Alcohol Use

      New onset alcohol use was one of the areas of assessment in the Millennium Cohort Study, a 21 year population-based, longitudinal study of over 77,047 active military and Reserve/National Guard personnel that investigated health concerns related to deployments (
      • Smith T.C.
      • Jacobson I.G.
      • Hooper T
      • LeardMann C.A.
      • Boyko E.J.
      • Smith B.
      • Gackstetter G.D.
      • Wells T.S.
      • Amoroso P.J.
      • Gray G.C.
      • Riddle J.R.
      • Ryan M.A.
      the Millennium Cohort Study Team
      Health impact of US military service in a large population-based military cohort: findings of the Millennium Cohort Study, 2001-2008.
      ). Reserve/Guard personnel were at higher risk for heavy drinking, binge drinking, and alcohol-related problems when compared to nondeployed reservists following deployment. In the active component troops, an increased risk of newly reported binge drinking was observed in those who reported combat exposure. When comparing new binge-like and problem drinking by gender following deployment, binge drinking was reported in 21.4% males versus 15.3% females and problem drinking reported in 4.2% males and 3.0% females (Smith et al., 2011).
      These findings are consistent with an earlier report by
      • Lande R.G.
      • Marin B.A.
      • Chang A.S.
      • Lande G.R.
      Survey of alcohol use in the U.S. Army.
      where 1010 U.S. Army personnel at the Walter Reed Army Medical Center participated in a survey regarding alcohol usage while deployed. Even though alcohol possession, manufacturing, distributing, or consumption is prohibited, over a quarter of the military personnel reported alcohol use while deployed. Binge drinking was more likely to occur among the younger military personnel who reported relationship problems (
      • Lande R.G.
      • Marin B.A.
      • Chang A.S.
      • Lande G.R.
      Survey of alcohol use in the U.S. Army.
      ).
      When considering gender differences in alcohol-use (men=685; women=325), men were more likely to engage in binge drinking, but when using the public health guidelines for safe alcohol consumption (men, 14 drinks/week; women, 7 drinks/week), women (9.1%) were more likely to engage in unsafe or borderline unsafe drinking patterns than men (5.1%.). There were also differences in consequences of alcohol consumption between men and women. Men were more likely to engage in acts of aggression than women; but women were more likely to do something that later caused feelings of regret. Both men (5.3%) and women (3.4%) had seriously considered suicide when intoxicated (
      • Lande R.G.
      • Marin B.A.
      • Chang A.S.
      • Lande G.R.
      Gender differences and alcohol use in the U.S. Army. Special communication.
      ).

      Family Separation

      Family separation during deployment is a major source of stress for many women deployed to Iraq and Afghanistan and contributes to the development of PTSD. Single mothers who left their children with grandparents or other family members report that they had a particularly difficult time with the separation (
      • Dutra L.
      • Gubbs K.
      • Greene C.
      • Trego L.L.
      • McCartin T.L.
      • Kloezeman K.
      • Morland L.
      Women at war: Implications for mental health.
      ). Divorce rates of deployed women are reported to be almost three times the rate for male service members. Unlike males, female service members are more likely to be married to other service members. Marriages of enlisted members are at higher risk than marriages of officers who tend to be older (
      • Karney B.R.
      • Crown J.S.
      ). There are multiple reports of the negative impact on children of deployed service members (
      • Barker L.H.
      • Berry K.D.
      Developmental issues impacting military families with young children during single and multiple deployments.
      ,
      • Fraser C.
      Family issues associated with military deployment, family violence, and military sexual trauma.
      ,

      Mulhall, E. (2009). Supporting she ‘who has borne the battle’. Women Warriors. Iraq and Afghanistan Veterans of America, Retrieved from http://media.iava.org/IAVA_WomensReport_2009.pdf.

      ,
      • Warner C.H.
      • Appenzeller G.N.
      • Warner C.M.
      • Grieger T.
      Psychological effects of deployment on military families.
      ).

