Sexually Transmitted Infections and Sexual Dysfunctions Among Newly Returned Veterans with and Without Military Sexual Trauma

Home , Sexual dysfunction

International Journal of Sexual Health, 24:45–59, 2012 ISSN: 1931-7611 print / 1931-762X online DOI: 10.1080/19317611.2011.639592

SEXUALLY TRANSMITTED INFECTIONS AND SEXUAL DYSFUNCTIONS AMONG NEWLY RETURNED VETERANS WITH AND WITHOUT MILITARY SEXUAL TRAUMA

Jessica A. Turchik1,3, Joanne Pavao1, Deborah Nazarian2,3, Samina Iqbal4, Caitlin McLean1, Rachel Kimerling1,5 1National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA 2VA Advanced Fellowship Program in Mental Illness Research and Treatment, VA Palo Alto Health Care System, Menlo Park, California, USA 3Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA 4Center of Excellence in Women’s Health, VA Palo Alto Health Care System, Menlo Park, California, USA 5Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, California, USA

ABSTRACT. This cross-sectional study examined the odds of being diagnosed with a sexually transmitted infection (STI) or a sexual dysfunction disorder (SDD) among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) American veterans receiving care in the Veter- ans’ Health Administration (VHA) in relation to whether or not they have experienced military sexual trauma (MST). Among those veterans who experienced MST, the inﬂuence of a diagnosis of posttraumatic stress disorder, a depressive disorder, or a substance use disorder on the odds of being diagnosed with an STI or SDD was also examined. The study utilized nationwide VHA records of 420,725 OEF/OIF male and female veterans who used VHA services in ﬁscal years 2002 to 2010. Veterans who reported a history of MST were more likely to have a number of STIs and SDDs compared with veterans without a history of MST. Among veterans with MST, the risk for having an STI or SDD increased with the presence of certain mental health diagnoses. Implications for clinical practice and assessment with veterans are discussed.

KEYWORDS. Sexual trauma, veterans, military, sexually transmitted infections, sexual dysfunctions

Military sexual trauma (MST) is the Vet- vides free treatment to veterans for MST-related erans Health Administration’s (VHA) term for mental or physical health conditions. Research unwanted and threatening sexual harassment shows that 15.1% of OEF/OIF female veter- or assault that occurred during military ser- ans and 0.7% of male veterans who received vice, and it affects a signiﬁcant number of services from VHA reported a history of MST U.S. veterans returning from the recent wars (Kimerling et al., 2010). Similar to ﬁndings con- in Afghanistan (Operation Enduring Freedom cerning sexual trauma among civilians, veter- [OEF]) and Iraq (Operation Iraqi Freedom ans who endorse MST have been found to [OIF]). VHA conducts universal screening of have greater rates of both mental health prob- all veterans for sexual trauma and also pro- lems (e.g., posttraumatic stress disorder [PTSD],

Received 18 October 2011; accepted 5 November 2011. This article not subject to U.S. copyright law. Writing of this manuscript was supported by the VA Advanced Fellowship Program in Mental Illness Research and Treatment, VA Office of Academic Affiliations. The authors would like to thank Meghan Saweikis, M.S. for her programming assistance. The views and opinions of authors expressed herein do not necessarily reflect those of the Department of Veterans Affairs or the U.S. Government. Address correspondence to Jessica A. Turchik, Ph.D., National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA. E-mail: [email protected]

