Editor’s note: This article is the first of a two-part series about female combat casualties. The next installment will be published in the May issue.
Today, women represent nearly 15 percent of active duty military and 18 percent of guard and reserve forces. Although female service members experience unprecedented levels of combat exposure in the global war on terror, they account for just 2 percent of the total wartime casualties.
Contemporary combat protective equipment has resulted in unprecedented survival rates, but also a proportionate increase in extremity injuries that require extensive treatment and rehabilitation. Such injuries present challenges to patients and caregivers from the military, Veterans Affairs (VA), and civilian health systems who provide long-term care for service members. Registries such as the Joint Theater Trauma Registry and the Military Orthopaedic Trauma Registry have been created to study injury patterns, track treatment practices and outcomes, and develop clinical practice guidelines.
Despite faster evacuation, improved surgical techniques, and forward deployment of medical care, rates of amputation remain roughly similar among U.S. conflicts over the past 50 years due to the increased degree of primary tissue destruction associated with modern weaponry. As of January 2011, more than 1,164 service members from Operation Iraqi Freedom and Operation Enduring Freedom had sustained at least one major limb loss. Female veteran amputees may face psychological and social reintegration challenges and comorbid physical and mental health conditions that differ from those faced by their male colleagues. Female war amputees represent a very small group of veterans whose unique reintegration and rehabilitation needs require further investigation.
Amputation is highly associated with depression and post-traumatic stress disorder (PTSD). In noncombat trauma literature, women are twice as likely as men to be affected by major depression and other mental disorders following traumatic events. On the other hand, in combat trauma literature, men and women have a similar prevalence of mental health conditions, despite women having a lower exposure to combat trauma, suggesting that women are vulnerable to other wartime stressors.
Overall satisfaction with physical outcomes is lower and perceived limitations are higher in service members with mental health conditions, leading to lost work time and increased healthcare utilization. The Military Extremity Trauma Amputation/Limb Salvage study found that among patients with severe lower limb injury requiring amputation or limb salvage, 38.3 percent screened positive for depressive symptoms, 13 percent had scores indicating major depression, and 17.9 percent were diagnosed with PTSD. During the initial preoperative course of treatment, it is difficult to determine whether patients are suffering, because the onset of an acute stress disorder may not present for weeks to months. In a sample of veterans attending a VA women’s health clinic, 37 percent of patients endorsed symptoms of depression, 56 percent endorsed symptoms of anxiety, and 45 percent screened positive for at least one mental health disorder. Interventions that target depressive symptoms and pain management, as well as self-management skills, may be especially suitable for the needs of the female amputee population.
Other traumatic events prior to amputation may have a significant impact on the incidence of PTSD and other complications. Female veterans are more likely than males to experience all forms of traumatic events other than combat, such as premilitary physical or sexual abuse; an estimated 81 percent to 93 percent of female veterans experience a traumatic event at some point in their lives. Prior mental health needs may have been suppressed due to the perception that requesting mental health support may affect career or deployment opportunities.
Because PTSD is a primary link between trauma and poor outcomes, identifying and addressing the history of trauma often associated with amputation are essential for successful rehabilitation and reintegration. The estimated lifetime prevalence of PTSD for female veterans attending VA primary care clinics is 27 percent, or 2.5 times the rate of females in the general population. However, after separation from the military, only 3 percent to 4 percent of female veterans receive PTSD diagnoses from the VA for trauma-related mental health problems, and they are more likely to seek care from non-VA mental health services. Because PTSD interventions are often provided in a group format dominated by males, females may be reluctant to disclose sexual trauma in that setting. Emphasis on early identification of sexual assault history among veterans is crucial to ensure that they receive adequate aid to overcome barriers to seeking the care necessary for recovery.
Community reintegration is difficult for many service members, as war trauma brings about profound life changes and requires major occupational, social, and emotional adjustments. Loss of a limb can affect post-service job capabilities, social interaction, self-esteem due to a distorted body image, and independence. Approximately 40 percent of veteran amputees reported difficulty with transition to civilian life; 49 percent expressed difficulty with community involvement; 35 percent to 49 percent reported limited productivity; 28 percent to 45 percent reported problems with social relations, including separation and divorce; 31 percent reported problems with substance abuse; and 57 percent reported difficulty with anger control. Those with PTSD are even more likely to report difficulty in those areas.
