Department of Veterans Affairs 

Health Services Research & Development Service Evidence-based Synthesis Program

Health Effects

of Military Service

on Women Veterans 

Prepared for: 

Department of Veterans Affairs 

Veterans Health Administration 

Health Services Research & Development Service 

Washington, DC 20420 

Prepared by: 

Evidence-based Synthesis Program (ESP) Center 

West Los Angeles VA Medical Center 

Los Angeles, CA 

Paul G. Shekelle, M.D., Ph.D., Director 

May 2011 

Investigators: 

Principal Investigator:

 Paul G. Shekelle, M.D., Ph.D. 

Co-Investigators: 

Fatma Batuman, M.D.

Bevanne Bean-Mayberry, M.D., M.H.S.

Caroline Goldzweig, M.D., M.S.P.H.

Christine Huang, M.D.

Donna L. Washington, M.D., M.P.H.

Elizabeth M. Yano, PhD, M.S.P.H.

Laurie C. Zephyrin, M.D., M.P.H., M.B.A. 

Research Associate:


Isomi M. Miake-Lye, B.A.
 
Health Effects of Military Service on Women Veterans Evidence-based Synthesis Program 

PREFACE 

Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis 

Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare 

topics of particular importance to VA managers and policymakers, as they work to improve the 

health and healthcare of Veterans. The ESP disseminates these reports throughout VA. 

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help: 

•		 develop clinical policies informed by evidence, 

•		 guide the implementation of effective services to improve patient outcomes 

and to support VA clinical practice guidelines and performance measures, and 

•		 set the direction for future research to address gaps in clinical knowledge. 

In 2009, an ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight and guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system. 

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov. 

Recommended citation:, Batuman F, Bean-Mayberry B, Goldzweig CL, Huang C, 

Miake-Lye IM, Washington DL, Yano EM, Zephyrin LC, Shekelle PG. Health Effects of 

Military Service on Women Veterans. VA-ESP Project # 05-226; 2011. 

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the West Los Angeles VA Medical Center, Los Angeles, CA 

funded by the Department of Veterans Affairs, Veterans Health Administration, Office of 

Research and Development, Health Services Research and Development. The findings 

and conclusions in this document are those of the author(s) who are responsible for its 

contents; the findings and conclusions do not necessarily represent the views of the 

Department of Veterans Affairs or the United States government. Therefore, no statement 

in this article should be construed as an official position of the Department of Veterans 

Affairs. No investigators have any affiliations or financial involvement (e.g., employment, 

consultancies, honoraria, stock ownership or options, expert testimony, grants or patents 

received or pending, or royalties) that conflict with material presented in the report. 

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Health Effects of Military Service on Women Veterans Evidence-based Synthesis Program 

EXECUTIVE SUMMARY 

BACKGROUND 

In response to a growing need to understand the effects of military service on health status, 

this report supplements our prior review by focusing directly on the reproductive and trauma 

effects on women in the military or Veterans who have been deployed. The goal is to broaden the 

knowledge of VA policy leaders and clinicians about post-deployment health issues for women. 

The Key Questions were: 

Key Question #1: What research has been published on the effects of deployment on postdeployment reproductive outcomes? 

We operationalized “reproductive effects” to encompass the following: fertility issues, birth 

defects, menstrual effects (e.g., change in cycles, loss of cycles), urinary tract infections, sexually 

transmitted infections, and reproductive cancers (e.g., cervical, ovarian, etc). 

Key Question #2: What research has been published on post-trauma sequelae in OEF/OIF 

women Veterans, including: mental health problems, suicide, cardiovascular disease, risky health 

behaviors (including: tobacco use, hazardous alcohol use, substance abuse, suicide, homicide, 

assaultive behavior, and eating disorders), and other post-trauma sequelae? 

METHODS 

We searched PubMed in August 2010 using standard search terms. Titles, abstracts, and articles 

were reviewed in duplicate by team members trained in the critical analysis of literature. Articles 

were classified according to subject category and narratively summarized in evidence tables. 

