Combating sexually transmitted infections in U.S. active-duty servicewomen: A social-ecological view of sociodemographic risk factors

Abstract

Background:

Sexually transmitted infections (STIs) are a significant health issue among U.S. military personnel. Active-duty servicewomen (ADSW) make up <20% of the U.S. military yet account for more than 33% of all military STI diagnoses. STI prevention is critical to military health and readiness.

Objectives:

This review sought to (1) examine STI prevalence and risk factors among ADSW, (2) identify disparities by age, race, and rank, and (3) evaluate barriers to STI prevention and care. It also summarized evidence-based interventions to guide military public health strategies.

Design:

This systematic review of peer-reviewed articles and military health reports examined how demographic factors affect STI rates.

Data Sources and Methods:

Four databases were searched with a medical librarian’s guidance using STI- and military-related terms. Two reviewers independently screened 1833 records, selecting 17 studies (1996–2025) that met inclusion criteria. Data were narratively synthesized. Risk of bias was assessed using Covidence’s standard domains.

Results:

Of the 1833 articles and reports screened from databases including PubMed and ProQuest, 17 were included. Preliminary analysis showed that ADSW have higher STI rates than servicemen. STI rates were highest among those who were young, junior enlisted, Black, and reported binge drinking. ADSW <25 years have the highest STI rates, with those aged 17–24 accounting for over 60% of chlamydia cases. Racial disparities exist within STI incidence rates; Black ADSW <25 years old experience the highest chlamydia rates (10,500 per 100,000), twice as high as White ADSW. Confidentiality concerns, stigma and limited access to healthcare services hinder care. Proposed interventions include enhancing military-specific sexual health education, expanding access to sexual health care, and implementing risk reduction programs.

Conclusion:

High STI rates among young ADSW highlight the need for targeted interventions. Prioritizing ADSW’s health helps achieve the nation’s public health goals, strengthening population health and force sustainability.

Plain language summary

Understanding why young U.S. active-duty service women have higher rates of sexually transmitted infections and exploring strategies to improve their sexual health and reduce infection risks across different branches of the military

Sexually transmitted infections (STIs) are a growing problem for people who serve in the U.S. military. Active-duty women get STIs more often than civilian women and active-duty men. Even though women make up less than 20% of active-duty service members, they account for more than 33% of all STI cases within the military. We looked at articles from 1996 to 2025 and focused on studies published after 2012 as there is not much research on this topic in the last decade. Our goal was to better understand why STIs are so common for young women in the military and what can be done to improve their health.

We found that the highest risk is among women in junior ranks, especially those under 25 years old. Black active-duty women have even higher rates of infection (10,500 cases per 100,000 service members) compared to white active-duty women (5,200 cases per 100,000 service members). Risk factors include binge drinking, trouble accessing medical care, and fears about privacy. These risks are linked to bigger issues in the military. Some of these issues are stigma, gender inequality, and too few medical providers trained in women’s sexual health. Some women even avoid getting care for STIs because they fear their private information will be exposed to leadership.

We also looked at what has been done to lower STI risk, like education tools, mobile health apps, and screenings designed to find people at higher risk. While some of these helped, they are not widely used across the military.

To lower STI rates and improve sexual health, the military needs to do more than offer unengaging classes or increased screenings. It must address the real causes like stigma, lack of privacy, and inequitable care. Policies and programs must be designed to work for active-duty women.

Keywords

sexually transmitted infections STI active-duty military servicewomen sexual health women’s health military sexual trauma interventions sexual health stigma

Introduction

Context: sexually transmitted infections in the U.S. military

Sexually transmitted infections (STIs) are a persistent and costly public health concern in the U.S. military, where unique occupational and cultural factors put service members (SMs) at increased risk of contracting an infection. STI prevention is essential for individual health and a critical component of military force readiness.

