Female veterans and TBI: 3 things you should know 

“TBI is not just a young man’s disease.”

At Constant Therapy, we’re passionate about calling attention to urgent, often overlooked aspects of brain recovery and rehabilitation—and we’ve written extensively about issues specific to both veterans’ and women’s health in the past. Did you know, though, that the growing ranks of female veterans constitute a unique patient subset with dedicated health care needs and obstacles?

While this has always been a reality for women who served in the military, heightened awareness of female veterans’ specialized health needs has never been more crucial. This is especially true where traumatic brain injury, or TBI, is concerned. Indeed, according to the U.S. Department of Veterans Affairs, “women are the fastest-growing group in the Veteran population.” Their share in the U.S. military overall is projected to grow from 4% in 2000 to 18% by 2040—and today alone there are over 2 million female veterans living in the United States. Just as important, female service members in coming years are more likely to deploy to combat positions—exposure to which can increase the likelihood of developing TBI— as the full effect of the Defense Department’s 2016 repeal of gender-targeted role restrictions begins to take hold. 

In this post, we provide an overview of three key things about TBI that female veterans, their caregivers, and clinicians should know about. 

What the research shows about female veterans and TBI

1) Evidence indicates that being a woman may be a risk factor for worse TBI recovery outcomes across various metrics—and hormonal influences might play a role  

Researchers have found that women, on average, fare worse than men in various measures of TBI outcomes. One frequently cited analysis of gender-related disparities in TBI outcomes, for example, found that women tended to report worse neurobiological and psychiatric symptoms (such as memory impairment, headache, fatigue, anxiety, and depression) in the medium-to-long term following the initial injury than men. Such a finding aligns with a growing body of research into TBI outcomes in the military which suggests that female service members are more likely than male service members to report symptoms of and meet the criteria for post-concussion syndrome (PCD) following mTBI diagnosis. 

Another study that directly evaluated gender-based TBI outcomes among veterans with confirmed deployment-related mTBI likewise found that even after controlling for blast exposure—which was more prevalent among men— female veterans were at significantly higher risk of developing depression, non-PTSD anxiety disorders, PTSD with depression, and multiple psychiatric disorders. 

Of course, this is not to suggest that all female veterans with TBI—or only they—will experience these symptoms. First and foremost, every single recovery journey is unique. Beyond that, it is exceptionally difficult to parse data about cognitive and emotional outcomes precisely because there are well-noted overlaps between the manifestations of TBI and certain psychiatric disorders, especially PTSD. Just as PTSD can cause physical changes to the brain that might account for cognitive side effects like impaired memory, so too can TBI result in behavioral changes like depression and irritability. And, importantly, simultaneous diagnoses of PTSD and TBI—a common occurrence, especially in the military—can exert mutual influence. Moreover, as we discuss later in this post, female veterans indeed face elevated risk factors for sustaining TBIs, and the injury’s specific etiology could itself account in part for these outcome differences, particularly with regard to psychiatric symptoms. 

Taken together, however, the above findings do raise the possibility that the observed disparities in TBI outcomes between men and women might be explained by biological or mechanistic factors. Unfortunately, definitive answers as to what might explain such differences are still elusive; most likely, a variety of factors—genetic, cellular, biological, and psychosocial—all play a role. Notably, studies have found evidence that fluctuating progesterone levels during the menstrual cycle might affect mTBI outcomes and that oral contraceptive use was associated with fewer postconcussion symptoms. More research is needed into this potential link which, if further substantiated, would have implications for all veterans with a menstrual cycle, regardless of their gender identity. 

2) Female veterans face additional risk factors for sustaining TBI, especially from intimate partner violence

In addition to potential biological factors, deployment in a range of military roles is associated with greater TBI risk. Importantly, that risk is not confined to combat roles; among female veterans diagnosed with deployment-related TBI, a study found that the cause of their injuries varied from blasts (61%) and various forms of blunt trauma (37%) to falls (36%) and motor vehicle accidents (31%). 

Just as crucial, however, female veterans are also at a higher risk of sustaining TBIs as a result of intimate partner violence (IPV). Unfortunately, one in three female veterans will suffer from IPV in her lifetime, as compared to under 25% of civilian women, and the head, face, and neck are the most frequent targets of physical IPV assaults. Tragically, a study among female veterans found that of those who underwent a TBI evaluation, 63% reported experiencing IPV. And a history of IPV, in that study, was tracked with worse neurobehavioral symptoms and a higher likelihood of being diagnosed with back pain and a substance use disorder. Continued prevention efforts and support for victims, especially for female veterans, are therefore absolutely essential to combat IPV and reduce this risk factor. 

If you are experiencing intimate partner violence in any form—whether physical, sexual, psychological, or stalking—please consider visiting the free resources at the end of this article. No matter what anyone says, it is not your fault. If you feel your physical safety is in danger, call your local emergency services immediately.   

