Home > RNJ > 2009 > May/June > Stress Response in Female Veterans: An Allostatic Perspective

Stress Response in Female Veterans: An Allostatic Perspective
Maureen Wimberly Gror, PhD RN FAAN Candace Burns, PhD ARNP

Women serving in the military face many sources of stress, such as separation from home and family, sexual harassment and assault, and deployment to traumatic war zones. Some women are vulnerable to the effects of these stressors, resulting in deleterious mental and physical health outcomes. Understanding these risks through the theoretical model of allostasis can help identify those who will be most vulnerable and help healthcare providers prevent some negative outcomes and improve rehabilitation for some women when they return stateside. Women may be more likely than men to present with mental health problems such as posttraumatic stress disorder and depression after military service. They also may be at increased risk, based on their war-zone stress response, for disparate illness such as medically unexplained illness, cancer, and heart disease. The need for care for these women is expected to increase as more women are deployed to conflicts.

Rehabilitation nurses often care for victims of war, usually men, who sustain traumatic injury. A growing number of patients include female soldiers who have been deployed to war zones. Their injuries usually do not cause obvious physical impairments, but physical war-related trauma certainly does occur in deployed women. Women are more likely to experience long-term mental, rather than physical, health consequences after deployment, and, because of this, they may be at higher risk for certain chronic illnesses (Cloitre, Cohen, Edelman, & Han, 2001). They often do not seek or receive heath care within Veterans Administration rehabilitation services for these illnesses. This article explores the vulnerabilities, types of stress, and risks for women deployed to war zones and examines these variables using the theoretical model of allostasis.

Women have been deployed to combat zones in Iraq and Afghanistan and usually are engaged in violence-exposed support jobs in the military (Pessin, 2005). Although women are not formally engaged in frontline combat, they are nevertheless exposed to extreme danger and stress in positions such as truck drivers, mechanics, and medical personnel. Occasionally, female soldiers in Iraq have been in situations in which they have handled machine guns and killed the enemy (Scharnberg, 2005). Little is known about the effects of these experiences on women soldiers, particularly the long-term consequences, because few studies have been conducted to examine this new generation of female soldiers. Rehabilitation for these women may become a major need in the future. One recent study found that women were at least as likely as men to exhibit depression and posttraumatic stress disorder (PTSD) 3 months after ending deployment (Adler, Huffman, Bliese, & Castro, 2005). Other studies have suggested that women have a greater likelihood of experiencing mental health disturbances after deployment to war zones (Gahm, Lucenko, Retzlaff, & Fukuda, 2007). There is additional concern that soldiers engaged in the current conflicts in Afghanistan and Iraq appear to be experiencing high rates of PTSD (18%) among both male and female soldiers (Hoge et al., 2004). A further concern is the recent report of mild cognitive impairments, not attributable to depression or PTSD, that were found in returning soldiers (Vasterling et al., 2006). The relationship of gender to these effects of combat exposure is not known.

The allostatic model of stress (McEwen & Wingfield, 2003) suggests that soldiers are at risk for both mental and physical health consequences resulting from stress. Both men and women experience many stressors during deployment (separation from loved ones, exposure to violence and death, and, even for men, sexual assault). Although the majority of soldiers are remarkably resilient, there is evidence that some deployed military women are particularly vulnerable to the sequelae of stress. Some of the factors that produce stress vulnerability in female soldiers who have been deployed are presented in this article as well as approaches to assessment and intervention for rehabilitation nursing.

Characteristics of Women Who Join the Military

As of 2006, 1,372,669 active-duty (AD) personnel and 1,101,565 Reserve personnel (excluding the Coast Guard) comprised the military force. Women on AD comprised 14.5% (199,545) of the force, with 46% married, compared to men in the force, of whom 56.5% are married. In the Reserve force, 38.6% of women are married, compared to 54% of men. AD personnel tend to be somewhat younger than the Reserve force (85% of AD personnel are 35 years old or younger). The Reserve force is somewhat older, with 34.5% being 36 years old or older, compared to only 15% for AD personnel. AD women are far more likely to be married to other military personnel (dual marriages) than men: 22.6% compared to 4.2%. Women in the Reserve force follow the same patterns, with 8.6% reporting dual marriage, compared to 1.3% for men (excluding the National Guard, which does not report dual marriage; U.S. Goverment Accountability Office, 2005). The U.S. Army AD component reveals that women are more likely to represent ethnic minorities than men (42.4% of women are White, 39% are Black, 11% are Hispanic, 4% are Asian, and 3.7% are classified as “other”). Men are predominately White (63.9%), 19% Black, 10.3% Hispanic, 3.8% Asian, and 3% “other” (Office of the Deputy Under Secretary of Defense, 2007).

Very little data are available to describe personal characteristics of female military recruits. There is some evidence that these women represent a unique subset of American women. For example, compared to nonmilitary age cohorts, these women report a 36% premilitary prevalence of rape, nearly three times the lifetime incidence of nonmilitary women (Merrill et al., 1998). In a survey of female Navy recruits (N = 2,431), 25% reported experiencing rape before entering the military (Stander, Merrill, Thomsen, Crouch, & Milner, 2007). There also is a higher incidence of childhood sexual abuse history in female recruits, which increases the possibility of “revictimization” (Merrill et al.). Those women who had high levels of violence exposure during childhood were more likely to be repeatedly assaulted while in the military (Sadler, Booth, Mengeling, & Doebbeling, 2004). This suggests that military recruits who are women may have lifestyles and life circumstances that significantly differ from nonmilitary comparison samples. It also suggests that female military recruits may have certain vulnerabilities that may increase their risks for psychological and physical health problems. Women who join the military appear more likely than men to endure stress and trauma before deployment, which increases their risk for stress-related problems. In fact, many women join the military to escape from oppressive or traumatic environments. These vulnerabilities may not be discovered during premilitary screening because women may not want to reveal such personal and disturbing events. Postdeployment health visits may be the first opportunity to uncover these preexisting stressors. With knowledge of the possibility of trauma and violence marking female soldiers’ histories, nurses must make women comfortable enough to reveal their histories and describe the trauma that occurred during their deployment.

