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Women in the U.S. military are technically barred from serving in combat specialties, positions, or units; however, since Operation Desert Storm, women have served in forward positions in greater numbers. This increased involvement in combat zones has resulted in exposures to trauma, injury, and a myriad of environmental hazards associated with modern war. Some of these hazards present new health risks specifically relevant to women who have been deployed to or recently returned from Iraq or Afghanistan or both. To address this evolving public health concern, the Society for Women’s Health Research (SWHR) convened a 1-day interdisciplinary scientific conference, with speakers and attendees from civilian, military, and veteran settings. The purpose of the conference was to reveal the state-of-the-science on the health of the female veteran and to focus attention on recent advances in biomedical research related to female veterans’ health. The following topics were discussed: mental health (posttraumatic stress disorder [PTSD] and depression), urogenital health, musculoskeletal health, and traumatic brain injury (TBI).
In July 2011, the Society for Women’s Health Research (SWHR) convened a 1-day, interdisciplinary scientific conference on female veterans’ health entitled, “What a Difference an X Makes: The State of Women’s Health Research. A Focus on Female Veterans.” Researchers and medical professionals from academia and the military presented new research findings and shared future perspectives related to the female veteran population. This report focuses on research highlights related to mental health (posttraumatic stress disorder [PTSD] and depression), urogenital health, musculoskeletal health, and traumatic brain injury (TBI).
According to the conference’s Keynote Speaker, Betty Moseley-Brown, Ed.D., Associate Director of the Veterans Administration (VA) Center for Women Veterans (CWV), there are nearly 1.84 million living female veterans (8.1%) of the approximately 23 million surviving veterans in the United States, and this number is projected to increase.1 Further, the number of female veterans enrolled in VA healthcare is expected to double in the next 5 years.2 The Congressionally mandated CWV is meeting the needs of female veterans by monitoring and coordinating VA programs for women and advocating for a cultural transformation within the military and among civilians to recognize the service and contributions of women in the military.3 The CWV also strives to connect female veterans to the VA and provide them with essential programs, including employment, suitable housing, child care options, and opportunities for social interaction (B. Moseley-Brown, personal communication). In order to help the VA to better serve and improve health outcomes of the growing female veteran population, future biomedical research must consider the specific needs of this unique population. The following discussions of the latest research in PTSD, depression, urogenital health, musculoskeletal health, and TBI in female veterans emphasize this requirement.
Posttraumatic Stress Disorder
Women and PTSD: Are women veterans different?
PTSD is defined by symptoms that last > 1 month and include reexperiencing of a traumatic event, persistent avoidance of stimuli associated with a traumatic event, and numbing of general responsiveness and persistent symptoms of increased arousal, both absent before the traumatic event. Kathryn Magruder, M.P.H., Ph.D., Medical University of South Carolina, stated that PTSD is twice as prevalent in women (10.4%–12.3%) as in men (5.0%–6.0%).4,5 However, trauma exposure is more common in men than women (61% vs. 51%), and men are more likely to be exposed to multiple traumatic events.5 Men also experience a wider variety of trauma types (fire, disaster, physical assault, combat, threat with a weapon) compared to women (sexual assault/child abuse). These data present a PTSD paradox: If men have more traumatic experiences, why do women have more PTSD? Dr. Magruder suggested three reasons for this paradox: (1) women experience traumas that are higher risk for PTSD, specifically sexual assault/abuse, (2) women have longer duration of PTSD symptoms, and (3) women have stronger reactions to traumatic events.
Dr. Magruder discussed additional studies investigating the interplay among gender, traumatic events, and PTSD in veterans. Studies have demonstrated similar PTSD risk between male and female veterans, but compared to male veterans, female veterans experience fewer combat situations and are exposed to more military sexual trauma (MST).6,7 It is not known, however, if the rates and types of premilitary trauma differ between male and female veterans or if the currently used trauma exposure scales capture the experience of women differently. Dr. Magruder stressed additional research gaps related to comparisons between female veterans and nonveterans, such as a lack of prevalence data regarding PTSD, rates of sexual harassment/assault, and social support. Prevalence data also are unavailable to indicate differences among populations of female veterans, such as variations in trauma exposures experienced by female veterans in different war eras. In conclusion, Dr. Magruder emphasized the need to continue to be sensitive to gender issues in terms of prevention, detection, and advancing treatment of female veterans.
Stress X gender: What we know and don’t know about the neurobiology of PTSD in women
According to Ann Rasmusson, MD, Boston University School of Medicine, even though PTSD prevalence is higher in women in the general population, recent studies have not demonstrated sex differences in risk in the military. In a study of 340 female and 252 male Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans within 1 year of deployment, no sex differences were observed in risk for posttraumatic stress symptoms, mental health functioning, or depression when controlling for combat-related exposure.8 Despite these findings, Dr. Rasmusson believes that further research should investigate the influence of biologic sex on the neurobiology of PTSD, which could ultimately result in better treatments.
Dr. Rasmusson described studies investigating the role of several neuromodulators of the stress response that may uniquely influence risk, recovery, and comorbidity of PTSD in women. Allopregnanolone and its stereoisomer, pregnanolone (ALLO), are neurohormones synthesized from progesterone in the brain and released from the adrenal glands in response to stress. One study by Dr. Rasmusson et al. examined the levels of progesterone and ALLO in the cerebrospinal fluid (CSF) of healthy women and women with PTSD.9 During the follicular phase of the menstrual cycle, ALLO levels in women with PTSD were only 40% of levels in healthy controls and were negatively correlated with PTSD and depression symptoms (A. Rasmusson, personal communication). It appeared that there was a block in the conversion of progesterone to ALLO. Consistent with these findings, further pilot data showed that both CSF progesterone and ALLO levels in healthy women increased by 200%–300% between the follicular and luteal phases of the menstrual cycle, as expected, whereas in the pilot subject with PTSD, progesterone increased by 500%–600%, but ALLO levels increased by only about 25%. A more definitive study of ALLO levels across the menstrual cycle in women with PTSD is underway.
Dr. Rasmusson described how sex differences in ALLO modulation may influence PTSD in women and men. The male gonadal hormone testosterone increases gene expression of an enzyme that synthesizes ALLO. A study of male participants in the U.S. Military’s Survival, Evasion, Resistance and Escape training (SERE School) found that extreme training stress decreased testosterone.10 A study is underway to ascertain if ALLO level are also low in men with PTSD. Other studies have examined cortisol output, another stress hormone, in men and women with comorbid PTSD/major depressive disorder (MDD).11,12 Results demonstrated decreased cortisol output in men but an increase in women with PTSD/MDD. Because ALLO provides negative feedback to the hypothalamic-pituitary-adrenal axis, it is possible that low ALLO levels in women with PTSD/MDD contribute to the high cortisol levels in these women. In other PTSD subpopulations in whom cortisol synthesis may be limited under stress, it is possible that the low cortisol levels may contribute to low ALLO levels. Dr. Rasmusson, therefore, emphasized that the mechanisms underlying the neurobiology of stress and PTSD are highly complex and are likely to exhibit sex differences.
Sex steroids and affective adaptation in women
Depression is twice as prevalent in women as in men and is a leading cause of disease-related disability in the western world, according to Peter Schmidt, M.D., National Institute of Mental Health (NIMH), National Institutes of Health (NIH). Depression causes increased risk for osteoporosis, cardiovascular disease, metabolic syndrome, dementia, and 50% cardiovascular mortality in postmenopausal women. Lifetime prevalence of unipolar depression in women is higher compared to men (15%–25% vs. 4%–12%). In spite of this, depression still remains undiagnosed and undertreated, and the efficacy of long-term use of selective-serotonin reuptake inhibitors (SSRIs) is disputed.
