Race,Gender,and Post-Traumatic Stress Disorder in the U.S. Military

Abstract

U.S. service women were exposed to more combat-related trauma in recent wars compared to prior conflicts and consequently faced an increased risk of trauma-related mental health outcomes. In this study, we examined gender by race differences in self-reported post-traumatic stress disorder (PTSD) symptoms and clinician diagnoses in a large sample of U.S. Black and White service men and women returning from Iraq and Afghanistan, to determine whether women overall and Black women in particular are at an increased risk of PTSD compared to Black and White men. Using three PTSD measures—two symptom-based measures assessed at different times and one diagnosis measure—we found more traumatic combat exposures were associated with higher PTSD risk for service women compared to service men, but there was no additional increase in risk of PTSD for Black females.

Keywords

military post-traumatic stress disorder gender race trauma

Military service members returning from deployment to Iraq and Afghanistan (Operation Iraqi Freedom [OIF]/Operation Enduring Freedom [OEF]) are at increased risk for developing mental health problems (Hoge et al., 2004; Shen, Arkes, Kwan, Tan, & Williams, 2010). Specifically, previous studies report a greater likelihood of depression (see Adamson et al., 2008; James, Van Kampen, Miller, & Engdahl, 2013; Pittman, Goldsmith, Lemmer, Kilmer, & Baker, 2012; Wells et al., 2010), alcohol and substance abuse (see Bray et al., 2010; James et al., 2013; Pittman et al., 2012), and post-traumatic stress disorder (PTSD) among OIF and OEF veterans (see James et al., 2013; Shen et al., 2010). Of particular concern is the relatively high percentage of service members reporting symptoms of PTSD. Studies estimate PTSD prevalence between 5% and 20% among nontreatment-seeking, previously deployed service members, with disparities in estimates largely due to measurement and sample differences (Ramchand et al., 2010). Given that over 2.5 million American service members have served in Iraq and Afghanistan since 2001, the mental health burden of previously deployed men and women is substantial.

Traumatic stress exposure is a necessary cause for PTSD, but other risk factors may predispose certain individuals or groups to develop PTSD. For example, in a study of Vietnam War veterans, Dohrenwend and colleagues (2013) found that while 98% of those with PTSD had traumatic combat exposure, only 31% of those with traumatic combat exposure developed PTSD. Some prior research shows that women in the armed forces may be at particularly high risk of developing PTSD following exposure to trauma while deployed (see Crum-Cianflone & Jacobsen, 2014 for a review), but most of the studies that show an elevated risk for women are based on treatment-seeking Veterans Affairs samples (e.g., Hassija, Jakupcak, Maguen, & Shiphers, 2012) or samples from a single military base (e.g., Luxton et al., 2010). A meta-analysis of gender and PTSD risk that included both military and civilian studies was conducted prior to OIF/OEF found female gender to be more predictive of PTSD in civilian-only samples (Brewin, Andrews, & Valentine, 2000). On the other hand, a 2015 meta-analysis focused on OIF/OEF veterans specifically concluded that males may be at greater risk (Fulton et al., 2015). Thus, a study examining gender differences in the risk of PTSD using a large, representative sample of service men and women is still needed.

In addition to the question about gender differences, there is also literature on racial differences in the development of PTSD among veterans. As with the extant studies on gender, conclusions from studies that focus on race vary based upon the sample, the measures, the time period, and so forth. Thus, there is no clear answer on whether members of racial minority groups are at an increased risk of experiencing PTSD following traumatic combat exposure. For example, one study found no differences between Black and White service members after controlling for combat exposure (MacDonald, Chamberlain, & Lon, 1997), but a meta-analysis from the same time period identified Black individuals as being at higher risk when adjusting for combat exposure (Brewin et al., 2000). A later meta-analysis containing studies from 2007 to 2013 concluded that the prevalence of PTSD increased with the percentage of minority subjects in the studies reviewed, suggesting that minority service members may be at higher risk. Most of the studies included in the meta-analysis were based upon samples of veterans utilizing the Veteran’s administration health-care system and were consequently not representative of the population of veterans as a whole (Fulton et al., 2015). Beyond the lack of clarity about potential gender and racial differences in PTSD, to our knowledge, researchers have yet to consider how race and gender may jointly impact PTSD outcomes among service men and women. As such, this study uses a large, representative sample of Black and White U.S. service men and women to examine PTSD risk at the intersection of race and gender.

We have reason to believe that Black service women may be at differential risk for PTSD compared to others, but the direction could be either for the better or for the worse based on the theoretical and substantive literatures from both military and civilian populations. The differential vulnerability hypothesis suggests that Black service women may be more vulnerable to the effects of traumatic combat exposure because lower status groups, such as racial minorities and women, may have fewer or less effective resources to cope with acute stress (Kessler, 1979; Kohn & Hudson, 2002). Alternatively, some findings suggest that Black women could be less vulnerable to the effects of trauma exposure due to having better coping resources than White women (Rosenfield, 2012). Because of the lack of clarity on race and gender differences in PTSD following exposure to combat-related trauma, and because no studies have examined the intersection of race and gender with respect to this issue, we performed an exploratory analysis of the intersection of gender and race on a large, representative sample of U.S. military service members with ample representation of Black and White women using both self-reported, symptom-based measures and diagnoses in the context of health encounters with military service providers.

