Women Veterans: The Faces of a New Generation

1. Women Veterans: The Faces of a New Generation Gina Painter, LCSW Women Veterans Program Manager George E. Wahlen Department of Veterans Affairs Medical Center Salt Lake City Health Care System March 14, 2013

2. History of Women in the Military U.S. Coast Guard Women Reserves Semper Paratus-”Always Ready” Women have informally served since the inception of our nation’s military 1776-Molly Pitcher, Battle of Fort Washington 1778-Revolutionary War Margaret Corbin & Mary McCauley Battle of Monmouth 1861-Civil War 400+ women in combat on both sides WWI- Women have formally been a part of the U.S. Armed Forces since the inception of the Army Nurse Corps in 1901 WWII- given Veteran status 1960’s-officially recognized as Vets 1992-VA authorized to provide gender specific care and MST counseling

3. History of Women in the U.S. Military

4. As Women Veteran Population Increases, Total Vet Population Declines

5. THEN And…

6. NOW…

7. OEF/OIF/OND • OEF (Operation Enduring Freedom) – Afghanistan, Georgia, Kyrgyzstan, Pakistan, Tajikistan, Uzbekistan, the Philippines • OIF (Operation Iraqi Freedom) -Iraq, Kuwait, Saudi Arabia, Turkey • OND (Operation New Dawn) -Iraq

8. Women Veterans Profile • 1.8 Million living WV-fastest growing cohort w/in Veteran community • Women serve in every branch of the military • Women serve as pilots, gunners, police, truck drivers • Women soldiers see intense combat and receive combat related injuries- are more likely to be service connected than male Veterans • More educated than male Veterans • Average age of WV is 48 year, compared to 63 years for male Veterans • More often divorced, single parents-30k single moms deployed • Fastest growing segment of the homeless Veteran population • 1 in 5 WV of the OEF/OIF/OND wars are diagnosed with PTSD • 1 in 5 WV seen by VA responded yes when screened for MST

9. Stressors of War: Physical • Injury-combat/non-combat • Heavy Gear • Heavy equipment • Noise • Driving/walking long distances • Extreme Temperature • Sleep deprivation • Diet issues • Hygiene issues • Toxic agents • Infectious agents • Multiple immunizations • *Blast wave/head injury-**TBI

10. Traumatic Brain Injury TBI symptoms: • Memory • Concentrating • Headaches • Loss of balance • Dizziness • Sleep problems • Fatigue/Irritability

11. Stressors of War Psychosocial Psychological Social functioning Marital/parenting issues Occupational/financial concerns Risk of re-deployment Spiritual/existential • Anticipation of combat • Combat trauma • Non-combat trauma • Separation from family/home • Deprivation

12. Post-Deployment OIF/OEF Reintegration Stressors Specific to Women Family issues are paramount Adjusting to civilian lifestyle Role transition-soldier to caregiver Partner conflict-Domestic violence Employment Feeling unable to relate or talk about experiences Parenting skills Homelessness Young children Mental Health issues Individuation from family of origin

13. Women Veterans and Homelessness • Women Veterans: ~8% of homeless Veteran population; 2X more likely to be homeless than non-Veteran women* • The risk of women veterans becoming homeless is 4x greater than for male veterans • 23-29% of female veterans seeking VA medical care reported experiences of sexual assault. • FY 2011: VA served ~198,908 homeless, at-risk, or formerly homeless Veterans(7.7% or 15,303 women) • VA homeless programs include: • HUD-VASH Program • Grant Per Diem Program (GPD) • Supportive Services for Veterans Families (SSVF) Program: • Homeless Veterans Support Employment Program (HVSEP • Veterans Homeless Prevention Demonstration Program (VHPD)

14. Higher Physical and MH Needs • Studies show that 31% of women Veterans have both medical and mental health conditions compared with 24% of male Veterans • A higher proportion of female Veterans (22%) are diagnosed with mental health problems than male veterans (50.7% of OEF/OIF/OND seen at VA 2011) • Most common diagnoses among women Veterans seeking care are: • PTSD • hypertension • depression • high cholesterol, low back pain, gyn problems and diabetes.

