Jill B. LaMantia, MSN, RN, NP, considers herself a touchy-feely person, always ready with a hug — something her patients and their families always appreciated when she worked as a pediatric nurse practitioner. But soon after she started working at the Veterans Administration West New York Healthcare System in Buffalo six years ago, LaMantia embraced a woman who had post-traumatic stress disorder. The hug, meant to be comforting, triggered a panic attack in the patient. ”You could see it in her eyes,” LaMantia, director of the womens program there, said. ”It was almost like she wasn’t here anymore. She was reliving the trauma she’d had in the military. Just in one second.”
Since then she asks permission which is almost always granted before offering a comforting touch or hug to the female veterans she works with. Her experience is one example of how VA nurses are developing expertise in caring for female veterans with PTSD and of how the VA is working to create a more welcoming, safe place for women exposed to trauma while serving in the military. LaMantia and other VA nurses want to get the word out to their non-VA colleagues that they have the research, training, education and experience in caring for female veterans with PTSD.
A negative example of gender equality
PTSD in veterans historically has been linked to men who served in combat zones. But according to VA studies, women – who make up about 15% of active-duty soldiers and 20% of the National Guard and U.S. reserves, and are the fastest growing group of U.S. veterans – experience PTSD at about the same rate as men. One in five women who served in Iraq and Afghanistan has been diagnosed with PTSD, and nearly 30% of female Vietnam veterans suffered from PTSD at some point in their postwar lives. Nearly all of the estimated 10,000 women who served in Vietnam were nurses, according to VA statistics.
Some PTSD in female veterans results from combat or other stressors, but much is related to military sexual trauma – assault or repeated and threatening sexual harassment during service, said psychologist Margret Bell, PhD, the VA’s national deputy director for military sexual trauma. One in four female veterans screened by the VA reported sexual trauma during their service, according to VA reports. Some studies indicate nearly half of women who’ve experienced military sexual trauma eventually develop PTSD, according to VA research.
Symptoms of PTSD include reliving the trauma; nightmares; avoidance of situations that might trigger memories of the trauma; feelings of numbness; and increased arousal such as difficulty sleeping and concentrating, jumpiness and irritability. PTSD linked to military sexual trauma can be even more complex because it often involves betrayal – an assault or harassment by a boss or a colleague, someone the veteran knew and trusted, said Ursula Kelly, PhD, ANP-BC, PMHNP-BC, nurse scientist at the Atlanta VA Medical Center and assistant professor at the Emory University Nell Hodgson Woodruff School of Nursing, who is researching PTSD related to military sexual trauma. ”These are the people who are supposed to have your back.”
Helping our soldiers
Though PTSD is linked to chronic pain, anxiety, insomnia and other debilitating conditions, many women don’t know what it is or even that they have it, according to nurses who work with female veterans. “They are incredibly resilient,” Kelly said, describing the female veterans she sees who go to work, raise children and care for family members, telling themselves it’s normal to never leave the house except to go to work, or to have no friends, or to shop at midnight when everyone else is asleep. ”They soldier on because they are soldiers.”
In a small study of female veterans with PTSD related to military sexual trauma, Kelly found the average time between when trauma occurred and when the woman finally reported it was 28 years. Sometimes the symptoms, repressed for so long, are triggered by a second trauma, or when the woman’s last child leaves the house, she said. Sometimes family members realize something is wrong.
Evidence-based psychotherapies and medication have help eased symptoms of PTSD and depression, which also is linked to sexual trauma, in many female veterans, said Amy Street, PhD, acting director of the women’s health sciences division at the VA’s National Center for PTSD. Kelly has seen promising results – a reduction in startle-response, reports of decreased chronic pain and insomnia – from a small study involving therapeutic yoga, which gives participants control over their movements. Instructors invite participants to raise their hands or get into a position, rather than telling them.
