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November/ December 2013 Women, War, and PTSD

Are female warriors more likely to be traumatized by combat?

By Laura Kasinof

Former U.S. Army medic Jennifer Pacanowski’s speech was punctuated by loud laughter, even when the topic of conversation turned quite dark. “I’m looking for bombs,” she said, driving south on the New Jersey Turnpike, “so if anyone tries to blow up this roadway, I’ll be ready for it.” She laughed again, acknowledging the ridiculousness of her statement but unable to let go of the tricks her mind was playing.

Pacanowski, who’s thirty-three now, served in 2004 as an ambulance driver in Iraq, where she accompanied military convoys from the Al Asad Air Base in western Anbar Province, one of the most violent regions in a violent war. Despite serving in a “noncombat” role, Pacanowski often found herself in the line of enemy fire, witnessing firsthand the carnage of fatal roadside bombs or being forced to take cover during sniper attacks.

When she left the Army two years later, Pacanowski struggled to reintegrate back home and instead retreated to a log cabin in the Poconos, where she spent years “drinking too much,” she said, and rarely went outside. All she “wanted was to feel numb,” she told me. “How could I come home and not feel safe? At war, I wasn’t frightened by the mortars. Then I came back to America and couldn’t leave my house. It didn’t make sense to me at the time. I preferred to be angry and live in denial.” In 2007, Pacanowski was diagnosed with post-traumatic stress disorder, or PTSD.

While Pacanowski has since regained her footing—thanks, she says, to her supportive family, as well as to her work training bullmastiffs and volunteering with nonprofits serving veterans’ needs—both her difficulty returning home from war and her diagnosis are far from uncommon. The women who served in Iraq and Afghanistan (they now make up about 15 percent of the armed services) all technically held noncombat roles, but many, like Pacanowski, served on the front lines. Since the start of the war in Afghanistan in 2001, 149 women have been killed in the line of duty, and many more, like Pacanowski, have been diagnosed with PTSD or other psychological disorders as a result of their service.

The U.S. Department of Defense (DOD) announced its decision to lift the ban on women serving in combat roles in January of this year, opening up potentially thousands of new positions to female soldiers within the infantry, artillery, and Special Forces. This major policy change was widely praised by Republicans and Democrats, conservatives and liberals alike. Military leaders testified to the vital role that women have played in Iraq and Afghanistan while civil rights advocates argued that, without the badge of having officially served in combat, women have long been denied the recognition and career mobility they rightly earned for their wartime service.

But there’s another, less celebratory side of the story, too. In the past year, the media has uncovered the actual day-to-day experience of many women in the armed forces. It’s now headline news that female soldiers are routinely harassed, assaulted, and raped by their fellow soldiers or, worse, commanding officers; others have been deployed as young mothers with small children or infants at home, and others have returned from war pregnant. Still others, like Pacanowski, have simply struggled to negotiate the psychological whiplash between war and peace—between the expectations of a soldier abroad and those of a daughter, girlfriend, wife, mother, or office employee at home.

While it’s clear that war is hell for everyone, men and women alike, it’s unclear how the unique female experience in the barracks, on the battlefield, and back at home may affect them differently. Female veterans are already more likely than male veterans to be homeless, divorced, or raising children as single parents. Female vets under fifty are more than twice as likely as their male counterparts to kill themselves. And a growing body of research suggests that female vets may also be more susceptible than men to psychological disorders, including PTSD.

Those facts and new research—indeed, the very discussion of gender differences in the armed forces—are often incendiary, but they should not be taken as an argument against equality in the armed forces. Instead, they should be the catalyst for a worthwhile discussion. After all, we owe it to our veterans to study how some women experience war and homecoming differently, and to determine what can be done to better support female soldiers—women who are now poised, for the first time in history, to be deployed in large numbers in combat positions overseas.