15. Conditions More Common in Women than Men • Back problems • Joint Disorders • Post Traumatic Stress Disorder (PTSD) • Reproductive Health Conditions • Depression • Mild- 6.8% vs. 4.1% Major-3.3% vs. 1.4% • Musculoskeletal Problems 4.6% vs. 4.1% • Adjustment Disorders 4.1% vs. 3.5% • Skin Disorders 3.9% vs. 2.6% • Hearing Disorders

16. Mental Health Disorders in Female OEF/OIF Veterans Seen in VA

17. Readjustment Back to Civilian • Completely NORMAL to go through period of readjustment from active combat service member to civilian (from holding a weapon to a TV remote) • Readjustment phase can take from 6 months to 2 years or longer depending on the individual • Common issues include but not limited too: • Increased irritability/anger • Difficulty communicating/shutting people out/isolation • Sleep disturbances • Erratic behavior/ mood swings • Aggressive driving

18. Mental Health Disorders in Female OEF/OIF Veterans Seen in VA • Personality disorders • Somatization- medically unexplained physical complaints; stomach, headache, pain, diarrhea • Sexual dysfunction • Eating disorders • Self-injurious behavior

19. What is MST? • VA’s definition of MST comes from federal law but in general is sexual assault or repeated, threatening sexual harassment that occurred during a Veteran’s military service • Can occur on or off base, while a Veteran was on or off duty • Perpetrator identity does not matter • Both men and women can experience MST • Era of service does not matter • MST is an experience, not a diagnosis

20. What is MST? • Any sort of sexual activity in which someone is involved against his or her will • Someone may be: • Physically forced into participation • Unable to consent to sexual activities (e.g., intoxicated) • Pressured into sexual activities (e.g., with threats of consequences or promises of rewards)

21. How Common is MST? • This can be difficult to know, as sexual trauma is frequently underreported • About 1 in 5 women and 1 in 100 men have told their VHA healthcare provider that they experienced sexual trauma in the military • These data speak only to the rate among Veterans who have chosen to seek VA healthcare • Because MST is an experience, not a diagnosis, these data cannot address what percent of those who screened positive need or want treatment • Although women experience MST in higher proportions than do men, because of the large number of men in the military there are significant numbers of men and women seen in VA who have experienced MST

22. Not All Traumas Are Created Equal National Comorbidity Survey Probability of Developing PTSD (Kessler et al, 1995)

23. Not All Traumas Are Created Equal Study of Gulf War Veterans Probability of Developing PTSD (Kang et al., 2005)

24. Impact of MST • People are remarkably resilient after experiencing trauma • There is no one way that Veterans respond to MST • Many cope quite well and recover without professional help • Some continue to have difficulties at times or strong reactions to certain situations • Some experience more profound or longer-term problems • May be particularly likely for multiply traumatized Veterans • OEF/OIF/OND Veterans’ MST experiences may be relatively recent and their distress more acute

25. Impact, Part 1: Diagnoses Commonly Associated With MST • Among users of VA health care, the mental health diagnoses most commonly associated with MST are: • PTSD • Depressive Disorders • Anxiety Disorders • Bipolar Disorders • Drug and Alcohol Disorders • Schizophrenia and Psychoses

26. Diagnoses Associated With Sexual Trauma More Generally • Other mental health diagnoses common among sexual trauma survivors include: • Eating Disorders • Dissociative Disorders • Somatization Disorder • Rates of sexual trauma are high amongst individuals with certain personality disorders • A range of physical health conditions are also associated with sexual trauma Asthma Chronic Pain Syndromes- fibromyalgia Gastrointestinal issues Breast cancer Migraines Heart attacks GYN issues Obesity Sexual dysfunction

27. Impact, Part 2:Common Symptoms and Problems • Extremes of emotion and emotional lability • Emotional disengagement or flatness • Difficulties with attention, concentration, and memory • Re-experiencing and strong emotional reactions to reminders • Hypervigiliance • Trouble sleeping, nightmares • Suicidal thoughts or behavior • Self-harm • Disordered eating • Dissociation • Drinking and drug use • Revictimization • Difficulties with hierarchical environments

