A Study of the Health of Australia's Vietnam Veteran Community

Volume II Female Vietnam Veterans Survey and Community Comparison Outcomes

Executive Summary

[Drawn directly from a final draft of the Report, prepared by DVA. Any errors are those introduced by my transcription - Clive Mitchell-Taylor A direct cross-reference to the final document will be provided in place of this extract, when and if the information is posted to the Internet by DVA. DVA copyright applies to this extract as it does to the Report itself.]


This study of the health and morbidity of Vietnam veterans was established by the Commonwealth Government following Ex-Service Organisation (ESO) representation and the study by the Department of Veterans' Affairs, Mortality of Vietnam Veterans: The Veteran Cohort Study, released in May 1997. Two prior morbidity studies of male Vietnam veterans exist, one undertaken in 1983 titled Australian Veterans Health Studies and the other The Australian Vietnam Veterans Health Study, by O'Toole et al, published in 1996.

Volume I of the study, the male survey results, was released in April 1998. This report is Volume II of the findings and presents the results of the health survey of female Vietnam veterans. A final report covering the results of validation arising from the recommendations contained in Volume I, will be published as Volume III.

It should be noted that, of the female veterans, only those who served in Vietnam in the Army, Air Force, Navy and certain philanthropic organisations are eligible for benefits under the Veterans' Entitlements Act 1986 (VEA). As this study was undertaken by the Repatriation Commission, its findings relate principally to that Act. Non-military female veterans may be covered for conditions incurred whilst in employment in Vietnam under other arrangements.

Aims of the Study

The Vietnam veterans morbidity study covers both male and female veterans. The aims are to:

Study Planning and Design

A Study Advisory Committee was established in April 1996 to oversee the conduct of all aspects of the study.

The Advisory Committee was chaired by the Repatriation Commissioner. In addition to medical officers, senior officers and supporting staff from DVA, its membership comprised representatives from each of. the Returned and Services League of Australia (RSL), Vietnam Veterans' Association of Australia (VVAA), and the Australian Veterans And Defence Services Council (AVADSC).

ACNielsen Research Pty Ltd was engaged to conduct the survey of veterans and representatives of ACNielsen reported to the Advisory Committee. Professionals in statistical methodology and epidemiology were engaged to provide data and professional advice to the Committee.

For the purpose of the study, the Advisory Committee accepted the definition of Vietnam veterans contained in the Nominal Roll of Vietnam Veterans:

All members of the Australian Defence Force (ADF) and the Citizen Military Forces (CMF) who landed in Vietnam or entered Vietnamese waters including those who were seconded to the Army of the Republic of Vietnam (ARVN), the United States Air Force (USAF), the United States Navy (USN) and any other allied service, all members of Australian Army Training Teams Vietnam, all members, male and female, of civilian medical and surgical teams, all members of philanthropic organisations, all members of the Australian Forces Overseas Fund and all official entertainers and war correspondents who saw service in Vietnam during the period between 23 May 1962 and 1 July 1973

When considering design options for the male and female study, the Advisory Committee decided to survey all Vietnam veterans who could be located. The committee believed that it was important for all veterans to have the opportunity to participate in the study and ESO advice was that this was the expectation of the veteran community. Further, it was believed that a survey of the entire population of veterans had the benefit of allowing for the identification of rare conditions.

The decision to survey all locatable veterans dictated that the study instrument would be a mailed-out, self-reporting questionnaire. Three distinct questionnaires were developed: male veteran, female veteran, and widow(er)s/divorced and separated partner(s).

The Advisory Committee agreed that the study should be conducted in three phases, with the need for Phases 2 and 3 dependent upon the outcome of Phase 1. The agreed Phases were:

Phase 1 - A mailed survey of all surviving Vietnam veterans.

Phase 2 - Analysis of Phase 1, production of a report on the outcome of Phase 1, and decision on potential Phase 3 studies.

Phase 3 - Follow-on investigations if required, including the possibility of interview of a representative sample of Vietnam veterans.

