Lifetime Sexual Assault and Cervical Cytologic Abnormalities Among Military Women

"You want people to listen to you": Patient experiences of women's healthcare within the Veterans Health Administration

OBJECTIVE

To identify constructs that are critical in shaping Veterans' experiences with Veterans Health Administration (VA) women's healthcare, including any which have been underexplored or are not included in current VA surveys of patient experience.

DATA SOURCES AND STUDY SETTING

From June 2022 to January 2023, we conducted 28 semi-structured interviews with a diverse, national sample of Veterans who use VA women's healthcare.

STUDY DESIGN

Using VA data, we divided Veteran VA-users identified as female into four groups stratified by age (dichotomized at age 45) and race/ethnicity (non-Hispanic White vs. all other). We enrolled Veterans continuously from each recruitment strata until thematic saturation was reached.

DATA COLLECTION/EXTRACTION METHODS

For this qualitative study, we asked Veterans about past VA healthcare experiences. Interview questions were guided by a priori domains identified from review of the literature, including trust, safety, respect, privacy, communication and discrimination. Analysis occurred concurrently with interviews, using inductive and deductive content analysis.

PRINCIPAL FINDINGS

We identified five themes influencing Veterans' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Each emergent theme was associated with multiple of the a priori domains we asked about in the interview guide.

CONCLUSIONS

Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA fail to address several aspects of experience highlighted by our study, including bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination. Understanding distinct factors that influence women and gender-diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.

Abnormal cervical cancer screening results among US Veteran and non-Veteran participants in the National Health Interview Survey (NHIS)

Female Veterans report cervical cancer risk factors at higher rates than non-Veterans. Using data from the National Health Interview Survey (NHIS), we tested whether Veterans with a recent cervical cancer screening test were more likely than non-Veterans to have received an abnormal result. NHIS is a population-based cross-sectional household survey with a stratified, multistage sampling design. We pooled screening data from 2010, 2015, and 2018, and restricted the sample to female participants without a hysterectomy who had a cervical cancer screening test in the prior 3 years. The primary outcome was self-reported abnormal result on a Pap and/or HPV test in the prior 3 years. Our main predictor was Veteran status. We used survey-weighted multivariable logistic regression to estimate odds of an abnormal screening result in the prior 3 years as a function of Veteran status, controlling first for age and survey year, then adding sociodemographic and health factors in subsequent models. The sample included 380 Veterans and 25,102 non-Veterans (weighted total population 104.9 million). Overall, 19.0% of Veterans and 13.7% of non-Veterans reported an abnormal cervical cancer screening test result in the prior 3 years (unadjusted p = 0.03). In the adjusted regression model, the previously observed association between Veteran status and abnormal screening result was explained by differences in sociodemographic and health factors between Veterans and non-Veterans (aOR 1.21, 95%CI 0.78-1.87). Nearly 1 in 5 Veterans with a recent cervical cancer screening test received an abnormal result. Clinicians should address modifiable risk factors and provide evidence-based follow-up for abnormal results.

Incidence and risk factors for postpartum mood and anxiety disorders among women veterans

BACKGROUND

Our aim was to determine rates of postpartum mood and anxiety disorders (PMADs) among U.S. women Veterans and the overlap among PMADs. We further sought to identify PMAD risk factors, including those unique to military service.

METHODS

A national sample of women Veterans completed a computer-assisted telephone interview (N = 1414). Eligible participants were aged 20-45 and had separated from service within the last 10 years. Self-report measures included demographics, general health, reproductive health, military exposures, sexual assault, childhood trauma, and posttraumatic stress disorder (PTSD). The PMADs of interest were postpartum depression (PPD), postpartum anxiety (PPA) and postpartum PTSD (PPPTSD). This analysis included 1039 women Veterans who had ever been pregnant and who answered questions about PPMDs related to their most recent pregnancy.

RESULTS

A third (340/1039, 32.7%) of participants were diagnosed with at least one PMAD and one-fifth (215/1039, 20.7%) with two or more. Risk factors common for developing a PMAD included: a mental health diagnosis prior to pregnancy, a self-report of ever having had a traumatic birth experience, and most recent pregnancy occurring during military service. Additional risk factors were found for PPD and PPPTSD.

CONCLUSION

Women Veterans may be at an increased risk for developing PMADs due to high rates of lifetime sexual assault, mental health disorders, and military-specific factors including giving birth during military service and military combat deployment exposures.

Gonorrhea and Chlamydia Testing and Case Rates Among Women Veterans in the Veterans Health Administration

BACKGROUND

United States (US) rates of sexually transmitted infection (STI) in women, especially gonorrhea and chlamydia, have increased over the past decade. Women Veterans may be at increased risk for STIs due to high rates of sexual trauma. Despite the availability of effective diagnostic tests and evidence-based guidelines for annual screening among sexually active women under age 25, screening rates for gonorrhea and chlamydia remain low in the US and among Veterans.

OBJECTIVE

To examine patient characteristics and health system factors associated with gonorrhea and chlamydia testing and case rates among women Veterans in the Veterans Health Administration (VHA) in 2019.

DESIGN

We performed a retrospective cohort study of all women Veterans in VHA care between January 1, 2018, and December 31, 2019.

PARTICIPANTS

Women Veteran patients were identified as receiving VHA care if they had at least one inpatient admission or outpatient visit in 2019 or the preceding calendar year.

KEY RESULTS

Among women under age 25, 21.3% were tested for gonorrhea or chlamydia in 2019. After adjusting for demographic and other health factors, correlates of testing in women under age 25 included Black race (aOR: 2.11, CI: 1.89, 2.36), rural residence (aOR: 0.84, CI: 0.74, 0.95), and cervical cancer screening (aOR: 5.05, CI: 4.59, 5.56). Women under age 25 had the highest infection rates, with an incidence of chlamydia and gonorrhea of 1,950 and 267 cases/100,000, respectively. Incidence of gonorrhea and chlamydia was higher for women with a history of military sexual trauma (MST) (chlamydia case rate: 265, gonorrhea case rate: 97/100,000) and those with mental health diagnoses (chlamydia case rate: 263, gonorrhea case rate: 72/100,000.) CONCLUSIONS: Gonorrhea and chlamydia testing remains underutilized among women in VHA care, and infection rates are high among younger women. Patient-centered, system-level interventions are urgently needed to address low testing rates.