Throughout U.S. history, there has been both an awareness of the effect of war on the human psyche and an effort to protect people from it. As far back as the Revolutionary War, doctors whispered of “soldiers’ heart,” and after World War I, similar symptoms became known as “shell shock.” During much of World War II and into the 1960s, fathers were kept from direct combat, partly out of fear of destroying the family structure back at home, and partly because it was thought that they would not fight if they had too much to come home to. During the war in Vietnam, the exemption for fathers was gradually phased out, but the symptoms of shell shock were so prevalent, it was at last assigned an official name: in 1980, the American Psychological Association (APA) listed PTSD among the mental health disorders, catapulting the abbreviation into the cultural lexicon in books and movies and newspaper headlines.

Unsurprisingly, the majority of those who have suffered in the past century from combat-induced PTSD have been men. While thousands of women served in Vietnam and Korea as nurses, air traffic controllers, support staff, intelligence officers, and other vital positions, they were by and large kept from the front lines. Only eight military women died over the course of the Vietnam War. In 1988, the DOD established what was known as the “risk rule,” in which women were explicitly prohibited from serving in units or missions where the risk of exposure to direct combat, hostile fire, or capture was equal to or greater than the risk in the combat units they supported.

Operation Desert Storm in the early ’90s changed all that. Because of the nature of the engagement, almost everyone deployed—men and women, ambulance drivers and infantry—was physically “at risk.” In response to that changing reality, then Defense Secretary Les Aspin tweaked the risk rule in 1994, opening up all military jobs to women except those below the brigade level where the “primary mission” was to engage in direct combat. The new rule led to an increase in women’s roles in U.S. military operations in Somalia and the Balkans in the ’90s, but it wasn’t until the past decade that female soldiers, in larger numbers than ever before, began to fill roles that put them directly in the line of enemy fire.

In the wars in Iraq and Afghanistan, when less than 1 percent of Americans served on active military duty in an all-volunteer army, the U.S. armed forces relied more than ever on female soldiers in the field to perform vital tasks and to increase the quality of enlisted soldiers. In 2005, when House Republicans introduced language in the annual defense authorization bill that would have restricted women’s roles in warfare, it was Donald Rumsfeld and top leaders of the military who lobbied fiercely against it. The offending language was lifted from the bill in short order.

The next major move toward opening up combat roles to women came in 2011, when the Military Leadership Diversity Commission, convened by Congress three years earlier, released a report recommending that the ban on women in combat be eliminated entirely. The report cited primarily the roles that women were already playing on the front lines, and only briefly alluded to issues surrounding mental health. It addressed the subject only long enough to dismiss it: women were not more likely than men to develop PTSD, the commission found, citing as evidence a single Department of Veterans Affairs (VA) study that found conflicting results about gender differences in PTSD rates and a New York Times article quoting DOD officials on the subject.

During Secretary of Defense Leon Panetta’s short tenure at the department, the appropriate role of women in wartime stayed on the agenda. In February 2012, the DOD announced that it would open up 14,325 positions to women within combat units that had previously been off-limits, and the following January, Panetta and Joint Chiefs of Staff Chairman Martin Dempsey announced the elimination of the ban on women in combat. “When I went to the battlefields in Iraq and Afghanistan, I saw a lot of women who were out there in uniform, pretty much who were performing a lot of roles men had formally performed,” Panetta told me over the phone from his office at the Panetta Institute in Northern California. “They were there on the front lines. I saw them. I had a chance to talk to them. I was always very impressed by their spirit and desire to serve. They performed well. They did the job.… Deep down, I had a real sense of injustice that they weren’t being given at least a chance to seek those positions.”

While the decision to lift the ban did not open up all positions to female soldiers at once, it did jump-start a series of tough conversations. All branches of the armed forces must now spend the next two years (the process is slated to be finished by January 2016) deciding how they will integrate women. This is especially crucial in the Army and the Marine Corps. Each branch must defend its decisions to both the DOD and Congress in cases where certain positions will remain only available to men. Jon Aytes, head of the Military Personnel Policy Branch for the Marine Corps, said the process of deciding which roles will be opened to women is “deliberate” and “measured,” and will include research into how combat affects a woman’s mental health. “You got to look at the whole body and whole person,” Aytes said. “There is a mental capacity that goes into that. That is something that we … need to make sure we look at as people are coming back.”

