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Sunday, 25 September 2011

What are the Psychological Issues Encountered by Women in the Armed Forces, and How Might they be Resolved?

At present women make up nine percent of the UK’s total military strength, and the number looks set to rise further.[1] Physical injuries are the most obvious effects of warfare, although the number of psychiatric battle casualties is far greater than those killed or physically disabled, and the effects can be equally as devastating. Both men and women in the Forces face the possibility of psychological issues, although recent statistics from the Ministry of Defence show that women in the three main service branches are more than twice as likely to suffer than their male counterparts. Seven in every thousand servicewomen experience symptoms, compared with only three in every thousand males.[2] These findings parallel similar studies on civilian personnel, where women consistently demonstrate higher rates of psychological disturbance than men.

The period between 1997 and 2005 saw a marked increase in psychological issues being reported by female members of the British Armed Forces,[3] with female soldiers in combat support units reporting twice as many symptoms again as women in administrative roles.[4] Although women are excluded from specialised duties where the primary duty is ‘to close with and kill the enemy’,[5] they do serve in positions, such as convoy drivers and medics, which place them in the same line of enemy fire as a combat role.[6] The changing conditions and demands of modern warfare may also exacerbate the emergence of psychological issues in women. The military has always been an environment of unique stresses, but in current combat zones, tours of duty have been extended, and traditional front-lines essentially dissolved. Women are thus potentially exposed to increasingly dangerous work assignments, frequent relocation, and harsher conditions than ever before. These external factors certainly contribute to psychological issues found in both male and female service members, although ‘deployment, combat stress, and environmental and occupational exposures may affect women differently than men’.[7]

There is a broad spectrum of disorders classified as ‘psychological issues’, which have evolved from pre-1914 to the present. They can affect both sexes, range from short-term to lifelong in length, and can be categorised as mild, moderate, or severe in effect. The military has employed the Brief Symptom Inventory (BSI) as a means to investigate the prevalence of mental health issues in service personnel, and to compare how gender effects the onset of psychiatric symptoms. The BSI is a self-report symptom scale that charts present psychological status and distress, and  classifies nine principal symptom dimensions, namely: anxiety neuroses; somatizations; obsessive-compulsive behaviour; hostility; depression; paranoid ideation; psychotism; interpersonal sensitivity, and phobic anxiety.[8] Additional acute syndromes include, short-term stress disorders and reactions, battleshock, combat stress reaction (CSR), and mild traumatic brain injury (mTBI). Evidence gathered from this research suggests women experience higher rates of acute illnesses, particularly eating and sleeping disorders, whilst they are also more susceptible to the longer-term (chronic) disorders; running ‘about five times the risk of experiencing post-traumatic stress disorder than men, and about twice the risk of a major depressive episode’.[9]

It should be noted here that there are many different forms of combat and environment, and as such, there is no single and uniform psychological effect of deployment. When discussing psychological issues, it must be remembered that they are a complex and varied phenomenon, and individuals often have different psychological reactions to external stimuli. I will focus on the behavioural, environmental, and social stressors that women in the British Forces face in modern warfare; and the psychological issues that arise as a result of them.

The military milieu is comprised of both generic, and unique, stressors. Stress is an umbrella term used to denote a negative manifestation of a psychological reaction in response to an external stressor. ‘Stress is a ubiquitous occurrence among active duty military personnel and has been associated with a variety of mental health and job performance outcomes.’[10] Women account for one of the categories of personnel most susceptible to occupational stress, and when they experience distress or upset, their feelings manifest themselves in psychological complaints or psychosomatic illness. Contrastingly, men are socialized to ignore symptoms,[11] and thus tend to respond by turning towards alcohol and/or stimulants.[12]

Stress is a psychiatric issue in its entirety, and generates symptoms including: fatigue; slower reaction times; indecision; inability to prioritise, and detachment from their surroundings. It can also be a precursor for more major syndromes: it can be transient, in the form of Combat Stress Reaction (CSR), or a life-long issue, as in some cases of post-traumatic stress disorder (PTSD). Both forms produce a range of behavioural issues, rooted in psychiatric upset. There has not been much research into why women are more susceptible to stress and psychological impairment than men, although it has been proven that they are particularly sensitive to the onset of a stress reaction.

