Overview
We are all concerned about our soldiers and veterans we actually know very little about the experiences of women in the military and as veterans. Because it is both a new and changing field, there are a lot of questions yet to be asked and many studies yet to be conducted. However, what we do know about women in war is widely covered in a new textbook by Elspeth Cameron Ritchie and Anne L Naclerio, titled Women at War. Although my areas of expertise include stress, psychological trauma and women working in a man's world, I not only learned a lot from this book, my consciousness and interest were raised.
To give a general sense of the scope of the textbook, the book is divided into 5 sections: background, women at war, what happens to women when they come home from the war, psychological issues, and veteran issues. Of the 40 authors, four are psychiatrists, and 15 are mental health professionals. Despite the fact that there are so many authors, the book holds together very well and there is little redundancy.
Directed at clinicians who care for women who are or who have been in the military, most of the chapters are relatively short, 10 to 20 pages, and very readable. Moreover, the brevity of the chapters in no way undermines their value as a resource. The contributing authors provide extensive references to back up their substantive arguments and point to further reading on the subjects being covered. For example, the chapter on the prevention of malaria concludes with nine pages of references and the very informative chapter on traumatic brain injury provides ten pages of references. In addition to offering a fascinating history of women in the military going back to the Revolutionary War, the editors also add a somewhat international perspective by including a chapter on women who served in the Australian military. Although only successful in this single chapter from Australia, the comparison is useful because the recognition of women in the military “…has not yet entered mainstream Australian society, and female military service remains largely ‘invisible” (Ritchie & Neclerio, p 44).
Some facts regarding women who have served are presented along side those who were not technically in combat roles. One example worth noting is the data on women in combat. Women comprise 15% of the United States (US) military but they have only recently been allowed into combat roles. Nevertheless, women who are technically not in combat roles are frequently involved in firefights. The psychological impact of serving in combat does not appear to vary according to gender. Compared to the civilian population, women in the military have the same rates of combat-related PTSD as men. With regard to women home from war, “one infantry Soldier said, simply, “My eyes have witnessed more than my soul can handle”… [Training involves] “the over-rehearsal of combat skills” and “once over-learned, it takes time for this conditioning to be unlearned” (p 163).
Gender-specific Traumas and Health Challenges
Other facts presented offer a profile of the multiple physical traumas women soldiers experience that are unique to their gender. Rates of sexual trauma among women who are deployed are also higher than in civilian samples. In fact, stressors for women in the military are more often related to sexual assault than combat. Women in the military have a threefold increased risk for suicide as compared to civilian women and the risk continues after discharge. Almost 90% did not have a history of deployment. One to two military women die by suicide every month, 75% by drug overdose. Common precipitants are failed and/or abusive relationships. Although military women are less likely to report intimate partner violence than civilian women, the rates of such intimate partner violence are higher among military women than among civilian women. Military women are less likely to report than civilian women. In 2006, the US Department of Veterans Affairs (VA) established a Military Support Team to address military sexual trauma through an impressive program of education, screening, and outreach.
The authors point out that the military health service is relatively well equipped to handle trauma and other conditions that are not gender based, but unfortunately “the care women Service members are receiving for common female conditions are left wanting” (p 712). The most common medical conditions that affect women are the same conditions that affect men (p 67): musculoskeletal complaints and upper respiratory infections. Medical issues more specific to women include “how to urinate privately and safely in the field, or how to dispose of feminine hygiene products” (p 50). Military gear also makes it cumbersome to urinate and there is no privacy, so women wear diapers and withhold fluids which increase the risk for heat injuries and urinary tract infections. Almost 50% of Army women experience a urinary tract infection; a figure 20 times greater than that for deployed men. Vaginitis is another common problem among females in the field and more research is needed to determine if uniform modifications would increase airflow, decrease friction, and decrease the risk of genitourinary infection. Menstruation is often handled by using oral contraceptives with withdrawal bleeding four times a year (p 59).
Contraception is another issue and the rate of unplanned pregnancy is double that of the general population. There are advantages to implants and intrauterine devices but many women stop using birth control when they deploy, must change their birth control methods, or have access issues. Given that pregnancy termination services are not available to military women, the fact that more women are hospitalized for labor and delivery than for any other condition (p 81) is not surprising. Beyond “common female conditions,” issues in the prevention of malaria for women at war are complex, including psychiatric side effects, interactions with hormonal contraception, and risks of birth defects. As more women are assigned to combat roles, we can expect the incidence of traumatic brain injuries to increase. Among women veterans of Afghanistan and Iraq receiving care in the VA, 13% screened positive for traumatic brain injury.
Conclusion
As I noted early in this review, I learned a great deal about the experience of women in the military from this book and my consciousness was raised. My only criticism is that despite the authors' attempts at providing definitions for key terms, the book would have been stronger if a list of acronyms and their definitions were offered. In addition to my strong recommendation of this new textbook, the VA offers online course modules on military culture www.deploymentpsych.org/military-culture. We should all take them.
Conflict of Interest
The author identified no conflicts of interest.