by Elisabeth Houtsmuller, PhD, Managing Editor, Hayes Directory Reports and Director, Mental and Behavioral Health Services
The last decade has seen an unprecedented number of women enlist in the military. Over 240,000 women have served in Afghanistan or Iraq since 2001, close to 15% of the U.S. forces deployed there. More than 750 have been wounded in action and 137 killed. Thousands more—20% by the military's count—have come home with posttraumatic stress disorder (PTSD), a debilitating anxiety disorder. Particularly disturbing is that roughly 1 out of 5 women veterans report military sexual trauma (sexual assault or repeated, threatening acts of sexual harassment), and for women veterans with PTSD, that is 1 out of 3. Military sexual trauma leads to PTSD more often than any other trauma, including civilian sexual trauma and military combat. It also is associated with higher rates of other mental health problems.
Treatment for PTSD is essential. If untreated, PTSD can lead to a host of other conditions and a downward spiral that may include depression, alcohol and drug abuse, various health conditions, divorce, social isolation, and the likelihood of further trauma. This downward spiral is most visible in the 7500 women veterans who are homeless, most of whom are thought to have PTSD. Unfortunately, there still is a strong stigma associated with mental health problems in the military. In addition, one of the symptoms of PTSD, especially in women, is avoidance of things that may trigger memories of the trauma. And when you are trying to avoid anything that reminds you of what happened, it is especially difficult to recognize you need help, to go find it, and to keep treatment appointments.
In response to heavy criticism regarding mental health care for veterans, the VA has taken a number of steps to make care more accessible. It has increased the number of healthcare workers and reduced the requirements for eligibility for PTSD treatment compensation. It has opened a number of women veteran clinics to provide a safe environment for women. But women veterans still underutilize VA healthcare compared with men, and right now, most women veterans with PTSD do not receive adequate treatment.
The good thing is that there are PTSD treatments that work. There is strong evidence for several psychotherapy approaches (e.g., cognitive-behavioral therapy, exposure therapy, eye movement desensitization and reprocessing). What we do not know is how well they work for women who have experienced military sexual abuse. Research on PTSD treatments has focused on civilians and male veterans, and there are virtually no studies on women veterans. There are things unique to this group that may complicate recovery from PTSD, and that may affect which treatments work best and whether women stay in treatment. In a military setting, the victim often continues to be exposed to the perpetrator, who may be higher in rank; social support may be limited; and victims and perpetrators may be dependent on each other for survival. We need to know whether the treatments that work best for civilian women with PTSD also work best for women veterans, whether some aspects of treatment should be adjusted for this group, and how to make sure these women are able to stay in treatment.
In this time of scarce resources, and given what we know about the consequences of untreated PTSD, it is especially important to make sure that the treatments that are offered are treatments that work. We need evidence from research studies to decide which treatments those are. For the women who have come back with PTSD, and for many of the 50,000 women veterans who are expected to come home in the next 5 years, this is urgent.