The VA also trains its providers to deliver trauma-informed care in all settings, Street said. All VA users, men and women, are routinely asked if they’ve ever experienced military sexual trauma and are screened for PTSD. Clinicians are trained in procedures such as asking before touching and being aware of the association between military sexual trauma, and physical and mental health. Even housekeepers at her facility are educated about PTSD, LaMantia said, and announce themselves to patients and explain what they are doing to avoid triggering panic attacks or other symptoms.
Any physical examination, including oral exams, is a potential trigger for women with PTSD related to sexual trauma, VA nurses said, and VA providers are trained to give patients complete control by explaining what they are doing in detail and offering women the choice of stopping the exam at any time. A common one is getting them ready for a pelvic exam, said Denise Bartlett, MSN, RN, FNP-BC, female veterans program manager at the San Francisco VA Healthcare System. She has entered a room ready to do an exam and found her patient fully dressed with tears in her eyes.
When examining veterans, Bartlett said, she’s careful to explain everything she does as she touches the patient’s neck, chest, all the way to the pelvic exam. Even then, she said, she had one patient who started to panic. ”When that happens, you need to give her control over the situation,” Bartlett said. “And that’s what I did by offering to stop, let her get dressed and leave the room, or I could continue and explain it in great detail, whatever she was the most comfortable with. I think that’s something primary care providers have to remember – you have to give [patients] the control to deal with the current situation.”
Every VA medical center has a military sexual trauma coordinator, and any woman veteran who has experienced military sexual trauma is eligible for VA treatment no matter how long ago the incident happened or how long they served, Bell said. The women don’t need documentation or proof; they can get counseling at no charge, she said.
But to help female veterans, VA nurses said, they must get them into the VA healthcare system. Studies show between 11% and 17% of all female veterans get care at the VA, as opposed to 26% of men, though women who use VA services tend to use them for more of their care, said Patty Hayes, PhD, chief consultant for women’s health services at the Veterans Health Administration Patient Care Services. Women who have served in the military don’t always see themselves as veterans, Hayes said. ”They think veteran means you had to have served in combat.” Or they don’t know what VA services are available, she said, and often the providers they see don’t know either.
Women with PTSD related to military sexual trauma especially are reluctant to go to the VA because they associate it with the institution where they were assaulted or harassed, Kelly said, and because most VA patients are men, whose presence could trigger emotions related to their trauma. The buildings of many VAs, older and designed for male veterans, might seem threatening to them. ”Things are changing,” Kelly said, “but were not there yet in terms of it being a comfortable place for women.” Often women come to the VA because other veterans who’ve gone through similar experiences have told them about the services, she said.
Though most female veterans seek healthcare outside of the VA, many providers don’t think to ask if their women patients have served in the military, said Cindy Fitzgerald, PhD, RN, FNP-BC, interim associate dean of academic affairs and director of the doctor of nursing practice program at Washington State University College of Nursing in Spokane, who has done research projects involving female veterans. “We still don’t have a context in our head for thinking of a young woman as a veteran,” Fitgerald said. Even patients with PTSD diagnoses may run into biases from providers who believe the condition is over-diagnosed or don’t feel confident treating mental health conditions, she said.
Nurses who want to connect patients with VA services can offer to contact the local VA on their behalf and ask if a VA nurse or the manager of the women’s program could call them, Fitzgerald said. LaMantia gets frequent calls from providers with reluctant patients and meets women veterans at the door. ”Many of them are so afraid to come into this building, but they’re so thankful when they do because they’re finally getting help,” she said.
LaMantia recently secured $3.6 million to build a new 11,000-square-foot women’s center in Buffalo — one she hopes will be welcoming to female veterans from the outside as well as inside. She has seen architectural videos from Washington, D.C., showing models specifically designed for women with PTSD, depression, anxiety and other mental health issues that include serene lobbies, comfortable exam rooms and quiet sliding doors and don’t create a space where someone could hide. ”All these little things that you just wouldn’t think about unless you were assaulted,” she said. “In the old days we didn’t think about this, but now we’re really in tune to it.”
Cathryn Domrose is a staff writer.
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