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1.  Sexual Behaviors and Sexually Transmitted Infections in a Nationally Representative Sample of Women Veterans and Nonveterans 
Journal of Women's Health  2014;23(3):246-252.
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.
PMCID: PMC3952661  PMID: 24328438
2.  Sexual Behaviors and Sexually Transmitted Infections Among Male Veterans and Nonveterans 
American Journal of Men's Health  2017;11(4):791-800.
Little is known about the sexual health of male veterans. This study used nationally representative data from the 2011 to 2013 National Survey of Family Growth to compare sexual behaviors and history of sexually transmitted infections (STIs) between male veterans and nonveterans. The sample included 3,860 men aged 18 to 44 years who reported ever having sex with a man or woman. The key independent variable was veteran status. Sexual behavior outcomes included ≥6 lifetime female partners, ≥10 lifetime partners of either sex, ≥2 past-year partners of either sex, having past-year partners of both sexes, and condom nonuse at last vaginal sex. STI outcomes included past-year history of chlamydia, gonorrhea, or receiving any STI treatment; lifetime history of herpes, genital warts, or syphilis; and an aggregate measure capturing any reported STI history. Logistic regression models were used to evaluate associations between veteran status and each outcome. In models adjusting for age, race/ethnicity, education, income, and marital status, veterans had significantly greater odds than nonveterans of having ≥6 lifetime female partners (OR = 1.5, 95% CI [1.02, 2.31]). In models adjusting for age and marital status, veterans had significantly greater odds of having partners of both sexes in the past year (OR = 4.8, 95% CI [1.2, 19.8]), and gonorrhea in the past year (OR = 3.2, 95% CI [1.2, 8.5]). Male veterans were thus significantly more likely than nonveterans to have STI risk factors. Health care providers should be aware that male veterans may be at higher risk for STIs and assess veterans’ sexual risk behaviors.
PMCID: PMC5675318  PMID: 28625118
male reproductive health; sexually transmitted diseases/infections; risk behaviors; health screening; quantitative research
3.  Health Disparities Among Sexual Minority Women Veterans 
Journal of Women's Health  2013;22(7):631-636.
Lesbian and bisexual (i.e., sexual minority) identity is more common among women veterans than among male veterans. Unique health issues have been identified among women veterans and among sexual minority women, but little is known about women who are both sexual minorities and veterans. This study aimed to compare demographic and health information from sexual minority women veterans with sexual minority women non-veterans and heterosexual women veterans.
Behavioral Risk Factor Surveillance Survey data were pooled from ten U.S. states that elected to ask sexual identity during 2010. The analytic sample was comprised of women who identified both their sexual identity and veteran status (n=1,908). Mental health indicators were frequent mental distress, sleep problems, low social/emotional support, and low satisfaction with life. Health risk indicators included current smoking, overweight, and obesity. Physical health status was defined by three components: disability requiring assistive equipment, >14 days of poor physical health in the past 30 days, and activity limitations.
Compared with heterosexual women veterans, sexual minority women veterans had higher odds of mental distress (odds ratio [OR]=3.03, 95% confidence interval [CI]: 1.61–5.70) and smoking (OR=2.31, 95%CI: 1.19–4.48). After adjusting for demographic correlates, sexual minority women veterans had three times the odds of poor physical health (OR=3.01, 95%CI: 1.51–5.99) than their sexual minority non-veteran peers.
Results suggest sexual minority women veterans may experience unique health disparities relevant to provision of care in both Veterans Affairs (VA) and non-VA healthcare systems. Future research requires availability of data that include sexual minority status.
PMCID: PMC3761433  PMID: 23746281
4.  General Household Emergency Preparedness: A Comparison Between Veterans and Nonveterans 
Prehospital and disaster medicine  2014;29(2):134-140.
Despite federal and local efforts to educate the public to prepare for major emergencies, many US households remain unprepared for such occurrences. United States Armed Forces veterans are at particular risk during public health emergencies as they are more likely than the general population to have multiple health conditions.
This study compares general levels of household emergency preparedness between veterans and nonveterans by focusing on seven surrogate measures of household emergency preparedness (a 3-day supply of food, water, and prescription medications, a battery-operated radio and flashlight, a written evacuation plan, and an expressed willingness to leave the community during a mandatory evacuation). This study used data from the 2006 through 2010 Behavioral Risk Factor Surveillance System (BRFSS), a state representative, random sample of adults aged 18 and older living in 14 states.
The majority of veteran and nonveteran households had a 3-day supply of food (88% vs 82%, respectively) and prescription medications (95% vs 89%, respectively), access to a working, battery-operated radio (82% vs 77%, respectively) and flashlight (97% vs 95%, respectively), and were willing to leave the community during a mandatory evacuation (91% vs 96%, respectively). These populations were far less likely to have a 3-day supply of water (61% vs 52%, respectively) and a written evacuation plan (24% vs 21%, respectively). After adjusting for various sociodemographic covariates, general health status, and disability status, households with veterans were significantly more likely than households without veterans to have 3-day supplies of food, water, and prescription medications, and a written evacuation plan; less likely to indicate that they would leave their community during a mandatory evacuation; and equally likely to have a working, battery-operated radio and fiashlight.
These findings suggest that veteran households appear to be better prepared for emergencies than do nonveteran households, although the lower expressed likelihood of veterans households to evacuate when ordered to do so may place them at a somewhat greater risk of harm during such events. Further research should examine household preparedness among other vulnerable groups including subgroups of veteran populations and the reasons why their preparedness may differ from the general population.
PMCID: PMC4704093  PMID: 24642181
Emergency preparedness; general household preparedness; veteran
5.  Health Care Use, Health Behaviors, and Medical Conditions Among Individuals in Same-Sex and Opposite-Sex Partnerships 
Medical care  2016;54(6):547-554.
Prior research documents disparities between sexual minority and nonsexual minority individuals regarding health behaviors and health services utilization. However, little is known regarding differences in the prevalence of medical conditions.
To examine associations between sexual minority status and medical conditions.
Research Design
We conducted multiple logistic regression analyses of the Medical Expenditure Panel Survey (2003–2011). We identified individuals who reported being partnered with an individual of the same sex, and constructed a matched cohort of individuals in opposite-sex partnerships.
A total of 494 individuals in same-sex partnerships and 494 individuals in opposite-sex partnerships.
Measures of health risk (eg, smoking status), health services utilization (eg, physician office visits), and presence of 15 medical conditions (eg, cancer, diabetes, arthritis, HIV, alcohol disorders).
Same-sex partnered men had nearly 4 times the odds of reporting a mood disorder than did opposite-sex partnered men [adjusted odds ratio (aOR) = 3.96; 95% confidence interval (CI), 1.85–8.48]. Compared with opposite-sex partnered women, same-sex partnered women had greater odds of heart disease (aOR =2.59; 95% CI, 1.19–5.62), diabetes (aOR= 2.75; 95% CI, 1.10–6.90), obesity (aOR =1.92; 95% CI, 1.26–2.94), high cholesterol (aOR = 1.89; 95% CI, 1.03–3.50), and asthma (aOR=1.90; 95% CI, 1.02–1.19). Even after adjusting for sociodemographics, health risk behaviors, and health conditions, individuals in same-sex partnerships had 67% increased odds of past-year emergency department utilization and 51% greater odds of ≥3 physician visits in the last year compared with opposite-sex partnered individuals.
