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

  • Ginny L. Ryan
    Correspondence
    Reprint requests: Ginny L. Ryan, M.D., M.A., University of Iowa Hospitals and Clinics, Reproductive Endocrinology & In Vitro Fertilization, 31332 PFP, 200 Hawkins Drive, Iowa City, Iowa 52242.
    Affiliations
    Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
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  • Michelle A. Mengeling
    Affiliations
    Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa

    Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa

    VA Office of Rural Health, Veterans Rural Health Resource Center–Central Region, Iowa City VA Health care System, Iowa City, Iowa
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  • Brenda M. Booth
    Affiliations
    Center for Mental Healthcare Outcomes and Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas

    Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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  • James C. Torner
    Affiliations
    Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa

    Department of Neurosurgery and Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
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  • Craig H. Syrop
    Affiliations
    Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
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  • Anne G. Sadler
    Affiliations
    Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa

    Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa
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      Objective

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

      Design

      Cross-sectional, computer-assisted telephone interview study.

      Setting

      Two Midwestern Veterans Administration (VA) medical centers.

      Patient(s)

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

      Intervention(s)

      None.

      Main Outcome Measure(s)

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

      Result(s)

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

      Conclusion(s)

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

      Key Words

      Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/ryang-childlessness-female-veterans-sexual-assault/
      The lifetime risk of sexual assault for the general, nonmilitary population of women in the United States is between 15% and 20% (
      • Tjaden P.
      • Thoennes N.
      Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey.
      ,
      • Rand M.R.
      National crime victimization survey: criminal victimization.
      ,
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • et al.
      The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report.
      ), with incidence rates showing a significant decrease in recent years to 2.1 attempted, completed, or threatened rapes or sexual assaults per 1,000 women in the year 2010 (
      • Planty M.
      • Langton L.
      • Krebs C.
      • Verzofsky M.
      • Smiley-McDonald H.
      Special report: female victims of sexual violence, 1994-2010.
      ). In contrast, studies have shown an emerging epidemic of sexual assault in the military. A May 2013 report, for example, detailed 6.1% of female active duty service members reporting unwanted sexual contact in 2012 alone (29 times the rate shown above in the general population) (

      Lardner R. Sexual assaults in military rose to over 26,000 in 2012: Pentagon survey. The Huffington Post, May 7, 2013. Available at: http://www.huffingtonpost.com/2013/05/07/sexual-assaults-military_n_3229790.html. Accessed May 23, 2013.

      ). On the basis of this report, officials estimate that as many as 26,000 military members may have been sexually assaulted in 2012, up 35% from 2011 (

      Lardner R. Sexual assaults in military rose to over 26,000 in 2012: Pentagon survey. The Huffington Post, May 7, 2013. Available at: http://www.huffingtonpost.com/2013/05/07/sexual-assaults-military_n_3229790.html. Accessed May 23, 2013.

      ). Other studies consistently show that military service is high risk for assault, with between 11% and 48% of female veterans reporting sexual trauma during this time (
      • Suris A.
      • Lind L.
      Military sexual trauma: a review of prevalence and associated health consequences in veterans.
      ,
      • Sadler A.G.
      • Booth B.M.
      • Nielson D.
      • Doebbeling B.N.
      Health-related consequences of physical and sexual violence: women in the military.
      ,
      • Kimerling R.
      • Street A.E.
      • Pavao J.
      • Smith M.W.
      • Cronkite R.C.
      • Holmes R.H.
      • et al.
      Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq.
      ,
      • Kimerling R.
      • Street A.E.
      • Gima K.
      • Smith M.W.
      Evaluation of universal screening for military-related sexual trauma.
      ,
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.
      • Frayne S.
      The Veterans Health Administraion and military sexual trauma.
      ,
      • Sadler A.G.
      • Booth B.M.
      • Doebbeling B.N.
      Gang and multiple rapes during military service: health consequences and health care.
      ). Women in the military are also at increased risk of having been sexually assaulted in childhood, with rates of 25%–46% (
      • Polusny M.A.
      • Dickinson K.A.
      • Murdoch M.
      • Thuras P.
      The role of cumulative sexual trauma and difficulties identifying feelings in understanding female veterans' physical health outcomes.
      ,
      • Sadler A.G.
      • Booth B.M.
      • Cook B.L.
      • Torner J.C.
      • Doebbeling B.N.
      The military environment: risk factors for women's non-fatal assaults.
      ).
      Although President Obama recently signed into law a defense bill that expands efforts to prevent military sexual assault and strengthen protections for victims (

      AP/The Huffington Post. Obama signs defense bell cracking down on military sexual assault. The Huffington Post, December 26, 2013. Available at: http://www.huffingtonpost.com/2013/12/26/obama-defense-bill_n_4505228.html. Accessed January 8, 2014.

      ), the Pentagon also announced early in 2013 that women would no longer be excluded from ground combat positions, with a goal of full integration by 2016 (

      Pelledrin C. Dempsey: Allowing women in combat strengthens joint force. American Focus Press Service, US Department of Defense. Available at: www.defense.gov/news/newsarticle.aspx?id=119100. Accessed May 23, 2013.

      ). Thus military service presents female service members with high sexual assault and increasing combat-related trauma risks, not to mention deployment-related family disruptions. All of these exposures may impact veterans' overall health, as well as reproductive health, choices, and outcomes. One study published by Frayne et al. in 1999 reported that women experiencing sexual assault during military service were 2.5 times more likely than their military colleagues to answer “yes” to the question, “Is there something about your military experience that interfered with your desire or ability to have children?” (
      • Frayne S.M.
      • Skinner K.M.
      • Sullivan L.M.
      • Tripp T.J.
      • Hankin C.S.
      • Kressin N.R.
      • et al.
      Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military.
      ). In the same study, assaulted women were also more likely to report “a problem getting pregnant,” miscarriage, chronic pelvic pain, dysmenorrhea, premenstrual syndrome, abnormal menses, and endometriosis. Compounding these risks, female veterans are more likely to develop posttraumatic stress disorder (PTSD) after traumatic exposures than their male counterparts (
      • Zinzow H.M.
      • Gubaugh A.L.
      • Monnier J.
      • Suffoletta-Maierle S.
      • Frueh B.C.
      Trauma among female veterans: a critical review.
      ), and in-military sexual assault may be particularly traumatizing owing to perpetration by trusted colleagues, use of weapons, and frustration with lack of military response (
      • Frayne S.M.
      • Skinner K.M.
      • Sullivan L.M.
      • Tripp T.J.
      • Hankin C.S.
      • Kressin N.R.
      • et al.
      Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military.
      ).
      A thorough understanding of female veterans' reproductive health concerns is vital given that there are more than 1.8 million female veterans in the United States, and women represent the fastest growing segment of military veterans in this country. With 14% of current active duty forces, 17% of Reserve and National Guard members, and a full 20% of all new military recruits being women, it is expected that 10.7% of all veterans will be women by the year 2020 (

      Department of Veterans Affairs Office of Media Relations. Women Veterans Task Force draft plan released. VA seeks public comment on strategies. Press release, May 15, 2012. Available at: www.va.gov/opa/pressrel/pressrelease.cfm?id=2314. Accessed April 6, 2013.

