Drawing on 20+ years in Army medicine, Dell Med Orthopedic Surgeon Dr. Anthony Johnson highlights the unique needs of females after combat trauma and explores how changes in treatment can promote their mental and physical recovery.
By Katherine Corley
Population Health Scholar
University of Texas System
Dual Degree Master's Student in Journalism and Global Policy
UT Austin Moody College of Communication & UT Austin LBJ School of Public Affairs
“Women respond differently to trauma than men do….and when we treat women like men, they have inferior outcomes.”
Dr. Anthony Johnson
Orthopedic Surgery and Orthopedic Sports Medicine
Anthony Johnson can’t remember her name, but decades later can still see her face. She was a transporter helping to ship supplies in preparation for the initial phase of Operation Iraqi Freedom. While on a ship, she was crushed between two tanks, and became a bilateral, above-the-knee amputee under Dr. Johnson’s orthopedic care at Brooke Army Medical Center (BAMC) at Ft. San Antonio. Celebrities and businesses came to visit the wounded troops, but most of these good will visits were very male-centric, “like a team from Hooters,” Johnson said. “Can you imagine if you’re an injured female and a bunch of women arrive in skimpy outfits? I saw the look on her face and that’s what caught my eye. And then every time I did my rounds, I noticed that she was not bouncing back from her injuries like the males were.”
That planted a seed in Johnson’s mind. As more wounded female soldiers continue to arrive at BAMC, he realized how much the treatment and recovery protocol for disabled veterans was biased towards men, and was not meeting the particular needs of women. He began to push for research on the health outcomes of female veterans, and served as the inaugural Custodian of the Military Orthopaedic Trauma Registry to collect granular data on the treatment and recovery of orthopedic trauma survivors to enable further study. He continues to advocate for appropriate treatment for female trauma survivors and other special populations in his new role at The University of Texas at Austin Dell Medical School.
Johnson is the Orthopedic Surgery Residency Program Director for Dell Medical School and the Orthopedic Sports Medicine Clinical Director at UT Health Austin’s Musculoskeletal Institute. He also oversees the Special Population and Adaptive Sports Medicine Education & Community Outreach program. During his 28-year military career, he served as a Medical Corps officer, an Orthopedic Surgeon for the Joint Special Operations Command, and the Chair of the Department of Orthopedic Surgery at Brooke Army Medical Center at Ft. San Antonio. He also deployed to Iraq three times, and has also served as the Team Physician and Director of Medical Operations for 15 international competitions, including the Para-Pan American, Paralympic, and Military World Games.
We spoke to Dr. Johnson about his work treating female combat casualties and about the need for gender-appropriate innovations to improve mental and physical health.
Texas Health Journal: Tell me about the difference in outcomes for female casualties.
Anthony Johnson: When Operations Enduring and Iraqi Freedom started, I was an orthopedic surgery resident at Brooke Army Medical Center at Ft. Sam Houston, which is the Army’s only Level 1 Trauma Center. About 50% of the casualties from the war were brought to us for treatment, and I started noticing that we were seeing a lot of females who were wounded. I suggested to my chair at the time that we do a study on female casualties, but the research protocol was not approved. When I came back to BAMC as faculty in 2009, I started studying female casualties. And then I noticed that despite women only comprising 2% of the more than 50,000 combat casualties, there was a difference in survival between men and women. Women get injured less in war, but they die about twice as often in a combat theatre as men. This is contrary to everything we know from animal models and civilian trauma (car accidents, gunshots, etc.), in which females have higher rates of survival compared to males. Being female improves recovery from trauma in civilian life, but not in the military wartime trauma population. We are still figuring out why, but are starting to gain some insights.
What have you learned about treating traumatic injuries in females?
Women respond differently to trauma than men do. They rebound differently and have different needs, and when we treat women like men, they have inferior outcomes. There is also a huge male bias in research. People systematically exclude women from research because of the risk of pregnancy. So almost all our research is based on males, which also means almost all our treatment is based on males. And there is a difference between gender appropriate treatment and gender segregating treatment, so this can be a fine line to walk.
One example is what we learned about how we rehabilitate knee injuries for women. The greatest determinant of functional outcomes after any type of knee injury after surgery is the functional strength of the quadriceps, so the stronger your quadriceps are, the better function you will have overall. We have world class rehabilitation facilities, and we are pushing people in recovery to include quad strengthening. But we found that when it came time to do weight-bearing quad exercises, some women would just leave. Thankfully, I had a female patient who told me that she doesn’t do those exercises because she experiences stress urinary incontinence, which is something that some women experience after they have kids. This patient said, “Those weight exercises are embarrassing for me in a roomful of men, because if I strain hard enough lifting weights, I wet my pants, so I don’t do them.” So we set aside exercise areas only for women, but luckily we had a physical therapist at the Center for the Intrepid who came up with a creative way to strengthen the quadriceps—blood flow restriction therapy—that doesn’t involve heavy weight lifting. We tested this method, and it was incredible—two outliers showed a 700% increase in strength in six weeks. So now we can use that method to rehabilitate women with knee injuries, instead of asking them to use the weight-bearing technique, which could be uncomfortable or embarrassing for them.
Another example of the reason we need more research on outcomes for women is that we had a female veteran with a pelvic fracture ask me what impact her injury could have on childbirth. I didn’t know, so I asked my ob-gyn colleagues, but they didn’t know either. They said, if there’s any question about safety, we can just do a C-section. But I was like, what happens if the woman doesn’t want a C-section, because now this is impacting the woman’s autonomy. So I went to research it. I found out that the impact of having a prior pelvic fracture on a woman’s ability to give birth may be overstated.