Sexual Assault

A major stressor for deployed military women is the common threat of sexual assault. Sexual assaults also occur among men, but women are most vulnerable. In a national survey of 555 female veterans who had served in Vietnam and in subsequent eras, 30% reported being raped during their time of service (Sadler, Booth, Cook, & Doebbeling, 2003). In a study of 540 female veterans, 28% reported they were raped while in the military (Sadler, Booth, & Doebbeling, 2005). Of these women, 10% reported repeated or gang rapes. Because risk factors for rape (e.g., drug and alcohol abuse, sleeping arrangements, sexual harassment allowed by officers) could be identified, many were preventable. This could make rape victims feel somewhat accountable or even guilty, and therefore less likely to report the rape at the time. Further, women may be in a subservient position to the assailant and find themselves in powerless circumstances. The health effects of these violent experiences are significant, particularly for those who were gang raped. Aside from the dangers of sexually transmitted diseases and pregnancy, rape during military service carries with it a higher risk of PTSD (Himmelfarb, Yaeger, & Mintz, 2006). Sexual trauma along with combat exposure appear to be important risk factors for later development of PTSD.

Although of lesser magnitude than assault, sexual harassment also is a stressor for deployed military women and is a predictor of later PTSD symptoms (Murdoch et al., 2003). Sexual harassment was reported by 79.8% of military women.

Separation Stress

Both men and women in the military are at risk for separation stress, particularly if they have left behind their families. In a recent analysis of British military noncombatants (the majority of whom were men) who were evacuated from Iraq to a psychiatric inpatient facility in the United Kingdom, only 3% had war-related mental health trauma. As the result of separation from their normal environments, the remainder of subjects had symptoms that manifested primarily as depression (Turner et al., 2005). The authors point out that these individuals were most likely vulnerable before entering the military. A study of Reserve nurses (all women) deployed during Operation Desert Storm showed a relationship between anxiety and separation from loved ones and financial concerns (Wynd & Dziedzicki, 1992). These women had specific concerns about their children’s care while they were deployed. More women are serving in the military during the current conflicts than ever before, and research is needed to identify the relationships between family separation and disruption and these women’s mental and physical health. Married soldiers of both genders are at high risk for marital and family disruption and at greater risk for divorce than nonmilitary Americans after returning from deployment to combat zones (Stanley et al., 2005). This further contributes to their stress and potential isolation.

Deployment Stress

Soldiers in Iraq and Afghanistan are placed at high risk for personal injury or death, most have witnessed the death of another person, and the majority has reported shooting at the enemy (Hoge et al., 2004). Guerilla warfare and bombs and threats also are experienced by female soldiers. In Adler and colleagues’ 2005 study of men and women deployed to similar noncombat units in war zones, women began the experience with higher distress scores; after many months of deployment, men and women reported equivalent amounts of PTSD and depression. The stress-response pattern was different, perhaps due to habituation or to womens’ styles of social-network-related coping. In another study of gender difference in stress response among soldiers deployed to Gulf War, women reported more interpersonal stressors, and these stressors had a greater effect on the mental health status of women than men (Vogt, Pless, King, & King, 2005). Deployments to war zones or for peacekeeping can lead to health and family problems, depending upon the rate and length of deployments (Adler et al.). Previous combat deployments were associated with greater risk of PTSD for both male and female veterans (Wolfe, Erickson, Sharkansky, King, & King, 1999).

For AD men and women soldiers, deployment to Iraq results in mild neuropsychological compromises, according to Vasterling and colleagues (2006). In this study, 25% of returning soldiers scored higher than the Center for Epidemiologic Studies Depression Scale cutoff for depression, and 11.6% met criteria for PTSD. The cognitive compromises reported were mild, but, nevertheless, potentially important for their everyday performance, and included altered attention and memory. Given that American female soldiers are being exposed to combat-related stress at a rate unlike that experienced at any other time in history, returning soldiers must deal with their emotional and physical responses to extraordinary stress.

One important characteristic of female soldiers is the greater probability that they have endured serious abuse or trauma before deployment in the armed services. This leads to an increased risk for PTSD in women compared to men. Although most women will not have severe or chronic mental health problems at the end of their deployment, all women will have developed strategies for dealing with their emotional responses to the stressors related to deployment. Some of these strategies may be adaptive and healthy, and some may be damaging and ultimately lead to health problems. According to Killgore, Stetz, Castro, and Hoge (2006), soldiers returning from combat with mental health problems are not likely to report these concerns, fearing stigma, and instead tend to seek help for somatic symptoms, which may be exaggerated in the presence of serious psychiatric disorders. Pierce (2005) found that military women deployed to the Persian Gulf War self-reported significantly more health problems 6 years later compared to women deployed elsewhere. The war-zone-deployed military women reported 29 of 48 health problems at higher frequency than the comparison group.


The allostatic model of stress (McEwen & Wingfield, 2003) provides a lens through which to view the potential effects of deployment-related stress in military women on long-term health status. Allostatic load in female veterans can contribute to the development of later chronic psychological and physical illness. Because these soldiers may be redeployed and will be tomorrow’s veterans, rehabilitative health care—provided at an unprecedented rate and cost—may be required. An understanding of the risks for illness and the pathogenic pathways will help to design preventative strategies to improve health and decrease negative outcomes.

