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Witness Testimony of Maureen Murdoch, M.D., MPH, Minneapolis Veterans Affairs Medicical Center, Center for Chronic Disease Outcomes Research, Veterans Health Administration, U.S. Department of Veterans Affairs (on behalf of herself)

Mr. Chairman and members of the Subcommittees, thank you for the opportunity to appear before you today to present findings from my team’s research on possible disparities in PTSD disability awards among race and gender groups.  I must note the views presented today are mine and do not necessarily represent the views of the Department of Veterans Affairs (VA) and reflect the results of my studies and not necessarily the findings of other research.

Background

PTSD is the most common psychiatric condition for which veterans seek VA disability benefits.  Long-term health studies indicate women have a higher prevalence of PTSD than men, and may be more susceptible to PTSD.  Conversely, African American or blacks appear to have similar risks for PTSD compared to whites.

In 2000, my colleagues and I began investigating if there were race and gender disparities in VA disability awards for post-traumatic stress disorder (PTSD).  We assembled a representative sample of almost 5,000 men and women veterans who applied for PTSD disability benefits between 1994 and 1998. 

We developed and tested four hypotheses:

  1. Veterans reporting more severe PTSD symptoms would be more likely to be Service-Connected for PTSD than veterans reporting less severe PTSD symptoms.
  2. Veterans reporting more severe disablement would be more likely to be Service-Connected for PTSD than veterans reporting less disablement.
  3. Veterans with combat experience would be more likely to be rated Service-Connected for PTSD than veterans not in combat.
  4. These three covariates (PTSD symptom severity, degree of disability, and combat exposure) would explain any race or gender differences in VA PTSD disability awards.

Results of the Studies

Overall, the 3,337 respondents were highly symptomatic.  About eighty percent met our definition for PTSD and sixty-two percent were service connected for PTSD.  Our results yielded several interesting findings.  Concerning the relationship between PTSD service connection and gender, despite fewer major medical complications and superior physical functioning, women’s overall role functioning was similar to men’s.  Almost ninety-four percent of men and twenty-nine percent of women reported at least some combat exposure.  Most importantly, once combat exposure was controlled, the effect of gender on service connection for PTSD became insignificant.  Specifically, more than ninety percent of combat-injured veterans, regardless of gender, became service-connected for PTSD.  Those with higher levels of combat exposure were substantially more likely than those with lower levels to be service connected for PTSD.  Since men had notably greater exposure to combat, they likewise had higher rates of service connection.  In sum, instead of a gender bias in awards for PTSD service connection, we found evidence of a combat advantage that disproportionately favored men and adversely affected women.

We also compared PTSD symptom severity and Social Adjustment scores of veterans reporting sexual assault and combat exposure.  We found, on average, veterans reporting combat alone had marginally less severe PTSD symptoms than those reporting sexual assault.  Veterans reporting only combat exposure also reported significantly better Social Adjustment Scores than those reporting sexual assault.  Men and women who reported sexual assault were equally unlikely to be service connected for PTSD.

In our investigation of racial disparities, we found that the African Americans in our sample were just as likely to be service connected for other disorders, but were substantially and significantly less likely than other respondents to be service connected for PTSD.  The negative association between African Americans and service connection for PTSD was not found for any other racial or ethnic group.  Among veterans receiving service connection for PTSD, the service-connected rating was almost identical, regardless of race – an average rating of forty-three percent for African Americans versus forty-five percent for all other veterans.  Controlling for gender, African Americans’ modified combat exposure scores were similar to other veterans, but African Americans were significantly less likely to have a documented combat injury.  With full adjustment, the estimated probability of being awarded service connection for PTSD was forty-three percent for African American veterans compared with fifty-six percent for other respondents.  Examining clinicians were about seven-tenths as likely to diagnose PTSD in African Americans as they were for other veterans, although this difference was not statistically significant.

Discussion About the Studies

There are several issues warranting consideration when evaluating this research.  First, the pool of respondents was selected based upon their submitted claims for PTSD service connection, while our questions focused on their current health and adjustment status.  It is distinctly possible that those with the greatest need at the time of their application have been receiving treatment and may now actually report better health outcomes than their peers.  Second, the study relied on veterans’ self-reports of their PTSD symptom severity, degree of disability, and trauma history, which may not have been clinically accurate or universally consistent.

Recommendations

In order to strengthen and expand this research, future studies should identify and evaluate veterans shortly after applying for PTSD disability benefits.  In addition, we need to collect and assemble more data from the claims files.  Finally, future studies should investigate claims for disorders other than PTSD.

Mr. Chairman, this concludes my statement.  I am pleased to respond to any questions you or the Subcommittee members may have.  Thank you.