Australian veteran sexual health: ‘…you are the first person I’ve spoken to about it.’
Kosta Douvos
A * , Louise Bourchier A , Meredith J. Temple-Smith B and Sue Malta A
A
B
Abstract
Sexual health and functioning outcomes have been shown to be poor among veterans due to factors associated with military service, as well as barriers to healthcare access. However, there is currently limited research attempting to assess the scope and extent of these issues in the Australian context.
Ten qualitative, semi-structured interviews were conducted with Australian professionals working within or adjacent to veteran sexual health and were analysed using inductive thematic analysis.
Sexual health and functioning issues commonly develop among Australian veterans due to a variety of physical, psychological and social factors. Factors include mental ill-health, physical illness and injury, use of medication, and relationship strain. These contribute to physiological dysfunctions, poor sexual behaviours and difficulties in forming healthy, meaningful intimate relationships. Barriers, such as lack of awareness and understanding, stigma, and structural barriers, were suggested to interfere with healthcare access and worsen outcomes. Key informants recommended increasing provider training, research and military support, as well as de-stigmatising sexual health issues.
Veteran sexual health is not often on the radar of Australian health and research professionals. Our study is one of few studies in the Australian context, highlighting the need to conduct more research to better manage veteran sexual health and functioning needs.
Keywords: Australia, healthcare access, help-seeking, key informants, military, qualitative analysis, sexual health and functioning, veteran health.
Introduction
Although active service members are generally healthier than civilian counterparts,1 veterans experience poor physical and mental health outcomes as a result of military service. Risk factors associated with these outcomes are compounded by barriers to healthcare access among this population, which is considered a priority group in the Australian National Men’s Health Strategy 2020–2030.2 Despite this, there still remains limited understanding and acknowledgement of the impact of military service on sexual health and functioning outcomes among Australian veterans.
Sexual dysfunctions have been reported to occur at higher rates among veterans than civilians. These include issues, such as erectile dysfunction,3–5 high-risk sexual behaviour6,7 and compulsive sexual behaviour.8,9 Sexually transmitted infections are also higher in veteran populations.10
Physical, social, and psychological factors associated with military service – and particularly combat exposure – as well as the transition back to civilian life itself, may contribute to poor health outcomes.11 In addition, mental health disorders, such as PTSD,12–14 depression,15–18 and alcohol and substance use disorders,17–19 have been shown to contribute to sexual dysfunction, which is often exacerbated by the pharmacological interventions commonly used to treat these disorders.20,21
Physical health conditions also contribute to poor overall sexual health and functioning among veteran populations. Hypertension20 and diabetes,20 for example, are more common in veterans and can worsen sexual functioning, as can acute and chronic injuries suffered during service, such as traumatic brain injury16 and spinal cord injury.20
Sexual health and functioning is also impacted indirectly through relationship strain. The duration of military deployments and the physical and psychological costs of service can limit the capacity for healthy sexual engagement.22,23 Not only can poor mental or physical health directly interfere with the emotional attachment necessary for healthy and satisfying sexual relationships, they often limit a veteran’s ability to work or contribute to domestic duties, placing additional strain on relationships.24
The majority of the Australian veteran population is aged 65–74 years,25 and although aging likely also contributes to poor sexual health and functioning outcomes, sexual difficulties have been described in veterans of all ages and are not strictly age-dependent.20,26
Prior research has also identified a number of barriers to healthcare access among veteran populations that impact sexual health and functioning. Perceived stigmatisation,4 feelings of shame, embarrassment or discomfort,26 lack of awareness of the issue or its treatability,26 and perceived lack of expertise or training on the part of the provider18 have all been reported to interfere with sexual healthcare provision.
As there is limited research on this issue in Australia, our study sought to investigate what is known and understood by Australian health professionals about the sexual health needs of Australian Defence Force (ADF) veterans.
