NINE

Human Sexuality and Women in the Area of Operations

AMY CANUSO

The content of this chapter is intended to begin a dialogue about the normal and expected sexual experiences of women in the military on deployment and in the war zone. It is a highly charged topic that may be very difficult for some to broach openly. However, if not addressed, unfortunate outcomes, such as pregnancy requiring evacuation, potentially life-threatening ectopic pregnancies, and sexually transmitted diseases, may result.

This is not a discussion on sexual assault, although sexual assault in the military continues to be often considered as an epidemic. At the time of this writing, Senators McCaskill and Gillibrand continue to revise and champion a bill before the US Senate that would keep commands from overturning sexual assault convictions, require a civilian impartial review, and mandate dishonorable discharges for military members convicted of sexual assault. The fact that so many active duty women have experienced sexual assault while serving in the US military continues to make the topic of consensual human sexual activity at war awkward, problematic, and even taboo. It is in no way the intent of this chapter to compare sexual assault with the topic of female sexuality for active duty women. The two may be considered completely separate topics for this discussion.

However, human sexuality and sexual responsiveness remain important to the understanding of the cumulative psychological and emotional human experience of our active duty Service members. Clinicians should explore the topic of sexuality with women prior to deployment, and post-deployment. This topic merits discussion to ensure both cognitive and medical preparation of the active duty woman who deploys in service of her country, along with the possible processing of experiences after her deployment. This is the end of the introduction.

The idea of consensual sexual relationships in the area of operations has produced a vivid landscape for many books and screenplays. Visualize the story of a young nurse who falls in love with the Soldier she cares for; or one might remember the MASH series and the somewhat ruckus, clandestine encounters between doctors and nurses, with a laugh track keeping the story light and far from reality—the scene appears more like a fraternity house movie.

We have very little knowledge of the actual amount of consensual sexual activity that is occurring during deployments between military members because very little research is done on that topic. In the recent past, all sexual activity between two Service members during deployment was forbidden. However, in 2008 the lift on the ban for sexual activity between unmarried active duty members of the US Armed Services deployed, and between unmarried and of the same rank, was lifted (Brown, 2008).

In 2010 the US Department of Defense added emergency contraception to its list of contraceptive options that “typically” are available at medical facilities, and theoretically includes the medical facilities in the area of operations. Even though there may be an official direction, the Commanding Officer of an individual unit may have the option of putting forth his or her own ban on sexual activity, either as explicit order or by “strongly discouraging” sexual activities. Some Commanding Officers report that such relationships can deteriorate unit cohesion and can be problematic. So even if one is in a consensual relationship with an unmarried person of one’s same rank, one may either be banned from engaging in sexual activity or may opt not to, fearing unit reprimand.

Very little of this subject matter is known in the open because there is very little that is recorded or researched regarding the consensual sexual activity between active duty members. Few are willing to come forward and speak openly. Somehow, though, pregnancies and sexually transmitted diseases (STDs) continue to occur; divorces and perhaps even marriages have resulted from sexual relationships during an overseas deployment.

What we do know is that active duty women on deployments do get pregnant and do contract sexually transmitted infections. Studies indicate that as many 12% of deployed women had an unplanned pregnancy during deployment in 2008 (Holt, Grindlay, Taskeir, & Grossman, 2011; Grindlay & Grossman, 2013). Another study indicates that 13.2% of active duty women who visited a military-run gynecological clinic in Iraq between 2007 and 2008 had complaints of vaginal infections that included sexually transmitted infections (Foster & Alviar, January 2013). From these studies and others, there have been reports that women were not offered or were not able to continue contraception when they were deployed, either due to the military not having the supply or a belief that sex does not happen in the war zone. Women reported that the subject of contraception was not discussed with them prior to deployment by their primary care provider, illustrating the need for clinicians to be cognizant of this subject matter with their active duty female patients.

The above indicates that there is a disparity between the Department of Defense’s stance on providing contraception to women during deployment, the military stance on consensual sexual relationships with active duty members during deployment, and the outcomes that military women have unplanned pregnancies and contact sexually transmitted infections during deployment. It may be that women are afraid to ask for contraception or STD prevention, as it may indicate that they are promiscuous or that they are violating orders or policy (Rabie & Magann, 2013).

Being in the area of operations amplifies inherent sexual feelings in many different ways. Active duty women may find themselves in a difficult “Catch 22” of suppressing and/or denying natural feelings due to personal, cultural, or unit scrutiny. The dissonance of subconscious versus conscious desires, fears, moral judgments, anxiety, and emotional discord should be considered when addressing mental health wellness with women who have served in the US military.

