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Co-Occurring Disorders and Military Justice

Women Veterans with Co-Occurring Disorders

Mental and substance abuse disorders are prevalent among female and male veterans. The presence of both disorders is connected to other negative outcomes such as justice involvement, homelessness, family disruption including violence, and unemployment. In community studies, Post Traumatic Stress Disorder (PTSD) alone and co-occurring with substance abuse is more common in women. This might be due to the type and frequency of trauma that community women are exposed to and its impact on developing PTSD. With co-occurring disorder of PTSD and substance abuse, co-morbid conditions often include diagnoses such as depression, physical illness, lower compliance with treatment, and poorer social outcomes.

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Women and PTSD

Soldiers who experience combat-related trauma such as being in a firefight, being shot at, handling dead bodies, and seeing or knowing someone who is killed are more likely to develop PTSD. The likelihood of developing PTSD is also higher among wounded soldiers. The U.S. Air Force has the highest percentage of women (20 percent) compared with Army (14 percent) and Marines (6 percent). Army and Marines have the highest number and length of deployments to Iraq and Afghanistan, which might account for the lower rates of combat-related PTSD among female soldiers. However, when women soldiers are exposed to combat trauma, they are more likely to develop PTSD. This, in turn, increases risk of co-occurring disorder.

Co-occurring disorders in women and stress

Stress is often at the heart of co-occurring disorders and is connected with relapse among individuals in recovery. Women and men soldiers report high levels of stress across the spectrum of their lives, and women (22 percent) and men (30 percent) both report using alcohol — as well as healthy mean — to cope with stress. Heavy drinkers (compared with non-drinkers) in the military are more likely to report:

  • "a lot" of stress at work and at home
  • that their mental health interfered with usual activities
  • suicidal thoughts in the past year
  • serious psychological distress
  • physical or sexual abuse

They are also more likely to meet screening criteria for:

  • generalized anxiety disorder
  • depression
  • PTSD

Co-occurring disorders is a risk factor for justice involvement. While there is no official tally of how many women veterans with co-occurring disorder are in U.S. jails and prisons, the increase of women into the military, multiple deployments, and women in combat are indicators that these numbers will likely increase. Justice involvement has a negative impact on many aspects of women's lives including separation from children, limited housing, and barriers to treatment. While women in the military have, for some period of post-deployment, have access to behavioral and general health care, benefits are often interrupted with incarceration.

Domestic violence

Domestic violence is the leading cause of injury to women in the United States and accounts for up to one-third of women's visits to hospital emergency rooms. Risk for domestic violence overlaps with other types of victimization, and these risk factors are higher in military women.

  • One in four female veterans under the age of 50 report having been the victim of domestic violence in the past year
  • Seven percent of female veterans over age 50 say they have experienced partner violence in the past year. Their lifetime experiences with domestic violence are 40 percent for younger and 20 percent for older women veterans. This compares with a two percent victimization rate in the past year and 25 percent rate of lifetime abuse among all women in the U.S.
  • Among the female veterans reporting partner violence, most call it "serious" violence such as being beaten, choked, or kicked. Many report the violence as life-threatening such as involving a weapon.
  • Women who experience domestic violence are at risk for developing substance abuse disorder, mental health disorders such as depression and PTSD, homelessness, and other physical health and social problems.

The Defense Department's Family Advocacy Program reports that incidents of reported family violence — spousal and child abuse — are increasing after many years of decline. The rise may be due to changes in reporting or in an actual increase in domestic violence; the reason is unknown. The rate of confirmed partner abuse peaked in 2001, declined through 2008, and then began to rise and has continued to increase. Child maltreatment cases also rose during this time period. Most of the alleged perpetrators of both spousal abuse and child abuse are active duty male military members. Most reports conclude that while spousal abuse is higher in the military, child abuse and maltreatment is lower than in the civilian community.

Who is at risk for domestic violence in the military?

  • Women with a history of childhood physical and sexual abuse have a higher incidence of domestic violence.
  • Women with a history of adult physical and sexual abuse are at elevated risk for repeated violent victimization.
  • Women of reproductive age are at highest risk for spousal abuse.
  • Families that experience multiple deployments have higher rates of family violence.
  • Members of the National Guard and Reserves are at unique risk due to unexpected length of separation.
  • Service members who admit to beating their female partner admit to doing it more than three times in the past year.

What happens when there is a domestic violence report in a military family?