3) Female veterans are underscreened for and underdiagnosed with TBI

As is unfortunately the case for women across many conditions in health care, female veterans are often underscreened for —and, as a result, underdiagnosed with—TBI. In fact, a study found that at Veterans Health Administration (VHA) outpatient centers, female veterans were not only screened at significantly lower rates for TBI than male veterans but were also much less likely to undergo a comprehensive evaluation even after a positive TBI screen. This discrepancy is possibly due to the erroneous but widespread notion that only female veterans who served in direct combat roles are at heightened risk of TBI or as a result of misconceptions of TBI as being a “young man’s disease.” In sharp contrast, both direct and indirect exposure to combat, as well as other factors like IPV, demand the careful screening of all female service members and veterans for TBI at their regular checkups. 

What you can do to help

If you or your loved one is a female veteran, it is important for you not only to know your unique risk factors for TBI but also to feel empowered to advocate for yourself in medical settings. 

Meanwhile, clinicians, researchers, and policymakers must all continue to work in tandem to push for a greater understanding of how TBI and other conditions uniquely affect women overall, and female veterans, in particular, so that they receive the care they deserve. 

To learn more about intimate partner violence (IPV) and/or to seek help, please visit the following resources:

• National Domestic Violence Hotline: 1-800-799-SAFE (7233) or TTY 1-800-787-3224*
• Rape, Abuse & Incest National Network’s (RAINN) National Sexual Assault Hotline:  1-800-656-HOPE (4673)
• Veterans Crisis Line: 1-800-273-TALK (8255) 
• The Women Veterans Call Center: 1-855-829-6636
• Centers for Disease Control and Prevention: Intimate Partner Violence. 
• U.S. Department of Veterans Affairs – Women Veterans Health Care: Intimate Partner Violence.

For additional reading, check out the following: 

• Amoroso, T., & Iverson, K. M. (2017). Acknowledging the Risk for Traumatic Brain Injury in Women Veterans. The Journal of Nervous and Mental Disease, 205(4), 318–323. https://doi.org/10.1097/NMD.0000000000000621
• Associations between traumatic brain injury from intimate partner violence and future psychosocial health risks in women | Elsevier Enhanced Reader. (n.d.). https://doi.org/10.1016/j.comppsych.2019.05.001
• Brickell, T. A., Lippa, S. M., French, L. M., Kennedy, J. E., Bailie, J. M., & Lange, R. T. (2017). Female Service Members and Symptom Reporting after Combat and Non-Combat-Related Mild Traumatic Brain Injury. Journal of Neurotrauma, 34(2), 300–312. https://doi-org.ezproxy.cul.columbia.edu/10.1089/neu.2016.4403
• Cogan, A. M., McCaughey, V. K., & Scholten, J. (2020). Gender Differences in Outcomes after Traumatic Brain Injury among Service Members and Veterans. PM&R, 12(3), 301–314. https://doi.org/10.1002/pmrj.12237
• Davis, D. P., Douglas, D. J., Smith, W., Sise, M. J., Vilke, G. M., Holbrook, T. L., Kennedy, F., Eastman, A. B., Velky, T., & Hoyt, D. B. (2006). Traumatic brain injury outcomes in pre- and post-menopausal females versus age-matched males. Journal of Neurotrauma, 23(2), 140–148. https://doi.org/10.1089/neu.2006.23.140
• Farace, E., & Alves, W. M. (2000). Do women fare worse: A meta-analysis of gender differences in traumatic brain injury outcome. Journal of Neurosurgery, 93(4), 539–545. https://doi.org/10.3171/jns.2000.93.4.0539
• Iverson, K. M., Dardis, C. M., & Pogoda, T. K. (2017). Traumatic brain injury and PTSD symptoms as a consequence of intimate partner violence. Comprehensive Psychiatry, 74, 80–87. https://doi.org/10.1016/j.comppsych.2017.01.007
• Iverson, K. M., Hendricks, A. M., Kimerling, R., Krengel, M., Meterko, M., Stolzmann, K. L., Baker, E., Pogoda, T. K., Vasterling, J. J., & Lew, H. L. (2011). Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related traumatic brain injury: A gender comparison. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 21(4 Suppl), S210-217. https://doi.org/10.1016/j.whi.2011.04.019
• Mihalik, J. P., Ondrak, K. S., Guskiewicz, K. M., & McMurray, R. G. (2009). The effects of menstrual cycle phase on clinical measures of concussion in healthy college-aged females. Journal of Science and Medicine in Sport, 12(3), 383–387. https://doi.org/10.1016/j.jsams.2008.05.003
• Persistent post-concussive symptoms (Post-concussion syndrome)—Symptoms and causes. (n.d.). Mayo Clinic. Retrieved June 20, 2022, from https://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/symptoms-causes/syc-20353352
• TBI and PTSD: Navigating the Perfect Storm. (2013, March 7). BrainLine. https://www.brainline.org/article/tbi-and-ptsd-navigating-perfect-storm
• U.S. Dept. of Veterans Affairs. (2022, June 11). VR5 | Women Veteran Resources. https://www.youtube.com/watch?v=2utyv_WrWXA

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