THE INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL REPORT PTSD COMPENSATION AND MILITARY SERVICE:
FINDINGS REGARDING POSTTRAUMATIC STRESS DISORDER (PTSD) AND WOMEN VETERANS
Janice L. Krupnick, Ph.D.
Professor, Department of Psychiatry
Director, Trauma and Loss Program
Georgetown University Medical Center
Health Committee Liaison
Committee on Veterans’ Compensation for Posttraumatic Stress Disorder
Institute of Medicine and National Research Council
The National Academies
Subcommittee on Disability Assistance and Memorial Affairs and Subcommittee on Health
Committee on Veterans’ Affairs
U.S. House of Representatives
July 16, 2009
Good morning, Mr. Chairman, Mr. Ranking Member, and members of the Committee. My name is Janice Krupnick and I am a Professor in the Department of Psychiatry at the Georgetown University Medical Center and Director of the Center’s Trauma and Loss Program. Thank you for the opportunity to testify on the content of the National Academies report PTSD Compensation and Military Service. The committee’s work—which was conducted between March 2006 and July 2007—was requested by the Department of Veterans Affairs, which provided funding for the effort. I provided input to this committee while serving as a member of the Institute of Medicine Committee on Gulf War and Health—Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress and its Subcommittee on Posttraumatic Stress Disorder (PTSD).
I’m pleased to be here today to share with you some of the results of the PTSD Compensation… report and the knowledge I’ve gained as a clinical psychologist and researcher on traumatic stress. I will briefly address five issues in this testimony:
- the prevalence of military sexual assault,
- the relationship between sexual assault and PTSD,
- PTSD comorbidities and recovery for women,
- PTSD compensation and women veterans and
- the PTSD Compensation… report’s conclusions and recommendations regarding women veterans.
The prevalence of military sexual assault
It is recognized that the circumstances of military service may create barriers to reporting sexual assault above and beyond those extant in other sectors of the population. That said, the prevalence of reported sexual assault in the military is alarming. A synthesis of 21 studies by Goldzweigh and colleagues found that 4.2 to 7.3 percent of active duty military females had experienced a military sexual assault (MSA), while 11 to 48 percent of female veterans reported having experienced a sexual assault during their time in the military. A survey by Campbell and Raja (2005) found that among 104 female veterans and reservists who disclosed that they were sexually assaulted while in military service, 13 percent reported sexual assault from a marital partner and 8 percent from a date. Eighty-two percent of the perpetrators in these MSAs were military peers or supervisors. The women in this sample also reported a great deal of secondary victimization by the military and by the VA system, an experience that is known to make the PTSD symptoms worse. Other studies have found subsequent secondary victimization and sexual harassment, exposing the women to additional trauma over and above rape and combat.
The relationship between gender, sexual assault and PTSD
A substantial body of literature documents measurable gender differences in PTSD frequency and severity. A well-conducted meta-analysis published in 2006 by Tolin and Foa found that PTSD was twice as prevalent in females as in males after controlling for potential confounders. There are several possible reasons for this, including sex differences in the cognitive response to the traumatic event, immediate coping strategies, and the willingness to admit symptoms. Women are more likely to experience chronic trauma, such as repeated childhood sexual assault by a family member or recurring intimate partner violence. Women are also more commonly the victim in cases of multiple traumas. Research indicates that sexual-assault experiences are strongly associated with PTSD in both civilian and military populations.
PTSD comorbidities and recovery for female veterans
Studies of female veterans indicate that PTSD symptoms and PTSD diagnoses are associated with comorbidities such as depression, substance abuse, smoking, and physical health problems as well as with increased medical utilization. Females are more likely than males to have major depressive disorder along with PTSD and tend to experience symptoms for a longer duration and have more associated physical health problems than do males.
For female veterans, postmilitary social support from family and friends both reduces the risk of developing PTSD and aids in recovery from the disorder, according to the few studies of PTSD recovery in this population. Female veterans were more comfortable in a specialized treatment program for women; it increased their participation as measured by attendance and commitment, but had no effect on outcomes.
The PTSD Compensation… committee observed that studies of PTSD treatment for female veterans are badly needed, and noted that it was important to ensure that the study samples were sufficiently large to disentangle the differential treatment effects for women whose trauma is primarily MSA versus those whose trauma is primarily combat or to determine if multiple traumas are part of the etiology of the PTSD experience.
