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Improving Veteran Engagement With Mental Health Care
The VA is intent on reducing and preventing veteran deaths by suicide. Most veteran who die by suicide, however, did not get treatment from the VHA, emphasizing the need for improved outreach to those veterans who are not part of the VA health care system.
I will begin by reviewing some reasons why veterans do not go to the VHA or to other mental health treatment centers and how we can change that. I am well aware that the health care providers at the DoD and VHA—including myself—feel overwhelmed by the influx of patients already at their doorstep. Thus, many providers are ambivalent about bringing in more patients when timely access remains a challenge. However, it is critical to engage patients in care to try to improve their lives and, hopefully, bring down the suicide rate.
Another critical issue then is hiring additional clinical providers and administrative staff. More providers are essential for timely patient care. If phones are not answered and patients cannot make appointments, they become frustrated and give up, especially if they already are ambivalent about seeking treatment.
Mental Health Service Experiences
Active-duty service members’ experience of the mental health service ranges from helpful to humiliating. Why is this? The helpful part is easy. The military has hundreds of finely trained professional mental health care providers who try their best to help the soldiers, marines, airmen, and sailors recover from the stress of combat or from providing humanitarian assistance. They use up-to-date therapeutic techniques and medication.
At the humiliating end of the spectrum, many service members are sent to behavioral health for “clearance” before they are administratively separated, ie, discharged without benefits. The separation may be for a variety of administrative discharges, such as a personality disorder; other mental health or medical disorders; or less than honorable discharges. The labels of the discharge vary in the different services, but the disappointment remains.
If the service member is enrolled in a drug and alcohol program (eg, the Army Substance Alcohol Program), the standard is total abstinence. If a service member fails to achieve abstinence, he or she may be discharged without benefits. The denial of benefits is controversial but is still the standard. I recommend a harm reduction model, eg, less drinking or drug use, which may be more achievable in many cases.
The waiting room of a military mental health or behavioral health clinic usually is occupied with service members who are facing a variety of discharges from the military (considered “losers”). Sitting in a crowded waiting room, sometimes for hours, can be humiliating.
To be clear, the clinic experience is not always humiliating. At many Wounded Warrior clinics, the environment is more welcoming. For example, at the National Intrepid Center of Excellence and other specialty clinics, the atmosphere is much more therapeutic.
Significantly, the negative feelings from the routine military clinics often translate into reluctance to go to a mental health clinic at the VHA or elsewhere. To reduce the stigma, the military has switched from using the term mental health to behavioral health, but a name change does not really change the stigma.
Ending the Stigma
To reduce the stigma, DoD has deployed many public service announcements (PSAs). These often have positive messages, such as: It is a sign of strength to accept help; Being mentally injured is like having a broken leg; I am a 3-star general, I have PTSD, and I got help—you can too. Unfortunately, these messages do not resonate with many service members: They have seen many of their friends discharged after seeking mental health services (although that may not have been the actual reason for their discharge). Hoping for a promotion may lead to avoidance of care out of fear that treatment will lead to being passed over for promotion.
Reluctance
When service members come to the VA, it is often with a defeatist attitude. “My wife said I need to come, or she will divorce me.” “I cannot concentrate in school, and I am failing classes.” “My girlfriend threw me out, and I have no place to live.” There is an initial interview with a mental health provider—often after a long waiting period. Often the veteran does not return for a follow-up.
Unquestionably, psychiatric and psychological treatments benefit service members—but the treatments also have drawbacks. Psychiatric medications, although potentially helpful often cause weight gain and sexual adverse effects. Trauma-based therapies deliberately force service members to reexperience the trauma. Reliving the traumatic experience is inherently painful. Additionally, there may be practical concerns, such as getting to the clinic, traffic, and parking.
Solutions
So how do we engage the veteran? There are several well-established practices. I am a big supporter of all veteran outreach. The veteran service organizations (VSOs) are well established but traditionally appeal to older veterans. However, VSOs are working to reach younger veterans in the context of outreach or sporting activities. Peer outreach also works well with veterans in or out of the VA system connecting with their fellow veterans. I favor engaging veterans through baseball games, kayaking, picnics, and other athletic/social activities. These are nonthreatening ways to engage the veteran and his or her family. Using animals, especially dogs and horses, also is a good way to connect.
Clinical Strategies
When I treat veterans who are ambivalent—which the younger ones usually are—I ask where they live, then when or where did they serve, and what was their military occupational specialty. In other words, I ask them about their strengths.
Besides the standard depression and PTSD symptoms, I ask about sexual health, knowing that it often is a major concern. I describe the wide range of PTSD treatments, using the “3 buckets” model to describe them. The 3 buckets are psychiatric medication, talking therapies, and everything else. The last bucket includes exercise, yoga, meditation, animal-assisted therapies, and others, such as transcranial magnetic stimulation and stellate ganglion block.
Veterans often are more comfortable with the last bucket, as it allows them more options. With this knowledge the service members have more tools, so they feel less helpless and more in charge of their health care.
Conclusion
There are many reasons why service members do not seek mental health care. Stigma is one that is often cited. Also, they often associate mental health treatment with humiliation. We have a duty to change that paradigm.
The VA is intent on reducing and preventing veteran deaths by suicide. Most veteran who die by suicide, however, did not get treatment from the VHA, emphasizing the need for improved outreach to those veterans who are not part of the VA health care system.
I will begin by reviewing some reasons why veterans do not go to the VHA or to other mental health treatment centers and how we can change that. I am well aware that the health care providers at the DoD and VHA—including myself—feel overwhelmed by the influx of patients already at their doorstep. Thus, many providers are ambivalent about bringing in more patients when timely access remains a challenge. However, it is critical to engage patients in care to try to improve their lives and, hopefully, bring down the suicide rate.
Another critical issue then is hiring additional clinical providers and administrative staff. More providers are essential for timely patient care. If phones are not answered and patients cannot make appointments, they become frustrated and give up, especially if they already are ambivalent about seeking treatment.
Mental Health Service Experiences
Active-duty service members’ experience of the mental health service ranges from helpful to humiliating. Why is this? The helpful part is easy. The military has hundreds of finely trained professional mental health care providers who try their best to help the soldiers, marines, airmen, and sailors recover from the stress of combat or from providing humanitarian assistance. They use up-to-date therapeutic techniques and medication.
At the humiliating end of the spectrum, many service members are sent to behavioral health for “clearance” before they are administratively separated, ie, discharged without benefits. The separation may be for a variety of administrative discharges, such as a personality disorder; other mental health or medical disorders; or less than honorable discharges. The labels of the discharge vary in the different services, but the disappointment remains.
If the service member is enrolled in a drug and alcohol program (eg, the Army Substance Alcohol Program), the standard is total abstinence. If a service member fails to achieve abstinence, he or she may be discharged without benefits. The denial of benefits is controversial but is still the standard. I recommend a harm reduction model, eg, less drinking or drug use, which may be more achievable in many cases.
The waiting room of a military mental health or behavioral health clinic usually is occupied with service members who are facing a variety of discharges from the military (considered “losers”). Sitting in a crowded waiting room, sometimes for hours, can be humiliating.
To be clear, the clinic experience is not always humiliating. At many Wounded Warrior clinics, the environment is more welcoming. For example, at the National Intrepid Center of Excellence and other specialty clinics, the atmosphere is much more therapeutic.
Significantly, the negative feelings from the routine military clinics often translate into reluctance to go to a mental health clinic at the VHA or elsewhere. To reduce the stigma, the military has switched from using the term mental health to behavioral health, but a name change does not really change the stigma.
Ending the Stigma
To reduce the stigma, DoD has deployed many public service announcements (PSAs). These often have positive messages, such as: It is a sign of strength to accept help; Being mentally injured is like having a broken leg; I am a 3-star general, I have PTSD, and I got help—you can too. Unfortunately, these messages do not resonate with many service members: They have seen many of their friends discharged after seeking mental health services (although that may not have been the actual reason for their discharge). Hoping for a promotion may lead to avoidance of care out of fear that treatment will lead to being passed over for promotion.
Reluctance
When service members come to the VA, it is often with a defeatist attitude. “My wife said I need to come, or she will divorce me.” “I cannot concentrate in school, and I am failing classes.” “My girlfriend threw me out, and I have no place to live.” There is an initial interview with a mental health provider—often after a long waiting period. Often the veteran does not return for a follow-up.
Unquestionably, psychiatric and psychological treatments benefit service members—but the treatments also have drawbacks. Psychiatric medications, although potentially helpful often cause weight gain and sexual adverse effects. Trauma-based therapies deliberately force service members to reexperience the trauma. Reliving the traumatic experience is inherently painful. Additionally, there may be practical concerns, such as getting to the clinic, traffic, and parking.
Solutions
So how do we engage the veteran? There are several well-established practices. I am a big supporter of all veteran outreach. The veteran service organizations (VSOs) are well established but traditionally appeal to older veterans. However, VSOs are working to reach younger veterans in the context of outreach or sporting activities. Peer outreach also works well with veterans in or out of the VA system connecting with their fellow veterans. I favor engaging veterans through baseball games, kayaking, picnics, and other athletic/social activities. These are nonthreatening ways to engage the veteran and his or her family. Using animals, especially dogs and horses, also is a good way to connect.
Clinical Strategies
When I treat veterans who are ambivalent—which the younger ones usually are—I ask where they live, then when or where did they serve, and what was their military occupational specialty. In other words, I ask them about their strengths.
Besides the standard depression and PTSD symptoms, I ask about sexual health, knowing that it often is a major concern. I describe the wide range of PTSD treatments, using the “3 buckets” model to describe them. The 3 buckets are psychiatric medication, talking therapies, and everything else. The last bucket includes exercise, yoga, meditation, animal-assisted therapies, and others, such as transcranial magnetic stimulation and stellate ganglion block.
