Female veterans are less likely to be compensated for PTSD because of the difficulty of proving sexual assault, an expert says.
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The last time she saw him alive, he was begging to be saved.
"I don't want to die," the soldier pleaded as hospital medics tended to burns all over his body. "Please, don't let me die!"
Later, when they would meet in her dreams, the soldier wouldn't say anything at all. And though she wanted to talk to him, she never knew what to say.
"I'd just watch him go about his life the life he had before he died," she said.
It has been nearly four years since Marie returned home from the war. She is still haunted by her experiences there.
But the ghosts of those she saw dead and dying in Iraq are only a small part of her distress. Far more painful, she feels, has been the way she has been treated since coming home.
Civilian friends, unable to understand what she went through in Iraq, have distanced themselves from her. Some military comrades have mocked her, sexually harassed her and when she complained to her superiors cut her out of her most vital social support network. Government officials, responsible for assessing her psychological wounds, have told her she's unworthy of compensation.
Nearly a quarter of a million women have served in Iraq and Afghanistan. Female veterans suffer from post-traumatic stress disorder, known as PTSD, at about the same rate as their male counterparts and some studies have suggested that women may be more vulnerable to war-related psychological trauma. But military culture and a post-military support system designed by men, for men can make it difficult for women to access the help they need.
So they often suffer alone.
Marie, a junior enlisted woman in her mid-20s, still serves in a Utah-based reserve unit. The Salt Lake Tribune agreed to identify her by her middle name because she fears retribution from military superiors for speaking out.
She mourns for the woman she used to be. But she insists she doesn't regret her decision to join the military.
"I had the privilege of serving my nation," she said. "That's the one thing, maybe the only thing, they can't take away from me."
'If they won't help me, who will?' • After offering to spend her off-duty hours helping at Air Force Theater Hospital at Joint Base Balad in northern Iraq, Marie realized hospital work wasn't for her. But after a boisterous argument with another member of her unit, her commanding officer sent her back to the hospital as punishment.
"He specifically ordered me to work in the emergency room," she said. "He said it was to remind me of how good I had it."
Among her duties: Cleaning up the body of an Iraqi soldier mutilated in a bomb attack.
"His teeth had been blown into the roof of his mouth," she said, curling her lips in recollected revulsion. "He had a huge head wound and it was still bleeding, dripping blood onto the floor. And his guts were just hanging out of his stomach."
The dead soldier would later join the burn victim in her nightmares. Sometimes she went sleepless in an effort to avoid their visits.
During the daytime she felt restless, anxious and lonely. She lost her connections to many of her civilian friends who simply couldn't understand what she'd been through. But at least for a time, Marie felt she could count on the support of members of her unit, many of whom were having similar struggles.
Then, less than a year after her return from Iraq, she lost that support, too.
At work, a member of her unit began to make sexually derogatory comments toward her. And it only got worse when she asked him to stop, she said.
Women in the military are officially encouraged to report harassment to their commanders, and she did. But while the direct harassment ended, so too did the cherished relationships she had with many of her unit's other members.
"Suddenly I was being excluded from everything that was going on," she said. "People wouldn't talk to me."
Not long after, the man she accused of harassment was given an award for exemplary service. And with that, Marie said, her humiliation was complete. She transferred into the reserves, a move that extended her enlistment by several years.
"I'd just had enough," she said of her decision to leave the active-duty military. "I felt completely abandoned. I felt like I was dirt."
Distrustful of the military medical system, Marie confided in a civilian psychiatrist, who diagnosed her with PTSD. Citing her work in the hospital and her service in Balad during a period of frequent mortar and rocket attacks, she submitted a claim for compensation to the Veterans Benefit Administration.
When the response came in the mail on a Saturday afternoon, she anxiously ripped it open.
"They said I didn't have any post-traumatic stress at all," she said. "I cried and I cried that night, and I cried for the next two days. I was thinking, If they won't believe me, who will? If they won't help me, who will?"
'I'm going to have to really earn her trust' • The women's clinic at the Veterans Affairs Medical Center in Salt Lake City has offered a range of services to qualifying women veterans for more than a decade. But Gina Painter, its manager for the past two years, said it's still not well-known. "We have staff members who don't even know that we have a women's clinic," she said.
That's in spite of the fact that the number of female patients at the VA has doubled in the past six years nationally and is expected to double again in the next six. Painter attributes the lack of awareness to the glacial way large bureaucracies accept change.
The average female patient at the VA is 48 years old but a rapidly increasing number are younger than 30. Male patients, meanwhile, average 61 years old and, with tens of millions of veterans from World War II, Korea and Vietnam in or approaching their twilight, their ranks are getting older. In Utah, male patients are even older, averaging about 68 years old.
