Beginning with the US Revolutionary War, women informally supported military efforts through roles such as cooks, seamstresses, and nurses. Some women took efforts to support patriotic duties a step further by disguising themselves as men, taking up arms against the British forces at such well known battles as the Battles of Monmouth, Germantown, Fort Washington, and Savannah (De Pauw, 1981). However, it was not until the Spanish American War in 1901, when the US Army established the permanent Nurse Corps that women could formally serve in the military (US Department of the Army [DA], n.d.). Over the course of the next 120 years, the opportunities and roles available to women continued to expand to include a variety of critical occupations in the US and overseas. Currently, 16% of active-duty enlisted personnel are women, and nearly 18% of all US Army Officers are women (US Department of Defense [DoD], 2018). As they continue to rise in numbers and in rank, women play an increasingly critical role in today’s military.
One of the most groundbreaking actions concerning women in the military came in 2013 with repeal of the Direct Ground Combat Exclusion Rule for Female Soldiers by the US Department of Defense (Roulo, 2013). The Direct Combat Exclusion Rule had restricted certain military occupations and excluded female military personnel from roles involving direct combat. Over the next 2 years, military services were required to conduct a Women in the Service Review (WISR) of policies and standards for women in service across the military (DoD, 2015). In 2015, WISR was completed, and in an historic transformation of the US military, the US Secretary of Defense announced all combat occupations were open to women. Four years later, more than 700 women have been recruited for or transferred to post-integration combat roles (DoD, 2015).
Combat teams have been at a disadvantage when trying to connect with local populations during counterinsurgency (COIN) operations due to a lack of female presence. Often teams were unable to gain information, enlist aid, and conduct effective searches among female members of local populations. This became even more significant when engaging populations in societies with high levels of gender segregation, such as in Iraq and Afghanistan. As a result, women from non-combat units temporarily worked alongside all-male combat units to interact with local female populations and help facilitate the implementation of their mission. Often these women received minimal or no job specific training, support, or follow-on care compared to the male units with which they worked (Lemmon, 2015). In 2009, the Special Operations community saw the need to have female soldiers trained to integrate and assist Special Operations Command (SOC) units in implementing the COIN mission. These women were specially trained to directly interact with, provide medical care for, search, and question Iraqi and Afghan women and children while supporting information operations in advising commanders on Civil-Military Operations in the local female community. In 2010, a Cultural Support Team (CST-1) a 64-women team, assessed for their high degree of talent, but untrained for formal cultural liaising were deployed in immediate support of SOF units (Tracy, 2016). CST-2 immediately entered training at the US Army John F. Kennedy Special Warfare Center and School (USAJFKSWCS), and were deployed by August 2011 (Tracy, 2016).
These female soldiers worked side-by-side with SOC units in Afghanistan as enabler attachment units for both direct action and village stability operations teams. As noted by SOC leadership, CSTs were to serve as an enduring competency within US Army Special Operations command, with their formation serving as a landmark moment in providing communication with females and adolescents in theatre (Tracy, 2016). While this decision was heralded as a significant advancement in promoting gender equality within the military, it failed to acknowledge the fact that women in the military have experienced combat long before they were formally recognized as eligible members of combat units per the Direct Exclusion Rule. This meant that although serving in forward combat locations, and at times experiencing direct involvement resulting in combat injuries and death, these women were not recognized as combat contributors and did not receive the same follow on medical or re-integration support as their male peers.
As women began to serve in more complex combat-related roles in the military, particularly the War in Afghanistan (2001–present) and the Iraq War (2003–2011) leading to American-led intervention in Iraq (2014–present), researchers began to look at what might constitute psychological distress in contemporary warfare. These importantly include urban warfare tactics in Afghanistan and Iraq such as guerrilla attacks, improvised explosive devices (IEDs), and uncertainty between safe zones and war zones (Carlock, 2007). Second, contemporary battlefield medicine has improved so greatly that it has significantly increased survivability (Reisman, 2016). More soldiers return, but they carry with them greater physical and psychological trauma.