While the differential vulnerability hypothesis has not been explicitly tested in the military context, studies have examined differential responses to stress by race and gender in general. More women served in the recent wars than in previous conflicts and were exposed to more violence from combat-like situations and treating the victims of war (see Feczer & Bjorklund, 2009; Jeffreys, 2007; Maguen et al., 2010; Women in Military Service, 2011). Several studies identified an increased risk of PTSD for deployed women in the military (see Luxton et al., 2010; Seelig et al., 2012; see Haskell et al., 2010 for an exception). For example, one study that began data collection prior to the start of OIF and OEF found that among those who served in the conflicts, women were at higher risk of self-reported PTSD overall compared to men, controlling for combat exposure (Smith et al., 2008). Seelig and colleagues (2012) reported that combat-related exposures were especially important for PTSD development among female service members, as the greatest risk to develop PTSD following deployment was among those with such exposures.

In terms of race and PTSD among military personnel, Brewin, Andrews, and Valentine (2000) explored 77 studies on PTSD and trauma exposure and found that among military samples, racial minority status was associated with an increased risk for PTSD, potentially because racial minorities in general are at higher risk of experiencing combat-related trauma, though this finding applies to Black men more than Black women (Brewin et al., 2000; Fontana, Rosenheck, & Desai, 2010).

In addition to the unresolved questions about race, gender, and PTSD risk in general, there is a further question about the intersection of race and gender and PTSD risk. While the differential vulnerability hypothesis addresses gender and race differences in mental health problems, intersectionality approaches deal with how the joint experience of race and gender impacts mental health (Kohn & Hudson, 2002; Rosenfield, 2012). More broadly, the intersectionality paradigm focuses on how various aspects of identity such as race, gender, class, and sexual orientation interrelate in the context of systemic social inequality (Collins, 1990; Crenshaw, 1989). Intersectionality acknowledges that the experience of being female may be different for Black and White women, and the experience of being Black may be different for Black women than Black men, and thus studying the intersection of race and gender cannot be reduced to examining the additive effects of race + gender. Although many intersectionality scholars reject categories such as race and gender due to the need to deconstruct categories and acknowledge the heterogeneity within them, others assert that existing categories can be used to document interrelationships of inequality among different social groups or statuses (McCall, 2005). McCall (2005) argues that “intercategorical” quantitative studies that examine the statistical interaction of various categories, such as race and gender, can contribute to the understanding of intersectionality by being explicitly comparative. “If structural relationships are the focus of analysis, rather than the underlying assumption or context of the analysis, then categorization is inevitable” (McCall, 2005, p. 1786).

Thus, using an intercategorical approach tested by statistical interaction, we ask the question, does being both female and Black increase the risk of PTSD in the military context? Indeed, some civilian studies find higher risk of mental health issues for Black women compared to White women (see Franko et al., 2005; Gazmararian, James, & Lepkowski, 1995; Kessler et al., 1994; Spence, Adkins, & Dupre, 2011), but others find lower risk and refer to this phenomenon as the “paradox” of Black women’s mental health (see review by Rosenfield, 2012). Most of the work examining the intersection of race and gender focuses on distress or depression, and so it remains an empirical question whether Black service women are at increased or decreased risk of PTSD relative to White service women and to Black and White service men.

Further, in addition to potentially being at different levels of risk for experiencing symptoms and disorder, it may also be the case that help seeking and/or diagnostic patterns may differ by these statuses as well. There is a large body of work on civilian populations which demonstrates that women are more likely than men to seek treatment for mental health issues. For example, multiple nationally representative epidemiological studies find that, controlling for symptomatology, men are significantly less likely to seek mental health treatment than women (Kessler, 1994; Kessler et al., 2005; Lin, Goering, Offord, & Campbell, 1996; Wang et al., 2005). Theory and empirical evidence supports two main explanations for the discrepancy—traditional gender attitudes, which portray men as weak for acknowledging emotional problems or seeking help, and stigma, which may disproportionately affect men (Addis & Mahalik, 2003; Corrigan, 2004; Van Voorhees et al., 2005, 2006). Indeed, Sareen and colleagues (2007) find that attitudinal issues are stronger barriers to seeking treatment than financial issues.