A combination of individual-level, provider-level, and system-level approaches are needed to reduce disparities in medical conditions and health care utilization among sexual minority individuals.
PMCID: PMC5137194  PMID: 26974678
sexual orientation; health disparities; health care utilization; minority health
6.  A Population-Based Study on Alcohol and High-Risk Sexual Behaviors in Botswana 
PLoS Medicine  2006;3(10):e392.
In Botswana, an estimated 24% of adults ages 15–49 years are infected with HIV. While alcohol use is strongly associated with HIV infection in Africa, few population-based studies have characterized the association of alcohol use with specific high-risk sexual behaviors.
Methods and Findings
We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks/week for men) as a dependent variable. We also assessed gender-specific associations between alcohol use as a primary independent variable (categorized as none, moderate, problem and heavy drinking) and several risky sex outcomes including: (a) having unprotected sex with a nonmonogamous partner; (b) having multiple sexual partners; and (c) paying for or selling sex in exchange for money or other resources. Criteria for heavy drinking were met by 31% of men and 17% of women. Adjusted correlates of heavy alcohol use included male gender, intergenerational relationships (age gap ≥10 y), higher education, and living with a sexual partner. Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined, including unprotected sex (AOR = 3.48; 95% confidence interval [CI], 1.65 to 7.32), multiple partners (AOR = 3.08; 95% CI, 1.95 to 4.87), and paying for sex (AOR = 3.65; 95% CI, 2.58 to 12.37). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR = 3.28; 95% CI, 1.71 to 6.28), multiple partners (AOR = 3.05; 95% CI, 1.83 to 5.07), and selling sex (AOR = 8.50; 95% CI, 3.41 to 21.18). A dose-response relationship was seen between alcohol use and risky sexual behaviors, with moderate drinkers at lower risk than both problem and heavy drinkers.
Alcohol use is associated with multiple risks for HIV transmission among both men and women. The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Alcohol use is associated with multiple risks for HIV transmission in men and women. The findings underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Editors' Summary
Human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS), is most commonly spread through unprotected sex with an infected partner. HIV enters the body through the lining of the sex organs, rectum, or mouth, and destroys immune system cells, leaving the infected person susceptible to other viruses and bacteria. Although HIV education and prevention campaigns emphasize the importance of safe sex in reducing HIV transmission, people continue to become infected by having unprotected sex (that is, not using a condom) with either a nonmonogamous partner or multiple sexual partners, or in situations where they are paying for or selling sex. Research in different populations suggested that heavy alcohol use is associated with risky sexual behaviors. This is because alcohol relaxes the brain and body, reduces inhibitions, and diminishes risk perception. Drinking alcohol may further increase the risk of becoming infected with HIV through its suppressive effects on the immune system.
Why Was This Study Done?
Alcohol abuse is widespread in sub-Saharan Africa where most HIV infections occur and has been associated with risky sexual behaviors. It may therefore be one of the most common, potentially modifiable HIV risk factors in this region. However, research to date has concentrated on the association between alcohol consumption and risky sex in people attending HIV-treatment clinics or recruited at beer halls, and these populations may not be representative of the general population of sub-Saharan Africa. In this study, the researchers have investigated the potential role of alcohol in perpetuating the HIV epidemic by undertaking a population-based study on alcohol use and high-risk sexual behaviors in Botswana. Nearly a quarter of adults are infected with HIV here, and alcohol abuse is also common, particularly in the townships.
What Did the Researchers Do and Find?
The researchers recruited a random cross-section of people from the five districts of Botswana with the highest number of HIV-infected individuals and interviewed all 1,268 participants using a questionnaire. This included general questions about the participants (for example, their age and marital status) and questions about alcohol use, sexual behavior, and knowledge of HIV. Overall, 31% of the men in the study and 17% of the women were heavy drinkers—more than 21 drinks/week for men, 14 for women; a drink is half a pint of beer or a glass of wine. Heavy alcohol use was associated with being male, being in an intergenerational relationship (at least 10 years age difference between partners; intergenerational sex facilitates the continued spread of HIV in sub-Saharan Africa), having had more education, and living with a sexual partner. Among men, those who drank heavily were three to four times more likely to have unprotected sex or multiple partners or to pay for sex than nondrinkers. Among women, there was a similar association between heavy drinking and having unprotected sex or multiple partners, and heavy drinkers were eight times as likely to sell sex as nondrinkers. For both men and women, the more they drank, the more likely they were to have risky sex. The study did not address behavior among same-sex partnerships.
What Do These Findings Mean?
This study indicates that heavy alcohol consumption is strongly and consistently associated with sexual risk behaviors in both men and women in Botswana. Because of the study design, it does not prove that heavy alcohol use is the cause of such behaviors but provides strong circumstantial evidence that this is the case. It is possible that these results may not apply to neighboring African countries—Botswana is unique in being relatively wealthy and in its government being strongly committed to tackling HIV. Nevertheless, taken together with the results of other studies, this research strongly argues for the need to deal with alcohol abuse within HIV prevention programs in sub-Saharan Africa. Strategies to do this could include education campaigns that target both alcohol use and HIV in schools and in social venues, including beer halls. But, stress the researchers, any strategy that is used must consider the cultural and social significance of alcohol use (in Botswana, alcohol use is a symbol of masculinity and high socioeconomic status) and must simultaneously tackle not only the overlap between alcohol use and risky sexual behavior but also the overlap between alcohol and other risk behaviors such as intergenerational sex.
Additional Information
Please access these Web sites via the online version of this summary at
US National Institute of Allergy and Infectious Diseases factsheet on HIV infection and AIDS
US Department of Health and Human Services information on AIDS
US Centers for Disease Control and Prevention information on HIV/AIDS
US National Institute on Alcohol Abuse and Alcoholism patient information on alcohol and HIV/AIDS]
Aidsmap, information on HIV and AIDS provided by the charity NAM,which includes some information on HIV infections and alcohol
AVERT information on HIV and AIDS in Botswana
PMCID: PMC1592342  PMID: 17032060
7.  The Burden of Obesity Among a National Probability Sample of Veterans 
Few national data exist about the prevalence of obesity and the resulting health burden among veterans.
We analyzed data from the 2003 Behavioral Risk Factor Surveillance System (n = 242,362) to compare rates of obesity among veterans who do and do not utilize the VA, compared with nonveterans. We used bivariate analyses to describe the association of obesity with lifestyle factors, disability, and comorbid disease, and multivariate analysis to assess the independent association of obesity with VA care.
