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Lesbian, gay, and bisexual men and women in the US military: Updated estimates
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https://escholarship.org/uc/item/0gn4t6t3
Author
Gates, Gary
Publication Date
2010-01-01
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Lesbian, gay, and bisexual men and women in the US military:
Updated estimates
May 2010
by Gary J. Gates
Executive Summary
This research brief uses new data from the American
Community Survey and the General Social Survey to
provide updated estimates of how many lesbians,
gay men, and bisexuals (LGB) are serving in the US
military. It also updates estimates of the cost of the
i
US military’s “Don’t Ask/Don’t Tell” (DADT) policy.
Key findings from the analyses are as follows:
An estimated 48,500 lesbians, gay men, and bisexuals are serving on active duty or in the ready reserve in the US military
and an additional 22,000 are in the standby and retired reserve forces, accounting for approximately 2.2% of military
personnel.
o Approximately 13,000 LGB people are serving on active duty (comprising 0.9% of all active duty personnel) while
nearly 58,000 are serving in the various guard and reserve forces (3.4%).
o While women comprise only about 14% of active duty personnel, they comprise more than 43% of LGB men and
women serving on active duty.
Lifting DADT restrictions could attract an estimated 36,700 men and women to active duty service along with 8,700 more
individuals to the ready reserve.
Since its inception in 1994, the “Don’t Ask/Don’t Tell” policy has cost the military between $290 million and more than a
half a billion dollars.
o The military spends an estimated $22,000 to $43,000 per person to replace those discharged under DADT.
Introduction
A widely cited study published in 2004 (Gates 2004) used
Census 2000 data to estimate that approximately 65,000
lesbian, gay, and bisexual men and women were serving in
the US military, accounting for 2.8% of military personnel. In
February 2005, the Government Accountability Office (GAO)
released a report showing that the costs of discharging and
replacing service members fired for homosexuality during the
policy’s first ten years, from fiscal year 1994 through fiscal
year 2003, totaled at least $217 million (adjusting original
figures to 2009 dollars). In 2006, the Palm Center at the
University of California, Santa Barbara convened a Blue
Ribbon Commission which challenged those GAO estimates
and suggested that the DADT policy actually cost nearly $415
million (also adjusted to 2009 dollars). This research brief
updates estimates of the number of LGB men and women
serving in the military using 2008 data sources and offers new
estimates for the cost of the DADT policy through 2008.
Data and Methodology
LGB men and women in the military
Analyses estimating the number of LGB people in the military
replicate the statistical methods used in Gates (2004) and are
described in the Appendix. The analyses incorporate new
estimates of the size of the LGB community derived from the
2008 General Social Survey (Davis and Smith 2009). For these
analyses, the percent LGB in the population is defined as the
percent of men and women who either identify as gay,
lesbian or bisexual or who have had exclusively same-sex
sexual partners in the last five years. Data from same-sex
couples in the 2008 American Community Survey are used to
estimate the fraction of LGB men and women who are on
active duty or who have served in the guard or reserve.
Estimates of the size and sex composition of active duty
personnel come from US Department of Defense personnel
ii
and procurement statistics and are as of September, 2008.
Data on the size and sex composition of the guard and ready
reserve are reported in the US Census Bureau’s 2010
iii
Statistical Abstract and are also from 2008.
Comparing prior and new estimates
Two key differences should be considered when comparing
these estimates to those derived in Gates (2004). Gates
(2004) assumed an underlying prevalence estimate of LGBs in
the general population of 3% for women and 4% for men.
These analyses use the most recent estimates of LGB
prevalence derived from the 2008 General Social Survey and
assume that 3.3% of men and 5.2% of women are LGB.
Mathematically, this means that new estimates of LGB
prevalence in the military will be lower for men and higher
for women.
The cost of Don’t Ask/Don’t Tell
Existing cost estimates for DADT come from the GAO (2005)
and Palm Center Blue Ribbon Commission (2006). Both
attempt to estimate costs for the first ten years of the policy
(1994-2003). During that period, 9,682 individuals were
discharged under DADT. In order to estimate the costs from
2004 through 2008, this analysis derives a cost per discharge
(total costs divided by number of DADT discharges) for the
first decade of the policy using both GAO and Palm Center
estimates. Those figures are then multiplied by the 3,279
DADT discharges from 2004-2008 to estimate the additional
cost accruals. All figures are adjusted and reported in 2009
iv
dollars.
Findings
LGB men and women in the military
Similar to estimates based on Census 2000 data showing that
approximately 65,000 LGB men and women were serving in
the military, updated estimates shown in Table 1 suggest that
71,000 LGB men and women are currently serving,
comprising 2.2% of military personnel (a full summary of
findings, including upper- and lower-bound estimates is
shown in Appendix Table A). Of that 71,000, approximately
48,500 are serving either in on active duty or in the ready
reserve, the portion of the guard and reserve forces who are
most likely to be called into active duty.
Table 1. LGB personnel on active duty and in the
guard/reserve.
% LGB
(among
military
personnel)
All
Men
Women
Active Duty
0.9%
0.6%
2.9%
Guard/Reserve
3.4%
2.3%
8.7%
Total Military
2.2%
1.5%
6.2%
12,952
7,216
5,736
Active Duty
# LGB
Standby Reserve
Retired Reserve
Total Military
One way to assess the effect of lifting restrictions on LGB
service in the military is to assume that, absent Don’t
Ask/Don’t Tell restrictions, the percent of LGB men and
women in the military would be the same as their percentage
in the population.
Under this assumption, lifting DADT restrictions would attract
an additional 36,700 individuals (32,000 men and 4,700
women) to active duty service.
Since the estimated
percentage of lesbians in the ready reserve exceeds the
estimated percentage in the population, we assume no
change for women among those personnel. However, there
would be an additional 8,700 men among the ready reserve
ranks.
The cost of Don’t Ask/Don’t Tell
The Palm Center and GAO estimates imply that the
government incurs costs of an estimated $22,000 to $43,000
per person as a result of DADT-related discharges. From
2004-2008, an additional 3,279 men and women have been
discharged, suggesting additional costs of $74-140 million in
that time period (see Table 2).
Table 2. Cost estimates of Don’t Ask/Don’t Tell (in 2009
dollars).
Palm Center
Blue Ribbon
Commission
(2006)
35,599
21,285
14,314
636
380
256
21,684
12,965
8,719
70,871
41,846
29,025
Several patterns persist when comparing these analyses to
those using Census 2000 reported in Gates (2004). Lesbians
and bisexual women are still substantially more likely to serve
in the military than are gay/bisexual men or heterosexual
women. An estimated 2.9% of women on active duty are
lesbian/bisexual compared to only 0.6% of men. Women in
same-sex couples are twice as likely as other women to
report either being on active duty or serving in the guard or
reserve.
Government
Accountability
Office (2005)
$414.7 million
$217.2 million
$42,835
$22,430
Additional costs, 2004-2008:
3,279 discharges
(2004-2008)
$140.5 million
$73.6 million
Total cost
$555.2 million
$290.7 million
Estimate of costs, 1994-2003
Guard/Reserve
Ready Reserve
Additional troops if DADT restrictions are lifted
Cost per DADT discharge:
9,682 discharges
(1994-2003)
These figures suggest that since the inception of Don’t
Ask/Don’t Tell, the US government has had to spend between
$290 million and more than a half billion dollars to implement
the policy.
