Health Effects of Military Service on Women Veterans Evidence-based Synthesis Program 

APPENDIX 1. SEARCH STRATEGIES 

REPRODUCTIVE (8/4/2010) 

DATABASE SEARCHED & TIME PERIOD COVERED:

 PubMed – 1966-8/4/2010 

LANGUAGE:

 English 

SEARCH STRATEGY: 

reproductive OR reproduction OR pregnan* OR birth* OR fertility OR infertility OR infertile 

OR menstrual OR menstruation OR menses OR urinary tract OR sexually transmitted OR hiv 

OR cervical OR ovarian OR genital OR gynecologic* OR “Congenital Abnormalities”[Mesh] 

AND 

veteran*[tiab] OR veteran*[mh] OR military personnel 

AND 

female* OR women* OR woman OR gender OR women’s health 

================================================ 

OEF/OIF (8/2/2010) 

DATABASE SEARCHED & TIME PERIOD COVERED:

 PubMed – 1990-8/2/2010 

LANGUAGE:

 English 

SEARCH STRATEGY: 

veteran*[tiab] OR veteran*[mh] OR military personnel 

AND 

female* OR women* OR woman OR gender OR women’s health 

AND 

gulf war OR persian gulf OR “desert storm” OR iraq* OR afghanistan OR OEF OR OIF OR 

“enduring freedom” OR afghan 

============================================================= 

DATABASE SEARCHED & TIME PERIOD COVERED:

 PsycINFO – 1990-8/2/2010 

LANGUAGE:

 English 

SEARCH STRATEGY: 

veteran* OR military personnel 

AND

 female* OR women* OR woman OR gender 

26
 
Health Effects of Military Service on Women Veterans Evidence-based Synthesis Program 

AND
 

gulf war OR persian gulf OR “desert storm” OR iraq* OR afghanistan OR OEF OR OIF OR 

“enduring freedom” OR afghan 

Population Group: Female
 

Search modes - Phrase Searching (Boolean) 

=============================================================
 

DATABASE SEARCHED & TIME PERIOD COVERED:

 CINAHL (Cumulative Index to Nursing & Allied Health Literature) – 1990-8/2/2010 

LANGUAGE:

 English 

SEARCH STRATEGY: 

veteran* OR military personnel
 

AND
 

female* OR women* OR woman OR gender
 

AND
 

gulf war OR persian gulf OR “desert storm” OR iraq* OR afghanistan OR OEF OR OIF OR 

“enduring freedom” OR afghan 

Gender: Female 

Search modes - Phrase Searching (Boolean) 

=============================================================
 

DATABASE SEARCHED & TIME PERIOD COVERED:

 Social Science Abstracts – 1990-8/2/2010 

LANGUAGE:

 English 

SEARCH STRATEGY: 

veteran* OR military personnel 

AND 

female* OR women* OR woman OR gender 

AND 

gulf war OR persian gulf OR “desert storm” OR iraq* OR afghanistan OR OEF OR OIF OR 

“enduring freedom” OR afghan 

Search modes - Phrase Searching (Boolean) 

27
 
ce on Women Veterans Evidence-based Synthesis Program 

QUESTION #1 EVIDENCE TABLE

racteristics Sample Size Design/Objective Main Measures Main Findings 

Gulf War Vet

n-deployed 

 who were 

waii Birth 

m in 1989-

17,187 military infants of GWV and NDV in Hawaii were identified. 

Compare prevalence of selected congenital anomalies between: 1. GWV and NDV conceived 

before the war 

2. GWV and NDV conceived 

during or after war 

48 major birth defects prevalence among military births in Hawaii through the first year of life 

Prevalence of 48 selected birth defects was similar in NDV and GWV groups in conceptions that happened before the war and conceptions during and after the Gulf war. Among GWV infants, the prevalence of 48 selected birth defects did not differ among prewar and postwar conceptions. 

3. Prewar/postwar conceptions of GWV populationbased study Limitations: small numbers of case infants with birth defects- not enough statistical power for rare birth defects. 

Unable to evaluate role of maternal GWV exposure because small numbers of births in female GWV (165 births) in Hawaii. 

a and inpa

m military 

1,558 females Compare reproductive outcomes of Gulf War with postwar conceptions of women 

deployed and non-deployed. 

Adverse reproductive outcomes, spontaneous abortions, ectopic pregnancies 

Gulf War exposed conceptions and non-deployed conceptions had similar outcomes. However, Gulf War Veterans postwar conceptions were at increased risk of ectopic pregnancies and spontaneous abortions. 

Gulf War Vet

n-deployed 

 who were 

kansas, 

nia, Georgia, 

a Birth De

 population

ct registries, 

 11,961 military infants of GWV and 33,052 military infants of NDV registered in Arkansas, Arizona, California, Georgia, Hawaii and Iowa were identified. 

Determine prevalence of selected congenital anomalies between: 1. GWV and NDV conceived 

before the war 

2. GWV and NDV conceived 

during or after war 

3. Prewar/postwar conceptions of GWV populationbased study 

48 major birth defects prevalence among military births in Hawaii through the first year of life 

Higher prevalence of tricuspid valve insufficiency, aortic valve stenosis, and renal agenesis or hypoplasia in infants conceived to post war GWV men. Higher prevalence of hypospadias in infants conceived postwar to female GWV. Above persisted after adjustment for known risk factors and population differences. No difference in risk for any of combined 48 selected defects by deployment status. 