Panetta, however, resisted the idea of considering research on gender differences in PTSD when deciding which combat roles will be open to women. His position reflects the feelings of many in our society, both among civil rights activists and the military. After all, suggesting that women may be somehow weaker, or more psychologically fragile, has been and remains an unsavory idea, both politically and socially. “From what I saw as secretary, I am absolutely convinced that women can be just as tough as men when it comes to dealing with these kinds of issues,” Panetta said.

But comparing the relative “toughness” of men and women may not be the best way of looking at the question. The truth is, men and women have demonstrably different experiences both at war and at home. In the barracks, on the battlefield, and in homecoming gatherings, female soldiers are often the extreme minority among their peers and are therefore treated differently, both socially and professionally. They are not, almost by definition, “brothers in arms.” While some female soldiers report bonding deeply with their fellow male soldiers, others say they spend their deployments feeling alienated, marginalized, or outright threatened by their comrades; women are disproportionately the victims of rape, sexual assault, and harassment by fellow soldiers. Upon returning home—an event that, ironically, often triggers symptoms of PTSD in both men and women—the female experience is also arguably different from the male one, in part because of the social expectations of what a veteran looks like, and in part because of the roles that women, as mothers and often primary caregivers, are expected to fulfill in America.

At veterans’ events, Pacanowski, the Iraq veteran, said it is often assumed that she is a girlfriend or wife of a combat veteran, not one herself. Stacy Keyte, a former member of the Texas National Guard who also served in Iraq, reiterated the point: “It’s something when you don’t see very many pictures of women in uniform hugging their children or being welcomed by their children,” she said. “Commercials, the touching ones, are always showing the guy and his baby. What about the mothers who leave their infants? I think it would help if there was just some acknowledgment.”


Homecoming: Iraq War veteran Jennifer Pacanowski reading her writing in May 2012 at an event sponsored by Warrior Writers, a nonprofit helping veterans express themselves through art.

Kimberly Olson, a retired Air Force colonel and director of Grace After Fire, a nonprofit organization in Fort Worth, Texas, that helps female veterans reintegrate into society, said social expectations are hugely important. “When you deploy, you are trained to shoot, survive, to do your job. You aren’t trained to the classic female roles. We don’t say, ‘Be more nurturing.’ No, [you] enter into a very male, aggressive structure,” she said. “Those same traits don’t help re-bonding with your two-year-old, or your loving relationship with your husband. [A female veteran] has to find that on her own after being a woman again after being a warrior.”

Keyte, for example, was married and caring for her one-year-old son when she was called to Fort Hood in 2005 to train before being deployed to Iraq. “That was probably one of the hardest things I have had to do, was to leave him,” she said, referring to her son. “You were worried about yourself, and it’s hard to explain but I was more worried about my son.” Within hours after Keyte arrived in Tikrit, Iraq, the base came under direct shelling and rocket attacks—assaults that continued to occur sporadically throughout her deployment. To deal with the situation, Keyte said, she “created a shell,” emotionally.

A year later, upon returning home to Texas, she couldn’t simply change back to who she’d been, she said. Instead, she found herself reaching for her guns when she heard a sound a night, feeling distant from her son, and being wracked with guilt. Now, years later, Keyte works for Olson’s organization, Grace After Fire, helping other women deal with the flood of emotions—including guilt about having been away or, sometimes, guilt that they don’t feel guilty—that they face upon leaving the military and rejoining family, friends, and children.

Sarah Mess, who served as an Army medic in Somalia in the ’90s, became a mother a decade after she returned from deployment—a role that, she says, has made her PTSD symptoms worsen. “I survived [my PTSD] because I was able to isolate. I could do those things because I was single, and I can’t do them now. Now I feel like I’m in a pressure cooker,” she told me when we met in the basement of a local arts center in New Jersey, where she joins other veterans once a week to make works of art out of their old military uniforms in a project called Combat Paper.