Sexual violence history predicts changes in vaginal immune parameters during sexual arousal

OBJECTIVE

To examine the influence of sexual arousal on vaginal mucosal inflammatory cytokine and antibody production in healthy women with and without histories of childhood and/or adult sexual violence.

METHODS

Ninety-one premenopausal healthy women (ages 18-42) attended a single laboratory session in which they provided vaginal fluid samples before and after viewing one neutral and one erotic film. While viewing the films, participants' vaginal sexual arousal was recorded using vaginal photoplethysmography.

RESULTS

Of the 91 participants, 41 (45%) reported no history of sexual violence, 17 (19%) reported a history of childhood sexual abuse (CSA) only, 19 (21%) reported a history of adult sexual assault (ASA) only, and 10 (11%) reported a history of both CSA and ASA, with 4 participants choosing not to provide information on their sexual violence history. For women with a history of ASA but not CSA, there was a significant increase in vaginal IL-1β following arousal, while for women with a history of CSA (with or without ASA), there was a significant decrease. Women without CSA histories had a significant increase in vaginal IgA following sexual arousal, while women with CSA histories had a decrease.

CONCLUSION

Sexual arousal possibly plays a role in modifying vaginal immune responses in young, healthy women. Moreover, these effects may vary depending upon sexual assault histories, such that relative to women without assault histories, women with a history of early life sexual trauma showed significantly altered vaginal immune responses following sexual arousal. If replicated, these findings may help explain the increased risk for sexually transmitted infections observed among women with sexual assault histories.

Sexually Transmitted Infections in the U.S. Military: A Sexual Health Paradigm to Address Risk Behaviors, Unintended Pregnancy, Alcohol Use, and Sexual Trauma

To address the ongoing epidemic of sexually transmitted infections (STIs) in the United States, the National Academies of Sciences, Engineering, and Medicine (National Academies) conducted a consensus study on STI control and prevention in the United States to provide recommendations to the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. The culminating report identified military personnel as one of the priority groups that require special consideration given the high prevalence of STIs and their associated behaviors (e.g., concurrent sexual partners and infrequent condom use) that occur during active duty service. Universal health care access, the relative ease and frequency of STI screening, and the educational opportunities within the military are all assets in STI control and prevention. The report offers a comprehensive framework on multiple and interrelated influences on STI risk, prevention, health care access, delivery, and treatment. It also provides an overview of the multilevel risk and protective factors associated with STIs that could be applied using a sexual health paradigm. The military context must integrate the multilevel domains of influences to guide the effort to fill current gaps and research needs. The Department of Defense, with its large clinical and preventive medicine workforce and its well-established universal health care system, is well positioned to enact changes to shift its current approach to STI prevention, treatment, and control. STI control based on highlighting behavioral, social, cultural, and environmental influences on service members' sexual health and wellness may well drive better STI care and prevention outcomes.

Intimate Partner Violence Screening for Women in the Veterans Health Administration: Temporal Trends from the Early Years of Implementation 2014-2020

Thousands of women Veterans experience intimate partner violence (IPV) each year. The Veterans Health Administration (VHA) has encouraged IPV screening in Veterans Affairs medical centers (VAMCs) since 2014. Through retrospective analysis of VHA administrative data from fiscal year (FY) 2014 into FY2020, we examined IPV screening implementation outcomes of reach and adoption, as well as screen-positive rates using descriptive and multivariate linear regression analyses. We examined reach and screen-positive rates overall and as a function of childbearing age (18-44 vs. 45+ years). In FY2014 only one VAMC was screening women for IPV; by FY2020, over half of VAMCs had adopted IPV screening. This rollout of IPV screening was associated with a large increase in the number of women primary care patients screened (from fewer than 500 in FY2014, to nearly 35,000 in early FY2020). Overall, among women screened, 6.7% screened positive for IPV; this rate was higher among women of childbearing age (8.1% vs. 5.6%). Despite the spread of IPV screening practices during the early years of implementation in VHA, additional work is needed. This study is the first comprehensive analysis of implementation outcomes associated with VHA's IPV screening efforts, and lays the groundwork for ongoing evaluation and quality improvement.

The Relationship Between Sexual Assault History and Cervical Cancer Screening Completion Among Women Veterans in the Veterans Health Administration

Background: Sexual assault affects one in three US women and may have lifelong consequences for women's health, including potential barriers to completing cervical cancer screening and more than twofold higher cervical cancer risk. The objective of this study was to determine whether a history of sexual assault is associated with reduced cervical cancer screening completion among women Veterans. Materials and Methods: We analyzed data from a 2015 survey of women Veterans who use primary care or women's health services at 12 Veterans Health Administration facilities (VA's) in nine states. We linked survey responses with VA electronic health record data and used logistic regression to examine the association of lifetime sexual assault with cervical cancer screening completion within a guideline-concordant interval. Results: The sample included 1049 women, of whom 616 (58.7%) reported lifetime sexual assault. Women with a history of sexual assault were more likely to report a high level of distress related to pelvic examinations, and to report ever delaying a gynecologic examination due to distress. However, in the final adjusted model, lifetime sexual assault was not significantly associated with reduced odds of cervical cancer screening completion (OR 1.35, 95% CI 0.93-1.97). Conclusions: Contrary to our expectations, sexual assault was not significantly associated with gaps in cervical cancer screening completion. Three- to five-year screening intervals may provide sufficient time to complete screening, despite barriers. Trauma-sensitive care practices promoted in the VA may allow women to overcome the distress and discomfort of pelvic examinations to complete needed screening. ClinicalTrials.gov (#NCT02039856).

Experiencing Sexual Assault and/or Stalking-Related Behavior is Associated with Binge Drinking and Substance Use Consequences in Deployed U.S. Servicewomen

BACKGROUND

Being deployed is a risk factor for poor postdeployment mental health outcomes in U.S. servicewomen, including harmful drinking. However, to our knowledge, no studies have examined deployment-related sexual assault and exposure to stalking-related behavior in relation to binge drinking and substance use consequences in this population.

