Reproductive Care in the Military
By BaoChau Le
For over two years, the United States military has been failing to meet its goal of new recruits. The Air Force and Navy fell short by a few thousand new recruits, but the Army had 10,000 fewer recruits than it needed. (Sisk 2024) Failure to meet recruitment goals could have detrimental consequences for military readiness and effectiveness. The Department of Defense defines military readiness as “the ability of military forces to fight and meet the demands of assigned missions.” (Cronk and Whitlock 2022) Military readiness includes, in addition to positioning and materiel, having enough personnel with everything they need, including housing for their families and all the equipment, training, and provisions required for them to meet their full potential. It is important, therefore, that the military do everything in its power to attract, retain, and care for its troops. Yet, we often overlook an important factor that contributes to these objectives: access to contraceptives and comprehensive reproductive healthcare.
Every year approximately eight to ten thousand women join the US armed forces and are introduced to the option to continue or begin their birth control journey. (“Facts and Figures,” n.d.) Contraceptives do much more than just prevent unintended pregnancies. They also can be used to stabilize hormones, prevent endometriosis and menstrual migraines, and otherwise contribute to the overall wellbeing of service members. However, access to contraceptive use in the military is difficult due to logistical and informational barriers. In this essay, I will analyze the approach that the military has taken when it comes to educating its service members on contraceptive availability and access. Then, I will compare it to the harsh realities that women in the military face when trying to access birth control. Lastly, I will also expand on how the recent Dobbs decision affects service women, their access to abortions, and the state of national security.
The Ideal
The Military Health System (MHS) and its healthcare program, TRICARE, are the main organizations responsible for all medical decisions and services to which military members are entitled. When a recruit undergoes Basic Training, they are mandated to sit through a sexual education course that covers the different types of contraceptives provided by MHS and TRICARE. Those who are already using contraceptives are permitted to bring it into Basic Training and are guaranteed that the armed forces will continue to provide the same medication into their service. Those who are not on birth control are highly encouraged to start. (“Walk-in Contraceptive Services | TRICARE,” n.d.) Members can choose from short-term reversible contraceptives (SARC) such as oral contraceptive or long-term reversible contraceptives (LARC) like vasectomies or copper and hormonal IUDs. MHS also provides condoms and emergency contraceptive pills to all military bases. Furthermore, all contraceptives are accessible and free of charge, so no service members are not burdened by the cost when choosing which contraceptive works best for them. (Bustamante 2022)A recent study conducted by MHS found that over half of all service women, both active-duty and reserves, utilized some sort of contraceptive. Twenty-four percent of service member use short-term oral contraceptive, commonly known as birth control pills, while twenty-two percent of women utilized LARC options. (Division 2022) The study also noted that SARC use is more common amongst service women who are younger than 30 and LARC are more common among older service women.
Theoretically, if someone wants to access contraceptives, then they could visit their nearest MHS center, as all of them offer appointments and walk-in consultations. Then together with their doctor, service women can choose which contraceptive would be the best choice for them. MHS and TRICARE state that contraceptives are free and easily obtained to ensure that all service women can maximize their operational readiness. Without fear of unintended pregnancies, STDs, and other reproductive health concerns, service women can perform to the best of their abilities and carry out the objectives of the United States military.
The Reality
While MHS boasts an accessible and inclusive reproductive healthcare program, the reality is far from what the website advertises. For starters, service women are 1.5 times more likely to undergo an unintended pregnancy than a civilian. (Holt et al. 2011; Enewold et al. 2010) This already is an indication that contraceptives and sexual education are not as accessible as the military claims them to be.
There are many logistical obstacles when it comes to providing contraceptives, especially to active-duty members who are deployed abroad. Shipment and storage requirements vary for different contraceptives and can make it difficult for active-duty soldiers to receive them. Oral contraceptives are the easiest to ship because they do not require refrigeration, but blockages into conflict zones could greatly delay their arrival. Hormonal insertion contraceptives such as IUDs, the NuvaRings, hormonal shots, the patch, and Nexplanon require refrigeration before their use. Therefore, there must be refrigeration options during transport and storage at military bases abroad. This is not always feasible as bases and camps do not always have a constant power source and improper refrigeration could lead to contraceptives losing their effectiveness. Beyond shipment and storage, there are also difficulties with administration of contraceptives. Oral contraceptives must be taken at the same time every day to be most effective. Service women who are constantly moving across time-zones cited that it was difficult to keep up with their schedule and would end up taking the contraceptive sporadically or stop all-together because it got to be too cumbersome. Long-term contraceptives are a more convenient option but require renewal, where medical personnel must be present to properly insert the contraceptive. As a result of shipment delays, transport difficulties, and lack of medical personnel, service women have had to abruptly halt their usage of contraceptives. This can lead to hormonal imbalance, unplanned pregnancies, or escalation of endometriosis and growth of ovarian cysts, all of which impact affected women’s ability to perform military operations and duties.
