Female veterans encounter multiple health challenges when transitioning from military to civilian life. Gender disparities in physical health conditions, environmental exposure, and socioeconomic factors contribute to the vulnerabilities impacting female veterans. Numerous health conditions, if recognized promptly, can improve the health trajectory of a female veteran. Healthcare providers and nurses play a critical role in the care of female veterans in the US. Such expert care includes anticipation of veterans' potential short- and long-term health challenges and related medical costs. This article examines health concerns unique to female veterans and outlines ways for nurses to recognize and address the psychological, physical, and other medical concerns of female soldiers transitioning to civilian healthcare.
Healthcare considerations for veterans transitioning into civilian life
Women constitute 15% of active US military forces and 19% of reserve units. Nearly 2 million female veterans have served in the US military.1 By 2040, the Veterans Affairs (VA) expects females to make up 18% of the veteran population. Every year, more than 30,000 females leave the military.1
Female armed force members encounter unique stressors and threats that impact their health while serving and after retiring from active duty. These include gender differences in combat, posttraumatic stress disorder (PTSD), sexual assault (SA), interpersonal stressors, reproductive and gynecologic health issues, and homecoming readjustment.2
Reintegrating into civilian life can be a challenging time for a veteran. When female veterans complete their military service and return to civilian life, they face challenges that are little understood and rarely recognized.3,4 Considering patients' military history is critical to ensuring they receive quality and appropriate healthcare. Nurses must consider a veteran's unique experiences to ascertain information such as training, length of service, diseases, medications, environmental stress, injuries, disabilities, stress, anxiety, regrets, and remorse.5
It is important to remember that many females may not volunteer information about military service or even identify themselves as veterans.6 When obtaining a veteran patient's health history, developing a therapeutic alliance between veterans and healthcare professionals that promotes empathy, respect, and trust can yield positive outcomes.7
To design an effective patient-centered plan of care, healthcare professionals must include critical elements in the patient's military history, including deployment status, specific occupation in the military, and any history of trauma. Discussions relevant to reproductive and mental health are also helpful.
Gender-specific issues
Transitioning to civilian healthcare can be challenging for some female veterans. The military provides up to 90 days of healthcare following active duty for females who have not received a service-related disability.8 Among soldiers diagnosed with an illness or injury incurred during active duty, service-related disabilities must be fully assessed before they leave the military. Veterans who have a designated disability status can receive health benefits through the VA for 5 years after active duty.9 They can also access health systems based on private or public insurance at VA and non-VA facilities. Regardless of education, insurance, or income status, veterans are reevaluated by the VA after 5 years to assess a need for continued healthcare maintenance.8 To provide high-quality healthcare for female veterans adjusting to civilian life, nurses need to identify the significant challenges they encountered while on active duty.
Military sexual trauma (MST)
MST refers to SA and sexual harassment or threats experienced during military service.9 Diagnosing MST requires a comprehensive assessment, which includes asking questions about being pressured into sexual activity with negative repercussions if the person refuses to cooperate; sexual contact without consent; being overpowered and physically forced to have sex; being touched or grabbed in a sexual way that makes one uncomfortable; receiving comments regarding one's body; and unwanted and threatening sexual advances.10 MST can lead to depression, substance abuse, isolation, anger, and sleep problems, among many other concerns.
While the Department of Defense (DOD) acknowledges the occurrence of MST, it is underreported.11 According to a 2016 DOD report, two-thirds of female soldiers did not report SA due to embarrassment, shame, guilt, and fear of retaliation.12,13 Some noted concerns that their trauma would not be acknowledged by their superiors.13 In 2018, about 20,500 service members-including 13,000 females-reported sexual assaults and rape. However, the number of reported MST incidents could be underrepresented.14,15
A Service Women's Action Network survey found that MST is the most prevalent factor affecting female veterans' mental health.16 Furthermore, Yale Law School's Veterans Legal Services found that benefit claims among female veterans with PTSD are often related to MST; comparatively, reported benefit claims of male veterans with PTSD were mostly combat-related.10 This is discouraging as female veterans were also reported to receive lower benefits than their male counterparts.10
Family readjustment and motherhood
Female soldiers face prolonged separations from their children due to deployment, resulting in significant stress before, during, and following deployment.17 Issues with readjusting to family life when returning home have been reported by female soldiers.18 They may face normative challenges in reestablishing relationships, routines, and roles. Careful assessment of a mother's experiences and family adjustment issues can support the female veteran transitioning out of the military.
