This document summarizes the history of women's roles in the military and discusses trauma experienced by women veterans, particularly post-traumatic stress disorder (PTSD) and military sexual trauma (MST). It traces the increasing roles of women from the American Revolution to present-day conflicts. It then discusses the high rates of trauma experienced by women veterans both during childhood and military service. Symptoms and treatments for PTSD and MST are outlined. The document advocates for trauma-informed care for women veterans and lists resources for support.

1. A BSN Capstone Project
By
Michele Boivin
Jacksonville University

3.  During the American Revolution some women
disguised themselves as men because women
were not allowed to fight.
 During the Civil War women were hired as
nurses, cooks and in other supportive roles.
 Dr. Mary Walker, an Army surgeon who
served during the Civil War, was the first and
only woman awarded the Congressional Medal
of Honor.

4.  The Army Nurse Corps and Navy Nurse Corps were established.
 Women were officially considered part of the military during
World War I.
 During World War II more than 350,000 women were recruited.
Women began to take on larger missions, flying airplanes and
serving overseas.
 During the Korean and Vietnam conflicts women took on more
roles previously assigned to men.

5.  In 1973 the all-volunteer force was established. Since
then the percentage of women in active duty has
jumped from 3% of the force to more than 15% today.
 In the first Gulf War, Desert Storm, more women saw
action.
 15% of all military personnel in Iraq during Operation
Iraqi Freedom were women. In this war, women
soldiers served in 91% of military specialties including
leadership roles, roles in combat, supportive services,
and healthcare to name a few.

7.  According to the Diagnostic and Statistical Manual of Mental
Disorders, fifth edition, (DSM5), the hallmark of PTSD centers
around the following criteria:
A. Persistent re-experiencing of the traumatic event.
B. Avoidance of reminders of the trauma such as people, places, and
activities.
C. Marked alterations in arousal and reactivity associated with the
traumatic event.
D. Negative altercations in cognitions and mood associated with the
traumatic event.
E. Duration of the disturbance is more than 1 month.
F. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
G. The disturbance is not attributable to the physiological effects of a
substance or another medical condition.

8.  Feeling depressed,
anxious, emotionally
numb, isolated, and
alone
 Uncontrollable anger,
rage
 Hypervigilance, easily
startled
 Fear of Crowds, panic
attacks
 Difficulty sleeping and
nightmares or night
terrors
 Irritability
 Poor concentration
 Motor restlessness
 Problems with drugs
and/or alcohol
 Anhedonia – lack of
energy and interest in
things
 Develop physical health
problems such as
chronic pain, migraines,
high blood pressure,
and diabetes

9. Reexperiencing the traumatic event: recurrent
recollections, flashbacks, images, thoughts,
nightmares, a sense of reliving the event, or
distress on exposure to reminders of the event.
“The littlest tasks seem to overwhelm me. I mean
the first time I went to the commissary I almost
broke down right there at the register. I couldn’t
decide what to do….” Cheryl, Army Reservist
who served 13 months in Iraq.

10. A Tale of Two Stressors:
Combat-Related Trauma (CRT)
And
Military Sexual Trauma (MST)

11. Women Veterans experience trauma at higher rates than the
general population.
 More than 50% of women Veterans experience some type of
interpersonal violence before joining the military.
 27-49% of women Veterans have experienced childhood
sexual abuse.
 35% of women Veterans have experienced childhood
physical abuse.
 As adults, 24-49% of women Veterans have experienced
sexual assault.
 46-51% of women Veterans have experienced physical
assault.
 39% of women Veterans report that they have experienced
domestic violence.

12. Exposure to traumatic stress increases the risk of developing
significant health and mental health challenges such as PTSD.
 According to the Veterans Administration (VA), approximately
20% of women Veterans of Operation Enduring Freedom
(OEF)/Operation Iraqi Freedom (OIF) have been diagnosed with
PTSD.
 Women Veterans with histories of civilian sexual assault are up to
5 times more likely to develop PTSD than those without sexual
assault histories.
 Women Veterans with histories of sexual assault in childhood are
7 times more likely to develop PTSD.
 Additional challenges associated with a history of sexual assault
include major depression, anxiety, physical health issues, and
substance abuse.
81-93% of women Veterans have been exposed to trauma over their
lifetime.