Methods
This study was reported according to the COREQ (COnsolidated criteria for REporting Qualitative research) guidelines.27
Theoretical framework and justification of methodology
As there is little known about this topic within the Australian context, we conducted an exploratory study. A qualitative approach was employed to engage the topic without set assumptions.28 A constructivist paradigm was deemed appropriate to investigate how these issues manifested within sociocultural and structural factors that comprise Australian military and health system contexts. Semi-structured interviews with key informants were used to establish the scope of these issues within Australia.
Sampling and population
Given the exploratory nature of this study, professionals working in Australia with expertise in a variety of fields within or adjacent to veteran sexual health, including psychiatrists, psychologists, physicians and researchers, were recruited as key informants.
Participants were sampled largely by snowball sampling via researchers’ professional networks. Additional sampling occurred on the basis of recommendations by recruited key informants themselves, or identification via online searches. Sampling was purposeful and deliberately aimed to select information-rich cases from various disciplines within these networks to ensure that data collected provided a full and nuanced understanding of the phenomenon under study.29
Key informants were initially emailed with an explanation of the study and an invitation to participate. Once participants expressed interest, interviews were scheduled. No key informants were known by the interviewer (KD) prior to commencement of the interview; however, many were known by or affiliated with other members of the research team. Only one prospective key informant declined to participate in the study due to busyness.
Data collection
Interviews were conducted using Zoom Meetings webcam call by KD, a male student researcher with a background and interest in health sciences. Verbal consent was obtained from participants before the interview commenced.
Interviews were semi-structured, and focused on what is known and is presently undertaken to address veterans’ sexual health needs in Australia. Field notes were not taken during the course of the interviews. Interviews were recorded on Zoom and transcribed using Otter.ai software, before being adjusted manually by KD to correct any inaccuracies and remove identifying information. Transcripts were not returned to participants for post hoc adjustment; however, participants were contacted if further clarification was required. By the end of the last interview, it was clear that little new data were obtained, indicating data saturation was reached or almost reached.
Data analysis
The data were analysed using inductive thematic analysis.30 Themes were conceptualised as ‘domain summaries’; that is, summaries of the range of meaning in the data related to a particular topic or domain of discussion. As such, findings were organised around shared topics, but not shared meaning.31
Each transcript was read by KD, and data were placed into groupings that formed the domain summaries for analysis. Two additional coders (SM and LB) analysed half of the interview transcripts to validate the coding.
Results
Sample
Twelve key informants were invited to be interviewed and 11 agreed. Ten interviews were conducted in total with 11 key informants (one interview involved two key informants), who were interviewed by KD from 23 June to 10 August 2022. Interviews averaged 27 min in length (range 10–40 min). Despite efforts to recruit female participants, all participants were male, accurately reflecting the domination of military medicine by male professionals. The majority of participants were medical practitioners, predominantly in general practice, sexual health or mental health. Key informants had a variety of affiliations with tertiary institutions and other organisations, including the ADF. The majority of participants had at least 15 years of experience in their field. They worked in various states around Australia, largely in metropolitan settings (Tables 1 and 2).
| Characteristic | Number (of participants) | |
|---|---|---|
| Sex | ||
| Male | 11 | |
| Female | 0 | |
| Primary role in medical profession | ||
| Medical practitioner | 5 | |
| Researcher | 4 | |
| Administrator | 2 | |
| Primary affiliation | ||
| Tertiary institution | 2 | |
| ADF | 1 | |
| Health organisation | 7 | |
| Veteran organisation | 1 | |
| Primary field | ||
| Psychiatry | 1 | |
| Sexual health | 4 | |
| Andrology | 2 | |
| General practice | 2 | |
| Trauma | 1 | |
| Psychology | 1 | |
| No. of years in field | ||
| >15 years | 8 | |
| <15 years | 3 | |
| State or territory | ||
| Vic | 7 | |
| NSW | 2 | |
| Qld | 2 | |
| WA, SA, NT, ACT, Tas | 0 | |
| Geographical location | ||
| Metropolitan | 9 | |
| Rural | 2 |
| KI1 | Psychiatrist at leading non-profit post-traumatic mental health organisation | |
| KI2 | Sexual health physician and director of rural sexual health clinic | |
| KI3 | Andrologist researcher and director of male reproductive health organisation | |
| KI4 | CEO of male reproductive health organisation | |
| KI5 | Active ADF physician | |
| KI6 | Retired sexual health physician and Vietnam War medical officer | |
| KI7 | Trained psychologist and director of leading veteran counselling service | |
| KI8 | Sexual health researcher and gerontology PhD | |
| KI9 | Veteran and trauma researcher | |
| KI10 | General practitioner at sexual health clinic | |
| KI11 | Sexual health researcher |
Findings
Three main domains were identified from analysis of these interviews: (1) veteran sexual health, (2) barriers to sexual health care, and (3) recommendations for improvement. A number of sub-domains were identified, as shown in Table 3.