Burden of STIs among active-duty servicewomen

Despite comprising less than 20% of the active-duty force across the military branches, including Navy, Army, Marine Corps, Coast Guard, and Air Force, active-duty servicewomen (ADSW) account for over 33% of all STI diagnoses in the military.^1–3 This disparity stems from both inherent biological differences and structural barriers to care. ADSW in junior ranks experience the highest STI rates compared to their male counterparts.^3–5 Risk is further compounded by social and structural factors linked to racial or ethnic minority status, lower educational attainment, and normalized behaviors including binge drinking and casual sex.^1,6,7 Military culture, including stigma surrounding sexual health, and access to health services impacts STI risk factors.^8,9

Structural and cultural contributors to disparities

Military life presents a distinct set of factors that can heighten STI risk. High operational demands, frequent relocation, and prolonged periods away from family or support systems can create emotional stress and isolation, which may increase engagement in high-risk behaviors.^1,9 In addition, the military’s social environment often implicitly and explicitly encourages alcohol use, a pattern that can further shape decision-making and contribute to behaviors associated with greater STI vulnerability.^6,7 ADSW also encounter challenges such as confidentiality concerns, stigma, and limited access to gender-responsive care; these factors that may hinder timely testing, treatment, and preventive services.^1,8,10

Systemic gaps in women’s health care delivery

Despite growing representation, ADSW navigate a military health system (MHS) that was designed without accounting for their specific health needs. This legacy of a system designed around a historically male armed force continues to shape how sexual health services are delivered and for whom they are optimized. When reflecting on their time in the military, women Veterans described pervasive gender-specific challenges that intensify the effects of an MHS not build around their needs, including encountering barriers to appropriate care and support.¹¹ This functional approach to women’s health overlooks key realities, such as the impact of military sexual trauma (MST), the needs of LGBTQ+ SMs, and the long-term consequences of untreated STIs. Gender-minority and sexual-minority SMs report gaps in provider competency, inconsistent access to gender-affirming or inclusive care, and medical mistrust stemming from policies surrounding transgender SMs.^12–14 Studies highlight that transgender and gender-diverse active-duty SMs report elevated stress, discrimination, and concerns about confidentiality when seeking reproductive health care.^12–14 This may further deter timely STI screening or treatment. These systemic limitations intersect with known risk factors for ADSW and may contribute to delayed screening, underutilized preventive care, and unmanaged long-term consequences of untreated STIs.

Research gap

While previous studies have examined STI prevalence and the associated risk factors among SMs, few have focused specifically on the experiences of ADSW. Literature published within the past decade lacks synthesis on how sociodemographic disparities and structural barriers shape STI risk in this population. No recent review applies a multilevel lens, such as the Social Ecological Model, to examine disparities among ADSW. This limits understanding of the interconnected drivers of risk and the adequacy of current prevention approaches.

Purpose of this review

By centering ADSW in the analysis of STI disparities, this review examined how sociodemographic factors influence the incidence of STIs and evaluated the effectiveness of intervention strategies currently in place. Addressing STI rates in this population requires a multifaceted response, one that integrates clinical screening with structural reforms, health education, leadership modeling, and trauma-informed care.

Materials and methods

Data sources

A comprehensive literature search was developed in collaboration with a Health Sciences Librarian (KG) and conducted across four databases: PubMed (U.S. National Library of Medicine), Embase (Elsevier), Scopus (Elsevier), and ProQuest Military Database. The search strategy used a combination of Medical Subject Headings (MeSH) and keyword terms related to: (1) military service or positions; (2) women; and (3) sexually transmitted infections. The search was conducted on April 17, 2025, and all citations were imported into Covidence for de-duplication. Reporting for this review followed PRISMA 2020 guidelines from Page et al.¹⁵ (see Figure 1).

Figure 1.

PRISMA flow diagram.

Eligibility framework (PEO)

Eligibility criteria were structured using a population—exposure—outcome (PEO) framework to guide study selection.

Population (P)

ADSW across five U.S. military branches (Army, Marine Corps, Navy, Coast Guard, and Air Force). Studies including mixed gender were eligible only if outcomes for ADSW were reported separately or could be extracted.

Exposure (E)

Military service-related determinants of STI risk or interventions targeting STI prevention. Exposures included individual factors (e.g., age, sexual behaviors), interpersonal factors (e.g., partner concurrency, relationships), community/organizational determinants (e.g., deployment cycles, installation resources), and policy-level influences (e.g., mandating screening, confidentiality policies, rank hierarchy).

Outcome (O)

Primary outcomes included STI incidence, prevalence, screening patterns, and sexual health-seeking behaviors among ADSW. Secondary outcomes included intervention acceptability, feasibility, or effectiveness in improving STI prevention or care access.