Sustaining breastfeeding following active duty can be difficult. Exposures and injuries sustained during military service impact postpartum health behaviors.19 Recognizing the needs of military members who are breastfeeding, the US military has allocated private areas for pumping in domestic and international military bases.19
Evidence suggests that breastfeeding reduces the incidence of hypertension, diabetes, heart disease, postpartum depression, and ovarian and breast cancers.20 Healthcare providers in both the civilian and VA sectors should ascertain the patient's breastfeeding and reproductive history when caring for female veterans.21
Further research is needed to improve healthcare for the female military members who had to stop breastfeeding. Supportive resources must be provided to veteran mothers who have missed child development as well as to their families to ensure holistic, comprehensive care.
Genitourinary complications
Military deployment is defined as an assignment away from the personnel's home station to somewhere outside the continental US and its territories.22 The lack of sanitary conditions and severely hot climates in some deployment scenarios prevent females from urinating, which may cause a urinary tract infection (UTI).23 Some female soldiers restrict their intake of fluids, hold urine, or even use layers of padding to absorb urine.11 These methods are breeding grounds for health issues such as chronic UTIs and pyelonephritis during and after service. Contributing factors associated with uterine complications include UTIs and pelvic organ prolapse.
Reproductive health and menstrual suppression
A survey on contraception use and unintended pregnancy among female soldiers during deployment found that one-third were unable to access contraceptives.24 Forty-one percent had difficulty obtaining refills for prescriptions.24
Irregular menstrual cycles, menorrhagia, and dysmenorrhea are some of the leading causes of sick calls among female soldiers who are deployed.25 Fifteen percent of female soldiers reported inability to work due to challenges in their menstrual cycles and 35% had at least one gynecologic issue during deployments.25-27 Prevention strategies to suppress menstrual flow and prevent pregnancy should include types of contraception, access, and education early in the female service women's career before deployment.28 Contraceptive menstrual suppression can be implemented in the prescreening health physical exam before deployment.
Homelessness
Homelessness among US veterans is a significant problem. Female veterans are four times more likely to become homeless than their male peers.29 The Annual Homeless Assessment Report by the Department of Veterans Affairs has reported that the rate of homelessness of males is decreasing, but the number of female veterans found homeless has increased 135% from 2009 to 2019.30 The VA estimates that female veterans are at least twice as likely to be homeless as nonveteran females. Factors contributing to the high rate of homelessness include childhood adversity, substance use disorders, relationship termination, MST, intimate partner violence (IPV), PTSD, and unemployment.31 Female veterans with mental health issues may be unable to maintain productive employment, housing stability, and family contacts.32
Recognizing that female veterans are at great risk of homelessness, specialized programs have been implemented. Every VA Medical Center and regional benefits office has a dedicated advocate to ensure that females get the healthcare benefits and housing assistance needed when transitioning to civilian life.33 When obtaining a health history and performing a physical assessment, nurses and healthcare providers can refer female veterans to their nearest VA facility and to other services and resources that can help them rebuild their lives.
Mental health
Female veterans have a greater depression rate compared with their male counterparts (21% and 16%, respectively).34 The rate of PTSD in civilian females is 5%. Mental health should be ascertained during an assessment screening by all healthcare providers.