With the lines blurred between traditional notions of combat and non-combat military activities, determining which activities constitute combat and recognizing the soldiers who performed such actions becomes increasingly more difficult. In 2005, the Chief of Staff of the United States Army authorized the creation of the Combat Action Badge (CAB) to provide special recognition to soldiers from non-infantry or non-medical units who have engaged the enemy, or have been personally engaged by the enemy, in a combat situation. This award was particularly focused on combat contributions Post-9/11, with no authorizations granted prior to September 18, 2001, thus focusing on Operation Iraqi Freedom, Operation Enduring Freedom, and later operations (DA, 2019b). Criteria for the CAB are as follows:
A soldier must be personally present and under hostile fire while performing satisfactorily in accordance with the prescribed rules of engagement, in an area where hostile fire pay or imminent danger pay is authorized … a soldier must also be performing in an offensive or defensive act while participating in combat operations, engaging, or being engaged by the enemy. A soldier must be performing their assigned duties associated with the unit’s combat mission in an area where hostile fire pay or imminent danger pay is authorized. (DA, 2019b, pg. 110–111)
In the case of the CSTs, although they were integrated with combat units and fought side-by-side on many missions, their combat contribution was often unrecognized due to their return to non-combat commands, or unit concerns about violating the combat exclusion policy, an issue that fellow servicewomen working with conventional units had long experienced. The CAB is strongly considered when applying for some competitive leadership positions, may be considered in promotions, and is an integral in determining one’s experience in both leadership roles and instruction of subordinates (DA, 2019a).
In addition to career advancement, the CAB is often used to link injury or illness as combat-related for follow on medical care. Upon discharge, veterans are entitled to disability compensation from the Department of Veteran Affairs (VA) as a function of disabilities incurred during their tour of duty. This rating, known as the Service-Connected Disability Rating (SCDR), rated 0% to 100% (in gradients of 10%), is determined based on the extent of injuries incurred and the post-service impact on earning potential in the civilian sector (Veteran Benefits Act, 1968). Prior to assessment of an SCDR, the VA uses a combination of a physical exam and documentation to verify the veracity of a claim. As many mental health issues, such as combat related Post Traumatic Stress Disorder may often not present until many years post-incident, documentation of combat activity, such as the CAB, may prove vital to obtaining necessary services for care (Veteran Benefits Act, 1968). Lastly, many VA services are also tied to the SCDR such as assistance with employment via Vocational Rehabilitation & Employment (requiring a 10% rating) and no cost health care and medication (50% rating), therefore providing lifelong benefits to the combat veteran (US Department of Veterans Affairs [DVA], 2019).
The purpose of this study is to highlight the service of the female CST members and to explore their experience with combat related activities. Researchers sought to explore these issues through participant-engaged research, focused on partnering with key stakeholders in the CST community to ask relevant questions and make meaningful inquiries into their combat experience. As the nature of their occupation placed them in close-quartered contact with the frontlines of combat missions, many CSTs felt their contributions to the war effort should be recognized as combat. However, what is defined as combat varies. In this pilot study, the experiences of the CSTs are compared to various definitions of combat, first through the definition of the US Army CAB, second, the criteria of the Millennium Cohort study, and lastly via a definition created by key stakeholders within the CST community and trialed in this project. With this aim, the purpose of this study is three-fold: first, to create a platform where CST members can describe their experiences, secondly to evaluate the current definitions of combat and the potential inadequacies in defining modern combat experiences, and thirdly, to demonstrate the impact the lack of recognition has had on CST members.
In the approach to investigation, the survey instrument development process was separated into three distinct stages. In the first stage, the research team partnered with a key stakeholder from amongst the CSTs to identify components of the CST service and combat experience. Primary themes identified included: combat experience, combat definitions, recognition for military service, gendered biases, and mental health. Utilizing a Participant-Centered Research methodology (Johnson & Smalley, 2019), the research team created a mixed-methods survey instrument to assess the themes of interest. In the second stage of the research process, an additional three CST stakeholders were identified. These stakeholders reviewed the survey created by the research team. These stakeholders served as early reviewers of the instrument and gave substantial feedback on how to best pose questions and use precise language to elicit optimal responses from the intended participant population. The third and final stage of the research was the release of the survey to the target participant population.