Inclusion and exclusion criteria

Researchers included English language studies conducted in 1996–2025, as 1996 marked the year the Navy and Marine Corps began STI testing for all female recruits and the Army implemented STI testing during well-women exams. Researchers placed additional emphasis on studies published after 2012 due to limited recent data on the STI burden in ADSW. The age range of focus was 17–25. Studies were selected that (1) included ADSW in any branch of the U.S. military, (2) examined sociodemographic factors (e.g., age, rank, race/ethnicity) as they relate to STI incidence or barriers to prevention or care in the military, (3) featured interventions or programs targeting STI prevention, education, or sexual health promotion that addressed barriers to care, including stigma, confidentiality, and/or accessibility issues, (4) included comparisons between different age groups, military ranks, branches, or deployment statuses or comparisons between ADSW and other military or civilian groups, (5) involved contexts of military healthcare delivery, including systems of care, payer structures such as TRICARE, and distinctions between on-base and off-base services, (6) included incidence or prevalence of STIs, (7) reported outcomes related to barriers to prevention and care and the impact of prevention strategies and sexual health education, (8) outcomes related to behavior change, (9) outcomes related to measures of health service utilization or sexual health-seeking behaviors, and (10) published as peer-reviewed articles, systematic reviews, government reports, or dissertations that included quantitative, qualitative, or mixed-methods studies.

Studies focused solely on men, recruits, reservists, and veterans were excluded, as well as outcomes that did not separate data by gender or age, or were outside the scope of public health, sexual health, or health services research. Additionally, studies focused on human papillomavirus vaccination were excluded. Full search strategies are provided in the Supplemental Material.

Analytical approach and validation

This study employed a structured narrative synthesis consistent with PRISMA 2020 guidelines. Quantitative estimates (e.g., incidence rates, prevalence) were extracted directly from included studies where reported; no new statistical calculations were performed. Due to heterogeneity in study design, outcome definitions, surveillance methods, and denominators, formal meta-analysis was not conducted.

Extracted quantitative measures were organized by key parameters known to influence STI risk, including age group, STI type, military branch, and comparator population (e.g., male SMs or civilian women). These comparisons are presented descriptively and summarized in tabular form (see Table 1).

Table 1.

Comparative STI outcomes among active-duty servicewomen.

Author (year)	Branch(es)	Population/age group	STI type(s)	Outcome measure	Key quantitative findings
Goyal et al. (2012)	Army, USMC	ADSW (varied ages)	Chlamydia (primarily)	Incidence	Chlamydia rates up to 7× higher than civilian women
Stahlman et al. (2014)	Army, Navy, USAF, USMC, USCG	Unmarried ADSW	Any STI	Annual prevalence	6.9% of ADSW reported an STI in the past year vs 4.2% of men
Deiss et al. (2016)	Army, Navy, USAF, USMC, USCG	ADSW (career span)	Chlamydia, Gonorrhea	Incidence (per 100 PY)	Chlamydia: 3.5/100 PY; Gonorrhea: 1.1/100 PY (vs 0.7 and 0.4 in men)
AFHSD (2016) (Owings)	Army, Navy, USAF, USMC, USCG	ADSW (all ages)	Chlamydia, Gonorrhea	Incidence (per 1000 PY)	Chlamydia incidence 161.9/1000 PY, >2× male rate
AFHSD (2016) (Tourdot)	Army	ADSW <25	Chlamydia	Incidence (per 100,000 PY)	Declined from 11,028 to 8793 per 100,000 PY (2011–2014)
Deiss et al. (2019)	Navy	ADSW 18–25	Chlamydia	Prevalence	10% positivity among asymptomatic women
Hood et al. (2021)	Army	Enlisted ADSW	Any STI	Incidence	ADSW had higher STI rates than male counterparts
Jordan et al. (2021)	Army	ADSW <25	Chlamydia, Gonorrhea	Incidence	Highest STI rates among women <25, especially Black women
AFHSD (2024)	Army, Navy, USAF, USMC, USCG	ADSW <25	Chlamydia, Gonorrhea, Syphilis	Incidence	Consistently highest STI rates among junior enlisted women <25

PY: person years; STI: sexually transmitted infection; ADSW: active-duty servicewomen.

Study selection

The study selection process was conducted by two researchers (GS and JD) using Covidence in three phases: title and abstract review, full-text review, and data extraction. Consensus between the reviewers was reached after each phase. The two researchers independently screened 1833 articles by title and abstract using predefined inclusion and exclusion criteria. Ninety-eight articles deemed potentially relevant advanced to the full-text screening phase, also conducted independently by each reviewer.

Following the full-text review, 17 articles were deemed relevant and selected for data extraction by both reviewers. The reviewers independently extracted data from each of the 17 articles that met the inclusion criteria.

Conflict resolution

Discrepancies between reviewers were resolved by consensus; inter-rater agreement was assessed using Cohen’s kappa.

