THE PSYCHOLOGICAL HEALTH AND WELLBEING EXPERIENCES OF FEMALE MILITARY VETERANS: A SYSTEMATIC REVIEW OF THE QUALITATIVE LITERATURE

ABSTRACT

This paper focuses on the psychological health and wellbeing of female veterans post-deployment. Women in the military are a minority group who, in addition to facing exposure to traumatic events due to the nature of the work, face additional stressors whilst deployed. It is argued that these exposures and experiences place individuals at a significantly higher risk of finding it difficult adjusting post-deployment. A systematic review of the literature related to female veterans’ experiences upon returning home from deployment was therefore conducted. Eight in depth qualitative studies met the inclusion criteria for the study and were analysed using thematic analysis. Five key themes were identified in the papers: (1)Bringing the war home, (2) Post-deployment Adjustment, (3) Loss, (4) Failed Belongingness and (5) Post-traumatic growth. These provide a useful insight into the different psychological health and wellbeing experiences that female veterans encounter. Additionally, the associated effects upon the individual and their families and communities are considered.

Keywords: Female veterans, post-deployment, psychological wellbeing, systematic review

Key messages:

Female veterans are a minority group who, in addition to facing exposure to traumatic events due to the nature of work, face additional stressors whilst deployed

They are commonly viewed as being at a higher risk of finding it difficult to adjust post-deployment

A systematic review of the qualitative research was conducted to chronicle the lived experiences of female veterans

The review reveals how female veterans make sense of their transition out of the military

Several female veterans process their experiences and develop through post-traumatic growth

Tailored support is needed for female veterans who are facing difficulties through their transition

BACKGROUND

The number of women serving in the Regular Forces in the United Kingdom (UK) is increasing. Figures show an increase of 0.2% from 2014 to 2015 and women now form 10.1% of the total regular armed forces(1) (p. 23). Further, since2016, a phased approach has been adopted to enablewomen soldiers from the UK to serve in front line combat roles in the forces(2). Prior to this, women were excluded from Ground Close Combat (GCC) roles “where the primary role is to close with and kill the enemy”(3) (p. 2). Despite women not being formally engaged in GCC, they have consistently been exposed to combat related trauma(4–7). For instance, recent wars have seen women sharing the same risks with men in combat zones due to unclear front lines, with many of the roles being undertaken by female medics. The 2014 GCC review carried out by the Ministry of Defence concluded that mental health problems were recognised as being higher in female soldiers than their male counterparts, particularly with the current trends in the diagnosis of Post-Traumatic Stress Disorder (PTSD). Not too dissimilar to the UK, literature from the United States (US) also indicates that exposure to war zones are a substantial threat to women’s mental health(8,9).

Almost understandably a majority of research in this area focuses on the diagnoses of PTSD, with statistics showing women are at a higher risk than men to experience the disorder(10). Common mental health issues, such as anxiety and depression, have also been found to be twice as high in the armed forces than in the general population. According to new figures, 25% of women in the forces present with such issues compared to 12% in the general population(11–13). Additionally, these results occurred less with women in combat roles, even though combat is commonly associated with PTSD diagnoses(14). Literature suggests a contributing outcome to these statistics is the prolonged periods away from close family and friends who are usually there to help deal with stressors when at home(15,16). Excessive alcohol consumption was also found to be particularly high amongst female veterans when compared to the general female population in the UK(14,17,18), again a finding that corresponds with US literature, e.g.(19). Much of the US literature also concerns a high level of military sexual trauma(20). In contrast, research from the UK suggests women often face sexual harassment within the forces, however much of this goes unreported(21).

Study aim

The need to improve veterans’ health care was emphasised in the mandate from the UK Government to Health Education England(22,23). Furthermore, with the chance of the GCC ruling looking ever more likely within the UK, female soldiers will be increasingly at risk of encountering traumatic events. As such, this study aims to synthesise the existing literature exploring the impact of such experiences upon female veterans with a view to developing guiding principles that will aid the support of these individuals.