      ,

      National Center for Veterans Analysis and Statistics. Veteran population. Available at: www.va.gov/VETDATA/Veteran_Population.asp. Accessed April 6, 2013.

      ,

      Women Veterans Health Care. Facts and statistics about women veterans. The changing face of women veterans. Available at: http://www.womenshealth.va.gov/WOMENSHEALTH/facts.asp. Accessed April 6, 2013.

      ). Congress has appropriately mandated that gender-specific services be made available for all female veterans, and this charge is being met by a number of initiatives led by the Women Veterans Health Strategic Health Care Group, including installation of Women Veterans Program Managers at each Veterans Health Administration (VA) facility. These managers coordinate a combination of services at local VA sites with fee-based referrals to non-VA providers because comprehensive reproductive health services are not currently available through the VA health system. One study, for example, revealed that 56 of 133 VA sites did not have a gynecologist available, and such sites were less likely to offer a full range of gynecologic services, such as intrauterine device placement and infertility evaluation (
      • Seelig M.D.
      • Yano E.M.
      • Bean-Mayberry B.
      • Lanto A.G.
      • Washington D.L.
      Availability of gynecologic services in the department of veterans affairs.
      ). A more recent focus group analysis of female veterans suggested that perceived gender discrimination and knowledge gaps negatively impact VA-based reproductive health care seeking and that female veterans express a desire for better coverage for advanced infertility care (
      • Mattocks K.M.
      • Nikolajski C.
      • Haskell S.
      • Brandt C.
      • McCall-Hosenfeld J.
      • Yano E.
      • et al.
      Women veterans' reproductive health preferences and experiences: a focus group analysis.
      ).
      The analysis presented here is part of a larger project whose goal was to assess the antecedent risks and subsequent reproductive health consequences of physical and sexual assault in premenopausal female veterans, as well as barriers to appropriate health services. The goal of this subanalysis was to follow up on Frayne's 1999 study (
      • Frayne S.M.
      • Skinner K.M.
      • Sullivan L.M.
      • Tripp T.J.
      • Hankin C.S.
      • Kressin N.R.
      • et al.
      Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military.
      ) and further investigate associations between lifetime attempted or completed sexual assault (LSA) and voluntary and involuntary childlessness and related care seeking in female veterans.

      Materials and methods

       Participants and Procedures

      This was a cross-sectional observational study approved by the institutional review boards of the University of Iowa and the Iowa City VA Medical Center. Subjects included women aged ≤52 years enrolled at one of two Midwestern VA Medical Centers or outlying clinics either in the 5 years preceding study interviews or during the study period (July 2005–August 2008). Potential participants were identified using electronic VA records. Enrollment in the VA could have been initiated to receive health care, complete a disability claim, enroll in a registry, or respond to Veteran outreach.
      An introductory letter and consent forms with postage-paid, preaddressed return envelopes were mailed to potential subjects, providing them with a toll-free number through which to schedule interviews, ask questions, or refuse participation. Within 2 weeks after the introductory letter, eligible subjects who did not initiate contact were recruited into the study by telephone, with a maximum of eight call attempts. These mail and telephone protocols were repeated for potential subjects until contact was made or subjects were deemed unreachable. When address or telephone problems occurred, efforts were made to find current contact information using directory assistance, Internet “white pages,” the VA's Computerized Record System, and Accurint (a confidential Lexis Nexis research tool) (2009). Women refusing participation were asked for reasons for their refusal and three questions related to the original purpose of the study (gynecologic health) to allow comparison with participants: [1] “In general, would you say your health is excellent, very good, good, fair, or poor?”; [2] “Have you ever been told you have had an abnormal Pap smear?”; [3] “In the last year, approximately how many times have you seen a doctor or health care provider for gynecologic health issues?”
      For the purpose of the funded grant and primary goal of the larger study (to look at the reproductive health of premenopausal veterans at low risk of gynecologic malignancy), subjects were screened to reduce involvement of those at high risk of cervical dysplasia, genital malignancy, and/or natural menopause. Included participants completed a computer-assisted telephone interview that included questions related to demographics, lifetime sexual assault, gynecologic diagnoses and procedures, general and mental health history, health risk behaviors, and care seeking. Survey items came from multiple sources, including validated measures or prior published work, or were original to this study. The interviews took an average of 1 hour and 16 minutes, and the majority was completed in a single phone call (89%). Participants who completed the interview were reimbursed $30.00.

