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Abstract
Introduction Limited UK research focuses on female military veterans’ gender-related experiences and issues when accessing civilian mental healthcare support. This study sought to illuminate a preliminary understanding of any gender differences in barriers that may discourage them accessing mental healthcare support.
Methods A total of 100 participants completed an open online survey of UK triservice veterans who identified as having experienced postmilitary mental health problems. They completed a 30-item Barriers to Access to Care Evaluation scale and were asked to elaborate using free-text questions. Resulting quantitative data were analysed for gender-related differences, while the qualitative text was thematically explored.
Results While stigma, previous poor experience of mental healthcare and a lack of trust in civilian providers were found to act as barriers to postmilitary support for both men and women, significantly more women reported that their gender had also impacted on their intention to seek help. Women also commented on the impact of gender-related discrimination during service on their help-seeking experiences.
Conclusions While efforts are being made by the UK Ministry of Defence to reduce barriers to mental healthcare for those still serving in the Armed Forces, it has been more difficult to provide a similar level of support to the veteran population. With little veteran research focusing on the specific experiences of women, this study suggests that female veterans encounter specific access barriers and issues related to their gender. Further research is therefore needed to ensure these findings are addressed.
- quality in health care
- mental health
- psychiatry
- qualitative research
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Key messages
This project investigates gender differences in barriers to accessing mental healthcare for UK military veterans for the first time.
Stigma associated with mental healthcare and a lack of trust in civilian healthcare professionals act as barriers in both male and female veterans.
Significantly more female veterans reported that their gender had impacted on their intention and experience of help-seeking, compared with men.
Female veterans reported that negative gender stereotypes and lack of recognition of their veteran status from civilian healthcare professionals had discouraged them from seeking help postdischarge.
Introduction
The number of female military veterans in the UK is increasing, with the proportion of women in the veteran population expected to grow to 13% by 2028.1 Despite this, only 2% of veteran research mentions women, and an even smaller percentage focuses on women.2
The military remains a male-dominated institution internationally, in which stereotypically masculine characteristics (eg, strength and courage) are privileged above those associated with femininity (eg, emotionality and caring).3 Furthermore, the minority status of women in the Armed Forces means that support services for veterans have often been built around the needs of men, leading to male-focused and male-dominated support, for example, in the US Veterans’ Health Administration (VHA)4 and the UK veteran statutory and charity support sector.5 As such, the interplay of the masculine military culture and societal gender norms has been highlighted as crucial in understanding the experiences of veterans.3 The term ‘gender’ rather than ‘sex’ is used throughout this paper to reflect the norms, behaviours and roles associated with gender as a social construct, as opposed to the biological and physiological characteristics associated with ‘sex’.6
Barriers to accessing mental health services among veterans are well researched in the UK, and include a lack of military specialist healthcare professionals and anticipated mental health-related stigma.7–10 However, as studies in this area have included predominantly male samples and have not conducted analyses by gender, the applicability of these findings to women remains unclear. A systematic review examining the barriers to accessing mental health services for female veterans identified a paucity of UK research.11 US research identified in this review suggests that while female veterans experience several barriers common to their male colleagues (eg, help-seeking stigma, negative perceptions of services), they also experience unique barriers associated with accessing male-dominated veteran-specific mental healthcare environments (eg, lack of gender-sensitive treatment options and feeling uncomfortable/unwelcome). Moreover, female veterans in the US report less satisfaction with veteran-specific male-centric healthcare services,12 and are shown to underuse these services.13
Given the separate arrangement of veteran healthcare in the US (ie, via the VHA), the applicability of US research exploring barriers to care among female veterans accessing mental healthcare in the UK is unknown. Indeed, healthcare services in the UK are provided to veterans alongside civilians via the NHS.14 15 However, veteran-specific NHS mental health services were established in 2017 in the UK, and alongside a number of military veteran charities, provide mental healthcare tailored specifically for the veteran population.14 Women’s needs were not specifically considered during the development of these services.16 Furthermore, research based on small qualitative samples in the UK supports the suggestion that women feel unwelcome in male-dominated veteran healthcare environments, and do not feel civilian healthcare services meet their needs.17 18 As such, this study seeks to address the US bias in our understanding of female veteran’s mental healthcare needs, by providing a preliminary investigation of gender differences in engagement and barriers to mental healthcare in a sample of UK veterans.