28
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

5 military GWV offspring To compare overall risk of Occurrence of birth • No increase in birth defects among children of 

993 • 30.151 live 

births born to 29,468 male GWV 

birth defects among offspring of GWV to offspring of non deployed Veterans (NDV) 

defects noted in the medical file. ICD-9-CM code related to congenital malformations 

GWV. 

• Prevalence of any birth defect was 7.45% for 

deployed Veterans and 7.59% for non-deployed Veterans (RR 0.98, 95% CI 0.93-1.03). 

• 32,638 live 

births born to 31,646 male NDV 

• 3,847 live 

births to 3722 women GWV 

• 8,825 live 

births to 8494 women NDVW 

• No significant association between service in the 

Gulf War and prevalence of any birth defect for male Veterans (OR 0.97, 95% CI 0.91-1.03) or female Veterans (OR 1.07, 95% CI 0.94-1.22). 

• The unadjusted OR for having an infant with 

severe birth defects was 1.03 (95% CI 0.92-1.15) for male active-duty Veterans, 0.92 (95% CI 0.71-1.20) for female active duty Veterans, and 1.00 (95% CI 0.90-1.10) for men and women combined. 

• Limitation: military facilities only. 

oyed female 46 Female Relationship between sexual This study Chronic fatigue is one of the most chronic 

 Veterans dysfunction in female Gulf evaluated sexual conditions reported by Gulf War Veterans. Includes 

 Jersey War Veterans female dysfunction 22 healthy subjects and 26 with fatigue. Female 

r Research in Veterans with sexual dysfunction was reported by 10% of control 

and without chronic and by 60% of those with fatigue (p value < .002). fatigue. 19% vs 81% (p value < .001) decrease in libido. 

erans in 

 during the 

65 through 

8,280 US women Veterans (4140 deployed, 4140 not deployed) 

Comparison of self-reported pregnancy outcomes among women Veterans who were deployed to Vietnam and those who were not 

Risk of having children with moderate to severe birth defects was significantly elevated among Vietnam Veterans. 

The risk of birth defects among index children was significantly associated with mother’s military service in Vietnam. 

erans in 

 during the 

65 through 

4,140 Female Structured telephone 

interview including history of gynecologic cancer 

The association between the risk of GYN cancer and military service in Vietnam 

Female Vietnam Veterans did not experience a higher prevalence of GYN cancer in the 30 years since the conflict. 

ns 11,441 Gulf War 

Veterans and 9476 control subjects 

Comparison of reproductive outcomes among US Gulf War Veterans and non-Gulf War Veterans 

Miscarriages and birth defects 

This survey suggests that female Gulf War Veterans report significantly higher rates of birth defects than do military control subjects. 

29
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

d Case Cases born Oct Population based Case control Association • No statistically significant associations between 

National Birth 1999 to Dec study- National Birth Defects between cohorts maternal or paternal military service and elevated 

on Study 2003. 150 cases Prevention Study (NBDPS) and active duty risk of selected birth defects. 

and 3 exposed cases 

birth over 30 major defects • Of the 35 birth defects presented, 5 exhibited adjusted odds ratios above 1.50: hydrocephalus, 

atrioventricular septal defects, anomalous pulmonary venous return, heterotaxia, and omphalocele – though not statistically significant. 

 statistically significant. None of the odds ratios 1.00 were

• Tricuspid atresia exhibited the highest crude 

odds ratio (2.03), but that decreased to 1.43 after adjustment for maternal age, race/ethnicity, and education. 

eployed to 

 

10,00 Female and 15,000 Male 

Literature review and analysis of VA and DoD health registries to determine healthcare use and needs of female Veterans 

Diagnoses and symptoms by gender 

This article found female health care needs to be similar to those of their male counterparts, with the exception of gynecologic issues. More data is needed, especially for determining long-term health care needs after deployment. 

d registries 

e Live born 

ldren born 

t to National 

 in two units 

sissippi from 

994 

54 children 6 mothers were Veterans (including one family with both parents Veterans) 

Data reviewed from 2 population based registries 1. Metropolitan Atlanta 

Congenital Defects Program 

2. Centers for Disease 

Controls’ Birth Defects Monitoring Program California Birth Defects Monitoring Program 

Birth Defects Still Births Deaths 

• The observed number of birth defects among 

was not greater than expected on the basis of population-based registries. 

• 3 cases of major birth defects, 2 cases of minor 

birth defects, No stillbirths, no deaths. 

30
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

 post Gulf 

oD Manpower 

525 Female Conducted a survey to collect 

demographic data, as well as physical and mental health data 

Multiple statistical analyses were used to describe women’s physical/ emotional health the two times point following the GW. 

