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Weitlauf JC, Cypel YS, Davey VJ. Mortality of Women Vietnam War-Era Veterans. Womens Health Issues 2023:S1049-3867(23)00068-3. [PMID: 37088602 DOI: 10.1016/j.whi.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 04/25/2023]
Abstract
PURPOSE Our objectives were to 1) understand the scope of the current mortality literature on U.S. women Vietnam War-era veterans and 2) identify major themes and knowledge gaps that might guide future research. METHODS A systematic scoping review was conducted. Electronic bibliographic databases were searched for studies published on women Vietnam War-era veterans' mortality between 1973 and 2020. Inclusion and exclusion criteria were applied, study information was charted using pre-established design parameters, and studies deemed eligible were retained for a more in-depth review. FINDINGS One hundred nineteen studies were initially identified. Of these, six were ultimately retained for critical review. External cause, all-cause, cancer, and cardiovascular mortality were prominent outcomes across studies. Although both methodology and outcomes varied by study, unifying themes emerged. Prominent themes included a) historic barriers to accurately identifying and classifying this veteran cohort, b) historic barriers to comprehensive assessment of their health and mortality risk, and c) the healthy soldier effect and its limitations. Research gaps identified in this review reflect a need to pay more attention to sex differences in mortality risk and military occupational and sex-specific health risk confounders in mortality models. CONCLUSIONS The research literature examining mortality among women Vietnam War-era veterans is circumscribed in size and scope. Questions about the roles of salient military occupational exposures and health risk factors on mortality risks and trends in this cohort remain unaddressed. These questions should be areas of focus in next steps research.
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Affiliation(s)
- Julie C Weitlauf
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, California.
| | - Yasmin S Cypel
- Epidemiology Program, Post Deployment Health Service (12POP5), Office of Patient Care Services, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Victoria J Davey
- Office of Research & Development (10X2), Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, District of Columbia
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History of Non-Fatal Physical Assault Is Associated with Premature Mortality for Whites but Not Blacks. J 2018. [DOI: 10.3390/j1010009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Exposure to trauma increases the long-term risk of mortality, and experiencing non-fatal physical assault is not an exception. To better understand population heterogeneity in this link, the current study explored Black–White differences in the association between history of non-fatal physical assault and risk of all-cause mortality over a 25-year period in the United States. Data came from the Americans’ Changing Lives (ACL) study that followed 3617 non-institutionalized respondents for up to 25 years. History of non-fatal physical assault at baseline was the predictor. Outcome was time to death due to all-cause mortality during follow-up from baseline (1986) to follow-up (2011). Confounders included gender, age, and baseline socio-economic status (education and income), health behaviors (smoking and drinking), and health status (chronic medical conditions, self-rated health, and body mass index). Race was the moderator. Cox regressions were used for multi-variable analysis. History of non-fatal physical assault at baseline was associated with an increased risk of mortality, above and beyond baseline socioeconomic status, health behaviors, and health status. Race interacted with history of non-fatal physical assault on mortality, suggesting a stronger effect for Whites compared to Blacks. In race-specific models, history of non-fatal physical assault was associated with risk of mortality for Whites but not Blacks. The current study showed that experiencing non-fatal physical assault increases the risk of premature death above and beyond demographics, socioeconomic status, health behaviors, and health status. Experiencing non-fatal physical assault may have a larger effect on premature mortality among Whites than Blacks. Future research is needed on how Blacks and Whites differ in the health consequences of social adversities.
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Gibson CJ, Gray KE, Katon JG, Simpson TL, Lehavot K. Sexual Assault, Sexual Harassment, and Physical Victimization during Military Service across Age Cohorts of Women Veterans. Womens Health Issues 2016; 26:225-31. [DOI: 10.1016/j.whi.2015.09.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 10/22/2022]
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Ryan GL, Mengeling MA, Summers KM, Booth BM, Torner JC, Syrop CH, Sadler AG. Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms. Am J Obstet Gynecol 2016; 214:352.e1-352.e13. [PMID: 26475424 DOI: 10.1016/j.ajog.2015.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/30/2015] [Accepted: 10/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population. OBJECTIVES The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population. STUDY DESIGN We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)-enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ(2), Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ(2) and Student t tests. RESULTS Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V. CONCLUSION Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women's health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.