RESULTS 

We screened 2,359 titles, rejected 2,302 based on systematic criteria, and performed a more 

detailed review of 57 articles that met criteria. From these, we identified 15 articles relating to 

Key Question #1 (post-deployment reproductive effects) and 29 relating to Key Question #2 

(post-trauma sequelae among OEF/OIF women Veterans). 

Key Question #1. What research has been published on the effects of deployment 

on post-deployment reproductive outcomes? 

The evidence base for reproductive effects of deployment of women Veterans is modest, mostly 

consisting of single studies of specific deployments and particular outcomes. Of note, there have 

been no published assessments of reproductive effects of the current (since 2003) deployments. 

Data about reproductive effects from past deployments are insufficient to reach strong 

conclusions. Because many of the outcomes of interest (birth defects, gynecologic cancers) are 

rare, large sample sizes are needed to assess for possible associations, and often times response 

rates for large sample studies are below desirable levels. This makes the interpretation of findings 

questionable. 

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Health Effects of Military Service on Women Veterans Evidence-based Synthesis Program 

Key Question #2. What research has been published on post-trauma sequelae 

in OEF/OIF women Veterans, including: mental health problems, suicide, 

cardiovascular disease, risky health behaviors (including: tobacco use, 

hazardous alcohol use, substance abuse, suicide, homicide, assaultive behavior, 

and eating disorders), and other post-trauma sequelae? 

The 13 publications focusing on the post-deployment mental health of our OEF/OIF Veterans 

found increased risks for new-onset depression, suicide, and firearm suicide; discrepancy 

between the mental health needs and utilization of mental health services, greater risks for mental 

disorder hospitalizations, and higher utilization of non-mental health medical services among 

Veterans with mental health diagnoses; and higher risks for mental diagnoses among certain 

subgroups. 

The post-trauma sequelae highlights three visible issues: 1) early TBI data show a preponderance 

of men from the military; ongoing evaluation is needed to understand what, if any, gender 

issues may be important for ongoing care; 2) alcohol use in recently returning women Veterans 

presents greater risk at lower levels of consumption for women with other risk conditions (PTSD 

MST, combat trauma); and 3) health care utilization by gender and diagnosis requires ongoing 

follow-up because while women may initiate contact with VA sooner, utilization did not differ. 

Moreover, conditions examined so far for deployed or post-deployed women manifest differently 

(pain syndromes) or differ in cause for evacuation from theatre. Individual studies also examined 

a number of other possible associations, such as eating disorders, pain, post-deployment distress, 

etc.; data are too sparse to draw firm conclusions. 

CONCLUSIONS 

With the continued expansion of women’s role in the military, better understanding of the 

potential health effects of military service on women during and after their miltary service is 

essential. While the emerging literature in this area is relatively limited to date, several important 

themes are nonetheless apparent. 

The evidence on the influence of military service on reproductive health is mixed and relies on a 

modest literature base. Generally, pregnancy outcomes do not appear to differ among deployed 

vs. undeployed women. However, while several studies demonstrate non-significant differences 

by deployment status, others present contradictory evidence on the influence of military service 

on rates of spontaneous abortion, stillbirths, and ectopic pregnancies. Influences on birth 

outcomes raise more questions than they answer. Only one study reported birthweights, which 

did not appear to differ by deployment experience of their mothers. More studies have focused 

on birth defects: about half indicate there are no significant differences in birth defect rates 

among deployed vs. non-deployed women, whereas the other half report higher rates that are not 

statistically significant (reflecting problems in statistical power associated with sample sizes for 

these rare events) or in fact reflect higher rates. 

The evidence on post-trauma sequellae among OEF/OIF women (soldiers and Veterans) is also 

relatively limited, and reflects a chief emphasis on mental health issues. Most of these studies 

are descriptive, and allude to gender differences in diagnosis, impact and health care utilization. 

