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Abstract
Introduction 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 while deployed. It is argued that these exposures and experiences place individuals at a significantly higher risk of finding it difficult adjusting post deployment. This paper focuses on the psychological health and well-being of female veterans post-deployment.
Methods A systematic review of the literature related to female veterans' experiences upon returning home from deployment was conducted.
Results 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.
Conclusions These studies provide a useful insight into the different psychological health and well-being experiences that female veterans encounter. Additionally, the associated effects upon the individual and their families and communities are considered.
- Female Veterans
- Post-deployment
- Psychological wellbeing
- Systematic review
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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 while 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.
Introduction
The number of women serving in the Regular Forces in the 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 Furthermore, since 2016, a phased approach has been adopted to enable women soldiers from the UK to serve in front-line combat roles in the forces,2 as 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 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 USA also indicates that exposure to war zones is 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 that in the general population. According to new figures, 25% of women in the forces present with such issues compared with 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 period 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 among female veterans when compared with the general female population in the UK,14 ,17 ,18 again a finding that corresponds with US literature.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
The need to improve veterans' healthcare 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 the population, intervention, comparison and outcomes model of Sackett, Richardson, Rosenbery and Haynes24 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) criteria25 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 to answer 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 well-being) 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 (eg, the Armed Forces & Society journal). The search resulted in 3605 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
Inclusion and exclusion criteria
The flow diagram (Figure 1) summarises the search process. The review has used the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ procedure of identification, screening and eligibility of the studies.28 After inclusion and exclusion criteria and hand-sourced additional studies, 12 studies were included in the quality appraisal.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the article search process in the systematic review of the literature.
Quality criteria and assessment
Barker et al 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. ‘Evolving guidelines for publication of qualitative research’ were drawn upon to appraise the 12 papers, and if they complied with the seven criteria,30 they were included in the review. Four papers were excluded 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 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 synthesis32 was achieved using the findings/discussion section in each included study. ‘Descriptive themes’ were drawn out of the data followed by the development of ‘analytical themes’. The identification of the themes was partly guided by the research question and partly grounded in the data and was informed by the procedures of thematic analysis,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. While many of the themes remained close to the primary studies, the analytical 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 were already open to public use.
Findings
Characteristics of included studies
Eight relevant studies were identified (Table 2).
Characteristics of the included studies
All studies were primary qualitative research which involved interviewing female veterans who had previously been deployed to one or more training operations; all of the studies included were conducted with female veterans from the USA. Seven out of eight studies employed in-depth semistructured 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 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 approaches34 ,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 studies31 ,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, two studies36 ,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.
Synthesis of data
The analysis generated 5 master themes and 14 subthemes. An overview is provided in Table 3 and these are described in turn below.
Descriptive and analytical themes found from the studies
Bringing the war home
The concept of ‘bringing the war home’, as articulated by Conard and Tilley,34 was evident in seven of the papers reviewed. Although this is also pervasive to many of the themes below, this is summarised here as trauma-related difficulties.
Trauma-related difficulties
Mental health difficulties that evolved from exposure to trauma were one of the most prevalent experiences reported in all eight studies. In particular, PTSD symptoms such as hypervigilance/hyperarousal, depression and, less prevalent, anger were reported. These came alongside the experience of living in constant fear of harm’s way or being ‘triggered’ into traumatic response in front of, or by, particular family members.34 An additional commonality between all studies was the report of military sexual trauma. The women in these studies who experienced PTSD symptoms were more likely to have also suffered from military sexual trauma.34 ,35 ,37 ,39
Elliott36 and Gutierrez et al 37 also found grief played a big part in their combat-related experiences. This predominantly related to the loss of comrades which was reflected upon more fully once deployment had ended.
Post-deployment adjustment
Adjusting to postdeployment life was a significant theme that was reported in the studies. This manifested in a number of ways, but highlighted the many challenges that individuals had adjusting back to their family and social lives post deployment.
Anger
Many female veterans found themselves becoming angry at trivial/insignificant situations post deployment. For example, Elliott36 found that military nurses were more likely to become angry at others for making what they perceived as trivial situations into important situations, but female veterans' anger was often perceived as being demeaned by society.40
Career
Many female veterans were concerned about their career prospects post forces.34 What once was a structured routine job in the military was now a mundane way of employability where neither gratification nor reward was anticipated by the female veterans.36 Not knowing what to do careerwise was also concerning for some individuals. For instance, dealing with traumatic experiences as a medic led to a resistance when searching for job opportunities in similar fields post-deployment.37
Compassion fatigue
The studies commonly noted that the female veterans presented with compassion fatigue post-deployment. Conard and Tilley34 quote participants who have felt insensitive or unable to empathise with others any more, while Elliott recognised that the women felt guilty that they could not provide the compassion that they longed after any more, having implications on their career and family life.36
Coping
Coping strategies were developed in response to the challenges of readjustment into civilian life. Upon returning home, veterans found that they used various coping strategies to articulate tensions from service to civilian life. Maladaptive coping mechanisms such as substance abuse, thoughts of engaging in violence40 and even suicide ideation were common ways of coping with the adjustment.37 Avoidance and isolation31 were just some of the maintaining factors which led to difficulties upon readjusting.