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Affiliation(s)
- Ginny L Ryan
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, IA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA.
| | - Michelle A Mengeling
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA; Veterans Affairs Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City Veterans Affairs Health Care System, Iowa City, IA
| | - Karen M Summers
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Brenda M Booth
- Center for Mental Healthcare Outcomes and Research, Central Arkansas Veterans Healthcare System and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR
| | - James C Torner
- Department of Neurosurgery and Surgery, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Craig H Syrop
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Anne G Sadler
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA
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Barth SK, Kimerling RE, Pavao J, McCutcheon SJ, Batten SV, Dursa E, Peterson MR, Schneiderman AI. Military Sexual Trauma Among Recent Veterans: Correlates of Sexual Assault and Sexual Harassment. Am J Prev Med 2016; 50:77-86. [PMID: 26232906 DOI: 10.1016/j.amepre.2015.06.012] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 06/12/2015] [Accepted: 06/18/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Military sexual trauma (MST) includes sexual harassment or sexual assault that occurs during military service and is of increasing public health concern. The population prevalence of MST among female and male veterans who served during Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) has not been estimated to our knowledge. The purpose of this study is to assess the population prevalence and identify military correlates of MST, sexual harassment, and sexual assault among OEF/OIF veterans. METHODS MST was assessed in the 2009-2011 National Health Study for a New Generation of U.S. Veterans, a survey of 60,000 veterans who served during the OEF/OIF eras (response rate, 34%, n=20,563). Weighted prevalence estimates and AORs of MST, sexual harassment, and sexual assault among women and men were calculated. Gender-stratified logistic regression models controlled for military and demographic characteristics. Data analyses were conducted in 2013-2014. RESULTS Approximately 41% of women and 4% of men reported experiencing MST. Deployed men had lower risk for MST compared with non-deployed men, though no difference was found among women. However, veterans reporting combat exposure during deployment had increased risk for MST compared with those without, while controlling for OEF/OIF deployment. Among women, Marines and Navy veterans had increased risk for MST compared with Air Force veterans. MST was significantly higher among veterans who reported using Veterans Affairs healthcare services. CONCLUSIONS These prevalence estimates underscore the importance of public awareness and continued investigation of the public health impact of MST.
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Affiliation(s)
- Shannon K Barth
- Department of Veterans Affairs, Office of Public Health, Post Deployment Health, Epidemiology Program, Washington, District of Columbia.
| | - Rachel E Kimerling
- Department of Veterans Affairs, VHA Mental Health Services and National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California
| | - Joanne Pavao
- Department of Veterans Affairs, VHA Mental Health Services and National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California
| | - Susan J McCutcheon
- Department of Veterans Affairs, VHA Mental Health Services, Washington, District of Columbia
| | | | - Erin Dursa
- Department of Veterans Affairs, Office of Public Health, Post Deployment Health, Epidemiology Program, Washington, District of Columbia
| | - Michael R Peterson
- Department of Veterans Affairs, Office of Public Health, Post Deployment Health, Epidemiology Program, Washington, District of Columbia
| | - Aaron I Schneiderman
- Department of Veterans Affairs, Office of Public Health, Post Deployment Health, Epidemiology Program, Washington, District of Columbia
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Hoggatt KJ, Williams EC, Der-Martirosian C, Yano EM, Washington DL. National prevalence and correlates of alcohol misuse in women veterans. J Subst Abuse Treat 2014; 52:10-6. [PMID: 25661517 DOI: 10.1016/j.jsat.2014.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 12/05/2014] [Accepted: 12/14/2014] [Indexed: 11/28/2022]
Abstract
Our goal was to estimate the prevalence and correlates of alcohol misuse in women veterans and to assess the associations between alcohol misuse and mental health (MH) care utilization in a group comprising both Veterans Health Administration (VA) healthcare system users and non-users. We assessed alcohol misuse using survey-based AUDIT-C scores. The prevalence of alcohol misuse was 27% in VA users and 32% in non-users. Prevalence rates were higher for VA users who were younger, served in OEF/OIF, or had combat exposure and for VA non-users who screened positive for posttraumatic stress disorder or sexual assault in the military. In contrast to VA users, VA non-users with alcohol misuse had a low prevalence of past-year MH care despite having indications of MH care need. Our results on alcohol misuse prevalence, its correlates, and its association with MH care may aid program planning and resource allocation in VA and non-VA settings.
