Group members described their military backgrounds and the cultural and occupational factors that contributed to development of pain and psychological issues. The majority of participants ascribed their pain onset to strenuous basic training regimes, excessive load bearing, and ill-fitting equipment. Many back and lower limb conditions were attributed to carrying disproportionately heavy packs and wearing men’s boots during long marches. Role- and service-specific duties also led to chronic overuse injuries. It was collectively perceived that few adaptations to training regimes, equipment, or facilities were made to accommodate female physical differences, leading to greater injury rates.

The military environment was described by numerous participants as a “boys club,” where females were commonly degraded and ostracised. Adverse experiences included bullying, abuse, and misogynistic attitudes. Some participants related being “broken” both physically and psychologically during training, while many alluded to experiences of military sexual abuse and “pranks,” which were not addressed by senior authorities.

Group members discussed feeling discouraged from seeking help due to the stigma of being labelled a “malingerer.” There was a common perception that health needs were minimised or dismissed. Participants regularly described how they felt required to “suck it up” and continue on, due to the military obligation to comply with orders; they had to accept pain as part of the job. Ongoing impacts of this belief and stoicism on reduced help-seeking behaviour were shared by some and validated within groups.

Group members commonly recounted how pain was initiated early in their military career, stemming from recruit training or early deployments. Many injuries recurred frequently, affected adjacent joints, and multiple surgeries or interventions were reported, suggesting suboptimal outcomes. Frequently, participants had experienced delays in obtaining a definitive diagnosis for prolonged periods of time before accessing appropriate treatment. These delays were often attributed to misdiagnosis, inadequate efforts to investigate aetiology, and a perception that minimal treatment standards were employed to reduce the burden of care for the providers.

The complex interactions of comorbid physical and mental health conditions were discussed. Constancy of pain and inability to perform daily activities commonly led to feelings of depression, stress and anxiety, and a perception of not being believed intensified frustrations. Participants felt that many issues were “brushed off” by healthcare providers as symptoms of menopause, or age-related changes, making some participants feel disregarded.

Group members related how their pain experience seemed to be a “vicious cycle,” discussing the flow-on effects of pre-existing health conditions, or resultant treatment side effects. Many participants experienced pain affecting adjacent joints over time. Often, prescribed medications had undesirable side effects, such as dependence, gastrointestinal symptoms, liver damage, and cognitive and mental health impacts. Although some were averse to taking medications due to adverse reactions, ineffectiveness, and personal choice, others took to self-prescribing additional over-the-counter medications. Weight gain was not only an undesirable side effect of certain medications but also related to reduced activity levels and inability to exercise.

Chronic pain affected all aspects of participants’ lives, ranging from psychological and physiological impacts to social and family interactions, as well as detrimental impacts on careers. Chronic pain impacted mood, leading to impatience, irritability, and feelings of desperation, as one participant claimed, “I just didn’t want to live in that much pain” (Participant 2, Army). Participants described behavioural changes and social withdrawal, and pain impacted their ability to attend family functions and other social events. Sense of self was challenged, many participants reported a perceived loss of self-esteem and often felt a sense of personal inadequacy or worthlessness. The impact of pain on ability to exercise was an important issue. Exercise was seen by some as a means of stress reduction, and the loss of this coping mechanism was challenging as many struggled to find alternative activity. The loss of extreme military fitness and change to being unable to exercise was detrimental to sense of identity and mental wellbeing.

Difficulties were faced juggling work/life responsibilities, whilst managing pain symptoms simultaneously. Most participants felt a burden of responsibility, commonly putting their children’s or partner’s needs first, and neglecting their own health care needs. Trying to coordinate healthcare appointments with caring for dependants was challenging, with some emphasising the impact of child-care and respite arrangements and expenses on healthcare accessibility.

Group members described many experiences of perceived judgement and negative assumptions, not only from healthcare providers, but also from the general community. Some were based on a lack of understanding of military service stressors, and the assumption that only combat experience contributed to significant injury or they were “too young” to have experienced that degree of injury. Some participants also expressed the belief that there was a particular female-specific stigma of having PTSD, describing the greater societal acceptance of males being diagnosed with the condition than females contributing to “segregation of treatment.”

Chronic pain was perceived as an invisible condition, and participants felt they were often treated with little empathy as the extent of their disability and pain was not apparent. Some attributed this to their stoicism in the face of pain—as two participants agreed, stating, “You just get on with it” (Participant 1, Navy) and “Yeah, we’re women” (Participant 3, Navy). The perception of women being innately strong and resilient prevailed. This attitude persisted from military service, where the culture was to just “harden up.”