As for race, studies show that Black individuals are less likely than White individuals to seek mental health treatment in general (Kessler et al., 1994; Neighbors, 1988; Wang et al., 2005). In fact, comparing results from the National Comorbidity Study conducted in 1990–1992 to the National Comorbidity Study Replication conducted between 2001 and 2003, Kessler and colleagues (2005) found that while the rate of mental health service utilization had increased over time, the Black–White gap in service utilization increased as well. Potential explanations for the gap include lower socioeconomic status, less access to quality health care, cultural mistrust of medical professionals, and greater perceptions of stigma among Blacks (Muntaner et al., 1999; Schnittker, Freese, & Powell, 2000; Schnittker, Pescosolido, & Croghan, 2005; Wang et al., 2005; Whaley, 2001). Given that the military context encompasses less socioeconomic inequality and more equal access to quality health care compared to the general population, the cultural mistrust or stigma explanations may be the most relevant to the current study. Beyond treatment seeking, several studies demonstrate that women are more likely than men to be diagnosed with emotional disorders, given the same symptoms and that alcohol use among men may mask emotional symptoms (Nolen-Hoeksema, 2012). Based on current evidence, it is unclear how diagnoses may differ systematically by race.

Deployment represents a unique context to explore issues of differential vulnerability, as service members are removed from their home environment, their usual routines, and their extended social networks. Given the potential isolation and stress of being a Black woman in a White, male-dominated workplace, being female and Black in the U.S. military may foster a situation for problematic stress response following exposure to trauma. In this study, we explored differential vulnerability in relation to the intersection of gender and race in a large sample of U.S. military personnel. In addition to self-report, we also examined medical diagnoses, as there may be differences in prevalence of symptoms but also in treatment seeking and the likelihood of receiving a diagnosis for symptoms.

Methods

Data for this study were obtained from the Defense Medical Surveillance System, The Armed Forces Health Surveillance Center, U.S. Department of Defense, Silver Spring, Maryland (January 2008–March 2009; data retrieved January 6, 2011). The analytic sample included all active duty service members who returned from military operations in OIF or OEF between January 1, 2008, and March 16, 2009, and completed the post-deployment health assessment (PDHA) and the post-deployment health re-assessment (PDHRA). National Guard and Reserve members were not included in the sample. Service members returning from deployment are required to complete the PDHA and PDHRA, which include a self-report survey, usually completed online, or, less often, by telephone, as well as information collected by a health-care provider in a face-to-face interview (U.S. Department of Defense [DoD], 2006). The PDHA is completed within 30 days of departure from theater, and the PDHRA is administered between 90 and 180 days after return (DoD, 2006). Completion of the surveys is monitored by military command, and thus participation is mandatory.

Individuals taking the PDHA and PDHRA report their past and current health conditions, symptoms related to their mental and physical health, exposure concerns, and relevant demographic information. After completing the self-report section, individuals meet with health-care professionals to discuss their responses and receive follow-up information or referrals as needed. All data were deidentified and a unique identifier was used to link the PDHA with the PDHRA (Bickman et al., 2009). Analysts at the DoD linked PDHRA assessments to the corresponding PDHA report for each service member, ensuring that both assessments came from the same deployment. The date of departure on each form had to be within 90 days of each other in the service member’s records, and the PDHA had to be recorded prior to the PDHRA. For some respondents, more than one PDHA existed and in that case one PDHA was randomly selected. The study sample was limited to active duty service members serving in OIF and OEF and further limited to Black and White service members only. The resulting sample consisted of 48,718 linked files. Reasons for nonlinkage include one or more assessments being out of the date range of data collected for this study, the date of the PDHRA being earlier than the date the PDHA was completed, and the PDHA and PDHRA coming from different deployments (Bickman et al., 2009).

We combined the linked self-report and clinician-report information available on the PDHA and PDHRA with health-care encounter (HCE) data collected by the military on all active duty service members when they receive treatment through the TRICARE system (which includes care from military treatment facilities and outsourced facilities). The HCE data included dates of service, diagnostic information, and procedures. Approximately 21% of the sample received a mental health diagnosis at an HCE in the 6 months following deployment. Finally, some demographic information, such as education level, military component, and race, were extracted from the Defense Enrollment Eligibility System database.

Measures

Dependent Variables

PTSD

PTSD risk was assessed using the Primary Care 4-item PTSD screen (PC-PTSD; Prins et al., 2004) on both the PDHA and the PDHRA. PTSD diagnoses were determined based on International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes in the HCE data. Service members were asked if they had, “any experience that was so frightening, horrible, or upsetting that, in the past month,” they (1) had nightmares, (2) avoided situations, (3) were constantly on guard or watchful, or (4) felt numb or detached from others (PDHA and PDHRA). Per coding guidelines, if service members reported two or more symptoms, they were coded as 1, which indicated a positive screen for PTSD risk. The diagnostic measure was equal to 1 if the respondent received a PTSD diagnosis (ICD-9 = 309.81) at an HCE within 6 months following return from deployment (World Health Organization, 1977). If respondents did not have an HCE at all or if they had an HCE with a different diagnosis, they were coded as 0 for PTSD. Hence, we used 3 PTSD measures—PDHA risk, PDHRA risk, and HCE diagnosis. About 9% of respondents screened positive on the PDHA and around 10% screened positive on the PDHRA. A little more than 4% of service members had positive screens for PTSD on both the PDHA and the PDHRA. Nearly 6% of respondents reported two or more symptoms on the PDHRA but not the PDHA. At HCEs, 2.6% of service members received a diagnosis.