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Affiliation(s)
- Katherine J Hoggatt
- VA Greater Los Angeles Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Sepulveda, CA, USA; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| | - Emily C Williams
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, HSR&D, VA Puget Sound, Seattle, WA, USA; Department of Health Services, University of Washington, Seattle, WA, USA
| | | | - Elizabeth M Yano
- VA Greater Los Angeles Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Sepulveda, CA, USA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Donna L Washington
- VA Greater Los Angeles Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Sepulveda, CA, USA; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Ryan GL, Mengeling MA, Booth BM, Torner JC, Syrop CH, Sadler AG. Voluntary and involuntary childlessness in female veterans: associations with sexual assault. Fertil Steril 2014; 102:539-47. [PMID: 24875400 DOI: 10.1016/j.fertnstert.2014.04.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 04/25/2014] [Accepted: 04/25/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess associations between lifetime sexual assault and childlessness in female veterans. DESIGN Cross-sectional, computer-assisted telephone interview study. SETTING Two Midwestern Veterans Administration (VA) medical centers. PATIENT(S) A total of 1,004 women aged ≤52 years, VA-enrolled between 2000 and 2008. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Sociodemographic variables, reproductive history and care utilization, and mental health. RESULT(S) A total of 620 veterans (62%) reported at least one attempted or completed sexual assault in their lifetime (LSA). Veterans with LSA more often self-reported a history of pregnancy termination (31% vs. 19%) and infertility (23% vs. 12%), as well as sexually transmitted infection (42% vs. 27%), posttraumatic stress disorder (32% vs. 10%), and postpartum dysphoria (62% vs. 44%). Lifetime sexual assault was independently associated with termination and infertility in multivariate models; sexually transmitted infection, posttraumatic stress disorder, and postpartum dysphoria were not. The LSA by period of life was as follows: 41% of participants in childhood, 15% in adulthood before the military, 33% in military, and 13% after the military (not mutually exclusive). Among the 511 who experienced a completed LSA, 23% self-reported delaying or foregoing pregnancy because of their assault. CONCLUSION(S) This study demonstrated associations between sexual assault history and pregnancy termination, delay or avoidance (voluntary childlessness), and infertility (involuntary childlessness) among female veterans. Improved gender-specific veteran medical care must attend to these reproductive complexities.
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Affiliation(s)
- Ginny L Ryan
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa.
| | - Michelle A Mengeling
- Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; VA Office of Rural Health, Veterans Rural Health Resource Center-Central Region, Iowa City VA Health care System, Iowa City, Iowa
| | - Brenda M Booth
- Center for Mental Healthcare Outcomes and Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas; Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - James C Torner
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa; Department of Neurosurgery and Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Craig H Syrop
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Anne G Sadler
- Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa; Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Five-year trends in women veterans' use of VA maternity benefits, 2008-2012. Womens Health Issues 2014; 24:e37-42. [PMID: 24439945 DOI: 10.1016/j.whi.2013.10.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 10/09/2013] [Accepted: 10/11/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND An increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time. OBJECTIVE The goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits. DESIGN We undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012. PARTICIPANTS We included pregnant veterans using VHA maternity benefits for delivery. MAIN MEASURES Measures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator. KEY RESULTS During the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran). CONCLUSIONS Over a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care for pregnant veterans and ensure care coordination systems are in place to address the needs of pregnant veterans with service-connected disabilities.