Sex differences in the effects of reproductive steroids on the brain may help explain a woman’s greater susceptibility to depression. Whereas much research has been done to investigate the basic physiology behind depression in general, Dr. Schmidt stated that no physiologic research has been done specifically in female veterans. Levels of reproductive steroids fluctuate at hormonal transitions across the female life span, which are critical time points for susceptibility to mood disorders, such as perimenopausal depression and premenstrual dysphoric disorder (PMDD).13,14 The menopause transition is associated with increased risks of both first-onset and recurrent depression, with episodes clustering during the late menopause transition and early postmenopause. The prevalence of depression in these groups is 20%–30%. In a small study Dr. Schmidt’s group conducted at NIMH, estrogen induced remission of depressive symptoms in perimenopausal women with depression.15 Additional data demonstrated that estrogen withdrawal precipitated depressive symptoms in only those perimenopausal women who had past major or minor depression (within 2–4 years). Dr. Schmidt stressed that a direct link between estrogen loss at the menopause transition and depression has not been firmly demonstrated.
Changes in levels of sex steroids also play a role in PMDD (prevalence 3%–8%), with symptoms occurring in the luteal phase of the menstrual cycle when progesterone and estrogen levels increase. Interestingly, women who suffer from PMDD do not exhibit abnormal levels of gonadal hormones, again indicating differential susceptibility to gonadal influences on depression among women. Treatments for PMDD may involve SSRIs or therapies that suppress hormonal fluctuations and ovulation. A study using Lupron, a gonadotropin-releasing hormone agonist that suppresses ovarian hormone production, demonstrated reduction in PMDD symptoms and provided evidence for gonadal hormone effects on brain function.13
Depression and other mental health conditions among OEF/OIF women veterans
Kristin Mattocks, Ph.D., M.P.H., Yale University, cited three key points regarding female veterans seeking mental healthcare at the VA by referring to data published in the sourcebook entitled Women Veterans in the Veterans Health Administration, Volume 1 (December 2010). First, the VA must pay immediate attention to the needs of very young and elderly female veterans and must prepare for an impending large, new cohort of elderly female veterans. Second, between 2000 and 2009, the proportion of female veterans with service-connected disabilities increased. Finally, both men and women have a high frequency rate for mental health visits at the VA, but the rate for women is higher than that of men after age 45. Additional studies demonstrated that OEF/OIF postdeployment (1–6-years window) depression rates were consistently higher among women compared to men.16,17
Dr. Mattocks discussed two of her research projects using the Women Veterans Cohort Study (WVCS) launched in 2007. The WVCS plans to (1) assess gender differences in healthcare costs, service use, and health outcomes among OEF/OIF veterans enrolled in VA care and (2) examine pregnancy and mental health among OEF/OIF veterans. The first project involves assembling an administrative cohort (550,849 men, 74,535 women) of OEF/OIF veterans in the Northeast and Midwest. A prospective survey is collecting data on combat exposure, MST, quality of life, non-VA care, reproductive health history, pain, eating behaviors, and so on. The second project is studying pregnancy and mental health conditions among OEF/OIF female veterans. Untreated mental health conditions during pregnancy may lead to poor maternal outcomes (substance abuse, loss of employment, divorce, and suicidal ideation/suicide), poor outcomes in offspring (low birth weight and infant neglect/abuse), and maternal depression. This has been studied extensively, but few studies have focused on female veterans and depression/PTSD during pregnancy. Dr. Mattocks emphasized that studying pregnancy and concomitant mental health problems in the VA is complicated, as contract providers (fee basis) outside the VA provide most prenatal care in the VA. Therefore, little information is available about the quality of prenatal care or the outcomes of pregnancy.
Results from the WVCS pregnancy project demonstrated that compared to nonpregnant veterans, veterans with a pregnancy were more likely to be younger, Hispanic, unmarried, less educated, enlisted service members rather than officers, and active duty service members rather than members of the Guard or Reserves.18 Interestingly, veterans with a pregnancy were twice as likely to receive a mental health diagnosis during pregnancy compared to nonpregnant veterans. Most of these pregnant veterans experienced mental health conditions before pregnancy. Dr. Mattocks discussed the implications of her study, which are (1) many OEF/OIF female veterans suffer from significant mental health problems, and it is unclear if these are a direct result of combat/trauma exposure, (2) patterns of VA and non-VA care among OEF/OIF female veterans, including use of VA and private mental healthcare during pregnancy, are not well understood, (3) coordination between VA and private obstetric and mental health systems is crucial, and (4) private providers should inquire about veteran status, ask about combat/trauma exposure, and screen for mental health conditions, including PTSD.
Pelvic floor disorders in female veterans
Christine Sears, M.D., Walter Reed National Military Medical Center, discussed urogenital health disorders (urinary tract infections [UTIs], pelvic organ prolapse [POP], urinary incontinence [UI], and bladder pain syndrome [BPS]) and how the military environment may expose women to higher risk for these conditions. One study determined the UTI prevalence in veterans to be 4.3% in women and 1.7% in men.19 Women in active duty are often exposed to conditions that may increase their risk of UTI, such as poor hygiene, decreased access to care and bathrooms, postponed urination, and fluid restriction, and data from a study of 841 deployed women reported that 18.4% experienced UTI during deployment.20
POP is defined as the descent of the bladder, uterus, and rectum as a result of weakening of the muscles and connective tissue within the pelvic floor. Risk factors for POP include age, number of vaginal and multiple deliveries, high birth weight deliveries, chronic cough, obesity, genetic susceptibility, and manual labor.21 POP may be a concern for women in the military, as strenuous activity, including basic and paratrooper training, could increase risk above that caused by general risk factors. Dr. Sears presented data from an observational study of 116 women at the United States Military Academy (USMA), where 50% of the women exhibited some loss of pelvic support after training.22 A follow-up study revealed a significant correlation between paratrooper training and worsening pelvic support and prolapse.23 Although this particular study implicates strenuous military training on the future pelvic health of female veterans, additional studies are needed.
Dr. Sears stressed that areas for future study also include addressing the long-term effects of strenuous military activity and other high impact exposures on UI. UI, which is leakage of urine, is defined as stress incontinence (caused by coughing, sneezing, laughing, jumping, and exercise) or urge incontinence (feeling the need to urinate). According to Dr. Sears, a study of over 3.5 million users of VA healthcare services reported prevalence of primary diagnosis UI to be 2.2% in women and 0.5% in men.19 Dr. Sears referred to the USMA study data that demonstrated 19% of the women had UI, which was more commonly associated with running as the aerobic activity.22 Finally, BPS is a chronic condition that causes pain with filling of the urinary bladder and severely impacts quality of life. A study of VA users from 1999 to 2002 found that women were almost twice as likely as men to suffer from BPS.24 Interestingly, the prevalence of BPS and other urologic health conditions in this veteran population increased during this time period, emphasizing the need for future research.
Female casualties of Operations Enduring Freedom and Iraqi Freedom
CPT Jessica Cross Rivera, M.D., San Antonio Medical Center and U.S. Army Institute of Surgical Research, provided four statements on current casualty data: (1) the rate of survival after combat injury is higher in OEF/OIF compared to the Vietnam War and World War II, (2) most (54%) of the OEF/OIF injuries are orthopaedic in nature and cause most of the long-term disability, (3) women experience more nonbattle injuries than men, and (4) women with battle injuries have higher mortality than men. Combat musculoskeletal injuries to the extremity were caused most often by explosions and were associated with disabilities and degenerative arthritis, which ranks as the most common unfitting condition and cause of long-term disability for combat-injured service members.25–27
According to CPT Cross Rivera, casualties in women serving in OEF/OIF or overseas contingency operations account for < 2% of all casualties, and of these, 61% are nonbattle injuries.28 Compared to the nearly equal mortality rates of wounded soldiers in Iraq (14% women vs. 12% men), a striking 36% fatality rate exists for female casualties in Afghanistan compared to 17% in men.28 The reason for the fatality disparity by deployment region and gender, as well as the types of combat exposures most likely to cause fatal injuries in female soldiers, is unknown. More research related to the female soldier’s response to injury is necessary, including acute physiologic reactions, exposure and evacuation, root cause of mortality, rehabilitation differences, and long-term disability outcomes.
