Introduction
Traumatic experiences that military personnel encounter during their profession predispose them to posttraumatic stress disorder (PTSD). Research has shown that PTSD that military personnel experience in their lives emanates from cumulative stressors of pre-deployment, deployment, and post-deployment experiences (Fisher, 2008, p. 50; Fullerton, & Ursano, 2004, p. 1374). The traumatic experiences that military personnel undergo determine the nature and extent of PTSD that they develop in their lives. Although both male and female veterans develop PTSD, recent studies have shown that there is a differential occurrence of PTSD in terms of gender (Tull, 2009, p. 16; Fullerton, & Ursano, 2004, p. 1374). In addition to traumatic experiences of the military, female veterans experience trauma due to sexual abuse. Tull (2009) argues that female veterans who have experienced sexual abuse are more predisposed to PTSD as compared to other traumatic experiences (p. 2). Since female veterans have high chances of sexual abuse in the military, they are more susceptible to PTSD than male veterans are. Hence, female veterans experience military sexual trauma (MST) in addition to the traumatic experiences of their profession. This means that MST contributes significantly to the increasing incidences of PTSD among female veterans. Therefore, how does PTSD associate with MST among female veterans, and what are the implications of MST in healthcare?
Posttraumatic Stress Disorder
PTSD is a psychological disorder that results from traumatic experiences that people encounter in the course of life. Traumatic experiences such as witnessing ordeal deaths, death threats, sexual abuse, and living in a humiliating environment create anxiety that ultimately leads to PTSD when one is unable to endure and cope with challenges in life. According to the National Institute of Mental Health (2011), PTSD causes a person to re-experience past trauma through nightmares and flashbacks that occur frequently for more than a month and interfere with normal psychological functions (p. 4). PTSD impairs psychological functions and disables the mental and physical ability of a person. Moreover, PTSD interferes with the normal life of a person as it results in loss of interest in activities, pessimism, fatigue, insomnia, irritability, persistent aches, and feelings of hopelessness amongst other symptoms.
Since PTSD reflects past experiences of a person, psychotherapists study past traumatic experiences so that they can customize appropriate therapy that suits the needs of a patient. In the case of the military, traumatic experiences that relate to war, sexual abuse, family, and environment predispose military personnel to PTSD. According to Fullerton and Ursano (2004), PTSD can occur due to psychological trauma, neuroendocrinology reaction, neuroanatomy anomaly, and genetic variation (p. 1375). The psychological trauma that emanates from psychological and physically traumatic experiences predisposes one to PTSD. For instance, traumatic experiences of war, rape, torture, and working environment trigger development trauma that cumulatively leads to PTSD. In neuroendocrinology reaction, biochemical changes in the brain affect neurotransmissions and subsequently result in posttraumatic stress disorder. Congenital defects such as neuroanatomy anomaly and genetic variation also contribute to the occurrence of posttraumatic stress disorder.
MST and the Relationship with PTSD in Military Women
Sexual abuse or assault has been increasing in the past two decades in the United States military. This upward trend has prompted researchers to establish its causes and consequences to female veterans. Numerous studies have established that military sexual trauma, due to sexual assault, is one of the key factors that predispose female veterans to PTSD (Suris, & Lind, 2008, p. 260; Zinzow, Grubaugh, Monnier, & Frueh, 2007, p. 388). Statistical studies have shown that the occurrence of PTSD has gender orientation in that, the greater percentage of female veterans suffers from PTSD as compared to their male counterparts (William, & Bernstein, 2010, p. 142; Skinner, Kressin, Frayne, 2000, p. 303). Gender disparity in the occurrence of PTSD is attributable to higher incidences of sexual assault in female veterans than in male veterans. Williams and Bernstein (2010) assert that sexual assault among female veterans in the United States causes military sexual trauma, which contributes to the development of PTSD (p. 142). It means that MST is a crucial factor that contributes to increasing incidences of PTSD among female veterans.