Informational Barriers to Contraceptive Use
Unfortunately, the biggest obstacle when it comes to accessing contraceptives for service women is not shipment and transport, but lack of awareness in which contraceptives exist and how they work. It should be noted that the majority of female military recruits hail from the South and the Midwest.(“Facts and Figures,” n.d.; Sisk 2024) In these regions of the United States, sexual education often is not required and, when it is taught, tends to be abstinence-focused.(“State Profiles,” n.d.) Therefore, many service members enter the armed forces with little to no knowledge regarding reproductive health, sexual wellness, and how to use contraceptives. It is the military’s duty to educate soldiers on these topics, but a survey conducted by MHS reveals that over half of service women do not recall receiving contraceptive or sexual education training throughout their career. (Seymour et al. 2021) Furthermore, another alarming study divided participants into age groups and across all age groups knowledge of contraceptive usage and sexual health was considered inadequate. For example, only 35 percent of the participants knew that mid-cycle is the most likely time for conception and that emergency contraceptives must be taken within 48 hours of intercourse.(“ Unintended Pregnancy and Contraceptive Use Among Women in the U.S. Military: A Systemic Literature Review,” n.d.; Borsay-Trindle, Pass, and Gilzean 1991) An interview with female soldiers who served in Iraq revealed that they simply were told not to engage in sexual intercourse and that abstinence should be prioritized. Birth control was not discussed or even offered to these soldiers. (Grindlay, 2013) This lack of sexual education and awareness is a large contributor to the number of unintended pregnancies among service women.
When contraceptives were available, service women often faced significant gaps in their knowledge of contraceptive use and effectiveness, leading to adverse outcomes. A study indicated that a significant portion of participants did not understand how oral contraceptives work. (Seymour et al. 2021; Borsay-Trindle, Pass, and Gilzean 1991; Holt et al. 2011) They did not know that contraceptives had to be taken consistently and at approximately the same time every day to be effective. Some even recalled using oral contraceptives in the same manner they would use emergency contraceptives, only taking them after sexual intercourse. Another study by Ibis Reproductive Health highlighted that service women were either unaware of or faced restrictions when trying to access intrauterine devices (IUDs). (Ibis Reproductive Health, 2017) Both non-hormonal and hormonal IUDs were approved by the FDA in 2000, but there were concerns about their usage in nulliparous women. (Ibis Reproductive Health, 2017) Physicians and researchers worried that using IUDs in women who had not given birth could result in permanent sterilization. (Project 2024) As a result, nulliparous women in the military were often rejected when requesting IUDs. Service women deployed during the early 2000s recalled being barred from receiving the IUD, with little to no explanation. (Ibis Reproductive Health, 2017) It wasn’t until after 2010, when the Centers for Disease Control and Prevention (CDC) released guidelines on contraceptive use and clarified that nulliparous women could safely use IUDs without affecting their fertility, that military physicians started to prescribe IUDs more frequently. (Batig 2017; Division 2022; Grindlay, 2013) One comprehensive study noted that once these guidelines were published and more service women knew about IUDs, usage in the military increased significantly. (Batig 2017)
Dobbs Decision
Under the Hyde Amendment, it is prohibited for federal funding to cover abortions unless the mother’s life was endangered, or the pregnancy was a result of rape or incest. As a result, service women could not have abortions performed and covered at military facilities unless their pregnancies fell into one of these two categories. (“Hyde Amendment,” n.d.; “Does TRICARE Cover Abortion?,” 2023 ) If service women wanted an abortion, then they would have to travel to a civilian facility. With the Dobbs decision, the authority to provide and regulate abortions is now given to the state and its legislative body. (Newton 2022) Consequently, 25 states have now either severely limited access to abortions, fully banned them, or criminalized abortions. (“Abortion Laws by State,” 2023) Civilian facilities are being shut down in states where abortion is restricted or banned and those who perform or undergo an illegal abortion could be fined or jailed. (“Abortion Laws by State,” 2023)
It is estimated that 40 percent of active service women currently reside in states that are hostile towards or flat-out prohibits abortions. (Hunter et al., 2022) This means that if these service women were to experience an unintended pregnancy, they would have to choose between carrying the pregnancy to term, taking time off to travel to a state where abortions are still accessible, or have under-the-table dangerously performed on them. All of which poses a threat to military readiness and the overall well-being of service women. The physical and emotional toll of an unplanned pregnancy could affect a service member’s ability to perform their duties, restrict their abilities to be deployed, and result in a loss of human resources. In response to how the Dobbs decision negatively impacts military readiness, the Department of Defense has passed a memorandum that ensures compensation for those who need to travel for abortion access. (Department of Defense, 2022; Sullivan 2022) Firstly, the time that a service women must alert their commander of their pregnancy is extended to 20 weeks, instead of the previous 2 weeks. (“Does TRICARE Cover Abortion?,”) This would give service women more time to consider their option and prepare themselves. If they decide to go through with the abortion, then the DOD will cover travel fees and allow personnel to travel with them if they cannot travel alone. (Department of Defense, 2022) Lastly, service women will not be impacted negatively when they take time off to receive abortion care. (Department of Defense, 2022)
The ongoing restrictions on abortion access places an undue burden on service women, threatening both their personal well-being and the operational readiness of the military. The DOD’s recent measures to support service women who are navigating these challenges is crucial to sustaining military readiness.
Conclusion
Unplanned pregnancies take a high toll on service members as they must deal with both the physical and emotional ramifications of the situation, and it restricts them from being able to be deployed and carry out the military duties. This in turn would affect the efficiency and effectiveness of military operations as leaders must find substitutes and alter plans and strategies. Being timely, adaptable, and flexible are all key aspects of military readiness that ensures operations are done efficiently and effectively. Military readiness what keeps the United States safe and secure in the face of evolving threats. It is also a multi-faceted approach that needs to prioritize reproductive health and contraceptive care. A robust contraceptive program will empower individuals with the knowledge to make informed decisions about their sexual health and allow service members to prioritize family planning and their careers. Access to a comprehensive contraceptive care ultimately is a strategic imperative that impacts military readiness and defense effectiveness.
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