13. 1. Receiving hostile or friendly fire
2. Participating in atrocities (harming civilians,
mutilating enemy bodies, torturing prisoners
such as at Abu Ghrab prison)
3. Witnessing atrocities with no participation
4. Sexual trauma encountered during active
military duty (sexual harassment and assault)
5. Noncombat nonsexual trauma (training
accidents) encountered in the course of
military duties

14. (CRT)

15.  Women are not always trained for combat. Yet they often take part in
stressful and dangerous combat or combat-support missions.
 More women are receiving hostile fire, returning fire, and seeing
themselves or others getting hurt. And with no clear front lines, danger is
always near.
 Women can feel vulnerable because there are fewer female soldiers. They
may feel specifically targeted by enemies.
 Women often feel pressure to prove themselves, are treated differently
than their male counterparts, and don’t feel the same brotherhood
camaraderie as men. This cohesiveness among the men creates a certain
comfort and trust in soldiers. Women don’t develop this support system
and stress levels increase.
 Many women often feel overloaded with the feeling that “their lives at
home are on hold” when they are deployed. They worry about their
young children and elderly parents as they often are the primary
caregiver at home.
 41% of women Veterans report that they have been exposed to CRT.

16. “People always think about the guys. They think
women are just in the back. But even though I
was a supply clerk, I was at war, right up there
handling things with the guys. We all had our
M16s and our chemical masks with us at all
times.” Sabrina O’Connell, Phoenix, Arizona
Army Veteran

17. “As a female officer, I was the only female lieutenant.
And it was a little different for that reason. I didn’t
feel like I could ever show feelings or weakness.
Always had to kind of just be on my own. Didn’t
want anybody to see any weakness because I wanted
to prove I was worthy of being there (Iraq).”
Leann, first lieutenant and convoy commander with
the National Guard, served 14 months in Iraq.

18.  In the military you are trained to keep going, to stay on mission,
despite adversity, stress or even wounds. Adjustment to the
different pace of home life can be difficult.
 One of the effects of deployment is you get very tight with your
unit. When soldiers return home, they don’t know how to relate
to their family and friends. They become isolated and withdrawn
or they just spend their time with their “battle buddies”. This can
be therapeutic to a certain extent, but it also can be bad for
marriages and other relationships.
 After returning home, some women find it is hard to return to the
“mommy role”. They may find that they have more conflicts with
their children.
 The longer the deployment, such as for 12 months or more, the
more grown up a child is when a soldier returns home. This can
be a difficult adjustment as a preteen is now a teenager with more
independence.
 Female trauma experts say women often avoid taking care of
themselves because they’re so busy taking care of others. Female
soldiers returning home often avoid dealing with CRT by busying
themselves with other things.

19. (MST)

20. Military sexual trauma (MST) is defined by
the VA as any sexual activity where you are
involved against your will such as sexual
assault or rape, being groped or subjected
to verbal abuse or other forms of sexual
harassment.

21. Of women Veterans accessing VA services:
 Approximately 1 in 4 women Veterans screen
positive for MST.
 Prevalence of sexual assault in the military among
women Veterans ranges from 20-48%.
 80% of women Veterans have reported being
sexually harassed.
 20% of women Veterans who served in OIF/OEF
have been identified as having experienced MST.
 Women in the military are at higher risk for MST
than men.

22. In the VA, under federal mandate, screening for
MST involves asking the following two questions:
“When you were in the military,
1. Did you receive uninvited and unwanted
sexual attention, such as touching, cornering,
pressure for sexual favors, or verbal remarks?
2. Did someone ever use force or the threat of
force to have sexual contact with you against
your will?

23.  More than 20% of female soldiers are sexually
assaulted while serving.
 A female soldier is far more likely to be raped by a
fellow service member than killed in combat.
 Approximately 25% of victims did not report being
raped because the person to report to was the
rapist.
 Since 2006, more than 95,000 service members have
been sexually assaulted in the military.
 The military prosecutes less the five percent of
these sexual assault cases. Less than a third of
those result in imprisonment.

