[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
ELIMINATING THE GAPS: EXAMINING WOMEN VETERANS' ISSUES
=======================================================================
JOINT HEARING
before the
SUBCOMMITTEE ON DISABILITY ASSISTANCE
AND MEMORIAL AFFAIRS
and the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
JULY 16, 2009
__________
Serial No. 111-34
__________
Printed for the use of the Committee on Veterans' Affairs
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51-873 WASHINGTON : 2010
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
JOHN J. HALL, New York, Chairman
DEBORAH L. HALVORSON, Illinois DOUG LAMBORN, Colorado, Ranking
JOE DONNELLY, Indiana JEFF MILLER, Florida
CIRO D. RODRIGUEZ, Texas BRIAN P. BILBRAY, California
ANN KIRKPATRICK, Arizona
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida HENRY E. BROWN, Jr., South
VIC SNYDER, Arkansas Carolina, Ranking
HARRY TEAGUE, New Mexico CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas JERRY MORAN, Kansas
JOE DONNELLY, Indiana JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
July 16, 2009
Page
Eliminating the Gaps: Examining Women Veterans' Issues........... 1
OPENING STATEMENTS
Chairman John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs................................ 1
Prepared statement of Chairman Hall.......................... 58
Hon. Doug Lamborn, Ranking Republican Member, Subcommittee on
Disability Assistance and Memorial Affairs..................... 3
Prepared statement of Congressman Lamborn.................... 59
Hon. Harry Teague................................................ 4
Hon. John Boozman................................................ 25
WITNESSES
U.S. Government Accountability Office, Randall B. Williamson,
Director, Health Care.......................................... 28
Prepared statement of Mr. Williamson......................... 78
U.S. Department of Veterans Affairs:
Bradley G. Mayes, Director, Compensation and Pension Service,
Veterans Benefits Administration........................... 37
Prepared statement of Mr. Mayes.......................... 102
Irene Trowell-Harris, RN, Ed.D., Director, Center for Women
Veterans................................................... 40
Prepared statement of Dr. Trowell-Harris................. 103
Lawrence Deyton, M.D., MSPH, Chief Public Health and
Environmental Hazards Officer, Veterans Health
Administration............................................. 43
Prepared statement of Dr. Deyton......................... 106
______
Disabled American Veterans, Joy J. Ilem, Deputy National
Legislative Director........................................... 5
Prepared statement of Ms. Ilem............................... 59
Grace After Fire, Kayla M. Williams, MA, Member, Board of
Directors, and Author, Love My Rifle More Than You: Young and
Female in the U.S. Army........................................ 13
Prepared statement of Ms. Williams........................... 76
Krupnick Janice L., Ph.D., Committee on Veterans' Compensation
for post-traumatic Stress Disorder, Institute of Medicine and
National Research Council, The National Academies, and
Professor, Department of Psychiatry, Director, Trauma and Loss
Program, Georgetown University Medical Center.................. 32
Prepared statement of Dr. Krupnick........................... 99
National Association of State Women Veterans Coordinators, Inc.,
First Sergeant Delilah Washburn, USAF (Ret.), President, and
Houston Regional Director, Texas Veterans Commission........... 11
Prepared statement of Sergeant Washburn...................... 73
Service Women's Action Network, Anuradha P. Bhagwati, MPP,
Executive Director............................................. 7
Prepared statement of Ms. Bhagwati........................... 68
Society for Women's Health Research, Phyllis E. Greenberger,
M.S.W, President and Chief Executive Officer................... 30
Prepared statement of Ms. Greenberger........................ 97
Wounded Warrior Project, Dawn Halfaker, Vice President, Board of
Directors...................................................... 9
Prepared statement of Ms. Halfaker........................... 70
SUBMISSION FOR THE RECORD
Michaud, Hon. Michael H., Chairman, Subcommittee on Health, and a
Representative in Congress from the State of Maine............. 110
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Debbie Halvorson, Member of Congress, U.S. House of
Representatives, to Judith Sterne, Director, Office of
Congressional and Legislative Affairs, U.S. Department of
Veterans Affairs, letter dated July 24, 2009, and VA
responses.................................................. 112
ELIMINATING THE GAPS:
EXAMINING WOMEN VETERANS' ISSUES
----------
THURSDAY, JULY 16, 2009
U.S. House of Representatives,
Subcommittee on Disability Assistance
and Memorial Affairs,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
The Subcommittees met, pursuant to notice, at 10:01 a.m.,
in Room 334, Cannon House Office Building, Hon. John Hall
[Chairman of the Subcommittee on Disability Assistance and
Memorial Affairs] presiding.
Present for Subcommittee on Disability Assistance and
Memorial Affairs: Representatives Hall, Rodriguez, and Lamborn.
Present for Subcommittee on Health: Representatives Brown
of Florida, Teague, and Boozman.
OPENING STATEMENT OF CHAIRMAN HALL
Mr. Hall. Good morning, ladies and gentlemen. The Committee
on Veterans' Affairs, Subcommittee on Disability Assistance and
Memorial Affairs and the Subcommittee on Health joint hearing,
Eliminating the Gaps: Examining Women Veterans' Issues; will
now come to order.
I am grateful to have the opportunity to Chair or Co-Chair,
as the case may be, the hearing today and would start by asking
you to rise for the Pledge of Allegiance.
[Pledge of Allegiance.]
Mr. Hall. Thank you.
The Ranking Member, Mr. Lamborn, from the Subcommittee on
Disability Assistance and Memorial Affairs is here. We are
awaiting the arrival of hopefully our triple booked Chairman of
the Subcommittee on Health, Mr. Michaud, but we will go ahead
and get things underway.
I am particularly eager to recognize the women veterans in
this room today and to be enlightened by their experiences with
the U.S. Department of Veterans Affairs (VA).
VA owes them the proper benefits and care just like their
male counterparts. They are a unique population since they
comprise only 1.8 million of the 23.4 million veterans
nationwide and deserve specialized attention.
So VA's mission to care for them must not only be achieved,
but also monitored and supported as well. Sadly that is not
always the case.
In response to reports of disparities during the 110th
Congress, the Disability Assistance and Memorial Affairs and
Health Subcommittees held a joint hearing on women and minority
veterans.
This Congress, the 111th, too, has been very active in its
oversight activities to assist women veterans and a record
number of them have testified at various hearings.
Additionally, on May 20th, full Committee Chairman Filner
hosted a special roundtable discussion with women veterans from
all eras who were able to paint a picture of military life as a
female in uniform and then as a disabled veteran entering the
VA system.
In many cases, they have served alongside their male
counterparts, but have not had the same recognition or
treatment.
Chairman Filner also hosted a viewing and discussion
session with the Team Lioness Members who were on search
operations and engaged in firefights. But, since there is no
citation or medal for this combat service, their claims are not
always recognized by the VA as valid, and, so they are denied
compensation.
The Disability Assistance and Memorial Affairs Subcommittee
has all too often received reports about destroyed, lost, and
unassociated records that either never make it from the U.S.
Department of Defense (DoD) to the VA or the VA loses them once
they are in its possession.
Therefore, it is no surprise that women veterans are at a
greater disadvantage since their military assignments and
records are less likely to reflect their actual service, their
exposure to combat, or other traumatic events.
Also, women who have suffered the harm of military sexual
trauma (MST) often do not report those crimes; therefore, they
have limited documentation that can be used as evidence when
they seek VA assistance. This often results in a denial of
benefits.
Even when they do report incidents of harassment or
assault, perpetrator conviction rates are only 5 percent. These
reports are seen as unsubstantiated.
This result is especially unfair given that 78 percent of
female servicemembers report some form of sexual harassment
according to a DoD survey.
Studies have shown that for generations, women veterans
have been less likely than men to be granted service connection
for their post-traumatic stress disorder (PTSD) even though
data shows that women are more likely to report symptoms and to
seek treatment.
Also, I fear that when the 5 years of open enrollment
afforded to current conflict veterans ends, then these women
will be denied treatment as they will no longer qualify for
health care since they are not service-connected.
Without service-connection, they are not eligible for other
VA assistance, such as vocational rehabilitation and employment
services or housing, their problems do not get better, they get
worse.
Congress cannot allow that to happen to our Nation's
daughters who have served. VA needs to ensure that their claims
for disability benefits are fairly and judiciously heard. Women
veterans should be able to request female compensation and
pension (C&P) service officers, adjudicators, and examiners if
they so desire.
VA employees should be properly trained to be sensitive to
the injuries and illnesses women veterans claim and to treat
them with the dignity and the respect that they deserve.
VA should collect gender-specific data and conduct research
on the disabilities that specifically afflict female veterans.
VA outreach efforts should target women of all ages,
ethnicities, and communities. They must know that they are
indeed veterans and deserve the same benefits, services, and
burial rights as their brothers in arms are afforded.
The future of the military will be more reliant on the
selfless service and the sacrifices of this Nation's daughters,
mothers, and sisters. Coming home must be free of abuse,
disparity, and inequality so that transitioning female
servicemembers can continue to be productive employees and
community leaders while maintaining healthy lifestyles and
raising families.
I look forward to hearing from the esteemed panels of
witnesses assembled today as we attempt to eliminate any gaps
hindering access to benefits and to care for our women
veterans.
I yield to Ranking Member Lamborn for his opening
statement.
[The prepared statement of Chairman Hall appears on p. 58.]
OPENING STATEMENT OF HON. DOUG LAMBORN
Mr. Lamborn. Thank you, Mr. Chairman.
I welcome our witnesses to this hearing to discuss
challenges facing women veterans. I appreciate your
contributions to this discussion and hope they will lead to
improvements that we can all agree on.
Without question, America's women, are and always have
been, an integral part of our Nation's defense. In more than
two centuries of service to our country, women servicemembers
have produced an honorable legacy. This legacy has only been
enriched by the intrepid and resolute accomplishments of
today's women in the Global War on Terror. Women make up nearly
10 percent of our Nation's 24 million living veterans and those
serving on active duty represent more than 15 percent of our
Armed Forces.
Our challenge is to ensure that women veterans, and indeed
all veterans, received world-class health care and benefits for
their service to our Nation.
The VA Centers for Women Veterans and the Departments'
associated advisory committees are charged with increasing
awareness of VA programs, identifying barriers and inadequacies
in VA programs, and influencing improvement.
We do not look to these VA programs to merely identify and
report. We seek their input to effect policy and to help bring
about the intended results.
In that regard, I look forward to hearing about the
challenges facing women such as gender-specific health care,
PTSD, and military sexual trauma.
I thank the witnesses for their testimony and I yield back.
[The prepared statement of Congressman Lamborn appears on
p. 59.]
Mr. Hall. Thank you, Mr. Lamborn.
Mr. Teague, would you like to make an opening statement?
Welcome, by the way.
OPENING STATEMENT OF HON. HARRY TEAGUE
Mr. Teague. Yes. Thank you. Mr. Chairman, Ranking Member, I
would. I will be brief in my statement so that we can get on to
business.
But I think that everybody has had enough of us talking
about this issue and we need to hear from the experts and let
them tell us what the problems are and what we need to do to
ensure that all female veterans get a chance to get the help
that they deserve and the benefits that they have earned.
I would like to thank all of the panelists for coming
forward today and testifying. To all the women who have served
in our Armed Forces, let me say thank you for your service. You
have defended our Nation with honor and dignity and the work
that you are doing now, the fight you are engaged in now on
behalf of all of your compatriots is to be commended.
Once again, it seems that we as a government are falling
short. I think that most of us on this Committee are frankly
quite shocked at some of the stories and incidents that we have
heard over the past few months during hearings on different
legislation and the roundtable that Chairman Filner hosted
earlier this year.
It seems that far too many gaps exist and too many
obstacles have been erected that keep women from getting the
care that they need and deserve.
Basic information that should be gathered by the VA is not
being processed and far too many instances when we try to find
new ways to fix these problems and close the gender disparity
that exists, we cannot create a solution because we do not have
the basic statistics that would tell us what we need.
I am afraid to say that from the looks of things, the
answer that we would get when we ask for information would be a
simple we do not know. That is just unacceptable to me and I
would say that it is unacceptable to the Members of this
Committee. And that is what leads us here today.
I want all of you to know that your statements and your
recommendations are not falling on deaf ears. I hear you. This
Committee hears you and we will do what we can to make sure
that the entire country and our VA hears you and your concerns.
All veterans deserve to get the treatment we promised
regardless of their gender. If there are barriers to accessing
that care, then we will just have to knock them down one at a
time. So let us get started.
Thank you, Mr. Chairman.
Mr. Hall. Thank you, Mr. Teague.
I will remind the panelists that your complete written
statements have been made a part of this hearing record. Please
limit your remarks, if you can, so that we may have sufficient
time to follow up with questions once everyone has had the
opportunity to testify.
On our first panel is Ms. Joy J. Ilem, Deputy National
Legislative Director for the Disabled American Veterans (DAV);
Ms. Anuradha P. Bhagwati, Executive Director for Service
Women's Action Network (SWAN); Ms. Dawn Halfaker, Vice
President on the Board of Directors for the Wounded Warrior
Project (WWP); Ms. Delilah Washburn, President of the National
Association of State Women Veterans Coordinators, Inc., and
Houston Regional Director for the Texas Veterans Commission;
and Ms. Kayla M. Williams, MA, Member, Board of Directors,
Grace After Fire, Author, Love My Rifle More Than You: Young
and Female in the U.S. Army.
Welcome to all of our panelists, and we will start with Ms.
is it Ilem or Ilem?
Ms. Ilem. Ilem.
Mr. Hall. Ms. Ilem, you are now recognized for 5 minutes.
STATEMENTS OF JOY J. ILEM, DEPUTY NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS; ANURADHA P. BHAGWATI,
MPP, EXECUTIVE DIRECTOR, SERVICE WOMEN'S ACTION NETWORK; DAWN
HALFAKER, VICE PRESIDENT, BOARD OF DIRECTORS, WOUNDED WARRIOR
PROJECT; FIRST SERGEANT DELILAH WASHBURN, USAF (RET.),
PRESIDENT, NATIONAL ASSOCIATION OF STATE WOMEN VETERANS
COORDINATORS, INC., AND HOUSTON REGIONAL DIRECTOR, TEXAS
VETERANS COMMISSION; AND KAYLA M. WILLIAMS, MA, MEMBER, BOARD
OF DIRECTORS, GRACE AFTER FIRE, AND AUTHOR, LOVE MY RIFLE MORE
THAN YOU: YOUNG AND FEMALE IN THE U.S. ARMY
STATEMENT OF JOY J. ILEM
Ms. Ilem. Thank you, Mr. Chairman and Ranking Member. Thank
you for inviting the Disabled American Veterans to participate
in this joint hearing on women veterans.
The changing roles of women in the military, increasing
numbers of women coming to VA for care, and the impact of war
on women's health represent a number of new challenges for VA
in meeting the unique needs of women veterans today.
It is apparent from the recently released report of the VA
Under Secretary for Health Work Group on Women Veterans that VA
is aware of the shortcomings in its women health program and
making a concerted effort to systemically address the
significant challenges it faces to bring care provided to women
veterans on par with male veterans.
The report outlines a number of critical challenges VA
faces in caring for women and, more importantly, provides a
road map for change. Some of the most critical issues
identified in the report include significantly increasing
utilization rates of younger women accessing VA care, the
systemic fragmentation of primary care delivery for women
veterans, too few proficient, knowledgeable providers with
expertise in women's health, and a number of identified
outpatient quality disparities for women veterans.
Additionally, VA researchers report a number of access
barriers for women, including lack of child care services,
privacy, safety and comfort concerns, and unique post
deployment mental health reintegration issues for newly
discharged women veterans who served in Operations Iraqi and
Enduring Freedom.
The work group states its primary objective is to ensure
every woman veteran has access to a qualified health care
provider who can deliver coordinated, comprehensive primary
women's health, including gender-specific care, preventative
and mental health services.
It plans to achieve these goals through a number of key
policy recommendations and if implemented, these reforms will
change the face of VA health care for women veterans in the VA
health care system and in turn greatly improve the health of
women.
This ground-breaking report represents progress. However,
we question if the women's health program directors have the
resources to build adequate infrastructure and program capacity
and the internal support necessary at the highest levels to
make the reforms it says are necessary.
Without question, this is a major undertaking for VA, but
we are hopeful with the attention, oversight, and collaboration
of the Health Subcommittee that an implementation plan can be
expeditiously carried out.
Identifying and eliminating gaps that exist for women in VA
disability benefits is also critical to DAV. Although certainly
not exclusive to women, military sexual trauma and compensation
claims for related conditions continue to affect many women
veterans.
Unfortunately, if a sexual assault is not officially
reported during military service, establishing service
connection for a related condition is very challenging.
According to an Institute of Medicine (IOM) report on PTSD
compensation, significant barriers prevent women veterans from
being able to substantiate their experiences of MST, especially
in combat arenas.
An area of special concern for DAV relates to collaboration
between the DoD Sexual Assault Prevention Response Office or
SAPRO and the Veterans Benefits Administration (VBA). Current
DoD policy allows servicemembers to file restricted or
unrestricted reports of sexual assault.
In the case of a restricted report, the servicemember opts
to not initiate an investigation but does have the right to
have an official record of the incident filed, a medical
examination conducted, and access to medical and mental health
treatment as necessary.
Obviously these records are critical to substantiating a
claim for disability compensation from the VBA if the veteran
has a chronic disability related to the MST and chooses to file
a claim following military service.
DAV is concerned that VBA policy manuals lack reference to
SAPRO or how to obtain documentation from restricted DoD MST
reports. We ask the Disability Assistance Subcommittee to work
with VBA to confirm their collaboration with DoD on this issue.
Women veterans also report difficulty in verifying special
assignments during military service outside their established
military occupational specialty that exposed them to combat. As
you noted, the prime example are the women Lioness Team
Members, many of whom have had difficulty verifying combat
stressors associated with their claims for PTSD due to lack of
documentation in their military records or on discharge forms.
Women veterans report that lack of understanding on behalf
of Veterans Health Administration (VHA) and VBA staff about the
changing nature of modern warfare and women's roles in the
military further complicate these matters.
Although there has been increasing attention paid to the
impact of military service on women, it is clear that a number
of gender disparities exist for women in accessing VA benefits
and services. Therefore, we appreciate the attention to these
issues and hope the Subcommittees will consider other gaps that
may exist beyond the limited number we have brought forth in
our statement today.
Mr. Chairman, again, thank you and other Members of the
Subcommittees for your leadership and continued support on
women veterans' issues and we appreciate the opportunity to
participate in this hearing. Thank you.
[The prepared statement of Ms. Ilem appears on p. 59.]
Mr. Hall. Thank you, Ms. Ilem.
Ms. Bhagwati, you are recognized for 5 minutes.
STATEMENT OF ANURADHA P. BHAGWATI, MPP
Ms. Bhagwati. Good morning, Mr. Chairman and Members of the
Committee. My name is Anuradha Bhagwati and I am a former
Captain in the United States Marine Corps.
I currently serve as Executive Director of the Service
Women's Action Network, SWAN, a nonpartisan, nonprofit
organization founded by female veterans based out of New York
City. SWAN specializes in policy analysis, advocacy, and legal
services for all servicewomen and women veterans and their
families.
Despite the progress that the VA has made in addressing the
recent influx of women veterans into the VA system, the
delivery of health care and the awarding of disability ratings
to women veterans remains grossly inadequate.
Every day SWAN receives calls from women veterans of all
eras and ages whose experiences at VA hospitals or with the VA
claims system has led them to give up not just on the VA, but
also on life.
Mistreatment by the VA is enough reason for many
traumatized women veterans to fall through the cracks and end
up victims of drug and alcohol abuse, unemployment,
homelessness, or suicide.
Women veterans who have already been mistreated by the
military are often doubly traumatized by harassment or
mistreatment at VA facilities.
Knowledge about the epidemic of military sexual trauma,
MST, sexual harassment, assault, and rape, which is yet to be
fully recognized by the Armed Forces, has also yet to be
adequately integrated into the daily operations of VA hospitals
and the awarding of VA compensation to both male and female
veterans.
MST screening at hospitals around the Nation appears to be
inconsistent at best. A shortage of female physicians and
counselors, a rapid turnover of inexperienced residents, a
preponderance of culturally conservative administrative staff,
and poorly trained, apathetic, or unprofessional medical staff
contributes to a lack of understanding about how to treat
veterans who suffer from symptoms related to MST.
However, I must emphasize that regardless of medical
condition, women veterans when compared to their male
counterparts, are largely subjected to unequal treatment at VA
facilities nationwide.
The following anecdotes illustrate just a few of the VA's
institutional failures to deliver proper health care to women
veterans.
One Iraq veteran who checked herself in to inpatient
psychiatric care during a particularly bad PTSD episode was
forced to share a bathroom with male veterans, including a
peeping Tom. When she told her nurse she felt uncomfortable
eating her meals with male veterans, the nurse threatened that
she would not be fed at all.
An Afghanistan veteran, a single mother, who was raped in
theater by a fellow servicemember cannot bear to enter a VA
facility out of sheer terror of retriggering the trauma from
her assault. Like many other women veterans, she pays for
counseling out of pocket so as not to subject herself to
further trauma.
One veteran recently received her annual PAP smear with a
male gynecologist, who did not enforce the requirement to have
a female staff Member present during the examination. When this
veteran mentioned to the gynecologist that she had experienced
MST, he left the room and barked down the hall we have another
one.
Many of these examples illustrate a larger point that VHA
requires an enormous cultural shift in order to treat female
patients with dignity and respect and to acknowledge the
specific needs of women veterans.
With respect to benefits, both female and male veterans
applying for compensation from the VBA for conditions related
to MST face overwhelming odds against being awarded a
disability rating. However, the full extent to which women
veterans are denied disability compensation has yet to be
comprehensively examined.
Veterans with MST often feel that the benefit system is
rigged against them as proving that one's stressor occurred in
service can be extremely difficult, if not impossible.
The VBA fails to understand that servicemembers rarely feel
comfortable or sufficiently safe from harm to report rape,
sexual assault, or harassment for two main reasons. Reports of
sexual assault and harassment are often simply ignored by
commanders military-wide and servicemembers who report sexual
assault or harassment are often threatened or punished after
reporting.
While DoD's failure to enforce its own sexual assault and
equal opportunity (EO) policies are the subject of another
hearing, it must be emphasized that unless the climate within
the Armed Forces changes such that servicemembers are
guaranteed protection and support after reporting sexual
assault or EO violations that it is unjust and grossly
irresponsible of the VA to expect veterans to provide the
current standard of proof for a stressor related to MST.
H.R. 952, entitled the ``Combat PTSD Act'' introduced by
Representative Hall presumes that a combat veteran's PTSD is a
result of exposure to a stressor while in theater. I suggest
that similar legislation be proposed for veterans who suffer
from PTSD or other symptoms of military sexual trauma so that
veterans with MST are not punished or traumatized further by
the VA.
MST counseling and a physician's diagnosis of MST related
medical conditions should be sufficient for VBA to award a
disability rating to a veteran.
Recommendations to bring the gaps in care for women
veterans: Require that the VA remedy the shortage of female
physicians, female mental health providers, and MST counselors
at VA hospitals nationwide.
Also, require that VA provide the option of female-only
counseling groups for female combat veterans and female as well
as male only counseling groups for female and male survivors of
MST.
Require VA to implement a program to train, educate, and
certify all staff, including administrative and medical, in
Federal equal opportunity regulations on MST to reduce the
discriminatory and hostile atmosphere toward women veterans.
I am running out of time here, Mr. Chairman, so I have
included a few recommendations for the record as well. Thank
you.
[The prepared statement of Ms. Bhagwati appears on p. 68.]
Mr. Hall. Thank you, Ms. Bhagwati for your very excellent
and moving testimony. We will come back to those remaining
points during the question and answer period.
Ms. Halfaker, is that the correct pronunciation?
Ms. Halfaker. Yes, sir.
Mr. Hall. You are now recognized for 5 minutes.
STATEMENT OF DAWN HALFAKER
Ms. Halfaker. Thank you.
Mr. Chairman and Members of the Subcommittees, thank you
for inviting Wounded Warrior Project to offer our views on
eliminating gaps facing women veterans.
Mr. Chairman, I am testifying not only this morning as Vice
President of the Wounded Warrior Project but as a retired Army
Captain who was severely injured in combat in Baquba, Iraq, in
2004. After that, I spent nearly a year in Walter Reed Army
Medical Center and I continue to receive treatment at VA
facilities.
It has been my experience that VA hospitals can be
imposing. VA hospitals do not offer the level of comfort and
security necessary for women like me and female veterans to
cope with mental and physical injuries of combat.
With unprecedented numbers of women veterans returning from
Iraq and Afghanistan with visible and invisible wounds like me,
I would like to focus my remarks on the health-related issues.
Women now make up 11 percent of veterans of Operation
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). VA
reports that some 44 percent of female OIF and OEF veterans
have enrolled with VA and use VA health care from 2 to 10
times.
Women in the military are at significantly higher risk of
developing PTSD, depression, and other war-related mental
disorders than their male counterparts and are also at higher
risk for sexual trauma than their civilian peers.
Sexual assault has long-lasting effects on women's health,
particularly mental health. Given the likely prevalence of PTSD
and other mental health problems in this population and the
health risk of such conditions going untreated, we must focus
not on only those who are seeking treatment but also on those
who are not.
While women have become one of the fastest-growing VA
patient populations, studies indicate that many women veterans
are simply not availing themselves of VA care. There are
several reasons. Frequent lack of knowledge regarding
eligibility for VA care, widespread perceptions that pursuing
VA care would be stigmatizing, and concern regarding hassles
and quality of VA care.
We certainly cannot assume that those who are forgoing VA
care have no health issues. To the contrary, given the
prevalence and unique impact of PTSD among those who deployed
to Iraq and Afghanistan, we see a need for greater focus on the
mental health of all returning warriors.
And given the high rates of military sexual trauma among
those who are deployed, it is particularly important that the
VA reach out to returning women veterans.
VA certainly has attempted to increase its outreach to new
veterans, but no single step is likely to change the perception
of those who, for example, view VA as a system for older males
or have concerns about the quality of VA care and their own
safety and security at the facilities.
The bottom line is that VA should take an aggressive
approach to eliminating barriers that deter returning women
veterans from pursuing the help that they need.
Specifically we propose that Congress direct VA to employ,
train, and deploy women OEF/OIF veterans to conduct outreach to
their peers to include one-on-one outreach to address negative
perception and to build trust.
Clearly VA also faces difficult systemic problems in
bridging the gaps in care and services for women veterans.
Among them is the wide variability women veterans encounter in
care at VA facilities.
As documented in a 2007 survey, VA facilities have adopted
a variety of clinic models for providing primary health care to
women veterans. Those facilities also reflect significant
variability in whether specialized women's health service such
as mammography are available on site or only through contract
arrangements.
Ongoing research should help determine how best to
structure VA care delivery for women's health to achieve
quality of care and patient satisfaction. But difficulty in
determining what are optimal models for delivering that care
should not stand in the way of setting sound policy on clear-
cut health delivery issues.
To illustrate, VA has failed to take a firm position on the
question of providing access to female mental health
professionals where there is a history of sexual trauma. The VA
directive that sets minimum clinical requirements for providing
mental health care states only that facilities are strongly
encouraged, when clinically indicated, to give veterans being
treated for military sexual trauma the option of being assigned
a same sex mental health provider.
