Racial and Ethnic Disparities in Reproductive Health Outcomes Among Women Veterans: A Research Note

Abstract

There are a growing number of U. S. women veterans. The goal of this study was to examine the frequency of reproductive health conditions, as well as racial/ethnic disparities within reproductive health concerns, among a sample of women veterans who were referred by their primary care providers for a psychiatric evaluation. Cross-sectional data were collected from 701 women veterans in a Women’s Health Clinic at a VA Medical Center. The most commonly reported reproductive health conditions were dyspareunia, pelvic pain, and sexually transmitted infections (STIs). Other reproductive health conditions reported by women veterans included endometriosis, polycystic ovary syndrome (PCOS), and osteoporosis. Black women veterans had significantly higher rates of endometriosis compared with the other racial/ethnic groups. Prevalence of PCOS, dyspareunia, osteoporosis, STIs, pelvic pain, perinatal loss, and infertility treatment did not differ across race/ethnicity. Health care providers working with women veterans should engage in regular screening of reproductive health conditions for women across all demographic groups.

Keywords

veterans health care gender issues minority issues

There are approximately two million U.S. women veterans, accounting for roughly 10% of the overall veteran population (U.S. Department of Labor, 2020). In addition, women make up 20% of veterans between the ages of 18 and 34, indicating increased representation during child-bearing years (U.S. Department of Labor, 2020). In the next two decades, the population of women veterans is projected to increase by roughly 6% (Department of Veterans Affairs, 2017). These increases will continue to have direct implications for the provision of gender-sensitive care within the Veteran’s Affairs Healthcare System (VA).

Within women’s health settings, reproductive health care focuses on a wide range of health conditions associated with the reproductive life cycle which can include (but are not limited to) endometriosis, uterine fibroids, polycystic ovary syndrome (PCOS), sexually transmitted infections (STIs), and gynecological cancer. These conditions have been linked to reproductive health outcomes such as pelvic pain and infertility (Angin et al., 2019; Practice Committee of the American Society for Reproductive Medicine, 2012).

Among women veterans, the prevalence of reproductive health conditions has received limited attention in the literature. Recent research has highlighted the importance of access to gender-specific care in order for women veterans to receive adequate reproductive health screening (Ferras et al., 2022). A study by Katon and colleagues (2015) found that 43% of female veterans were diagnosed with at least one reproductive health condition including menstrual disorders, endometriosis, menopausal disorders, and osteoporosis. In addition, compared with civilian populations, women veterans are more likely to test positive for herpes simplex virus-type two and report a higher prevalence of risky sexual behavior across the lifetime (Katon et al., 2018). Women veterans may be at risk of reproductive and gynecological concerns as active deployment may increase risk of pregnancy complications (Wood et al., 2016). In addition, given that women veterans are more likely than male veterans and both male and female civilians to have lifetime and past-year diagnoses of post-traumatic stress disorder (Lehavot et al., 2018), they are also at increased risk of presenting with reproductive health concerns such as pelvic pain (Panisch & Tam, 2020). While informative, these studies highlight that more work is needed to understand prevalence of reproductive and gynecological conditions in this population (Wood et al., 2016).

In addition to the importance of gender-sensitive practices, racial and ethnic diversity within the military and veteran population highlights the need for culturally sensitive health care. Approximately 30% of women veterans identify as a person of color (Department of Veterans Affairs, 2017), with 19% of women veterans identifying as Black, 9% as Hispanic, and 2% as Asian. Culturally informed models of care are particularly important given evidence of racial disparities across several women’s health outcomes (Bougie et al., 2019; Wellons et al., 2008). When compared with White women, prevalence rates of endometriosis (Bougie et al., 2019; Missmer et al., 2004), STIs (Centers for Disease Control and Prevention, 2019), infertility (Stephen & Chandra, 2006; Wellons et al., 2008), and perinatal loss (Harb et al., 2014; Mukherjee et al., 2013) are higher among women of color. In addition, PCOS prevalence rates have varied greatly across ethnicity and race (Ding et al., 2017), with some studies reporting statistically similar prevalence rates between Black and White women (Azziz et al., 2004) and others reporting higher PCOS rates in Hispanic and White women compared with Black women (Lo et al., 2006).