METHODS

A community sample of post-9/11 servicewomen from the Midwest, including both veterans and those actively serving (N = 991), completed computer-assisted telephone interviews after deployment. Logistic regression models examined associations between deployment-related sexual assault (attempted or completed) and stalking-related behavior (e.g., being left unwanted things, having property vandalized), and the likelihood of reporting binge drinking and substance use consequences after controlling for covariates.

RESULTS

U.S. servicewomen experiencing deployment-related sexual assault and/or stalking-related behavior were more likely to report binge drinking in the past 4 weeks and at least one negative consequence of substance use in the past year. Also, 21.56% of the sample reported experiencing any deployment-related sexual assault and/or stalking-related behavior, 17.34% reported any stalking-related behavior and no sexual assault, 2.42% reported both sexual assault and stalking-related behavior, and 1.80% reported sexual assault and no stalking-related behavior. The most commonly endorsed behaviors were being followed or spied on (9.09%), receiving unsolicited correspondence (8.34%-8.74%), and having someone show up at places you were (6.90%).

CONCLUSIONS

U.S. servicewomen experiencing sexual assault and/or stalking-related behavior during deployment may be at higher risk for binge drinking and experiencing negative consequence of substance use when compared with their peers not reporting these stressors.

Trauma-Informed Care on Labor and Delivery

The integration of trauma-informed care practices into the care of obstetric patients requires an understanding of psychological trauma, its impact on this population, and how trauma-informed care can be adapted to improve outcomes for those patients with a previous history of trauma or for those that experience peripartum trauma. System-based changes to policies, protocols, and practices are needed to achieve sustainable change. Maternal morbidity and mortality that result from trauma-related and other mental health conditions in the peripartum period are significant. Innovative approaches to the prevention of negative birth experiences and retraumatization during labor and delivery are needed.

The Impact of Sexual Trauma on the Sexual Health of Women Veterans: A Comprehensive Review

Sexual trauma, particularly childhood sexual trauma, is a potent risk factor for sexual health difficulties among civilian women. Women veterans report elevated rates of sexual trauma compared to their civilian peers, including sexual trauma during military service, perhaps making women veterans even more vulnerable to sexual health difficulties. A comprehensive review of the peer-reviewed literature on the relationship between sexual trauma and sexual health in women veterans was conducted. Inclusion criteria were measurement of sexual trauma and sexual health (i.e., sexual function or sexual satisfaction), a U.S. veteran sample including women veterans, and written in English. This process identified 18 articles. Results indicated that similar to the pattern observed among civilian women, sexual trauma was associated with an increased risk of sexual dysfunction and low sexual satisfaction among women veterans. Sexual pain was the most common sexual dysfunction among women veterans. Comorbid post-traumatic stress disorder and depression were identified as correlates of sexual dysfunction. Gaps in the literature included limited use of validated measures of sexual health and inconsistencies in the assessment of sexual trauma history. Future research is needed on the interrelationships between sexual trauma, sexual health, and mental health to inform treatment recommendations for improving sexual health among women veterans.

Cervical Cancer Screening in South Florida Veteran Population, 2014 to 2020: Cytology and High-Risk Human Papillomavirus Correlation and Epidemiology

Objective This project aims to use our robust women's health patient data to analyze the correlation between cytology and high-risk human papillomavirus (Hr-HPV) testing, study the performance of Hr-HPV testing for detecting cytology lesions, and examine epidemiologic measures of human papillomavirus (HPV) infections in the women's veteran population. Methods We collected patient data from 2014 to 2020 from our computerized patient record system. We performed HPV assays using the cobas® 4800 system (Roche Diagnostics, Basel, Switzerland). The cobas HPV assay detects HPV 16, HPV 18, and 12 other HPV types (31, 33, 35, 39, 45, 51, 56, 58, 59, 66, and 68). We organized cytology results and Hr-HPV assays with Microsoft Access and Microsoft Excel (Microsoft Corporation, Washington, USA) for analysis. Results A total of 9437 cervical specimens were co-tested. High-grade cytology lesions - high-grade intraepithelial lesion (HSIL) or higher and atypical squamous cells, cannot exclude HSIL (ASC-H) - were overwhelmingly positive for Hr-HPV (94.1% and 87.2%, respectively). Low-grade cytology lesions - low-grade squamous intraepithelial lesion ((LSIL) and atypical squamous cells of undetermined significance (ASC-US) - were positive for Hr-HPV in lower percentages (72.6% and 54.9%, respectively). Hr-HPV testing had a sensitivity of 91.3%, a specificity of 93.1%, a positive predictive value of 16.4%, and a negative predictive value of 99.8% for detecting high-grade cytology lesions. Hr-HPV testing had a lower performance for detecting low-grade cytology lesions. Ten cases had high-grade cytology and negative Hr-HPV test. Out of 10 such patients, nine showed no dysplasia (six) or low-grade dysplasia (three) on subsequent biopsy. Overall, 14.4% of tests were positive for Hr-HPV. The highest positive Hr-HPV test rates were in the third and eighth decades of life, 25.1% and 22.0%, respectively. However, the eighth decade consisted of a small sample of only 50 women. In women over 30 years of age with Hr-HPV infections, HPV types 16 and 18 were present in 11.7% and 6.4% of tests, respectively. Other HPV types were present in 82.3% of tests. Conclusions Hr-HPV testing has a high performance in detecting high-grade cytology lesions and a lower performance for detecting low-grade cytology lesions. However, studies show that LSIL rarely progresses to cervical intraepithelial neoplasia grade 3 or higher (CIN3+), suggesting minimal to no impact on cervical cancer screening. We believe our findings are in accordance with recent studies and affirm the guidelines that recommend primary Hr-HPV testing as the preferred screening method. The percentage of positive Hr-HPV tests and rates for age and HPV types 16 and 18 in our women's veteran population suggest similar HPV prevalence to that of the general US population.