“Your four-year-old is there, and you better keep your emotions in, or else you’re going to fuck him up,” she said. “I pretend I’m okay and run into the bathroom so he can’t see me crying, and say, ‘Oh, I got something in my eye.’ It’s a poison, this PTSD, because it can affect other people.”

And then, of course, there’s the issue that’s received so much attention in the press of late: the prevalence of rape and sexual abuse in the military. While none of the women I spoke with for this story had suffered from military sexual trauma (MST), the armed services’ catch-all term, an estimated 20 percent of all women who use VA health care have been sexually assaulted, abused, or raped during their time in the U.S. military. Civil rights groups that get their stats from independent researchers put the number even higher, at around 30 percent.

Those huge numbers go a long way toward explaining why women react differently to war and carry different psychological burdens home with them, mental health experts say. Women in the military must also face “negative consequences for reporting [abuse or harassment] or they may have to continue working with someone who has assaulted them, or they were assaulted by a commanding officer,” said Janice Krupnick, research professor at Georgetown University’s Department of Psychiatry, who works with female veterans. “That adds an extra source of stress and difficulty.”

Even for women who don’t experience MST directly—like Pacanowski and Keyte—tamer versions of relentless sexual harassment can play a major role in inducing anxiety. Some of the female veterans I spoke with said that phrases associated with the female gender—like “acting like a girl” or “being a woman”—are often used as derogatory euphemisms for “weakness” during training drills and elsewhere. As a result, female soldiers feel the additional pressure to demonstrate that they’re just as tough as men. “It was a mentality that thought women should be barefoot and pregnant in the kitchen [and it] was told to my face,” Keyte told me. “That was the environment I was in. It made me more tough on people. I was tough on myself.”

So how do we determine whether women suffer more in war and its aftermath, or even that they suffer differently than their male counterparts? The short answer is that, as of now, we can’t. There has yet to be a definitive study looking at precisely this question, although there is a growing body of evidence suggesting that women may be more susceptible than men to specific psychological disorders, like PTSD and depression, especially in certain circumstances.

One landmark study, published by the APA’s Psychological Bulletin in 2006, examined twenty-five years of research on a wide spectrum of trauma and found that women are about twice as likely as men to develop PTSD after experiencing traumatic events. The study found that women were especially more likely to develop PTSD after types of assaultive violence, such as accidents, conflict, or physical abuse. A recent study by the University of California, San Francisco, also seemed to corroborate the APA’s research, finding that women develop a stronger conditioned response to fear than men, which may explain their increased propensity to develop PTSD after combat. A 2008 study by the RAND Corporation similarly found that female veterans were 1.7 times more likely to report PTSD symptoms than men and 2.4 more times likely to be depressed than their male counterparts, and several reports published by the VA’s National Center for PTSD found that women are more likely than men to develop the disorder.

A more recent study published in BMC Psychiatry in May 2013 by the Institute for Veterans and Military Families also found that female Marines who had been deployed to Iraq or Afghanistan were more prone to PTSD or depression than their male counterparts. “Research is needed to determine the factors responsible for these elevated levels of mental disorders among military women,” the report noted.

But all of those studies, however much they point at a trend, raise more questions than they answer. A May 2012 article published on the Web site of New York Behavioral Health, a mental health organization dedicated to treating psychological disorders of all kinds, noted that while there have been more studies focusing on biological causes for gender disparities in reactions to trauma, such as hormonal differences in the brain, there has yet to be a conclusive study on the matter.

Furthermore, most of the studies mentioned above rely on self-reporting or surveys—imprecise metrics at best, in part because it’s possible that women are simply more likely than men to report on their emotions. A different VA-sponsored study published in 2011 did not find a correlation between gender and PTSD, except when the trauma experienced was personal injury, in which case women were at greater risk for PTSD than men, but the study was based on mental health checklists that service members were required to complete upon returning from overseas service. The veterans I spoke with told me that no one fills out those checklists truthfully, because if they admit they’re struggling with PTSD-related symptoms, their trip home could be delayed by mental health exams.