Sexual inequality and gender division are key social contributors to the development of stress, and other psychological issues, in servicewomen. One of the fundamental causes of division is rooted in the British Defence Policy, which excludes women from certain specialisations within the military. Their selection criteria and training standards also differ to men’s, although the majority of women in the Forces feel they should be granted complete equality, as disparity reinforces internal misogyny and creates a sense of ‘us’ and ‘them’; where women become the unvalued Other.[13] In the theatre of war; particularly in challenging deployments, or assignments to remote military bases, the feeling of belonging to a group is of paramount importance, as isolation and lack of female support and guidance can generate self-doubt, stress, anxiety and depression in women, as ‘morale, cohesion and esprit de corps [act] as buffers against psychological breakdown in combat operations’.[14] 

Feelings of exclusion are a frequent complaint of servicewomen. This is in part due to the prevalent belief, ‘that the presence of females in combat groups [dilutes] the male bonding, and decreases unit effectiveness.’[15]  Despite research findings to the contrary, this genus of belief persists, and reinforces the categorisation of women as second-class citizens, whilst acting as a catalyst for many negative effects on their psychological make-up. Such views also mean it can also take time for women to build new and trusting friendships, which adds to the burden of the stress of feeling alone.

Although familial concerns affect both sexes, they tend to appear as precursors to psychological stress more frequently in women, than in men. The nature and number of women’s roles may also contribute to psychological issues, brought on through stress. Gove and Hughes (1979), argue that excess stress in females can be traced to women’s greater role obligations, including that of a wife, mother and soldier. The strict contrast between these roles can cause stress and anxiety can lead to women experiencing a lack of satisfaction in both motherhood and warfare. Leaving their families for long periods of time, and often at short notice, also results in feelings of helplessness.

Despite the fact that British society is highly emancipated and dedicated to promoting equality, the level of sexual harassment in the Armed Forces is surprisingly high, and is not lessening. Sexual harassment is a relatively common issue faced by women in the military, which must be, in part, due to the patriarchal and misogynist environment and hierarchy of the Armed Forces. ‘Sexual harassment’ encompasses any unwelcome sexual attention, while sexual assault is one of the primary causes of major psychological issues, such as PTSD, Major Depressive Disorder (MDD), and Military Sexual Trauma (MST), found in female military populations. Even the threat of sexual assault can negatively contribute to an individual’s psychological state, and leave women feeling alone, anxious and depressed. It has been argued that the elevated number of psychological issues reported by women is due to the fact they are at much higher risk from MST, which is essentially a uniquely feminine problem.

The institutional sexual inequality, and reservations concerning a woman’s place and role in the military, also contribute to the stressors, and resultant psychological issues experienced by women. The Forces were historically a male-only environment, and even in today’s world, ‘there is no doubt that masculinities form a major element in the construction of military identities and that much of this will appear as aggressive, threatening, and deeply misogynist’.[16] This misogyny which undermines women as it questions their role and worth in the military. For example, in 1979, James Webb wrote an article entitled Women Can’t Fight[17], and as recently as 1991, Rear Admiral Williams, made sexist comments concerning the Talihook scandal of 1991, stating: ‘a lot of female Navy pilots are go-go dancers, topless dancers or hookers’.[18]