Associations Between Sexual Assault and Reproductive and Family Planning Behaviors and Outcomes in Female Veterans

OBJECTIVE

To examine the relationship between lifetime sexual assault (defined as someone having experienced sexual assault in their lifetime) and reproductive health care seeking, contraception usage, and family planning outcomes in female veterans.

METHODS

We conducted a secondary analysis of data collected between 2005 and 2008 from computer-assisted telephone interviews with 1,004 female veterans aged 20-52 years who were enrolled at two Midwestern Department of Veterans Affairs (VA) health care systems. Participants were asked about reproductive, mental, and general health histories, and about lifetime sexual assault. We assessed associations between reproductive histories and contraceptive use among participants who reported lifetime sexual assault, compared with those who had not experienced lifetime sexual assault, by using bivariate and multivariable logistic regression analyses. Lastly, we examined reasons why these participants had not sought Pap test screening.

RESULTS

More than half (62%) of participants reported experiencing lifetime sexual assault. Because there was an association between older age and history of lifetime sexual assault (P<.001), we stratified the analysis by age. Women with a history of lifetime sexual assault were more likely to have had unprotected intercourse for a year or more (adjusted odds ratio [aOR] 2.31, 95% CI 1.35-3.96) and a teen pregnancy (aOR 2.10, 95% CI 1.07-4.12) than women who did not report lifetime sexual assault. When stratified by age, women aged 40-52 years with a history of lifetime sexual assault were more likely to report more than a year of unprotected sex, teen pregnancy, and not seeking prenatal care with their first pregnancy, than women aged 40-52 who did not report lifetime sexual assault. Women who experienced lifetime sexual assault were more likely to report not seeking Pap tests in the past owing to fear and anxiety when compared with women who had not experienced lifetime sexual assault.

CONCLUSION

Female veterans who reported lifetime sexual assault had differences in family planning behaviors compared with women who did not report lifetime sexual assault. These findings have implications for clinicians and VA policymakers when determining family planning and reproductive care delivery needs for female veterans of reproductive age.

Lifetime History of Sexual Assault and Emergency Department Service Use among Women Veterans

BACKGROUND

Although sexual assault survivors are at increased risk for adverse physical and mental health outcomes and tend to use more health care services, little is known about women veterans' lifetime history of experiencing sexual assault (lifetime sexual assault [LSA]) and emergency department (ED) use. We sought to examine associations between experiencing LSA, mental health diagnoses, and ED use among women veterans.

METHODS

Computer-assisted telephone interviews were conducted with 980 women veterans enrolled at two Veterans Affairs (VA) Medical Centers to assess history of experiencing LSA, health care use, sociodemographic characteristics, and military history. Administrative data provided VA use, mental health, and medical diagnoses. Logistic regression analyses examined associations between experiencing LSA and mental health diagnoses and past 5-year ED use. Classification tree analysis characterized ED use in participant subgroups.

RESULTS

Sixty-four percent of participants visited a VA or non-VA ED during the previous 5 years. Women veterans with histories of mental health diagnoses and who experienced sexual assault had an odds of ED use almost two times greater than those with no history of experiencing sexual assault and no mental health diagnoses. The odds were similar for experiencing attempted (adjusted odds ratio, 1.85) and completed (adjusted odds ratio, 1.95) sexual assault. Classification tree analysis identified reliance on VA care and the composite variable representing experiencing LSA and mental health diagnoses as factors that best discriminated ED users from nonusers.

CONCLUSIONS

Experiencing LSA is associated with greater ED use in women veterans enrolled in the VA. Whether finding this reflects greater emergent health care needs, suboptimal access and treatment for conditions that could be managed in other settings, lack of health care coordination, or some combination of these factors is unclear.

Reproductive Health of Women Veterans: A Systematic Review of the Literature from 2008 to 2017

The literature on the reproductive health and healthcare of women Veterans has increased dramatically, though there are important gaps. This article aims to synthesize recent literature on reproductive health and healthcare of women Veterans. We updated a literature search to identify manuscripts published between 2008 and July 1, 2017. We excluded studies that were not original research, only included active-duty women, or had few women Veterans in their sample. Manuscripts were reviewed using a standardized abstraction form. We identified 52 manuscripts. Nearly half (48%) of the new manuscripts addressed contraception and preconception care (n = 15) or pregnancy (n = 10). The pregnancy and family planning literature showed that (1) contraceptive use and unintended pregnancy among women Veterans using VA healthcare is similar to that of the general population; (2) demand for VA maternity care is increasing; and (3) women Veterans using VA maternity care are a high-risk population for adverse pregnancy outcomes. A recurrent finding across topics was that history of lifetime sexual assault and mental health conditions were highly prevalent among women Veterans and associated with a wide variety of adverse reproductive health outcomes across the life course. The literature on women Veterans' reproductive health is rapidly expanding, but remains largely observational. Knowledge gaps persist in the areas of sexually transmitted infections, infertility, and menopause.

Extragenital chlamydia infection among active-duty women in the United States Navy

BACKGROUND

Pharyngeal and anorectal reservoirs of gonorrhea (GC) and chlamydia (CT) are increasingly recognized among heterosexual women. While a number of studies performed at sexually transmitted disease (STD) clinics have found a high prevalence of extragenital GC/CT infection, such screening is typically not offered during routine primary care visits for women. We sought to define the prevalence of and factors associated with extragenital GC/CT among women in the U.S. Navy.

METHODS

We recruited servicewomen stationed in San Diego, California, between the ages of 18 and 25 who presented for an annual physical exam between January and September, 2017. Nucleic acid amplification testing was performed on swabs collected at endocervical, oropharyngeal and anorectal sites to assess the presence of GC/CT. An anonymous behavioral questionnaire was also administered to characterize sexual risk. Descriptive statistics were used to compare women with and without a prior history of any sexually transmitted infection (STI) (self-report) along with a current GC/CT diagnosis. This study was approved by the Institutional Review Board of the Uniformed Services University of Health Sciences.