525 women participated in the study following the war and again in a follow up study two years later (sampled from members of the Air Force: active, guard, or reserve). Measures included general physical health, gender specific health, “Gulf War Syndrome,” and PTSD. Multiple statistical analyses were used to describe women’s physical and emotional health at two time points following the war. Deployed female Veterans reported significantly more general and gender specific health problems than did women who were not deployed in that conflict. Findings from this study suggest the need for further study concerning gynecological and reproductive health. 

on-deployed 

terans 

2,233 female, 2,159 male participants 

Comparison of deployed and non-deployed Veterans surveyed on self-reported reproductive outcomes 

Reproductive outcomes (birth weight, number of pregnancies) 

• No difference in number of pregnancies, birth 

weight of infants. 

• Neither gender of deployed Gulf War Veterans 

significantly differed from non-deployed Veterans 

Adverse reproductive outcomes (ectopic pregnancies, stillbirths, miscarriages) 

in adverse reproductive outcomes. 

iofacial 

es (US and 

tched to 832 

atrician and 

years old 

2) 

Birth year of cases to controls were 1996-2002. There were 232 cases and 832 controls. Four mothers and 30 fathers served in the military, and 10 control mothers and 100 control fathers also served in the military 

Retrospective Case-control study Describe relationship between Hemifacial microsomia HFM) (Goldenhar syndrome) risk and parental military service (including Gulf War) 

Measure Gulf War Service that occurred between 5 and 11 years before pregnancy Odds ratio of risk of multi adjusted odds ratio of HFM in those serving in the Gulf war for five to 11 years before pregnancy. Association of gulf or military service with HFM 

• Mothers of 4 cases and 10 controls reported 

military service before and after pregnancy. 

• Neither military service overall or Gulf War 

Service was associated with HFM risk. Odds ratio for any parental military service was elevated- but not statistically significant. 

• Parental army service assoc with 2.4 fold increase 

of HFM- after adjusting for race, income, twin, and low body mass. (OR 2.4, 95% CI 1.4-4.2), parental GW army service (OR 2.8, 95% CI 0.8-9.6); 

• Association with any parent served in the Gulf War 

was not increased (OR 0.8, 95% CI 0.3-2.3). 

 in DoD 

ess 

Clinical 

ram at Tripler 

Center 

17 females, 16 served in Gulf War and 1 dependent of Gulf War Veteran 

Description of the sample’s treatments during the program and reproductive histories 

N/A Services and histories are described, with 8 Veterans 

experiencing gynecologic problems while serving in the Gulf, and 43% since returning in 1991. Six patients became pregnant after returning, with 1 patient suffering miscarriages. 

31
ce on Women Veterans Evidence-based Synthesis Program 

QUESTION 2 EVIDENCE TABLE

racteristics Sample Size Design/Objective Main Measures Main Findings 

male 

ombat arms 

n a NATO 

ssion to the 

perations that 

y, Bosnia

d Croatia 

Females 1,225 Males 2,114 

Observational; To examine the effects of stressor duration (deployment length) and stressor novelty (no prior deployment experience) on the psychological health of male and female military personnel returning from a peacekeeping deployment 

Correlations between demographics, deployment experience, and dependent variables by gender; length of deployment and mean scale score of depressive and posttraumatic stress symptoms by gender; deployment experience and mean scale score of depressive and posttraumatic stress symptoms by gender 

Longer deployments and 1st-time deployments 

were associated with an increase in distress scores. However, the relationship between deployment length and increased distress was found only for male soldiers. 

d OEF/OIF 

ervists, who 

rolled for 

he VA San 

e System 

battery of 

etween April 

6 

339 Observational; To 

more comprehensively characterize the OEF/ OIF mental health concerns, examining the relationship between demographic factors, military service characteristics, combat-related injury, and mental health symptoms 

Demographic and military service-related characteristics, mental health caseness, predictors of PTSD 

• A minority (36%) did not screen positive for 

mental health symptoms; the remainder met threshold for caseness of PTSD, depression, or substance and alcohol abuse. 

• Using a hierarchical logistic regression model, 

gender, age, race, and rank were not significantly related to PTSD caseness, whereas most recent branch of service and report of injury during combat were. 

• Follow-up analyses revealed that trauma history 

and combat exposure varied by branch of service. 

ons to 2 

s over a 5 

 a closed 

ad trauma 

ombat 

q 

Females 7 Males 401 

Observational; To describe a military hospital experience with severe closed and penetrating central nervous system trauma associated with conventional and unconventional warfare 

Primary measures include type of injury, mechanisms, initial Glasgow coma scale (GCS), discharge GCS score, admission injury severity score (ISS), total intensive care unit (ICU) days, Glasgow Outcome Scale scores at discharge, 6 months, and 1-2 years 

Most head injuries were male (98%), and most sustained penetrating brain injury with explosive blast accounting for the predominant mechanism of injury. The presence of CSF leak, vascular injury, and penetrating trauma resulted in higher ISS levels and ICU stays. (No gender specific results are reported.) 

