The health and wellbeing of female veterans: A review of the literature

By Samantha Crompvoets In   Issue Volume 19 No. 2 .

This paper examines health and wellbeing issues  that emerged in a systematic review of  the war, peacekeeping and peacemaking experiences of female veterans. Research questions that informed the search were: firstly,  what is known about the experiences of female veterans, and in particular, military nurses;    and secondly, what  influences the perceptions of a veteran  of their health and wellbeing? Components of wellbeing that emerged included the ability to cope, ease of access to services and support, satisfaction with parenting, the effects of sexual harassment, and symptoms of PTSD (Post Traumatic Stress Disorder). Perceptions of wellbeing were both informed and challenged by the womens individual and collective identities, for example a professional identity, military identity, being a parent and being female.  There has been little  research into  the sense of self and identity for women in the military today. However, what we do know suggests that identity can have an impact on a woman’s health and her access to services. Tensions emerge at the nexus of nurse, warrior, mother and woman and they can have adverse effects on women’s health and wellbeing, inhibiting some women from seeking appropriate support. Female nursing veterans are a group at increased risk of  many mental health conditions. The increased risks are the result of the many tensions and realities of serving on a military deployment. Not only the sensory exposure to the dead  and dying, but the personal, emotional conflicts inherent in caring for the sick and wounded in a war zone.  Female veterans are a group who need health services that understand their unique needs, with well informed and appropriately trained health care providers.

The percentage of women in the Defence forces is increasing, with women comprising 13.5% of Australia’s Defence Force1, 14.6% of the US military2 and 9.1% of the British Armed Forces3.
What is known about the health and wellbeing of these women as they take up more front-line like roles, moving away from the more traditional female military roles of nurse and medics? What do their experiences tell us about their health and wellbeing?

Research has shown that the newest generation of female veterans may face growing occupational challenges4 and unique threats to their mental health5. In the Australian Defence Force (ADF), women work across a diverse range of occupations. However, women comprise a small percentage of these categories overall. Categories with the highest percentage of women are largely administration and health related (see Table 1)6.
Table 1 Occupation categories for ADF women by number and percentage

Occupation categories with highest number of women     ARMY    NAVY    RAAF 1    Ordnance corps n=847    Supply n=552    Clerical n=478 2    Transport corps n=395    Seaman n=394    Supply n=341 3    Medical corps n=325    Communications n=346    Support ops n=224
Occupation categories with highest percentage of women 1    Dental corps 65.35%    Admin 100%    Dental 90.48% 2    Nursing corps 62.26%    Management exec 60.61%    Clerical 70.50% 3    Psychology corps 50.81%    Health services NS 56.73%    Medical 63.08% (includes nurses)
This paper examines the health and wellbeing issues emerging from a systematic review of the war, peacekeeping and peacemaking experiences of  female veterans.. Health is commonly defined as a state of complete physical, mental and social well-being and is not merely the absence of disease or infirmity7.  This paper is part of a larger qualitative study funded by the Australian Department of Veterans Affairs (DVA), examining the health and wellbeing of female veterans, in particular, military health personnel.
Research questions that informed the search were:
•    What is known about the experiences of female veterans, and in particular military nurses? •    What impacts on veterans’ perceptions of their health and wellbeing? Papers included in this review indicate the overall lack of research into recent veterans histories4,5,8, and highlight the need for more reliable data on the risks associated with various military occupations, deployment to specific locations, and stressful deployment experiences. Even occupations such as healthcare specialists may expose women to the same serious risks as front-line fighters9.
Of the 35 articles and reports included in this review, 21 pertained to experiences of military nurses in Vietnam. Only two related to the experiences of nurses in more recent wars.
Following an overview of the search method, this paper will discuss components of wellbeing that emerged in the research. These include:
•    ability to cope •    access to services and support •    satisfaction with parenting •    the effects of sexual harassment •    symptoms of PTSD.
Perceptions of wellbeing were both informed and challenged by womens’ individual and collective identities, for example a professional identity, military identity, being a parent and being female.
Tensions emerge at the nexus of nurse, warrior, mother and woman and can have adverse effects on women’s health and wellbeing, inhibiting some from seeking appropriate support and healthcare.