Among the military population, one study reported that a large percentage of women veterans undergoing a hysterectomy were diagnosed with pelvic pain or endometriosis, with 65.3%, 69.7%, and 71.8% identifying as Black, White, and Latina women, respectively (Callegari et al., 2019). In an active-duty sample, higher prevalence rates of PCOS were observed among White and Black women compared with other racial groups (Hopkins & Wilson, 2019). With respect to STIs, one study found that Black women soldiers are more likely to report chlamydia compared with White women soldiers (Gaydos et al., 1998). In contrast, another study found that White veterans were more likely to report a history of STI compared with veterans in other racial and ethnic groups (Goyal et al., 2017). Furthermore, Mattocks and colleagues (2015) found that post-9/11 female veterans with an infertility diagnosis were more likely to be Black and Hispanic. In addition, Black non-Hispanic veterans and Hispanic veterans were found to have higher prevalence of pregnancy loss and complications than White veterans (Quinn et al., 2020; Wells et al., 2006). Finally, women veterans who identify as a racial minority are more likely to have chronic pelvic pain compared with a majority racial group (Volpe et al., 2020).

Given the current growth rate of women serving in the military and the subsequent impact on the VA Healthcare System, it is important for research to continue examining the unique gender-related physical health conditions impacting women veterans while also evaluating potential disparities among women who identify as a member of a racial and/or ethnic minority group. The goal of the current study is to explore the interrelationships among reproductive health and racial identity status in a sample of women veterans. Specifically, the study aims to (a) describe the frequency of reproductive health conditions in a sample of women veterans receiving mental health services in a primary care setting and (b) examine racial and ethnic disparities among reproductive health concerns. Understanding these interrelationships will enhance clinical knowledge of this population’s needs as well as inform clinical practice guidelines further addressing the implications of such disparities in the provision of culturally sensitive care.

Materials and Method

Data were collected as part of routine psychiatric practice in a Women’s Health Clinic at a VA Medical Center, as previously described by Miller and Ghadiali (2018). The current data were collected between December 2013 and February 2020, yielding an initial sample of 784 women. Nonveteran spouses (n = 83) were excluded from the sample to optimize generalizability given potential subgroup differences. The study group (n = 701) was comprised of women veterans who were referred for a psychiatric evaluation in a primary care clinic with co-located mental health services. Study participants completed a self-report Women’s Mental Health Questionnaire in which women reported demographic information, psychiatric history, reproductive status, medical history including reproductive health conditions, and other health-related variables. Information from the questionnaire was confirmed by the evaluating psychiatrist, which included discussion with the patient and collateral information obtained from medical records, which was then entered into a clinical data repository. Following approval from the local VA Institutional Review Board, a deidentified dataset was pulled from the clinical data repository.

For the purposes of the current study, variables extracted from the data repository included demographics and reproductive health outcomes. Forced choice responses were collected for relationship status (Yes/No), paid employment (Yes/No), and educational attainment (grade school/high school or general educational development [GED]/College/Postgraduate). Race and ethnicity were entered into the data repository based on categorical descriptors within VA medical records which includes race (White, Black or African American, Asian, Unknown) and ethnicity (Hispanic or Latino, Not Hispanic or Latino, Unknown). These variables were recoded into a combined racial/ethnic variable. Due to relatively small numbers among several racial and ethnic groups, Black Hispanic and Asian veterans were grouped with participants who indicated “Mixed/Other,” which will be referred to as the Asian/Mixed/Other (AMO) group. Final racial/ethnic variables for data analysis resulted in the following groups: Black, White Non-Hispanic, Hispanic, and AMO. Individuals for whom race and/or ethnicity was coded as “Unknown” (n = 23) and transgender veterans (n = 8) were excluded from inferential analysis but were included in descriptive analysis of demographic characteristics. Reproductive history, which included current reproductive status, number of pregnancies, planned or unplanned pregnancy status, and pregnancy outcome (live birth, miscarriage, abortion, and stillbirth), was self-reported. Conditions associated with reproductive health, including PCOS, endometriosis, dyspareunia, STIs, pelvic pain, and osteoporosis, were reported by women checking boxes indicating the conditions they have experienced.

Data analysis was conducted in Microsoft Excel (Version 2016). Chi-square tests were conducted to examine whether prevalence rates of women’s health conditions differed significantly across the four racial/ethnic groups in our sample (Black, non-Hispanic White, Hispanic, and AMO). Differences in average numbers of pregnancies and unplanned pregnancies within each racial/ethnic group were analyzed using one-way analysis of variance (ANOVA) to determine if mean lifetime incidence rates differed between groups. Effect sizes for chi-square and ANOVA tests were determined to be statistically significant when p values were less than .05.