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Decker SE, Rosenheck RA, Tsai J, Hoff R, Harpaz-Rotem I. Military sexual assault and homeless women veterans: clinical correlates and treatment preferences. Womens Health Issues 2014; 23:e373-80. [PMID: 24183412 DOI: 10.1016/j.whi.2013.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 09/08/2013] [Accepted: 09/11/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Both homeless women and women who have experienced military sexual assault (MSA) are at high risk of serious psychological sequelae. However, little is known about the combined impact of MSA and current homelessness on psychological distress, or about distinctive treatment preferences among homeless female veterans affected by MSA. METHODS This observational study compared clinical symptoms, pre-military experiences, and treatment preferences among 509 female veterans with and without MSA who enrolled in 11 VA Homeless Women Veterans Programs. RESULTS Over one third of participants (41.1%) reported MSA. In multivariate analyses, homeless female veterans who reported MSA endorsed greater severity of PTSD and other psychiatric symptoms. Those who had experienced MSA were more likely to report interest in treatment, and treatment focused on safety was reported as especially attractive. CONCLUSIONS Among homeless female veterans, MSA is associated with greater mental health symptoms and greater interest in safety-focused treatment. Services targeting the needs of homeless MSA survivors should be encouraged.
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Affiliation(s)
- Suzanne E Decker
- VA New England Mental Illness Research, Education, and Clinical Center, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.
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LeardMann CA, Pietrucha A, Magruder KM, Smith B, Murdoch M, Jacobson IG, Ryan MA, Gackstetter G, Smith TC. Combat Deployment Is Associated with Sexual Harassment or Sexual Assault in a Large, Female Military Cohort. Womens Health Issues 2013; 23:e215-23. [DOI: 10.1016/j.whi.2013.05.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/16/2013] [Accepted: 05/17/2013] [Indexed: 11/25/2022]
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Hamilton AB, Poza I, Washington DL. "Homelessness and trauma go hand-in-hand": pathways to homelessness among women veterans. Womens Health Issues 2011; 21:S203-9. [PMID: 21724142 DOI: 10.1016/j.whi.2011.04.005] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 04/15/2011] [Accepted: 04/18/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Veterans comprise a disproportionate fraction of the nation's homeless population, with women veterans up to four times more likely to be homeless than non-veteran women. This paper provides a grounded description of women veterans' pathways into homelessness. METHODS Three focus groups were held in Los Angeles, California, with a total of 29 homeless women veterans. RESULTS Five predominant "roots" (precipitating experiences) initiated pathways toward homelessness: 1) childhood adversity, 2) trauma and/or substance abuse during military service, 3) post-military abuse, adversity, and/or relationship termination, 4) post-military mental health, substance abuse, and/or medical problems, and 5) unemployment. Contextual factors, which promoted development of homelessness in the setting of primary roots, included women veterans' "survivor instinct," lack of social support and resources, sense of isolation, pronounced sense of independence, and barriers to care. These contextual factors also reinforced persistence of the roots of post-military adversity and mental health and substance abuse problems, serving to maintain cycles of chronic homelessness. CONCLUSION Collectively, these multiple, interacting roots and contextual factors form a "web of vulnerability" that is a target for action. Multiple points along the pathways to homelessness represent critical junctures for VA and community-based organizations to engage in prevention or intervention efforts on behalf of women veterans. Considering the multiple, interconnected challenges that these women veterans described, solutions to homelessness should address multiple risk factors, include trauma-informed care that acknowledges women veterans' traumatic experiences, and incorporate holistic responses that can contribute to healing and recovery.
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Affiliation(s)
- Alison B Hamilton
- VA HSR&D Center of Excellence for Study of Healthcare Provider Behavior, Los Angeles, California 90073, USA.
