Funded by the VA HSR&D (Project# SDR 10-012)

Spotlight on Women Cyberseminar Series
W t W G d Diff 

Women a

t

War: 

Gen

der Differe

War

-Zone Stressors and Zone Stressors and

Postdeployment Mental Health 

U S OEF/OIF V t U

.

S. OEF/OIF

Ve

terans

Da ne Vogt PhD & Am Street Da

wne Vogt, PhD

& Amy Street, 

Women s’ Health Sciences Division NCPTSD Health Sciences Division, NCPTSD

VA Boston Healthcare System &Division of Psychiatry, Boston University 

School of Medicine School of MedicineADVANCING SCIENCE AND PROMOTING UNDERSTANDING OF TRAUMATI
Presentation Structure

• Presentation of Study #1

• Presentation of Study #2

• Discussion and Q&A
Presentation #1: Gender Difference

Combat-Related Stress Ex

posure 

Postdeployment Mental Health 

D V t Ph D Dawne 

Vog

t, Ph.D.,

Women’s Health Sciences Division

National Center for PTSD

VA Boston Healthcare System

Rachel Vau

g, , hn Mark Glickman, Mark Schul

Mari-Lynn Drainoni, Rani Elwy, & Susan Eis

in press at in press at Journal of Abnormal Psychology Journal of Abnormal Psychology

ADVANCING SCIENCE AND PROMOTING UNDERSTANDING OF TRAUMATI
Introduction

•Female service members have experienced unprecedof combat exposure in U.S. wars in Afghanistan and Ira

•Women’s expanded role in the military•E i’ nem es’ i d ncreased use of guerilla warfare t ti ac cs

•Great deal of attention in the p po ular media, but so faempirical attention

•Most OEF/OIF studies thus far have not reported gender‐spanalyses, but this is changing changing•No in‐depth evaluation of gender differences in nature and 

combat experiences
Introduction

•Anecdotal Anecdotal evidence evidence indicates indicates that female OEF/OIF OEF/OIF se

se

members have experienced combat exposure at high 

•Some evidence that levels of combat exposure for OE

deployed women not that different from OEF/OIF‐dep

men

•45% women vs. 50% men in national sample reported somexposure (Jacobson (Jacobson et al., 2008)•Among Iraq‐deployed combat support troops (Hoge, Clark, 

2007):

•47% men vs. 36% women report firefights firefights

•15% men vs. 7% women report shooting at the enemy

•38% women vs. 29% men report handling human rema
Relevant Literature

•Women’s increased exposure to combat raises questiothere are gender differences in mental health conseque

combat exposure

•B d roa er lit t era ure i di t n ca es women are at hi hg er r

health problems following variety of traumatic even

Foa, 2006)

•Literature based primarily on noncombat traumas and csamples from prior cohorts•Effect smaller smaller when limited limited to combat trauma samples samples

•Some recent evidence that combat may impact wonegatively than men

•Focus on extreme ends of the combat and PTSD spectru
Current Study

•Focus of current study

•Examine gender differences in combat‐related stressor

sample of OEF/OIF OEF/OIF service service members members•Examine gender differences in combat stressor ‐ postd

mental health associations

•Study builds on prior research:

•Focuses on sample with sufficient dispersion in women

exposure for gender comparisons across comparable le

•More fine‐grained approach to conceptualizing comba

and ment l a h lth ea than most st di u es

•Application of sampling design and nonresponse bias w

produce results that are op y timally representative of the population•Attention to both statistical and clinical significance
Current Study

•Primary Hypotheses

•Men expected to report slightly higher exposure t

related stressors

•Combat‐related stressors expected to be more st

associated with p py ostdeployment mental health pr

women, but effect expected to be small
M hd et o

•National National sample of 340 female and 252 male OEF/OI

OEF/OI

within one year of returning from deployment (2009)

•Sample stratified on gender and Active Duty vs. NG/R

•Application of modified Dillman et al. (2009) approacsurvey data collection•Completed Completed mail surveys surveys received received from 57% of those 

have received survey materials
Sample Characteristics

•Background Characteristics

•Mean age at time of survey was 34 years (SD = 9)