Veterans often are more comfortable with the last bucket, as it allows them more options. With this knowledge the service members have more tools, so they feel less helpless and more in charge of their health care.
Conclusion
There are many reasons why service members do not seek mental health care. Stigma is one that is often cited. Also, they often associate mental health treatment with humiliation. We have a duty to change that paradigm.
The VA is intent on reducing and preventing veteran deaths by suicide. Most veteran who die by suicide, however, did not get treatment from the VHA, emphasizing the need for improved outreach to those veterans who are not part of the VA health care system.
I will begin by reviewing some reasons why veterans do not go to the VHA or to other mental health treatment centers and how we can change that. I am well aware that the health care providers at the DoD and VHA—including myself—feel overwhelmed by the influx of patients already at their doorstep. Thus, many providers are ambivalent about bringing in more patients when timely access remains a challenge. However, it is critical to engage patients in care to try to improve their lives and, hopefully, bring down the suicide rate.
Another critical issue then is hiring additional clinical providers and administrative staff. More providers are essential for timely patient care. If phones are not answered and patients cannot make appointments, they become frustrated and give up, especially if they already are ambivalent about seeking treatment.
Mental Health Service Experiences
Active-duty service members’ experience of the mental health service ranges from helpful to humiliating. Why is this? The helpful part is easy. The military has hundreds of finely trained professional mental health care providers who try their best to help the soldiers, marines, airmen, and sailors recover from the stress of combat or from providing humanitarian assistance. They use up-to-date therapeutic techniques and medication.
At the humiliating end of the spectrum, many service members are sent to behavioral health for “clearance” before they are administratively separated, ie, discharged without benefits. The separation may be for a variety of administrative discharges, such as a personality disorder; other mental health or medical disorders; or less than honorable discharges. The labels of the discharge vary in the different services, but the disappointment remains.
If the service member is enrolled in a drug and alcohol program (eg, the Army Substance Alcohol Program), the standard is total abstinence. If a service member fails to achieve abstinence, he or she may be discharged without benefits. The denial of benefits is controversial but is still the standard. I recommend a harm reduction model, eg, less drinking or drug use, which may be more achievable in many cases.
The waiting room of a military mental health or behavioral health clinic usually is occupied with service members who are facing a variety of discharges from the military (considered “losers”). Sitting in a crowded waiting room, sometimes for hours, can be humiliating.
To be clear, the clinic experience is not always humiliating. At many Wounded Warrior clinics, the environment is more welcoming. For example, at the National Intrepid Center of Excellence and other specialty clinics, the atmosphere is much more therapeutic.
Significantly, the negative feelings from the routine military clinics often translate into reluctance to go to a mental health clinic at the VHA or elsewhere. To reduce the stigma, the military has switched from using the term mental health to behavioral health, but a name change does not really change the stigma.
Ending the Stigma
To reduce the stigma, DoD has deployed many public service announcements (PSAs). These often have positive messages, such as: It is a sign of strength to accept help; Being mentally injured is like having a broken leg; I am a 3-star general, I have PTSD, and I got help—you can too. Unfortunately, these messages do not resonate with many service members: They have seen many of their friends discharged after seeking mental health services (although that may not have been the actual reason for their discharge). Hoping for a promotion may lead to avoidance of care out of fear that treatment will lead to being passed over for promotion.
Reluctance
When service members come to the VA, it is often with a defeatist attitude. “My wife said I need to come, or she will divorce me.” “I cannot concentrate in school, and I am failing classes.” “My girlfriend threw me out, and I have no place to live.” There is an initial interview with a mental health provider—often after a long waiting period. Often the veteran does not return for a follow-up.
Unquestionably, psychiatric and psychological treatments benefit service members—but the treatments also have drawbacks. Psychiatric medications, although potentially helpful often cause weight gain and sexual adverse effects. Trauma-based therapies deliberately force service members to reexperience the trauma. Reliving the traumatic experience is inherently painful. Additionally, there may be practical concerns, such as getting to the clinic, traffic, and parking.
Solutions
So how do we engage the veteran? There are several well-established practices. I am a big supporter of all veteran outreach. The veteran service organizations (VSOs) are well established but traditionally appeal to older veterans. However, VSOs are working to reach younger veterans in the context of outreach or sporting activities. Peer outreach also works well with veterans in or out of the VA system connecting with their fellow veterans. I favor engaging veterans through baseball games, kayaking, picnics, and other athletic/social activities. These are nonthreatening ways to engage the veteran and his or her family. Using animals, especially dogs and horses, also is a good way to connect.
Clinical Strategies
When I treat veterans who are ambivalent—which the younger ones usually are—I ask where they live, then when or where did they serve, and what was their military occupational specialty. In other words, I ask them about their strengths.
Besides the standard depression and PTSD symptoms, I ask about sexual health, knowing that it often is a major concern. I describe the wide range of PTSD treatments, using the “3 buckets” model to describe them. The 3 buckets are psychiatric medication, talking therapies, and everything else. The last bucket includes exercise, yoga, meditation, animal-assisted therapies, and others, such as transcranial magnetic stimulation and stellate ganglion block.
Veterans often are more comfortable with the last bucket, as it allows them more options. With this knowledge the service members have more tools, so they feel less helpless and more in charge of their health care.
Conclusion
There are many reasons why service members do not seek mental health care. Stigma is one that is often cited. Also, they often associate mental health treatment with humiliation. We have a duty to change that paradigm.
Cultural Competency and Treatment of Veteran and Military Patients With Mental Health Disorders
About 2.5 million U.S. service members have served in conflicts since September 11, 2001. Estimates of the numbers of service members who have deployed to Iraq and Afghanistan and have posttraumatic stress disorder (PTSD) range from 15% to 25%.1-3
This special issue contains several excellent articles about PTSD and comorbidities, including insomnia and depression. Although there are service members who have pure PTSD, in the experience of most clinicians, that is the exception rather than the rule.2 For example, insomnia may lead to patients’ excessive drinking to try to sleep. Numbing and avoidance from the excessive drinking leads to relationship problems and often divorce. Relationship problems are subsequently a key driver of suicide.4,5
Also included in this issue is a series of articles examining the case study of William, who has multiple sclerosis (MS), a disease usually in the domain of neurologists, rather than psychiatrists. However, given the physical, cognitive, and social stresses of MS, it is not surprising that comorbid depression is extremely common, appearing in about half of patients with MS over their lifetime.6 The multidisciplinary approach to care described in this series is critical for successful treatment.
There are well-established guidelines for the treatment of PTSD, developed by the American Psychiatric Association, DoD, and VA, often referred to as evidence-based treatments. However, there are many patients who are either unwilling or unable to adhere or who do not respond to the evidence-based treatments. Although these patients are often called treatment-resistant or refractory, it is also likely that the treatments are not engineered toward service members. That may be due to (1) unacceptable adverse effects from medication; (2) difficulties attending frequent appointments, especially for cognitivebehavioral treatments; (3) the reluctance of many service members to relive their trauma and/or talk about it; or
(4) the stigma of seeking treatment.2,7
The physical stresses of military service, including wounds and injuries, involve corresponding pain and disability. Alcohol, depression, PTSD, and traumatic brain injury have long been associated with one another, but sometimes musculoskeletal injuries are left out of the discussion. The musculoskeletal issues have led to service members being treated with opiates, which can cause dependence and addiction.4,5 In both military and civilian populations, many patients switch from legal opiates to illegal heroin. Many service members, especially after discharge from the military, thus start a slide into substance dependence, unemployment, and homelessness. Unfortunately, death by heroin overdose is increasingly common.8
Suicide rates among U.S. Army personnel have been increasing since 2004, surpassing comparable civilian suicide rates in 2008. The other service branches have not seen such a dramatic rise, but suicide is still a troubling problem. Suicide rates peaked in army active-duty troops over the past few years but are still rising in reservists. Suicides are most prevalent among young white males but have been increasing in older ages and females
as well.4,5
Risk factors for suicide among active-duty members are well known, because data are systemically collected. These include relationship difficulties, financial and occupational problems, pain and physical disability, and access to weapons.4,5
Cultural Compentency
The concept of moral injury is related to but different from PTSD, which is a medical diagnosis. In general, most authors conceptualize moral injury as an insult caused either by shame of killing or the guilt induced when fellow service members die while one has survived. Although not well studied by the medical community, most agree that it is a corrosive condition, which contributes to relationship difficulties and suicide.
A theme throughout military medicine is one of cultural competency: If you are not in the military, how can you understand the military culture? As a start, one of the easy ways is for a provider to ask patients about their military occupational specialty, basic and advanced training, and where they have been stationed. Ask when and where they have been deployed. Learn what their military rank is/was, and ask how they want to be addressed. Some will prefer to be addressed by rank, others by their first name. An important piece of advice for providers: Combat veterans do not want to be seen as victims. Treat them as battle-hardened or maybe battle-scarred, and respect their service.
At present, 15% of active-duty military, 17% of National Guard/Reserves, and 20% of new recruits are women. The recent wars in Iraq and Afghanistan have engendered a growing population of female veterans seeking health care through VA. Thus, women are among the fastest growing segments of new users of VA health care: As many as 40% of women returning from Iraq and Afghanistan may elect to use the VA, for a variety of medical and mental health reasons. In the civilian world, women experience PTSD at twice the rate than do men. In the military, available statistics suggest that the rate is about the same.
There are certain occupations that may lead to an increased rate of PTSD. Medical staff are exposed to horrifically wounded service members and local populations. They and others may have been involved with detainee medical issues. In addition, many service members, including individual augmentees and other reservists, were assigned to detainee missions, such as at Guantanamo Bay and Abu Ghraib. In general, reservists may not have the support of a cohesive unit.