Earlier, there has been inadequate research regarding gender occurrence of PTSD but increasing incidences of sexual abuse have led to the realization that MST could be a factor that determines the differential occurrence of PTSD in men and women veterans. Himmelfarb, Yaeger, and Mintz (2006) argue that female veterans are more susceptible to PTSD as compared to men since women have additional trauma due to MST (p. 839). Therefore, MST that female veterans experienced during their duties adds to traumatic experiences of life and predisposes them to develop posttraumatic stress disorder. Although women are working exceptionally hard to expand their roles in the military, increasing cases of sexual abuse and subsequent development of PTSD is threatening their significant contribution in the military because MST correlates with the occurrence of PTSD among female veterans.
Overall, numerous research findings have shown that MST is a significant factor that predisposes female veterans to PTSD. MST that emanates from experiences such as rape, sexual harassment, and other kinds of sexual abuse traumatize women, and thus cumulative experiences of sexual assaults ultimately result in the development of posttraumatic stress disorder. Chaumba and Bride (2010) argue that MST is an issue that affects female veterans by making them prone to PTSD and other types of depressions (p. 293). Therefore, MST in female veterans correlates with the occurrence of posttraumatic stress disorder, meaning that it is one of the principal factors that determine gendered occurrence and prevalence of PTSD among military personnel.
Prevalence of PTSD and MST in Military Populations
Currently, over 200,000 women have joined the United States military and form approximately 14% of the military population. An increasing population of women in the military has led to new dynamics of PTSD because gender difference exists. The expansion of women’s roles into the military has predisposed them to more traumatic experiences than usual, which has contributed to the development of PTSD among women. Thus, MST considerably predisposes women to PTSD because women have high incidences of sexual abuse as compared to their counterparts. According to Society for Women’s Health Research (2010), the prevalence of PTSD among the American population is 2.6%, while among military veterans is 17% (p. 2). High incidences of PTSD among military veterans indicate the nature of traumatic experiences that are present in the military profession. Hence, traumatic experiences such as shootings, bombings, deaths of friends, and harsh environments traumatize military personnel and subsequently make to develop posttraumatic stress disorder, if they do not receive appropriate therapy to help them cope with cumulative trauma.
Epidemiologically, there is significant gender disparity in the occurrence of MST. Female veterans have high incidences of MST as compared to male veterans because they experience greater numbers of sexual abuses. According to Hyun, Pavao, and Kimerling (2009), data collected by the Veterans Health administration shows that about 21.5% of women had military sexual trauma, while about 1.1% of men had experienced MST (p. 1). Such disparity in the prevalence of MST among military personnel shows that sexual abuse severely affects women by predisposing them to posttraumatic stress disorder. MST explains why females have high incidence rates of posttraumatic stress disorder. Moreover, it provides a basis where psychotherapists can focus on helping female veterans to cope with their traumatic experiences and alleviate or prevent the occurrence of posttraumatic stress disorder.
MST is a significant factor that predisposes female veterans to posttraumatic stress disorder. A body of evidence has suggested that female veterans who have experienced rape, sexual harassment, or any form of sexual abuse have a high probability to develop posttraumatic stress disorder. According to Skinner, Kressin, and Frayne (2000), 23-33% of female veterans confessed to having experienced MST in the course of their duty (p. 297). This means that about a third of female veterans have experienced one or more forms of sexual abuse. Since MST makes female veterans susceptible to PTSD, then about a third of female veterans are at are developing PTSD given that trends of sexual abuse are increasing. Further statistical analysis shows that about 42% of female veterans who had PTSD also had military sexual trauma. It means that MST contributes about 40% of the cases of posttraumatic stress disorder, which female veterans develop due to traumatic experiences of their profession.
