Amy Street, clinical psychologist

A Veterans Affairs clinician studies posttraumatic stress disorder in the armed forces' growing female population. Interview by Emmanuel Romero

May 25, 2009

Photo courtesy of Bostonia magazine, Fall 2008/Boston University

Art icon Rosie the Riveter served World War II America as a heartening reminder of what female citizens could contribute to the country's war efforts. Women's roles in war have since changed. Now, the global war on terror has pushed women into the thick of battle, deeper than ever.

Amy Street, a clinical psychologist with the National Center for PTSD at the VA Boston Healthcare System, helps servicewomen returning home from the war readjust to civilian life. Since the U.S. deployed troops to Afghanistan and Iraq early this decade, Street has been treating a growing number of female veterans who experience complications from combat, including depression and neurological damage. Most prominently, these servicewomen suffer from posttraumatic stress disorder, or PTSD.

PTSD, common in victims of violent crimes, has long been associated with returning veterans. Patients relive harrowing memories of their trauma and can experience other symptoms such as insomnia, fits of rage, and difficulty concentrating. They can become withdrawn and emotionally stunted. Untreated, PTSD makes it impossible to put a shattered life back together again.

Prior to the global war on terror, PTSD in servicewomen usually followed an episode of military sexual assault, according to Street. While the VA still helps servicewomen with sexual assault, more women now have symptoms related to combat. In previous wars, women served in the military as nurses and clerks. Now, they drive Humvees to transport supplies and rescue the wounded. Official policy forbids women from holding combat jobs during war. This isn't always practical, as guerrilla tactics in modern warfare still draw women into battle. Because women remain an under-studied segment of the armed forces, psychologists know little about combat-related PTSD in servicewomen.

Data on rates of PTSD in men and women in the military already exist. However, these data do not reveal whether there are differences in how men and women in the armed forces experience PTSD. Street and her colleagues are constructing a study to explore these gender differences. The research can help fellow psychologists understand the struggles America's servicewomen will tackle back home.

Street discussed the study after she spoke on female veterans and PTSD at the 2009 meeting of the American Association for the Advancement of Science in Chicago. The views expressed here by Street, who also is an assistant professor of psychiatry at the Boston University School of Medicine, are hers alone and do not necessarily reflect the views of the Department of Veterans Affairs.

Is one gender more likely to experience PTSD than the other?

Yes. In the general population, women are much more likely to experience PTSD than are men. About twice as likely.

Why is that?

We don't know exactly why that is. One idea is that maybe women are just more likely to report that they're having these symptoms, but that doesn't really seem sufficient. It's not the case that women experience more traumatic events than do men. In fact, the opposite is true. But there is an idea that perhaps the types of traumatic experiences that women are more likely to experience, like sexual assault, or physical assault from an intimate partner that is repeated over time, are more likely to lead to PTSD. They are more severe in terms of the development of PTSD than are the types of events that men experience, like motor vehicle accidents or physical assaults between two strangers.

Are we seeing any of these gender differences within the military?

In terms of combat-related PTSD, these data are really just coming out now. We're at the very early stages of doing this research. So we're pretty limited in what kinds of conclusions we can draw. But the preliminary data from veterans from Iraq and Afghanistan suggest that there are actually pretty limited gender differences.

Why is it so hard to draw any conclusions about women and PTSD from the preliminary data?

Despite the fact that women's roles in the military are increasing, they still represent a relatively small proportion of all deployed troops. I think it's around 15 percent. To answer these types of questions, you need very large sample sizes. You include more women in the study than you would naturally encounter in the population. Until we have studies in which women are oversampled and we include very detailed information on things like level and amount of combat exposure, then we won't have the data we need.

Are you conducting research on PTSD in servicewomen right now?

Sure. My colleagues and I are about to move into the field with a large survey research project of men and women who served in the wars in Iraq and Afghanistan. It's a survey that looks at things like sexual harassment and sexual assault experienced during the war zone. [It] characterizes what level of combat exposure women are likely to have, and how that differs from men's experiences.