This extraordinarily sensitive subject is not one which VA
should provide encouragement. Rather, VA should require that a
woman veteran who has experienced sexual trauma have access to
a female health professional on request.
While access to needed care for women veterans has improved
markedly in the last decade, the overwhelming majority of VA's
patients are men. Many VA providers have limited exposure to
women patients, but VA facilities do appear to be working to
adapt to the changing demographics of our Armed Forces.
The Department and its facilities must continue to take
steps to accommodate women veterans from modifying delivery
systems to ensuring that they meet privacy expectations, but
they must be cognizant of the still widespread perceptions that
VA facilities are geared only toward male patients and that
some Department clinicians lack sensitivity to women's issues.
Addressing those concerns is an issue of leadership that will
become ever more important if the VA is going to win trust of
this new generation of women veterans.
This concludes my statement. I would be pleased to answer
any questions you may have.
[The prepared statement of Ms. Halfaker appears on p. 70.]
Mr. Hall. Thank you, Ms. Halfaker.
Ms. Washburn, you are recognized for a 5-minute statement.
STATEMENT OF FIRST SERGEANT DELILAH WASHBURN,
USAF (RET.)
Sergeant Washburn. Mr. Chairman and distinguished Members
of the Subcommittees, on behalf of the National Association of
State Women Veterans Coordinators, I am honored to have this
opportunity to testify this morning and to present the views of
the State Women Veteran Coordinators of all 50 States.
The primary barriers women veterans face in accessing the
VA health care across the country are lack of reliable
transportation, unavailability of child care, lack of an
integrated primary care and mental health care, lack of gender
sensitivity of health care providers and staff to women-
specific issues, limited hours of women veterans' clinics,
women veterans' clinics that are difficult to locate or are not
perceived as personally safe and comfortable for women veterans
and their children, and unsafe inpatient VA health facilities
for women veterans.
And we are happy to expound on any of these barriers at the
conclusion of my remarks.
We found that the VA medical centers (MCs) do not
consistently assess and treat domestic violence victims across
the country. VA medical providers must be trained to ensure
women veterans who are victims of domestic violence are treated
to the standards set forth by the Joint Commission on
Accreditation of Healthcare Organizations and that State
reporting requirements are consistently met to protect these
victims.
Mammography is another area that quality care is an
accident of geography for women veterans. There is no formal
program for tracking mammography results and follow-up of
abnormal mammograms to ensure women veterans receive
consistent, timely, and high-quality care.
We suspect Congress would be appalled by the differences in
timeliness-to-treatment data for abnormal mammograms at VA
medical centers across this Nation.
Because females are officially excluded from combat roles
in the military, women veterans have a greater burden of proof
in establishing the link between post-traumatic stress disorder
and combat. There is no such thing as an infantry woman. So
women who are supply clerks, mechanics and truck drivers are
going on combat patrols with the infantry and with the Marines.
And because there is no clear front line on the ground in Iraq
and Afghanistan, female servicemembers are exposed to direct
fire, improvised explosive devices, sniper fire, and constant
threats from insurgents without the benefits of the awards and
decorations to prove they were in combat.
We wholeheartedly endorse H.R. 952, which would amend Title
38 to presume service connection for post-traumatic stress
disorder based solely on a servicemember's presence in a combat
zone. The legislation would not only appropriately recognize
the service and sacrifice of women veterans, it would
significantly decrease the backlog of VA claims for our combat
veterans.
Psychiatric conditions related to sexual trauma have a
devastating effect on women veterans' health functioning. We
are strongly supporting the VA Advisory Committee on Women
Veterans' recommendation that the VBA develop the ability to
identify and track the status and outcome of all claims related
to sexual assault.
VBA cannot currently speak with any authority as to the
number of military sexual trauma-related claims submitted
annually, the processing times for these claims, the rate of
compensation that is granted or denied, or the types of
disabilities that are most often associated with MST.
There are insufficient therapists licensed and experienced
in counseling sexual trauma victims in the VA system to provide
appropriate care for women veterans.
Additionally, many women are not comfortable with male
therapists or mixed-gender therapeutic groups. Women veterans
should have the option to use fee-based or contract services to
obtain mental health care if a qualified MST counselor is not
available or if a woman provider and/or women's groups are not
available.
Many women veterans still lack information and awareness of
benefits. The VA and the State Department of Veterans Affairs
must reduce this inequity by reaching out to women veterans
regarding their rights and entitlements.
We suggest implementation of a grant program that would
allow the VA to partner with the State Women Veteran
Coordinators to perform outreach specifically targeted to women
veterans at the local level.
Finally, we strongly recommend a plot allowance for
veterans' interment be increased to a thousand dollars in order
to offset operational costs to State Veterans Cemeteries. The
current burial plot allowance of $300 per qualified interment
provides less than 15 percent of the average cost of interment.
In conclusion, Chairman and distinguished Members of the
Subcommittee, we respect the important work that you are doing
to provide support and services to women veterans who answered
the call to serve our country.
The National Association of State Women Veteran
Coordinators remains dedicated to doing our part, but we urge
you to be mindful of the increasing financial challenge States
face. As you address the fiscal challenge at the Federal level,
we ask that you keep this mindful.
This concludes my statement and we are happy to answer any
questions.
[The prepared statement of Sergeant Washburn appears on p.
73.]
Mr. Hall. Thank you, Ms. Washburn.
Ms. Williams, you are now recognized for 5 minutes.
STATEMENT OF KAYLA M. WILLIAMS, MA
Ms. Williams. Mr. Chairman and Members of the
Subcommittees, thank you for hearing me speak today. On behalf
of women veterans, I would like to thank you all for your
commitment to meeting the changing needs of our Nation's
veterans.
My name is Kayla Williams. I am on the Board of Directors
of Grace After Fire, a nonprofit dedicated to helping women
veterans.
As a soldier with the 101st Airborne Division, I spent a
year in Iraq serving alongside my male peers. With our flak
vests on, we were all soldiers first.
However, it was clear on our return that people did not
understand what military women experience. I was asked both
whether I was allowed to carry a gun and if I was in the
infantry. This confusion extends beyond the general public.
Women veterans are less likely to self-identify as veterans,
which is the first barrier to accessing benefits. You must be
aware that you are eligible for them.
An active outreach program for those leaving military
service is necessary but insufficient. Women who served in
previous eras must also be made aware of their eligibility for
veterans' benefits and health care through vigorous outreach
and education.
There are a number of challenges for women seeking or using
VA benefits or health care. Some of the same impact on male and
female veterans and others disproportionately affect women.
Here are some that I consider particularly important.
Women who are supposedly barred from combat may face
challenges proving to VA employees who are unclear about the
nature of modern warfare that their PTSD is service connected.
It is, therefore, vital that all VA providers and particularly
health care providers fully understand that women do see combat
in OEF and OIF so that they can better serve women veterans.
The transition from DoD to VA remains imperfect. As you
mentioned, Mr. Chairman, lost records and missing paperwork are
frequent complaints. Electronic medical records are absolutely
imperative.
The backlog of unprocessed disability claims is now over
400,000. Though average processing time has declined, it is
still too long.
My husband, a disabled veteran, had to go on unemployment
while waiting for his VA disability benefits to go through, a
humiliating experience for a combat-wounded warrior.
Adequate training of claims processors is also vital.
Inconsistencies in disability ratings have resulted in
thousands of dollars in annual payment differences between
regions for veterans with similar disabilities.
The Post-9/11 GI Bill, a significant improvement in
education benefits that will allow many thousands of veterans
the chance to attain first-rate education, also has several
gaps.
For example, time that National Guard Members have spent
while activated under Title 32 does not count toward Post-9/11
GI Bill eligibility. A legislative fix is required to repair
this inequity.
In addition, while time and brick and mortar schools may be
best for both veterans and their peers, those who are
struggling to raise small children who are more likely to be
women or those coping with PTSD may face significant barriers
getting into classrooms. Full benefits, including the housing
allowance, should be provided to veterans pursuing their
educations online.
Raising the amount of tuition assistance for veterans
attending private schools on only the tuition at State schools
hurts those who attend private schools in States like
California which charges only fees at State schools. The
calculation should be based on both tuition and fees at State
schools.
Astonishingly, the housing stipend for disabled veterans in
this area is less than half of what it would be for those using
the Post-9/11 GI Bill if they choose to use vocational rehab. I
find that absolutely outrageous. Don't our injured heroes
deserve the same housing allowance that I would receive?
Finally, due to the complicated provisions of the Post-9/11
GI Bill, I believe that the decision to switch to it from the
Montgomery GI Bill should be reversible for 1 year and not
permanent as it is currently.
Women who are more likely to be the primary caregivers of
small children may require help getting that child care in
order to attend appointments at the VA. Currently, VA
facilities are not always prepared to accommodate the presence
of children. Veterans have to change babies' diapers on the
floors of some VA hospitals because restrooms lack even the
most basic changing facilities.
A friend of mine whose babysitter canceled at the last
minute and brought her infant and toddler to a VA appointment
was told by her provider that that was not appropriate and she
should not bother to come in if she could not find child care.
Facilities in which to nurse and change babies, increased
use of telehealth programs, child care assistance, or at least
patience with exigent circumstances would ease burdens on all
veterans with small children.
Veterans have made up a disproportionate percentage of the
homeless population for some time. Although VA has initiatives
to try to help homeless veterans, they are insufficient. In
addition, although the number of homeless women veterans has
begun to rise dramatically, VA programs to serve this
population and especially those with children are wholly
inadequate. Changes are urgently required to better meet the
needs of this population.
Women in the military are also far more likely to be
married to other servicemembers than their male counterparts.
These women veterans must worry not only about their own
readjustments but also their husbands' challenges. The VA must
consider this dual role that women veterans may be balancing as
both the givers and seekers of care. And legislators should
back bills providing increased support to caregivers of wounded
warriors.
In order to best meet the needs of all veterans, I urge the
development of enhanced relationships not only between the DoD
and the VA but also with those community organizations that
stand ready and willing to fill gaps in services. Public/
private partnerships can allow all of us to come together to
meet the needs of our veterans in innovative and exciting ways.
Thank you for your attention.
[The prepared statement of Ms. Williams appears on p. 76.]
Mr. Hall. Thank you, Ms. Williams.
I just wanted to mention, counsel has reminded me to tell
you that the full House Veterans' Affairs Committee just passed
H.R. 3155, the Caregivers Assistance Bill, out of the full
Committee to the floor of the House. So that bill is moving.
Thank you, all of you, for your testimony, for your service
to our country and to our veterans.
I would start with Ms. Ilem and ask when the DAV trains its
service officers, does it provide special sensitivity training
on issues pertinent to female veterans, for instance, MST?
Ms. Ilem. Yes. As far as I am aware within our service
program, I mean, there is definitely discussion of MST claims.
We have a number of women national service officers (NSOs)
around the country, but it is provided to all of our NSOs,
information about VA's, you know, manuals and regulations
looking for different evidence to help them support their
claims and different ways that they can help----
Mr. Hall. How many of your service officers are female? Can
they assist in developing claims even if the veteran is from
another State?
Ms. Ilem. Yes. Our NSOs can provide services to anyone. I
think of our NSO Corps of about 260, I would have to look at
the exact number, but I think there is a range of about 30 now.
There has been a number of recent new hires of women veterans,
especially from OEF/OIF populations.
Mr. Hall. During the time that the DAV has been working
with VA on these issues relating to women veterans, what is
your observation on how well VA has responded to the concerns
you have raised and how successfully are they addressing those
issues?
Ms. Ilem. I think I mentioned in my testimony one of the
concerns I have had, I have been reaching out to VBA for some
time, and we would appreciate the Subcommittee's assistance
just to verify especially on the SAPRO/DoD, the DoD Sexual
Assault Response and Prevention Office. Looking at their policy
issues, it appears that, you know, there is some problem that
they may have in being able to release those records even with
the--for restricted reports of military sexual assault even
with the consent of the veteran. And so trying to work with VBA
staff just to try and see if they are collaborating with them
to work through some of these barriers and to make sure that
their claims developers are aware of the SAPRO policies and
where in each of the military services these records are kept
and for how long and can VA with the consent of the veteran get
access to those reports which can include a physical
examination as well as mental health and counseling treatment.
So we think those records are critical and we would ask
that the Subcommittee try and work to see if VA does, in fact,
collaborate with SAPRO on those policies.
Mr. Hall. Thank you.
And, Ms. Bhagwati, is the lack of legal representation more
detrimental to women when their claims are the result of a
crime?
Ms. Bhagwati. I am sorry. The lack of legal work?
Mr. Hall. Legal representation.
Ms. Bhagwati. Absolutely, sir. I am finding that without
the assistance of an attorney, many of those legal claims would
just be left behind. It takes a lot of courage, stamina,
financial assistance for a veteran, either male or female, to
pursue and appeal reconsideration of a claim.
A lot of pride and a lot of issues wrapped around a
veteran's identity go into the claims process. And when a claim
is rejected by the VA, even when the claim is deemed to be sort
of sufficient to get an awarding of compensation, when that
denial happens, it can be life shattering. And many veterans,
both male and female, just fall off the map.
Mr. Hall. I understand more all the time as we have these
hearings about the issues surrounding reporting problems with
MST, but what about domestic violence that takes place while
the wife is on active duty? How are those instances of PTSD or
other disabilities resulting from those injuries adjudicated by
the VA?
Ms. Bhagwati. Sir, that remains to be seen. I mean, I think
a lot of data, as both the Congressman and Ms. Halfaker pointed
out, has not been collected on domestic violence in particular.
Right now I can tell you anecdotally. We are working on a
case in the Marine Corps with an non-commissioned officer (NCO)
who is going through a commissioning program whose partner
spent 5 days in jail for attempting to kill her. And that
partner who spent 5 days in jail is now in Officer Candidate
School. So that shock factor, I mean, it is almost unbelievable
that that could happen. But there are ways around the system
and DoD needs to explore that.
Mr. Hall. Unfortunately, there are ways around the system,
not just for men who assault women, but also for men who
assault men. There is one case in particular that I am familiar
with in my district. But it is more egregious and harder to
rectify when it is an attack on a female soldier.
Ms. Halfaker, for the more seriously injured female
veteran, is there an outreach effort made directly to them? Are
there OEF/OIF coordinators trained to specifically interact
with them regarding their needs?
Ms. Halfaker. Sir, I think there are much needed outreach
programs. I do not think there is anything specifically
targeted for women veterans. And I think that that is where you
get a lot of women initially slipping through the cracks,
especially with the Guard/Reserve component.
And I also believe that, you know, peer support is probably
a good way to start advocating. It has been the Wounded Warrior
Project's experience that women, and particularly this
generation, of veterans are much more responsive and receptive
to kind of learning about programs and things like that through
their peer network. So I think that the VA needs to explore
ways to promote outreach using peer networks and things like
that.
As far as the OEF/OIF coordinators at the hospitals, I
mean, it was my experience that there is a lot of inconsistency
and variability. The VA facility that I go to, the model just
to have any kind of coordinator was stood up incredibly late
and it is my sense that the coordinators could use a lot more
education on the specific programs and clinical care that women
need and how women can best access that care.
Mr. Hall. Thank you.
Ms. Washburn, your suggestion to track MST data has been
made by the Center for Women Veterans and its Advisory
Committee but has not yet been implemented by the VBA.
How effective do you think the Center and the Committee are
in promoting these issues and acting as change agents on behalf
of the women they represent?
Sergeant Washburn. I believe those things that are imposed
by Congress get done. I believe those recommendations sometimes
do not.
Mr. Hall. Can you provide us with any more information on
the training protocol that the State Women Veterans
Coordinators receive in order to assist veterans in filing
claims. Second, what outreach activities do your women
coordinators perform?
Sergeant Washburn. Most of our women veteran coordinators
are also State service officers and are also accredited with
other service organizations such as the American Legion,
Veterans of Foreign War, Military Order of Purple Heart. So we
hold more than just one military organization credential.
So whenever we have the opportunity to counsel with our
veterans, whether it is male or female, we have to maintain the
accreditation that the Department of Veterans Affairs mandates
for service officers. So we have annual training. We have
testing and we are proficient at doing those jobs as service
officers.
And in most cases, with the new training force that we see
in the regional offices with all the new employees that have
been hired, most of our service organizations and veteran
coordinators are more knowledgeable than the new VA employees.
So we are doing the very best job that we can do to help
train up some of the new VA employees by pointing out things
that they have missed in the letter of the law that says that
they can grant benefits.
So we are doing our very best job as service officers to
continue to not only help them through the maze, the
bureaucratic maze of getting their VA claims processed.
Mr. Hall. Thank you.
Ms. Williams, I am going to ask you this question and then
ask each of the other panelists quickly, because my time is
long expired here, quickly give me an answer.
If VA and the DoD could do one thing to better assist women
veterans, what would that be?
Ms. Williams. I believe that electronic medical records are
absolutely imperative to prevent problems with lost paperwork
and missing files, missing records, and that that would really
help smooth the transition from the DoD to the VA.
Mr. Hall. Ms. Washburn?
Sergeant Washburn. Yes, sir.
Mr. Hall. Ms. Washburn. I am just asking for an answer to
that same question just quick if you could.
Sergeant Washburn. The one thing that I think that they
could do immediately that will make a difference, and not just
for gender-specific issues we are talking about, we no longer
have to worry about providing the stressor for post-traumatic
stress disorder.
If you are in combat, it is conceded and let us press on
with getting a diagnosis and rate those claims and get them off
the table because the near million claims that are pending is
just something that we cannot continue to live with. It is a
barrier to veterans getting their benefits.
Mr. Hall. Thank you for the wonderful endorsement of my
bill, H.R. 952.
Ms. Halfaker. Outreach.
Mr. Hall. Ms. Bhagwati?
Ms. Bhagwati. The one thing----
Mr. Hall. Microphone, please.
Ms. Bhagwati. Sorry, sir. One thing on the DoD side would
be enforcement of EO policy and sexual assault policy. On the
VA side, it would be education and training of claims officers
about what it is like to be a woman in uniform.
Ms. Ilem. I think just true collaboration on all levels
within VHA and VBA would be really extremely important. There
are just so many areas where they can benefit working together
to really solve the problem. It just cannot be done piecemeal
and it helps to work on the preventative side with DoD and
during that transition period for women coming to VA.
Mr. Hall. Thank you.
If our Members from the Disability Assistance Subcommittee
would not object, I would go to our only Member of the Health
Subcommittee who is here, Ms. Brown.
Ms. Brown of Florida. Thank you, Mr. Chairman, and thank
you for holding this hearing.
I am going to be very brief. In the early nineties, I
called for the first women veterans' hearings and then we had a
roundtable discussion a couple of months ago and it seems as if
things have not improved. Part of it is the culture.
If you were making recommendations to VA or to Congress,
what would you recommend that we do to change the culture? This
question is for all panelists. We can start with Ms. Williams.
Ms. Williams. That is a great question and I think one that
both the Department of Defense and the VA are struggling with
every day.
I truly believe that this conflict is going to change the
way that women are treated within the military and the VA
because young leaders, young soldiers, and servicemembers, they
serve alongside women in combat. As they grow in their
leadership positions through time, they are used to serving
alongside women. They are beginning to recognize that women are
servicemembers, too, that they are not just females that happen
to show up sometimes.
And that change in attitude will slowly trickle through the
rest of the system, but that is going to take a very long time.
I do think cultural change can also come from systemic changes.
When I first got out of the military, I went to the VA
facility in Washington, DC, which I must admit was an atrocious
experience for me. The facility was not clean. I was not given
coordinated care and I had a truly unpleasant experience that
scared me away from the VA for many years.
Just last month, I went to the VA facility in Martinsburg,
West Virginia, and had a profoundly different experience at
their OEF/OIF integrated care clinic. I saw several providers.
I was led from one appointment to the other to make sure that I
knew where I was going. I was sensitively asked about MST,
about my combat experiences. And this model is one that I think
is worthy of emulation, though it may not be perfect in every
facility.
They also have a women's care clinic. So I know that by
putting these facilities in place, staffing them with the right
people that proper care can be given.
Ms. Brown of Florida. When you first went to the facility,
that was when?
Ms. Williams. I went to the DC VA in 2006 and then I went
to the Martinsburg VA just last month.
Ms. Brown of Florida. Okay.
Yes, ma'am.
Sergeant Washburn. That is an excellent question. There are
several points that I would like to share with you.
In today's culture, I can see just from the veterans that
talk with us that some of the problems they face are that now
we have appointments that come in the mail to us and we are
notified of five or six different appointments. They are not on
the same day. And these are people that are trying to hold a
job down and they just cannot go to all of these appointments.
And then we have child care on top of that. We cannot take
off from work, so the hours that they are being seen is an
issue. We have children that we have to provide care for
because we cannot take them to the VA. We already know that.
And those are concerns.
And why can we not do a better job at scheduling? Why can
we not provide it during hours that they are available? If it
is once a month on a Saturday, why can we not do a women's
clinic once a month on a Saturday? If we are doing women's
health on a Wednesday, why can we not do that from 12:00 noon
to 6:00 p.m. to give them an opportunity to go after work and
where there would be someone else to help with children?
So those are some things that we need to look at that I
think culturally we have to change.
When we are talking about military sexual trauma, there are
so many of the cases that are identified by DoD and where DoD
is taking action under the Uniform Code of Military Justice.
And we already see that these women are having medical
problems, physical as well as mental health issues. And why
don't we get them through the medical evaluation process
because that is a disability?
And it would help us if DoD would step up and if they have
an opportunity to be afforded a Military Evaluation Board or a
Physical Evaluation Board, let us get it done because we are
finding all too often after we do finally get them through the
VA system, we are going back to do correction in the military
record.
So DoD could do a better job. If it is an opportunity where
they can meet the requirements of a medical evaluation, let us
get it done.
Ms. Brown of Florida. Those are very good suggestions. I do
not know why we cannot do that Saturday or Sunday afternoon and
have someone there to take care of the kids. I do not see why
we cannot, because you were talking about the waiting list and
what did you say it was, the waiting list for women?
Sergeant Washburn. We do have appointments that come out
through the VA computer system that will oftentimes not
consolidate those appointments to get you there on 1 day. And
oftentimes we have folks that are coming in from a rural area--
--
Ms. Brown of Florida. Right.
Sergeant Washburn [continuing]. That are traveling 100 or
200 miles to the large VA medical center. So that is a
hardship. Transportation is a hardship.
Ms. Brown of Florida. Right. It is a hardship. Question, do
we have any, and I have been thinking about it, do we give any
kind of a gas voucher or anything like that?
Sergeant Washburn. There are some organizations, whether it
is Disabled American Veterans, where they have a transportation
program. There are some organizations, Veterans of Foreign
Wars, that give vouchers. And oftentimes the VA medical centers
have moneys for that as well, but it is not the norm and not
everyone knows that they can get help. We are just not
advertising it.
Ms. Brown of Florida. Okay. All right. Thank you.
Ms. Halfaker. Yeah. I think that, perception and culture
can change through action. I think, some of the recommendations
that Wounded Warrior Project is prepared to make are actions
such as outreach, peer support, consistency in the way VA
delivers care and services to women veterans.
And it is interesting. I have had the exact same experience
as Ms. Williams. First went from Walter Reed Army Medical
Center to the VA facility in Washington, DC, and just have had
horrible experience after experience there. And, you know,
again, they have made some strides in trying to coordinate an
OEF/OIF care model where they have the case managers and things
like that, but, again, I do not think that the women veterans
who are continuing to receive care have actually felt any of
the changes. Certainly there has been no change in culture at
that particular VA.
Ms. Brown of Florida. That is the one in DC?
Ms. Halfaker. Yes, ma'am.
Ms. Brown of Florida. Is it just bad for women or is it bad
for everybody?
Ms. Halfaker. I think that is a good question. I mean, I
think that it was initially bad for me just because, you know,
when you do just walk through the doors of the VA, it is not a
pleasant environment. It is not a safe environment. You know,
oftentimes you may encounter somebody, you know, yelling,
catcalling at you, making a crude remark. And I think it is a
true culture shock going from the military where that would
never be tolerated to a VA facility, you know, where you are
trying to get care----
Ms. Brown of Florida. You know, this is the second or third
time I have heard about the catcalls and I just do not know how
you deal with it because they are not in the military any
longer. They are a civilian and we face this problem if we are
walking down the street and we see a work crew or something.
Ms. Halfaker. Yes, ma'am. I mean, I think that it is a
leadership issue, if I was the Director of that hospital, I
would do whatever I had to do to ensure that that environment
could not happen. So I think it is a leadership issue.
Ms. Williams. And, if I may, ma'am, I do believe that that
facility inadequately serves both male and female veterans. My
husband's care at that VA was so bad. He was sent back and
forth between multiple clinics, told he was in the wrong place.
His paperwork was lost. He felt the doctors did not care about
him. His experience there was so bad that he has since refused
to go back to the VA at all and relies exclusively on civilian
providers even though they are less familiar with blast
injuries and post-traumatic stress that results from combat.
Ms. Brown of Florida. Just quickly, Ms. Bhagwati.
Ms. Bhagwati. Ma'am, my personal experiences with the VA
hospital in New York City have been personally devastating and
I pay out of pocket for as much care as I need. I use the VA
right now for emergency care.
You know, I have experienced MST and I had a very bad
experience with a claim. And, you know, it does not take much
to disappoint me right now with VA care. Every time I walk in
there, I go with, you know, open arms, a generous spirit. I
hope to be received well. There are some fantastic health care
providers there, but by and large, both male and female staff
members and medical staff do not understand what it is like to
be a woman in uniform.
Ms. Brown of Florida. You know, part of the problem is the
VA and the number. When I suggested that perhaps we may need to
do vouchers so that people can go outside, I got real push-back
on the women.
So, if the service is not there. What can we do to change
the system? When I talk to women veterans, they want to go to
the VA, but the service is not what they want.
Ms. Bhagwati. Well, ma'am, I think we need to push the VA
to provide equal services for women.
Ms. Brown of Florida. Yes.
Ms. Bhagwati. That needs to be done comprehensively. We
cannot give up on the VA. But I just need to stress that
especially for women who have been traumatized, now, that can
be through sexual trauma, post-traumatic stress from combat,
whatever the case may be, if they are experiencing negative
episodes at the VA hospitals, they may just turn away and never
come back. So fee-based care needs to be an option.
If you talk to women who have been working around MST for a
while, they will, I would say by and large, they agree that
fee-based care needs to be accessible for survivors of MST,
whether that is harassment----
Ms. Brown of Florida. It should be an option?
Ms. Bhagwati. Absolutely.
Ms. Brown of Florida. Okay. That is what I am thinking.
Yes, ma'am.
Ms. Ilem. I would just say very briefly I think one of the
best things that is happening is this hearing right here today
with VA staff from both VHA and VBA being here able to listen
to women veterans recount their experiences both in the health
care and benefit system. I think that is the beginning of
cultural change for the VA itself.
And I was pleased in the recent report on the Women's
Health Work Group that they talked about this very thing, the
cultural shift that needs to take place in VHA all the way from
every staff member who comes in contact with women and not just
the clinicians but everyone needs to be brought up, you know,
be educated and given information about the roles of women in
the military today.
But most of all, accountability is mentioned, that it is a
leadership issue. And I am hoping we can come back in short
time for a followup hearing and you will hear some different,
you know, that change has occurred.
