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. Author manuscript; available in PMC: 2019 Aug 30.
Published in final edited form as: Addict Behav. 2018 Apr 10;84:144–150. doi: 10.1016/j.addbeh.2018.04.007

Regular past year cannabis use in women veterans and associations with sexual trauma

Kendall C Browne a,b,c,d,*, Marketa Dolan c, Tracy L Simpson a,b,c, John C Fortney b,d, Keren Lehavot b,c,d
PMCID: PMC6716375  NIHMSID: NIHMS1047152  PMID: 29684763

Abstract

Introduction:

This study sought to describe the prevalence of regular past year cannabis use (i.e., at least monthly use) in women veterans, to characterize women veterans reporting this level of use, and to examine the independent contributions of sexual trauma across the lifespan on regular past year cannabis use.

Methods:

A national online survey on women veterans’ health, with targeted oversampling of lesbian and bi-sexual women, collected data from US armed forces women veterans, 18 or older, living in the US (N = 636).

Results:

Eleven percent of women reported regular cannabis use (5% heterosexual women; 21% lesbian/bisexual women). In bivariate analysis, identifying as a sexual and/or racial ethnic minority, younger age, being un-married, reporting lower income, receiving VA services, smoking tobacco, and screening positive for alcohol misuse were positively associated with regular cannabis use. Additionally, a greater percentage of cannabis users reported experiencing childhood and adult sexual trauma and screened positive for posttraumatic stress disorder (PTSD) when compared to peers who did not use any drugs. In a multivariate model, the number of life eras women endorsed experiencing sexual trauma was significantly associated with regular cannabis use even when adjusting for demographic variables and PTSD symptoms.

Conclusions:

Among women veterans, regular cannabis use is fairly common among those who are sexual and racial/ethnic minorities, younger, unmarried, receiving VA services, and reporting alcohol or tobacco use, PTSD symptoms, and/or multiple sexual traumas across the lifespan. Screening and assessment may be important to consider in healthcare settings serving this veteran population.

Keywords: Cannabis, Marijuana, Sexual trauma, Veterans, Women

1. Introduction

Women are one of the fastest growing segments of the United States veteran population (National Center for Veterans Analysis and Statistics, 2015). The Department of Veterans Affairs (VA) has identified substance use (i.e., alcohol and drug use) as an important health concern and research priority among this veteran group (Cucciare, Simpson, Hoggatt, et al., 2013; Hoggatt, Jamison, Lehavot, et al., 2015; Institute of Medicine, 2010; Yano, Bastian, Bean-Mayberry, et al., 2011). However, information about women veterans’ substance use, particularly cannabis use, one of the most widely used drugs of abuse, remains sparse (Bean-Mayberry, Yano, Washington, et al., 2011; Bonn-Miller, Harris, & Trafton, 2012; Hoggatt et al., 2015; Institute of Medicine, 2010; Substance Abuse and Mental Health Services Administration, 2014; Yano et al., 2011).

National epidemiological data suggest cannabis use has risen among civilian women in the United States over the past decade (e.g., estimated prevalence 2001–2002 = 2.6%; 2012–2013 = 6.9%) (Hasin, Saha, Kerridge, et al., 2015). Cannabis use is associated with a range of concerning outcomes, including acute memory and learning impairment, increased risk for cognitive decline, medical disorders (e.g., chronic bronchitis), mental health symptoms (e.g., exacerbation of psychotic symptoms), psychosocial impairments, other substance use, and onset of cannabis use disorder (CUD) (Secades-Villa, Garcia-Rodríguez, Jin, et al., 2015; Volkow, Baler, Compton, et al., 2014; Volkow, Swanson, Evins, et al., 2016). Female cannabis users rate subjective effects of cannabis associated with risk of abuse (i.e., use has “good” effect) more favorably than male peers and also indicate greater willingness to “take it again” (Cooper & Haney, 2014). Furthermore, in a prospective study, cannabis use was associated with an increased risk of later psychological distress among women, though not in men (Danielsson, Lundin, Allebeck, et al., 2016).