Administrative Issues
Service members need to be physically and mentally fit for duty, according to various regulations.9 If service members have a severe mental illness, they usually will receive a medical evaluation to assess whether or not they are fit for duty. Service members may be medically discharged if found not fit for duty. They may also be medically retired, depending on the severity of their condition, which carries significant disability benefits. The Medical and Physical Evaluation Boards, now called the Integrated Disability Evaluation System, is a complex process.10
The diagnosis of PTSD does not necessarily lead to a medical discharge. If service members respond to treatment, they may be found fit for duty. Alternatively, with actual practice varying according to the service branch, unfortunately they may be administratively discharged without benefits.
Service members may or may not want to be assessed by a Medical Evaluation Board, which offers both benefits and potential shame. Those who want to stay in the military, in general, do not want to see a mental health care provider, because they fear for their jobs. However, those who are nearing the end of their enlistment or planning to retire have many pressures to endorse PTSD symptoms. These include the financial benefits of medical retirement (often at 50% of their base pay), including free medical care and other benefits.
Military, VA, and other providers need to know how to diagnose and treat these psychologic and neurologic brain injuries and disorders. They also need to know when and how to refer elsewhere for further evaluation and treatment. Finally, because PTSD is very much in the public discourse, providers should be prepared to engage in a dialogue with the public.
1. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: Rand Corporation; 2008.
2. Treatment of posttraumatic stress disorder in military and veteran populations. Institute of Medicine Website. http://www.iom.edu/Reports/2014/Treatment-for-Posttraumatic-Stress-Disorder-in-Military-and-Veteran-Populations-Final-Assessment.aspx. Published June 20, 2014. Accessed March 9, 2015.
3. Joint mental health advisory team VII (J-MHAT 7) report. U.S. Army Website. http://armylive.dodlive.mil/index.php/2011/05/joint-mental-health-advisory-team-vii-j-mhat-7-report. Published May 24, 2011. Accessed March 9, 2015.
4. Ritchie EC. Suicides and the United States army: Perspectives from the former psychiatry consultant to the army surgeon general. Cerebrum. 2012(2012):1.
5. Black SA, Gallaway MS, Bell MR, Ritchie EC. Prevalence and risk factors associated with suicides of Army soldiers. Milit Psychol. 2011;23(4):433-451.
6. Wallin MT, Wilken JA, Turner AP, Williams RM, Kane R. Depression and multiple sclerosis: Review of a lethal combination. J Rehabil Res Dev. 2006;43(1):45-62.
7. Hoge C. DSM-5 PTSD screening may miss previously diagnosed soldiers. Healio Website. http://www.healio.com/psychiatry/ptsd/news/online/%7B4e137bbf-4bc0-4c31-b6b2-77e83e9b09d9%7D/dsm-5-ptsd-screening-may-miss-previously-diagnosed-soldiers. Published August 25, 2014. Accessed March 10, 2015.
8. Rudd RA, Paulozzi LJ, Burleson RW, et al; Centers for Disease Control (CDC). Increases in heroin overdose deaths—28 states, 2010 to 2012. MMWR Morb Mortal Wkly Rep. 2014;63(39):849-854.
9. U.S. Army. Standards of Medical Fitness, 2011. Army Regulation 40-501. U.S. Army Website. http://www.apd.army.mil/pdffiles/r40_501.pdf. Published August 4, 2011. Accessed March 10, 2015.
10. Army Physical Disability Evaluation System. The army integrated disability evaluation system. U.S. Army Website. http://usarmy.vo.llnwd.net/e2/rv5_downloads/features/readyandresilient/ARMY_IDES.pdf. Accessed March 10, 2015.
About 2.5 million U.S. service members have served in conflicts since September 11, 2001. Estimates of the numbers of service members who have deployed to Iraq and Afghanistan and have posttraumatic stress disorder (PTSD) range from 15% to 25%.1-3
This special issue contains several excellent articles about PTSD and comorbidities, including insomnia and depression. Although there are service members who have pure PTSD, in the experience of most clinicians, that is the exception rather than the rule.2 For example, insomnia may lead to patients’ excessive drinking to try to sleep. Numbing and avoidance from the excessive drinking leads to relationship problems and often divorce. Relationship problems are subsequently a key driver of suicide.4,5
Also included in this issue is a series of articles examining the case study of William, who has multiple sclerosis (MS), a disease usually in the domain of neurologists, rather than psychiatrists. However, given the physical, cognitive, and social stresses of MS, it is not surprising that comorbid depression is extremely common, appearing in about half of patients with MS over their lifetime.6 The multidisciplinary approach to care described in this series is critical for successful treatment.
There are well-established guidelines for the treatment of PTSD, developed by the American Psychiatric Association, DoD, and VA, often referred to as evidence-based treatments. However, there are many patients who are either unwilling or unable to adhere or who do not respond to the evidence-based treatments. Although these patients are often called treatment-resistant or refractory, it is also likely that the treatments are not engineered toward service members. That may be due to (1) unacceptable adverse effects from medication; (2) difficulties attending frequent appointments, especially for cognitivebehavioral treatments; (3) the reluctance of many service members to relive their trauma and/or talk about it; or
(4) the stigma of seeking treatment.2,7
The physical stresses of military service, including wounds and injuries, involve corresponding pain and disability. Alcohol, depression, PTSD, and traumatic brain injury have long been associated with one another, but sometimes musculoskeletal injuries are left out of the discussion. The musculoskeletal issues have led to service members being treated with opiates, which can cause dependence and addiction.4,5 In both military and civilian populations, many patients switch from legal opiates to illegal heroin. Many service members, especially after discharge from the military, thus start a slide into substance dependence, unemployment, and homelessness. Unfortunately, death by heroin overdose is increasingly common.8
Suicide rates among U.S. Army personnel have been increasing since 2004, surpassing comparable civilian suicide rates in 2008. The other service branches have not seen such a dramatic rise, but suicide is still a troubling problem. Suicide rates peaked in army active-duty troops over the past few years but are still rising in reservists. Suicides are most prevalent among young white males but have been increasing in older ages and females
as well.4,5
Risk factors for suicide among active-duty members are well known, because data are systemically collected. These include relationship difficulties, financial and occupational problems, pain and physical disability, and access to weapons.4,5
Cultural Compentency
The concept of moral injury is related to but different from PTSD, which is a medical diagnosis. In general, most authors conceptualize moral injury as an insult caused either by shame of killing or the guilt induced when fellow service members die while one has survived. Although not well studied by the medical community, most agree that it is a corrosive condition, which contributes to relationship difficulties and suicide.
A theme throughout military medicine is one of cultural competency: If you are not in the military, how can you understand the military culture? As a start, one of the easy ways is for a provider to ask patients about their military occupational specialty, basic and advanced training, and where they have been stationed. Ask when and where they have been deployed. Learn what their military rank is/was, and ask how they want to be addressed. Some will prefer to be addressed by rank, others by their first name. An important piece of advice for providers: Combat veterans do not want to be seen as victims. Treat them as battle-hardened or maybe battle-scarred, and respect their service.
At present, 15% of active-duty military, 17% of National Guard/Reserves, and 20% of new recruits are women. The recent wars in Iraq and Afghanistan have engendered a growing population of female veterans seeking health care through VA. Thus, women are among the fastest growing segments of new users of VA health care: As many as 40% of women returning from Iraq and Afghanistan may elect to use the VA, for a variety of medical and mental health reasons. In the civilian world, women experience PTSD at twice the rate than do men. In the military, available statistics suggest that the rate is about the same.
There are certain occupations that may lead to an increased rate of PTSD. Medical staff are exposed to horrifically wounded service members and local populations. They and others may have been involved with detainee medical issues. In addition, many service members, including individual augmentees and other reservists, were assigned to detainee missions, such as at Guantanamo Bay and Abu Ghraib. In general, reservists may not have the support of a cohesive unit.
Administrative Issues
Service members need to be physically and mentally fit for duty, according to various regulations.9 If service members have a severe mental illness, they usually will receive a medical evaluation to assess whether or not they are fit for duty. Service members may be medically discharged if found not fit for duty. They may also be medically retired, depending on the severity of their condition, which carries significant disability benefits. The Medical and Physical Evaluation Boards, now called the Integrated Disability Evaluation System, is a complex process.10
The diagnosis of PTSD does not necessarily lead to a medical discharge. If service members respond to treatment, they may be found fit for duty. Alternatively, with actual practice varying according to the service branch, unfortunately they may be administratively discharged without benefits.
Service members may or may not want to be assessed by a Medical Evaluation Board, which offers both benefits and potential shame. Those who want to stay in the military, in general, do not want to see a mental health care provider, because they fear for their jobs. However, those who are nearing the end of their enlistment or planning to retire have many pressures to endorse PTSD symptoms. These include the financial benefits of medical retirement (often at 50% of their base pay), including free medical care and other benefits.
Military, VA, and other providers need to know how to diagnose and treat these psychologic and neurologic brain injuries and disorders. They also need to know when and how to refer elsewhere for further evaluation and treatment. Finally, because PTSD is very much in the public discourse, providers should be prepared to engage in a dialogue with the public.