| Domains | Sub-domains | ||
|---|---|---|---|
| 1 | Veteran sexual health | ||
| 2 | Barriers to sexual health care | 2.1 Lack of understanding/awareness 2.2 Stigma 2.3 Infrastructure | |
| 3 | Recommendations for improvement | 3.1 Provider training 3.2 Research attention 3.3 Military support 3.4 Destigmatisation |
Participants described a common set of factors which contribute to poor sexual health and functioning outcomes among veterans.
They all have … roughly the same story to tell. (KI2)
Commonly cited factors included mental health disorders, such as PTSD, depression and alcohol or substance misuse, and medications used to treat these disorders were reported to often worsen sexual functioning. Physical health conditions, such as diabetes, were also cited to interfere with sexual health.
…it’s not uncommon for [veterans] with active mental health problems like PTSD or depression or substance abuse to have … sexual difficulties, as part of the syndrome that they’re experiencing… It was not uncommon that medications used to treat post-traumatic stress disorder and depression could also cause sexual dysfunction. (KI1)
Participants reported that sexual health among veterans was impacted directly by poor physical and mental health after service, but also indirectly, through strain put on relationships in managing these health conditions, as well as through impacts in the domains of sleep and pain.
There can be a range of other indirect influences through things like sleep, pain… Another area of problem that was fairly common was … an impact that … their mental health would have upon their relationships. And … then you would have concerns within the relationship having potentially detrimental effects upon their sexual functioning. (KI1)
These factors, as well as other factors, such as aging and androgen misuse, were all said to contribute to sexual health and functioning issues.
…there seems to be a lot of androgen use within the military … and that, of course, can have a huge impact on your sexual and reproductive health function. (K10)
Participants noted that despite similar risk factors, sexual difficulties can vary significantly in their presentation. These were said to range from physiological dysfunctions and hormone issues to poor sexual behaviours or an inability to form healthy, meaningful intimate relationships.
…there isn’t a neat category that they all fall into. (KI2)
Although some participants reported that sexual health issues commonly occurred among veterans, others said that they rarely present in clinical settings at all. However, participants were unsure whether this was due to rarity of these issues among Australian veterans, or due to barriers to help-seeking behaviour limiting uptake of sexual health services. One participant suggested that, as many patients are often dealing with a variety of comorbid, deleterious conditions, managing sexual health symptoms are often not a treatment priority.
…it hasn’t been something that has been a massive issue, in my experience… as an Army doctor … I don’t know whether that … is because people are just reluctant to talk about it, or whether it’s a reasonably rare thing. (KI5)
I think when somebody’s severely unwell, not coping, their relationships are struggling, their ability to work is deteriorating, at the more severe end of the spectrum they might be at risk of suicide or self-harm … substance abuse might be out of control … when they’re presenting in clinical settings, they’re very rarely saying Doc, I’m here because … I can’t get it up. (KI1)
In any case, failure to present with sexual difficulties and initiate treatment was thought to worsen health outcomes, and lead to a greater illness burden among veterans.
I suspect there’s a lot of … undiagnosed, untreated … sexual dysfunction out there in that group. (KI10)
A number of barriers to sexual health care were identified, at patient–provider and health system levels. These were thought to impact both healthcare access and healthcare provision. Barriers were attributed to lack of understanding and awareness, stigma, and structural limitations.