Risk of bias assessment

Risk of bias was evaluated in all 17 relevant articles using the Cochrane Risk of Bias tool: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other potential sources of bias. Reviewers assigned judgments of low, high, or unclear risk for each domain. Any disagreements were resolved through discussion and consensus.

Using Cohen’s kappa, reviewers demonstrated substantial raw agreement. The overall proportional agreement was 0.72, and the Cohen’s kappa coefficient was 0.33, indicating fair agreement beyond chance. Table 2 presents the full agreement matrix and associated calculations.

Table 2.

Agreement matrix and calculations.

Classification	Count
GS include, JD include	15
GS include, JD exclude	12
GS exclude, JD include	15
GS exclude, JD exclude	56
Proportionate agreement	0.724
Random agreement probability	0.587
Cohen’s kappa	0.333

Data synthesis

A narrative synthesis approach was used to summarize the findings across studies due to heterogeneity in study designs, populations, and outcome measures. Key themes were grouped by sociodemographic risk factors, identified barriers to care, intervention effectiveness, and health service utilization. Findings were mapped onto the socio-ecological model (SEM), a multilevel framework developed by Urie Bronfenbrenner that illustrates how individual behavior is shaped by and intertwined with broader social systems.¹⁶ The SEM highlights levels of influence—individual, interpersonal, community/organizational, and policy/enabling environment.¹⁶ These shape human development and behaviors.

Results

Across 17 studies examining STIs within 5 branches of the U.S. Military (see Figure 2), evidence consistently shows a disproportionate burden among ADSW.

Figure 2.

Representation of U.S. military branches in articles reviewed.

Study heterogeneity

Considerable heterogeneity was observed across the included studies in terms of study design, ranging from surveillance analyses to qualitative studies and intervention evaluations. Sample sizes varied widely—from small qualitative cohorts to studies with more than 10,000 SMs. Article data sources drew from installation-level clinic data, MHS claims, and anonymous surveys. Branch representation varied, with the Army most frequently included; the Navy was represented in several studies, and fewer datasets specifically focused on the Air Force, Marine Corps, and Coast Guard. Measured outcomes included STI incidence, behavioral correlates, and intervention efficacy. A detailed summary of the 17 included studies, including author, study design, setting/population, branch representation, and outcomes assessed, is provided in Table 3. Although this variability limited direct comparisons across studies, it allowed for the identification of consistent patterns that emerged across diverse methodologies.

Table 3.

Characteristics of included studies.

First author (year)	Design	Setting/population	Branches	Key findings
Goyal (2012)	Review	U.S. military women	Army, Marine Corps	High-risk behaviors are common.
Stahlman (2014)	Cross-sectional	10,250 unmarried personnel	Army, Navy, USAF, USMC, USCG	Women reported more STIs; binge drinking linked to higher risk.
Braun 2016	Integrative review	ADSW	Army, Navy, USAF, USMC	Identified gaps in SRH access; need for gender-specific care.
Deiss (2016)	Cohort	Active-duty personnel	Army, Navy, USAF, USMC, USCG	ADSW STI rates exceeded men; highest risk: young, Black, lower education.
AFHSD (2016) (Owings)	Surveillance	Active-duty 2010–2014	Army, Navy, USAF, USMC, USCG	ADSW chlamydia incidence higher than men; young, junior rank highest risk.
AFHSD (2016) (Tourdot)	Surveillance	Army women <25	Army	High chlamydia burden among women under 25; screening coverage generally high.
Deiss (2019)	Survey + testing	Navy women 18–25	Navy	Condomless anal sex and binge drinking common.
Hood (2021)	Cross-sectional	Army enlisted	Army	Women had higher STI rates; multiple partners and low prevention behaviors predictive.
Hopkins (2021)	Scoping review	ADSW	Army, Navy, USAF, USMC, USCG	Chlamydia and gonorrhea increased 2013–2018; syphilis tripled.
Jeffery (2021)	Cross-sectional	Active-duty LGB groups	Army, Navy, USAF, USMC, USCG	LGB personnel had higher STIs, binge drinking, and sexual assault.
Jordan (2021)	Surveillance	Army 2015–2019	Army	Female soldiers <25 had highest STI rates; Black ADSW disproportionately affected.
Boyer (2022)	Commentary	U.S. military personnel	Army, Navy, USAF, USMC, USCG	STIs remain highest infectious disease burden; calls for sexual health paradigm change.
Kunz (2022)	Intervention	Military treatment facility	Army	KISS intervention improved knowledge and condom use; no new STIs at follow-up.
Gautam (2023)	Program evaluation	Fort Bragg clinic	Army	CDC 5Ps tool improved identification of asymptomatic high-risk patients.
Vargas (2024)	Mixed methods	Military installations	Army, Navy, USAF, USMC, USCG	Mission Wellness app improved SRH communication; moderate satisfaction.
AFHSD (2024)	Surveillance	Active-duty 2015–2023	Army, Navy, USAF, USMC, USCG	Women had much higher STI rates; highest in junior enlisted <25.
Vargas (2025)	Qualitative	Installation clinics	Army, Navy, USAF, USMC	Stigma, confidentiality fears, and staffing shortages hinder SRH care.