Once the final version of the survey was created by the researchers and stakeholders, the survey was distributed by the key stakeholder. Participants were recruited from a private Facebook group created and moderated by CST members. Group administrators verify that each prospective member was a CST before allowing them to enter the group to maintain a safe and secure place for members to find support. This distribution model utilizes a modified snowball sampling protocol which a preferred methodology for initial research with difficult to access groups (Naderifar et al., 2017). The survey was distributed via the Qualtrics XM (Provo, UT, USA) survey platform. This system allowed for secure and anonymous survey responses to be collected. The research team then analyzed the quantitative data with descriptive statistics. This project received approval from the Rocky Vista University and Ohio University Institutional Review Board (#2018–0037).
In total, 23 CSTs completed this pilot survey. At the time of this survey, there were 75 CSTs members of the Facebook group invited to participate, representing a response rate of 30.7% (23/75). All research participants (23) identified as female. In terms of racial background, White/Caucasian was the most prominently represented group (21/23; 87.5%). 78.26% (18) participants identified as heterosexual, 13.04% (3) identified as bisexual, and bisexual or other represented 4.35% of the group respectively. A summary of the demographic information of respondents can be found in Table 1.
|RESPONDENTS||TOTAL N (%)|
Of the survey respondents, 12 (54.54%) identified their military status as active-duty Army, 3 (13.64%) as Army Reserves, and 1 (4.55%) each from the National Guard, Individual Ready Reserve, and Active Guard Reserve. Four respondents (18.18%) identified themselves as retired from the military. A majority of respondents reported the rank of officer (85.71%), followed by 2 enlisted ranks (9.52%), and one warrant officer (4.76%). In this cohort, 100% have been deployed at least once on behalf of the US military, with 86.36% reporting one or more deployments to active conflict zones. The military history and statuses of respondents has been summarized in Table 2.
|Current Military Status|
|Active-Duty Army||10 (45.45)|
|Army Reserves||3 (13.64)|
|National Guard||1 (4.55)|
|Active Status – Army Reserves/NG||2 (9.09)|
|Active Guard Reserve||1 (4.55)|
|Warrant Officer||1 (4.76)|
|Ever deployed on behalf of US Military||23 (100)|
|Deployed to an active conflict zone||19 (86.36)|
As the recognition of combat experience was a major theme of importance, several questions were asked regarding combat action and related experiences. The two major criteria of the US Army Combat Action Badge include: working in an area where fire pay or imminent danger pay was authorized, and actively engaging or being engaged by an enemy combatant. Fifteen respondents (71.42%) reported that they had worked in an area where fire or imminent danger pay was authorized and had actively engaged or were being engaged by an enemy combatant, thus fulfilling the primary criteria for the Combat Action Badge. Under the Millennium Cohort Study, one of the largest studies of military health to date, there are 14 items included in their combat inclusion criteria. To meet this combat definition, only one of the 14 criteria must be met. Eighteen of the respondents (85.71%) met the Millennium Cohort Study definition of combat experience. In between the scopes two previously defined terms of combat, the stakeholders created an 8-item scale for determining what they believed was an accurate description of combat experience. Utilizing this 8-item scale, 17 (80.95%) respondents meet this new definition of combat action. Table 3 contains the responses to the three definitions of combat.