Key Independent Variables

Race and gender: Race (1 = Black) and gender (1 = Female) were obtained from military records. About 10% of the sample were female and approximately 14% were Black.

Combat-related trauma: Respondents were asked on the PDHA if they had (1) seen people killed or wounded or encountered dead bodies, (2) engaged in direct combat in which the service member discharged a weapon, or (3) felt that they were in great danger of being killed. These items were summed to form an additive measure that ranged between 0 and 3 traumatic exposures. About 56% of the sample reported no traumatic combat exposure; 23% reported 1, 13% reported 2, and 8% reported all 3.

Control Variables

Demographic characteristics

We included measures of pay grade (as an indicator of socioeconomic status), marital status (single and divorced/widowed/separated compared to married), age, educational attainment (more than high school = 1), the service member’s military branch, whether they were deployed to Iraq (vs. Afghanistan), and duration of most recent deployment (measured in months). Also, to control for the potential confounding effects of other health problems, we included variables measured during the PDHA and PDHRA clinical assessment that indicated if the service members were under care for physical or mental health issues. In this sample, the mean pay grade level was E-5/E-6. The U.S. military pay grade system is determined by level (e.g. E = “enlisted member”, “O” = officer) and years in service. More than half of the respondents were currently married. The average age of the sample was 28 years old, which compares to the larger U.S. military population in which the average age of the active duty population is 28.5 years old (DoD, 2010). About 14% of service members had more than a high school education. Sixty percent were members of the Army, about 23% were Air Force, 13% were Marine Corp, and 4% were Navy, which is similar to the deployed U.S. military as a whole. As a comparison, Army service members account for 67% of those who have deployed during OEF and OIF (Bonds, Baiocchi, & McDonald, 2010). Service members on average had been deployed for 10 months. Over 80% of those in the sample had been deployed to Iraq. Nearly 13% of service members were under care for a health issue at the time of the PDHA, and the number increased to about 16% at the time of the PDHRA.

Analyses

We used hierarchical logistic regression to model the odds of PTSD on the PDHA, the PDHRA, and in the HCE data using Stata 12.0 (StataCorp, 2011). The hierarchical models included a random intercept for military unit to account for unit-level correlation among observations. Each model examined a different aspect of PTSD risk. The PDHA model addressed early stress response. Since service members complete the PDHA immediately upon return from deployment, those who screen positive for PTSD began experiencing symptoms before or shortly after return. Because service members take the PDHRA several months after returning, this measure captures those who are still experiencing symptoms or those who begin experiencing symptoms at a later date. Finally, the HCE diagnosis model utilized stricter criteria for PTSD; that is, it counts as positive only for those who sought treatment and received a diagnosis at a military health-care facility.

Because of the large sample size, we interpreted odds ratios of PTSD as measures of effect size rather than relying on statistical significance alone. We used α = .05 as a cutoff for hypothesis tests, despite the large sample size because we were testing two- and three-way interactions that contain small cell sizes. We tested the differential vulnerability hypothesis with a three-way interaction consisting of Female × Black × the Count of Traumatic Combat Exposures. The three-way interaction examined whether the slope of traumatic combat exposures differs for Black women compared to other status combinations. In other words, we can conclude that Black women are more (or less) vulnerable to the effects of traumatic combat exposure if the slope increase is higher (or lower) for Black women compared to other status combinations. In addition to the interaction terms, we also examined differences in predicted probabilities computed by gender, race, and number of traumatic combat exposure combinations with other covariates set to their actual values and then averaged across observations. Relying solely on interaction terms to test for group differences in nonlinear models can be problematic if baseline rates of disorder are different because the interaction term measures change on a ratio scale (Mustillo, Landerman, & Land, 2012; Norton, Wang, & Ai, 2004).

Results

Prior to determining if Black women were more vulnerable to the effects of traumatic combat exposure for the differential vulnerability hypothesis, we conducted a bivariate analysis to assess if the rates of exposure varied by race and gender status. Table 1 indicates that there were differences in the rates of traumatic combat exposure, as only 31% of Black women in the sample had such experiences while deployed, compared to 36% of White women, 42% of Black men, and 46% of White men. Black and White women were exposed to fewer combat stressors on average than men.

Table 1.

Descriptive Statistics of Study Variables From the Post-Deployment Health Assessment (PDHA), Post-Deployment Health Reassessment (PDHRA), and Health-Care Encounter (HCE) Data by Race and Gender.