Also similar to estimates from Census 2000 data, these
updated figures suggest that LGB men and women are more
common among those in the guard and reserve than among
those on active duty, 3.4% versus 0.9% respectively.
One contrast with the estimates based on data from Census
2000 is that the updated figures show lower proportions of
LGB men and women on active duty (1.8% in prior estimates
versus 0.9% using 2008 data) and higher proportions in the
guard and reserve (3.2% versus 3.4%).
2
References
Davis, JA and Smith, TW. General social surveys 2008[machine-readable data file] /Principal Investigator, JA Davis; Director and CoPrincipal Investigator, TW Smith; Co-Principal Investigator, PV Marsden; Sponsored by National Science Foundation.
Chicago: National Opinion Research Center [producer]; Storrs, CT: The Roper Center for Public Opinion Research, University
of Connecticut [distributor], 2009.
Gates, GJ. Gay Men and Lesbians in the Military: Estimates from Census 2000, The Urban Institute, September 2004.
Gates, GJ and Steinberger, M. Same-Sex Unmarried Partner Couples in the American Community Survey: The role of misreporting,
miscoding and misallocation, working paper presented at the Population Association of America Annual Meeting, Detroit,
MI, April 2009.
US Government Accountability Office. Financial Costs and Loss of Critical Skills Due to DOD’s Homosexual Conduct Policy Cannot Be
Completely Estimated, GAO-05-299, February 2005.
Palm Center Blue Ribbon Commission. Financial Analysis of “Don’t Ask, Don’t Tell”: How much does the gay ban cost? Palm Center,
University of California, Santa Barbara, February 2006.
APPENDIX
Deriving the Proportion of Lesbians, Gay Men, and Bisexuals Serving in the Military
The ideal way to derive the number of lesbians, gay men, and bisexuals currently serving on active duty would be to conduct a
random survey of active duty personnel and ask respondents to identify their sexual orientation. Clearly, the DADT policy restricts
such a survey. However, applying a common statistical procedure known as Bayes Rule allows one to derive an estimate of the
proportion of men and women in the military who are LGB. The procedure requires the following key estimates:
1. The proportion of all LGB individuals in the U.S. who are in the military
2. The proportion of the non-LGB population in the U.S. who are in the military
3. The proportion of the US population who are LGB.
All respondents in the 2008 American Community Survey Public Use Microdata Sample (PUMS) indicate if they are currently on
active duty or serving in the guard or reserve. Estimates in these analyses use the proportion of those in same-sex couples who say
they are in the military as a proxy for (1), an estimate of the fraction of LGB people in the military. Similarly, information about
those not in same-sex couples is used to derive an estimate for (2). Findings from the 2008 General Social Survey suggest that 3.3%
of men and 5.2% of women either identify as LGB or have had exclusively same-sex sexual partners in the last five years. Those
estimates are used to derive (3).
Equation (1) shows the Bayes’s rule calculation used to derive P(LGB|M), the probability that someone is lesbian, gay, or bisexual
given that he or she is in the military.
P(LGB |M)
P(LGB)P(M|LGB)
P(LGB)P(M|LGB) P(H)P(M|H)
Equation (1)
The terms of the equation and sources for each are as follows:
P(LGB):
Probability that an adult in the population is LGB. The analyses use estimates from the 2008 General Social
Survey: 3.3% for men and 5.2% for women.
P(M|LGB):
Probability that someone is in the military given that he or she is LGB. This estimate is derived from the
proportion of individuals in same-sex unmarried partner couples who report military service.
P(H):
Probability that an adult in the population is heterosexual. This is calculated as one minus the fraction of
LGB men and women in the adult population (96.7% for men and 94.8% for women).
P(M|H):
Probability that someone is in the military given that he or she is heterosexual. ACS figures are used to
estimate the proportion of the adult population other than those in same-sex unmarried partnerships who
report active military service.
Estimates are calculated separately for men and women as they differ substantially in the probability of serving in the military.
Same-sex couples in the 2008 American Community Survey
Same-sex couples in the 2008 ACS PUMS are identified when a household includes two adults of the same sex where one is
designated as either a “husband/wife” or an “unmarried partner” of the other. US Census Bureau procedures recode all same-sex
husbands and wives to be unmarried partners in the PUMS data. Gates and Steinberger (2009) have shown that a potentially large
3
portion of same-sex couples who designate one partner as a “husband/wife” may be comprised of different-sex married couples
who miscode the sex of one of the spouses. While same-sex spouses cannot be directly identified in the 2008 ACS data, Gates and
Steinberger (2009) show that a variable indicating that the original marital status response has been altered provides a proxy for
indicating that a same-sex unmarried partner couple originally used the terms husband or wife to describe a partner. Consistent
with their recommendations, the sample used in these analyses is restricted to only those couples whose marital status was not
altered (meaning they called themselves “unmarried partners”) along with couples who responded via a computer-assisted
interview that verifies the sex of any same-sex husband or wife. The data are further restricted to only men and women aged 18-60
since very few individuals over age 60 are serving in the military.
American Community
Survey, 2008
General Social
Survey, 2008
Appendix Table A. Estimates of the percent and number of LGB people in the US military.
LGB-identified or
same-sex sexual
behavior in last
five years
Estimate
Men
Women
95% Confidence Interval
Low
High
Men
Women
Men
Women
3.3%
1.9%
4.3%
Total
Active duty
Guard/reserve
5.2%
0.2%
0.9%
3.5%
4.6%
3.2%
6.9%
5.4%
0.1%
0.8%
Same-sex couples
0.04%
0.01%
0.5%
0.5%
0.4%
1.2%
0.2%
1.1%
1.2%
1.3%
0.2%
0.5%
0.2%
1.5%
6.7%
4.1%
4.4%
Active duty
Guard/reserve
1.1%
1.2%
0.2%
0.5%
Other adults
1.1%
0.2%
1.2%
0.4%
Active duty
0.6%
2.9%
0.1%
Guard/reserve
2.3%
8.7%
0.8%
% LGB
0.9%
0.1%
3.4%
Derived estimates
All military
1.5%
1.4%
6.2%
2.2%
Active duty
Ready reserve
Standby reserve
Retired reserve
All military
7,216
2.2%
0.5%
2.4%
3.0%
0.8%
5,736
12,952
21,285
14,314
35,599
380
256
636
12,965
8,719
21,684
41,846
29,025
70,871
14.4%
6.1%
Number of LGB
774
407
1,181
7,722
6,685
14,407
138
119
257
4,704
4,072
8,776
13,338
11,284
24,622
11.1%
4.3%
18,093
13,360
31,453
40,784
23,677
64,461
728
423
1,151
24,843
14,422
39,265
84,448
51,882
136,330
i
This brief replaces a version published in January 2010. The prior version had incomplete figures for the size of the guard and reserve. Percentages of LGB in the
military have not been altered, only the number of LGB in the guard and reserve forces, which are now separated by ready, standby, and retired reserve forces.
ii
See http://siadapp.dmdc.osd.mil/personnel/MILITARY/rg0809.pdf for statistics on all active duty personnel and
http://siadapp.dmdc.osd.mil/personnel/MILITARY/rg0809f.pdf for statistics on women.
iii
See http://www.census.gov/compendia/statab/2010/tables/10s0501.pdf for data on the Guard and Reserve and
http://www.census.gov/compendia/statab/2010/tables/10s0503.pdf for data on the sex ratio in the Army and Air Force National Guard. This sex ratio is applied to
all Guard and Reserve estimates.
iv
Adjustments use the US Bureau of Labor Statistics Consumer Price Index inflation calculator found at http://www.bls.gov/data/inflation_calculator.htm.