       Measures

      Standard demographic measures were assessed (Table 1). Current insurance status was assessed by asking subjects whether they had Medicare, Medigap, Medicaid, TRICARE, Civilian Health and Medical Program of the Department of Veterans Affairs, Veterans Affairs Medical Center, or private insurance. To assess sexual orientation, subjects were asked for their current sexual preference and for any history of having sex with women. To assess gynecologic care seeking at the VA, subjects were asked if they had “ever sought care for gynecologic issues at the VA” or if they “had a Pap smear at the VA in the last 5 years.”
      Table 1Sample characteristics and obstetric/gynecologic data by LSA history.
      ParameterTotal (n = 1,004), %, mean (SD)No LSA (n = 380), %, mean (SD)LSA (n = 620), %, mean (SD)P value
      For comparisons between No LSA and LSA.
      Sample characteristics
       Demographics
      Age, y (mean)38.3 (8.8)36.4 (8.9)39.5 (8.6)<.0001
      White race808080.87
      Currently married444543.58
      Highest education level high school151615.48
      Household income,
      Six responded “Don't know” and nine refused to answer.
      US$ (mean)
      45,054 (48,916)44,000 (31,912)45,751 (57,065).58
      Health insurance
      Three responded “Don't know.”
      848583.24
      Private health insurance404437.04
      Ever sought gynecologic care at VA706276<.0001
      Heterosexual
      Five responded “Don't know” and two refused to answer.
      949792.0002
      Ever same sex partnerships11615<.0001
       Health characteristics (n = 1,004)
      PTSD
      Five answered “Don't know.”
      (ever diagnosed)
      241032<.0001
      Depression (ever diagnosed)
      Four answered “Don't know.”
      533464<.0001
      STI (ever diagnosed)362742<.0001
      Obstetric/gynecologic data
       Ever pregnant (n = 1,003)777279.0042
       Pregnancy (n = 764)
      Age at first pregnancy
      One answered “Don't know.”
      (mean)
      21.9 (4.4)22.8 (4.3)21.5 (4.5).0002
      Number of pregnancies (mean)2.7 (1.7)2.5 (1.5)2.9 (1.7).0004
      Ever terminated a pregnancy271931.0007
      No. of pregnancy terminations (mean)0.39 (0.8)0.26 (0.6)0.46 (0.9).0001
       Experienced postpartum dysphoria
      Ever experienced depression or blues.
      (n = 642)
      554462<.0001
       Infertililty
      Tried to have a baby but couldn't (n = 1,004)191223<.0001
      Evaluated for infertility (n = 190)526448.058
      Treated for infertility (n=119)556252.35
      a For comparisons between No LSA and LSA.
      b Six responded “Don't know” and nine refused to answer.
      c Three responded “Don't know.”
      d Five responded “Don't know” and two refused to answer.
      e Five answered “Don't know.”
      f Four answered “Don't know.”
      g One answered “Don't know.”
      h Ever experienced depression or blues.
      Sexual assault questions were guided by the definition adopted by the American Medical Association (
      American Medical Association
      Strategies for treatment and prevention of sexual assault.
      ) and The American College of Obstetrician and Gynecologists (
      • American College of Obstetricians and Gynecologists
      Sexual assault.
      ) and specifically adapted from those used in the National Violence Against Women Survey (
      • Tjaden P.
      • Thoennes N.
      Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey.
      ), (widely used measures) (
      • Kreisel B.W.
      Rape and sexual victimizations, measurement of.
      ,
      • Sadler A.G.
      • Mengeling M.A.
      • Syrop C.H.
      • Torner J.C.
      • Booth B.M.
      Lifetime sexual assault and cervical cytologic abnormalities among military women.
      ,
      • Sadler A.G.
      • Booth B.M.
      • Mengeling M.A.
      • Doebbeling B.N.
      Lifespan and repeated violence against women during military service: effects on health status and outpatient utilization.
      ,
      • Sadler A.G.
      • Booth B.M.
      • Cook B.L.
      • Doebbeling B.N.
      Factors associated with women's risk of rape in the military environment.
      ), and from the “Survey of Rape in Iowa” (

      Kilpatrick DG, Ruggiero KJ. Rape in Iowa: a report to the state. Charleston, SC: National Violence Against Women Prevention Research Center, Medical University of South Carolina, 2003.

      ). This American Medical Association definition includes any sexual act that occurred without a woman's consent involving the use or threat of force or against the woman's wishes, and includes attempted or completed sexual penetration of the vagina, mouth, or rectum by penis, fingers, or object. Sexual assaults in which an attempt was made but penetration did not occur were deemed attempted LSA; completed LSA were assaults in which penetration did occur. This definition was read to participants before beginning this interview section, and women were asked whether they had experienced any such act in the past. Women reporting one or more LSA were then asked further questions related to the occurrence(s), including the number of incidents and whether these occurred during childhood (age <18 years), in adulthood before the military (age 18 to military entry), during military service (regular military, military Reserves, or National Guard), and in adulthood after military service. Several questions were asked solely of women who reported a completed sexual assault: [1] Have you “ever delayed childbearing as a result of the rape?”; [2] Have you “ever decided not to have children as a result of the rape?”; and [3] “As a direct result of the rape, did you have an early termination of pregnancy (an abortion)?” Response options for these three questions included yes, no, don't know, and refuse to answer.
      All participants who reported ever having been pregnant were asked how many of their pregnancies “had resulted in an early pregnancy termination (that is, an abortion).” A dichotomous variable was created from these data to represent whether a participant had ever terminated a pregnancy (i.e., no vs. one or more terminations). These data were not limited to those who had experienced LSA. Results were used in bivariate and multivariate analyses. Postpartum depression and blues were assessed by asking, “Were you ever depressed after the delivery of any of your children?” and “Did you ever cry a lot or have mood swings after the delivery of any of your children?” These questions were modified from clinical instruments used at the University of Iowa. For the purposes of analysis, participants who answered “yes” to either question were considered to have experienced “postpartum dysphoria.”
      To assess history of sexually transmitted infection (STI), all participants were asked whether they had ever been diagnosed with pelvic inflammatory disease, gonorrhea, chlamydia, syphilis, herpes, venereal warts or human papillomavirus, or HIV/AIDS (
      • Shafer M.A.
      • Boyer C.B.
      • Shaffer R.A.
      • Schachter J.
      • Ito S.I.
      • Brodine S.K.
      Correlates of sexually transmitted diseases in a young male deployed military population.
      ). Infertility was assessed in all participants by asking, “Have you ever wanted to have a baby but couldn't?” Infertility evaluation and treatment history was also based on self-report: “Were you ever evaluated by a health care professional for infertility?” and “Did you ever receive treatment for infertility?” History of PTSD was assessed by asking subjects whether they had ever been diagnosed with this disorder by a clinician. The associated trauma was not assessed. The PTSD diagnosis was operationalized as a dichotomous variable for analysis. Current probable PTSD was assessed using validated PTSD screening instruments, including the Posttraumatic Symptom Scale (
      • Foa E.B.
      • Zoellner L.A.
      • Feeny N.C.
      • Hembree E.A.
      • Alvarez-Conrad J.
      Does imaginal exposure exacerbate PTSD symptoms?.
      ,
      • Foa E.B.
      • Cashman L.
      • Jaycox L.
      • Perry K.
      The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale.
      ).