•75% Caucasian, 18% African‐American, 9% other

•12% of the sample identified identified as Hispanic Hispanic or Latino

•42% Active Duty, 28% National Guard, 30% Reservist

•58% Army, 21% Air Force, 17% Navy, 4% Marines

•69% OIF, 31% OEF•88% still in military

•Several gender differences on demographic/military ch

•Female veterans slightly younger than male veterans•Male veterans more likely to be married

•Male veterans more likely to be living with children

•Men reported reported higher salaries salaries than women

•Men more likely to have served in Marines
Measures of C b om at‐Rl d e ate Stress

Combat Exposure Exposure: Traditional Traditional warfare warfare experiences experiences su

weapon, being fired on, going on missions and patrol

Aftermath of Battle: Exposure to consequences of co

including experiences such as observing human rema

dealing with prisoners prisoners of war/detainees war/detainees

Perceived Threat: Fear for one's safein the war zone, especially as respo

exposure to circumstances of comb

Difficult Living and Working Environ

Exposure to repeated or day‐to‐day 

pressures related to life in the war z
Measures of P dl ost eployment M l enta H 

Posttraumatic Stress Symptomatology: military vers

PTSD Checklist (PCL)

Depression and Substance Abuse: Two of the six Be

Symptom Identification Scale (BASIS‐24) subscales u

assess depression/functioning depression/functioning and substance substance abuseMental Health Functioning: The Veterans RAND Sho(VR‐12) used to assess the impact of mental health 

functioning
A lil na ytical Strategy

•Weighted Weighted analyses analyses in STATA software software package package to adjus

oversampling and nonresponse bias so that results cou

projected to the larger population population•Calculated means for all deployment stressor and menmeasures and independent samples t‐tests to evaluate 

differences
A lil na ytical Strategy ( ) cont.

•Hierarchical regression using transformed outcome va

evaluate gender differences in associations between co

stressors and postdeployment mental health

•16 potential interactions evaluated

•Accounted for effect of prior life stress exposure and emilitary military sexual harassment harassment to isolate isolate unique effects effects of c

exposure
Results

Women Men

S d V i bl

Mean SE Mean SE Mean Diff CI Diff 

Study Variables

Combat-Related Stressors

Combat Exposure 20.89 0.46 25.70 0.92 4.81 2.79 – 6.83 4

Exposure to Aftermath of Battle 22.57 0.68 25.92 0.95 3.35 1.05 – 5.65 2Perceived Threat 39.97 0.87 41.52 0.94 1.55 -0.96 – 4.07 1Difficult Living/Working Difficult Living/WorkingEnvironment 45.24 0.78 50.91 1.05 5.66 3.08 – 8.24 4

Other Stressors

Prior Life Stressors 2.97 0.21 2.30 0.22 -0.67 -1.26 – -0.8 ‐2Sexual Harassment/

Assault 8.95 0.23 7.34 0.12 -1.61 -2.12 – -1.09 ‐6Assault

* p < .05
Results

Women Men

Study Variables Mean SE Mean SE Mean Diff CI Diff 

Postdeployment Mental 

H lth ea

Posttraumatic StressSymptomatology 30.16 0.99 31.34 1.26 1.19 -1.96 – 4.33 Mental Health Functioning 40.58 0.65 40.68 0.68 0.10 -1.74 –1.95 Depression 0.96 0.06 0.95 0.07 -0.01 -0.20 – 0.17 Substance Abuse 0.25 0.03 0.47 0.06 0.22 0.09 – 0.35 

Note. *p < .05; † indicates X2 value
Results

Table 3Summary of Multiple Regression Analyses Predicting Postdeployment Mental Hea

VariablePosttraumatic Stress Symptomatology B CI B SE B 

Step 2§

Gender 0.04 -0.31 – 0.38 0.17 0C bt om a E i XG d Experiences X Gender 0 02 . -0 04 . – 0 07 . 0 03 . 0 Aftermath of Battle X Gender - 0.02 -0.06 – 0.02 0.02 -Perceived Threat X Gender 0.01 -0.03 – 0.04 0.02 0Difficult Living/Working Environment X Gender 

0.01 -0.02 – 0.04 0.02 0

§Step 1 and the main effects in Step 2 of each regression have been excluded from this table; *p < .05
Table 3 continued