About 2.5 million U.S. service members have served in conflicts since September 11, 2001. Estimates of the numbers of service members who have deployed to Iraq and Afghanistan and have posttraumatic stress disorder (PTSD) range from 15% to 25%.1-3
This special issue contains several excellent articles about PTSD and comorbidities, including insomnia and depression. Although there are service members who have pure PTSD, in the experience of most clinicians, that is the exception rather than the rule.2 For example, insomnia may lead to patients’ excessive drinking to try to sleep. Numbing and avoidance from the excessive drinking leads to relationship problems and often divorce. Relationship problems are subsequently a key driver of suicide.4,5
Also included in this issue is a series of articles examining the case study of William, who has multiple sclerosis (MS), a disease usually in the domain of neurologists, rather than psychiatrists. However, given the physical, cognitive, and social stresses of MS, it is not surprising that comorbid depression is extremely common, appearing in about half of patients with MS over their lifetime.6 The multidisciplinary approach to care described in this series is critical for successful treatment.
There are well-established guidelines for the treatment of PTSD, developed by the American Psychiatric Association, DoD, and VA, often referred to as evidence-based treatments. However, there are many patients who are either unwilling or unable to adhere or who do not respond to the evidence-based treatments. Although these patients are often called treatment-resistant or refractory, it is also likely that the treatments are not engineered toward service members. That may be due to (1) unacceptable adverse effects from medication; (2) difficulties attending frequent appointments, especially for cognitivebehavioral treatments; (3) the reluctance of many service members to relive their trauma and/or talk about it; or
(4) the stigma of seeking treatment.2,7
The physical stresses of military service, including wounds and injuries, involve corresponding pain and disability. Alcohol, depression, PTSD, and traumatic brain injury have long been associated with one another, but sometimes musculoskeletal injuries are left out of the discussion. The musculoskeletal issues have led to service members being treated with opiates, which can cause dependence and addiction.4,5 In both military and civilian populations, many patients switch from legal opiates to illegal heroin. Many service members, especially after discharge from the military, thus start a slide into substance dependence, unemployment, and homelessness. Unfortunately, death by heroin overdose is increasingly common.8
Suicide rates among U.S. Army personnel have been increasing since 2004, surpassing comparable civilian suicide rates in 2008. The other service branches have not seen such a dramatic rise, but suicide is still a troubling problem. Suicide rates peaked in army active-duty troops over the past few years but are still rising in reservists. Suicides are most prevalent among young white males but have been increasing in older ages and females
as well.4,5
Risk factors for suicide among active-duty members are well known, because data are systemically collected. These include relationship difficulties, financial and occupational problems, pain and physical disability, and access to weapons.4,5
Cultural Compentency
The concept of moral injury is related to but different from PTSD, which is a medical diagnosis. In general, most authors conceptualize moral injury as an insult caused either by shame of killing or the guilt induced when fellow service members die while one has survived. Although not well studied by the medical community, most agree that it is a corrosive condition, which contributes to relationship difficulties and suicide.
A theme throughout military medicine is one of cultural competency: If you are not in the military, how can you understand the military culture? As a start, one of the easy ways is for a provider to ask patients about their military occupational specialty, basic and advanced training, and where they have been stationed. Ask when and where they have been deployed. Learn what their military rank is/was, and ask how they want to be addressed. Some will prefer to be addressed by rank, others by their first name. An important piece of advice for providers: Combat veterans do not want to be seen as victims. Treat them as battle-hardened or maybe battle-scarred, and respect their service.
At present, 15% of active-duty military, 17% of National Guard/Reserves, and 20% of new recruits are women. The recent wars in Iraq and Afghanistan have engendered a growing population of female veterans seeking health care through VA. Thus, women are among the fastest growing segments of new users of VA health care: As many as 40% of women returning from Iraq and Afghanistan may elect to use the VA, for a variety of medical and mental health reasons. In the civilian world, women experience PTSD at twice the rate than do men. In the military, available statistics suggest that the rate is about the same.
There are certain occupations that may lead to an increased rate of PTSD. Medical staff are exposed to horrifically wounded service members and local populations. They and others may have been involved with detainee medical issues. In addition, many service members, including individual augmentees and other reservists, were assigned to detainee missions, such as at Guantanamo Bay and Abu Ghraib. In general, reservists may not have the support of a cohesive unit.
Administrative Issues
Service members need to be physically and mentally fit for duty, according to various regulations.9 If service members have a severe mental illness, they usually will receive a medical evaluation to assess whether or not they are fit for duty. Service members may be medically discharged if found not fit for duty. They may also be medically retired, depending on the severity of their condition, which carries significant disability benefits. The Medical and Physical Evaluation Boards, now called the Integrated Disability Evaluation System, is a complex process.10
The diagnosis of PTSD does not necessarily lead to a medical discharge. If service members respond to treatment, they may be found fit for duty. Alternatively, with actual practice varying according to the service branch, unfortunately they may be administratively discharged without benefits.
Service members may or may not want to be assessed by a Medical Evaluation Board, which offers both benefits and potential shame. Those who want to stay in the military, in general, do not want to see a mental health care provider, because they fear for their jobs. However, those who are nearing the end of their enlistment or planning to retire have many pressures to endorse PTSD symptoms. These include the financial benefits of medical retirement (often at 50% of their base pay), including free medical care and other benefits.
Military, VA, and other providers need to know how to diagnose and treat these psychologic and neurologic brain injuries and disorders. They also need to know when and how to refer elsewhere for further evaluation and treatment. Finally, because PTSD is very much in the public discourse, providers should be prepared to engage in a dialogue with the public.
1. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: Rand Corporation; 2008.
2. Treatment of posttraumatic stress disorder in military and veteran populations. Institute of Medicine Website. http://www.iom.edu/Reports/2014/Treatment-for-Posttraumatic-Stress-Disorder-in-Military-and-Veteran-Populations-Final-Assessment.aspx. Published June 20, 2014. Accessed March 9, 2015.
3. Joint mental health advisory team VII (J-MHAT 7) report. U.S. Army Website. http://armylive.dodlive.mil/index.php/2011/05/joint-mental-health-advisory-team-vii-j-mhat-7-report. Published May 24, 2011. Accessed March 9, 2015.
4. Ritchie EC. Suicides and the United States army: Perspectives from the former psychiatry consultant to the army surgeon general. Cerebrum. 2012(2012):1.
5. Black SA, Gallaway MS, Bell MR, Ritchie EC. Prevalence and risk factors associated with suicides of Army soldiers. Milit Psychol. 2011;23(4):433-451.
6. Wallin MT, Wilken JA, Turner AP, Williams RM, Kane R. Depression and multiple sclerosis: Review of a lethal combination. J Rehabil Res Dev. 2006;43(1):45-62.
7. Hoge C. DSM-5 PTSD screening may miss previously diagnosed soldiers. Healio Website. http://www.healio.com/psychiatry/ptsd/news/online/%7B4e137bbf-4bc0-4c31-b6b2-77e83e9b09d9%7D/dsm-5-ptsd-screening-may-miss-previously-diagnosed-soldiers. Published August 25, 2014. Accessed March 10, 2015.
8. Rudd RA, Paulozzi LJ, Burleson RW, et al; Centers for Disease Control (CDC). Increases in heroin overdose deaths—28 states, 2010 to 2012. MMWR Morb Mortal Wkly Rep. 2014;63(39):849-854.
9. U.S. Army. Standards of Medical Fitness, 2011. Army Regulation 40-501. U.S. Army Website. http://www.apd.army.mil/pdffiles/r40_501.pdf. Published August 4, 2011. Accessed March 10, 2015.
10. Army Physical Disability Evaluation System. The army integrated disability evaluation system. U.S. Army Website. http://usarmy.vo.llnwd.net/e2/rv5_downloads/features/readyandresilient/ARMY_IDES.pdf. Accessed March 10, 2015.
1. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: Rand Corporation; 2008.
2. Treatment of posttraumatic stress disorder in military and veteran populations. Institute of Medicine Website. http://www.iom.edu/Reports/2014/Treatment-for-Posttraumatic-Stress-Disorder-in-Military-and-Veteran-Populations-Final-Assessment.aspx. Published June 20, 2014. Accessed March 9, 2015.
3. Joint mental health advisory team VII (J-MHAT 7) report. U.S. Army Website. http://armylive.dodlive.mil/index.php/2011/05/joint-mental-health-advisory-team-vii-j-mhat-7-report. Published May 24, 2011. Accessed March 9, 2015.
4. Ritchie EC. Suicides and the United States army: Perspectives from the former psychiatry consultant to the army surgeon general. Cerebrum. 2012(2012):1.
5. Black SA, Gallaway MS, Bell MR, Ritchie EC. Prevalence and risk factors associated with suicides of Army soldiers. Milit Psychol. 2011;23(4):433-451.
6. Wallin MT, Wilken JA, Turner AP, Williams RM, Kane R. Depression and multiple sclerosis: Review of a lethal combination. J Rehabil Res Dev. 2006;43(1):45-62.
7. Hoge C. DSM-5 PTSD screening may miss previously diagnosed soldiers. Healio Website. http://www.healio.com/psychiatry/ptsd/news/online/%7B4e137bbf-4bc0-4c31-b6b2-77e83e9b09d9%7D/dsm-5-ptsd-screening-may-miss-previously-diagnosed-soldiers. Published August 25, 2014. Accessed March 10, 2015.
8. Rudd RA, Paulozzi LJ, Burleson RW, et al; Centers for Disease Control (CDC). Increases in heroin overdose deaths—28 states, 2010 to 2012. MMWR Morb Mortal Wkly Rep. 2014;63(39):849-854.
9. U.S. Army. Standards of Medical Fitness, 2011. Army Regulation 40-501. U.S. Army Website. http://www.apd.army.mil/pdffiles/r40_501.pdf. Published August 4, 2011. Accessed March 10, 2015.
10. Army Physical Disability Evaluation System. The army integrated disability evaluation system. U.S. Army Website. http://usarmy.vo.llnwd.net/e2/rv5_downloads/features/readyandresilient/ARMY_IDES.pdf. Accessed March 10, 2015.