4
Social Science & Medicine 74 (2012) 537e545
Contents lists available at SciVerse ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
Women at war: Understanding how women veterans cope with combat and
military sexual trauma
Kristin M. Mattocks a, e, *, Sally G. Haskell a, b, Erin E. Krebs a, c, Amy C. Justice a, b, Elizabeth M. Yano a, d,
Cynthia Brandt a, b
a
Department of Veterans Affairs, Health Services Research and Development Services 810 Vermont Avenue Northwest, Washington DC 20420-0002, USA
Yale University, 333 Cedar Street, New Haven, CT 06510, USA
Indiana University School of Medicine HSRD (11H), Roudebush VAMC 1481 W. 10th Street, Indianapolis, IN 46202, USA
d
University of California, Los Angeles, Center for Health Sciences, 650 Charles E. Young Drive South 16-035, Los Angeles, CA 90095-1772, USA
e
University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, Massachusetts 01655, USA
b
c
a r t i c l e i n f o
a b s t r a c t
Article history:
Available online 11 December 2011
The wars in Iraq (Operation Iraqi Freedom, OIF) and Afghanistan (Operation Enduring Freedom, OEF) have
engendered a growing population of US female veterans, with women now comprising 15% of active US
duty military personnel. Women serving in the military come under direct fire and experience combatrelated injuries and trauma, and are also often subject to in-service sexual assaults and sexual harassment. However, little is known regarding how women veterans cope with these combat and military sexual
trauma experiences once they return from deployment. To better understand their experiences, we conducted semi-structured interviews with nineteen OEF/OIF women veterans between JanuaryeNovember
2009. Women veterans identified stressful military experiences and post-deployment reintegration
problems as major stressors. Stressful military experiences included combat experiences, military sexual
trauma, and separation from family. Women had varying abilities to address and manage stressors, and
employed various cognitive and behavioral coping resources and processes to manage their stress.
Published by Elsevier Ltd.
Keywords:
Coping
Adaptation
Mental health
Sexual harassment
Stress
Trauma
Women
Iraq
Afghanistan
USA
Veterans
War
Introduction
Since the inception of the wars in Iraq (Operation Iraqi Freedom,
OIF) and Afghanistan (Operation Enduring Freedom, OEF), more
than 150,000 United States female service members have been
deployed overseas (Department of Defense, 2010). Over one
hundred and sixty women have been killed during their OEF/OIF
deployments (Department of Defense, 2010), thousands of women
have been seriously injured, and an unknown number suffer
significant mental health problems as a result of their exposure to
combat-related violence, military sexual trauma, and other
stressors during their military deployments (Mulhall, 2009). Recent
studies suggest that more than 15% of service members returning
from Iraq and 11% of service members returning from Afghanistan
have met the screening criteria for major depression, generalized
* Corresponding author. University of Massachusetts Medical School, Department
of Quantitative Health Sciences, 421 North Main Street, Leeds, MA 01053-9764,
USA. Tel.: þ1 413 584 4040.
E-mail address: Kristin.Mattocks@va.gov (K.M. Mattocks).
0277-9536/$ e see front matter Published by Elsevier Ltd.
doi:10.1016/j.socscimed.2011.10.039
anxiety, or posttraumatic stress disorder (Hoge et al., 2004; Hoge,
Terhakopian, Castro, Messer, & Engel, 2007).
Women’s wartime experiences and the challenges they face
when trying to reintegrate into their work, family, and social lives
post-deployment have been overshadowed by the experiences of
male OEF/OIF veterans facing similar challenges. A substantial body
of research has examined the consequences of combat zone
deployment, including the prevalence of posttraumatic stress
disorder (PTSD), traumatic brain injury (TBI), depression, substance
abuse and other physical and mental health problems among
returning war veterans, but the majority of this research has
focused on male veterans (Baker et al., 2009; Cohen et al., 2010;
Erbes, Westermeyer, Engdahl, & Johnsen, 2007; Jakupcak et al.,
2009; McDevitt-Murphy et al., 2010; Schnurr, Lunney, Bovin, &
Marx, 2009; Seal et al., 2010, 2009). The justification for the focus
on male veterans is twofold. First, male troops substantially
outnumber female troops and, therefore, greater numbers of male
veterans return to the United States with serious mental and
physical health problems. Second, the types of military occupational roles that male servicemembers have occupied have, at least
538
K.M. Mattocks et al. / Social Science & Medicine 74 (2012) 537e545
until recently, given them more direct exposure to combat-related
trauma and stress than women. Though a growing number of
studies have begun to focus on women’s medical and mental health
conditions after return from deployment, few studies have examined women’s experiences in war, and how they cope with these
experiences once they return to the United States and try to reintegrate with their families, jobs, and communities.
Previous research has examined both deployment and postdeployment stressors experienced by military personnel (King,
King, Vogt, Knight, & Samper, 2006; Street, Vogt, & Dutra, 2009;
Vogt, Pless, King, & King, 2005; Vogt, Samper, King, King, &
Martin, 2008). Deployment-related stressors can include missionrelated stressors, such as combat experiences and difficult living
and working environments, as well as interpersonal stressors,
including concerns about family disruptions and sexual harassment. Post-deployment stressors include exposure to stressful life
events after deployment, which may include stressors related or
unrelated to deployment, and may also include efforts at reintegration. In the past two decades, legislative and Department of
Defense (DOD) policy changes have greatly expanded the occupational roles available to women serving in the military (Donegan,
1996; Mulhall, 2009). These expanded occupational roles have
broadened women’s exposure to combat-related violence and the
stress of military service. Though women are still prohibited from
serving in direct combat roles (e.g. infantry) they may serve in
a variety of positions that put them at risk for injury or death. The
wars in Iraq and Afghanistan have further blurred the line between
combat and non-combat roles, as these wars have been characterized by guerilla fighting in urban war zones (Street et al., 2009).
For example, serving as a member of the military police (MP) is
considered a non-combat occupation, but women serving as MPs
provide convoy and unit security, control traffic, and enforce military regulations. These roles may require female soldiers to search
for improvised explosive devices (IEDs), which have caused up to
75% of fatalities in Afghanistan in 2009 (Joint Improvised Explosive
Device Defeat Organization). Consequently, though women do not
serve in direct combat positions, a recent study suggests that
approximately three quarters of women deployed to Iraq have been
exposed to one or more combat experiences (Dutra et al., 2011),
which is on par with studies comprised of primarily OEF/OIF male
servicemembers (Milliken, Auchterlonie, & Hoge, 2007).
Actual or perceived danger is only one source of stress faced by
female servicemembers (Kang, 2006). Women serving in the military must also cope with the threat of gender-based violence during
deployment (Kimerling, Gima, Smith, Street, & Frayne, 2007;
Kimerling et al., 2010; Yaeger, Himmelfarb, Cammack, & Mintz,
2006). “Gender-based violence” is a term introduced in 1993 as
the United Nationals adopted the Declaration of Violence Against
Women, which describes violence against women as “Any act of
gender-based violence that results in, or is likely to result in,
physical, sexual, or psychological harm or suffering to women
including threats of such acts, coercion or arbitrary deprivations of
liberty, whether occurring in public or private life” (p.1). Genderbased violence, specifically violence against women, is highly
prominent, particularly in the context of war, and may be inflicted
upon both civilian and military women alike (Linos, 2009), though
whether there is a differential effect on civilian and military women
is unknown. Military sexual trauma (MST) is the term used by the
Department of Veterans Affairs to refer to sexual assault or
repeated, threatening sexual harassment that occurred while the
veteran was in the military. Recent evidence from OEF/OIF veterans
suggests that 15.1% of women and 0.7% of men reported military
sexual trauma when screened (Kimerling et al., 2010).