Method
Participants
A total of 101 participants were recruited via an open online survey link for a convenience sample of UK male and female veterans (triservice) who self-identified as having experienced mental health problems following discharge from military service. The survey link was distributed across social media (Twitter, Facebook and LinkedIn) and to members of various veterans’ organisations. Participation was voluntary and participants were required to provide informed consent online. Inclusion was based on participants confirming that they had served (but were not currently serving) in the UK Armed Forces and had experienced mental health problems (diagnosed or otherwise) following discharge.
Procedure
A survey was created using Online Surveys (www.onlinesurveys.ac.uk), and data were collected between April and July 2020.
Measures
Demographic and military service information was collected from participants, including: age, gender, sexual orientation, ethnicity, nationality, service branch, rank on discharge and length of service. Participants were asked whether they had received support or treatment for their mental health problems while serving in the military and/or since leaving the military.
If participants indicated they had received support/treatment since discharge, they were then invited to confirm which services they had accessed from the following: ‘NHS veteran-specific mental health services’ (ie, the transition, intervention and liaison services or complex treatment service), ‘NHS mainstream mental health services’ (ie, non-veteran-specific NHS services), ‘veteran/military specialist charity or third-sector organisation’, ‘non-veteran/military charity or third-sector organisation’, ‘private treatment’ or ‘other’. Participants were also asked how long after discharge they first accessed mental health support/treatment, and when they had last received support/treatment.
All participants completed the Barriers to Access to Care Evaluation scale (BACE),19 which requires participants to rate whether the 30 listed treatment barriers have ever ‘stopped delayed or discouraged’ them from seeking professional mental healthcare on a scale of 0 (not at all) to 3 (a lot). The BACE consists of three subscales, providing a score for stigma-related, attitudinal and instrumental barriers to care.
Finally, participants were asked whether their military experience and/or gender had impacted on their intention to seek help and/or their experience of accessing support or treatment for their mental health postdischarge. Participants were asked to elaborate on this using free-text questions. The full survey was piloted with a small group of veterans prior to launch to ensure comprehension.
Data analysis
Data from Online Surveys were analysed using the IBM SPSS Statistics 26. Of the 101 survey responses, one participant did not provide their gender, and was excluded, leaving 100 participants for analysis (43 female, 57 male). Participant characteristics and history of mental health treatment were descriptively analysed and are presented using frequencies and percentages, stratified by gender. Comparative analyses of categorical data by gender (ie, demographic and military data, questions related to engagement and experience of mental health services) were carried out using χ2 and Fisher’s exact tests. BACE scores are reported by gender for the full scale and each subscale. These variables were found to be not normally distributed using a Shapiro-Wilk test, and non-parametric Mann-Whitney U tests were used to test for gender differences. Responses to open-text questions were qualitatively analysed by looking at common themes within each gender category.
Results
Participant characteristics
Table 1 provides the participant characteristics for the female (n=43) and male (n=57) veterans who took part in this study. All participants were over the age of 31, with the largest proportion in the age group of 41–50 years. All participants were UK nationals and the majority were white British, and identified as heterosexual. Both women and men had most commonly served in the Army, were non-commissioned on discharge and had left service over 10 years ago. No significant group differences were identified for any participant characteristics.
Participant characteristics
History of mental health treatment
Table 2 shows the mental health treatment history of participants. The majority of both female and male veterans had not received support/treatment during service, but had received support/treatment following discharge. Of those who had received support/treatment since discharge (n=75), approximately a fifth of both female and male veterans had taken over 15 years to seek help following discharge. A significant gender difference was found when participants were asked when they last received support/treatment, with women most likely to currently be in treatment and men most likely to have been in treatment 1–3 years ago.