Results

Demographic information about participants and prevalence rates of study outcomes are presented in Table 1. The most commonly reported reproductive health conditions were dyspareunia (21.2%), pelvic pain (18.3%), and STIs (17.5%). Other reproductive health conditions reported included, endometriosis (10.3%), PCOS (6.9%), and osteoporosis (4.4%). A total of 490 women reported a history of pregnancy and of those, 51.8% (n = 254) experienced perinatal loss. In addition, 5% of the sample (n=34) reported a history of infertility treatment.

Table 1.

Sample Characteristics and Study Outcomes Across Race/Ethnicity.

Study Variable	Black	Non-Hispanic White	Hispanic	AMO
Demographics
Mean age	43	42	35	33
Relationship status (Single)	63.58%	46.55%	55.77%	50%
Employed	50.16%	43.27%	55.77%	59.38%
Highest level of education
Grade school	<1%	<1%	0%	0%
High school	27.27%	26.84%	26.92%	28.13%
College	53.57%	60.29%	69.23%	59.38%
Postgraduate	17.85%	12.5%	3.85%	12.5%
Reproductive status^a
Menstruating	55.23%	56.88%	73.08%	75%
Pregnant	1.31%	3.27%	5.77%	9.38%
Postpartum	1.31%	2.60%	1.92%	6.25%
Perimenopausal	9.48%	4.09%	9.62%	6.25%
Natural menopause	14.71%	17.10%	3.85%	0%
TAH w/o BSO	11.48%	7.06%	1.92%	0%
TAH w/ BSO	6.54%	8.55%	3.85%	3.13%
Reproductive Health Conditions
Dyspareunia	22.65%	20.15%	19.23%	21.88%
Pelvic Pain	22.26%	16.12%	19.23%	9.38%
STIs	18.71%	16.12%	13.46%	31.25%
Endometriosis	14.84%	8.06%	1.92%	0%
PCOS	7.42%	7.33%	3.85%	6.25%
Osteoporosis	4.84%	5.49%	1.92%	0%
History of pregnancy	79.02%	72.24%	63.27%	67.74%
History of perinatal loss	54.24%	49.47%	48.39%	47.62%
Infertility treatment	4.98%	5.40%	4.17%	3.13%
Mean N of pregnancies	2.24	1.79	1.65	1.35
Mean N of Unp. pregnancies	1.57	1.02	0.98	0.94

Note. AMO = Asian/Mixed/Other; TAH = total abdominal hysterectomy; BSO = bilateral salpingo-oophorectomy; Unp. = Unplanned; PCOS = polycystic ovary syndrome.

Percentages do not add up to 100% due to participants having overlap in reproductive status (ex. postpartum and menstruating).

Prevalence rates of endometriosis differed significantly, χ² (3, N = 670) = 16.00, p = .001, such that Black women veterans had higher rates of endometriosis compared to the three other racial/ethnic groups. Prevalence of PCOS χ² (3, N = 670) = 1.38, p = .709, dyspareunia, χ² (3, N = 666) = .69, p = .875, osteoporosis, χ² (3, N = 667) = 1.46, p = .692, STI, χ² (3, N = 667) = 5.32, p = .150, pelvic pain, χ² (3, N = 667) = 5.56, p = .135, perinatal loss, χ² (3, N = 478) = 1.26, p = .738, and infertility treatment, χ² (3, N = 640) = .40, p = .941, did not differ across race/ethnicity.

While not considered reproductive health outcomes, we also examined differences in the mean number of lifetime pregnancies and unplanned pregnancies among the racial/ethnic groups in the sample. Black women veterans had significantly higher mean number of pregnancies, F(3, 644) = 4.90, p = .002, and unplanned pregnancies, F(3, 592) = 7.50, p < .001 compared to non-Hispanic White, Hispanic, and AMO women veterans.

Discussion

The goal of the present study was to report the frequency of reproductive health conditions in women veterans, examine racial and ethnic disparities among reproductive health concerns, and contribute to the understanding of gender-specific needs in the VA health care system. Rates of endometriosis, PCOS, dyspareunia, and STIs in this sample were found to be comparable to the general population (Angin et al., 2019; Kreisel et al., 2021; Seehusen et al., 2014; Zondervan et al., 2002); however, participants did endorse slightly higher rates of pelvic pain compared with the general population (Dydyk & Gupta, 2022). These results highlight the need for adequate assessment and trauma-informed treatment of reproductive health concerns within the VA and civilian health care systems, especially as women veterans report high rate of trauma exposure and those with a history of trauma are more likely to present with reproductive health concerns such as pelvic pain (Panisch & Tam, 2020). A more detailed list of clinical implications and policy recommendations is presented in the appendix.

