The wars in Iraq and Afghanistan have focused attention on the issue of posttraumatic stress disorder (PTSD) in women veterans. Many people, including those in the media, have questioned whether PTSD prevalence is elevated in female OEF/OIF personnel because of the unique roles performed by these women'specifically the greater direct exposure to combat relative to the exposure women had in prior wars. The question is especially important given the high prevalence of women among OEF/OIF veterans who use the VA: according to a May 2008 report by VHA's Office of Public Health and Environmental Hazards, women comprise 12 percent of the OEF/OIF veterans who have sought VA health care.
Among civilians, PTSD prevalence is higher in women than in men. According to the National Comorbidity Survey Replication, 9.7 percent versus 3.6 percent have lifetime PTSD. The gender difference in PTSD is partially explained by a gender difference in traumatic exposure. A recent meta-analysis found that women are more likely than men to experience the kind of traumas, such as rape and sexual assault, that carry a high risk of PTSD in both men and women.1 Differential exposure also occurs in veterans. Investigators in an ongoing HSR&D-funded study recently reported that the prevalence of military sexual trauma (MST) in VA patients was 21.8 percent in women and 1.1 percent in men.2 However, the meta-analysis found that the odds ratio for PTSD following MST was much higher in the women (8.8) than in the men (3.0), paralleling findings that women are also more likely than men to develop PTSD in response to other events, including nonsexual assault or disasters. Warzone exposure may be unique. In the meta-analysis, there was no gender difference in the prevalence of PTSD due to warzone exposure among veterans.
To understand these findings, it is helpful to look back to the National Vietnam Veterans Readjustment Study, which was based on a nationally representative sample of veterans that included an oversampling of women. Lifetime PTSD prevalence was 26.9 percent in women and 30.9 percent in men, and current PTSD prevalence (in the mid-1980s) was 8.5 percent in women and 15.2 percent in men. The likely explanation for the gender difference is that the men and women who served in Vietnam differed on numerous risk and protective factors, e.g., the women were older, more educated, more likely to be officers and to serve in medical roles, and less likely to experience combat.
Fast forwarding to the present, a recent report by the Rand Corporation on OEF/OIF veterans illustrates the importance of accounting for differences in individual characteristics and type of warzone exposure when comparing PTSD prevalence in male and female veterans.3 In unadjusted analysis, the relative risk of PTSD was 1.03 among women (vs. men), but in analyses that adjusted for demographic and exposure variables, the relative risk was 1.69--significantly higher among women than men.
But prevalence is only the tip of the iceberg. PTSD is associated with psychiatric and physical comorbidity, impaired functional status, reduced quality of life, health risk behaviors, and increased service utilization. HSR&D has supported a number of studies to facilitate greater understanding about these aspects of PTSD in women veterans. Past studies have examined the physical health burden associated with PTSD, the antecedents and consequences of military sexual harassment, and gender differences in compensation and pension claims approval process.
The portfolio of current studies addresses a wide range of topics too. In the Women Veterans Cohort Study, Brandt and colleagues are assembling a longitudinal cohort of male and female OEF/OIF veterans to examine gender disparities in utilization and outcomes, including PTSD. Another longitudinal cohort study is a follow-up of male and female Marines who were initially assessed at Parris Island between 1997 and 1999; this study will examine the effects of MST on PTSD and health behaviors. One study is focusing on the effects of physical and sexual assault on women who served in the Reserves or National Guard, who may have increased risk of PTSD and poor outcomes.
Studies like these are complemented by HSR&D-funded projects of ways to enhance the treatment of PTSD in both male and female veterans, including telehealth delivery, the use of decision aids, integrated primary care, and combined treatment for PTSD and substance abuse. Through their efforts, VA researchers are helping to meet the needs of our newest veterans as well as those with chronic PTSD--and the unique needs of women remain at the forefront of these efforts.