       Data Analysis

      Preliminary analyses examined history of self-reported pregnancy termination(s), infertility, and infertility treatment among three categories of sexual assault: [1] no LSA; [2] attempted only LSA; [3] at least one completed LSA. Results were used to determine whether attempted and completed sexual assault histories should be treated as separate categories or combined into one category representing any sexual assault history. Analyses were also performed to compare history of pregnancy termination, infertility, and infertility treatment between participants who experienced sexual assault during military service and those who experienced sexual assault outside military service.
      Because of small numbers in each racial minority category, all participants describing a nonwhite race were combined in the racial minority category and compared with white race for the purposes of analysis.
      We examined bivariate relationships between LSA and key demographic and clinical (obstetric/gynecologic and mental health) variables. Demographic variables analyzed were race, age (as a continuous variable), marital status, education, income (as a continuous variable), insurance status, and sexual orientation. In addition, self-reported obstetric/gynecologic variables included number of pregnancies, age at first pregnancy, any past termination of pregnancy and number of terminations, infertility, past evaluation for infertility, past treatment for infertility, past diagnosis of sexually transmitted infection, and history of gynecologic care seeking at the VA. Mental health variables assessed included PTSD (ever diagnosed and current probable PTSD) and combined responses to queries of past experience with postpartum depression and/or postpartum blues (considered together as “postpartum dysphoria”).
      Bivariate analyses were conducted using t tests (age, number of pregnancies, age at first pregnancy, number of pregnancy terminations), χ2 tests of independence (race, marital status, education, insurance, private insurance, VA gynecologic care, sexual orientation, pregnancy termination, infertility, infertility treatment, STI diagnosis, ever diagnosed PTSD and current probable PTSD, postpartum dysphoria), and the Wilcoxon-Mann-Whitney test (income). Multivariate logistic regression models were used to identify the independent contribution of LSA to pregnancy termination and to infertility by controlling for specific covariates that were clinically relevant and/or associated in bivariate analysis with P≤.10.

      Results

       Participant Response

      Sixty-nine percent of the identified sample (1,670 of 2,414) were located and invited to participate, and 63% of those women agreed. Ninety-five percent of women who agreed to participate completed their interviews, giving a final sample size of 1,004 women (Fig. 1). The most common reasons for declining to participate included the following (more than one could be given): too busy (31%), lack of interest (30%), and not wishing to discuss gynecologic care because the topic is too personal or stressful (8%). Sixty-four percent of the 615 nonparticipating responders answered the three questions listed above in Materials and Methods. There were no significant differences in age or in current health, ever having had an abnormal result on Papanicolaou smear, or in the number of gynecologic health visits in the past year between participants and nonparticipating responders.
      Figure thumbnail gr1
      Figure 1Study sample of female veterans (aged 20–52 years) enrolled at two Midwestern VA medical centers or their outlying clinics from July 2005 through August 2008.

       Sociodemographic Data

      Sociodemographic data are listed in Table 1. Subjects ranged from 20 to 52 years old, with a median age of 40 and a mean age of 38 years. The majority was white (80%), heterosexual (94%, though 11% reported having had sex with women in their lifetimes), and had at least some college education (85%) and some form of health insurance (84%), with approximately half of those women privately insured. Ninety-five percent of subjects were enlisted personnel, and 44% were married at the time of interview. Seventy percent of subjects had ever sought gynecologic care at the VA.

       Lifetime Sexual Assault Data

      Almost two-thirds of subjects (620 of 1,004; 62%) reported a sexual assault exposure during their lifetime (LSA). One participant said she did not know about being sexually assaulted, and three refused to answer the LSA queries. Rate of LSA by period of life was as follows: 41% of participants in childhood, 15% in adulthood before the military, 33% in military, and 13% after the military (not mutually exclusive). A total of 511 subjects (51%) reported a completed assault: 31% of subjects in childhood, 11% in adulthood before the military, 25% in military, and 11% in adulthood after the military. In this population that had experienced a completed assault, the mean number of assaults was 7 (SD 9.1, median 2, range 1–56).
      The analyses of pregnancy termination and infertility among LSA categories showed that attempted LSA results were most similar to completed LSA results (pregnancy termination: n = 764; 19% no LSA, 29% attempted LSA, 31% completed LSA, P=.002; and infertility: n = 1,000; 12% no LSA, 20% attempted LSA, 24% completed LSA, P<.0001). Infertility treatment showed no overall statistical difference among LSA groups (n = 118; 62% no LSA, 50% attempted LSA, 53% completed LSA, P=.86) (data not shown in tables). Therefore, for the purposes of the bivariate and multivariate analyses, attempted sexual assault was combined with completed sexual assault to create a lifetime sexual assault (LSA) group.

       LSA and Military Service

      Many servicewomen had experienced sexual assault in multiple time periods (i.e., childhood, premilitary adulthood, in military, and postmilitary adulthood). Table 2 provides odds ratios for pregnancy termination and infertility by LSA time periods. In general, 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. Because pregnancy termination was not tied to a specific sexual assault, a multivariate logistic regression taking into account age and sexual assaults across time periods showed that women who were sexually assaulted during military service were more likely to terminate a pregnancy (adjusted odds ratio 1.66; 95% confidence interval 1.18–2.34). Similar results were found for infertility, with women assaulted during childhood, in military, or in postmilitary adulthood more likely to self-report infertility than those veterans without LSA exposure. When all time periods were included, only women sexually assaulted in childhood and/or in military service were more likely to report infertility. Bivariate and multivariate analyses were performed using LSA and did not differentiate LSA by time period.
      Table 2Self-reported pregnancy termination and infertility by LSA time period.
      Sexual assault (SA) occurrence time periodTermination (n = 764)Infertility (n = 1,000)
      OR (95% CI)AOR (95% CI)OR (95% CI)AOR (95% CI)
      No lifetime SA (reference group)1.01.01.01.0
      Childhood (age <18 y)1.55 (1.12–2.13)1.37 (0.97–1.92)1.93 (1.40–2.65)1.69 (1.21–2.36)
      Before military service1.28 (0.84–1.96)0.99 (0.63–1.55)1.44 (0.95–2.18)1.06 (0.68–1.63)
      During military service1.85 (1.33–2.57)1.66 (1.18–2.34)1.76 (1.27–2.44)1.51 (1.08–2.12)
      Post-military service1.62 (1.05–2.49)1.29 (0.82–2.03)1.54 (1.00–2.39)1.14 (0.72–1.80)
      Note: AOR = adjusted odds ratio and includes age, childhood, adult before military service, in-military, and post-military sexual assault; CI = confidence interval; OR = odds ratio.