Failed belongingness
Returning from military duties left some individuals in a liminal space; they were unsure where they now belonged as a person. The themes below relate to the ways that the studies reported this phenomenon.
Atypical gender role
While on deployment, female veterans believed they had developed atypical identities that were not recognised upon their return.31 Such identities made it difficult in fulfilling what were perceived to be traditional female roles, particularly as they perceived their military identity as being very masculine in nature.35 Anger, a symptom of PTSD, was seen to demean female veterans in a gender-specific way. For example, Worthen and Ahern40 found that anger was consistently trivialised in women, whereas men's anger was more commonly believed to be associated with strength. For some, there was also a strong desire to fulfil a more traditional female role when reintegrated back into civilian life. However, this was not always possible as the individuals' identities had changed significantly, thus proving a great challenge, if not an impossible one, for the female veterans to fully make sense of.31
Equivalence
Equivalence between female veterans and their male counterparts was felt to be imbalanced by some of the participants in the studies. Conard and Scott-Tilley34 reported that females felt discriminated and talked down to while on deployment which left them feeling embarrassed and anxious about their performance upon their return.
Help-seeking
In some cases, help-seeking was believed to be a sign of weakness due to the reinforcement of the military identity.34 ,37 Findings also indicated that seeking help is perceived as burdensome in the military and that this culture overspills into civilian life where the belief is reinforced. In contrast, however, not all help-seeking was seen as negative. Being a part of a group of people who were going through similar experiences was likely to result in seeking additional support.31 ,38
Reintegrating
Demers35 described individuals as being ‘caught between two cultures’ when transitioning from military to civilian culture, and Elliott noted that individuals are unable to ‘fit back into society’.36 Female veterans recognised a loss of social connections and being a burden on others which resulted in failed belongingness and negative coping strategies;37 they also did not trust their own environment anymore due to the changes and adjustments of reintegration.36 Additionally, Koenig et al 38 characterised a difficult reintegration process with a ‘reverse culture shock’, where specific ways of being are presented in different contexts (military and civilian); however, when this is reversed (military behaviour/identity in a civilian world), sociocultural tensions arise from the complexity of the situation.
Loss
The theme ‘loss’ can be found in all eight reviewed studies. Facing the reality of multiple losses played a major role in the psychological well-being for female veterans.
Civilian identity
Some individuals reported mourning their civilian identity, noting that they can no longer remember what it was like to have that identity. Many female veterans felt their ‘gender identity’ (referred to above) was a part of their loss when joining the forces, and upon returning home they struggled with making sense of their new identity.35 The loss of their civilian identity also meant it was harder for female veterans to relate to other civilians who had not been in service.37
Military identity
As well as recognising military identity loss,37 studies found that female veterans actually mourned their military identity.35 ,36 Furthermore, a loss of structure that military life provided caused anger during the reintegration process.36 ,40 For some, experiencing an absence of identity in their field of specialism became frustrating, easily losing patience in themselves.35
Self-worth
The women expressed concerns about causing others distress because of an inability to cope with their own problems, or a failure to think for themselves and figure out solutions to problems on their own.37 Additionally, Mattocks et al 39 noted that some female veterans felt they did not deserve the help offered to them by the Veterans Association in the USA and that it should go to other male veterans who need it more. The reasons for this thinking were however not fully unravelled.
Post-traumatic growth
Although many of the findings above pose great challenges for female veterans, there was also a positive side in some women's experiences. This came through in what might be conceptualised as post-traumatic growth.
Making meaning
Many female veterans were in the process of making constructive meaning of their new lives. Individuals viewed it positively that they were losing their masculinised identity for a more feminine one, while grappling with the transition into the civilian world. Furthermore, findings go on to show that some female veterans valued finding others to accept their stories as part of the reintegration process.35
New ways of being
The reports from one study showed that military experience contributed to the development of a transformed identity, with individuals gaining more self-confidence as they grew from the experience into ‘strong, capable women’.31 This also links to a theme in recognising the need to move forward and ‘try on’ ways of being female, imagining new possibilities for their future.31 ,35
Discussion
Revisiting the research question
This systematic review set out to answer one research question: ‘What is known about the psychological health and well-being experiences of female military veterans?’ The analysis of the data revealed 5 main themes and 14 subthemes related to the question posed. Although all eight studies had different aims, there was still enough scope to be able to pull all the research together and synthesise it to answer the broader question. While adverse themes were found (bringing the war home, postdeployment adjustment, loss, failed belongingness), an encouraging theme of post-traumatic growth from deployment experiences was also evident in the body of literature.
Discussion in relation to previous research
Commensurate with much of the literature in this area, PTSD, and its associated symptoms, is a major contributor to the psychological health and well-being of female military veterans.8–10 This was evident within seven of the studies included within this review and links to the theme of ‘bringing the war home’.34–40 PTSD was not specifically referred to within one paper,31 but it did make indications that female veterans suffered with the consequences of PTSD. Furthermore, common mental health issues that are observed in broader military populations11–13 and military sexual trauma,21 ,42 although not always categorised as these, also appeared to contribute significantly to the experiences of the women involved.