45 46 INTERNATIONAL JOURNAL OF SEXUAL HEALTH depressive disorders, substance use disorders rious short- and long-term consequences associ- [SUDs]) and physical health problems (e.g., ated with infection (Aral, 2001; Cohen, 1998). greater number of reported symptoms, liver These consequences include increased risk for disease, obesity), even after controlling for a infertility, cervical and genital cancer, and HIV, number of demographic and military service- as well as the tremendous economic burden related variables (Frayne et al., 1999; Kimerling, of STI-related health costs (Chesson, Blandford, Gima, Smith, Street, & Frayne, 2007; Kimerling Gift, Tao, & Irwin, 2004). The examination et al., 2010). One crucial area of health that of STIs may be particularly important among has consistently been linked to sexual victim- younger OEF/OIF veterans given that the Cen- ization is sexual health (see van Berlo & En- ters for Disease Control and Prevention found sink, 2000, and Weaver, 2009, for reviews); that of the estimated 19 million new annual however, this is an area that has not been STIs in the United States, almost 50% occur in well studied among veterans who report ex- personsaged15to24yearsold(Weinstock, periencing MST. The goal of the current study Berman, & Cates, 2004). In fact, military ser- was to examine two important areas of sex- vice members have been noted to have higher ual health dysfunction—sexually transmitted in- rates of STIs compared with civilian samples fections (STIs) and sexual dysfunction disorders (Melton, 1976; Sena˜ et al., 2000). Despite these (SDDs)—among OEF/OIF veterans in relation to potentially high rates, the prevalence of STIs whether or not they reported a history of MST. among veterans with MST is unknown; how- Sexual assault appears to be associated with ever, one national study of veterans who were a higher risk for acquiring an STI, with studies VHA users found that rates of HIV were signif- finding elevated rates of STIs among those who icantly higher among men who reported MST report sexual assault and high rates of sexual vi- versus those without a history of MST (Kimerling olence among those who report STIs, although et al., 2007). No previous studies have exam- prevalence rates range widely across studies ined other STIs by MST status in veterans, and (see Lambda & Murphy, 2000, and Reynolds, no studies have examined these relationships Peipert, & Collins, 2000, for reviews). For in- specifically among OEF/OIF veterans. stance, one study of college women found that In the United States, it is estimated that those who reported a history of sexual assault between 10% to 52% of men and 25% to were more likely to have a human papillo- 63% of women have sexual functioning con- mavirus (HPV) infection than those without an cerns (Heiman, 2002; Laumann, Paik, & Rosen, assault history (Kahn, Huang, Rosenthal, Tissot, 1999). The percentages are likely higher among & Burk, 2005). Another study of low-income those with a sexual assault history, as studies African American women found that those with have found higher rates of reported sexual dys- HIV were more likely to report a sexual assault function among women who report sexual as- history than those in a matched control group sault as compared with those who do not re- who were HIV-negative (Kimerling, Armistead, port sexual assault among both clinical (e.g., & Forehand, 1999). Jenny et al. (1990) exam- Becker, Skinner, Abel, & Cichon, 1986; San- ined the risk for acquiring an STI as a result juan, Langenbucher, & Labouvie, 2009) and of a vaginal sexual assault among a group of community samples (e.g., Elliott, Mok, & Briere, women and girls who presented to a medi- 2004; Golding, Wilsnack, & Learman, 1998; cal center within 72 hours following an assault. Laumann et al.; Steel & Herlitz, 2007). Although Testing was conducted upon initial presentation not specific to sexual dysfunction, research has as well as at a follow-up appointment. Jenny et found that veteran women who report a history al. found that the prevalence of preexisting STIs of sexual assault report lower sexual satisfac- was high among these women but that there tion than those with no assault history (McCall- was a substantial additional risk for STI trans- Hosenfeld, Liebschutz, Spiro, & Seaver, 2009). mission as a result of sexual assault. Sexual functioning among men who have ex- Although most STIs are treatable, research perienced sexual assault has received less at- on STIs is important given the number of delete- tention than in women; however, at least three J. A. TURCHIK ET AL. 47 studies using community samples (Elliott et al.; SDDs among returning OEF/OIF veterans who Laumann et al.; Steel & Herlitz) and one study used VHA services in FY 2002 to FY 2010. Data utilizing university students (Turchik, in press) from VHA’s National Patient Care Database have found evidence that there is a higher rate (clinical and administrative data from the elec- of reported sexual dysfunctions among men tronic medical record of patients who use VHA) who report sexual victimization compared with was matched to data from the OEF/OIF Roster those without a victimization history. (database of OEF/OIF veterans who have sepa- Research has demonstrated that individu- rated from military service and are enrolled in als with MST (Kimerling et al., 2007, 2010), VHA). OEF/OIF veterans were included in the as well as those with STIs (Cook et al., 2006; present study if they had at least two VHA vis- Erbelding, Hutton, Zenilman, Hunt, & Lyketsos, its (one primary care visit and one additional 2004; Hwang et al., 2000) or SDDs (Heiman, VHA face-to-face outpatient visit in FY 2002 to 2002; Johnson, Phelps, & Cottler, 2004; Zem- FY 2010), had provided a response to the VHA ishlany & Weizman, 2008) are at higher risk MST screening items, and had a nonmissing age for developing mental health disorders, such as value ≥ 18 (N = 420,725). The purpose of re- PTSD, depression, and SUDs. Although etiolo- quiring at least two VHA visits was to exclude gies and causal factors of these relationships are patients who had only presented once, such as nuanced, it is clear that there is a correlation be- for a one-time enrollment exam. The present tween sexual trauma, sexual health, and mental study was approved by the Stanford University health. Individuals with a history of MST and a Institutional Review Board. mental health disorder may be at particular risk The study sample included a total of for a sexual health issue. 420,725 veterans (52,484 female; 368,241 The current study had one major aim and a male). The age range was 18 to 70 years, with a second, more exploratory aim. The main aim of median age of 28 years old. Nearly all veterans the current study was to determine the preva- in the sample (98.6%) had a high school degree lence of diagnoses of STIs and SDDs among or equivalency, and 20.0% had at least some OEF/OIF veterans with and without reported college education. Table 1 provides further in- MST who utilized VHA services in fiscal years formation on sample demographics. (FY) 2002 to 2010. These rates were also examined by sex given the inherent sex differ- Variables ences for many of these disorders. The sec- MST. ond exploratory aim of the current study was to explore whether the presence of a coexisting VHA uses a clinical reminder in the elec- mental health diagnosis—specifically PTSD, de- tronic medical record to screen for MST using pressive disorders, or SUDs—is associated with the following two items: “While you were in higher rates of STIs and SDDs among those the military: (1) Did you receive uninvited and OEF/OIF veterans who screened positive for unwanted sexual attention, such as touching, MST. It was hypothesized based on previous cornering, pressure for sexual favors, or verbal literature (e.g., Erbelding et al., 2004; Heiman, remarks?; (2) Did someone ever use force or 2002; Zemishlany & Weizman, 2008) that the threat of force to have sexual contact with you addition of a mental health diagnosis would in- against your will?” Patients were coded as pos- crease an individual’s risk for having a sexual itive for MST if an affirmative response was en- health diagnosis among those with a history of dorsed for either item. MST.