Review approach

Systematic reviews aim to comprehensively identify all relevant studies to answer a particular question. A particular type of systematic review, a narrative review, is most suited to synthesizing primary studies and exploring heterogeneity descriptively, rather than statistically10. This is the method used in this paper.
Four databases were systematically searched: Pubmed, Psychinfo, Scopus and Web of Science. In addition specific journals were hand searched, including, but not limited to, ADF Health, Military Medicine, War & Society, Journal of Women’s Health, Military Psychology, and Women & Health. Furthermore, two Australian reports known to the author were included for analysis . Where possible, MeSH terms  were used for database searches. The following series was used: (“Military Personnel” OR “Military Nursing” OR “Hospitals, Military” OR “Psychology, Military” OR “Military Psychiatry” OR “Military Medicine”) AND (“Women” OR “Female” OR “Women’s Health”). This resulted in a total of 718 titles. In addition the terms identity, role, health, nurse, Australia, Vietnam, and veterans were added individually to search results.
The final search resulted in 428 titles. Abstracts were searched using the exclusion criteria pre-1985, i.e. the article was not written in English, studies of specific diseases where gender was not mentioned, specific exposures, male sample only, or a very small female sample in a large quantitative study, studies into training injuries, letters to the Editor, and commentaries.

After applying these exclusion criteria and after duplicates were  removed, 45 full articles were reviewed. Reference lists of these articles were also hand searched. Thirty three  articles and two reports were included in the final review. These were derived from a total of 25 studies that examined aspects of military nursing and female veterans (USA n= 19, Australia n = 5, UK n= 1). These studies (actual data collection) were clustered primarily around the mid 1990s.

Health, wellbeing and veteran identity
A lot has been written about the identity of military women in Vietnam, in particular nurses. The identity of a military nurse was something that was well marketed through recruitment drives during the Vietnam War. Through appealing to patriotism, femininity and duty advertisements for recruitment promised career, educational and personal advancement11. An important facet of the recruitment campaign was to emphasize that Army nurses remained feminine, assuring nurses that they did not fit the stereotypes of military women. The ideal army nurse then was outwardly feminine, sought traditional ways to serve their country by  providing a psychological boost to soldiers, and they might even find a husband in the process11. Dixon Vuic argues that these images upheld the very old ties between nursing and femininity, including sexual images of nursing.

The role of the military nurse in Vietnam as surrogate mother, sister and wife was highlighted by an interviewee in Norman’s study: ‘You represented so much to them [the patients]. You were stability, you were home, you were American womanhood’12.
In contrast to an identity that distanced women from masculine military culture, other research has revealed that a symbiotic relationship of carer and warrior can arise as a consequence of the strategies used by military nurses. Griffiths & Jasper13 argue that these strategies create a psychological comfort zone, allowing the individual to adopt the persona of warrior nurse when needed and thereby allowing them to respond in an appropriate way to the unique challenges of nursing in a conflict zone. Griffiths & Jasper go further to suggest that key rites of passage mark the transition from nurse-to-warrior,  for example, as  in a direct threat. The roles of nurse and warrior are contrasting, and, they  argue, necessitate a compartmentalisation of identity.
Far from negotiating duel identities, problems have also been associated with the lack of an identity for a female veteran having retuned to civilian life5,14. Feldman et al14 emphasised  the  need to devise practical strategies to assist female veterans to carve out an identity within the existing veteran community. This idea has not been explored.

There has been  little research exploring a  sense of self and identity for women in the military today. However, what we do know suggests that such a sense of identity can have an impact on women’s health and influence the access to services.

Emergent in this review of literature is that women’s sense of self and belonging to the military community can have implications regarding if, how and when women seek health care, and which services or support networks they access.

The main themes that emerged in this review concerned professional and personal aspects of military nursing, and issues for these women post deployment. In particular PTSD – interventions, prevalence, diagnosis; coping; parenting satisfaction; ageing veterans; social support; access to services – structural and cultural barriers; sexual trauma/harassment, and reintegration post deployment.

Gender and Post Traumatic Stress Disorder (PTSD)
A meta-analysis of studies examining sex-specific risk of potentially traumatic events (PTEs) and post traumatic stress disorder (PTSD) found that female participants were more likely than male participants to meet criteria for PTSD, although they were less likely to experience PTEs15. With particular reference to combat, war or terrorism, of interest was that the pooled studies (96 studies) showed a significant difference according to the method of data collection. There was  a significantly greater sex difference for questionnaire studies (which showed more PTSD among female participants) than for interview studies (which showed no sex difference in PTSD). It is not known why this is the case, but suggests that males are perhaps more likely to under-report psychiatric symptoms in self-report questionnaires as compared with female participants. This could be because open expression of fear is discouraged by the traditional masculine gender role.
In contrast, research by Feczer & Bjorkland16 suggests that there is a gender bias in the diagnosis of PTSD within the US Veterans Affairs (VA) healthcare system, with male veterans receiving a much higher rate of diagnosis than women, while women who developed PTSD symptoms because of a sexual assault during their military service were far less likely to receive a PTSD diagnosis.
Other studies have also found that prevalence of PTSD is elevated among women who serve in the military5,16-18 and symptoms have been related to parenting dissatisfaction19,20 and difficulty adjusting to family life post war19. The presence of PTSD symptoms  have  been found to have important implications with regard to the family life of female Vietnam veterans19. Female Vietnam veterans, most of whom were nurses, were often exposed to several different forms of trauma, including severe injuries of their patients, mutilated bodies and death, sexual harassment and victimisation5, and the stress of living in a war zone17,18,21.
Significant negative relationships have been found between symptoms of PTSD (namely avoidance/numbing and hyperarousal) and parenting satisfaction in female Vietnam veterans who had biological children20. In particular, higher levels of certain PTSD symptoms, for example sleep disturbance, have been shown to adversely affect women’s satisfaction in the parenting role20. Cognitive behaviour therapy has been found to be an effective treatment for PTSD in female veterans and active duty military personnel22.