Addressing Sexual Health With Patients
Why start this new column on mental health with an article that focuses on sexual health? Surely that is the domain of family practice, urology, gynecology, endocrinology, or some other discipline. While it is true that all these disciplines and many others are central to the diagnosis and treatment of sexual health, mental health providers need to be an integral part of the conversations.
I have a problem with arbitrarily separating mental health and behavioral health from physical health. Mental health is directly affected by physical health and vice versa. If a woman has a urinary tract infection, she is not feeling mentally or sexually healthy. If a man has erectile dysfunction (ED), he seldom is at the top of his game emotionally. For our war-wounded who lack limbs or who have genitourinary injuries, optimal sexual functioning can be a challenge.
I am probably preaching to the choir here, so I will not belabor the point. However, I will develop this point by using lessons learned from combat-injured service members, the psychiatric adverse effects (AEs) of commonly used psychiatric medications, and most important, asking about sexual health as part of taking a mental health history.
The War-Wounded
Since 9/11, 2.7 million U.S. service members have served in wars. Much discussion has been focused on posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), the invisible wounds of war. Probably about 25% of service members who have been deployed have PTSD, and about 300,000 service members have TBI.1 About 50,000 have other physical injuries. These injuries directly affect intimate relationships.
The signature weapon of the wars in Iraq and Afghanistan was the bomb, or improvised explosive device. Motor vehicle accidents and gunshot wounds also have added to the myriad of injuries. Physical war wounds involve sexual functioning. These include, but are not limited to, lower extremity amputations, genitourinary injuries, and facial disfigurement or burns. All of these may involve multiple surgeries, pain, and disability and can significantly impact self-esteem.
One of the many lessons I have learned in putting together my most recent book, Intimacy Post Injury: Combat Trauma and Sexual Health, is that there is a void in the recent general medical and popular literature about optimizing sexual health in those with injuries or diseases.2 The majority of wounded warriors are men, but injuries happen to women service members as well. Of course, sexual assault causes severe harm to intimate relationships as well.
At this time, most injured personnel are still in the Military Health System (MHS) or have transitioned to the VHA. However, many service members also will be treated in the civilian health system.
Psychiatric Medications and Sexual Adverse Effects
The treatment of PTSD, depression, and other psychiatric conditions often involves medications that have sexual AEs. Sexual AEs usually refer to problems with erectile function (impotence), difficulties with ejaculation, lack of orgasm or desire, or lack of lubrication for women. Selective serotonin reuptake inhibitors (SSRIs) have a very high incidence of sexual AEs, ranging from 30% to 70%.3 When I speak with clinicians about their anecdotal experience, the percentage always is high, usually more than 50%. Other psychiatric medications, such as antipsychotics, older antidepressants, and stimulants also have sexual AEs, and narcotics are notorious for their sexual AEs.
Fortunately, many solutions exist. For SSRIs, the solutions include lowering the dose of the offending agent, switching to another agent, drug holidays, or adding other medications, such as bupropion or cyproheptadine. Family practice and other physicians are very familiar with phosphodiesterase inhibitors, such as sildenafil, tadalafil, and vardenafil. Although these medications have AEs and are very expensive, they work well for impotence.
Other solutions are nonpharmacologic: Setting aside time for intimacy can be crucial. Gels and creams can help with lubrication. Communication with providers and between partners and families is the most important ingredient.
Asking About Sexual Health
I encourage all medical personnel who treat active-duty service members or veterans to (1) discuss sexual health with their patients; (2) learn the basics of how to evaluate, treat, or refer ED, including SSRI AEs; and (3) understand how to discuss the effects of physical injury, pain, and disability on sexual functioning.
The conversation should touch on sexual activity, satisfaction with intimacy, exposure to sexually transmitted diseases, and if appropriate, previous sexual abuse. The appropriate time and place for a conversation about sexual health depends on the setting. In the outpatient setting, I bring up the subject after I ask about sleep and appetite and before I ask about suicidal and homicidal thoughts; others may choose elsewhere in the patient history. However, asking about sexual issues may or may not be appropriate in an emergency department situation.
Providers often are uncomfortable with asking about sexual issues, perhaps more so if they are young and female and the patient is older and male. Therefore, I encourage expanded training in medical school and throughout residency.
Sexual Difficulties and Suicide
In the military, the suicide rate has been rising from about 10 per 100,000 per year in 2004 to about 20 per 20,000 in this decade.4,5 According to the VA Office of Suicide Prevention, about 20 veterans die by suicide daily.6 One question that has received little attention is the relationship between sexual difficulties and suicide. Although there has been an important focus on causes of suicide in the military and veterans, little is known about the important issue of how many service members die by suicide because of impotence.
We do know a lot about the big picture as to why service members die by suicide. In about two-thirds of the completed suicides, there were relationship issues. In addition, there are often legal, occupational, and financial difficulties. About two-thirds of service members die by suicide using firearms. Jumping and strangulation are other common methods.4,5
But there is much we do not know. What percentage of relationship difficulties are related to sexual dysfunction? Is ED the straw that breaks the camel’s back and leads to the shot to the chest? Other subjects outside the scope of this column (but included in Intimacy Post Injury) include sexual therapy, fertility, adaptations for those with disabilities, reproductive AEs of toxin exposure, and surgeries that include penile transplantation.
My hypothesis is that sexual problems, specifically ED or impotence, contribute to feelings of failure and inadequacy and thus to suicidal or homicidal thoughts.
Conclusion
Health care providers do not always talk to patients about their sexual health and may barely mention the sexual AEs of psychiatric or other medications. In whatever setting you practice, you should not neglect asking questions about sexual health, as it is a critical issue for many of our patients and should be for us.
1. Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder, Board of Health of Selected Populations. Treatment of Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: National Academies Press; 2014.
2. Ritchie EC, ed. Intimacy Post-Injury: Combat Trauma and Sexual Health. New York: Oxford University Press; 2016.
3. Higgins A, Nash M, Lynch AM. Antidepressant-associated sexual dysfunction: impact, effects and treatment. Drug Healthc Patient Saf. 2010;2:141-150.
4. Black SA, Gallaway S, Bell MR, Ritchie EC. Prevalence and risk factors associated with suicides of army soldiers 2001-2009. Mil Psychol. 2011;23:433-451.
5. Ritchie EC. Suicides and the United States army: perspectives from the former psychiatry consultant to the army surgeon general. Cerebrum. 2012;2012:1.
6. U.S. Department of Veterans Affairs. Suicide among veterans and other Americans 2001-2014. http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf. Published August 3, 2016. Accessed December 27, 2016.
Why start this new column on mental health with an article that focuses on sexual health? Surely that is the domain of family practice, urology, gynecology, endocrinology, or some other discipline. While it is true that all these disciplines and many others are central to the diagnosis and treatment of sexual health, mental health providers need to be an integral part of the conversations.
I have a problem with arbitrarily separating mental health and behavioral health from physical health. Mental health is directly affected by physical health and vice versa. If a woman has a urinary tract infection, she is not feeling mentally or sexually healthy. If a man has erectile dysfunction (ED), he seldom is at the top of his game emotionally. For our war-wounded who lack limbs or who have genitourinary injuries, optimal sexual functioning can be a challenge.
I am probably preaching to the choir here, so I will not belabor the point. However, I will develop this point by using lessons learned from combat-injured service members, the psychiatric adverse effects (AEs) of commonly used psychiatric medications, and most important, asking about sexual health as part of taking a mental health history.
The War-Wounded
Since 9/11, 2.7 million U.S. service members have served in wars. Much discussion has been focused on posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), the invisible wounds of war. Probably about 25% of service members who have been deployed have PTSD, and about 300,000 service members have TBI.1 About 50,000 have other physical injuries. These injuries directly affect intimate relationships.
The signature weapon of the wars in Iraq and Afghanistan was the bomb, or improvised explosive device. Motor vehicle accidents and gunshot wounds also have added to the myriad of injuries. Physical war wounds involve sexual functioning. These include, but are not limited to, lower extremity amputations, genitourinary injuries, and facial disfigurement or burns. All of these may involve multiple surgeries, pain, and disability and can significantly impact self-esteem.
One of the many lessons I have learned in putting together my most recent book, Intimacy Post Injury: Combat Trauma and Sexual Health, is that there is a void in the recent general medical and popular literature about optimizing sexual health in those with injuries or diseases.2 The majority of wounded warriors are men, but injuries happen to women service members as well. Of course, sexual assault causes severe harm to intimate relationships as well.
At this time, most injured personnel are still in the Military Health System (MHS) or have transitioned to the VHA. However, many service members also will be treated in the civilian health system.
Psychiatric Medications and Sexual Adverse Effects
The treatment of PTSD, depression, and other psychiatric conditions often involves medications that have sexual AEs. Sexual AEs usually refer to problems with erectile function (impotence), difficulties with ejaculation, lack of orgasm or desire, or lack of lubrication for women. Selective serotonin reuptake inhibitors (SSRIs) have a very high incidence of sexual AEs, ranging from 30% to 70%.3 When I speak with clinicians about their anecdotal experience, the percentage always is high, usually more than 50%. Other psychiatric medications, such as antipsychotics, older antidepressants, and stimulants also have sexual AEs, and narcotics are notorious for their sexual AEs.
Fortunately, many solutions exist. For SSRIs, the solutions include lowering the dose of the offending agent, switching to another agent, drug holidays, or adding other medications, such as bupropion or cyproheptadine. Family practice and other physicians are very familiar with phosphodiesterase inhibitors, such as sildenafil, tadalafil, and vardenafil. Although these medications have AEs and are very expensive, they work well for impotence.