Ms. Brown of Florida. Thank you, Mr. Chairman, for being
patient with me.
Mr. Hall. Thank you, Ms. Brown.
Ms. Brown of Florida. Thank you.
Mr. Hall. Mr. Rodriguez, you are now recognized for 11
minutes.
Mr. Rodriguez. Thank you very much. Thank you and let me
apologize for being here late.
I know now more than ever we have the largest number of
women than we have ever had in the military, so the numbers are
going to grow on the VA side. I know that we have done some
legislation to try to look at providing the care that is needed
out there and we are not anywhere close to what is needed.
So, I know that, for example, in the rape area, what else
do we need to do in there to really provide the services?
I just visited a couple of the sites and I know that in
some areas, we are doing a clinic and section within the
hospital for women. If that is the direction that we need to
take, I know that we will probably need to look at using a peer
group also that will go around the country as a commission just
to look at women's services in our hospitals, whether that
might make any sense to oversee that and come back with
recommendations to us like we have done on post-traumatic
stress.
So we are trying to establish centers of post-traumatic
stress in our hospital facilities, but what has startled me now
is that we still continue to have a large number of rapes that
should not be there, the suicides that are occurring.
I know that in terms of the treatment that women get in
comparison to men is still in some cases discriminatory because
I have received situations and feedback from that.
I was wondering from a policy perspective, what should we
be looking at long term? Do we need a commission to oversee
that and come back with recommendations or do we need something
else, especially as it deals with rape and suicide and those
kind of things?
Ms. Ilem. I mean, the VA Advisory Committee on Women
Veterans makes a number of--they do a site visit every year, an
annual site visit to VA and then each do different site visits
to different facilities and they correlate that in their
report. I think that is one opportunity to really, you know,
review those recommendations. The women veterans that serve on
there do a very thorough job, I think, in addressing that.
But I think at the facility level, it would be really good
to have women veteran users of the system to participate with
the women veterans' coordinators to have either regular
townhall meetings or discussion groups where women can really
give them feedback, continual feedback on these services, how
they are being treated, how they feel their care, the quality
of care that is being provided. And I think that is critical to
the users of each system to really get at the different
facility----
Mr. Rodriguez. To localize it.
Ms. Ilem. At a local level.
Mr. Rodriguez. I hear the reports on Walter Reed and
supposedly that is one of our better hospitals. So I can just
imagine in terms of how it is elsewhere where you do not have,
you know, as much services as you do have up here, because in
other areas, the veterans are even worse situations.
And so--I am sorry?
Ms. Bhagwati. Sir, veterans, both male and female, who have
been assaulted or harassed and are experiencing symptoms of
military sexual trauma need a safe space within VA hospitals.
That is very difficult to provide when you are dealing with
gigantic facilities. The preponderance of patients are male.
Mr. Rodriguez. Is there a need for a new component or
something or outreach?
Ms. Bhagwati. I mean, service needs to be done. I think the
VA has headed in the right direction. There are some facilities
which do provide sort of safer access, women only, and I know
there is research being done into what women patients prefer.
But, again, male veterans also suffer from MST and so, you
know, just focusing on the gender exclusively does not really
serve the male veterans with MST because they will not feel
safe entering a male facility either. So there needs to be
private, safe spaces in which men or women who have experienced
MST can heal.
Mr. Rodriguez. Is there any model out there that we can
look at that might be different, maybe an outreach model?
Ms. Bhagwati. I know that there are hospitals which are
exploring that and I cannot name them, sir, but I am pretty
sure that members of the VA can answer that question.
Ms. Halfaker. Yes, sir. There is a great facility. I was on
the Veterans' Affairs Committee for OEF/OIF veterans and
families. And we had the privileges of looking at, I think,
what I would consider one of the best practices in VA as far as
military sexual trauma treatment. It is a residential facility.
I believe it is in Menlo Park, California.
And, you know, it is a phenomenal facility, but the problem
is outreach. I do not know any woman that knows that it exists.
There were certainly women patients that were there. I mean,
they had incredible stories of how they had progressed through
their trauma. It was an all female facility. They segregated
obviously males and females. They also have a male clinic
there. And it was incredible to hear the stories.
And I think that, you know, some type of commission,
whether it is the Standing Women's Committee or another
Committee, can go out there, identify those best practices, and
also not only in dealing with, you know, sexual trauma and
things like that but also in just care delivery, standard
female care delivery and figuring out what are the best
practices, doing some research, and then----
Mr. Rodriguez. What is the name of that facility in
California?
Ms. Halfaker. I believe it is the one in Menlo Park. And I
am sure that VA could follow up and give you a lot of
information.
Mr. Rodriguez. Do you know if they have any others besides
that one?
Ms. Bhagwati. Sir, there are several residential programs
for MST around the Nation. I have also heard very good things
about them.
I would say the problem is, though, that most of these
residential programs require that you take time off from your
life, whether it is work, your children, whatever the case may
be, for 2 to 3 months at a minimum, which is excellent
treatment. The quality of treatment is great for survivors of
MST, but to actually be able to enroll can be a problem. You
really need to take time off and that is difficult for anyone
who needs to work a job, anyone who is trying to keep their
lives together or who has children.
The other thing I would say to answer your original
question is we need to look closer at the relationship between
health and benefits because lots of women I know who have been
assaulted or raped, who have been denied by the benefit side,
it is doubly traumatizing because you are basically getting a
diagnosis from VHA counselors, psychiatrists, and physicians
saying, yes, you have PTSD from your assault, yes, you have
depression from your assault. But then for the VBA to say you
do not have PTSD, you do not have depression, and maybe you
were not even assaulted to begin with, it is not a very
efficient system.
I think the VHA and VBA need to coordinate better so that
the benefit side supports the physicians, the counselors, and
psychiatrists who are treating MST patients.
Mr. Rodriguez. I know we have had one too many suicides,
also. In terms of the number of women's in proportion to the
number of men's suicides, if there are any differences there or
anything? I also want to go back to the original questions also
on rape.
Sergeant Washburn. One of the things that I think that we
need to consider is that women are also looking at whether or
not we have integrated care. If I can go to a women's clinic
and have care for primary care needs or wellness needs and I
also can have mental health care in that same clinic, that
means I am not having to walk over four or five different
buildings to the place where the mentally ill are being treated
because, okay, I had a traumatic event. I am not mentally ill.
So you can understand their perception. They are not going
to want to go to those facilities where it is VA mentally ill
are housed. There is a difference. So the integrated care for
where I can go to get my wellness care or to go to get my
mammography or my PAP smear, this is a place where I am
comfortable. Maybe it is pink. Maybe there are a lot of women
there. And, oh, by the way, they have someone there that wants
to talk to them about mental health.
And, you know, those are the women that are going to sit
back and say I did have a traumatic event and I do want to talk
about it now because the environment is right to do that in. It
is not the stigmatism of I am mentally ill and I have to go
over to where the mentally ill patients are. There is a
difference.
Mr. Rodriguez. Thank you.
Ms. Williams. We all know that the suicide rate among
soldiers has been shockingly high this year. Unfortunately, I
do not think that any of us have any real solid sense of the
numbers among the veterans' population. And that is something
that I think would be an important area for research. Since not
all veterans enroll in the VA, I am not convinced that anybody
is fully tracking the number of veteran suicides.
In terms of military sexual trauma, I would like to address
a slightly different angle, which is trying to tackle it on the
front end. It is my understanding that rapists tend to be
repeat offenders. And, unfortunately, as the Chairman
mentioned, the number of prosecutions within the Department of
Defense is atrociously low.
I understand that during these conflicts the military may
be worried about retaining qualified soldiers and I would love
to see a paradigm shift within the Department of Defense in
which they would understand that they can choose to lose either
one male soldier who may be a repeat rapist or multiple female
servicemembers who may be sexually assaulted by that man.
So if we look at it in that frame of retention, it is
important to realize that female soldiers are just as vital as
male soldiers. And it is important to dramatically increase the
number of prosecutions so we can try to drive down the rate of
military sexual trauma at the front end.
Mr. Rodriguez. Okay. I know you gave me 11 minutes, but let
me ask another question and you do not have to respond, but
maybe you can get to our staff.
If in the process of bringing to light, for example, the
suicide, where we are at in terms of those issues, rape, and
then services or even recommendations for a commission to
oversee that or how we use peer to peer, if you have any
suggestions, especially on the U.S. Government Accountability
Office (GAO) making an assessment on one thing or another that
might help us come up with some solution, feel free to contact
the office and see what we might be able to do.
And thank you very much for your testimony. Thank you.
Mr. Hall. Thank you, Mr. Rodriguez.
I would now recognize our acting Ranking Member, Dr. John
Boozman.
OPENING STATEMENT ON HON. JOHN BOOZMAN
Mr. Boozman. Thank you very much, Mr. Chairman.
I just want to very briefly thank you all for being here,
for your service, and also for a very, very good discussion on
such an important topic.
Like all shortfalls that we try and address in the VA, you
have to understand the problem first and you all have really
been very, very helpful not only in discussion today but in
your written testimony. So I thank you and I thank you for your
advocacy.
I have three daughters and, you know, really am very, very
interested in this and really quite alarmed about some of the
things that you brought up. And I have heard this in the past,
so it's something that we need to deal with. We do appreciate
your advocacy. Our women are serving our country in a very
valiant way as they have for many years, but particularly now.
And so, again, thank you for your service and, again, thank you
for your contribution.
Mr. Hall. Thank you, Dr. Boozman.
To all of our panelists, thank you so much for your
testimony and for your service to our country, to our veterans
and to our female veterans.
Before we wrap this panel up, Ms. Brown has one more
question.
Ms. Brown.
Ms. Brown of Florida. Yes. It is just a follow-up question
because the more I listen, the more I am convinced that we may
need additional options for the VA veteran because we seem like
kind of an isolated situation.
I mean, I have gone to Walter Reed and I have gone to
Bethesda and I am very pleased with the services that are
provided there. But, the VA has a different culture, and I do
not mean--it is just a different culture and we are working
through it and trying to improve it.
But I do not believe that you can wait until they get
there. Every single one of you has said I do not go there, I do
not use it, it is not an option. Well, if you are taking the
money out of your purse to pay for the services, why can you
not take a voucher and go to the services that you are going
to?
I am just saying I think that should be an option. Can you
respond to that because each one of you are going somewhere
else and you are paying for it? We have made a commitment to
you that you are going to have a certain quality of service.
Ms. Ilem. I would just say that it is very distressing to
hear that so many of the women here on the panel have had such
a negative experience with VA. And I myself use the Washington
VA Medical Center. I have had a good experience. I have been
going there for 12 years since I have been here in DC.
Is it perfect? No. But I found the women veterans' program
to be very good as well as the primary care services that I
have personally received.
However, I think VA does have an option to provide fee-
based care if they have a particular situation, especially if
somebody is very uncomfortable, they have experienced MST or
they have a situation where they have had a negative experience
with the VA. They do have the option to provide fee-based care
where VA can pay for that.
And certainly if VA cannot provide a certain type of care,
they do not have the specialists, you know, they definitely,
you know, need to fee base that care out and give that person
the option. But they do that for, for example, maternity care
routinely.
So I think, you know, the options are there. I think people
have had difficulty in getting VA to do that.
We heard on a panel just the other day in the Senate, one
woman veteran let me know that, you know, she had asked for a
different therapist. She did not get along with that therapist
that she was assigned but was told no, you know, that she could
not change. And that is obviously a very personalized
relationship. You need to have somebody that you trust and that
you have a good rapport with.
So, again, I mean, I think in those cases, they definitely
should have that option, but I would like to see VA step up to
meet the needs of women veterans, change the culture in VHA and
VBA so that VA can be a provider of choice for women.
Ms. Bhagwati. Ma'am, at the New York Hospital, the New York
VA Hospital, I have been a patient there for at least 3 years
now and I attend the pain management clinic. And I am telling
you this story because I think it is a good example of why the
fee-based care system needs to be improved.
It took me 10 months to get an appointment. I was on a
waiting list for 10 months for an acupuncture pain management
clinic which is an excellent clinic, but took quite a while and
I could not wait a year. I mean, chronic pain is not something
that you really wait around for a year to resolve.
And then following that, I waited an additional 3 to 4
months for a chiropractic appointment. During that time, I had
to pay out of pocket and the care that I get paying out of
pocket is better.
I think that the VA is making strides, especially in the
sort of holistic department, and that I think it can be
incredibly helpful for both male and female veterans. But the
services need to be improved.
There is very little understanding about, again, what it is
like to be a women in uniform, what the specific needs of women
veterans are in those clinics even though they do provide
decent care.
When I did eventually a year and a half later apply for
fee-based care because it was an option at that point and I
found a couple of allies within the hospital who were helping
me with that, it was rejected because, again, of a sort of
defunct, inefficient system in which an attending physician who
has been at the VA hospital for probably the greater part of
his life refused permission for me to get fee-based care
because he did not believe in chiropractic care.
Now, I do not know if personal opinions--I do not think
personal opinions should have anything to do with the providing
of health care to veterans, but you find a lot of that kind of,
you know, maybe the older, more conservative elements of the VA
basically working against the more modern, effective, efficient
methods and modalities.
Ms. Brown of Florida. And so in that case----
Mr. Hall. Ms. Brown, excuse me.
Ms. Brown of Florida. Yes.
Mr. Hall. I am going to have to--that is a second 5 minutes
now. We have two other panels waiting.
Ms. Brown of Florida. Yes.
Mr. Hall. So if I could ask our other witnesses to submit
their response to your question.
Ms. Brown of Florida. Right, right. And thank you. You have
been very patient.
Mr. Hall. Thank you very much.
Ms. Brown of Florida. Thank you.
Mr. Hall. Thank you.
Mr. Rodriguez. Can I just ask a quick question?
Mr. Hall. Mr. Rodriguez, one quick follow-up, please.
Mr. Rodriguez. This has nothing to do with that, but I want
to know how you reckon with the ``do not ask, do not tell''
policy, and if you think it is appropriate to leave it intact,
raise your hand and not just--do not raise your hand. You do
not even have to. No tell----
Ms. Williams. Do not ask, do not tell.
Mr. Rodriguez. Do you think you could deal with that,
change that?
Mr. Hall. Okay. Thank you, all of our first panelists, for
your eloquent statements. We will take them to heart and do the
best we can to implement the suggestions you have made. You are
now excused.
We will call our second panel to the witness table. Mr.
Randall B. Williamson, Director of Health Care for the U.S.
Government Accountability Office; Ms. Phyllis Greenberger,
Chief Executive Officer and President for the Society of
Women's Health Research; and Ms. Janice L. Krupnick, Ph.D.,
Professor for the Department of Psychiatry, Director, Trauma
and Loss Program at Georgetown University Medical Center, on
behalf of the Committee on Veterans' Compensation for Post
Traumatic Stress Disorder, Institute of Medicine (IOM) and
National Research Council, the National Academy of Sciences.
Welcome to our three witnesses. Your full statements have
been entered into the record.
Mr. Williamson, you are now recognized for 5 minutes.
STATEMENTS OF RANDALL B. WILLIAMSON, DIRECTOR, HEALTH CARE,
U.S. GOVERNMENT ACCOUNTABILITY OFFICE; PHYLLIS E. GREENBERGER,
M.S.W, PRESIDENT AND CHIEF EXECUTIVE OFFICER, SOCIETY FOR
WOMEN'S HEALTH RESEARCH; AND JANICE L. KRUPNICK, PH.D.,
PROFESSOR, DEPARTMENT OF PSYCHIATRY, DIRECTOR, TRAUMA AND LOSS
PROGRAM, GEORGETOWN UNIVERSITY MEDICAL CENTER, ON BEHALF OF
COMMITTEE ON VETERANS' COMPENSATION FOR POST TRAUMATIC STRESS
DISORDER, INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL,
THE NATIONAL ACADEMIES
STATEMENT OF RANDALL B. WILLIAMSON
Mr. Williamson. Thank you, Mr. Chairman and Members of the
Subcommittees. I am pleased to be here today as the
Subcommittees consider issues related to VA's delivery of
health care services for women veterans.
VA provided health care services to over 281,000 women
veterans in fiscal year 2008, an increase of 12 percent in just
2 years. Looking ahead, VA estimates that while the total
number of veterans will decline by 37 percent by the year 2033,
the number of women veterans will increase by more than 17
percent over the same period, thereby putting greater demands
on VA's health care system to meet the physical and mental
health care needs of women veterans.
Women veterans seeking care at VA medical facilities need
access to a full range of health care services, including basic
gender-specific services such as cervical cancer screening and
clinical breast examinations, specialized gender-specific
services such as obstetric care and treatment of reproductive
cancers, and mental health care services such as care for
depression and anxiety.
In addition, women veterans from conflicts in Iraq and
Afghanistan present new challenges for VA's health care system.
These women have experienced a greater exposure to combat than
women participating in previous conflicts.
VA data show that as many as 20 percent of the women
veterans of Iraq and Afghanistan have been diagnosed with post-
traumatic stress disorder. An alarming number have also
experienced sexual trauma while in the military. As a result,
many have complex physical and mental health care needs.
VA has taken some bold steps to fulfill its commitment to
provide high-quality health care service for women veterans.
However, much remains to be done in some areas to fully
implement the new initiatives.
In my testimony today, I will discuss three aspects of our
ongoing work on women's health care issues based largely on
work we did at 19 VA facilities.
First, the on-site availability of health care services for
women veterans at VA facilities; second, the extent to which VA
facilities are following VA policies for delivering health care
services for women veterans; and, third, some key challenges
that VA facilities face in providing health care for women.
Regarding the availability of services, we found that basic
gender-specific services, including pelvic and clinical breast
examinations, were available on site at all nine VAMCs and
eight of the ten community-based outpatient clinics (CBOCs)
that we visited. All of the VAMCs we visited offered at least
some other specialized gender-specific services such as
treatment for abnormal cervical screening tests and breast
cancer.
Among CBOCs, the two largest facilities we visited offered
an array of specialized gender-specific care on site. The other
eight referred women to other VA or non-VA facilities for most
of these services.
Outpatient mental health services for women were widely
available at VAMCs and most of the eight Vet Centers we
visited, but were more limited at some CBOCs.
Also, only two VAMCs offered residential treatment programs
for women who experienced sexual trauma. None had dedicated
inpatient psychiatric units for women.
Regarding the extent to which VA facilities are following
VA policies for delivering health care service for women
veterans, we found that none of the VAMCs and CBOCs we visited
was fully compliant with VA policy requirements related to
privacy for women veterans in all clinical settings where those
requirements applied.
For example, many of the facilities we visited lacked
adequate visual and auditory privacy in their check-in areas,
proper orientation of exam tables, and access to private
restrooms adjacent to rooms where gynecological examinations
were performed.
Further, the facilities we visited were in various stages
of implementing VA's new initiative to provide comprehensive
primary care for women veterans.
Finally, officials at facilities that we visited identified
challenges they face in providing health care services to the
increasing numbers of women veterans seeking VA health care.
One challenge involves space constraints. For example, the
number, size, and configuration of exam rooms as well as
limited space for women's bathrooms sometimes made it difficult
for facilities to comply with VA privacy requirements for women
veterans.
Officials also reported challenges in hiring providers with
specific training and experience in women's health care,
including treatment for women veterans with post-traumatic
stress disorder or who had experienced military sexual trauma.
So overall, while VA has taken important steps in many
areas to improve health care services for women veterans, some
areas still require increased attention.
Mr. Chairman, that concludes my remarks.
[The prepared statement of Mr. Williamson appears on p.
78.]
Mr. Hall. Thank you, Mr. Williamson.
Ms. Greenberger, your statement is entered into the record.
You are recognized now for 5 minutes.
STATEMENT OF PHYLLIS E. GREENBERGER, M.S.W.
Ms. Greenberger. Thank you very much.
Thank you, Mr. Chairman and Members of the Subcommittees,
for the opportunity to address this important and timely issue.
The Society for Women's Health Research is a nonprofit
advocacy organization dedicated to improving women's health
through research and through the advancement of the science of
sex and gender differences.
The Society's focus since 1995 has clearly demonstrated
that sex and gender differences exist throughout all conditions
that affect women differently, disproportionately, or
exclusively and research needs to be done to identify those
differences and to understand their implications for diagnosis
and treatment.
Since this area of research is relatively new in scientific
terms, we have many more questions than answers. Women veterans
and the VA in general needs to take what we already know and
recognize and apply it and use their unique network to advance
research into those conditions that disproportionately affect
women veterans where little is known. And as we have discussed,
women are currently the fastest-growing sector of VA users.
The most pressing issues, as you have heard, of course, are
related to mental health issues, including PTSD, depression,
anxiety, and behavioral issues, which often may result in
suicide, alcohol and drug abuse. Differences in chronic pain
and immune response, and possibly cancer related to chemical
and biological exposures as well as musculoskeletal issues.
And, of course, conditions that affect all women to some
extent, but in many cases are amplified by the unique
experience of women veterans.
Although the Society has been advocating for research and
funding in sex differences, we know that research done at both
public and private institutions as well as research at the VA
that there are still few trials that include women and in those
that do, insufficient numbers in clinical trials to identify
differences.
Sex analysis in animal samples in basic research is
generally not even noted or examined. As more women enter the
military and both those women who are currently serving and as
these women veterans grow older, there needs to be greater
examination and understanding of the differences in order for
them to receive the appropriate care.
The Society has long encouraged women to participate in
research. In addition, we pioneered the field of sex and gender
differences and we remain the preeminent organization in this
field.
We sponsor interdisciplinary research in sex differences in
both the Society and its new Organization for the Study of Sex
Differences, hold scientific conferences, and publish
information how sex and gender differences can affect a
person's health.
The Society stands ready to assist the VA in increasing
participation of women in research and building its research
capacity.
In a recent scientific symposium that we held on PTSD in
women returning from combat, it was noted that therapy needs to
be different, that some antidepressants work better in men, and
that a significant number of women veterans have the dual
trauma from their combat experience, as was said earlier,
combined with sexual and psychological abuse in the military.
A 2008 VA study reported that 15 percent of women in Iraq
and Afghanistan experienced sexual assault or harassment and 59
percent of those were at a higher risk for mental health
problems. With the VA currently reporting that 71 percent of
the military now have been exposed to combat, getting proper
mental health treatment is critical.
This meeting that we held also illustrated what is not yet
known and developed a research agenda, which is encapsulated in
the White Paper that we submitted to the Committee for this
meeting.
Not surprisingly, the VA, along with many public and
private institutions, still maintains a male norm and
atmosphere where women's unique needs and sensibilities are not
taken into consideration or understood.
Women may feel stigmatized and are hesitant to speak out.
Many women veterans do not identify themselves as veterans and
seek care outside the system.
The Society recommends that Congress request an update on
the research conducted by the Veterans Health Administration
since the establishment of its women's health research agenda
in November 2004 and further recommends that Congress provide
the VA with the funding necessary to conduct research that will
result in improved care for women veterans.
More funding needs to be available for research into sex
differences and better coordination is needed among the VA
Centers throughout the country to increase the number of women
in clinical trials to understand the differences and their
implication for treatment.
I want to thank you again for this opportunity.
[The prepared statement of Ms. Greenberger appears on p.
97.]
Mr. Hall. Thank you, Ms. Greenberger.
Dr. Krupnick, you are now recognized for 5 minutes.
STATEMENT OF JANICE L. KRUPNICK, PH.D.
Dr. Krupnick. Good morning, Mr. Chairman, Mr. Ranking
Member, and members of the community. I would like to thank you
for the opportunity to testify on the content of the National
Academies' report on PTSD compensation and military service.
I will briefly address five issues in this testimony, the
prevalence of military sexual assault, the relationship between
sexual assault and PTSD, PTSD comorbidities and recovery for
women, PTSD compensation and women veterans, and the PTSD
Compensation report's conclusions and recommendations regarding
women veterans.
As has been discussed earlier, the prevalence of reported
sexual assault in the military is alarming. A synthesis of
studies found that 4.2 to 7.3 percent of active-duty military
females had experienced a military sexual assault, MSA, while
11 to 48 percent of female veterans reported having experienced
a sexual assault during their time in the military.
A 2005 survey found that among 104 female veterans and
Reservists who disclosed they were sexually assaulted while in
military service, 13 percent reported sexual assault from a
marital partner and 8 percent from a date. Eighty-two percent
of the perpetrators in these MSAs were military peers or
supervisors.
The women in the sample also reported a great deal of
secondary victimization by the military and by the VA system,
an experience that is known to make PTSD symptoms worse.
Other studies have found subsequent secondary victimization
and sexual harassment exposing the women to additional trauma
over and above rape and combat.
A substantial body of literature documents measurable
gender differences in PTSD frequency and severity. A
metanalysis published in 2006 found that PTSD was twice as
prevalent in females as in males after controlling for
potential confounders.
There are several possible reasons for this, including sex
differences and the cognitive response to the traumatic event,
immediate coping strategies, and the willingness to admit
symptoms.
Women are more likely to experience chronic trauma such as
repeated childhood sexual assault by a family member or
intimate partner violence. Women are also more commonly the
victims in cases of multiple traumas.
Research indicates that sexual assault experiences are
strongly associated with PTSD in both civilian and military
populations. Studies of female veterans indicate that PTSD
symptoms and PTSD diagnoses are associated with comorbidities
such as depression, substance abuse, smoking, and physical
health problems as well as with increased medical utilization.
Females are more likely than males to have major depressive
disorder along with PTSD and tend to experience symptoms for a
longer duration. They also have more physical problems than do
males.
For female veterans, post-military social support from
family and friends both reduces the risk of developing PTSD and
aids in recovery from the disorder according to the few studies
of PTSD recovery in this population.
Female veterans were more comfortable in a specialized
treatment program for women which increased their participation
as measured by attendance and commitment although it had no
affect on outcomes.
The PTSD Compensation Committee observed that studies of
PTSD treatment for female veterans are badly needed and noted
that it was important to ensure that study samples were
sufficiently large to disentangle the differential treatment
effects for women whose trauma is primarily military sexual
assault versus those whose trauma is primarily combat or to
determine if multiple traumas are part of the etiology of the
PTSD experience.
Very little research exists on the subject of PTSD
compensation and female veterans. A 2003 study determined that
a significantly smaller proportion of females had their PTSD
deemed to be service-connected as compared to males. And this
was primarily related to the lower rate of combat exposure
among females.
Subsequent research found that when MSA was substantiated
by a Veterans Benefits Administration, VBA, claim file,
service-connected PTSD determinations increased substantially.
Unfortunately, there are huge barriers to women being able
to independently substantiate their experiences of MSA
especially in the combat arena.
I just want to get to the several conclusions and
recommendations that were made with regard to women veterans.
The Committee concluded that the most effective strategy for
dealing with problems with self-reports of traumatic exposure
is to ensure that a comprehensive, consistent, and rigorous
process is used throughout the VA to verify veteran-reported
evidence. It, therefore, recommended that the VBA conduct more
detailed data gathering on the determinants of service
connection and ratings for MSA-related PTSD claims, including
the gender-specific coding of MSA traumas for analysis
purposes.
Since I am out of time, I will just refer you back to the
written materials that you have received, which indicate the
rest of the other recommendations.
[The prepared statement of Dr. Krupnick appears on p. 99.]
Mr. Hall. Thank you, Dr. Krupnick.