Feczer & Bjorkland16 outline a trajectory of recovery and re-engagement with life in a case study of a female Operation Iraqi Freedom (OIF) veteran. Seeking treatment, although challenging, was a source of empowerment. After some of her symptoms were relieved with medication, she was  able  to talk openly about her experiences in Iraq. At  this stage of recovery, narrative reconstruction transforms the traumatic memory into tolerable forms. This mechanism for achieving personal coherence for veterans has been discussed elsewhere23. In the final state of recovery there is a reconnection to a new future, or, as in this case study,  to a new career. This points to the importance of talking as a means of not only debriefing but reconnecting with a coherent sense of self.

Talking through experiences as a means to vent, reflect and make sense of deployment experiences has been found to be a beneficial mechanism of coping for women veterans14,16,23. This method of coping does not necessarily fit within the male-dominated military culture14,15.
For female Vietnam nursing veterans ,coping was encouraged  through maintaining perspective (taking one day at a time), using support systems (their peers and colleagues), inner strength (spirituality), diversional activities (sport), alcohol, drugs and humour24. Guidance for nurses today can be gained through the lessons learned by Vietnam nurses25. In addition to appropriate clinical and psychological training prior to deployment, Scannell-Desch found that the writing of journals, the establishment of mutual support systems and the sharing of experiences with colleagues during war deployments  were all recommended as essential personal care strategies by military nurses25.

Parenting satisfaction
In addition to the causal links that have been explored between PTSD and parenting, further research has shown that because the family system is a critical source of social support for many, it is important to consider the impact of the separation of veterans from and their reintegration into the family system as a consequence of deployment. This issue may be particularly relevant to veteran women, given concerns  that  family/relationship disruptions are more strongly associated with post-deployment mental health for female rather than male service members26.
Research suggests that deployment may be particularly stressful for some military mothers who must manage their family responsibilities from afar, potentially exposing female service members to the dual stress associated with both war zone and family-related concerns14. This stress may be exacerbated for some by the ease of communication with family back home by either phone or email that is unique to contemporary wars5.

Ageing veterans
As they age women veterans have particular health care needs27. In a study that included a male-only sample, it was been noted that PTSD can manifest itself in elderly veterans because unresolved memories may resurface when these veterans experience situational stressors, such as changes in living environment (for example retirement) and the loss of spouse or other family members  or friends28.
Research has shown that womens retirement experiences can differ from mens with regard to attachment to work, professional identity, social contacts, family roles/obligations and community involvement29,30.

Similarly, while studies have examined the effects of quality of life in older veterans, information as to gender has not been included, or females have not been included in the sample31. Studies have shown that health promotion and personal autonomy can positively affect quality of life in older veterans. It is unknown what the effects are for women.

Experiences of service, coping mechanisms and support structures may  inform us as to how female Vietnam veterans are dealing with these issues as they age.

Social support
Job stress, job satisfaction and social support in military nursing have  been linked to increased smoking behaviour32, and a lack of social support at the time of homecoming acts  as a powerful mediator of trauma17. The beneficial effects of social support on well-being have been shown in various studies. Less is known about the factors which constrain or enhance the availability of social support. Research by Cotten et al. found that in a study of women from different military eras, social support was lowest among Vietnam and post-Vietnam era women33. This study points to the importance of examining factors that constrain and enhance supportive activities and relationships.
Participants from the study by Feldman and coworkers14 highlighted the need for female ADF members to be linked into existing community services while still serving, to facilitate their access to appropriate community health and social support after transitioning to civilian life. The development of an information gateway for female veterans to also access gender-specific services, once they were integrated back into the community, was considered vital for future cohorts.