Developing technologies for the wounded warrior
Barbara Boyan, Ph.D., Georgia Institute of Technology, emphasized the need for advances in technology specifically for the wounded warrior. Wounds sustained by military personnel during deployment are highly complex, involving multiple tissues, such as skin, muscle, nerve, vasculature, tendons, ligaments, and bone. The unique nature of injuries suffered in modern combat zones poses new challenges for biomedical engineers, as the nature of these wounds is not commonly experienced in civilian trauma. In a study of service members from OEF/OIF, the majority of combat injuries were to the extremities (54%) and head and neck (29%).27 Although studies on cartilage damage and reconstruction in the knee in civilian populations are extensive, Dr. Boyan stated that research has not focused on the nose and trachea, which are important areas of cartilage damage in soldiers. Researchers must understand differences in the healing processes of a variety of body regions to improve outcomes in all wounded service members.
In addition, new technologies to treat combat injuries must incorporate the study of sex differences; however, most technologies for treating wounds were designed and tested using male animal models. Dr. Boyan stated that sex differences have been demonstrated in vitro in bone cells (e.g., male cells respond better to vitamin D) and in tissue grafting (e.g., female cells respond better to surface design approaches), which indicate a potential influence of sex on healing and regeneration. Therefore, the long-term outcomes of regenerative strategies may be influenced by sex, and technologies must be responsive to sex-based differences accordingly for optimum results. The sex-based effects observed in the cited studies highlight the need to closely evaluate sex differences in the evolution and application of new technologies.
Dr. Boyan focused on efforts of the Center for Advanced Bioengineering for Soldier Survivability (CABSS), which was established by Congress to address the crucial need for regenerative medicine related to combat injuries.29 In collaboration with the Georgia Institute of Technology, CABSS develops new treatments tailored specifically for wounded warriors. One goal of CABSS is to develop enabling technologies for intraoperative and percutaneous delivery of musculoskeletal stem cells for treatment of bone and cartilage injuries to the extremities, head, and neck. Further, CABSS has established animal models that mimic injury of composite tissue, which closely mirrors battlefield wounds. CABSS is developing new technologies for bone and facial reconstruction, making stems cells clinically useful, and translating basic science to commercially available treatments that provide better outcomes to wounded military personnel.30
Traumatic Brain Injury
Traumatic brain injury: Same or different?
TBI covers a spectrum of injury severity and is categorized as mild (brief period of cerebral dysfunction followed by a relatively rapid improvement in condition), moderate (manifested by longer periods of cerebral dysfunction often with more noticeable posttraumatic signs and symptoms), and severe and penetrating (often requiring prolonged hospitalizations, with a less predictable long-term recovery). According to Kimberly Meyer, ACNP-BC, CNRN, Defense and Veterans Brain Injury Center and University of Louisville Hospital, TBI severity distribution between the military and civilian population is similar, and mild TBI is by far the largest percentage of injury severity in both sexes. Men sustain the majority of TBIs, and there are few published studies on TBI in women in the military. Of the 81,850 cases reported in 2010 by the Armed Forces Health Surveillance Center, 12% (9,732) of the cases were women with a TBI diagnosis. Ms. Meyer emphasized that when discussing the impact of TBI on female veterans, it is important to consider that (1) the differences in blast and blunt trauma may play a role in treatment paradigms and recovery and (2) emerging literature suggests that gender differences may play a role in recovery.
Ms. Meyer mentioned that several studies have looked at gender differences and their impact on mortality after TBI in civilians, but results have been inconsistent. For example, Yeung et al., found no gender differences in mortality in Asian and Australian subpopulations, whereas Dischinger et al. reported that women > age 55 had higher mortality than men following isolated, severe TBI.31,32 Gender differences in symptom type during long-term TBI recovery have been documented, but studies differ on which gender has better outcomes.33–35 Except for visual memory, which may be better in women, similar cognitive outcome was observed in men and women with TBI36; however, men were found to have higher risk for developing dementia after TBI.37 Regarding rehabilitation, older women fared better than men, had shorter length of rehabilitation stay, and had increased use of home health services.38 Ms. Meyer stressed that gender differences studies may have variable results because of selection bias, sample size, and injury severity; therefore, scientifically rigorous studies are needed.
Hidden in plain sight: How sex differences led us to a treatment for traumatic brain injury
According to Donald Stein, Ph.D., Emory University, an estimated 1.4 million TBIs per year are diagnosed in the United States alone, resulting in 50,000 deaths annually. At least 5.3 million Americans have long-term/lifelong disability due to TBI. In 2004, the economic burden (medical and indirect costs due to loss of productivity) of TBI was estimated at $60 billion. Dr. Stein provided data from the Trauma Registry, U.S. Army Institute of Surgical Research, which reported that at Walter Reed Army Medical Center, 28% of the evacuated injured military personnel from Iraq and Afghanistan who had sustained hostile fire injuries had TBI.
Dr. Stein emphasized that there currently is no treatment to stop loss of brain cells postinjury. Dr. Stein believes that TBI is one of the toughest problems in medicine because the injury to the brain (and destruction of brain cells) is immediate following trauma, and the many complicated biochemical processes after injury continue to destroy brain cells and affect multiple organ systems from days to weeks postinjury. The potential use of progesterone as a TBI therapy was based on three crucial early observations by Dr. Stein: (1) anecdotal reports suggested women recover better from stroke and trauma than do men, (2) the specific estrous cycle phase at the time of brain injury in female rats affected outcomes, and (3) female rats high in progesterone at the time of injury had better outcomes than animals high in estrogen when the brain damage was inflicted. Further, exogenous progesterone treatment significantly reduced cerebral edema in female and male animals and improved functional recovery in cognitive/sensory tasks and motor performance. As Dr. Stein explained, progesterone is naturally present in brains of both sexes, dramatically reduces brain swelling, has potent anti-inflammatory and anti-oxidant properties, and stimulates growth factor expression in response to injury. A successful phase 2 clinical trial, ProTECT II, for brain injury showed a lower mortality rate in the progesterone treatment group compared to placebo over a 30-day period. 39 These results were corroborated by an independent clinical trial in China,40 and two phase 3 trials are currently ongoing. Thus, progesterone may be an ideal TBI therapy, and further studies into the amount and timing of delivery are required.
Although women are technically barred from serving in combat, since Operation Desert Storm, women have been deployed to forward positions in greater numbers. This increased involvement in combat zones and the associated risk from exposure to trauma, injury, and environmental hazards present new health consequences for woman that must be addressed for both actively serving women and female veterans. Considering that the female segment of the military continues to increase, female veterans’ health must be situated at the forefront of the biomedical research and health policy agendas. Biomedical research in veterans that incorporates the study of sex and gender differences will translate to better health outcomes for female veterans and will help the Department of Veterans Affairs to better serve the needs of female veterans. Access to gender-appropriate care and an advanced understanding of the unique health needs of the female veteran are essential. Improved outreach should continue to raise further awareness among the female veterans seeking healthcare and also interest researchers to pursue areas within their work that include studies relevant to female veterans.