Sexual health diagnoses. METHODS International Classiﬁcation of Diseases, Data Sources and Study Population Ninth Revision Clinical Modiﬁcation (ICD-9- This cross-sectional study examined the as- CM; National Center for Health Statistics & sociation of MST status with diagnosed STIs and Centers for Medicare & Medicaid Services, 48 INTERNATIONAL JOURNAL OF SEXUAL HEALTH

TABLE 1. Prevalence of Any Sexually Transmitted Infection (STI) and Any Sexual Dysfunction Disorder (SDD) by Patient Characteristics Among OEF/OIF Veterans

Any STI (n = 40,152; 9.5%) Any SDD (n = 26,287; 6.2%)

Nn% n %

Sex Women 52,484 17,600 33.51,253 2.4 Men 368,241 22,552 6.125,025 6.8 Age 18–27 years 206,554 25,996 12.65,668 2.7 28+ years 214,171 14,156 6.620,610 9.6 Race/ethnicity White 208,084 15,518 7.510,616 5.1 Black 46,790 6,442 13.84,670 10.0 Hispanic 45,402 4,757 10.53,016 6.6 Other/Unknown 120,449 13,435 11.27,976 6.6 Marital statusa Married 181,194 11,818 6.516,959 9.4 Never married 218,232 25,973 11.97,202 3.3 Divorced/separated/widowed 21,059 2,333 11.121,059 10.0 Military component Active duty 218,699 24,324 11.111,266 5.2 National Guard/Reserve 202,026 15,828 7.815,012 7.4 Military rank Enlisted 392,620 38,285 9.824,303 6.2 Ofﬁcer 28,105 1,867 6.61,975 7.0 Military branch Air Force 39,099 4,357 11.12,649 6.8 Army 273,148 24,367 8.918,636 6.8 Navy/Coast Guard 50,797 6,074 12.03,063 6.0 Marines 57,681 5,354 9.31,930 3.3 Number of OEF/OIF deployments One deployment 276,425 27,811 10.117,932 6.5 More than one deployment 144,300 12,341 8.68,346 5.8 Time enrolled in VHA < 3 years 230,321 16,025 7.010,402 4.5 3–9 years 190,404 24,127 12.715,876 8.3

N = 420,725. χ 2 tests were performed and all demographic categories were signiﬁcantly different at p < .001. aTotal n for marital status lower than other variables due to missing values (marital status n = 420,485; unknown n = 240).