An important finding related to the frequency of reproductive-linked concerns was the high prevalence of pregnancy loss in this sample, which represents a twofold risk compared with the general population (Dugas & Slane, 2022). Previous research has found that women veterans present with multiple medical conditions that increase the risk of pregnancy complications (e.g., gestational diabetes, preeclampsia, and pre-term birth) as well as mental health conditions that can impact pregnancy outcomes (Katon et al., 2018). Given that perinatal loss is associated with adverse mental health outcomes (Vitale et al., 2017), it may be particularly important for health care providers to follow-up on history of perinatal loss and fertility issues among women veterans to ensure adequate referral to appropriate mental health resources. Notably, the participants in the present study were referred for a psychiatric evaluation by their primary care provider, indicating that this sample likely has greater rates of mental health conditions compared with women veterans more broadly. However, higher rates of pelvic pain and pregnancy loss in this sample highlight the potential link between adverse reproductive events or reproductive health conditions on mental health.

Regarding the second aim of this study, which sought to explore racial and ethnic disparities in reproductive health concerns, only endometriosis differed significantly across racial and ethnic groups, with endometriosis being more prevalent among Black women veterans. This is particularly noteworthy as existing research on prevalence rates of endometriosis among Black women vary widely (Shafrir et al., 2018), which may be related to several factors. First, endometriosis was historically and erroneously considered to be a disease that only impacts White women, which has contributed to inequities in the accuracy of diagnosis and treatment of endometriosis in Black women (Jacoby et al., 2010). Second, a diagnosis necessitates access to services that have historically been less available to Black women due to inequities in health care (Shafrir et al., 2018). Thus, the present study’s findings support the need for careful monitoring and screening for reproductive health concerns across all women veterans as well as continued education on implicit biases among health care providers to address stereotypes that may contribute to inequitable care. These implications are underlined by our finding that Black women veterans reported the highest prevalence of pelvic pain of any racial or ethnic group. Although the effect size was not significant, the finding challenges myths about Black individuals experiencing less pain compared with White individuals (Trawalter & Hoffman, 2015).

The present study was not without limitations. First, racial and ethnic identity were obtained based on medical record data and not directly reported by the participants during the study, which may contribute to inaccuracies in racial and ethnic identity. Second, items on the questionnaires were asked in a lifetime history, yes/no format, which does not provide information about chronicity, age of onset, or other variables that could lend useful information. Third, the number of women veterans in each racial and ethnic group was restricted, which led to collapsing several groups together to have a sufficient number of cases available for analysis. However, the sample still allowed for analyzing differences across three highly represented racial and ethnic groups in the U.S. civilian and military population (White, Black, and non-Black Hispanic). It is recommended that future research utilize culturally inclusive recruitment strategies to optimize participation by diverse groups of women veterans. Finally, as mentioned previously, participants in this sample were referred for psychiatric evaluation, indicating the presence of a mental health condition. Thus, rates of reproductive health conditions or adverse reproductive events (including pregnancy loss) may be higher in this population compared with women veterans more broadly.

Conclusion

In a relatively diverse sample of women veterans, there were high rates of perinatal loss history as well as racial disparity in the prevalence of endometriosis. This is the first known study to report racial differences in endometriosis among women veterans. The findings indicate that providers working with women veterans should engage in regular screening and evaluation of reproductive health conditions across women of all demographic groups. This is particularly important for Black women who have been traditionally underdiagnosed, given barriers to health care access as well as stereotypical beliefs among medical providers that has led to the downplaying of endometriosis and pain among Black women.

Footnotes

Appendix

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Katherine Collison, PhD, completed her clinical internship at Edward Hines, Jr. VA Hospital, and is currently a clinical research postdoctoral fellow at the Family Institute at Northwestern University.

Jessica P. Naftaly, PhD, completed her internship at Edward Hines, Jr. VA Hospital, and her postdoctoral training at the University of Michigan, Michigan Medicine. She is currently a clinical lecturer and licensed clinical psychologist in the division of gastroenterology at the University of Michigan, Michigan Medicine.

Kathleen Colangelo, PhD, is a licensed clinical psychologist in the state of Illinois and currently employed at the Edward Hines, Jr. VA Hospital. She received her PhD in counseling psychology from the University of Akron. Her clinical training included postdoctoral fellowship at the Louis Stokes Cleveland VA Medical Center and predoctoral internship at the VA Maryland Healthcare Center System.

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