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Contents: Original Research

Associations Between Sexual Assault and Reproductive and Family Planning Behaviors and Outcomes in Female Veterans

Edmonds, Stephanie W. PhD, RN; Mengeling, Michelle A. PhD; Syrop, Craig H. MD, MHCDS; Torner, James C. PhD; Sadler, Anne G. RN, PhD

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doi: 10.1097/AOG.0000000000004278
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A history of sexual assault during one's lifetime (lifetime sexual assault) is a common experience among female veterans,1–6 and it can alter their reproductive lives.4,7–11 Female veterans who experienced lifetime sexual assault have more pregnancies and at a younger age and are more likely to undergo induced abortions than women who had not experienced lifetime sexual assault.9 Department of Veterans Affairs (VA)–enrolled women who experienced lifetime sexual assault also report delaying or avoiding childbearing because of their sexual assaults.9

One possible link between increased pregnancies and induced abortions in the veteran population is that contraceptive use rates are lower among veterans as compared with nonveterans.7 Given that the VA provides all methods of contraception free of charge,12,13 enrolled veterans should have better contraception access than nonveterans. One potential reason that women with a history of lifetime sexual assault do not use contraception is avoidance of reproductive health care owing to potential re-traumatization. Women who experience sexual assault may be less likely to have recommended cervical cancer screening,14 be more likely to experience discomfort,15,16 and have negative emotional thoughts and feelings during vaginal examinations.16

Because an association between contraception use and lifetime sexual assault has implications for reproductive health care delivery, we sought to determine whether female veterans who have experienced lifetime sexual assault have differences in reproductive health care seeking, contraception usage, and family planning outcomes than those who have not experienced lifetime sexual assault. We also compared the reasons female veterans reported for not having a Pap test and for not using contraception in the past between veterans who have experienced lifetime sexual assault and those who have not.

METHODS

This article details a secondary analysis of the Sexual Violence and Women Veterans' Gynecologic Health Study. Details of this study can be found elsewhere.11 The University of Iowa and Iowa City VA Medical Center's Institutional Review Boards approved the study, and all participants provided written consent.

From 2005 to 2008, a cross-sectional interview was conducted with female veterans younger than 53 years. Given the primary study goals of determining female veterans' risk factors associated with cervical cytologic abnormalities, women were excluded from participation if they acknowledged a history of in utero diethylstilbestrol exposure or were currently receiving immunosuppressant therapy. The study team identified female veterans who were enrolled in two large Midwestern VA health care systems within the previous 5 years using the Veterans Health Information System & Technology Architecture, sent potential participants introductory letters and consents, and then called women 2 weeks after the mailing until they made contact or determined a woman was unreachable. A total of 2,414 female veterans were identified. Following a recruitment protocol, 1,670 of the 2,414 (69.2%) were located and invited to participate. From these 1,670 women we contacted, 1,004 of 1,055 consenting participants completed the interview (95.2%) to provide a final available response rate of 60.1% (Appendix 1, available online at https://links.lww.com/AOG/C191). The mean duration of the interview was 1 hour and 16 minutes, and participants who completed the interview received $30 in compensation.

Trained female interviewers conducted computer-assisted telephone interviews using Blaise17 Survey Development software, as previously reported. Interviewers collected self-reported data on sociodemographic variables, lifetime violence exposures, physical and mental health histories (eg, posttraumatic stress), and health care utilization within and outside the VA. Sexual orientation was asked as, “Which of the following best describes your current sexual preference?” with response options of heterosexual, lesbian, or bisexual. The interviewers defined sexual assault to participants as “someone making you have sex against your will by using force or threatening to harm you or someone close to you. Sexual assault can involve a man or boy forcing you to have sex by putting his penis in your vagina, your mouth, or your anus. Sexual assault can also involve a male or female putting their tongue in your vagina, or fingers or objects in your vagina or anus.” This definition was adopted from the American Medical Association and the American College of Obstetricians and Gynecologists.18,19 For this study, completed sexual assault was defined as completed penetration; attempted assaults were defined as sexual assaults that did not include penetration. Participants who reported not experiencing attempted or completed sexual assault were categorized as not experiencing lifetime sexual assault.