RESULTS

Of the 75 patients who were approached, 60 subjects were enrolled in the study, including white 20 (33.3%), black/African American 18 (31.0%), Hispanic/Latina 13 (21.7%) and Asian/Pacific Islander 9 (15.5%) women. Among all the women, six (10.0%) were diagnosed with CT infection, all via endocervical exam. Of these, five (8.3%) had concurrent anorectal infection, including two cases (3.3%) accompanied by pharyngeal infection. Of the subjects, 15 (25.0%) reported anal intercourse in their most recent sexual encounter, most of which was condomless (13/15, 86.7%). A high number of women who reported sex with a casual male partner (19/45, 42.2%) reported rarely or never using condoms; last, 41.7% consuming at least 3 drinks on a typical drinking day, and one-third of the reported drinking more than once per week.

CONCLUSIONS

We found a high prevalence of anorectal CT infection, although no infections were detected without concurrent endocervical involvement. Nonetheless, the high prevalence of condomless anal intercourse reported by participants argues for further study and ongoing consideration of extragenital screening among high-risk patients. Behavioral interventions are also warranted given the high prevalence of sexual and related risk factors.

Ethnic Minority Status and Experiences of Infertility in Female Veterans

BACKGROUND

In the general population, infertility is increasingly prevalent in ethnic minority women; these women suffer longer and are less likely to access care. There is a paucity of data regarding the issue of race and infertility in the growing female military veteran population.

MATERIALS AND METHODS

This cross-sectional observational study involved computer-assisted telephone interviews of 1,004 Veterans Administration (VA)-enrolled women aged ≤52 years.

RESULTS

Racial minority veterans were more likely than white veterans to self-report infertility (24% vs. 18%), equally likely to report infertility evaluation (52% vs. 52%), and less likely to report receiving infertility treatment (31% vs. 63%). Differences in self-reported infertility (odds ratios [OR]: 1.50, 95% confidence interval [CI]: 1.02-2.22) and infertility treatment (OR: 0.32, 95% CI: 0.13-0.81) were retained after controlling for age, income, marital status, education, insurance, history of pelvic inflammatory disease, and lifetime sexual assault. While racial minority veterans were equally as likely as white veterans to be evaluated for infertility, white and racial minority groups reported different reasons for not seeking evaluation.

CONCLUSIONS

Consistent with civilian studies, our data suggest that racial minority VA-enrolled female veterans are more likely to self-report infertility and less likely to receive infertility treatment. Future research should investigate whether these findings are consistent nationwide and regardless of VA enrollment, and if minority veterans have unique barriers to care. A better understanding of how the VA might improve awareness of infertility evaluation and treatment options, especially for racial minority veterans, is needed.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Longitudinal associations between mental health conditions and overactive bladder in women veterans

BACKGROUND

One in 5 recently deployed US women veterans report overactive bladder symptoms. Mental health conditions such as depression and anxiety commonly co-occur in women with overactive bladder, but temporal relationships between these outcomes have not been well studied, and the mechanism behind this association is unknown. The Women Veterans Urinary Health Study, a nationwide longitudinal study in recently deployed women veterans, was designed to better understand relationships between overactive bladder and mental health conditions.

OBJECTIVE

We sought to estimate the 1-year incidence and remission of overactive bladder and to identify the impact of depression, anxiety, posttraumatic stress disorder, and prior sexual assault on 1-year overactive bladder incidence and remission rates.

STUDY DESIGN

Participants of this 1-year prospective cohort study were female veterans separated from military service who had returned from Iraq or Afghanistan deployment within the previous 2 years. Eligible women were identified through the Defense Manpower Data Center and recruited by mail and telephone. Telephone screening confirmed participants were ambulatory, community-dwelling veterans and excluded those with urinary tract fistula, congenital abnormality, or cancer; pelvic radiation; spinal cord injury; multiple sclerosis; Parkinson disease; stroke; or current/recent pregnancy. Data collection included computer-assisted telephone interviews performed at enrollment and 1 year later. The interview assessed demographic and military service characteristics; urinary symptoms and treatment; depression, anxiety, and posttraumatic stress disorder symptoms and treatment; and a lifetime history of sexual assault. Overactive bladder was identified if at least moderately bothersome urgency urinary incontinence and/or urinary frequency symptoms were reported on Urogenital Distress Inventory items. Exposures included depression, anxiety, posttraumatic stress disorder, and lifetime sexual assault, assessed at baseline using validated questionnaires (including the Patient Health Questionnaire and Posttraumatic Stress Disorder Checklist). Associations between exposures and overactive bladder incidence and remission were estimated using propensity score adjusted logistic regression models.

RESULTS

In all, 1107 (88.0%) of 1258 eligible participants completed 1-year interviews. Median age was 29 (range 20-67) years and 53% were nulliparous. Overactive bladder was identified at baseline in 242 (22%), and 102 (9.2%), 218 (19.7%), 188 (17.0%), and 287 (25.9%) met criteria for baseline depression, anxiety, posttraumatic stress disorder, and lifetime sexual assault, respectively. At 1 year, overactive bladder incidence was 10.5% (95% confidence interval, 8.6-12.8%), and remission of overactive bladder was 36.9% (95% confidence interval, 30.8-43.4%). New overactive bladder occurred more often in women with baseline anxiety (21% vs 9%), posttraumatic stress disorder (19% vs 9%) and lifetime sexual assault (16% vs 9%) (all: P < .01). After adjustment, anxiety (odds ratio, 2.4; 95% confidence interval, 1.4-4.1) and lifetime sexual assault (odds ratio, 1.7; 95% confidence interval, 1.0-2.8) predicted 1-year incident overactive bladder. Overactive bladder remission occurred less often in those with baseline depression (19% vs 41%, P < .01) and anxiety (29% vs 42%, P = .03). After adjustment, depression decreased 1-year overactive bladder remission risk (odds ratio, 0.37; 95% confidence interval, 0.16-0.83). Overactive bladder treatment was uncommon and not associated with remission.

CONCLUSION

Anxiety, depression, and prior sexual assault-common postdeployment problems for women veterans-influence the natural history of overactive bladder. Providers should screen for mental health conditions and sexual assault in women with newly diagnosed or persistent overactive bladder.

Human Papillomavirus Testing by Veterans Administration Women's Health Providers: Are They Adhering to Guidelines?

