Nearly 90 percent of soldiers wounded in the wars in Afghanistan and Iraq - some 35,000 - survived battle injuries, thanks to breakthroughs in US state-of-the art military medicine, among them, surgical techniques, regenerative medicine and prosthetics. Neither the Department of Defense (DoD) nor the Veterans Health Administration (VHA), though, was prepared with the same cutting-edge treatment for the one in three women soldiers in those same wars - an estimated 70,000 - who were sexually assaulted by fellow soldiers.
The VHA is the agency within the US Department of Veterans Affairs (VA) responsible for picking up the pieces of lives injured and shattered by combat, war trauma and military sexual assault. It will be faced, over the next months and years, with a tsunami of severe injury and illness from the DoD's largely feckless sexual assault prevention programs.
Following the first Persian Gulf War, a series of Congressional hearings on women veterans' issues in 1992 led to authorizing the VA to provide outreach and counseling for women veterans who had suffered military sexual assault, services that were extended to male veterans soon after. By 1999, the VA put in place a universal screening program for military sexual trauma (MST) for all veterans using their services. Since 2004, those who have screened positive for MST are eligible for free medical treatment for any MST-related illness, injury or mental health condition. Each VA facility has assigned a MST coordinator to supervise the screening and treatment referral process and provide education and training for clinicians.
All of these initiatives are crucial, essential and rightful for the tens of thousands of veteran survivors. Yet, they are only as effective as the outreach to sexual trauma survivors, the percent of women veterans using the VA medical system, the MST screening protocol, the understanding and recognition of complex health sequelae from sexual trauma, the clinical talent and compassion of the health providers and each VA facility's capacity of treatment.
A Catalogue of Illnesses
In 2007, the first study of the VA's MST program was published in the American Journal of Public Health. It collated the immense burden of illness associated with MST, drawn from the records of nearly 150,000 women treated as outpatients by the VA in 2003. Women diagnosed with MST (about 22 percent) had two to three times more mental health problems, including anxiety disorders, schizophrenia, psychosis, depression and dissociative disorders. Similarly, they suffered higher rates of alcohol use, eating disorders, liver diseases, chronic pulmonary disease and hypothyroidism. MST doubled the women veterans' risk of suicide and intentional self-harm.
One of the most compelling findings of this study is that post-traumatic stress disorder (PTSD) is more common among women veterans with MST than among women who report sexual assault in civil society. Advocates, clinicians and investigators who have listened to women vets and studied the military environment agree that the unique mix of life endangerment, broken trust, isolation and daily exposure to the perpetrator is lethal for the victim. Not only is military sexual assault more toxic than combat exposure, but it also appears to be more toxic than nonmilitary sexual assault.
Sexual harassment in the military also significantly contributes to female veterans' PTSD symptoms. Underscoring its severe impact, an analysis of a nationally representative sample of 3,000 veterans applying for disability found that PTSD among women from military sexual harassment is comparable to that of combat exposure among men.
A report by the Society for Women's Health Research on PTSD in women returning from combat reinforced the gravity of health care needs for women veterans. Survivors of military sexual assault suffer PTSD at greater rates than veterans of combat exposure. Yet, PTSD symptoms may not manifest until months after the traumatic event and, thus, will be missed in an early post-military medical visit. Further, many women veterans choose health care through the private and/or public sectors where veteran status is rarely ascertained.
Who Treats Women Vets?
A 2004 VA study found that, of the women veterans who served in the Iraq and Afghanistan wars and left active duty, 17 percent received health care from the VA. Thus, the majority of women with MST are either going without medical care or being treated by private- or public-sector health providers. Health care providers not familiar with MST and women's roles and exposures in the military - likely, most of them - may not recognize and may misdiagnose PTSD symptoms. Further, physicians may be unfamiliar with the VA system of MST screening and free care for survivors. And even if familiar, they may not want to lose patients to the VA system. Altogether, a plethora of pitfalls exist in the health care system for the huge number of women veterans abused in the military. Among these is the traditional and prevailing military context of PTSD - one that can isolate and ill serve women.
PTSD: Different for Women
Historically the VA system has been built around the needs of male veterans. PTSD still carries with it the male stereotype from Vietnam, where men were shattered seeing their buddies blown apart, notes Sara Corbett in her powerful piece in The New York Times Magazine, "The Women's War." In this sense, she adds, PTSD has gained dignity from "the province of men who earned their affliction only after having their best buddies die in their arms ..." But this hard-won combat-centric respect can also isolate women veterans whose PTSD lacks this contextual dignity.