       LSA and PTSD

      Approximately one-quarter of participants self-reported ever having been diagnosed with PTSD. Similarly, approximately one-quarter of participants screened positive for probable PTSD. Those who experienced LSA were more likely to self-report a PTSD diagnosis (32% vs. 10%, P<.0001) compared with those with no LSA. Similar results were found for current probable PTSD (33% vs. 10%, P<.0001). Because results were similar using either past PTSD diagnosis or current probable PTSD, and to be consistent with the retrospective focus of the study, we used self-report of past diagnosis of PTSD for our bivariate and multivariate analyses. Among those sexually assaulted, 47% (293 of 620) identified LSA as their most traumatic event.

       Sociodemographic Factors Associated with LSA

      Female veterans exposed to 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. Race, educational attainment, current marital status, and mean annual income were not associated with assault history (Table 1).

       LSA and Health Outcomes

      Table 1 shows the results of bivariate analyses for association between LSA status and clinical obstetric/gynecologic and mental health diagnoses. A history of 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). Of the 490 assaulted (attempted or completed) veterans who had ever been pregnant, 152 (31%) had terminated a pregnancy in their lifetimes. This was significantly higher than the 19% of veterans without a sexual assault history who reported a history of pregnancy termination. Veterans with a history of attempted or completed sexual assault 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%). Of note, female veterans with LSA history were significantly more likely to self-report experiencing postpartum dysphoria (62% vs. 44%) and three times as likely to have been diagnosed with PTSD (32% vs. 10%).
      Twenty-two servicewomen reported becoming pregnant as a direct result of a completed assault, and 10 of these women (45%) chose an early termination of that pregnancy (data not shown in tables). Twenty-three percent of all women who had experienced a completed LSA (n = 511) reported ever having delayed or foregone pregnancy “as a result of the rape.”
      Table 3 shows the results of the multivariate logistic regression analyses. For female veterans, LSA and age remained independently associated with pregnancy termination and infertility after controlling for other variables.
      Table 3LSA and other factors associated with self-reported pregnancy termination and infertility: multivariate logistic regression analysis.
      Associated factorTermination (n = 764)Infertility (n = 1,000)
      LSA1.96 (1.24–3.08)2.02 (1.38–2.94)
      Older age1.03 (1.00–1.06)1.02 (1.01–1.04)
      Depression (ever diagnosed)1.31 (0.86–2.01)
      Postpartum dysphoria (ever experienced postpartum depression or blues)1.33 (0.89–1.99)0.84 (0.79–1.65)
      PTSD (ever diagnosed)
      Five participants responded “Don't know” and are not included in the above results.
      0.79 (0.49–1.28)1.14 (0.79–1.65)
      STI1.24 (0.89–1.74)
      Note: Values are odds ratio (95% CI).
      a Five participants responded “Don't know” and are not included in the above results.

      Discussion

      The American College of Obstetricians and Gynecologists recently published a Committee Opinion entitled “Health Care for Women in the Military and Women Veterans,” in which six broad areas of focus for improved health care were identified (
      • Committee on Health Care for Underserved Women
      Committee opinion: health care for women in the military and women veterans.
      ). These included understanding reproductive health risks of military service, screening for military sexual trauma and PTSD, and promoting a research agenda to study the effect of military status on reproductive health. Researchers from the VA had previously published a similar call to action in the VA Women's Health Research Agendas of 2004 and 2010 (
      • Yano E.M.
      • Bastian L.A.
      • Bean-Mayberry B.
      • Eisen S.
      • Frayne S.
      • Hayes P.
      • et al.
      Using research to transform care for women veterans: advancing the research agenda and enhancing research-clinical partnerships.
      ). The present study contributes in an important way to this effort, with a large amount of detailed and sensitive reproductive data gathered from more than 1,000 female veterans.
      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. Although a mean number of seven assaults (for those veterans who have been assaulted) sounds alarmingly high, this is unfortunately consistent with findings from other studies that have found means of 5–9 lifetime sexual assaults (
      • Cook J.M.
      • Pilver C.
      • Dinnen S.
      • Schnurr P.P.
      • Hoff R.
      Prevalence of physical and sexual assault and mental health disorders in older women: findings from a nationally representative sample.
      ) and ranges of 2–36 total assaults just during military service (
      • Sadler A.G.
      • Booth B.M.
      • Mengeling M.A.
      • Doebbeling B.N.
      Lifespan and repeated violence against women during military service: effects on health status and outpatient utilization.
      ). The study also confirms and further expands upon suggested associations between sexual assault history and certain reproductive outcomes. We found that sexual assault was associated with both voluntary and involuntary childlessness. Specifically, approximately one in four female veterans who had experienced a completed sexual assault had “delayed or avoided” pregnancy as a result of her assault. A history of attempted or completed sexual assault increased the risk that a female veteran had also undergone pregnancy termination or experienced infertility in her lifetime, even when controlling for a history of depression, postpartum dysphoria, PTSD, or STI, and assaulted veterans were less likely to be evaluated for infertility.
      Data from the general US population suggests that approximately 22% of all pregnancies (not including miscarriages) end in abortion (
      • Jones R.K.
      • Kooistra K.
      Abortion incidence and access to services in the United States, 2008.
      ) and that 3 in 10 women will have an abortion by the age of 45 years (
      • Jones R.K.
      • Kavanaugh M.L.
      Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion.
      ). Although overall rates in this study of veterans (19%–31%) were not substantively different from these general population rates, it is remarkable to note the differences in veteran abortion rates based on sexual assault history and to see the number of abortions these women have undergone as a direct result of a sexual assault. Intimate partner violence (including rape) has been associated with higher risk of pregnancy termination and with repeat terminations in the general population (
      • Hall M.
      • Chappell L.C.
      • Parnell B.L.
      • Seed P.T.
      • Bewley S.
      Associations between intimate partner violence and termination of pregnancy: A systematic review and meta-analysis.
      ,
      • Sarkar N.N.
      The impact of intimate partner violence on women's reproductive health and pregnancy outcome.
      ). It is interesting to consider why those veterans assaulted in military (during their time in service) may have terminated pregnancies more often than those assaulted either before or after military service. As previously mentioned, PTSD is disproportionately common after in-military sexual assault, and this may be one reason why pregnancy is particularly unwelcome for these women.
      Comparing our study's infertility findings to larger population rates is difficult owing to the wide variety of operational definitions used in the literature. The National Survey of Family Growth's impaired fecundity measure (all women regardless of marital status who are not surgically sterile and for whom it is difficult or impossible to get pregnant or carry a pregnancy to term) showed in the 2006–2010 survey a current incidence for all 15–44-year-old women of 10.9% and a lifetime incidence of 21.2% (

      Centers for Disease Control and Prevention. National Survey of Family Growth. Key statistics from the National Survey of Family Growth. Available at: http://www.cdc.gov/nchs/nsfg/abc_list_i.htm#infertility. Accessed May 24, 2013.