Despite concerning consequences, research estimating cannabis use prevalence in women veterans is limited to a few studies examining mixed-gender samples. Studies utilizing National Survey on Drug Use and Health data found an estimated 3.5% of men and women veterans reported past month cannabis use, with prevalence almost four times higher (11%) among veterans ages 21 to 34 (Golub, Vazan, Bennett, et al., 2013; Wagner, Harris, Federman, et al., 2007). Given that gender differences in drug use prevalence are consistently identified (Davis & Fattore, 2015), examining prevalence of cannabis use specifically among women veterans and better characterizing women reporting such use remains an important endeavor. Additionally, evaluating cannabis use by sexual orientation may be particularly important as sexual minority women are overrepresented among female veterans and have been found to demonstrate disproportionately high rates of cannabis use (Gates, 2010; Trocki, Drabble, & Midanik, 2009).

There is a growing literature attempting to understand correlates of and risk factors for cannabis use and to identify individuals in need of prevention or intervention efforts. One possible risk factor is history of trauma exposure. Both history of trauma and cumulative trauma exposure across the lifespan were associated with cannabis use in a large national civilian sample (Kevorkian, Bonn-Miller, Belendiuk, et al., 2015). The role of specific types of trauma exposure has also been examined (Werner, McCutcheon, Agrawal, et al., 2016). In a large sample of European American and African American civilian women, sexual trauma was the only trauma type found to increase the hazard for cannabis use initiation, though this relationship was only significant for African American women prior to age 15 (Werner et al., 2016).

Sexual trauma exposure occurring at different points across the lifespan may have varying associations with adult substance use (Booth, Mengeling, Torner, et al., 2011; Hankin, Skinner, Sullivan, et al., 1999; Hughes, McCabe, Wilsnack, et al., 2010; Ullman, Relyea, Peter-Hagene, et al., 2013). For instance, a positive association was detected between lifetime substance use disorder (SUD) status and the number of life eras during which women veterans reported sexual trauma (i.e., childhood, pre-military, in-military and post-military rape) (Booth et al., 2011). Cannabis use, which is more prevalent than SUDs and/or other illicit drug use, was not specifically assessed. It remains unknown whether sexual trauma exposure is a risk factor for cannabis use in women veterans, and because this group has very high rates of sexual trauma (Zinzow, Grubaugh, Monnier, et al., 2007), it is an important relationship to evaluate.

To this end, the present study sought to describe cannabis use prevalence in women veterans completing a national online survey, to characterize women veterans reporting cannabis use, and to explore the independent contributions of sexual trauma occurring across the lifespan on women veterans’ cannabis use, including the contributions of childhood sexual abuse; adult sexual assault before, during and after the military; and cumulative sexual trauma exposure (i.e., number of different life eras in which sexual trauma was reported). Because sexual minority women may be at particularly high risk for cannabis use (Trocki et al., 2009), we were also interested in examining prevalence separately across sexual orientation and incorporating this variable in all analyses. In light of prior literature (Kevorkian et al., 2015), we hypothesized greater cumulative sexual trauma exposure would be significantly associated with cannabis use.

2. Method

2.1. Participants and procedures

Data were collected as part of a larger parent study conducted by VA researchers via a web-based survey between February and May 2013. Women age 18 or older, biologically born female and currently identifying as a woman, living in the United States (US), and a veteran of the US armed forces were eligible to voluntarily participate (i.e., no compensation). The parent study was advertised as an anonymous survey about the unique life experiences of women veterans. Advertisements were disseminated via online list servs for women veterans and Facebook. Informed consent was obtained via an information statement. Because the parent study aimed to oversample lesbian and bi-sexual women veterans to understand their unique health needs, ads targeting this group were also used. The research was approved by the VA Puget Sound Health Care System Institutional Review Board.