Several factors that make female veterans susceptible to MST as compared to male veterans are the harsh military environment, the dominance of male veterans, and socio-demographic characteristics. A harsh military environment during deployment provides an environment that favors sexual harassment of women. Moreover, male dominance in the military explains why women are more prone to sexual assault since male veterans overpower them. According to Suris and Lind (2008), socio-demographic characteristics such as rank, level of education, age of joining military and history of sexual assault are factors that determine susceptibility to sexual abuses and consequently MST (p. 252). It means that women, who join military at the age of 19 or below, having experienced childhood sexual abuses, low level of education, and serving at lower ranks in military, are at double risk of experiencing sexual violence.
Mental Health Consequences Associated with MST
MST is a form of trauma that is prevalent in female veterans due to their predisposition in military. Literature review has revealed that MST does not only relate to PTSD but other mental conditions such as depression, anxiety, bipolar disorders, associative disorders, and personality disorders. Hence, MST is a class of trauma that has a considerable effect on mental health. According to Department of Veteran Affairs (2011), MST elicits emotional and psychological reactions that have a detrimental effect on mental functions (p. 3). In terms of emotions, MST triggers strong emotions that have a depressive effect on mental functions. Military personnel with experiences of MST feel irritable, depressed and having nightmares. Thus, emotional reactions that MST elicits have a severe effect on mental health of an individual for they cause physiological disturbances of neurotransmitters in central nervous system and subsequently impair coordination of the brain.
Moreover, MST has a direct impact on the brain by interfering with psychological processes. Like other stressors, MST adds traumatic pressure on the brain and cause psychological disturbances that affect the functioning of the brain. Zinzow, Grubaugh, Monnier, and Frueh (2007) argue that, MST affects mental health since it causes loss of attention, memory, and concentration making soldiers unable to concentrate on their duties (p. 394). Due to loss of memory and presence of depressive feelings, people with MST tend to resort to drug abuse as a means of calming emotional reactions and nightmares. Experiences of MST continually haunt victims of sexual abuse for they develop defensive attitude that make them live in fear, anxiety and do away with everything that seems to remind them about their ordeal. For instance, one may resign from military and look for other profession that deem safe and free from any form of sexual abuse or one may decide not to get married again in life. Such decisions are mere reflection of psychological trauma that MST causes in an individual.
Physical health Consequences Associated with MST
Experience of MST has physical health consequences that impair physical functioning of a body. Given that sexual abuses entail an assault, they cause physical injuries on victims. A study done to establish sexual satisfaction of women who have undergone sexual abuse shows that there is decreased sexual satisfaction (McCall-Housenfed, Liebschutz, Spiro, & Seaver, 2009, p. 4). The study revealed that sexual abuses, such as rape or sexual assault, have an injurious effect on sexual and reproductive parts causing one to lose sensation that is integral in sexual satisfaction. Thus, women who have experienced sexual assault no longer enjoy sex as before. According to McCall-Housenfed, Liebschutz, Spiro, and Seaver (2009), women who experienced sexual assault in the course of life commonly have chronic gynecological complaints relative to general women (p. 7). Hence, sexual assault predisposes women to develop complex and chronic gynecological conditions such as menstrual problems, back pain, chronic fatigue, vaginal and cervical damage, as well as other forms of injuries. Therefore, sexual abuse can have primary physical effects on reproductive organs of victims and subsequently affect reproductive and physical health.
In addition to primary effects on reproductive organs, sexual abuse can have secondary physical effect on gastrointestinal and urinal tract. Sexual assault can damage gastrointestinal and urinal tract, and affect digestion, regulation of hormones and excretion of wastes. Ordeal cases of sexual assault have led to damaged reproductive organs and related organs. These damages have forced many victims of sexual assault to have reconstruction of their urinal and gastrointestinal tracts together with reproductive parts. Since urinal and gastrointestinal tracts play a significant role in homeostasis, their improper functioning has serious health consequences, which include digestion difficulties, excretion problems, poor metabolism of food and obesity. Laumann, Paik, and Rosen (1999) argue that sexual assault does not only cause sexual dysfunction but also affect metabolic activities of the body, which consequently lead to deteriorating health conditions (p. 541). Ultimately, the victim of sexual assault become disabled both physically and physiological due to medical conditions that result from physical injuries. Thus, MST has grave physical consequences that can potentially disable an individual, particularly women for they are prone to sexual assaults.