2008) diagnosis codes were used to classify dia trachomatis, Neisseria gonorrheae,andMy- STIs and SDDs. Drawing on previous litera- coplasma genitalium (e.g., Soper, 2010) and ture and the expert opinion of the physician may be an indicator for untreated and undi- author on this article, we selected and cat- agnosed STIs. The following 15 nonoverlap- egorized relevant ICD-9-CM codes into spe- ping, mutually exclusive STI categories were in- cific STI categories. STIs of bacterial (e.g., cluded: HPV–genital/anal warts, HPV–cervical chlamydia), fungal (e.g., candidiasis), viral (e.g., dysplasia (women only), HPV–anal dysplasia, HIV), parasitic (e.g., pubic lice), and pro- HPV–unspecified site (ICD-9-CM code 079.4), tozoal (e.g., trichomoniasis) causes that are PID (women only), candidiasis/vulvovaginitis, commonly spread by sexual contact were in- herpes simplex, trichomoniasis, chlamydia, cluded. Additionally, pelvic inflammatory dis- HIV/AIDS, scabies/pubic lice, gonorrhea, hep- ease (PID) was included because in the ma- atitis B, syphilis, and other venereal disease jority of cases, but certainly not all, the micro- (e.g., lymphogranuloma venereum, granuloma bial etiology of the disease is linked to sexually inguinale). ICD-9-CM codes for SDDs were transmitted microorganisms, including Chlamy- classified based on the mental health diagnos- J. A. TURCHIK ET AL. 49 tic categories in the Diagnostic and Statistical umented the relationship between MST and Manual of Mental Disorders-Fourth Edition sociodemographics among OEF/OIF veterans (DSM-IV; American Psychiatric Association (e.g., Kimerling et al., 2010); thus, the first [APA], 1994). The following four SDD cate- analysis focused on the unique relationship of gories were examined: sexual pain disorders any STI or any SDD and sociodemographics (e.g., dyspareunia, vaginismus), sexual desire and military characteristics. Logistic regressions disorders (e.g., hypoactive sexual desire, de- were used to examine the prevalence of STIs creased libido), sexual arousal disorders (e.g., and SDDs by MST history and sex. Adjusted dysfunction of sexual excitement, impotence), odds ratios (AORs) with 95% confidence inter- and orgasmic disorders (e.g., female orgasmic vals (CIs) were calculated, while adjusting for disorder, premature ejaculation). In addition to veteran’s age (categorized as above or below the aforementioned categories, we also created the median age) and the amount of time en- three additional grouping variables. These in- rolled in VHA care. These variables were included “any STI” (defined as any diagnosis of cluded as they may influence whether a vet- the above 15 STI categories), “any HPV” (de- eran is more likely to be exposed to or develop fined as having a diagnosis of HPV–genital/anal a disorder/infection and/or to have symptoms warts, HPV–cervical dysplasia, HPV–anal dys- detected and diagnosed. Given the rarity of plasia, or HPV–unspecified site), and “any some of the STI and SDD diagnoses, adjusted SDD” (defined as any diagnosis of one of the exact logistic regressions were used for analyses four SDDs listed above). where expected cell count was less than 5 (as noted in Table 2). These were performed because exact conditional inferences are prefer- Mental health diagnoses. able to using the maximum likelihood method to calculate logistic regression parameters in Mental health conditions were classified us- cases of unbalanced binary data with covari- ing the Agency for Healthcare Research and ates, sparse data, and small sample sizes (Mehta Quality’s Clinical Classifications Software (Elix- & Patel, 1995). Additionally, due to concerns hauser, Steiner, & Palmer, 2008), which maps that the inclusion of PID may affect the results of ICD-9-CM diagnosis codes to nonoverlapping this analysis, we performed a sensitivity analysis, mental health diagnostic categories in the DSM- while excluding PID from our definition of any IV (APA, 1994). The present study included STI, and found no differences in the adjusted the following mental health categories: PTSD, odds of receiving an STI diagnosis by MST sta- depressive disorders, and SUDs. To examine tus. Lastly, among individuals with a history of PTSD (ICD-9-CM code 309.81) separately from MST, a logistic regression model was used to ex- other anxiety disorders, we made minor mod- plore whether a diagnosis of PTSD, depressive ifications to the classification scheme. The Ap- disorder, or SUD increased the odds of hav- pendix lists the specific ICD-9-CM codes used ing an STI or an SDD, while controlling for the to categorize STI, SDD, and mental health con- other mental health conditions in the model. ditions. All three mental health variables were entered simultaneously into the model. AORs with 95% CIs were reported for these exploratory analy- Statistical Analyses ses. Data were analyzed using Statistical Analy- sis Software (SAS), version 9.2, and Predictive Analytics SoftWare (PASW), version 18.0, for RESULTS Windows. Chi-square tests were used to examine the prevalence of any STI and any SDD Frequencies diagnosis by sociodemographics and by mili- In the study, 33.5% of women and 6.1% tary characteristics. Previous literature has doc- of men had at least one STI diagnosis, and 50

TABLE 2. Prevalence of Sexually Transmitted Infections (STIs) and Sexual Dysfunction Disorders (SDDs) by Military Sexual Trauma (MST) History and Sex

Women Men

MST (n = 8,773) No MST (n = 43,711) MST (n = 2,637) No MST (n = 365,604) % % AORa (95% CI) % % AORa (95% CI)