28. Impact, Part 2:Common Symptoms and Problems • Difficulties in core areas of functioning and well-being • Interpersonal difficulties or avoidance of relationships • Difficulties getting and maintaining employment • Difficulties with parenting • Difficulties with identity and sense of self • Spirituality issues/crisis of faith

29. Not All Traumas Are Created Equal • Research has shown that sexual assault is more likely to result in symptoms of PTSD than are most other types of trauma, including combat • Research also suggests that sexual assault in the military may be more strongly associated with PTSD and other health consequences than is civilian sexual trauma

30. Not All Traumas Are Created Equal • Sexual trauma that occurs in a military context may be even more damaging than sexual trauma that occurs in civilian settings • Women who experienced a military sexual assault reported negative consequences beyond those of women who experienced child sexual abuse • Among women veterans, MST was found to be more strongly associated with PTSD than was premilitary or postmilitary sexual trauma (Suris et al, 2007; Himmelfarb et al, 2006)

31. MST is An Interpersonal Trauma • Perpetrated by another human being • Frequently a friend, intimate partner, or other trusted individual • Involves a profound violation of boundaries and personal integrity • Sends confusing messages about what is acceptable and expected behavior from a trusted other, what rights/needs the victim has, and what is “theirs” versus publicly available • May be particularly confusing in the military context where rely on others to be “Servicemembers in arms” • Has significant implications for survivors’ subsequent relationships and understanding of themselves

32. MST May Be Ongoing Over Time • In the military, there are often few boundaries between work and home life and in both spheres individuals may interact with the same group of people • Survivors may continue to have interactions with their perpetrator • May be ongoing potential for revictimization • Can increase feelings of helplessness and of being trapped • Parallels with childhood abuse

33. Social Support May Be Limited • At the time of experiences, may be far from friends and family • Availability of social support is also impacted by societal messages, especially to the extent they are internalized • At homecoming or discharge, may believe or be told by others that their experiences are not as “legitimate” as combat trauma experiences • May not disclose to providers or seek out help • May not report experiences to authorities • Experience of OEF/OIF/OND Veterans may be different due to Department of Defense reforms • Problematic given research identifying social support as the most consistent and best predictor of recovery after trauma • Negative reactions to disclosure are particularly harmful

34. Gender Differences • Gender role socialization can impact reactions to sexual trauma • Sadly, sexual trauma may be congruent with traditional societal frameworks of femininity (ie., women are passive, vulnerable, weak) • But for men, the experience is more likely to violate traditional male gender norms (ie., men are strong, aggressive, dominant) • Men and women are likely to have many of the same reactions (ie, fear, shock, helplessness, sense of disbelief) at the time of the sexual trauma • Research has also identified gender-specific reactions and coping strategies • Little to no research on how these differences might or might not play out in Veterans’ reactions and behavior

35. Overall… • A sexual trauma history creates dilemmas for survivors • Whether to trust others, when you know that even friends and “family” may prove untrustworthy • Whether to trust yourself, when you know the consequences of being wrong • Whether to form relationships and get your needs for connection met, when you know how severely others could hurt you • How to reconcile experiences of MST with the ideals that may have led you to join the military • Whether to prioritize safety or freedom • Confusing behavior can result from trying to manage the conflicting needs underlying these dilemmas

36. What is the Department of Defense Doing? • For information about the Department of Defense’s current efforts, please visit: • www.myduty.mil or • www.sapr.mil • Change Strips Unit COs of Handling Rape Reports A policy change that strips unit commanders of the authority to decide how to handle reported rapes marks a significant departure from military tradition and, advocates say, could mean more justice for victims. Beginning June 28, company and battalion commanders will no longer have disposition authority for reported rapes, sexual assaults and sodomy, according to the Department of Defense. More Info: http://www.military.com/daily-news/2012/06/04/change-strips-unit-cos-of-handling-rape-reports.html?comp=7000023317843&rank=1