Veterans with complete data on the variables of interest were included in the present study (n = 647). Eleven participants who did not report past year cannabis use but did endorse past year use of other drugs (i.e., cocaine, stimulants, and non-prescribed opiates) were excluded, resulting in a final convenience sample of 636 women veterans. Women who reported alcohol or tobacco use were retained.

2.2. Measures

2.2.1. Demographic characteristics

Demographics included age, sexual orientation, marital status, race/ethnicity, total household income, and receipt of VA services.

2.2.2. Childhood sexual abuse

The Childhood Trauma Questionnaire (CTQ) (Bernstein, Fink, Handelsman, et al., 1994) assessed history of child abuse and neglect. Twenty-five items form five subscales (emotional neglect, physical neglect, emotional abuse, physical abuse, and sexual abuse) scored from 1 (never true) to 5 (always true), with higher scores indicating more abuse/neglect. The 5-item sexual abuse subscale (e.g., “Someone tried to touch me in a sexual way or tried to make me touch them”; α = .97) was used in the present study.

2.2.3. Adult sexual trauma

Participants were asked to indicate how many times someone had oral, anal or vaginal sex with them without consent during three time periods: before military service (i.e., between 18th birthday and beginning of military service), during military service, and after military service. Item wording was drawn from the Sexual Experiences Survey (SES) (Koss, Abbey, Campbell, et al., 2007) and has been used in previous research (Lehavot & Simoni, 2011).

2.2.4. Cumulative sexual trauma

A composite variable was created to measure sexual trauma exposure across the lifespan. If a participant endorsed any of the five CTQ sexual abuse items, they were considered to have experienced child-hood sexual abuse (0 = no, 1 = yes). This strategy was also applied to adult sexual assault items. An initial variable was calculated by summing across the four time periods examined (i.e., childhood; before, during, after military). The categories for three and four time periods were combined after initial descriptive statistics revealed only five women in the main outcome group (i.e., cannabis use) endorsed four trauma periods. The final variable ranged from 0 (i.e., no trauma) to 3 (i.e., trauma in ≥3 time periods).

2.2.5. PTSD

The 17-item Posttraumatic Stress Disorder Checklist – Civilian (PCL-C) (Weathers & Ford, 1996; Wilkins, Lang, & Norman, 2011) assessed PTSD symptoms (α = 0.97). Items are summed for a total score ranging from 17 to 85 with higher scores indicating greater PTSD symptom severity.

2.2.6. Cannabis and other substance use

Participants were asked, “In the past year, how often do you use the following...?”: a) cannabis, b) cocaine, c) stimulants, and d) non-pre-scribed opiates. Responses included: not at all, once a month, 2–3 times per month, once a week, 2–3 times per week, 4–5 times per week, every day. Thus, a positive endorsement of cannabis use reflected at least monthly use in the past year and is referred to in the present study as “regular past year cannabis use”. The following question assessed tobacco use, “Do you now smoke cigarettes every day, some days, or not at all?”. The 10-item Alcohol Use Disorders Identification Test (AUDIT) (Saunders, Aasland, Babor, et al., 1993) assessed past 12 month alcohol use, with a score ≥ 8 indicative of alcohol misuse.

2.3. Analyses

Descriptive statistics estimated prevalence of regular cannabis use in the past year (i.e., at least monthly use versus no use) in the full sample as well as separately for heterosexual and lesbian/bisexual women veterans. As is often the case with substance use variables, the cannabis variable was highly skewed, with the majority of participants reporting no use. Given this non-normality and the nominal item responses, the cannabis variable was dichotomized to reflect presence/absence of regular use in the past year in all bivariate and regression analyses. Use of other drugs, including tobacco, were also coded di-chotomously and examined for descriptive purposes. Tests of the bi-variate relationships between cannabis use and factors previously shown to be associated with drug use were conducted to characterize women veterans reporting regular past year cannabis use in comparison to women veterans who did not report any past year drug use exclusive of alcohol and tobacco (Bonn-Miller et al., 2012; Booth et al., 2011; Davis, Bush, Kivlahan, et al., 2003; Hankin et al., 1999; Hasin et al., 2015; Hughes, McCabe, et al., 2010; Kelley, Brancu, Robbins, et al., 2015; Kevorkian et al., 2015). These factors included: demographic variables, tobacco and alcohol use, childhood sexual abuse and adult assault variables, the cumulative sexual trauma variable, and PTSD symptoms. Independent sample t-tests for continuous normally-distributed variables, chi-square tests of independence for categorical count variables, and an independent samples Mann-Whitney U test for the non-parametric cumulative sexual trauma variable were used.