USAF: United States Air Force; USMC: United States Marine Corps; USCG: United States Coast Guard; LGB: lesbian, gay, bisexual; SRH: sexual and reproductive health; STI: sexually transmitted infection; ADSW: active-duty servicewomen; KISS: knocking out infections through safer sex.

Applying the social ecological model to STI risk in ADSW

In the context of STIs among ADSW, the SEM highlights the interaction between personal risk behaviors, interpersonal relationships, community norms, and institutional or policy level factors unique to the military environment (see Figure 3). Findings clustered most strongly at the policy and organizational levels.

Figure 3.

Social-ecological determinants of STI risk among active-duty servicewomen.

At the individual level, studies describe influences such as age, biological susceptibility, sexual practices, inconsistent condom use, binge drinking, and prior STI history. The interpersonal level highlights the roles of partner dynamics, including partner concurrency, partner risk behaviors, influence from peers, and experiences of MST. At the community level, unit and branch norms, deployment environments, base culture, and the availability of screening services shape both exposure risk and health-seeking behaviors. Finally, at the policy level, screening requirements, confidentiality regulations, healthcare staffing and access constraints, and lack of standardized prevention practices can reinforce multilevel determinants of STI risk by shaping health related decision making. Framing these findings collectively through the SEM provides a comprehensive lens for understanding how factors across levels contribute to the disproportionate STI burden observed among ADSW.

Elevated STI burden among ADSW

Across nine studies, there was consistent evidence that ADSW have a disproportionate burden of STIs, particularly chlamydia and gonorrhea.^{1–4,6,7,9,17,18} These trends were reported across five branches of the military, but were especially pronounced in the Army and Navy, where routine screening is more common and thus results are better documented.^{1–4,6,7,9,17,18}

Multiple sources highlighted the magnitude of the disparity. Goyal et al. found ADSW had chlamydia rates seven times higher than civilian women. Deiss et al. reported chlamydia and gonorrhea rates of 3.5 and 1.1 per 100 person-years among ADSW, compared to 0.7 and 0.4 for their male counterparts. Stahlman et al., drawing from 10,250 military personnel, found 6.9% of unmarried, sexually active ADSW had an STI in the past year, versus 4.2% of men.

These elevated rates were not isolated to one branch but especially observed across Army^3–5 and Navy^1,8,19 populations, with slight variations likely due to differences in testing protocols and data availability.

Sociodemographic disparities in STI burden

Four studies emphasized sociodemographic risk factors that exacerbate STI burden within the ADSW population. Junior enlisted (E1–E4) women, especially those under age 25, non-White, unmarried, and stationed in the Army or Navy, were most frequently identified as high-risk.^2,3,17,18

AFHSD and Jordan et al. both emphasized the intersection between rank, race, and age in shaping risk, with junior enlisted Black women under 25 comprising the highest-burden subgroup. These sociodemographic disparities have remained consistent over time and were present in studies from 2012 through 2025.

Risk-enhancing norms and behaviors

Seven studies discussed individual and cultural risk behaviors that contribute to STI transmission, including inconsistent condom use, multiple sexual partners, early sexual debut, and binge drinking.^{4,6,7,9,18,20} These behaviors were often normalized in military environments, especially among younger enlisted personnel.

Binge drinking emerged as a key behavioral driver across studies. Stahlman et al. linked it to higher partner counts, while Vargas et al. found binge drinking to be a significant predictor of STI positivity. Jeffery et al. further noted that bisexual women were more likely to report risky behaviors and higher STI rates than their heterosexual peers.

Notably, these risk behaviors were not evenly distributed across branches. Army^3–5 and Navy^1,8,19 studies cited the highest levels of alcohol misuse and sexual risk-taking, which may reflect differences in base culture and deployment cycles.