SF-12 M t l H lth F ti i 12 Mental Health Functioning† B CI B SE B 

Step 2§

Gender - 0 04 . -0 25 . – 0 17 . 0 11 . Combat Experiences X Gender 0.02 -0.02 – 0.05 0.02 Aftermath of Battle X Gender - 0.02 -0.05 – 0.01 0.01 Perceived Threat X Gender 0.02 -0.00 – 0.04 0.01 Difficult Living/Working Environment X - 0.01 -0.03 – 0.01 0.01 Gender 

† Due to the transformation of the mental health functioning variable, all results should be interpreted in 

§Step 1 and the main effects in Step 2 of each regression have been excluded from this table; *p < .05
Table 3 continued 

Depression Depression B CI B SE B Step 2§

Gender 0.02 -0.04 – 0.08 0.03 Combat Experiences X Gender 0.00 -0.01 – 0.01 0.01 Aftermath of Battle X Gender - 0.01 -0.01 – 0.00 0.00 - Perceived Threat X Gender 0.00 -0.01 – 0.01 0.00 Difficult Living/Working Environment X 

Gender 

0.01 -0.00 – 0.01 0.00 

§Step 1 and the main effects in Step 2 of each regression have been excluded from this table; *p < .05
Table 3 continued

Substance Abuse Substance Abuse B CI B SE B Step 2§

Gender - 0.56 -1.18 – 0.06 0.32 Combat Experiences X Gender - 0.01 -0.10 – 0.07 0.04 Aftermath of Battle X Gender - 0.08* -0.14 – 0.01 0.03 Perceived Threat X Gender - 0.00 -0.06 – 0.06 0.03 Difficult Living/Working Environment X 

Gender 

- 0.00 -0.07 – 0.06 0.03 

§Step 1 and the main effects in Step 2 of each regression have been excluded from this table; *p < .05
Conclusions

•As expected, men reported slightly more exposure to t

objective warfare exposure variables

•Small effect suggests women’s exposure to these stres

only slig y htl lower than men’s exposure

•Highlights need for increased attention to women’s excombat‐related stressors in assessment and treatment 

OEF/OIF Veterans

•Other stressors stressors need to be considered considered as well
Conclusions

•Despite Despite lower combat exposure exposure, women reported reported sim

sim

perceived threat to what was observed for men

•Possible that women’s increased vulnerability to ot

stressors may have contributed to women’s percept

(e.g., MST)•In addition addition, given the nature of insurgency insurgency warfare warfare

of threat may not be limited to individuals in comba

•Also possible that the threshold for women to expis lower than for men
Conclusions

•Only one of 16 interactions achieved conventional levstatistical significance

•Revealed stronger negative association for men, not wome

•Null results difficult to interpret, inclusion of CIs and 

allowed evaluation of clinical significance

•CIs and effect sizes were small, indicating that lack of statistsignificance not due to problem with power

•Overall, findings suggests similar levels of resilience t

stressors for women and men

•Consistent with recent commentary by Hoge et al (2007), c

great equalizer of risk due to persistent level of threat
Future Directions

•Longitudinal study designs

•Cross‐sectional designs introduce possibility of retrospective 

•Replicate Replicate with clinician clinician‐administered administered measures measures

•Self‐report measures of mental health

•Examination across full deployment timeframe to assesterm outcomes

•Study limited to specific deployment period (2007‐2008) and within a year of return from deployment deployment
Take‐Home

•Both exposure to combat‐related stressors and associa

mental health in the year following return from deploym

more si il m ar than diff t eren for f l ema e and male OEF/OI

OEF/OI

members

•Contrasts with widely accepted view that women are m

vulnerable to trauma exposure than men

•Future research needed to promote better understandthat contrib contrib te u to similar similar le els v of resilience resilience to combat 

well as limits of phenomenon
For additional citations and/or more informati

please contact:

Dawne Vogt, PhD

Women’s Health Sciences Division

National National Center for PTSD (116B‐3)

Boston VA Healthcare System

150 South Huntington Ave.

Boston, MA 02130‐4893

Dawne.Vogt@va.gov

Note: This research was supported, in part, by a DVA Heal ht Servic

Development Service grant (IAC 06‐259‐2 Predicting Post‐Deplo

Health, Substance Abuse, and Service Needs; PI: Sue Eise
Presentation #2: Presentation #2:

The Role of Gender in the Ex

pe

of Veterans Deployed in Suppor

Wars in Afghanistan and IraWars in Afghanistan and Ira

Amy E. Street, Ph.D., 

Women’s Health Sciences Division

National Center for PTSD

VA Boston Healthcare System

Jaimie L. Gradus, Dsc, MPH

Hannah L. Giasson, B

A

Dawne Vogt, PhD

Patricia Resick, PhD

ADVANCING SCIENCE AND PROMOTING UNDERSTANDING OF TRAUMATI
The Role of Women in the

Global War on Terrorism

• The contribution of female service members in

OEF/OIF/OND OEF/OIF/OND is greater greater than in any other U S. .

conflict.