BACKGROUND

Evidence-based guidelines have been created by professional societies, including the United States Preventive Services Task Force (USPSTF) and American Society for Colposcopy and Cervical Pathology (ASCCP), for use of human papillomavirus (HPV) cotesting in cervical cancer screening. We investigated whether Veterans Health Administration (VA) providers at one VA medical center follow these guidelines.

MATERIALS AND METHODS

Retrospective chart review of women aged 21-65 who had an HPV test ordered with pap testing in fiscal year 2014 at one Veterans Administration (VA) medical center to evaluate concordance of HPV ordering with screening (USPSTF) and management (ASCCP) guidelines. We collected data on patient characteristics and gynecologic history and documented the reason, if given, for HPV testing.

RESULTS

Of the 210 eligible HPV tests evaluated, 142 tests (68%) were determined to be guideline discordant. Of the 142 guideline-discordant tests, 90 had no documented reason for HPV testing in the chart. Site of care was not significant.

CONCLUSIONS

This study demonstrates potential overuse of HPV testing among women's health providers at one VA medical center. This may indicate that VA providers lack an understanding of HPV cotesting guidelines. Further studies are needed to characterize VA provider adherence to HPV testing guidelines nationally. Implementation of educational interventions and decision aids may improve VA providers' adherence to guidelines.

Lifetime Sexual Assault and Sexually Transmitted Infections Among Women Veterans

OBJECTIVE

Women veterans report a high prevalence of sexual assault. Unfortunately, there are limited data on the reproductive health sequelae faced by these women. Our objective was to evaluate the association between completed lifetime sexual assault (LSA) and sexually transmitted infections (STIs) among a cohort of women veterans, adjusting for sexual risk behaviors.

MATERIALS AND METHODS

We conducted a retrospective study among women veterans aged 51 years or younger who enrolled for care at two Veterans Administration (VA) healthcare sites between 2000 and 2008. Participants completed a telephone interview assessing reproductive health and sexual violence history. We compared the frequencies of past STI diagnoses among those who had and had not experienced LSA. We used logistic regression to assess the effect of sexual assault with history of an STI diagnosis after adjusting for age, sexual risk behaviors, and substance abuse treatment.

RESULTS

Among 996 women veterans, a history of STIs was reported by 32%, including a lifetime history of gonorrhea (5%), chlamydia (15%), genital herpes infection (8%), and human papillomavirus infection (15%), not mutually exclusive; 51% reported LSA. Women with a history of LSA were significantly more likely to report a history of STIs (unadjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.45-2.50; adjusted OR 1.49, 95% CI 1.07-2.08).

CONCLUSIONS

Women veterans who have experienced LSA are at increased risk for lifetime STI diagnoses. To adequately address the reproductive health needs of the growing population of women veterans, STI risk assessments should include queries of military service and LSA histories.

Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms

BACKGROUND

Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population.

OBJECTIVES

The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population.

STUDY DESIGN

We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)-enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ(2), Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ(2) and Student t tests.

RESULTS

Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V.

CONCLUSION

Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women's health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.

Centers for Disease Control and Prevention 2015 Human Papillomavirus Vaccine Recommendations for Sexually Assaulted Patients: A Review and Update

Individuals who have been sexually assaulted are at risk for contracting human papillomavirus (HPV), the most common sexually transmitted infection. One of the best methods in protecting against contracting the HPV is to receive the HPV vaccine. To date, national sexual assault protocols and guidelines do not include information on HPV vaccination. The current 2015 Centers for Disease Control and Prevention has updated their recommendations for sexually assaulted patients to now receive the HPV vaccine. This article reviews information on HPV, HPV vaccines, and specific considerations for patients who have been sexually assaulted.

Post-sexual assault health care utilization among OEF/OIF servicewomen

BACKGROUND AND OBJECTIVES

Few who experience sexual assault seek health care immediately. Yet many become heavy users of health care resources in the years postassault because sexual violence has been linked with both acute and chronic health consequences. Our objective was to investigate servicewomen's medical and mental health (MH) care utilization after sexual assault in-military (SAIM) and identify reasons for not seeking care.

METHODS

In a retrospective cross-sectional Midwestern community sample of OEF/OIF Active Component and Reserve/National Guard servicewomen, currently serving and veterans, computer-assisted telephone interviews were conducted with 207 servicewomen who experienced SAIM.

RESULTS

A quarter (25%) received post-SAIM MH care and 16% medical care. Utilization of medical care tended to be sooner (within the first month) and MH care later (6 mo to 1+ y). Most sought care on a military base, a third from civilian providers, and 10% sought MH from Veterans Health Administration. Servicewomen were more likely to have utilized medical care if they had experienced a completed SAIM and made a Department of Defense SAIM report and MH care if they were white, experienced on-duty SAIM, and made a Department of Defense SAIM report. The most common reason for not seeking medical care was due to belief that care was not needed. Reasons for not utilizing medical or MH care included embarrassment, confidentiality concerns, and fear of adverse career consequences.

CONCLUSIONS

Few servicewomen utilized post-SAIM care, thus assault-specific health consequences were likely unaddressed. Given the severe and chronic consequences of sexual assault, our findings emphasize need for military, Veterans Health Administration, and civilian providers to query SAIM history to provide timely and optimal care.

Pap test use is lower among female-to-male patients than non-transgender women

BACKGROUND

A paucity of empirical research to date has examined cervical cancer screening in female-to-male (FTM) transgender men who retain their natal reproductive structures compared to non-transgender women.

PURPOSE

To examine patient and provider characteristics associated with being up-to-date on Pap tests, with a focus on gender identity and sexual orientation.

METHODS

Retrospective chart review of 5,232 patients (4,882 women, 350 FTM transgender men) at an urban community health center. All HIV-negative primary care patients aged 21-64 years (inclusive) with at least one medical visit during the 2012 calendar year and who had a cervix as of December 31, 2012, were included. Data were analyzed in 2013 using a multilevel logistic regression model nesting patients within providers.