As a result of institutionalized inequality, several studies suggest that women engaged in occupations that have traditionally been considered male domains, (such as, military police, mechanics or pilots), frequently experience role strain and environmental stress. They feel ‘their competence is not given due recognition, and they have to work twice as hard as men to prove their worth. They also feel they are constantly under scrutiny for even minor slip-ups’.[19] The pressure of feeling unvalued in comparison to their male colleagues again leads to depression, anxiety and obsessive compulsive disorders.
In comparison to the relatively personal issues generated from behavioural and social stressors, environmental factors cause a different kind of psychological upset. As women are now routinely exposed to combat situations, they run a higher risk of death or injury, and may witness others being hurt or killed. They may have to kill for themselves and must constantly be alert, while the aftermath of battle can be equally as traumatic.  Exposure to the consequences of battle commonly involves moving human remains, observing devastated communities, and addressing prisoners of war.   Such factors greatly increase the chance of a psychological issue developing, and female personnel in combat theatres are ‘particularly likely to develop stress-related disorders’.[20] Studies also reveal that women are more likely to be affected by PTSD, and often suffer from more pronounced and debilitating forms of the disorder than men. These are worrying results, especially when viewed in light of the large number of female troops who returned from Vietnam,  having experienced great trauma, and resultantly turned to drugs, alcohol, or suicide.

The above findings correlate with recent figures that reveal a markedly elevated trend of suicide among young women in the Forces. It shows they ‘have nearly triple the suicide rates of women who never served in the military”.[21] These results underscore that psychological issues are a very real and significant feature in warfare, and prompt questions concerning whether the military mental health support network is adequate. How might psychological issues be resolved, and how can the physical and psychological wellbeing of servicewomen be protected and preserved?

Gender inequality and the stigmatisation of mental health disorders are two key elements that demand attention when ascertaining treatment for psychological issues. Firstly, military practise must be reviewed from a grassroots level, and awareness raised in an attempt to eradicate misogyny. Servicemen from all echelons of the Forces should be briefed on sexual equality and the mental health implications that can arise from feelings of isolation and victimisation. Effort should also be directed towards engineering total equality in the working arena, wherever possible. When questioned, servicewomen told of their resentment for ‘preferential’ treatment as a result of their sex, and expressed the belief that uniform selection criteria, training standards and work schedule would help dissolve the  gender divisions and promote equality. They desire a fair opportunity to prove their worth to the male comrades, and reverse the widespread portrayal of women as the weaker-sex. At a social and behavioural level, if the perception of military women were to change to a more positive one, it would have a very beneficial effect on the psychological issues that are splinter reactions to this underlying cause.

Stigma concerning the reporting of mental health syndromes is another vital concern, for although a large percentage of service members suffer from  a psychological issue at some point in their careers, only relatively few seek out treatment. A 2008 Rand Corp study approximated that a fifth of service personnel returning from the Afghanistan and Iraq wars reported symptoms of post-traumatic stress disorder or major depression, although only half sought treatment. The stigma attached to reporting, and receiving treatment for mental health problems is a major reason why this percentage is so low. There is an ingrained perception within the military that weakness is concomitant with mental health issues, and individuals fear that by disclosing such personal issues, their platoon and seniors may lose confidence in their ability and treat them differently, and their whole military career may be jeopardised. This belief seems especially true of women, who have fought for years  to earn their place and respect within the Forces, and do not want to risk their present status by admitting to psychological issues.

However, the consequences of not pursuing professional treatment can be terrible and far-reaching, and effort must be made by the ‘military medical community to take the lead in removing the stigma or perceived punishment associated with mental illness’:[22] reporting issues should not have a detrimental effect on an individual’s career, or generate any negative judgement.  If stigma could be eradicated, it would help diminish the problem of long-term psychological issues, improve job performance and satisfaction, better the overall mental health of military professionals and reduce the risk of suicide (as a by-product of stress-related syndromes).