A hierarchical logistic regression was used to examine the independent contributions of sexual trauma occurring across the lifespan on women veterans’ regular past year cannabis use. Demographic variables were entered in Step 1 and childhood, adult, and cumulative sexual trauma variables were entered in Steps 2–4 in a sequential fashion. As PTSD symptoms have also been associated with cannabis use and CUD (Kevorkian et al., 2015), PTSD symptom severity was entered in Step 5 to determine if relationships identified in prior steps remain significant when accounting for these symptoms.

A sensitivity analysis was conducted to examine the impact of multicollinearity among sexual trauma variables. Correlations among the single time period childhood and adult sexual trauma variables and the cumulative sexual trauma variable were examined. An additional hierarchical regression model was specified that included only the cumulative sexual trauma variable without the childhood sexual abuse and adult sexual assault variables. The results for this model (Supplemental Table 1) and from a model including only childhood and adult sexual trauma variables (Table 3, Step 3) did not differ from the full model (Table 3, Step 5). As a result, the full model with all sexual trauma variables was retained and is presented here. All analyses were conducted using SPSS v19.

Table 3.

Logistic regression model with past year cannabis use the as the outcome (N=636).

Step 1 Step 2 Step 3 Step 4 Step 5
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Age 0.96 0.94–0.98** 0.96 0.94–0.98** 0.96 0.94–0.98** 0.96 0.94–0.98** 0.96 0.94–0.98**
Lesbian or bisexual 4.22 2.40–7.41** 4.00 2.26–7.05** 3.98 2.24–7.07** 4.18 2.33–7.50** 4.08 2.27–7.34**
Not married 1.44 0.79–2.64 1.43 0.78–2.62 1.40 0.77–2.56 1.37 0.74–2.53 1.41 0.76–2.63
Non-white 1.53 0.80–2.94 1.46 0.76–2.82 1.44 0.74–2.78 1.46 0.74–2.87 1.41 0.72–2.79
Income (Ref.: < $15K–35K)
 $36–50K 1.66 0.85–3.25 1.68 0.86–3.30 1.64 0.83–3.25 1.64 0.82–3.29 1.60 0.79–3.25
 $51–70K 1.28 0.56–2.97 1.30 0.56–3.01 1.25 0.54–2.91 1.28 0.54–3.03 1.40 0.59–3.33
 > $71K 0.97 0.44–2.14 0.99 0.45–2.19 1.03 0.46–2.30 1.08 0.48–2.45 1.24 0.54–2.83
CSA 1.18 0.99–1.40 1.08 0.88–1.32 0.94 0.75–1.19 0.90 0.71–1.14
Before military SA 1.11 0.98–1.26 1.01 0.88–1.17 1.01 0.87–1.16
During military SA 1.02 0.91–1.15 0.94 0.82–1.07 0.89 0.78–1.03
After military SA 0.97 0.82–1.14 0.91 0.76–1.09 0.90 0.75–1.08
Cumulative ST (Ref.: 0)
1 1.46 0.61–3.45 1.37 0.57–3.29
2 2.28 0.93–6.02 2.26 0.88–5.78
3 6.29 2.00–19.8** 5.70 1.78–18.24**
PCL-C 1.02 1.00–1.04*
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Note. SE = standard error. OR = odds ratio. CI = confidence interval. CSA = childhood sexual abuse. SA = sexual assault. ST = sexual trauma. PCL-C = Posttraumatic Stress Disorder Checklist – Civilian. Ref. = reference group.