The effect of deployment on men and women may also differ as
a result of women’s responsibilities at home. Though the gap in
household responsibilities has narrowed over the years (Bianchi,
Milkie, Sayer, et al, 2000), women still have more responsibilities
for child care, cooking meals, housekeeping, and other tasks.
Consequently, when women deploy, responsibilities for these
activities must be given to spouses, family members, or friends,
contributing to women’s deployment-related stress (Vogt et al.,
2005). Recent studies suggest that over 40 percent of active duty
women have children (Department of Defense, 2006), yet rising
divorce rates for female servicemembers (Adler-Baeder, Pittman, &
Taylor, 2006) place added stress on women who must find alternate
arrangements for childcare during deployment. More than 30,000
single mothers have deployed to Iraq and Afghanistan (Department
of Defense, 2010), but while children of partnered women usually
stay with their other parent during their mother’s deployment,
children of single mothers typically move in with other relatives
(e.g. grandparents, aunts) (Kelley et al., 2002). Furthermore,
deployment stress may be more profound among women in the
Guard and Reserve. As Guard and Reserve members are primarily
used in the civilian sector, deployment of women in the Guard and
the Reserve involves transitions to and from their usual jobs, prolonged departure from their families, and less social support from
their home communities as compared to active duty personnel
living on a military base (Foster, 2011).
These and other stressors experienced by women during their
military deployments are well-documented (King et al., 2006;
Street et al., 2009; Vogt et al., 2008). How women in the military
cope with both deployment and post-deployment stressors is the
subject of recent scientific inquiry. Much of the literature has
focused exclusively on the relationship between inadequate coping
processes and psychological outcomes, such as post traumatic
stress disorder (Engel, Liu, McCarthy, Miller, & Ursano, 2004; Farley
& Catano, 2006; Hoge et al., 2007; Lambert, 2004; Rodrigues &
Renshaw, 2010; Sharkansky et al., 2000; Suvak, Vogt, Savarese,
King, & King, 2002), while other literature focuses on physiological responses to stress (Bruner & Woll, 2011). Other literature has
focused on risk factors for inadequate coping responses among
women in the military, including pre-deployment factors (childhood environment, prior stressors) and post-deployment factors
(other life stressors and social support) (Carter-Visscher et al., 2010;
King, King, Fairbank, Keane, & Adams, 1998; Vogt & Tanner, 2007).
Ferrier-Auerbach, Erbes, Polusny, Rath, and Sponheim (2010) found
that women deployed to a combat zone were more likely to
experience emotional distress in response to combat trauma than
men, and that frequent contact with friends and family at home and
leadership support during deployment may improve the ability to
cope with deployment-related stressors.
Moos and Schaefer’s model of coping resources and processes
(1993) suggests that coping resources, including personal and
social factors that influence how individuals manage life crises and
transitions, as well as coping processes, which are the cognitive and
behavioral efforts that individuals use in stressful situations, are
important to consider when evaluating how individuals cope with
stress. Cognitive approach coping strategies are those in which an
individual appraises the situation, and evaluates how to handle the
situation using the coping resources available at that time (Lazarus
& Folkman, 1984). Behavioral approach coping strategies are those
strategies used to seek guidance, support, and positive concrete
actions to deal directly with the stressor. In contrast, cognitive
avoidance strategies are those aimed at denying or minimizing the
seriousness of a crisis or its consequences, as well as accepting
a situation as it is and deciding it cannot be changed. Conversely,
behavioral avoidance coping strategies involve trying to replace the
losses involved in a certain situation with alternative rewards, such
as binge eating or substance abuse. Studies have examined
deployment-related stressors and coping strategies separately
K.M. Mattocks et al. / Social Science & Medicine 74 (2012) 537e545
(King et al., 2006; Rodrigues & Renshaw, 2010; Vogt et al., 2005),
but as the two areas are closely interwoven, both need to be
considered together to fully understand the full impact of women’s
wartime experiences and the impact these experiences on women’s
readjustment after military service.
Given these gaps in the literature, what is needed is a thorough
examination of women’s experiences with combat zone deployment, and an assessment of gender-specific deployment-related
stressors and coping strategies. Thus, this study was conducted to
examine U.S. women’s military deployment experiences, including
combat-related exposure, military sexual trauma, separation from
family, and gender discrimination in the military, and to explore the
nature of women’s coping strategies after return from military
deployment.
Methods
Setting and sample
This study is a qualitative study nestled in a larger research
study, the Women Veterans Cohort Study (WVCS). WVCS is a twophase longitudinal study examining healthcare utilization, health
outcomes, and costs of care among a cohort of OEF/OIF male and
female veterans in VA care. The sampling frame for the overall
study is the OEF/OIF roster, provided to the VA by the Department
of Defense Manpower Data Center’s (DMDC) Contingency Tracking
System. The OEF/OIF roster is a database of veterans who have
separated from OEF/OIF military service and enrolled in VA
healthcare between 10/1/2001e04/30/2008 (N ¼ 406,802). Roster
information includes veterans’ sex, race, date of birth, deployment
dates, armed forces branch (Army, Navy, Air Force, Marines, or
Coast Guard) and component (National Guard, Reserve or active
duty). Our final sample included 43,078 women who served in OEF/
OIF and received VHA health care after return from deployment.
Phase I of the WVCS study is a database analysis of gender
differences in healthcare utilization, healthcare costs, and health
outcomes of the 406,802 male and female veterans in the OEF/OIF
database. Data on veterans identified through the OEF/OIF roster
were linked to administrative and clinical data contained within
the VHA National Patient Care Database (NPCD) and Decision
Support Systems (DSS). These databases provide healthcare utilization information and cost data, pharmacy and laboratory data,
and health encounters and coded diagnostic and procedure data
associated with inpatient and outpatient encounters.
Phase II of the study is a prospective survey of male and female
OEF/OIF veterans at two large VA facilities, one in the northeast and
one in the midwest. Letters were sent to all male and female
veterans on the OEF/OIF roster who lived within 100 miles of each
facility (n ¼ 2000). Patients expressing interest in the study either
met with or called the research coordinator. Prospective subjects
were read a description of the study, had questions answered about
enrollment and possible adverse consequences of participation,
and were screened for eligibility. Eligibility criteria included the
ability to speak and read English, and participation in Operation
Enduring Freedom or Operation Iraqi Freedom. Those who agreed
to participate were given an appointment at which they signed the
informed consent and were asked to complete the baseline survey.
Participants were also asked to complete follow-up surveys one
and two years, respectively, after the baseline survey. The current
study, as well as the larger WVCS study, was approved by the VA
Connecticut Healthcare System and by Yale University.
Six hundred and fifty veterans on the OEF/OIF roster were
women registered to receive care at the northeast VA facility. Of
these women, 74 agreed to participate in Phase II (prospective
survey) component of the study. These 74 women were asked by
539
a research associate if they would be interested in participating in
a semi-structured interview with a trained qualitative interviewer.