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Sadler AG, Mengeling MA, Syrop CH, Torner JC, Booth BM. Lifetime Sexual Assault and Cervical Cytologic Abnormalities Among Military Women. J Womens Health (Larchmt) 2011; 20:1693-701. [DOI: 10.1089/jwh.2010.2399] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anne G. Sadler
- Comprehensive Access & Delivery Research and Evaluation (CADRE), Mental Health Service Line, Iowa City VA Health Care System, Iowa City, Iowa
| | - Michelle A. Mengeling
- Comprehensive Access & Delivery Research and Evaluation (CADRE), Mental Health Service Line, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Craig H. Syrop
- Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - James C. Torner
- Department of Epidemiology, University of Iowa College of Public Health, Departments of Neurosurgery and Surgery, Carver College of Medicine, Iowa City, Iowa
| | - Brenda M. Booth
- Center for Mental Healthcare Outcomes and Research, Central Arkansas Veterans Healthcare System and Department of Psychiatry, and University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Bean-Mayberry B, Yano EM, Washington DL, Goldzweig C, Batuman F, Huang C, Miake-Lye I, Shekelle PG. Systematic Review of Women Veterans’ Health: Update on Successes and Gaps. Womens Health Issues 2011; 21:S84-97. [DOI: 10.1016/j.whi.2011.04.022] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 04/20/2011] [Accepted: 04/20/2011] [Indexed: 11/30/2022]
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Suris A, Lind L. Military sexual trauma: a review of prevalence and associated health consequences in veterans. TRAUMA, VIOLENCE & ABUSE 2008; 9:250-269. [PMID: 18936282 DOI: 10.1177/1524838008324419] [Citation(s) in RCA: 225] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This article reviews the literature documenting the prevalence of military sexual trauma (MST) and its associated mental and physical health consequences. Existing research indicates that prevalence rates of MST vary depending on method of assessment, definition of MST used, and type of sample. Risk factors for MST have been identified as including age, enlisted rank, negative home life, and previous assault history. MST has been associated with increased screening rates of depression and alcohol abuse, in addition to significantly increased odds of meeting criteria for post-traumatic stress disorder. In addition, MST has been associated with reporting increased number of current physical symptoms, impaired health status, and more chronic health problems in veterans. Available research on health care utilization and MST is also discussed. Researchers are encouraged to utilize standardized definitions of MST, employ standardized assessment methodology, and utilize more male veterans in future research. Policy and practice implications are discussed.
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Affiliation(s)
- Alina Suris
- Department of Veterans Affairs, North Texas Health Care System, Dallas, USA
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Polusny MA, Dickinson KA, Murdoch M, Thuras P. The role of cumulative sexual trauma and difficulties identifying feelings in understanding female veterans' physical health outcomes. Gen Hosp Psychiatry 2008; 30:162-70. [PMID: 18291298 DOI: 10.1016/j.genhosppsych.2007.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 11/23/2007] [Accepted: 11/26/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine the role of alexithymia (difficulties identifying one's emotions) in understanding the link between PTSD symptoms and negative health outcomes in sexually victimized female veterans. We hypothesized that having experienced multiple types of sexual trauma across the lifespan, experiencing greater severity of PTSD symptoms, and reporting difficulties in identifying emotions would be associated with increased negative health outcomes. METHOD Anonymous cross-sectional survey of a convenience sample of 456 female veterans enrolled in a VA clinic within the prior year. Data collected included demographics, lifetime trauma exposure, psychological and medical symptoms, emotion recognition problems (alexithymia), health-risk behaviors, and health care utilization. RESULTS A total of 57.5% of participants reported a lifetime history of sexual trauma. After controlling for sexual trauma history, PTSD symptoms, and other well-established predictors of health care utilization in the VA medical system such as pre-disposing, enabling and need-based factors, hierarchical regression analyses showed that alexithymia independently explained unique variance in participants' physical health complaints and in their odds of reporting at least one outpatient urgent care visit in the past year. CONCLUSIONS These data suggest that emotion recognition problems may contribute to poorer health outcomes in sexually traumatized women veterans beyond what is explained by sexual trauma exposure, health risk behaviors and PTSD. Psychological interventions that enhance emotion identification skills for women who have experienced sexual trauma could improve health perceptions and reduce need for acute health care.