      ). Our question (“Have you ever wanted to have a baby but couldn't?”) was exploratory and is not one of the standard measures found in the literature. Subjects may have responded in the affirmative if they had desired a baby when not with a male partner or while deployed, instead of owing to impaired fecundity. The range of reported infertility based on this query in our population (12%–23%), however, was not substantively different from the above National Survey of Family Growth results. It is again intriguing to see the differences in these self-reported infertility rates within our veteran population based on sexual assault history and still present when controlling for increased risk of STI and age. There are no comparable data on associations between sexual assault and infertility in the general population. Future studies can capitalize on these findings and use multiple, validated infertility measures and larger representative populations of male and female veterans to further investigate whether veterans have a high risk of impaired fecundity and whether those exposed to sexual assault and other traumas are at a particularly high risk.
      Female veterans with a sexual assault history in this study also reported extremely high rates of PTSD, confirming results found in the literature from our team and others (
      • Booth B.M.
      • Davis T.D.
      • Cheney A.M.
      • Mengeling M.A.
      • Torner J.C.
      • Sadler A.G.
      Physical health status of female veterans: contributions of sex partnership and in-military rape.
      ,
      • Sadler A.G.
      • Mengeling M.A.
      • Fraley S.S.
      • Torner J.C.
      • Booth B.M.
      Correlates of sexual functioning in women veterans: mental health, gynecologic health, health status, and sexual assault history.
      ,
      • Booth B.M.
      • Mengeling M.
      • Torner J.
      • Sadler A.G.
      Rape, sex partnership, and substance use consequences in women veterans.
      ), and more than half of parous veterans interviewed reported experiences consistent with postpartum blues or depression. Systematic reviews of the literature on perinatal depression in the general US population suggest point prevalence ranging from 6.5% to 12.9% of childbearing women; however, these diagnoses were based on clinical assessments or structured clinical interviews, and rates did not include “maternity blues” or minor depression (
      • Gavin N.I.
      • Gaynes B.N.
      • Lohr K.N.
      • Meltzer-Brody S.
      • Gartlehner G.
      • Swinson T.
      Perinatal depression: a systematic review of prevalence and incidence.
      ). Thus we cannot directly compare our results with these reported rates. Once again, however, it is the significant increase in these concerning symptoms in veterans with a sexual assault history rather than the absolute numbers (although these are certainly alarming) that are highlighted by this study. Additionally, although these reported symptoms of postpartum dysphoria were common, they were not independently associated with abortion or infertility in women with a history of sexual assault exposure.
      When results of this study are added to previous literature showing that LSA and PTSD in female veterans are associated with lower measures of general physical health (which worsens with greater number of assaults) (
      • Sadler A.G.
      • Booth B.M.
      • Nielson D.
      • Doebbeling B.N.
      Health-related consequences of physical and sexual violence: women in the military.
      ,
      • Sadler A.G.
      • Booth B.M.
      • Doebbeling B.N.
      Gang and multiple rapes during military service: health consequences and health care.
      ,
      • Sadler A.G.
      • Booth B.M.
      • Mengeling M.A.
      • Doebbeling B.N.
      Lifespan and repeated violence against women during military service: effects on health status and outpatient utilization.
      ,
      • Booth B.M.
      • Davis T.D.
      • Cheney A.M.
      • Mengeling M.A.
      • Torner J.C.
      • Sadler A.G.
      Physical health status of female veterans: contributions of sex partnership and in-military rape.
      ) and higher rates of eating disorders (
      • Forman-Hoffman V.L.
      • Mengeling M.
      • Booth B.M.
      • Torner J.
      • Sadler A.G.
      Eating disorders, post-traumatic stress, and sexual trauma in women veterans.
      ), substance abuse disorder (
      • Booth B.M.
      • Mengeling M.
      • Torner J.
      • Sadler A.G.
      Rape, sex partnership, and substance use consequences in women veterans.
      ), abnormal cervical cytology (
      • Sadler A.G.
      • Mengeling M.A.
      • Syrop C.H.
      • Torner J.C.
      • Booth B.M.
      Lifetime sexual assault and cervical cytologic abnormalities among military women.
      ), problems with sexual functioning and pain during intercourse (even after one sexual assault) (
      • Sadler A.G.
      • Mengeling M.A.
      • Fraley S.S.
      • Torner J.C.
      • Booth B.M.
      Correlates of sexual functioning in women veterans: mental health, gynecologic health, health status, and sexual assault history.
      ), and other gynecologic issues (
      • Frayne S.M.
      • Skinner K.M.
      • Sullivan L.M.
      • Tripp T.J.
      • Hankin C.S.
      • Kressin N.R.
      • et al.
      Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military.
      ), it becomes increasingly clear that this country's female veterans may be at substantial risk for certain reproductive outcomes and decreased quality of life after assault(s). There could be a number of reasons for these associations between sexual assault trauma and voluntary and involuntary childlessness, and these reasons are likely interrelated. Given that natural reproduction is a complicated process involving the relative physiologic health of two individuals as well as consistent intimacy between them, there are a number of possible points that could be disrupted by sexual assault trauma. These include direct tissue injury to the pelvis from trauma or infection, secondary pelvic pain or vaginismus making intercourse unbearable, neuroendocrine dysregulation due to PTSD, related eating disorder or other chronic stress, inability to maintain intimate relationships with members of attacker's gender, or avoidance of pregnancy due to desire to protect potential children from similar trauma. Furthermore, optimally early and effective treatment for these issues requires availability and utilization of appropriate health care systems, a willingness to discuss sensitive topics, and effective treatment options.
      To elucidate cause-and-effect relationships between sexual assault trauma and reproductive outcomes, future studies must take into account these many possible factors and must track the time course of insult and disease. Existing frameworks, such as Julia Seng's conceptual model of the impact of lifetime exposure to sexual assault violence on adverse maternal and fetal/child outcomes (
      • Seng J.S.
      A conceptual framework for research on lifetime violence, posttraumatic stress, and childbearing.
      ), would be helpful in organizing such studies. Dr. Seng, a researcher and nurse-midwife, adapted a Centers for Disease Control and Prevention framework for research on violence occurring around pregnancy. Her modified framework adds cumulative lifetime abuse trauma and gives PTSD a greater emphasis as a possible contributing factor for adverse health outcomes through behavioral and neuroendocrine pathways. Semi-structured qualitative inquiry would also be valuable to investigate how sexual assault and its many consequences may impact ability to conceive, indecision about childbearing, or desire to avoid childbearing.
      Because we only interviewed women veterans who were enrolled at two Midwestern US VA Medical Center or outlying clinics, the generalizability of findings are reduced by the lack of geographic, ethnic, and racial diversity. This study is also limited by the potential reporting bias inherent in this type of retrospective interview study of sensitive health issues. Nonparticipants may have been more likely to have a history of trauma and/or undesired reproductive outcomes. Participating women may also not have been comfortable discussing sensitive topics like abortion or infertility with interviewers over the phone. Both of these issues would likely lead to an underestimation of sexual assault and pregnancy termination, however. Because of the cross-sectional nature of the study, we are also unable to assess temporal associations between assault history and childlessness outside of the question that specifically asked about termination of pregnancy conceived through rape. We cannot say that attempted or completed sexual assault caused our subjects' reproductive outcomes because unmeasured confounders could cause the differences we found between groups.
      The VA may be in a better position than community primary care providers to anticipate and treat sexual assault and combat-related trauma and mental health issues such as PTSD in veterans, and leadership has articulated an interest in expanding to provide more reliable comprehensive women's health services (
      • Bean-Mayberry B.
      • Yano E.M.
      • Bayliss N.
      • Navratil J.
      • Weisman C.S.
      • Scholle S.H.
      Federally funded comprehensive women's health centers: leading innovation in women's healthcare delivery.
      ). However, it 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. In the present and near future, the reality is that many female veterans will primarily seek gynecologic care in the civilian system, and others will be referred by primary VA providers for obstetric and specialty gynecologic care. These veterans deserve the highest standards of reproductive care.