Women who agreed to participate in the semi-structured interview
(n ¼ 19) signed a separate consent form for the semi-structured
interview. Each woman was paid $25.00 for participating in the
interview. Interviews lasted, on average, 45 min, and were conducted
between JanuaryeNovember 2009. For the purposes of analysis and
reporting, each woman was assigned a pseudonym by the author.
At the conclusion of the study, we ascertained mental health
conditions for each woman by reviewing mental health diagnoses
in the VA’s administrative and clinical data contained within the
VHA National Patient Care Database (NPCD). We focused on mental
health conditions (depression, PTSD, and anxiety disorder) that are
highly prevalent, and often disabling, conditions among veterans in
the VA. Women veterans were considered to have a mental health
diagnoses if they had 2 or more outpatient or 1 or more inpatient
ICD-9-CM code for major and mild depression, PTSD, or anxiety
disorder at any time since their enrollment into the VA Healthcare
System. To reduce potential information bias caused by a distorted
evaluation of information regarding the relationship between
stress and coping mechanisms and mental health diagnoses of the
participants, the investigators did not link specific comments from
the participants to clinical mental health diagnoses assigned by VA
clinicians.
Data collection and analysis
A semi-structured interview format allowed respondents to talk
freely about their military experiences, including their jobs in the
military, living conditions during deployment, deployment-related
stressors, challenges of returning to the United States after
deployment, and stress-related coping mechanisms. The interview
guide was revised during the course of data collection and analysis
so that categories and dimensions (properties) of categories could
be found and more fully explored. Interviews were audio-recorded,
transcribed, and entered into Atlas.ti (Scientific Software Development, 1997).
Each transcript was read in its entirety by two members of the
study team to gain a sense of each veteran’s experience. We used
open coding, where each coder independently reviewed the transcripts line-by-line, creating code definitions as concepts emerged
inductively from the data. Coders met to compare codes, resolve
discrepancies, and review the code structure. The constant
comparative method of qualitative analysis was used to compare
coded segments of text to expand existing themes and identify new
themes. Codes were refined until we reached a final coding structure, including a total of 20 codes capturing the major concepts in
the data, which was then applied to all of the transcripts. The
themes presented in the current analysis emerged from specific
codes focused on participant experiences of deployment stressors,
participant post-deployment experiences, participant familial and
social context, and participant coping strategies.
Results
Nineteen women who served in OEF/OIF participated in the
interviews. The mean age of the sample was 37; the women ranged
from 23 to 55 years of age. Fifty percent of the women were members
of the National Guard and 40% were members of the Army or Navy
Reserves. Of the 19 women interviewed, seventy-nine percent were
white; all had at least a high school degree, 26% had a Bachelor’s
degree, and 32% had a graduate or professional degree. Thirty-two
percent of the women in the study had a clinical diagnosis of
PTSD, while 11% had a diagnosis of major depression, and another
11% had received a diagnosis of anxiety disorder.
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Women veterans who had recently returned from war identified
stressors that fell into two major categories, as described by others
(King et al., 2006; Vogt et al., 2008)dstressful military experiences
and post-deployment reintegration problems. We identified
subgroups of stressors in each of these categories. Women’s ability
to address and manage stressors varied considerably and they
employed various cognitive and behavioral coping resources and
processes to manage their stress. Below is a detailed description of
each of the major subgroups of stressors followed by a description
of the behavioral and cognitive coping strategies women used to
alleviate the stress.
Stressful military experiences
Combat-related experiences
Women in this study reported observing horrific combatrelated violence, and many acknowledged that these experiences
had left them struggling with significant mental health problems,
including PTSD and depression. For most women, these experiences were linked to their occupational roles during deployment.
Women who were medics, nurses, members of the military police,
or convoy drivers reported stressors such as carnage in emergency
rooms, perceived danger while patrolling unsecured areas, and the
threat of IED explosives along the routes they drove.
One woman in the group, Maria, served as a member of the
military police patrolling the streets of Baghdad. Maria had been
diagnosed with PTSD following her return from deployment, and
had been hospitalized several times because of her suicidal ideation
in response to the painful experiences she had endured in Iraq.
Though several years had passed since her deployment, she could
not keep back the tears when she shared her experiences:
I had the unfortunate experience of having to kill a child, an Iraqi
child. Our convoy had broken down and this kid came running
for us, he wouldn’t stop and it was me and my battle buddies or
the kid and they were using kids as bait. The kid was trying to
sell us Coca-Cola soda, but really the kid was wired. So it had to
be the kid that was going.
Combat-related stress occurred not only among women who
patrolled the streets of Baghdad, but also among women working in
emergency rooms or on medical transport missions. Jean described
the day-to-day challenges she faced as an emergency room nurse in
Iraq, with the duel stresses of caring for those who had been injured
and fearing for her own safety:
We got patients literally from wherever the battlefield of the day
was. We took care of soldiers and civilians including children
and probably saw the worst that could be done to a human
being by another human being. It’s not like we saw traumas
every single day but the ones that we had were pretty brutal. We
saw people with their limbs blown off, severe head injuries,
children, you know, with bad injuries, and even military
working dogs that got hurt in the course of the battle. We were
probably mortared almost every single day and sometimes the
VBIEDs (Vehicle Borne Improvised Explosive Devices) were so
powerful when they exploded outside the gate that, you know, it
knocked us down it was so loud and forceful.
Military sexual trauma
One of the most difficult types of stress faced by women during
their military deployments was the threat of sexual trauma.
Consistent with other studies (Kimerling et al., 2007, 2010; Yaeger
et al., 2006), women experienced different forms of sexual
trauma, including sexual harassment, sexual coercion, and even
rape. Often, women spoke of how sexual harassment or sexual
coercion was tied to opportunities for promotion. Women who
were promoted were assumed to have performed sexual favors for
those in charge. Grace recounted her experience:
We would drive past {male soldiers} on the base and they made
hand signals for different sexual things that they wanted to do to
somebody. I mean these guys were married and most of them
their wives were pregnant, you know, at home with their kids or
just had kids and they were deployed. But, you know, they did it
even more when I would say, you know, you need to stop. And
then I brought it up to my superiors. I was like this needs to stop.
This is just getting ridiculous and then it went on even worse
and they did nothing. They did absolutely nothing.
Every time I got promoted, every single time, they would start
by saying ‘Oh it’s only because you slept with so and so or you
gave so and so a blow job or you did that or you did this and it’s
obviously completely not true.
Similarly, Glenda tells of her experiences with sexual harassment and rape in the military.
One of the problems over in Iraq for female soldiers is that there
is a lot of sexual harassment and rape is huge. And it does not
matter if you’re 18 or 58. It does not matter. Women serving over
there don’t have to be worried about enemy fire. They have to be
worried about the guy that’s next to them, you know, that’s
supposed to be protecting and taking care of them and a lot of
times he becomes like public enemy number one for them.
Separation from family
Women spoke about the challenges of serving in the military
while also being a mother to young children. Several women left for
Iraq or Afghanistan for more than a year and made difficult decisions about with whom to leave their children during deployment.
Some women felt comfortable leaving their children with their
husbands; other women in the group, particularly single mothers,
made the decision to leave their children with grandparents. Jill
came from a large military family and grew up with a father who
spent much time away for military duties. As a child, Jill was used to
her mother caring for her four siblings and herself as a single
parent, so Jill did not find it as difficult as she had imagined to leave
her daughter behind with her mother:
When I left for Iraq, my daughter was four months old. But it
really wasn’t too bad because it was the perfect age for her. You
know, she didn’t really know too much of what was going on,
like she would now. And it wasn’t too bad for me because I don’t
think I got too big on the mother thing yet because she was only
four months old. So it wasn’t really too hard to even let go
because I hadn’t been a mother that long.