Because we have votes about to be called, I am going to
defer my questions and recognize Ms. Brown for some questions.
Ms. Brown of Florida. I am going to be very brief.
Mr. Williamson, in reading your testimony, you indicated
that one of the major problems is women's privacy that the VA
has not established in the facilities.
Given the financial situation and given the number of
males, what would be your recommendation? You heard my
questions earlier and you have seen the push-back that women
are giving to this issue. But, what would you recommend that we
recommend to the VA?
Mr. Williamson. I think, Ms. Brown, that, as I have said
before, I think that things such as privacy requirements are
fairly easy to accomplish, things like orienting exam tables in
the right direction away from the door are fairly easy.
So I think one of the solutions is to instill management
commitment at the local level that will make sure that these
get done, these kinds of things get done.
Part of it is attributed to facilities as well. I mean,
many of the VA facilities are older and----
Ms. Brown of Florida. That is right.
Mr. Williamson [continuing]. They are not set up for that,
but they are working in that direction. But I really think that
management commitment, that commitment exists at the top, I
think.
But I think as you get down into the facilities, you know,
if I were to do one thing, it would be try to instill that,
have oversight and accountability as part of it. I mean, you
need information to make sure people are doing what they are
supposed to. So that is the kind of thing I would do.
Ms. Brown of Florida. Well, you know, when I first got
elected in what, 1992, we had a facility in Orlando that was
older and I went in there and it was just like a zoo because
there were so many people. Well, we were able to get a new
hospital and we were able to set it up where women could have
their privacy. So I think part of it is that we have a lot of
old facilities that are overcrowded.
Mr. Williamson. Right. Exactly. And I think one of the
other things that is very important is get the people who
design the facilities and set up the specifications in tune
with Dr. Deyton's office and Dr. Hayes' office to really make
sure that communication exists and that we really have the
specifications for privacy and other things built into those
new facilities or facilities that get modified.
Ms. Brown of Florida. Thank you.
And another issue was the catcalls.
Mr. Williamson. You want me to----
Mr. Hall. You have a written response to that.
Ms. Brown of Florida. Yeah. I am going to yield back my
time.
Mr. Hall. Thank you, Ms. Brown.
Mr. Boozman?
Mr. Boozman. Thank you, Mr. Chairman.
In the interest of time with votes coming up, I really just
want to ask one question. Then we will have some others that we
would like to submit for the record.
Again, thank you for your testimony.
Mr. Williamson, your review has shown that the facilities
that you visited were in various stages of compliance in
implementing VA's comprehensive primary care initiative for
women and that the VA had not set a deadline for compliance
with the policy.
I guess what I would like to know, I think really what we
would all like to know is what a reasonable timeframe is for
which VA should require full compliance and then, you know,
kind of go from there. And then further, you know, do you think
that VA will be capable of meeting, you know, some sort of
timeframe?
Mr. Williamson. That is a very good question. I do not have
a total answer. I mean, that is a tough one.
About a third of the facilities now are what you would say
complying with that and two-thirds are not obviously. But it
involves a lot of different issues. It involves the facilities
themselves which I have talked a little bit about in terms of
having the facilities segregated and providing the exam rooms
that would, you know, be suitable for women.
But it is also having providers, a set of providers that
can provide comprehensive primary care and that does not exist
in many facilities right now. They have not had a chance to
develop a cadre of providers that they need to.
Other facilities have done quite well. So it is those kind
of things. But, you know, I think it may be a good question for
Dr. Deyton on the third panel to ask him that question because
I do not have a time table and I could not answer that
question.
Mr. Boozman. Okay. Well, I really think we need to get one.
And the other thing is I know myself, Mr. Hall, Ms. Brown,
you know, all of us are very willing to provide the resources.
We all agree, I think everybody in this room agrees that this
is something that just has to be done. But unless we do start
setting time tables and things like that, it will get done
eventually, but it will get done a lot longer than, you know,
if we have some reasonable goals. And, yet, we need to provide
the resources if you need some more.
Thank you.
Mr. Hall. Thank you, Dr. Boozman.
Mr. Williamson, based on your analysis of VA's provision of
health care services to women veterans, in your opinion, what
are the implications for women veterans in need of compensation
and pension exams and is VA properly equipped to conduct these
exams given the gender differences in disease onset and the
presentation of symptoms?
Mr. Williamson. Mr. Chairman, our work on this particular
body of this engagement did not consider the benefit side. And
so I really am not equipped to answer that question.
However, if you submit that for the record, we do have my
colleagues who do the disability side of those issues can
certainly address those questions.
Mr. Hall. I am a little bit concerned that women veterans
who are going outside the system and paying to get private
diagnosis and care and treatment may run into problems when
they come back to ask for compensation from the VBA, that is a
question, I guess, that our next panel can address also.
But moving on, Ms. Greenberger, are there unique assessment
instruments for women's health and quality of life that VA
could apply to its disability claims processing system?
Ms. Greenberger. Well, I do not know in terms of the claims
systems.
Mr. Hall. Would you please push your mic?
Ms. Greenberger. I am sorry. It is on.
What we address is there are two issues, a lot of issues,
but one, of course, is issues, conditions that affect women
exclusively, gynecological, reproductive. And obviously with
the right specialists, you know, OB/GYNs, that is pretty much
taken care of.
Our major concern is all these other conditions that affect
women veterans and also affect other women that we do not
really know how they should be treated differently. That is the
research that we are doing and that is why we think that the
VA, particularly because of your focus and other Committees'
focus and the time and what we are seeing now, that they are in
a unique position with the women's population, and all these VA
Centers to start looking at what these differences are. And
that information could be translated not only to the women
veterans but to women generally because we do not have this
kind of research yet and this is what we are trying to advance.
Mr. Hall. Thank you.
Dr. Krupnick, can you expound on the IOM report
recommendation that the VA provide a minimum level of benefit
without regard to a person's state of health at a particular
point in time after a C&P exam? Would a minimum benefit package
be advantageous in addressing evidentiary issues faced by women
veterans?
Dr. Krupnick. Well, I do not know that the Committee spoke
to that, but I can say that I think that a minimum package
would be advantageous.
I think one of the big problems with documentation of some
of the traumatic stressors for women is that, for example, in
the case of military sexual assault or even sexual harassment,
it is difficult to document because many of these events occur
in secret. It is not the same as being able to document having
been at a specific combat area.
So I think it would be wise to have a minimum package that
is available for anybody who is in a combat area.
Mr. Hall. The IOM noted the disparities in the rates of
service-connection between male and female veterans and
recommended further research.
What were the specific areas or conditions that it thought
were more in need of future study?
Dr. Krupnick. Let me see if I have that in the--felt that
more research was needed on the as yet unexplained gender
differences and vulnerability to PTSD, which could identify sex
specific approaches to prevention and treatment and on more
effective means for preventing military sexual assault and
sexual harassment.
I know that at the moment, there, at least in the
Washington, DC, VA, there is some attempt to move in the
direction of more gender-specific treatment and adapting some
treatments that were used for civilian sexual assault for women
who have experienced military sexual assault. And I am
personally starting a pilot study myself to do a gender-
specific treatment for women who have experienced trauma in the
military.
Mr. Hall. Last, when the IOM made its recommendation on
training and testing materials on military sexual assault-
related claims, did it review literature that it thought
pertinent, which could be incorporated into such a syllabus for
raters?
Dr. Krupnick. There was a whole report on PTSD diagnosis
and assessment, which was very specific about instruments and
methods that could be used for raters.
Mr. Hall. Doctor, one last question. If the VA was using a
standard electronic template to conduct C&P exams, might women
get a more complete exam that better associated their symptoms
with the criteria for certain conditions and MST outlined in
the rating schedule?
Dr. Krupnick. Well, I agree that the idea of electronic
records would be a great boon to things being done. I think
there is already in the system a very comprehensive method for
assessments for VBA ratings. Unfortunately, they are not always
used as comprehensively as the specifications provide.
So perhaps if there was an electronic template, that might
be advantageous in making sure that that happens.
Mr. Hall. Well, I thank you all on this panel for your
testimony. It has been extremely illuminating and helpful.
We have about 10 minutes remaining on this vote, so we will
ask our third panel to be patient. They are used to this, I am
afraid, by now.
But thank you, Mr. Williamson, Ms. Greenberger, and Dr.
Krupnick, for your participation and contribution to our
learning process and developing solutions to these problems for
women veterans.
The hearing will now recess until votes are completed.
[Recess.]
Mr. Hall. The hearing of the joint Health and Disability
Assistance and Memorial Affairs Subcommittees of the Veterans'
Affairs Committee will resume.
Thank you for your patience.
Members of our third panel, Bradley Mayes, Director of
Compensation and Pension Service of the Veterans Benefits
Administration, U.S. Department of Veterans Affairs;
accompanied by Dr. Patricia Hayes, Chief Consultant, Women
Veterans Health Strategic Health Group, Veterans Health
Administration; Lawrence Deyton, M.D., Chief of Public Health
and Environmental Hazards Office, Veterans Health
Administration; and Irene Trowell-Harris, RN, Ed.D., Director
of the Center for Women Veterans for the Office of the
Secretary, U.S. Department of Veterans Affairs.
I thank you for your patience and, again, for being here to
testify before the Subcommittee and for your work on behalf of
our Nation's veterans. Your full statement, as always, is
entered into the record.
Mr. Mayes, you are now recognized for 5 minutes.
STATEMENTS OF BRADLEY G. MAYES, DIRECTOR, COMPENSATION AND
PENSION SERVICE, VETERANS BENEFITS ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY PATRICIA M.
HAYES, PH.D., CHIEF CONSULTANT, WOMEN VETERANS HEALTH STRATEGIC
HEALTH GROUP, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS; IRENE TROWELL-HARRIS, RN, ED.D., DIRECTOR,
CENTER FOR WOMEN VETERANS, U.S. DEPARTMENT OF VETERANS AFFAIRS;
AND LAWRENCE DEYTON, M.D., MSPH, CHIEF PUBLIC HEALTH AND
ENVIRONMENTAL HAZARDS OFFICER, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF BRADLEY G. MAYES
Mr. Mayes. Thank you, Mr. Chairman, and thank you for
providing me the opportunity to speak today on the important
topic of assisting women veterans.
Although women have been associated with military
activities since the founding of our Nation, their role has
increased dramatically in recent years. The expanded role of
women in the military has also brought about increased
responsibilities and risk taking.
Women serving in Iraq and Afghanistan face combat activity
similar to their male counterparts as aircraft pilots, convoy
transportation specialists, military police officers, and
members of civilian pacification teams. Women have increasingly
been in harm's way and have incurred more service-related
physical and mental disabilities as a result.
America has approximately 1.8 million women veterans. They
make up approximately 7.7 percent of the total number of
veterans awarded service connection. The number of women
receiving VA compensation and pension increased from 203,000 in
2006 to over 250,000 in June of 2009. This represents a 23-
percent increase in less than 3 years.
So far this fiscal year, the number of women veterans
receiving benefits who served in the current overseas
contingency operations has increased by nearly 10,000. Although
women veterans represent 12 percent of those who served in
these operations, they represent 15 percent of those awarded
service connection for a disability.
VA has taken a number of steps to keep pace with women
veterans' changing role in the military and their increased
prevalence within the VA system. VA established the Advisory
Committee on Women Veterans in 1983 as a panel of experts on
issues and programs affecting women veterans. Since then, we
have worked to implement its recommendations for improving
services to women veterans.
A major issue of current concern for this Committee, as we
heard from the earlier panels as well, is the occurrence of
military sexual trauma among women on active duty and the
disabilities that may result.
The Committee has recommended that VA address this issue to
the greatest extent possible. The claims of women veterans who
seek disability compensation for post-traumatic stress disorder
based on military sexual trauma are specifically addressed in
VA's regulation at 38 CFR section 3.304(f)(4).
In 2002, VA amended its PTSD regulations to emphasize that
if a PTSD claim is based on an in-service personal assault
which includes military sexual trauma claims, evidence from
sources other than the veteran's military records may be used
to corroborate the in-service traumatic event. Such evidence
may include, but is not limited to, records from law
enforcement authorities, rape crisis centers, mental health
counseling centers, and hospitals, as well as statements from
family members, associates, or clergy.
Service medical and personnel records are also reviewed in
order to discover evidence of behavior changes that may support
the occurrence of the traumatic event.
In addition, prior to making a decision on the claim, VA
provides an appropriate medical or mental health professional
with the available evidence and asks for an opinion as to
whether the evidence is consistent with a military sexual
trauma incident.
These procedures take into account the sensitive nature of
military sexual trauma and the difficulty in obtaining
supporting evidence.
As a further means to implement recommendations of the
Advisory Committee on Women Veterans, the Veterans Benefits
Administration has engaged in outreach efforts. When active-
duty military personnel are separated from service or National
Guard and Reserve Members are demobilized, we provide
information to them under the Transition Assistance Program
(TAP) at their military base. This predischarge program
explains the array of benefits available from VA and assists
individuals with filing disability claims.
One mandatory section of the TAP briefing is a presentation
on military sexual and other personal traumas. This is intended
to alert separating servicemembers that VA is aware of the
military sexual trauma problem and inform them that counseling,
treatment, and disability compensation are available.
Outreach efforts are also conducted at the VA regional
offices on a continuing basis. Each office employs a women
veterans' coordinator who is well-versed in personal trauma
issues, including those of military sexual trauma, as well as
gender-specific disability issues, and who acts as a liaison
with the women veterans' program manager at the local VA health
care facility.
These coordinators also work with the regional office
homeless veterans' coordinators to address the problems of
homeless women veterans.
A nationwide VA women veteran coordinator training
conference is scheduled for later this year in August in St.
Paul, Minnesota. At the conference, VA will present updated
information and skill training to the coordinators and topics
will include outreach methods, clinical perspectives on
personal trauma, and women veterans' health issues.
In conclusion, VA has recognized the service provided to
our Nation by women veterans and the importance of providing
them with the assistance that they so much deserve.
VBA has moved forward along with VHA to address the issues
that are unique to women veterans. We have developed special
regulations for the adjudication of PTSD claims based on
military sexual trauma.
Regarding compensation for gender-specific disabilities, we
provide special monthly compensation for breast tissue loss and
monetary assistance for the children of women veterans who
develop birth defects.
We have also engaged in nationwide outreach to facilitate
women veterans' access to VA benefits. We realize that VA needs
to keep pace with the changing needs of women who have served
in the military and we are ready to take whatever steps are
necessary in the future to properly assist women veterans.
Thank you, Mr. Chairman, and I will be happy to answer
questions.
[The prepared statement of Mr. Mayes appears on p. 102.]
Mr. Hall. Thank you, Mr. Mayes.
Director Trowell-Harris, you are now recognized for 5
minutes.
STATEMENT OF IRENE TROWELL-HARRIS, RN, ED.D.
Dr. Trowell-Harris. Chairman Hall, Members of the
Subcommittees, I am pleased to testify today on behalf of the
Department of Veterans Affairs regarding women veterans'
issues.
Through recommendations made by the Secretary's Advisory
Committee on Women Veterans, collaborations between the Center
for Women Veterans and VA administrations and proactive
measures taken by the Veterans Health Administration, Veterans
Benefit Administration, and National Cemetery Administration
(NCA), VA continues to transform to meet the anticipated needs
of women veterans.
I greatly appreciate the Committee's diligence in bringing
forth discussion on this very important and timely issue.
The Center for Women Veterans was created by Public Law
103-446 in November 1994. As Director, I serve as the Chief
Advisor to the Secretary on all issues related to women
veterans and serve as a designated Federal officer to the
Secretary's Advisory Committee on Women Veterans.
The Center's mission is to ensure that women veterans have
access to VA benefits and services on par with male veterans,
that VA programs are responsive to the gender-specific needs of
women veterans, and that joint outreach is performed to improve
women veterans' awareness of VA services, benefits, and
eligibility criteria, and that women veterans are treated with
dignity and respect.
The Center accomplishes its mission by monitoring the
Department's programs and policies to ensure that they are
responsive to the needs of women veterans. This is done by
recommending policies and legislative proposals to the
Secretary and analyzing the impact of these proposals on women
veterans, by collaborating with VA's administrations to make
women veterans more knowledgeable about changes in VA policies,
by ensuring that the Advisory Committee on Women Veterans is
educated about VA to ensure clear, meaningful recommendations,
and by coordinating the development, distribution, and
processing of Committee reports and by coordinating an annual
Committee site visit to VA health care facilities, regional
offices, Vet Centers, national cemeteries, and other related
programs such as homeless and transitional housing.
Caring for our women veterans does not stop within the
confines of the Department. We conduct extensive outreach,
coordination, and collaboration with other agencies that is
Federal, State, and local as well as with veterans'
organizations and community-based organizations concerned with
women veterans' issues.
The Advisory Committee was established in 1983 pursuant to
Public Law 98-160. The Committee is charged with advising the
Secretary of benefits and health services for women veterans,
assessing the needs of women veterans, reviewing VA programs
and activities designed to meet those needs, and developing
recommendations addressing unmet needs.
The Advisory Committee is required to submit a biennial
report to the Secretary incorporating its findings and
recommendations. There are currently 13 Committee Members,
including two Operation Enduring Freedom and Operation Iraqi
Freedom veterans.
The Advisory Committee meets twice a year at VA's Central
Office (VACO) and receives briefings from VHA, VBA, NCA, and
staff offices. These briefings update the Advisory Committee on
the status of VA programs and the progress and recommendations
and respond to concerns raised during site visits.
The Advisory Committee uses information from the site
visits and briefings to formulate its recommendations to the
Secretary in biennial reports. To obtain information regarding
the delivery of health care and services for women veterans,
the Advisory Committee conducts site visits to VA facilities
throughout the country. During these visits, the Committee
tours the facilities and meets with senior officials to discuss
services and programs available to women veterans.
In addition, the Committee also hosts open forums at site
visits with the women veterans' community encouraging women
veterans to discuss issues and ask questions related to VA
benefits and services. Copies of the 25 most frequently asked
questions are distributed at the town hall meeting.
The Advisory Committee completed a site visit in June 2009
to the Veterans Affairs North Texas Healthcare System
facilities in Dallas and Bonham, Texas.
The purpose of site visits are to provide an opportunity
for Committee Members to compare the information they receive
from briefings provided by administrations with the activity in
the field. This effort is to ensure that policies established
in VACO are implemented in VA medical facilities and other
facilities that serve and impact women veterans which are
people-centric, results driven, and forward looking.
VA is grateful for the work of the Advisory Committee
because its activities and reports play a vital role in helping
the VA assess and address the needs of women veterans.
In the 2008 report, the Advisory Committee on Women
Veterans made 20 recommendations with supporting rationale,
including ten topical areas.
The Center collaborates frequently with veterans
administrations and staff offices to ensure that the Department
thoroughly addresses the Committee recommendations.
The 2008 report, including responses, was provided to House
and Senate Veterans' Affairs Committees on September 26, 2008.
Recommendations stem from data and information gathered in
briefings from VA officials, Department of Labor and Defense,
Members of the House and Senate Congressional Committee staff
offices, women veterans, researchers, veterans service
organizations (VSOs), internal VA reports, and site visits to
VHA, VBA, and NCA facilities.
The Committee is confident that the 20 recommendations and
supporting rationale reflect value-added ways for VA to
strategically and efficiently address many needs of women
veterans.
Anecdotally and in research, women veterans tell us they
want and need recognition and respect, employment, suitable
housing, access to and receipt of high-quality health care,
child care options, opportunities for social interaction, and
that they want to make a difference.
Every 4 years, VA sponsors a summit on women veterans'
issues. The fourth quadrennial summit was held on June 20-22,
2008, in Washington, DC. The purpose of the summit was to look
at the issues and recommendations from the 2004 summit, review
VA's progress on these issues, provide information on current
issues, and develop recommendations and a plan for continuously
addressing the progress on women veterans' issues.
More than 400 individuals attended, including women
veterans, women veterans' program managers and coordinators,
Congresswoman Susan Davis and Congressional staff from the
Senate and House Veterans' Affairs Committees, women veterans'
organizations, representatives from other collaborating
Federal, State, and local agencies, VSOs, and members of
active-duty military, Guard and Reserve.
The program consisted of 11 breakout sessions, plus VA
updates since 2004. For the first time, we held a town hall
meeting to discuss national issues affecting women veterans,
viewed the Public Broadcasting Service Lioness documentary.
Lioness looks at five women from an Army Engineering Battalion
in Iraq who were drawn into battle and the fallout from their
experiences, and had an open discussion with the directors and
soldiers featured in that film.
Based on feedback received from the summit participants,
the Center is posting updates on women veterans' issues on its
Web site. We change those quarterly.
Many of the recommendations made by the Advisory Committee
have been instrumental in transforming VA to assist in meeting
the needs of women veterans and to help bridge the gaps in
services and benefits.
To address the challenges of enhancing primary care for
women veterans, VA has done the following:
Elevated the Women Veterans Health Program Office on VA's
organizational chart to the Women Veterans Health Strategic
Health Care Group as part of VA's readiness for the influx of
new women veterans. This group provides programmatic and
strategic support to implement positive changes in the
provision of care for women veterans. Appointed a full-time
Women Veterans Program manager at every VA medical facility.
Initiated implementation of comprehensive primary care,
including gender-specific care, at every VA site. Ensured
accurate representation of women veterans' population through
analysis and data. Expanded the women's health knowledge base
among VA providers. Sought to recruit primary care physicians
who have knowledge and interest in women's health. Started to
integrate mental health with primary care to enable a
comprehensive women's health care program. Started to change
the overall culture of VA to become more inclusive of women
veterans, and recognize their military service and
contributions to the Nation.
In conducting collaborative outreach, the Center takes
every opportunity to collaborate with VSO, policy, women and
minority groups, other Federal and State agencies and community
organizations to outreach to women veterans.
This is done by providing keynote speeches at national
conventions and women veterans' forums, participating in
Congressional roundtable discussions on the needs of women
veterans, collaborating with VA administrations, staff offices,
and other advisory Committees, providing information to
minority women, including those who live on reservations,
through the Center for Minority Veterans, participating on the
homeless veterans' work group to ensure that the needs of women
veterans who are homeless with children are addressed, working
with the Congressional Caucus for Women's Issues to recognize
and honor our Nation's servicewomen and women veterans at an
annual wreath laying ceremony at the Women in Service for
America Memorial, and representing the Secretary at the monthly
White House Interagency Council meeting on women and girls,
addressing the needs of women veterans nationally in
collaboration with the Department of Defense.
This concludes my testimony. I will be pleased to answer
any questions. Thank you.
[The prepared statement of Dr. Irene Trowell-Harris appears
on p. 103.]
Mr. Hall. Thank you.
Dr. Deyton, you now are recognized.
STATEMENT OF LAWRENCE DEYTON, M.D.
Dr. Deyton. Good afternoon, Mr. Chairman. Thank you for the
opportunity to discuss how VA has provided and will continue to
improve health care available for women veterans.
As you know, Mr. Chairman, VA Secretary Shinseki has
testified that enhancing primary care for women veterans is one
of VA's top priorities.
VA has a long history of serving women who have served our
Nation and the documentation of continued improvements in VA's
service to these women and heroes is a fact of which all VA
employees and the Nation can be proud.
With the recognition of the significant increases in the
numbers and the new roles of women in service in recent years,
VA has redoubled our efforts to assess and improve the care and
services delivered to our women veterans.
These efforts were initiated by the creation of the Women
Veterans' Strategic Health Care Group into 2008. And as Dr.
Trowell-Harris has said, that was a recommendation of the
commission.
And since her appointment as its first chief last spring,
Dr. Patricia Hayes, sitting to my right, has led VA in an
intense and continuing effort to improve health care delivery
to women veterans.
With the support of VA leadership, this systemwide effort
has revitalized VA's women veterans' health programs and
expanded the focus beyond gender-specific care to comprehensive
care for our women veterans.
VA is currently in the midst of implementing an aggressive
and innovative program to deliver comprehensive women's health
care that specifically addresses concerns that we heard on the
first panel about fragmented care, quality disparities, and the
lack of provider proficiency in women's health.
Our goal is to fundamentally improve the experience of
women veterans when they come to their VA.
At its core, Dr. Hayes and her colleagues have designed a
system for VA care, which will ensure every woman veteran has
access to a VA primary care provider capable of meeting all her
health care needs.
Women veterans need to feel welcomed in their VA setting
and we well recognize that has not always been the case. As
part of redefining how comprehensive care will be delivered,
adjustments to the VA health care environment are being made to
assure all women veterans' dignity, privacy, and security.
Mr. Chairman, many new programs have been initiated, which
are indicative of the change in the culture of VA and how we
assure our women veterans receive the very best care they
deserve from a grateful Nation.
These programs include promulgation of VA-wide standards
for comprehensive women veterans' health and a requirement that
all VA facilities meet those standards, targeted enhancement of
mental health services for women veterans' needs, distribution
of over $32 million to purchase diagnostic equipment, including
mammography, scanners for assessment of osteoporosis, and other
health care equipment, requirement for every VA medical center
to employ a full-time Women Veterans Program Manager by
December 1st, 2008, creation of educational programs on women's
health for VA primary care providers, which has trained 216 VA
providers to date, creation of the first women veterans'
reproductive health program to address those crucial concerns,
particularly of our younger women veterans, supportive
multifaceted research on women veterans' health, and
improvement of communications and outreach to women veterans.
While significant efforts are underway, Mr. Chairman, for
both improved care and outreach, we recognize that more must be
done. We appreciate the GAO's preliminary findings on VA's
provision of health services to women veterans, which has
allowed us to identify additional opportunities to improve.
While some of the GAO preliminary findings represent
improvements which are in process, others represent a lapse in
our attention to the standards VA has set.
My colleagues and I are particularly distressed to learn
about the lapses which GAO documented in established VA
standards for privacy and dignity. Based on GAO's preliminary
report, the acting Under Secretary for Health has ordered an
immediate VA-wide review and assurance of compliance with
existing privacy, security, and dignity policies to be
completed by August 31st.
In addition, the acting Under Secretary for Health has
asked that review of privacy, security, and dignity measures be
set as a vision performance monitor for next fiscal year.
Mr. Chairman, VA's commitment to women veterans is
unwavering. We stand now at a unique moment in time where our
actions and plans today will build the system that will provide
equal care to all of America's veterans regardless of gender.
Thank you, Mr. Chairman, for holding this hearing. We
appreciate it and are happy to take your questions.
[The prepared statement of Dr. Deyton appears on p. 106.]
Mr. Hall. Thank you, Dr. Deyton.
Dr. Hayes, would you like to make a statement before we go
to questions.
Ms. Hayes. No. I appreciate the offer, sir, but I will wait
for questions.
Mr. Hall. Okay. Thank you.
Director Mayes, in your testimony, you noted that 250,000
women are receiving compensation and pension. Do you have a
further breakdown between the rates of pension and the rates of
compensation? In spite of that increase, the IOM noted that
women were less likely to be granted claims for PTSD. Do you
have any data on the number of women service-connected for
PTSD?
Mr. Mayes. Mr. Chairman, I do not have that data with me,
but that is one I would like to take for the record and we can
provide that following the hearing.
[The VA subsequently provided the following information:]
Seventeen thousand, seventy-five women veterans are service-
connected for PTSD. This includes 56 women veterans who are in
receipt of nonservice-connected pension but also are service
connected for PTSD.
Mr. Hall. That would be much appreciated. Thank you.