The question guiding this systematic review was developed using Sackett, Richardson, Rosenbery and Haynes's (1997)(24) population, intervention, comparison, and outcomes (PICO) model to facilitate the identification of relevant information. The variables of interest included female veterans (population), deployments to one or more operations (intervention), compared with male combat veterans where possible/relevant (comparison) on their (female veterans) psychological experiences (outcome). Additionally, the research question also took into consideration the ‘FINER’ (feasible, interesting, novel, ethical, and relevant) criteria(25) attempting to fill any gaps in existing knowledge. With this in mind, the following research question was proposed:

What is known about the psychological health and well-being experiences of female military veterans?

METHODOLOGY

A systematic review was conducted to identify relevant studies related to the research question noted above(26). Although qualitative research is not traditionally included in systematic reviews(27), this material proved directly relevant to the aim of the study, notably to collate the experiential accounts of female veterans. As such, the focus of this work was solely qualitative research.

Search Terms and Strategy

The following series of search terms were used in this review: (veterans OR ex-service personnel OR ex-military OR ex-forces OR ex-soldier OR servicewomen) AND (mental health OR psychological well-being OR wellbeing) AND (post forces OR post deployment) AND (females OR female OR women OR woman). Six databases (PsychINFO, EBSCOPlus, Science Direct, PubMed, Assia, Wiley Online Library) were searched alongside specific journals of relevance (e.g. the ‘Armed Forces Society’ Journal). The search resulted in 3,605 titles being identified from the databases searched.

Inclusion and Exclusion Criteria

The studies were then reviewed and inclusion and exclusion criteria applied. Table 1 shows the inclusion and exclusion criteria. No date inclusion was included as female veterans around the world have been exposed to traumatic experiences post deployment for a considerable amount of time(4–7).

Table 1: Inclusion and exclusion criteria

Parameters / Inclusion Criteria / Exclusion Criteria
Participants /
  • Female participants who have been in the forces
  • Female participants who are now post-forces
  • No age restrictions
/
  • Participants who are male
  • Females on deployment
  • Physical health related

Study Type /
  • Peer-reviewed, primary research studies.
  • Qualitative studies
/
  • Theoretical papers, editorials, commentaries, book chapters, dissertations or thesis, and grey literature.
  • Quantitative and mixed method studies.

Outcomes /
  • Studies that report the psychological wellbeing of female veterans post forces
  • Studies that report individuals’ experiences of transitioning and adjusting from the forces to civilian life
/
  • Studies that do not focus female veterans post forces, experiences of transitioning
  • Not focused on female veterans psychological wellbeing post forces
  • Limited focus on female veterans in a large scale study

Publication Status /
  • Published studies
  • No date limitations
/
  • Unpublished studies as they may well be of lower methodological quality

Country of Origin / Studies conducted in any country are eligible.
Language / English language / Not English language.

The flow diagram below (Figure 1) summarises the search process. The review has used the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ (PRISMA) procedure of identification, screening and eligibility of the studies(28). After inclusion and exclusion had been applied and additional studies that had been handpicked from references of cited literature, twelve studies were to be included in the quality appraisal.

Figure 1: PRISMA flow diagram of the article search process in the systematic review of the literature.

Quality Criteria and Assessment

Barker, Pistrang, and Elliott (2002)(29) maintain that all quality appraisals of methodological research have their advantages and disadvantages and that no single research method is inherently superior to any other (p. 245). In this instance, Elliott, Fischer, and Rennie's (1999)(30)‘Evolving guidelines for publication of qualitative research’ were drawn upon to appraise the remaining papers. If the retrieved studies corresponded with the seven criteria from Elliott et al. (1999)(30), they were considered relevant for the review.

When assessing the quality of the papers using Elliott, Fischer and Rennie’s (1999)(30) criteria, four further studies were removed from the analysis, thus leaving eight. All four papers were omitted as they did not meet the criterion “owning one’s perspective”(30). In contrast the papers included transparent statements related to the authors’ perspective of the data, for example Suter et al. (2006)(31) acknowledged that the research was led within a feminist framework and follows basic feminist values of taking into consideration women’s experiences and empowering the socially marginalised.

