January 11, 2018
Results of a national study led by Assistant Professor of Community Health Education Elizabeth Evans, with others at the U.S. Department of Veterans Affairs (VA) and the University of California, Los Angeles, suggest that risk for alcohol and drug use disorders among United States military veterans is increased by childhood adversity, and in ways that are different between women and men and different compared to the civilian population.
Evans says that in the general population, fewer women than men have an alcohol or drug use disorder. “Veterans are different in that there is no gender difference in the prevalence of these problems,” she explains. “Among veterans a similar proportion of women and men – about 37 percent – have ever had an alcohol or drug use disorder.”
She adds, “This finding that women veterans are similar to men veterans and are so different from civilian women, is unexpected. Also surprising are the high rates of childhood adversity among veterans, especially among women; 68 percent of women veterans report some childhood adversity, and they have the highest rates of childhood sexual abuse.” Study results appear in a recent early online edition of Social Psychiatry and Psychiatric Epidemiology and will be in print this year.
Evans points out, “One of the implications of this study is the need to assess for childhood adversity, to help people recognize its relationship with substance use and cope with its health impacts. When people join the military or when veterans access healthcare at the VA or in the community would be good times to assess and treat childhood adversity, and we’re often missing those opportunities now.”
The test for adverse childhood experiences, known as an ACE score, measures a person’s experiences before age 18 of physical, sexual or emotional abuse and neglect, and household dysfunction, for example a parent’s problematic substance use, incarceration, mental illness or suicide, she and co-authors point out. There is a well-established dose-response relationship between childhood adversity and many health conditions, including substance use disorders.
To examine differences by U.S. military veteran status and gender in associations between childhood adversity and lifetime alcohol and drug use disorders, Evans and colleagues analyzed nationally representative data from 379 female and 2,740 male veterans and 20,066 female and 13,116 male civilians from the 2012-13 National Epidemiologic Survey on Alcohol and Related Conditions. They used logistic regression, tested interaction terms and calculated predicted probabilities by veteran status and gender, controlling for covariates.
The researchers found that with increasing exposure to adversity in childhood, risks of alcohol use disorder among civilian men and women grew more similar but for drug use disorder, the gender differences in risk widened. By contrast, among veterans more childhood adversity elevated men’s alcohol risk and increased women’s drug risk. The authors speculate that among veterans with greater exposure to childhood adversity, men may be more likely than women to use alcohol, while women may be more likely than men to use drugs.
Evans notes, “In general right now, we don’t assess for childhood adversity until there’s a problem, in particular with alcohol or drugs, or attempts to harm oneself or others. However, we know that childhood adversity is an early life experience that is associated with anxiety, depression, and other risk factors for later health and social problems. We in public health, along with others in the community, can do more to prevent childhood adversity altogether. Also, more can be done to assess and address childhood adversity when it does occur so that we mitigate or undo its harmful effects. The need for such efforts is especially critical now given the devastating impacts of the current opioid epidemic on families and communities.”
Another contribution of this work not reported before, says Evans, is what she and colleagues learned about men’s health and childhood adversity. She notes, “A lot of studies of childhood adversity focus on sexual abuse among women, and they only examine data on patients treated in clinical settings. In this study, we examine differences by gender in exposure to different types of childhood adversity and we provide findings that are representative of the U.S. population.”
“We see that more than half of men, both civilians and veterans, have been exposed to childhood adversity including physical abuse but also neglect and household dysfunction, and this is associated with men’s alcohol and drug use in adulthood,” she adds. “This highlights the need to address childhood adversity in ways that encompass and specifically target men.”
Evans points out, “As the role of women in our nation’s military expands, we need to better understand the gender-specific patterns of alcohol and drug use and whether patterns by gender are different for veterans and if so, why. Provision of health and social services can be improved to better meet the needs of all veterans, and in particular for women.”
This work was funded through the VA’s Health Services Research and Development awards. Evans is now leading a study of complementary and alternative medicine to address musculoskeletal pain, mental illness and opioid use among women and men veterans.