Veterans who use the VA for health care have the highest rates of obesity compared with veterans who do not use the VA and nonveterans (27.7% vs 23.9% vs 22.8%, P < .001). Only 27.8% of veterans who receive health care at the VA are of normal weight (vs 42.6% of the general population, P < .001), 44.5% are overweight, 19.9% have class I obesity, 6% have class II obesity, and 1.8% are morbidly obese (an estimated 82,950 individuals). Obese veterans who utilize the VA for services have higher rates of hypertension (65.8%) and diabetes (31.3%), are less likely to follow diet and exercise guidelines, and more likely to report poor health and disability than their normal-weight counterparts.
Veterans who receive care at the VA have higher rates of overweight and obesity than the general population. At present, less than half of VA medical centers have weight management programs. As the largest integrated U.S. health system, the VA has a unique opportunity to respond to the epidemic of obesity.
PMCID: PMC1831589  PMID: 16918734
veterans; obesity
8.  Perceived Racial Discrimination in Health Care: A Comparison of Veterans Affairs and Other Patients 
American journal of public health  2009;99(Suppl 3):S718-S724.
We compared rates of perceived racial discrimination in health care settings for veteran and nonveteran patients and for veterans who used the Veterans Affairs health care system and those who did not.
Data were drawn from the 2004 Behavioral Risk Factor Surveillance System. We used logistic regression to examine whether perceived racial discrimination in health care was associated with veteran status or use of Veterans Affairs health care, after adjusting for patient characteristics.
In this sample of 35 902 people, rates of perceived discrimination were equal for veterans and nonveterans (3.4% and 3.5%, respectively; crude odds ratio [OR]=1.00; 95% confidence interval [CI]=0.77, 1.28; adjusted OR=0.92; 95% CI=0.66, 1.28). Among veterans (n= 3420), perceived discrimination was more prevalent among patients who used Veterans Affairs facilities than among those who did not (5.4% vs 2.7%; OR=2.08; 95% CI=1.04, 4.18). However, this difference was not significant after adjustment for patient characteristics (OR=1.30; 95% CI=0.54, 3.13).
Perceived racial discrimination in health care was equally prevalent among veterans and nonveterans and among veterans who used the Veterans Affairs health care system and those who did not.
PMCID: PMC2774170  PMID: 19443818
9.  Pain among veterans with spinal cord injury 
The Department of Veterans Affairs Veterans Health Administration cares for approximately 15% of persons with spinal cord injury (SCI) in the United States. However, the nature and characteristics of pain among veterans with SCI are not well understood. This study used a postal survey to compare veterans with SCI and nonveterans with SCI on pain intensity; pain interference; functioning; and other pain, demographic, and medical characteristics. Veterans tended to be older than nonveterans but these groups were otherwise comparable on demographic and medical variables. Veterans were not significantly different from nonveterans on pain intensity or pain interference. Veterans reported lower levels of functioning than nonveterans and higher levels of pain-related catastrophizing. However, differences in functioning between veterans and non-veterans were attributable to age differences between the groups. In summary, differences between veterans with SCI and nonveterans with SCI were few and small in magnitude, suggesting that veterans with SCI are not at greater risk for pain and pain-related problems. However, pain-related catastrophizing may be a particular concern among veterans with SCI.
PMCID: PMC2612118  PMID: 19009466
age; catastrophizing; chronic pain; functioning; pain; pain intensity; pain interference; rehabilitation; spinal cord injury; veterans
10.  Physical health indicators among lesbian, gay, and bisexual U.S. Veterans 
Annals of epidemiology  2013;23(7):448-451.
To provide information about lesbian, gay and bisexual (LGB) veterans’ health status, diagnoses, and health screening behaviors compared with heterosexual veterans.
Data are from ten states’ 2010 Behavioral Risk Factor Surveillance System (BRFSS) surveys that contained sexual orientation data for veterans (n=11,665). Chi-square tests and multiple logistic regression were used to examine outcomes among LGB and heterosexual veterans.
More LGB veterans than heterosexual veterans reported current smoking, not seeking medical care due to cost, and activity limitations. Compared with heterosexual veterans, LGB veterans had greater odds of ever having an HIV test (OR=5.42; 95%CI: 3.28–8.96) but lower odds of diabetes diagnosis (0.55 (0.34–0.89).
Findings from this sample suggest patterns of health behaviors and outcomes among LGB veterans that are both unique from and similar to results from general samples of LGB persons. With the formal end of the “Don’t Ask, Don’t Tell” policy that discriminated against LGB people in the military, institutions such as the Department of Veterans Affairs (VA) are likely to see an increase in its current population of LGB veterans. The VA stands in a unique place to meet the health equity needs of this minority population.
PMCID: PMC3698572  PMID: 23688720
11.  Cigarette Smoking, Reduction and Quit Attempts: Prevalence Among Veterans With Coronary Heart Disease 
Cigarette smoking increases the risk of illness and early death for people with coronary heart disease. In 2010, Brown estimated prevalence rates for smoking among veterans and nonveterans with or without coronary heart disease in the United States, based on the 2003 through 2007 data from the Behavioral Risk Factor Surveillance System (BRFSS). Recent changes in BRFSS methods promise more accurate estimates for veterans. To inform assessment of efforts to reduce smoking, we sought to provide prevalence rates for smoking behaviors among US veterans with coronary heart disease and to compare rates for veterans with those for civilians.
We conducted a cross-sectional analysis of participants who responded to BRFSS from 2009 to 2012. Accounting for complex BRFSS sampling, we estimated national prevalence rates by sex for smoking status, frequency, and quit attempts; for those with and those without coronary heart disease; for civilians; for veterans and active duty personnel combined; and, after adjusting for BRFSS mingling of active duty personnel and veterans, for veterans only. We examined differences between veterans and civilians by using age-standardized national estimates.
Among men with coronary heart disease, more veterans than civilians smoked and more were daily smokers, but veterans were no more likely to attempt to quit. Among women with coronary heart disease, we found no differences between civilians and veterans.
Cigarette smoking is more prevalent among male veterans with coronary heart disease than among their civilian counterparts. Not distinguishing active duty personnel from veterans can materially affect prevalence estimates intended to apply solely to veterans.
PMCID: PMC4807437  PMID: 27010844
12.  Health-Related Quality of Life in Veterans and Nonveterans with HIV/AIDS 
Journal of General Internal Medicine  2006;21(Suppl 5):S39-S47.
To compare health-related quality of life (HRQoL) between patients receiving care in Veterans Administration (VA) settings (veterans) and non-VA settings (nonveterans), and to explore determinants of HRQoL and change in HRQoL over time in subjects living with HIV/AIDS.
One hundred veterans and 350 nonveterans with HIV/AIDS from 2 VA and 2 university-based sites in 3 cities interviewed in 2002 to 2003 and again 12 to 18 months later.
We assessed health status (functional status and symptom bother), health ratings, and health values (time tradeoff [TTO] and standard gamble [SG] utilities). We also explored bivariate and multivariable associations of HRQoL measures with a number of demographic, clinical, spiritual/religious, and psychosocial characteristics.
