Journal of Counseling Psychology 2014, Vol. 61, No. 3, 392-403

In the public domain DOI: 10.1037/cou0000019

Trauma, Posttraumatic Stress Disorder, and Depression Among Sexual Minority and Heterosexual Women Veterans Keren Lehavot and Tracy L. Simpson VA Puget Sound Health Care System, Seattle, Washington, and University of Washington

This study examined the impact of various traumas across the life span on screening positive for current posttraumatic stress disorder (PTSD) and depression among heterosexual and sexual minority women veterans. Women veterans were recruited over the Internet (N = 706, 37% lesbian or bisexual) to participate in an anonymous, online survey. We assessed childhood trauma; adult sexual assault and adult physical victimization before, during, and after the military; combat exposure; perceived sexist discrim­ ination during military service; sexual minority military stressors; past-year sexist events; and whether participants screened positive for PTSD or depression. Binary logistic regressions were used to generate odds ratios and 95% confidence intervals for PTSD and depression, stratified by sexual orientation and controlling for demographic characteristics. Lesbian and bisexual women reported higher rates of trauma across the life span, although in some instances (e.g., sexual assault during and after military service, combat exposure), they did not differ from their heterosexual counterparts. Childhood trauma and traumas that occurred during military service added the most variance to both PTSD and depression models. Sexual assault during military service appeared to be especially harmful with respect to screening positive for PTSD for both sexual orientation groups. Results revealed a number of other predictors of mental health status for women veterans, some of which differed by sexual orientation. Findings indicate a significant burden of interpersonal trauma for both heterosexual and lesbian/bisexual women veterans and provide information on the distinct association of various traumas with current PTSD and depression by sexual orientation. Keywords: women veterans, lesbian and bisexual, PTSD, depression, trauma

Women veterans are a rapidly growing segment of the U.S. veteran population, currently accounting for 8% of veterans and estimated to reach 14% of this population by 2033 (Yano et al., 2010). A large proportion of women veterans identify as lesbian or bisexual (LB; Blosnich, Bossarte, Silver, & Silenzio, 2013; Gates, 2010). Data from the Behavioral Risk Factor and Surveillance Survey indicated that among veterans in same-sex relationships, 25% were female, whereas only 6% of veterans in opposite-sex relationships were female (Blosnich et al., 2013). Despite their rising numbers, our knowledge of women veterans’ health needs is

limited, and only a handful of studies have been conducted on sexual minority veterans (Goldzweig, Balekian, Rolon, Yano, & Shekelle, 2006; Lehavot & Simpson, 2013). These underrepre­ sented populations may be of significant interest to counseling psychologists, many of whom work and train in the Veterans Health Administration (VA) and in communities where veterans seek services. In this study, we examined the differential impact of various traumatic experiences across the life span (pre-, during, and postmilitary service) on screening positive for posttraumatic stress disorder (PTSD) and depression—two highly prevalent con­ ditions—for both heterosexual and LB women veterans.

Women Veterans, Trauma, and Mental Health Keren Lehavot, Mental Illness Research, Education, and Clinical Center (MIRECC), VA Puget Sound Health Care System, Seattle, Washington, and Department of Psychiatry and Behavioral Sciences, University of Washington; Tracy L. Simpson, MIRECC and Center of Excellence in Substance Abuse Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, Washington, and Department of Psychiatry and Behavioral Sciences, University of Washington. This material is the result of work supported by resources from the U.S. Department of Veterans Affairs Office of Academic Affiliations, Ad­ vanced Fellowship Program in Mental Illness Research and Treatment, and the VA Puget Sound Health Care System, Seattle, Washington. The views expressed in this article are those of the authors and do not represent the views of the Department of Veterans Affairs or the United States govern­ ment. Correspondence concerning this article should be addressed to Keren Lehavot, 1660 South Columbian Way (S-116-POC), Seattle, WA 98108. E-mail: [email protected]

Women veterans are exposed to high rates of trauma, including events preceding and following military service (e.g., childhood abuse, adult sexual and physical assault) as well as military-related incidents (e.g., military sexual trauma [MST], combat exposure). Almost all women veterans report at least one traumatic event at some point in their lives (81 %—93%; Zinzow, Grubaugh, Monnier, Suffoletta-Maierle, & Frueh, 2007). Several studies demonstrate that they report greater likelihood of nonmilitary trauma than civilian women, and nearly one quarter report that they joined the military to escape an abusive home life (Dichter, Cerulli, & Bossarte, 2011; Sadler, Booth, Mengeling, & Doebbeling, 2004; Schultz, Bell, Naugle, & Polusny, 2006). During service, the estimated prevalence of MST ranges from 30% in a representative sample of women veterans (Sadler et al., 2004) to 71% in a PTSD disability-seeking sample (Murdoch, Polusny, Hodges, & O’Brien, 392

TRAUMA, PTSD, AND DEPRESSION AMONG WOMEN VETERANS

2004). Although women are less likely to experience multiple instances of combat exposure than men, they are just as likely to experience at least one instance of combat exposure when de­ ployed (Vogt, Pless, King, & King, 2005). Although less overt than assault or combat, women veterans face other types of experiences by virtue of their gender that may impact their mental health, such as discrimination and sexism. These experiences fall on the spectrum of gender-based violence, a term introduced in 1993 that describes violence against women as “any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women including threats of such acts, coercion, or arbitrary depri­ vations of liberty” (United Nations, 1993, p. 1). For example, women veterans have reported experiencing stressors such as sexual harassment or coercion being tied to opportunities for promotion (Mattocks, Haskell, Krebs, Justics, & Yano, 2012). Military vocabulary has also been described as laden with denigrations of feminine traits and gender slurs (Ashford & HuetVaughn, 2000). These high rates of exposure to trauma and gender-based vio­ lence place women veterans at increased risk for poor mental health. Two recent studies demonstrated that, compared with ci­ vilians, women veterans report worse health-related quality of life and greater likelihood of having depressive and anxiety disorders (Lehavot, Hoerster, Nelson, Jakupcak, & Simpson, 2012; Shen & Sambamoorthi, 2012). Elevated rates of current PTSD (e.g., 21%33%; Davis, Bush, Kivlahan, Dobie, & Bradley, 2003; Dobie et ah, 2004) and current depression (e.g., 7%-29%; Bader, Ragsdale, & Franchina, 2001; Davis et al., 2003; Grubaugh, Monnier, Magruder, Knapp, & Frueh, 2006) are relatively common.