Any STI 37.732.7 1.27 (1.21–1.34) 10.06.1 1.76 (1.54–2.00) Any human papillomavirus (HPV) 20.918.3 1.20 (1.13–1.27) 4.63.4 1.40 (1.17–1.69) HPV–genital/anal warts 3.02.3 1.31 (1.14–1.51) 4.43.3 1.36 (1.13–1.65) HPV–cervical dysplasia 18.816.6 1.18 (1.11–1.26) bb b HPV–anal dysplasia 0.210.1 1.31 (0.77–2.24) 0.00.0 7.42 (0.18–46.70)c HPV–unspeciﬁed site 1.11.0 1.12 (0.90–1.39) 0.10.1 1.04 (0.13–3.80)c Pelvic inﬂammatory disease 18.115.6 1.21 (1.14–1.29) bb b Candidiasis/vulvovaginitis 5.44.5 1.22 (1.10–1.35) 0.00.0 26.95 (0.57–241.34)c Herpes simplex 4.12.9 1.44 (1.28–1.62) 1.61.0 1.68 (1.24–2.28) Trichomoniasis 1.61.2 1.33 (1.10–1.61) 0.20.1 2.32 (0.75–5.47)c Chlamydia 0.80.7 1.09 (0.84–1.42) 0.20.1 1.32 (0.43–4.04)c HIV/AIDS 0.60.4 1.79 (1.33–2.43) 0.90.1 6.57 (4.04–9.91)c Scabies/pubic lice 0.40.2 2.04 (1.37–3.04) 0.60.3 2.36 (1.46–3.82) Gonorrhea 0.30.2 1.37 (0.88–2.13) 0.30.1 2.33 (0.92–4.85)c Hepatitis B 0.20.1 1.33 (0.76–2.30) 0.20.2 0.77 (0.29–2.06) Syphilis 0.10.1 1.62 (0.84–3.11) 0.50.1 5.77 (3.31–10.06)c Other venereal disease 2.01.5 1.40 (1.18–1.66) 2.61.3 2.05 (1.61–2.62) Any SDD 3.42.2 1.57 (1.38–1.80) 11.46.8 1.75 (1.55–1.98) Sexual pain disorders 2.71.7 1.57 (1.35–1.82) 0.00.0 4.82 (0.12–29.08)c Sexual desire disorders 0.60.4 1.47 (1.08–1.99) 0.60.3 1.77 (1.06–2.96) Sexual arousal disorders 0.20.1 3.01 (1.59–5.72) 10.86.5 1.72 (1.51–1.95) Orgasmic disorders 0.10.0 2.27 (0.62–7.08)c 0.30.2 1.88 (0.81–3.84)c

AOR = Adjusted Odds Ratio; CI = conﬁdence interval. Signiﬁcant AORs are bolded. aAdjusted for age group and time in VHA. bMen cannot get this infection. cAdjusted exact logistic regressions were calculated for the variables. J. A. TURCHIK ET AL. 51

2.4% of women and 6.8% of men had at least bies/pubic lice, and other venereal disease (all one SDD diagnosis. Among those with an STI ps < .05). Men with a history of MST were diagnosis, 33.4% of women and 9.9% of men more likely to have the following STI diagnoses had more than one diagnosis with a median compared with those without a history of MST: of one STI diagnoses among both men (maxi- any HPV, HPV–genital/anal warts, herpes sim- mum = 7) and women (maximum = 6). If PID plex, HIV/AIDS, scabies/pubic lice, syphilis, and is excluded from the diagnoses, 25.7% of the other venereal disease (all ps < .05). It was note- women had at least one STI diagnosis, 22.1% worthy that the odds of having HIV/AIDS (AOR had more than one, and the median number of = 6.57) and syphilis (AOR = 5.77) were partic- STI diagnoses was one. Furthermore, 16.7% of ularly high for men with a history of MST. women and 0.7% of men reported a history of MST during VHA screening. Sexual dysfunction disorders. STIs and SDDs by Patient Characteristics Among women, those with a history of MST were more likely to have been diagnosed with a The prevalence rates of STIs and SDDs in sexual pain disorder, sexual desire disorder, or relation to veterans’ sociodemographic factors sexual arousal disorder compared with women and military service variables are shown in Ta- without a history of MST (all ps < .05). The odds ble 1. All examined variables, including sex, of having a sexual arousal disorder were partic- age, race/ethnicity, marital status, military com- ularly high among women with a history of MST ponent, military rank, military branch, number (AOR = 3.01). Among men, those with a history of OEF/OIF deployments, and time enrolled in of MST were more likely to have a diagnosis of VHA, were significantly associated with having sexual desire disorder or sexual arousal disorder < any STI and any SDD diagnosis (all ps .001). compared with men without a history of MST Compared with men, women were significantly (all ps < .05). more likely to have an STI but were less likely to have an SDD. Younger veterans were more likely to have an STI, whereas older veterans STI and SDD Diagnoses by Mental were more likely to have an SDD. Health Condition and Sex Among Veterans With a History of MST STI and SDD Diagnoses by MST History Among those veterans who reported a his- and Sex tory of MST, the adjusted odds of an STI or The adjusted odds of receiving a diagnosis an SDD diagnosis were examined in relation of an STI or an SDD as a function of MST history to whether the veteran had a PTSD, depres- and sex are shown in Table 2. Both women and sive disorder, or SUD diagnosis. These analyses men with a history of MST were more likely to were split by sex and were adjusted for comor- have a diagnosis of an STI or an SDD compared bidity of PTSD, depressive disorders, and SUDs with those who did not have a history of MST (see Table 3). (all ps < .05). Sexually transmitted infections. Sexually transmitted infections. In the adjusted logistic regression analyses, Women with a history of MST were more among women with a history of MST, those likely to have the following STI diagnoses com- with a diagnosis of PTSD, a depressive disor- pared with those without a history of MST: any der, or an SUD were significantly more likely HPV, HPV–genital/anal warts, HPV–cervical to have an STI compared with women with- dysplasia, PID, candidiasis/vulvovaginitis, her- out a diagnosis of PTSD, a depressive disorder, pes simplex, trichomoniasis, HIV/AIDS, sca- or an SUD, respectively (all ps < .01). Among 52