	Total	White Men	Black Men	White Women	Black Women
Demographic characteristics	N = 48,718	n = 38,323	n = 5,700	n = 3,470	n = 1,225
Pay grade	2.04 (1.30)	2.03 (1.31)	1.96 (1.05)	2.24 (1.49)	2.06 (1.17)
Marital status
Single	32.91	33.31	25.84	37.03	41.47
Married	57.24	58.52	61.84	42.74	36.82
Divorced/separate/widowed	9.85	8.17	12.32	20.23	21.71
Age	27.98 (6.65)	27.74 (6.57)	29.54 (6.91)	27.74 (6.59)	29.14 (6.86)
High school diploma	13.88	13.33	13.56	19.16	17.71
Military characteristics
Military branch
Air Force	23.28	22.26	18.63	40.15	28.90
Army	59.85	59.04	69.26	50.89	67.10
Marines	12.99	14.70	8.42	5.39	2.04
Navy	3.88	4.00	3.69	3.57	1.96
Months deployed	10.03 (4.58)	9.97 (4.52)	10.86 (4.61)	9.15 (4.91)	10.36 (4.66)
Iraq (vs. Afghanistan)	82.56	82.30	84.35	81.90	84.33
Traumatic combat exposures
0	55.90	54.43	57.79	64.29	69.22
1	22.87	22.32	24.33	26.25	23.76
2	13.40	14.15	12.60	8.70	6.94
3	7.83	9.10	5.28	0.76	0.08
Health variables
Receiving medical care—PDHA	12.78	12.13	13.60	16.80	17.88
Receiving medical care—PDHRFA	16.30	15.66	16.82	21.33	19.51
Posttraumatic Stress—PDHA	8.98	8.96	9.14	8.36	10.94
Posttraumatic Stress—PDHRA	9.73	9.62	9.88	10.37	10.61
Posttraumatic Stress—HCE	2.59	2.65	1.88	3.11	2.61

In Table 2 Model 1, we present regression results from models regressing self-report PTSD risk from the PDHA on female, Black, and Female × Black. The odds ratios for female and Black show that the odds of screening positive for PTSD on the PDHA were no different for White women compared to White men or between Black men and White men. The interaction term was significant and shows that the odds of positive PTSD screen were 34% higher for Black women compared to White women than for Black men compared to White men (odds ratio [OR] = 1.337). In Table 2, Model 2 we added the three-way interaction among race, gender, and traumatic combat exposure. Examining the main effects first, with the three-way interaction term in the model (and the constituent two-way interactions), the odds ratio for female remained not significant, indicating the odds of a positive PDHA screen for PTSD in White women with zero traumatic combat exposures were about the same as their White male counterparts. The main effect for Black became significant, indicating that the odds of PTSD for Black men with zero combat exposures were 31% higher compared to White men, while the main effect for combat exposure shows almost a threefold increase in the odds of PTSD for each additional traumatic combat exposure for White men (OR = 2.893). As for the two-way interaction terms in Model 2, Female × Combat exposure shows that the odds of PTSD increased more steeply with more traumatic combat exposures for White women compared to White men (OR = 1.384). Specifically, for each additional traumatic combat exposure, the odds of positive PTSD screen increased by 38%. The two-way interaction for Black × Combat exposure was not significantly different from 0, nor was the three-way interaction term.

Table 2.

Logistic Regression Results of Post-Traumatic Stress Disorder on Race, Gender, Their Interaction, and Covariates, Post-Deployment Health Assessment.

Status characteristics	OR	95% CI	OR	95% CI	OR	95% CI
Female	1.007	[0.879, 1.153]	1.096	[0.876, 1.373]	1.078	[0.858, 1.353]
Black	1.021	[0.921, 1.131]	1.307**	[1.099, 1.554]	1.206*	[1.012, 1.437]
Female × Black	1.337*	[1.043, 1.713]	1.158	[0.775, 1.732]	1.178	[0.786, 1.767]
Combat exposure			2.893***	[2.778, 3.013]	2.854***	[2.736, 2.976]
Female × Combat Exposure			1.384***	[1.171, 1.636]	1.398***	[1.180, 1.657]
Black × Combat Exposure			0.926	[0.838, 1.023]	0.935	[0.845, 1.035]
Female × Black × Combat Exposure			1.206	[0.868, 1.677]	1.213	[0.869, 1.693]
Control variables
Pay grade					0.790***	[0.760, 0.820]
Marital status (compared to married)
Single					0.824***	[0.758, 0.896]
Divorced/separate/widowed					1.159**	[1.038, 1.295]
Age					1.018***	[1.011, 1.025]
High school diploma					1.085	[0.976, 1.207]
Military branch
Air Force					0.840*	[0.724, 0.975]
Marines					0.697***	[0.570, 0.853]
Navy					0.994	[0.781, 1.266]
Months deployed					1.010	[0.998, 1.022]
Iraq (vs. Afghanistan)					1.366***	[1.210, 1.541]
Under medical care					2.208***	[2.023, 2.409]

Note. n = 8,718. Exponentiated coefficients. Confidence intervals in brackets.

*p < .05. **p < .01. ***p < .001.

With control variables in the model (Table 2, Model 3), the main effects, two-way and three-way interaction ORs remained substantively the same. Higher pay grade, being single compared to married, and being in the Air Force or Marine Corp were associated with lower risk of PTSD, while being divorced, widowed, or separated; being older; being in Iraq (vs. Afghanistan); and being in treatment for a health condition were all significantly associated with higher PTSD risk.

