Understanding the Long-Term Impacts of Combat: Genital Injury in UK Male Military Veterans (2024)

Beneath the umbrella term “combat injury” are thousands of different conditions, each bringing unique experiences and challenges to the people living with them. This includes genital injury, which for many veterans may come with challenges related to mental well-being, fertility problems, and difficulties discussing their medical issues, even with doctors.

During the conflicts in Iraq and Afghanistan in the early 2000s, genital injuries were reported among UK and U.S. male military personnel at record rates. Patterns of combat-genital injury have been reported after many conflicts, including World War II, Northern Ireland, and the Baltics. However, more recently genitourinary injuries have occurred in “unprecedented numbers.” Some 13 percent of all U.S. combat casualties between 2001 and 2013 were injured in this way, a significant increase from previous levels of 2–5 percent. A very small number of female personnel have also sustained genital injuries.

In Afghanistan and Iraq, around 10 percent of all battlefield injuries for UK forces affected the genitourinary system. Further analysis indicated that these were often polytraumatic injuries, where two or more severe injuries occurred in the same or different parts of the body.

What about these conflicts caused this increase? Both involved notable use of improvised explosive devices (IEDs), which often cause a particular injury pattern involving multiple amputations, pelvic fractures, and genital/perineal injuries. There were also advances in battlefield medicine. Troops in Afghanistan and Iraq often had access to rapid evacuation, tourniquet application, advanced resuscitation techniques, and multi-disciplinary damage control surgery. This meant that injuries which had previously been fatal now had increased survival rates.

There has been research on combat-genital injury before. Most of it has been medically focused, concentrating on documenting where injuries are and what type, how they are immediately managed, and surgical reconstruction. However, there has been some limited exploration of how these injuries affect mental and sexual well-being.

Male personnel who sustained combat-genital injuries in Afghanistan and who were receiving immediate post-injury rehabilitation, took part in a 2014 study in the UK. The soldiers reported a loss of gender identity and high expectations for recovering their sexual function. They attributed higher importance to their genital injuries compared to other injuries like leg amputations. Psychological well-being was found to be higher when fertility outcomes were known earlier. The soldiers were willing to discuss issues with the researcher and would have liked more openness among clinical staff in discussing their genital injury.

To date, this research remains the only in-depth exploration of the psychosexual impact of UK combat-genital injury. In the United States, while psychosexual issues are often alluded to in published papers, they have not been the focus. However, evidence from research with civilians with urogenital cancers, spinal cord injury, and other male sexual function concerns demonstrate the value men place on their sexual and reproductive capacity. A strong relationship exists between their genitals and sense of identity, demonstrating the potential impact of combat-genital injury.

To start to address this gap in understanding, in 2021 we were awarded a small grant to conduct an exploratory pilot study investigating the long-term impacts of combat-genital injury in UK male military veterans, and to assess the feasibility of conducting larger-scale research. This is the first study in the United Kingdom to examine the long-term experiences and outcomes of male veterans who sustained a combat-genital injury. It contributes to our understanding by taking a holistic approach, moving the discussion beyond medical management, and incorporating themes such as mental health, body image, and the impact on relationships. In the few female veterans with similar injuries to date, the impacts present differently, since the anatomy is different. Their experiences are another overlooked area, which should also be investigated in separate research.

The research team developed an anonymous cross-sectional online survey in consultation with various stakeholders, including those with lived experience of combat-genital injury. Eleven eligible male UK veterans who had sustained a combat-genital injury took part. All were white men with a mean age of 49.8 years. All were serving as regular members of the British Armed Forces at the time of injury. Nine were injured during post-9/11 operations, two pre-9/11, and the majority were injured due to IEDs. They experienced long-term challenges related to their genital injury, including low self-esteem, sexual function difficulties, and fertility concerns. A paper fully reporting the findings is currently being peer reviewed for publication in an academic journal.

Beyond this, research specifically on the longer-term psychosocial and sexual impacts of these injuries has remained limited in the United Kingdom and globally. Our research could create a starting point for addressing such gaps and makes a significant and novel contribution to the evidence base. Taken alongside other evidence from the United Kingdom work in 2014 and emerging evidence from the United States, our work demonstrates the need for greater discussion and support not only during rehabilitation, but over the long term to address the enduring psychosocial and sexual impact of combat-genital injury.

Since we commenced our research, Russia's full-scale invasion of Ukraine started and continues, with a new cohort of soldiers of all genders subject to life-changing genitourinary injuries. More than ever, further research is needed in this area to build on our findings and help soldiers by developing suitable, accessible support.

Mary Keeling is a research leader in defence and security at RAND Europe and Natalie Hammond is senior lecturer at the Department of Social Care and Social Work at Manchester Metropolitan University. Keeling and Hammond have been collaborating on research in this area for the past three years, with funding awarded while Keeling was senior research fellow at the University.