LB Women, Trauma, and Mental Health In the general population, LB women are recognized as a minority group at significant risk for increased exposure to vio­ lence and multiple health disparities (Institute of Medicine, 2011). Several studies have demonstrated that LB women are more likely to report sexual and physical abuse than heterosexual women in both childhood and adulthood (e.g., Balsam, Rothblum, & Beauchaine, 2005; Moracco, Runyan, Bowling, & Earp, 2007). More­ over, minority stress theory posits that sexual minorities are ex­ posed to added environmental stress because of their sexual minority status, which in turn leads to mental health problems (Meyer, 2003). Such stressors include overt experiences of dis­ crimination as well as internalized feelings of anxiety or shame and hiding one’s sexuality from others. LB women who have served in the military may be especially likely to have been exposed to assault, discrimination, and minor­ ity stressors that could impact their mental health. Although “Don’t’ Ask Don’t Tell”—the policy that precluded lesbian, gay, and bisexual (LGB) individuals from serving openly—was re­ pealed in 2011 (NBC News, 2011), the military has a long history of discharging LGB individuals for their sexual minority status. Discrimination within the military also appears to be common, with one study reporting that nearly half of LGB veterans reported experiences of discrimination in the military and 47% reported at least one experience of assault (American Psychological Associ­ ation Joint Divisional Task Force on Sexual Orientation and Mil­ itary Service, 2009). Another study indicated that both male and

393

female LGB veterans were more likely to screen positive for PTSD and depression than a comparison sample of veterans and that negative military experiences related to one’s sexual orientation were associated with these mental health symptoms (Cochran, Balsam, Flentje, Malte, & Simpson, 2013). We know of only a few studies to date in which LB and heterosexual women veterans have been compared, two of which assessed trauma and/or mental health. One study revealed that rates of lifetime rape were significantly higher among women veterans who ever had a female sexual partner compared with those who only had male partners (73% vs. 48%; Booth, Mengeling, Torner, & Sadler, 2011). Another study with Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women veterans revealed that self-identified LB women reported signifi­ cantly higher rates of childhood sexual abuse and MST than heterosexual women (Mattocks et al., 2013).

Trauma Type and Mental Health Given the high rates of trauma that both heterosexual and LB women veterans likely encounter, learning which trauma types have the greatest impact on PTSD and depression has important clinical implications. Although all trauma experiences are ad­ verse and worthy of addressing, they may not all have a similar impact on mental health. If this is the case, such information could alert clinicians to the type of trauma (e.g., childhood, adult assault, combat) that might be exerting the most influence on PTSD or depression for a specific patient population and thus needs to be specifically targeted in treatment. It may also provide useful data for policy makers, educational campaigns, and organizations determining priorities for prevention efforts. A few studies have examined the differential impact of trauma type on mental health among women veterans, although none have examined the role of sexual orientation. One study of women veterans revealed that sexual assault in childhood was associated with a fivefold increased risk in PTSD diagnosis, adult civilian sexual assault with a sevenfold increased risk, and sexual assault during military service with a ninefold increased risk (Surfs, Lind, Kashner, Borman, & Petty, 2004). Nonethe­ less, this study did not consider the impact of nonsexual trau­ matic events, nor did the analyses adjust for the various sexual assault experiences simultaneously. In another study, Dutra and colleagues (2011) found that military sexual harassment was more strongly associated with PTSD than combat exposure in a small sample of active duty women, although other traumatic events were not assessed. Similarly, a study with both male and female OEF/OIF veterans revealed that combat exposure was not uniquely associated with PTSD or depression, whereas sexual harassment and assault during deployment were associ­ ated with depression (Vogt et al., 2011). This study, however, also did not examine other typical traumas reported by women veterans, such as physical assaults and childhood trauma. Un­ like these previous findings, Hassija and colleagues (2012) found that combat exposure, but not childhood trauma or adult sexual and physical assault, was associated with PTSD and depressive symptoms among treatment-seeking OEF/OIF and Gulf War women veterans. Nonetheless, this study did not distinguish between assaults taking place before, during, or after military service. Taken together, it remains unclear which

LEHAVOT AND SIMPSON

394

trauma experiences may be especially pernicious for women veterans, especially when considering a diverse national sam­ ple. In the current study, we sought to (a) examine differences in trauma exposures and mental health by sexual orientation and (b) evaluate the impact of various types of traumatic events across the life span on screening positive for PTSD and depres­ sion, stratified by sexual orientation. Examining rates of trauma exposures and mental health by sexual orientation is an essen­ tial first step to advance our knowledge of both LB and het­ erosexual veterans, whereas evaluating the differential effects of traumas on mental health for these groups can help inform future intervention efforts. We focused on traumatic events known to impact women’s mental health, including childhood trauma; adult sexual and physical victimization before, during, and after military service; combat exposure; discrimination during military service; and past-year sexist events. With re­ spect to discrimination, all women were asked about the degree to which they were isolated or encountered discrimination by virtue of being a woman during military service, and LB women were additionally asked about the degree of anxiety and con­ cealment they experienced in the military as a result of their sexual orientation, in line with minority stress theory. We expected LB women veterans to report higher rates of trauma exposure and mental health problems but did not theorize that the types of traumas impacting PTSD and depression would differ by sexual orientation. Moreover, we hypothesized that sexual assault during military service would uniquely predict positive PTSD and depression screenings for both LB and heterosexual veterans, given extant literature suggesting its robust influence. We improve on the existing literature by including multiple trauma types in the same analysis, examin­ ing both PTSD and depression as outcomes, incorporating sex­ ual orientation as an important factor both by group definition and by including an additional measure for the LB women, and using a large, national sample of women veterans.

Method Procedure and Participants Data were collected via a web-based survey about women veterans’ health between February and May 2013. The study was advertised as an anonymous survey focused on the unique life experiences of women who had served in the military, and ads specifically targeting LB women veterans were also used. Ads were disseminated using Facebook advertising as well as through Listervs and online groups serving veterans, women veterans, LGB veterans, and the wider LGB community. Participants who followed the survey link provided in the ad were taken to a web-based information statement, which explained eligibility cri­ teria (age 18 or older; biologically born female and current iden­ tification as a woman; living in the United States; and a veteran of the U.S. armed forces), the anonymous nature of the survey, and risks and benefits of participating. The survey took approximately 40 minutes to complete, and women were not compensated for participating. The research was approved by the Institutional Re­ view Board at VA Puget Sound Health Care System.