Participants spoke of the lack of research in this space, and the gap that exists between the prevailing sexual health literature and clinical practice. They reported that healthcare provider expertise is lacking in two main ways: a limited awareness of the at-risk nature of veterans’ sexual health; and a limited understanding of how best to manage these issues in clinical settings.
…there’d be a … very small percentage of … clinicians that would have that … awareness… There’s virtually no research at all. (KI7)
I think where it’s still falling behind is the translation of that knowledge to GP practice … and potentially to even specialists. (KI8)
Participants indicated that lack of understanding on the part of veterans themselves regarding the sexual health impacts of their service, as well as their general lack of health consciousness and health literacy, also impact access to health care.
I don’t think that there would be … a prominent consciousness amongst this group, that their military service … was related to … having sexual difficulties. (KI1)
Finally, as expert Australian health and research professionals with decades of experience in relevant fields, participants drew attention to their own lack of understanding and awareness of veteran sexual health needs.
…you’re the first person I’ve ever spoken to about it. – KI5
I know nothing about that really. (KI7)
I think it’s terribly, poorly understood. I know nothing about it at all. (KI11)
Another key barrier cited by key informants was stigma. They spoke of various types of stigma that interfere with veteran help-seeking, which they thought pervade not only the public sphere, but also military and medical settings. First, participants made reference to the general stigma around sexual health and sexuality in Australia.
It’s still kind of a taboo area … being able to talk about it… ‘Erectile’ … even just the whole vocabulary around it. (KI10)
Due to the overlap between veterans and the aging population, some participants also suggested that ageism and stigma around sex in later life would also function as a barrier to healthcare access. Finally, many participants described the way in which sexual difficulties are stigmatised, particularly among hypermasculine, male-dominated groups, such as the military and veteran communities. The implications of sexual difficulties upon masculinity among these groups, and the general emphasis placed on resilience and stoicism within the army, were thought to lead to poor help-seeking among veterans.
There is a machismo culture in army… I suspect that it can sometimes … lead to … veterans not wanting to talk about things that it might be helpful to talk about… It’s not a very manly thing to admit, I suppose. (KI5)
Infrastructure barriers to sexual healthcare access among veterans were also cited. Many emphasised the difficulty experienced by veterans transitioning back to the civilian health system post-service, which they thought was caused by service members being ’spoon-fed’ health care in the military. In addition, issues with health pathways and medical records impacted continuity of care post-service.
…you go from being an 18-year-old with no idea about health to being spoon-fed your health care, to then leaving the armed forces, and you’ve got no clue at best … as to what to do… Health records even can be an issue, as to how much of your health records then … are able to be moved across to the general population. (KI4)
Participants also shared concerns about financial barriers within the current infrastructure that limit veteran access to sexual health care. Not only were sexual health clinics deemed poorly funded and under-resourced, participants noted that not all veterans receive adequate government support for health care. This barrier was thought to be worse in rural settings.
…Sexual health clinics aren’t well funded, for a start … There isn’t affordable psychiatric help in the city … It’s a lack of … sexual health units … It’s a lack of … providers of care … It’s a lack of everything really! (KI2)
In line with these barriers, key informants made a variety of recommendations. These were largely centred around the domains of provider training, research, military support and de-stigmatisation of sexual health issues.
To improve the management of veterans’ sexual health needs, participants cited healthcare provider training within primary care as critical to improvement. Veteran counselling services were also seen as worthwhile allocating resources to. Participants also indicated the need to increase awareness among healthcare providers of the potential for veterans to have poor sexual health. Giving health providers confidence to routinely include sexual health as a prompt when consulting with veterans may require additional training. As one GP participant noted:
…training in interview techniques for … questions about sexual health … I think by practicing it and going through it and seeing it modelled … would certainly be helpful … [and providing] resources demonstrating appropriate ways to take a sexual history… (KI10)
Participants also indicated that more research into these issues is necessary to better understand the issue in the Australian context and improve provider training. They indicated both quantitative and qualitative methodologies as worthwhile, and one participant stressed the importance of conducting research closely partnered with veteran organisations and veterans themselves.