The consequences of pain impacted participants’ career prospects, in both military and civilian situations. During military service, these women avoided seeking healthcare for fear of being downgraded, restricted from duties, or medically discharged. Some participants described current civilian situations where they were unable to work or had to change jobs to accommodate physical limitations. Many described the challenges of trying to balance a full-time job with attendance at healthcare appointments. This added stress to many participants, who needed to maintain the physical capacity to work, yet could not meet both work and pain management requirements. Some adopted unhelpful coping strategies in an attempt to manage chronic pain. These strategies included “topping up” prescribed medications with over-the-counter medications, exceeding prescribed doses, or excessive alcohol consumption.

Various financial costs were identified as a potential barrier to obtaining optimal health care. Some participants described significant personal outlay for healthcare, either when claims were rejected, or having to pay up front followed by a prolonged delay in DVA compensation.

Difficulty in finding a clinician with whom they could establish rapport and trust was a challenge. Group members collectively emphasised the importance of “getting the right fit” when it came to satisfaction with their healthcare provider.

Poor social support was identified as a barrier to accessing health care. Without adequate support and resources, participants struggled to find time to attend treatments, particularly around caretaking responsibilities, or had disappointing treatment experiences. Examples included attending appointments with children, organising transport home from a day surgery, or as one participant said, “He’s still serving…he’s good, but you’re at home with the kids and you’ve got no network…you’ve got no idea where to turn to” (Participant 10, Army).

Various time restraints were seen as barriers, ranging from personal situations to systemic factors. The inability to attend all health care appointments while fulfilling work requirements was challenging. Others felt there was insufficient time during healthcare sessions to address complex needs. Delays in obtaining treatment were attributed to long wait lists to access healthcare providers or services, notably more difficult for rural participants. A frustration expressed by some participants was the multiple General Practitioner (GP) appointments required to renew referrals for ongoing treatment, particularly when accessing multidisciplinary care.

Group members in regional or rural centres expressed access difficulties, often having to travel to the capital city to see specialists or undergo surgery, incurring greater travel and time costs. Some participants related how long drives to and from appointments would aggravate their pain, often negating the effect of treatment (e.g., physiotherapy). Numerous logistical challenges were faced when participants were required to relocate. Finding a new healthcare team was difficult, with little information available to assist, so participants depended largely on word of mouth or social media groups for advice. Some participants expressed a desire for a central data repository, so a new practitioner had access to their medical history, reducing need to retell their story yet again. These frustrations were associated with a lack of continuity of care and inadequate handover.

Participants shared frustration about DVA not covering some treatments, especially for managing complex health issues. They felt care was not person-centred and did not provide full, tailored support. Inconsistencies in approvals of service-related injuries, such as non-acceptance of a secondary condition related to a primary pain condition were discussed within groups. For example, acceptance of a low back condition for treatment, but not related joints such as the sacroiliac joint or hip. Discussions arose around limited available treatment options, in situations where participants found relief from alternative therapies not subsidised by DVA (e.g., massage), and a limited range of choice available in particular therapeutic options.

Participants felt their health care management was impacted by many providers not accepting DVA patients, as the DVA fee schedule deficit did not cover current provider rates. As one participant stated, “Some of them don’t wanna [sic] see you under DVA because they don’t wanna [sic] have to do the reports, the paperwork…they don’t get paid as much, either” (Participant 20, Air Force). This limited specific health care options, as well as continuity of care, as expressed by one participant, “…my spinal surgeon had pulled the pin on DVA. So, he doesn’t see DVA patients anymore. So that continuity of treatment has gone for me now” (Participant 1, Navy).

Group members faced challenges adapting to a new healthcare system after transition from ADF to civilian life. Emerging from the defence system, where healthcare is managed and funded by the ADF, participants often struggled to obtain a Medicare card and understand its function in accessing the public healthcare system. Many were not aware of the services available through DVA, and a number chose not to access DVA support. While improvements in the ADF discharge process were acknowledged by some—particularly those with more recent separations—limitations to the handover from defence to civilian systems were raised. Some participants emphasised that preparing early for the transition process was vital, as many ADF members felt unprepared to manage their own health care post-service.