Health Care Utilization
PTSD and MST have attracted significant attention from the healthcare system since there has been increasing cases of sexual assault of women in military, which would severely affect growing role of women in military if not addressed in time. Researchers in the healthcare system have found out that, MST is serious healthcare issue that needs appropriate attention. This condition predisposes female veterans to posttraumatic stress disorder, a condition that psychotherapists and psychiatrists are yet to understand fully. It is evident that focusing on PTSD without looking at its root causes, like military sexual trauma, is a futile effort that will not reduce incidences of posttraumatic stress disorder. In this view, the healthcare system is focusing on both preventive and therapeutic measurements to reverse trends of PTSD among female veterans. Classen, Palesh, and Aggarwal (2005) assert that, given grave consequences of sexual assault, it is imperative for healthcare system to provide a comprehensive view of how MST relates with PTSD (p. 114). Hence, it is evident that MST predisposes female veterans to posttraumatic stress disorder, which has provided a basis of understanding differential gendered occurrence of the disorder.
Due to the importance of MST and PTSD in health, healthcare system has provided different therapeutic approaches aimed at helping military personnel to cope with traumatic experiences of their profession. Commonly used therapeutic approaches are trauma-focused cognitive-behavioral therapy, chemotherapy, and family therapy amongst other combined therapies. Usually, cognitive behavioral therapy and chemotherapy are effective forms of therapies that the healthcare system offers to victims of sexual assault to help them cope with sexual trauma and relieve pain respectively. According to Smith and Segal (2011), healthcare system provides free counseling and psychotherapy to military veterans and their respective families at various local Veteran Affairs hospitals (p. 3). Moreover, the United States Department of Veteran Affairs provides a 24-hour help lines so that anyone experiencing acute PTSD can get service and treatment in time. Such provisions have boosted healthcare capacity in combating PTSD among military veterans.
Implications for Treatment
Healthcare system has used multi-therapeutic approaches in helping veterans to cope with MST and posttraumatic stress disorder. These approaches include psychoeducation, pharmacotherapy, stress inoculation training, prolonged-exposure therapy, and cognitive behavior therapy. As numerous studies have found out that MST predisposes female veterans to posttraumatic stress disorder, the use of multi-therapeutic approaches is effective in alleviating the impact of MST and subsequently prevents the occurrence of posttraumatic stress disorder (Skinner, Kressin, Frayne, 2000, p. 299; Classen, Palesh, & Aggarwal, 2005, p. 117). According to Fontana, Rosenheck, and Desai (2010), difference in traumatic experiences of Afghanistan and Iraq wars coupled with gender differences in occurrence of PTSD need consideration in design of Veteran affairs programs and treatment of female veterans (p. 754). Therefore, given that diverse treatment approaches have different effects on MST and posttraumatic stress disorder, the research paper seeks to establish differential implications of each treatment approach.
Psychoeducation
Psychoeducation is an effective approach of treating military sexual disorder and PTSD among military veterans and their families. Purpose of psychoeducation is to enhance awareness of MST and PTSD and provide strategies of coping with the disorders. Psychoeducation provides a basis that enhances understanding of MST as one of the factors that predispose female veterans to posttraumatic stress disorder. For female veterans to cope with military sexual trauma, they should be in a position to understand how to manage traumatic experiences and prevent their cumulative impact that leads to development of posttraumatic stress disorder. Fisher (2008) argues that, psychoeducation is an effective form of treatment because it enhances understanding of PTSD and reduces symptoms associated with the disorder (p. 47). Thus, psychoeducation is the best treatment method of enhancing awareness of psychological disorders such as PTSD and MST among female veteran patients.