Compared with nonveterans, the veteran population was older (47.7 vs 42.0 years) and consisted of a higher proportion of males (97% vs 83%), of participants with a history of injection drug use (23% vs 15%), and of subjects with unstable housing situations (14% vs 6%; P<.05 for all comparisons). On scales ranging from 0 (worst) to 100 (best), veterans reported significantly poorer overall function (mean [SD]; 65.9 [17.2] vs 71.9 [16.8]); lower rating scale scores (67.6 [21.7] vs 73.5 [21.0]), lower TTO values (75.7 [37.4] vs 89.0 [23.2]), and lower SG values (75.0 [35.8] vs 83.2 [28.3]) than nonveterans (P<.05 for all comparisons); however, in multivariable models, veteran status was only a significant determinant of SG and TTO values at baseline. Among other determinants that were associated with multiple HRQoL outcomes in baseline and follow-up multivariable analyses were: symptom bother, overall function, religiosity/spirituality, depressive symptoms, and financial worries.
Veterans reported significantly poorer HRQoL than nonveterans, but when controlling for other factors, veteran status was only a significant determinant of TTO and SG health values at baseline. Correlates of HRQoL such as symptom bother, spirituality/religiosity, and depressive symptoms could be fruitful potential targets for interventions to improve HRQoL in patients with HIV/AIDS.
PMCID: PMC1924783  PMID: 17083499
HIV; AIDS; quality of life; veterans
13.  Associations between Intimate Partner Violence and Health among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(3):e1001609.
Ana Maria Buller and colleagues review 19 studies and estimate the associations between the experience and perpetration of intimate partner violence and various health conditions and sexual risk behaviors among men who have sex with men.
Please see later in the article for the Editors' Summary
Intimate partner violence (IPV) among men who have sex with men (MSM) is a significant problem. Little is known about the association between IPV and health for MSM. We aimed to estimate the association between experience and perpetration of IPV, and various health conditions and sexual risk behaviours among MSM.
Methods and Findings
We searched 13 electronic databases up to 23 October 2013 to identify research studies reporting the odds of health conditions or sexual risk behaviours for MSM experiencing or perpetrating IPV. Nineteen studies with 13,797 participants were included in the review. Random effects meta-analyses were performed to estimate pooled odds ratios (ORs). Exposure to IPV as a victim was associated with increased odds of substance use (OR = 1.88, 95% CIOR 1.59–2.22, I2 = 46.9%, 95% CII2 0%–78%), being HIV positive (OR = 1.46, 95% CIOR 1.26–1.69, I2 = 0.0%, 95% CII2 0%–62%), reporting depressive symptoms (OR = 1.52, 95% CIOR 1.24–1.86, I2 = 9.9%, 95% CII2 0%–91%), and engagement in unprotected anal sex (OR = 1.72, 95% CIOR 1.44–2.05, I2 = 0.0%, 95% CII2 0%–68%). Perpetration of IPV was associated with increased odds of substance use (OR = 1.99, 95% CIOR 1.33–2.99, I2 = 73.1%). These results should be interpreted with caution because of methodological weaknesses such as the lack of validated tools to measure IPV in this population and the diversity of recall periods and key outcomes in the identified studies.
MSM who are victims of IPV are more likely to engage in substance use, suffer from depressive symptoms, be HIV positive, and engage in unprotected anal sex. MSM who perpetrate IPV are more likely to engage in substance use. Our results highlight the need for research into effective interventions to prevent IPV in MSM, as well as the importance of providing health care professionals with training in how to address issues of IPV among MSM and the need to raise awareness of local and national support services.
Please see later in the article for the Editors' Summary
Editors' Summary
Intimate partner violence (IPV, also called domestic violence) is a common and widespread problem. Globally, nearly a third of women are affected by IPV at some time in their life, but the prevalence of IPV (the proportion of the population affected by IPV) varies widely between countries. In central sub-Saharan Africa, for example, nearly two-thirds of women experience IPV during their lifetime, whereas in East Asia only one-sixth of women are affected. IPV is defined as physical, sexual, or emotional harm that is perpetrated on an individual by a current or former partner or spouse. Physical violence includes hitting, kicking, and other types of physical force; sexual violence means forcing a partner to take part in a sex act when the partner does not consent; and emotional abuse includes threatening a partner by, for example, stalking them or preventing them from seeing their family. The adverse effects of IPV for women include physical injury, depression and suicidal behaviour, and sexual and reproductive health problems such as HIV infection and unwanted pregnancies.
Why Was This Study Done?
IPV affects men as well as women. Men can be subjected to IPV either by a female partner or by a male partner in the case of men who have sex with men (MSM, a term that encompasses homosexual, bisexual, and transgender men, and heterosexual men who sometimes have sex with men). Recent reviews suggest that the prevalence of IPV in same-sex couples is as high as the prevalence of IPV for women in opposite-sex relationships: reported lifetime prevalences of IPV in homosexual male relationships range between 15.4% and 51%. Little is known, however, about the adverse health effects of IPV on MSM. It is important to understand how IPV affects the health of MSM so that appropriate services and interventions can be provided to support MSM who experience IPV. In this systematic review (a study that identifies all the research on a given topic using predefined criteria) and meta-analysis (a study that combines the results of several studies using statistical methods), the researchers investigate the associations between the experience and perpetration of IPV and various health conditions and sexual risk behaviours among MSM.
What Did the Researchers Do and Find?
The researchers identified 19 studies that investigated associations between IPV and various health conditions or sexual risk behaviours (for example, unprotected anal sex, a risk factor for HIV infection) among MSM. The associations were expressed as odds ratios (ORs); an OR represents the odds (chances) that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. The researchers estimated pooled ORs from the data in the individual studies using meta-analysis. The pooled lifetime prevalence of experiencing any IPV (which was measured in six studies) was 48%. Exposure to IPV as a victim was associated with an increased risk of substance (alcohol or drug) use (OR = 1.88, data from nine studies), reporting depressive symptoms (OR = 1.52, data from three studies), being HIV positive (OR = 1.46, data from ten studies), and engagement in unprotected sex (OR = 1.72, data from eight studies). Perpetration of IPV was associated with an increased risk of substance abuse (OR = 1.99, data from six studies).
What Do These Findings Mean?