*

p < .05.

**

p < .01.

3. Results

3.1. Sample characteristics

Table 1 provides sample descriptive information.

Table 1.

Sample descriptives and bivariate associations with demographic variables, other drug use, sexual assault variables, and PTSD.

Variable All
(N = 636)		 Past year cannabis
use
(N = 71)		 No Past year drug
use
(N = 565)
N % N % N %
Sexual orientationa,**
 Heterosexual 393 62 20 28 373 66
 Lesbian or bisexual 243 38 51 72 192 34
Race/Ethnicitya,*
 White 544 86 55 77 489 87
 Non-white 92 14 16 23 76 13
Marital statusa,*
 Not married 351 55 49 69 302 53
 Married 285 45 22 31 263 47
Household incomea,*
 < 15K–35K 218 34 28 40 190 33
 $36–50K 114 18 20 28 94 17
 $51–70K 99 16 10 14 89 16
 > $71K 205 32 13 18 192 34
VA servicesa,**
 Received 446 70 61 86 385 68
 Did not receive 189 30 10 14 179 32
Tobacco usea,**
 Non-smoker 472 74 35 49 437 77
 Smoker 158 25 36 51 122 22
Alcohol usea,**
 AUDIT negative 528 83 38 54 490 87
 AUDIT > 8 103 16 31 44 72 13
CSAa,**
 Yes 315 49 48 68 267 47
 No 321 51 23 32 298 53
Before military SAa,**
 Yes 176 28 32 45 144 25
 No 460 72 39 55 421 75
During military SAa,*
 Yes 255 40 38 54 217 38
 No 381 60 33 46 348 62
After military SAa
 Yes 96 15 13 18 83 15
 No 540 85 58 82 482 85
Cumulative STa,**
 0 197 31 12 17 185 33
 1 179 28 16 22 163 29
 2 145 23 19 27 126 22
 3 + 115 18 24 34 91 16
PCL-Ca,**
 PCL negative 425 67 32 45 393 70
 PCL-C > 50 211 33 39 55 172 30
Variable Mean SD Mean SD Mean SD
Ageb,** 49.9 13.8 42.4 12.2 50.8 13.7
AUDIT scoreb,** 4.3 5.1 8.5 7.3 3.8 4.6
CTQ CSA scaleb,* 2.0 1.4 2.4 1.5 2.0 1.4
Before military SAb,** 1.1 2.1 1.8 2.8 0.96 2.0
During military SAb 1.4 2.4 1.5 2.3 1.4 2.4
After military SAb 0.6 1.8 0.6 1.8 0.6 1.8
PCL-C scoreb,** 40.6 20.1 50.9 18.7 39.3 19.9
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Note. AUDIT = Alcohol Use Disorder Identification Test. CTQ = Childhood Trauma Questionnaire. CSA = childhood sexual abuse. SA = sexual assault. ST = sexual trauma. Possible range of scores on CTQ SA scale is 1–5. Possible range of scores for before, during, and after military SA is 0–9.

a

Chi-square or Mann-Whitney U statistic.

b

T-test statistic.

*

p < .05.

**

p < .01.

3.2. Regular past year Cannabis use prevalence

In the full sample, seventy-one (11%) women reported regular past year cannabis use, with 25 women (4%) endorsing use once a month, 16 (2%) endorsing use multiple times a month, 18 (3%) endorsing use multiple times a week, and 12 (2%) endorsing daily use. Of women identifying as heterosexual in the sample, twenty (5%) reported regular cannabis use in the past year. Of women identifying as lesbian/bisexual in the sample, 51 (21%) reported regular cannabis use in the past year use (Table 1).

3.3. Characterizing women veterans reporting regular past year Cannabis use

Demographic variables that were significantly associated with regular past year cannabis included identifying as a lesbian or bisexual, identifying as a racial/ethnic minority, younger age, being unmarried, earning lower income, and receiving VA services (Table 1). Identifying as a current smoker and screening positive for alcohol misuse were also positively associated with regular past year cannabis use. Of the women veterans reporting regular past year cannabis use, eleven (15%) also reported using at least one other drug (cocaine, stimulants, or non-prescribed opiates; not included in Table 1).