The predicted probabilities generated from this model show that the probability of PTSD increased for all four groups as traumatic combat exposure increased but that the increase for Black and White women was significantly greater than for Black or White men (Figure 1). Although the increase for Black women was steeper than White women, the difference was not statistically significant as determined by the overlapping confidence intervals and confirmed with a Wald’s test.

Figure 1.

Probability of positive post-traumatic stress disorder (PTSD) screen on post-deployment health assessment (PDHA) by race, gender, and number of traumatic combat exposures with 95% confidence intervals (CIs).

Table 3, Model 1, presents the results for PTSD on the PDHRA regressed on the two-way interaction of female and Black. Results show that the main effect for female was significant and positive such that odds of screening positive for PTSD on the PDHRA were 18% higher for White women compared to White men (OR = 1.178). Neither the main effect for Black nor the two-way interaction term was significant. The OR for the three-way interaction with combat exposure was not significantly different from zero in Table 3, Model 2, but the main effect for combat exposure and the two-way interaction between female and combat exposure were both significant and positive, indicating that an increase in traumatic combat exposure was associated with an increase in the odds of positive PTSD screen for White men and White women compared to White men. Adding the control variables in Table 3, Model 3, did not change those results, and the effects of the control variables were largely consistent with the PDHA models. The only substantive differences was that Marines were no longer less likely to screen positive for PTSD on the PDHRA than Army service members (OR = .937) and members of the Navy were more likely (OR = 1.379). The predicted probabilities from this model were consistent with those from the PDHA model (Figure 2).

Table 3.

Logistic Regression Results of Post-Traumatic Stress Disorder on Race, Gender, Their Interaction, and Covariates, Post-Deployment Health Reassessment.

Status characteristics	OR	95% CI	OR	95% CI	OR	95% CI
Female	1.178**	[1.042, 1.332]	1.222*	[1.023, 1.460]	1.192	[0.994, 1.430]
Black	1.015	[0.920, 1.119]	1.200*	[1.037, 1.387]	1.117	[0.964, 1.296]
Female × Black	0.966	[0.759, 1.228]	1.091	[0.784, 1.518]	1.121	[0.801, 1.568]
Combat exposure			2.075***	[2.002, 2.151]	1.972***	[1.900, 2.048]
Female × Combat Exposure			1.299***	[1.121, 1.505]	1.347***	[1.159, 1.567]
Black × Combat Exposure			0.937	[0.853, 1.028]	0.945	[0.859, 1.039]
Female × Black × Combat Exposure			0.819	[0.601, 1.118]	0.804	[0.585, 1.106]
Control variables
Pay grade					0.771***	[0.743, 0.800]
Marital status (compared to married)
Single					0.861***	[0.796, 0.932]
Divorced/separate/widowed					1.321***	[1.194, 1.462]
Age					1.015***	[1.008, 1.022]
High school diploma					1.062	[0.959, 1.176]
Military branch (compared to Army)
Air Force					0.668***	[0.581, 0.768]
Marines					0.981	[0.831, 1.158]
Navy					1.379**	[1.124, 1.692]
Months deployed					1.023***	[1.012, 1.034]
Iraq (vs. Afghanistan)					1.079	[0.967, 1.203]
Under care					3.170***	[2.952, 3.403]

Note. N = 48,718. Exponentiated coefficients; confidence intervals in brackets.

*p < .05. **p < .01. ***p < .001.

Figure 2.

Probability of positive post-traumatic stress disorder (PTSD) screen on post-deployment health assessment (PDHA) by gender, race, and number of traumatic combat exposures with 95% 95% confidence intervals (CIs).

The final set of models test differential vulnerability in the context of PTSD diagnosis at an HCE. The two-way interaction term between female and Black in Table 4, Model 1, was not significant and neither was the main effect for female. The main effect for Black was significant, indicating that Black men have 29% lower odds of a PTSD diagnosis compared to White men (OR = .711). In Table 4, Model 2, with the three-way interaction term among female, Black, and traumatic combat exposure in the model, the main effect for female continued to be nonsignificant, and the main effect for Black became nonsignificant. The main effect for combat exposure shows that for every additional traumatic combat exposure, the odds of PTSD diagnosis increased by 76% for White men (OR = 1.758). The two-way interaction term for Female × Combat Exposure was significant but the one for Black × Combat Exposure was not. Thus, the odds of PTSD increased more with every additional traumatic combat exposure for White women compared to White men (OR = 1.358) but not for Black men compared to White men. The three-way interaction term was not significant. Hence, women appear to be more vulnerable to traumatic stress exposure than men, but Black women do not have any additional risk compared to White women.

Table 4.

Logistic Regression Results of Post-Traumatic Stress Disorder on Race, Gender, Their Interaction, and Covariates, Health-Care Encounter Data.