Impact of MST and psychological stress

MST has been consistently linked to increased STI risk and engagement in high-risk behaviors.^6,9,20 ADSW affected by MST face compounded vulnerability, as the psychological impact of MST may impair their ability or willingness to seek care, use protection, or access treatment services.⁶ These barriers are intensified by hypermasculine institutional norms and fear for LGBTQ+ SMs, as bisexual ADSW experience both MST and STIs at a higher rate.^9,20 These findings underscore the urgent need for trauma-informed, gender-sensitive approaches to STI prevention and care.

Effectiveness of tailored sexual health interventions

Three recent studies evaluated interventions tailored to the military context.^10,21,22 Two programs, knocking out infections through safer sex (KISS)²¹ and the CDC’s 5 Ps tool (partners, practices, protection, past history of STIs, and pregnancy intentions),²² were adapted for use at Army installations. The Mission Wellness mobile app¹⁰ was designed to support communication between SMs and their partner(s) about sexual and reproductive health (SRH).

KISS incorporates interactive workshops and peer education to engage young SMs effectively.²¹ Overall, KISS was effective at improving STI knowledge and preventing new infections among 18- to 30-year-olds.²¹

Gautam and Orrino demonstrated that the 5 Ps tool enhances clinical screening by providing a structured, patient-centered sexual history framework that improves risk assessment accuracy. This tool, developed by the CDC, successfully identified asymptomatic high-risk individuals, particularly young ADSW under 30-years-old.²²

Vargas et al. used the Mission Wellness app to integrate educational content with confidential messaging features to facilitate ongoing partner dialogue and health monitoring. Vargas et al. found moderate user satisfaction with the Mission Wellness app, suggesting potential expansion across branches.

While promising, all three interventions were limited to Army settings and have not yet been widely evaluated within other military branches.

Barriers to care: accessibility and confidentiality

Four studies identified systemic barriers to STI prevention, including lack of confidentiality, limited appointment times, and understaffing. This is particularly prevalent on smaller installations and in Army clinics.^3,8,10,22

ADSW often avoided seeking care due to fears about career impact or judgment under the Military Command Exception.^3,8,10 This act permits HIPAA certified leadership to access health information under specific circumstances.¹⁰ Additionally, Gautam and Orrino and Vargas et al. emphasized that even when care was sought, long wait times and provider shortages delayed treatment. These barriers cut across branches but were especially acute in Army health facilities.

Discussion

Overview

STIs continue to pose a significant and disproportionate burden on ADSW, particularly those who are young, enlisted, and from marginalized racial or ethnic groups.^1,4,9 Comparable CDC surveillance data show similar disparities among U.S. civilian women, with the highest rates of chlamydia occurring among young women aged 20–24, and with Black women experiencing the highest burden (1342.2 per 100,000) compared with White women (236.6 per 100,000).²³ While these patterns mirror civilian disparities, the mechanisms shaping risk and care-seeking differ in important ways due to military-specific structures (e.g., Military Command Exception, rank hierarchy). Applying the SEM lens shows that these disparities emerge from interacting influences at multiple levels, including individual behaviors, interpersonal dynamics, community norms, and institutional structures. Across the 17 studies reviewed, consistent patterns highlight how multilevel influences shape both exposure and care-seeking behaviors among ADSW.^{1,2,5,7–10,21,22,24}

Individual level

Commonly cited factors such as younger age, biological susceptibility, inconsistent condom use, binge drinking, and prior STI history, provide important but incomplete explanations for the elevated risk profile of ADSW. While these behaviors and characteristics influence vulnerability, utilizing the SEM emphasizes that they are often shaped by conditions at higher levels. For instance, alcohol use may reflect unit norms and the social environment of installations, while inconsistent condom use may be linked to relationship instability, coercion, or limited autonomy. These factors connect to interpersonal and organizational influences.

Interpersonal level

Interpersonal level findings reinforce how partner behaviors and experiences shape STI risk. The SEM helps to clarify that interpersonal dynamics are not solely relational but shaped by wider institutional power structures and cultural norms. ADSW who experience MST or intimate partner violence (IPV) may face heightened STI risk not only due to direct exposure as well as trauma, fear of retaliation, and relational power imbalances that discourage disclosure and care seeking.^1,10,15 This level also intersects with rank: younger, lower-ranking ADSW may have limited power to negotiate safer sex or seek prompt care within hierarchical settings.