Similarly, Carol recounted how she handled the stress of being
away from her children during the year and a half she was
deployed:
When I went to Iraq, it was tough to leave my three kids but I felt
I had a job to do and I couldn’t worry too much about home. You
shut off your mind to it, I think, because it’s a whole separate
world and you just say, ok, this is what I am, this is what I’m
doing. When I talked to my kids on the phone it was just surface
level stuff, not trying to get too deeply into what was going on
with them because then the emotional side of me would come
and its just so hard to try and deal with the harsh environment
that you’re in and still deal with the emotions of kids and the
fact that you’re missing them. When you talk to them, you just
keep it simple, just simple things. And then you just go back to
K.M. Mattocks et al. / Social Science & Medicine 74 (2012) 537e545
what you’re doing, go back to your work. But it was the clear,
clear separation that I really had to make that decision that I was
going to separate myself from home and what was going on
there. I knew my husband could handle it. He would be fine and
get through it.
Post-deployment reintegration problems
The other major category of stressors identified by women
included challenges of reintegrating into society upon return from
war. Simple everyday tasks like driving down the highway become
problematic for women suffering from the lingering effects of war.
Some women were formally diagnosed with PTSD upon return to
the United States and others just guessed that PTSD was the reason
their daily lives were difficult to negotiate.
Leaving the war behind
Many women talked about the seeming threats associated with
mundane tasks after having served in a war-torn area. Nancy, who
was receiving treatment for PTSD at the time of the interview,
recounted her struggle with leaving the war behind:
When I first returned, I was paranoid of everything and everybody within my perimeter, 360. I’m driving in the middle lane of
the highway and I’m watching everything and it’s raining and
I’m like ‘Oh, no! There’s somebody coming up on my left!’ and
I’m holding onto that steering column and it’s like life, limb, and
eyesight.
Janet had similar experiences
You know carcasses, the dead deer on the side of the road, still
irks me, still freaks me out and I’m looking real quick and I’m like
‘I’m coming into your lane, buddy because I’m not even trying to
drive by this thing cause God knows if it’s going to blow up!’.
Arlene had been constantly exposed to mortar attacks during
her deployment in Iraq and continued to find daily routines
challenging:
When I first came home they were dynamiting near a grocery
store where I shop. The first time I heard it I went right down to
the ground in the store. But, I didn’t lie flat, though. I caught
myself and then I pretended I was looking for something on the
bottom shelf. I was like, “Well, I’ll just pretend I’m really looking
at something on the bottom shelf here”.
Nightmares are almost a given. Every night at least, at least once I
have a bad dream. It’s to the point where I wake up soaked in
sweat. I mean just completely drenched. I don’t even know how I
can sweat that much and the bed sheets are completely soaked
and my husband will wake up and be like what the hell? What’s
going on? You know, because I’ll be screaming or I’ll be shaking or
I’ll fight in my sleep and the dreams are always about the same
thing. They’re always about me being raped and killed every
single time. The people change but it’s always the same plot and
it’s always the same concept. And in the end I always die.
Disrupted relationship with family and friends
The majority of women in the study made conscious decisions
not to discuss their military experiences with friends or family.
Most women felt their friends and family members would not
understand what they had experienced, so rather than reach out to
share their difficult memories, they kept them to themselves.
Sharon worked as a nurse practitioner at an army base in Iraq and
541
explained how difficult it was for her to share the memories of the
horrific damage she had witnessed to human bodies while working
in the trauma unit:
I very rarely, very rarely, talk about my experience in Iraq. You
know you should talk about it, but treating people that have
been blown up and all that is not that relatable of an experience
to most people you meet.
Other women spoke of returning home to find household
matters in disarray. Several women found that their husbands or
fiancés had mismanaged their bank accounts, and that a significant
amount of money had been squandered while they were serving in
Iraq or Afghanistan.
I came back (from Iraq) a little angry because here I was over
there and I came to find out my husband had been flying all over
the country and going out drinking every night with the guys on
the money I was making while I was over there. He was
supposed to have been paying off bills and when I come home it
was like ‘You were having a grand old party and you didn’t pay
off anything!’ I asked him, ‘Where’s all the money? I mean,
where’d all the money go?’
When Rita deployed to Iraq, she left her three children with her
husband who cared for them well. But when she returned from
deployment, she found it difficult to find her place in the family
again, and learned that her husband had done some things slightly
differently than she had done them. Perhaps most importantly, she
found that her children had changed in many ways, and getting to
know her children again was a challenge. Rita recounts,
When I returned I didn’t know my kids anymore. Before I left, I
knew their dress sizes, their shoe sizes, everything about them.
But I was gone for a year and a half and so much changed in that
time. I still remember the first day I took my son to school after I
returned. I took him to school and made his lunch and picked
him up at the end of the day. I said, “Oh, you didn’t eat your Fig
Newtons”, and he said, “Ma! I don’t eat Fig Newtons anymore!”
Often forgotten among veterans are the young men and women
who must return to college campuses to resume classes after their
deployments. With the exception of a recent RAND report detailing
reintegration problems among OEF/OIF veterans in New York State
(Schell & Taneilian, 2011), no published studies have examined the
challenges that veterans face when they return to college classrooms.
Some universities have dedicated spaces for returning war veterans,
but others have no special programs to assist them with reintegration
into university life. Jill, a college student, discussed the challenges of
returning from Iraq to a college campus filled with fellow student
who did not understand her deployment experiences:
I really didn’t talk to people about serving in Iraq when I got
back because not really many people wanted to know stories.
My friends didn’t really understand. Like I don’t talk to a lot of
them anymore only for the fact that when I went away in their
minds it was almost like ‘well, she’s not talking to me anymore
so I’m not going to talk to her’. So we lost communications while
I was over there and I took it as ‘well, if you don’t want to talk to
me while I’m getting shot at and in a combat zone, then I don’t
want to be your friend’.
Coping strategies
Participants described post-deployment behaviors, thoughts,
and perceptions that fit into three major coping strategies: behavioral avoidance, cognitive avoidance and behavioral approach. Each
of those coping strategies is described in detail below.
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Behavioral avoidance coping
Consistent with prior research on coping mechanisms, women
veterans engaged in various forms of behavioral avoidance coping
strategies (Moos & Schaefer, 1993). By using this approach, women
engaged in behaviors aimed at replacing stressful deployment
feelings with alternate sources of satisfaction. Women identified
four major behavioral coping strategies they used to cope with
post-deployment stress: binging and purging, compulsive
spending, over-exercising, and prescription drug abuse. Consistent
with prior studies, women veterans tended to overeat or binge eat
as a coping mechanism (Arnow, Kenardy, & Agras, 1995; Henderson
& Huon, 2002; Ozier et al., 2007; Timmerman & Acton, 2001; de
Zwaan, Nutzinger, & Schoenbeck, 1994). Women veterans often
described coupling their overeating with isolation. For example,
Maria noted that she had spent nearly two months in an inpatient
psychiatric unit shortly after her return from Iraq for PTSD and
suicidal ideation. Her hospitalization helped “some”, but she
explained that she remains in a deep depression and has been
unable to keep a job in the years since she returned from Iraq. To
cope with her memories of Iraq, Maria relies on food.
