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Women At War: An Interview With Dr. Elspeth Cameron Ritchie

by Elspeth Cameron Ritchie
April 6, 2018

This interview with Dr. Elspeth Cameron Ritchie, the author of Women at War, was conducted and condensed by Tatti Ribeiro for frank news.

When it comes to women's issues in combat, and female veterans, where should civilians start?

We have been at war since 9/11, and during that period of time 2.7 million males and females have deployed. Mainly to Iraq and Afghanistan and other nasty places around the world, and have come back. About 10% of those have been women. So that's a lot of women, former or present service members.

For both men and women they've lived for long periods of time in nasty or dangerous places where they can be shot at, or bombs can go off any time. Specifically for female service members who are now veterans, there's been a lot of trying to figure out how to manage in that environment. Where you're in a very male dominated environment usually about 90 percent male.

You have your gynecological needs. The what do you do about having a period? For example if you're in a place where there's no toilets or the porta potties are overflowing with feces. Or you're trying to figure out, in a more global sense, what you're going to do about your reproduction.

Women in the military are usually in their reproductive years.

So am I going to get married? Am I going to start a family? Am I going to get pregnant? What happens if I get pregnant when I don't want to? Am I in a place that may not provide any kind of safe services for terminating a pregnancy?

That's sort of the overview. Let me add one more piece that civilians back home may not think of which is, if you're in a hot dirty environment with few showers, it's really easy to get things like urinary tract infections or vaginitis, and nobody likes to talk about those things. But if you're suffering from a UTI it can get pretty uncomfortable.

If you talk about these things and talk about them being an issue, then you can figure out how to solve the problem.

Who's responsible for implementing the solutions once you find them?

Traditionally in the military it's logistics. So logistics carries bullets, and bandages, and tampons, and baby wipes, and everything you might need. But for logistics to do that they need to have people saying “hey, this is important to do”. So I would say it’s a combined responsibility.

You have this book saying “hey, this is important”,  but do you think it also takes more external pressure for women’s issues to be taken seriously?

Absolutely. So the book you're referring to Women At War is an attempt to gather everything we know about women at the time of the publication and put it together in one place. But simply having a book doesn't mean that that information is going to translate. To the military's credit they've had a lot of interest in women's health issues, and prior to 9/11 we had a very active group that looked at women's health issues and made recommendations. But then 9/11 happened, we went to war in Afghanistan and then in Iraq, and people got really, really busy. And these issues were sort of pushed to the side. Now with women being allowed in combat units there's more of a resurgence in interest in this information.

How can you make female soldiers, airmen, sailors, Marines be successful?

They have been successful in the past but they've been successful despite nobody paying attention to these issues. Now, how can you optimize their success?

How quickly do you think these suggestions could be implemented? What would that look like and what does it take?

That is a good question and there's some things that are easy and there are some things that are hard. So easy is getting tampons into the supply change. There’s something called a female urinary device which is basically a funnel that you can urinate into. To make that actually be useful, when you’re wearing your uniform, and your Kevlar vest, and your helmet, and your gas mask…well that's another piece of it.

A third level of difficulty is when you get into anything that has to do with reproduction because Congress gets involved. So for example, the issue about providing Plan B in a deployment setting, or abortion's not being legal in Korea, or Japan, or Italy, where many of our service members are stationed…and so what does somebody do if they find themselves pregnant when they don't want to be? That's a really hard nut to crack

Does the military support a woman's right to choose?

I'm not going to speak for the military. I have been retired for a while, and I wouldn't want to speak for the military on that subject anyway.

I think in general though, if you look at part of their job as to promote readiness and people's ability to deploy they're going to want to prevent problems. Whether it's preventing stress fractures, or trench foot back from World War II, or an unintended pregnancy.

So ideally there would be a lot of preventive measures and certainly the medical departments, speaking specifically for the medical department from the military, as a whole I think is a group with very fine people who will do the best they can to keep everybody medically healthy.

What does the V.A. need to do to keep up with the new influx of women returning from service?

So just to clarify, I until recently worked for the VA, but I do not speak for the V.A. So this is based on observation. I have pretty extensive familiarity with the VA. I think the V.A. is trying its best to provide services for female veterans. In many places they have female clinics, women's veterans clinics that are very nicely appointed, newly refurbished. But it's a big system, a big bureaucracy with limited flexibility.

What about childcare in the military and at the V.A.?

They're very different systems, just to make sure your audience understands, the military is when you're active duty. And actually the military is very good at providing child care, and have long hours, and take into account people who are deploying or working long hours. Having said that there is still more structure to a male military member, married to a female civilian spouse, who often doesn't work, or has partial work, than they are oriented towards a female service member. But the military has good childcare.

The V.A. on the other hand is not set up for child care. They're not focused on the family. Their mission is to take care of the veterans. And so it would be a tremendous outlay of money and cost to try to provide child care. So again I need to split those missions apart. One of the challenges for the V.A. is that they have an incredibly large mission because you not only have 2.7 million who have recently served in Iraq and Afghanistan and other veterans entitled to V.A. benefits, but you also have the aging population of the Vietnam veterans and to a certain extent World War II, although those there are less among us now. But there is a tremendous amount of business already for the V.A.