Strengths and Limitaitons of the Female Survey

The major limitation of the survey of the health of female Vietnam veterans was that only half of the potential survey population could be located. This resulted in an apparent under-representation of married women due to the difficulty in locating those whose names had changed since service in Vietnam.

The small cohort size of female Vietnam veterans (484 versus 59,520 male veterans) combined with the incomplete sample (278 female veterans located) makes it difficult to reach definitive conclusions in regards to this study.

Of the women who were contacted and defined themselves as Vietnam veterans (that is, were in scope of the study), 8 1 % returned completed questionnaires.

The return rates of completed questionnaires were high for ex-service personnel: Army 46/47 Air Force 72/106. This makes the data subset from these groups a potentially valuable tool for further examination of the health of these veterans, as it is less subject to the sampling problems that applied to the remainder of the female Vietnam veteran cohort. There were no Navy female veterans.

Survey Methodology

Address lists compiled by the Department of Veterans' Affairs and Ex-Service Organisations were used as a means of locating female Vietnam veterans for the purposes of this study.

Of the 484 female Vietnam veterans on the Nominal Roll 278 were located. A copy of the relevant questionnaire was posted to each female Vietnam veteran whose address was obtained.

Survey Response

From the 278 questionnaires that were posted, 223 completed questionnaires were returned. There were three respondents who wrote in to say that they were not Vietnam veterans. These responses were classified as being out of scope of the survey. Thus the response rate for the female Vietnam veterans survey was 8 1 % (calculated from 223 responses out of a possible 275).

Comparitive Data

Where practical, community data were obtained on the prevalence of the conditions surveyed in the questionnaire. This enabled comparisons to be made between the number of veterans reporting each condition and the expected prevalence in a representative community sample.

A number of difficulties were encountered when comparing data from other community surveys with the data from the female veterans survey.

The first was that of relevance of community data. The most relevant comparisons would be those from surveys where the definition of a condition was compatible with that used in the veterans survey, and where a match in the age of participants, their socio-economic status (including occupation) and the time period under consideration could be made. These criteria were generally not able to be fully satisfied.

Another difficulty was that Australian data were not always available. When Australian data were not found, international comparisons have been offered where possible, or it is noted that comparative community data are simply not available.

The questions asked in other community health surveys were often not directly comparable with questions from the female veterans questionnaire. The veteran survey results show the overall prevalence of conditions post-Vietnam, including an unknown proportion which would have been cured since the time of diagnosis. Community surveys typically do not seek such a long-term prevalence, and instead record a present time 'snapshot' of prevalence, or the prevalence over a specific interval, often 12 months. Where possible, allowances have been made for this by selecting comparable data, by calculations (for example by age adjustment or adjusting incidence to prevalence), or in the interpretation offered.

Another point of contention is that some of the medical conditions in the survey can be defined or measured in a number of different ways. The varying definitions used in the reference surveys and the veterans health study make direct comparisons of some of the results problematic. Care has been taken to ensure that the comparisons presented are based on compatible definitions: however in cases where the most appropriate definition is uncertain, a number of alternative comparisons have been listed. Inconsistency of definition may lead to biases that are unable to. be quantified, but allowance for this has been made where appropriate.

It should be noted that the US Department of Veterans Affairs has commissioned a study into the health of US female Vietnam Veterans. The US study is to be released in 1999. Once released, the results of the US study will be considered by DVA. This may lead to additional research into the health of Australian female Vietnam Veterans.

General Comment on Survey Findings

The findings from the female survey, summarised below are the result of initial analysis.

Locations were found for only 57% of the total female Vietnam veteran cohort. There is also an apparent sample bias towards single rather than married/defacto female Vietnam veterans. As health status is linked to marital status, this has had an unknown but probably major impact on the study results. The relatively small size of the total female veteran cohort further amplifies the uncertainties of interpretation introduced by this possible bias.

The results of this study are drawn from the 223 completed questionnaires that were received from participants. This number represents only 46% of the female Vietnam veterans recorded on the Nominal Roll.

Developing a register of female Vietnam veterans would enable the profile for the cohort to be expanded and enhance any further study of this group.