      Mental health of deployed women

      Suicide

      Suicide is a major health concern for the deployed women. Preliminary survey data of the All Army Study and New Soldier Study (Army STARRS) conducted through a partnership between NIMH and the US Army indicate that the overall suicide rate unexpectedly increased for OEF/OIF deployed women between 2003 and 2008 from 5.1 to 15.2 per 100,000. The rate for suicide for men also increased from 14.8 to 21.1 per 100,000 (

      National Institute of Mental Health. (2011). Science Update: Army STARRS Preliminary Data Reveal Some Potential Predictive Factors for Suicide. Retrieved from http://www.nimh.nih.gov/science-news/2011/army-starrs-preliminary-data-reveal-some-potential-predictive-factors-for-suicide.shtml

      March). Further analyses of patterns and predictors of suicide are ongoing. However, for both male and female service members, being married was associated with a lower risk of suicide during deployment (15 per 100,000 for married compared to 24.5 per 100,000 for those never married).

      Posttraumatic Stress Disorder (PTSD)

      True mental health casualty of women is unknown, but according to a descriptive study of 103,788 veterans (n=13,652 women) first seen at VA health care facilities following OEF/OIF service, there were minimal gender differences in mental health diagnoses. Twenty-five percent of the veterans received a mental health diagnosis; when psychosocial problems were considered, nearly a third of OEF/OIF veterans were identified as having either mental health diagnoses and or psychosocial problems. The single most common mental health diagnosis was PTSD. Over half (52%) of those with a mental health diagnosis met the criteria for PTSD which represented 13% of all OEF/OIF veterans in the study (
      • Seal K.H.
      • Bertenthal D.
      • Miner C.R.
      • Sen S.
      • Marmar C.
      Bring the war back home. Mental health disorders among 103788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities.
      ). It appears that combat and combat-related experiences are related to PTSD in men and combat-related experiences and sexual trauma account for the equally high rate in women.
      There is wide variability in the reported prevalence of PTSD (from 0.6 to 31%) after combat military service. This variability is primarily due to the heterogeneity in study populations (e.g. operational units engaged in direct combat, population-based, or samples) methodologies, and the year of the study (
      • Kok B.C.
      • Herrell R.K.
      • Thomas J.L.
      • Hoge C.W.
      Posttraumataic stress disorder associated with combat service in Iraq or Afghanistan.
      ). Other factors that influence study results include deployment location, unit difference, and branch of service, demographic factors, and active and reserve components. Generally, lower prevalence rates are reported in the population-based studies.
      The Millennium Cohort Study found that new onset self-reported symptoms of posttraumatic stress disorder (n=50,184) developed in 4.3% of deployed and 2.3% of non-deployed cohorts. In those who were deployed and reported combat exposures, 7.6% reported symptoms. Combat exposure was defined as any of the following: witnessing a person's death due to war, disaster, or tragic event, witnessing instances of physical abuse (torture, rape, or beating), dead or decomposing bodies, maimed soldiers or civilians, and prisoners of war or refugees). Being female or divorced was associated with higher risks of PTSD (
      • Smith T.C.
      • Ryan M.A.K.
      • Wingard D.L.
      • Slymen D.J.
      • Sallis J.F.
      • Kritz-Silverstein for the Millennium Cohort Study Team
      New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: Prospective population based US military cohort study.
      ).
      In 2009 the Joint Mental Health Advisory Team 6 (MHAT 6) surveyed operational level troops in Afghanistan by cluster sampling maneuver battalions (n=638; all male) and support and sustainment units (n=722; 83.2% male; 16.2% female). Acute stress was reported in 11.9% of the maneuver battalions and 13.4% is the support/sustainment units. The top five concerns were not getting enough sleep, boring repetitive work, lack of time off for personal time, continuous operations, and lack of privacy/personal space (

      Mental Health Advisory Team (MHAT) 6 (2009). Operation Enduring Freedom 2009 Afghanistan. Mental Health Advisory Team 6 (MHAT 6), November 6, 2009. Office of the Command Surgeon US Forces Afghanistan (USFOR-A) and Office of the Surgeon General United States Army Medical Command. Retrieved from http://www.armymedicine.army.mil/reports/mhat/mhat_vi/MHAT_VI-OEF_Redacted.pdf