History of mental health treatment, stratified by gender
Figure 1 shows the frequency of participants accessing each type of mental health service, stratified by gender. Of those who had received support/treatment since discharge (n=75), the majority of female veterans reported accessing mainstream NHS services (60.5%), and male veterans most commonly reported accessing either mainstream NHS services (33.3%) or specialist veteran charities/third-sector organisations (31.6%). Women were significantly more likely to report accessing NHS mainstream services compared with men (p<0.05). No other significant group differences were identified in type of support/treatment accessed following discharge (p>0.05).
Type of support/treatment accessed following discharge from the military.
Barriers to accessing mental healthcare
BACE scores are shown in Figure 2. Highest scores for both female and male veterans were seen on the Stigma subscale. While women scored higher on each subscale and overall compared with men, group differences on the subscales and overall were not significant (p>0.05).
The Barriers to Access to Care Evaluation scale (BACE) scores stratified by gender.
The impact of military experience and gender on help-seeking
Table 3 shows respondents’ positive endorsement of the questions relating to the perceived impact of military service and gender on intention to seek help and experience of support postdischarge, stratified by gender. Significant group differences were found for the gender-related items only, with women significantly more likely to report that their gender had impacted on their intention to seek help and experience of support postdischarge.
Positive endorsement of the impact of military service and gender on help-seeking
For all the above questions, participants were given the options to answer with an open text box, and themes emerging from these answers are discussed ahead.
Impact of experience in the Armed Forces on help-seeking and experience of using services
Both female and male veterans described how the culture of the Armed Forces could continue to influence veterans postdischarge. A need for mental health support was associated with weakness, and the desire not to be perceived as weak was cultivated during military service, and continued postdischarge. This negatively impacted some participants’ abilities to seek help, along with their experiences of support/treatment:
HMF [Her Majesty’s Forces] demand physical and mental robustness. To see yourself as ‘weak’ in either area goes against this ingrained sense of strength. It was only when I felt close to crisis that I saw no alternative but to seek help, for my own and my family’s benefit. Male, Army Veteran.
I never wanted the weakness of my mental health on my records. I went into a policing environment and that had a very similar effect on my ability to ask for help or to understand the impact of my mental health. Female, Army Veteran.
One female participant’s response suggests that the negative implications of weakness may be more acute for women in a traditionally male military culture:
I feel that I have the stiff upper lip mentality due to my Army service. It was seen as a weakness to be ill in any way and that was harder for a woman in a man’s world. Female, Army Veteran
Some participants described disappointment when transitioning from military to civilian healthcare:
Whilst in-service, I valued the team support I received for my serious injury, as there were regular clinics and input from doctors, physios, remedial PT [Physical Training] and mental health professionals. It has been difficult to replicate that approach through the NHS post-discharge and it has felt like I’m having to retell the whole story, which is quite distressing. Male, RAF Veteran
However, the impact of poor experiences of mental healthcare in-service on trust in mental healthcare professionals was also reported by some participants. This theme was more prominent for female veterans:
Due to bad experiences with therapists while serving, it took me a while to engage, trust and open up with the therapist I have now. Female, Army Veteran
Some participants felt uncomfortable with civilian service providers, either due to negative cultural perceptions or feeling that civilians were unable to understand their experiences:
People don’t understand unless they have served. Male, Army Veteran
Impact of gender-related experiences in the Armed Forces on help-seeking
For those who elaborated on this question, there was clear distinction between male and female responses. Male veterans described the impact of ‘male psychology’, with masculinity at odds with help-seeking and accepting mental health needs:
Possibly due to being male and the feeling that I need to be seen as being strong and able to cope. Male, RAF Veteran
Female veterans reported a lack of understanding and negative stereotypes around women’s mental health, leading them to feel their care needs were not taken seriously:
Doctors seem to label me as neurotic or say I’m feigning a lot of symptoms. Female, Army Veteran
Women noted some gender-specific barriers to help-seeking related to their military service. Some spoke of the increased desire to prove their strength, due to disparagements around gender and weakness in the Armed Forces:
The female gender is often used as an insult to male soldiers, that is, ‘You're such a girl/whine like a girl’, that it made me want to prove that I was strong and the military hadn’t affected me. Female, Army Veteran
Women are perceived as weak and mental illness is seen as a weakness. It is a double hit. You spend your Army career trying to be like the men and hiding any mental issues to fit in. Female, Army Veteran
Second, female veterans reported misconceptions and a lack of recognition of women as Armed Forces personnel as negatively impacting treatment:
When you tell your story there is cynicism as some still don’t believe women can have real PTSD, as don’t serve on ‘front line’. Female, Army Veteran
Discussion
Research focused on gender differences in the barriers to care experienced by veterans has been primarily conducted in the US. This research suggests that male and female veterans both experience help-seeking stigma associated with accessing mental health services, but that there may be additional gender-related barriers associated with accessing male-dominated veteran healthcare support for women. The findings of this study provide preliminary evidence of a similar experience in UK veterans.