Veterans advocate Susan Avila Smith speaks from her own experience: "If you're in combat, you can talk about [PTSD] in group therapy ... You can say, 'Yeah, I was in this battle and I saw my friends blown up ... But nobody raises their hand and yells out in the middle of the VA: 'Yeah, I was raped in the military, was anyone else? Do we have something in common."' Additionally, women victims of military sexual assault can be retraumatized in PTSD or other mental health groups where men are talking about sex crimes. Others working with women vets point out that women vets are more likely to return to a primary parenting role and, once home, they may be less encouraged by their spouse to get help than men are by their wives and, moreover, ashamed to reveal their sexual assault.
Social worker Karen Cutright manages Cincinnati VA's comprehensive care program for veterans of the wars in Afghanistan and Iraq, which has treated more than 400 women among 4,000 veterans seen at the facility. She agrees that more is expected of women vets returning to their families than male vets, particularly for younger women with children. Psychologist Kate Chard, who directs the PTSD Division at the Cincinnati Veterans Affairs Medical Center in Fort Thomas, concurs, saying that women soldiers are expected to bounce back for their families and "pick up where they left off ... It's a little more permissive for men to check out temporarily from their families than it is for the women." She adds that women vets with PTSD are heavily burdened by guilt for not rebounding as a perfect mother, whereas "men are more likely to be in a state of constant anger."
VA Capacity Lacking
An October 2011 survey of mental health providers (psychiatrists, psychologists, nurses and social workers) in the Department of Veterans Affairs found that 70 percent did not have enough staff to meet veterans' needs. Forty percent of those medical providers interviewed said they are so booked that they cannot meet the two-week window for an appointment with a new patient. Nearly half reported that patients are being denied care because appointments are not available outside regular office hours.
On any given night, 200,000 veterans are homeless, for reasons of inadequate employment, low wages, lack of affordable housing, mental illness and insufficient and inaccessible health care. One in 11 women veterans are homeless; and 40 percent of homeless female vets report being raped while in the military. Veterans have a higher rate of unemployment and homelessness than civilians; and government programs for shelters, transitional and permanent housing and job training are severely under-resourced. The National Coalition for Homeless Veterans estimates that the VA serves only about one-quarter of homeless veterans.
Disability Compensation: Nonexistent
Every independent evaluation of the DoD performance in dealing with sexual abuse, from unit level response to the agency's prevention and tracking office (SAPRO), has impugned the military for its denial, victim blaming and negligence in collecting evidence and keeping evidentiary records. The consequence for survivors of military sexual assault is that the documentation they need for a disability determination doesn't exist and they are cheated of disability compensation from the VA for their resulting extreme debilitation. In 2010 alone, 58,733 women screened positive for MST. Considering a DoD prosecution rate of 8-10 percent and also a low reporting rate on the part of victims, more than 53,500 of these veterans would most likely lack adequate military records for disability compensation when they need it. A military catch-22 that one Congresswoman is determined to abolish.
In spring 2011, Rep. Chellie Pingree introduced legislation, H.R. 930, to assure that survivors of military sexual violence receive the same military service-related compensation for their physical injuries and mental health conditions that combat veterans are currently given for wounds of war - finally addressing the VA's gross double standard for victims of military sexual abuse. The legislation would require the VA to accept veterans' statements about the history of their sexual abuse in the military and the suite of health problems that ensued, without corroborating internal documentation, police reports, or eyewitness accounts. The Service Women's Action Network (SWAN) underscored the significance and justice of this legislation. "Survivors of military sexual violence often face multiple forms of retaliation after reporting their attacks, including improper mental health diagnoses that force them out of the military. Service members who are diagnosed with Personality Disorders not only face the certainty of being kicked out of the military, but also the denial of critical veterans' benefits."
* * *
The VA treats victims of the military's systemic failures to prevent its soldiers from sexually harassing and assaulting other soldiers. But treatment without prevention is a doomed solution, whether the issue is domestic violence, child abuse, drug abuse or industrial pollution. This series on military sexual assault has consciously focused on women in the military because of the extreme rate of harassment and sexual assault perpetrated by drill sergeants, soldiers and commanders on women who chose to serve their country. Men are also raped in the military. Given a much lower rate of military sexual assault (between 1 and 3 percent in various studies), but the larger number of male soldiers, researchers estimate that equal numbers of men and women suffer from military sexual abuse. The reforms proposed by veterans, advocacy groups, legislators, investigators and independent task forces in the final section of this series, "Reforming a Recalcitrant Military," are ones that would help protect all recruits and soldiers, female and male, from the epidemic of sexual crime in their midst. They aim to hold commanders accountable, change the hyper-masculine military culture, aggressively prosecute perpetrators and provide all the needed victim services and disability.
 Society for Women's Health Research, 2009, "PTSD in Women Returning from Combat: Future Directions in Research and Service Delivery."