This is a project I’ve been working on for the past year. This project was developed to save lives, inform, and bring the military community together. It will save lives by making it easy for suicidal veterans to connect to a person who can help them right away. It will provide information and links that veterans in need can get to without spending hours searching for it.
There are two very distinct groups of veterans. There are the veterans in immediate need. This group includes the veterans that were in country in the heart of the fight and the people that were sexually assaulted. The other group is the veterans that have no needs the CEOs and presidents of all different companies. Maybe by bringing these two groups together we can help one another like we did when we were serving together. I’d like to hear from you if you think there is a need for my kind project.
The first time I experienced what I now understand to be post-traumatic stress disorder, I was in a subway station in New York City, where I live. It was almost a year before the attacks of 9/11, and I’d just come back from two months in Afghanistan with Ahmad Shah Massoud, the leader of the Northern Alliance. I was on assignment to write a profile of Massoud, who fought a desperate resistance against the Taliban until they assassinated him two days before 9/11. At one point during my trip we were on a frontline position that his forces had just taken over from the Taliban, and the inevitable counterattack started with an hour-long rocket barrage. All we could do was curl up in the trenches and hope. I felt deranged for days afterward, as if I’d lived through the end of the world.
By the time I got home, though, I wasn’t thinking about that or any of the other horrific things we’d seen; I mentally buried all of it until one day, a few months later, when I went into the subway at rush hour to catch the C train downtown. Suddenly I found myself backed up against a metal support column, absolutely convinced I was going to die. There were too many people on the platform, the trains were coming into the station too fast, the lights were too bright, the world was too loud. I couldn’t quite explain what was wrong, but I was far more scared than I’d ever been in Afghanistan.
I stood there with my back to the column until I couldn’t take it anymore, and then I sprinted for the exit and walked home. I had no idea that what I’d just experienced had anything to do with combat; I just thought I was going crazy. For the next several months I kept having panic attacks whenever I was in a small place with too many people—airplanes, ski gondolas, crowded bars. Gradually the incidents stopped, and I didn’t think about them again until I found myself talking to a woman at a picnic who worked as a psychotherapist. She asked whether I’d been affected by my war experiences, and I said no, I didn’t think so. But for some reason I described my puzzling panic attack in the subway. “That’s called post-traumatic stress disorder,” she said. “You’ll be hearing a lot more about that in the next few years.”
I had classic short-term (acute) PTSD. From an evolutionary perspective, it’s exactly the response you want to have when your life is in danger: you want to be vigilant, you want to react to strange noises, you want to sleep lightly and wake easily, you want to have flashbacks that remind you of the danger, and you want to be, by turns, anxious and depressed. Anxiety keeps you ready to fight, and depression keeps you from being too active and putting yourself at greater risk. This is a universal human adaptation to danger that is common to other mammals as well. It may be unpleasant, but it’s preferable to getting eaten. (Because PTSD is so adaptive, many have begun leaving the word “disorder” out of the term to avoid stigmatizing a basically healthy reaction.)
Because PTSD is a natural response to danger, it’s almost unavoidable in the short term and mostly self-correcting in the long term. Only about 20 percent of people exposed to trauma react with long-term (chronic) PTSD. Rape is one of the most psychologically devastating things that can happen to a person, for example—far more traumatizing than most military deployments—and, according to a 1992 study published in the Journal of Traumatic Stress, 94 percent of rape survivors exhibit signs of extreme trauma immediately afterward. And yet, nine months later 47 percent of rape survivors have recovered enough to resume living normal lives.
Combat is generally less traumatic than rape but harder to recover from. The reason, strangely, is that the trauma of combat is interwoven with other, positive experiences that become difficult to separate from the harm. “Treating combat veterans is different from treating rape victims, because rape victims don’t have this idea that some aspects of their experience are worth retaining,” says Dr. Rachel Yehuda, a professor of psychiatry and neuroscience and director of traumatic-stress studies at Mount Sinai Hospital in New York. Yehuda has studied PTSD in a wide range of people, including combat veterans and Holocaust survivors. “For most people in combat, their experiences range from the best to the worst of times,” Yehuda adds. “It’s the most important thing someone has ever done—especially since these people are so young when they go in—and it’s probably the first time they’re ever free, completely, of their societal constraints. They’re going to miss being entrenched in this very important and defining world.”
Oddly, one of the most traumatic events for soldiers is witnessing harm to other people—even to the enemy. In a survey done after the first Gulf War by David Marlowe, an expert in stress-related disorders working with the Department of Defense, combat veterans reported that killing an enemy soldier—or even witnessing one getting killed—was more distressing than being wounded oneself. But the very worst experience, by a significant margin, was having a friend die. In war after war, army after army, losing a buddy is considered to be the most distressing thing that can possibly happen. It serves as a trigger for psychological breakdown on the battlefield and re-adjustment difficulties after the soldier has returned home.
Terrible as such experiences are, however, roughly 80 percent of people exposed to them eventually recover, according to a 2008 study in the Journal of Behavioral Medicine. If one considers the extreme hardship and violence of our pre-history, it makes sense that humans are able to sustain enormous psychic damage and continue functioning; otherwise our species would have died out long ago. “It is possible that our common generalized anxiety disorders are the evolutionary legacy of a world in which mild recurring fear was adaptive,” writes anthropologist and neuroscientist Melvin Konner, in a collection called Understanding Trauma. “Stress is the essence of evolution by natural selection and close to the essence of life itself.”
A 2007 analysis from the Institute of Medicine and the National Research Council found that, statistically, people who fail to overcome trauma tend to be people who are already burdened by psychological issues—either because they inherited them or because they suffered trauma or abuse as children. According to a 2003 study on high-risk twins and combat-related PTSD, if you fought in Vietnam and your twin brother did not—but suffers from psychiatric disorders—you are more likely to get PTSD after your deployment. If you experienced the death of a loved one, or even weren’t held enough as a child, you are up to seven times more likely to develop the kinds of anxiety disorders that can contribute to PTSD, according to a 1989 study in the British Journal of Psychiatry. And according to statistics published in the Journal of Consulting and Clinical Psychology in 2000, if you have an educational deficit, if you are female, if you have a low I.Q., or if you were abused as a child, you are at an elevated risk of developing PTSD. These factors are nearly as predictive of PTSD as the severity of the trauma itself.
Suicide by combat veterans is often seen as an extreme expression of PTSD, but currently there is no statistical relationship between suicide and combat, according to a study published in April in the Journal of the American Medical Association Psychiatry. Combat veterans are no more likely to kill themselves than veterans who were never under fire. The much-discussed estimated figure of 22 vets a day committing suicide is deceptive: it was only in 2008, for the first time in decades, that the U.S. Army veteran suicide rate, though enormously tragic, surpassed the civilian rate in America. And even so, the majority of veterans who kill themselves are over the age of 50. Generally speaking, the more time that passes after a trauma, the less likely a suicide is to have anything to do with it, according to many studies. Among younger vets, deployment to Iraq or Afghanistan lowers the incidence of suicide because soldiers with obvious mental-health issues are less likely to be deployed with their units, according to an analysis published in Annals of Epidemiology in 2015. The most accurate predictor of post-deployment suicide, as it turns out, isn’t combat or repeated deployments or losing a buddy but suicide attempts before deployment. The single most effective action the U.S. military could take to reduce veteran suicide would be to screen for pre-existing mental disorders.