Comparative and exploratory study established that psychoeducation is an effective treatment of posttraumatic disorder and recommended that it is suitable for military veterans and their families. Psychoeducation supports that families are pivotal in the treatment of posttraumatic stress disorder. Families cushion military veterans from experiencing acute stress disorder that aggravates the development of posttraumatic stress disorder. Grinage (2003) recommends that, since treatment of PTSD and MST requires a multi-therapeutic approach, combined therapies enhance the effectiveness of psychoeducation treatment (p. 2405). Hence, it implies that psychoeducation can only be effective and reliable in treating PTSD and MST when applied with other therapeutic interventions.
Pharmacotherapy
Pharmacotherapy is an evidence-based approach of treating PTSD and related complications. Since PTSD elicits flashbacks, nightmares and irritability, pharmacotherapy is an effective treatment that brings about a calming effect on the brain and neural reactions. A study has shown that PTSD requires medications that can alleviate trauma by mediating through neural reactions in the body (Stein, 2011, p. 6). Antidepressants such as imipramine, sertraline, paroxetine, and phenelzine are effective in alleviating clinical conditions such as nightmares, flashbacks, numbing, and irritability. According to Stein (2011), medications that inhibit serotonin uptake by acting like inhibitors offer first-line of chemotherapy since they are effective in treatment of acute stress disorders that lead to PTSD (p. 8). This means that pharmacotherapy is effective in alleviating and controlling effects of clinical symptoms in a patient. Pharmacotherapy is relevant intervention in the treatment of acute and emergency cases of PTSD since; it has immediate calming effect and restores patient physical and psychological conditions for subsequent psychotherapy. Hence, female veterans with acute conditions of PTSD need pharmacotherapy to depress their state of irritability and hyperactive arousal.
Stress Inoculation Training
Stress inoculating training provides patients of PTSD with essential skills that aid them in coping with anxiety and stressors. Usually, posttraumatic stress disorders recur when patients encounter trauma reminders that trigger emotional and psychological reactions and subsequently lead to the disorder. Lee, Gavriel, Drummond, and Richard (2002) argue that, psychotherapists train patients to identify predisposing factors that act as reminders of traumatic experiences and make appropriate responses alleviate their impacts (p. 1081). Psychotherapists offer appropriate skills such as deep breathing, muscle relaxing, and psychological management of anxiety. Premise of stress inoculating training is that early intervention of PTSD by patients can help alleviate development of the disorder. Since MST is the main factor that predisposes female veterans to posttraumatic stress disorder, stress inoculating training offer essential coping skills that enable them to identify trauma reminders and make appropriate responses prevent the occurrence of posttraumatic stress disorder. Thus, stress inoculating training offers life skills that enable individuals to cope with factors that predispose one to posttraumatic stress disorder.
Prolonged-Exposure Therapy
Since reminders of traumatic experiences that one has undergone elicit posttraumatic stress disorder, prolonged-exposure therapy seeks to reduce effects of the reminders on an individual. Normally, people with PTSD develop fears of traumatic experiences and try to avoid trauma reminders. Thus, basis of prolonged-exposure therapy is to reduce fears that bring about unfavorable reactions like flashbacks and nightmares by exposing patients to trauma reminders so that they become accustomed to them and reduce avoidance. According to Lee, Gavriel, Drummond, and Richard (2002), psychotherapists perform prolonged-exposure therapy by exposing patients to trauma reminders for a long period or creating imaginations that elicit traumatic experiences (p. 12). Continued exposure or elicitation of traumatic experiences lessens fear and anxiety, which one develops due to trauma. Hence, prolonged-exposure therapy is an effective treatment of MST and PTSD because it enables female veterans to confront trauma reminders rather than avoiding them.