– Over 230 000 230,000 women have been deployed deployed to Afgha

Afgha

and Iraq representing 11.5% of U.S.

forces in these conflicts

– The scope of women’s roles in t t

warzone is broader than ever 
Not all Deployment Stressors are Com

Related

• Being female confers increased risk for

experiencing interpersonal stressors stressors d

deployment

– Sexual assault (Military Sexual Trauma)– Sexual harassment ( y Military Sexual Traum– Gender‐based harassment– Lack of support support from military military peers or lea

lea

Street, Vogt & Dutra. (2009) Clinical Psychology Review 
Sexual Trauma During Combat Deploym

Af h i t Afghanistan and Iraq

• Significant media attention and Veteran reports of 

trauma to healthcare providers

• Empirical data on experiences of sexual harassmen

assault in these war zones was slow in coming

• First publ h d is e study: 125,729 OEF/OIF Veteran us

Healthcare (14% female), using data draw from VA

electronic medical records

• Among the OEF/OIF cohort:

– 17 2%. women and .8% men experienced experienced sexual trauma

• Compared to Veterans of all cohorts:

– 21.4% women and 1.1% of men experienced sexual trau

Kimerling, Street et al. (2010). American Journal of Public Health
Exploring the Changing Role of Wo

in Tod ’ ay s Military

• Women’s changing roles in recent combat o

raises important questions‐

– What is the scope of women s’ exposure exposure to trau

trau

combat experiences?

– To what extent are women being exposed to ot

traumatic experiences, e.g., sexual trauma, du

deployment?

– Are women and men differentially impacted by 

the war zone?
The Women at War Survey

• A mail survey of OEF/OIF OEF/OIF Veterans Veterans designed designed 

answer questions with particular relevance 

women Veterans

• Women over‐sampled relative to their pres

OEF/OIF

• Men also sampled so that gender differenc

be tested

•Measurement focused on assessment assessment of a wide rang

deployment stressors and of mental health problems
The Women at War Survey: Sa

• Sampled from VA’s Environmental Epidemiology OEF

• Veterans who had separated from active duty military• V t e erans who served as A ti c ve D t u y and as R /G d eserves/Guard• Veterans who served over the entire period of service in O

• Followed Followed multiple multiple mailing mailing survey methodology methodology reco

reco

by Dillman (2009)

• Sample size: 2,344 (51% female)

• Response rate: 48.6%• Responders Responders generally generally similar similar to non‐responders responders, wit

exception of age

– Used non‐response bias sample weights in all analyses to a

differences
Military Service Characteri

Males

(n

= 1139)

Number of OEF/OIF OEF/OIF Deployments Deployments

* 1.44 (0.76

M (SD)

1.44 (0.76

Total Number of Months Deployed to OEF/OIF* 12.17 (8.45M (SD)Location of Deployment:

% dl d ep oye

d

t

o I * raq

* 68 7% 

% deployed to Afghanistan

% deployed to “other”*

68.7%14.7%28.4%

Military Occupation Specialty:

% served Combat

‐Arms*

% served Combat

‐Support*

33.2%44.7%

pp 

% served Service

‐Support* 20.8% 

* Denotes a significant difference between genders, p<.05
Question of Interest

1. How do male and female military personnel diffe

exposure exposure to deployment deployment stressors stressors in the war zon

‐Are women experiencing combat trauma? How much rela

their male counterparts?

‐Are women experiencing other types of “traditional” depl

stressors? How much relative to their male counterpa

‐Are women experiencing interpersonal traumas? How mu

relative to their male counterparts?