  • All incidents of family violence are reported to the Family Advocacy Program who coordinates the investigation with civilian agencies such as local law enforcement.
  • Confidentiality protocols allows adult victims of abuse to seek medical assistance and counseling without reporting the abuse to law enforcement.
  • All branches of the military provide medical care, legal assistance, and counseling to victims of domestic violence.

Homelessness among women veterans with co-occurring disorders

Women veterans with co-occurring disorder are at high risk for homelessness among other negative life outcomes. Women veterans are as much as four times more likely to be homeless than non-veterans.

There are more services that target male veterans than women veterans who are homeless. Both veterans and providers report that the VA meets the medical and substance abuse treatment needs for homeless veterans but falls short in meeting the demands that are high priorities among women veterans such as child and legal assistance for child support.

Among other unmet needs is legal assistance for warrants and fine, long term permanent housing, and family reconciliation assistance. As women continue to make up a larger portion of veterans, they will also comprise a larger portion of homeless veterans, many of whom have complicated treatment needs such as co-occurring disorder and trauma.

Why are women veterans more likely to be homeless than non-veterans?

  • Women veterans have similar childhood trauma histories as non-veteran women with similar backgrounds.
  • Women veterans have higher education levels and are more likely to be in a stable relationship than non-veterans, two protective factors.
  • The all-volunteers era veterans have greater rates of homelessness than earlier era veterans such as Vietnam, Korea, and the Second World War.

Military sexual trauma

Military sexual trauma (MST) is severe or threatening forms of sexual harassment and assault. The U.S. Department of Veterans Affairs reports that at least 20 percent of OEF and OIF female veterans have experienced MST.

Women veterans also report higher rates of pre- and post-military adult sexual trauma, domestic violence, and childhood physical and sexual trauma than civilian women, resulting in a complex overlap of symptoms and treatment. Most incidents that result in MST occur where the victim lives and works, often near to the perpetrator. The VA now conducts MST screening on all military personnel, and most incidents of military sexual assault and harassment are not reported to authorities.

Why is MST so prevalent among female veterans?

  • Sexual harassment and sexual assault are higher in male-dominated work environments such as the military and higher during periods of combat.
  • Multiple deployments of women and men during OEF and OIF increase risk of MST exposure.
  • MST is higher among women veterans with multiple pre military traumas, and women veterans report higher rates of these pre military trauma experiences than civilian women.
  • Women veterans with MST and other pre military trauma histories often report joining the military to escape their violent environments.
  • Women veterans with MST and combat exposure are 5 times more likely to develop PTSD than those who experience one type of trauma.
  • Women veterans who experience both military sexual assault and sexual harassment are more likely to develop PTSD than other women veterans.

Women veterans with MST have higher rates of:

  • Substance abuse
  • Mental health disorders such as depression
  • PTSD, especially with pre-military trauma histories
  • Physical illness
  • Service utilization
  • Homelessness
  • Post-military victimization
  • High risk behaviors
  • Social isolation

Incidents resulting in MST are more prevalent than incidents of sexual harassment and assault in civilian populations. Many active duty women and men who experience unwanted sexual contact in the military do not report it to a DOD authority. MST results in poorer outcomes including increased substance use and mental health disorders as well as compromised general health.

Resources and Links

  • Family Advocacy Program (FAP) provides services for military families experiencing child abuse and domestic abuse. Services include prevention, early identification and intervention, support for victims, and treatment for offenders. There are 181 stateside family advocacy programs.

  • The VA National Center for PTSD, PTSD 101 course module on military sexual trauma provides a review of sexual harassment and assaults and the prevalence rates of these events in the military. This course describes the mental health impact of sexual trauma and implications for care.

  • American Women Veterans is a non-profit organization dedicated to engaging and advocating for new and improves policies for women veterans and their families through outreach campaigns, retreats, conferences and symposiums. Separate web pages on advocacy, resources, volunteers, and servicewomen, veterans and their families' stories are provided.

  • This guide provides an overview of the unique experiences and needs of women veterans. In addition, it offers best practices, resources and self-assessment tools aimed at improving effectiveness in engaging female veterans. The guide offers knowledge and guidelines for modifying practices with the goal of increasing re-entry outcomes.

  • The National Resource Directory web pages for women provides reviews of information, programs and services to support veterans and their families to support recovery, rehabilitation and community reintegration. Separate pages are available on women's health, sexual assault and domestic violence, women and family shelters, education and employment, and programs and services.