RESULTS

FTM patients were significantly less likely to be up-to-date on Pap tests (AOR=0.63, 95% CI=0.47, 0.85) compared to non-transgender women, after adjusting for individual- and provider-level factors. Behaviorally bisexual patients, compared to patients who had sex with men exclusively, were more likely to be up-to-date (AOR=1.73, 95% CI=1.32, 2.26); patients reporting only sex with women were not significantly more or less likely to be up-to-date (AOR=1.01, 95% CI=0.83, 1.23).

CONCLUSIONS

Transgender patients are not accessing the same level of preventive cervical screening care as non-transgender female patients. There is a need to better understand barriers to care in this population. Contrary to findings in other settings, history of sex with women was not negatively associated with Pap utilization.

Reporting sexual assault in the military: who reports and why most servicewomen don't

BACKGROUND

Public and congressional attention to the Department of Defense's (DoD's) efforts to prevent and respond to sexual assault in the military (SAIM) is increasing. To promote reporting, the DoD offers (1) restricted reporting, allowing confidential reporting to designated military personnel without triggering an official investigation, and (2) unrestricted reporting, which initiates a criminal investigation.

PURPOSE

To identify factors associated with officially reporting SAIM by examining demographic, military, and sexual assault characteristics and survey reporting perceptions and experiences. Differences between active component (AC) (full-time active duty) and Reserve and National Guard (RNG) were explored.

METHODS

A Midwestern community sample of currently serving and veteran servicewomen (1,339) completed structured telephone interviews. RNG interviews were conducted March 2010 to September 2010 and AC interviews from October 2010 to December 2011. Data were analyzed in 2013. Logistic regression analyses examined demographic, military, and SA characteristics related to SAIM reporting. Bivariate statistics tested differences between AC and RNG.

RESULTS

A total of 205 servicewomen experienced SAIM and 25% reported. More AC servicewomen experienced SAIM, but were no more likely to report than RNG servicewomen. Restricted reporting was rated more positively, but unrestricted reporting was used more often. Reporters' experiences corroborated non-reporters' concerns of lack of confidentiality, adverse treatment by peers, and beliefs that nothing would be done. Officers were less likely to report than enlisted servicewomen.

CONCLUSIONS

Actual and perceived reporting consequences deter servicewomen from reporting. SAIM undermines trust in military units, mission readiness, and the health and safety of all service members.

Voluntary and involuntary childlessness in female veterans: associations with sexual assault

OBJECTIVE

To assess associations between lifetime sexual assault and childlessness in female veterans.

DESIGN

Cross-sectional, computer-assisted telephone interview study.

SETTING

Two Midwestern Veterans Administration (VA) medical centers.

PATIENT(S)

A total of 1,004 women aged ≤52 years, VA-enrolled between 2000 and 2008.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Sociodemographic variables, reproductive history and care utilization, and mental health.

RESULT(S)

A total of 620 veterans (62%) reported at least one attempted or completed sexual assault in their lifetime (LSA). Veterans with LSA more often self-reported a history of pregnancy termination (31% vs. 19%) and infertility (23% vs. 12%), as well as sexually transmitted infection (42% vs. 27%), posttraumatic stress disorder (32% vs. 10%), and postpartum dysphoria (62% vs. 44%). Lifetime sexual assault was independently associated with termination and infertility in multivariate models; sexually transmitted infection, posttraumatic stress disorder, and postpartum dysphoria were not. The LSA by period of life was as follows: 41% of participants in childhood, 15% in adulthood before the military, 33% in military, and 13% after the military (not mutually exclusive). Among the 511 who experienced a completed LSA, 23% self-reported delaying or foregoing pregnancy because of their assault.

CONCLUSION(S)

This study demonstrated associations between sexual assault history and pregnancy termination, delay or avoidance (voluntary childlessness), and infertility (involuntary childlessness) among female veterans. Improved gender-specific veteran medical care must attend to these reproductive complexities.

Overactive bladder and mental health symptoms in recently deployed female veterans

PURPOSE

We estimate the prevalence of current overactive bladder symptoms in recently deployed female veterans, and determine if overactive bladder symptoms are associated with problems commonly reported after deployment including mental health symptoms and prior sexual assault.

MATERIALS AND METHODS

Baseline data were analyzed from a nationwide cohort study of urogenital symptoms in female veterans. Women returning from deployment to Iraq or Afghanistan in the prior 2 years and ending military service were eligible. Self-reported data were collected by computer assisted telephone interview. Overactive bladder and mental health conditions were identified using standardized definitions as well as validated urinary and mental health instruments. Associations between overactive bladder and depression, post-traumatic stress disorder, anxiety and sexual assault were assessed in separate logistic regression models using propensity scores to adjust for confounding.

RESULTS

The 1,702 participants had a mean (SD) age of 31.1 (8.4) years and were racially/ethnically diverse. Overall 375 participants (22%; 95% CI 20.1, 24.1) reported overactive bladder. Mental health outcomes included post-traumatic stress disorder (19%), anxiety (21%), depression (10%) and prior sexual assault (27%). All outcomes were associated with overactive bladder (adjusted OR 2.7, 95% CI [2.0, 3.6], 2.7 [2.0, 3.5], 2.5 [1.5, 4.3] and 1.4 [1.1, 1.9], respectively).

CONCLUSIONS

Overactive bladder symptoms occurred in 22% of recently deployed female veterans, and were associated with self-reported mental health symptoms and traumatic events including prior sexual assault. Screening and evaluation for bothersome urinary symptoms and mental health problems appear warranted in female veterans presenting for primary and urological care after deployment.

The role of borderline personality disorder and depression in the relationship between sexual assault and body mass index among women veterans

This article examines lifetime sexual assault (LSA) and mental health history as risk factors associated with body mass index (BMI) in a population of women veterans. This cross-sectional study of a retrospective cohort of 948 Veterans Affairs (VA)-enrolled midwestern enlisted rank women veterans included computer-assisted telephone interviews. Findings show that 33.4% of the participants had a BMI of 30.0 or more meeting the criteria for obesity and 62.5% reported lifetime attempted or completed sexual assault. Greater BMI was positively associated with older age, less education, LSA, depression, and borderline personality disorder (BPD) and negatively associated with current substance use disorder in multivariate models. Mediation analysis found that the relationship between sexual assault and BMI was completely mediated by BPD and depression. Interventions should combine physical and mental health care in gender-specific services for overweight women veterans with trauma histories and mental health conditions.