A total of 1,145 individuals entered the survey, and of these, 918 participated. Seventeen individuals were ineligible because they were transgender (n = 10); underage (n = 1); or did not identify their birth sex, current gender, or both (n = 6). Of the remaining 901 eligible participants, 195 identified their sexual orientation as “other” (n = 14), did not provide information on their sexual orientation (n = 8), or did not complete neither the PTSD nor the depression items (n = 173), leaving a final sample of 706 women veterans. Compared with the 706 women in the final sample, the 195 excluded women were on average younger, more likely to be racial minorities, and less likely to have a postgraduate education (all ps < .05). There were no differences on marital status, income, or military branch between the two groups. Missing data were rare for the 706 women in the final sample, ranging from n = 1 (50) as an indicator of a positive screen for PTSD, which has been similarly used with other samples of women veterans (e.g., Dobie et al., 2004; Vogt et al., 2005). Depression. The eight-item Patient Health Questionnaire (PHQ-8; Kroenke, Spitzer, & Williams, 2001; Kroenke et al., 2009) was used to screen for depression. The measure assesses how often the participant has been bothered by a range of depres­ sive symptoms (e.g., “little interest or pleasure in doing things,” “feeling down, depressed, or hopeless”) ranging from 0 (not at all) to 3 (nearly every day) over the last 2 weeks, with higher scores indicating greater depressive symptoms. The PHQ-8 has demon­ strated similar operating characteristics to the well-validated PHQ-9, which is identical to the PHQ-8 but includes one addi­ tional item on suicidal ideation and whose internal reliability has been reported to be .86-.89 and test-retest reliability to be .84 (Kroenke & Spitzer, 2002; Kroenke et al., 2001). The PHQ-8 also has good construct validity, as evidenced by substantial impair­ ment across multiple domains of health-related quality of life for those classified as depressed (Kroenke et al., 2009). Cronbach’s alpha in the current study was .94. A cutoff point of 10 or higher has been identified as optimal for defining current depression and was used as an indicator of a positive screen (Kroenke et al., 2009).

Analysis Participant characteristics were compared for women veterans by sexual orientation (LB vs. heterosexual), PTSD status ( < .05. * > < . 0 1 . * * > < .0 0 1 .

TRAUMA, PTSD, AND DEPRESSION AMONG WOMEN VETERANS with those who did not screen positive. LB women (vs. hetero­ sexual women) and those screening positive for PTSD (vs. those who did not) were also more likely to have served in the Army. Women who screened positive for PTSD and depression were less likely to have a postgraduate education compared with those who did not screen positive. Thus, age, marital status, income, educa­ tion, and service in the Army were included as demographic covariates in multivariate analyses.

397

82% also screened positive for depression, whereas 75% of those screening positive for depression also screened positive for PTSD.

PTSD and Depression Models Table 3 presents hierarchical, logistic regression models for PTSD and depression by sexual orientation. For all four models, demographic characteristics were entered on the first step, child­ hood trauma on the second step, adult victimization variables that took place before the military on the third step, victimization variables that took place during the military on the fourth step, and victimization variables that took place after the military on the fifth step. Collinearity diagnostics confirmed that variance inflation factor (VIF) and tolerance values for all trauma variables were within acceptable limits (VIF values between 1.06 and 1.56; tol­ erance values between .64 and .94). PTSD. For both heterosexual and LB women veterans, vari­ ables that predicted screening positive for PTSD in a multivariate context included childhood trauma, sexual assault during the mil­ itary, physical victimization during the military, and past-year sexist events. Combat exposure was uniquely predictive of PTSD status for LB women only, and physical victimization after the military was uniquely predictive of PTSD for heterosexual women only. Moreover, serving in the Army (vs. other branches of the military) was associated with PTSD for heterosexual but not LB women, whereas lower income was associated with PTSD for LB but not heterosexual women when taking all other variables into consideration. Notably, sexual assault during military service had the highest odds ratio for both heterosexual (AOR = 2.53) and LB (AOR = 4.10) women in increasing risk for PTSD, and was especially high for the LB women. The final PTSD models ac­ counted for 35% of the variance for heterosexual women and 36% of the variance for LB women. For both groups, trauma variables that occurred during the military added the most amount of vari­ ance to the model (11% added variance for heterosexual women, 16% added variance for LB women). Depression. Similar to the PTSD models, serving in the Army was associated with depression for heterosexual but not LB women, whereas lower income was associated with depression for

Bivariate Relationships Between Trauma Variables and Sexual Orientation, PTSD, and Depression Table 2 provides descriptive information on trauma variables by sexual orientation, PTSD status, and depression status. Compared with heterosexual women veterans, LB women reported higher rates of childhood trauma and higher rates of adult sexual assault and physical victimization before entering the military. During military service, they reported higher rates of physical victimiza­ tion but similar rates of sexual assault, combat exposure, and discrimination due to being a woman. After the military, they reported higher rates of physical victimization and past-year sexist events than heterosexual women, but did not differ on rates of sexual assault. Notably, rates of sexual assault were highest for both LB and heterosexual women during military service, and decreased substantially afterward (from 42% to 14% for LB women and from 38% to 16% for heterosexual women). LB women were also more likely to screen positive for depression than heterosexual women, although there were no statistically significant differences between the two groups on PTSD status. Women screening positive for PTSD and those screening pos­ itive for depression were more likely than those not screening positive for these conditions to report higher levels of trauma exposure for all measures. Among the LB women only, those screening positive for PTSD scored higher on the LGB Military Stressors scale than those who did not screen positive (M = 3.46, SD = 0.89 vs. M = 3.08, SD = 0.87), f(256) = -3 .4 2 , p = .001, as did those who screened positive for depression versus those who did not (M = 3.36, SD = 0.92 vs. M = 3.08, SD = 0.89), f(255) = —2.44, p < .05. Of those screening positive for PTSD,

Table 2 Main Study Variables by Sexual Orientation, PTSD, and Depression Variable

Lesbian/Bisexual (n = 264)

Heterosexual (n = 442)

PTSD (n = 233)

No PTSD (n = 447)

Depression (n = 260)

No depression (n = 438)

Childhood trauma, M (SD) ASA before military, % APV before military, % ASA during military, % APV during military, % Combat, % WWSS, M (SD) ASA after military, % APV after military, % Past-year sexist events, M (SD) PTSD, % Depression, %

2.31 (0.93)*** 34** 54*** 42 60* 35 1.66 (1.24) 14 57** 1.89 (0.80)* 39 44**

1.97 (0.84) 24 41 38 52 35 1.54 (1.29) 16 45 1.76 (0.81) 32 34

2.53 (0.97)*** 42*** 62*** 65*** 80*** 47*** 2.27(1.30)*** 27*** 70*** 2.29 (0.96)***

1.88 (0.75)

1.86 (0.75)

38 28 44 30 1.25 (1.12) 9 38 1.57 (0.56)

2.49 (0.96)*** 41*** 60*** 5 9 *** 76*** 42*** 2.18 (1.28)*** 24*** 6 8 *** 2.19 (0.96)*** 75***

82***

14

21

21

37 29 42 30 1.24 (1.13) 11

38 1.58 (0.59) 10

Note. PTSD = posttraumatic stress disorder; ASA = adult sexual assault; APV = adult physical victimization; WWSS = Women’s Wartime Stressor Scale. *p < .05. * > < .0 1 . **> < .001.