Additionally, a greater percentage of cannabis users, compared to those who endorsed no past year drug use, reported having experienced childhood sexual abuse and adult sexual assault before and during, but not after, military service. Cumulative sexual trauma was also significantly associated with regular past year cannabis use, such that a greater percentage of cannabis users endorsed experiencing sexual trauma during three or more time periods compared to those who reported no past year drug use. Finally, a greater percentage of cannabis users screened positive for PTSD when compared to peers who did not use any drugs.

3.4. Examining independent contributions of sexual trauma on regular past year Cannabis use

Table 2 provides correlations among variables included in the hierarchical logistic regression model. In this model (Table 3), child-hood sexual abuse was not associated with regular past year cannabis use when adjusting for demographic factors (Step 2). Similarly, adult sexual assault variables before, during, and after the military were not significantly associated with regular past year cannabis use when included in the model (Step 3). Cumulative sexual trauma exposure, however, was significantly associated with cannabis use when entered in the next step (Step 4). Specifically, compared to women who reported no sexual trauma, women who endorsed three or more periods of sexual trauma had increased odds of regular past year cannabis use. This association remained significant when adjusting for current PTSD symptoms, which was found to be a significant independent risk factor for cannabis use (Step 5). Younger age and sexual minority status also remained significant correlates in the final model.

Table 2.

Bivariate correlations among variables in logistic regression model (N=636).

Variable 1 2 3 4 5 6 7 8 9 10 11
1 Age –
2 Lesbian or bisexual −0.117** –
3 Not married 0.035 −0.168** –
4 Non-white −0.128** 0.026 −0.011 –
5 Income 0.220** −0.165** 0.407** − 0.050 –
6 CSA − 0.012 0.146** −0.024 0.083* −0.085* –
7 Before military SA − 0.021 0.103** −0.051 0.077 −0.112** 0.486** –
8 During military SA − 0.033 −0.016 −0.078* − 0.004 − 0.059 0.126* 0.247** –
9 After military SA 0.014 −0.046 −0.026 0.006 −0.090* 0.167** 0.348** 0.436** –
10 Cumulative Sexual − 0.061 0.089* −0.084* 0.067 −0.121** 0.584** 0.594** 0.514** 0.436** –
11 PCL-C − 0.272** 0.116** −0.101* 0.110** − 0.249** 0.326** 0.294** 0.440** 0.255** 0.452** –
12 Cannabis Use −0.193** 0.245** −0.099* 0.081* −0.097* 0.102* 0.128** 0.024 0.001 0.161** 0.181**
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Note. CSA = childhood sexual abuse. SA = sexual assault. ST = sexual trauma. PCL-C = Posttraumatic Stress Disorder Checklist – Civilian.

*

p < .05.

**

p < .01.

4. Discussion

To our knowledge this is the first study to describe cannabis use prevalence specifically among women veterans, to characterize women veterans reporting such use, and to explore the independent contributions of sexual trauma on cannabis use. Overall prevalence of regular past year cannabis use (11%) was higher than past year cannabis use rates detected in civilian women (i.e., 6.4–6.9%) but slightly lower than reported past year prevalence among women active duty military personnel (13.4%) (Hasin et al., 2015; Ko, Farr, Tong, et al., 2015; Stahlman, Javanbakht, Cochran, et al., 2015). When examined by sexual orientation, prevalence of regular past year cannabis use was similar to past year prevalence rates previously reported in hetero-sexual (e.g., 5.0%–6.9%) and lesbian/bisexual (e.g., 5.2–37.8%) civilian women (Hasin et al., 2015; Hughes, Szalacha, & McNair, 2010; Trocki et al., 2009). The high prevalence among sexual minority women veterans in the current sample (21%) is especially noteworthy and suggests a need to examine unique factors, such as minority stress, that may affect their cannabis use. Furthermore, it is important to note that past year cannabis use was defined as at least monthly use in the present study, a higher threshold than is often used in studies of past year cannabis use prevalence where “any use” is considered indicative of past year use.