It seems intuitively obvious that combat is connected to psychological trauma, but the relationship is a complicated one. Many soldiers go through horrific experiences but fare better than others who experienced danger only briefly, or not at all. Unmanned-drone pilots, for instance—who watch their missiles kill human beings by remote camera—have been calculated as having the same PTSD rates as pilots who fly actual combat missions in war zones, according to a 2013 analysis published in the Medical Surveillance Monthly Report. And even among regular infantry, danger and psychological breakdown during combat are not necessarily connected. During the 1973 Yom Kippur War, when Israel was invaded simultaneously by Egypt and Syria, rear-base troops in the Israeli military had psychological breakdowns at three times the rate of elite frontline troops, relative to their casualties. And during the air campaign of the first Gulf War, more than 80 percent of psychiatric casualties in the U.S. Army’s VII Corps came from support units that took almost no incoming fire, according to a 1992 study on Army stress casualties.
Conversely, American airborne and other highly trained units in World War II had some of the lowest rates of psychiatric casualties of the entire military, relative to their number of wounded. A sense of helplessness is deeply traumatic to people, but high levels of training seem to counteract that so effectively that elite soldiers are psychologically insulated from even extreme risk. Part of the reason, it has been found, is that elite soldiers have higher-than-average levels of an amino acid called neuropeptide-Y, which acts as a chemical buffer against hormones that are secreted by the endocrine system during times of high stress. In one 1968 study, published in the Archive of General Psychiatry, Special Forces soldiers in Vietnam had levels of the stress hormone cortisol go down before an anticipated attack, while less experienced combatants saw their levels go up.
All this is new science, however. For most of the nation’s history, psychological effects of combat trauma have been variously attributed to neuroses, shell shock, or simple cowardice. When men have failed to obey orders due to trauma they have been beaten, imprisoned, “treated” with electroshock therapy, or simply shot as a warning to others. (For British troops, cowardice was a capital crime until 1930.) It was not until after the Vietnam War that the American Psychiatric Association listed combat trauma as an official diagnosis. Tens of thousands of vets were struggling with “Post-Vietnam Syndrome”—nightmares, insomnia, addiction, paranoia—and their struggle could no longer be written off to weakness or personal failings. Obviously, these problems could also affect war reporters, cops, firefighters, or anyone else subjected to trauma. In 1980, the A.P.A. finally included post-traumatic stress disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders.
Thirty-five years after acknowledging the problem in its current form, the American military now has the highest PTSD rate in its history—and probably in the world. Horrific experiences are unfortunately universal, but long-term impairment from them is not, and despite billions of dollars spent on treatment, half of our Iraq and Afghanistan veterans have applied for permanent disability. Of those veterans treated, roughly a third have been diagnosed with PTSD. Since only about 10 percent of our armed forces actually see combat, the majority of vets claiming to suffer from PTSD seem to have been affected by something other than direct exposure to danger.
This is not a new phenomenon: decade after decade and war after war, American combat deaths have dropped steadily while trauma and disability claims have continued to rise. They are in an almost inverse relationship with each other. Soldiers in Vietnam suffered roughly one-quarter the casualty rate of troops in World War II, for example, but filed for disability at a rate that was nearly 50 percent higher, according to a 2013 report in the Journal of Anxiety Disorders. It’s tempting to attribute this disparity to the toxic reception they had at home, but that doesn’t seem to be the case. Today’s vets claim three times the number of disabilities that Vietnam vets did despite a generally warm reception back home and a casualty rate that, thank God, is roughly one-third what it was in Vietnam. Today, most disability claims are for hearing loss, tinnitus, and PTSD—the latter two of which can be exaggerated or faked. Even the first Gulf War—which lasted only a hundred hours—produced nearly twice the disability rates of World War II. Clearly, there is a feedback loop of disability claims, compensation, and more disability claims that cannot go on forever.
Part of the problem is bureaucratic: in an effort to speed up access to benefits, in 2010 the Veterans Administration declared that soldiers no longer have to cite a specific incident—a firefight, a roadside bomb—in order to be eligible for disability compensation. He or she simply has to report being impaired in daily life. As a result, PTSD claims have reportedly risen 60 percent to 150,000 a year. Clearly, this has produced a system that is vulnerable to abuse and bureaucratic error. A recent investigation by the V.A.’s Office of Inspector General found that the higher a veteran’s PTSD disability rating, the more treatment he or she tends to seek until achieving a rating of 100 percent, at which point treatment visits drop by 82 percent and many vets quit completely. In theory, the most traumatized people should be seeking more help, not less. It’s hard to avoid the conclusion that some vets are getting treatment simply to raise their disability rating.
In addition to being an enormous waste of taxpayer money, such fraud, intentional or not, does real harm to the vets who truly need help. One Veterans Administration counselor I spoke with described having to physically protect someone in a PTSD support group because some other vets wanted to beat him up for faking his trauma. This counselor, who asked to remain anonymous, said that many combat veterans actively avoid the V.A. because they worry about losing their temper around patients who are milking the system. “It’s the real deals—the guys who have seen the most—that this tends to bother,” this counselor told me.
The majority of traumatized vets are not faking their symptoms, however. They return from wars that are safer than those their fathers and grandfathers fought, and yet far greater numbers of them wind up alienated and depressed. This is true even for people who didn’t experience combat. In other words, the problem doesn’t seem to be trauma on the battlefield so much as re-entry into society. Anthropological research from around the world shows that recovery from war is heavily influenced by the society one returns to, and there are societies that make that process relatively easy. Ethnographic studies on hunter-gatherer societies rarely turn up evidence of chronic PTSD among their warriors, for example, and oral histories of Native American warfare consistently fail to mention psychological trauma. Anthropologists and oral historians weren’t expressly looking for PTSD, but the high frequency of warfare in these groups makes the scarcity of any mention of it revealing. Even the Israeli military—with mandatory national service and two generations of intermittent warfare—has by some measures a PTSD rate as low as 1 percent.
If we weed out the malingerers on the one hand and the deeply traumatized on the other, we are still left with enormous numbers of veterans who had utterly ordinary wartime experiences and yet feel dangerously alienated back home. Clinically speaking, such alienation is not the same thing as PTSD, but both seem to result from military service abroad, so it’s understandable that vets and even clinicians are prone to conflating them. Either way, it makes one wonder exactly what it is about modern society that is so mortally dispiriting to come home to.
Any discussion of PTSD and its associated sense of alienation in society must address the fact that many soldiers find themselves missing the war after it’s over. That troubling fact can be found in written accounts from war after war, country after country, century after century. Awkward as it is to say, part of the trauma of war seems to be giving it up. There are ancient human behaviors in war—loyalty, inter-reliance, cooperation—that typify good soldiering and can’t be easily found in modern society. This can produce a kind of nostalgia for the hard times that even civilians are susceptible to: after World War II, many Londoners claimed to miss the communal underground living that characterized life during the Blitz (despite the fact that more than 40,000 civilians lost their lives). And the war that is missed doesn’t even have to be a shooting war: “I am a survivor of the AIDS epidemic,” a man wrote on the comment board of an online talk I gave about war. “Now that AIDS is no longer a death sentence, I must admit that I miss those days of extreme brotherhood … which led to deep emotions and understandings that are above anything I have felt since the plague years.”
What all these people seem to miss isn’t danger or loss, per se, but the closeness and cooperation that danger and loss often engender. Humans evolved to survive in extremely harsh environments, and our capacity for cooperation and sharing clearly helped us do that. Structurally, a band of hunter-gatherers and a platoon in combat are almost exactly the same: in each case, the group numbers between 30 and 50 individuals, they sleep in a common area, they conduct patrols, they are completely reliant on one another for support, comfort, and defense, and they share a group identity that most would risk their lives for. Personal interest is subsumed into group interest because personal survival is not possible without group survival. From an evolutionary perspective, it’s not at all surprising that many soldiers respond to combat in positive ways and miss it when it’s gone.