      ).
      In a secondary analysis of a Canadian gender study that included the comparison of traumatic events, work stress and mental disorders in regular force women (active component) with reserve women, the regular force women were more likely to be exposed to trauma events and reported higher levels of work stress related to authority/control of job, psychological demand, and physical exertion; whereas reserve force women were more likely to report job insecurity. Regular force women were more likely to report PTSD symptoms than their male counterparts. Both regular and reserve women were more likely than the males to have major depression, mood disorders and anxiety disorder. Regular force women were more likely to report social phobias and reserve women more likely to have panic disorders (
      • Mota N.P.
      • Medved M.
      • Wang J.
      • Asmundson G.J.G.
      • Whitney D.
      • Sareen J.
      Stress and mental disorders in female military personnel: Comparisons between the sexes in a male dominated profession.
      ).
      In a retrospective study,
      • Skopp N.A.
      • Reger M.A.
      • Reger G.M.
      • Mishkind M.C.
      • Raskind M.
      • Gahm G.A.
      The role of intimate relationships, appraisals of military service, and gender on the development of posttraumatic stress symptoms following Iraq deployment.
      examined risk and protective factors for combat-related PTSD (n=2583; 93.5% male) of soldiers at post-deployment. They found that unit support and confidence in military leadership are associated with lower levels of PTSD. However, family separations are stressful and a perceived loss or decrease in intimate relationships is associated with an increased risk of PTSD in women, but not in men. They suggest that these findings are consistent with current literature that indicates intimate partner's emotional validation of traumatic events is more important for females than males (
      • Skopp N.A.
      • Reger M.A.
      • Reger G.M.
      • Mishkind M.C.
      • Raskind M.
      • Gahm G.A.
      The role of intimate relationships, appraisals of military service, and gender on the development of posttraumatic stress symptoms following Iraq deployment.
      ).

      Depression and Other Mental Health Problems

      Similar to the general population, depression in the OEF/OIF/OND service members is more likely to occur in women than in men who have higher rates of alcohol and substance abuse (
      • Maguen D.
      • Cohen B.
      • Ren L.
      • Bosch J.
      • Kimerling R.
      • Seal K.
      Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder.
      ). Adult sexual trauma (
      • Dedert E.A.
      • Green K.T.
      • Calhoun P.S.
      • Yoash-Gantz R.
      • Taber K.H.
      • Mumford M.M.
      • Beckham J.C.
      Association of trauma exposure with psychiatric morbidity in military veterans who have served since September 11, 2001.
      ) and combat exposures are associated with depression in women. In a prospective study of depression following combat deployment of men (n=30,041) and women (n=10,1788), service members exposed to combat had the highest occurrence of new onset depression (5.7% in males; 15.7% in females), followed by those not deployed (3.9 and 7.7%) and deployed service members not exposed to combat without had the lowest occurrence (2.3 and 5.1%) (
      • Wells T.S.
      • LeardMann E.A.
      • Fortuna S.O.
      • Smith B.
      • Smith T.C.
      • Ryan M.A.
      • Millennium Cohort Study Team
      A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan.
      ).
      Depression is highly comorbid with PTSD and MST in women (n=26,527) with
      • Maguen D.
      • Cohen B.
      • Ren L.
      • Bosch J.
      • Kimerling R.
      • Seal K.
      Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder.
      reporting that depression was diagnosed in 75% of women with PTSD and MST and 67% of women with PTSD without MST. In their retrospective review of Department of Veterans Affairs administrative data of 213,803 Iraq and Afghanistan veterans, co-morbid mental disorders diagnoses for women with PTSD (n=7255) included depression, anxiety disorders, (panic and obsessive compulsive disorders), adjustment disorders, alcohol use disorder, substance use and eating disorders (anorexia, bulimia).
      Sleep disturbances are common during deployment and often continue at home for both males and females. Generator and aircraft noises are present 24 hours a day; sleeping conditions are primitive with service members below the rank of major sharing a small CHU (containment housing unit). Difficulty initiating/maintaining sleep and nightmares associated with PTSD make it even more difficult to sleep (
      • Gellis L.A.
      • Gehrman P.R.
      • Mavandadi S.
      • Oslin D.W.
      Predictors of sleep disturbances in Operation Iraqi Freedom/Operation Enduring Freedom veterans reporting a trauma.
      ). Other sleep disturbances such as obstructive sleep apnea, excessive awakenings, daytime sleepiness, and hypoxia have been reported in redeployed combat veterans in PTSD, traumatic brain injury, major depression and anxiety disorders (
      • Capaldi V.F.
      • Guerrero M.L.
      • Killgore W.D.
      Sleep disruptions among returning combat veterans from Iraq and Afghanistan.
      ).

