Article Text

Download PDFPDF

Sexually transmitted infections in the military: new challenges for an old problem
  1. Joel C Gaydos1,
  2. Kelly T McKee Jr2,
  3. Dennis J Faix3
  1. 1US Army Public Health Center, Aberdeen Proving Ground, Maryland, USA
  2. 2Quintiles, Inc., Durham, North Carolina, USA
  3. 3Naval Health Research Center, San Diego, California, USA
  1. Correspondence to Dr Joel C Gaydos, US Army Public Health Center, Bldg. E-5158 Blackhawk Road, Aberdeen Proving Ground, MD 21010-5403, USA; joel.c.gaydos.civ{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

The report by Harbertson et al1 in this journal addresses sexually transmitted infections (STIs) and sexual behaviours in US Service Members. The authors documented STIs as a current problem in shipboard personnel and highlighted evolving military sexual networks that must be evaluated and understood if STI prevention and control programmes are to be effective.1 During 2012–2014, Harbertson et al collected questionnaire data on 2453 members of the US Navy and Marine Corps who were deployed on ships to describe them demographically, define their risk behaviours for STIs and ascertain their STI histories. Their results revealed a population with an average age of 26 years, with 10% reporting a history of an STI sometime prior to deployment.1 The last time a similar shipboard questionnaire study of US Service Members was published was 1993.1 ,2 In the earlier study, Malone et al2 evaluated 1755 Sailors and Marines with a mean age of 23 years, and 22% reported ever having had an STI.

The Harbertson and Malone studies are similar in that both used questionnaires to assess STIs and risk factors for acquiring STIs in Service Members deployed on ships.1 ,2 The dissimilarities are striking and important. Malone studied only men; 21% of Harbertson’s group were women.1 ,2 (Deployment of women on US Navy combatant ships began in 1994.3) Harbertson noted that women now comprise ∼17% of shipboard crews.1 Malone's study focused on risk factors for STIs following the historical paradigm of a military consisting mainly of men, many of whom had contact with commercial sex workers; 49% of his subjects reported sexual contact with a prostitute.2 Harbertson focused on identifying the many, complex sexual networks that may exist among Service Members and other beneficiaries of the Department of Defence Military Health System (MHS) in a mixed gender working environment where gays openly serve in uniform, a relatively recent change in the US Military.1 ,4 Among Harbertson's subjects who had a sexual encounter in the last year without multiple partners, <1% had contact with a prostitute.1 She documented opposite sex, same sex and bisexual encounters with the possibility of genital, oral and anal infections in all groups.1 She also found that 67% of her subjects reported their last sexual contact to be a beneficiary of the MHS. This finding may offer an opportunity to improve contact tracing and follow-up since the MHS provides healthcare to all US Service Members and their families worldwide.

The 22 years separating the above publications have seen major advancements in the recognition, diagnosis and prevention of STIs.4 ,5 Our appreciation of the importance of Chlamydia trachomatis, Trichomonas vaginalis and viral STIs has increased; accuracy and turnaround time for our diagnostic tests have improved and we have effective STI vaccines.4 ,5 However, our ability to apply new knowledge, new diagnostic tests and preventive measures requires an understanding of the demographic and risk variables of the populations with which we are working, the dynamics of their interpersonal relationships, the infectious agents present and the sites of infection that we must consider in making diagnoses and providing treatment. Obtaining and updating this information require an organised, ongoing effort. Assumptions that communities are the same, similar or static, even in the military, can mislead.

From a public health infectious diseases perspective, the global military community consists of many possible variations that change frequently and includes shipboard communities, large fixed military installations, often with many civilians, that may or may not be in close communication with nearby civilian communities, deployed military units in close contact with civilian communities and units comprising militaries of different nations operating together as a multi-national force. Within any of these variations, the personal interactions and group dynamics may be distinct. In describing infectious diseases in military populations, the traditional epidemiological unit of choice, that is, the population at risk used to determine rates and assess transmission dynamics, was usually the military unit, such as a company or squadron. Military organisations are well-defined units with personnel rosters and assigned housing and work areas. However, this simple approach may miss the importance of different social groups, even within small military units and the contacts that exist across military unit lines and across military–civilian boundaries. In applying a geographical information system for infectious diseases surveillance at a large US military installation, Zenilman6 found that for gonorrhoea, clustering of cases was related to where soldiers lived, not the military unit to which they were assigned.

The phase of the military deployment cycle may also influence the risk of acquiring an STI. This cycle may be defined by four periods: pre-deployment, deployment, post-deployment and dwell time.7 The pre-deployment period is occupied by personal and military tasks in preparation for deployment and an absence from routine daily living. Actual deployments vary in duration, quality of life and stress related to enemy threat and other variables, which may be personal in nature. The post-deployment period presents the challenges of readjustment to routine daily living. Dwell time refers to the interval between deployments. Anecdotally, military public health practitioners have suspected that STI rates do change over the deployment cycle. However, the fragile natures of deployment-related screening programmes for STIs and public health surveillance systems in deployed settings, particularly in areas of combat, have not supported reliable longitudinal studies.8 Harbertson's study is the first part of a longitudinal study, the pre-deployment phase of the cycle.1 Questionnaire data for the year preceding deployment were obtained within 2 weeks after leaving port.1 Publication of their results from the deployment and post-deployment phases should follow.

The Harbertson study should cause leaders and practitioners of Military Medicine to reflect on several important areas:

  1. There is no single, simple military paradigm that can be used to implement effective screening, treatment and prevention programmes for Service Members. Reliable, recurring studies to identify and define sexual networks, core groups and high-risk groups and the importance of deployments and the deployment cycle on the occurrence of STIs must be done to inform contact tracing, screening, treatment and prevention programmes.9–11

  2. Military medical practitioners must have the skills necessary to take good travel and sexual histories from a diverse group of patients with different risks for acquiring STIs, determine the appropriate diagnostic specimens to collect and initiate appropriate treatment. Military laboratories must be able to support the clinicians, a challenge that includes the capability to process oral and anal specimens for STI agents, in addition to genital specimens.12

  3. Current practices for deployment-related STI screening deserve review. Harbertson found 10% of her sexually active shipboard population had an STI sometime preceding deployment, supporting concern that a high percentage of these Service Members may have taken an STI to sea.1

Military Service Members are international travellers with connections in both military and civilian communities. Some, like members of reserve military forces, regularly transition from one community to the other. Eventually, Service Members become veterans and may seek medical care in programmes established for veterans. The concerns identified above for practitioners of Military Medicine also deserve consideration by civilian primary care and public health practitioners who care for members of the military, veterans and their families.



  • Contributors This work was conceived and written jointly by JCG, KTM Jr and DJF.

  • Competing interests The views expressed are those of the authors and do not necessarily reflect the policies of Quintiles, Inc., the US Department of Defense, the Departments of the Army or Navy or the US Army Medical Department.

  • Provenance and peer review Commissioned; internally peer reviewed.

Linked Articles