32
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

mple of all 

 Veterans 

npatient VA 

ram for 

in a 3-year 

ic random 

ess men that 

 during same 

Females 310 Males 315 

Observational; (1) to study gender differences in predictors of readmission to inpatient drug treatment among homeless Veterans because VA medical centers currently do not have services that are designed specifically for women; (2) are 

Re-admission to inpatient drug treatment in a twoyear follow-up 

Sexual and physical abuse in childhood or during active duty in the military and during the past 2 years were most potent predictors of readmission for women than men. Women’s readmission was heightened by increases in depression, suicidal thoughts, and traumatic events. Women’s readmission was lessened by greater family, friend, church or other support. -Men’s readmission increased with greater substance abuse, aggression, and cognitive impairment. Men’s readmission decreases with employment stability and job satisfaction. 

abuses at different stages of life span, combat exposure, and recent traumatic events commensurate predictors, do employment, housing, family or friend relationships and spirituality mediate (3) or moderate (4) relationships between trauma and relapse. 

of Veterans 782,789 Observational; To Odds of utilizing mental • Younger women Veterans (<35 years old) were 

tpatient compare gender health and specialty significantly less likely and older women (≥35) 

 in FY99 differences in mental mental health services more likely to use any mental health services in 

 mental health disease burden by gender, age, and comparison with their male counterparts. 

ce abuse (SA) 

and outpatient mental health utilization among Veterans utilizing Veterans Health Administration (VHA) mental health 

diagnostic category • Similar findings were observed for younger 

women diagnosed with SA or mood and anxiety disorders, but not among Veterans with PTSD or bipolar and psychotic disorders, among whom there were no gender or age differences. 

services • In the case of specialized services for SA or PTSD, 

women younger than 55 with SA or PTSD were significantly less likely to use services than men. 

• Women Veterans underutilized specialty mental 

health services in relation to men but receipt of mental health care overall in FY99 varied by age and diagnosis. 

33
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

of Veterans 

VA healthcare 

 7, 2001 and 

 followed until 

249,440 Observational; To 

compare utilization across three groups of Iraq and Afghanistan Veterans: those without mental disorders, those with mental disorders other 

Variations in utilization of VA non-mental health services by mental health diagnoses 

• Veterans with mental disorders had 42-146% 

greater utilization than those without mental disorders, depending on the service category (all p<0.001). 

• Those with PTSD had the highest utilization in all 

categories: 71-170% greater utilization than those without mental disorders (all p< 0.001). 

than PTSD, and those with PTSD 

• In adjusted analyses, compared with Veterans 

without mental disorders, those with mental disorders other than PTSD had 55% higher utilization of all non-mental health outpatient services; those with PTSD had 91% higher utilization. 

• Female sex and lower rank were also 

independently associated with greater utilization. 

e and male 

ing Freedom 

ation Iraqi 

Veterans 

re services in 

Females 240 Males 1,380 

Observational; To examine gender differences in the utilization of VA outpatient health care services 

Outpatient VA service use included basic care (e.g., primary care, mental health, or specialty care). Initiation of care was defined as one visit or more to outpatient care after return from deployment and intensity of utilization was defined as the total number of outpatient visits during the study period. 

Women were more likely to be younger, single, and non-white compared to men. Women were more likely to use outpatient care services (OR 1.47, 95% CI 1.09, 1.98), but once initiated, frequency of visits over time did not differ by gender (incident rate ratio [IRR] 1.07, 95% CI 0.90, 1.27). 

 use screening N/A Clinical Practice Not applicable Potential benefits include more effective and 

umatic stress Guideline; comprehensive care to a growing female population 

ic brain To provide nurse with a history of military service seen for routine 

ry sexual practitioners with a care. Brief screening instruments can help providers 

ilian setting brief screening tools formulate accurate diagnoses of service related 

to be used during conditions with appropriate treatment and referral. routine office visits to assist with accurate identification of post military health concerns 

34
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

ample of 

 Veterans 

Program of 

er (NEPEC) 

ught treatment 

alized program 

rved in a war 

 1 of 3 recent 

Total 36,413 (Sex not specified) 

Observational; To compare current Iraq/ Afghanistan Veterans with 4 samples of outpatient and inpatient Persian Gulf and Vietnam Veterans 

Socio-demographic characteristics, traumatic exposures (i.e., receiving hostile/friendly fire, participating in atrocities, and witnessing atrocities without participating), and clinical status including 

Recent Iraq/ Afghanistan Veterans differed most notably from Vietnam Veterans by being younger, more likely to be female, less likely to be married or separated/divorced, more often working, less likely to report exposure to atrocities in military. Iraq/Afghanistan Veterans less often diagnosed with substance abuse disorders, manifested more violent behaviors, and had lower rates of VA disability compensation because of PTSD. 