Someone mentioned [during your presentation] that the women who do join the armed forces are more prone to have experienced traumatic events in their past.

That's true. Some research suggests that women in the military have higher rates of pre-military traumatic events than their civilian counterparts.

Why that might be possible?

One anecdotal experience that some of the veterans report is that they had difficult childhoods or family systems that were not supportive or were even abusive. The military may have been a really fantastic opportunity for them to get out of that family system, make a good income, and find a different life for themselves. That kind of negative experience may have been the impetus for them to join the military.

Is there anything about the military environment that could complicate PTSD in women?

One study in particular looked at Gulf War I veterans. That study suggested that male veterans were more likely to have experienced combat trauma and that female veterans were more likely to have experienced sexual trauma. Many other stressors were pretty similar—things like living in a difficult environment, working in a difficult environment, the stress of being apart from family and friends. But female veterans were more likely to report feeling as if they were not supported by their peers and supervisors. There may be this kind of general harassment that's not sexually based, but it's perhaps gender based. Women [may] perceive that others in their unit think they are less competent or can't be trusted during difficult missions.

How important is it to consider the level of exposure to combat when studying PTSD in female soldiers?

It's very important. Even though women's roles in the military are really expanding, the average woman, as compared to the average man, is still likely to have less combat experiences. It's difficult to compare men to women on things like combat-related PTSD without knowing exactly how much combat they experienced. There are a couple of ways to do that. One is to limit your sample to men and women who have had pretty similar types of jobs in the military.

"We can be supportive of our warriors, be they male or female. That's something we didn't have in Vietnam. It has the potential to make a real difference in the mental health of our veterans."

What types of jobs would you be looking at?

There's one study [that focuses] on jobs in the military generally referred to as combat-support positions. In Iraq and Afghanistan, that often includes things like driving Humvees and convoys to deliver supplies or retrieve wounded. Those are potentially very dangerous jobs in this war, because those often come under fire or are at great risk from improvised explosive devices.

When people think of veterans and PTSD, they may think of Vietnam vets who have become chronically homeless, mentally ill, or self-medicating with drug abuse. What can people expect to see in women returning from overseas?

In the years since the Vietnam War, our understanding of PTSD as a phenomenon and how to effectively treat it has really improved. I'm very hopeful that we can encourage folks who are struggling with these kinds of symptoms to seek health care sooner rather than later, and have their PTSD treated effectively before it leads to things like long-term substance abuse or homelessness. We're hoping we can treat people more effectively than perhaps we saw following other past wars.

One treatment is cognitive behavioral therapy. How does that work?

In general, those types of treatments are characterized by a short-term, very goal-oriented focus. They're focused pretty solidly on the “here and now.” PTSD treatment includes “exposure therapy,” which means that if there's a particular event that can be tied to the PTSD, therapy will focus on retelling that event until the memory is no longer as frightening or scary. If a veteran had, for example, survivor's guilt, or struggles with memories of something they did or didn't do during their war zone service, [we] can really take a look at those thoughts, make sense of them in the light of day.

How has that mental health support for returning soldiers changed since Vietnam?

I think one issue is broad support from society. One of the lessons I hope we've learned since that time is that it is important to separate our thoughts and beliefs about the warriors from our thoughts and beliefs about the war. Regardless of how we feel as a society about these wars in Iraq and Afghanistan, we can be supportive of our warriors, be they male or female. We can know that our warriors deserve our thanks and our care, regardless of our political beliefs. That's something we didn't have in Vietnam that, I think, as a country we have really learned. [It has the] potential to make a real difference in the mental health of our veterans as they return.

Emmanuel Romero, a graduate student in the Science Communication Program at UC Santa Cruz, earned a B.S. in biology from San Francisco State University. He has worked as a reporting intern at the Monterey County Herald, "Are We Alone?", a radio program produced by the SETI Institute, and the news office of Stanford University. He will work as a summer writing intern at the California Institute for Regnerative Medicine (the state stem-cell institute) in San Francisco.

© 2009 Emmanuel Romero