Allostasis is a conceptual model of stress that examines the influence of both predictable high-demand life stages and unpredictable challenges, such as those associated with war stress, that require biobehavioral adjustment. Allostasis is the process of achieving stability through change, allowing for flexibility in biological and behavioral states in response to external environmental and developmental perturbations (Landys, Ramenofsky, & Wingfield, 2006). The primary mediators of allostasis include stress hormones, the immune system, and neurological responses (McEwen & Wingfield, 2003) because they are necessary factors in rapid responses to change. The sustained activity of these primary mediators ultimately produces a particular allostatic state, but may eventually cause pathophysiological damage to the organism, or allostatic load. Over time, allostatic load may cause cumulative pathophysiologic effects that contribute to disease and senescence (Stewart, 2006). Allostatic load constitutes the negative effect of being forced to adapt to adverse and uncertain situations, whether they be physical threats or psychological distress, due either to excessive stress or inefficient operation of the stress response (McEwen & Seeman, 1999).

Systems involved in maintaining allostasis include the stress responses activated by the sympathetic nervous system (SNS) and the hypothalamic- pituitary-adrenocortical axis (HPA) and the proinflammatory cytokines released by many cells in response to stress-related chemicals. Circulating catecholamines released by the SNS act on the cardiovascular system to increase cardiac function and blood flow to essential organs and energy and metabolic resources for the fight-or-flight response. The catecholamines also assist the immune system by redistributing immune cells so they can more easily reach a site of injury. In addition, norepinephrine stimulates responsive cells such as macrophages to release proinflammatory cytokines (Black, 2006). Catecholamines also act to increase alertness and arousal. The SNS can be tonically more active in some people, or highly reactive to real and potential threats such as those associated with war zone deployment.

HPA axis activation occurs along with SNS activation but is more gradual in its effects. HPA axis activation results in the release of corticotrophin-releasing hormone (CRH) from the hypothalamus, which activates the pituitary to release adrenocorticotrophic hormone (ACTH). ACTH then acts on the adrenal cortex to release cortisol. Cortisol increases food intake and allows metabolic fuel to be available for the stress response and suppresses functions not essential for survival, such as reproduction (Landys et al., 2006). Cortisol also enhances the effects of the SNS on cardiovascular function during stress states (McEwen & Wingfield, 2003). Cortisol is an allostatic hormone that changes depending on time of day, season, and reproductive state. It now is known that the cortisol rise that occurs upon awakening is a key determinant of adaptation to routine activities of daily living (Wust, Federenko, Hellhammer, & Kirschbaum, 2000).

Cortisol suppresses immunity and inflammation and downregulates the excessive inflammatory and immune processes that could be activated by stressors caused by predation such as injury and wounding (Suzuki et al., 2002). Without cortisol, these may become runaway processes that could lead to unremitting inflammation and tissue destruction. Excessive secretion of cortisol to manage stress over a long period may contribute to allostatic load and disease.

Inflammatory cytokines also are primary mediators of allostasis. These cytokines are released by multiple cell types in response to stress. Proinflammatory cytokines such as interleukin-1 (IL-1), IL-6, and tumor necrosis factor-alpha (TNF-α) provoke inflammatory changes. These cytokines produce cytokine elevations within the central nervous system that lead to many behavioral changes. They act on the liver to cause the release of acute-phase proteins such as C-reactive protein.

A significant number of illnesses have been conceptualized as developing as a result of allostatic load, including hypertension, obesity, diabetes, cardiovascular disease, and autoimmune and inflammatory disorders (McEwen & Wingfield, 2003). The brain may also sustain the effects of allostatic load. Normally, glucocorticoids and catecholamines act to enhance memory of a stress event, presumably so a person can learn to avoid the event. However, chronic and repetitive stress leads to shrinkage and atrophy of areas of the brain including the amygdala and hippocampus. The hippocampus is involved in long-term memory storage, and stress-related atrophy can lead to memory and cognitive impairments (McEwen, 2000).

The mechanisms of diseases due to allostatic overload largely are related to the pathophysiological effects of unremitting and chronic exposure of body systems to primary mediators (secondary outcomes). Because these mediators activate defensive functions involving cardiovascular parameters, metabolic functions, immune defenses, and the nervous system, these are the systems that are most likely to sustain allostatic load.

Allostasis and Deployment

Women appear to respond to stress, particularly stress within social contexts, with a greater stress response than men, and subsequently are more likely to develop allostatic load (Stroud, Salovey, & Epel, 2002). Women generally demonstrate stronger relationships between perceived stress and physiological responses than men (Goldman, Glei, Seplaki, Liu, & Weinstein, 2005) after traumatic stress. Interpersonal stressors are particularly salient for women (Stroud et al.), but the exposure to war-related dangers and trauma and the sight of terribly damaged and dead bodies of men, women, and children may be a source of lifelong stress for both genders. Nurses particularly should note that because there are fewer women in the military, there are fewer sources of peer support that might help female soldiers deal with their feelings in the postdeployment period. A woman’s way of dealing with stress is to seek social resources and supports, particularly for managing long-term stress (Adler et al., 2005). It is not typical for female soldiers to receive their postdeployment health care within the Veteran’s Administration healthcare system, so they may not have any contact with other women who have had similar combat experiences or healthcare professionals who can relate their health status to their deployments.

The stress associated with war-zone deployment may become so severe for some that allostatic load may become too great to maintain healthy balance and function. Although the extreme might be represented by PTSD, other manifestations of such stress may occur (depression, anxiety, or unhealthy lifestyle). The inflammatory response system may dominate and deplete the adaptive resources for these susceptible women and provoke a pathophysiological state in which stress results in increased proinflammatory cytokines, acute-phase reactants, dysregulated immune function, and altered neurophysiology and endocrinology—all predictive of psychosocial and physical health outcomes. The relationships between stress and health must be studied in women who have served in the current conflicts to better understand this type of stress and its possible consequences. Figure 1 depicts an allostasis model that potentially could be useful in future research. This model examines the impact of war zone stress on health in female soldiers.