Self-efficacy and resilience
Self-efficacy is the strongest predictor of successful reintegration, followed by available services and assistance, attitudes and support, and perceived disability. Female veterans with amputations express concern that their psychological adjustment is significantly influenced by social perceptions, issues with negative body image, and concerns about personal safety. Female amputees perceive those influences as more significant for them than for men with similar injuries.
Factors associated with positive adjustment to limb loss include increasing time since limb loss, greater social support, higher satisfaction with prosthesis, active coping attempts, lower amputation level, lower pain summaries, and an optimistic personality disposition. Factors associated with limited adjustment include depression, activity restriction, increased feelings of vulnerability, poorer self-rated health, anxiety about body image, and social discomfort. Some amputees, expecting rejection by families and friends, preemptively withdraw from social interaction. Social discomfort involving acknowledgement of an amputation or prosthesis may be a marker for poor adjustment and potential depression. Fostering protective factors such as mental toughness and strong social support is vital for psychosocial adjustment.
Body image and sexuality in rehabilitation
A positive correlation exists between an amputee’s evaluation of her body image and lowered self-esteem and life satisfaction. Up to 50 percent of amputees report moderate disturbance of body image during the first year post-injury. An amputee’s perception of his or her body image does not improve with time without intervention. Workshops about body image, individual therapy, and peer support from positive amputee role models can help patients improve self-image.
Sexuality is an important component of identity, and sexual satisfaction is one of the strongest determinants of quality of life. Despite basic needs for physical intimacy and partnership, dominant cultural attitudes regarding sexuality exclude individuals who deviate from the ideal of physical attractiveness absent of physical defect. Pain, pain medication, and the degree to which one can negotiate sexual positioning may significantly affect both sexual interest and activity. Women report a significantly higher degree of sexual dysfunction than men at six and 12 months post-injury.
Amputation-related changes in self-esteem are a concern for many patients and contribute to increased psychological distress and perceived relationship strain. Patients who struggle with body image are at greater risk of experiencing sexual dysfunction. Likewise, negative body image corresponds with avoidance of sexual behavior, and females are more likely to espouse negative views of their bodies. Forty-five percent of women in the Trauma Recovery Project reported feeling less sexually attractive, and 39 percent reported a decrease in sexual pleasure after injury. Self-perceived attractiveness and fear of rejection by potential partners may lead individuals to avoid sexual interaction. Those who care for amputees must remain cognizant that sexuality is an important means of expressing intimate feelings, and the presence of a supportive spouse or partner has been repeatedly shown to benefit amputees throughout rehabilitation.
Limited availability of information and an underappreciation for the relation of sexual dysfunction to overall functional outcomes may contribute to relative inattention of medical personnel to issues related to post-injury sexual activity. Only 7 percent of amputees reported discussing sexuality and sexual function with medical personnel during the rehabilitation process, but nearly 50 percent reported problems with sexual function. Resumption of sexual activity may help increase patients’ self-esteem and acceptance of their amputations. Thus, proactive counseling about sexuality during the rehabilitation process may moderate patients’ sexuality-based anxieties and, in turn, improve quality of life.
The incidence of female military trauma is predicted to increase. Acknowledging the unique needs of female amputees can direct therapies and research to improve outcomes. Exploring veterans’ benefits and resource education, providing family education, facilitating participation in adapted sports and recreation, and providing opportunities to create meaningful connections with other service members with similar health conditions are approaches that may address the contexts of service members’ health conditions and the reintegration process for female wartime amputees.
Craig A. Kampfer, MD, is with the San Antonio Uniformed Services Health Education Consortium in the Department of Orthopaedic Surgery at the San Antonio Military Medical Center at Joint Base San Antonio (JBSA)-Fort Sam Houston in Texas.
Jessica C. Rivera, MD, is with the U.S. Army Institute of Surgical Research at JBSA-Fort Sam Houston.
Christina M. Hylden, MD, is with the San Antonio Uniformed Services Health Education Consortium in the Department of Orthopaedic Surgery at the San Antonio Military Medical Center at JBSA-Fort Sam Houston.
Anthony E. Johnson, MD, is with the Department of Surgery and Perioperative Care at the Dell Medical School at the University of Texas at Austin.
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