Consistent with demographic patterns detected in previous veteran and civilian research, we found a greater proportion of cannabis users were sexual minority women, racial/ethnic minorities, younger, unmarried, and women reporting lower income (Bonn-Miller et al., 2012; Hasin et al., 2015; Hughes, Szalacha, & McNair, 2010; Ko et al., 2015; Substance Abuse Mental Health Services Administration, 2016; Trocki, Drabble, & Midanik, 2005). Our findings also suggest women veterans endorsing regular cannabis use may use or misuse other substances at higher rates than peers who do not use cannabis (Secades-Villa et al., 2015). Future research examining the impact of cannabis use on certain subgroups may be needed, including mediators or moderators that explain use and consequences among vulnerable populations.

Despite significant bivariate associations, sexual traumas occurring at specific periods during the lifespan (i.e., childhood sexual abuse and adult sexual assault variables) were not associated with regular past year cannabis use when adjusting for demographic variables. Cumulative sexual trauma exposure, however, was significantly associated with regular past year cannabis use. Compared with those endorsing no sexual trauma, individuals endorsing three or more periods of sexual trauma exposure had six times the odds of reporting cannabis use. A growing number of studies suggest that cumulative trauma exposure may play an important role in increasing the risk of adult substance use and misuse (Booth et al., 2011; Kelley et al., 2015; Khoury, Tang, Bradley, et al., 2010). For instance, Booth and colleagues (Booth et al., 2011) found cumulative periods of rape exposure were significantly associated with SUD, such that the odds of having a SUD increased from 1.6 to 6.7 across the cumulative variable (reference group = no history of rape; range 0–4), which is remarkably similar to the pattern seen in the present sample. Results identifying similar patterns related specifically to cannabis use are beginning to emerge in civilian samples (Kevorkian et al., 2015), and such findings are further supported by results of the present women veteran-focused study.

This study has several important clinical implications. Given the rates of cannabis use detected, cannabis use screening and assessment practices may be important to consider in a variety of health services settings serving women veterans, particularly as cannabis becomes more widely available and legal consequences are removed. Knowledge of a woman veteran’s use for recreational or medicinal purposes may impact the treatment plan for physical and/or mental health conditions being treated by a provider. Furthermore, knowledge of a woman veteran’s use for medicinal reasons provides an opportunity to discuss the risks associated with cannabis use and explore alternative treatments, including those that may involve less risk. For instance, such conversations would be important if a women veteran is pregnant or thinking of becoming pregnant and reporting ongoing cannabis use (Gunn, Rosales, Center, et al., 2016). Additionally, providers working with women veterans who use cannabis should also be attentive to individual reasons for use among their patients. The fact that cumulative trauma exposure and PTSD symptom severity were associated with cannabis suggests that self-medication may be a factor, as has been demonstrated in the larger substance use literature (Simpson, Stappenbeck, Luterek, et al., 2014). If a women veteran uses cannabis to manage symptoms following multiple trauma exposures across her lifetime, addressing this pattern of use within the context of treatment—and in a gender-sensitive manner that acknowledges women’s heightened risk for sexual trauma specifically (Turchik & Wilson, 2010)—may be useful. Additionally, if a veteran’s cannabis use contributes to avoidance behaviors targeted in frontline evidence-based interventions for PTSD (e.g., Prolonged Exposure Therapy), it could impede treatment progress. Discussing her use and potentially establishing goals to reduce and/or limit use during the course of treatment may be indicated (e.g., eliminating use immediately before or after session and while doing homework).