of Veterans Females 18,481 Observational; Measures included pain No significant difference was present for the 

oster from 

wer Data 

g all personnel 

US Military 

 1, 2001 

 2007 who 

ervices 

are before 

Males 134,731 To evaluate sex 

differences in the prevalence, severity, and persistence of pain among OEF/ OIF Veterans seen at VA outpatient clinic visits during the year after returning from deployment 

numeric rating scores recorded at all outpatient visits, defined moderate to severe pain as >/= 4 rating, persistent pain defined as 3 or more pain scores >/= 4 recorded in at least 3 different months, ICD-9 codes for diagnoses of PTSD or depression if codes occurred on two or more outpatient visits, and demographic data 

probability of pain assessment by sex in bivariate and regression analysis (RR 0.98, 95%CI 0.96, 1.00). Female Veterans were less likely to report any pain compared to male (RR 0.89, 95%CI 0.86, 0.92). Among those with pain, female Veterans were more likely to report moderate-severe pain (RR 1.05, 95%CI 1.01, 1.09) and less likely to have persistent pain (RR 0.90, 95%CI 0.81, 0.99). When stratified by diagnosis, Veterans with depression or PTSD were more likely to be assessed for pain (p<.0001). However, there was no significant difference in the proportion of Veterans assessed for pain by sex in those with PTSD and depression (p>.05 in both cases). 

of Veterans 

or alcohol use 

 1, 2006, and 

007, and under 

Females 2,009 Males 10,083 

Observational; To evaluate the recognition and management of alcohol misuse in OEF/OIF Veterans enrolled in the VA system 

Alcohol Use Disorders Identification Test Consumptions questions (AUDIT-C 10 question); military service information; documentation of brief intervention, referral, and completed referral for treatment 

Age-specific and total prevalence of alcohol misused was higher for younger OEF/OIF men vs. non OEF/ OIF men. Rates of alcohol misuse were lower in both OEF/OIF and non OEF/OIF women. No significant difference was observed in the prevalence of alcohol misuse between OEF/OIF and non OEF/OIF women. 

d sample of Total 42,174 Observational; To Disordered eating from Women deployed with combat exposures were 

d military (Sex not specified) investigate disordered 8 question survey from 1.78 times more likely to develop disordered eating 

 on rosters eating levels before the Patient Health (95%CI 1.02, 3.11) and 2.35 times more likely to lose 

00 from and after deployment Questionnaire, weight an extreme amount of weight (95%CI 1.17, 4.70). 

ort Study to determine the change from baseline to 

prospective association follow up by self-report, between stressful demographics and military life events and the data development of eating disorders 

35
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

s aged 18 

rom the 

o 2006 

 Death 

m 

28,534 Observational; To 

examine the rate, prevalence, and relative odds of firearm use among Veteran suicide decedents in 

Total and firearm specific suicide rates by gender, Veteran status, and age groups 

• Across the age groups, male and female Veterans 

had higher firearm suicide rates than non-Veterans. 

• Among males and females, younger Veterans (18-

34 years) had the highest firearm and total suicide rates. 

the general population • The male and female Veteran suicide decedents 

were, respectively, 1.3 and 1.6 times more likely to use firearms relative to non-Veterans after adjusting for age, marital status, race, and region of residence. 

• Although violent death and use of firearms 

are generally associated with men, the results reported here suggest that firearms among female Veterans deserve particular attention among health professional within and outside the Veterans Affairs system. 

eployed 

 from OEF/ 

Females 32 Males 183 

Observational; To gather psychometric information on the newly developed Post-Deployment Readjustment Inventory (PDRI); validity testing 

PDRI global scale and 6 subscales, General information form, Brief Symptom Inventory (BSI), Posttraumatic ChecklistMilitary version (PCL-M), demographics, and 5 items assessing exposure to war stressors: MST; being injured; and witnessing others injured or killed 

The PDRI was highly correlated with the BSI, the PCL-M, and the items for substance abuse. Exposure to war events, scores of readjustment and symptoms were compared across gender. Overall MANOVA was not significant. However, they differed on type of exposure. Women reported a higher rate of MST than men, and men reported higher rate of witnessing others injured or killed than women. 

ectional 

e Veterans 

l Registry of 

 stratified by 

d of service, 

nd non-black) 

Females 1,496 Observational; To 

investigate the effects of military sexual assault and combat exposure on women Veterans’ use of Veterans Health Administration (VHA) services and perceptions of VHA care. 

Military sexual assault history, combat exposure, use of VHA services, satisfaction with VHA services 

Women Veterans with histories of military sexual assault reported more use of VHA services, but less satisfaction, poorer perceptions of VHA facilities and staff, and more problems with VHA services compared to women Veterans without histories of sexual assault. Combat exposure was related to more problems with VHA staff, although few other differences were observed for women with and without histories of combat exposure. 

36
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

n referred to a Females 1,298 Observational; Survey items completed Women referred for LUTS evaluations had higher 

r urinary tract 

compared to 

ary care clinic 

center 

To characterize the association of psychiatric comorbidities and sexual trauma with lower urinary tract symptoms (LUTS) 

included the Incontinence Impact Questionnaire-7 to assess quality of life and Urogenital Distress Inventory -6 to assess symptoms, sexual trauma screening, pregnancy and birth histories, and psychiatric co-morbidities. 

rates of psychiatric co-morbidities (64.5% vs. 25.9%, p<.001) and sexual trauma (49.6% vs. 20.1%, p<.001) compared to women in primary care. Stepwise multivariate regression demonstrated that higher UDI-6 scores associated with age<50 and history of miscarriage, while higher IIG-7 scores associated with psychiatric co-morbidities and history of miscarriage. 

data from 

sectional 

 Paralyzed 

rica (PVA) 