Self Reported Medical History of the Veterans
(Questionnaire Part A and E)

When asked to assess their health as excellent, very good, good, fair or poor (Question E I of the survey) 12% of veterans who responded reported their health as excellent, 27% as very good, 37% as good, 19% as fair, and 5% as poor.

The majority of female veteran respondents thus reported that their health was good or very good. However, community comparison indicates that the female veterans are less likely than other Australian women of the same age to classify their overall health as excellent or very good, and more likely to report their health as being good or fair. The female respondents and the community comparison group were equally likely to classify their health as poor (5% in both cases).

Although the female respondents' rating of their health falls below that of their community counterparts, their view of their health is more positive than that of male veterans. Female veterans were twice as likely as male veterans to report their health as excellent or very good, and three times less likely to report their health as poor.

The response to Question E1 reflects the trend of a number of specific conditions reported in excess by female veterans in Part A of the questionnaire.

Recognising the sampling limitations of the survey, the conditions for which there is apparent statistically significant excess in female veterans in comparison to the general community are:

An excess level is defined as statistically in excess of what may be expected in a community sample.

These conditions are presented in alphabetical order. Where appropriate, provisional judgements are made about the public health importance of the differences between the veteran and comparison populations in the commentary of Section 7 of the Female Vietnam Veterans Morbidity Study report.

It is a reasonable hypothesis that some aspect of the association between the veterans and their service in Vietnam may have contributed to these conditions. However, because of the small sample size and potential sample bias in the survey group, none of these conditions (with the probable exception of malaria) should be considered to have a properly established association with war service. It is also generally not possible to distinguish between factors that would have led women to be recruited for service, and environmental or other possible causes of disease that these women may have experienced while in, or since leaving, Vietnam.

Notwithstanding, the overall outcome lends some weight to the hypothesis that the general health of female Vietnam veterans is worse than that of other Australian women of comparable age. It should be noted that the degree of severity of this finding does not seem as marked as in male veterans.

It is noted that the prevalence of Post Traumatic Stress Disorder (PTSD) does not appear to be excessive in female veterans. However, other psychiatric conditions (panic attacks, depression) appear to be significantly in excess. This result supports the recommendation flowing from the male survey results that there should be a broader diagnostic and treatment focus on mental health conditions in veterans, notwithstanding the incidence of PTSD

Additionally, in regard to the hypothesis that the prevalence of cancer is greater in Vietnam veterans than in other Australians of comparable age, the findings of this study appear consistent with this hypothesis for a cumulative total of all the cancers investigated. It should be noted that the findings are not as pronounced as those for the male survey.

A particular hypothesis that this study set out to investigate is that the cumulative prevalence of hysterectomy amongst female veterans is greater than in a comparable age cohort within the general female population of Australia. The survey results indicate that the cumulative prevalence of hysterectomy appears to be comparable to that for Australian women in a similar age group.

Although there are acknowledged limitations associated with the reliability of self reported surveys, it is not recommended that validation of the responses made by female veterans be undertaken. Treatment, compensation and counselling, if required, for the conditions surveyed are already available under the VEA to eligible veterans following diagnosis and acceptance of a claim.

The survey results can thus be accepted as indicative without the need for further research. It is recommended that veterans reporting suffering the conditions should be urged to seek acceptance of the condition for treatment and compensation purposes, if they have not already done so.

It is also recommended that the Department of Veterans' Affairs uses the responses to Parts A and E as a guide in planning the coverage of treatment and counselling services, and of preventative programs for female Vietnam veterans.

The male study reports that the prevalences of Multiple Sclerosis and cancers are significantly higher than in a comparable community sample. Those results are being validated. Results for these conditions in the female study do not show an excess. Nevertheless, it is recommended that the cases reported in the female study be considered alongside the male validation study results.

For veterans entitled under the VEA, compensation is governed by Statements of Principles (SOPS) prepared for individual medical conditions by the Repatriation Medical Authority (RMA). It is recommended that the findings of the survey be referred to the RMA for their consideration.

It is further recommended that the outcomes of this survey be forwarded to the Australian Defence Force for use in refinement of preventative measures. Similarly, it is recommended that the findings be referred to Comcare for consideration.