      Reintegration challenges for women veterans

      The negative consequences of exposure to military stress through the lifespan are well documented for male service members and include troubled relationships with family members, co-workers, and intermittent symptom re-occurrence (
      • Bramsen I.
      • Deeg D.J.
      • van der Ploeg E.
      • Fransman S.
      Wartime stressors and mental health symptoms as predictors of late-life mortality in World War II survivors.
      ,
      • Chatterjee S.
      • Spiro A.
      • King L.
      • King D.
      • Davison E.
      Research on aging military veterans: Lifespan implications of military service.
      ,
      • Johnson H.
      • Thompson A.
      The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: A review.
      ,
      • Op Den Velde W.
      • Deeg D.J.
      • Hovens J.E.
      • Van Duijn M.A.
      • Aarts P.G.
      War stress and late-life mortality in World War II male civilian resistance veterans.
      ). Quality of life is reduced in PTSD in both men and women (
      • Schnurr P.P.
      • Lunney C.A.
      Exploration of gender differences in how quality of life relates to posttraumatic stress disorder in male and female veterans.
      ). Post-deployment challenges for women are just emerging.

      Relationship Issues

      Military life is stressful on couples' relationships and many spouses of service members believe that the demands of military service and deployments lead to divorce. According to spouses, the strains of the military life minimize opportunities for intimacy, prevent effective problem-solving, and create new problems to solve (
      • Karney B.R.
      • Crown J.S.
      ). Interpersonal issues associated with sexual trauma and PTSD pose additional stresses for the MST victims whose relationships are already strained (
      • Kelly U.A.
      • Skelton K.
      • Patel M.
      • Bradley F.
      More than military sexual trauma: Interpersonal violence, PTSD, and mental health in women veterans.
      ,
      • Marshall A.D.
      • Robinson L.R.
      • Azar S.T.
      Cognitive and emotional contributors to intimate partner violence perpetration following trauma.
      ,
      • Allard C.B.
      • Nunnink S.
      • Gregory A.M.
      • Klest B.
      • Platt M.
      Military sexual trauma research: A proposed agenda.
      ,
      • Edwards Kearns
      • Gidycz C.A.
      • Calhoun K.S.
      Predictors of victim–perpetrator relationship stability following a sexual assault: A brief report.
      ). In some instances, MST can result in the victim being withdrawn and non-communicative upon returning home. If the victim maintained a sexual relationship with the perpetrators while deployed, issues of trust and infidelity can erode the relationship at home leading to marital conflict, intimate partner violence, and divorce.
      Studies are showing that women who develop symptoms of PTSD and depression following interpersonal trauma are at higher risk for future intimate partner violence (IPV) (
      • Iverson K.M.
      • Gradus J.L.
      • Resick P.A.
      • Suvak M.K.
      • Smith K.F.
      • Monson C.M.
      Cognitive–behavioral therapy for PTSD and depression symptoms reduces risk for future intimate partner violence among interpersonal trauma survivors.
      ,
      • Resick P.A.
      • Williams L.F.
      • Suvak M.K.
      • Monson C.M.
      • Gradus J.L.
      Long-term outcomes of cognitive–behavioral treatments for posttraumatic stress disorder among female rape survivors.
      ). Whereas, psychoeducation programs are effective for women who have not experienced IPV, they may not be as effective for those who have been victims of IPV. Cognitive–behavior therapy has been shown to reduce the symptoms of PTSD and depression and reduce the risk of future IPV in women who are interpersonal trauma survivors (
      • Iverson K.M.
      • Gradus J.L.
      • Resick P.A.
      • Suvak M.K.
      • Smith K.F.
      • Monson C.M.
      Cognitive–behavioral therapy for PTSD and depression symptoms reduces risk for future intimate partner violence among interpersonal trauma survivors.
      ). It also appears that these outcomes are long-lasting (
      • Resick P.A.
      • Williams L.F.
      • Suvak M.K.
      • Monson C.M.
      • Gradus J.L.
      Long-term outcomes of cognitive–behavioral treatments for posttraumatic stress disorder among female rape survivors.
      ). Recently, a report on 15 week randomized-controlled cognitive–behavior conjoint couple therapy trial in a Department of Veterans Affairs outpatient setting and a university-based research center when one partner had PTSD symptoms showed symptom improvement in the target group when compared to couples placed on a wait-list (
      • Monson C.M.
      • Fredman S.J.
      • Macdonald A.
      • Pukay-Martin N.D.
      • Resick P.A.
      • Schnurr P.P.
      Effect of cognitive–behavioral couple therapy for PTSD; A randomized controlled trial.
      ).

