This article focuses on violence against women -- epidemiology; health consequences, including the relationship of domestic violence to posttraumatic stress disorder (PTSD); and medical and societal responses to such violence -- as it relates to active members and veterans of the United States armed services.
Violence against women has myriad health, economic, and social consequences, which have been reviewed elsewhere.[1,2] Globally, the health burden from violence against women is comparable to that of HIV, tuberculosis, and cardiovascular disease. According to a recent poll of 3300 American women by the Center for the Advancement of Women, reducing domestic violence and sexual assault topped the list of respondents' concerns.
Over the past 2 decades, increasing attention has been focused upon violence and sexism in the US military. In the 1991 Tailhook scandal, more than 100 officers at a Navy convention sexually assaulted and harassed dozens of women. Not one of the offenders was convicted. An investigation found that Navy brass had tacitly approved such behavior for years. In 1996, a series of sexual assaults at the Aberdeen Proving Ground in Maryland led to charges against a dozen Army drill instructors; several officers were reprimanded. Then, in 2004, 3 returning veterans who had served in Special Forces in Afghanistan killed their spouses.
More than 210,000 women are on active US military duty. Almost 60,000 female troops have been deployed overseas to support the wars in Iraq and Afghanistan.Approximately 1 in 7 US military personnel in Iraq is female. These women, as well as the civilian partners of active and veteran US service members, are at high risk for partner abuse and sexual assault.
Victims of military domestic violence are predominantly the female, civilian spouses of active duty personnel. More than half of victims have been married for 2 years or less, and many have children. Among the Services, the Army consistently has shown the highest rates of domestic violence, followed by the Marines, Navy, and Air Force.
Significant numbers of women enter the military with histories of victimization, just as some male recruits have violent pasts. For instance, among US Navy recruits, 46% of women reported being the victim of attempted (9%) and completed (36%) rape before entering the Navy. Fifteen percent of male recruits admitted perpetrating attempted (4%) or completed rape (11%) before entering the Navy.
Once in the armed services, recruits become part of a warrior culture. Bellicose military vocabulary is laden with denigrations of feminine traits, and gender slurs motivate men to act aggressively toward women. Until 1999, pornography could easily be purchased by servicemen at US military base commissaries, which ranked among the largest purchasers of hard-core pornography. Military bases are commonly associated with prostitution, which is tacitly accepted by commanding officers and local authorities. For example, more than 5000 women, mainly from the Philippines and the former Soviet Union, were trafficked into South Korea in the mid 1990s, primarily to work as “entertainers” at bars near US military bases. The use of rape as a weapon of war, including by US soldiers, marks one of the most extreme examples of interpersonal violence.
The military provides social, economic, and psychological benefits that are not uniformly available to families in the civilian world, including job security and social support. Nevertheless, military families face unique stressors, including relocations, long work tours, frequent family separations, and dangerous work assignments. These stressors can increase the risk for family violence. Child abuse and witnessing domestic violence during childhood are also risk factors for aggression, as is alcohol use and abuse.
Combat stress after entry into the service increases the likelihood of males perpetrating abuse. Veterans with combat exposure have more marital problems, as do veterans with PTSD.[19,20] In a study conducted during the first Gulf War, the probability of severe spousal aggression by US Army soldiers was significantly greater for those who were returning from deployment than among those not deployed, suggesting that exposure to potential or real battles increases the likelihood of a soldier abusing his partner. An estimated one third of male veterans with PTSD engage in partner violence, a rate 2 to 3 times higher than that for non-PTSD veterans and non-PTSD civilians.
Between 1997 and 2001, more than 10,000 cases of spouse abuse per year occurred in the armed forces, including 114 homicides. These numbers are likely a large underestimate, as the military does not usually count intimate partners, such as girlfriends, as domestic abuse victims. Another report alleges 218 domestic murders in the US military between 1995 and 2004. In a sample of 616 active duty military women, 22% reported physical abuse and/or sexual assault while in the service. A 2004 Pentagon survey of the 3 military academies revealed that 1 in 7 female cadets said she had been a victim of sexual abuse -- ranging from unwanted advances to rape -- during the previous 5 years. Only a third of the incidents were reported.
In a national phone survey of 558 Vietnam (and subsequent era) women veterans (response rate 96%), almost half (48%) admitted experiencing interpersonal violence during military service, including rape (30%), physical assault (35%), or both (16%).Using the same database, Sadler and colleagues found that 5% of veterans reported repeated rape and another 5% gang rape. A smaller study of physical abuse, sexual abuse, and rape among women veterans seeking care at the Baltimore Veterans Affairs Medical Center (response rate 52%) found that 68% reported at least 1 form of abuse and 27% reported all 3. Sexual abuse was the most common (55%), followed by physical abuse (48%) and rape (41%). Among a national sample of women Veterans’ Administration (VA) outpatients, 23% reported military-related sexual assault.
Hankin and colleagues found that women who were victimized were more likely to report chronic health problems, lower health-related quality of life, prescription medication use for emotional problems, failure to complete college, and annual incomes below $25,000. Prevalences of current depression and alcohol abuse were, respectively, 3 and 2 times higher among those who reported experiencing military-related sexual assault. Sadler and colleagues found that women veterans who reported repeated exposure to interpersonal violence during military service had significantly more outpatient visits, poorer self-rated health status, and more often reported a history of childhood violence and post-military violence than their nontraumatized peers. Those exposed to interpersonal violence tend to show high levels of secondary victimization, ie, feelings of guilt, depression, anxiety, distrust of others, and reluctance to seek further help.