24.  Women are more likely to blame themselves for MST.
 Sexual assault is more likely to cause PTSD than any
other events.
 As a result of CRT and MST, female veterans are four
times more likely to become homeless than civilian
women.
 Women veteran survivors of MST have decreased rates
of seeking preventive and primary reproductive health
care.
 Most women Veterans don’t seek care at the VA
because it is a male dominated environment and they
want to avoid it because it reminds them of the
traumatic incident.

25. “This is the worst trauma, (MST), to deal with.
When the veteran leaves a combat zone and
comes home, he or she leaves the enemy behind.
When a woman comes home after being assaulted
by another veteran, the threat is still there.”
Duane Knutson, founder of Chandler, Arizona
based non-profit organization called the United
States War Veteran’s PTSD Foundation. Click on
the photo below to visit “The Clothesline Project”.

27.  Women are the fasting growing group of Veterans.
 According to the National Center for PTSD, women in
the military run a double risk of developing PTSD –
10% of women versus 4% of male service members –
for reasons ranging from battle stress and sexual
harassment to assault.
 27% of female Vietnam Veterans suffered from PTSD
sometime during their postwar lives.
 Among women Veterans of the conflicts in Iraq and
Afghanistan, 20% have been diagnosed with PTSD
 Women may take longer to recover from PTSD and are
four times more likely than men to experience long-
lasting PTSD.

28. Women are more likely to develop PTSD if they:
 Have a past mental health problem
 Experienced a very severe or life-threatening
trauma
 Were sexually assaulted
 Were injured during the event
 Had a severe reaction at the time of the event

29.  Women Veterans have less extensive social
supports and more are unmarried than male
Veterans.
 Women Veterans are also less likely to be
employed or are paid a lower wage than male
Veterans.
 More women Veterans are single parents than
their male counterparts.
The more intense, the longer the duration or more
severe the trauma, the more likely a person is to
develop PTSD.

30. Some PTSD symptoms are more common in
women than men. Women are more likely to:
 Be jumpy, easily startled and afraid
 Have more trouble feeling emotions
 Avoid things that remind them of the trauma
 Feel depressed and anxious
 Suffer more comorbid mental and physical
health problems

32. Treatment may involve an evaluation of symptoms or
problems to determine the best course of treatment.
Treatment options could involve any of the following:
 Medication
 Individual counseling
 Group therapy
 Substance abuse treatment
 Educational and support groups for dealing with
emotional symptoms of PTSD
 Family counseling
 Female only trauma groups

33. Every VA in this country now has a Women Veterans Program Manager.
 Women’s Stress Disorder Treatment Teams (WSDTTs) – WSDTTs are
special outpatient mental health programs that focus on PTSD and other
problems related to trauma.
 Specialized Inpatient and Residential Programs – These are live-in
programs for women Veterans who need more intense treatment and
support. While in these programs, women live either in the hospital or in
a residence with other women.
 Cohort Treatment and Separate Wings for Women – These programs are
co-ed live-in programs. Some of these programs have separate space for
women.
 Women Veterans Comprehensive Health Centers – Complete health
centers for Women Veterans. Not all VA locations have these centers.
Check with your local Women Veterans Program Manager.
 Women Veterans Homelessness Program – This program can help
women Veterans find shelter if they are homeless or at risk of being
homeless. Certain VA locations have programs for homeless women
Veterans and their children. Check with your local VA for assistance.

34. As awareness of the prevalence and impact of
trauma in the lives of women Veterans has
increased, there has been a corresponding shift
toward trauma-informed care as a best practice to
support recovery. Trauma-informed care is an
organization-wide approach that is grounded in
an understanding of and responsiveness to the
impact of trauma that emphasizes physical,
psychological, and emotional safety for both
providers and survivors; and creates
opportunities for survivors to rebuild a sense of
control and empowerment.