      Parenting Issues

      Over 40% of the military members have children with single parents representing 5.3% of the active component and 9.4% of the reserve component (

      Office of Deputy Under Secretary of Defense Military Community and Family Policy. (2012). 2011 Demographics Profile of the Military Community. U. S. Department of Defense. Retrieved from http://www.militaryonesource.mil/12038/Project%20Documents/MilitaryHOMEFRONT/Reports/2011_Demographics_Report.pdf.

      ). Military mothers are typically younger, more likely single or in a dual-military relationship, and of lower socio-economic status (). There is a paucity of literature related to a mother's experiences and parenting challenges postdeployment. While there is little formal literature related to women's postdeployment experiences, there are clinical reports that suggest initially there is a honeymoon period where everything is fine. As the returning parent begins re-defining the parent–child relationship, the children's developmental changes and the impact of the separation can create barriers and increase attachment insecurity (
      • DeVoe E.R.
      • Ross A.
      The parenting cycle of deployment.
      ). Barriers in communication with her now older children, can lead to feelings hurt or rejection. She finds her military style of interacting is ineffective in her family setting. As she re-assumes her family role, the at-home parent or grandparent may resent the loss of responsibility. Often role negotiation is necessary around parenting, household roles, and financial functioning. Extrapolating from the studies on fathers returning to the parenting role, if there are PTSD symptoms, alcohol use, and depression in the returning parent, there are even more complicated parenting challenges (
      • Gewirtz A.H.
      • Erbes C.R.
      • Polusny M.A.
      • Forgatch M.S.
      • DeGarmo D.S.
      Helping military families through the deployment process: Strategies to support parenting.
      ,
      • Gewirtz A.H.
      • Polusny M.A.
      • DeGarmo D.S.
      • Khaylis A.
      • Erbes C.R.
      Posttraumatic stress symptoms among National Guard soldiers deployed to Iraq: Associations with parenting behaviors and couple adjustment.
      ).
      Children of deployed parents are at risk for psychological, behavioral and academic problems. In a meta-analysis of existing literature, a small association between deployment and poorer adjustment was found, especially in the middle childhood (
      • Card N.A.
      • Bosch L.
      • Casper D.M.
      • Wiggs C.B.
      • Hawkins S.A.
      • Schlomer G.L.
      • Borden L.M.
      A meta-analytic review of internalizing, externalizing, and academic adjustment among children of deployed military service members.
      ). Other researchers have found an increase in emotional and behavioral problems in children when a parent was deployed. A major mediating factor influencing behavioral problems in children of deployed parents is parental psychopathology (
      • White C.J.
      • de Burgh H.T.
      • Fear N.T.
      • Iversen A.C.
      The impact of deployment to Iraq or Afghanistan on military children: A review of the literature.
      ). Additionally, as the number of deployments increase, there is a cumulative effect on the children that remains even after the deployed parent returns (
      • Lester P.
      • Peterson K.
      • Reeves J.
      • Knauss L.
      • Glover D.
      • Mogil C.
      • Duan N.
      • Beardslee W.
      The long war and parental combat deployment: Effects on military children and at-home spouses.
      ).