SCI&D 

rom the CDC 

 Risk Factor 

tem (BRFSS) 

n-SCI&D 

p 

Females 593 Observational; To 

compare disease prevalence and preventive service use among female Veterans in general and those with spinal cord injuries and disorders (SCI&D) 

Disease/condition prevalence (asthma, diabetes, myocardial infarction, stroke, coronary heart disease, high blood pressure, high cholesterol, tooth decay/gum disease, injuries), health status (general health, physical and mental health), and use of preventive services (cholesterol check, dental care, influenza and pneumonia vaccinations, colon screening, breast and cervical cancer screening) among women Veterans with and without SCI&D 

Female Veterans with SCI&D were similar in age and race but were better educated and less likely to be employed than female Veterans in general. Coronary heart disease (CHD) prevalence was higher in those with SCI&D (17% vs. 8%, p < 0.0001). Health status was lower in SCI&D (27%) than in general female Veterans (41%), p = 0.002. Fewer women with SCI&D, than female Veterans in general reported having received recommended dental care (56% vs. 69%, p=0.004), colon screening in prior 5 years (59% vs. 72%, p = 0.023) or prior 10 years (67% vs. 92%, p < 0.0001), mammogram (84% vs. 91%, p = 0.019), and Pap smear (88% vs. 98%, p < 0.0001). There were no differences in receipt of respiratory vaccinations or cholesterol screening. 

37
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

inal cord 

rders (SCI&D) 

e Spinal Cord 

istry (SCD-R) 

Total 8,983 98% male 

Observational; To describe inpatient and outpatient health care utilization of Veterans with SCI&D; to determine whether health care utilization patterns differ based on residing longer or shorter distances from sources of care; to determine if VA facility closest to patient is bypassed in order to receive care at another VA facility 

Utilization defined as any inpatient or outpatient health care services, history of illness (defined as 1 hospitalization in the prior year), travel distance between the zip code center to the VA facility used, and travel distance to the nearest VA 

Patients used OP services less frequently when VA facilities were farther away from their residences. Male Veterans with SCI&D were less likely than females Veterans to utilize OP care (p<.0000). Being male reduced the number of OP visits by 27%. 

rs with 

njury (war 

n war 

ed to one VA 

or physical and 

rapy between 

and December 

Females 10 Males 109 

Dissertation/ Observational; To identify which variables are most associated with therapy intensity and functional clinical outcomes in war wounded traumatic brain injury soldiers from OEF/OIF 

Therapy intensity was measured in terms of duration, functional independent measure (FIM), FIM change and FIM efficiency, Severity of injury and TBI polytrauma/blast comorbidities 

War wounded TBI patients had lower admission FIM scores (M = 77.09, SD = 41.55), admission Mobility FIM scores (M = 21.66, SD = 12.85) and spent longer time between initial injury and admission to rehabilitation (M = 92.81, SD = 110.80) than the non-war wounded admission FIM scores (M = 68.18, SD = 32.23), admission Mobility FIM scores (M = 19.00, SD = 10.78), and shorter time between initial injury and admission to rehabilitation (M = 57.58, SD = 63.91). (No specific findings were given by gender. Gender was used in models.) 

38
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

h inpatient or 4,670,968 Observational; To Mortality ratios for • Overall, for men and women combined, suicide 

es utilization 

ity during 

or fiscal year 

from the 

Patient Care 

examine suicide rates among VHA patients and compare them with rates in the general population 

suicide risks among VHA patients for age and gender subgroups compared with those in the general US population 

risks among VHA patients were 66% higher than those observed in the general US population. 

• VHA rates were 43.13/100,000 person-years for 

men and 10.41/100,000 person-years for women. 

• For male patients, the age-adjusted standardized 

mortality ratio was 1.66; for females, it was 1.87. 

• Male patients aged 30-79 years had increased 

risks relative to men in the general population; standardized mortality ratios ranged from 2.56 (ages 30-39 years) to 1.33 (ages 70-79 years). 

• Female patients aged 40-59 years had greater risks 

than did women in the general population, with standardized mortality ratios of 2.15 (ages 40-49) and 2.36 (ages 50-5 years). 

e members 

ir PDHA 

ts to OIF/OEF 

Females 1,061 Males 7,777 

Dissertation/ Observational; To identify the health concerns and symptoms that changed, during and after deployment and predicted repeat PDHA 

Post Deployment Health Assessment (PDHA), and demographics 

Results yielded significant values for age, gender, service, and length of deployment with changes in health concerns. Females were less likely than males to report health changes (OR 0.542, 95%CI 0.470, 0.626). There was a significant correlation between service members that were female (r=.26, p=.013); had shorter deployments (r=-.050, p=.000); and were older (r=.28, p=.009) for increased changes in their second PDHA. Change in health symptoms occurred for 12 of 19 symptoms measured. 

female 

uthern 

edical Center 

Females 36 Observational; To 

examine the rates of co-morbid PTSD and substance abuse in an all-female OEF/ OIF Veteran sample, and to investigate the differences in substance abuse in women screening positive vs. screening negative for PTSD 

Alcohol Use Disorders Identification Test (AUDIT 10) for alcohol screening, Drug Abuse Screening Test (DAST), the Davidson Trauma Scale (DTS) to measure PTSD symptomatology, demographics, discharge type, and screening items for exposure to combat and problems with alcohol 

Thirty-one percent (11) of this small sample of OEF/ OIF female Veterans screened positive for PTSD symptoms, 47% (17) screened positive for high-risk drinking and 6% (2) screened positive for drug abuse. Alcohol and drug misuse were both good predictors of PTSD symptoms. Increase awareness and screening for both PTSD and alcohol problems in female Veterans is paramount. 