These findings suggest that MSM frequently experience IPV and that exposure to IPV is associated with several adverse health conditions and sexual risk behaviours. There were insufficient data to estimate the lifetime prevalence of IPV perpetration among MSM, but these findings also reveal an association between IPV perpetration and substance use. The accuracy of these findings is limited by heterogeneity (variability) between the studies included in the meta-analyses, by the design of these studies, and by the small number of studies. Despite these and other limitations, these findings highlight the need to undertake research to identify interventions to prevent IPV among MSM and to learn more about the health effects of IPV among MSM. They highlight the importance of health care professionals being aware that IPV is a problem for MSM and of training these professionals to assess MSM for IPV. Finally, these results highlight the need to improve the availability and effectiveness of support services to which health care professionals can refer MSM experiencing or perpetrating IPV.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization provides detailed information on intimate partner violence
The US Centers for Disease Control and Prevention provides information about IPV and a fact sheet on understanding IPV that includes links to further resources
The UK National Health Service Choices website has a webpage about domestic violence, which includes descriptions of personal experiences
The US National Domestic Violence Hotline provides confidential help and support to people experiencing IPV, including MSM; its website includes personal stories of IPV
The US Gay Men's Domestic Violence Project/GLBTQ Domestic Violence Project provides support and services to MSM experiencing IPV; its website includes some personal stories
The UK not-for-profit organization Respect runs two advice lines: the Men's Advice Line provides advice and support for men experiencing domestic violence and abuse and the Respect Phoneline provides advice for domestic violence perpetrators and for professionals who would like further information about services for those using violence/abuse in their intimate partner relationships
The UK not-for-profit organization ManKind Initiative also provides support for male victims of IPV
The UK not-for-profit organization Broken Rainbow UK provides help and support for lesbians and MSM experiencing IPV
MedlinePlus provides links to other resources about domestic violence (in English and Spanish)
The UK charity Galop gives advice and support to people who have experienced biphobia, homophobia, transphobia, sexual violence, or domestic abuse
PMCID: PMC3942318  PMID: 24594975
14.  Patterns of Hospice Care Among Military Veterans and Non-veterans 
Historically, hospice use by veterans has lagged behind that of non-veterans. Little is known about hospice use by veterans at a population level.
To determine whether veteran and non-veteran hospice users differ by demographics, primary diagnosis, location of care, and service utilization.
Using the 2007 National Home and Hospice Care Survey, we identified 483 veteran and 932 non-veteran male hospice users representing 287,620 hospice enrollees nationally. We used chi-square and t-tests to compare veterans and non-veterans by demographic characteristics, primary diagnosis, and location of hospice care. We used multivariate regression to assess for differences in hospice diagnosis and location of care, adjusting for demographic and clinical factors. We also compared length of stay and number of visits by hospice personnel between veterans and non-veterans using multivariate regression.
Veteran hospice users were older than non-veterans (77.0 vs. 74.3 years, P = 0.02) but did not differ by other demographics. In adjusted analyses, cancer was a more common primary diagnosis among veterans than non-veterans (56.4% vs. 48.4%; P = 0.02), and veteran hospice users were more likely than non-veterans to receive hospice at home (68.4% vs. 57.6%; P = 0.007). The median adjusted length of stay and number of nurse or social worker visits did not differ by veteran status (all P > 0.10), but veterans received fewer home health aide visits than non-veterans (one every 5.3 days vs. one every 3.7 days; P = 0.002).
Although veteran and non-veteran hospice users were similar on most demographic measures, important differences in hospice referral patterns and utilization exist.
PMCID: PMC4031299  PMID: 24275325
Hospice; veterans; clinical case mix; demographics; health care utilization; nationally representative data
15.  Alcohol Use and Selected Health Conditions of 1991 Gulf War Veterans: Survey Results, 2003-2005 
Preventing Chronic Disease  2011;8(3):A52.
A sizable literature has analyzed the frequency of alcohol consumption and patterns of drinking among veterans. However, few studies have examined patterns of alcohol use in veterans of the first Gulf War or factors associated with problem drinking in this population. We examined the frequency and patterns of alcohol use in male and female veterans who served in the 1991 Gulf War or during the same era and the relationships between alcohol use and selected health conditions.
We analyzed data from a follow-up survey of health information among population-based samples of 15,000 Gulf War and 15,000 Gulf Era veterans. Data had been collected from 9,970 respondents during 2003 through 2005 via a structured questionnaire or telephone survey.
Posttraumatic stress disorder (PTSD), major depressive disorder (MDD), unexplained multisymptom illness (MSI), and chronic fatigue syndrome (CFS)–like illness were more frequent among veterans with problem drinking than those without problem drinking. Approximately 28% of Gulf War veterans with problem drinking had PTSD compared with 13% of Gulf War veterans without problem drinking. In multivariate analysis, problem drinking was positively associated with PTSD, MDD, unexplained MSI, and CFS–like illness after adjustment for age, sex, race/ethnicity, branch of service, rank, and Gulf status. Veterans who were problem drinkers were 2.7 times as likely to have PTSD as veterans who were not problem drinkers.
These findings indicate that access to evidence-based treatment programs and systems of care should be provided for veterans who abuse alcohol and who have PTSD and other war-related health conditions and illnesses.
PMCID: PMC3103557  PMID: 21477492
16.  Preferences regarding Genetic Research Results: Comparing Veterans and Nonveterans Responses 
Public Health Genomics  2010;13(7-8):431-439.
Communicating genetic research results to participants presents ethical challenges. Our objectives were to examine participants’ preferences in receiving future genetic research results and to compare preferences reported by veteran and nonveterans participants.
Secondary analysis was performed on data collected in 2000–2004 from 1,575 consent forms signed by Mexican-American participants enrolled in 2 genetic family studies (GFS) in San Antonio: The Family Investigation of Nephropathy and Diabetes (FIND) and the Extended FIND (EFIND). The consent forms for these studies contained multiple-choice questions to examine participants’ preferences about receiving their (1) clinical lab results and (2) future genetic research results. The FIND and EFIND databases had information on subjects’ demographic characteristics and some selected clinical variables. We identified veterans using the Veterans Health Administration's (VHA's) centralized data repository. We compared veterans’ and nonveterans’ preferences using Student's t test for continuous variables and χ2 test for discrete variables. A logistic regression analyzed subjects’ preference for receiving their research results, controlling for other socio-demographic and clinical variables.
The sample included 275 (18%) veterans and 1,247 (82%) nonveterans. Our results indicated a strong desire among the majority of participants 1,445 (95%) in getting their clinical lab research results. Likewise, 93% expressed interest in being informed about their future genetic results. There was no significant difference in veterans’ and nonveterans’ preference to disclosure of the research results (χ2 test; p > 0.05). Regression analysis showed no significant relationship (p = 0.449) between the outcome (receiving research results) and veterans’ responses after controlling for demographics and educational levels.
Participants believed they would prefer receiving their genetic research results. Veterans are similar to nonveterans in their preferences. Offering genetic research results to participants should be based on well defined and structured plans to enhance interpretation of genetic data.
PMCID: PMC3025894  PMID: 20829581
Common complex diseases; Ethics; Genetic family studies; Research results
17.  Nicotine Dependence and Its Risk Factors Among Users of Veterans Health Services, 2008-2009 
Preventing Chronic Disease  2011;8(6):A127.
Tobacco use is the leading preventable cause of death in the United States and is disproportionately higher among veterans than nonveterans. We examined the prevalence of nicotine dependence and its associated risk factors among veterans who used health services in the US Department of Veterans Affairs (VA) system.
Using a case-control design, we compared all VA health service users in fiscal year 2008-2009 (N = 5,031,381) who received a nicotine dependence diagnosis with those who did not. Independent risk and protective factors associated with receiving a nicotine dependence diagnosis were identified using logistic regression analysis. We conducted subgroup analyses on 2 groups of particular policy concern: homeless veterans and veterans who served in Iraq and Afghanistan.