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Affiliation(s)
- Melissa A Polusny
- Department of Veterans Affairs Medical Center, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55455, USA.
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Zinzow HM, Grubaugh AL, Monnier J, Suffoletta-Maierle S, Frueh BC. Trauma among female veterans: a critical review. TRAUMA, VIOLENCE & ABUSE 2007; 8:384-400. [PMID: 17846179 DOI: 10.1177/1524838007307295] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
This article reviews the literature documenting the nature and prevalence of traumatic experiences, trauma-related mental and physical health problems, and service use among female veterans. Existing research indicates that female veterans experience higher rates of trauma exposure in comparison to the general population. Emerging data also suggest that female veterans may be as likely to be exposed to combat as male veterans, although not as directly or as frequently. Female veterans also report high rates of posttraumatic stress disorder, which has been associated with poor psychiatric and physical functioning. Although sexual assault history has been related to increased medical service use, further research is needed to understand relationships between trauma history and patterns of medical and mental health service use. Researchers also are encouraged to employ standardized definitions of trauma and to investigate new areas, such as treatment outcomes and mediators of trauma and health. Policy and practice implications are discussed.
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Affiliation(s)
- Heidi M Zinzow
- National Crime Victims Research and Treatment Center, Medical University of South Carolina, SC, USA
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Himmelfarb N, Yaeger D, Mintz J. Posttraumatic stress disorder in female veterans with military and civilian sexual trauma. J Trauma Stress 2006; 19:837-46. [PMID: 17195980 DOI: 10.1002/jts.20163] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examines relationships among military sexual trauma (MST), nonmilitary sexual trauma, and posttraumatic stress disorder (PTSD). A sample of 196 female veterans was assessed for trauma occurring before, during, and after military service, and for current PTSD. The prevalence of MST was higher than that of premilitary and postmilitary sexual trauma. Premilitary trauma did not significantly increase the odds of experiencing MST, but did increase the odds of experiencing postmilitary sexual trauma. Logistic regression analyses revealed MST was more strongly associated with PTSD than was premilitary or postmilitary trauma. Women with MST had the greatest increased odds of developing PTSD. Understanding risk factors for and taking steps to prevent MST may reduce cases of PTSD in female veterans.
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Affiliation(s)
- Naomi Himmelfarb
- VA West Los Angeles Healthcare Center, Women's Comprehensive Healthcare Center, and the Department of Psychiatry and Biobehavioral Science, UCLA David Geffen School of Medicine, Los Angeles, CA 90073, USA.
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Yaeger D, Himmelfarb N, Cammack A, Mintz J. DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. J Gen Intern Med 2006; 21 Suppl 3:S65-9. [PMID: 16637949 PMCID: PMC1513167 DOI: 10.1111/j.1525-1497.2006.00377.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study compares rates of posttraumatic stress disorder (PTSD) in female veterans who had military sexual trauma (MST) with rates of PTSD in women veterans with all other types of trauma. METHODS Subjects were recruited at the Women's Comprehensive Healthcare Center when attending medical or psychiatric appointments or through a mailing; 230 women agreed and 196 completed the study. They completed questionnaires on health and military history, along with the Stressful Life Events Questionnaire (SLEQ). Those who met DSM-IV PTSD Criterion A completed the PTSD Symptom Scale-Interview (PSS-I) on which PTSD diagnoses were based. RESULTS Ninety-two percent reported at least 1 trauma. Forty-one percent had MST, alone or with other trauma, and 90% had other trauma, with or without MST. Overall, 43% of subjects with trauma had PTSD. Those with MST had higher rates of PTSD than those with other trauma. Sixty percent of those with MST had PTSD; 43% of subjects with other traumas (with or without MST) had PTSD. Military sexual trauma and other trauma both significantly predicted PTSD in regression analyses (P=.0001 and .02, respectively) but MST predicted it more strongly. Prior trauma did not contribute to the relationship between MST and PTSD. DISCUSSION Findings suggest that MST is common and that it is a trauma especially associated with PTSD.