      References

        • Tjaden P.
        • Thoennes N.
        Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey.
        (Report no. NCJ 183781) US Department of Justice, National Institute of Justice, Washington, DC2000
        • Rand M.R.
        National crime victimization survey: criminal victimization.
        (Report no. NCJ 224390) US Department of Justice, Office of Justice Programs, 2008, Washington, DC2007
        • Black M.C.
        • Basile K.C.
        • Breiding M.J.
        • Smith S.G.
        • Walters M.L.
        • Merrick M.T.
        • et al.
        The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report.
        National Center for Injury Prevention and Control, Centers for Disease and Prevention, Atlanta, GA2011
        • Planty M.
        • Langton L.
        • Krebs C.
        • Verzofsky M.
        • Smiley-McDonald H.
        Special report: female victims of sexual violence, 1994-2010.
        (Report no. NCJ 240655) US Department of Justice, Office of Justice Programs, Washington, DC2013
      1. Lardner R. Sexual assaults in military rose to over 26,000 in 2012: Pentagon survey. The Huffington Post, May 7, 2013. Available at: http://www.huffingtonpost.com/2013/05/07/sexual-assaults-military_n_3229790.html. Accessed May 23, 2013.

        • Suris A.
        • Lind L.
        Military sexual trauma: a review of prevalence and associated health consequences in veterans.
        Trauma Violence Abuse. 2008; 9: 250-269
        • Sadler A.G.
        • Booth B.M.
        • Nielson D.
        • Doebbeling B.N.
        Health-related consequences of physical and sexual violence: women in the military.
        Obstet Gynecol. 2000; 96: 473-480
        • Kimerling R.
        • Street A.E.
        • Pavao J.
        • Smith M.W.
        • Cronkite R.C.
        • Holmes R.H.
        • et al.
        Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq.
        Am J Public Health. 2010; 100: 1409-1412
        • Kimerling R.
        • Street A.E.
        • Gima K.
        • Smith M.W.
        Evaluation of universal screening for military-related sexual trauma.
        Psychiatr Serv. 2008; 59: 635-640
        • Kimerling R.
        • Gima K.
        • Smith M.W.
        • Street A.
        • Frayne S.
        The Veterans Health Administraion and military sexual trauma.
        Am J Public Health. 2007; 97: 2160-2166
        • Sadler A.G.
        • Booth B.M.
        • Doebbeling B.N.
        Gang and multiple rapes during military service: health consequences and health care.
        J Am Med Womens Assoc. 2005; 60: 33-41
        • Polusny M.A.
        • Dickinson K.A.
        • Murdoch M.
        • Thuras P.
        The role of cumulative sexual trauma and difficulties identifying feelings in understanding female veterans' physical health outcomes.
        Gen Hosp Psychiatry. 2008; 30: 162-170
        • Sadler A.G.
        • Booth B.M.
        • Cook B.L.
        • Torner J.C.
        • Doebbeling B.N.
        The military environment: risk factors for women's non-fatal assaults.
        J Occup Environ Med. 2001; 43: 325-334
      2. AP/The Huffington Post. Obama signs defense bell cracking down on military sexual assault. The Huffington Post, December 26, 2013. Available at: http://www.huffingtonpost.com/2013/12/26/obama-defense-bill_n_4505228.html. Accessed January 8, 2014.

      3. Pelledrin C. Dempsey: Allowing women in combat strengthens joint force. American Focus Press Service, US Department of Defense. Available at: www.defense.gov/news/newsarticle.aspx?id=119100. Accessed May 23, 2013.

        • Frayne S.M.
        • Skinner K.M.
        • Sullivan L.M.
        • Tripp T.J.
        • Hankin C.S.
        • Kressin N.R.
        • et al.
        Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military.
        J Womens Health Gend Based Med. 1999; 8: 835-845
        • Zinzow H.M.
        • Gubaugh A.L.
        • Monnier J.
        • Suffoletta-Maierle S.
        • Frueh B.C.
        Trauma among female veterans: a critical review.
        Trauma Violence Abuse. 2007; 8: 384-400
      4. Department of Veterans Affairs Office of Media Relations. Women Veterans Task Force draft plan released. VA seeks public comment on strategies. Press release, May 15, 2012. Available at: www.va.gov/opa/pressrel/pressrelease.cfm?id=2314. Accessed April 6, 2013.

      5. National Center for Veterans Analysis and Statistics. Veteran population. Available at: www.va.gov/VETDATA/Veteran_Population.asp. Accessed April 6, 2013.