LEHAVOT AND SIMPSON

398

Table 3 Logistic Regression Models fo r PTSD and Depression Among Heterosexual and Lesbian/Bisexual Women Veterans Heterosexual Block

AOR

1. Age Marital status Education Income Army 2. Childhood trauma 3. ASA before military APV before military 4. ASA during military APV during military Combat WWSS LGB military stressors 5. ASA after military APV after military Past-year sexist events

0.98 1.11 0.75 0.81

[0.96, [0.59, [0.54, [0.63,

2.31 1.49

[ 1.31 , 4 .09] [ 1.03 , 2 . 15]

1.43 0.72

[0.75, 2.72] [0.39, 1.35]

2.53 2.10

[ 1.39 , 4 .60] [ 1.09 , 4 .07 ]

1.20 1.25

[0.65, 2.20] [0.97, 1.62]

[95% Cl]

Lesbian/Bisexual Cox & Snell R2

AOR

[95% Cl]

Cox & Snell R2

1.00 0.87 0.84

[0.97, 1.03] [0.39, 1.93] [0.54, 1.31]

.06

0.69

[0 .51 , 0 .93 ]

PTSD

L Age Marital status Education Income Army 2. Childhood trauma 3. ASA before military APV before military 4. ASA during military APV during military Combat WWSS LGB military stressors 5. ASA after military APV after military Past-year sexist events

1.00] 2.11] 1.03] 1.03]

1.20

[0.56, 2.60]

2.02 1.88

[ 1.08 , 3 .80] [ 1.25 , 2 .82]

1.00 0.92 0.78 0.82

[0.98. [0.51, [0.57, [0.65,

1.82 1.72

[ 1.07 , 3 . 11] [ 1.21, 2 .45 ]

1.79 0.68 1.68

[0.97, 3.30] [0.38, 1.23] [0.95, 2.96]

2.14

[ 1. 16, 3 .96]

1.02] 1.68] 1.05] 1.03]

.11

.19 .21 .32

.35

Depression .08

.18 .20 .31

1.34

[0.67, 2.71]

1.74

[ 1. 18, 2 .58 ]

0.77 1.45

[0.36, 1.67] [0.68, 3.07]

4.10 2.43 3.27

[ 1.96, 8 .61 ] [ 1. 11, 5 .33 ] [ 1.48 , 7 .21 ]

1.10 1.42 1.65 0.58

[0.79, [0.93, [0.57, [0.27,

2.41

[ 1.39, 4 . 19]

1.00 1.35 0.86

[0.98, 1.03] [0.66, 2.75] [0.59, 1.25]

0.62

[0 .48 , 0 .82 ]

0.96

[0.52, 1.78]

1.52

[ 1.07 , 2 . 16]

0.70 1.52

[0.35, 1.40] [0.79, 2.93]

2.50

[ 1.29 , 4 .86 ]

[0.90, [0.83, [0.79, [0.85, [0.31, [0.53,

[ 1.05, 2 .45 ]

1.33

[0.75, 2.38]

1.54

[ 1.20 , 1.98]

0.87

[0.41, 1.82]

1.79

[ 1.00 , 3 .21]

1.77 1.62 1.06 1.22 0.78 1.03

1.38

[0.93, 2.03]

1.60

.33

1.53] 2.16] 4.78] 1.27]

3.48] 3.18] 1.41] 1.74] 1.97] 2.00]

.16 .17 .33

.36

.07

.14 .15 .23

.25

Note. Marital status, Army, ASA, APV, and combat were scored such that 0 = no and 1 = yes. PTSD = posttraumatic stress disorder; AOR = adjusted odds ratio; Cl = confidence interval; ASA = adult sexual assault; APV = adult physical victimization; WWSS = Women’s Wartime Stressor Scale; LGB = lesbian, gay, and bisexual. Adjusted odds ratios from final regression equation; significant values are in bold.

LB but not heterosexual women. For both groups, childhood trauma was a significant predictor of screening positive for de­ pression, with a one-unit increase in the CTQ increasing the odds of a positive screen by 1.72 for heterosexual women and by 1.52 for LB women. For heterosexual women, physical victimization both during and after the military were each associated with increased odds of depression, as was greater perceived discrimi­ nation during the. service due to being a woman. For LB women, sexual assault during military service and past-year sexist events were associated with screening positive for depression. The final depression models accounted for 33% of the variance for hetero­ sexual women and 25% of the variance for LB women. For both groups, childhood trauma and trauma variables that occurred dur­ ing military service added more variance to the model than trauma variables that occurred during adulthood either before or after the military.

Discussion In this study, we examined differences in traumatic events and mental health for LB versus heterosexual women veterans and

assessed the relative impact of the traumatic events on screening positive for current PTSD and depression for the two groups. Rates of trauma were alarmingly high in our sample of women veterans. Approximately one third of LB women and one quarter of hetero­ sexual women reported adult sexual assault prior to the military, whereas 38%-42% reported sexual assault during military service. Rates of physical victimization were even higher, with 60% of LB women and 52% of heterosexual women reporting such exposure during military service. Although LB women were significantly more likely to report higher rates of trauma than heterosexual women in most instances (i.e., childhood trauma; adult sexual assault before the military; adult physical victimization before, during, and after the military; and past-year sexist events), there were some similarities, including similar rates of combat exposure and sexual assault during and after military service. In addition to the overall high rates of trauma in the sample, current positive screens for PTSD (39% LB, 32% heterosexual) and depression (44% LB, 34% heterosexual)— using stringent cutoff criteria— were higher than what has previously been reported in the litera­ ture for women veterans (Bader et al., 2001; Davis et al., 2003;

TRAUMA, PTSD, AND DEPRESSION AMONG WOMEN VETERANS

Dobie et al., 2004; Grubaugh et al., 2006). Plausible explanations for these elevated rates might be increased awareness of mental health issues as a result of the VA’s strong outreach efforts or completion of the survey items in a private or home setting versus a clinical setting, although such possibilities need to be further examined.