Deployment, Stress, and Health

An outcome of deployment that first was reported after the Persian Gulf War in 1991 was termed Gulf War Syndrome (GWS), or medically unexplained illness. A metaanalysis of studies of this multisystem illness found that Gulf deployment most strongly was associated with chronic fatigue syndrome (Thomas, Stimpson, Weightman, Dunstan, & Lewis, 2006). GWS may be a prototype of war-stress immune dysfunction (Everson, Kotler, & Blackburn, 1999). These authors point out that the role of stress and immunity in GWS is unknown, but it is plausible that immune cytokine balance may shift toward the humoral immune profile due to stress hormone dynamics in veterans with GWS. However, a later study did not discover significant differences between veterans with and without GWS on a panel of immunological parameters (Everson, Shi, Aldridge, Bartolucci, & Blackburn, 2002).

The most extreme response to war is PTSD. PTSD is a state that may follow trauma exposure, and is associated with hypervigilance, impaired concentration and memory, insomnia, irritability, exaggerated startle reactions, and intrusive memories (Southwick & Yehuda, 1997). These symptoms (reexperiencing, avoidance or numbing, and hyperarousal) must be present for at least 1 month and must cause “clinically significant distress and/or impairments in social, occupational, and/or other important areas of functioning” (American Psychiatric Association, 2000).

PTSD should be diagnosed by an experienced psychiatric healthcare provider who uses the approved criteria and face-to-face assessment conducted over an adequate time interval. It is important to note that individuals with PTSD may not recognize their symptoms as psychiatric and present to the healthcare system as the result of alcohol abuse or dependence, which is a common problem in those with PTSD (Hyer, McCranie, & Peralme, 1993). There also is a high frequency of comorbid psychiatric conditions in PTSD (Black et al., 2004).

Stigma associated with psychiatric diagnoses is prevalent among military men and women. Postdeployment screening has revealed that only about one-third of veterans who served in Iraq and who believed they had developed significant mental health problems during their deployments received psychiatric care (Hoge et al., 2004). Early diagnosis of PTSD and intervention before the disease becomes chronic and debilitating is an important aspect of health care. It is important to assure veterans of confidentiality and communicate that their illness is common and treatable.

Women are more likely than men to develop this aftermath of trauma (Holbrook, Hoyt, Stein, & Sieber, 2002). The basal state in PTSD is associated with hypocortisolemia and exaggerated sympathetic reactivity (Goenjian et al., 1996; Kellner, Baker, & Yehuda, 1997; Resnick, Yehuda, Pitman, & Foy, 1995). PTSD is characterized by heightened SNS arousal that is triggered when affected people are presented with auditory and visual reminders of a traumatic event. There is evidence that the state of arousal experienced during the time of the traumatic event produces a kind of conditioned encoding of memory of the event and the psychophysiological state associated with it (Southwick & Yehuda, 1997). In combat veterans, even 20 years after a trauma, the urinary excretion of catecholamines still is higher than in controls (Kosten, Mason, Giller, Ostroff, & Harkness, 1987). The fundamental mechanism for this exaggerated sympathetic reactivity may be associated with chronically elevated catecholamine levels (Perry, Giller, & Southwick, 1987). The sympathetic nervous system seems to be excessively responsive to ordinary daily stress in people with PTSD. The other major stress axis, the HPA response, appears to be downregulated. Several studies have confirmed that combat veterans with PTSD have lower morning cortisol (Boscarino, 1996) and lower 24-hour cortisol levels (Yehuda, 1997). Studies have shown that PTSD victims have upregulated glucorticoid receptors, perhaps in response to lower glucocorticoid output from the HPA axis (Southwick & Yehuda). A possible mechanism for lower cortisol is increased sensitivity for negative feedback regulation at the level of the hypothalamus or pituitary gland, such that an altered supersensitivity to serum cortisol levels exists when less-than-normal cortisol shuts off the HPA. CRH is hypersecreted in PTSD, as measured by serial cerebrospinal fluid sampling, suggesting that hypocortisolemia is the result of a blunted ACTH response (Baker et al., 1999). In PTSD, the basal neuroendocrine state differs from that associated with the stressed state. In the basal condition, cortisol levels are lower and catecholamine levels are tonically higher (Yehuda, Resnick, Schmeidler, Yang, & Pitman, 1998). Yehuda and colleagues suggest that hypocortisolemia may be associated with avoidance, while excess catecholamines may be associated with arousal and intrusive symptoms.

The immune system also is changed in PTSD, with altered sensitivity of the HPA and hypocortisolemia along with higher T lymphocytes in the circulation, two influences that might predict a higher incidence of autoimmune disorders in this population (Boscarino, 2004). Rheumatoid arthritis, psoriasis, insulin-dependent diabetes, and thyroid disease were found to be present at a greater frequency in people with PTSD, particularly those who had comorbid psychiatric diagnoses. This study only examined veterans who were men, but the predominance of autoimmune diseases among women may suggest that women are more at risk. In a study of women with PTSD, delayed-type hypersensitivity reactions (which are a measure of cellular immune competence) were increased, as was skin barrier function when compared to controls in response to stress, although activated lymphocytes were not increased in this study (Altemus, Dhabhar, & Yang, 2006). Serum levels of proinflammatory cytokines also were increased in subjects with PTSD (Maes et al., 1999; Spivak et al., 1997). Because the immune system is activated in the natural state more so in women than in men, women are far more at risk for hyperimmune syndromes such as autoimmune disease (Walsh & Rau, 2000). Moreover, women are twice as likely to experience depression than men, which increases their general vulnerability to stress (Bebbington, 1996). When a woman is diagnosed with an autoimmune disorder, the history should include a stress and mental health history, with exploration of whether she has been exposed to trauma, has served in the armed services, or has a history or current symptoms of PTSD.

