June 26, 2014 —
Summary of "Voluntary and Involuntary Childlessness in Female Veterans: Associations with Sexual Assault," Ryan et al., Fertility and Sterility, May 26, 2014.
"[M]ilitary service presents female service members with high sexual assault" risk and, as more women become eligible for combat roles, "increasing combat-related trauma risks, not to mention deployment-related family disruptions," which can "impact veterans' overall health, as well as reproductive health, choices and outcomes," according to Ginny Ryan of the University of Iowa's Carver College of Medicine and colleagues.
The researchers aimed to follow up on a 1999 study that found associations between sexual assault among female military service members and reproductive and mental health issues, and to "further investigate associations between lifetime attempted or completed sexual assault (LSA) and voluntary and involuntary childlessness and related care seeking in female veterans."
The researchers interviewed pre-menopausal women enrolled in one of two Midwestern Veterans Affairs Medical Centers or affiliated clinics during the study period (July 2005 to August 2008) or the five years prior.
Participants completed a telephone interview that included questions about attempted and completed LSA, pregnancy and abortion history, postpartum mental health, sexually transmitted infections, and post-traumatic stress disorder. The researchers also collected demographic information.
The researchers then analyzed participants' "histor[ies] of self-reported pregnancy termination(s), infertility, and infertility treatment among three categories of sexual assault:  no LSA;  attempted only LSA;  at least one completed LSA." They also compared those factors "between participants who experienced sexual assault during military service and those who experienced sexual assault outside military service."
In addition, the researchers examined relationships between LSA and various demographic and clinical variables, such as race, marital status and mental health, among others.
A total of 1,004 women from an initial sample of 2,414 participated in the study. Participants ranged from ages 20 to 52, and most were white (80%), heterosexual (94%), insured (84%) and had completed at least some college (85%). Seventy percent of participants had sought gynecological care at a VA clinic.
The researchers found that 62% of participants said they had experienced LSA, with 41% reporting an assault in childhood, 15% in adulthood before the military, 33% in the military and 13% after the military. The researchers noted that the categories were not mutually exclusive. Fifty-one percent of participants reported a completed LSA.
According to the study, 19% of participants who said they were never assaulted reported having an abortion, compared with 29% of those who experienced attempted LSA and 31% of those who experienced completed LSA. In addition, 12% of those who had not experienced LSA said they have experienced infertility, compared with 20% who experienced attempted LSA and 24% who experienced completed LSA.
LSA and Military Service
The study found that "women sexually assaulted in childhood, in military, or in postmilitary adulthood (not mutually exclusive) were more likely to self-report having ever terminated a pregnancy compared with those women without LSA exposure." These populations also were more likely to report infertility. However, "[w]hen all time periods were included, only women sexually assaulted in childhood and/or in military service were more likely to report infertility," the study found.
LSA and PTSD
The researchers found that about one-quarter of participants self-reported a PTSD diagnosis, and about one-quarter "screened positive for probable PTSD." The percentages were higher among women who had experienced LSA (32% and 33%, respectively) and lower among women who had not experienced LSA (10% and 10%, respectively).
Veterans who reported LSA "tended to be older (39.5 vs. 36.4 years), more likely to seek gynecologic care at the VA (76% vs. 62%), and less likely to endorse a current sexual preference for men (92% vs. 97%) than veterans who had not experienced LSA."
LSA and Health Outcomes
The researchers found that LSA was "significantly associated with past diagnosis of sexually transmitted infection (42% vs. 27%), earlier age at first pregnancy (21.5 vs. 22.8 years), and a greater number of pregnancies (2.9 vs. 2.5)."
Overall, 31% of the women who experienced LSA and had ever been pregnant had terminated a pregnancy in their lifetimes, a rate that was "significantly higher" than the 19% of veterans who had not experienced LSA, had ever been pregnant and had terminated a pregnancy.
In addition, veterans who reported LSA "were almost twice as likely to self-report infertility (23% vs. 12%) though significantly less likely to be evaluated for infertility once identified (48% vs. 64%)." They were also more likely to report postpartum depression (62% vs. 44%) and to have been diagnosed with PTSD (32% vs. 10%).
Further, 23% of women who reported completed LSA said they delayed or forwent pregnancy "'as a result of the rape.'"
"The study confirms the disturbingly high rate of lifetime sexual assault trauma in female veterans (both during military service and before or after military service) found by other studies," as well as the "associations between sexual assault history and certain reproductive outcomes," such as abortion, infertility and "voluntary and involuntary childlessness," the researchers wrote.
They added that while the rate of women who have had an abortion (31%) and the rate of pregnancies that ended in abortion among veterans (19%) were not substantively different than rates in the general population rates (33% and 22%, respectively), "it is remarkable to note the differences in veteran abortion rates based on [LSA] and to see the number of abortions these women have undergone as a direct result of a sexual assault."
Similarly, they wrote that the level of lifetime infertility found in the study (23%) was not very different from available data on infertility in the general population (21.2%), but it is "again intriguing to see the differences in these self-reported infertility rates within [the] veteran population based on sexual assault history."
In the same manner, "it is the significant increase in [PTSD and maternal mental health] symptoms in veterans with a sexual assault history rather than the absolute numbers (although these are certainly alarming) that are highlighted by this study," the researchers added.
They noted, "[I]t is important that all women's health providers ask their patients about military service and understand how female veterans' reproductive health may have been affected in complicated ways by this service," especially as many female veterans "will primarily seek gynecologic care in the civilian system."