Interpersonal Traumas Multivariate analyses predicting positive PTSD and depression screens for LB and heterosexual women revealed both similarities and differences between the two groups. Childhood trauma was a significant predictor of both PTSD and depression for both sexual orientation groups, even in the context of multiple other trauma variables. This finding is consistent with a large literature suggest­ ing that childhood abuse is detrimental for adult mental health and has a host of negative consequences (Balsam, Lehavot, Beadnell, & Circo, 2010; Hillberg, Hamilton-Giachritsis, & Dixon, 2011). Studies examining ways through which childhood trauma leads to adult psychopathology among women have highlighted the medi­ ating roles of decreased social support, increased stress in adult­ hood, and dysregulation of the hypothalamic-pituitary-adrenal axis (Shea, Walsh, MacMillan, & Steiner, 2005; Vranceanu, Hobfoll, & Johnson, 2007). These may be especially important issues to consider for women veterans, given previous research suggesting longer durations of childhood abuse and greater likelihood of being sexually abused by a parental figure compared with civilians (Schultz et al., 2006). Sexual assault during military service was a significant predictor of PTSD for both heterosexual and LB women veterans, as well as a significant predictor of depression for LB women. In fact, in all three of these multivariate models, sexual assault during military service had the highest odds ratio compared with all other vari­ ables. This finding parallels several other studies that have also indicated that sexual assault during military service is uniquely associated with adverse mental health (e.g., Dutra et al., 2011; Surfs et al., 2004; Vogt et al., 2011). In two studies with women veterans with PTSD, MST was identified as the most traumatic event experienced during service compared with other traumas (Fomeris, Butterfield, & Bosworth, 2004; Yaeger, Himmelfarb, Cammack, & Mintz, 2006). Moreover, although sexual assault during the military was associated with PTSD for both heterosex­ ual and LB women, our findings indicate that this relationship may be stronger for LB women. One potential explanation for this is that military sexual assaults directed toward LB women may have been more likely to be motivated or perceived to be motivated by the woman’s sexual orientation (e.g., as a “punishment” or “les­ son”). Among sexual minorities, victimization that is perceived to be due to sexual orientation has been found to result in poorer mental health symptoms than victimization that is perceived not to be related to sexual orientation (Herek, Gillis, & Cogan, 1999). In addition to sexual assault, adult physical victimization both during and after the military was a significant predictor of PTSD and depression for heterosexual women, and such victimization during military service was a significant predictor of PTSD for LB women. This builds on prior literature with male veterans that has shown that physical assault both during and after military service was associated with PTSD symptom severity (Clancy et al., 2006). Among women veterans, Sadler and colleagues (2001) found that

399

threatened or completed physical assault during military service was more common than sexual assault, similar to findings from our study. In addition, unlike sexual assaults, whose rates decreased by more than half after military service for both heterosexual and LB women in our sample, rates of physical victimization only slightly decreased. Reasons for the persistent elevated rates of physical victimization are unclear, although this could constitute a more “acceptable” form of violence against women. These findings highlight the importance of public policy, education campaigns, and prevention and intervention programs addressing physical victimization that occurs both during and after military service.

Combat Combat exposure was uniquely associated with a positive PTSD screen only for LB women and was not associated with PTSD for heterosexual women or with depression for either group. The finding that combat, when considered in addition to interpersonal stressors, did not emerge as a significant predictor of mental health outcomes for heterosexual women parallels some previous studies that have examined such variables concurrently (e.g., Dutra et al., 2011; Vogt et al., 2011). Nonetheless, the finding that combat exposure significantly increased odds of positive PTSD screening by threefold for LB women but not heterosexual women was unexpected and should be further explored in future research. It is possible that LB women feel more isolated in combat situations than heterosexual women, have less social support in the aftermath of combat, or experienced greater numbers of combat situations. Testing these hypotheses, however, is outside the scope of the current analysis.

Discrimination and Minority Stress Greater frequency of past-year sexist events also predicted a positive PTSD screen for both LB and heterosexual women and a positive depression screen for LB women. Meanwhile, greater perceived discrimination during military service due to being a woman was associated with a positive depression screen for het­ erosexual women. This pattern of results suggests that social discrimination, even in the form of daily occurrences of sexist events, has a significant impact on mental health. Previous re­ search supports these findings. For example, reports of everyday sexism were moderately associated with PTSD symptoms among a general sample of women (Berg, 2006) and with psychological distress among lesbians (Szymanski, 2005). Minority stress theory predicts that stressors associated with one’s disadvantaged social status (e.g., sexual orientation) are associated with mental health (Meyer, 2003). Although LGB mil­ itary stressors were associated with screening positive for PTSD and depression among LB women at the bivariate level, these stressors were not associated with either PTSD or depression when taking other trauma variables into account. One possibility for this null finding is that the measure primarily assessed anxiety and concealment around sexual orientation, which is only one type of minority stressor potentially faced by sexual minorities. Other minority stressors, such as discrimination due to LGB status (e.g., ostracism from one’s military unit, being a target for interrogation and harassment) should also be assessed in future studies.

400

LEHAVOT AND SIMPSON

Background Characteristics Beyond trauma-related variables, some demographic factors remained significantly associated with PTSD and depression status in adjusted analyses. For heterosexual women only, serving in the Army (vs. other branches) was associated with increased risk of PTSD and depression. For LB women only, lower income was associated with increased risk of PTSD and depression. This finding is especially striking as LB women were also more likely than heterosexual women veterans to report incomes in the lowest bracket (i.e., 16% of LB women vs. 9% of heterosexual women reported a household yearly income ^$15,000) and less likely to report incomes in the highest bracket (i.e., 23% of LB women vs. 38% of heterosexual women reported a household yearly income of S $ 7 1,000). A recent report drawing from four data sets con­ cluded that LGB adults are at greater risk for being in poverty than their heterosexual counterparts (Badgett, Durso, & Schneebaum, 2013). These results, in addition to our findings indicating an association between income and mental health for LB women, support the importance of considering LGB-specific policies that address income disparities, perhaps by reducing employment dis­ crimination and discrimination in family policy and benefits.

Implications and Future Directions The study’s findings have important implications for clinicians working with women veterans. Clinicians in the community should routinely assess for history of military service, as most women veterans do not receive their care in the VA (Murdoch et al., 2006). Interpersonal traumas are highly prevalent among this population and are strongly predictive of PTSD and depression status. Child­ hood trauma and traumas that occurred during military service added the most variance to both PTSD and depression models, suggesting the need for careful assessment of both of these time periods. Perhaps both of these time periods represent stages where women feel more vulnerable when exposed to such traumas. Cognitive-behavioral techniques that promote examination of cog­ nitions related to these events may help reduce symptoms, partic­ ularly feelings of worthlessness, guilt, and shame that are often present in both PTSD and depression (Nishith, Nixon, & Resick, 2005; Schnurr et al., 2007). Moreover, those working with LB veterans should be aware of this group’s overall higher rates of trauma exposure, in many instances before, during, and after military service. Despite the recent overturn of Don’t Ask Don’t Tell (NBC News, 2011), most women veterans will have served during a time when being open about their sexual orientation was unacceptable, and exploration of their military experiences and perceived discrimination related to trauma exposure may be help­ ful for case conceptualization and treatment planning. Given the impact of childhood and military traumas on mental health for both LB and heterosexual women, future research needs to examine how these two constructs might be related to one another and ultimately to adult mental health. Previous studies with both LB and heterosexual women civilians have shown that childhood abuse is associated with increased risk of revictimiza­ tion in adulthood and that history of both child and adult victim­ ization is associated with higher levels of psychological distress than history of only one type of victimization (Balsam, Lehavot, & Beadnell, 2011). Understanding the relationships among childhood trauma, traumas during military service, and mental health for

women veterans is thus a critical next step. Moreover, relation­ ships among income, sexual orientation, and mental health should also be further explored given our findings that LB women were more likely to report lower incomes than heterosexual women veterans and that lower income was associated with their mental health status but not with heterosexual women’s mental health. It is possible that LB women are economically disadvantaged due to their sexual orientation and that this is a risk factor for worse mental health; alternatively, they may be more prone to having difficulty coping with a mental health condition that could impact their economic situation. Clarification of these questions could guide appropriate action and intervention.