Community level

At the community level, the SEM highlights the influence of unit culture, peer norms, and the structural realities of military life. Findings show that bases with insufficient sexual health staffing, inconsistent screening availability, or limited confidential services create an environment in which ADSW cannot easily access timely or gender responsive care.^2,5,10 High operational tempo, frequent relocation, and deployment settings also influence exposure risk and disrupt continuity of care.^1,8 Similar associations are noted in civilian datasets, where frequent residential mobility and limited access to consistent healthcare are linked with higher STI incidence.²³ Additionally, unit norms surrounding alcohol and stigma around sexual health operate at this level to shape interpersonal dynamics and discourage help seeking.^1,7,8 The SEM makes it clear that individual behaviors are often direct outcomes of these organizational constraints.

Policy/enabling environment level

The policy/enabling environment level exerted some of the strongest influences identified in the SEM. The Military Command Exception, allowing certain health information to be shared with authorized leadership, undermines confidentiality and disproportionately affects junior enlisted ADSW.¹⁰ Screening guidelines, MHS norms, and culture collectively shape interpersonal trust with providers and influence care-seeking behaviors.^1,5–7 Although these policies are not explicitly designed to create disparities, they indirectly create inequitable outcomes by interacting with gender, race, and rank.

Structural determinants

Structural determinants, such as mandatory gendered screening requirements and deployment cycles, emerged as critical contributors to disparities. Mandatory screening policies require annual chlamydia and gonorrhea testing for women but not men, creating gendered surveillance patterns that reinforce stigma, increase perceived burden on ADSW, and allow asymptomatic male partners to remain undiagnosed. To compare, CDC civilian recommendations emphasize risk-based screening for all individuals regardless of gender; however, the female screening requirements are similarly more robust than male.²⁵

Deployment cycles can interrupt care continuity and increase situational risk through limited access to services and altered social environments. Together, these structural factors shape unequal patterns of detection, care access, and risk, ultimately reinforcing gendered disparities in STI outcomes.

Racism and rank as cross-cutting influence

Synthesizing the SEM findings, the consistent overrepresentation of Black ADSW among STI diagnoses cannot be interpreted solely through biological susceptibility or individual behaviors.^1,9 An SEM perspective emphasizes how structural racism operates across policy, organizational, and interpersonal levels. Implicit bias, inequitable access to care, differential screening experiences, and the cumulative impact of racism collectively shape elevated SRH outcomes among Black women.²⁶

Rank also emerged as a critical, yet underexplored, structural determinant influencing risk and care access.^9,10,24 When utilizing a social ecological lens, rank is not merely an individual characteristic but an institutional feature that shapes interpersonal dynamics. The hierarchical nature of military rank influences interpersonal power and sexual negotiation, with findings showing that junior enlisted ADSW experience compounded vulnerability stemming from limited autonomy, fear of professional consequences, and diminished capacity to advocate for health care.²⁷ Fear of negative career repercussions and breaches of privacy further restricts healthcare utilization, particularly for those navigating MST or IPV.^1,10,15 Despite its clear relevance, few studies specifically evaluate how rank shapes sexual health outcomes, stressing a major research gap.

Gaps in access to SRH services

Unequal access to SRH services across installations reflects the SEM’s organizational level gaps. Smaller or remote commands often lack providers trained in sexual health, limiting ADSW’s ability to receive consistent screening, prevention counseling, or trauma-informed care.^2,5 While some sexual health interventions show promise, many were not designed specifically with ADSW needs in mind and have not been scaled to diverse military settings.^10,21,22 This lack of tailored, gender-responsive interventions perpetuates disparities and highlights gaps at both the community and institutional levels.

Implications for practice

Interpreting these results through the SEM demonstrates that STI disparities among ADSW arise from intersecting influences rather than isolated behaviors. Strengthening confidentiality protections, standardizing screening protocols to reduce gender asymmetries, and increasing provider accessibility may help mitigate inequities. Addressing structural factors such as deployment-related care disruptions and power differentials due to rank is also critical. To ensure these efforts are grounded in real-world needs, embedding ADSW perspectives in policy development, training initiatives, and program evaluation can ensure that interventions align with lived realities. These insights stress that effective STI prevention must move beyond individual education and confront other conditions shaping sexual health. An equity focused approach is essential for reducing disparities and improving SRH outcomes across the force.