There are obvious psychological stresses on a person in a group, but there may be even greater stresses on a person in isolation. Most higher primates, including humans, are intensely social, and there are few examples of individuals surviving outside of a group. A modern soldier returning from combat goes from the kind of close-knit situation that humans evolved for into a society where most people work outside the home, children are educated by strangers, families are isolated from wider communities, personal gain almost completely eclipses collective good, and people sleep alone or with a partner. Even if he or she is in a family, that is not the same as belonging to a large, self-sufficient group that shares and experiences almost everything collectively. Whatever the technological advances of modern society—and they’re nearly miraculous—the individual lifestyles that those technologies spawn may be deeply brutalizing to the human spirit.
“You’ll have to be prepared to say that we are not a good society—that we are an anti-human society,” anthropologist Sharon Abramowitz warned when I tried this theory out on her. Abramowitz was in Ivory Coast during the start of the civil war there in 2002 and experienced, firsthand, the extremely close bonds created by hardship and danger. “We are not good to each other. Our tribalism is about an extremely narrow group of people: our children, our spouse, maybe our parents. Our society is alienating, technical, cold, and mystifying. Our fundamental desire, as human beings, is to be close to others, and our society does not allow for that.”
This is an old problem, and today’s vets are not the first Americans to balk at coming home. A source of continual embarrassment along the American frontier—from the late 1600s until the end of the Indian Wars, in the 1890s—was a phenomenon known as “the White Indians.” The term referred to white settlers who were kidnapped by Indians—or simply ran off to them—and became so enamored of that life that they refused to leave. According to many writers of the time, including Benjamin Franklin, the reverse never happened: Indians never ran off to join white society. And if a peace treaty required that a tribe give up their adopted members, these members would often have to be put under guard and returned home by force. Inevitably, many would escape to rejoin their Indian families. “Thousands of Europeans are Indians, and we have no examples of even one of those aborigines having from choice become European,” wrote a French-born writer in America named Michel-Guillaume-Saint-Jean de Crèvecoeur in an essay published in 1782.
One could say that combat vets are the White Indians of today, and that they miss the war because it was, finally, an experience of human closeness that they can’t easily find back home. Not the closeness of family, which is rare enough, but the closeness of community and tribe. The kind of closeness that gets endlessly venerated in Hollywood movies but only actually shows up in contemporary society when something goes wrong—when tornados obliterate towns or planes are flown into skyscrapers. Those events briefly give us a reason to act communally, and most of us do. “There is something to be said for using risk to forge social bonds,” Abramowitz pointed out. “Having something to fight for, and fight through, is a good and important thing.”
Certainly, the society we have created is hard on us by virtually every metric that we use to measure human happiness. This problem may disproportionately affect people, like soldiers, who are making a radical transition back home.
It is incredibly hard to measure and quantify the human experience, but some studies have found that many people in certain modern societies self-report high levels of happiness. And yet, numerous cross-cultural studies show that as affluence and urbanization rise in a given society, so do rates of depression, suicide, and schizophrenia (along with health issues such as obesity and diabetes). People in wealthy countries suffer unipolar depression at more than double the rate that they do in poor countries, according to a study by the World Health Organization, and people in countries with large income disparities—like the United States—run a much higher risk of developing mood disorders at some point in their lives. A 2006 cross-cultural study of women focusing on depression and modernization compared depression rates in rural and urban Nigeria and rural and urban North America, and found that women in rural areas of both countries were far less likely to get depressed than urban women. And urban American women—the most affluent demographic of the study—were the most likely to succumb to depression.
In America, the more assimilated a person is into contemporary society, the more likely he or she is to develop depression in his or her lifetime. According to a 2004 study in The**Journal of Nervous and Mental Disease, Mexicans born in the United States are highly assimilated into American culture and have much higher rates of depression than Mexicans born in Mexico. By contrast, Amish communities have an exceedingly low rate of reported depression because, in part, it is theorized, they have completely resisted modernization. They won’t even drive cars. “The economic and marketing forces of modern society have engineered an environment promoting decisions that maximize consumption at the long-term cost of well-being,” one survey of these studies, from the Journal of Affective Disorders in 2012, concluded. “In effect, humans have dragged a body with a long hominid history into an overfed, malnourished, sedentary, sunlight-deficient, sleep-deprived, competitive, inequitable and socially-isolating environment with dire consequences.”
For more than half a million years, our recent hominid ancestors lived nomadic lives of extreme duress on the plains of East Africa, but the advent of agriculture changed that about 10,000 years ago. That is only 400 generations—not enough to adapt, genetically, to the changes in diet and society that ensued. Privately worked land and the accumulation of capital made humans less oriented toward group welfare, and the Industrial Revolution pushed society further in that direction. No one knows how the so-called Information Age will affect us, but there’s a good chance that home technology and the Internet will only intensify our drift toward solipsism and alienation.
Meanwhile, many of the behaviors that had high survival value in our evolutionary past, like problem solving, cooperation, and inter-group competition, are still rewarded by bumps of dopamine and other hormones into our system. Those hormones serve to reinforce whatever behavior it was that produced those hormones in the first place. Group affiliation and cooperation were clearly adaptive because in many animals, including humans, they trigger a surge in levels of a neuropeptide called oxytocin. Not only does oxytocin create a glow of well-being in people, it promotes greater levels of trust and bonding, which unite them further still. Hominids that were rewarded with oxytocin for cooperating with one another must have out-fought, out-hunted, and out-bred the ones that didn’t. Those are the hominids that modern humans are descended from.
According to one study published in Science in June 2010, this feedback loop of oxytocin and group loyalty creates an expectation that members will “self-sacrifice to contribute to in-group welfare.” There may be no better description of a soldier’s ethos than that sentence. One of the most noticeable things about life in the military is that you are virtually never alone: day after day, month after month, you are close enough to speak to, if not touch, a dozen or more people. You eat together, sleep together, laugh together, suffer together. That level of intimacy duplicates our evolutionary past very closely and must create a nearly continual oxytocin reward system.
When soldiers return to modern society, they must go through—among other adjustments—a terrific oxytocin withdrawal. The chronic isolation of modern society begins in childhood and continues our entire lives. Infants in hunter-gatherer societies are carried by their mothers as much as 50 to 90 percent of the time, often in wraps that keep them strapped to the mother’s back so that her hands are free. That roughly corresponds to carrying rates among other primates, according to primatologist and psychologist Harriet J. Smith. One can get an idea of how desperately important touch is to primates from a landmark experiment conducted in the 1950s by a psychologist and primatologist named Harry Harlow. Baby rhesus monkeys were separated from their mothers and presented with the choice of two kinds of surrogates: a cuddly mother made out of terry cloth or an uninviting mother made out of wire mesh. The wire-mesh mother, however, had a nipple that would dispense warm milk. The babies invariably took their nourishment quickly in order to rush back and cling to the terry-cloth mother, which had enough softness to provide the illusion of affection. But even that isn’t enough for psychological health: in a separate experiment, more than 75 percent of female baby rhesus monkeys raised with terry-cloth mothers—as opposed to real ones—grew up to be abusive and neglectful to their own young.
In the 1970s, American mothers maintained skin-to-skin contact with their nine-month-old babies as little as 16 percent of the time, which is a level of contact that traditional societies would probably consider a form of child abuse. Also unthinkable would be the common practice of making young children sleep by themselves in their own room. In two American studies of middle-class families during the 1980s, 85 percent of young children slept alone—a figure that rose to 95 percent among families considered “well-educated.” Northern European societies, including America, are the only ones in history to make very young children sleep alone in such numbers. The isolation is thought to trigger fears that make many children bond intensely with stuffed animals for reassurance. Only in Northern European societies do children go through the well-known developmental stage of bonding with stuffed animals; elsewhere, children get their sense of safety from the adults sleeping near them.
