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Gender Differences in PTSD

As more women join the military, researchers are beginning to examine the higher frequency of TBI and PTSD in women By Neelum T. Aggarwal, MD

Recent data from the Veteran’s Affairs (VA) Administration notes that women comprise nearly 12% of all soldiers who served in Iraq and Afghanistan. More than 79% are under age 40; 88% are enlisted, and 12% are officers. As troops try to re-integrate into civilian life, the clinical literature is noting differences in cognition, and physical and emotional health-related issues. Some, but not all, reports suggest that female veterans may seek more outpatient primary care visits than males, in addition to having more mental and “cognitive” health visits than males. In addition, other reports note that female VHA users are more likely than their male counterparts to have mild and major depression, adjustment disorders, and musculoskeletal and skin disorders.

Some findings are thought to be associated with the incidence of physical attacks, harassment, and combat-related exposure. Both traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are thought to occur in higher frequency among female military veterans, yet recent data suggest that over 50% of returning female veterans do not realize the signs and symptoms of TBI/PTSD, and many think that they can handle these situations without medical intervention. Also, women often find themselves immediately immersed in family care issues without having their own personal care needs met. Whether true gender differences exist in PTSD or other related cognitive and health conditions is a subject only recently examined by researchers.

In the U.S. population, the overall prevalence of PTSD is 5-10%, with women having a two-fold higher prevalence of PTSD than men. These civilian prevalence rates were similar to those of military women examined prior to the wars in Iraq and Afghanistan. Data from the Millennium Cohort of over 75,000 service members (>20,000 women) noted that women had a higher rate of pre-deployment PTSD (3.2% vs. 2.2%, adjusted OR of 1.4%) compared to men, measured by the PTSD checklist civilian version. Post-deployment data on PTSD, however, has been scant, with some reports noting emerging cognitive issues associated with PTSD in addition to co-morbid medical conditions.

Existing PTSD studies are often grouped into service branch areas and active duty veteran status. Data sets limited to the Army have shown that positive PTSD screening scores were twice as likely in women compared to men. These studies, conducted from 2006-2008, assessed combat experience using a yes/no, four-item questionnaire that asked about being injured or wounded. Higher levels of PTSD with higher levels (i.e., intensity) of combat experience were noted for women than for men.

In the U.S. Millennium Cohort Study, which compared new onset PTSD in men and women from all service branches, both active reserve and the National Guard, combat exposure was indicated by one positive response to any of the following items assessing whether the veteran had witnessed: death due to war, disaster, tragic event; instance of physical abuse; maimed or dead bodies of soldiers, civilians, prisoners of war or refugees. New onset PTSD was noted in 3.8% of women, compared to 2.4% of men, with women showing higher odds of new onset PTSD compared to men, in three of four service areas. (Army 1.7%, Air Force 2.0%, Navy/Coast Guard 1.73%)

A National Guard study surveyed members who were deployed from 2005-2007 (n= >25,000). Positive scores for PTSD three months post-deployment were found in 18% of women compared to 14.5 % of men; however, at 12 months post-deployment, more males reported positive PTSD scores than women (17.9% of females vs. 24.1% of males). When adjusted for combat experience/exposure, men had decreased odds of screening positive for PTSD compared to women at three months post-deployment and no gender differences were observed at 12 months post-deployment.

Finally, medical data from across multiple VA medical centers have noted that male veterans were more likely to have health care visits or diagnoses of PTSD (diagnosed by the ICD-9 criteria) compared to females (22% vs. 17%). This finding supports clinical data suggesting that women may not recognize the signs and symptoms of PTSD, or simply choose to manage this issue on their own.

The data emerging on PTSD highlights potential gender differences in a condition that often affects veterans. PTSD can be chronic and potentially debilitating since it is associated with impairment in cognitive, physical, and social functioning. Given the expanding roles of women in the military, more research in this area is needed. Long-term follow-up studies should examine potential modifiable factors that could reduce the risk of PTSD and optimize intervention strategies for female members of the military.

Dr. Aggarwal is a cognitive neurologist, co-leader of the NIH-funded Rush Alzheimer’s Disease Clinical Core, and vice chair of the board of the Westside Institute of Science and Education (WISE), a 501(c)3 research corporation that serves the Jesse Brown VA Medical Center in Chicago.

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