As discussed in Chapter 3, sexual assault is one of the two leading risk factors (combat is the other) for PTSD (Breslau et al. 2002; Kessler et al. 1995). Sexual victimization in military women was found to have a dose-response relationship with PTSD, according to two studies (Murdoch et al. 2006; Wolfe et al. 1993a), and sexual assault is associated with poorer health outcomes in female veterans (Goldzweig et al. 2006). Kang et al. (2005) found that among 2131 female and 9310 male Gulf War veterans, PTSD was associated with in-theater sexual harassment and assault in women (OR 5.41, 95% CI 3.19-9.17) and men (OR 6.21, 95% CI 2.26-17.04). The risk of having PTSD associated with combat was almost identical in men (OR 4.45, 95% CI 3.54-5.60) and women (OR 4.03, 95% CI 1.97-8.23) and showed a dose-response relationship with increasing combat. Sexual assault, however, was a greater risk factor for PTSD than was combat exposure in both men and women.

Race and Ethnicity

Research results on the role of race and ethnicity as risk factors for stress-related illness are mixed but in general support the conclusion that blacks and Hispanics are at greater risk for developing psychiatric disorders, particularly PTSD, as a result of deployment. In the VES, nonwhite veterans had a poorer psychologic status 15-20 years after the war than did white veterans (CDC 1988). Findings from the NVVRS indicate that black and Hispanic veterans had a higher prevalence of PTSD than whites (Kulka et al. 1990). Among theater veterans, the prevalence of current PTSD in the NVVRS was 27.9% in Hispanics, 20.6% in blacks, and 13.7% in whites and others (Kulka et al. 1990). Those proportions held even when racial differences in combat exposure were controlled for as minority groups had a greater number of war-zone exposures.

The Hawaii Vietnam Veterans Project (HVVP), modeled on the NVVRS, determined that veterans of Japanese ancestry had a lower prevalence of PTSD than whites (Friedman et al. 2004). Schnurr et al. (2003) studied 530 veterans drawn from the NVVRS and the HVVP, and found that black, Hispanic, and native Hawaiian men were more likely and Americans of Japanese descent were less likely than white men to have a lifetime diagnosis of PTSD and that Hispanic male veterans were more likely to have current PTSD than males in other ethnic groups (Schnurr et al. 2004). In a study of 1377 American Legionnaires who had served in Vietnam and were followed for 14 years, minority race contributed to a more chronic course of PTSD; however, the minority sample was too small for further investigation (Koenen et al. 2003). It has been suggested that the racial gap in prevalence or course of PTSD in Vietnam veterans might stem from racism in the military, overidentification with a nonwhite enemy, exacerbation of existing stress by institutional racism, and lower financial or emotional resources after the war (Marsella et al. 1993).

Several studies of Gulf War veterans have also found that minority-group veterans had a greater prevalence of PTSD. In a study by Kang et al. (2003), nonwhite veterans had a greater prevalence of PTSD than white veterans, but the category “nonwhites” was not divided into minority subgroups, and there was no adjustment for socioeconomic factors other than age and marital status. There was no difference between whites and nonwhites in prevalence of CFS. A study of 653 Gulf War veterans from Louisiana with relatively high minority-group participation (35%) found that minority-group troops, particularly men, tended to report greater psychologic distress and more PTSD symptoms than white men (Sutker et al. 1995a); however, as in the Kang study, there was no stratification beyond “nonwhite status” and no adjustment for other factors that may have contributed to the reporting differences. Adjusted for age, sex, race, rank,



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