…It’s about bridging the research and making it more available to GPs, in particular, so that when they get … vulnerable groups like … veterans … they’re a little more proactive in getting these people to tell their story and … what’s troubling them … sexually. (KI8)
Another avenue cited by participants to improve outcomes for veterans was through optimising health support from the military. One participant suggested that the very screening and recruitment process was ineffective at limiting the entry of individuals with pre-existing mental health conditions into the army, which contributes to poor health outcomes. Others highlighted the role that the military should play in this space during and post-service in both health promotion and establishing clearer health pathways.
I think there is more work that could be done, when you’re in the armed forces, to understanding even your own health and what you need to do when you’re out. (KI3)
Participants also indicated the importance of de-stigmatising and normalising sexual health issues, both in the public health sphere and particularly within veteran communities to improve help-seeking and consequent health outcomes.
…some public education campaigns specifically for Veterans Affairs to try to raise awareness among veterans about these sexual health issues and then … try to remove some of the stigma associated with it and get a conversation going within that group. (KI10)
Discussion
This study highlighted a number of key issues that have an impact on the sexual health and wellbeing of Australian veterans. Although there is limited research to contextualise the present study, findings align with earlier research into the management of veteran sexual health needs in other countries.
Participants identified common risk factors that often co-occur and contribute to poor sexual health and functioning outcomes among veterans. These primarily included psychological conditions, such as PTSD, depression and alcohol misuse – and the pharmacotherapies used to treat them – which have all been implicated in prior research conducted in other countries. Notably, androgen misuse was cited as potentially detrimental to sexual health among Australian veterans, a factor that has not been encountered upon review of the international literature into veteran sexual health.
Participants indicated that clinical presentation for sexual difficulties varies significantly among veterans, with some reporting that sexual health issues among veterans rarely presented in clinical settings at all. It was not clear whether this was due to low rates of sexual difficulties within this demographic or barriers interfering with presentation of these issues. Because sexual health issues are described extensively among veterans in a number of countries, including America,3,15,19 Canada,32 Croatia,14,33 Israel,23,34 Iran26 and Turkey,35 the latter seems most plausible. In any case, participants expressed that there likely exists much undiagnosed and untreated sexual dysfunction among the Australian veteran population, which is consistent with research into other demographics. Less than 30% of patients endorsing sexual health concerns report actually discussing these issues with providers and seeking treatment.36
A lack of understanding and awareness of the sexual health needs of veterans was highlighted as the primary barrier to healthcare access and provision. Participants believed that provider expertise was lacking in two ways: there was a low awareness of veterans’ health risks, and there was limited clinical expertise around engaging with veteran patients about sexual difficulties. In line with this, Sadler et al. pointed to lack of training in sexual assessment as a key reason why sexual health issues are suboptimally managed in clinical settings.18 Further, veterans themselves were thought to have limited health awareness and understanding of the sexual health impacts that their military service may have, resulting in poor help-seeking behaviour. Prior research in a similar demographic also highlighted patients’ lack of awareness – particularly lack of awareness that sexual dysfunction is treatable – as a relevant barrier to sexual healthcare provision.16 Finally, participants indicated their own lack of understanding of these issues. In the context of Australian health care at large, this seems to suggest that relevant health experts may be poorly equipped to identify and manage these issues.
Various kinds of stigma were also cited by participants as interfering with sexual healthcare access and provision, including the general stigma around sexual health and sexuality in Australia, ageist views towards sexuality, and hypermasculinity in military and veteran groups. Wilcox et al. similarly indicated that stigma is a leading barrier to seeking and maintaining treatment for mental health problems within this demographic, and can, lead to an exacerbation of symptoms.4 Research among older people is consistent with such concerns about ageism expressed by some participants, suggesting that this demographic is reluctant to discuss sexual health issues with primary care providers due to fears that they do not meet societal expectations surrounding sex in later life.37 As the largest proportion of the Australian veteran population is between 65 and 74 years of age, such concerns are highly relevant to this demographic.25 Hypermasculinity and how it interacts with help-seeking among veterans is not well-documented, but given the implications sexual difficulties may have upon perceptions of masculinity, such a phenomenon seems plausible.