Suicide
Suicide has been the second leading cause of death among US service members since 2010.35 In 2017, the VA reported suicide rates among female veterans surpassed the rate of male veterans.36 Rates of suicide decreased 14.9% in 2019 for female veterans and continue to trend down in both male and female veterans in 2021.37 Preventive approaches based on gender differences have been developed.38 Female veterans who have experienced MST and violence are at high risk for self-harm and suicidal ideation.39
Suicidal risks and behaviors should be assessed in female veterans who have experienced IPV and MST. Female veterans who are at risk for suicide can be assessed in both civilian and veterans' healthcare facilities. Immediate support is always available through the Veteran's Crisis Line. Qualified professionals and responders are available 24 hours a day to support female veterans who are at acute risk for suicide.
PTSD
Symptoms of PTSD include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about an event. PTSD can develop after experiencing or witnessing a life-threatening event like combat, a natural disaster, a car crash, or sexual assault.40 PTSD has been reported in 20% of female veterans who served in the conflicts in Iraq and Afghanistan.41 In 2015, 11.8% of female veterans were diagnosed with PTSD, the highest incidence of health disorders in female veterans.42 Nearly 48,000 female veterans received compensation for PTSD and accounted for roughly 12% of all service-connected disabilities for female veterans.
Just over 20% of both female and male veterans have reported symptoms of probable PTSD.41 Females appeared to be at higher risk for depression and men at higher risk for alcohol use.43 These findings indicate that mental disorders are gender-linked conditions resulting from societal norms governing expressions of sadness and substance use. There could also be a sex-linked component. The associations of harassment and combat stress with probable PTSD were similar across genders.43 Despite evidence from the general population that the prevalence of PTSD is twice as high in females than in men, data from specific traumatized veterans suggest that sex-specific PTSD risk varies significantly.41
Major depression
Female veterans have been found to have higher rates of depression than civilian women and veteran men.34 Approximately 26,500 female veterans received compensation for major depressive disorder.42 To be diagnosed with depression, symptoms must be present for at least 2 weeks. Depression types include persistent depressive disorder, perinatal depression, psychotic depression, and seasonal affective disorder.44
Hospitalizations for psychiatric illness among female veterans are twice that of male veterans. Some females have experienced one or more episodes of MST.45 Half of the females obtaining care at the VA between 2002 and 2014 were receiving care for a mental health diagnosis. It is estimated that the primary diagnosis of those female veterans was depression.46
Social support and financial comfort are significant factors that affect depression in female veterans. Improving social support in conjunction with psychotherapy has been found to be a productive intervention in mental health treatment.47
Identifying depressive disorders following deployment can be an important direction for clinical practice. Nurses working with female veterans with depression can encourage regular contact with family, friends, and peers in conjunction with professional treatment. Encouraging female veterans to join support groups following active duty can be beneficial for treating their depression.48
Cultural awareness
Nurses can create a sensitive atmosphere by providing private and safe areas for female veterans to voice their medical issues and concerns.49
Healthcare professionals must familiarize themselves with the challenges impacting female veterans to address their needs. Connecting female veterans to VA services may facilitate the needed comprehensive healthcare.
Nurses' role
Despite the need for screening veterans, female veterans are not being asked if they ever served in the military.50 To address this issue, an acronym was created for nurses and healthcare providers to follow that can be addressed on the initial screening of a female patient. This can be done in all healthcare settings including non-VA hospitals, urgent care facilities, female-based clinics, and even during a telehealth appointment. Screening will help ensure that these women have access to healthcare support services to inform treatment planning and increase awareness of their strengths and unique challenges.50 The acronym SERVE can be used to start a conversation when obtaining a health history from a female veteran (see SERVE: Questions for initial patient screening).
Conclusion
Acknowledging the need for civilian healthcare providers to understand the experiences that female soldiers encountered while on active duty can foster an environment where the female veteran receives a comprehensive assessment. Encouraging cultural awareness, unique healthcare stressors of female veterans, and training in healthcare institutions can support the delivery of effective, equal, and comprehensive care for the women who have dedicated their time and service to their country.
SERVE: Questions for initial patient screening
* Did you Serve in the military?
* Were you Exposed to any chemicals, trauma during your service?
* Do you have any Recent illnesses related to your military service?
* What was your Vocation or role in the military?
* Are there any Experiences that impacted your physical health or mental well-being?
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