A third issue that is important but rarely discussed or researched is the sexual quality of life for female disabled veterans, as this is an area that impacts a person’s relationships and health. After pelvic trauma, the rate of sexual pain or complications increases, and after amputation, women will often refrain from initiating sexual contact, so sexual quality of life reduces dramatically. If you survey patients, they often won’t bring this up. However, once you bring this up, they’ll report that they wish people would talk to them about it. One reason we don’t know much about this topic is that the military and the VA tend to explore topics like this in a group setting, and most women, particularly female amputees, will not talk about their sexual needs or inadequacies in a room full of men. So that is another example of how we could be providing more gender-appropriate treatment for female disabled veterans.
These stories illustrate the need for more research on the experiences, needs, and outcomes of female disabled veterans.
How does Post-Traumatic Stress Disorder impact female veterans differently?
Research from both civilian and military trauma demonstrates that if you have an anxiety spectrum disorder like PTSD, your mental and physical health outcomes following traumatic injury are poor. Remarkably, having psychological distress (such as PTSD) predicts poor outcomes after injury even more than the severity of the injury itself. And we now know that women tend to get PTSD both more commonly and more severely than men. One of the reasons for this is that, unlike men who only have to worry about combat trauma, women have to worry about military sexual trauma as well. For a male soldier, when you’re deployed, there are certain times when you fear for your safety (mortar attacks, IEDs, etc.), but when you’re in the military base with your buddies, you tend to feel pretty safe. But if you’re a female soldier, you experience threat both off and on the base. You’re surrounded by guys all the time on the base, and so there is a constant threat for military sexual trauma. So, as a female, you can’t ever let your guard down. If a soldier can regularly return from a state of “hyperarousal” (abnormally heightened anxiety) to a state of feeling safe, the rate of PTSD is very low. But female soldiers’ hyperarousal never goes down, because they are always worried about their personal or physical safety.
This constant hyperarousal leads to higher rates of PTSD among female veterans. And if you are a female veteran with a war injury, your ability to defend yourself from assault has decreased, which further increases anxiety. Notably, the rate of homelessness among female veterans is much higher vs. the male population, and many of these homeless female veterans have experienced military sexual trauma.
Why do female veterans have a different experience than males after they return home?
Female veterans don’t get the automatic recognition and respect that male veterans do. For instance, San Antonio, TX, is a very military-oriented city with lots of veterans and active duty military. If you are a male amputee and look physically fit, and you’re walking in the San Antonio airport, people will approach you assuming that you’re a combat veteran and thank you for your service. In contrast, if you are a physically fit female amputee, people will generally assume that you had cancer or were in a car accident. Female veterans want to be seen as veterans, but they are not recognized as readily as males are.
Additionally, since there are far fewer female veterans, they often do not have the supportive peer network that males do when they return home. If you are a male disabled veteran, it’s fairly easy to find another male disabled veteran with a similar experience. However, as a female disabled veteran, it’s quite hard to find another female disabled veteran who shares your experience, even in a strong military city like San Antonio. It’s even harder for those females to find peers they can relate to once they have returned to their hometowns. Peers are very important in the military. The warrior ethos is that you never leave a fallen comrade. I have deployed twice with one of my closest and best friends, who is a general surgeon, and to this day our wives call us battle buddies. But if you’re a female soldier, you may not have a battle buddy within your unit, or you may be assigned to be battle buddies with another male, simply because of the math. Thus, female soldiers don’t have the same close peer group in a combat zone that males do, and then they also lack the support of a close peer group when they get home.
Peers are equally as important in successful recovery from injury once a soldier returns home. There’s a stigma against mental illness overall, but it can be really bad in the military, so we have to be creative to get wounded veterans, particularly amputees, the support they need. One way we have found to deal with this is to use peer support. We will send a veteran amputee who is successfully healing and coping with the injury to talk to a newer amputee, so they can say, “Hey, this is what I went through, similar to what you’re going through, and these are the thoughts I had—I’m sure you’ll experience them if you haven’t already—and it’s going to be okay.” Peer support is very powerful because you can share a frame of reference with someone. And because of the limited number of female disabled veterans, particularly female veteran amputees, they don’t get the same peer support that male veterans do, which is really impactful on recovery.
What type of data do you have on best practices in treatment and recovery for female veterans?
The American Academy of Orthopaedic Surgeons, the Orthopaedic Trauma Association, and the Society of Military Orthopaedic Surgeons formed the Extremity War Injuries Taskforce to push for the formation of a registry called the Military Orthopaedic Trauma Registry to collect detailed information on orthopedic combat trauma so that we can use data to gain insight on best practices. This new database is far more comprehensive for Extremity War Injuries than the previous Department of Defense Trauma Registry, and collecting information for each casualty can take up to 8 person-hours, as we record everything from point of injury to dependent care, including complications, type of interventions, etc. Once we get all of the data entered, this level of detail will provide a great deal more information on the recovery patterns of female casualties and will enable research on best practices for treatment for both genders.
What are the different challenges and benefits of civilian medicine?
Well, one thing that is more challenging in civilian medicine is the insurance plans. In the military, all of my patients had the same military insurance plan, while some of the types of things I might want to do to treat my civilian patients may not be covered by the different insurance plans.
I am still committed to serving special populations as a civilian doctor. Currently I have a general orthopedic clinic because UT Health Austin is a new clinical enterprise, but I would like to build up my referrals and infrastructure so that in about five years my clinic can be focused on special populations. If you are an able-bodied runner, it’s easy to find someone to take care of you, but it is much harder to find specialized orthopedic care if you are disabled or an amputee. Dell Medical School has given me the opportunity to create a program to support special populations that others may not be serving.