Combat Stress, PTSD, and Health

Studies of the relationship between combat-related stress and health have been largely carried out with men. For women, the relationship between rape and sexual assault and development of PTSD has been examined. Combat-related stress was linked to poor health in Israeli veterans 20 years after their wartime experiences (Benyamini & Solomon, 2005). The types of disorders reported were poorer general health, more chronic diseases, and somatic symptoms (digestive problems, weight loss, chest pains, headache, joint aches, and fatigue). In an analysis of physical health symptoms in Gulf War veterans, those diagnosed with PTSD reported the highest number of symptoms, with veterans with other mental health problems reporting the next highest number, and healthy veterans reporting the lowest number. Fatigue, joint pain, sleep disturbances, memory loss, and headaches were the most common symptoms experienced (Engel, Liu, McCarthy, Miller, & Ursano, 2000). In a recent report on Iraq War veterans, those with PTSD had the highest number of somatic symptoms when measured 1 year after return from combat-zone duty. As with other studies, the prevalent somatic symptoms were difficulty sleeping, low energy, joint pain, and back pain (Hoge, Terhakopian, Castro, Messer, & Engel, 2007). Male veterans with PTSD were more likely to have osteoarthritis, diabetes, higher cholesterol, and heart disease when matched with veterans with alcohol dependence (David, Woodward, Esquenazi, & Mellman, 2004). The same relationship between severe combat stress and a number of physical health problems was found in a study of male Vietnam veterans (Boscarino, 1996).

Women exposed to severe trauma and those with PTSD also may develop significant health problems. Women with PTSD have poorer health outcomes than trauma victims who do not develop PTSD (Friedman & Schnurr, 1995). Women who have been raped report lower perceived health status, more somatic symptoms, and more negative health behaviors than nonvictims. They also report more headaches, chronic pain syndromes, gynecological disorders, gastrointestinal disorders, morbid obesity, and substance abuse. A study conducted in a multidisciplinary pain clinic found that women who reported sexual assault had more chronic pelvic, abdominal, and stomach pain compared to other groups (Green, Flowe-Valencia, Rosenblum, & Tait, 1999). In another study, 36% of women studied with chronic pelvic pain had a history of sexual assault (Lampe et al., 2000). Premenstrual syndrome also is more common as a rape sequela (Koss & Heslet, 1992). Military women who were raped were more likely to report chronic health problems, use prescription medication for emotional problems, fail to complete college, and receive annual incomes lower than $25,000 (Sadler, Booth, Nielson, & Doebbeling, 2000). They are also more likely to develop heart disease, obesity, and asthma (Frayne et al., 1999). Suicide is more common among women who have been sexually assaulted (Davidson, Hughes, George, & Blazer, 1996).

Rehabilitation nurses have the opportunity to work with physically injured veterans of both genders. The unique stress vulnerabilities of women should be incorporated into the plan of care. Although the need to restore function in women who have been physically injured clearly is a focus, holistic nursing care includes assessments and interventions for war-zone stress effects. A number of screening tools are available for nurses. These include the Davidson Trauma Scale, the PTSD Checklist, the Posttraumatic Diagnostic Scale, the Keane PTSD Scale, the Mississippi Scale for Combat-Related PTSD, and the Impact of Events Scale (Institute of Medicine, 2006). These scales can help determine the need for a diagnostic work-up for PTSD.

The relationships among stress, gender, and health outcomes in female soldiers are not well understood among primary healthcare providers. Rehabilitation experts must communicate these facts to practitioners who care for the general health concerns of postdeployed female soldiers. When these women are cared for within the rehabilitation services systems, attention to PTSD symptoms must not overshadow the potential physical health problems described in this article. The history and assessment must be comprehensive to fully uncover health status. It is critical to gather information about length of deployment (Adler et al., 2005).

There is support for the idea that allostatic load may contribute to chronic disease. In a study of 826 elderly women (median 75 years of age), 12.7% reported a history of sexual assault. This history was associated with a higher incidence of arthritis and breast cancer, and multiple episodes of assault carried a two- to three-fold increased risk of these diseases (Stein & Barrett-Connor, 2000). Therefore, interventions that address physical health problems are incomplete if mental health problems are not fully explored.

Environmental threats—as well as the physical and psychological threats previously discussed—are associated with war. Environmental exposures to oil well fire smoke in Gulf War I appear to increase the odds of asthma in female Gulf War veterans (Cowan, Lange, Heller, Kirkpatrick, & De Bakey, 2002). Risk for amyotrophic lateral sclerosis (Lou Gehrig’s disease) also is higher among veterans (Horner et al., 2003). Certain cancers (pancreatic and uterine) appear to be more common in nurses who were deployed to Vietnam, and nondeployed Vietnam-era nurses have higher-than-expected lung cancer mortality (Thomas, Kang, & Dalager, 1991). These data were extracted from secondary data and potential confounders could not be controlled in this retrospective analysis.