Cognitive-Behavior Therapy
Cognitive-behavior therapy is effective in treating PTSD because it does not only alleviate symptoms, but also improve the quality of life by transforming behavior. Cognitive-behavior therapy is like combined therapy of exposure and cognitive therapies. Exposure therapy tries to accustom patients to traumatic experiences with a view of alleviating reactions due to encounter of trauma reminders. Such encounters elicit sharp reactions in patients and subsequently lead to development of posttraumatic stress disorder. For female veterans with military sexual trauma, cognitive behavioral therapy offers an opportunity of exposing them to varied trauma reminders and ultimately dispels their fears and anxiety. Cook, Walser, Kane, Ruzek, and Woody (2006) assert that, cognitive-behavioral therapy is appropriate in treating female veterans for it aims at alleviating sexual trauma, changing behavior, and promoting the lives of patients (p. 91). In cognitive-behavioral therapy, psychotherapists help patients to go through traumatic experiences by guiding them to identify and analyze possible remedies for preventing and managing posttraumatic stress disorder.
Implications for Research, Practice, and Policy
Research
The research has demonstrated there is a differential occurrence of PTSD in both male and female veterans. The gendered occurrence of PTSD is due to MST that mainly affects female veterans. Since numerous studies have shown that MST is one of the key factors that predispose female veterans to posttraumatic stress disorder (Chaumba, & Bride, 2010, p. 293; Himmelfarb, Yaeger, & Mintz, 2006, p. 840), future researchers must find out if other confounding factors that mediate occurrence of PTSD exist. More research studies have suggested that traumatic experiences of different wars have different impacts on the development of posttraumatic stress disorder (Fontana, Rosenheck, & Desai, 2010, p. 754; Kean, 2008, p. 3). For instance, a recent survey of veterans deployed to Iraq and Afghanistan showed that they have different susceptibilities to posttraumatic stress disorder. Kean (2008) asserts that PTSD is a complex disorder with an interplay of many factors such as military experiences, family life, childhood experiences, community, and spiritual life amongst many factors (p. 3). Thus, researchers should not presume that MST is the only factor that causes the gendered occurrence of posttraumatic stress disorder. Therefore, they should delve beyond individual life and examine social aspects, for they also predispose one to posttraumatic stress disorder.
Practice and Policy
The research findings that MST significantly predisposes female veterans to PTSD have considerable implications for the planning and development of health practice and policy. According to Holbrook, Hoyt, Stein, and Sieber (2002), there have been insufficient studies and thus health practice and policy generalized that both male and female veterans experience similar traumatic experiences and have equal susceptibility to PTSD (p. 886). Therefore, military personnel underwent the same screening procedures and received similar treatment. However, increasing roles of women in the military led to increased cases of sexual abuse, which consequently resulted in the emergence of military sexual trauma. MST is a form of trauma that mainly affects women because they are more susceptible to sexual assaults from their male counterparts in the military. Salvatore (2007) argues that increasing cases of MST among female veterans need gendered interventions (p. 78). United States Department of Veteran Affairs needs to design and develop new gendered screening, treatment, and management practices that recognize gender variability in the occurrence of posttraumatic stress disorder. Moreover, policies that enhance the rehabilitation of female veterans who have MST are essential to prevent the development of posttraumatic stress disorder.
Conclusion
Military personnel constantly encounter traumatic experiences in the course of their profession that ultimately predispose them to posttraumatic stress disorder. PTSD emanates from cumulative trauma that overwhelms an individual and causes severe psychological disturbances. Under posttraumatic stress disorder, a patient experiences symptoms such as flashbacks, nightmares, numbness, irritability, and hyperarousal. Due to the increasing roles of women in the military, it has become evident that the occurrence of PTSD has a gender perspective. Female veterans have high incidences of PTSD that is attributable to military sexual trauma, which mainly affects them. In this view, healthcare researchers need to delineate factors that predispose female veterans to PTSD and design appropriate screening, treatment, and gender-sensitive management practices.
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