September 11, 2001, is a day burned into the consciousness of all Americans old enough to remember that day. For members of the U.S. military, it was also the beginning of more than 14 years of war, variously called the war on terror, Operation Enduring Freedom (Afghanistan), Operation Iraqi Freedom (Iraq), Operation New Dawn (Iraq) and the Long War. The Long War encapsulates the repeated deployments into combat zones in Afghanistan and Iraq, as well as the Horn of Africa and to humanitarian assistance operations.
For women, 9/11 also ushered in a steadily increasing role in the U.S. military. No longer mainly nurses, as in the Vietnam War, or primarily in support roles, as in the Gulf War, female service members have been in the thick of the conflicts in Iraq and Afghanistan.
Only recently have women officially been allowed into the Military Occupational Specialty (MOS) of combat occupations. Combat occupations are typically the “warfighters”; however, it is now widely accepted that women have been in combat since long before 9/11. For example, the deployment to Somalia in 1993 started as a humanitarian assistance operation and was later turned into a combat mission. More recently, in the Long War, numerous roles open to women, such as military police and truckers, have been frequently involved in firefights.
Research and data about women in the military have had a relapsing course. After the first Gulf War, there were a number of articles focusing on the health issues of women deployed there. The main reasons for redeployment to the U.S. were abnormal pap smears gathered before deployment and positive pregnancy screens. In the late 1990s, there was a considerable amount of research, mainly covered under the loose rubric of the Defense Women’s Health Research Project.1
In 2002, I organized a symposium at the Women in Military Service Memorial, which focused on the prevention of urinary tract infections in the field, unintended pregnancy while deployed, and stress fractures. Partly because of the repeal of the combat exclusion rule and partly because the Long War seems to be winding down, recently there have been a number of activities and publications about women in combat. With COL Anne L. Naclerio, MD, MPH, I recently coedited Women at War, a collection of 19 articles that bring together much of the available information and experience on women service members’ health and mental health.2 We hope that it will further spur interest and research on the topic.
The lack of data on female service members is in contrast to the extensive scientific literature on male service members. The Walter Reed Army Institute of Research and the Mental Health Advisory teams both have focused on combat troops, which have been primarily male. The Millennium Study includes women, but its results are just beginning to emerge. The VA has data on female veterans, but only a small number of female veterans go to the VA, and VA studies on women have focused primarily on military sexual assault. Although this area is very important, there are many other issues that female service members deal with, including reproductive and genitourinary concerns.
The Women at War volume begins to address this problem. Chapters examine data on deployment-related issues, posttraumatic stress disorder (PTSD) in female service members, and intimate partner violence. Due to a lack of quantitative data, other chapters summarize either civilian data or data on male service members, then move to extrapolate for service women. A few chapters are more anecdotal, describing the experience of being a female sailor on a ship or a mother on deployment.
Reproduction and Gynecology
Much of the current discussion about women in the military focuses on physical strength. Can she carry a 60-round rucksack? Can she load artillery rounds? In contrast, issues about reproduction and gynecology are understudied in the recent literature on female service members.
Urinary tract infections (UTIs) are a major issue for women in the field. Much of the concerns that female service members have are about bathrooms. Is the latrine—maybe used by many other service members—clean enough to sit on? Women often restrict fluids to avoid going to the filthy or nonexistent bathrooms and thus get UTIs or become dehydrated. Managing menses in austere conditions is another dilemma. Can I change my tampon while driving on the roads in Iraq? Should I be on oral contraception while deployed to regulate menses?
Although sexual assault has received considerable attention, consensual sex has received much less. A taboo area seems to be the sexual desires of women who deploy. But young women—and most women who deploy are young—do have sexual desires, perhaps heightened by the daily exposure to death and close bonding in the combat zone. The literature is totally devoid on this topic. If contraception is scarce, pregnancies happen. In the worst cases, this results in ectopic pregnancies, resulting in life-threatening emergencies and expensive medical evacuations. In the best cases, unexpected pregnancy results in an evacuation from the war zone. There is no systematic data on availability of birth control.