Status Characteristics	OR	95% CI	OR	95% CI	OR	95% CI
Female	1.216	[0.986, 1.501]	1.169	[0.859, 1.590]	1.089	[0.797, 1.489]
Black	0.711**	[0.579, 0.873]	0.816	[0.606, 1.098]	0.744	[0.550, 1.007]
Female × Black	1.180	[0.749, 1.861]	1.499	[0.815, 2.757]	1.651	[0.891, 3.058]
Combat exposure			1.758***	[1.654, 1.869]	1.670***	[1.565, 1.782]
Female × Combat Exposure			1.358*	[1.073, 1.720]	1.363*	[1.072, 1.733]
Black × combatexposure			0.943	[0.780, 1.140]	0.944	[0.777, 1.148]
Female × Black × Combat Exposure			0.694	[0.390, 1.234]	0.683	[0.380, 1.225]
Control Variables
Pay grade					0.711***	[0.662, 0.764]
Marital status (compared to married)
Single					0.637***	[0.549, 0.739]
Divorced/separate/widowed					1.100	[0.920, 1.315]
Age					1.023***	[1.011, 1.035]
High school diploma					1.043	[0.869, 1.251]
Military branch (compared to Army)
Air Force					0.930	[0.733, 1.179]
Marines					1.219	[0.932, 1.594]
Navy					2.088***	[1.535, 2.840]
Months deployed					0.997	[0.977, 1.016]
Iraq (vs. Afghanistan)					0.946	[0.792, 1.130]
Under care					4.080***	[3.611, 4.609]

Note. Exponentiated coefficients; confidence intervals in brackets. N = 48,718.

*p < .05. **p < .01. ***p < 0.001.

In the model with control variables (Table 4, Model 3), the main effects and interaction terms were substantively consistent with Model 2. In terms of the control variables, higher pay grade and single marital status (compared to being married) were both associated with lower odds of PTSD diagnosis and older age, being in the Navy (compared to being in the Army), and being under care for a health issue at the time of the PDHA or PDHRA were associated with higher odds of PTSD diagnosis.

In terms of the predicted probabilities from this model, Black men had the lowest probability of a diagnosis and White women the highest. White men and Black women had about the same probability of diagnosis (Figure 3). The only significant contrast was between Black men and White women with 2 and 3 exposures as seen by the lack of overlap between their confidence intervals. The predicted probabilities show White women as having the highest probability of a diagnosis as well as the steepest change with additional exposures, followed by Black women, and then White men and Black men, but the confidence intervals among White women, Black women, and White men overlapped. Similarly, the confidence intervals among Black men, White men, and Black women overlapped. Thus, the only significant difference was between Black men and White women. Wald’s tests confirmed this conclusion.

Figure 3.

Probability of post-traumatic stress disorder (PTSD) diagnosis by gender, race, and number of traumatic combat exposures with 95% 95% confidence intervals (CIs).

Discussion

With the United States having participated in two conflicts simultaneously, and many service members serving multiple deployments, the prevalence of PTSD in the armed forces is high. Further, during OIF and OEF, women were exposed to more combat-related trauma than ever before. With the recent elimination of the policy barring women from serving in combat roles in the U.S. military, the number of women exposed to combat will only increase in future conflicts. Most studies of PTSD in the military focus on men exclusively or just control for gender, often due to sample size restrictions. The small samples or convenience samples upon which many studies are based have not had enough female representation to explore gender differences, much less gender by race differences (e.g. Hoge et al., 2004; Maguen, Ren, Bosch, Marmar, & Seal, 2010). The current study used data from over 45,000 formerly deployed service members, including over 4,500 women total and more than 1,200 Black women. Hence, we had sufficient data to examine how gender and race intersect in the context of postdeployment PTSD.

Based on the differential vulnerability hypothesis, we examined whether being female, being Black, and being female and Black increased the vulnerability to combat exposure with three different PTSD measures—two symptom-based measures from different time points and one diagnosis measure. The first symptom-based measure came from the PDHA, a self-reported instrument that service members take shortly after redeployment. The second symptom-based measure came from the PDHRA, a similar self-reported instrument that service members take between 3 and 6 months after redeployment. As such, we had an early measure of PTSD symptomatology and a later measure to catch symptoms that take time to manifest. Some studies show that PTSD has a latency period and can take months or even years for symptoms to manifest (Bremner et al., 1996; Solomon, Mikulincer, & Waysman, 1991). The diagnostic measure captured service members who received a diagnosis at a health-care visit in the TRICARE system in the 6 months following deployment.

Given the conflicting results in prior research about whether being female or being Black is associated with increased (or decreased) vulnerability to combat-related trauma, we examined the intersection of race, gender, and combat trauma with two-way and three-way interaction terms. We found an elevated risk on both self-report measures for White and Black women compared to White and Black men as exposure to traumatic combat increased, but no additional risk for Black women compared to White women. Our results are in accord with past scholarship by Seelig and colleagues (2012) that identifies deployed women with combat-related exposure as being at greater risk to develop PTSD during redeployment as well as with general population studies (e.g., Luxton, Skopp, & Manguen, 2010; Stein, Walker, & Forde, 2000).