Current Marital Status
(Questionnaire Part B)

Part B of the survey sought to ascertain the marital status of veterans. Responses to this part show that the numbers of married, separated, divorced and widowed female veterans are lower than would be expected in a similar group of Australian women, while the number of female veterans who never married greatly exceeds community expectations.

This finding could be the result of the inability to locate about half of the female Vietnam veterans.

As it stands, the finding tends to support a hypothesis that the marital-status profile of female veterans is different to that of the general population. The primary difference lies in the number who never married.

Health of Partner(s)
(Questionnaire Part C)

In this part, 13% of respondents reported that service in Vietnam, or health problems arising as a consequence of their service in Vietnam, have had a serious adverse effect on current or past partners. Fourteen per cent (14%) reported physical or psychological health problems in their partners which may be related to the veteran's Vietnam service. Stress (14%) anxiety (12%) and insomnia/sleep disturbance (9%) were the most commonly cited conditions. Thirteen per cent (13 %) of respondents reporting these conditions indicated that treatment for their partner had been required.

Part C of the questionnaire sought to ascertain the effect of the health of veterans on the health of their partners.

Community comparisons are not available for these data. The responses themselves, lend some support to the hypothesis that the health status of the veteran has an effect on the health status of the immediate family. Again, these findings may have been affected by sample bias.

These findings support the recommendation made in the male veterans report that the level of resources available for counselling on mental health conditions experienced by veterans and their families be reviewed for adequacy.

Health of Children
(Questionnaire Part D)

Fertility and Adverse-Pregnancy Outcomes
(fertility, stillbirth, miscarriage, termination, ectopic pregnancies and live births with labour complications)

Seventeen per cent (17%) of female veterans reported trying for more than twelve months without success to conceive a child. Twenty-six per cent (26%) reported a miscarriage, 9% a termination, 3% a child that was stillborn, 1 % an ectopic pregnancy, and 4 1 % a birth with labour complications.

Reliable estimates of infertility, miscarriage and stillbirth rates are difficult to obtain from community data. Notwithstanding, all conditions surveyed appeared to be within or under the expected community rates with the potential exception of stillbirth.

In relation to the number of children, female veterans reported a total of 215 births since the first day of service in Vietnam. This is approximately half the number that might have been expected based on the Australian average. This result, and others concerning fertility and adverse pregnancy outcomes, may have been affected by the number reporting never having married, and by sample bias.

Sight and Hearing Conditions, Psychiatric Conditions and Major Illnesses

One per cent (1 %) of veterans reported that at least one of their children had suffered an eye condition not correctable by spectacles, and 6% reported children with long-term hearing or ear problems. Twenty-eight per cent (28%) indicated that a child had suffered a major illness. In regard to mental health issues, 7% of veterans reported that they had one or more children diagnosed with a psychiatric problem and 23% reported having one or more children with an anxiety disorder.

Definitional problems precluded precise comparison with community data for these conditions, but it was concluded that it was unlikely that any of these conditions were occurring excessively in the children of female Vietnam veterans.

Congenital Abnormalities

Responses were sought from veterans in relation to diagnoses of spina bifida, anencephaly, Down's syndrome, tracheo-oesophageal fistula, cleft lip or palate, absent or extra body parts, and other abnormalities in their children.

Responses indicated one instance each of Down's syndrome, tracheo-oesophageal fistula and absent body parts, and two instances of extra body parts. Fifteen instances of other abnormalities were reported.

These responses neither confirm nor refute an increased level of genetic abnormality in the children of Vietnam veterans. The sample size of the survey was too small to give the statistical power needed to enable valid comparison of the rates of these relatively rare conditions.

Responses to the male survey indicated an increased incidence of such defects, and the male report recommended that the reported rates be validated as c. matter of urgency. The validation* results will be contained in Volume Ill of the results of the Vietnam Veterans Morbidity Study. For reasons stated below, the results of the female study will not be validated. However, it is recommended that the findings of the female veterans study be considered in conjunction with the Volume Ill results when developing potential policy action.