I’d like to pivot to your own service. You had a very successful career in the Army. You’re a colonel. Why did you join?

The short answer is I joined the military because they paid for medical school. And that was a great decision, one of the best I made in my life, because it enabled me to go to medical school and not have any debt afterwards. Backtracking a little bit, my father served in the Korean War, my grandfathers both served in World War II. Like many of their generation the men usually serve, but I did not grow up in a military household. So for me, it was also an atypical career choice. It wasn't something, for example, in college my friends ever thought I’d do. I was a hippie back then at Harvard.

But I went to an expensive medical school and they paid for it. And then I did my internship and residency at Walter Reed, and went on to keep being offered interesting jobs with lots of chances to travel and really do a lot. That's one thing that the military offers at a relatively young age, you usually have a lot of both support, but also responsibility, a lot of authority. And so that was useful. So military pays for a lot of different schools, college or some other professional schools, besides medical school, or they have loan repayment programs. So I would urge anybody who's looking at school and the cost of schooling to talk to a recruiter and see whether they could get some or all of their schooling paid for. Of course you owe some time to the military afterwards depending on the program the time will be different, but again, I thought it was a great decision. And my friends and colleagues who have been in the military have been very happy with that.

Was psychiatry your immediate focus when you entered medical school? Or was that something that came to you later?

It was not my immediate focus for undergraduate. I did a double major in biology and folklore and mythology. I didn't know it at the time, but that was perfect for going into psychiatry because you're looking at various plants that have pharmaceutical properties, you're looking at anthropology, human behavior, and it was a good background. But when I went to medical school, like many students, I debated between internal medicine, neurology, flirted with surgery, and then settled on psychiatry as being the most interesting of all the different fields of medicine.

It's especially relevent to the military. 

Yeah, absolutely, and that has been true since World War I at least. Great advances in medicine are often done on the battlefield. And that's true for surgery. It's true for Emergency Medicine. It's true for psychiatry, and that's another hour at a discussion that I won't go into right now. Specifically for post-traumatic stress disorder and the idea of stigma — first let me define PTSD in case your readers don't know what it is:

post-traumatic stress disorder is by definition a delayed response to trauma.

There's a number of different symptoms to include: intrusive thoughts, flashbacks, nightmares, which you can kind of deal with. And then there's numbing and avoidance, and that is actually harder on family relationships. And then there's some other symptoms. What I see most often in veterans is they can't go into malls, they can't tolerate crowded places, it can be hard to drive, they get road rage, then they get panic attacks. But having said that. These are all reactions that in many cases go way over time. It's when the reaction is so severe that you can't go out of a house and you sit in the basement drinking Jack Daniels with your shotgun. That's when it really does get dangerous.

Do you think that the treatment options that are available are good enough?

No. But there's a lot out there.

When I talk to my patients about treatment for PTSD I talk about three buckets for treatment. First, I talk about medication. Second, about psychotherapy or talking therapy. And the third bucket is everything else, which includes things like yoga, meditation, or acupuncture.

Coming back to the first bucket, as a psychiatrist that's what I do, is medication. We do have medications that are used for post-traumatic stress disorder. Usually we talk about safe, mild antidepressants called SSRI’s, selective serotonin reuptake inhibitors, that's a long name. Your readers will have heard of some of them like Prozac, Paxil, Zoloft. The problem with these medications is they have some side effects, and specifically they have sexual side effects. In many cases that includes delayed erection, lack of erection, delayed ejaculation, lack of libido or desire, and most of the young men and women that I treat don't want to be on medications with sexual side effects.

I always talked about bucket number two and bucket number three as well. Bucket number two being psychotherapy. The third bucket, the everything else, I really like because it gives a person a control over their symptoms with less side effects. So if you think of PTSD simplistically as a disorder where your adrenaline is unchecked, your fear or flight response is on, things like meditation, yoga, exercise, it can all calm down the brain. There's also some interesting work being done with working with animals for example and especially horses and dogs. And then finally there's a range of newer treatments that we're just beginning to get the data on. Those are things like cranial magnetic stimulation and others that I think are very promising, again with less side effects than the medications.

Do you think there's anything to say about the reception of veterans coming home today? Compared with our other wars?

First of all, I think that the environment is much better for veterans now than it was for example in Vietnam when they were spat on and called baby killers. When I was in uniform in the airport, and that's one of the things I miss since I retired, people would always come up to me and say thank you for your service. Having said that “thank you for your service” is nice but it doesn't necessarily help. What most veterans are interested in is finding a job and being able to support their family.

If you've got jobs to offer or other services to provide for veterans that can be very helpful. I would emphasize you have to know what the needs are before you rush out and offer services. A lot of times people kind of hang out their shingles and say, “free mental health care” and nobody will come to that, or free this or that, free stress balls. Well you know that's not necessarily very helpful. So see what the needs are in your community. And then whatever you can do to help meet those needs.