She was 19 years old, weighed barely 100 pounds and had a blond ponytail hanging out from under her Kevlar helmet.
"This is what is different about this war," Lt. Col. Richard Rael, commander of the 515th Corps Support Battalion, said of the scene at the time. "Women are fighting it. Women under my command have confirmed kills. These little wisps of things are stronger than anyone could ever imagine and taking on more than most Americans could ever know."
But today, two years after the start of an Iraq war in which traditional front lines were virtually obliterated and women were tasked to fill lethal combat roles more routinely than in any conflict in U.S. history, the nation may be just beginning to see and feel the effects of such service.
Thousands of women, like the male veterans of so many wars before, are returning home emotionally damaged by what they have seen and done. These female troops appear more prone to post-traumatic stress disorder, or PTSD, than their male counterparts.
And studies indicate that many of these women suffer from more pronounced and debilitating forms of PTSD than men, a worrisome finding in a nation that remembers how many traumatized troops got back from Vietnam and turned to drugs and violence, alcohol and suicide.
One children's book increasingly popular among military families illustrates what the effects of this most recent war might mean for society in the years and even decades to come: "Why Is Mommy Like She Is? A Book for Kids About PTSD."
STUDY UNDER WAY
In the wake of such concerns, the Veterans Affairs Department has launched a pioneering $6 million study of PTSD among female veterans. It is the first VA study to focus exclusively on female veterans; 8 percent to 10 percent of active-duty and retired military women suffer from PTSD, a rate nearly twice as high as that among men.
"PTSD is a very real problem for women who serve in the military," said Paula Schnurr, one of the study's lead researchers and the deputy executive director of the VA's National Center for PTSD in White River Junction, Vt. "This study is specifically addressing that, and we hope it will not only help us treat women coming home from Iraq, but all those who have ever served and struggled with PTSD in any conflict before."
The study's findings are not due until the end of the year, but researchers already have made some startling discoveries that are illustrative of the nature of PTSD among female veterans and of the U.S. military.
According to Schnurr, data indicate that female military personnel are far more likely than their male counterparts to have been exposed to some kind of trauma or multiple traumas before joining the military or being deployed in combat. That may include physical assault, sexual abuse or rape.
"The speculation is that many of them are joining the military to get away from adverse environments," said Schnurr, also a professor of psychiatry at Dartmouth College, speaking of the nearly 216,000 U.S. women on active duty and the nearly 151,000 who are part of the reserves and National Guard.
The implication of such a finding on PTSD research is considered significant. Because most research indicates that a person is at greater risk of developing PTSD — or developing more severe PTSD — when he or she has had past traumas, many female troops are deploying to war zones already heavily predisposed to react adversely to the intense fear, killing and loss routinely encountered there.
"The evidence is conclusive," said Rachel MacNair, an expert in the psychological effects of violence and PTSD. "The greater the trauma in your life, the greater the symptoms of PTSD."
KILLING DEEPENS TRAUMA
MacNair, however, focuses on another factor that she believes more acutely affects the rate of PTSD among veterans of Iraq: whether they have killed during their deployment.
In 1999, MacNair earned her doctorate at the University of Missouri-Kansas City with a study that analyzed the data from the National Vietnam Veterans Readjustment Study, a landmark congressionally funded project that studied nearly 1,700 veterans.
Her findings were stark: Troops who had killed — or believed they had killed — suffered significantly higher rates of PTSD than those who had not.
"It is very clear that being shot at is traumatic, or losing your buddy is traumatic, but the act of shooting and killing another human being, something that goes against every instinct we have, is the biggest trauma of all," said MacNair, who calls this kind of PTSD "perpetration-induced traumatic stress."
That hypothesis by MacNair, who is strongly critical of the military, is supported by history and by military experts.
S.L.A. Marshall, one of the earlier official Army historians, estimated after studying World War II veterans that only 15 percent had fired their weapons during battle. He asserted from his interviews with soldiers that their failure in battle was because they were more afraid of killing than of being killed. Other studies show that even the most poorly treated prisoners of war had lower rates of PTSD than front-line soldiers because the prisoners no longer were in a position where they had to kill.