Prevalence of Cancer in Female Veterans' Children

Responses were sought to the incidence of three specific forms of cancer in female veterans' children: leukaemia, Wilms' tumour and cancer of the nervous system. An opportunity was also provided to report any other forms of cancer the children had.

Two cancers were reported: one case of Wilm's tumour, and one of melanoma.

The statistical power of the survey was insufficient to either confirm or refute the hypothesis of an increased prevalence of cancer in the children of female Vietnam veterans.

Responses to the male survey indicated an increased incidence of cancers in children, and the male report recommended that the reported rates be validated as a matter of urgency. The validation results will be contained in Volume 111 of the results of the Vietnam Veterans Morbidity Study. The results of the female study will not be validated. However, it is recommended that the findings of the female veterans study be considered in conjunction with the Volume Ill results when developing potential policy action.


Veterans were asked whether any of their children had died from illness, suicide, accident or any other reason. Four deaths from illness, and one from accident/other reason were reported. No deaths from suicide were reported.

Community comparison of these responses is not possible. The exact number of children and their age distribution for the purpose of making a comparison is unknown. The reason is that the question sought responses in relation to all of the veterans' children, but the survey only requested that veterans enumerate the number of children born after service in Vietnam. The total number of children born to the veterans, and the number born prior to Vietnam service, is unknown. The survey also did not seek the age of the children. However, at face value, reported instances of deaths do not seem excessive.

Responses to the male survey indicated an increased incidence of suicide and accidental death in the children of male Vietnam veterans. The male report recommended that the reported rates be validated as a matter of urgency. The validation results will be contained in Volume Ill of the results of the Vietnam Veterans Morbidity Study. The results of the female study will not be validated. However, it is recommended that the findings of the female veterans study be considered in conjunction with the Volume Ill results when developing potential policy action.


Consideration was given as to whether validation should occur as a result of the female veterans survey. On balance, a decision was made that validation would not be recommended.

The decision was taken in the light of the following points:


As a result of the outcomes of the female veterans survey the following recommendations are made:

For Female Vietnam Veterans with Entitlement Under the VEA

  • It is recommended that the results in this report be accepted by DVA as indicative of the health status of female Vietnam veterans.
  • It is recommended that DVA uses the responses to Parts A and E of the survey as a guide in planning the coverage of treatment and counselling services, and of preventive programs.'
  • It is recommended that the level of resources available for counselling veterans and their families experiencing mental health conditions be reviewed for adequacy.
  • It is recommended that veterans reporting the conditions surveyed in Part A of the questionnaire be urged to submit a claim under the VEA for these conditions if they have not already done so.
  • It is recommended that while recognising the importance of PTS1), there be a broader diagnostic and treatment focus on other mental health conditions common in veterans.
  • No validation of survey findings is recommended. However, it is recommended that the results obtained for the following conditions be considered in conjunction with the male validation study as additional data:
  • Multiple Sclerosis;
  • All Cancers (with the exception of non-melanotic skin cancers);
  • Children's Conditions:
    • Down's Syndrome;
    • Tracheo-oesophageal Fistula;
    • Absent Body Parts;
    • Extra Body Parts;
    • Wilm's Tumour; and
    • Accidental Death.
  • It is recommended that the findings of the survey be referred to the RMA for their consideration, particularly in respect to:
    • Hydatidiform Mole;
    • Asthma;
    • Eczema and Dermatitis; and
    • Hepatitis.

General Recommendations

  • It is recommended that DVA develop a register of information, including mailing addresses for living female Vietnam veterans and causes of death for deceased female Vietnam veterans. This register would provide a sound basis for any further studies into the health of Australian female Vietnam veterans.
  • It is recommended that DVA consider the feasibility of undertaking further research in this area in light of the soon to be released US study into the health of female Vietnam veterans.
  • It is recommended that the findings of the survey be drawn to the attention of the Australian Defence Force for use in the refinement of preventative measures.
  • It is recommended that the findings of the survey be drawn to the attention of the organisations responsible for the compensation support of non-military veterans.

Back to homepage Back to homepage Back to homepage