Many female soldiers currently deployed to areas of extreme danger and conflict are vulnerable to stress. This information should reach those who recruit and enroll women into the military. Although the majority of female soldiers will be resilient and recover from the stress of these deployments, some will develop stress responses as severe as PTSD. This is perpetuated by the occurrence of separation stress, sexual harassment, and assault and war-zone stress. PTSD symptoms can occur and remain chronic shortly after trauma exposure, or may appear years later. Within the military environment, women are taught ways in which to deal with war-zone stress, but the actual practice of these methods (which include relaxation, meditation, prayer, exercise, and good nutrition) is not monitored. It is important to understand who is at risk and how the symptomatology may manifest. A number of physical health comorbidities associated with the diagnosis of PTSD may appear many years later. These comorbidities may be prevented with adequate assessment and diagnosis of female veterans upon their return from deployment. Fragmentation of health care for the 1.7 million current female veterans remains a major problem, however. Most female veterans receive their routine health care from primary care providers, with less use of Veterans Administration healthcare services by younger women (Washington, Yano, Simon, & Sun, 2006). Within primary care practices, approximately one in every 100 female patients is a veteran, some of whom might be eligible for VA health services but choose non-VA healthcare providers instead (Murdoch et al., 2006). But most healthcare providers probably are unaware of their patients’ military backgrounds and the unique risks they may have that are related to their wartime service experiences and exposures.

The goals of rehabilitation nursing are to restore skills so people who have sustained illness or injury can regain maximum self-sufficiency and function. Caregivers who need to provide optimal health care to restore full normal functioning must know about the experiences and traumas of military women, particularly those who have served in war zones. This information also needs to be shared with other healthcare providers. It also is a nursing goal to prevent long-term chronic illness, which is an allostasis model prediction. Further studies of the stress experience and outcomes of women deployed to war zones is necessary. This research has implications for the health of women and their families.

About the Authors

Maureen Wimberly Groër, PhD RN FAAN, is the Gordon Keller Professor at the University of South Florida College of Nursing in Tampa, FL. Address correspondence to her at mgroer@health.usf.edu.

Candace Burns, PhD ARNP, is a colonel in the U.S. Army Reserve and professor at the University of South Florida College of Nursing in Tampa, FL.


Adler, A., Huffman, A., Bliese, P., & Castro, C. (2005). The impact of deployment length and experience on the well-being of male and female soldiers. Journal of Occupational Health Psychology, 10, 121–137.

Altemus, M., Dhabhar, F., & Yang, R. (2006). Immune function in PTSD. Annals of the New York Academy of Sciences, 1071, 167–183.

American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: American Psychiatric Association.

Baker, D., West, S., Nicholson, W., Ekhator, N., Kaschow, J., Hill, K., et al. (1999). Serial CSF corticotrophin releasing hormone levels and adrenocortical activity in combat veterans with posttraumatic stress disorder. American Journal of Psychiatry, 156, 585–588.

Bebbington, P. (1996). The origins of sex differences in depressive disorder: Bridging the gap. International Review of Psychiatry, 8, 295–332.

Benyamini, Y., & Solomon, Z. (2005). Combat stress reactions, posttraumatic stress disorder, cumulative life stress and physical health among Israeli veterans twenty years after exposure to combat. Social Science Medicine, 61, 1267–1277.

Black, D., Carney, C., Peloso P., Woolson, R., Schwartz, D., Voelker, M., et al. (2004). Gulf War veterans with anxiety: Prevalence, comorbidity, and risk factors. Epidemiology, 15, 135–142.

Black, P. H. (2006). The inflammatory consequences of psychologic stress: Relationship to insulin resistance, obesity, atherosclerosis and diabetes mellitus, type II. Medical Hypotheses, 67, 879–891.

Boscarino, J. (1996). Posttraumatic stress disorder, exposure to combat, and lower plasma cortisol among Vietnam veterans: Findings and clinical implications. Journal of Clinical and Consulting Psychology, 64, 191–201.

Boscarino, J. (2004). Posttraumatic stress disorder and physical illness: Results from clinical and epidemiologic studies. Annals of the New York Academy of Sciences, 1032, 141–153.

Cloitre, M., Cohen, L., Edelman, R., & Han, H. (2001). Posttraumatic stress disorder and extent of trauma exposure as correlates of medical problems and perceived health among women with childhood abuse. Women’s Health, 34, 1–17.

Cowan, D., Lange, J., Heller, J., Kirkpatrick, J., & De Bakey, S. (2002). A case-control study of asthma among U.S. Army Gulf War veterans and modeled exposure to oil well fire smoke. Military Medicine, 167, 777–782.

David, D., Woodward, C., Esquenazi, J., & Mellman, T. (2004). Comparison of comorbid physical illnesses among veterans with PTSD and veterans with alcohol dependence. Psychiatry Services, 55, 82–85.

Davidson, J., Hughes, D., George, L., & Blazer, D. (1996). The association of sexual assault and attempted suicide within the community. Archives of General Psychiatry, 53, 550–555.

Engel, C., Liu, X., McCarthy, B., Miller, R., & Ursano, R. (2000). Relationship of physical symptoms to posttraumatic stress disorder among veterans seeking care for Gulf War-related health concerns. Psychosomatic Medicine, 62, 739–745.

Everson, M., Kotler, S., & Blackburn, W. (1999). Stress and immune dysfunction in Gulf War veterans. Annals of the New York Academy of Sciences, 876, 413–418.

Everson, M., Shi, K., Aldridge, P., Bartolucci, A., & Blackburn, W. (2002). Immunological responses are not abnormal in symptomatic Gulf War veterans. Annals of the New York Academy of Sciences, 966, 327–342.

Frayne, S., Skinner, K., Sullivan, L., Tripp. T., Hankin, C., Kressin, N., et al. (1999). Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military. Journal of Women’s Health and Gender Based Medicine, 8, 835–845.

Friedman, M., & Schnurr, P. (1995). The relationship between trauma, posttraumatic stress disorder, and physical health. In M. Friedman, D. Charney, & A. Deutch (Eds.), Neurobiological and clinical consequences of stress from normal adaptation to post-traumatic stress disorder (pp. 507–524). Philadelphia: Lippincott-Raven.