Depression and suicide are major foci, demonstrating the highest rates of incident depression 

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Health Effects of Military Service on Women Veterans Evidence-based Synthesis Program 

among women who are deployed and also exposed to combat. Interestingly, deployment without 

such exposure was associated with lower rates of incident depression than non-deployment. 

Women Veterans also had higher risks for depression than men, though lower substance use 

disorders. Suicide risk was reported as being lower among women Veterans, but the standardized 

mortality ratio among female Veterans is reportedly higher than that of male Veterans. Several 

of these studies focused on the differences among Veterans vs. non-Veterans more than women 

vs. men. For example, the suicide rate among all Veterans (male and female) is estimated to be 

66 percent higher than that of the general population. Also, among suicide decedents, women 

Veterans were 1.6 times more likely to use firearms (compared to non-Veterans). 

The literature on mental health needs and utilization among OEF/OIF women Veterans was 

also descriptive and limited. Younger women Veterans were less likely than young male 

Veterans to use mental health services, which was in contrast to older Veterans (i.e., older 

women Veterans were more likely to use mental health services than older male Veterans). This 

pattern held overall and for those with substance abuse or mood/anxiety disorders, whereas 

no gender differences were found for PTSD care-seeking. Female soldiers had higher risks of 

hospitalization for mental disorders, and were more likely to be psychiatric evacuees from the 

field. 

The remainder of the literature on other post-trauma sequelae was variable in topic. The evidence 

of problem-drinking among OEF/OIF women Veterans is mixed (two studies which present 

contradictory findings). Some of this literature focuses on examing gender differences. For 

example, predictors of women Veterans’ readmission rates for inpatient drug treatment include 

sexual and physical abuse before, during and after deployment (vs. substance abuse, aggression, 

and cognitive impairment among men). OEF/OIF women had higher rates of military sexual 

trauma (MST); and women with MST used VA care more, were less satisfied and had lower 

perceptions of VA facilities and staff, with particular problems with VA staff among those who 

had also had combat exposure. OEF/OIF women were less likely to witness the level of killing 

that men experienced and were less likely to have traumatic brain injuries (TBI), compared to 

men. Effects of deployment among OEF/OIF women included higher rates of moderate to severe 

pain, higher distress after the first deployment, and, when added with combat experiences, high 

rates of eating disorders and extreme weight loss. 

FUTURE RESEARCH 

In summary, differential effects of military service by gender are apparent, though the volume 

and quality of the literature is as yet modest. Given that the published scientific literature not 

uncommonly reflects prior years’ research investment in different topic areas, we anticipate 

that the investment in women’s health research by the U.S. Departments of Veterans Affairs 

and Defense will contribute to a rapidly growing literature base on the health effects of military 

service on women over the next several years. Such growth may warrant an updated systematic 

review, comparable to the overarching review that was recently updated,4

 which demonstrated 

that more articles were published between 2004 and 2008 than the previous 25 years combined. 

More research is needed on the reproductive health effects of military service. Currently, the 

evidence is mixed with respect to impacts on pregnancy and birth outcomes. One case control 

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Health Effects of Military Service on Women Veterans Evidence-based Synthesis Program 

study reported an association between rates of birth defects and deployment status, begging the 

question about what elements of military service (or pursuit of service) might be contributing 

factors. The available literature also lacks descriptive evidence of the range of reproductive 

health issues that women in the military and women Veterans face. Currently, there are studies in 

progress that may well contribute substantively to this knowledge base, but that are not yet in the 

published literature. 

The VA research portfolio on OEF/OIF Veterans’ health and health care will also contribute 

to the emerging literature on the consequences of military service among OEF/OIF women 

Veterans. The current literature lays some of the groundwork but does so less comprehensively 

(spanning topics of mental health, physical health, social function, and so on) than would be 

optimal. Future research should begin to fill these gaps to produce an increasingly detailed 

portrait of their post-trauma sequelae. 

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