PTSD compensation and female veterans
Very little research exists on the subject of PTSD compensation and female veterans. A 2003 study by Murdock and colleagues did determine that a significantly smaller percentage of females had their PTSD deemed to be service connected as compared to males, and that this was primarily related to the lower rates of combat exposure among females. Subsequent research by Murdock (2006) found that, when MSA was substantiated in a Veterans Benefits Administration (VBA) claim file, service-connected PTSD determinations increased substantially. Unfortunately, there are huge barriers to women being able to independently substantiate their experiences of MSA, especially in a combat arena. A 2004 US Air Force report cited by the committee noted that these barriers included
lack of privacy/confidentiality[,]… stigma, fear, or shame; fear of disciplinary action because of a victim’s misconduct; fear of being reduced in the eyes of one’s commander/colleagues; fear of re-victimization; and fear of perceived operational impacts, including loss of security clearances, effect on training, and impact on overseas deployments (US Air Force, 2004; p. 10).
Available information suggests that female veterans are less likely to receive service related compensation for PTSD and that this is, at least in part, a consequence of the relative difficulty of substantiating exposure to noncombat traumatic stressors—notably, MSA. The committee noted that PTSD training and reference materials for VBA raters address MSA, but scant attention is paid either to the challenges of documenting it as an in-service stressor or to approaches to addressing this problem.
The PTSD Compensation… report’s conclusions and recommendations regarding women veterans
The committee responsible for the PTSD Compensation… report reached several conclusions and recommendations related to women veterans on the basis of their review of papers, reports, and other scientific information. It also identified research needs.
The committee concluded that “the most effective strategy for dealing with problems with self reports of traumatic exposure is to ensure that a comprehensive, consistent, and rigorous process is used throughout the VA to verify veteran-reported evidence.” It therefore recommended that the Veterans Benefits Administration “conduct more detailed data gathering on the determinants of service connection and ratings level for MSA-related PTSD claims, including the gender-specific coding of MSA-related traumas for analysis purposes.”
The committee observed that appropriate management of MSA-related claims begins with the proper documentation of incidents that occur during active service. Therefore, improved training of military medical and nursing personnel on how to document and collect evidence regarding sexual assault is needed. The committee thus recommended that VBA “develop and disseminate reference materials for raters that more thoroughly address the management of MSA-related claims” and that “training and testing on MSA-related claims should be a part of [a] certification program … for raters who deal with PTSD claims.”
Citing the gaps it found in the information base, the committee noted that “more research is needed on the as yet unexplained gender differences in vulnerability to PTSD, which could help identify useful sex-specific approaches to prevention and treatment, and on more effective means for preventing military sexual assault and sexual harassment.”
The PTSD Compensation… committee also reached a series of other findings and recommendations regarding the conduct of VA’s compensation and pension system for PTSD that are detailed in the body of our report. The National Academies previously provided the subcommittee with copies of this report and would happy to fulfill any additional requests for it.
Thank you for your attention. I’m happy to answer your questions.
Publications referenced in this testimony
Campbell R, Raja S. 2005. The sexual assault and secondary victimization of female veterans: help-seeking experiences with military and civilian social systems. Psychology of Women Quarterly 29(1):97–106.
Goldzweig CL, Balekian TM, Rolon C, Yano EM, Shekelle PG. 2006. The state of women veterans’ health research: results of a systematic literature review. Journal of General Internal Medicine (Suppl. 3):S82–S92.
Institute of Medicine. 2007. PTSD Compensation and Military Service. Washington, DC: National Academies Press. [Online]. Available: http://www.nap.edu/catalog.php?record_id=11870 [accessed July 13, 2009].
Murdoch M. 2006. PTSD Disability Benefits: A Focus on Gender. Presentation to the Committee on Veterans’ Compensation for Posttraumatic Stress Disorder, July 6, 2006. Washington, DC.
Murdoch M, Hodges J, Hunt C, Cowper D, Kressin N, O’Brien N. 2003. Gender differences in service connection for PTSD. Medical Care 41(8):950–961.
U.S. Air Force. 2004. Report concerning the assessment of USAF sexual assault prevention and response – August 2004. Office of the Assistant Secretary of the Air Force (Manpower and Reserve Affairs).[Online]. Available: http://www.ncdsv.org/images/USAF_ReportConcerningAssessmentUSAFSexualAssaultPreventionAndResponse_8-2004.pdf [accessed July 13, 2009].
An archived webcast of the hearing can be found on the House Veterans' Affairs Committee's Web site.