Gahm, G., Lucenko, B., Retzlaff, P., & Fukuda, S. (2007). Relative impact of adverse events and screened symptoms of posttraumatic stress disorder and depression among active duty soldiers seeking mental health care. Journal of Clinical Psychology, 63, 199–211.

Goenjian, A., Yehuda, R., Pynoos, R., Steinberg, A., Tashjian, M., Yang, R., et al. (1996). Basal cortisol and dexamethasone suppression of cortisol among adolescents after the 1988 earthquake in Armenia. American Journal of Psychiatry, 153, 929–934.

Goldman, N., Glei, D. A., Seplaki, C., Liu, I. W., & Weinstein, M. (2005). Perceived stress and physiological dysregulation in older adults. Stress, 8, 95–105.

Green, C., Flowe-Valencia, H., Rosenblum, L., & Tait, A. (1999). Do physical and sexual abuse differentially affect chronic pain states in women? Journal of Pain Symptom Management, 18, 420–426.

Himmelfarb, N., Yaeger, D., & Mintz, J. (2006). Posttraumatic stress disorder in female veterans with military and civilian sexual trauma. Journal of Traumatic Stress, 19, 837–846.

Hoge, C., Castro, C., Messer, S., McGurk, D., Cotting, D., & Koffman, R. (2004). Combat duty inIraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13–22.

Hoge, C., Terhakopian, A., Castro, C., Messer, S., & Engel, C. (2007). Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq War veterans. American Journal of Psychiatry, 164, 150–153.

Holbrook, T., Hoyt, D., Stein, M., & Sieber, W. (2002). Gender differences in long-term posttraumatic stress disorder outcomes after major trauma: Women are at higher risk of adverse outcomes than men. Journal of Trauma, 53, 882–888.

Hyer, L., McCranie, E., & Peralme, L. (1993). Dual diagnosis: PTSD and alcohol abuse. NCP Clinical Newsletter, 3, 3–4.

Horner, R., Kamins, K., Feussner, J., Grambow, S., Hoff-Lindquist, J., Harati, Y., et al. (2003). Occurrence of amyotrophic lateral sclerosis among Gulf War veterans. Neurology, 61, 742–749.

Institute of Medicine. (2006). Posttraumatic stress disorder: Diagnosis and assessment. Washington, DC: The National Academies Press.

Kellner, M., Baker, D., & Yehuda, R. (1997). Salivary cortisol in Desert Storm returnees. Biological Psychiatry, 41, 849–850.

Killgore, W., Stetz, M., Castro, C., & Hoge, C. (2006). The effects of prior combat experience on the expression of somatic and affective symptoms in deploying soldiers. Journal of Psychosomatic Research, 60, 379–385.

Koss, M., & Heslet, L. (1992). Somatic consequences of violence against women. Archives of Family Medicine, 1, 53–59.

Kosten, T., Mason, J., Giller, E., Ostroff, R., & Harkness, L. (1987). Sustained urinary norepinephrine and epinephrine elevation in post-traumatic stress disorder. Psychoneuroendocrinology, 12, 13–20.

Lampe, A., Solder, E., Ennemoser, A., Shubert, C., Rumpold, G., & Sollner, W. (2000). Chronic pelvic pain and previous sexual assault. Obstetrics and Gynecology, 96, 929–933.

Landys, M., Ramenofsky, M., & Wingfield, J. (2006). Actions of glucocorticoids at a seasonal baseline as compared to stress-related levels in the regulation of periodic life processes. General and Comparative Endocrinoogy, 148, 132–149.

Maes, M., Lin, A., Delmeire, L., Van Gastel, A., Kenis, G., De Jongh, R., et al. (1999). Elevated serum interleukin-6 (IL-6) and IL-6 receptor concentrations in posttraumatic stress disorder following accidental man-made traumatic events. Biological Psychiatry, 45, 833–839.

McEwen, B. (2000). Effects of adverse experiences for brain structure and function. Biological Psychiatry, 48, 721–731.

McEwen, B., & Seeman, T. (1999). Protective and damaging effects of mediators of stress. Elaborating and testing the concepts of allostasis and allostatic load. Annals of the New York Academy of Sciences, 896, 30–47.

McEwen, B., & Wingfield, J. (2003). The concept of allostasis in biology and biomedicine. Hormones and Behavior, 43, 2–15.

Merrill, L., Newell, C., Milner, J., Koss, M., Hervig, L., Gold, S., et al. (1998). Prevalence of premilitary adult sexual victimization and aggression in a Navy recruit sample. Military Medicine, 163, 209–212.

Murdoch, M., Bradley, A., Mather, S., Klein, R., Turner, C., & Yano, E. (2006). Women and war. What physicians should know. Journal of General Internal Medicine, 21(Suppl. 3), S5–S10.

Murdoch, M., Hodges, J., Hunt, C., Cowper, D., Kressin, N., & O’Brien, N. (2003). Gender differences in service connection for PTSD. Medical Care, 41, 950–961.

Office of the Deputy Under Secretary of Defense. (2007). Department of Defense demographics report: FY 2006. Retrieved March 1, 2009, from https://cs.mhf.dod.mil/content/dav/mhf/QOL-Library/Project%20Documents/MilitaryHOMEFRONT/Reports/2006%20Demographics.pdf.

Perry, B., Giller, E., & Southwick, S. (1987). Altered platelet alpha 2-adrenergic binding sites in posttraumatic stress disorder. American Journal of Psychiatry, 144, 1511–1512.

Pessin, A. (2005). Role of women in US military gets renewed debate. Retrieved January 29, 2008, from www.voanews.com/english/archive/2005-05/2005-05-31-voa49.cfm?CFID=180138346&CFTOKEN=52077193.

