Women in the British Armed Forces are grappling with chronic bouts of urinary tract infections (UTIs), thrush and incontinence because their health is treated as an afterthought, senior practitioners and support workers have claimed.
Unsanitary conditions, ill-fitting uniforms and having to hold in urine for long periods of time are just some of the challenges women in the military face that has an effect on their health, experts told i.
Women also face difficulties with managing their periods while serving and some struggle with fertility after deferring the decision to have children until the end of their career, Michelle Firmin, a Senior Armed Forces and Veterans Practitioner, said.
The Ministry of Defence (MoD) has said it has recently introduced a number of products and policies to “improve the lived experience of women who serve in the Armed Forces”, including “improved toilet devices for women in austere environments, and greater accessibility to sanitary products for women on exercise” from summer 2022.
Over the summer, the MoD also published new policies to support women through menopause and breastfeeding, while also developing the Servicewomen’s Health Handbook to educate the chain of command about women’s health needs.
However, support workers and veteran practitioners are still receiving reports of women developing infections from unsanitary conditions, and struggling to adjust to civilian life due to issues surrounding fertility and menopause.
Sources from within the British Armed Forces have reported being unable to access effective treatment for chronic UTIs while serving and being forced to pull out of training and operations due to recurring infections.
Ms Firmin, who set up an online support group for service women and veterans, said many reported “difficulties with managing menstrual cycles, peri-menopause and menopause symptoms”, especially when they were outnumbered by men in their job.
She said: “Some spoke of their struggle to balance the decision of having children while serving with their career and promotion prospects, some deferring this decision to have children until the end of their career, to then face fertility difficulties as a result of deferment in having children.”
Salute Her – the only independent charity dedicated to supporting female veterans in the UK – helps women through difficulties that emerge while serving in the military, from persistent UTIs and thrush to dealing with incidents of sexual assault and rape.
“When women are deployed, it’s really noticeable that they have many, many challenges,” said Paula Edwards, a counsellor and expert in military mental health from Salute Her. “UTIs, periods, and thrush – those kinds of health issues that impact women specifically – are a massive problem,” she added.
Out of 3,000 women registered with the charity, Ms Edwards said the majority have suffered from thrush, incontinence, recurring or chronic UTIs, bladder pain or other gynecological problems.
Thrush tends to grow in warm, moist conditions and develops if the balance of bacteria changes, according to the NHS website. Therefore, being deployed to hot, humid conditions – that are often less than sanitary – can put women at risk of developing a recurring infection.
Tight clothing and “ill-fitting” uniforms can complicate the problem, Ms Edwards said.
The MoD recently committed £13.7 million to resolving PPE shortfalls for women’s body armour and combat clothing and ensuring it is fit for purpose and comfortable for everyone.
It was only in June 2021 that the defence department launched the Menstrual Supply Box initiative meaning service women would be given sanitary and hygiene products while working in austere locations. Previously, Ms Edwards said many could not get hold of sanitary products without having to ask a senior officer, who was often male.
Dr Rajvinder Khasriya, a consultant urogynaecologist at Whittington Health NHS Trust, said that conditions in the military can be a “barrier to accessing care” for patients struggling with chronic or recurrent UTIs.
For many patients who develop a UTI, their experience is extremely painful but short-lived. But for thousands of others, a one-off acute attack turns into a chronic infection that dominates their lives and lasts for months or even years.
Dr Khasriya, a UTI specialist, expressed concern that “personnel are often away on military exercises with little access to toileting facilities or medical care”.
She said: “Like elite athletes, these patients mostly only have access to a single physician who may not understand chronic/recurrent UTI. This can become a barrier to accessing care.
“It may well be difficult to come forward with a chronic, unrelenting condition when your job involves a lot of physical strain, for fear of repercussions or being considered not able to cope. I can only think that this leads to suffering in silence.”
A source from the Royal Military Academy Sandhurst told i UTIs are a “big deal” for some serving women, with one female cadet forced to come off her final training exercise twice due to a recurring UTI. This two-week challenge is a vital part of training and it lies between an officer cadet being commissioned as an Army officer.
They said the Academy is making “an effort to engage with the problem” by testing ongoing to see whether the use of shewees and portable toilet systems could help women to urinate more easily.
However, it is still “a challenge” that is “hard to eradicate” because being in harsh conditions for extended periods of time causes your body to “deteriorate” meaning rashes and infections become more common.