Navigation of the different systems involved in obtaining healthcare often proved challenging, as one participant expressed, “So the public health system is not set up to really deal with someone with complex and chronic pain and…and, the red tape for getting things through…It just seems to be getting harder and harder” (Participant 20, Air Force). Some participants felt the public healthcare system was unable to provide sufficient access to services they perceived were necessary for dealing with the complexities of their conditions. One participant had been directed to the National Disability Insurance Scheme (NDIS) for individual services not covered by DVA. Although advocates are available through DVA to assist in the claims process, a reluctance to pay for this service was expressed by some, and dissatisfaction with advocates by others, due to perceived inconsistencies in information provided. Some participants enlisted family support to assist in dealing with DVA, as they felt unable to manage it themselves.

Some participants expressed dissatisfaction with the treatment they had received within both civilian and military settings. In the civilian system, they often felt that treatment was inadequate for their complex needs, as healthcare professionals did not understand the impact of military service. They perceived there was a lack of holistic treatment approaches, and lack of thoroughness in examination and diagnosis. They described situations where physical treatment approaches were basic, or cases where medications were prescribed with little education about side effects and safe usage. There was a perception that civilian GPs were too eager to prescribe medications as their primary treatment approach.

Instances were described where patient confidentiality and privacy were not respected or maintained by other service members (e.g., medics), engendering mistrust and a perception that females were degraded as they were not part of the “boys club.”

Some participants described incidences where personal medical records had been lost or mismanaged. These included mention of missing military records, mismanagement of patient records during handovers, and occasions where their health condition had not been recorded. Numerous healthcare experiences were related, which group members felt degraded due to misogyny and sexist attitudes and often characterised by dismissive comments from male practitioners about “chick stuff,” and attributing symptoms immediately to menopause or age.

Discussions revealed varied awareness of participants’ entitlements and available DVA services. Group members collectively endorsed perceptions that providers often lacked knowledge of veteran entitlements, compensable DVA claims and available veteran services. However, on the positive side, participants’ felt that a powerful source of information was through word of mouth, from other veterans, female veteran forums, and social media groups.

Group members reflected on the challenges of being active participants in their health care management, often needing to push for their needs to be acknowledged. Whilst some took on the role of self-advocate with passion, navigating systems and negotiating for care, many found this role exhausting in the context of “fighting” against the barriers while managing pain. As one participant shared, “…but, you know, when you’re in pain…you don’t feel up to, you know, standing up for yourself. It’s just like, oh, here we go again” (Participant 17, Navy). The emotional and cognitive burden sometimes led to a sense of defeat or resignation, with individuals stepping back from pursuing services due to feeling overwhelmed.

Group members shared strategies or services they found beneficial for their personal pain management, including individual coping strategies or activities, as well as community resources and supports. These encompassed veteran specific medical centres, counselling services, connection with ESOs, and online educational modules. While most participants noted engagement with pain specialists, few disclosed awareness of available persistent pain management multidisciplinary services. Group members emphasised the importance of building a regular multidisciplinary team with coordination support to manage complex needs, with several valuing opt-in services that checked in with them between appointments.

Allied health services were found to be beneficial, and gentle treatment approaches, such as stretching and hot packs, were supported. Walking was advocated as both a physical and psychologically beneficial activity. Some participants shared that cognitive behavioural therapy (CBT) was reported to be of benefit for pain management, and group therapy sessions for mental health provided an avenue for support and motivation from peers. Other beneficial activities volunteered across groups included yoga, massage, acupuncture, hydrotherapy, and natural substances such as magnesium and prescribed cannabis medications.

Most participants expressed a desire for more trauma informed health care that takes into account gender differences in military experiences. For example, having mixed gender groups in PTSD treatment programs may create barriers for some female veterans who have experienced gender-based trauma (e.g., military sexual abuse) or feel uncomfortable around male veterans due to military culture perceptions (e.g., the perceived “boys club” mentality). A desire was also expressed for female-veteran-only spaces and forums, where peer support was important.

It was expressed that more female focused support is required within the DVA. Having support from good advocates, family, friends, and other female veterans facilitated access to appropriate care.

Certain characteristics in healthcare providers were perceived as important in improving the healthcare experience. Many group members expressed a preference for seeing a female practitioner, or one that had a greater knowledge of women’s health needs, particularly in relation to military stressors on the body. Participants emphasised the importance of clinicians’ listening skills; being heard, understood, and believed. All participants expressed a strong preference for providers who had a military background, or a high degree of military cultural competency. That is, they valued a common language and knowledge of military roles, and greater awareness of available veteran-focused services and the DVA system.

Finally, group members were invited to provide thoughts and ideas regarding the content of an education module to be developed as an outcome of this project (Table 3). Participants emphasised the need for education in military cultural competence to understand both predisposing pain experiences and systemic factors required to coordinate access to optimal holistic healthcare.