This study is the first to investigate gender differences in the barriers to mental healthcare in a sample of veterans in the UK (43 women and 57 men). Our analysis suggests that female and male veterans report similar levels of stigma, attitudinal and instrumental barriers. The highest scores for both women and men were observed in the BACE Stigma subscale, which measures aspects of stigma and discrimination that individuals believe will be associated with receiving mental health treatment/support (eg, concern about being seen as weak). A connection between the military culture and perceived mental health stigma is a common finding in mixed gender samples of veterans in the UK7–10 and internationally,20 and has been linked to the military values of emotional strength and perseverance.21 Our study extends these findings specifically to UK female veterans for the first time.
This is supported by participants’ qualitative responses regarding the impact of military service on help-seeking. Both men and women reported that the desire not to be perceived as weak was cultivated during military service, and discouraged help-seeking postdischarge. However, there was indication that for some women this stigma may have its origins in gender-related discrimination experienced during service. Indeed, women reported feeling that they had to work harder than men to be accepted during military service, due to perceptions of weakness associated with their gender. These findings are in line with previous qualitative work in the UK, which suggests that women feel they have to work twice as hard as men to be accepted into the masculine military culture, in which they feel undervalued and overlooked.17 Furthermore, women in the current study were significantly more likely to agree that their gender had hindered their help-seeking postdischarge. Women reported that disparagement around being female and the perception of female weakness in the Armed Forces had discouraged them from seeking help.
Respondents’ comments also suggested a lack of understanding among civilian healthcare professionals of the issues faced by female veterans, as well as a lack of recognition that women may have experienced the same traumas as men during service. While these limited qualitative findings are not generalisable, they mirror previous US research in this area,11 which indicates that women in receipt of mental health treatment through the VHA do not feel recognised as veterans, and that their military-related experiences were not taken seriously.22–24 Furthermore, they concur with previous UK research in a small qualitative sample,18 in which female veterans reported a lack of recognition from civilian support services of their combat and frontline roles and that they may be dealing with the same type of trauma as male veterans.
Regarding engagement with mental health services, our results indicate that a similar proportion of female and male veterans had accessed support during and after military service. However, female veterans appeared to have sought help more quickly following discharge and were more likely to currently be in treatment than male veterans. This is in line with previous research carried out with current and ex-serving military samples in the UK, in which women are shown to be significantly more likely to access formal medical support than their male counterparts.25 26
However, female veterans were significantly more likely to report accessing NHS mainstream (ie, non-veteran-specific) mental health services than male veterans (60.5% vs 33.3%). Male veterans were most likely to have accessed either mainstream NHS services (33.3%) or specialist veteran charities/third-sector organisations (31.6%). This finding is interesting considering research in the US and preliminary research in the UK that suggests women feel uncomfortable in male-dominated veteran support services.13 17 18 It is possible that mainstream NHS services, in which the need for gender-sensitive services has been recognised,27 are better meeting women’s needs than veteran-specific mental health services. Additionally, it is also possible that female veterans do not identify with the term ‘veteran’ and as a result do not engage with veteran-specific services. Indeed, previous research with UK veterans found that women were less likely to consider themselves veterans compared with men (31% vs 55%)28 and see the term ‘veteran’ as belonging to those in older male generations of veterans.18
However, the current study found that while male veterans were more likely to access support via veteran-specific charities (women: 18.6%; men: 31.6%), only a small proportion of both genders had accessed NHS veteran-specific mental health services (women: 20.9%; men: 14%). This does not appear to be due to availability, as the majority of veterans reported being in current receipt of treatment, or receiving treatment within the past 3 years (ie, following the launch of the NHS Transition, Intervention and Liaison Services in 2017).29 These findings suggest further research is required to determine whether NHS veteran-specific services are effectively engaging and meeting the mental health needs of veterans.