In the HCE model, we found higher odds of diagnosis for White women only, which means that there is a discrepancy between the symptoms reported on the self-report measures and the diagnoses received at HCEs for Black women. That is, Black women appear to not receive diagnoses at rates that match their positive screens on the self-report measures. In post hoc analyses, we found evidence that White women seek treatment at higher rates compared to the other groups. Of those who screened positive for PTSD on either the PDHA or the PDHRA, 55.5% of males had an HCE for a mental health issue while 64.9% of females did the same, but White females sought care at much higher rates than Black females (86.4% compared to 59%). Post hoc analyses further suggested that women who screened positive for PTSD and sought treatment were more likely to receive a depression diagnosis than a PTSD diagnosis. Taken together, these findings imply that the apparent underdiagnosis of Black women may be due in part to these service members not seeking treatment from TRICARE providers. Additional research on race, gender, and treatment seeking is clearly warranted.

Of the three PTSD measures, Black women were only at an increased risk compared to White women in the PDHA model—the early symptom measure—without the three-way interaction term. In this model, the two-way interaction term was significant, and the rate of change in predicted probabilities for Black females was significantly higher than for White men, Black men, or White women. Being female increased the risk of PTSD symptoms, but being Black in addition to being female increased the risk even more but only when not accounting for combat exposure. Notably, Black women were exposed to less traumatic combat stress than any other group. When combat exposure was not controlled for in the model, Black women were at greater risk, but once combat exposure was taken into account, their risk was no longer higher. That this effect was significant when not controlling for combat exposure suggests that analyses in which subjects have been exposed to trauma at different levels but fail to control for (or interact) combat exposure with race and gender suffer from omitted variable bias and results may be spurious. Omitted variable bias could explain some of the discrepancies in findings on racial differences from study to study.

Despite the strengths of sample size and representativeness of the overall military population, this study had several limitations. The PTSD measure used on the PDHA and PDHRA is not a diagnostic measure and thus does not correspond to clinical diagnosis of PTSD. At the same time, although the PDHA and PDHRA are confidential, they are conducted by individuals working for the DoD. It is likely that service members underreport mental health symptoms out of concern that positive responses could impact their career advancement or delay their return home following deployment. It is also possible that the propensity to underreport may differ by gender, conflating the findings. For example, if males are more likely to underreport symptoms compared to females, findings could be biased. Along the same lines, men may also be more likely to self-medicate symptoms of PTSD with alcohol or drugs, which could affect symptom reporting (Leeies, Pagura, Sareen, & Bolton, 2010).

Further, the diagnosis measure underreports PTSD because not all service members utilize service from Tricare and discharged service members are not eligible to receive treatment at these facilities. Some active duty service members may choose to seek treatment privately to prevent a mental health condition from appearing on their military medical record or not seek treatment at all. Mental health conditions continue to be stigmatized in the military and many service members fear seeking treatment could adversely impact their military advancement (Britt, Greene-Shortridge, & Castro, 2007). In fact, Hoge and colleagues (2004) found that service members who needed mental health care reported 2 times as much concern for stigmatization than those who did not need mental health care. We also lacked data on key covariates, such as exposure to prior violence, social support, coping strategies, and other factors that could be associated with gender and race differences in stress response. Finally, this study focused on a single racial/ethnic minority group, but there are other racial/ethnic groups serving in the military including Latinos, Asian Americans, Pacific Islanders, and Native Americans. Little is known about the experience of PTSD among these groups, and more research is needed in this area.

Despite these limitations, this is the first large-scale study to our knowledge with sufficient representation of Black females to examine the intersection of race and gender with regard to PTSD in the military context utilizing both self-report and diagnostic data. Given the gender difference in all 3 measures, these findings suggest that additional support and services for women exposed to trauma during military deployment is warranted to offset the apparent increased prevalence of elevated posttraumatic stress symptoms. The excessive risk appears immediately following redeployment and is still present 3–6 months later. Targeted interventions for service women beginning immediately after return from deployment will likely reduce the risk of developing PTSD. Future research should examine specific factors that may contribute to vulnerability among women, such as childhood trauma (Schultz, Bell, Naugle, & Polusny, 2006; Seifert, Polusny, & Murdoch, 2011), sexual assault (Merrill et al., 1998), and lower unit support as well as any aspects of training that may be deficient. Identifying such factors would allow military command to focus on prevention efforts prior to deployment in addition to interventions following deployment. Addressing potential issues at multiple stages of the deployment cycle will benefit women in the U.S. Armed Forces and reduce the substantial mental health burden associated with the combat theater.

Footnotes

Authors’ Note

Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was carried out in cooperation with Force Health Protection and Readiness (FHP&R). The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702-5014 is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs and the United States Army Medical Research and Materiel Command (USAMRMC) under Award No. W81XWH-09-2-0172.

Supplemental Material

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