TABLE 3. Prevalence of Sexually Transmitted Infections (STIs) and Sexual Dysfunction Disorders (SDDs) Among Veterans With a History of Military Sexual Trauma by Mental Health Diagnosis and Sex

AnySTI AnySDD

Women (n = 8,773) Men (n = 2,637) Women (n = 8,773) Men (n = 2,637)

Presence of Diagnosis % AORa (95% CI) % AORa [95% CI] % AORa [95% CI] % AORa [95% CI]

† PTSD 40.6 1.17 (1.06–1.28) 11.5 1.34 (0.99–1.80) 3.91.13(0.87–1.47) 14.1 1.60 (1.20–2.13) Depressive Disorder 40.6 1.25 (1.13–1.38) 11.3 1.18 (0.88–1.57) 4.1 1.80 (1.35–2.41) 14.3 1.61 (1.21–2.14) SUD 45.4 1.32 (1.18–1.49) 12.7 1.33 (1.00–1.76) 3.9 1.01 (0.74–1.37) 14.0 1.12 (0.86–1.46)

N = 11,410. PTSD = posttraumatic stress disorder; SUD = substance use disorder; AOR = Adjusted Odds Ratio; CI = confidence interval. Significant AORs are bolded. aAdjusted for PTSD, depressive disorder, and SUD diagnoses. † p = .05. J. A. TURCHIK ET AL. 53 men with MST, only SUD was significant in the it is likely that the rates of STIs and SDDs are model (p = .048). underestimated in the present study because sexual health concerns are often underreported and underdiagnosed (Committee on Prevention Sexual dysfunction disorders. and Control of Sexually Transmitted Diseases, Among women with a history of MST, those Institute of Medicine, 1997). with a diagnosis of a depressive disorder were The current study also found that among significantly more likely to have an SDD com- those who reported MST, having a mental pared with women without a diagnosis of a de- health diagnosis of PTSD, a depressive disor- pressive disorder (p < .001). Among men with der, or an SUD increased one’s risk for hav- MST, those with a diagnosis of PTSD or a de- ing a sexual health diagnosis. These findings pressive disorder were more likely to have an are consistent with research demonstrating rela- SDD diagnosis compared with men without a tionships between sexual trauma and increased diagnosis of PTSD or a depressive disorder (ps risk for mental health conditions (e.g., Kimerling < .01). et al., 2010) and research demonstrating relationships between mental health conditions and sexual health problems (Erbelding et al., 2004; Kennedy, Dickens, Eisfeld, & Bagby, 1999). DISCUSSION However, when controlling for all three diag- The goals of the current study were to ex- noses, some of the relationships were nonsignif- amine the prevalence rates of STIs and SDDs icant, suggesting that some mental health diag- among OEF/OIF veterans with and without re- noses are more likely to contribute to a sex- ported MST and to explore whether the pres- ual health problem than others. For instance, ence of comorbid mental health disorders are only SUD diagnoses were significantly related to associated with rates of these sexual health dis- STIs among men, and only depressive disorders orders among veterans who reported MST. Re- were related to SDDs among women. Further sults demonstrated that a number of STI and research is needed to explore the complex rela- SDD diagnoses were more common among vet- tionships between sexual trauma, sexual health, erans who report a history of MST. In fact, there and mental health disorders. were no instances in which any of the sex- It is noteworthy that among the sociodemo- ual health diagnoses were significantly higher graphic differences, women were more likely among those who did not report a history of to have an STI diagnosis and men were more MST even after controlling for veterans’ age likely to have an SDD diagnosis. The higher and length of time enrolled in VHA. The higher rates of SDDs among men were mainly tied to rates of STI and SDD diagnoses among those the rates of erectile dysfunction/impotence di- with MST are consistent with research find- agnoses, which accounted for the vast majority ings among nonveteran samples with histories of SDDs among men. The sex differences in of sexual assault (e.g., Elliott et al., 2004; Jenny the overall rates of STI diagnoses are partly at- et al., 1990). It should be noted that not all tributable to the fact that we included some di- STIs and SDDs examined in the current study agnoses that only applied to women (e.g., PID). were significantly related to MST status; thus, Several other factors also likely contributed to it is not simply the case that all diagnoses are differences between the sexes in STI diagno- more common among those with MST. For in- sis rates. These factors include the following: stance, among the STIs, diagnoses of HPV–anal Young women until age 25 may be at a greater dysplasia, chlamydia, hepatitis B, and gonor- risk for some STIs due to the physiologic or im- rhea were not associated with MST status for munologic immaturity of the cervix (e.g., Bolan, either men or women. It should also be noted Ehrhardt, & Wasserheit, 1999); some public that given that these rates are based only on health organizations recommend that all sex- clinical diagnoses recorded in patients’ charts, ually active women younger than 25 years old 54 INTERNATIONAL JOURNAL OF SEXUAL HEALTH are screened for chlamydia and gonorrhea (e.g., pressant medication (e.g., selective serotonin Meyers et al., 2008); and many women re- reuptake inhibitors; Montejo, Llorca, Izquierdo, ceive routine pelvic examinations and/or Pa- & Rico-Villademoros, 2001) have been shown panicolaou (Pap) smears, where STIs, particu- to be related to sexual dysfunction. An addi- larly asymptomatic ones, may be more likely tional proposed mechanism is that the stress to be detected during screenings. Taken to- related to sexual assault may suppress victims’ gether, these various factors may have differ- immune system, therefore making it more likely entially contributed to increased rates of STI for infections to occur (Coker, Sanderson, Fad- among women veterans. There were also differ- den, & Pirisi, 2000). However, given the in- ences in the patterns of results by sex. Among ability to determine temporal relationships, the women, candidiasis, trichomoniasis, and sex- ordering of these effects could happen in a mul- ual pain disorders were significantly related to titude of ways, and it may be that having a MST status; however, these were not signifi- mental health disorder increases one’s likeli- cant among men. In contrast, syphilis was sig- hood for experiencing sexual assault. There is nificant for men but not women. We cannot evidence that substance abuse has a recipro- elucidate the specific mechanisms for these sex cal relationship with sexual assault (Kilpatrick, differences in this cross-sectional study, but they Acierno, Resnick, Saunders, & Best, 1997) and warrant further examination. is not simply a cause or effect of assault. Such SDDs may be a direct result of MST, but it evidence supports theories suggesting that sex- is unlikely that