39
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

 of Iraq and 

 completed an 

 the study 

50 Observational; To 

examine the mental health needs and barriers to mental health service use specifically for female Veterans of the wars in Iraq and Afghanistan 

Combat exposure and mental health symptoms, mental health services utilization, comparisons between treatment seeker and non-treatment seekers, barriers to seeking mental health services in the VA system 

• The most frequently reported concerns for which 

participants indicated they needed counseling were depression, relationship issues, anxiety, and anger management. 

• Although 78% of respondents reported that they 

felt they needed treatment in the past year, 42% of these individuals indicated that they did not seek counseling. 

• Two commonly reported barriers to seeking mental 

health services in the VA were long waiting periods for appointments and prior bad experiences. 

• Mental health concerns and symptoms of returning 

female Veterans indicate the need for treatment, but a significant gap remains in the self-reported need for assistance and seeking of services. 

ecutive 

s who were 

ed to the 

nal Medical 

in Germany 

of operations 

chiatric 

 November 4, 

0, 2004 

1,264 Descriptive; To 

characterize the demographic and clinical information of OEF and OIF military personnel who were psychiatrically evacuated from the theater of operations 

Demographic and administrative characteristics, psychiatric diagnoses 

• When compared with all returned OEF/OIF 

Veterans, psychiatric evacuees were more likely to be: female, under the age of 31 years, AfricanAmerican or Hispanic, enlisted and National Guard/Reserve. 

• Over 80% of patients were evacuated during the 

first 6 months, compared with 17% during the second 6 months of deployment. 

• The most common diagnostic categories were 

adjustment disorders (37.6%), mood disorders (22.1%), personality disorders (15.7%) and anxiety disorders (15.4%); 16.5 % received no psychiatric diagnosis. 

• Only 5% of evacuees returned to OEF/OIF duty. • Almost half of evacuated patients received no 

diagnosis or no adjustment disorder diagnosis, suggesting clinical improvement since a decision for evacuation was made. 

40
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

terans who 

sers of VA 

their OIF and 

vice from 

ough March 

289,328 Observational; 

To investigate longitudinal trends and risk factors for mental health diagnoses among Iraq and Afghanistan Veterans 

Prevalence of mental health diagnoses 

• Of 289,328 Iraq and Afghanistan Veterans, 106,726 

(36.9%) received mental health diagnoses; 62,929 (21.8%) were diagnosed with PTSD and 50,432 (17.4%) with depression. 

• Adjusted 2-year prevalence rates of PTSD increased 

4 to 7 times after the invasion of Iraq. 

• Active duty Veterans younger than 25 years had 

higher rates of PTSD and alcohol and drug use disorder diagnoses compared with active duty Veterans older than 40 years (adjusted relative risk = 2.0 and 4.9, respectively). 

• Women were at higher risk for depression than were 

men, but men had over twice the risk for drug use disorders. 

• Greater combat exposure was associated with higher 

risk for PTSD. 

up of OEF and 

o received VA 

ces between 

d March 31, 

84,972 Observational; To 

evaluate OEF and OIF Veterans’ utilization of VA mental health services, looking at 3 main factors: predisposing, enabling, and need factors 

VA mental health services utilization and the intensity of VA mental health services utilization 

• Of 49,425 Veterans with newly diagnosed PTSD, 

only 9.5% attended 9 or more VA mental health sessions in 15 weeks or less in the first year of diagnosis. 

• Engagement in 9 or more VA treatment sessions 

for PTSD within 15 weeks varied by predisposing variables (age and gender), enabling variables (clinic of first mental health diagnosis and distance from VA facility), and need (type and complexity of mental health diagnoses). 

• Only a minority of Iraq and Afghanistan Veterans 

with new PTSD diagnoses received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis. 

 (and their Females 72 Observational; To Partner treatment Although large majorities of partners rated individual 

who served perform an initial experiences and ratings of (64%) and family therapy (78%) to help cope with 

War, had needs assessment of treatment needs; partners’ PTSD in the family as extremely or very important, 

TSD and partners of Vietnam assessment of her need for only 28% had received any mental health care in the 

d disability Veterans with combat- individual treatment and previous six months. Significant predictors of desire 

ipated in the related post-traumatic the partner’s appraisal of for individual treatment included partner’s anxiety and 

and current stress disorder (PTSD) family treatment being patient-partner contact, and partner’s age and severity 

h a female and to assess the extremely important (yes/ of the patient’s PTSD symptoms were significant 

 from two VA partners’ current rates no). predictors of family treatment. The most commonly 

of treatment use. requested service was a women-only group. 