Other solutions are nonpharmacologic: Setting aside time for intimacy can be crucial. Gels and creams can help with lubrication. Communication with providers and between partners and families is the most important ingredient.
Asking About Sexual Health
I encourage all medical personnel who treat active-duty service members or veterans to (1) discuss sexual health with their patients; (2) learn the basics of how to evaluate, treat, or refer ED, including SSRI AEs; and (3) understand how to discuss the effects of physical injury, pain, and disability on sexual functioning.
The conversation should touch on sexual activity, satisfaction with intimacy, exposure to sexually transmitted diseases, and if appropriate, previous sexual abuse. The appropriate time and place for a conversation about sexual health depends on the setting. In the outpatient setting, I bring up the subject after I ask about sleep and appetite and before I ask about suicidal and homicidal thoughts; others may choose elsewhere in the patient history. However, asking about sexual issues may or may not be appropriate in an emergency department situation.
Providers often are uncomfortable with asking about sexual issues, perhaps more so if they are young and female and the patient is older and male. Therefore, I encourage expanded training in medical school and throughout residency.
Sexual Difficulties and Suicide
In the military, the suicide rate has been rising from about 10 per 100,000 per year in 2004 to about 20 per 20,000 in this decade.4,5 According to the VA Office of Suicide Prevention, about 20 veterans die by suicide daily.6 One question that has received little attention is the relationship between sexual difficulties and suicide. Although there has been an important focus on causes of suicide in the military and veterans, little is known about the important issue of how many service members die by suicide because of impotence.
We do know a lot about the big picture as to why service members die by suicide. In about two-thirds of the completed suicides, there were relationship issues. In addition, there are often legal, occupational, and financial difficulties. About two-thirds of service members die by suicide using firearms. Jumping and strangulation are other common methods.4,5
But there is much we do not know. What percentage of relationship difficulties are related to sexual dysfunction? Is ED the straw that breaks the camel’s back and leads to the shot to the chest? Other subjects outside the scope of this column (but included in Intimacy Post Injury) include sexual therapy, fertility, adaptations for those with disabilities, reproductive AEs of toxin exposure, and surgeries that include penile transplantation.
My hypothesis is that sexual problems, specifically ED or impotence, contribute to feelings of failure and inadequacy and thus to suicidal or homicidal thoughts.
Conclusion
Health care providers do not always talk to patients about their sexual health and may barely mention the sexual AEs of psychiatric or other medications. In whatever setting you practice, you should not neglect asking questions about sexual health, as it is a critical issue for many of our patients and should be for us.
Why start this new column on mental health with an article that focuses on sexual health? Surely that is the domain of family practice, urology, gynecology, endocrinology, or some other discipline. While it is true that all these disciplines and many others are central to the diagnosis and treatment of sexual health, mental health providers need to be an integral part of the conversations.
I have a problem with arbitrarily separating mental health and behavioral health from physical health. Mental health is directly affected by physical health and vice versa. If a woman has a urinary tract infection, she is not feeling mentally or sexually healthy. If a man has erectile dysfunction (ED), he seldom is at the top of his game emotionally. For our war-wounded who lack limbs or who have genitourinary injuries, optimal sexual functioning can be a challenge.
I am probably preaching to the choir here, so I will not belabor the point. However, I will develop this point by using lessons learned from combat-injured service members, the psychiatric adverse effects (AEs) of commonly used psychiatric medications, and most important, asking about sexual health as part of taking a mental health history.
The War-Wounded
Since 9/11, 2.7 million U.S. service members have served in wars. Much discussion has been focused on posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), the invisible wounds of war. Probably about 25% of service members who have been deployed have PTSD, and about 300,000 service members have TBI.1 About 50,000 have other physical injuries. These injuries directly affect intimate relationships.
The signature weapon of the wars in Iraq and Afghanistan was the bomb, or improvised explosive device. Motor vehicle accidents and gunshot wounds also have added to the myriad of injuries. Physical war wounds involve sexual functioning. These include, but are not limited to, lower extremity amputations, genitourinary injuries, and facial disfigurement or burns. All of these may involve multiple surgeries, pain, and disability and can significantly impact self-esteem.
One of the many lessons I have learned in putting together my most recent book, Intimacy Post Injury: Combat Trauma and Sexual Health, is that there is a void in the recent general medical and popular literature about optimizing sexual health in those with injuries or diseases.2 The majority of wounded warriors are men, but injuries happen to women service members as well. Of course, sexual assault causes severe harm to intimate relationships as well.
At this time, most injured personnel are still in the Military Health System (MHS) or have transitioned to the VHA. However, many service members also will be treated in the civilian health system.
Psychiatric Medications and Sexual Adverse Effects
The treatment of PTSD, depression, and other psychiatric conditions often involves medications that have sexual AEs. Sexual AEs usually refer to problems with erectile function (impotence), difficulties with ejaculation, lack of orgasm or desire, or lack of lubrication for women. Selective serotonin reuptake inhibitors (SSRIs) have a very high incidence of sexual AEs, ranging from 30% to 70%.3 When I speak with clinicians about their anecdotal experience, the percentage always is high, usually more than 50%. Other psychiatric medications, such as antipsychotics, older antidepressants, and stimulants also have sexual AEs, and narcotics are notorious for their sexual AEs.
Fortunately, many solutions exist. For SSRIs, the solutions include lowering the dose of the offending agent, switching to another agent, drug holidays, or adding other medications, such as bupropion or cyproheptadine. Family practice and other physicians are very familiar with phosphodiesterase inhibitors, such as sildenafil, tadalafil, and vardenafil. Although these medications have AEs and are very expensive, they work well for impotence.
Other solutions are nonpharmacologic: Setting aside time for intimacy can be crucial. Gels and creams can help with lubrication. Communication with providers and between partners and families is the most important ingredient.
Asking About Sexual Health
I encourage all medical personnel who treat active-duty service members or veterans to (1) discuss sexual health with their patients; (2) learn the basics of how to evaluate, treat, or refer ED, including SSRI AEs; and (3) understand how to discuss the effects of physical injury, pain, and disability on sexual functioning.
The conversation should touch on sexual activity, satisfaction with intimacy, exposure to sexually transmitted diseases, and if appropriate, previous sexual abuse. The appropriate time and place for a conversation about sexual health depends on the setting. In the outpatient setting, I bring up the subject after I ask about sleep and appetite and before I ask about suicidal and homicidal thoughts; others may choose elsewhere in the patient history. However, asking about sexual issues may or may not be appropriate in an emergency department situation.
Providers often are uncomfortable with asking about sexual issues, perhaps more so if they are young and female and the patient is older and male. Therefore, I encourage expanded training in medical school and throughout residency.
Sexual Difficulties and Suicide
In the military, the suicide rate has been rising from about 10 per 100,000 per year in 2004 to about 20 per 20,000 in this decade.4,5 According to the VA Office of Suicide Prevention, about 20 veterans die by suicide daily.6 One question that has received little attention is the relationship between sexual difficulties and suicide. Although there has been an important focus on causes of suicide in the military and veterans, little is known about the important issue of how many service members die by suicide because of impotence.
We do know a lot about the big picture as to why service members die by suicide. In about two-thirds of the completed suicides, there were relationship issues. In addition, there are often legal, occupational, and financial difficulties. About two-thirds of service members die by suicide using firearms. Jumping and strangulation are other common methods.4,5
But there is much we do not know. What percentage of relationship difficulties are related to sexual dysfunction? Is ED the straw that breaks the camel’s back and leads to the shot to the chest? Other subjects outside the scope of this column (but included in Intimacy Post Injury) include sexual therapy, fertility, adaptations for those with disabilities, reproductive AEs of toxin exposure, and surgeries that include penile transplantation.
My hypothesis is that sexual problems, specifically ED or impotence, contribute to feelings of failure and inadequacy and thus to suicidal or homicidal thoughts.
Conclusion
Health care providers do not always talk to patients about their sexual health and may barely mention the sexual AEs of psychiatric or other medications. In whatever setting you practice, you should not neglect asking questions about sexual health, as it is a critical issue for many of our patients and should be for us.
1. Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder, Board of Health of Selected Populations. Treatment of Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: National Academies Press; 2014.
2. Ritchie EC, ed. Intimacy Post-Injury: Combat Trauma and Sexual Health. New York: Oxford University Press; 2016.
3. Higgins A, Nash M, Lynch AM. Antidepressant-associated sexual dysfunction: impact, effects and treatment. Drug Healthc Patient Saf. 2010;2:141-150.
4. Black SA, Gallaway S, Bell MR, Ritchie EC. Prevalence and risk factors associated with suicides of army soldiers 2001-2009. Mil Psychol. 2011;23:433-451.
5. Ritchie EC. Suicides and the United States army: perspectives from the former psychiatry consultant to the army surgeon general. Cerebrum. 2012;2012:1.
6. U.S. Department of Veterans Affairs. Suicide among veterans and other Americans 2001-2014. http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf. Published August 3, 2016. Accessed December 27, 2016.
1. Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder, Board of Health of Selected Populations. Treatment of Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: National Academies Press; 2014.
2. Ritchie EC, ed. Intimacy Post-Injury: Combat Trauma and Sexual Health. New York: Oxford University Press; 2016.
3. Higgins A, Nash M, Lynch AM. Antidepressant-associated sexual dysfunction: impact, effects and treatment. Drug Healthc Patient Saf. 2010;2:141-150.
4. Black SA, Gallaway S, Bell MR, Ritchie EC. Prevalence and risk factors associated with suicides of army soldiers 2001-2009. Mil Psychol. 2011;23:433-451.
5. Ritchie EC. Suicides and the United States army: perspectives from the former psychiatry consultant to the army surgeon general. Cerebrum. 2012;2012:1.
