the initial C&P exam if there was some reason to expect a change in the veteran’s status or by a treatment, vocational, or rehabilitation professional upon completion of these services.

GENDER AND MILITARY SEXUAL ASSAULT

Gender and sexual assault are two important intersecting issues to consider when discussing the subject of PTSD compensation among veterans. A substantial body of literature has emerged that documents measurable gender differences in PTSD frequency and severity. A recent, well-conducted meta-analysis of more than 200 studies meeting reasonable inclusion criteria and including military as well as civilian samples found that PTSD was twice as prevalent in females as in males, even controlling for potential confounders, including study methods (Tolin and Foa, 2006). This gender difference holds up even though males report significantly more traumatic events than do females overall. Males do report significantly less sexual assault than females do, however (Tolin and Foa, 2006). Tolin and Foa (2006) concluded that sex differences in the prevalence of adult and child sexual abuse may account for some of the disparity in PTSD rates between men and women but that the variance they found in the meta-analysis was not completely due to this difference. After controlling for type of trauma, the largest gender difference they found was in adult nonsexual assault. However, the exact type of traumatic experience was not well differentiated in most studies. For instance, adult nonsexual assault was usually not differentiated between chronic (e.g., intimate partner violence, with female victimization more likely) and acute (such as robbery, with male victimization more likely). One potential methodological contributor to the observed variance relates to PTSD measurement, with “[t]he sex difference in PTSD [seeming] most clear when the PTSD assessment is explicitly linked to one specific traumatic event” (p. 978).

Tolin and Foa were able to rule out some of the possible reasons for the gender differences, but the studies they reviewed were not able to rule out gender differences in cognitive response to the event, immediate coping strategies, or amount of fear associated with experience. There also may be sex differences in willingness to admit symptoms because of differences in gender role expectations or in pretrauma psychiatric history and trauma exposure during military service. Sex differences are particularly likely in chronic trauma, such as repeated childhood sexual assaults by a family member or recurring intimate-partner violence, or in a history of multiple traumas, which may be more frequent among females than males. Researchers seldom examine sex-specific effects of various types of trauma, or chronic versus episodic or one-time events, even though these different



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