Among all recent VA health service users, 15% (n = 749,353) received a diagnosis of nicotine dependence. Substance abuse, other mental health diagnoses, and homelessness were identified as major risk factors. Veterans who served in Iraq and Afghanistan were not found to be at increased risk compared to veterans from other war eras. Major risk and protective factors within the subgroups of homeless veterans and veterans who served in Iraq and Afghanistan were broadly similar to those in the general VA population.
Given that other studies have found higher rates of nicotine dependence among veterans, this risk behavior may be underdiagnosed in VA medical records. Veterans who are homeless or have mental health or substance abuse problems are at highest risk and should be targeted for smoking prevention and cessation interventions. These results support, in principle, efforts to integrate smoking cessation programs with mental health and homeless services.
PMCID: PMC3221569  PMID: 22005620
18.  Comparing the smoking behavior of veterans and nonveterans. 
Public Health Reports  1997;112(3):212-218.
OBJECTIVES: The authors analyzed self-reported questionnaire data from the 1987 National Medical Expenditure Survey (NMES) to determine the smoking patterns of veterans. METHODS: Using NMES data, the authors compared veterans versus nonveterans overall, women veterans versus women nonveterans, Vietnam-era veterans versus other veterans, and veterans whose usual source of medical care was the Department of Veterans Affairs (VA) system versus veterans who received care elsewhere. RESULTS: The likelihood of ever having smoked cigarettes was higher for veterans than for nonveterans and for women veterans than for women nonveterans. The prevalence of current smoking was higher for veterans than for nonveterans and higher for those seeking care within the VA system than for other veterans. CONCLUSIONS: Given the enormous health care costs associated with smoking, health promotion efforts should be developed to reduce the high rate of smoking among veterans--especially those who are consumers of VA health care.
PMCID: PMC1381994  PMID: 9160055
19.  Military Service and Men's Health Trajectories in Later Life 
This study examines differences in the relationship between veteran status and men's trajectories of health conditions, activities of daily living limitations, and self-rated health.
We use data on 12,631 men drawn from the 1992–2006 waves of the Health and Retirement Study to estimate growth curve models that examine differences in health trajectories between nonveterans and veterans, veterans with and without wartime service, and war service veterans who served during World War II, Korea, Vietnam, and multiple wars.
The results indicate that veterans have better health at the mean age of 66.2 years, but experience greater age-related changes in health than nonveterans. Similarly, men who served during wartime have better health at the mean age, but more age-related changes in health than men who did not serve during wartime. Among war veterans, Vietnam veterans are in poorer health at the mean age, but they experience less substantial age-related health changes than men who served during previous wars.
Although veterans experience better health relative to nonveterans around retirement age, they have poorer health than nonveterans among the oldest old. These findings inform our understanding of the veteran–nonveteran health-mortality paradox found in previous research and suggest a health crossover among veterans and nonveterans in later life.
PMCID: PMC2954333  PMID: 20864570
Growth curve models; Health; Military service; Veterans
20.  Selected Health Conditions Among Overweight, Obese, and Non-Obese Veterans of the 1991 Gulf War: Results from a Survey Conducted in 2003–2005 
Several health conditions and concerns have been reported to be increased among Gulf War veterans including post-traumatic stress disorder (PTSD), chronic fatigue syndrome (CFS), CFS-like illness, and unexplained multi-symptom illness (MSI). As the cohort of Gulf War veterans advance in age, they are likely to be at risk of not only certain deployment-related health conditions but also chronic diseases associated with lifestyle factors.
To clarify relationships between PTSD, CFS-like illness, MSI, and obesity, we analyzed data from a cross-sectional survey of health information among population-based samples of 15,000 Gulf War veterans and 15,000 veterans who served during the same era. Data had been collected from 9,970 respondents in 2003–2005 via a structured questionnaire or telephone survey.
Based upon body mass index (BMI) estimated from self-reported information about height and weight, the percentages of Gulf War and Gulf Era veterans who were overweight (BMI 25 to ≤ 29.9), were 46.8% and 48.7%, respectively. The percentages who were obese (BMI ≥ 30) were 29.6% and 28.3%, respectively. Without adjustment for Gulf deployment status (Gulf War vs Gulf Era), age, sex, or other factors, PTSD, MSI, CFS-like illness, and other chronic health conditions were more common among obese veterans than those who were normal weight (BMI 18.5 to ≤ 24.9). In multivariate analyses, PTSD was positively associated with obesity after adjustment for age, sex, Gulf deployment status, rank, income, education, and current smoking. In the model for PTSD, the adjusted odds ratio for obesity was 1.5 (95% CI 1.2–1.8). No associations were observed between BMI categories and CFS-like illness or MSI in multivariate analysis.
Gulf War and Gulf Era veterans who were obese were more likely to have certain chronic health conditions including PTSD. Associations between Gulf status and CFS-like illness and MSI identified in the 2003–2005 follow-up survey were not accounted for by group differences in the prevalence of overweight or obesity.
PMCID: PMC3125597  PMID: 21731594
Body mass; chronic fatigue syndrome; obesity; post-traumatic stress disorder; survey; veterans
21.  Prevalence and Risk of Homelessness Among US Veterans 
Understanding the prevalence of and risk for homelessness among veterans is prerequisite to preventing and ending homelessness among this population. Homeless veterans are at higher risk for chronic disease; understanding the dynamics of homelessness among veterans can contribute to our understanding of their health needs.
We obtained data on demographic characteristics and veteran status for 130,554 homeless people from 7 jurisdictions that provide homelessness services, and for the population living in poverty and the general population from the American Community Survey for those same jurisdictions. We calculated prevalence of veterans in the homeless, poverty, and general populations, and risk ratios (RR) for veteran status in these populations. Risk for homelessness, as a function of demographic characteristics and veteran status, was estimated by using multivariate regression models.
Veterans were overrepresented in the homeless population, compared with both the general and poverty populations, among both men (RR, 1.3 and 2.1, respectively) and women (RR, 2.1 and 3.0, respectively). Veteran status and black race significantly increased the risk for homelessness for both men and women. Men in the 45- to 54-year-old age group and women in the 18- to 29-year-old age group were at higher risk compared with other ages.
Our findings confirm previous research associating veteran status with higher risk for homelessness and imply that there will be specific health needs among the aging homeless population. This study is a basis for understanding variation in rates of, and risks for, homelessness in general population groups, and inclusion of health data from US Department of Veterans Affairs records can extend these results to identifying links between homelessness and health risks.
PMCID: PMC3337850  PMID: 22280960
22.  Associations between Intimate Partner Violence and Termination of Pregnancy: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(1):e1001581.
Lucy Chappell and colleagues conduct a systematic review and meta analysis to investigate a possible association between intimate partner violence and termination of pregnancy.
Please see later in the article for the Editors' Summary
Intimate partner violence (IPV) and termination of pregnancy (TOP) are global health concerns, but their interaction is undetermined. The aim of this study was to determine whether there is an association between IPV and TOP.