A cross-sectional survey of 4918 US military veterans seeking VA disability benefits for PTSD (with an effective response rate of 68%) found that, among men, 6.5% of combat veterans and 16.5% of noncombat veterans reported in-service or post-service sexual assault. Among women, 69% of combat veterans and 87% of noncombat veterans reported in-service or post-service sexual assault. The risk of PTSD after sexual assault is similar in both female and male veterans to that seen following high levels of combat exposure. Suris and colleagues found that female veterans who had suffered sexual assault while in the military were 9 times more likely to have PTSD than those who did not suffer such an assault.
Abused women in the military (and civilian spouses concerned about their husbands’ prospects for continued service and promotion) are often fearful of reporting incidents because of the lack of confidentiality and privacy, as well as limited victim services. Many victims fear retaliation and damage to their careers or being portrayed as disloyal. In fact, those who do report are often punished, intimidated, or ostracized.[5,34] Often, perpetrators of the most vicious crimes are transferred to another base or offered marriage counseling and anger management classes in lieu of more severe punishment.
Although data are not available for the other branches of the military, nearly 5000 accused sex offenders in the Army, including rapists, have avoided prosecution and the possibility of prison time since 1992. Between 1988 and 1993, approximately 80% of abusers who left the military received honorable discharges. Of those who remained in the military, 54% were promoted (compared with 65% of the overall military population). Over the past 10 years, twice as many accused Army sex offenders were given administrative punishment as were court-martialed.
In response to recently increased complaints of abuse in the military and to a US Department of Defense (DOD) survey showing that 7.4% of Air Force Academy cadets reported that they were victims of rape or attempted rape during their tenure there, the DOD conducted a review in February 2004 of its sexual assault policies and programs. Findings included the following: reports of more than 1000 incidents of sexual assault in 2003 alone; incomplete and poorly integrated data systems and records on reports of sexual assault; significant gaps in the documentation of victim treatment and case disposition; inconsistent policies and procedures aimed at preventing sexual assault; and many barriers to reporting, including junior personnel who were not aware of reporting options and victims’ perceived (and in some cases real) lack of privacy and confidentiality.
The DOD report concluded that “the lack of focus and assigned responsibility for sexual assault issues within the Office of the Secretary of Defense has resulted in a lack of policy, development and implementation, as well as inconsistent oversight and inattention to developing and ensuring adherence to performance standards.” Recommendations for improved policies and procedures were presented to the Secretary in April 2004. Many have not yet been acted upon.
By the completion of the report, more than 100 incidents of rape and sexual assault, perpetrated by male US soldiers, had been reported by US women soldiers serving in Iraq and Afghanistan. Many victims did not receive even the most basic medical care, such as emergency contraception, rape evidence kits, testing for sexually transmitted infections, prophylactic treatment or testing for HIV, and rape crisis counseling. Prosecution of these crimes was often delayed indefinitely, and many servicewomen continued to serve in the same unit with their assailants. Disturbing reports of sexual abuse and humiliation at the Abu Ghraib and Guantanamo military prisons have also surfaced.[39,40,41,42]
Recent news reports also have described religious harassment of non-Christians at the Air Force Academy, perhaps fueled by the school’s location in the heart of fundamental Christendom and by the stigmatization of Moslems that has accompanied recent terrorist violence and the wars in the Middle East.[43,44]
The transitional compensation program of the US Army provides financial and other benefits to the families of service members discharged for child or spouse maltreatment, including victim assistance and offender rehabilitation. Although the VA provides lifetime sexual assault counseling to all military veterans, such treatment is only available after one leaves the service. Today most counseled patients are males, who suffer lower rates of sexual assault but make up a large majority of veterans. Women on the front lines, who risk capture and being held as a prisoner of war (which puts them at risk for sexual assault), should strongly consider commencing birth control pre-deployment with an intrauterine device or implants. Finally, victims should contact local domestic violence organizations or the Miles Foundation, a Connecticut-based advocacy group for military victims of domestic violence (telephone: 203-270-7861; Web page: https://hometown.aol.com/milesfdn/myhomepage/).
Progress toward reducing violence against women in the military and against the civilian partners of active and retired servicemen will require a change in the sexist ideologies and practices long associated with militarism and war. Improvements in victim services, including enhanced confidentiality, and the appointment of a central authority within the DOD to investigate and prosecute violent crimes are urgently needed. Other reforms designed to decrease interpersonal violence could include the following: enhanced curricular offerings to teach trainees and practicing clinicians how to recognize and manage the sequelae of domestic violence; increased funding of domestic violence shelters; laws to decrease the easy availability of firearms; more funding for research, treatment, and prevention; and changes in law and policy to protect victims and to improve the status of women.[1,45]
At the international level, the following initiatives have gained acceptance as vehicles to improve the status of women and decrease their victimization:
The Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW), adopted by the United Nations General Assembly in 1979, which calls for equality of the sexes in political, social, cultural, civil, and other fields.
UN Security Council Resolution 1325 (adopted in 2000), which mandates the protection of, and respect for, the human rights of women and girls and calls on all parties to armed conflict to take specific measures to protect women and girls from gender-based violence, particularly rape and sexual violence.[14,46]
The International Criminal Court (ICC), established by international treaty in 2002, which codifies accountability for gender-based crimes against women during military conflict by defining sexual and gender violence of all kinds of war crimes.
Regrettably, the United States has not signed UNSCR 1325, nor joined 162 other countries in ratifying CEDAW. Despite the fact that 139 countries have signed on to the ICC, the United States has failed to do so, in part out of fear that its own soldiers may be prosecuted for crimes against humanity, including rape. The United States should show its commitment to improving women's rights worldwide by taking action on these items. The women and men who risk their lives in service to the ideals for which the United States should stand deserve such justice.
Medscape Ob/Gyn. 2005;10(2) © 2005 Medscape
Cite this: Violence Against Women in the Military - Medscape - Sep 13, 2005.