A former army nurse, who asked to remain anonymous, said that specialist treatment is not accessible to service women as primary care is usually the only available treatment – meaning general practice and occupational health.
Army doctors will refer soldiers to hospitals and specialists when necessary. However, they are unlikely to recognise the warning signs of a chronic UTI developing as there is not widespread awareness among GPs, pharmacists and doctors in the civilian health service of the realities of a chronic infection.
i previously revealed that outdated testing methods can lead to up to 50 per cent of infections being missed and some women undergo unnecessary, painful invasive treatments after being misdiagnosed with an incurable condition called interstitial cystitis (IC) following referral to a urologist.
Therefore, Dr Cat Anderson – a bladder infection specialist – suggested that army doctors and nurses may not be aware of chronic UTI, leaving a potential infection to become embedded in the urinary tract.
“They understand acute UTI and recurrent UTI but like most doctors and nurses, pharmacists and laboratory staff, not all realise what chronic UTI really is,” she said, “They tend to think of IC or recurrent UTI and it’s always a surprise when I explain embedded infection to them.”
What is a chronic UTI?
Specialists say the infections, which often begin as an acute bout of cystitis, can occur when bacteria become embedded within the bladder wall and become difficult to treat with short courses of antibiotics.
The illness can affect women, men, children and the elderly and can leave them bedbound, feeling suicidal, and unable to work, sleep, leave the house or socialise with their friends and family.
Symptoms can include daily bladder and pelvic pain, the constant urge to urinate and pain or a burning sensation while peeing. Many sufferers also struggle with their mental health as they come to terms with living with the condition.
There are specialists within the UK who are treating for the condition, including an NHS clinic run by the Whittington Hospital in London.
Patients are often given a longer course of antibiotics that can sometimes last for more than a year until their infection is cleared and have fresh urine samples examined under a microscope for signs of the infection.
There are flaws in the dipstick tests which are currently used by GPs to test whether a bacterial infection is present in the urinary tract, which can be inaccurate and lead to infections being missed or misdiagnosed.
Instead, specialists advise sending urine samples off for analysis in a laboratory but the former army nurse said this is not normally an option – particularly when women are deployed on operations.
However, she added that giving longer courses of antibiotics needed to treat embedded infections is “not generally an issue” as doctors will treat “the best they can with what they have”.
Ms Edwards of Salute Her said some women employ “techniques to avoid going to the toilet” while on tours of duty and military exercises such as holding in their urine for long periods of time and reducing their liquid intake, even in hot and humid conditions.
This is partly due to practical reasons, but it can be because “they don’t want to draw attention to themselves as they don’t want to be mocked or humiliated” by their peers when urinating outside or using a makeshift toilet with limited privacy, she told i.
She added that some toilet facilities, such as on airplanes and tanks “are not fit for purpose because they’re designed for males”.
Older models of the C-130 Hercules plane have a urinal at the back with a privacy screen that men can use, while women have to use what is known as a “honey bucket”. This is essentially a bin that women have to sit on with limited privacy.
Tanks do not have any toilet facilities, meaning soldiers have to go outside to relieve themselves – which can be an embarrassing experience for women who have to expose much more of themselves to urinate.
“Women feel like they don’t matter. They feel like they don’t matter when they’re serving in the military and they definitely feel like they don’t matter when they come out in the civilian world,” said Ms Edwards.
Ms Firmin, who set up an online support group for service women and veterans, also said women have reported recurrent UTIs during deployment “due to some areas women would have served in being perhaps less than sanitary”.
The group was launched by Norfolk and Suffolk NHS Foundation Trust (NSFT) and is part of the trust’s Veterans Integrated Service. Ms Firmin set it up after becoming aware of the specific difficulties women face when transitioning to civilian life while she worked for the MoD.
Women come to her group to access support for a range of problems with their mental and physical health, including anxiety, depression, PTSD and issues surrounding fertility, periods and menopause.
A Ministry of Defence spokesperson said: “As part of our longstanding commitment to be a more inclusive employer, several policies and products to support chain of command, line managers and peers have been introduced to improve the lived experience of women who serve in the Armed Forces.
“In 2022 this included introducing improved toilet devices for women in austere environments, and greater accessibility to sanitary products for women on exercise or deploying alongside new policies on breastfeeding and menopause and a Servicewomen’s Health Handbook, designed to educate both individuals and the chain of command.”
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