How such findings translate to the Iraq war is clear. Unlike previous conflicts, where women rarely were pulling the triggers or running the weaponry that left enemies dead on the battlefield, they routinely are doing so in Iraq, as Lt. Col. Rael pointed out on that cold December day on the outskirts of Baghdad.
On top of that, they are being taken prisoner, as was Pvt. Jessica Lynch during the initial invasion; they, like their male counterparts, are being constantly mortared and ambushed by a guerrilla insurgency; and they are watching fellow troops go home grievously wounded or dead in numbers not seen since the war in Vietnam.
"It all adds up," said MacNair, "but the act of having killed does seem to be the factor that tips the scales in favor of PTSD."
TREATMENT HAS STIGMA
Of the nearly 245,000 veterans returning from Iraq and Afghanistan, almost 12,500 have been to VA counseling centers for readjustment problems and symptoms of PTSD. In addition, a study in The New England Journal of Medicine found that up to 17 percent of troops returning from Iraq were suffering from PTSD or other readjustment problems.
So far, no statistics have been released detailing how many of these patients are women, but numerous support groups have sprung up specifically for women with PTSD. In one Internet chat group, Sisters Bound by Honor, women struggling with PTSD talk with one another about their experiences.
Yet the women who most need counseling to help them deal with what they witnessed in Iraq and Afghanistan — like their male counterparts — are the most unlikely to seek it.
A Defense Department study of combat troops returning from Iraq found that soldiers and Marines deeply suffering from PTSD and readjustment problems were not likely to seek help because of the stigma such an act might carry. In the study, 1 in 6 veterans acknowledged symptoms of severe depression and PTSD, but 6 in 10 of those same veterans feared their commanders and fellow troops would treat them differently and lose confidence in them if they sought treatment for their problems.
That seems especially true of women, who have fought for years to be assigned positions in the Army that once were off limits to them. A number of female Iraq war veterans suffering from PTSD declined to be interviewed for this article.
HOPE FOR FUTURE
Still, former Army Lt. Col. Dave Grossman, who taught psychology at West Point and wrote the book "On Killing," which closely documented the link between killing and PTSD, believes the treatment of PTSD among the veterans of Iraq could be the most effective in combat history. Using an analogy to obesity, he said that after past wars, only those traumatized soldiers "who were 400 pounds overweight got attention or treatment."
"But, now," Grossman said, "we are so sensitive to PTSD and its effects that we can notice the person who is the equivalent of just 20 or so pounds overweight, and we can help them then, long before they have the psychiatric equivalent of high blood pressure and heart attack."
The study of female veterans suffering from PTSD may be just such a start.
The study includes hundreds of women and aims, among other things, to discover which clinical treatments are most effective for women with the disorder.
Half of the women will be treated through prolonged exposure therapy, in which each woman will be guided for 10 weeks through vivid remembering of the traumatic event or events until her emotional response decreases through "habituation." Schnurr, one of the study's directors, compares habituation to the way city dwellers grow immune over time to loud noises such as police sirens or car alarms.
"The goal is that the memory of the traumatic event is no longer as startling, as terrifying, when it comes," she said.
The other half of the women will be treated with what is known as "present-centered therapy," a treatment that focuses on helping a patient deal with her current life challenges rather than the memory of past traumas.
"Both therapies are appropriate and helpful to some degree," Schnurr said, "but we expect that the prolonged exposure will be the most effective. If that is the case, I think we will begin using that treatment much more — and more effectively — in the years to come."
Although the goal of the study is to determine which therapies work best for women suffering from PTSD, experts agree that if the study is conclusive it eventually may be applied to tens of thousands of Iraq war veterans, male and female alike.
"It is our hope that we can find ways to help these women," Schnurr said. "But, more than that, we are hoping to draw some conclusions that can help us in the treatment of PTSD across the board. That means men and women, soldiers and Marines, those who are suffering for reasons having nothing to do with combat at all."Chicago Tribune