Data Synthesis

Thematic synthesis(32) was achieved using the findings/discussion section in each included study. ‘Descriptive themes’ were drawn out of the data followed by the development of ‘analytic themes’. The identification of the themes was partly guided by the research question “What is known about the psychological health and well-being experiences of female military veterans?” and partly grounded in the data. This process was informed by the procedures of thematic analysis outlined by Braun and Clarke (2006)(33), with themes aiming to capture the importance of the data in relation to the research question, and represent some level of meaning or patterned response within the data set (p.10). Whilst many of the themes remained close to the primary studies, the analytic themes represented a stage of interpretation where the reviewer goes ‘beyond’ the primary studies and develops new, interpretive constructs(32).

Ethical Considerations

Ethical clearance was obtained from the University Research Ethics committee of the institution of the authors. This confirmed that the current review only employed secondary data that was already open to public use.

FINDINGS

Characteristics of included studies

Eight relevant studies were identified. Table 2 outlines the included studies and provides a summary of their key characteristics .

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Table 2: Characteristics of the included studies

Bibliographic Details / Aims / Sample Characteristics / Design / Measures/Method / Analysis / Findings
1. Conard &
Scott-Tilley
(2015)(34)
US / To discover the experiences of female veterans in order to understand the impacts of combat on their physical and mental health, and to shed light on directions for future research. / 12 female veterans
deployed to the Gulf War II.
Navy (n=6)
Army (n=2)
Air Force (n=2)
Marines (n=2)
Aged 19 to 41 years / Qualitative study / Face to face, semi-structured and open-ended individual interviews, ranging from 30 to 60 minutes / Data were analysed using Colaizzi’s (1978) descriptive phenomenological method. / 7 themes: living in constant fear while deployed; combat has different meanings; bringing the war home; fear of being forever changed; disrespect from fellow military members; physical health—for better or worse; combat has rewarding experiences
2. Demers (2013)(35)
US / To explore the experiences of female Iraq War veterans, understanding the challenges of reintegrating into civilian life and the impact on mental health. / 17 female veterans deployed to Iraq.
Navy (n=4)
Army (n=10)
Marines (n=3)
Aged 22 to 43 years / Qualitative, narrative inquiry / Preliminary electronic surveys sent out and a focus Group using a face to face semi-structured interview guide / Identification of codes. Creation of categories & themes. / 2 major themes: Women at war; Coming home
3. Elliott (2015)(36)
US / To (1) describe the military nurses’ experiences during the post-deployment phase; and (2) describe the meaning of the post-deployment experience. / 10 veterans; 3 males and 7 females. Only female accounts were used.
Army (n=8)
Air Force (n=2) (females not specific to any force)
Aged 26 to 63 years / Qualitative, narrative inquiry / Face to face in-depth semi- structured interviews / Thematic analysis / Description of the experience had five themes: learning to manage changes in the environment; facing the reality of multiple losses; feeling like it’s all so trivial now; figuring out where I ‘fit’ in all the chaos; and working through the guilt to move forward.
Description of the meaning of the experience had two themes: serving a greater purpose and looking at life through a new lens
4. Gutierrez et al., (2013)(37)
US / To explore the women’s experiences and potential suicide risk factors according to the Interpersonal Psychological Theory of Suicide, including burdensomeness, failed belongingness, and acquired ability. / 19 female veterans,
Iraq (n= 18)
Afghanistan (n=1)
Aged 24 to 52 years / Qualitative study / Face to face Interviews, ranging from 25 to 75 minutes / hermeneutic conversation between the text and the researcher(s), discussing transcriptions and developing themes / Transcripts were reviewed and themes emerged regarding women being a minority within their environment and deployment-related stressors. These experiences seemed to influence participants’ views of the world and ways of coping
5. Koenig et al., (2014)(38)
US / To describe returning veterans’ transition experience from military to civilian life and to educate health care providers about culture-centred communication that promotes readjustment to civilian life. / 31 veterans; 17 male and 14 females. Only female accounts were used.