In 2006, VA opposed implementing a new diagnostic code for
military sexual trauma and, yet, in 2006 and in 2008 in
response to the recommendations contained in the Advisory
Committee on Women Veterans' reports, VA stated that it agreed
with the underlying rationale for tracking MST claims.
I understand that the VBA indicated that it checks its
system against the VHA system to identify any records that are
not properly matched as MST. However, it seems that VA can only
properly track these claims if they are labeled as such when
they are entered into the VA system.
So three-part question here. Would not an initial
diagnostic code for MST further increase the ability of the VBA
to track MST claims and would not labeling claims as MST as
early as possible help prevent claims from being labeled more
generically or not labeled at all? I will let you answer that
one first.
Mr. Mayes. Okay. Thank you, Mr. Chairman.
First of all, we agree we need to be able to collect data
regarding military sexual trauma claims. Let me take the issue
of a unique diagnostic code first.
Military sexual trauma is not a disability per se. Military
sexual trauma or personal assault can lead to disabling
conditions. What we are dealing with frequently is veterans,
both male and female, dealing with post-traumatic stress
disorder as a result of military sexual trauma or personal
assault which is a form of military sexual trauma.
So when we evaluate an individual for disability
compensation, what we are looking to do is to assign
compensation based on a disabling condition or disease. And so
in the case of these MST claims, it is frequently post-
traumatic stress disorder.
We do have the capability to identify decisions on post-
traumatic stress disorder claims that are related to military
sexual trauma. And, in fact, in fiscal year 2008, we assigned
service connection for post-traumatic stress disorder for
female veterans 2,465 times. So 2,465 female veterans were
granted service connection for PTSD due to military sexual
trauma.
I believe that the recommendation made by the Advisory
Committee is trying to get at other disabilities that could
result from military sexual trauma and we do not have those
tags, military sexual trauma tags associated with other
disabilities.
But since it is not necessarily a disability, we would not
have a diagnostic code for that.
Does that answer the question, sir?
Mr. Hall. Yes, it does. Thank you. Yes. Does the VBA
currently have a method for identifying and tracking MST claims
and how can it be improved to ensure that all women veterans'
claims for MST are identified and tracked?
Mr. Mayes. When we have a claim that is pending, if it is a
post-traumatic stress disorder claim, we do have a mechanism to
differentiate that claim from other types of claims. We have
what is called an end-product modifier. And in our system, we
can segregate out those PTSD claims.
I would like to take for the record the question regarding
military sexual trauma because I am not absolutely sure that we
can further segregate out MST-related PTSD claims. So I will
take that one for the record.
[The VA subsequently provided the following information:]
VA tracks claims for PTSD that are granted due to personal
trauma. VA defines personal trauma as events of human design
that threaten or inflict harm that have lingering physical,
emotional, or psychological symptoms. VA further classifies
``personal trauma'' cases into subcategories. The total number
of women veterans who are service-connected for PTSD under the
applicable subcategories:
------------------------------------------------------------------------
------------------------------------------------------------------------
Sexual Assault/Harassment 4,400
------------------------------------------------------------------------
Personal Assault 960
------------------------------------------------------------------------
Other Unknown--Trauma 372
------------------------------------------------------------------------
User made no selection 42
------------------------------------------------------------------------
Total Number of Female Veterans with service-connected PTSD 5,774*
due to
Personal Trauma
------------------------------------------------------------------------
* Entry of a designation of the source of PTSD is not a mandatory field
to successfully prosecute a claim. Therefore, the number may be higher
than the 5,774.
Mr. Hall. Okay. Thanks. You can get back to us on that.
What is the VBA doing to track disability claims by gender
specifically for MST and domestic violence? This might be
another one for the record. Can you provide a breakdown on the
conditions for which female veterans are granted or denied
service connection? And what percentage of disabled female
veterans take advantage of the insurance programs?
Mr. Mayes. Well, I will start with the insurance programs.
That one I will have to take for the record. I do not have
information on that.
[The VA subsequently provided the following information:]
Although VA does not have actual participant numbers for the
Servicemembers' Group Life Insurance (SGLI) program, VA can
estimate the number of active-duty women covered based on the
average participation rate of 99 percent. Currently there are
about 205,000 women on active duty, therefore, VA estimates
approximately 203,000 would have SGLI.
The participation rate for Members of the Guard and Reserve
is 94 percent. There are about 151,000 women in the Guard and
Reserves. VA estimates approximately 142,000 women in the
Reserves/Guard have SGLI. Participants in SGLI are
automatically covered by Traumatic SGLI.
Of the 431,792 veterans currently enrolled in Veterans' Group
Life Insurance (VGLI), 52,376 (12.13 percent) are women.
Approximately 188,000 covered by VGLI are service-connected. Of
that, 25,259 (13.43 percent) are women.
Veterans Mortgage Life Insurance (VMLI) participation rates--
Of the 174,500 veterans currently enrolled in Service Disabled
Veterans Insurance, approximately 9,200 (5.2 percent) are
women. Approximately 100 (4.3 percent) of the 2,300 VMLI
participants are women.
Mr. Mayes. But, again, I can give you a breakdown of male
and female veterans that have been granted or denied for post-
traumatic stress disorder due to military sexual trauma.
Now, I have the number granted. I do not have the numbers
denied with me today, but I can get those. It would require a
query into our database.
[The VA subsequently provided the following information:]
Twenty-two thousand, two hundred eighty-three women veterans
have been denied service connection for PTSD.
Mr. Hall. Okay. Thank you.
What are the most prevalent conditions for which women file
claims? Does this match the prevalence for treatment of those
conditions and has VBA obtained the list of women treated for
MST that it committed to get from VHA?
Mr. Mayes. I will answer the first question. The types of
claims that female veterans are submitting does in general, I
would say, mirror the claims submitted for male veterans. By
far and away, the most frequent claimed disabilities are
orthopedic disabilities or musculoskeletal conditions. And that
sounds reasonable to me given the fact that these
servicemembers, whether they are men or women, are carrying a
lot of weight on their person with the body armor and the rucks
that they are carrying.
So hearing loss is another frequently claimed disability.
PTSD is also in the top ten. So we have that information. I do
not have all of those disabilities at hand right now, but those
would be the types of disabilities that veterans would be
claiming, whether they were men or women.
Mr. Hall. In response to a recommendation in the Women
Advisory Committee's 2006 report, VA used gender and diagnostic
codes in a VA Office of Policy, Planning, and Preparedness and
Institute for Defense Analyses (IDA) joint study on State-by-
State VA regional office (VARO) variation, variation in
disability claims ratings and benefits to find any significant
correlations.
Can you tell us the results of this study, if it has been
completed, and how the data has been used?
Mr. Mayes. Could you repeat that study? I am not sure I am
familiar with----
Mr. Hall. Sure.
Mr. Mayes [continuing]. What you are referring to, Mr.
Chairman.
Mr. Hall. It is a study by the VA Office of Policy,
Planning, and Preparedness and the Institute for Defense
Analyses, joint study in response to a recommendation by the
Women's Advisory Committee's 2006 report, a study on State-by-
State VARO variation in disability claims ratings and benefits
to find any significant correlations.
We just want to know if the study has been done, if you
have seen it, what the results are, if they are in, when will
the study be completed. If it is not completed, we request a
status report.
Mr. Mayes. I am aware that the Institute for Defense
Analyses did a variance study following the Office of Inspector
General's (OIG's) review of post-traumatic stress disorder and
individual unemployability claims. I believe that was in 2005.
And we actually contracted with the Institute following the
OIG's findings and looked at the variance across regional
offices.
I am not aware that that was gender specific. So if that is
the study that you are referencing, what they found was that
the variance across jurisdictions was--they were looking at the
average annual benefit payment. And because there were some
States that had more veterans that were either 100 percent or
in receipt of a total evaluation due to individual
unemployability, those States, because of the difference
between the 90 percent and the 100 percent rate, it is
significant, those States were skewed higher.
And so, what the IDA found was that those States where you
had a higher proportion of veterans in receipt of benefits,
whether male or female, as I recall, those States that had a
higher percentage of veterans either service-connected for PTSD
or in receipt of benefits due to individual unemployability,
they were more likely to have a higher average annual payout.
So that was a driver of some of the variance that was observed
by both the OIG and the Institute for Defense Analyses.
And then they went on to talk about other variables such
as, as I recall, whether or not you were enlisted or officer,
whether you were represented or not. For example, there was
some significance, statistical significance associated with
being represented by a veterans service organization as opposed
to not being represented.
So if that is the study you are referencing, those are some
of the findings that IDA found following the OIG review.
Mr. Hall. Thank you, Mr. Mayes.
I have one more thing if you could respond to us for the
record. By correspondence, the Advisory Committee on Women
Veterans recommended also in 2006 that VA should expand its Web
site to include a secure site where veterans can check the
status of their claims. VA concurred in this recommendation
indicating that the one VA registration and eligibility and
contact management program has been under development since
2005.
So if you could get back to us on the status of that
program and how successfully you think it has been implemented.
[The VA subsequently provided the following information:]
VBA is actively participating and leveraging the work being
accomplished within the Benefits Executive Council for the
eBenefits portal. This provides an opportunity to leverage
capabilities that are being implemented to meet the needs of
both VA and DoD that will ultimately enhance our Web presence.
The eBenefits portal was directed in July 2007, as a result of
the President's Commission on the Care for America's Returning
Wounded Warriors, to provide a single information source for
servicemembers/veterans. Through the continual evolvement of
the eBenefits portal, users can find tailored benefit
information and services in one place, rather than scattered
across multiple Web sites.
The eBenefits portal has been developed as a secure
servicemember/veteran-centric Web site focused on the health,
benefits, and support needs of servicemembers, Veterans, and
their family members. The portal consists of both a public Web
site and a secure portal that allows an authenticated user
personalization and customized benefit information based upon
the user's profile. VBA is able to take advantage of this
design to allow our users to find the information and services
they need, when they need them. There are currently several
major milestones that are scheduled for the March 2010,
eBenefits release that will be instrumental in providing self-
service capabilities (such as checking claim status,
automatically requesting a certificate of eligibility for the
home loan program, and electronic submission of an application
for the Specially Adapted Housing Grant.
Mr. Hall. I wanted to ask since this is officially a Health
Subcommittee meeting as well, although we do not have Members
of that Subcommittee here due to double and triple booking of
Committee meetings, but on their behalf, I would like to ask
Dr. Deyton and Dr. Hayes what does VHA do to ensure that female
veterans are getting competent and qualified C&P examiners?
Does the mini-residency training program that you mentioned
address the issues of conducting C&P exams?
Dr. Deyton. Let me take a bigger picture first. The issue
of competency is huge for the VA system. We all know it has
been a predominantly male health care system for a long time.
I am a VA clinician myself. I have a clinic every Friday.
And I am one of those clinicians who need the mini residency
competency for seeing female veterans.
The program that Dr. Hayes and her colleagues in the
Employee Education System has put together is a very intense
mini residency to bring a primary care provider like myself up
to speed on women veterans' health issues. I think 216
clinicians have gone through that now.
I do not know whether C&P clinicians have gone through that
or not. Do you?
Ms. Hayes. Not to date. And we have trained primarily
community-based outpatient clinic providers and 90 medical
center providers right now. That particular mini residency is
for basic primary care skills. So that would not necessarily
direct specifically to some of the questions that might be
raised in a C&P exam.
Dr. Deyton. But I think your point is a very good one and
it is something that frankly we can go back and begin to work
with our colleagues both who run the C&P program itself as well
as our colleagues in the Employee Education System because
there may be a focused set of educational materials that we
will want to develop specifically targeted to C&P.
And so thank you very much for the question and we will
take that and go back with it.
[The VA subsequently provided the following information:]
The Compensation and Pension Examination Program (CPEP)
provides training on gender and certain specific examination
types. CPEP training does not specifically provide training on
women's health issues (other than as appropriate to the
specific examination or disability type). However, the Veterans
Health Administration (VHA) does have a primary care training
program for VHA providers that addresses gender-based issues
and Compensation and Pension (C&P) practitioners are eligible
for this training program.
The current Women's Health Mini Residency Training is
designed for primary care providers who need to enhance or
refresh their skills in providing gender specific care,
performing cervical cancer screenings and breast evaluations
while also expanding their knowledge of contraceptive
counseling and treatment, osteoporosis management and
treatment, and menopause counseling and treatment. Most female-
specific issues that are presented during C&P examinations are
referred to the Women's Health providers at the facility
because these practitioners are experienced in providing these
women's health examinations.
Mr. Hall. Thank you.
What do you do when a female veteran has requested a female
examiner and none are currently available on staff at a medical
center?
Ms. Hayes. If you are speaking about the C&P exams, the
female veteran has a distinct right and may request a female
examiner. The policy right now would be that the VA would
either arrange for an alternate site or work with her in terms
of when they could arrange that exam.
But I will get back to you if there is any specific
question about those not being provided. I am not aware of
those not being provided.
Mr. Hall. I guess this probably varies from facility to
facility, region to region, but what are we talking about in
terms of scheduling delays ordinarily?
Ms. Hayes. That one I am actually not prepared. What really
I think the focus is the patient has the right to request a
same gender provider, a female provider in the case of women.
And we honor that in terms of our policy.
So I do not know of any delays caused by it, but we are
really focusing on the issue that the patient has that right
and we want to respect that.
Mr. Hall. Right. I understand that. But are we talking
hours, days? Assuming there is nobody currently at the
facility, a female examiner available at that time----
Ms. Hayes. I think, sir, it would be totally dependent on
what type of exam it was----
Mr. Hall. Uh-huh.
Ms. Hayes [continuing]. And how specialized the provider
would need to be.
Mr. Hall. Yes.
Ms. Hayes. And so I do not know that I can answer that
specifically.
[The VA subsequently provided the following information:]
The VHA national average for C&P examinations is 29 days. C&P
examinations for females asking to be seen by a female provider
only are scheduled in as timely a manner as possible to
accommodate the veteran's request.
Mr. Hall. Okay. At what forum does VA regularly address
women's issues jointly with the DoD? During the Joint Executive
Council?
Ms. Hayes. I think you and Dr. Trowell-Harris.
Dr. Deyton. Why don't you start with that?
Dr. Trowell-Harris. At the Advisory Committee on Women
Veterans, we have the DACWITS Director. It is the Defense
Advisory Committee on Women in the Services. She is on the
Advisory Committee on Women Veterans as an ex officio.
I attend DACWITS meetings as an ex officio for VA. We do
have staff members also attending the Secretary's Benefits
Executive Council, and the Health Executive Council. And when
they address women veterans' issues, they make sure that those
are all included.
We also have on our Committee representatives from the U.S.
Departments of Labor, Health and Human Services, and other
agencies also currently working with DoD in conjunction with
the White House Interagency Council on Women and Girls that is
looking at women veterans' issues, but we constantly coordinate
with DoD on various issues and they do call on us frequently
when they have their meetings to help them set up the agenda.
I have presented at the DACWITS Committee several times.
Dr. Hayes was there recently and other va staff members with
expertise on women veterans' issues do present there. So we
constantly are in contact with them and they are in contact
with us addressing mutual interest items on servicemembers' and
women veterans' issues.
Dr. Deyton. Let me add to that, sir. As part of the Health
Executive Council, there are multiple Subcommittees and work
groups, joint VA/DoD Committees, one called Deployment Health
of which I am the VA Co-Chair. I know Dr. Hayes has talked to
that group. And there are issues related to deployment health
and the women veterans who are deployed, women servicemembers
who are deployed. Topics have come up there. I think there is
also a sexual assault----
Ms. Hayes. I am the VA representative to the Sexual Assault
Advisory Committee of the Department of Defense and also attend
the meetings for the Sexual Assault Prevention and Response
Office. So we collaborate in terms of these issues of
transition of servicemembers who have experienced sexual
assault. Particularly that is my area of representation and
policy on that Committee.
Mr. Hall. The IOM suggested a prevalence of domestic
violence among male veterans and the data shows that over 50
percent of female veterans marry other servicemembers and that
they may experience domestic violence, but the VA has a limited
number of batterer intervention programs throughout its entire
system.
What is VA doing to expand the Batterer Intervention
Programs and does it have a strategic plan to address domestic
violence?
Dr. Deyton. I do not know. We are happy to get----
Mr. Hall. Well, honest answers are good.
Dr. Deyton. That is right. We will get back to you on that.
[The VA subsequently provided the following information:]
VA recognizes the importance of addressing this issue and is
taking action to focus on issues for perpetrators or victims of
domestic violence. The following information describes
specifically what mental health services VA provides for
victims of domestic violence as well as for those at risk of
becoming abusive.
With regard to providing care for victims of domestic
violence, VA has several programs:
1. VHA sponsors trainings and ongoing consultations to
implement ``Seeking Safety,'' a present-focused therapy
originally designed for clients with trauma histories who are
simultaneously experiencing symptoms of post-traumatic stress
disorder (PTSD) and substance use disorders. Maintaining
overall safety is the goal of this therapy, but it also helps
clients attain safety in their relationships, as well as with
their thinking, behavior, and emotions. ``Seeking Safety''
includes 25 treatment topics including Setting Boundaries in
Relationships, Healthy Relationships, Taking Good Care of
Yourself, and Red and Green Flags. Given the significant focus
on maintaining safe and healthy interpersonal relationships,
``Seeking Safety'' has great relevance for the treatment of
women and men who have experienced interpersonal violence.
``Seeking Safety'' also has been empirically tested among
homeless women veterans (Desai et al., 2008) and is widely used
among VA's Mental Health Residential Rehabilitation Treatment
Programs.
2. VA has developed a Continuing Medical Education Program
on Military Sexual Trauma. This independent study module
contains both a chapter on Risk for Revictimization and one on
Intimate Partner Violence.
3. VHA's Employee Education System (EES) is in the final
stage of reviewing an online training module on Family
Relationship Issues, to be used by clinicians serving currently
returning veterans. There is also an EES Satellite Broadcast on
Domestic Violence scheduled for FY 2010.
4. Across the VA system there are examples of trainings and
emerging best practices related to domestic violence. For
example, the Bedford VA Medical Center (VAMC) held a daylong
conference for mental health providers on working with both
perpetrators and survivors of domestic violence. Also at
Bedford a psychologist has been working within the integrated
primary care service to screen women veterans coming to their
women's health clinic to determine if they have experienced
domestic violence and to coordinate both crisis and long-term
care plans for those who screen positive as current victims of
domestic violence or who are looking for treatment for
emotional consequences of domestic violence that may have
occurred in the past. They recently received a $25,000 grant
from the Women Veterans Health Strategic Health Care Group to
continue this screening and to provide education and training
for all primary care providers on the overall health effects of
domestic violence on veterans and the importance of primary
care screening.
For veterans with anger management problems who are, or are
at risk of becoming, physically abusive to family members, VA
also offers several programs:
1. PTSD programs in VA offer anger management services as a
component of care, given the prominence of irritability and
anger-related aggression as a potential feature of the PTSD
syndrome.
2. EES is in the final stages of revising an online training
module on anger management for clinicians assisting currently
returning veterans.
3. Eight VAMCs offer Intimate Partner Violence (IPV)
programs directed at the abusing partner. These programs employ
a variety of models, including the Duluth IPV model and
Cognitive Processing Therapy. For example, at the Boston VAMC,
a psychologist is conducting research on preventive couples'
groups for Operation Enduring Freedom and Operation Iraqi
Freedom veterans and their significant others. This individual
also runs a group for veterans who are currently involved in
violent relationships. The Cincinnati VAMCs IPV program has
been certified since 2004 for use with the prison reentry
population by the Ohio Department of Corrections.
4. The Veterans Integrated Systems Network 2 has provided
training during Fiscal Year 2009 on addressing domestic
violence with an emphasis on detecting suicidality in violent
partners. The training was provided by two experts in the
field: Dr. Susan Horwitz and Dr. Kate Cerulli, University of
Rochester Department of Psychiatry. The 6 hour training was
entitled ``Partner Violence and Military Veteran's
Relationships: Recognition and Response'', was provided to
clinicians in--Albany, Syracuse, Canandaigua, Buffalo, and Bath
VA Medical Centers.
Mr. Hall. Thank you.
African American women are joining the military at a
greater rate than any other cohort. What is the VA doing about
outreach to this population and addressing their specific needs
when they submit applications for assistance?
Dr. Deyton. Sir, I know that we have a very proactive
Center for Minority Veterans Affairs and I know that the
Director of that would love to be sitting here and answer the
question in much more detail than I can. But I know that they
have multiple programs and services and outreach to minority
veterans.
Irene, do you have any specifics about----
Dr. Trowell-Harris. We work very closely with the Center
for Minority Veterans looking at issues related to African
Americans and others, and especially looking at issues related
to Native American women on reservations, but we do work very
closely with them on--with their recommendations on that.
[The VA subsequently provided the following information:]
The Center for Women Veterans and Center for Minority
Veterans address the needs of women veterans for VA as an
integrated outreach program. This is done by extensive
collaboration, outreach and participation in joint initiatives
and workgroups on women veterans issues including African
American women veterans.
Department of Defense--work in collaboration with
the DoD Advisory Committee on Women in the Services (DACOWITS)
VA administrations and staff offices
Other Federal agencies such as DOL, HHS, HUD
State agencies
State women veterans coordinators
Faith-based and Community Initiatives
Policy and legislative groups
Veterans Service Organizations
County and private agencies
Women and minority groups such as NAACP, LULAC,
National Association of Black Veterans
There were no recommendations in the 2008 Advisory Committee
on Women Veterans (ACWV) report to Congress specifically
addressing the needs of African American women veterans. Based
on ACWV discussion with the National Cemetery Administration,
an outreach Web site was established specifically targeting
women and minority veterans (www.cem.va.gov). The Center for
Minority Veterans does have designated staff members assigned
to monitor and address the needs of various minority groups
including African American women and men veterans.
Mr. Hall. Dr. Trowell-Harris, you also stated that progress
was being made on a number of women veterans' issues, but none
of those areas were related to benefits, if I remember
correctly.
What has the Center done or what is it doing to improve
awareness and access to VA compensation and pension for women
veterans?
Dr. Trowell-Harris. When we have a recommendation on that,
the ones that have already been addressed regarding the
military sexual trauma, we make those recommendations to the
VA. And the way we get those issues is, again, from working
with veterans nationally, with Congressional staff, and with VA
administrations. So any benefits issue that comes to us, we
make that as part of the recommendation.
And we did have several in the 2008 report to the Secretary
and the Congress. Any new issues coming up now will be dealt
with in the 2010 report which we are crafting now based on site
visits, information from various sources to look at the new
recommendations for the Secretary.
Mr. Mayes. Mr. Chairman, if I might add to that, one of the
things that the Committee recommended was that in our outreach
material we make reference to women in the military, women in
uniform. And we are working right now on a tri-fold pamphlet
similar to what we put together for the predischarge Benefits
Delivery at Discharge Program and the Quick Start Program.
So we have a draft of that pamphlet that will outline
specific benefits that are available to female women veterans.
And also, as I mentioned in my testimony, we target women
veterans and in particular, we talk about military sexual
trauma in our TAP briefings. So we are trying to raise
awareness in those TAP briefings.
Last year, we did 108 stand-downs. Again, we are out there
in the community and it is all veterans, but there are some
unique things that we are doing for female veterans as well.
Mr. Hall. In a study conducted by Dr. Maureen Murdoch, she
found that 71 percent of male veterans had their claims for
PTSD granted while only 52 percent of females were granted
their claims.
Furthermore, the IOM concluded that there are huge barriers
to women being able to independently substantiate their
experiences of MSA, especially in a combat arena, as we heard
from our earlier panel, which results, of course, in less
service-connection awards for PTSD.
What has the Center for Women Veterans done? What can the
VBA do to address these claims and the disparity issues
identified by Dr. Murdoch and the IOM?
Dr. Trowell-Harris. You can address that one.
Mr. Mayes. Well, I can take that. There are a number of
things that we have done and there are some things that we are
doing.
The first thing we did is we reduced the evidentiary burden
through rule making for female--well, any veteran, not just
female veterans, any veteran filing a claim for post-traumatic
stress disorder due to military sexual trauma. That was the
regulation that I referenced in my testimony.
So we understand that there may not be records for a
variety of reasons, such as people do not want to go to their
supervisors and talk about this. We understand that. In some
cases, there can be a stigma attached. There is the assertion
that commands do not deal with this well.
So we understand that there is difficulty in sometimes
securing those records. So we reduced the evidentiary burden
such that we look for markers. And I believe I mentioned some
of those in my testimony and I will just reference back to
that.
It could be things like evidence from law enforcement
authorities or rape crisis centers, mental health counseling
centers. There could be a degradation in a servicemember's
performance, absenteeism. There are many things that we are
looking for and we will accept those, that evidence, those
markers as evidence.
And then what we will do before we decide that claim is we
will collect that evidence and present that evidence to the
examining clinician and ask for their opinion. Does this
evidence suggest that, in fact, there was a military sexual
trauma incident that warrants service connection?
But there is no question that these claims can be difficult
to prove.
Mr. Hall. No doubt. The fog of war enveloping all and then,
of course, if an incident happens, it involves two people, and
when there are no other witnesses this can be very difficult.
But those are some ways to approach it by analyzing the
results.
I wanted to ask about the media advertising and outreach
that VA is doing to promote the awareness of benefits provided
under laws that Congress has passed either by VSOs advertising
or VA in concert with them or VA by itself. There is
advertising done for personnel recruitment and for loan
guarantee activities.
Has the Center for Women Veterans done anything so far to
recommend or advocate for VA to improve its outreach to women
or advertising to women about the benefits and services that
are available for their specific problems or is this something
you are already working on? Is this something that we could
encourage you to work on?
Dr. Trowell-Harris. Yes. In our 2008 report, we recommended
that in all publications to the media, et cetera, that they
include and portray women veterans because originally and
initially when you look at VA pamphlets, you do not see the
face of a female veteran on there. And many times you do not
see the face of a minority women veteran on there.
So that was one of our recommendations. And there have been
several pamphlets produced within the past 8 months since our
report that accurately reflect in the media, that, you know, of
all the women veterans.
As a good example of that, too, we ask NCA to do outreach
particularly targeting women and minorities. And they have a
pamphlet out, but they also have a wonderful Web site, which is
really very nice, which really targets women veterans,
including women of color.
And we are constantly monitoring when we see pamphlets or
we see posters or magazines out there to make sure that they
are really diverse. And, again, once in a while, we do come
across something that is not diverse and we let the division
know about that, whether it be VHA, VBA, NCA, or other offices.
So thank you.
Mr. Hall. Thank you.
I wish we had somebody from DoD here that I could ask this
question to as well, but I would ask you to, if you can, get
back to us with any observations that you may have on this
question.
In the last year or so since the economic downturn started
in this country, there has been no problem in recruiting for
our Armed Forces. They have all met their recruitment goals as
other employment became harder to find.
But for a couple years before that, with the War in Iraq
producing heavy casualties and the economy doing better, there
were well-publicized and published reports about an increase in
morals waivers by the Armed Services in terms of recruiting.
Reports stating that they were accepting people into the Armed
Services who previously would not meet their standards under
their ordinary rules.
I do not know if there is a way of correlating the
timeframe when that was happening, the numbers of people, the
recruits who were brought under morals waivers, and see if
there is any correlation between that timeframe and any change
in the incidence of military sexual trauma.