Limitations The current study has several limitations that should be consid­ ered. Because advertisements for participation were used exclu­ sively over the Internet via online groups and Facebook, our sample may not generalize to all women veterans. Nonetheless, a representative survey of women veterans suggests that the majority have Internet access (Lehavot et al., 2013). Moreover, online methods have frequently been used by researchers to sample hard-to-reach populations such as sexual minorities (e.g., Feinstein, Goldfriend, & Davila, 2012; Lehavot & Simoni, 201 la), and may also be particularly useful in recruiting women veterans whose numbers at any one specific geographic site might be limited. Second, we grouped women into sexual orientation cate­ gories on the basis of their self-identification as LB or heterosex­ ual, although such labels may be limiting, and only offering lesbian/gay and bisexual as sexual minority labels could have introduced some selection bias into the sample. We also combined women who self-identified as lesbian and bisexual to increase statistical power given the relatively smaller number of bisexual women. Lesbian and bisexual women are not a homogenous group, and may have unique experiences that set them apart with respect to trauma experiences. Although much research has com­ bined the two groups (e.g., Booth et al., 2011; Mattocks et al., 2013), studies with larger samples of bisexual women considering them separately are needed. Moreover, transgender participants were excluded in this study. Given the unique experiences of discrimination faced by transgender women, an exploration of those concerns was beyond the scope of this investigation, which focused on the experiences of cisgender (i.e., when biological sex matches gender identity) LB and heterosexual women veterans. Third, all measures were self-report, and measures of PTSD and depression did not consist of diagnostic interviews. The anony­ mous, online nature of our survey precluded us from taking such an approach. Measures used, however, have good psychometric properties and are widely used in the field. Some measures were nonetheless truncated due to the length of the survey and to avoid overlap with other items (e.g., two items from the four-item WWSS scale). Fourth, the cross-sectional study design raises the possibility of recall bias and also prevents us from testing causal relationships. It is possible that current mental health status may impact reporting on earlier life experiences. We also do not know when women may have initially developed PTSD or depression. Longitudinal designs that assess constructs of interest across time would enhance our understanding of these relationships. Finally, although multiple types of trauma exposures and experiences were

TRAUMA, PTSD, AND DEPRESSION AMONG WOMEN VETERANS

included in the current study, we did not examine specific char­ acteristics associated with each trauma, such as frequency or severity. Despite these limitations, the current study extends prior re­ search on women and sexual minority veterans. Unlike much of the previous literature on women veterans, we included assessment of multiple trauma types across the life span to better understand their relative impact on two common and often debilitating mental health conditions: PTSD and depression. We recruited a large, national sample, including a sizable proportion of LB women veterans, who are highly represented among women veterans yet sorely understudied. Unlike the two previously published studies comparing LB and heterosexual women on trauma, these women were recruited outside of the VA setting and represented greater diversity with respect to age and military service (Booth et al., 2011; Mattocks et al., 2013). The study design allowed us to compare their rates of trauma exposure with heterosexual women veterans, as well as investigate predictors of PTSD and depression by sexual orientation group.

Conclusion In conclusion, our findings indicate that women veterans are exposed to high rates of trauma. LB women veterans reported higher rates of trauma exposure across the life span, although in some instances (e.g., sexual assault during and after military ser­ vice and combat exposure), they did not differ from their hetero­ sexual counterparts. Sexual assault during military service ap­ peared to be especially harmful with respect to screening positive for PTSD for both groups. Results also revealed a number of other unique predictors of mental health status for women veterans, highlighting the need for clinicians, researchers, and policy makers to promote women’s resiliency and well-being in the face of adversity, conduct future research with a sexually diverse female veteran population, and use policy and educational campaigns to reduce the widespread and unacceptable level of violence against women and girls.

References American Psychiatric Association. (1994). Diagnostic and statistical man­ ual o f mental disorders (4th ed.). Washington, DC: Author. American Psychological Association Joint Divisional Task Force on Sex­ ual Orientation and Military Service. (2009). Report o f the Joint Divi­ sional Task Force on Sexual Orientation and Military Service. Wash­ ington, DC: Author. Retrieved from http://www.apa.org/pi/lgbt/resources/ 19-44-taskforce-report.pdf Ashford, M. W., & Huet-Vaughn, Y. (2000). The impact of war on women. In B. S. Levy & V. W. Sidel (Eds.), War and public health (updated ed., pp. 186-196). Washington, DC: American Public Health Association. Bader, G., Ragsdale, K. G., & Franchina, J. J. (2001). Screening for mental health illness in a Veterans Affairs women’s health clinic. Psychiatric Services, 52, 1521-1522. doi:10.1176/appi.ps.52.11.1521 Badgett, M. V. L„ Durso, L. E., & Schneebaum. A. (2013). New patterns o f poverty in the lesbian, gay, and bisexual community. Los Angeles, CA: The Williams Institute. Available at http://williamsinstitute.law. ucla.edu/research/census-lgbt-dem ographics-studies/lgbt-povertyupdate-june-2013/ Balsam, K. F.. Lehavot, K., & Beadnell, B. (2011). Sexual revictimization and mental health: A comparison of lesbians, gay men, and heterosexual women. Journal o f Interpersonal Violence, 26, 1798-1814. doi: 10.1177/0886260510372946