All females had either been to Iraq and Afghanistan veterans and returned from deployment within the last two years. / Qualitative study / In-depth, semi-structured interviews / Grounded Practical Theory (GPT) / Veterans described disorientation when returning to civilian life after deployment. Veterans’ experiences resulted from an underlying tension between military and civilian identities consistent with reverse culture shock. Participants described challenges and strategies for managing readjustment stress across three domains: intrapersonal, professional/educational, and interpersonal.
6. Mattocks et al., (2012)(39)
US / To explore the nature of women’s coping strategies after return from military deployment. / 19 women who served in Iraq and Afghanistan
50% National Guard
40% Army or Navy reserves
Aged 23 to 55 years / Qualitative study / Semi-structured interviews / Codes identified, analysed & compared. Categories & themes created / Women veterans identified stressful military experiences and post-deployment reintegration problems as major stressors. Stressful military experiences included combat experiences, military sexual trauma, and separation from family. Women had varying abilities to address and manage stressors, and employed various cognitive and behavioural coping resources and processes to manage their stress
7. Suter et al., (2006)(31)
US / To explore female veteran's identity construction,
maintenance and reproduction. / 28 female veterans
All veterans belonged to Women Accepted for Voluntary Emergency Services (WAVES) in the Navy
Navy (n=25)
Marines (n=2)
Air Force (n=1)
21 served during World War II; 3 reported service during the Korean conflict, 2 the Vietnam War, 1 the Cold War, and 1 reported serving both in Vietnam and the Persian Gulf
Aged 51 to 91 / Qualitative study / Semi-structured Interviews face-to-face and over the
Telephone. / Smith's (1995)
techniques for conducting and analysing semi-structured interviews.
Informed by grounded theory. / Participants found the transition back to civilian life problematic, in part due to difficulties meeting traditional gender role expectations and in part due to isolation, as they no longer related to civilian women in their hometowns. Participants reported membership in this WAVES unit allows opportunities to reminisce and relate to women with similar experiences.
8. Worthen & Ahern (2014)(40)
US / The Causes, Course, and Consequences of Anger Problems in Veterans Returning to Civilian Life / 12 Afghanistan and Iraq war veterans in 2009–2011
Men (n=10)
Women (n=2) / Qualitative study / Semi structured interviews, using open-ended questions / The analysis was in two phases. a) Thematic Analysis and b) interpretive analysis of veterans’ experiences with anger during reintegration to civilian life / 3 themes: (a) loss of structure during reintegration to civilian life, (b) moral injury sustained through a wartime experience, and (c) posttraumatic stress disorder (PTSD)

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All studies were primary qualitative research which involved interviewing female veterans who had previously been deployed to one or more training operations. Interestingly, all of the studies included in the analysis were conducted with female veterans from the US. Seven out of eight studies employed in-depth semi-structured interviews, the aim being to engage in a deep and meaningful social interaction which is consistent with investigating life course transitions and culture(41), whereas Gutierrez et al. (2013)(37) used a structured interview process in keeping with a more deductive research design.

The qualitative data analysis procedures were sufficiently represented in all studies. Three studies used phenomenological approaches(34,35,37) where the emphasis was on describing the lived experiences of female veterans and how they made sense of their transitions, adjustments and psychological well-being post forces. Grounded Theory analysis was adopted for another three studies(31,38,39) where the findings offered more of an insight into the coping strategies and reconstructions of self, enhancing understanding of female veterans experiences and providing a meaningful guide to future research and implementation. In an attempt to capture female veterans meaning making processes related to their experiences, Elliott (2015)(36) and Worthen and Ahern (2014)(40) used Thematic Analysis as a means to identify patterns and offer up interpretations of the raw data, offering implicit and explicit ideas towards female veterans experiences post deployment.