More broadly, in most human societies, almost nobody sleeps alone. Sleeping in family groups of one sort or another has been the norm throughout human history and is still commonplace in most of the world. Again, Northern European societies are among the few where people sleep alone or with a partner in a private room. When I was with American soldiers at a remote outpost in Afghanistan, we slept in narrow plywood huts where I could reach out and touch three other men from where I slept. They snored, they talked, they got up in the middle of the night to use the piss tubes, but we felt safe because we were in a group. The Taliban attacked the position regularly, and the most determined attacks often came at dawn. Another unit in a nearby valley was almost overrun and took 50 percent casualties in just such an attack. And yet I slept better surrounded by those noisy, snoring men than I ever did camping alone in the woods of New England.
Many soldiers will tell you that one of the hardest things about coming home is learning to sleep without the security of a group of heavily armed men around them. In that sense, being in a war zone with your platoon feels safer than being in an American suburb by yourself. I know a vet who felt so threatened at home that he would get up in the middle of the night to build fighting positions out of the living-room furniture. This is a radically different experience from what warriors in other societies go through, such as the Yanomami, of the Orinoco and Amazon Basins, who go to war with their entire age cohort and return to face, together, whatever the psychological consequences may be. As one anthropologist pointed out to me, trauma is usually a group experience, so trauma recovery should be a group experience as well. But in our society it’s not.
“Our whole approach to mental health has been hijacked by pharmaceutical logic,” I was told by Gary Barker, an anthropologist whose group, Promundo, is dedicated to understanding and preventing violence. “PTSD is a crisis of connection and disruption, not an illness that you carry within you.”
This individualizing of mental health is not just an American problem, or a veteran problem; it affects everybody. A British anthropologist named Bill West told me that the extreme poverty of the 1930s and the collective trauma of the Blitz served to unify an entire generation of English people. “I link the experience of the Blitz to voting in the Labour Party in 1945, and the establishing of the National Health Service and a strong welfare state,” he said. “Those policies were supported well into the 60s by all political parties. That kind of cultural cohesiveness, along with Christianity, was very helpful after the war. It’s an open question whether people’s problems are located in the individual. If enough people in society are sick, you have to wonder whether it isn’t actually society that’s sick.”
Ideally, we would compare hunter-gatherer society to post-industrial society to see which one copes better with PTSD. When the Sioux, Cheyenne, and Arapaho fighters returned to their camps after annihilating Custer and his regiment at Little Bighorn, for example, were they traumatized and alienated by the experience—or did they fit right back into society? There is no way to know for sure, but less direct comparisons can still illuminate how cohesiveness affects trauma. In experiments with lab rats, for example, a subject that is traumatized—but not injured—after an attack by a larger rat usually recovers within 48 hours unless it is kept in isolation, according to data published in 2005 in Neuroscience & Biobehavioral Reviews. The ones that are kept apart from other rats are the only ones that develop long-term traumatic symptoms. And a study of risk factors for PTSD in humans closely mirrored those results. In a 2000 study in the Journal of Consulting and Clinical Psychology, “lack of social support” was found to be around two times more reliable at predicting who got PTSD and who didn’t than the severity of the trauma itself. You could be mildly traumatized, in other words—on a par with, say, an ordinary rear-base deployment to Afghanistan—and experience long-term PTSD simply because of a lack of social support back home.
Anthropologist and psychiatrist Brandon Kohrt found a similar phenomenon in the villages of southern Nepal, where a civil war has been rumbling for years. Kohrt explained to me that there are two kinds of villages there: exclusively Hindu ones, which are extremely stratified, and mixed Buddhist/Hindu ones, which are far more open and cohesive. He said that child soldiers, both male and female, who go back to Hindu villages can remain traumatized for years, while those from mixed-religion villages tended to recover very quickly. “PTSD is a disorder of recovery, and if treatment only focuses on identifying symptoms, it pathologizes and alienates vets,” according to Kohrt. “But if the focus is on family and community, it puts them in a situation of collective healing.”
Israel is arguably the only modern country that retains a sufficient sense of community to mitigate the effects of combat on a mass scale. Despite decades of intermittent war, the Israel Defense Forces have a PTSD rate as low as 1 percent. Two of the foremost reasons have to do with national military service and the proximity of the combat—the war is virtually on their doorstep. “Being in the military is something that most people have done,” I was told by Dr. Arieh Shalev, who has devoted the last 20 years to studying PTSD. “Those who come back from combat are re-integrated into a society where those experiences are very well understood. We did a study of 17-year-olds who had lost their father in the military, compared to those who had lost their fathers to accidents. The ones whose fathers died in combat did much better than those whose fathers hadn’t.”
According to Shalev, the closer the public is to the actual combat, the better the war will be understood and the less difficulty soldiers will have when they come home. The Israelis are benefiting from what could be called the shared public meaning of a war. Such public meaning—which would often occur in more communal, tribal societies—seems to help soldiers even in a fully modern society such as Israel. It is probably not generated by empty, reflexive phrases—such as “Thank you for your service”—that many Americans feel compelled to offer soldiers and vets. If anything, those comments only serve to underline the enormous chasm between military and civilian society in this country.
Another Israeli researcher, Reuven Gal, found that the perceived legitimacy of a war was more important to soldiers’ general morale than was the combat readiness of the unit they were in. And that legitimacy, in turn, was a function of the war’s physical distance from the homeland: “The Israeli soldiers who were abruptly mobilized and thrown into dreadful battles in the middle of Yom Kippur Day in 1973 had no doubts about the legitimacy of the war,” Gal wrote in the Journal of Applied Psychology in 1986. “Many of those soldiers who were fighting in the Golan Heights against the flood of Syrian tanks needed only to look behind their shoulders to see their homes and remind themselves that they were fighting for their very survival.”
In that sense, the Israelis are far more like the Sioux, Cheyenne, and Arapaho at Little Bighorn than they are like us. America’s distance from her enemies means that her wars have generally been fought far away from her population centers, and as a result those wars have been harder to explain and justify than Israel’s have been. The people who will bear the psychic cost of that ambiguity will, of course, be the soldiers.
A Bright Shining Lie
‘I talked to my mom only one time from Mars,” a Vietnam vet named Gregory Gomez told me about the physical and spiritual distance between his home and the war zone. Gomez is a pure-blooded Apache who grew up in West Texas. He says his grandfather was arrested and executed by Texas Rangers in 1915 because they wanted his land; they strung him from a tree limb, cut off his genitals, and stuffed them in his mouth. Consequently, Gomez felt no allegiance to the U.S. government, but he volunteered for service in Vietnam anyway. “Most of us Indian guys who went to Vietnam went because we were warriors,” Gomez told me. “I did not fight for this country. I fought for Mother Earth. I wanted to experience combat. I wanted to know how I’d do.”
Gomez was in a Marine Corps Force Recon unit, one of the most elite designations in the U.S. military. He was part of a four-man team that would insert by helicopter into enemy territory north of the DMZ and stay for two weeks at a time. They had no medic and no backup and didn’t even dare eat C rations, because, Gomez said, they were afraid their body odor would give them away. They ate Vietnamese food and watched enemy soldiers pass just yards away in the dense jungle. “Everyone who has lived through something like that has lived through trauma, and you can never go back,” he told me. “You are 17 or 18 or 19 and you just hit that wall. You become very old men.”
American Indians, proportionally, have provided more soldiers to America’s wars than almost any other ethnic group in this country. They are also the product of an ancient and vibrant warring culture that takes great pains to protect the warrior from society, and vice versa. Although those traditions have obviously broken down since the end of the Indian Wars, there may be something to be learned from the principles upon which they stand. When Gomez came home he essentially isolated himself for more than a decade. He didn’t drink, and he lived a normal life except that occasionally he’d go to the corner store to get a soda and would wind up in Oklahoma or East Texas without any idea how he got there.