6. U.S. Department of Veterans Affairs. Suicide among veterans and other Americans 2001-2014. http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf. Published August 3, 2016. Accessed December 27, 2016.
Female Service Members in the Long War
September 11, 2001, is a day burned into the consciousness of all Americans old enough to remember that day. For members of the U.S. military, it was also the beginning of more than 14 years of war, variously called the war on terror, Operation Enduring Freedom (Afghanistan), Operation Iraqi Freedom (Iraq), Operation New Dawn (Iraq) and the Long War. The Long War encapsulates the repeated deployments into combat zones in Afghanistan and Iraq, as well as the Horn of Africa and to humanitarian assistance operations.
For women, 9/11 also ushered in a steadily increasing role in the U.S. military. No longer mainly nurses, as in the Vietnam War, or primarily in support roles, as in the Gulf War, female service members have been in the thick of the conflicts in Iraq and Afghanistan.
Only recently have women officially been allowed into the Military Occupational Specialty (MOS) of combat occupations. Combat occupations are typically the “warfighters”; however, it is now widely accepted that women have been in combat since long before 9/11. For example, the deployment to Somalia in 1993 started as a humanitarian assistance operation and was later turned into a combat mission. More recently, in the Long War, numerous roles open to women, such as military police and truckers, have been frequently involved in firefights.
New Research
Research and data about women in the military have had a relapsing course. After the first Gulf War, there were a number of articles focusing on the health issues of women deployed there. The main reasons for redeployment to the U.S. were abnormal pap smears gathered before deployment and positive pregnancy screens. In the late 1990s, there was a considerable amount of research, mainly covered under the loose rubric of the Defense Women’s Health Research Project.1
In 2002, I organized a symposium at the Women in Military Service Memorial, which focused on the prevention of urinary tract infections in the field, unintended pregnancy while deployed, and stress fractures. Partly because of the repeal of the combat exclusion rule and partly because the Long War seems to be winding down, recently there have been a number of activities and publications about women in combat. With COL Anne L. Naclerio, MD, MPH, I recently coedited Women at War, a collection of 19 articles that bring together much of the available information and experience on women service members’ health and mental health.2 We hope that it will further spur interest and research on the topic.
The lack of data on female service members is in contrast to the extensive scientific literature on male service members. The Walter Reed Army Institute of Research and the Mental Health Advisory teams both have focused on combat troops, which have been primarily male. The Millennium Study includes women, but its results are just beginning to emerge. The VA has data on female veterans, but only a small number of female veterans go to the VA, and VA studies on women have focused primarily on military sexual assault. Although this area is very important, there are many other issues that female service members deal with, including reproductive and genitourinary concerns.
The Women at War volume begins to address this problem. Chapters examine data on deployment-related issues, posttraumatic stress disorder (PTSD) in female service members, and intimate partner violence. Due to a lack of quantitative data, other chapters summarize either civilian data or data on male service members, then move to extrapolate for service women. A few chapters are more anecdotal, describing the experience of being a female sailor on a ship or a mother on deployment.
Reproduction and Gynecology
Much of the current discussion about women in the military focuses on physical strength. Can she carry a 60-round rucksack? Can she load artillery rounds? In contrast, issues about reproduction and gynecology are understudied in the recent literature on female service members.
Urinary tract infections (UTIs) are a major issue for women in the field. Much of the concerns that female service members have are about bathrooms. Is the latrine—maybe used by many other service members—clean enough to sit on? Women often restrict fluids to avoid going to the filthy or nonexistent bathrooms and thus get UTIs or become dehydrated. Managing menses in austere conditions is another dilemma. Can I change my tampon while driving on the roads in Iraq? Should I be on oral contraception while deployed to regulate menses?
Although sexual assault has received considerable attention, consensual sex has received much less. A taboo area seems to be the sexual desires of women who deploy. But young women—and most women who deploy are young—do have sexual desires, perhaps heightened by the daily exposure to death and close bonding in the combat zone. The literature is totally devoid on this topic. If contraception is scarce, pregnancies happen. In the worst cases, this results in ectopic pregnancies, resulting in life-threatening emergencies and expensive medical evacuations. In the best cases, unexpected pregnancy results in an evacuation from the war zone. There is no systematic data on availability of birth control.
Motherhood is also a major issue for female service members who are normally in their prime reproductive years. Concerns about pregnancy, being a mother, and breast-feeding are central, and being a mother and/or wife deploying not only leads to all types of emotional issues, but also personal growth.
Sexual Assault and Mental Health Disorders
Military sexual assault is a highly publicized area that is covered widely in both the scientific literature and the media. The number of cases reported has been rising, but this may be partially due to better reporting. In the military, as in the civilian world, this is not a simple issue, and many sexual activities are partially consensual, partially coercive. Sexual assault can lead to a myriad of mental health issues, including guilt, depression, PTSD, and substance abuse. In many cases, it can also lead to an exit from military service for both parties.
Posttraumatic stress disorder is a common consequence of combat. It has been studied widely in military men after Vietnam and during the Long War. It has also been widely studied in civilian women, especially after sexual assault. Far less is known about combat-related PTSD in military women; however, the available statistics show that military women have rates of combat-related PTSD at about the same rate as men. What we do not know is whether their PTSD symptoms are similar or different. Depression, suicide, and traumatic brain injury are also common sequelae that are covered in Women at War. Substance abuse and homelessness are likewise critically important areas but areas that need more research.
Conclusions
Medical and academic volumes rely on scientific evidence, which should lead to evidence-based practice. From that standpoint, Women at War has been a challenging one to put together, chiefly because there has been so little recent comprehensive data on the psychological and physical health of female service members. Nonetheless, this volume seeks to gather the data that are available, add anecdotal but universal information, translate it into actionable information for clinicians, and make recommendations for future research. Important take-home messages for the clinician include asking their patient about their overall military service, their experiences in the theater of war, and the positive and negative effects of that service.
Female service members are a vital part of the nation’s military and have been heavily deployed beside their male counterparts since the Persian Gulf War in 1990. The tragedy of 9/11 dramatically increased the operational tempo for all the troops.
It is hoped that this volume will stimulate more understanding of the experiences of female service members, women at war, in order to have the experience be a better one. Throughout this volume is implicit and/or explicit commentary on the lack of research data on gender issues in the military. Clearly, more targeted understanding is needed.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs.
1. Friedl KE. Biomedical research on health and performance of military women: accomplishments of the Defense Women’s Health Research Program (DWHRP). J Womens Health (Larchmt). 2005;14(9):764-802.
2. Ritchie EC, Naclerio AL, eds. Women at War. New York, NY: Oxford University Press; 2015.
September 11, 2001, is a day burned into the consciousness of all Americans old enough to remember that day. For members of the U.S. military, it was also the beginning of more than 14 years of war, variously called the war on terror, Operation Enduring Freedom (Afghanistan), Operation Iraqi Freedom (Iraq), Operation New Dawn (Iraq) and the Long War. The Long War encapsulates the repeated deployments into combat zones in Afghanistan and Iraq, as well as the Horn of Africa and to humanitarian assistance operations.
For women, 9/11 also ushered in a steadily increasing role in the U.S. military. No longer mainly nurses, as in the Vietnam War, or primarily in support roles, as in the Gulf War, female service members have been in the thick of the conflicts in Iraq and Afghanistan.
Only recently have women officially been allowed into the Military Occupational Specialty (MOS) of combat occupations. Combat occupations are typically the “warfighters”; however, it is now widely accepted that women have been in combat since long before 9/11. For example, the deployment to Somalia in 1993 started as a humanitarian assistance operation and was later turned into a combat mission. More recently, in the Long War, numerous roles open to women, such as military police and truckers, have been frequently involved in firefights.
New Research
Research and data about women in the military have had a relapsing course. After the first Gulf War, there were a number of articles focusing on the health issues of women deployed there. The main reasons for redeployment to the U.S. were abnormal pap smears gathered before deployment and positive pregnancy screens. In the late 1990s, there was a considerable amount of research, mainly covered under the loose rubric of the Defense Women’s Health Research Project.1
In 2002, I organized a symposium at the Women in Military Service Memorial, which focused on the prevention of urinary tract infections in the field, unintended pregnancy while deployed, and stress fractures. Partly because of the repeal of the combat exclusion rule and partly because the Long War seems to be winding down, recently there have been a number of activities and publications about women in combat. With COL Anne L. Naclerio, MD, MPH, I recently coedited Women at War, a collection of 19 articles that bring together much of the available information and experience on women service members’ health and mental health.2 We hope that it will further spur interest and research on the topic.
The lack of data on female service members is in contrast to the extensive scientific literature on male service members. The Walter Reed Army Institute of Research and the Mental Health Advisory teams both have focused on combat troops, which have been primarily male. The Millennium Study includes women, but its results are just beginning to emerge. The VA has data on female veterans, but only a small number of female veterans go to the VA, and VA studies on women have focused primarily on military sexual assault. Although this area is very important, there are many other issues that female service members deal with, including reproductive and genitourinary concerns.
The Women at War volume begins to address this problem. Chapters examine data on deployment-related issues, posttraumatic stress disorder (PTSD) in female service members, and intimate partner violence. Due to a lack of quantitative data, other chapters summarize either civilian data or data on male service members, then move to extrapolate for service women. A few chapters are more anecdotal, describing the experience of being a female sailor on a ship or a mother on deployment.
Reproduction and Gynecology
Much of the current discussion about women in the military focuses on physical strength. Can she carry a 60-round rucksack? Can she load artillery rounds? In contrast, issues about reproduction and gynecology are understudied in the recent literature on female service members.