Poor experiences of treatment/support during military service were reported by both men and women. However, it is recognised that while recent initiatives have been introduced to enhance mental health support among Armed Forces personnel,14 improvements may take time to have effect and percolate through into improved statistical reporting.
The findings of this study suggest that while UK female veterans experience barriers common to male veterans in accessing mental health support (ie, stigma associated with seeking help cultivated during military service), they may also experience additional gender-related barriers. While women appear to access mental health support at higher rates and more quickly following discharge compared with men, they are more likely to access non-veteran-specific support and to report that gender-related experiences impact on their help-seeking.
In the US, the VHA continues implementing gender-sensitive/gender-specific mental health services, resulting in increased use of VHA services by women.30 While it is recognised that the structural differences between the mental healthcare provided to veterans in the US and UK (ie, dedicated federal services specifically for veterans in the US vs dedicated services within existing civilian support structures in the UK) make it difficult to directly transfer findings, parallel findings are beginning to emerge in relation to the experience of women during military service and the impact of this on help-seeking postdischarge. Given the low proportion of women accessing NHS and third-sector veteran-specific mental healthcare services in the UK, evidenced in this study, these services may wish to consider whether support provided is targeted towards and meets the unique mental health needs of women. Research is needed in the UK to investigate this further.
Limitations
Some limitations are of note. First, this was a preliminary investigation and the first to explore gender differences in barriers to care in UK veterans. As such, this study used a relatively small sample (n=100), limiting the statistical power associated with comparative group analyses. Furthermore, the sample was not representative of the wider veteran population31; participants were comparatively younger, there was an increased proportion of RAF veterans and women were oversampled to enable a comparative analysis. Second, due to the nature of anonymous self-report, we cannot confirm the military background or history of mental health difficulties and access to treatment of the respondents. Finally, the nature of the recruitment of a convenience sample (ie, via an open survey link) creates the potential for a self-selection bias, in which those with certain experiences or characteristics may be more likely to take part. Considering these issues, it will be important for future research to be carried out with a larger representative sample of veterans in the UK, and collaborative data collection with key organisations, such as the NHS and the Ministry of Defence, is needed to enable purposive sampling and to confirm veteran and mental health status.
Conclusions and future directions
This preliminary UK study reflects existing US research, with indication of gender-related issues emerging during help-seeking postdischarge. This may exacerbate existing barriers to accessing mental health treatment among female veterans. It is acknowledged that stigmatised perceptions of weakness are generally considered a factor that discourages access to treatment among serving military personnel, and efforts are being made to reduce this barrier for this serving community. However, to our knowledge, these efforts do not include a focus on gender-specific barriers. Further research is needed to explore the impact of gender-related experiences during military service on female veterans’ help-seeking within statutory and third-sector veteran support services in the UK, and how gender-specific barriers to care might be reduced by tailoring these services to better meet the needs of UK female veterans.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was provided by the Anglia Ruskin University School of Education and Social Care Research Ethics Panel.
References
Footnotes
Twitter @laurengmcb, @grahamcable_UK, @Abigail_Wood97, @BigFoss
Contributors LRG-McB carried out the data collection, analysis and drafting of the manuscript. GC and MF provided assistance in the drafting of the manuscript and approved the final version. ADW assisted with the analysis and provided editorial assistance in drafting the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.