      Health Issues

      There are a variety of health problems that are being associated with deployment to Iraq or Afghanistan, but there are too few studies to draw firm conclusion (

      Batuman, F., Bean-Mayberry, B., Goldzweig, C.L., Huang, C., Miake-Lye, I.M., Washington, D.L., Yano, E.M., Zephyrin, L.C., & Shekelle, P.G. (2011). Health Effects of Military Service on Women Veterans. VA-ESP Project # 05–226.

      ). In addition to the mental health problems, back problems, joint disorders, female reproductive health conditions, musculoskeletal disorders, skin disorders, and ear and sense organ disorders are emerging in the Veteran's Administration data base as common women's medical problems associated with deployment. Women are more likely to have musculoskeletal disorders (limb pain, myositis, myalgia, and muscle spasm) and skin disorders than men. The heavy body armor (initially designed for men) is thought to predispose women to musculoskeletal conditions (
      • Haskell S.G.
      • Mattocks K.
      • Goulet J.L.
      • Krebs E.E.
      • Skanderson M.
      • Leslie D.
      • Brandt C.
      The burden of illness in the first year home: Do male and female VA users differ in health conditions and in healthcare utilization.
      ).
      A concern for mental health nurses is the long-term health effects of traumatic exposure during the OEF/OIF/OND deployment, particularly related to MST. There is emerging evidence that war time deployment is associated with negative health outcomes related to allostasis, the process of adaptive functioning of the body system in response to stress (
      • McEwen B.
      • Basveld P.
      • Palmer M.
      • Anderson R.
      Allostatic load: A review of the literature 2012.
      ,
      • McFarlane A.C.
      The long-term costs of traumatic stress: Intertwined physical and psychological consequences.
      ). Allostatic overload, the long-term effects of repeated, chronic stress and wear and tear on the body and brain, results in over activation of the neuroendocrine and immune systems. Women service members who experienced sexual trauma, combat exposure and child or intimate partner abuse are hypothesized to be very vulnerable to developing an allostatic overload which leads to cumulative physiological changes such as hypertension, hyperlipidemia, obesity, and coronary heart disease. One small study found that female veterans with MST exposure (n=27) had significantly lower heart rate variability (predictor of cardiac and all-cause mortality) than a reference group of veterans with PTSD (n=99) from other trauma (

      Lee, E.A. (2011). Military sexual trauma exposure and heart rate variabilitiy outcomes in female veterans. (Doctoral Dissertation). Retrieved from Dissertations and Theses database. (UMI No. 3482438).

      ). There is a growing interest in this line of research (
      • Groër M.W.
      • Burns C.
      Stress response in female veterans: An allostatic perspective.
      ).

      Homelessness

      Prevalence data are sketchy and incomplete with characteristics of women veterans who are homeless limited to those who have contact with the Veterans Administration. The Department of Health and Human Services collects data on homeless women and homeless veterans, but does not collect detailed information of homeless women who are veterans. We know that veteran men and women are overrepresented in the homeless population with women veterans four times more likely to be homeless than non-veteran women (
      • Fargo J.
      • Metraux S.
      • Byrne T.
      • Munley E.
      • Montgomery A.E.
      • Jones H.
      • Culhane D.
      Prevalence and risk of homelessness among US veterans.
      ,
      • Hamilton A.B.
      • Poza I.
      • Washington D.L.
      Homelessness and trauma go hand-in-hand: Pathways to homelessness among women veterans.
      ). Limited VA data show that the number of women identified as homeless has more than doubled from 1380 in 2003 to 3328 in 2010 (

      U.S. Government Accountability Office. (2011). Homeless women veterans: Actions need to ensure safe and appropriate housing. Report to Congressional Requesters. GAO-12-182.