401

Balsam, K. F., Lehavot, K., Beadnell, B.. & Circo, E. A. (2010). Child abuse and mental health indicators among ethnically diverse lesbian, gay, and bisexual adults. Journal o f Consulting and Clinical Psychology, 78, 459-468. doi:10.1037/a0018661 Balsam, K. F., Rothblum, E. D., & Beauchaine, T. P. (2005). Victimization over the life span: A comparison of lesbian, gay, bisexual, and hetero­ sexual siblings. Journal o f Consulting and Clinical Psychology, 73, 477-487. doi:10.1037/0022-006X.73.3.477 Berg, S. H. (2006). Everyday sexism and posttraumatic stress disorder in women: A correlational study. Violence Against Women, 12, 970-988. doi: 10.1177/1077801206293082 Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M.. Wenzel, K„ . . . Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal o f Psychiatry, 151, 1132-1136. Blosnich, J., Bossarte, R., Silver, E., & Silenzio, V. (2013). Health care utilization and health indicators among a national sample of U.S. vet­ erans in same-sex partnerships. Military Medicine, 178, 207-212. doi: 10.7205/MILMED-D-12-00325 Booth, B. M., Mengeling, M., Tomer, J„ & Sadler, A. G. (2011). Rape, sex partnership, and substance use consequences in women veterans. Jour­ nal o f Traumatic Stress, 24, 287-294. doi:10.1002/jts.20643 Clancy, C. P., Graybeal, A., Tompson, W. P„ Badgett, K. S., Feldman, M. E., Calhoun, P. S., . . . Beckham, J. C. (2006). Lifetime trauma exposure in veterans with military-related posttraumatic stress disorder: Association with current symptomatology. Journal o f Clinical Psychi­ atry, 67, 1346-1353. doi:10.4088/JCP.v67n0904 Cochran, B. N., Balsam, K., Flentje, A., Malte, C. A., & Simpson, T. (2013). Mental health characteristics of sexual minority veterans. Jour­ nal o f Homosexuality, 60, 4 1 9 -4 3 5 . doi:10.1080/00918369.2013 .744932 D ’Augelli, A. R. (2005). Developmental and contextual factors and mental health among lesbian, gay, and bisexual youths. In A. M. Omoto & H. S. Kurtzman (Eds.), Sexual orientation and mental health: Examining identity and development in lesbian, gay, and bisexual people (pp. 37-54). Washington, DC: American Psychological Association. Davis, T. M., Bush, K. R., Kivlahan, D. R., Dobie, D. J.. & Bradley, K. A. (2003). Screening for substance abuse and psychiatric disorders among women patients in a VA Health Care System. Psychiatric Services, 54, 214-218. doi:10.1176/appi.ps.54.2.214 Dichter, M. E., Cerulli, C., & Bossarte, R. M. (2011). Intimate partner violence victimization among women veterans and associated heart health risks. Women’s Health Issues, 21, S190-S194. doi:10.1016/j.whi .2011.04.008, Dobie, D. J., Kivlahan, D. R.. Maynard, C., Bush, K. R., Davis, T. M., & Bradley, K. A. (2004). Posttraumatic stress disorder in female veterans: Association with self-reported health problems and functional impair­ ment. Archives o f Internal Medicine, 164, 394-400. doi: 10.1001/ archinte. 164.4.394 Dutra, L., Grubbs, K., Greene, C., Trego, L. L„ McCartin, T., Kloezeman, K., & Morland, L. (2011). Women at war: Implications for mental health. Journal o f Trauma and Dissociation, 12, 25-37. doi:10.1080/ 15299732.2010.496141 Feinstein, B. A., Goldfriend, M. R., & Davila, J. (2012). The relationship between experiences of discrimination and mental health among lesbians and gay men: An examination of internalized homonegativity and re­ jection sensitivity as potential mechanisms. Journal o f Consulting and Clinical Psychology, 80, 917-927. doi:10.1037/a0029425 Fomeris, C. A., Butterfield, M. I., & Bosworth, H. B. (2004). Physiological arousal among women veterans with and without posttraumatic stress disorder. Military Medicine, 169, 307-312. Gates, G. J. (2010). Lesbian, gay, and bisexual men and women in the U.S. military: Updated estimates. Retrieved from http://www3.law.ucla.edu/ williamsinstitute/pdf/GLBmili taryUpdate.pdf

402

LEHAVOT AND SIMPSON

Goldzweig, C. L., Balekian, T. M., Rolon, C., Yano, E. M„ & Shekelle, P. G. (2006). The state of women veterans’ health research. Journal o f General Internal Medicine, 21, S82-S92. doi: 10.1111/j. 1525-1497.2006 .00380.x Grubaugh, A. L., Monnier, J., Magruder, K. M., Knapp, R. G., & Frueh, B. C. (2006). Female veterans seeking medical care at Veterans Affairs primary care clinics: Psychiatric and medical illness burden and service use. Women and Health, 43, 41-62. doi:10.1300/J013v43n03_03 Hassija, C. M., Jakupcak, M., Maguen, S., & Shipherd, J. C. (2012). The influence of combat and interpersonal trauma on PTSD, depression, and alcohol misuse in U.S. Gulf War and OEF/OIF women veterans. Journal o f Traumatic Stress, 25, 216-219. doi: 10.1002/jts.21686 Herek, G. M., Gillis, J. R., & Cogan, J. C. (1999). Psychological sequelae of hate-crime victimization among lesbian, gay, and bisexual adults. Journal o f Consulting and Clinical Psychology, 67, 945-951. doi: 10.1037/0022-006X.67.6.945 Hillberg, T., Hamilton-Giachritsis, C., & Dixon, L. (2011). Review of meta-analyses on the association between child sexual abuse and adult mental health difficulties: A systematic approach. Trauma, Violence, and Abuse. 12, 38-49. doi: 10.1177/1524838010386812 Institute of Medicine. (2011). The health o f lesbian, gay, bisexual, and transgender people: Building a foundation fo r better understanding. Washington, DC: The National Academies Press. King, D. W., King, L. A., & Vogt, D. S. (2003). Manual fo r the Deploy­ ment Risk and Resilience Inventory (DRRI): A collection o f measures fo r studying deployment-related experiences o f military veterans. Boston, MA: National Center for PTSD. Klonoff, E. A., & Landrine, H. (1995). The Schedule of Sexist Events: A measure of lifetime and recent sexist discrimination in women’s lives. Psychology o f Women Quarterly, 19, 439-470. doi: 10.1111/j. 14716402.1995.tb00086.x Koss, M. P., Abbey, A., Campbell, R., Cook, S., Norris, J., Testa, M........ White, J. (2007). Revising the SES: A collaborative process to improve assessment of sexual aggression and victimization. Psychology o f Women Quarterly, 31, 357-370. doi:10.1111/j.l471-6402.2007.00385.x Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32, 509-515. Kroenke, K„ Spitzer, R. L„ & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal o f General Internal Medicine, 16, 6 0 6 -6 1 3 . doi: 10.1046/j. 1525-1497.2001 ,016009606.x Kroenke, K., Strine, T. W., Spitzer, R. L., Williams, J. B. W., Berry, J. T., & Mokdad, A. H. (2009). The PHQ-8 as a measure of current depression in the general population. Journal o f Affective Disorders, 114, 163-173. doi: 10.1016/j .jad.2008.06.026 Lehavot, K., Der-Martirosian, C., Simpson, T. L., Sadler, A. G., & Wash­ ington, D. L. (2013). Barriers to care for women veterans with posttraumatic stress disorder and depressive symptoms. Psychological Services, 10, 203-212. doi: 10.1037/a0031596 Lehavot, K., Hoerster, K., Nelson, K. M., Jakupcak, M., & Simpson, T. (2012). Health indicators for military, veteran, and civilian women. American Journal o f Preventive Medicine, 42, 473-480. doi: 10.1016/j .amepre.2012.01.006 Lehavot, K., & Simoni, J. M. (2011a). The impact of minority stress on mental health and substance use among sexual minority women. Journal o f Consulting and Clinical Psychology, 79, 159-170. doi: 10.1037/ a0022839 Lehavot, K„ & Simoni, J. M. (201 lb). Victimization, smoking, and chronic physical health problems among sexual minority women. Annals o f Behavioral Medicine, 42, 269-276. doi: 10.1007/s 12160-011-9289-6 Lehavot, K., & Simpson, T. L. (2013). Incorporating lesbian and bisexual women into women veterans’ health priorities. Journal o f General Internal Medicine, 28, 609-614. doi: 10.1007/s 11606-012-2291-2