Exercise was my addiction and I was constantly throwing up. I
got super skinny.
Other women in the study spoke of their inability to stop
spending money once they returned from deployment. Women
attributed this overspending to the stresses of returning to civilian
life, and noted that most of the overspending occurred in the first
year after return from deployment. Karen described what did to
cope with the memories she was having of her military
deployment:
My thing is I like to go to the casino by myself and I can be there
for eight hours by myself and I don’t hear anyone, I’m anonymous, no one knows who I am. I am just another person playing
a slot machine. I can go shopping. It makes me feel good. I’m
going to buy some cosmetics because it makes me feel good. I’m
gonna order that pair of shoes because it makes me feel good.
It’s more impulsive now than it was (before Iraq).
When I get into my depression I will just go and buy food, even
though I don’t really have enough money to buy food. When the
depression hits I just go to the grocery store and I go when
there’s no crowds, because I don’t like crowds. But I buy whatever I want and then I sit on the couch, whether it be with
chocolate or something else, and I buy enough to last me a week.
Unlike their male veteran counterparts who may rely on atrisk alcohol use to help them cope with post-deployment stress
(Erbes et al., 2007; Sayers, Farrow, Ross, & Oslin, 2009), women
in the study did not endorse alcohol, smoking, or illicit drug use
as mechanisms to cope with stress. However, some women
spoke of their increasing dependence on prescription drugs to
help them manage their feelings. Grace, in particular, spoke of
her reliance on her prescription medication for anxiety to help
her manage the feelings she was having after her return from
Iraq.
Similar to Maria, Grace relied on food control, as well as binging
and purging, to help her cope with the sexual harassment she
experienced during her deployment. As Ozier and colleagues
recently noted, individuals who are experiencing extreme stress,
such as Maria and Grace, can use food control and overeating as
a maladaptive way of coping with their stress (Ozier et al., 2007).
I think I definitely can overdo it with my medication and I find
myself looking forward to the time when I can take my medicine
at night because it just puts me in that, just that almost, you
know, vegetative state where I’m just like, you know, almost
drooling on myself and it just feels so good to just..it’s almost
like being drunk really.
Since I’ve returned from Iraq, I started to control my food and my
intake of food and its gotten to the point where I mean literally I
will only eat, I will only eat the same thing every day because I
know exactly what I’m putting in my body and how much is
going in and if I eat more than that there are times when I am so
hungry that I’m like I need to eat something and I’ll eat more and
I’ll go vomit because I know I can’t have more than that. I know
what I’m supposed to eat and then on days when I just can’t take
it anymore because I’m so hungry, I’ll vomit 3 or 4 times just to
make sure it’s all out and laxatives and all that stuff. And every
single day I measure my food. I know exactly what I’m putting
in. I know exactly what I’m eating. I know what...how much
and all the different amounts and everything versus how much I
work out and I can...I know and if I don’t..if I’m feeling too
bad and I can’t do something during a certain day, I won’t eat
because I know that I’m not exercising to work that off. So it’s
like food is a hard struggle for me.
Other women used extreme degrees of exercise to cope with
their stress. Studies on the relationship between physical activity
and stress have been inconsistent, with some studies showing
individuals exercise less when experiencing stress (Heslop et al.,
2001; Ng & Jeffery, 2003), while others showing an increase of
exercise with stress (Spillman, 1990). Sarah, age 23, described her
use of extreme exercise to cope with stress:
You know they always taught us to exercise. So when I returned,
I would exercise to excess and really to excess to the point where
I would be sick. But it would make me feel better about being
home. It was very strange not to be able to control my emotions.
It was like these very high highs and these very strange lows.
Cognitive avoidance coping
One characteristic of women veterans that was similar across all
types of avoidance behaviors was that women preferred to engage
in many activities (substance abuse, overeating, shopping) in
isolation. As Maria noted:
Yeah, I put on about twenty pounds when I came back. But I
think mostly it’s cause I would isolate myself. You know, I
found myself, saying.ok, I don’t want to be around people. I
don’t want to hear the stupid stuff they’re talking about, you
know?
Isolation has been identified by other researchers as a common
coping strategy after return from deployment (California
Department of Alcohol and Drug Programs, 2009; Goodman,
Smyth, Borges, & Singer, 2009; Vellenga & Christenson, 1995).
Rather than trying to reconnect with friends or family members or
share their experiences with other veterans, women in the current
study instead chose to remove themselves from others. Some
women, such as Jean, reported that once they returned to the
United States, the only way to cope with the feelings they experienced around their military service was to isolate themselves from
their friends and family:
Where before I would’ve been devastated if me and him weren’t
close. I mean, we aren’t talking now and I isolate myself in the
bedroom, I read my books, I could care less. He wants me to
sleep in the other room ‘cause I snore so much since I have come
back. Before that would’ve devastated me, now I don’t care
because I just want to be alone.
K.M. Mattocks et al. / Social Science & Medicine 74 (2012) 537e545
543
Other researchers have noted that social support is a recognized
resource for coping with stress and the isolation that may arise
from poor coping mechanisms (Thoits, 1986). Social support can be
defined as the availability of instrumental and emotional assistance
through interpersonal relationships (Kocot & Goodman, 2003).
Social support can be provided by informal networks, including
family, neighbors, and friends, or through formal networks,
including community agencies and systems. Women in the current
study rarely mentioned friends or family members as social support
mechanisms, and only one woman mentioned relying on the
statewide Vet Center as a social support network.
for women veterans who wanted to receive support regarding their
wartime experiences. Other women, such as Erica, noted that even
if they wanted to connect with other women veterans through
therapeutic support groups at the VA, they would not feel
comfortable seeking VA services for their problems:
Behavioral approach coping strategies
Discussion
While many women veterans spoke of the great difficulties they
had readjusting to civilian life in the United States, several women
spoke of the coping strategies they used to successfully navigate
their post-deployment stress. By utilizing behavioral approach
coping strategies (Moos & Schaefer, 1993), some women were able
to cope with stressful deployment experiences by taking concrete
action to deal with the stressful experiences they had during
deployment. Some women, like Jean, used exercise as a positive
strategy, relying on regular routines, such as running and yoga, to
help overcome negative emotions.
Women veterans in the study were no strangers to the stresses
associated with war. Whether experiencing trauma associated with
caring for critically injured victims of war, enduring sexual
harassment or rape from fellow military personnel, or returning to
parenting or marital relationships strained by the length of
deployment, many women who served in OEF/OIF experienced
substantial stress both during the war and upon return to the
United States.
Women veterans used both used both behavioral approach and
avoidance coping strategies as well as cognitive avoidance strategies for dealing with stress. As has been reported in other studies
(California Department of Alcohol and Drug Programs, 2009;
Goodman et al., 2009; Schell & Taneilian, 2011), women veterans
had a tendency to isolate themselves from others upon return from
deployment. Rather than reaching out to family and friends to seek
social support, some women relied on behavioral avoidance coping
strategies, including overindulgence in food, prescription drugs,
and exercise to alleviate the negative feelings they were having.
However, other women mentioned behavioral approach coping
strategies, including exercise, listening to music, breathing exercises, and speaking with other women veterans.
An important theme echoed across many of the interviews was
the sense that women’s experiences in war were not widely
understood or recognized upon return to the United States. As
noted in other studies (Mulhall, 2009), because women’s roles and
experiences in the military are often minimized or misunderstood
by family, friends, and healthcare professionals, women themselves
tend to minimize their contributions. Several women in the study
indicated that they did not feel their physical and mental health
ailments were worthy of VA care. In some cases women who
needed treatment for their war-related health problems chose not
to utilize their VA healthcare benefits, and either received no
treatment for their problems or sought private care for their
problems.