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Affiliation(s)
- Deborah Yaeger
- Women's Comprehensive Healthcare Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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20
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Goldzweig CL, Balekian TM, Rolón C, Yano EM, Shekelle PG. The state of women veterans' health research. Results of a systematic literature review. J Gen Intern Med 2006; 21 Suppl 3:S82-92. [PMID: 16637952 PMCID: PMC1513165 DOI: 10.1111/j.1525-1497.2006.00380.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Assess the state of women veterans' health research. DESIGN Systematic review of studies that pertained specifically to or included explicit information about women veterans. A narrative synthesis of studies in 4 domains/topics was conducted: Stress of military life; Health and performance of military/VA women; Health services research/quality of care; and Psychiatric conditions. MEASUREMENTS AND MAIN RESULTS We identified 182 studies. Of these, 2 were randomized-controlled trials (RCTs) and the remainder used observational designs. Forty-five percent of studies were VA funded. We identified 77 studies pertaining to the stress of military life, of which 21 reported on sexual harassment or assault. Rates of harassment ranged from 55% to 79% and rates of sexual assault from 4.2% to 7.3% in active duty military women and 11% to 48% among women veterans. Forty-two studies concerned the health and performance of military/VA women, with 21 studies evaluating sexual assault and posttraumatic stress disorder (PTSD) and their effect on health. Fifty-nine studies assessed various aspects of health services research. Eight studies assessed quality of care and 5, patient satisfaction. Twenty-five studies assessed utilization and health care organization, and findings include that women veterans use the VA less than men, that gender-specific reasons for seeking care were common among female military and veteran personnel, that provision of gender-specific care increased women veterans' use of VA, and that virtually all VAs have available on-site basic women's health services. Fifty studies were classified as psychiatric; 31 of these were about the risk, prevalence, and treatment of PTSD. CONCLUSIONS Most research on VA women's health is descriptive in nature and has concerned PTSD, sexual harassment and assault, the utilization and organization of care, and various psychiatric conditions. Experimental studies and studies of the quality of care are rare.
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Affiliation(s)
- Caroline L Goldzweig
- Southern California Evidence-Based Practice Center, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA.
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21
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Abstract
Most of today's 1.7 million women veterans obtain all or most of their medical care outside the VA health care system, where their veteran status is rarely recognized or acknowledged. Several aspects of women's military service have been associated with adverse psychologic and physical outcomes, and failure to assess women's veteran status, their deployment status, and military trauma history could delay identifying or treating such conditions. Yet few clinicians know of women's military history--or of military service's impact on women's subsequent health and well being. Because an individual's military service may be best understood within the historical context in which it occurred, we provide a focused historical overview of women's military contributions and their steady integration into the Armed Forces since the War for Independence. We then describe some of the medical and psychiatric conditions associated with military service.
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Affiliation(s)
- Maureen Murdoch
- Section of General Internal Medicine, Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, MN 55417, USA.