Limitations

Limitations of this review include the limited number of studies evaluating systemic or institutional interventions, and a reliance on cross-sectional or surveillance data that do not capture contextual factors such as lived experiences. Additionally, mandatory screening for ADSW may artificially inflate reported STI burden compared with servicemen.

Variation in study design, sample size, data sources, and branch-specific medical policies contributes to heterogeneity. This heterogeneity across studies further complicates synthesis and limits generalizability. All three interventions discussed were only implemented in Army settings, limiting generalizability across other military branches. Several studies relied on the same military surveillance databases, raising the possibility of overlapping samples. Research is also limited in its exploration of how intersecting identities (e.g., race, gender, sexual orientation, and rank) shape health access and outcomes in military settings. Notably, the National Guard and Space Force were not included in these studies, representing further gaps in literature.

Conclusion

Findings from this review indicate that STI disparities among ADSW stem from multilevel determinants operating across individual, interpersonal, community, and policy levels. The evidence suggests that interventions addressing stigma, confidentiality concerns, provider training, and access barriers may be particularly beneficial.^1,4,9,24 Approaches that incorporate culturally competent and trauma informed care, as well as SRH education that reflects the lived experiences of ADSW, may also enhance prevention and improve care utilization. These strategies align with the SEM framework, which highlights the need for interventions that operate across multiple levels rather than focusing exclusively on individual behavior.

Addressing STI disparities among ADSW requires not only targeted interventions, but a fundamental shift in how military institutions conceptualize and deliver SRH care. Policies that prioritize confidentiality, autonomy, and trauma informed practice will not only improve individual health outcomes but also foster greater trust in the MHS. Additionally, cross-sector collaboration with civilian public health experts, veterans’ organizations, and reproductive justice advocates can provide fresh insight into long-standing challenges and generate effective solutions. SEM informed strategies also highlight that community norms and interpersonal support networks are critical in shaping care-seeking behaviors, reducing stigma, and promoting sustained behavior change.

Clear research gaps emerged across the literature. Few studies evaluated the effectiveness of structural or policy-level interventions and, despite evidence of disproportionate STI burden among non-White ADSW, limited research examined racial and ethnic disparities. Branch specific differences in culture, operational tempo, and resource allocation remain underexplored. Future work would benefit from longitudinal designs, qualitative studies that center around the voices of ADSW, and comparative analyses across service branches to clarify how organizational contexts shape STI outcomes.

Overall, the findings suggest that STI prevention efforts in the military may be strengthened by adopting intersectional and SEM-informed approaches that account for the combined influences of race, gender, rank, mobility, and trauma. As the force continues to diversify, ongoing evaluation and adaptation of SRH policies and programs will be essential to ensuring effective, force ready care for all SMs.

Supplemental Material

sj-docx-1-whe-10.1177_17455057261438734 – Supplemental material for Combating sexually transmitted infections in U.S. active-duty servicewomen: A social-ecological view of sociodemographic risk factors

Supplemental material, sj-docx-1-whe-10.1177_17455057261438734 for Combating sexually transmitted infections in U.S. active-duty servicewomen: A social-ecological view of sociodemographic risk factors by Grace Smolen, Julia Donavant, Karen Grigg, Ellison Henry, Korie Rice and Minzhi Xing in Women's Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057261438734 – Supplemental material for Combating sexually transmitted infections in U.S. active-duty servicewomen: A social-ecological view of sociodemographic risk factors

Supplemental material, sj-docx-2-whe-10.1177_17455057261438734 for Combating sexually transmitted infections in U.S. active-duty servicewomen: A social-ecological view of sociodemographic risk factors by Grace Smolen, Julia Donavant, Karen Grigg, Ellison Henry, Korie Rice and Minzhi Xing in Women's Health

Footnotes

Acknowledgements

None.

ORCID iDs

Grace Smolen

Julia Donavant

Karen Grigg

Ethical considerations

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Author contributions

Grace Smolen: Conceptualization; Investigation; Formal analysis; Visualization; Writing – original draft; Writing – review & editing; Data curation; Project administration.

Julia Donavant: Investigation; Data curation; Formal analysis; Project administration; Writing – original draft; Writing – review & editing.

Karen Grigg: Methodology; Writing – original draft.

Ellison Henry: Validation; Writing – review & editing.

Korie Rice: Validation; Writing – review & editing.

Minzhi Xing: Supervision; Visualization; Writing – review & editing.

Funding

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

Declaration of conflicting interests

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

Data availability statement

Data for this study were obtained from existing publications. No new data were collected.

Supplemental material

Supplemental material for this article is available online.

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