New Study Spotlight: The AFTER Study: Armed Forces genital Trauma and psychosexual Experiences Research.

Welcome to 'New Study Spotlight', where we interview researchers about their new studies to raise awareness and keep you up to date with current research focused on the Armed Forces community. Read on to learn about new research, its importance and relevance, aims, and intended impact and benefit for the Armed Forces community. To learn about all current UK research with the Armed Forces community, you can search Ongoing Research here.

In this issue, we interviewed Dr Natalie Hammond (Manchester Metropolitan University), Dr Mary Keeling (RAND Europe), and Professor Nicola Fear (King's College London), about their new research: The AFTER Study: Armed Forces genital Trauma and psychosexual Experiences Research.

This research aims to understand the long-term psychosocial and sexual experiences of ex-Service personnel and their partners affected by conflict-related genital injuries, as well as identify unmet support needs and develop possible interventions and support materials.

Why is this research important, and why now?

Patterns of conflict-related genital injury have been reported after many conflicts, including World War II, Northern Ireland, and the Baltics. However, during the recent conflicts in Iraq and Afghanistan, genital injuries were reported among UK military personnel at record rates. Until recently, most research has focused predominantly on the medical management of these injuries, with little understanding of the long-term psychosocial and sexual impact.

One previous study, from 2014, focused on psychosocial experiences during immediate rehabilitation. The study found that servicemen who sustained conflict genital injury may experience low self-esteem, sexual function difficulties, fertility concerns, loss of gender identity, high expectations for the recovery of sexual function, and that they attribute higher importance to their genital injuries compared to other injuries^[1]. However, there is limited understanding about the experiences of those with genital injury in the long-term.

Recent UK research exploring the psychosocial impact of appearance-altering combat-injuries (e.g., limb loss and scarring) found emerging evidence among some participants of enduring challenges related to genital injuries for which they had not received any psychosocial support^[2,3]. Off the back of that research, Natalie and Mary secured a small pot of funding (from the University of the West of England, Bristol) to conduct a pilot study to investigate the long-term psychosocial and sexual experiences of ex-Servicemen with conflict-related genital injury, understand support needs, and assess the necessity and feasibility of conducting a larger study. This generated evidence of the long-term impact on psychological well-being, sexual functioning, and intimate relationships, of unmet support needs, and a need for a larger scale study to better understand the challenges and needed support^[4]. We were, therefore, extremely pleased when we saw that the Scar Free Foundation had secured funding from the Armed Forces Covenant Fund Trust to fund research into this important area, and even more pleased when we were successful in our application.

What is the problem in the world that this aims to address?

We know from research with civilians with cancer, spinal cord injury, and other male sexual function concerns, that men place a high value on their sexual and reproductive capacity and there is a strong relationship between their genitals and sense of identity. Genital changes can be psychologically distressing requiring support long after an initial diagnosis or injury. Additionally, there is an abundance of evidence that demonstrates the crucial role of romantic and intimate relationships for our overall well-being. The impact of conflict-related genital injuries in Service personnel has so far been seemingly overlooked and is therefore something that needs focused attention. The AFTER study will address this gap by generating evidence to inform our understanding of the impacts of conflict-related genital injury, what is associated with different outcomes and experiences, and how can those affected can be better supported. We hope that this will increase openness about the importance of restoring the ability to enjoy fulfilling intimate relationships, reduce any shame and stigma surrounding conflict-related genital injury, and ultimately work towards no ex-Service personnel and their partner affected by conflict-related genital injury feeling unsupported.

What questions will the research aim to answer?

This research will address two research questions:

RQ 1: How have conflict-related genital injuries, intimate scarring, or loss of function, affected ex-Service personnel and their partners' psychosocial (including relationships) and sexual well-being in the long-term?

RQ 2: What are the psychosocial and sexual well-being support needs of ex-Service personnel and their partners affected by conflict-related genital injuries, intimate scarring, or loss of function, and how can they be addressed?

By addressing these questions, this research aims to:

1. Understand the long-term psychosocial and sexual impact of conflict-related genital injury, intimate scarring, or loss of function. 
2. Develop evidence-based psychological interventions to address the long-term psychosocial and sexual impact of conflict-related genital injury, intimate scarring, and sexual dysfunction. 
3. Assess the acceptability and feasibility of any developed interventions.