Mattocks, K. M., Haskell, S. G., Krebs, E. E., Justice, A. C., & Yano, E. M. (2012). Women at war: Understanding how women veterans cope with combat and military sexual trauma. Social Science & Medicine, 74, 537-545. doi: 10.1016/j .socscimed.2011.10.039 Mattocks, K. M., Sadler, A., Yano, E. M., Krebs, E. E., Zephyrin, L., Brandt, C., . . . Haskell, S. (2013). Sexual victimization, health status, and VA healthcare utilization among lesbian and bisexual OEF/OIF veterans. Journal o f General Internal Medicine, 28, 604-608. doi: 10.1007/sl 1606-013-2357-9 Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674-697. doi:10.1037/0033-2909.129.5 .674 Moracco, K. E., Runyan, C. W., Bowling, J. M., & Earp, J. A. L. (2007). Women’s experiences with violence: A national study. Women’s Health Issues, 17, 3-12. doi:10.1016/j.whi.2006.03.007 Murdoch, M., Bradley, A., Mather, S., Klein, R., Turner, C., & Yano, E. M. (2006). Women and war: What physicians should know. Journal o f General Internal Medicine, 21, S5-S10. doi: 10.1111/j.l525-1497.2006 ,00368.x Murdoch, M., Polusny, M., Hodges, J., & O’Brien, N. (2004). Prevalence of in-service and post-service sexual assault among combat and non­ combat veterans applying for Department of Veterans Affairs posttraumatic stress disorder disability benefits. Military Medicine, 169, 392395. NBC News. (2011, July). Obama certifies end of military’s gay ban. Retrieved from http://www.msnbc.msn.com/id/43859711/ns/us_newslife/ Nishith, P., Nixon, R. D. V., & Resick, P. A. (2005). Resolution of trauma-related guilt following treatment of PTSD in female rape vic­ tims: A result of cognitive processing therapy targeting comorbid de­ pression? Journal o f Affective Disorders, 86, 259-265. doi: 10.1016/j.jad .2005.02.013 Ruggiero, K. J., Del Ben, K., Scotti, J. R., & Rabalais, A. E. (2003). Psychometric properties of the PTSD Checklist-Civilian Version. Jour­ nal o f Traumatic Stress, 16, 495-502. doi:10.1023/A:1025714729117 Sadler, A. G„ Booth, B. M., Cook, B. L., Tomer, J. C., & Doebbeling, B. N. (2001). The military environment: Risk factors for women’s non-fatal assaults. Journal o f Occupational and Environmental Medi­ cine, 43, 325-334. doi: 10.1097/00043764-200104000-00007 Sadler, A. G., Booth, B. M., Mengeling, M. A., & Doebbeling, B. N. (2004). Life span and repeated violence against women during military service: Effects on health status and outpatient utilization. Journal o f Women’s Health, 13, 799-811. doi: 10.1089/jwh.2004.13.799 Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7, 147-177. doi:10.1037/1082-989X .7.2.147 Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B„ Shea, M. T., Chow, B. K., . . . Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. Journal o f the American Medical Association, 297, 820-830. doi: 10.1001/jama.297.8.820 Schultz, J. R„ Bell, K. M„ Naugle, A. E„ & Polusny, M. A. (2006). Child sexual abuse and adulthood sexual assault among military veteran and civilian women. Military Medicine, 171, 723-728. Shea, A., Walsh, C., MacMillan, H., & Steiner, M. (2005). Child maltreat­ ment and HPA axis dysregulation: Relationship to major depressive disorder and post traumatic stress disorder in females. Psychoneuroendocrionology, 30, 162-178. doi:10.1016/j.psyneuen.2004.07.001 Shen, C., & Sambamoorthi, U. (2012). Associations between health-related quality of life and financial barriers to care among women veterans and women non-veterans. Women and Health, 52, 1-17. doi:10.1080/ 03630242.2011.641713

TRAUMA, PTSD, AND DEPRESSION AMONG WOMEN VETERANS Surfs, A., Lind, L., Kashner, T., Borman, P. D., & Petty, F. (2004). Sexual assault in women veterans: An examination of PTSD risk, health care utilization, and cost of care. Psychosomatic Medicine, 66, 749-756. doi:10.1097/01.psy.0000138117.58559.7b Szymanski, D. M. (2005). Heterosexism and sexism as correlates of psychological distress in lesbians. Journal o f Counseling and Develop­ ment, 83, 355-360. doi:10.1002/j,1556-6678.2005.tb00355.x United Nations. (1993). General Assembly: 48/104: Declaration on the elimination o f violence against women. Retrieved from http://www.un ,org/documents/ga/res/48/a48r 104.htm 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. doi: 10.1002/jts.20018 Vogt, D., Vaughn, R., Glickman, M. E., Schultz, M., Drainoni, M., Elwy, R., & Eisen, S. (2011). Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF veterans. Journal of Abnormal Psychology, 120, 797-806. doi:10.1037/a0023452 Vranceanu, A., Hobfoll, S. E., & Johnson, R. J. (2007). Child multi-type maltreatment and associated depression and PTSD symptoms: The role of social support and stress. Child Abuse & Neglect, 31, 71-84. doi: 10.1016/j.chiabu.2006.04.010 Weathers, F., & Ford, J. (1996). Psychometric properties of the PTSD

403

Checklist (PCL-C, PCL-S, PCL-M, PCL-PR). In B. H. Stamm (Ed.), Measurement of stress, trauma, and adaptation (pp. 250-252). Luther­ ville, MD: Sidran Press. Wolfe, J., Brown, P. I., Furey, J., & Levin, K. (1993). Development of a war time exposure scale for women. Psychological Assessment, 5, 330335. doi: 10.1037/1040-3590.5.3.330 Yaeger, D., Himmelfarb, N., Cammack, A., & Mintz, J. (2006). DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. Journal o f General Internal Medicine, 21, S65-S69. doi: 10.1 lll/j.l525-1497.2006.00377.x Yano, E. M., Hayes, P., Wright, S., Schnurr, P. P., Lipson, L., BeanMayberry, B., & Washington, D. L. (2010). Integration of women veterans into VA quality improvement research efforts: What research­ ers need to know. Journal o f General Internal Medicine, 25, 56-61. doi:10.1007/sl 1606-009-1116-4 Zinzow, H. M., Grubaugh, A. L., Monnier, J., Suffoletta-Maierle, S., & Frueh, B. C. (2007). Trauma among female veterans: A critical review. Trauma, Violence, and Abuse, 8, 384-400. doi: 10.1177/ 1524838007307295

Received December 6, 2013 Revision received March 10, 2014 Accepted March 10, 2014 ■

Copyright of Journal of Counseling Psychology is the property of American Psychological Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.