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22
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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; 14:764-802. [PMID: 16313206 DOI: 10.1089/jwh.2005.14.764] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In 1994, Congress provided dollar 40 M for biomedical research on issues of importance for military women. This supported 104 intramural and 30 extramural studies and launched an era of research to narrow the knowledge gap on protection and enhancement of health and performance of military women. Projects addressed issues specific to female physiology (e.g., gynecological health in the field, maternal malaria), problems with higher prevalence for women (e.g., marginal iron deficiency, stress fracture), and issues of drug and materiel safety that had only been extrapolated from studies of men (e.g., chemical agent prophylaxis, fatigue countermeasures). Several important assumptions about female physiology and occupational risks were found to be astoundingly wrong. Hormonal changes through the menstrual cycle were less important to acute health risks and performance than predicted, exercise did not increase risk for amenorrhea and consequent bone mineral loss, and women tolerated G-forces and could be as safe as men in the cockpit if their equipment was designed for normal size and strength ranges. Data on personal readiness issues, such as body fat, physical fitness, nutrition, and postpartum return to duty, allowed reconsideration of standards that were gender appropriate and not simply disconnected adjustments to existing male standards. Other discoveries directly benefited men as well as women, including development of medical surveillance databases, identification of task strength demands jeopardizing safety and performance, and greater understanding of the effects of psychosocial stress on health and performance. This surge of research has translated into advances for the welfare of service women and the readiness of the entire force; relevant gender issues are now routine considerations for researchers and equipment developers, and some key remaining research gaps of special importance to military women continue to be investigated.
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Affiliation(s)
- Karl E Friedl
- US Army Research Institute of Environmental Medicine, Natick, Massachusetts 01760-5007, USA.
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Sadler AG, Booth BM, Mengeling MA, Doebbeling BN. Life Span and Repeated Violence against Women during Military Service: Effects on Health Status and Outpatient Utilization. J Womens Health (Larchmt) 2004; 13:799-811. [PMID: 15385074 DOI: 10.1089/jwh.2004.13.799] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To determine whether the type or frequency of intentional violence experiences among women during military service influences health status or healthcare utilization. Differences in utilization and health status were also examined while controlling for life span violence exposures and important patient characteristic confounders. METHODS A cross-sectional survey of women veterans was conducted using a random sample stratified by region and era of service. Women veterans who served in the Vietnam and subsequent eras (n = 520) were selected from comprehensive women's healthcare centers' registries at Department of Veterans medical centers in Boston, Durham, Tampa, Minneapolis, Chicago, and Los Angeles (n = 8693). Socioeconomic information, violence exposure history, outpatient healthcare utilization, and assessment of health status (measured by the Medical Outcomes Study Short-Form 36) were obtained by structured telephone interview. RESULTS The type of violence women experienced was unrelated to differences in medical utilization. Women reporting repeated violence exposures during military service had significantly more outpatient visits in the year preceding the interview than singly or nontraumatized peers (16 vs. 9 and 8 visits, respectively, p < 0.05). Repeatedly assaulted women also had poorer health status (p < 0.05), and more often reported a history of childhood violence (p < 0.001) and postmilitary violence (p < 0.001). CONCLUSIONS Repeated violence exposure is a relatively common experience among women in the military, and this has substantial implications for their health.
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Affiliation(s)
- Anne G Sadler
- Psychology Service, Iowa City Veterans' Affairs Medical Center, Iowa City, Iowa 52246, USA.
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Sadler AG, Booth BM, Cook BL, Doebbeling BN. Factors associated with women's risk of rape in the military environment. Am J Ind Med 2003; 43:262-73. [PMID: 12594773 DOI: 10.1002/ajim.10202] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Health hazards specific to women workers have not been adequately documented. This study assessed military environmental factors associated with rape occurring during military service, while controlling for pre-military trauma experiences. METHODS A national cross-sectional survey of 558 women veterans serving in Vietnam or in subsequent eras was obtained through structured telephone interviews. RESULTS Rape was reported by 30% (n = 151) of participants, with consistent rates found across eras [corrected]. Military environmental factors were associated with increased likelihood of rape, including: sexual harassment allowed by officers (P < 0.0001), unwanted sexual advances on-duty (P < 0.0001) and in sleeping quarters (P < 0.0001). CONCLUSION Violence towards military women has identifiable risk factors. Work and living environments where unwanted sexual behaviors occurred were associated with increased odds of rape. Officer leadership played an important role in the military environment and safety of women. Assailant alcohol and/or drug abuse at time of rape was notable. Interventions and policies based on modifiable environmental risk factors are needed to increase protection for women in the workplace.
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Affiliation(s)
- Anne G Sadler
- Psychology Service, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa 52246, USA.
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