Lisa Jaycox, a senior behavioral scientist at the RAND Corporation, where she coauthored a report on mental disorders among veterans, says that diagnosing and treating PTSD is complicated by the fact that men and women often exhibit different symptoms of the disorder. “Women are more prone to ruminate about problems, whereas men are more likely to distract themselves,” she said. Women often tend to blame themselves for their anxiety, spiraling into depression and social isolation; men are more likely to turn to substance abuse, or commit acts of violence.

“There are social theories, economic theories, biological theories” for gender disparities in PTSD, and the way that people experience the illness, Jaycox said. “It’s not like one [explanation] is right. It’s probably a complicated combination of factors. And that is expected to be the case when looking at rates within the military as well.”

So what’s the right thing to do? Should we as a nation pass laws that protect female soldiers, as well as their families back home, as we once protected fathers and their wives and children back home, from the horrors and aftereffects of war? Should we hold off on integrating women into direct combat roles until sufficient research determines the risk to female soldiers’ mental health?

These are tough, controversial questions, but the consensus I found among female veterans was a little clearer, and twofold: They applauded the DOD’s decision to lift the combat ban, if for no other reason than it might increase awareness among both the public and the government that female soldiers returning from combat situations of all kinds are veterans in the same way male soldiers are. But the female soldiers with whom I spoke also believed that we should give women the unique—and, yes, gender-specific—support that they may need both abroad and after returning home.

Take, for example, the experience of female veterans at the VA, an organization long designed to cater largely to men. In January 2011, the VA Office of Inspector General released a study finding that women have had a harder time than men receiving treatment from the VA for service-related PTSD because they technically have not served in combat roles. Even after they’ve been diagnosed, the challenges are often formidable. On an afternoon last spring, I accompanied Pacanowski to the Philadelphia VA, which she described to me beforehand as “creepy.” The crowded waiting rooms were packed with older men whose leering gazes caused her to become noticeably uncomfortable. Her movements became stilted, and she began to stutter her words. At the receptionist’s desk, a stout, bearded vet who’d been at the counter before us ogled us. “I’ve been waiting all day to keep that spot warm for some pretty ladies,” he said. “Is that warm for you?” We moved out to the hallway to wait for her appointment to see a psychologist for her PTSD.

The VA has begun taking steps to improve some of those problems, establishing a new women’s veteran hotline to answer any questions about services provided, and awarding the largest number of grants ever to thirty-three of its facilities to expand health care tailored to women. But as of now, the standards for women’s health are not the same at VAs countrywide. The VA Medical Center in Washington, D.C., for example, has a complete women’s clinic with physicians and therapists available Monday through Friday, but in Fort Worth, Texas, the VA women’s health clinic was staffed in early 2013 by a single registered nurse and was only open three mornings a week, during work hours. A spokesperson at the VA told me that no new research on women and PTSD has been funded as a result of the elimination of the combat ban. But potentially “those researchers who have been examining impacts of combat exposure will be pursuing work in this area in the near term,” he said.

While it may be impossible to tease apart MST and sexual harassment from the prevalence of PTSD in women, or to quantify the various ways in which a woman’s experience differs from that of a man, the original questions remain. If we are poised to send women into war in greater numbers, or at least into official combat roles for the first time in our history, what can we do to guarantee their success in an arena that has historically been male and remains so today?

I posed this to Olson, the retired Air Force colonel who runs Grace After Fire. “If a veteran suffered violence in the service and he or she needs a safe place to come to seek treatment, we need to accommodate that.¬†We owe them that,” she said. “These kids volunteered to go in harm’s way for the benefit of the 99 percent of us. And if this is what they require, then we ought to give it to them, full stop.

Laura Kasinof is a freelance journalist based in Washington, D.C., where she is at work on a book about her three years as a reporter in Yemen. The reporting for this story was generously supported by the Fund for Investigative Journalism.

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