37. What is VHA Doing? • Universal screening • Veterans who report having experienced MST are offered a referral to mental health for further assessment and/or treatment • Free treatment • MST Coordinator at every VAMC and CBOC, to serve as a point person for MST issues Breeze Hannaford 801 582-1565 x2764 • Education and training of staff • Outreach to Veterans • National MST Support Team, to continue improving VHA’s response to MST

38. Free MST-Related Care • Free care is provided for all physical and mental health conditions related to MST • Service connection is not required • Treatment is independent of the VBA disability claims process • Veterans do not need to have reported the MST at the time or have other documentation • Veterans may be able to receive free MST-related care even if they’re not eligible for other VA care • There are no length of service or income requirements to receive MST-related care • Veterans with Other Than Honorable discharges may be able to receive MST-related care with VBA Regional Office approval

39. Specialized Mental Health Treatment For Women • Mental Health Provider in Primary Care • Outpatient Individual/Group Therapy • Outpatient Women’s Stress Disorder Treatment Teams (WSDTTs) and other teams specializing in the treatment of women • Inpatient and residential trauma programs with women-only cohorts or separate living areas for women (Sheridan, Palo Alto, Boston)

40. Video: You Served……You Deserve the Best Care Anywhere http://www.womenshealth.va.gov/WOMENSHEALTH/publications.asp#videos

41. What’s Happening at the SLC VA Women Veterans Program?

42. 16,000 (2012 projected)

43. Continuum of Health Care • Mental health/Social Work • Homeless/Housing services • Nutrition/weight management • Specialty care • Emergency care • Diagnostic services • Tele-health • Geriatric and extended care services • Employment service • Educational assistance • Fisher House • Rehabilitation • Medical Care including specialty care • Pharmacy • Residential/Inpatient including women specific • Substance Abuse • Transportation • Clothing and Personal Items • Financial compensation 43

44. Women Veterans Program Services • Primary Care • Gynecological Care • Maternity Care- birth at U of U • Birth Control • Genetic Counseling • Women’s Pharm D • Teleheath OB/GYN, Pharm • Infertility Evaluation and Treatment • Menopause Evaluation and Treatment • Osteoporosis Screenings and Treatment • Cervical cancer screenings • Mammograms-fee based • Wellness and Healthy Living • Nutrition and Weight Management • Smoking Cessation • Military Sexual Trauma Screening and Treatment • Mental Health Screenings and Treatment

45. Women’s Clinic MH Services • MH services are provided *(co-located) in the Women’s Clinic through the Mental Health Social Worker Amanda McNab, LCSW, x 5413 • Location: SLC VAMC, Building 1, 1st floor, near radiology • Women’s Clinic -x5414 *VHA Handbook 1330.01 Health Care Services for Women Veterans

46. Women Veterans Program Contacts • Gina Painter, LCSW- Women Veterans Program Manager x5423 • Dr. Susan Rose- Women’s Clinic Medical Director x2472 • Amanda McNab, LCSW Women’s Clinic MH Provider, x 5413 • Michelle Richens-Women’s Clinic RN Case manger x2699 • Shelley Medley, OB/Gyn RN x2471 • Susan Barnum- PSA, front desk x5414 • VA Women Veterans Health Care http://www.womenshealth.va.gov/

47. SLC VA Women’s ClinicBuilding 1, room 1D17 ext 5414 option 2

48. OB/GYN Program Dr. Susan Rose

49. Expanded OB/GYN Services • Obstetrics • Prenatal care including; clinics, labs, nutrition counseling, genetic counseling available at SLC VA for women who live within 50 miles of facility • Delivery at University of Utah Hospital • Non-VA funding for prenatal care available for women who live further than 50 miles from facility • Gynecology • Outpatient services: Pre-conceptual counseling, contraceptive management, evaluation and management of abnormal uterine bleeding, menopausal disorders, abnormal pap tests, urinary incontinence, etc. • Surgical services: laparoscopy, hysteroscopy, surgical sterilization, hysterectomies, repair of pelvic organ prolapse, incontinence, etc.

50. New Mother’s Room For patients and employees who are breastfeeding/ pumping Bldg. 1, 1st floor Room 1B02