      ).
      Prevalence and risk factors for homelessness were estimated from data collected from Homeless Management Information systems (HMIS) and American Community Survey (ACS) from seven jurisdictions. Veteran status and black race are associated with homelessness. For women, the risk for homelessness declines with age. Younger women 18–29 are at greatest risk for homelessness (
      • Fargo J.
      • Metraux S.
      • Byrne T.
      • Munley E.
      • Montgomery A.E.
      • Jones H.
      • Culhane D.
      Prevalence and risk of homelessness among US veterans.
      ). Factors associated with women veteran homelessness are childhood adversity, trauma and/or substance abuse during military service, post-military abuse, adversity, relationship termination, post-military mental health substance abuse and/or medical problems, and unemployment (
      • Hamilton A.B.
      • Poza I.
      • Washington D.L.
      Homelessness and trauma go hand-in-hand: Pathways to homelessness among women veterans.
      ). Sexual assault during military service, being disabled, and screening positive for an anxiety disorder or PTSD have also been associated with homelessness. Protective factors include being a college graduate or married (
      • Washington D.L.
      • Yano E.M.
      • McGuire J.
      • Hines V.
      • Lee M.
      • Gelberg L.
      Risk factors for homelessness among women veterans.
      ).

      Implications for research and practice

      The published findings related to mental health needs OEF/OIF/OND women are sobering and indicate that there are major mental health challenges facing our returning service members. One of the primary concerns is the increase in the number of suicides. Even though deployed service members are extensively assessed by the military during the reintegration process, they are returning home with undetected PTSD and MST, depression, and other mental health disorders which emerge several months later. It is unclear whether the symptoms existed during the deployment and reintegration processes and were undisclosed because of the stigma of having a mental health problems, the fear of career retribution or concern about being prevented from returning home or if the symptoms did not emerge until several months following deployment.
      It is clear that women who have been deployed to Iraq or Afghanistan have unique health and mental health care needs related to their wartime experiences. Careful assessment of suicide ideation, MST, PTSD, alcohol use and depression is crucial along with attention to physical injuries, sleep disturbances, and other biological changes. The Institute of Medicine recommends PTSD screening yearly for returning veterans (
      • IOM (Institute of Medicine)
      Treatment for posttraumatic stress disorder in military and veteran populations: Initial assessment.
      ). The development of a caring, trusting, recovery-oriented relationship will be particularly important for these women to be able to re-count their experiences and come to terms with the impact of the experience. The development of effective interventions is only beginning to be addressed. In addition to connection with mental health staff, the National Center for PTSD offers general considerations in care including connecting veterans with each other, offering practical help with specific problems related to workplace, family, friends and finances, and attending to the broader needs as a result of the impact of both pre-military and post-military stressors (
      • Ruzek J.I.
      • Curran E.
      • Friedman M.
      • Gusman F.D.
      • Southwick S.M.
      • Swales P.
      • Walser R.D.
      • Watson
      • Whealin F.
      Treatment of the returning Iraq war veteran.
      ).
      We do not yet understand the full consequences of the separation on the family unit. The divorce rate is increasing and some children of deployed mothers are having behavioral issues. As research is conducted, a better understanding of the dynamics will emerge in order to support family growth. Social support during deployment and reintegration process is emerging as important for healthy reintegration (
      • Khaylis A.
      • Polusny M.A.
      • Erbes C.R.
      • Gewirtz R.
      • Rath M.
      Posttraumatic stress, family adjustment, and treatment preferences among National Guard soldiers deployed to OEF/OIF.
      ). The military offers numerous programs to help families re-establish a healthy relationship. Access to mental health care and health care may be problematic for the returning veteran who may not have civilian health insurance and has to negotiate a new health care system. The Veterans Administration is expanding capacity for women veterans to access health and mental health services.

      Summary

      This review provided an overview of the mental health needs of the women who were deployed to Iraq and Afghanistan. There are many other health care needs that are also emerging, but are outside the scope of this article. For example, eating disorders are an emerging concern for deployed women. Health care providers have a unique set of challenges and mental health issues as a result of deployment. Research is needed to further expand knowledge of the mental health issues that plague our women warriors in order to support their recovery.

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