Several studies among groups of U.S. military women suggest that this population may be at high risk for STIs and HPV-related disease. This review of the available literature reveals gaps that should be investigated as part of efforts to improve the reproductive health of U.S. military women. Most data on high-risk behaviors and STIs in military women comes from studies of new recruits or those who are early in their military careers. It is unknown if the military environment leads to high-risk sexual practices or if those who join the military are more likely to engage in high-risk behaviors because of demographic factors that are independent of their military status. Furthermore, there are limited data on the prevalence of high-risk sexual practices that can cause STIs and cervical dysplasia in older servicewomen and veterans. Research investigating the true risk factors for STIs and cervical dysplasia among military women are needed.
Detection of chlamydia may be higher among servicewomen compared to the general population because military policy dictates that all female recruits, not just those seeking screening, be tested,60
but direct comparison of STI rates between military and civilian women who seek screening are unavailable. Although routine STI screening occurs for female military recruits, Reserve and National Guard members who can seek care outside of military treatment facilities may also be at high risk but may not be screened. Female veterans may also have similar risk factors for STI acquisition, but prevalence of infection and rates of screening are unknown in this population. Evaluation of STI prevalence in active duty servicewomen, Reserve and National Guard members, and female veterans compared to civilian women are needed to determine if servicewomen are a truly high-risk group that could benefit from targeted interventions.
Sexual assault during military service may place servicewomen at risk for STIs, including HPV infection, and cervical dysplasia, but further research evaluating these relationships is necessary. The American College of Obstetricians and Gynecologists recommends immediate availability of prophylaxis against STIs for victims of sexual assault.61
But servicewomen who are victims of sexual assault are unlikely to report trauma. In a study of women veterans, only 26% who were raped during military service reported the assault to a military official, and 31% sought medical attention.62
Among those who seek care, it is unknown how many get screened, test positive, or receive prophylactic medications for STIs. Only one study has evaluated the relationship between military sexual trauma and cervical dysplasia.27
Cervical cancer screening programs targeted to victims of military sexual assault may be warranted, but this association needs to be evaluated in a variety of veteran populations.
Cervical cancer screening rates are high among both active duty and veteran women. However, the available literature suggests that rates of cervical dysplasia may be higher for military women compared to those in the general population. Costs associated with evaluation and treatment of abnormal Pap tests may be averted with greater implementation of the HPV vaccine in eligible military women. Although the HPV vaccination is covered by TRICARE and available on the VA formularly,56, 63
limited data show that few military women use this service. Additionally, among those who receive HPV vaccination, it is unknown how many go on to develop cervical dysplasia, given that not all high-risk HPV types are covered in the vaccine.64
Greater collaboration between DOD and VA medical facilities will allow for a unique opportunity to follow vaccinated women over time to assess disease outcomes.
The population of active duty and veteran women is increasing. These women may seek healthcare services from a variety of sources, including military facilities, VA medical centers, and civilian physicians. Thus, all healthcare providers need to understand the reproductive health issues of this population. Active duty servicewomen may be at higher risk for STIs, including HPV-related diseases, than civilian women. Female veterans may share the same risk factors for these diseases as active duty servicewomen, yet little is known about the prevalence of STIs among female veterans. To adequately address the healthcare needs of this growing population, further research into their unique reproductive health issues is necessary.