But I for one would be interested in knowing if there is.
And, Dr. Deyton, you seem to----
Dr. Deyton. Actually, I do not have data, but I would like
to tell you, Mr. Chairman, that some of the surveillance and
epidemiology of the whole population that my office does may
pick up some data as the surveillance data matures.
We are the Office of Public Health and Environmental
Hazards and we do long-term surveillance of the populations of
veterans from the various conflicts and the various eras of
service. We can determine the kinds of utilization and
diagnostics that these veterans when they come to VA, what
services they use, what their diagnoses are, not individuals,
but as a whole group of veterans.
And so the hypothesis, sir, we could put to a test of
taking eras of service or years within eras and ask certain
questions about diagnoses or we would work with our DoD,
frankly, if there are reports in military service records or
law enforcement records about certain events or behaviors.
So it is a testable hypothesis and I am trying to tell you
we do have some resources that we could use to begin to try and
address that kind of question. So just information. I do not
have the answer though.
Mr. Hall. Well, I did not expect that you would, but that
is a good start. I think obviously it is important for the
future of our military, for the future of our male and female,
but especially our female servicemembers' safety and health.
I represent West Point. I am on the Board of Visitors at
West Point. We have had there among cadets who are not yet
deployed but are going through the rigors of training,
extremely high academic achievement standards, parental
pressure, and peer pressure and at the same time that they are
probably at the peak hormonal output a human being might be at,
which has some bearing on incidents of sexual harassment and
incidents that the Academy is dealing with.
All of the Academies have had this problem and they are
dealing with it as are the Services in trying to communicate
that we are on a team, the cadets and soldiers are brothers and
sisters who should be defending each other and sticking up for
each other, and what once was essentially a male fighting force
is now a co-ed fighting force and becoming more female all the
time. Regardless of what is classified as combat, they are
serving side-by-side as several of our panelists have pointed
out.
So, this is extremely important. I commend you for the work
that you have done. I know that you want this problem addressed
and solved as quickly as possible.
I am looking forward to the August 30th deadline that the
Secretary asked to be met. Also, I hope that we will not have
more hearings where we hear about facilities that are not set
up for the privacy that is needed for women to have
examinations or meetings or discussions that they need to have
about problems relating to these issues.
It is a process that will take us some time, but we are
serious about it. We, on this side of the table, are serious
about it. I know you are as well.
I thank you for your work for our veterans and I thank
those veterans and advocates who testified in the earlier
panels. I look forward to your written responses.
The Health Subcommittee Chairman, Congressman Michaud's
opening statement is accepted in the record. All Members will
have 5 days to revise and extend their remarks.
Thank you again for your patience. This hearing is
adjourned.
[Whereupon, at 2:15 p.m., the Subcommittees were
adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. John J. Hall, Chairman,
Subcommittee on Disability Assistance and Memorial Affairs
Good Morning Ladies and Gentleman:
I am grateful for the opportunity to be here today for a joint
hearing with my colleagues, Health Subcommittee Chairman Michaud, and
our Ranking Members, Mr. Lamborn and Mr. Brown. But, I am particularly
eager to recognize the women veterans who are in this room today and to
be enlightened by their experiences with the Department of Veterans
Affairs. VA owes them the proper benefits and care--just like their
male counterparts. However, they are a unique population, since they
comprise only 1.8 million of the 23.4 million veterans nationwide, and
deserve specialized attention. So, VA's mission to care for them must
not only be achieved, but monitored, and supported as well.
Sadly, that is not always the case. In response to reports of
disparities, during the 110th Congress the Disability Assistance and
Memorial Affairs and Health Subcommittees held a joint hearing on women
and minority veterans. This Congress too has been very active in its
oversight activities to assist women veterans and a record number of
them have testified at various hearings. Additionally, on May 20th,
Chairman Filner hosted a special Roundtable discussion with women
veterans from all eras who were able to paint a picture of military
life as a female in uniform and then as a disabled veteran entering the
VA system. In many cases, they have served alongside their male
counterparts, but have not had the same recognition or treatment.
Chairman Filner also hosted a viewing and discussion session with the
Team Lioness Members who were on search operations and engaged in
firefights, but since there is no citation or medal for this combat
service, their claims are not always recognized by VA as valid, so they
are denied compensation.
The Disability Assistance and Memorial Affairs Subcommittee has all
too often received reports about destroyed, lost, and unassociated
records that either never make it from the Department of Defense to VA
or VA loses once in their possession. Therefore, it is no surprise that
women veterans are at a greater disadvantage since their military
assignments and records are less likely to reflect their actual
service, exposure to combat or other traumatic events. Also, women who
have suffered the harm of military sexual trauma often do not report
those crimes and have limited documentation that can be used as
evidence when they seek VA assistance, often resulting in a denial of
benefits.
Even when they do report incidences of harassment or assault,
perpetrator conviction rates are only 5 percent, so these reports are
seen as unsubstantiated. This result is especially unfair given that 78
percent of female servicemembers reported some form of sexual
harassment according to a DoD survey. Studies have shown that for
generations women veterans have been less likely than men to be granted
service connection for their post-traumatic stress disorder, even
though data shows women are more likely to report symptoms and seek
treatment.
Also, I fear that when the 5 years of open enrollment afforded to
current conflict veterans ends, then these women will be denied
treatment as they will no longer qualify for health care since they are
not service connected. Without service connection, they are not
eligible for other VA assistance, such as vocational rehabilitation and
employment services or housing, so problems don't get better, they get
worse.
Congress cannot allow that to happen to this Nation's daughters who
have served her. VA needs to ensure that their claims for disability
benefits are fairly and judiciously heard. Women veterans should be
able to request female compensation and pension service officers,
adjudicators, and examiners, if they so desire. These employees should
be properly trained to be sensitive to the injuries and illnesses women
veterans claim and to treat them with the dignity and respect that they
deserve. VA should collect gender-specific data and conduct research on
the disabilities that specifically afflict female veterans. VA outreach
efforts should target women of all ages, ethnicities, and communities.
They must know that they are indeed veterans and deserve the same
benefits, services and burial rights as their brothers in arms have
come to expect.
The future of the military will be more reliant on the selfless
service and the sacrifices of this Nation's daughters, her mothers, and
her sisters. Coming home must be free of abuse, disparity, and
inequality so that transitioning female servicemembers can continue to
be productive employees and community leaders while maintaining healthy
lifestyles and raising families.
I look forward to hearing from the esteemed panels of witnesses
assembled today as we attempt to eliminate any gaps hindering access to
benefits and care for our women veterans.
Thank you. I now yield to Ranking Member Lamborn for his opening
statement.
Prepared Statement of Hon. Doug Lamborn, Ranking Republican Member,
Subcommittee on Disability Assistance and Memorial Affairs
Thank you Mr. Chairman,
I welcome our witnesses to this hearing to discuss Challenges
Facing Women Veterans.
I appreciate your contributions to this discussion and hope they
will lead to improvements we can all agree on.
Without question, America's women are, and always have been, an
integral part of our Nation's defense.
In more than two centuries of service to our country, women
servicemembers have formed a glorious legacy.
That legacy has only been enriched by the intrepid and resolute
accomplishments of today's women in the global war on terror.
Women make up nearly 10 percent of our Nation's 24 million living
veterans, and those serving on active duty represent more than 15
percent of our armed forces.
Our challenge is to ensure that women veterans--and indeed all
veterans--receive world class health care and benefits for their
service to our Nation.
The VA centers for women and the Department's associated advisory
committees are charged with increasing awareness of VA programs,
identifying barriers and inadequacies in VA programs, and influencing
improvement.
We do not look to these VA programs to merely identify and report.
We seek their input to affect policy and to help bring about the
intended results.
In that regard, I look forward to hearing about the challenges
facing women, such as gender-specific health care, PTSD, and Military
Sexual Trauma.
I thank the witnesses for their testimony and I yield back.
Prepared Statement of Joy J. Ilem,
Deputy National Legislative Director, Disabled American Veterans
Messrs. Chairmen and Members of the Subcommittees:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this joint oversight hearing focused on eliminating the gaps
and examining women veterans' issues. This hearing is extremely timely
given the changing roles of women serving in our armed forces today,
the 1.7 million women veterans who served previously, and the
dramatically growing number of women seeking health care and other
benefits from the Department of Veterans Affairs (VA).
NEED FOR GUARANTEEING EQUAL ACCESS TO SERVICES
Ensuring equal access to benefits and high quality health care
services for women veterans is a top priority for DAV. We have a
longstanding resolution from our membership of 1.2 million wartime
disabled veterans that seeks to ensure VA health care services for
women veterans, including gender-specific care, are provided to the
same degree and extent that services are provided to male veterans.
Also, given the undoubted greater exposure of servicewomen to combat,
we believe they should have equal access to supportive counseling and
psychological services incident to combat exposure. Military sexual
trauma (MST), while not exclusively a women's issue, is also of special
concern to DAV. Additionally, we urge VA to strictly adhere to its
stated policies regarding privacy and safety issues related to the
treatment of women veterans and to proactively conduct research and
health studies as appropriate, periodically review its women's health
programs, and seek innovative methods to address women's barriers to VA
health care and services, thereby better ensuring women veterans
receive the treatment and specialized services they rightly earned
through military service.
Likewise, for many years, the organizations that make up the
Independent Budget, (IB) AMVETS, DAV, Paralyzed Veterans of America
(PVA) and Veterans of Foreign Wars of the United States (VFW), have
included a special section in the IB emphasizing women veterans, in an
effort to call attention to the need to address many of the challenges
VA faces in providing high quality health services to women veterans in
a predominantly male-oriented health care system. Additionally, DAV
included a special focus on women veterans as part of our ongoing Stand
Up For Veterans campaign--focusing public attention on the unique needs
of women veterans--with a special emphasis on women who became disabled
during their wartime service.
Women veterans are the fastest growing segment of the veteran
population--and according to the Veterans Health Administration (VHA),
women are projected to account for one in every seven enrollees within
the next 15 years, compared to the one in every sixteen enrollees
today. Because of the large and growing number of women serving in the
military today, the percentage of women veterans is projected to rise
proportionately from 7.7 percent of the total veteran population in
2008, to 10 percent in 2018.\1\ Additionally, VA notes that women who
served in Operations Iraqi and Enduring Freedom (OEF/OIF) utilize VA
services at a higher rate than other veterans, including other women
veterans and male OEF/OIF veterans--with 44.2 percent of the 102,126
OEF/OIF women veterans having enrolled in VA, and 43.8 percent who
consume a range of two to ten visits annually. Earlier generations of
women veterans enrolled in VA health care at a 15 percent average
rate.\2\
---------------------------------------------------------------------------
\1\ U.S. Dept. of Veterans Affairs, Office of Public Health and
Environmental Hazards, Women Veterans Health Strategic Health Care
Group; Report of the Under Secretary for Health Workgroup: Provision of
Primary Care to Women Veterans, Page 5. Washington, DC: November 2008.
\2\ Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health,
Strategic Health Care Group, Department of Veterans Affairs; Women
Veterans Health Care, Evolution of Women's Health Care in the Veterans
Administration, Page 4. June 2009. www.amsus.org/sm/
presentations/Jun09-B.ppt.
---------------------------------------------------------------------------
As reported by VA, historically, women have underutilized VA health
care services in comparison to male veterans. In the past 5 years, on
average, 22 percent of men versus 15 percent of women have accessed VA
health care. Women veterans using VA health care are also younger--with
an average age of 48 compared to male veterans' average age of 61.
Among women users from OEF/OIF, more than 85 percent are under age 40
and of childbearing age, and nearly 60 percent are between the ages of
20-29.\3\ In addition, women veterans have been shown to have unique
and more complex health needs with a higher rate of comorbid physical
and mental health conditions; for example, 31 percent of women have
such comorbidities versus 24 percent of men. Even with this higher rate
of comorbidity, women veterans receive their primary and mental health
care in a fragmented model of VA health care delivery that complicates
continuity of care. In fact, according to the VHA Plan of Care Survey
for fiscal year 2007, 67 percent of sites provide primary care in a
multi-site/multi-provider model (i.e., with primary care provided at
one visit and gender-specific primary care at another visit), while
only 33 percent of facilities offered care to women in a one-visit
model for both services.
---------------------------------------------------------------------------
\3\ Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health,
Strategic Health Care Group, Department of Veterans Affairs; Women
Veterans Health Care, Evolution of Women's Health Care in the Veterans
Administration, Pages 6-7. June 2009. www.amsus.org/sm/
presentations/Jun09-B.ppt.
---------------------------------------------------------------------------
We have read with great interest a recently released VA publication
titled: Report of the Under Secretary for Health Workgroup: Provision
of Primary Care to Women Veterans, dated November 2008. VA's 2008
report reflects the most pressing challenges VA faces related to caring
for women veterans: specifically, developing the appropriate health
care model for women in a system that is disproportionately male
focused, the increasing numbers of women coming to VA for care, the
impact of changing demographics in the women veteran population and the
impact on VA health care delivery as well as the identified gender
disparities in quality of care for women veterans.\4\ Given the changes
in recent years, the Under Secretary's workgroup concluded that there
are now sufficient numbers of women veterans to support coordinated
models of service delivery to meet their needs, and that while women
will always comprise a minority of veterans in the VA system, they now
represent a critical mass as a group and should therefore be factored
into plans for focused service delivery and improved quality of
care.\5\
---------------------------------------------------------------------------
\4\ U.S. Dept. of Veterans Affairs, Office of Public Health and
Environmental Hazards, Women Veterans Health Strategic Health Care
Group; Report of the Under Secretary for Health Workgroup: Provision of
Primary Care to Women Veterans, Page 13. Washington, DC: November 2008.
\5\ U.S. Dept. of Veterans Affairs, Office of Public Health and
Environmental Hazards, Women Veterans Health Strategic Health Care
Group; Report of the Under Secretary for Health Workgroup: Provision of
Primary Care to Women Veterans, Page 6. Washington, DC: November 2008.
---------------------------------------------------------------------------
As directed by the VA Under Secretary for Health, the workgroup was
charged with defining the actions necessary to ensure that every woman
veteran has access to a VA primary care provider who can meet all her
primary care needs. The workgroup reviewed the current organizational
structure of VHA's women's health care delivery system, addressed
impediments to delivering their care in VHA, identified current and
projected future needs, and proposed a series of recommendations and
actions for the most appropriate organizational initiatives to achieve
the Under Secretary's goals.
We are impressed with the thoroughness of the review of women's
care in VHA by the workgroup, and also with the optimism of its
recommendations to improve women's health. If implemented nationally
its recommendations could assure that women veterans receive
coordinated, comprehensive, primary care at every VA facility from
clinical providers who are trained to meet their needs; an integration
of women's mental health with primary care in each clinic treating
women veterans; the promotion of innovation in women's health delivery;
enhanced capabilities of all staff interacting with women veterans in
VA health care facilities; and an achievement of gender equity in the
provision of clinical care within VA facilities.
VA HEALTH CARE FOR WOMEN VETERANS: CURRENT CHALLENGES
In the Provision of Primary Care to Women Veterans report the
workgroup identified seven specific challenges that VA must overcome in
order to deliver quality, comprehensive primary care to women veterans.
Challenge 1: VA recognizes that women have been under-
served in the veterans health care system. Utilization rates for men
have held at approximately 22 percent for many years--while utilization
rates for women range between 11-19 percent. Research shows that women
veterans do not self-identify as bona fide veterans, and are more
unlikely to be unaware of their enrollment eligibility.
Challenge 2: VA acknowledged there is a clear and growing
need for improved service delivery to women veterans in VHA. Given the
significantly higher VA utilization rates among women returning from
OEF/OIF as indicated above, VA expects the number of women veterans
coming to VA for care will likely double within the next 4 years.
Challenge 3: In recent years, VA reports have shown a
significant demographic shift related to women VA-users and notes the
impact of age-related health concerns for this population.
Challenge 4: The workgroup identified and acknowledged
gender disparities in quality of care in VHA between men and women.
Challenge 5: The workgroup identified routine
fragmentation of health care delivery to women veterans that poses
possible negative health outcomes.
Challenge 6: One of the most significant challenges VHA
faces according to this workgroup report is an insufficient number of
clinicians with specific training and experience in women's health.
Challenge 7: Finally, the workgroup identified that there
is inconsistent policy in place for women's health care delivery in
VHA.
Collectively these challenges constitute serious gaps in health
care services available to women veterans. Most notable is the finding
that the historical predominance of male veterans in the VA setting has
resulted in many providers lacking or having limited exposure to women
patients. According to the workgroup, women veterans' numerical
minority in VHA has created unique logistical challenges in creating
and sustaining delivery systems that assure VA's goal of equitable
access to high quality comprehensive services that include gender-
specific care. The workgroup however, noted there are now sufficient
numbers of women to justify a VA effort to produce coordinated models
of service delivery to meet their needs--and that as a group women
veterans should be factored in as a special population cohort in any
new strategic plans for service delivery.\6\ According to the report,
to a large extent, health care services offered to women veterans have
evolved in a patchwork fashion. Some facilities have strong champions
with expertise in women's health and offer comprehensive services in
one location; other facilities, however, require women to see several
providers for basic primary care services, and some VA facilities rely
heavily on fee-basis providers to care for enrolled women veterans.
---------------------------------------------------------------------------
\6\ U.S. Dept. of Veterans Affairs, Office of Public Health and
Environmental Hazards, Women Veterans Health Strategic Health Care
Group; Report of the Under Secretary for Health Workgroup: Provision of
Primary Care to Women Veterans, Page 16. Washington, DC: November 2008.
---------------------------------------------------------------------------
Likewise, the workgroup noted that almost all new users of the
system are under age 40--and of childbearing age--therefore, there is a
need for a focused shift in the provision of health care services. We
appreciate the workgroups sensitivity to all eras of women veterans as
it mentioned VA must continue to be sensitive to the needs of older
women veterans as well, since women over 55 years of age face high
risks for cardiac disease, cancers and the consequences of obesity
(such as Type 2 diabetes). One of the most troubling findings brought
forward in the report is that despite positive results on gender-
specific measures such as screening for cervical and breast cancer,
significant differences are recorded in VHA performance scores between
men and women on certain outpatient quality measures that are common to
both men and women. Specifically, depression and PTSD screening,
colorectal cancer screening and vaccinations were reported as less
favorable for women.
Of special note to DAV is reference in the report to a 2006 VA
study among women veterans who had not had access to health care in the
past 12 months. Of that group 18.7 percent were service-connected for
disability incurred in the line of duty.\7\ This finding--that service-
connected women veterans without access to health care, are not
enrolled in nor using VHA services--is especially troubling to DAV.
Clearly, there is a need to better understand why women choose to use--
or not use VA services and for improved outreach to this population of
service disabled veterans.
---------------------------------------------------------------------------
\7\ U.S. Dept. of Veterans Affairs, Office of Public Health and
Environmental Hazards, Women Veterans Health Strategic Health Care
Group; Report of the Under Secretary for Health Workgroup: Provision of
Primary Care to Women Veterans, Page 15. Washington, DC: November 2008.
---------------------------------------------------------------------------
Finally, the group noted that there are inconsistencies in VHA
policy for women veterans care. In previous directives issued by VA
Central Office, VA clinical staff were required to provide gender-
specific care on-site in VA facilities, but more recent versions of the
directives had shifted the emphasis to ``preferred'' rather than
``required.'' As a result, the workgroup reported that a decline in on-
site gynecological services has occurred with an increase in fee-basis
referral for those key women's health care services. The workgroup
noted that in contrast, gender-related care always has been recognized
as an integral part of primary care delivery for men in VA health care.
WORKGROUP REPORT RECOMMENDATIONS
Based on its findings--the workgroup made five key recommendations:
A summary of each recommendation is provided below.
Recommendation 1 focuses on the delivery of coordinated,
comprehensive primary women's health care at all VA facilities,
including the development of systems and structures for care delivery
that ensure every woman veteran has access to a qualified primary care
physician who can provide care for acute and chronic illnesses, gender
specific care, and preventative and mental health services.
Recommendation 2 seeks to ensure integration of women's
mental health care as a part of primary care.
Recommendation 3 focuses on promoting new ways of
providing care delivery for women through support of best practices
fitted to a particular facility or VISN configuration and the women
veteran population in that location or region.
Recommendation 4 addresses the need to cultivate and
enhance the capabilities of all VHA staff--including medical providers,
clinical support, non-clinical, and administrative staff, to meet the
comprehensive health care needs of women veterans.
Recommendation 5 seeks to achieve parity in clinical
performance measures and gender equity in clinical quality of care
issues by addressing the systemic reasons for the identified
disparities in outcomes for women using VA in order to effect change in
clinical practice.
These internal VA recommendations thoroughly address quality,
efficiency, access and equity of VA care for women who use VA services.
The workgroup found the need to improve all these areas in today's VA
health care programs for women veterans, and to better prepare these
programs for tomorrow's women veterans. We fully concur with the
recommendations made and urge that immediate action be taken to reform
the system to better meet the needs of women veterans and correct these
serious self-identified deficiencies.
WOMEN'S HEALTH RESEARCH AGENDA
Research plays an integral role in developing the most appropriate
health care delivery model for women veterans and promoting access to
high quality health care services. Over the years, VA researchers have
brought to light a number of important facts that, if acted upon, would
greatly improve the care that women veterans receive in VA health care
facilities.
DAV is pleased that VA's Office of Research and Development (ORD)
supports a comprehensive women's health research agenda, and that VA
has intensified its research on women's health in the last decade. The
first comprehensive VA women's health research agenda, which covered
biomedical, clinical, rehabilitative and health services research
(HSR&D), was directed by ORD in 2004 with the goal of positioning VA as
a national leader in women's health research. HSR&D is also currently
funding 27 research projects that examine the health and health care of
women veterans; the consequences of military sexual trauma and other
military traumas on both sexes; PTSD treatment in women; screening and
utilization as well as post deployment access and reintegration issues;
utilization; outcomes and quality of care for women veterans related to
ambulatory care; chronic mental and physical illness, alcohol misuse,
breast cancer and pregnancy outcomes. HSR&D is also in Phase II of a
study examining VA's approaches for delivering care to women veterans,
while another study is assessing the implementation and sustainability
of VA women's mental health clinics. These studies include OEF/OIF
populations.
We look forward to reviewing the results of these 27 research
projects, and applaud VA for standing in the forefront and leading the
way in assuring our women veterans that eventually they will secure the
same access to and quality of care that their male counterparts receive
in the VA health care system.
HEALTH CARE GAPS/SUMMARY
We congratulate the Women Veterans Health Strategic Health Care
Group for an extraordinarily forthcoming report and highly relevant
series of goal-oriented recommendations and action items. These
recommendations are fully consistent with a series of recommendations
that have been made in recent years by VA researchers, experts in
women's health, VA's Advisory Committee on Women Veterans, the
Independent Budget, and DAV.
We fully concur with the workgroup's conclusion that ``the debt
owed to all our veterans and to women in particular demands nothing
less than our full attention.'' However, addressing the goals
identified in the report will require VA's building the proper
resources, adequate infrastructure, program capacity and internal
support necessary at the highest levels to make the changes it says are
needed. Without question, this is a significant undertaking by VA and a
lot of hard work lies ahead to achieve the goals it has set out for
itself, but we are hopeful. We believe that, with the attention,
oversight and collaboration of the House Veterans' Affairs Committee,
VA can achieve implementation of the recommendations in this report.
Messrs. Chairmen, a number of public events focused on women
veterans have been held in recent months. All are essential to the
process of change; however, nothing is more important than taking
action. For these reasons DAV urges the Subcommittee on Health to
carefully consider the recommendations outlined in the Provision of
Primary Care to Women Veterans Report and to support VA's efforts to
achieve these reforms as expeditiously as possible.
We would like to point out that as of March 11, 2009, this landmark
report on women veterans was distributed to VA field facilities and to
regional network management offices within VHA. However, its
transmittal to the field by VA Central Office did not take the form of
a VHA directive; nor did it appear to convey any mandatory
implementation requirements or accountability on the part of local or
regional officials. It was simply transmitted to VA field elements as
an informational device, apparently for their discretionary use in
planning. We recognize that VA has been making a good faith effort to
move forward on its plans for improving women veterans' health
services, and it is clear from VA correspondence included at the end of
the report that at multiple levels work is underway to assess and
implement principles outlined in the report. However, we again note
there is no formal expression of policy or directive to fill the gaps
that this report identified.
For these reasons we ask for Congressional oversight and seek VA's
commitment to issue instructions to all VA health care personnel who
will be held accountable for implementation of this comprehensive
policy. The implementation phase should include establishing
performance measures for facility and network executive staffs,
submission of appropriate reports and provision of other oversight to
ensure these reforms are implemented and sustained at every VA facility
caring for women veterans. Additionally, we ask that Congress ensure VA
is provided sufficient resources to accomplish these essential reforms.
Messrs. Chairmen, as previously noted, women are a growing
population within the ranks of the active, reserve and Guard forces of
our Armed Services, and women veterans are streaming into VA health
care by the thousands. Soon women veterans will share ranks nearly two
million strong and will constitute one of every seven veterans enrolled
in VA health care. Expectations for VA to step up to this challenge are
high, and this report by VHA's own workgroup clearly reveals the
necessity for VA to make significant changes in the short term to begin
better addressing women's needs in the long term. This workgroup report
is an excellent beacon to show them the way, but we seek assurance that
its implementation will be faithfully executed.
WOMEN VETERANS: BENEFIT-RELATED ISSUES
Another area of concern for DAV relates to veterans' claims for
conditions resulting from military sexual trauma (MST). The prevalence
of sexual assault in the military is alarming and has been the object
of numerous military reports and Congressional hearings. Servicemembers
who have suffered MST often do not report the assault during military
service but experience lingering physical, emotional or psychological
symptoms following the incident. Unfortunately, many men and women who
experience these types of traumas do not disclose them to anyone until
many years after the fact. Under VHA policy, all patients are screened
for MST and free treatment is available for MST-related conditions at
VA health care facilities. Service connection or disability
compensation is not required for eligibility to treatment. A recent VA
study of 573,640 veterans screened for MST found that 22 percent of
women and 1.2 percent of men had positive screens.\8\ Another VA study
found that of 125,000 veterans screened, about 15 percent of OEF/OIF
women veterans, who use VA health care, reported experiencing sexual
assault or harassment during military service.\9\ VA research also
indicates that men and women who report sexual assault or harassment
during military service were more likely to have a diagnosis of a
mental health condition. According to VA, women with MST had a 59
percent higher risk for mental health problems, with the risk among men
was slightly lower, at 40 percent.\10\ The most common conditions
linked to MST were depression, PTSD, anxiety and adjustment disorders
and substance-use disorders.
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\8\ Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health,
Strategic Health Care Group, Department of Veterans Affairs; Women
Veterans Health Care, Evolution of Women's Health Care in the Veterans
Administration, Page 13. June 2009. www.amsus.org/sm/
presentations/Jun09-B.ppt.
\9\ U.S. Dept. of Veterans Affairs, VA Research Currents. November-
December 2008. http://www.research.va.gov/resources/pubs/docs/
va_research_currents_nov_dec_08.pdf.
\10\ Ibid.
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Unfortunately, if an assault is not officially reported during
military service, establishing service connection later on for
conditions related to MST is very challenging. These claims are
frequently denied by VA due to lack of evidence that causing extreme
frustration for veterans seeking VA disability compensation benefits.