Pierce, P. F. (2005). Monitoring the health of Persian Gulf War veteran women. Federal Nursing Service Award. Military Medicine, 170, 349–354.

Resnick, H., Yehuda, R., Pitman, R., & Foy, D. (1995). Effect of previous trauma on acute plasma cortisol level following rape. American Journal of Psychiatry, 152, 1675–1677.

Sadler, A., Booth, B., Cook, B., & Doebbeling, B. (2003). Factors associated with women’s risk of rape in the military environment. American Journal of Industrial Medicine, 43, 262–273.

Sadler, A., Booth, B., & Doebbeling, B. (2005). Gang and multiple rapes during military service: Health consequences and health care. Journal of the American Medical Women’s Association, 60, 33–41.

Sadler, A., Booth, B., Mengeling, M., & Doebbeling, B. (2004). Life span and repeated violence against women during military service: Effects on health status and outpatient utilization. Journal of Women’s Health, 13, 799–811.

Sadler, A. G., Booth, B. M., Nielson, D., & Doebbeling, B. N. (2000). Health-related consequences of physical and sexual violence: Women in the military. Obstetrics and Gynecology, 96, 473–480.

Scharnberg, K. (2005). Women GIs and post-traumatic stress disorder. Retrieved March 4, 2009, from www.military.com/NewContent/0,13190,Defensewatch_032805_Scharnberg,00.html.

Southwick, S., & Yehuda, R. (1997). Situation of threat. NCP Clinical Quarterly, 7, 1–7.

Spivak, B., Shohat, B., Mester, R., Avraham, S., Gil-Ad, I., Bleich, A., et al. (1997). Elevated levels of serum interleukin-1ß in combat-related post-traumatic stress disorder. Biological Psychiatry, 42, 345–348.

Stander, V., Merrill, L., Thomsen, C., Crouch, J., & Milner, J. (2007). Premilitary sexual assault and attrition in the U.S. Navy. Military Medicine, 172, 254–258.

Stanley, S., Allen, E., Markman, H., Saiz, C., Bloomstrom, G., Thomas, R., et al. (2005). Dissemination and evaluation of marriage education in the army. Family Process, 44, 187–201.

Stein, M., & Barrett-Connor, E. (2000). Sexual assault and physical health: Findings from a population-based study of older adults. Psychomatic Medicine, 62, 838–843.

Stewart, J. A. (2006). The detrimental effects of allostasis: Allostatic load as a measure of cumulative stress. Journal of Physiological Anthropology, 25, 133–145.

Stroud, L. R., Salovey, P., & Epel, E. S. (2002). Sex differences in stress responses: Social rejection versus achievement stress. Biological Psychiatry, 52, 318–327.

Suzuki, K., Nakaji, S., Yamada, M., Totsuka, M., Sato, K., & Sugawara, K. (2002). Systemic inflammatory responses to exhaustive exercise: Cytokine kinetics. Exercise Immunology Review, 8, 6–48.

Thomas, H., Stimpson, N., Weightman, A., Dunstan, F., & Lewis, G. (2006). Systematic review of multi-symptom conditions in Gulf War veterans. Psychological Medicine, 36, 735–747.

Thomas, T., Kang, H., & Dalager, N. (1991). Mortality among women Vietnam veterans, 1973–1987. American Journal of Epidemiology, 134, 973–980.

Turner, M., Kiernan, M., McKechanie, A., Finch, P., McManus, F., & Neal, L. (2005). Acute military psychiatric casualties from the war in Iraq. The British Journal of Psychiatry, 186, 476–479.

U.S. Goverment Accountability Office. (2005). Military personnel reporting additional service member demographics could enhance congressional oversight. GAO-05-952, United States Government Accountability Office, Report to Congressional Requesters, September, 2005.

Vasterling, J., Proctor, S., Amorosa, P., Kane, R., Heeren, T., & White, R. (2006). Neuropsychological outcomes of army personnel following deployment to the Iraq war. Journal of the American Medical Association, 296, 519–528.

Vogt, D., Pless, A., King, L., & King, D. (2005). Deployment stressors, gender, and mental health outcomes among Gulf War I veterans. Journal of Traumatic Stress, 18, 115–127.

Walsh, S. J., & Rau, L. M. (2000). Autoimmune diseases: A leading cause of death among young and middle aged women in the United States. American Journal of Public Health, 90, 1463–1466.

Washington, D., Yano, E., Simon, B., & Sun, S. (2006). To use or not to use. What influences why women veterans choose VA health care. Journal of General Internal Medicine, 21(Suppl. 3), S11–S18.

Wolfe, J., Erickson, D., Sharkansky, E., King, D., & King , L. (1999). Course and predictors of posttraumatic stress disorder among Gulf War veterans: A prospective analysis. Journal of Consulting and Clinical Psychology, 67, 520–528.

Wust, S., Federenko, I., Hellhammer, D. H., & Kirschbaum, C. (2000). Genetic factors, perceived chronic stress, and the free cortisol response to awakening. Psychoneuroendocrinology, 25, 707–720.

Wynd, C., & Dziedzicki, R. (1992). Heightened anxiety in Army Reserve nurses anticipating mobilization during Operation Desert Storm. Military Medicine, 157, 630–634.

Yehuda, R. (1997). Sensitization of the hypothalamic-pituitary-adrenal axis in posttraumatic stress disorder. Annals of the New York Academy of Sciences, 821, 437–441.

Yehuda, R., Resnick, H., Schmeidler, J., Yang, R., & Pitman, R. (1998). Predictors of cortisol and 3-mthoxy-4-hydroxy-phenylglycol responses in the acute aftermath of rape. Biological Psychiatry, 43, 855–859.