Somewhat mixed messages continue to be conveyed regarding women’s sexuality and cultural norms. For example, in the deployed setting, women are removed from the area of operations because of pregnancy; however, a male who is treated for an STD does not get sent home for engaging in sexual behavior. A woman who is then aerovaced out of the area when her command learns she is pregnant may often face the judgment of her unit (and herself) for leaving the mission; leaving the mission for any reason is often a source of guilt, and even shame, for military members who place a great deal of value in remaining part of the unit.

Even the topic of masturbation seems to be skewed in favor of males (Gottlieb, 2011) (Jones, 2013). Many men describe that in their unit there was a unspoken agreement for needed privacy during deployments, “taking turns being the last person out [of] the tent or hygiene tent.” However, the women I interviewed voiced that the topic was rarely or never discussed with their bunkmates when they were deployed.

The area of operations during OIF and OEF was and remains (in OEF) a primal environment. There is a heightened sense of danger, a sense of lawlessness, and often there is the reality of combat operations that may shorten life. There is a significantly skewed ratio of men to women, of about ten to one, but it is not necessarily more than the general population of the unit itself back in garrison.

For instance, most units deploy with roughly the same percentage of women who are part of the unit in garrison. Most women interviewed for this writing describe that there is far more focus on the difference in ratio between men and women during deployment than when stateside. One woman I interviewed explained, “When I go to the gym in the US on base I may be the only woman there, however, it causes little change in the other gym goers behaviors. But, when I went to the weights area of the forward operating base [most bases have some form of exercise equipment] my presence there seemed to make everyone stop and stare.”

One enlisted man I knew reported to me that that just seeing a woman when deployed was like seeing something rare. He describes a day during his deployment when he was giving an instructions course to a number of other young men when a young woman walked by in workout gear on her way to the hygiene tents. “We all just stopped and stared at her for almost a full 30 seconds. Then I just went back to teaching the men. I never would have done that stateside.”

One woman told me that it seemed to her that sexual issues came up more in her casual conversations with other women. Discussing how another active duty member looked in the gym, or discussing the attractiveness of a movie celebrity, was commonplace, but she never would have been comfortable with such subject matter in the United States, perceiving it to be unprofessional.

One can hypothesize as to the reasons that there may be an increase of perceived sexual consciousness among active duty members who are deployed. First, the area of operations is a constant reminder to many of life and death in the area of operations. Whether one is on a mission outside the wire or tending to incoming medevaced injuries in the hospital, it is common to see grave injuries and amputations, and to see death, sometimes daily.

There is the obvious geographic separation from partners, and so there is the absence of familiar companionship for the monogamous, and the absence of available partners for the others. There is also the conscious awareness of abstaining, which may add a heightened sense of “wanting what cannot be had.”

Many deployed personnel will cite that there is an increased sense of purpose; daily distractions and mundane, non-essential tasks are replaced by the goal-directed focus of the military mission. One woman I knew reported that having this sense of importance was empowering and liberating for her. She described that she felt stronger, like she was “living for the first time,” and that it caused her to experience her sexuality more overtly. “I’ve never thought about sex this much in my life. It’s like I’m a teenage boy.”

Deployed active duty personnel may find that they are confined to the area of a small forward operating base; on a larger operating base, they may only navigate between a small workspace, a small gym, a chow hall, a galley or other eating facility, and their living spaces. Restricted areas and restricted mobility force an increased awareness on small human interactions, subtle subtexts, and picking up small expressions. The environment lends to long hours with the same people, sometimes 12-hour days (or longer), and no days off.

One woman I interviewed stated that she became attracted to a colleague and had to work closely with him long hours every day. She reported to me that even though she loved her husband and had no desire to engage in an affair, she felt that there was nowhere for her to escape from looking at this man. Her suppression took on an obsessive-compulsive quality, and she began pulling at her eyelashes and biting her nails again for the first time in ten years.

It is also known by those who have deployed that there may be lots of downtime between the rushes of combat activity. Such downtime is time for the mind to wander, and with limited distractions one may find that the mind wanders toward thoughts of a sexual content. Finally, there is also the unconscious (and perhaps conscious) awareness that the area of operations, while dangerous, has many phallic representations.

Historically there have been connections between war and aggression and sexuality in humans. Centuries of accounts of women (and men) being sexually assaulted by warring captors, conquerers, military occupiers, security in refugee camps, returning victors, or liberating troops have noted these connections, which have been universal in war. Biology, sociology, and historical studies have weighed in on the topic, and a simple literature search reveals years of studies on the connection on how exposure to combat may facilitate the aggression-enhanced properties of sexuality.