To examine our primary outcomes (reproductive health care seeking and family planning outcomes), participants were asked about pregnancy history, including their ages at time of pregnancies, whether they received prenatal care and during which trimester they initiated this care, number of induced abortions [asked as “How many of your pregnancies resulted in an intentional early termination (that is an abortion)?”], and whether they had undergone tubal ligation. Participants' health seeking behaviors queried included time of last Pap test and pelvic examination, and contraceptive use behaviors such as whether they ever used birth control, whether they had used birth control in the previous 3 months, and the longest period of time they ever had unprotected sex (in years–months). We operationalized reproductive health care seeking as reported having had pelvic examinations, Pap tests, prenatal care, and contraception usage. Family planning outcomes were operationalized as history of conceiving, age of first pregnancy, and having an induced abortion.

To examine our secondary outcomes (associations between lifetime sexual assault, and reasons participants did not get a Pap test or reasons they had not use birth control in the past 3 months), participants were asked several questions. Items related to reasons for not getting a Pap test were collected by the interviewers saying, “Now I am going to read some reasons why some women don't get annual Pap smears. Please tell me how much the following reasons influence you're not getting annual Pap smears.” It is important to note that, at the time of this interview, Pap tests were recommended annually.20 The interviewers listed 19 different reasons for not getting a Pap test with response options as a lot, some, a little, and not at all. For the purposes of this study, we examined only the reasons that might be associated with lifetime sexual assault. For the question about reasons a participant did not use birth control, interviewers asked women who responded “no” to the questions “Have you used birth control within the last 3 months?” For the participants who responded “no” to using birth control in the last 3 months, the interviewers then listed 10 reasons why a woman might not use birth control and participants responded yes or no to each reason.

Demographic variables analyzed included age, race, current sexual orientation, highest rank in military (lower enlisted or officer), highest level of education, household income, number of times legally married, and current marital status. Race and ethnicity were asked as, “Many people claim more than one racial or ethnic ancestry. Because of this we would like you to answer yes or no to each of the following questions. Do you consider your racial–ethnic ancestry to be Native American or Alaskan Native?” Interviewers then asked the same question for Asian or Pacific Islander, Hispanic or Latina, Black or African American, and White or Caucasian ancestry. To increase sample sizes in each group, we combined race and ethnicity categories into three groups: 1) Black (those who responded yes to Black or African American but no to all other ancestry questions), 2) White (those who responded yes to White or Caucasian and no to all other ancestry questions), and 3) another race (those who responded yes to one of the questions in addition to or instead of Black or White). To examine health care access, we used items that queried current health insurance status, use of VA medical care in past 5 years, and use of gynecologic health care outside the VA in the past 5 years. To assess health status, we used self-reported items of general health (using one item that rated general health as excellent, very good, good, fair, or poor) and of anxiety, depression, and posttraumatic stress disorder (“has a heath care clinician ever diagnosed you with…”), and whether they had pain with intercourse (“Does it hurt you to have sexual intercourse?”).

Of the 1,004 women interviewed, five participants were excluded because they did not answer questions needed for this analysis, leaving a total sample of 999 participants. Initial analyses revealed that age differed significantly between those who reported lifetime sexual assault, with 55.4% of those aged 20–39 years reporting lifetime sexual assault, compared with 68.4% of those 40–52 years of age (P<.001). Because age represented a significant confounder (older women had more cumulative reproductive years in which to conceive), and most women completed childbearing by age 40 years,21 we stratified data using two age categorizations (ages 20–39 years and 40–52 years).

Bivariate analyses examined differences between women who had experienced sexual assault and those who had not, using the χ2 test for categorical variables. The outcomes of interest (seeking care, contraception use, and family planning outcome) were stratified by age, and P<.05 was considered significant. We also looked for differences in the outcomes of interest based on a history of sexual assault outside the military compared with sexual assault in the military to determine whether these could be combined into a lifetime sexual assault variable. We then used multivariable logistic regression, overall and stratified by age, to control for key demographic variables that were significant in the bivariate analysis (with the exception of sexual orientation owing to the low sample sizes for lesbian and bisexual participants). For specific frequencies of participants' sociodemographic characteristics by each outcome variable see Appendices 2–6, available online at https://links.lww.com/AOG/C191). We reported crude and adjusted odds ratios, 95% CIs, and P-values.

We report frequencies and percentages to describe the reasons that participants reported for not having an annual Pap test in the past and those who reported not using contraception in the past 3 months, and we then compared them using the χ2 test between those who have experienced lifetime sexual assault and those who have not. Because women who are 40–52 years old may not be using contraception owing to older age and perimenopause, we opted to only analyze reasons for not using contraception in women 20–39 years of age. All statistical analyses were carried out using SAS 9.4.