Although VHA openly provides treatment for alleged MST victims, many
would be eligible for compensation benefits but are unable to support
their claims with documentation of the stressor incidents. According to
an Institute of Medicine (IOM) National Research Council report on PTSD
compensation, significant barriers prevent women from being able to
independently substantiate their experiences of MST, especially in
combat arenas.\11\ The IOM report concluded that little research exists
on the subject of PTSD compensation and women veterans. The Committee
noted that available information suggests that women veterans are less
likely to receive service connection for PTSD and that this is related
to being unable to substantiate noncombat traumatic stressors such as
MST. (Also, with regard to women who were traumatized by direct or
indirect combat exposure, DoD faces several additional challenges that
are discussed farther on in this testimony.) The Committee further
noted that VA materials for rating these types of cases address MST but
that little attention is paid to the unique challenges of documenting
an in-service stressor or approaches for solving this problem.
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\11\ Institute of Medicine and National Research Council of the
National Academies, Committee on Veterans' Compensation for PTSD, Board
on Military and Veterans Health, Board on Behavioral, Cognitive, and
Sensory Sciences; PTSD Compensation and Military Service. Washington
DC, 2007.
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In 2005, the Department of Defense (DoD) established the Sexual
Assault Prevention and Response Office (SAPRO). This organization is
responsible for all DoD sexual assault policy and provides oversight to
ensure that each of the military service's programs complies with DoD
policy. SAPRO serves as the single point of accountability and
oversight for sexual assault policy, provides guidance to the DoD
components, and facilitates the resolution of issues common to all
military services and joint commands. The objectives of DoD's SAPRO
policy are to specifically enhance and improve: (1) prevention through
training and education programs, (2) treatment and support of victims,
and (3) system accountability.
Under DoD's confidentiality policy, military victims of sexual
assault have two reporting options--Restricted reporting and
Unrestricted reporting. Restricted reporting allows a sexual assault
victim to confidentially disclose the details of his or her assault to
specified individuals and receive medical treatment and counseling,
without triggering the official criminal or civil investigative
process. Servicemembers who are sexually assaulted and desire
restricted reporting under this policy may only report the assault to
the Sexual Assault Response Coordinator (SARC), Victim Advocate or a
Health Care Personnel (HCP). According to SAPRO, health care personnel
will initiate the appropriate care and treatment, and report the sexual
assault to the SARC in lieu of reporting the assault to law enforcement
or to the unit commander. Upon notification of a reported sexual
assault, the SARC will assign a Victim Advocate to the victim. The
assigned Victim Advocate will provide accurate information on the
process of restricted versus unrestricted reporting. At the victim's
discretion/request, appropriately trained health care personnel will
conduct a sexual assault forensic examination (SAFE), which may include
the collection of evidence. According to SAPRO, in the absence of a DoD
provider, the service Member can be referred to an appropriate civilian
facility for the SAFE.
Unrestricted reporting is recommended for victims of sexual assault
who request an official investigation of the crime in addition to
treatment and counseling. When selecting unrestricted reporting,
current reporting channels are used, e.g. chain of command, law
enforcement, report of the incident to SARC, or request health care
personnel to notify law enforcement. Upon notification of a reported
sexual assault, the SARC assigns a Victim Advocate. At the victim's
discretion/request, the health care personnel may conduct a sexual
assault forensic examination (SAFE), which may include the collection
of evidence. Details regarding the incident are limited to only those
personnel who have a legitimate need to know, according to SAPRO
policy.
According to the Director of SAPRO, in 2007, service Members made
2,688 total reports of sexual assault and that in 2,085 of those cases,
the unrestricted reporting option was chosen.\12\ While DoD reports
that it prefers complete reporting of sexual assaults to activate both
victims' services and law enforcement actions, it recognizes that some
victims desire only medical and support services and no command or law
enforcement involvement. The Department states its first priority is
for victims to be protected, treated with dignity and respect, and to
receive the medical treatment, care and counseling that they deserve.
We agree with that policy but we also want to protect each MST victim's
rights and benefits as a veteran.
---------------------------------------------------------------------------
\12\ Department of Defense; The Defense Resource on Sexual Assault
Prevention and Response, Volume 2, Issue 2; Spring 2008. http://
www.sapr.mil/Contents/News/ArchiveNewsletters/Spring%202008.pdf.
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DAV's primary concern is that VA be able to access the restricted
DoD records documenting reports of MST for an indeterminate period. We
have contacted Veterans Benefits Administration (VBA) staff on a number
of occasions to try to verify that VA is collaborating with DoD/SAPRO
to ensure access to these records if authorized by the veteran in
support of a benefits claim for conditions related to MST. To establish
service connection for PTSD there must be credible evidence to support
a veteran's assertion that the stressful event actually occurred. Once
a claim is filed VA has a number of standard sources it examines for
records to support a claim for a condition secondary to personal trauma
or MST. However, we do not see SAPRO-related reports listed in any of
VA's training and reference materials/manuals for developing claims for
service connection for PTSD based on MST. At this juncture we are
unable to confirm if VBA searches for ``restricted'' reports as an
alternative evidence source for information to substantiate the
veteran's claim. VA does list medical reports from civilian physicians
or caregivers who treated the veteran immediately after the trauma as
alternative evidence to seek out in these cases; however, we do not
know if VBA staff developing these claims are aware of DoD SAPRO
policies and would contact the veteran to see if a restricted report
was in fact filed, a physical examination conducted and if follow up
medical or mental health treatment records exist.
To maintain confidentiality in the case of restricted reporting,
DoD policy prevents release of MST-related records with limited
exceptions. However, VA is not specifically identified as an
``exception'' for release of records in DoD's policy and it is unclear
if VA, could gain access to these records even with permission of the
veteran. DoD does list VA is an advisory Member of the Sexual Assault
Advisory Council or (SAAC) which coordinates policy and review of the
Department's sexual assault prevention and response policies and
programs. We also have questions with respect to where and how physical
assessment records that are completed following the assault and
subsequent mental health treatment records related to the restricted
MST reports are kept and for how long. We are concerned that these
records may be kept separate from victimized service Members' medical
treatment and personnel records and whether each service maintains
these records in a different manner. According to DoD policy physical
evidence collected associated with a restricted report of the event is
destroyed after 1 year if the service Member or veteran does not wish
to pursue civil or criminal sanctions against the perpetrator.
We hope to confirm with the Subcommittee's oversight that VA is
indeed fully collaborating with DoD to ensure veterans who have
suffered MST and have filed claims for benefits for related conditions
gain VA's full assistance in accessing these important records in
support of their claims for disability. Additionally, we concur with
the recommendation made in the 2008 report of the VA Advisory Committee
on Women Veterans that suggested VBA identify and track claims related
to personal assault/MST to determine the number of claims submitted
annually, grant rates, denial rates, and types of conditions most
frequently associated with these claims. The Committee stated that
development of tracking systems could further guide studies on research
on all aspects of MST. Finally, we ask that VBA provide the
Subcommittees any information it has in its reference materials for
claims developers/raters that reflect its collaboration with DoD/SAPRO
and guidance to MST-related claims developers on how to access
supporting documentation from each military service in the case of both
restricted and unrestricted reporting options, including any
differences in records retention, security and disposal policies.
LIONESS TEAMS
As you may be aware, on March 31st of this year, DAV cosponsored a
screening of the LIONESS documentary on the Hill, hosted by Chairmen
Filner and Representatives Herseth Sandlin, Susan Davis and Judy
Biggert. The film was well received and told the story of the first
group of women Army support soldiers who were assigned to all-male
Marine infantry units in the Al Anbar province of Iraq during some of
the toughest fighting seen in that region. The role of the Lioness was,
and is, to defuse tension with Iraqi women and children during searches
of their homes and their persons. When these women first deployed to
Iraq, they performed their original military occupational specialty
(MOS) duties including truck mechanic, clerk and engineer, but were
called to serve in a different capacity inside male combat arms units.
The Lioness teams are still being deployed today in both Iraq and
Afghanistan, and unfortunately, starting from the first teams to the
present, this ``extraordinary'' service is not routinely noted in key
official DoD record documents, including the DD-214 or veterans
military discharge certificate. This absence of documentation makes
following up their care for PTSD or other post-deployment mental health
readjustment issues difficult when their worst hurdle is having to
prove that they served their country in this capacity and were exposed
to combat. We need to ensure that women who serve are cared for when
they return home no less so than men who served, and those who have
risked their lives, often without the additional training needed to
ensure their safety in theater, are not left to fend for themselves to
access needed VA benefits and services later in their lives.
A great deal of guidance is given to VA compensation claims
developers/raters on various service medals and devices that can be
used to support PTSD claims and on how to use DoD resources to
corroborate possible combat-related traumatic exposures. However, in
the case of many Lioness team members no award was provided and no
documentation exists in their discharge papers or in their military
records to confirm participation in this unique program.
We are aware that former service women, particularly those who
volunteered during the early stages of the Lioness program, have
encountered difficulties in gaining proper recognition for their
service, both within the services and when they leave active duty and
seek assistance from VA. Some former Lioness members report they have
had to find their own witnesses and documentation needed in recognition
of their actions under fire and to establish their combat experience
while deployed, in order to establish claims for disability benefits
from VBA. We remain concerned that there is no mechanism in place
within the military services to properly document servicemember
participation in unique operational missions outside of the
requirements of their assigned MOS--such as Lioness.
Several of the women featured in the Lioness documentary spoke
about the difficulties they personally experienced in accessing VA
health care and benefits related to post-deployment mental health
issues. One of the women reported that her male Vet Center counselor
found it difficult to believe she had participated in dozens of
missions where she was armed and engaged in combat. She hoped that in
the future VA would be better prepared and recommended VA hire more
women Vet Center counselors, women therapists, and OEF/OIF women
veteran peer counselors. One of the other women reported she had been
service connected for PTSD--but a 0 percent even though she complained
of chronic disturbing memories, difficulty sleeping and anxiety.
Clearly, the lack of documentation in these cases makes it more
difficult for adjudicators to establish service connection for
conditions related to military service. For these reasons we encourage
DoD and VA to collaborate to ensure the military services document the
additional duties some servicemembers perform and that VHA and VBA
staff are fully informed about these special duties women are asked to
carry out in today's military.
HOMELESS AND BURIAL BENEFITS FOR WOMEN VETERANS
Finally, we note two other areas that warrant the Subcommittees'
attention. The first being homelessness among women veterans. VA has
excellent programs for homeless veterans but women veterans present
unique challenges for VA within its programs. Frequently women are
reluctant to take advantage of VA's stellar programs such as
transitional housing, substance-use disorder programs and residential
rehabilitation and treatment programs, due to personal safety concerns
and because often they are the sole or primary caretakers of minor
children. In some facilities VA has struggled to maintain a welcoming,
secure and safe treatment setting especially for women who have serious
mental illness and/or been victims of MST.
While the overall number of homeless veterans has been decreasing
(approximately 131,000 on any given night), according to VA, the number
of homeless women veterans has nearly doubled to 6,500 in the last
decade, which equals approximately 5 percent of total homeless veteran
population. In a recent newspaper article \13\ VA is cited as reporting
that overall, female veterans are now between two and four times more
likely to end up homeless than their civilian counterparts. This
alarming jump is coupled with the report that 1 in 10 homeless veterans
under the age of 45 are women, and as more veterans return from
deployments in Iraq and Afghanistan, these numbers are expected to
rise. Combat-related stress and MST are both risk factors for
homelessness. These women present unique challenges to the VA system,
designed for use primarily by men, and very few facilities have
homeless programs designed specifically for women--and by law none are
able to accommodate children. It is also noted that about 75 percent of
these female veterans have been victims of sexual abuse and many have
substance-use and mental health problems that require specialized care.
Programs and treatment services for mental health, MST, substance-use
disorders, maintaining independent housing and gainful employment are
all essential to this vulnerable population. Therefore, we must ensure
that VA programs are properly adjusted to meet the unique and growing
needs of women veterans and that women have equal access to these
specialized services.
---------------------------------------------------------------------------
\13\ Bryan Bender. More Female Veterans Are Winding Up Homeless.
The Boston Globe, July 6, 2009. http://www.boston.com/news/nation/
washington/articles/2009/07/06/more_female_veterans_
are_winding_up_homeless/.
---------------------------------------------------------------------------
We are pleased that Congress has supported and VA is providing
grants to homeless veterans with special needs, including women
veterans who care for dependent children as well as HUD-Veterans
Affairs Supported Housing vouchers some of which, according to VA, have
now been awarded to women veterans with children. VA estimates that of
the 7,300 vouchers awarded to homeless veterans to date, 12 percent are
occupied by women veterans and 14 percent have one or more children in
the unit. We hope there is continued support to ensure women too have
access to these critical resources.\14\
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\14\ Peter H. Dougherty, Director, Homeless Veterans Programs,
Veterans Health Administration, U.S. Department of Veterans Affairs;
Testimony before the House Veterans' Affairs Committee on A National
Commitment to End Veterans' Homelessness. June 3, 2009. http://
veterans.house.gov/hearings/hearing.aspx?NewsID=404.
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The final issue for consideration relates to the 2008 report from
the Advisory Committee on Women Veterans, which notes an apparent
disparity of usage of VA burial benefits between eligible men and women
veterans through the National Cemetery Administration (NCA). The
Committee recommended that NCA enhance targeted outreach efforts in
areas where usage by women veterans does not reflect the women
veterans' population. NCA concurred with the recommendation and
asserted it would collect and analyze data concerning burial rates,
assess opportunities to reach more veterans, both male and female
through outreach activities and make a concerted effort to include
underrepresented veteran populations, to include women veterans, in its
outreach endeavors.
Messrs. Chairmen, again we thank you for the opportunity to share
our views at this important hearing focused on women veterans--and
eliminating the gaps in their care and benefits. It is clear that a
number of gender disparities exist for women veterans in both the VA
health and benefits systems. We appreciate the attention to these
issues and hope the Subcommittees will consider the vast array of gaps
that currently exist beyond the limited number we have brought forth in
our statement. We also ask that attention be paid to women within the
special disability populations to ensure their unique needs are met and
that they too are aware of their VA benefits and eligibility for health
care and specialized rehabilitation programs. We will appreciate your
consideration of our views on these pressing and important matters to
our Nation's women veterans. Thank you once again for the opportunity
to testify at this hearing. I would be pleased to address your
questions, or those of other Subcommittee Members.
Prepared Statement of Anuradha P. Bhagwati, MPP,
Executive Director, Service Women's Action Network
Good morning. My name is Anuradha Bhagwati. I am a former Captain
in the United States Marine Corps. I currently serve as Executive
Director of the Service Women's Action Network (SWAN), a non-partisan,
non-profit organization founded by female veterans, based out of New
York City. SWAN specializes in policy analysis, advocacy, and legal
services for all servicewomen, women veterans, and their families.
Despite the progress the Department of Veterans Affairs has made in
addressing the recent influx of women veterans into the VA system, the
delivery of health care and the awarding of disability ratings to women
veterans remains grossly inadequate.
Every day, SWAN receives calls from women veterans of all eras and
ages whose experiences at VA hospitals or with the VA claims system has
led them to give up not just on the VA, but also on life. Mistreatment
by the VA is enough reason for many traumatized women veterans to fall
through the cracks, and end up victims of drug and alcohol abuse,
unemployment, homelessness, or suicide.
Women veterans who have already been mistreated by the military are
often doubly traumatized by harassment or mistreatment at VA
facilities. Knowledge about the epidemic of Military Sexual Trauma
(MST)--sexual harassment, assault and rape--which has yet to be fully
recognized by the armed forces, has also yet to be adequately
integrated into the daily operations of VA hospitals and the awarding
of VA compensation to both male and female veterans.
MST screening at hospitals around the Nation appears to be
inconsistent, at best. A shortage of female physicians and counselors,
a rapid turn-over of inexperienced residents, a preponderance of
culturally conservative administrative staff, and poorly trained,
apathetic or unprofessional medical staff contributes to a lack of
understanding about how to treat veterans who suffer from symptoms
related to MST.
However, I must emphasize that regardless of medical condition,
women veterans, when compared to their male counterparts, are largely
subjected to unequal treatment at VA facilities nationwide. The
following anecdotes illustrate just a few of the VA's institutional
failures to deliver proper health care to women veterans:
One Iraq veteran who checked herself into inpatient
psychiatric care during a particularly bad PTSD episode was forced to
share a bathroom with male veterans, including a peeping tom. When she
told her nurse she felt uncomfortable eating her meals with male
veterans, the nurse threatened that she would not be fed at all.
An Afghanistan veteran--a single mother--who was raped in
theater by a fellow servicemember, cannot bear to enter a VA facility
out of sheer terror of re-triggering the trauma from her assault. Like
many other women veterans, she pays for counseling out of pocket so as
not to subject herself to further trauma.
One veteran recently received her annual pap smear with a
male gynecologist who did not enforce the requirement to have a female
staff member present during the examination. When this veteran
mentioned to the gynecologist that she had experienced MST, he left the
room and barked down the hall, ``We've got another one!''
Many of these examples illustrate a larger point: that the VHA
requires an enormous cultural shift in order to treat female patients
with dignity and respect, and to acknowledge the specific needs of
women veterans.
With respect to benefits, both female and male veterans applying
for compensation from the VBA for conditions related to MST face
overwhelming odds against being awarded a disability rating. However,
the full extent to which women veterans are denied disability
compensation has yet to be comprehensively examined. Veterans with MST
often feel that the benefits system is rigged against them, as proving
that one's stressor occurred in service can be extremely difficult, if
not impossible. The VBA fails to understand that servicemembers rarely
feel comfortable or sufficiently safe from harm to report rape, sexual
assault or harassment, for two main reasons: reports of sexual assault
and harassment are often simply ignored by commanders military-wide,
and servicemembers who report sexual assault or harassment are often
threatened or punished after reporting.
While the DoD's failure to enforce its own sexual assault and EO
policies are subject of another hearing, it must be emphasized that
unless the climate within the armed forces changes such that
servicemembers are guaranteed protection and support after reporting
sexual assault or EO violations, it is unjust and grossly irresponsible
of the VA to expect veterans to provide the current standard of proof
for a stressor related to MST.
H.R. 952 (entitled the COMBAT Act), introduced by Representative
Hall, presumes that a combat veteran's PTSD is a result of exposure to
a stressor while in theater; I suggest that similar legislation be
proposed for veterans who suffer from PTSD or other symptoms of MST, so
that veterans with MST are not punished or traumatized further by the
VA. MST counseling and a physician's diagnosis of MST-related medical
conditions should be sufficient for the VBA to award a disability
rating to a veteran.
Recommendations to Bridge the Gaps in Care for Women Veterans:
1. Require that the VA remedy the shortage of female physicians,
female mental health providers and MST counselors at VA hospitals
nationwide. Also require that the VA provide the option of female-only
counseling groups for female combat veterans, and female--as well as
male--only counseling groups for female and male survivors of MST.
2. Require the VA to implement a program to train, educate, and
certify all staff, including administrative and medical, in Federal
Equal Opportunity regulations and MST, to reduce a discriminatory and
hostile atmosphere toward women veterans.
3. Require the VA to increase accessibility of fee-based care for
veterans (both male and female) who have been diagnosed with Military
Sexual Trauma.
4. Require day-care facilities for veterans who are parents, as
well as more flexible evening or weekend hours for working veterans and
parents, at every VA hospital.
5. Require the VA to conduct a study into what percentage of
claims are denied with a breakdown by gender as well as type of injury/
condition, including both combat-related PTSD, and PTSD or other
conditions resulting from MST.
6. Require that VBA claims officers undergo intensive training and
education in MST and MST-related medical conditions.
7. Require that the VBA's submission requirements for MST claims
reflect a reasonable standard, such as proof of MST counseling during
or after service, and diagnosis of MST-related medical conditions.
8. Require the DoD to conduct a retention study to determine the
total impact of MST on re-enlistment rates of servicemembers.
Thank you for your time.
Prepared Statement of Dawn Halfaker, Vice President,
Board of Directors, Wounded Warrior Project
Mr. Chairmen and Members of the Subcommittees:
Thank you for inviting Wounded Warrior Project (WWP) to offer our
views on eliminating the gaps facing women veterans.
Wounded Warrior Project brings an important perspective to this
morning's hearing in light of the organization's goal--to ensure that
this is the most successful, well-adjusted generation of veterans in
our Nation's history.
Wounded Warrior Project was founded on the principle of warriors
helping warriors, and we pride ourselves on outstanding service
programs built on that principle. Our signature service programs
include peer mentoring, adaptive sporting events, and Project Odyssey--
a potentially life-changing program that engages groups of veterans
with combat stress and post-traumatic stress disorder in outdoor
adventure activities that foster coping skills and provide support in
the recovery process. (WWP is mounting its first Odyssey program for
women veterans.) WWP aims to fill gaps--both programmatic and policy--
to help wounded warriors thrive.
With growing numbers of women in uniform serving in hostile
theaters and exposed as never before to combat environments, women are
not only playing a much larger role in bolstering our war-fighting
capability, but unprecedented numbers are returning home with visible
and invisible wounds.
Let me note that I am testifying this morning not only as Vice
President of the Board of WWP, but as a retired Army captain who was
severely injured in combat in Baquba in 2004, and after nearly a year
at Walter Reed, have undergone further treatment at VA facilities.
I know this Committee appreciates the debt owed those who have
served their country. In meeting that obligation to this new generation
of warriors, we must examine the adequacy of existing programs. It is
vital that we identify and fill gaps that could compromise realization
of the high goals we should have for these young men and women.
I applaud this Committee and the Congress for its critical role in
moving the Department of Veterans Affairs to better serve women
veterans. With your insistence on affording women veterans equitable
access to needed care, women veterans today have access to a wide array
of gender-specific services (as well as primary care) in VA settings,
where a decade earlier such care was often provided only through
contract arrangements.
We focus our remarks this morning on key gaps in the health-care
arena. In doing so, we by no means suggest that there are not gaps in
benefits or other programs. Certainly pertinent advisory Committee
reports would suggest otherwise.
Today, with women making up 11 percent of veterans of Operations
Enduring and Iraqi Freedom, VA reports that some 44 percent of female
OEF/OIF veterans have enrolled with VA health care, and used VA health
care from two to ten times.\1\ Women veterans have become one of the
fastest growing VA patient populations. Notwithstanding these
statistics, there remain real concerns.
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\1\ VA Healthcare Utilization among OEF/OIF Veterans 3rd Quarter
FY08, V1a, Table 3. As cited in an online fact sheet from the
Department of Veterans Affairs Web site, Office of Public Health and
Environmental Hazards. Available from http://www.publichealth.va.gov/
womenshealth/facts.asp. Accessed 6 July, 2009.
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According to recent VA testimony, 45 percent of all veterans who
utilized VA health care through the end of fiscal year 2008 had a
possible mental health diagnosis.\2\ Women in the military are at
significantly higher risk of developing PTSD, depression, and other
war-related mental disorders than their male counterparts.\3\ Women in
the military are also at higher risk for sexual trauma than their
civilian peers,\4\ and the numbers of such occurrences are thought
likely to be significantly under-reported.\5\ Sexual assault has long-
lasting effects on women's health, particularly mental health.\6\ Thus,
given the likely prevalence of PTSD and other mental health problems in
this population, and the health risks of such conditions going
untreated, it is critical that we focus not only on those who are
seeking treatment, but also on those who are not.
---------------------------------------------------------------------------
\2\ United States House of Representatives, Testimony of Dr. Ira
Katz, Deputy Chief Patient Care Services Officer for Mental Health,
Veterans Affairs Administration, U.S. Department of Veterans Affairs,
before the House Committee on Veterans' Affairs, Subcommittee on
Health, Ira Katz (Washington DC: April 30, 2009).
\3\ James R. Riddle, Tyler C. Smith, Besa Smith, Thomas E. Corbeil,
Charles C. Engel, Timothy S. Wells, Charles W. Hoge, Joyce Adkins, Mark
Zamorski, and Dan Blazer from the Millennium Cohort Study Team,
``Millennium Cohort: The 2001-2003 baseline prevalence of mental
disorders in the U.S. military,'' Journal of Clinical Epidemiology, 60,
2007: 198.
\4\ R. Kimerling et al., ``The Veterans Health Administration and
Military Sexual Trauma,'' American Journal of Public Health 97, no. 12
(2007): 2160.
\5\ James R. Rundell, ``Demographics of and diagnoses in Operation
Enduring Freedom and Operation Iraqi Freedom personnel who were
psychiatrically evacuated from the theater of operations,'' General
Hospital Psychiatry 28 (2006): 355.
\6\ MA Mengeling, AG Sadler et al., ``The effect of women's health
outcomes by type of trauma exposure,'' Abstract presented at VA HSR&D
2009 National Meeting, Feb. 11, 2009.
Available from http://www.hsrd.research.va.gov/meetings/2009/
display_abstract.cfm?RecordID=
410. Accessed 6 July, 2009.
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Evidence suggests a number of reasons that lead returning women
veterans to forego VA care. One recent research study involving OEF/OIF
Reserve and National Guard servicewomen, for example, found frequent
lack of knowledge regarding eligibility for and access to VA care;
widespread perceptions that pursuing such care would be stigmatizing;
and consistent concern regarding hassles and quality of VA care.\7\
These findings generally mirror research results from a population-
based study of women veterans' perceptions about VA health care.\8\
---------------------------------------------------------------------------
\7\ MA Mengeling, BM Booth et al., ``Barriers to DVA care access
for Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)
Reserve and National Guard Servicewomen,'' Abstract presented at VA
HSR&D 2009 National Meeting, Feb. 11, 2009. Available from http://
www.hsrd.research.va.gov/meetings/2009/
display_abstract.cfm?RecordID=522. Accessed 6 July, 2009.
\8\ Donna Washington, Susan Kleimann, Ann Michelini, Kristin
Kleimann and Mark Canning, ``Women Veterans' Perceptions and Decision-
Making about Veterans Affairs Health Care,'' Military Medicine 172, no.
8 (2007): 813-815.
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We certainly cannot assume from these data that female OEF/OIF
veterans who are forgoing VA care have no health issues. To the
contrary, given the high prevalence and unique impact of PTSD and other
war-related mental health conditions among those who have deployed to
Iraq and Afghanistan, WWP urges that we focus on the mental health of
all returning warriors. And given the high rates of military sexual
trauma among women veterans of these deployments, it is particularly
important that VA reach out to returning women veterans.
Needed Outreach: Despite significant advances in VA health care for
women veterans, researchers have found that many women veterans are
unaware of the existence of VA women's health care services or of their
eligibility for such VA care. Such findings, along with research
indicating that women veterans may have adverse perceptions about VA
care, highlight the importance not only of providing more information
to this population, but of overcoming perceptions and misperceptions.
We see a need for aggressive, targeted outreach that takes account of
research showing that women veterans who have experienced military
sexual assault experience more distrust directed at medical staff, and
reduced willingness to seek further help at military and VHA facilities
than women who have sought treatment related to sexual assault at
civilian facilities.\9\
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\9\ MM Kelley, DS Vogt et al., ``Effects of military trauma
exposure on women veterans' use and perceptions of Veterans Health
Administration care,'' Journal of General Internal Medicine 23, no. 6
(2008): 741-7.