most STIs in the current study ual assault, mental health conditions, and sexual were a direct result of the MST (e.g., Jenny et health issues are interrelated (Schnurr & Green, al., 1990), especially given the varying timing 2004; Weaver). between the MST incident(s) and the veteran’s Although this study provides important in- entry into VHA care and the fact that MST en- formation on the association between STIs, compasses both sexual harassment and sexual SDDs, and MST, there are a few limitations assault experiences. Although we cannot deter- that must be noted. First, given the cross- mine causality in the current study, one possi- sectional nature of the data, it is impossible ble explanation for these findings may be that to determine the direction of the relationships MST leads to the development of mental health in the current study or to make inferences disorders, which consequently lead to factors concerning causality. Second, the study relied that present a higher risk for an STI or SDD on clinician-derived ICD-9-CM diagnoses, and (e.g., Lang et al., 2003; Seng, Clark, McCarthy, although generalizable to real-world practice, & Ronis, 2006; Weaver, 2009). For instance, they do not necessarily reflect definitive con- Lang et al. found that among female veterans, firmed diagnoses. Relatedly, MST as well as PTSD symptoms partially mediated the relation- sexual health and mental health diagnoses may ship between smoking, drinking behavior, and be underestimated and/or underreported due abnormal Pap smears. In fact, both men and to various issues (e.g., variations between clin- women with a history of sexual assault have icians in diagnosing and coding in the medical been found to engage in more health risk be- record, asymptomatic nature of STIs, embar- haviors, including risky sexual behaviors and rassment/stigma in reporting and seeking treat- substance abuse (e.g., Brener, McMahon, War- ment). Third, it is likely that veterans with a ren, & Douglas, 1999; Lang et al.), compared history of MST had more VHA visits than those with those without sexual assault histories that without a history of MST and thus may have had would put them at greater risk for STIs and increased opportunities to receive STI, SDD, SDDs. Another example of how mental health and/or mental health diagnoses. However, it is disorders may lead to sexual health problems also likely that those with STIs, SDDs, and men- is that they may result directly from the mental tal health diagnoses utilize more care than those health disorder or treatment, as both depression without these diagnoses regardless of MST sta- itself (e.g., Kennedy et al., 1999) and antide- tus. Another limitation is that premilitary and J. A. TURCHIK ET AL. 55 postmilitary sexual victimization were not ac- cent study of American medical students found counted for in the current study as there is a that only 57.6% reported feeling adequately strong relationship between sexual victimiza- trained to take a patient’s sexual history and tion and revictimization (see Classen, Palesh, only 37.6% felt adequately trained to address & Aggarwal, 2005, for a review). Prescription and treat a patient’s sexual concerns (Witten- medication usage was not controlled for in the berg & Gerber, 2009). Research has found that study, and this may have contributed to some of physicians often do not ask about patients’ sex- the SDDs. Lastly, the results of the current study ual health due to a number of factors, including pertain only to OEF/OIF veterans who sought insufficient training, embarrassment, lack of health care at VHA and may not be reflective confidence, underestimation of the prevalence of OEF/OIF veterans who choose not to utilize of sexual health problems, patient discomfort, VHA services or veterans of other eras. time pressure, and few perceived treatment Despite these limitations, there are a num- options (e.g., Kingsberg, 2006; Tsimtsiou et ber of unique strengths of the current study al., 2006; Nusbaum & Hamilton, 2002). Such that help move forward the research agenda research indicates that the VHA may want to in examining the relationship between sex- offer further training opportunities on sexual ual trauma and sexual health. These include health assessment and treatment to providers. the inclusion of both men and women with Furthermore, given that risky sexual be- sexual trauma, a large national sample, and haviors and substance abuse may be partially the examination of a wide range of STIs and contributing to the higher rates of STIs among SDDs. The current results underscore the need those with MST, providers should also be aware for longitudinal studies on sexual health that of these behaviors and provide appropriate take into account screening and health data. psychoeducation and counseling. The present It is especially important to include data col- study also highlights the importance of multi- lected during service members’ military ser- disciplinary collaboration between medical and vice so that sexual health issues can be tracked mental health care providers to adequately care across time and can be used to improve for veterans with sexual health concerns. Many care for veterans. Moreover, it is only with such veterans would likely benefit from both longitudinal data that researchers can tease medical services including STI testing, STI pre- apart the temporal relationship between MST, vention counseling, sexual health education, sexual health problems, and mental health and drug therapies, as well as mental health in- symptoms. terventions, including psychotherapy, couples’ This study also has a number of important counseling, psychoeducation, and behavioral clinical implications for assessment and treat- interventions for SDDs. Such services are partic- ment of STIs and SDDs among veterans with ularly relevant because having an STI/SDD is of- MST. One of the most salient implications of ten associated with various consequences (e.g., the current study is the importance of sexual lack of seeking care due to stigma, decrease health assessment with veterans, particularly in social relationships, depression, etc.) that are those with a history of MST, given the re- amenable to behavioral and psychosocial inter- lationships between MST, STIs, and SDDs. ventions. Coordination of care may be partic- Such assessment may increase detection of ularly beneficial for increasing access to men- problems, which may be particularly important tal health and medical services among OEF/OIF given the asymptomatic nature of most STIs, veterans with MST and STIs/SDDs. and may help ameliorate or prevent the potential negative health, social, and economic REFERENCES consequences of untreated STIs and SDDs. 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APPENDIX