He finally started seeing a therapist at the V.A. as well as undergoing traditional Indian rituals. It was a combination that seemed to work. In the 1980s, he underwent an extremely painful ceremony called the Sun Dance. At the start of the ceremony, the dancers have wooden skewers driven through the skin of their chests. Leather thongs are tied to the skewers and then attached to the top of a tall pole at the center of the dance ground. To a steady drumbeat, the dancers move in a circle while leaning back on the leather thongs until, after many hours, the skewers finally tear free. “I dance back and I throw my arms and yell and I can see the ropes and the piercing sticks like in slow motion, flying from my chest towards the grandfather’s tree,” Gomez told me about the experience. “And I had this incredible feeling of euphoria and strength, like I could do anything. That’s when the healing takes place. That’s when life changes take place.”
America is a largely de-ritualized society that obviously can’t just borrow from another society to heal its psychic wounds. But the spirit of community healing and empowerment that forms the basis of these ceremonies is certainly one that might be converted to a secular modern society. The shocking disconnect for veterans isn’t so much that civilians don’t know what they went through—it’s unrealistic to expect anyone to fully understand another person’s experience—but that what they went through doesn’t seem relevant back home. Given the profound alienation that afflicts modern society, when combat vets say that they want to go back to war, they may be having an entirely healthy response to the perceived emptiness of modern life.
One way to change this dynamic might be to emulate the Israelis and mandate national service (with a military or combat option). We could also emulate the Nepalese and try to have communities better integrate people of different ethnic and religious groups. Finally, we could emulate many tribal societies—including the Apache—by getting rid of parades and replacing them with some form of homecoming ceremony. An almost universal component of these ceremonies is the dramatic retelling of combat experiences to the warrior’s community. We could achieve that on Veterans Day by making every town and city hall in the country available to veterans who want to speak publicly about the war. The vapid phrase “I support the troops” would then mean actually showing up at your town hall every Veterans Day to hear these people out. Some vets will be angry, some will be proud, and some will be crying so hard they can’t speak. But a community ceremony like that would finally return the experience of war to our entire nation, rather than just leaving it to the people who fought.
It might also begin to re-assemble a society that has been spiritually cannibalizing itself for generations. We keep wondering how to save the vets, but the real question is how to save ourselves. If we do that, the vets will be fine. If we don’t, it won’t matter anyway.
We met her at an LA Collaborative meeting. That’s the Los Angeles Veterans Collaborative, a group of community stakeholders, agencies and representatives serving veterans and military families in Greater Los Angeles. Like the NVF’s Women Veteran Outreach Coordinator Leaphy Khim, this woman Is a veteran. The two of them sat together in an early morning focus group for women veterans. Melanie Brown raised the issue of the scarcity of services for women who were pre-9/11 vets like her. Many agencies serve post 9/11 veterans only. She was quick to volunteer to put together a list of agencies who work specifically with women veterans. She and Leaphy struck up a conversation that led to more conversations about their experiences as women vets, and the needs of women veterans.
Brown’s experience as a US Army veteran in the years before 9/11 held its own kind of combat. In a war zone, yes, but not what you’re expecting. This wasn’t the desert or the jungle. This was basic training. Brown made a short, animated documentary about her experience. Her “Lion in a Box” is available on Vimeo.
Watching it, I remembered the nurses in Vietnam, what they experienced in the field hospitals and also after hours. How their lives were so different from what they would have been stateside. And I thought of the women vets we see in our outreach. Mary Ann Mayer, our Women Veteran Outreach Director, says this about them. “Here is the incredible strength of women veteran survivors of MST. These women can get knocked down, and still not break. They inspire me every single day.”
It takes a special kind of woman to want to train for combat. Melanie Brown is that woman. It riles her when someone makes the assumption that because she was not in a designated combat zone, she had an easy time of it. Her experience of harassment and unfair treatment is painful to watch, the more so because you know it’s not unusual. At the risk of repeating myself, here’s from my blog of 8/4 this year:
Forty percent of military women have experienced MST (Military Sexual Trauma) while 67% have experienced sexual harassment. And these figures don’t include unreported cases. Multiple studies show that PTSD from Military Sexual Trauma (MST) is twice as severe as combat PTSD.
The level of reported incidents of MST have risen, but the number of cases actually going to court hasn’t kept pace with the increase of reports. What we (still) have here is a situation where there doesn’t seem to be accountability for actions. Attention is drawn to problems and issues, and that’s all well and good. That’s the first step. What we need is substantive change.
There are ranking officers in the military justice system who see the need for change. Likewise in the Senate. Likewise in the ranks of women veterans who are telling their stories now. Let’s hope it’s just a matter of time, but let’s do keep the pressure on.
If you know a veteran who needs help, here’s our Lifeline for Vets number where they can talk vet-to-vet: 888.777.4443.
Source: The KKK Recruiting Veterans
Source: The KKK Unmasked
Unfortunately, many soldiers experience traumatic brain injury when in combat, but is traumatic brain injury (TBI) linked to later combat posttraumatic stress disorder (PTSD)? Two recent studies examined the link between traumatic brain injury and PTSD in marines and army soldiers.
Link Between TBIs and Combat PTSD
In a study published last year, Association Between Traumatic Brain Injury and Risk of Posttraumatic Stress Disorder in Active-Duty Marines1 shows that 19.8% of Marines reported sustaining a deployment-related TBI where most (87.2%) were mild in nature. It was noted that while predeployment PTSD symptoms and severity of combat intensity did predict a higher risk of postdeployment combat PTSD, a better predictor was the experience of a TBI during deployment. Moderate or severe TBIs predicted the presence of PTSD symptoms at three months postdeployment more than mild TBIs did.
What this all means that a TBI during deployment actually predicts the presence of PTSD symptoms better than other known risk factors and that the more severe the TBI, the greater the risk of combat PTSD.
Deployment-Related TBIs and Future Risk of PTSD and Other Mental Illness
In the latest study, Prospective Longitudinal Evaluation of the Effect of Deployment-Acquired Traumatic Brain Injury on Posttraumatic Stress and Related Disorders: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)2, 4,645 soldiers who were deployed to Afghanistan were studied and results showed that 18% of soldiers experienced mild TBIs while 1.2% of soldiers experienced more-then-mild TBIs during deployment. Even after taking into account other known risk factors for combat PTSD causes such as pre-deployment mental health, prior TBIs and severity of deployment stress, it was found that:
- There was a greater risk of posttraumatic stress disorder at the three month and nine month mark.
- There was a greater risk of generalized anxiety disorder (GAD) at the three month and nine month mark.
- There was a greater risk of a major depressive episode at the three month mark.
- Suicide risk may be elevated at the three month mark but the relationship did not reach statistical significance.
This study shows that there is a risk of, not only PTSD for those who have suffered a TBI, but also other mental health issues as well.
The Link Between Traumatic Brain Injuries and Posttraumatic Stress Disorder
While we don’t currently understand why the link between TBIs and PTSD exists, it’s clear that it does. What this, like other studies, suggests is that PTSD is, indeed, a physical illness and not “all in one’s head” like some would have you believe (You Don’t Have A Mental Illness: It’s All In Your Head!). What this means for soldiers is that greater care should be taken in screening for PTSD after a TBI is sustained and, critically, even mild injuries can increase a soldier’s risk of PTSD.
While this may seem like a bleak finding, really it is not. What this finding does is further our understanding of combat PTSD and it allows us to further target risk groups to better treat those in the military as a whole; because, we know that treatment of combat PTSD is possible and we know that people successfully recover from combat PTSD every day.