For some women veterans the transition back to the United
States has been easy, but for many others it has been complicated
by marital problems, loss of friendships, divorce, job loss, and
trouble returning to pre-deployment daily routines. For those
women with children, being absent from their child’s life for up to
two years caused significant disruption in the child’s life, and
resulted in a readjustment process for both mother and child upon
return from deployment. None of the women in the study reported
that they received any help with this family readjustment process
from either the military or from the VA, and were left to renegotiate
their relationships with their children on their own. Providing care
to women and their families after return from deployment remains
an important challenge, as the VA is not currently mandated to
provide such services (American Legion, 2009).
It is unclear why women in the study did not seem to feel as
though they deserved services provided by the VA, or why they did
I purposely stretch. I have a yoga mat in the car. I find myself, go
out to the park, find a quiet spot, and stretch. If I do nothing else
for myself over the course of the day, that little bit of love is for
me, and only me.
Unlike some of the women who sought isolation upon return
from deployment, several women spoke of the importance of
reaching out to others to help them through difficult postdeployment experiences. In particular, several women spoke of
the importance of VA ‘vet centers’ that provided counseling and
resources to veterans who had recently returned from combat.
Carolyn, who had served as a medic in Iraq, was able to successfully
cope with some of her negative feelings by relying on strategies her
therapist had given her to manage her negative feelings:
My therapist at the Vet Center told me how to use breathing to
cope with stress. When you can’t sleep well, she taught me to
put one hand on your chest, one hand on your belly and you
breathe deeply and sense yourself on just the way your hand is
going up and down when you’re breathing. It puts me to sleep
every time. I don’t even need Tylenol PM anymore.
Several women spoke of the importance of coming together
with other women veterans to share their experiences with
deployment and support each other through difficult reintegration
experiences. Women viewed the opportunity to speak with other
women veterans as a therapeutic experience that allowed them to
cope with some of the stressful experiences they were having.
Carolyn shared:
You know, we women are all different; we all react differently,
we all have different coping mechanisms, and we all have
different ways of getting help. I like hearing what other women
veterans say and laughing when I think, “Oh my God! I went
through the same thing!. I can relate to what other women saw
there.
Unfortunately, women could think of few opportunities that
they had had to sit down with other women veterans and share
their experiences. Though a few women spoke of the individual
therapy they had received through the VA or through the vet
centers, women were hard-pressed to think of support groups just
The VA is a place where men–wounded men or retired men go.
But I feel that if I’m a woman veteran, or even if I’m a wounded
woman veteran, I don’t deserve to go to the VA because there
still may be World War II, Korean, or Vietnam vets who need the
VA. So I’m not going to go to the VA because there are so many
other guys who need it more than I do.
544
K.M. Mattocks et al. / Social Science & Medicine 74 (2012) 537e545
not advocate more strongly to receive the services they needed and
deserved. Other researchers have suggested that, like Vietnam
veterans, OEF/OIF veterans may have an ongoing sense of shame
which may hamper efforts at self-advocacy, which may arise from
perceptions regarding negative American attitudes toward war
(Vellenga & Christenson, 1995). Conversely, women veterans who
may have experienced some form of military sexual trauma may be
unwilling to utilize VA services, for fear of encountering the same
types of individuals who may have perpetrated the sexual trauma.
Finally, many women veterans who are returning to the United
States after months of deployment may feel that, despite their own
personal medical or mental health needs, the focus needs to shift
away from their own personal needs to the needs of their children
and other family members.
Importantly, several women in the study noted the importance
of connecting with other women veterans to share their experiences. As echoed in other studies (Schell & Taneilian, 2011), women
expressed a need to get together in person with other women
veterans, similar to Veterans of Foreign Wars (VFW) or veterans
service organizations (VSOs) of previous war eras. Because some
women choose not to use the VA for their healthcare needs, it is
important that women are able to make these connections in their
local communities or through state Departments of Veteran’s
Affairs. For example, the Connecticut Department of Veteran’s
Affairs sponsors the Connecticut Women Veterans’ Network (CT
VETNET), which was established to assist Connecticut women’s
veterans with information and access to benefits specifically for
women veterans. Through this network, women can gain access to
local resources and support networks for women veterans living in
nearby communities.
There are several important policy implications from the current
study. First, because some of the stressors that women have experienced during military service are related to military sexual trauma,
women veterans need to have access to gender-specific mental
health and substance abuse counseling. Currently, the VA offers
nearly 100 substance abuse programs with specialized services
targeted at women veterans. However, because not all women
veterans seek VA care for these problems and conditions, the VA
should establish collaborative relationships with state and
community-level mental health and substance abuse agencies to
provide access to needed care. In addition, because women veterans
remain the primary caregivers of young children, childcare is
a barrier for treatment for many women veterans seeking mental
health and substance abuse treatment. The recent passage of PL-111163, the “Caregivers and Veterans Omnibus Health Services Act of
2010” will allow the VA to carry out a 2-year pilot program to assess
the feasibility of childcare for qualified veterans who are the primary
caretakers of a child (Department of Veterans Affairs, 2010). Finally,
the recent passage of the GI bill allows veterans to receive tuition
subsidies for their college educations, but the Department of
Veteran’s Affairs must also work with college campuses to ensure
they have the resources they need to support veterans. Given
returning veterans are often juggling young families, jobs, injuries,
and possibly mental health conditions sustained during OEF/OIF
deployment, services need to be carefully tailored to these veterans’
needs (Yonkman & Bridgeland, 2009).
This study has several limitations. First, all women in the study
had enrolled in the VA for healthcare, so these women may have
been more likely to have been coping with difficult wartime
experiences and may have been struggling with coping mechanisms to help with these experiences. Second, there was wide
variation in the duration of time women in the study had returned
from deployment. Some women had been back for three months,
while others had returned from deployment over five years prior to
this study. As a result, women were at various stages of their coping
processes, and women who returned several years ago from
deployment may have not remembered some of the coping
mechanisms they used shortly after return from deployment. Third,
all interviews were conducted in Connecticut and a large majority
of the women were National Guard or Reserves members, so these
interviews are not representative of the larger population of
women veterans, particularly those women in active duty. Finally,
the interviewers were blinded to the identities and mental health
status of the women veterans interviewed for this study prior to the
interview, and information regarding mental health status was not
assigned to the research transcripts at the conclusion of the interview. Consequently, we were not able to differentiate coping
strategies based on mental health status of the women veterans in
this study.
In conclusion, our research helps to elucidate the experiences of
women veterans who have served in Iraq and Afghanistan, and
outline some of the major coping strategies these women are using
to help them negotiate the stresses of military service. Distinctions
between negative and positive coping strategies are important
because it is likely that the positive coping strategies may yield
better long-term outcomes and may be best promoted by postdeployment interventions specific to women veterans. Interventions to assist women veterans in the coping process must occur at
multiple levels (individual, family, community), and from multiple
institutions (VA, community-based providers). Appropriate interventions should increase the likelihood of healthy recovery from
war-related stress, and secondary and tertiary prevention strategies
are important components in post-deployment healthcare for
women veterans.
Acknowledgments
The authors are very grateful to Tan P. Pham, MPH, and Blair
Harrison, MPH, for their contributions to this manuscript.
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