|COMBAT DEFINITIONS AND SELF-REPORTED ACTIVITIES||YES N (%)||NO N (%)||MAYBE N (%)||TOTAL N (%)|
|Combat Action Badge|
|Worked in an area where fire pay or imminent danger pay was authorized||18 (85.7)||3 (14.3)||–||21 (100)|
|Actively engaging or being engaged by an enemy combatant||15 (83.3)||6 (28.6)||–||21 (100)|
|Total CAB Criteria Satisfied||15 (71.4)|
|Millennium Cohort Study Definition|
|Witnessed a person’s death due to war, disaster, or tragic event||16 (76.2)||4 (19.1)||1 (4.8)||21 (100)|
|Witnessed instances of physical violence/abuse||12 (57.1)||7 (33.3)||2 (9.5)||21 (100)|
|Seen dead or decomposing bodies or prisoners of war||12 (57.1)||9 (42.9)||–||21 (100)|
|Been exposed to or provided with countermeasures for chemical/biological/radiological (CBR) warfare agents or depleted uranium||–||17 (80.9)||4 (19.1)||21 (100)|
|Felt in danger of being killed||15 (71.4)||4 (19.1)||2 (9.5)||21 (100)|
|Been attacked or ambushed||13 (65.0)||6 (30.0)||1 (5.0)||20 (100)|
|Received small-arms fire||15 (71.4)||6 (28.6)||–||21 (100)|
|Cleared homes or buildings||15 (71.4)||4 (19.1)||2 (9.5)||21 (100)|
|Had an improvised explosive device explode nearby||9 (42.9)||9 (42.9)||3 (14.3)||21 (100)|
|Been wounded or injured||4 (20.0)||16 (80.0)||–||20 (100)|
|Seen or handled human remains||13 (61.9)||8 (38.1)||–||21 (100)|
|Known someone seriously injured or killed||16 (76.2)||5 (23.8)||–||21 (100)|
|Had members in unit seriously injured or killed||14 (70.0)||5 (25.0)||1 (5.0)||20 (100)|
|Been directly responsible for death of noncombatants or enemy combatants||6 (28.6)||10 (47.6)||5 (23.8)||21 (100)|
|Proposed Combat Criteria|
|Engaged in direct or indirect fire||15 (71.4)||6 (28.6)||–||21 (100)|
|Encountered an improvised explosive device (IED) explode in your vicinity||11 (52.4)||9 (42.9)||1 (4.8)||21 (100)|
|Attacked with, ambushed by, or exposed to chemical/biological/radiological (CBR) warfare agents||2 (9.5)||18 (85.7)||1 (4.8)||21 (100)|
|Been directly responsible for the death of noncombatants or enemy combatants||9 (42.9)||9 (42.9)||3 (14.3)||21 (100)|
|Been assigned duties you believed would likely result in a hostile engagement||16 (76.2)||5 (23.8)||–||21 (100)|
|Been wounded or injured as a result of a hostile engagement||2 (10.0)||16 (80.0)||2 (10.0)||20 (100)|
|Witnessed a person’s death or serious injury during a hostile engagement||14 (66.7)||7 (33.3)||–||21 (100)|
|Witnessed instances of physical abuse as a result of a hostile engagement||5 (23.8)||13 (61.9)||3 (14.3)||21 (100)|
Lastly, a final area of interest to the researchers and the stakeholders was the effect that being deployed on combat missions had on mental health. Sixty percent (12/20) of respondents said that they believed being a female servicemember deployed on a combat mission contributed to feelings of anxiety. Another 55% (11/20) CSTs reported their deployment on combat missions contributed to feelings of depression. Post-Traumatic Stress Disorder (PTSD) was linked to combat missions by 40% (8/20) of respondents, as well as 20% (4/20) of respondents stating their combat missions as a CST contributed to another form of psychological distress. Figure 1 contains a summary of these mental health findings.
As the CSTs were integrated with high intensity combat units, many of them faced direct combat exposure during a period of mandated combat exclusion. Per their responses to this survey, the majority of women (71.42%) met the conditions for the Combat Action Badge (CAB). However, many women reported through this survey being excluded from the CAB for various reasons, including returning to non-combat units and their commanding leadership’s concern that such recognition would be a violation of the Direct Exclusion Rule.
Additionally, many respondents (85.71%) indicated combat experience that met the Millennium Cohort study criteria. Although it has been criticized for being too inclusive, it does highlight a large number of potentially traumatic events that could contribute to decreased physical and mental health outcomes later in life (Bonanno et al., 2012). Per our stakeholder-informed 8-point question scale, 80.95% of participants satisfied this combat definition. This scale included more explicit references to the most intense combat related activities and represents a higher acuity of engagement than the Millennium Cohort definition. The differences between these definitions demonstrates a gap between recognized United States Army documentation for combat veteran status and those women who have experienced intense combat situations. In this discrepancy, there is lack of recognition of potentially traumatic events, which if neglected could be associated with problems that may develop at a later date (Kaplan, 2008).
It remains important to note that CSTs functioned as their own team adjunct to the all-male combat units. Although they were present under hostile fire and performing their assigned duties in areas where hostile fire pay or imminent danger pay was authorized, meeting the criteria for a CAB, eligible servicewomen were often not granted the award. In addition, the recognized US Army CAB criteria is restrictive to the point of excluding many female combat participants, such as female members of the CSTs surveyed for this study, potentially impacting future care (Duhart, 2011). With the awarding of the CAB, additional benefits are granted to the awardee. Some of these benefits include increased eligibility for VA Healthcare services and Combat-Related Special Compensation (Brubaker & Milner, 2015; Washington et al., 2013).