Access to services – structural and cultural barriers
There is a stigma attached to seeking psychological and psychiatric support within the ADF14 and the broader military community15. Issues regarding  access by female veterans to health services relate to a  lack of knowledge about eligibility and availability27. In addition,research has found issues for specific sub-groups based on ethnic/racial minorities34. Street et al5. suggest that it is possible that the perceptions of their needs by women veterans is unique, keeping them from seeking and receiving needed post-deployment healthcare services at non-veterans affairs facilities. There seems to be a gap between women being able to access veterans affairs (VA) resources, typically designed to assist men, and non -VA facilities which do not have appropriate knowledge or skills to deal with issues for women veterans5. General Practitioners can play a major role in maintaining veterans health and wellbeing14,21. Despite this, issues have been raised about the adequacy and effectiveness of the knowledge and resources available to GPs .

Sexual harassment and assault
In-service sexual assaults and sexual harassment have several long term health implications and are common in all female veteran cohorts, including WWII veterans21. Frequent psychosocial complications of sexual assault include increased suicide risk, PTSD, major depression, alcohol or drug abuse, long-term sexual dysfunction, disrupted social networks, and employment difficulties21.

Reintegration post deployment
The homecoming adjustment experiences of women veterans may play an important role in their post deployment wellbeing. Experiences related to readjustment to the primary caregiver role, public and personal perceptions of the ‘veteran woman’ identity, and access to post deployment healthcare services may be especially salient for women returning from deployment5.

A study of Australian war, peacekeeping and peacemaking veterans found that the nature of a female veterans military service, and the continuum of her experiences through the deployment cycle – pre deployment, deployment and post deployment – impact on the quality of her transition and reintegration into civilian life14. A female veteran’s experience of the deployment cycle, transition and reintegration was therefore found to significantly determine the potential demand for health and support services. Understanding the deployment cycle may therefore be integral towards ensuring a smooth transition and reintegration into community life.
Data from the Feldman et al.14 study raised women’s health concerns regarding:

•    women’s ability to maintain appropriate contraception in the short term •    dealing with menstruation and general hygiene issues •    the long term exposure to toxic substances •    drugs administered to all serving members on fertility and reproductive health •    accessing services outside of the ADF with professional staff who have experience of, and understanding about, their particular health circumstances.
Scannell-Desch & Doherty8 provide one of the first studies to examine the  actual  experience of female US military nurses in Iraq and Afghanistan. The  themes that emerged included deploying to war (travel there, living conditions, activities to create normalcy), remembrance of war (the most chaotic scene), nurses in harm’s way, kinship and bonding, personal wartime stress (including homecoming and the difficult adjustment), professional growth, and advice to deploying nurses.

The results indicated that wartime deployment was a difficult challenge, that lessons learned should be shared with nurses deploying in future years, that homecoming was more difficult than most nurses anticipated, and reintegration after coming home takes time and effort.
Feldman et al.14 found that appropriate debriefing was a crucial intervention to support personnel as they completed their deployment, their return to Australia and resumption of their roles at work and within their families and communities. Adjustment to civilian life following Vietnam took decades for some military nurses35. Social support during and after the experience in a war or conflict seems critical to nurses’ wellbeing in theatre  and upon return to their individual postwar environment36.

Female veterans are a group at increased risk of  many mental health conditions, with uncertain  access to appropriate health care.
The increased risks are the result of the many tensions and realities of serving on a military deployment. Not only the sensory exposure to the dead and dying, but the personal, emotional conflicts inherent in caring for the sick and wounded in a war zone.
The pressures on nurses from the Vietnam era to adhere to a predetermined and readily perpetuated set of professional and personal values – holistic, morally sound nursing, feminine looks and values – meant that they were confronted with personal and professional dilemmas with which t they were not necessarily equipped to deal.

How Australian female Vietnam veterans negotiate changing roles and identities as they approach or transition to retirement has important implications for developing appropriate levels of support for these women. It  is thus far unknown.

A diagnosis of PTSD may have much to do with the  ability of any individual to challenge cultural norms of the military and to seek help. Not to do so  may have negative consequences for a sense of self and may stifle  the ability to recover from the traumatic event.
Being able to debrief and comfort  one another is an important coping strategy for women veterans. This is  helped by being in a supportive environment that allows space for individuals to voice their anxieties and concerns, and more importantly  to reassure them.
What it means to be a mother away from her family on deployment has not been fully explored and warrants further study. Help with  reconciling the dual role of mother and military woman may result in prevention of possible mental health effects.

In addition, post deployment reintegration into civilian life may  mean that some women are in a state of limbo ,  belonging neither to  a military nor to a civilian culture and feeling that neither provides services that can help them with the health and wellbeing issues they may face. Female veterans are a group who need health services that understand their unique needs, with well-informed and appropriately trained health care providers.
It has been at least a decade since data were  collected on Australian female Vietnam veterans, and none exist on more recently deployed Australian military nurses. This review points to the need for further research to be undertaken into ageing veterans , exploring what support structures are in place and what needs to be developed.   A substantial gap exists in our understanding of  female veterans from wars more recent than Vietnam.



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