Urinary tract infections (UTIs) are a major issue for women in the field. Much of the concerns that female service members have are about bathrooms. Is the latrine—maybe used by many other service members—clean enough to sit on? Women often restrict fluids to avoid going to the filthy or nonexistent bathrooms and thus get UTIs or become dehydrated. Managing menses in austere conditions is another dilemma. Can I change my tampon while driving on the roads in Iraq? Should I be on oral contraception while deployed to regulate menses?
Although sexual assault has received considerable attention, consensual sex has received much less. A taboo area seems to be the sexual desires of women who deploy. But young women—and most women who deploy are young—do have sexual desires, perhaps heightened by the daily exposure to death and close bonding in the combat zone. The literature is totally devoid on this topic. If contraception is scarce, pregnancies happen. In the worst cases, this results in ectopic pregnancies, resulting in life-threatening emergencies and expensive medical evacuations. In the best cases, unexpected pregnancy results in an evacuation from the war zone. There is no systematic data on availability of birth control.
Motherhood is also a major issue for female service members who are normally in their prime reproductive years. Concerns about pregnancy, being a mother, and breast-feeding are central, and being a mother and/or wife deploying not only leads to all types of emotional issues, but also personal growth.
Sexual Assault and Mental Health Disorders
Military sexual assault is a highly publicized area that is covered widely in both the scientific literature and the media. The number of cases reported has been rising, but this may be partially due to better reporting. In the military, as in the civilian world, this is not a simple issue, and many sexual activities are partially consensual, partially coercive. Sexual assault can lead to a myriad of mental health issues, including guilt, depression, PTSD, and substance abuse. In many cases, it can also lead to an exit from military service for both parties.
Posttraumatic stress disorder is a common consequence of combat. It has been studied widely in military men after Vietnam and during the Long War. It has also been widely studied in civilian women, especially after sexual assault. Far less is known about combat-related PTSD in military women; however, the available statistics show that military women have rates of combat-related PTSD at about the same rate as men. What we do not know is whether their PTSD symptoms are similar or different. Depression, suicide, and traumatic brain injury are also common sequelae that are covered in Women at War. Substance abuse and homelessness are likewise critically important areas but areas that need more research.
Conclusions
Medical and academic volumes rely on scientific evidence, which should lead to evidence-based practice. From that standpoint, Women at War has been a challenging one to put together, chiefly because there has been so little recent comprehensive data on the psychological and physical health of female service members. Nonetheless, this volume seeks to gather the data that are available, add anecdotal but universal information, translate it into actionable information for clinicians, and make recommendations for future research. Important take-home messages for the clinician include asking their patient about their overall military service, their experiences in the theater of war, and the positive and negative effects of that service.
Female service members are a vital part of the nation’s military and have been heavily deployed beside their male counterparts since the Persian Gulf War in 1990. The tragedy of 9/11 dramatically increased the operational tempo for all the troops.
It is hoped that this volume will stimulate more understanding of the experiences of female service members, women at war, in order to have the experience be a better one. Throughout this volume is implicit and/or explicit commentary on the lack of research data on gender issues in the military. Clearly, more targeted understanding is needed.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs.
September 11, 2001, is a day burned into the consciousness of all Americans old enough to remember that day. For members of the U.S. military, it was also the beginning of more than 14 years of war, variously called the war on terror, Operation Enduring Freedom (Afghanistan), Operation Iraqi Freedom (Iraq), Operation New Dawn (Iraq) and the Long War. The Long War encapsulates the repeated deployments into combat zones in Afghanistan and Iraq, as well as the Horn of Africa and to humanitarian assistance operations.
For women, 9/11 also ushered in a steadily increasing role in the U.S. military. No longer mainly nurses, as in the Vietnam War, or primarily in support roles, as in the Gulf War, female service members have been in the thick of the conflicts in Iraq and Afghanistan.
Only recently have women officially been allowed into the Military Occupational Specialty (MOS) of combat occupations. Combat occupations are typically the “warfighters”; however, it is now widely accepted that women have been in combat since long before 9/11. For example, the deployment to Somalia in 1993 started as a humanitarian assistance operation and was later turned into a combat mission. More recently, in the Long War, numerous roles open to women, such as military police and truckers, have been frequently involved in firefights.
New Research
Research and data about women in the military have had a relapsing course. After the first Gulf War, there were a number of articles focusing on the health issues of women deployed there. The main reasons for redeployment to the U.S. were abnormal pap smears gathered before deployment and positive pregnancy screens. In the late 1990s, there was a considerable amount of research, mainly covered under the loose rubric of the Defense Women’s Health Research Project.1
In 2002, I organized a symposium at the Women in Military Service Memorial, which focused on the prevention of urinary tract infections in the field, unintended pregnancy while deployed, and stress fractures. Partly because of the repeal of the combat exclusion rule and partly because the Long War seems to be winding down, recently there have been a number of activities and publications about women in combat. With COL Anne L. Naclerio, MD, MPH, I recently coedited Women at War, a collection of 19 articles that bring together much of the available information and experience on women service members’ health and mental health.2 We hope that it will further spur interest and research on the topic.
The lack of data on female service members is in contrast to the extensive scientific literature on male service members. The Walter Reed Army Institute of Research and the Mental Health Advisory teams both have focused on combat troops, which have been primarily male. The Millennium Study includes women, but its results are just beginning to emerge. The VA has data on female veterans, but only a small number of female veterans go to the VA, and VA studies on women have focused primarily on military sexual assault. Although this area is very important, there are many other issues that female service members deal with, including reproductive and genitourinary concerns.
The Women at War volume begins to address this problem. Chapters examine data on deployment-related issues, posttraumatic stress disorder (PTSD) in female service members, and intimate partner violence. Due to a lack of quantitative data, other chapters summarize either civilian data or data on male service members, then move to extrapolate for service women. A few chapters are more anecdotal, describing the experience of being a female sailor on a ship or a mother on deployment.
Reproduction and Gynecology
Much of the current discussion about women in the military focuses on physical strength. Can she carry a 60-round rucksack? Can she load artillery rounds? In contrast, issues about reproduction and gynecology are understudied in the recent literature on female service members.
Urinary tract infections (UTIs) are a major issue for women in the field. Much of the concerns that female service members have are about bathrooms. Is the latrine—maybe used by many other service members—clean enough to sit on? Women often restrict fluids to avoid going to the filthy or nonexistent bathrooms and thus get UTIs or become dehydrated. Managing menses in austere conditions is another dilemma. Can I change my tampon while driving on the roads in Iraq? Should I be on oral contraception while deployed to regulate menses?
Although sexual assault has received considerable attention, consensual sex has received much less. A taboo area seems to be the sexual desires of women who deploy. But young women—and most women who deploy are young—do have sexual desires, perhaps heightened by the daily exposure to death and close bonding in the combat zone. The literature is totally devoid on this topic. If contraception is scarce, pregnancies happen. In the worst cases, this results in ectopic pregnancies, resulting in life-threatening emergencies and expensive medical evacuations. In the best cases, unexpected pregnancy results in an evacuation from the war zone. There is no systematic data on availability of birth control.
Motherhood is also a major issue for female service members who are normally in their prime reproductive years. Concerns about pregnancy, being a mother, and breast-feeding are central, and being a mother and/or wife deploying not only leads to all types of emotional issues, but also personal growth.
Sexual Assault and Mental Health Disorders
Military sexual assault is a highly publicized area that is covered widely in both the scientific literature and the media. The number of cases reported has been rising, but this may be partially due to better reporting. In the military, as in the civilian world, this is not a simple issue, and many sexual activities are partially consensual, partially coercive. Sexual assault can lead to a myriad of mental health issues, including guilt, depression, PTSD, and substance abuse. In many cases, it can also lead to an exit from military service for both parties.
Posttraumatic stress disorder is a common consequence of combat. It has been studied widely in military men after Vietnam and during the Long War. It has also been widely studied in civilian women, especially after sexual assault. Far less is known about combat-related PTSD in military women; however, the available statistics show that military women have rates of combat-related PTSD at about the same rate as men. What we do not know is whether their PTSD symptoms are similar or different. Depression, suicide, and traumatic brain injury are also common sequelae that are covered in Women at War. Substance abuse and homelessness are likewise critically important areas but areas that need more research.
Conclusions
Medical and academic volumes rely on scientific evidence, which should lead to evidence-based practice. From that standpoint, Women at War has been a challenging one to put together, chiefly because there has been so little recent comprehensive data on the psychological and physical health of female service members. Nonetheless, this volume seeks to gather the data that are available, add anecdotal but universal information, translate it into actionable information for clinicians, and make recommendations for future research. Important take-home messages for the clinician include asking their patient about their overall military service, their experiences in the theater of war, and the positive and negative effects of that service.
Female service members are a vital part of the nation’s military and have been heavily deployed beside their male counterparts since the Persian Gulf War in 1990. The tragedy of 9/11 dramatically increased the operational tempo for all the troops.
It is hoped that this volume will stimulate more understanding of the experiences of female service members, women at war, in order to have the experience be a better one. Throughout this volume is implicit and/or explicit commentary on the lack of research data on gender issues in the military. Clearly, more targeted understanding is needed.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs.
1. Friedl KE. Biomedical research on health and performance of military women: accomplishments of the Defense Women’s Health Research Program (DWHRP). J Womens Health (Larchmt). 2005;14(9):764-802.
2. Ritchie EC, Naclerio AL, eds. Women at War. New York, NY: Oxford University Press; 2015.
1. Friedl KE. Biomedical research on health and performance of military women: accomplishments of the Defense Women’s Health Research Program (DWHRP). J Womens Health (Larchmt). 2005;14(9):764-802.
2. Ritchie EC, Naclerio AL, eds. Women at War. New York, NY: Oxford University Press; 2015.