In 2000, the United States Department of Defense launched the largest prospective epidemiological study of military servicemembers called the Millennium Cohort Study (Chesbrough et al., 2001). While examining the effects of military service on health and wellness, the Millennium Cohort Study devised their own working definition of combat exposure for the purposes of their study. These criteria are less exacting than the requirements of the CAB but are meant to capture combat or combat-related activities that could cause distress from a mental health or physical health standpoint. Based upon these criteria, even more of our participants (85.7%) met this definition of combat. Meeting this definition does not impact military status or veteran benefits. It does, however, identify activities and experiences that leading military medical and psychological experts believe to have the potential to have negative physical or mental health consequences (Chesbrough et al., 2001). In comparison to the CAB definition of combat, these conditions are much more inclusive and suggest a larger portion of military servicemembers could be affected by combat related stressors.
In the early stages of the research process, the CST stakeholders expressed frustration with these two previously utilized combat definitions. Whereas the CAB criteria were found to be narrow and exclusive, they also found the Millennium Cohort Study to be too broad. Here CST stakeholders sought to create new metric by which to define combat. This metric contained eight activities, all experienced by various CST members, which the stakeholders believed constituted an appropriately precise definition of combat. An affirmative answer to any one of the eight criteria would satisfy this definition of combat. By including a CST-designed criteria for response in our questionnaire, and identifying specific activities most likely to cause distress, the CSTs participants had the opportunity to quantify their combat experiences against those criteria as well, while illuminating possible gaps in the current combat definitions and recognition criteria.
The issues highlighted by this survey indicate the difficulty that CSTs face in obtaining recognition that allows access to both career advancement and services. While the United States Army Combat Action Badge, granted in 2005, provides recognition and documentation for women in combat, its criteria remain restrictive. Many servicewomen remain unrecognized despite extensive combat exposure. The Pentagon-recognized Millennium Cohort Study, however, may be too inclusive and may potentially include veterans whose experiences, though honorable, may not meet the strict military definition of combat. To find a middle ground, by focusing on combat criteria seen in high intensity combat operations, and excluding those that may not be present in a combat zone, CSTs indicated an increased positivity rate when compared to the restrictive CAB criteria, indicating a potential recognition gap with consequences that can extend post service.
As current guidelines stand, CSTs are eligible for the CAB. Although some CSTs have been awarded CABs through non-CST deployments, CST combat exposure has not been recognized. Not only does this deprive these women of the opportunity to be recognized for their service, this lack of recognition also prevents them from obtaining further services and benefits that combat designation to which this would entitle them.
Based on the survey responses, many of the CSTs felt that their combat experiences had negatively impacted their mental health. Anxiety was the most common psychological stressor identified from their combat experiences, followed by depression and PTSD. In addition to recognizing their commendable service, a combat recognition would also validate the mental health struggles of the CSTs. One of the expanded benefits extended to CAB recipients is increased access to mental health treatment options, free of charge, through VA Healthcare and outpatient veteran centers. Without the ability to become eligible for these services, a structural barrier remains in place that prevents these women from equitably accessing the care they have earned.
The servicewomen who served in the Cultural Support Teams were integrated side-by-side with their male counterparts in combat units from the US Army Rangers and Special Forces. On these missions, they each had specific roles to perform. However, the violence that they faced did not discriminate based on gender. Many of these women engaged the enemy in combat which would qualify for the United States Army Combat Action Badge, without receiving the award. Without this recognition, many CSTs may have been potentially excluded from receiving the benefits provided to their male combat counterparts, including expanded access to healthcare treatment options, advancement opportunities, and additional financial compensation. In redefining the criterion associated with high intensity combat, CSTs may legitimize their combat experience and erase the artificial separation that exists between their male colleagues who were recognized for their combat action and themselves. The CSTs are proud of their service to their country and the legacy of this novel program. Recognition of their bravery and sacrifice should be made visible.
The authors have no competing interests to declare.
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