41
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

bases were 

Veterans 

bstance 

d Veterans 

se disorders 

y care but not 

Females 247 Males 8,082 

Observational; To investigate gender differences among Veterans receiving intensive outpatient (IOP) substance use treatment in a national VA sample and to compare women attending IOP with women with substance use disorders in VA primary care. 

Psychiatric and medical conditions that co-occur with substance use disorder 

Stigma was portrayed as a major disadvantage to treatment seeking. Yet most participants indicated that people would be supportive of treatment seeking. Reducing symptoms was a major advantage to care. Barriers included pride, not being able to ask for help, and not being able to admit to having a problem. 

w on gender

mong OEF/ 

rans 

N/A Systematic review/ 

meta-analysis; To highlight emerging issues relevant to the development of PTSD among women deployed to Iraq and Afghanistan 

Combat experiences in Iraq and Afghanistan, sexual assault and sexual harassment, exposure to other interpersonal stressors, the role of premilitary and postmilitary interpersonal trauma, homecoming readjustment 

Women are approximately twice as likely as their male counterparts to be diagnosed with PTSD. However, there are also indications that the gender-specific risk of PTSD differs substantially by type of traumatic event. 

e first panel 

ohort Study 

completed 

ow-up 

nd met 

 

40,219 Observational; To 

investigate relations between deployment and new-onset depression among US service members recently deployed 

Comparison of new-onset depression by deployment status and gender 

• Deployed men and women with combat exposures 

had the highest onset of depression, followed by those not deployed and those deployed without combat exposure. 

• Combat –deployed men and women were at 

increased risk for new-onset depression compared with nondeployed men and women (men: adjusted oddos ration [AOR]=1.32; 95% CI=1.13, 1.54; women: AOR=2.13; 95% CI=1.70, 2.65). 

• Conversely, deployment without combat exposures 

led to decreased risk for new-onset depression compared with those who did not deploy (men: AOR=0.66; 95% CI=0.53, 0.83; women: AOR=0.65; 95% CI=0.47, 0.89). 

42
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

oldiers 

eptember 

September 

ugh December 

473,964 Observational; To 

examine the magnitude and characteristics of mental disorder hospitalizations among 

Relative risks of mental disorder admissions in OIF and in OEF, attempted suicide/self-inflictedrelated admissions 

• There were a total of 1,948 psychiatric 

hospitalizations of deployed soldiers. 

• The most common mental problems were mood, 

adjustment, anxiety disorders (including PTSD). 

U.S. Army soldiers deployed in Iraq and Afghanistan through December 2004 

• Relative risk (RR) of mental disorders ranged from 

1.6 to 3 for females and 2 to 6 for enlisted soldiers compared to their counterparts. 

• Younger soldiers had 30-60% higher substance 

abuse disorders. 

• Combat units in Iraq demonstrated higher risk 

of any mental disorder and anxiety problems compared to combat support units. 

• Younger women had the highest incidence of 

attempted suicide/self-inflicted injuries. 

from the 

egistry for 

RDEP) from 

September 30, 

807,694 Observational; To 

report clinical and demographic factors associated with suicide among depressed 

Suicide, and association with patient age, race, gender, substance abuse diagnosis, diagnosis of PTSD, Hispanic ethnicity, 

• Of 807,694 Veterans meeting study criteria, 1683 

(0.21%) committed suicide during follow-up. 

• Increased suicide risks were observed among male, 

younger, and non-Hispanic White patients. 

Veterans in an attempt to determine what characteristics identified Veterans at high risk for suicide 

treatment location, prior VA hospitalization, service connection, and baseline medical comorbidity. 

• Veterans without service-connected disabilities, 

with inpatient psychiatric hospitalizations in the year prior to their qualifying depression diagnosis, with comorbid substance use, and living in the southern or western United States were also at higher risk. 

• Posttraumatic stress disorder (PTSD) with 

comorbid depression was associated with lower suicide rates, and younger depressed Veterans with PTSD had a higher suicide rate than did older depressed Veterans with PTSD. 

• Unlike the general population, older and younger 

Veterans are more prone to suicide than are middle-aged Veterans. 

43
ce on Women Veterans Evidence-based Synthesis Program 

racteristics Sample Size Design/Objective Main Measures Main Findings 

alization 

r casualties 

RANSCOM 

Command and 

on system 

 Joint Patient 

ation (JPTA) 

branches 

 Forces in 

ons 

Females 1,305 Males 11,766 

Observational; To describe the distribution of evacuated wounded in action (WIA) and Disease and Nonbattle Injury (DNBI) casualties sustained during the Major Combat Phase (OIF-1) and the Support and Stability Phase (OIF-2) of OIF involving the US Army and Marines 

Primary ICD-9 diagnoses, gender, service were obtained, and casualties were classified as WIA or DNBI, subcategories of ICD-9 diagnoses were also created 

The majority of casualties were DNBI (75%), Army personnel (83.5%) and were male (90%). Disease and nonbattle injury ICD-9 distributions differed by gender. The proportion of nonbattle injuries was significantly higher among men. Subcategories more common among women than men included neoplasms, mental disorders, diseases of the blood, respiratory, and genitourinary symptoms. 

44