‐Do the data look different if you define “exposure to deplo

stressors” more liberally or more stringently?
Deployment Stressors: Liberally Def

* * * * 

8.7

(6.9,11)

1.2

(.90,1.6

1.4 

(1.1,1.7)

.73 

(.59,.89)

.62 

(.50,.76)

*Denotes significant difference between genders
Deployment Stressors: Conservatively 

** * * 

.23

(.18, .30)

.38

(.31, .47)

---

b

----

1.9

(1.6, 2.4)

.84

(.70, 1

*Denotes significant difference between genders

b Could not be estimated
Question of Interest

2. How do male and female OEF/OIF Veterans differ 

reports reports of mental health problems problems following following

deployment?

‐Are women and men similar similar or different different in the frequency frequency 

probable PTSD diagnosis?

‐Are women and men similar or different in the freq y uenc 

mental health conditions, like depression, anxiety and

problematic alcohol use?
Gender Differences in Mental Health C

* 

.87

(.70, 1.1)

1.3

(1.1, 1.6)

1.1

(.86, 1.3)

*Denotes significant difference between genders
Question of Interest

3. What are the gender specific associations betwee

deployment stressors and PTSD?

‐What is the association between combat stress and PTSD 

women? How about for men?

‐What is the association between harassment stress and P

women? How about for men?
Associations between Combat Stres

Probable PTSD, by Gender

Women 

Adj. Odds Ratioa

(95% CI)

1 Point Change in Combat Stress 1.06 (1.04, 1.07) 5 Point Change in Combat Stress 1.31 (1.24, 1.39) a Model adjusted for combined harassment stress score Model adjusted for combined harassment stress scoreb No confounders identified, aOR identical to OR
Assoc at o s iations bet ee w n Ha ass e t rassment St es

r 

Probable PTSD, by Gender

Women 

Adj. Odds Ratioa

(95% CI)

A

1 Point Change Harassment Stress 1.06 (1.04, 1.09) 5 Pit o n Change in H t arassment Stress 1 36 . (1 23 . , 1 52) . 

a Model adjusted for total unit support score and combined combat stress scoreb Model adjusted for rank and combined combat stress score
Conclusions

• In terms of deployment stressors‐

– Almost 75% of women were exposed exposed to some leve

and combat aftermath Æ most women are exper

in these war zones

– Men were more likely to report exposure to comb

stressors Æ not surprising given than many comb

closed to women

– When stringently defined, more women reported 

aftermath of battle experiences then traditional c

assessment of these experiences sh ld ou be i ld

nc u 

accurately capture women’s exposures

– Women were much more likely to report experien

experien

harassment Æ investigations that don’t include th

underestimating the stressor burden for female m

personnel
Conclusions

• In terms of gender‐specific post‐deployment m

health conditions‐

– Female and male Veterans report probable PTSD in 

equal numbers, just over 20% of both groups

– Associations between stressors and probable PTSD 

remarkably similar

– Gender differences differences in PTSD in the general general populati

populati

replicated in this cohort of OEF/OIF Veterans

– Perhaps similarities in women’s and men’s military

experiences override override pre‐existing existing vulnerabilities vulnerabilities

– Gender‐specific risk of PTSD is not absolute, but m

examined within different trauma exposed g p rou s

– Depression (for women) and alcohol use (for men) 

gender‐linked expressions of post‐deployment dist
There Are Many Questions

Still to Be Answered Answered

• More work examining examining these same questions questions in diffe

diffe

samples, with different measurment

• Understanding Understanding how women s women’s roles within their fam

fam

spouses, daughters, mothers) may be uniquely imp

• Examining Examining the process process of homecoming homecoming and reinteg

reinteg

whether this differs for men and women

• Understanding women’s unique risk/resiliency fact

deployment problems and identifying points of inte

• Evaluating gender differences in the effectiveness o

tt t rea ments to guide gender‐specific tt t rea ment mat 
In Cl i os ng...

• While our work focuses primarily on stressful eve

associated mental health problems, it’s importan

the larger context in mind

• There is no doubt that service in a war‐zone com

challenges

• But these women (and men) serve with pride an

serve because they chose to

• They are strong, capable and resilient

• And we should feel honored to serve them
Thank you for your attention and int

For more information contact:

Amy Street, PhD

amy street@va gov amy.street@va.gov

Funding Support: Funding Support:

This research was supported by the National CenteOffice of Mental Health Services, Department of Ve