All of the studies in this review discussed the difficulties associated with post-deployment adjustment. Compassion fatigue was a repeated pattern throughout many of the studies. Some individuals would struggle in their career and family life to show compassion to others (and themselves). The experience left behind from traumatic exposure extended beyond the individual into female veterans' family culture. Such fatigue had a negative impact on the individual's compassionate self and at times led to dysfunctional marital and family adjustments or impacted upon parenting skills. Despite its prevalence in these studies, this does not appear as a major theme within the broader literature. This may possibly be attributed to a more in-depth interview process within the qualitative research designs that allowed the participants to explore their psychological experiences at a deeper level.
The coping strategies reported to appear similar to those within the wider literature.14 ,17–19 ,43 In contrast, however, the use of alcohol as a way of coping with their experiences while on deployment did not come up as a major theme. This may reflect the priorities of the women who took part, with alcohol consumption potentially being a symptom rather than a cause of any challenges they may face. Likewise, the anger that people felt in response to the way they had been treated by the forces after their deployment receives little attention. As indicated above, the different perceptions of anger from male veterans and female veterans by the wider society proved a complex dynamic for some individuals to navigate.
Concurring with the initial literature and the more recent studies on elevated risks for suicide among American female veterans,44 suicide was also significant for many in the findings.45 There were however no indications that those female veterans involved in these studies wanted to act upon their ideations, a position that contrasts much of the literature around the experiences of male veterans.46 Another important theme was that of failed belongingness. Gender role expectations were commonly mentioned in the findings; yet, female veterans found it hard to conform to stereotypical female roles such as being a caregiver.35 This has rarely been mentioned in the reviewed literature, as again, quantitative methods may not have been able to access these experiences so readily.
Loss, as an overall theme in both the literature and the findings of this review, appears to be central to female veterans' experience. Whether this relates to a loss of colleagues, loss of identity or a loss of the structure that military life once provided, such experiences can have a significant impact upon individuals' lives. This also has the potential to spill out into civilian lives, a factor further complicated by the acknowledgement that a previously held civilian identity has been lost. ‘Fitting in’ and reintegrating with civilian culture can therefore prove incredibly complex for some women.
Finally, the concept of post-traumatic growth was highlighted.38 In contrast to many of the other experiences, this was seen as a constructive theme where female veterans commented on how they were able to make meaning and experience new ways of being as a result from the challenges on deployment.31 Such a concept proves scarce in much of the original literature sourced, with a handful of articles exploring the experience of post-traumatic growth in the male veteran community.47
Strengths, limitations and future directions
This study provides a rigorous overview of the existing literature around the psychological health and well-being experiences of female military veterans. It provides an overview of the highest quality research in this area and has synthesised this into themes that will hopefully aid policy-makers and professionals working with this group of individuals and their families.
Limitations are always present within research, and this review is no exception. For instance, although several databases were searched, it may be possible that other papers can be found in other arenas. Furthermore, although stringent exclusion criteria were adhered to, the inclusion of further studies may have widened the net of experiences more. Linked to this, as this review kept its inclusion criteria purposefully open, there may be specific dynamics that are not accounted for in this selection of literature. For example, the age of the individuals and the particular role engaged in may all lead to specific dynamics to consider. Additionally, as all of the papers collated here reflect the situation with the USA, further work is needed to explore such experiences in other countries. Despite such limitations, this review provides a useful yardstick for considering future work in this area.
Implications and recommendations
The experiences described provide a useful insight into the experiences of female military veterans. Both commonalities and divergences are observed from the broader literature. In summary, however, it is believed that there are sufficient differences to consider the transition and adjustment issues for women differently to those of men. While many organisations may be familiar with the psychological aspects of postdeployment well-being, the more specific details including sociocultural facets of female veteran transitions may be less known. This research offers insight into the readjustment experiences and psychological well-being of these individuals. As professionals, we can begin to understand the challenges and opportunities female veterans encounter and possibly offer up solutions based on the experiences reported here, thus more fruitfully helping individuals to make sense of their changing identities by building and encouraging strong working alliances. An understanding of the findings addressed in this review may therefore help to increase empathy towards the experiences of female veterans and help to tailor appropriate support. For instance, being aware of the compassion fatigue for some individuals may help to shape services and resources for supporting female veterans’ families and communities.
References
Footnotes
Twitter Follow Gemma Jones @GemLouJones and Terry Hanley @drterryhanley
Contributors Conception or design of the work—GLJ and TH. Data collection—GLJ. Data analysis and interpretation—GLJ. Drafting the article—TH and GLJ. Critical revision of the article—TH and GLJ. Final approval of the version to be published—GLJ and TH.
Competing interests None declared.
Ethics approval Manchester Institute of Education, University of Manchester.
Provenance and peer review Not commissioned; externally peer reviewed.