RESULTS

More than half of participants reported a history of lifetime sexual assault (62.1%). Table 1 provides the characteristics of all the participants and compares those who had reported experiencing lifetime sexual assault and those who had not, stratified by age groups 20–39 years and 40–52 years. Overall, the group was predominantly White, had some college or higher education, and income greater than $30,000 per year.

T1
Table 1.:
Sociodemographic Characteristics by Lifetime Sexual Assault Status, Stratified by Age

In the 20–39-year-old age group, those who experienced lifetime sexual assault were more likely to: 1) be married two or more times (P=.004) and to be married or divorced at the time of the interview (P=.048), 2) have a higher proportion of lesbian or bisexual sexual orientation (P=.035), and 3) be of lower enlisted rank among those who reported lifetime sexual assault compared with those who did not (75.9% vs 65.9%, P=.015). Among the 40–52-year-old age group, those who had experienced lifetime sexual assault were more likely to: 1) have high school education only (P=.017), 2) be of lower enlisted rank (62.8% vs 47.5%, P=.001), and 3) use VA services (P<.001).

Lifetime sexual assault in both age strata was associated with poorer health status, but not with seeking routine reproductive health care (Tables 2 and 3). Women with lifetime sexual assault were more likely to: 1) have a self-reported history of depression, anxiety, and posttraumatic stress disorder; and 2) report having pain with sexual intercourse. There were no differences observed by lifetime sexual assault history for: 1) having a pelvic examination in the past 5 years, 2) having a Pap test in the past year, or 3) seeking care for painful sex.

T2
Table 2.:
Health Outcomes by Lifetime Sexual Assault Status, Stratified by Age
T3
Table 3.:
Age-Stratified Family Planning Behaviors by Lifetime Sexual Assault Status (N=999)

Women in the older age group who experienced lifetime sexual assault were significantly less likely to seek prenatal care with their first pregnancy (Table 4). Women aged 20–39 years had lower odds for seeking prenatal care with their first pregnancy, but this finding was not significant after adjustment for covariates.

T4
Table 4.:
Crude and Adjusted Odds Ratios Between Those With Lifetime Sexual Assault (Compared With Those With No Lifetime Sexual Assault) and Select Family Planning Behaviors, Stratified by Age

A significant relationship was found between sexual assault and contraception (Table 3). Women with lifetime sexual assault in the younger age group reported greater exposure to unprotected sex for 1 or more years (57.0% vs 48.3%, P=.005). In the older age group, 72.9% (vs 59.3%) were more likely to have gone 1 or more years of having unprotected sex (P=.003). Additionally, when adjusting for covariates, the total sample demonstrated 2-fold greater odds and older participants demonstrated 3-fold greater odds of having unprotected sex 1 year or more (Table 4). Women in the total sample were two times more likely and those who were 40–52 years of age at the time of the study were three times more likely to have had a teen pregnancy if they experienced lifetime sexual assault.

Reasons for avoiding Pap tests were consistent across age groups. Women who experienced lifetime sexual assault were more likely to provide multiple explanations, such as: 1) fear that a health care professional would ask about history of violence, 2) being anxious about the examination, 3) feeling out of control of their body, or 4) reporting that Pap tests are painful or embarrassing (Table 5). Women aged 40–52 years who experienced lifetime sexual assault were also significantly more likely to report that their health care professional did not recommend Pap tests. Additionally, a greater proportion of women aged 40–52 years reported having a hysterectomy (82.6%) as a reason for not getting a Pap test compared with women aged 20–39 years (14.8%).

T5
Table 5.:
Reasons for Not Getting a Pap Test in the Past

Among reasons for not using birth control, women aged 20–39 years of age who experienced lifetime sexual assault were significantly more likely to have not used contraception in the previous 3 months (P=.034). Among all the queried reasons for not using contraception, the only reason that showed a significant difference between groups was “not planning to have sex” in which women without a history of lifetime sexual assault were more likely to report this (P=.011, Table 6).

