Military Responds to High Rates of STIs in Active-Duty Female Servicemembers

by U.S. Medicine

May 6, 2013

PROVIDENCE, RI – Active-duty women have far higher rates of sexually transmitted infections (STIs) than their male colleagues or civilian counterparts, and the military services are trying to help young servicemembers avoid the types of behavior that can create medical issues.

Military women had STI rates three to seven times greater than women of the same age in the general population, according to an article published in the Journal of Women’s Health.

Dr. Vinita Goyal, MD, MPH, of Women and Infants’ Hospital, Providence, and colleagues

Active-duty women are more likely to be young, unmarried and from racial and ethnic minorities, all demographic groups with increased risk of STIs compared with the general population, noted Vinita Goyal, MD, MPH, of Women and Infants’ Hospital, Providence, and colleagues.1

In addition, a report on sexually transmitted infections among active-duty members of U.S. Armed Forces in Medical Surveillance Monthly Report (MSMR) found that, from 2000-12, military women had rates of diagnosis two to five times those among men. In a bit of good news, the MSMR report found that rates of human papillomavirus (HPV), gonorrhea and syphilis dropped steadily over the last four years.2

In part to meet this need, the Navy recently launched its Reproductive and Sexual Health Program. Designed to “encourage sailors, Marines, their families and health educators to access resources about preventing sexually transmitted infections” and unintended pregnancies, according to a Navy press release, the program was launched to coincide with the national Centers for Disease Control and Prevention’s Sexually Transmitted Disease Awareness Month.

The Navy campaign promotes the use of condoms in every sexual encounter, vaccination against HPV, regular screening for STIs, and use of a “buddy system when going out to prevent alcohol and sex related incidents.”

The cornerstone of the campaign is the Navy and Marine Corps Public Health Center’s (NMCPHC) Sexual Health and Responsibility Program (SHARP), which seeks to reduce the occurrence of STIs, including HIV, as well as unplanned pregnancies among sailors, Marines and their families to levels specified in selected Healthy People 2020 Objectives.

Unsafe Practices

Unsafe practices and skewed demographics may explain some of the difference seen between military and civilian women. “Studies of active-duty servicewomen, primarily new recruits, reveal a high prevalence of unsafe sexual practices, including sporadic condom use, multiple sexual partners and binge drinking, which compromises barrier contraceptive use,” wrote Goyal and colleagues.

The researchers reviewed the literature on high-risk sexual behaviors, STIs, and HPV–related disease among women in the armed services. Studies surveyed were published between 1991 and 2011. Where possible, the authors compared rates among civilian and military women.

Low rates of condom use likely contribute to high rates of STIs, note the researchers. A study included in the analysis found that 68% of Army servicewomen did not regularly use condoms and only 37% had used one with their last casual sexual partner. Among women with five or more sexual partners in the previous 12 months, 53% reported using a condom the last time they had sex.

A high number of sexual partners may also be a factor. Nearly 60% of active-duty women reported more than one sexual partner in the previous year, and 27% said they had more than one partner in the preceding three months. Of those, only 17% said their partner always used a condom.

Among female Army recruits, one-third reported binge drinking in the previous 30 days, about five times the civilian rate of 6% to 7%.

“Female Army recruits who participated in binge drinking were less likely to report using effective methods of contraception during their last sexual encounter,” Goyal and her co-authors noted. Similar percentages were seen in a study of female Marine recruits, 31% of whom reported having sex under the influence of alcohol or drugs in the three months before boot camp.

The data raise the question whether being in the service increased the incidence of binge drinking and unsafe sex. A survey of women veterans found that nearly one-quarter reported having unintended sex after drinking or using drugs before they joined the military, and one-third said they engaged in those behaviors while on active duty. One possible explanation comes from a qualitative survey which found that women in the Navy participated in binge drinking to “fit in with a predominantly male crew.”

“These high-risk sexual practices likely contribute to Chlamydia infection rates that are higher than the rates in the general U.S. population. Human papillomavirus (HPV) infection and cervical dysplasia may also be higher among young, active-duty servicewomen” for the same reasons, Goyal said.

About 14% of Marine female recruits tested positive for at least one STI at first screening compared to 8% of adolescent and young women 15- to 24-years-old in the general population. Risk factors for Chlamydia included younger age, black race, multiple sexual partners, a partner who sporadically used condoms and lower rank.

Screening Effect

Some of these higher rates might be attributed to increased screening in active-duty women, according to the MSMR article. The incidence rates of Chlamydia, HPV and gonorrhea peaked between 2006 and 2008, largely as a result of sharp increases in rates among the youngest servicewomen.

“It is likely that the implementation of the services’ screening programs for STIs among female service members as they entered active service and the subsequent annual screening for women under age 26 played a major role in the detection of these three STIs,” which are often asymptomatic in women, the report pointed out.

The MSMR report analyzed data from 2000 through 2012 on active-duty servicemembers from all branches. “Although the number of incident diagnoses of each STI was greater in men than women, the incidence rates for each STI were markedly higher among women than men,” noted the authors.

Active-duty women’s rates of Chlamydia infection ranged from four to five times that of men in the service, peaking at 406.7 per 10,000 person years in 2008 and falling to 332.6 per 10,000 person-years in 2012. For genital herpes simplex infections (HSV), rates among women dropped from nearly 80 to 63 per 10,000 person years between 2000 and 2010, while men’s rates remained below 16 per 10,000 person years during the entire study period. Female servicemembers had two to three times the rate of gonorrheal infection of men until 2012, when the ratio dropped to 1.7 as infections among women sharply declined.

For Chlamydia, HSV and gonorrhea, rates in women were highest among those in the youngest age groups, with women aged 17-19 often having rates of infection five to six times greater than women 25-29.

For HPV infections, dramatic declines in infection rates among women in the youngest age groups after 2007 accounted for much of the 42% drop in incidence rates (481 to 280 per 10,000 person years) for all women. “It is plausible that the introduction of the HPV vaccine for women and girls in 2006 started to affect the rates of acquisition of HPV infection in subsequent years,” the authors concluded.

While rates of STIs appear to be declining among military women, the high rates compared with the women in the general population and to men in the service underscore the need for increased focus on servicewomen’s sexual health.

“Understanding and addressing the needs of these women will give healthcare providers an opportunity to improve reproductive health care and perhaps lower the rates of sexually transmitted infections among servicewomen and female veterans,” according to Goyal.

1 Goyal V, Mattocks KM, Sadler AG. High-risk behavior and sexually transmitted infections among U.S. active duty servicewomen and veterans. Journal of Women’s Health. 2012;21(11):1155-1169.

2 Sexually transmitted infections, active component, U.S. Armed Forces, 2000-2012. MSMR. 2013;20(2):5-10.

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