Noteworthy limitations also exist. We evaluated prevalence and correlates of at least monthly cannabis use in the past year. As noted above, this definition limits comparison to previous research utilizing different definitions of past year use. Moreover, cannabis use response options did not include a category for women who used cannabis more than once but less than monthly in the past year, which could have resulted in the misclassification of these women. We were also unable to examine indicators of misuse or the presence of CUD as such data was not available. The use of a dichotomous cannabis use outcome variable, while appropriate in the context of the current study, limits the ability to examine the relationship between sexual trauma and varying frequencies of cannabis use. The present study utilized retrospective cross-sectional data. Thus, it was not possible to ascertain timing of trauma exposure as it pertains to the onset of cannabis use. It is possible that cannabis use pre-dated endorsed sexual trauma. This is also not a population-based sample as recruitment and data collection took place over the Internet, limiting the generalizability of our findings. Additionally, all measures were based on self-report, which are subject to recall bias or respondent misunderstanding. Finally, our logistic regression results may be affected by moderate collinearity among the sexual trauma variables (Pearson r coefficients ≤ 0.60). Nonetheless, as noted, results did not differ in our sensitivity analysis in which the cumulative sexual trauma variable was examined in a separate model (see Methods).

Due to the relatively small number of cannabis users in the present study, replication of findings with larger samples is needed. Future research should consider utilizing a continuous cannabis use outcome variable as well as emphasizing cannabis use trajectories and differential risk factors for use versus misuse. For example, a recent study found that while trauma exposure was associated with cannabis use, PTSD symptom severity (but not trauma exposure) was associated with CUD (Kevorkian et al., 2015). PTSD was a significant bivariate correlate of cannabis use in the present study and remained significant when entered into the full multivariate model, suggesting further examination of the role that PTSD symptoms may play in cannabis use is warranted. Additionally, exploring the degree to which experiences of discrimination, minority stress, and coping motives are associated with cannabis use are important future avenues for understanding and ultimately addressing cannabis use among women veterans, particularly in those who are sexual minorities and/or of younger age. Other types of trauma exposure (e.g., physical assault, combat) may also be important to consider (Werner et al., 2016). Taken together, such information could subsequently guide assessment, psychoeducation, and treatment efforts.

5. Conclusions

Results of the present study suggest cannabis use may be as prevalent among women veterans as it is among their civilian counterparts. As cannabis use becomes more widely available, it will be important to identify those most at risk for use and misuse as well as to understand the context of their use. Our findings indicate that particular subgroups of women veterans may be more likely to engage in regular cannabis use: sexual minority women, racial/ethnic minority women, younger women, women endorsing use of other substances (e.g., alcohol misuse, tobacco), women who have experienced sexual trauma across multiple life eras, and women who screen positive for PTSD. Screening and assessments that identify cannabis users and those who may be having problems associated with cannabis use may be important tools to consider in a variety of health settings serving this growing veteran population.

Supplementary Material

S1 Table

HIGHLIGHTS.

  • Overall, 11% of women veterans endorsed at least monthly cannabis use.

  • 5% of heterosexual and 21% of lesbian/bisexual women reported at least monthly use.

  • Use was associated with minority and marital status, younger age, and lower income.

  • Use was associated with tobacco and alcohol use and PTSD symptoms.

  • Experiencing sexual trauma across multiple life eras was associated with use.

Acknowledgements

This work was supported by resources from the US Department of Veterans Affairs Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment; the Denver-Seattle VA Health Services Research & Development (HSR&D) Center of Innovation at VA Puget Sound Health Care System; and the Center of Excellence in Substance Addiction Treatment and Education (CESATE) at the VA Puget Sound Health Care System. Dr. Lehavot was supported by a VA CSR&D Career Development Award (1IK2CX000867). There have been no conflicts of interest in the conduct or reporting of this research study. The views expressed in this article are those of the authors and do not represent the views of the Department of Veterans Affairs or the United States government.

Footnotes

Conflict of interest

There have been no conflicts of interest in the conduct or reporting of this research study.

Declarations of interest

None.

Supplementary data to this article can be found online at https://doi.org/10.1016/j.addbeh.2018.04.007.

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