Finally, infrastructure barriers resulted in difficulties transitioning back to the civilian health system post-service. These were thought to include poor health promotion during service, unclear health pathways, and limitations on funding and resources. Notably, although many participants speculated that poor health promotion within the Australian military likely results in reduced health literacy and health awareness among service members and veterans, prior research in other countries has demonstrated the contrary.38 The cause for this disagreement is unclear; however, our findings align with prior research advocating that the transition across to the civilian health system and civilian life be improved to optimise continuity of care and consequent health outcomes post-service.39
In light of veteran sexual health needs and relevant barriers to care cited by participants, a number of recommendations for improvement were made. Given primary care was seen as practically and financially accessible to veterans, the role of primary care providers in more targeted management of veterans’ issues was highlighted as a key area for improvement. This is consistent with other research that indicates that the primary care setting is the most accessible point of sexual health care for patients more broadly.40 Offering training and resources to assist with veteran sexual health is likely to yield the greatest benefit to veteran sexual health and functioning outcomes. Training would need to focus on both the sexual health issues faced by veterans and management of sexual dysfunction. Previous research has identified that patients, even those for whom sexual health is not the presenting complaint, are happy for their GP to be proactive in offering discussion of sexual health issues.26 Moreover, it has been suggested that a question about sexual issues should be included in routine inquiry into a veteran patient’s medical history. Veteran status could also be a routine question included in sexual history-taking for any patient.26 However, there is currently limited published guidance in the Australian context, and participants cited increased research as necessary to guide clinical approaches to managing sexual difficulties among veterans.
Participants also suggested that greater health promotion by the military would help improve and optimise veteran health consciousness and help-seeking post-service. Moreover, it is widely held in the literature that active service members are healthier than their civilian counterparts (i.e. the ‘healthy soldier effect’).1 This seems to suggest that health during service is not the issue, but rather health post-service, and this was supported by participants of the present study. Nonetheless, they cited poor health behaviours within the Australian military, such as androgen misuse, as cause for concern.
Participants also spoke to the need of de-stigmatising and normalising sexual health issues more broadly to increase veteran help-seeking and healthcare access. This is consistent with the broader literature into the uptake of health services more generally,41 and relevant literature among veteran groups of other countries,39 suggesting that stigma is a significant barrier to healthcare access.
Interestingly, despite many barriers to sexual health care that exist among the Australian veteran population, research indicates that veteran uptake of health service is greater than comparable civilians.42 Based on findings from the present study, this is likely not due to greater healthcare access or help-seeking behaviours among veterans, but a greater burden of disease that exists among veterans due to the psychological and physical costs of service. This is supported by the acknowledgement of Australian veterans as a priority group by the Department of Health in the National Men’s Health Strategy 2020–2030.2
The primary strength of the present study is that it is the first of its kind in Australian veteran sexual health. Being an exploratory study, it serves as a useful foundation for future research into the sexual health of Australian veterans, highlighting some key areas within which research is warranted. However, there were some limitations. First, convenience sampling may have meant some Australian health professionals with expertise in this research area were not included in the study. Second, the sample was comprised entirely of males. Female key informants likely could have provided additional, unique perspectives on how best to manage veteran sexual health in Australia, within a largely male-dominated sector, such as veterans’ affairs and the military more broadly. Third, in general, it was difficult to recruit key informants from military networks for this study, which are quite closed and difficult to penetrate. It would be valuable to gather opinions from those within the ADF in the future. Finally, although data saturation was likely not reached due to practical constraints, the data highlights that this is an area of future research need.
Conclusion
This study aimed to investigate what is known and understood about the sexual health needs of Australian veterans by Australian health and research professionals within relevant fields. Results showed that veteran sexual health is not often on the radar of healthcare providers, veterans themselves and the military. There is a need for increased research in this space to gauge the scope and extent of these issues in Australia, improve healthcare provider training, and inform future evidence-based care for veteran sexual health and functioning issues.
Data availability
The data that support this study cannot be publicly shared due to ethical or privacy reasons and may be shared upon reasonable request to the corresponding author if appropriate.
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