Methods and Findings
A systematic review based on a search of Medline, Embase, PsycINFO, and Ovid Maternity and Infant Care from each database's inception to 21 September 2013 for peer-reviewed articles of any design and language found 74 studies regarding women who had undergone TOP and had experienced at least one domain (physical, sexual, or emotional) of IPV. Prevalence of IPV and association between IPV and TOP were meta-analysed. Sample sizes ranged from eight to 33,385 participants. Worldwide, rates of IPV in the preceding year in women undergoing TOP ranged from 2.5% to 30%. Lifetime prevalence by meta-analysis was shown to be 24.9% (95% CI 19.9% to 30.6%); heterogeneity was high (I2>90%), and variation was not explained by study design, quality, or size, or country gross national income per capita. IPV, including history of rape, sexual assault, contraceptive sabotage, and coerced decision-making, was associated with TOP, and with repeat TOPs. By meta-analysis, partner not knowing about the TOP was shown to be significantly associated with IPV (pooled odds ratio 2.97, 95% CI 2.39 to 3.69). Women in violent relationships were more likely to have concealed the TOP from their partner than those who were not. Demographic factors including age, ethnicity, education, marital status, income, employment, and drug and alcohol use showed no strong or consistent mediating effect. Few long-term outcomes were studied. Women welcomed the opportunity to disclose IPV and be offered help. Limitations include study heterogeneity, potential underreporting of both IPV and TOP in primary data sources, and inherent difficulties in validation.
IPV is associated with TOP. Novel public health approaches are required to prevent IPV. TOP services provide an opportune health-based setting to design and test interventions.
Please see later in the article for the Editors' Summary
Editors' Summary
Intimate partner violence (sometimes referred to as domestic violence) is one of the commonest forms of violence against women and is a global health problem. The World Health Organization defines intimate partner violence as any act of physical, psychological, or sexual aggression or any controlling behavior (for example, restriction of access to assistance) perpetrated by the woman's current or past intimate partner. Although men also experience it, intimate partner violence is overwhelmingly experienced by women, particularly when repeated or severe. Studies indicate that the prevalence (the percentage of a population affected by a condition) of intimate partner violence varies widely within and between countries: the prevalence of intimate partner violence among women ranges from 15% in Japan to 71% in Ethiopia, and the lifetime prevalence of rape (forced sex) within intimate relationships ranges from 5.9% to 42% across the world, for example. Overall, a third of women experience intimate partner violence at some time during their lifetimes. The health consequences of such violence include physical injury, depression, suicidal behavior, and gastrointestinal disorders.
Why Was This Study Done?
Intimate partner violence can also lead to gynecological disorders (conditions affecting the female reproductive organs), unwanted pregnancy, premature labour and birth, and sexually transmitted infections. Because violence may begin or intensify during pregnancy, some countries recommend routine questioning about intimate partner violence during antenatal care. However, women seeking termination of pregnancy (induced abortion) are not routinely asked about intimate partner violence. Every year, many women worldwide terminate a pregnancy. Nearly half of these terminations are unsafe, and complications arising from unsafe abortions are responsible for more than 10% of maternal deaths (deaths from pregnancy or childbirth-related complications). It is important to know whether intimate partner violence and termination of pregnancy are associated in order to develop effective strategies to deal with both these global health concerns. Here, the researchers conducted a systematic review and meta-analysis to investigate the associations between intimate partner violence and termination or pregnancy. A systematic review identifies all the research on a given topic using predefined criteria; meta-analysis combines the results of several studies.
What Did the Researchers Do and Find?
The researchers identified 74 studies that provided information about experiences of intimate partner violence among women who had had a termination of pregnancy. Data in these studies indicated that, worldwide, intimate partner violence rates among women undergoing termination ranged from 2.5% to 30% in the preceding year and from 14% to 40% over their lifetime. In the meta-analysis, the lifetime prevalence of intimate partner violence was 24.9% among termination-seeking populations. The identified studies provided evidence that intimate partner violence was associated with termination and with repeat termination. In one study, for example, women presenting for a third termination were more than two and a half times more likely to have a history of physical or sexual violence than women presenting for their first termination. Moreover, according to the meta-analysis, women in violent relationships were three times as likely to conceal a termination from their partner as women in non-violent relationships. Finally, the studies indicated that women undergoing terminations of pregnancy welcomed the opportunity to disclose their experiences of intimate partner violence and to be offered help.
What Do These Findings Mean?
These findings indicate that intimate partner violence is associated with termination of pregnancy and that a woman's partner not knowing about the termination is a risk factor for intimate partner violence among women seeking termination. Overall, the researchers' findings support the concept that violence can lead to pregnancy and to subsequent termination of pregnancy, and that there may be a repetitive cycle of abuse and pregnancy. The accuracy of these findings is limited by heterogeneity (variability) among the included studies, by the likelihood of underreporting of both intimate partner violence and termination in the included studies, and by lack of validation of reports of violence through, for example, police reports. Nevertheless, health-care professionals should consider the possibility that women seeking termination of pregnancy may be experiencing intimate partner violence. In trying to prevent repeat terminations, health-care professionals should be aware that while focusing on preventing conception may reduce the chances of a woman becoming pregnant, she may still be vulnerable to abuse. Finally, given the clear associations between intimate partner violence and termination of pregnancy, the researchers suggest that termination services represent an appropriate setting in which to test interventions designed to reduce intimate partner violence.
Additional Information
Please access these websites via the online version of this summary at
The World Health organization provides detailed information about intimate partner violence and about termination of pregnancy (some information available in several languages)
MedlinePlus provides links to other resources about intimate partner violence and about termination of pregnancy (in English and Spanish)
The World Bank has a webpage that discusses the role of the health sector in preventing gender-based violence and a webpage with links to other resources about gender-based violence
The Gender and Health Research Unit of the South African Medical Research Council provides links to further resources about intimate partner violence (research briefs/policy briefs/fact sheets/research reports)
DIVERHSE (Domestic & Interpersonal Violence: Effecting Responses in the Health Sector in Europe) is a European forum for health professionals, nongovernmental organizations, policy-makers, and academics to share their expertise and good practice in developing and evaluating interventions to address violence against women and children in a variety of health-care settings
London School of Hygiene & Tropical Medicine's Gender Violence and Health Centre also has a number of research resources
The UK National Health Service Choices website provides personal stories of intimate partner violence during pregnancy
The March of Dimes provides information on identifying intimate partner violence during pregnancy and making a safety plan
PMCID: PMC3883805  PMID: 24409101
23.  Prevalence of Consensual Male–Male Sex and Sexual Violence, and Associations with HIV in South Africa: A Population-Based Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001472.
Using a method that offered complete privacy to participants, Rachel Jewkes and colleagues conducted a survey among South African men about their lifetime same-sex experiences.
Please see later in the article for the Editors' Summary
In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus.
Methods and Findings
In a cross-sectional study conducted in 2008, men aged 18–49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male–male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26–12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22–7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24–7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17–10.9).