35. A trauma-informed approach to care reflects
adherence to six key principles rather than a
prescribed set of practices or procedures. These
principles may be generalized across multiple types
of settings:
1. Safety
2. Trustworthiness and Transparency
3. Peer Support
4. Collaboration and mutuality
5. Empowerment, voice and choice
6. Cultural, historical, and gender issues

36. Key components of trauma-informed care for women Veterans
include:
 Training all staff on trauma and its impact and the core
principles of trauma-informed care.
 Creating safe and supportive environments.
 Providing comprehensive assessments that consider the
history of trauma, including trauma prior to, during, and
after military service.
 Providing trauma-specific mental health services.
 Involving women Veterans in all aspects of program
development.
 Adapting policies to support trauma-informed culture and
practice and to avoid causing additional trauma.
 Offering specific services for the children of women
Veterans.

37. Preliminary outcomes associated with trauma-
informed care demonstrate:
 Improvement in functioning and a decrease in
psychiatric and behavioral symptoms.
 Increased housing stability.
 Decreased need for crisis-based services.
 Enhanced self-identity skills and safety among
children.
 Greater collaboration among service providers.

38.  Vietnam Veterans of America, Women Veterans Committee – Reports
and information on a wide array of issues important to the women who
served in Vietnam and other wars.
 The Women Veterans Health Care Improvement Act of 2009 – This
legislation authorized a study to assess the physical, mental and
reproductive effects of conflict upon women who have served in Iraq and
Afghanistan. It will also help the VA to provide evidence-based
treatment to women with MST.
 WOVEN (Women Veterans Network) – A community of women
Veterans spanning all ages, services, ranks, experiences and geographies.
The network is woven together by a common desire to connect for social
support, share information and resources, and serve fellow Veterans and
local communities.
 Women Veterans of America – An advocacy organization founded by
and run for women Veterans.
 MilitaryWoman.org – An online meeting place for military women to
exchange information and provide information to women contemplating
military service.
 Department of Veterans’ Affairs Center for Women Veterans – Provides
information on health care, benefits, MST, and readjustment counseling.

39. Thank you for your service

40. American College of Obstetricians and Gynecologists. (2012). Women in the military and women veterans:
committee on health care for underserved women. Retrieved from:
http://www.acog.org/-/media/Committee-Opinions/Committee-on-Health-Care-for-Underserved-
Women/WomeninMilitary.pdf.
American Institutes for Research. (2013). Homelessness and trauma in the lives of women veterans. Retrieved from:
http://www.familyhomelessness.org/media/402.pdf.
Fontana, R., Rosenheck, R. & Desai, R. (2010). Female veterans of Iraq and Afghanistan seeking care from VA
specialized PTSD programs: comparison with male veterans and female warzone veterans of previous
eras. Journal of Women’s Health, 19(4),
751-757. doi:10.1089/jhw.2009.1389.
NAMI. (2014). Women veterans’ issues and treatment. Retrieved from:
http://www.nami.org?PrinterTemplate.cfm?section=Womens_Issues.
Oza, N. (2010). Female veterans cope with post traumatic stress disorder policy change at VA eases criteria to get
treatment for PTSD. The Arizona Republic. Retrieved from:
http://www.azcentral.com/arizonarepublic/news/articles/2010/11/9/20101109post-traumatic-stress-
disorder- female-veterans.html#ixzz3l7VHJOLI.
Robinson, J. (2013). The DSM-5’s new PTSD diagnostic criteria. Retrieved from:
http://navwaters.com/2013/06/14/the-dsm-5s-new-ptsd-diagnostic-criteria/.
U.S. Department of Veterans Affairs. (2014). PTSD: national center for PTSD women, trauma and PTSD. Retrieved
from: http://www.ptsd.va.gov/public/PTSD-overview/women/women-trauma-and-ptsd.asp.
U.S. Department of Veterans Affairs. (2014). PTSD: national center for PTSD women’s mental health services in the
VA. Retrieved from:
http://www.ptsd.va.gov.public/PTSDoverview/women/womens_mental_health_services.asp.
U.S. Department of Veterans Affairs. (2014). PTSD: national center for PTSD traumatic stress in women veterans.
Retrieved from: http://www.ptsd.va.gov/public/PTSD-overview/women/traumatic-stress-female-
vets.asp.