The needs of the two groups are vastly different. Last year, Salt Lake City's George E. Wahlen Veterans Affairs Medical Center became the first VA hospital in the country to deliver a baby. Meanwhile, a few hundred yards away, men in their 80s and 90s make up the majority of those staying at a VA-operated nursing home.
"It's a complete paradigm shift," Painter said.
Although hundreds of thousands of women served in uniform in World War II, Korea, Vietnam and intervening times of peace, it wasn't until 1988 that the VA began offering medical and mental health services to female veterans due mainly to a policy favoring vets who served in combat. Today, nearly all veterans are eligible for some level of VA services, but women still underutilize their entitlements.
Studies show that women suffer from PTSD at least as much as men. Although they make up about 14 percent of the fighting force in Iraq and Afghanistan, they comprise 6 percent of the patients from those wars who have been processed through a mental health intake clinic at the Salt Lake VA.
One possible reason: The VA has a long way to go before it reaches its goal of being a one-stop location for women's primary care. Only about a third of VA medical facilities have a gynecologist on staff. And according to a report from the Government Accountability Office earlier this year, the VA has done a poor job of protecting women's comfort and privacy. Among its observations: Only a small number of gynecological examination spaces have adjacent restrooms, as required by the VA's own rules. And in some clinics, the exam tables were oriented so women's feet faced the door. In at least one such instance, the door opened into the view of a mixed-gender waiting room.
"It's nothing nefarious," said Dan Murchie, a patient advocate at a clinic for veterans of the wars in Iraq and Afghanistan at the Salt Lake VA. "It's just that what has been set up for women is something like an afterthought."
But Murchie lamented the message that that sends to female veterans, especially those who might need mental health care.
"When I get a woman coming into my office, I already know that, more likely than not, I'm going to have to really earn her trust," he said. "Any little thing that makes her feel uncomfortable could make her bolt and if she does that, then I can't get her the help she might need."
'I'm not making this up' • Another substantial obstacle is what is found or not found in a woman's service records.
At war in Iraq and Afghanistan, women carry guns, drive on bomb-laden roads, stand watch on guard towers, take fire and return it.
They fight, they bleed and sometimes die.
But because women are technically barred from serving in U.S. military units in which direct ground combat is the primary mission, they have a higher burden of proof when it comes to establishing that they've suffered from war-related psychological trauma.
Murchie ruefully recalled one of the first women he tried to help with a benefits claim. "They shot her down like a duck on opening day," he said. "Not surprisingly, she walked out of here pretty disgruntled."
A new policy intended to give all veterans the benefit of the doubt when they file claims for disability benefits related to PTSD is expected to result in a higher approval rate for female vets, who generally don't have the word "combat" in their service records and must establish, through other evidence, that they suffered through traumatic experiences while at war.
Marie hopes benefits officials will reassess her claim more favorably under the new policy.
"It would mean a lot to me if they would just acknowledge that I'm not lying, I'm not making this up," she said. "This is my life and I am suffering. And when they deny all of that, it feels like it cheapens what I've been through."
For many female veterans, however, the more lenient rules likely won't help. That's because their psychological wounds have come not only as a result of combat trauma, but also from sexual harassment and assaults during their time in uniform.
Veterans seeking compensation for mental- or physical-health issues must provide proof that those issues are related to their military service. Victims who report the abuse when it happens create a record that can be relied upon later to support a claim.
But Department of Defense officials say about 80 percent of sexual assaults in the military go unreported.
"Victims are concerned about losing their privacy, fearful about being judged, fearful of retaliation and afraid that people will view them differently," Kaye Whitley, the director of the military's Sexual Assault Prevention and Response Office, told the House Committee on Veterans Affairs in May.
Testifying before the same committee in July, PTSD expert Janice Krupnick complained that what little study has been done "suggests that female veterans are less likely to receive service-related compensation for PTSD and this is, at least in part, a consequence of the relative difficulty of substantiating exposure to non-combat stressors," most notably, sexual assault, she said.
Nearly 60 percent of women screened for PTSD at the VA in Salt Lake City since 2008 have been identified as victims of sexual harassment, sexual abuse or rape during their time in the military.
Those who have suffered from harassment alone are likely in the minority. "Among the women I'm doing individual therapy with, I would say that at least 85 percent have had a sexual assault," said VA psychologist Tanya Miller.
"It's unacceptable," said Andrew Wittwer, a combat-veterans case manager at the Salt Lake VA hospital. "There are a lot of injuries that come out of serving in the military. Clearly, sexual trauma shouldn't be one of them."