In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.
Please see later in the article for the Editors' Summary
Editors' Summary
AIDS first emerged in the early 1980s among gay men living in the US, but it soon became clear that AIDS also infects heterosexual men and women. Now, three decades on, globally, 34 million people (two-thirds of whom live in sub-Saharan Africa and half of whom are women) are infected with HIV, the virus that causes AIDS, and 2.5 million people become infected every year. HIV is most often spread by having unprotected sex with an infected partner, and most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM; homosexual, bisexual, and transgender men, and heterosexual men who sometimes have consensual sex with men). Moreover, in the concentrated HIV epidemics of high-income countries (epidemics in which the prevalence of HIV infection is more than 5% in at-risk populations such as sex workers but less than 1% in the general population), male-to-male sexual contact remains the most important transmission route, and MSM often have a higher prevalence of HIV infection than heterosexual men.
Why Was This Study Done?
By contrast to high-income countries, HIV epidemics in sub-Saharan Africa are generalized—the prevalence of HIV infection is 1% or more in the general population. Because male-to-male sexual behavior is criminalized in many African countries and because homosexuality is widely stigmatized, little is known about the prevalence of consensual male–male sexual behavior in sub-Saharan Africa. This information and a better understanding of male–female sexual concurrency (having overlapping sexual relationships with men and women) and of how male-to-male transmission contributes to generalized HIV epidemics is needed to inform the design of HIV prevention strategies for use in sub-Saharan Africa. In addition, very little is known about male-on-male sexual violence. Such violence is potentially important to study because we know that male-on-female violence is associated with increased HIV risk for both victims and perpetrators. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers use data from a population-based household survey to investigate the lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) among men in South Africa and the association of these experiences with HIV infection.
What Did the Researchers Do and Find?
About 1,700 adult men from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces of South Africa self-completed a survey that included questions about their lifetime history of same-sex experiences using audio-enhanced personal digital assistants, a data collection method that provided a totally private and anonymous environment for the disclosure of illegal and stigmatized behavior; 1,220 of them also provided dried blood spots for HIV testing. Ninety-two men (5.4% of the participants) reported consensual sexual activity (for example, anal or oral sex) with another man at some time during their life; 9.6% of the men reported that they had been forced to have sex with another man (sexual victimization), and 3% reported that they had perpetrated sexual violence against another man. Most of the men who reported consensual sex with men, including those with current male partners, reported that they had a current female partner. Men with a history of consensual male–male sexual behavior were more likely to have been a victim or perpetrator of male-on-male sexual violence than men without a history of such experiences. Finally, men who reported consensual oral or anal sex with a man were more likely to be HIV+ than men without such a history, and perpetrators of male-on-male sexual violence were more likely to be HIV+ than non-perpetrators.
What Do These Findings Mean?
These findings provide new information about male–male sexual behaviors, male-on-male sexual violence, male–female concurrency, and HIV prevalence among men in two South African provinces. The precision of these findings is likely to be affected by the small numbers of men reporting a history of consensual male–male sexual behavior and of male-on-male sexual violence. Importantly, because the study was cross-sectional, these findings cannot indicate whether the association between consensual male–male sexual behaviors and increased risk of male-on-male sexual violence is causal. Moreover, these findings may not be generalizable to other regions of South Africa or to other African countries. Nevertheless, these findings suggest that information about the risks of male–male sexual behaviors should be included in HIV prevention strategies targeted at the general population in South Africa and that HIV prevention interventions for South African men should explicitly address male-on-male sexual violence. Similar HIV prevention strategies may also be suitable for other African countries, but are likely to succeed only in countries that have, like South Africa, decriminalized consensual homosexual behavior.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Jerome Singh
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, including summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and men who have sex with men, on HIV prevention, and on AIDS in Africa (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about HIV/AIDS among men who have sex with men (in English and Spanish)
Patient stories about living with HIV/AIDS are available through Avert; the charity website Healthtalkonline also provides personal stories about living with HIV
PMCID: PMC3708702  PMID: 23853554
24.  Firearm Ownership Among Military Veterans with PTSD: A Profile of Demographic and Psychosocial Correlates 
Military medicine  2016;181(10):1207-1211.
Posttraumatic stress disorder (PTSD), a condition that disproportionately affects military veterans, is associated with heightened rates of aggression and suicide. Although experience with firearms is common among this population, virtually nothing is known regarding who is more likely to own a firearm and whether firearm ownership is differentially associated with psychological and behavioral risk factors among veterans with PTSD. Of 465 veterans (79% male) entering PTSD treatment, 28% owned a firearm (median number of firearms among owners = 3, range 1-40). Firearm owners reported higher income, were less likely to be unemployed, and were more likely to be male, Caucasian, married, and living in permanent housing. Ownership was associated with higher combat exposure and driving aggression, yet lower rates of childhood and military sexual trauma, suicidal ideation, and incarceration. Ownership was not associated with previous suicide attempt, arrest history, number of traumas experienced, PTSD symptoms, or depression. Together, among a sample of treatment-seeking military veterans with PTSD, those who owned a firearm appeared to demonstrate greater stability across a number of domains of functioning. Importantly though, routine firearm safety discussions (e.g., accessibility restrictions; violence risk assessments) and bolstering of anger management skills remain critical when working with this high-risk population.
PMCID: PMC5308415  PMID: 27753553
Guns; Firearms; Veterans; PTSD; Trauma; Suicide
25.  Health Risk Behaviors of Afghanistan and Iraq War Veterans Attending College 
The population military veterans attending college is rapidly growing as veterans return from Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). We sought to describe patterns of student veterans’ health-related behaviors and how they might differ from their non-veteran peers.
We analyzed data from the 2008 Boynton College Student Health Survey (CSHS).
CSHS participants completed an anonymous online survey.
The CSHS sampled students (n=8,651) attending public, private, two-, and four-year postsecondary educational institutions in Minnesota.
The CSHS included items on substance use (including alcohol and tobacco), safety, nutrition, and physical activity.
We described demographics of OEF/OIF veteran, non-OEF/OIF veteran, and non-veteran students and used poisson regression to compute adjusted relative risks (ARR) with 95% confidence intervals to characterize associations between veteran status and health behaviors.
After controlling for demographics, veteran students reported more safety-, tobacco-, and alcohol-related risk behaviors compared to non-veteran students. For instance, compared to the non-veteran reference group, the ARR for past year smokeless tobacco use and physical fighting among for OEF/OIF veterans was 1.76 [CI: 1.31–2.35] and 1.48 [CI: 1.22–1.79] respectively. Veteran and non-veteran students display similar weight-related behaviors, though OEF/OIF veteran students were more likely to engage in strengthening exercises.
There are specific health risk behaviors which are particularly relevant for veterans attending postsecondary institutions. As veterans enroll in postsecondary education there is a unique window of opportunity for health promotion in this population.
PMCID: PMC3579508  PMID: 22040391
Veterans; Young Adult; Tobacco; Substance Abuse; Obesity; Safety

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