      6. Women Veterans Health Care. Facts and statistics about women veterans. The changing face of women veterans. Available at: http://www.womenshealth.va.gov/WOMENSHEALTH/facts.asp. Accessed April 6, 2013.

        • Seelig M.D.
        • Yano E.M.
        • Bean-Mayberry B.
        • Lanto A.G.
        • Washington D.L.
        Availability of gynecologic services in the department of veterans affairs.
        Womens Health Issues. 2008; 18: 167-173
        • Mattocks K.M.
        • Nikolajski C.
        • Haskell S.
        • Brandt C.
        • McCall-Hosenfeld J.
        • Yano E.
        • et al.
        Women veterans' reproductive health preferences and experiences: a focus group analysis.
        Womens Health Issues. 2011; 21: 124-129
        • American Medical Association
        Strategies for treatment and prevention of sexual assault.
        American Medical Association, Chicago, IL1995
        • American College of Obstetricians and Gynecologists
        Sexual assault.
        ACOG Educ Bull. 1997; : 1-7
        • Kreisel B.W.
        Rape and sexual victimizations, measurement of.
        in: Fisher B.S. Lab S.P. Encyclopedia of victimology and crime prevention. Sage Publications, Thousand Oaks, CA2010
        • Sadler A.G.
        • Mengeling M.A.
        • Syrop C.H.
        • Torner J.C.
        • Booth B.M.
        Lifetime sexual assault and cervical cytologic abnormalities among military women.
        J Womens Health. 2011; 20: 1693-1701
        • Sadler A.G.
        • Booth B.M.
        • Mengeling M.A.
        • Doebbeling B.N.
        Lifespan and repeated violence against women during military service: effects on health status and outpatient utilization.
        J Womens Health. 2004; 13: 799-811
        • Sadler A.G.
        • Booth B.M.
        • Cook B.L.
        • Doebbeling B.N.
        Factors associated with women's risk of rape in the military environment.
        Am J Ind Med. 2003; 43: 262-273
      7. Kilpatrick DG, Ruggiero KJ. Rape in Iowa: a report to the state. Charleston, SC: National Violence Against Women Prevention Research Center, Medical University of South Carolina, 2003.

        • Shafer M.A.
        • Boyer C.B.
        • Shaffer R.A.
        • Schachter J.
        • Ito S.I.
        • Brodine S.K.
        Correlates of sexually transmitted diseases in a young male deployed military population.
        Mil Med. 2002; 167: 496-500
        • Foa E.B.
        • Zoellner L.A.
        • Feeny N.C.
        • Hembree E.A.
        • Alvarez-Conrad J.
        Does imaginal exposure exacerbate PTSD symptoms?.
        J Consult Clin Psychol. 2002; 70: 1022-1028
        • Foa E.B.
        • Cashman L.
        • Jaycox L.
        • Perry K.
        The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale.
        Psychol Assess. 1997; 9: 445-451
        • Committee on Health Care for Underserved Women
        Committee opinion: health care for women in the military and women veterans.
        Obstet Gynecol. 2012; 120: 1538-1542
        • Yano E.M.
        • Bastian L.A.
        • Bean-Mayberry B.
        • Eisen S.
        • Frayne S.
        • Hayes P.
        • et al.
        Using research to transform care for women veterans: advancing the research agenda and enhancing research-clinical partnerships.
        Womens Health Issues. 2011; 21: S73-S83
        • Cook J.M.
        • Pilver C.
        • Dinnen S.
        • Schnurr P.P.
        • Hoff R.
        Prevalence of physical and sexual assault and mental health disorders in older women: findings from a nationally representative sample.
        Am J Geriatr Psychiatry. 2012; 21: 877-886
        • Jones R.K.
        • Kooistra K.
        Abortion incidence and access to services in the United States, 2008.
        Perspect Sex Reprod Health. 2011; 43: 41-50
        • Jones R.K.
        • Kavanaugh M.L.
        Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion.
        Obstet Gynecol. 2011; 117: 1358-1366
        • Hall M.
        • Chappell L.C.
        • Parnell B.L.
        • Seed P.T.
        • Bewley S.
        Associations between intimate partner violence and termination of pregnancy: A systematic review and meta-analysis.
        PLoS Med. 2014; 11: 31001581
        • Sarkar N.N.
        The impact of intimate partner violence on women's reproductive health and pregnancy outcome.
        J Obstet Gynaecol. 2008; 28: 266-271
      8. Centers for Disease Control and Prevention. National Survey of Family Growth. Key statistics from the National Survey of Family Growth. Available at: http://www.cdc.gov/nchs/nsfg/abc_list_i.htm#infertility. Accessed May 24, 2013.

        • Booth B.M.
        • Davis T.D.
        • Cheney A.M.
        • Mengeling M.A.
        • Torner J.C.
        • Sadler A.G.
        Physical health status of female veterans: contributions of sex partnership and in-military rape.
        Psychosomat Med. 2012; 74: 916-924
        • Booth B.M.
        • Mengeling M.
        • Torner J.
        • Sadler A.G.
        Rape, sex partnership, and substance use consequences in women veterans.
        J Trauma Stress. 2011; 24: 287-294
        • Sadler A.G.
        • Mengeling M.A.
        • Fraley S.S.
        • Torner J.C.
        • Booth B.M.
        Correlates of sexual functioning in women veterans: mental health, gynecologic health, health status, and sexual assault history.
        Int J Sex Health. 2012; 24: 60-77
        • Gavin N.I.
        • Gaynes B.N.
        • Lohr K.N.
        • Meltzer-Brody S.
        • Gartlehner G.
        • Swinson T.
        Perinatal depression: a systematic review of prevalence and incidence.
        Obstet Gynecol. 2005; 106: 1071-1083
        • Forman-Hoffman V.L.
        • Mengeling M.
        • Booth B.M.
        • Torner J.
        • Sadler A.G.
        Eating disorders, post-traumatic stress, and sexual trauma in women veterans.
        Mil Med. 2012; 177: 1161-1168
        • Seng J.S.
        A conceptual framework for research on lifetime violence, posttraumatic stress, and childbearing.
        J Midwifery Womens Health. 2002; 47: 337-345
        • Bean-Mayberry B.
        • Yano E.M.
        • Bayliss N.
        • Navratil J.
        • Weisman C.S.
        • Scholle S.H.
        Federally funded comprehensive women's health centers: leading innovation in women's healthcare delivery.
        J Womens Health. 2007; 16: 1281-1290