Many studies, though, are exclusively male-centric, are based on only male animal models, or are exclusively the act of sexual aggression, or deviant psychopathology in the male, which, for the purpose of this writing, is meant to be separate from female sexuality in the deployment setting (Archer, 2004), (Dayu et al., 2011). Such evaluations and endeavors essentially discredit (1) the perspective of female sexuality, and (2) the subjective meaning of sexuality. In order to fully appreciate the subject of female sexuality in the area of operations, a new model of evaluating the ways that women view and experience sexuality is needed, which may be as diverse as those of men, and likely are as difficult to measure qualitatively and quantatively.

One study indicates that the individuals’ meaning of sexuality is more important than the question of the sexual act itself. Libby and Strauss found that in student subjects the connection between sexual activity and violence and aggression behavior was more evident in individuals who viewed sexual activity as a dominating and exploitive act. The inverse was found with individuals who viewed sexual activity as a warm and affectionate act (Libby & Straus, 1980).

History also can give us some clues regarding the consensual sexual behaviors of women in wartime, though there is no precedence for active duty women who are embedded in US military units. In his book Gender and War: How the War System Shapes Gender and Vice Versa, Joshua Goldstein writes of the consensual and common interactions between European civilian women and American troops during World War II, as well as the “Victory Girls” of the United States who were consensual in showing their appreciation through sexual relations with returning Veterans (Goldstein, 2001). However, the line between consensual and coercive for women of history is thin and relatively uncertain. Similarly, based only on reports of women active duty members’ visits to military women’s clinics, there is no way to make conclusive statements or inferences regarding this topic, which has so little hard data to date.

Based on observations from this author and those women interviewed, it appears as though the US military is alone in its approach of expecting celibacy by military direction and denying the reality that sexual relations will occur between Service members. When visiting the Danish and British Battalion health clinics, I learned of the public health campaign for safe sexual encounters, even in the area of operations. They had free distribution of STD protection and birth control. There were posters in the halls of the hospital that encouraged safe sexual practices, and one entire clinic was devoted to sexual health. This effort occurred despite the British ban on sexual activity while deployed (Crossley, 2014).

Clinicians may be reluctant to speak with patients regarding sexuality during deployment, and patients may be reluctant to speak of this topic, which may be embarrassing, incriminating, and/or shameful. However, this dialogue could have great therapeutic value. Recently, many psychological health and resiliency programs have recognized the ways that good sexual health is part of full-person wellness, so it is important to be cognizant of how this vital part of our human experience (and lack of) contributes to the psychological experience of deployment. It is also important to explore how sexuality, perceived inappropriate feelings, and interactions represent deeper psychological conflicts and/or needs. Finally, it is possible that the area is ready for scientific evaluation in order to bring this subject out into the light.

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Bureau of Medicine and Surgery Public Website for Navy Medicine, page for Policies on Contraception. Retrieved on March 2, 2014, from http://www.med.navy.mil/bumed/womenshealth/Pages/contraception.aspx.

Brown, D. (2008, May 15). Ban on sex for soldiers in Afghanistan lifted… sort of. Stars and Stripes. Retrieved from http://www.military.com/features/0,15240,167950,00.html.

Crossley, L. (2014, February 15). The maternity military: How nearly 100 female soldiers have been sent home from the Afghan front line after getting pregnant. Daily MailOnline. Retrieved on March 1, 2014, from http://www.dailymail.co.uk/news/article-2560032/The-maternity-military-How-nearly-100-female-soldiers-sent-home-Afghan-frontline-getting-pregnant.html.

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Gottlieb, S. (2011, January 27). Sex and war and the Dutch Army: Don’t ask don’t tell. Radio Netherlands Worldwide. Retrieved on January 20, 2014, from http://www.rnw.nl/english/article/sex-and-war-and-dutch-army---'don't-ask-don't-tell'.

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Back up your Birth Control Day: US military expands access. Media Center of Public Website of Guttmacher Institute. Retrieved on March 1, 2014, from http://www.guttmacher.org/media/inthenews/2010/03/22/index.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+Guttmacher+(New+from+the+Guttmacher+Institute).

Holt, K., Grindlay, K., Taskeir, M., & Grossman, D. (2011). Unintended pregnancy and contraception use among women in the US military: A systemic literature review. Military Medicine, 17(9), 1056–1064.

Jones, B. (2013, October 8). US military cracks down on troop masturbation in Afghanistan. BusinessInsider. Retrieved on January 3, 2014, from http://www.businessinsider.com/military-cracking-down-on-masturbation-in-afghanistan-2013-10.

Libby, R., Straus, M. (1980, April) Make love not war? Sex, sexual meanings, and violence in a sample of university students. Archives of Sexual Behavior, 9(2), 133–148.

Rabie, N. Z., & Magann, E. F. (2013). Unintended pregnancies among US active-duty women. Women’s Health, 9(3), 229–231.