How will it answer these questions (method in lay terms)?

The project will take a participatory research approach. This means ex-Servicemen and intimate partners of ex-Servicemen will be included in the process from start to finish to ensure that the issues that are important to them are included in the study and that any resulting interventions/support materials are co-created with those they aim to support

To address the project aims, a mixed methods design will be taken, including six studies:

1. A literature review of existing international evidence about the experiences of those affected by conflict-related genital injury, intimate scarring, or loss of function.
2. A quantitative survey (n=100) with ex-Servicemen with conflict-related genital injuries, intimate scarring, or loss of function to understand their psychological, relationship, and sexual well-being and the factors associated with different outcomes and experiences.
3. A qualitative interview study with ex-Servicemen (n=20) who have sustained conflict-related genital injuries, intimate scarring, or loss of function, to gather deep experiential insights into their psychological, relationship, and sexual well-being experiences, and to explore support needs and preferences.
4. A qualitative interview study with the partners of ex-Servicemen (n=15) who sustained conflict-related genital injuries, intimate scarring, or loss of function, to gather deep experiential insights into their psychosocial, relationship, and sexual well-being experiences, and explore support needs and preferences.
5. Co-create possible evidence-based interventions or support materials. 
6. Acceptability and feasibility test any developed interventions or support materials.  

What are the intended impact and outcomes of the research?

This research has potential for considerable and measurable impact for the Armed Forces community. To our knowledge, this is the first UK study to investigate the long-term psychosocial and sexual impact of conflict-related genital injury. It will therefore generate new knowledge and evidence of the needs and experiences of those affected that will fill a knowledge and practice gap. This evidence will then be used to co-create identified interventions/support materials. We anticipate the participatory approach will ensure acceptability and feasibility of the interventions, leading to positive impact and transformational change for ex-Servicemen and their partners and their emotional and sexual well-being. We also envisage an impact on health policies and service provision across the MOD, Office for Veterans Affairs, and the NHS. Additionally, the work will be of interest internationally in both civilian and veteran communities.  

Who is conducting the research, and who has funded it?

The AFTER study is co-led by Dr Mary Keeling from RAND Europe, Dr Natalie Hammond from Manchester Metropolitan University, and Professor Nicola Fear from the King's Centre for Military Health Research, King's College London,  and in collaboration with Professor Dominic Murphy from Combat stress. It is funded by the Scar Free Foundation via the Armed Forces Covenant Trust.  

What are the project's key milestones?

The study officially started on 3^rd March 2025 and is a 2.5 year project. The key milestones will be:

• Ethics approval: September 2025
• Literature review complete: August 2025
• Survey study participant recruitment/data collection: September 2025 – June 2026
• Interviews with ex-Servicemen: September 2025 – February 2025
• Interviews with partners: March 2026 – August 2026
• Data analysis: March 2026 – March 2027
• Intervention/support materials co-creation: February 2027 – April 2027
• Intervention/support materials feasibility and acceptability testing: May 2027 – June 2027
• Dissemination, reporting, and knowledge exchange: July 2027 and beyond

Many thanks to Dr Natalie Hammond, Dr Mary Keeling, and Professor Nicola Fear, for authoring this New Study Spotlight.

Catch our next instalment to stay informed on new research projects involving the Armed Forces community. 

References

[1] Lucas, P. A., Page, P. R., Phillip, R. D., Bennett, A. N. (2014). The impact of genital trauma on wounded servicemen: Qualitative study. Injury, 45(5), 825–829. Available at: link

[2] Keeling, M., Williamson, H., Williams, V. S., Kiff, J., Evans, S., Murphy, D., Harcourt, D. (2022). Body image and psychosocial well-being among UK military personnel and veterans who sustained appearance-altering conflict injuries. Military Psychology, 35(1), 12–26. Available at: link

[3] Keeling, M., Sharratt, N. D. (2023). (Loss of) the super soldier: Combat-injuries, body image and veterans' romantic relationships. Disability and Rehabilitation, 45(2), 209–219. Available at: link

[4]​ Keeling, M., Hammond, N. (2024). Combat-genital injury in UK male military veterans: A pilot and feasibility study exploring long-term psychosocial and sexual experiences and support needs. Journal of Military Social Work and Behavioral Health Services, 12(2), 166–177. Available at: link