But it often is and it can be debilitating. In a 2005 study of veterans of the first U.S. war in Iraq, VA researchers found that military members who were sexually assaulted during their deployment were significantly more likely to have suffered from PTSD than those who were exposed to combat alone.
'I'm going to die all alone' • Researchers have known for decades that women suffering from PTSD have significantly different symptoms than men. It's also clear that women are far more likely to develop PTSD as a result of military sexual trauma than men.
But despite the hundreds of millions of dollars the government has spent on PTSD research, there has been scant investigation of gender-specific care. The VA usually offers men and women similar therapy. And despite the prevalence of sexual trauma as a primary or aggravating factor for many women's PTSD, the one thing female veterans can't access at the Salt Lake women's clinic is mental health treatment. They instead head to the facility's mental health ward.
Miller, who leads a therapy group for victims of military sexual trauma at the facility, acknowledged that not all of her patients are comfortable around men. She also conceded that a male psychiatry resident now serving as a co-facilitator makes for "a hard transition, because they don't trust men and they don't feel comfortable being vulnerable around men."
But Miller said she also believes that exposing victims of sexual trauma "to a kind, compassionate male is helpful in their recovery." But she noted that all women have a right to see a female therapist in individual sessions.
In one of the few studies to investigate treatment methods by gender, researchers at the National Center for PTSD found that "high levels of social support after the war played an important role for women veterans."
For Julianne Hancock, there's a bitter irony in that finding.
Serving with the Air National Guard in Balad in 2005, Hancock faced the same dangers as male soldiers. But often, she faced those dangers alone.
When mortars and rockets screamed down on the base, Hancock and her comrades fled to the nearest protective structure a concrete restroom. Because she was the only woman in her unit, Hancock was left to wait out the attacks alone in the women's latrine.
One day near Christmas, she recalled, "I was in that bathroom, all by myself, for hours. I remember thinking to myself: If I die, I'm going to die all alone, in a bathroom, on Christmas in the Middle East and that sucks."
Hancock said she laughed at that morbid idea at the time, but five years later, the isolation she felt is more apt to bring her to tears.
"I don't know how much of that isolation plays into the fact that things came to a tipping point for me, all these years later, but it's still painful," she said.
Now, as she struggles with VA bureaucracy in an effort to get help with the anger, anxiety and helplessness she's felt since her two tours of duty in Iraq, Hancock still feels alone.
"Right now I've got six doctors up there," she said. "And it doesn't seem like anyone is talking to anyone else. I've got to keep telling my story over and over and over again."
firstname.lastname@example.org RESOURCES AVAILABLE
Women Helping Women, support and education group, meets 5 p.m. to 6 p.m. on the second and fourth Wednesday of every month. Women's Clinic, Room 1D17, Building 1, George E. Wahlen VA Medical Center, 500 Foothill Drive, Salt Lake City.
Women Veterans Clinic, George E. Wahlen VA Medical Center 801-582-1565 ext. 5423.
Confidential VA chaplain services: 801-582-1565.
Salt Lake Vet Center, 1354 E. 3300 South, Salt Lake City; 801-584-1294.
Provo Vet Center, 1807 N. 1120 West, Provo; 801-377-1117
Upcoming talk: Mic Hunter, author of Honor Betrayed: Sexual Assault in the Military, will speak on Oct. 28 at the George E. Wahlen VA Medical Center from 7 p.m. to 8:30 p.m. Hunter will discuss the prevalence of sexual abuse in the military and the reasons it persists despite continued attempts to eliminate it. He will also discuss how the experience of military sexual assault is different from that of civilian sexual assault; and he will argue that homophobia contributes to sexual assault in the military. Hunter's talk will be held in Auditorium Building 9. Women and post-traumatic stress disorder
Women have long been exposed to stressful, violent and gruesome events while serving at war, but the number of women exposed to combat has increased dramatically with the advent of the wars in Iraq and Afghanistan.
For now, little is known about the unique needs and issues facing female veterans with PTSD.
Research has shown, however, significant differences in diagnosis and treatment.
In one recent survey of patients at Walter Reed Medical Hospital and Bethesda Naval Hospital, about 13 percent of active-duty patients with PTSD were women about equal to the rate at which women are serving in Iraq and Afghanistan.
But women are more likely to experience depressive symptoms related to PTSD, while men report more anger, nightmares and flashbacks, according to a 2009 report from the Society for Women's Health Research.
Women are also generally more responsive to psychotherapy, while men tend to have a stronger preference for medication, according to the report.
Yet the vast majority of research on the treatment of combat-related PTSD relates to treating the condition in men. After studying the issue for more than three decades after the end of the Vietnam War, for instance, Veterans Affairs only last fall began a comprehensive, multimillion-dollar effort to study the effects of PTSD on women who served in Vietnam.