Recently, issues such as female hygiene, contraception, family planning, pregnancy, preventative health care, and maintaining the balance between work and life while fulfilling military and personnel obligations have all come to the forefront of military and Veteran care and research agendas. Through the exemplary work of nurse scholars in the military and Veterans Administration health care systems, a growing body of literature addresses the physical, emotional, and social health issues and concerns unique to female service members during active duty in the United States, during deployment, and during nonactive duty as Veterans. The TriService Nursing Research Program has been instrumental in expanding the scope and impact of military nursing research. This program establishes research priorities for military nurse scientists, which include categories for Force Health Protection, Nursing Competencies and Practice, and Leadership, Ethics, and Mentoring. This program's long-standing grant mechanisms have led to many studies that examine interventions to improve women's health, translate evidence-based practices into clinical care, and inform and shape health policies (Uniformed Services University of the Health Sciences, 2011). Without support from the military and Veterans Administrations, advancement and dissemination of science related to women in the military and women Veterans would be limited.
To address these emerging concerns, the articles in the “In Focus” series in this issue of JOGNN demonstrate the extraordinary leadership of our military colleagues in advancing science and practice in women's health. All nurse scholars face challenges in generating and disseminating new knowledge, and accomplishing scholarship and timely dissemination during deployment are especially challenging. Our military scholars are to be commended for their exceptional work in exposing many of the challenges women face when they are deployed for combat or when they serve as military nurses who care for the injured.
Civilian nurses may have difficulty envisioning the combat war zone and related health care environments. The locations of theater or combat support hospitals (CSH) where military nurses practice place these nurses in “harm's way.” Nurses are not guaranteed of their safety, they have limited access to needed health care resources, and they are confined in unimaginable conditions of extreme temperatures without the basic necessities of daily living. Scannell-Desch and Doherty (2010) applied descriptive and phenomenological methodologies to elucidate feedback from 37 military nurses, 32 of whom were women deployed to Afghanistan and Iraq. The purpose of the study was to glean insight into these women's experiences. Seven themes emerged from the qualitative analyses of data that demonstrated the physical and emotional toll that deployment places on military nurses and their struggles with postdeployment adjustment. Unlike civilian nurses, active duty military nurses must fulfill military requirements to maintain fitness and combat readiness and have little control over where they practice. These distinctions are discussed by Kelly (2010) in a provocative article contrasting differences between battlefield and civilian nursing practice and environments.
Research and clinical review articles published in this issue demonstrate the resilience of women in the military during deployment and assignments on the home front. Recent studies have examined the vulnerability of female military service members in confronting issues surrounding their health and well-being. Unintended pregnancy is a significant problem for active duty military personnel. Holt and colleagues (2011) summarized findings from a systematic review of studies of unintended pregnancy and contraceptive use among military service members and reported that the rate of unintended pregnancies is higher among military women than the civilian population. Based on a sample of 3,745 active duty military women age 18 to 44 years complied from the 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, self-reported disclosure placed the incidence of unintended pregnancies at approximately 54% (Lindberg, 2011). After adjusting for underreporting for abortion, this translated into a rate for unplanned pregnancy of 117 per 1,000 women (Lindberg). Unfortunately, limited data were available related to overall contraceptive use, but this was definitely perceived as high priority for future research given the prevalence of sexual assault cases in the military (Holt, Grindlay, Taskier, & Grossman, 2011).
The incidence of sexually transmitted diseases (STDs) among deployed women, particularly chlamydia trachomatis, was higher among servicemembers serving in Iraq and was disproportionately greater in women than men. Rates for chlamydia among female service members in Iraq exceed 770.9 per 100,000 versus 192.6 per 100,000 for males (Aldous et al., 2011). Unlike trends observed in the general U.S. population, women in higher age groups compared to younger men and women deployed to Iraq and Afghanistan were diagnosed with chlamydia.
Investigators studying servicemembers returning from deployment who have sustained war-related injuries or manifest symptoms of post-traumatic distress syndrome (PTSD) have attempted to delineate gender-based differences that are vitally important to understanding the unique experiences and concerns of women. Differences in posttraumatic stress symptomatology were noted in a sample of 579 men and women deployed to Iraq and Afghanistan (Vogt et al., 2011). For women, concerns about relationship disruptions had a significant impact on posttraumatic stress symptomatology, and women reporting more concerns about disruptions in their relationships had less postdeployment social support. Based on this finding, the authors concluded that concerns about family disruptions had greater implications for women than men in their postdeployment adjustment. Preliminary data on PTSD outcomes among women following deployment also showed a significant association between military sexual harassment and PTSD symptoms (Dutra et al., 2011). Subsequent research will likely uncover a myriad of other contributing factors distinct and more prominent in women suffering from PTSD.
Thus far, thousands of military service members have been severely injured in the Iraq and Afghanistan wars. In an analysis of 40,531 combat casualties obtained from Defense Manpower Statistics between 2001 and 2009, Cross, Johnson, Wenke, Bosse, and Ficke (2011) revealed that female Veterans comprise only 1.9% of all casualties but 2.4% of all deaths. When death rates were partitioned by conflict, the percent death for women serving in Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) was 35.9% and 14.5%, respectively, yielding estimated death rates greater than males (Cross, Johnson, Wenke, Bosse, & Ficke). A search of The Joint Theatre Trauma Registry showed that combat-injured women suffered more facial and external injuries as well as more severe extremity injuries in contrast to nonbattle trauma (Cross et al.). Clearly, more research is needed to characterize the nature of injuries in women and the subsequent outcomes associated with rehabilitation and reintegration across transitions of care.
Moving forward, it will be critical to examine the influence of gender and the interaction of gender and race across all transitions in care to expand the existing knowledge of health care disparities for military servicemembers and Veterans. Researchers have already exposed prevailing gender disparities regarding access to care and delay in treatment (Washington, Bean-Mayberry, Riopelle, & Yano, 2011) and preferential treatment of health problems (Vimalananda, Miller, Palnati, Christiansen, & Fincke, 2011) among female Veterans. However, far fewer studies compare gender disparities in military and Veterans Administration health care settings to civilian care. To some degree, Harris (2011) set the stage for future research by providing a thoughtful, comparative analysis of root causes for disparities across these three health service settings that identifies gender as an important determinant for inequities in care. This “In Focus” series is a tribute to reducing disparities and narrowing the gaps in research for women in the military and Veterans.
As Americans, we are indebted to our military servicemembers and Veterans for their dedicated service to our country. We are extremely grateful to military nurse scientists for their valuable contributions to military science and practice and for all their efforts to improve the health and welfare of servicemembers and Veterans. To all military nurses and nurse Veterans, we thank you for your service to our country.