Post-traumatic stress is one of the more common complaints found in service personnel, and
in its potential to be a lifelong and completely debilitating disorder, it demands different treatment to the more transitory issues. Although there is a large volume of information regarding women’s experiences of trauma and PTSD, further investigation is needed into the unique risk factors for PTSD in women, in order to formulate a successful method of treatment or management. Development of healthcare and research programs purely for women would accelerate the process. The primary concern should be to distinguish these factors and address them as roots of the problem of psychological issue. A variety of effective treatments for PTSD have already been established, although further long-term study is needed to see if the outcome of rehabilitation is durable. Prolonged Exposure Therapy may be used to treat PTSD, whereby individuals are guided through months of vivid memory recall concerning traumatic events until their emotional response decreases through "habituation." ‘The goal is that the memory of the traumatic event is no longer as startling, as terrifying, when it comes.’[23] "Present-Centred Therapy" is another treatment often used, which focuses on addressing a patient’s present life situation, rather than past trauma. Finally, ‘group psychotherapy may help counteract the isolation of PTSD, where the “shattered self” may be reintegrated in the “inter-subjective” space of the individual patient-therapist relationship,’[24]

Better support networks, available throughout the whole deployment process, would help combat social and behavioural stressors. Better pre-deployment physical and psychological health screening would benefit female personnel, for evidence shows that servicewomen tend to have experienced greater levels of personal trauma before joining the Forces, than males or lifelong female civilians, and resultantly are at greater risk from developing a combat-induced traumatic disorder. Once deployed, support must be given in the field by trained mental health staff, which should include briefing on how to get help, ongoing assessment and treatment (if required), for any current issues. There is a need for gender-specific health care units in deployed locations, and qualified MST councillors should be present. Better long-term surveillance of health problems are also critical in the post-deployment period for monitoring the health and well-being of servicewomen. High levels of social support should be offered through easy access to counselling or therapy from a mental health professional or from a military chaplain.

Finally, when considering options to minimize environmental stressors, manifested in acute fear or anxiety issues, the importance of training cannot be over emphasized.

Case studies focused on the effect of environmental stress on body-handlers, and results revealed that personal and unit stress can be depleted by training and practise.  Although women report greater levels of stress than men in anticipation of body handling, after training and experience with body handling, the sex difference in anticipation diminishes.[25]

To conclude, psychological issues are the often unseen disturbances that have the potential to completely incapacitate servicewomen (and men). They are a very common occurrence and greater efforts should be directed towards re-categorising them into the same bracket as physical injury, and streamlining treatment procedures  It is impossible to completely eradicate the stressors that contribute to psychiatric problems, as trauma is an inevitable part of warfare, but the effects can be minimized. The military needs to evolve past gender and inequality issues and work towards removing the out-dated perception of mental health issues. Servicewomen and men lay down their lives for the country and should have access to the best training and healthcare, and not be stigmatised should they sustain a psychiatric condition.

[1] UK Defence Statistics (2005), p. 61
[2] Breslan, et al (1997), Archives of General Psychiatry, 54 (11), 1044-1048
[3] Rona, Fear, Hull & Wessley (2006), International Journal of Epidemiology, 36 (2), 325
[4] Bishop (1984), Health Psychology, 3 (6), 529
[6] Mattocks et al (2010), Journal of Women’s Health, 19 (12), 2159
[7]  Pierce (2005), Military Medicine, 170 (5), 349
[8] Britt, Castro &  Adler, eds., (2006), p. 16
[9] Hourani & Yuan (1999), Military Medicine, 164 (3) 174 
[10] Hourani, Williams & Kress (2006), Military Medicine, 171 (9), 849
[11] Bishop (1984), Health Psychology, 3 (6), 520
[12] Dohrenwend & Dohrenwend (1976), The American Journal of Sociology,  81 (6), 1447-1454
[13] de Beauvoir (1993)
[14] Britt, Castro & Adler, eds., (2006), p. 20
[15] Gal & Manglesdorff, eds., (1991), p. 734
[16] Morgan (1994), p. 177
[17] Sherman (2010), p. 261
[20] Goldstein (2001), p. 263
[22] Hourani &Yuan (1999), Military Medicine, 164 (3) 180
[24] Goldstein (2001), p. 263
[25] Norwood, Ursano & Gabbay (1997), Military Medicine, 162 (10) 647

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