Sexually Transmitted Infections (STIs), Sexual Dysfunction Disorders (SDDs), and Mental Health Diagnosis Speciﬁcations

ICD-9-CM Codes

Any STI Any human papillomavirus (HPV) HPV–genital/anal warts 078.10–11 HPV–cervical dysplasia 795.0, 795.00–09, 795.1, 795.10–19, 622.10–12, 233.1 HPV–anal dysplasia 230.5–6, 569.44, 796.7, 796.70–76, 796.79 HPV–unspeciﬁed site 079.4 Pelvic inﬂammatory disease 614.0–9, 615.0–1, 615.9, 616.0, 616.10–11, 616.8–9 Candidiasis/vulvovaginitis 112.1 Herpes simplex 054, 054.10–13, 054.19 Trichomoniasis 131.00–03, 131.09, 131.8–9 Chlamydia 078.88, 079, 079.98, 099.0–2, 099.41, 099.50–56, 099.59, 099.8 HIV/AIDS 042, 042.0–2, 042.9, 043.0–3, 043.9, 044.0, 044.9, 795.0, 795.10–11, 795.8, V08 Scabies/pubic lice 133.0, 132.2 Gonorrhea 098.0, 098.10–17, 098.19, 098.2, 098.30–37, 098.39–43, 098.49–53, 098.59, 098.6–7, 098.81–86, 098.89 Hepatitis B 070.2, 070.20–23, 070.3, 070.30–33, V0261 Syphilis 091.0–5, 091.50–52, 091.6, 091.61–62, 091.69, 091.7–8, 091.81–82, 091.89, 091.9, 092.0, 092.9, 093.0–1, 093.20–24, 093.8, 093.81–82, 093.89, 093.9, 094.0–3, 094.81–87, 094.89, 094.9, 095.0–9, 096, 097.0–1, 097.9 Other venereal disease 099.0–4, 099.40–41, 099.49, 099.50–56, 099.59, 099.8–9 Any SDD Sexual pain disorders 306.51, 625.0–1, 625.70, 625.79 Sexual desire disorders 302.71, 799.81 Sexual arousal disorders 302.72, 607.84 Orgasmic disorders 302.73–75 Mental health diagnoses Posttraumatic stress disorder 309.81 Depressive disorders 296.20–25, 296.30–35, 300.4, 3.11 Substance use disorders 291.0, 291.3–5, 291.8, 291.81–82, 291.89, 291.9, 292.85, 292.0, 292.11–12, 292.2, 292.81, 292.83–84, 292.89, 292.9, 303.00–02, 303.90–92, 304.00–02, 304.10–12, 304.20–22, 30.430–32, 304.40–42, 304.50–52, 304.60–62, 304.70–72, 304.80–82, 304.90–92, 305.00–02, 305.20–22, 305.30–32, 305.40–42, 305.50–52, 305.60–62, 305.70–72, 305.80–82, 305.90–92, 648.30–34, 965.00–02, 965.09 Copyright of International Journal of Sexual Health is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.