T6
Table 6.:
Reasons for Not Using Birth Control in Past 3 Months Among Women 20–39 Years of Age (n=215)

DISCUSSION

We examined the relationship between lifetime sexual assault and the reproductive health care seeking, contraception usage, and family planning outcomes for female veterans. Female veterans who experienced lifetime sexual assault were more than twice as likely to report unprotected sex for more than a year and were twice as likely to experience a teen pregnancy. These findings extend our prior research reporting postassault sequelae of teen pregnancies among female veterans who experienced lifetime sexual assault.9

We discovered that a history of sexual assault was associated with an effect on reproductive health care seeking. For women who avoided getting Pap tests, women with lifetime sexual assault were more likely to state that this avoidance was due to reasons such as fear that their health care professional will ask about violence, anxiety about the examination, feeling out of control of their body, and experiencing pain or embarrassment. These findings support other studies in nonveteran populations in which women who have been sexually assaulted reported concerns about seeking pelvic examinations owing to possible re-traumatization.14–16,22 Female veteran participants with lifetime sexual assault had double the odds of reporting pain with sex. An earlier study, along with our prior research, demonstrated increases in sexual pain among female veterans who experienced sexual assault.23,24

Women who had experienced lifetime sexual assault and who were 40–52 years of age at the time of the interview reported they had been less likely to seek prenatal care with their first pregnancy. In 2016, 1.6% of U.S. pregnancies that ended in live birth did not involve any prenatal care.21 By comparison, 24.2% of our entire sample, and 26.7% of women who experienced lifetime sexual assault, reported that they did not receive prenatal care with their first pregnancies. Similar to the reasons women with lifetime sexual assault reported for avoiding Pap tests, it is possible that fear of re-traumatization may hinder female veterans from seeking prenatal care. Given research reporting poorer maternal and fetal outcomes in women who do not seek prenatal care,25–27 this is a concerning finding.

Female veterans who experienced lifetime sexual assault were nearly twice as likely to have reported unprotected sex for a year or more. Conversely, others have found that female veterans who experienced military sexual trauma were more likely to have a prescription for contraception.28 A unique strength of our study is that we queried reasons that female veterans reported for not using contraception in the past 3 months compared with their history of lifetime sexual assault. The only significant difference we found between lifetime sexual assault history and reasons women had not used birth control recently was that more women who had not experienced lifetime sexual assault were not planning to have sex. This finding was unexpected; we had hypothesized that women who have experienced lifetime sexual assault would be less likely to plan for sex owing to potential discomfort, anxiety, or re-traumatization. Further research to investigate reasons why veterans with lifetime sexual assault are less likely to use contraception are indicated by this finding.

Finally, among all women in our study, we found that those who experienced lifetime sexual assault had almost double the odds for having reported a teen pregnancy. Our results indicating that teen pregnancies are more common among women with a history of sexual assault are consistent with other studies in nonveteran populations.29–31 When we examined this outcome according to age group, we found that the 40–52-year-old women were more than twice as likely to have reported a teen pregnancy, whereas there was no difference among women 20–39 years of age. We surmise that increases in access to improved contraceptive technologies, such as long-acting reversible contraception and emergency contraception, may represent one explanation for this age group related difference.

This study has several limitations. Geographically, participants were from two Midwestern VA facilities in a single state. Therefore, our findings may not be as generalizable to female veterans who do not use the VA or those across all geographic regions. We included sexual assault at any point during a woman's lifetime; thus, the assault could have occurred after a teen pregnancy or induced abortion, which potentially limits interpretation of those findings. Further, a response to querying the longest period of unprotected sex was not limited to only those who were at risk for unwanted pregnancies, for example those who were planning to get pregnant or those who had a female sex partner. Finally, as a secondary analysis of existing data, this report's sample size had been prespecified for a prior study's primary outcomes. Tailored questioning is an efficient method to reduce respondent burden but can result in unequal sample sizes of unique questions and, thus, affect our ability to demonstrate differences as robustly as if we had access to a larger sample size. These limitations are offset by the novel and important findings that this work can contribute to address key gaps in the literature.

Our findings have important implications for the provision of trauma-informed care of female veterans. Although not resolved by this study, it is possible that women who have experienced lifetime sexual assault have longer periods of time of unprotected sex or avoid prenatal care with their first pregnancy because they do not seek medical care out of fear of re-traumatization. As recommended by the American College of Obstetricians and Gynecologists, contraception care can be provided without invasive medical tests such as Pap tests and pelvic examinations.32 Despite this important recommendation, early evidence suggests that women continue to have unnecessary pelvic examinations and Pap tests,33,34 which imposes an undue care barrier for women who have experienced lifetime sexual assault. Therefore, the Veterans Health Administration and other health clinics must ensure they are not performing invasive examinations on women unnecessarily, especially for those with a history of sexual trauma. Clinicians and health organizations must deploy trauma-informed care approaches and policies to prevent re-traumatization, so women who experienced sexual assault may receive better health care and achieve better health outcomes.35

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