Sexual behaviors and sexually transmitted infections in a nationally representative sample of women veterans and nonveterans

BACKGROUND

Women veterans are a growing population with unique characteristics and documented health disparities. Few studies have examined their sexual behaviors and rates of sexually transmitted infections (STIs), and none have compared women veterans to nonveterans to identify potential sexual health disparities.

METHODS

We used data from the 1999-2010 National Health and Nutrition Examination Survey, a nationally representative U.S. survey. We compared lifetime sexual history (age at first intercourse, number of partners), sexual activity in the last year, and STIs between women veterans (n=151) and nonveterans (n=8738), adjusting for age, race/ethnicity, education, marital status, binge drinking, and survey year.

RESULTS

Compared to nonveterans, women veterans reported a younger age at first intercourse and a greater number of female and male lifetime sexual partners, and they were more likely to have ever had sex with a woman. They were also more likely than nonveterans to have genital herpes and genital warts.

CONCLUSIONS

Women veterans reported higher rates of sexual activity and STIs than nonveterans. Future research is needed to assess high-risk behaviors and determine what factors may underlie these associations. Providers should ensure thorough screening and intervention services are provided for this growing population.

Reproductive and other health outcomes in Iraq and Afghanistan women veterans using VA health care: association with mental health diagnoses

BACKGROUND

An increasing number of women serve in the military and are exposed to trauma during service that can lead to mental health problems. Understanding how these mental health problems affect reproductive and physical health outcomes will inform interventions to improve care for women veterans.

METHODS

We analyzed national Department of Veterans Affairs (VA) data from women Iraq and Afghanistan veterans who were new users of VA healthcare from October 7, 2001, through December 31, 2010 (n = 71,504). We used ICD-9 codes to categorize veterans into five groups by mental health diagnoses (MH Dx): Those with no MH Dx, posttraumatic stress disorder (PTSD), depression, comorbid PTSD and depression, and a MH Dx other than PTSD and depression. We determined the association between mental health category and reproductive and other physical health outcomes defined by ICD-9 codes. Categories included sexually transmitted infections, other infections (e.g., urinary tract infections), pain-related conditions (e.g., dysmenorrhea and dsypareunia), and other conditions (e.g., polycystic ovarian syndrome, infertility, sexual dysfunction). Models were adjusted for sociodemographic and military service factors.

RESULTS

There were 31,481 patients (44%) who received at least one mental health diagnosis. Women veterans with any mental health diagnosis had significantly higher prevalences of nearly all categories of reproductive and physical disease diagnoses (p < .0001 for adjusted prevalences). There was a trend of increasing prevalence of disease outcomes in women with PTSD, depression, and comorbid PTSD and depression (p for trend <.0001 for all outcomes).

CONCLUSIONS

Iraq and Afghanistan women veterans with mental health diagnoses had significantly greater prevalences of several important reproductive and physical health diagnoses. These results provide support for VA initiatives to address mental and physical health concerns and improve comprehensive care for women veterans.

High-risk behavior and sexually transmitted infections among U.S. active duty servicewomen and veterans

The number of women who are active duty service members or veterans of the U.S. military is increasing. Studies among young, unmarried, active duty servicewomen who are sexually active indicate a high prevalence of risky sexual behaviors, including inconsistent condom use, multiple sexual partners, and binge drinking, that lead to unintended and unsafe sex. These high-risk sexual practices likely contribute to chlamydia infection rates that are higher than the rates in the U.S. general population. Human papillomavirus (HPV) infection and cervical dysplasia may also be higher among young, active duty servicewomen. Little is known about the sexual practices and rates of sexually transmitted infections among older servicewomen and women veterans; however, women veterans with a history of sexual assault may be at high risk for HPV infection and cervical dysplasia. To address the reproductive health needs of military women, investigations into the prevalence of unsafe sexual behaviors and consequent infection among older servicewomen and women veterans are needed. Direct comparison of military and civilian women is needed to determine if servicewomen are a truly high-risk group. Additionally, subgroups of military women at greatest risk for these adverse reproductive health outcomes need to be identified.

Urinary incontinence, depression and posttraumatic stress disorder in women veterans

OBJECTIVE

To study associations between urinary incontinence (UI) symptoms, depression, and posttraumatic stress disorder in women veterans.

STUDY DESIGN

This cross-sectional study enrolled women 20 to 52 years of age registered at 2 midwestern US Veterans Affairs Medical Centers or outlying clinics within 5 years preceding study interview. Participants completed a computer-assisted telephone interview assessing urogynecologic, medical, and mental health. Multivariable analyses studied independent associations between stress and urgency UI and depression and posttraumatic stress disorder.

RESULTS

Nine hundred sixty-eight women mean aged 38.7 ± 8.7 years were included. Of these, 191 (19.7%) reported urgency/mixed UI and 183 (18.9%) stress UI. Posttraumatic stress disorder (odds ratio, 1.8; 95% confidence interval, 1.0-3.1) but not depression (odds ratio, 1.2; 95% confidence interval, 0.73-2.0) was associated with urgency/mixed UI. Stress UI was not associated with posttraumatic stress disorder or depression.

CONCLUSION

In women veterans, urgency/mixed UI was associated with posttraumatic stress disorder but not depression.

Unintended pregnancy and contraception among active-duty servicewomen and veterans

The number of women of childbearing age who are active-duty service members or veterans of the US military is increasing. These women may seek reproductive health care at medical facilities operated by the military, in the civilian sector, or through the Department of Veterans Affairs. This article reviews the current data on unintended pregnancy and prevalence of and barriers to contraceptive use among active-duty and veteran women. Active-duty servicewomen have high rates of unintended pregnancy and low contraceptive use, which may be due to official prohibition of sexual activity in the military, logistic difficulties faced by deployed women, and limited patient and provider knowledge of available contraceptives. In comparison, little is known about rates of unintended pregnancy and contraceptive use among women veterans. Based on this review, research recommendations to address these issues are provided.