---------------------------------------------------------------------------
VA certainly has attempted to increase its outreach to new
veterans, and better inform them regarding their health care
eligibility, as well as on readjustment and psychological health
issues. But no single step can be expected to change the paradigm for
women veterans who may view VA as a system for older male veterans, or
who may have concerns about the quality of its care or who--having
experienced sexual trauma in service--may be distrustful of government-
provided care. In that regard, there is a clear need for an aggressive
approach to eliminating the barriers that deter at least some returning
women veterans from pursuing needed help. We propose, in this regard,
that Congress direct VA to employ, train and deploy peers (other women
OEF/OIF veterans, including those who have had readjustment or mental
health issues) to conduct outreach to women OEF/OIF veterans, including
one-on-one outreach efforts to address negative perceptions and build
trust.
Peer-support: Given the importance of addressing the mental health
needs of returning veterans, it is not enough, in our view, simply to
get new veterans into treatment. Our treatment goals for veterans with
war-related mental health problems must be more than simply diminishing
or alleviating symptoms of a mental health condition. Rather, the
treatment goal should be focused on these veterans' thriving and
achieving productive, satisfying lives. (VA, as a matter of policy, has
adopted this ``recovery'' model of mental health care, though the gap
between policy and practice can be wide.) This ``recovery'' paradigm
does not dismiss the importance of medical treatment. But it recognizes
that approaches like peer-mentoring and peer-support can be critically
important to effective mental health care in empowering patients in a
way that clinicians generally cannot. In WWP's experience, peer-
mentoring and support can be powerful in helping OEF/OIF veterans cope
with PTSD and other war-related mental health conditions, and there is
ample research to suggest that peers' social support is an important
influence on psychological recovery and rehabilitation.\10\ Moreover,
we see evidence that this generation of veterans values peer-services.
To illustrate, a recent WWP survey of wounded warriors with whom we
have worked showed that:
---------------------------------------------------------------------------
\10\ C. Brewin, B. Andrews and J. Valentine, ``Meta-Analysis of
Risk Factors for Posttraumatic Stress Disorder in Trauma-exposed
Adults.,'' Journal of Consulting and Clinical Psychology 68, no. 5
(2000): 748-766; A Klein, R Cnaan and J Whitecraft, ``Significance of
Peer Social Support for Dually-Diagnosed Clients: Findings from a Pilot
Study,'' Research on Social Work Practice 8 (1998): 529-551, as cited
in Phyllis Solomon and Jeffrey Draine, ``The State of Knowledge of the
Effectiveness of Consumer Provided Services,'' Psychiatric
Rehabilitation Journal 25, no. 1 (2001): 24; David Riggs, Margaret
Rukstalis, Joseph Volpicelli, Danielle Kalmanson and Edna Foa,
``Demographic and social adjustment characteristics of patients with
comorbid posttraumatic stress disorder and alcohol dependence:
Potential pitfalls to PTSD treatment,'' Addictive Behaviors 28 (2003):
1726.
Seventy-five percent of respondents reported that talking
with another OEF/OIF veteran was helpful in dealing with mental health
concerns;
Fifty-six percent expressed the belief that peer to peer
counseling would be helpful in addressing their mental health concerns;
and
Forty-three percent reported that talking with another
OEF/OIF veteran had been the one most effective resource in helping
with mental health concerns.
In our view, peer-outreach and peer-mentoring and support can be
important elements in any strategic plan for meeting the mental health
needs of women OEF/OIF veterans (as they can be for all OEF/OIF
veterans).
Variability in provision of services: In offering these
suggestions, we must at the same time acknowledge that there are
difficult, systemic problems that VA faces in bridging gaps in care of,
and benefits and services for, women veterans. Among these challenges
is the fact that women veterans encounter wide variability in care from
facility to facility. As documented in a 2007 VA survey of its women's
health programs and practices, VA facilities have adopted a variety of
clinic models for providing primary health care for women veterans,
ranging from separate women's health clinics to mixed-gender general
primary care clinics. (And while most VA facilities have established
women's health clinics, many of those women's clinics offer gender-
specific exams only.) \11\ Significant variability also exists in
provision of specialized women's health services (such as mammography),
provided on-site in some instances and offsite under contract in
others.\12\ The 2007 survey also found that only a minority of
facilities have designated women's health providers in general
outpatient mental health care, an area VA acknowledges is one of
special concern for women veterans.\13\
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\11\ Elizabeth Yano, Bevanne Bean-Mayberry, and Andrew Lanto on
behalf of the Department of Veterans Affairs, Center for the Study of
Health Care Provider Behavior, ``What Does Women's Health Care Look
Like in the VA?'' A PowerPoint presentation (Washington, DC: June 10,
2008).
\12\ Ibid.
\13\ Ibid.
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Ongoing VA health-systems research should help determine how best
to structure VA care-delivery for women's health to achieve quality
care and patient satisfaction. But difficulty in determining what are
optimal models of care-delivery should not stand in the way of setting
sound policy on clear-cut health-delivery issues.
Access to same-gender health professionals: To illustrate, VA has
failed to take a firm position regarding the question of providing
access to female mental health professionals where there is a history
of sexual trauma. The VA directive defining minimum clinical
requirements for provision of mental health services states only that
``facilities are strongly encouraged, when clinically indicated, to
give veterans being treated for [military sexual trauma] the option of
being assigned a same-sex mental health provider . . .'' \14\ It is no
accident that facilities are simply being ``strongly encouraged,'' and
that clinicians are free, under that guidance, to ignore that
suggestion or reject a woman veteran's request for a same-sex provider
on the ground that it is not ``clinically indicated.'' The VHA Handbook
is otherwise quite clear in establishing requirements regarding many
other aspects of mental health delivery, and it specifically advises
``[s]ome services . . . are mentioned with wording indicating such that
they `may' be delivered, or that facilities are `encouraged' or
`strongly encouraged' to provide them. These indicate suggestions, not
requirements.'' \15\ WWP believes that VA should go further and require
that a woman veteran who has experienced sexual trauma have access to a
female health professional, on request.
---------------------------------------------------------------------------
\14\ Department of Veterans Affairs, Veterans Health
Administration, Uniform Mental Health Services in VA Medical Centers
and Clinics, VHA Handbook 1160.01 (September 11, 2008), para. 9, a(1).
\15\ Ibid, para. 3, a(3).
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The challenge of leadership: While access to needed care for women
veterans has undoubtedly improved markedly over time, the overwhelming
majority of those who obtain care at VA facilities are men. Many VA
providers have had limited exposure to women patients,\16\ but VA
facilities do appear to be working to adapt to the changing
demographics of our armed forces. The Department and its facilities
face challenges. They must continue to take steps to accommodate women
veterans--from modifying delivery systems to ensuring that they meet
privacy expectations. But they must be cognizant of still-widespread
perceptions that VA facilities are geared only to male patients and
that some Department clinicians lack sensitivity to women's issues.
Responding to and addressing those concerns are issues of leadership
that will become ever more important if VA is to win the trust of this
new generation of women veterans.
---------------------------------------------------------------------------
\16\ Yano, ``What Does Women's Health Care Look Like in the VA?''
---------------------------------------------------------------------------
VA and women veterans can continue to benefit, in that regard, from
the special oversight and advice provided by the Department's Advisory
Committee on Women Veterans and similar advisory bodies, as well as
from congressional oversight Committees. Today's hearing is an
important and welcome step in the ongoing effort to eliminate the gaps
facing women veterans.
This concludes my statement. I would be pleased to answer any
questions you may have.
Prepared Statement of First Sergeant Delilah Washburn, USAF (Ret.),
President, National Association of State Women Veterans Coordinators,
Inc., and Houston Regional Director, Texas Veterans Commission
INTRODUCTION
Mr. Chairmen and distinguished Members of the Subcommittees, on
behalf of the National Association of State Women Veterans Coordinators
(NASWVC) I am honored to have this opportunity to testify this morning
and present the views of the State Women Veterans Coordinators of all
fifty States.
The purpose of our Association is to facilitate reciprocal veterans
benefits and services for women veterans across the country. We
identify issues of concern to the women veterans community and develop
recommendations to address those concerns through legislative,
programmatic and outreach activities at both the State and Federal
level. Our vision is for women veterans to have equal access to the
benefits and services they have earned through military service without
problems or delays. We strive to ensure women veterans are aware of
their benefits by providing a network of advocates that spans the
country to conduct outreach, address questions, and resolve problems as
they arise.
The vast majority of our coordinators are themselves women
veterans, representing all branches of service, active duty and
reserves, officer and enlisted. We are primarily State veterans affairs
employees or designees. Because State government is the second largest
provider of services to all veterans and the ranks of women serving in
the military are steadily increasing, our role as Women Veterans
Coordinators continues to grow. We are partners with the Federal
Government, State governments, and Veterans Service Organizations. We
feel it is our responsibility to help Congress understand the unmet
needs of women veterans so that government at all levels can work
together to better accomplish our Nation's goals.
We applaud the leadership of Chairman Filner and Ranking Member
Buyer and the other distinguished Members of the House VA Committee, in
focusing attention on the capacity and capability of VA to equitably
and effectively provide care and services to women veterans. We
strongly support H.R. 1211 as passed by the House of Representatives on
June 23, 2009. We believe planning, readiness, oversight and
accountability are all necessary to meet the goals, requirements and
standards of the Nation and its veterans.
Health Care for Women Veterans
VA has already identified that our country's new women veterans are
younger and expect to use the VA health care system more consistently.
VA reports that of the more than 102,000 female OEF/OIF veterans, over
45,000 have enrolled in VA health care and nearly 20,000 of these women
use the system for between 2 and 10 visits. Among these returning women
veterans, 85 percent are below the age of 40 and 58 percent are between
20 and 29. In fact, the average age of female veterans using the VA
health care system is 48 compared to 61 for men. The needs of women
veterans are growing and already taxing the VA system, which
historically has focused on an older population of men.
The primary barriers women veterans face in accessing VA health
care across the country are:
Lack of reliable transportation
Unavailability of childcare
Lack of integrated primary care and mental health care
Lack of gender sensitivity of health care providers and
staff to women-specific issues
Limited hours of women veterans clinics, particularly for
working women
Women veterans clinics that are difficult to locate or
are not perceived as personally safe and comfortable for women veterans
and their children
Unsafe inpatient VA health facilities for women veterans
VA Medical Centers (VAMCs) do not consistently assess and treat
domestic violence victims across the country. VA medical providers must
be trained to ensure women veterans who are victims of domestic
violence are treated to the standards set forth by the Joint Commission
on Accreditation of Healthcare Organizations and that State reporting
requirements are met. Domestic violence is an area where central
oversight is necessary to ensure VAMCs are better able to serve victims
of violence, perhaps by placing the program under the Women's Mental
Health Program in the Office of Mental Health Services and including
domestic violence initiatives in VA's Uniform Mental Health Services
Package, these objectives could be met.
Mammography is another area that quality care is an accident of
geography for women veterans. There is no formal program for tracking
mammography results and follow-up of abnormal mammograms to ensure
women veterans receive consistent, timely, and high-quality care. We
suspect Congress would be appalled by the differences in timeliness-to-
treatment data for abnormal mammograms at VAMCs across the Nation.
Women Veterans Benefits
Because females are officially excluded from ``combat roles'' in
the military, women veterans have a greater burden of proof in
establishing the link between PTSD and combat. There is no such thing
as an ``infantry woman,'' so women who are supply clerks, mechanics,
and truckdrivers are going on combat patrols with the infantry and the
Marines. Because there is no clear frontline on the ground in Iraq and
Afghanistan, female service Members are exposed to direct fire,
Improvised Explosive Devices (IEDs), and constant threats from
insurgents without the benefit of the awards and decorations to prove
it. NASWVC wholeheartedly endorses H.R. 952, which would amend Title 38
to presume service-connection for PTSD based solely on a service
Member's presence in a combat zone. This legislation would not only
appropriately recognize the service and sacrifice of women veterans; it
would significantly decrease the backlog of VA claims for our combat
veterans.
Sexual harassment and sexual assault are far too prevalent in the
military; with the Pentagon confirming 1 out of 3 women who served her
country have been the victim of sexual assault. Psychiatric conditions
related to trauma have a devastating effect on women veterans health
functioning. NASWVC strongly supports the VA Advisory Committee on
Women Veterans' recommendation that VBA develop the ability to identify
and track the status and outcome of all claims related to personal/
sexual assault, not just the claims that happen to have been entered as
such in the claims processing system and not just the claims of women
veterans who have sought treatment at the VA. The Veterans Benefits
Administration (VBA) cannot currently speak with any authority as to
the number of Military Sexual Trauma (MST) related claims submitted
annually, the processing times for these claims, the rate compensation
is granted or denied, or the types of disabilities that are most often
associated with MST. The development of tracking systems could further
guide studies and research on all aspects of MST.
Just as more data is needed to assess the health needs and outcomes
of women veterans, so is more data needed to evaluate women veterans'
access to and receipt of VA compensation and pension benefits. VBA must
establish a method to consistently identify and track claims outcomes
for veterans by gender.
Mental Healthcare for Women Veterans
There are insufficient therapists licensed and experienced in
counseling sexual trauma victims in the VA system to provide
appropriate care for women veterans at VAMCs, clinics and Vet Centers.
Additionally, many women are not comfortable with male therapists or
mixed gender therapeutic groups. Women veterans should have the option
to use fee-based services to obtain mental health care if a qualified
MST counselor is not available or if a woman provider and/or women's
groups are not available.
Communication Within VA
The Veterans Health Administration (VHA) and the VBA obviously
deliver separate and distinct services to veterans. However, they serve
the same population and therefore, they should routinely communicate
with one another and ideally their information technology systems
should be linked. When veterans report something as simple as a change
of address or more importantly are granted a benefit, VBA does not
communicate the change to VHA even though it is likely to directly
impact enrollment, eligibility, and payment for VA health care. This
lack of communication adds to VA's image as a cumbersome and
unresponsive organization. Improvements in the ability of organizations
within VA to more effectively communicate would enhance the agency's
service capability to veterans.
Outreach to Women Veterans
While growth has occurred in VA health care due to increased
funding and improved access with Community Based Outpatient Clinics,
many women veterans are still shortchanged because they live in rural
areas or they lack information and awareness of their benefits. VA and
State Departments of Veterans Affairs must reduce this inequity by
reaching out to women veterans regarding their rights and entitlements.
NASWVC suggests implementation of a grant program that would allow VA
to partner with the State Women Veterans Coordinators to perform
outreach specifically targeted to women veterans at the local level.
Memorial Affairs
Although this is not a women veteran specific issue, NASWVC
strongly recommends the Plot Allowance for veterans' interment be
increased to $1,000. The average operational cost of interment in a
State veterans cemetery is over $2,000. This adds to the fiscal burden
of many State Departments of Veterans Affairs. The current burial plot
allowance of $300 per qualified interment provides less than 15 percent
of the average cost of interment. NASWVC recommends the Plot Allowance
be increased to $1,000 in order to offset operational costs. The
increase should also apply to the Plot Allowance for veterans'
interment in private cemeteries.
CONCLUSION
Mr. Chairman and distinguished Members of the Subcommittees, we
respect the important work you are doing to improve support and
services to women veterans who answered the call to serve our country.
NASWVC remains dedicated to doing our part, but we urge you to be
mindful of the increasing financial challenge that States face, just as
you address the fiscal challenge at the Federal level. I would like to
emphasize again, that we are advocates for women veterans and partners
with VA in ensuring equitable delivery of benefits and services to our
women
patriots.
This concludes my statement and I am happy to respond to your
questions.
__________
Biography for
First Sergeant (Retired) Pamela J.B. Cypert, M.Ed., LPCA,
Executive Advisor-Field Operations,
Kentucky Department of Veterans Affairs
First Sergeant (Retired) Pamela Cypert entered the Army directly
after graduating from High School in 1982. She completed Basic Training
and Advanced Individual Military Police Training at Fort McClellan,
Alabama and went on to successfully complete Basic Airborne Training at
Fort Benning, Georgia in 1983.
Throughout her 21 year career as a military police officer, 1SG
Cypert's leadership positions included team leader, squad leader,
platoon sergeant, drill sergeant, senior drill sergeant, instructor,
personal security agent, military police assignment manager, operations
sergeant and first sergeant. 1SG Cypert broke several barriers as a
female soldier. She was the first of her gender ever selected
Installation Drill Sergeant of the Year for Fort McClellan, Alabama,
she was the first female First Sergeant of an Airborne Military Police
Co. in the U.S. Army and she was the first female paratrooper in her
brigade to attain the prestigious title of a Centurion Jumper. She is a
Master Jumpmaster with over 100 military parachute jumps. Her duty
stations included Fort Bliss, Texas; Fort McClellan, Alabama;
Stuttgart, Germany; Department of the Army, Alexandria, Virginia; Fort
Myers, Virginia; and Fort Bragg, North Carolina.
1SG Cypert attended the full complement of military leadership
schools, culminating with the First Sergeant Course. In addition to her
entry-level training, she also successfully completed Drill Sergeant
School, Air Assault School, the Master Fitness Training Course, Rappel
Master School, the Protective Services Training Course, three Counter-
Terrorism Evasive Driving Courses, and the Advanced Airborne School's
Jumpmaster Course. She earned her Bachelor of Science Degree in
Psychology from Fayetteville State University, her Masters of Education
Degree in Mental Health Counseling from the University of Louisville,
and is a Licensed Professional Counseling Associate in the State of
Kentucky.
1SG Cypert's awards include six Meritorious Service Medals, three
Army Commendation Medals, seven Army Achievement Medals, the Joint
Meritorious Unit Award, seven Good Conduct Medals, two National Defense
Service Medals, the Master Parachutist Badge, Drill Sergeant
Identification Badge, Air Assault Badge, Gold German Armed Forces
Proficiency Badge, and German Parachutist Badge.
Upon her retirement from the Army in 2003, Mrs. Cypert began her
career in State government. She is currently an Executive Advisor for
the Kentucky Department of Veterans Affairs and the Women Veterans
Coordinator for the Commonwealth of Kentucky. She serves her community
as a therapist with Shelby Counseling Associates and resides in
Shelbyville, Kentucky with her husband, Tom and her youngest daughter,
Heather.
__________
BERTHA CRUZ HALL
Bertha Cruz Hall served in the U.S. Air Force from August 1968 to
August 1972. She worked in Personal Affairs and assisted survivors of
servicemen to obtain their benefits.
Immediately after her discharge from the Air Force she went to work
for the Texas Veterans Commission.
She retired as a Veterans Assistance Counselor Supervisor in 2002
with 30 years of service. She was the first Women Veterans Coordinator
for the State of Texas and held that title until her retirement. She
received numerous honors throughout her career from Service and
community organizations.
Bertha was appointed by the Secretary of Veterans Affairs to serve
on the VA Advisory Committee on Women Veterans in 1998 and served until
the expiration of her second term in 2004. She has served as a Member
and secretary of the Tarrant County Veterans Council; District Service
Officer for the American Legion; Adjutant of the Disabled American
Veterans Chapter 20, and Director VIP of the 20/4 Honor Society of
Women Legionnaires, Echelon 31 of Texas.
Bertha currently serves on the Fort Worth Homeless Veteran Program
and holds the office of secretary/treasurer. She serves on the Board of
Directors to the National Association of Women Veteran Coordinators,
Inc. and hold the office of Treasurer. She serves on the Board and
holds the office of Treasurer for the Disabled Veteran National
Foundation.
She resides in Hurst, Texas with her husband, Frank. They have 2
children and 4 grandchildren.
Statement of Kayla M. Williams, MA, Member, Board of Directors,
Grace After Fire, Author, Love My Rifle More Than You:
Young and Female in the U.S. Army
Chairmen and Members of the Subcommittees, thank you for hearing me
speak today. On behalf of women veterans, I would like to thank you all
for your commitment to meeting the changing needs of our Nation's
veterans.
My name is Kayla Williams. As a Soldier with the 101st Airborne
Division (Air Assault), I took part in the initial invasion of Iraq in
2003, and was there for approximately 1 year. As an Arabic linguist, I
went on combat foot patrols with the Infantry in Baghdad. During the
initial invasion, my team came under small arms fire. Later, in Mosul,
we were mortared regularly. I served right alongside my male peers:
with our flak vests on during missions, we were all truly Soldiers
first. However, it became--was clear upon our return that most people
did not understand what women in today's military experience. I was
asked whether as a woman I was allowed to carry a gun, and was also
asked if I was in the Infantry. This confusion about the role of women
in the military today extends beyond the general public. Women veterans
are less likely to self-identify as veterans, which is the first
barrier to accessing benefits: you must be aware that you are eligible
for them! An active outreach program for those leaving military service
is crucial, but insufficient. Women who served in previous eras must
also be made aware of their eligibility for veterans' benefits and
health care through vigorous outreach and education.
Even Veterans Affairs (VA) employees are still sometimes unclear on
the nature of modern warfare, which presents challenges for women
seeking care. For example, being in combat is linked to post-traumatic
stress disorder (PTSD), but since women are supposedly barred from
combat, they may face challenges proving that their PTSD is service-
connected. One of my closest friends was told by a VA doctor that she
could not possibly have PTSD for just this reason: he did not believe
that she as a woman could have been in combat. It is vital that all VA
employees, particularly health care providers, fully understand that
women do see combat in Operations Iraqi Freedom and Enduring Freedom so
that they can better serve women veterans.
Many of the other problems that women face when seeking to get
health care or benefits through the VA are by no means exclusive to
women: the transition from DoD to VA remains imperfect, despite efforts
to improve the process. Lost records and missing paperwork are frequent
complaints. The backlog of unprocessed disability claims is now over
400,000; though average processing time has declined, it is still over
5 months long.\1\ Efforts to alleviate this problem are laudable and
must be continued. Adequate training of claims processors is also
vital; inconsistencies in disability ratings has resulted in thousands
of dollars in annual payment differences for veterans with similar
disabilities.\2\
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\1\ Dao, James. ``Veterans Affairs Faces Surge of Disability
Claims,'' New York Times, 12JUL09. http://www.nytimes.com/2009/07/13/
us/13backlog.html?em.
\2\ Maze, Rick, ``Disability Pay Can Depend on Where You Live,''
Army Times, 17OCT07. http://www.armytimes.com/news/2007/10/
military_states_disabilitypayments_071016w/.
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Despite a growing number of community clinics and vet centers, many
veterans face lengthy travel times to reach a VA facility--a particular
burden during tough economic times. The falling housing market has also
hit veterans as it has so many other segments of the population. When
we bought in the DC area, for example, the average home price exceeded
the VA maximum; now that the value of our house has fallen we are
unable to refinance to a lower VA-backed rate despite the increased
loan ceiling because we owe more than our home is worth.
The Post-9/11 GI Bill, a significant improvement that will allow
many thousands of veterans the chance to attain first-rate educations,
does still have gaps. For example, time that National Guard Members
have spent while activated under Title 32 for domestic emergencies,
homeland security missions, or serving full-time under the AGR (Active
Guard and Reserve) program does not count toward Post-9/11 GI Bill
eligibility. A legislative fix is required to repair this inequity.\3\
In addition, while time in brick-and-mortar schools may be best for
both veterans and their peers, those who are struggling to raise small
children or cope with PTSD may face significant barriers getting into
the classroom. Providing full benefits, including the housing
allowance, would help veterans facing those barriers continue their
educations as well.
---------------------------------------------------------------------------
\3\ Philpott, Tom. ``Many Activated Guard Members Left Out of New
GI Bill Benefits,''
Kitsap Sun, 11JUL09. http://www.kitsapsun.com/news/2009/jul/11/tom-
philpott-many-activated-
guard-members-left/.
---------------------------------------------------------------------------
Other barriers may disproportionately affect women. For example,
since women are more likely to be the primary caregivers of small
children, they may require help getting childcare in order to attend
appointments at the VA. Currently, many VA facilities are not prepared
to accommodate the presence of children; several friends have described
having to change babies' diapers on the floors of VA hospitals because
the restrooms lacked changing facilities. Another friend, whose
babysitter canceled at the last minute, brought her infant and toddler
to a VA appointment; the provider told her that was ``not appropriate''
and that she should not come in if she could not find childcare.
Facilities in which to nurse and change babies, as well as childcare
assistance or at least patience with the presence of small children,
would ease burdens on all veterans with small children.
In addition, military women are far more likely to have suffered
Military Sexual Trauma (MST) than military men. When filing VA
disability claims for MST, there is a real risk that survivors will be
re-traumatized due to lack of sensitivity training for service
providers and because the burden of proof is placed on the survivor of
MST, who must provide written stressor statements, which is not the
case for men presenting with combat-related PTSD. Veterans lacking
lengthy and complete documentation may face significant challenges--yet
the current climate in the military still discourages victims of MST
from coming forward, limiting the likelihood that they will be able to
provide such documentation.
Veterans have made up a disproportionate percentage of the homeless
population for some time. Although the VA has initiatives to try to
help homeless veterans, they are insufficient. In addition, although
the number of homeless women veterans has begun to rise dramatically,
VA programs to serve this population are wholly inadequate: ``within
the VA's homeless shelter system, only 60 percent of shelters can
accept women, and less than 5 percent have programs that target female
veterans specifically or offer separate housing from men,'' a
particular problem for women vets who have suffered MST. In addition,
although 23 percent of female veterans in the VA's homelessness
programs have children under age 18, and meeting their needs is a
significant unmet challenge.\4\
---------------------------------------------------------------------------
\4\ Williamson, Vanessa and Erin Mulhall, ``Coming Home: The
Housing Crisis and Homelessness Threaten New Veterans,'' IAVA Issue
Report, JAN09.
---------------------------------------------------------------------------
Women in the military are also far more likely to be married to
other servicemembers; throughout the Department of Defense (DoD), 51.3
percent of married female enlisted active duty personnel reported being
in dual-service marriages, compared to only 8.1 percent of their male
counterparts.\5\ These women veterans must worry not only about their
own readjustments, but also their husbands' challenges. The VA must
consider the dual role women veterans may be balancing as both givers
and seekers of care.
---------------------------------------------------------------------------
\5\ ``Population Representation in the Military Services,'' Table
3.7, FY2004, available at: http://www.defenselink.mil/prhome/
poprep2004/enlisted_force/marital_status.html.
---------------------------------------------------------------------------
When struggling to cope with invisible wounds of war such as PTSD,
or when simply facing challenges readjusting post-combat, peer support
can be vital. However, there are things about my experience as a woman
in a war zone that my male peers do not understand. They cannot truly
know what it is like to fear not only the enemy, but also sexual
assault from your brothers in arms. They may be aware of, but not be
able to fully empathize with, the challenges of facing regular sexual
harassment. And they certainly do not understand what it is like to
feel invisible as a veteran, as many women veterans do. It is therefore
vital that the VA provide times or places where women veterans,
especially those who may have experienced military sexual trauma, can
feel safe and comfortable seeking help in a community of their peers.
This could come in the form of women-only clinics or even days, as well
as starting women-only group therapy sessions.
In order to best meet the needs of all veterans, I also urge the
development of enhanced relationships not only between the DoD and VA
but also with those community organizations that are ready and willing
to fill gaps in services. Public-private partnerships can allow all of
us to come together to meet the needs of our veterans in innovative and
exciting ways.
Thank you for working to assess the VA's gaps in and barriers to
benefits and health care services for women veterans, and for your
efforts to help all our Nation's veterans.
Prepared Statement of Randall B. Williamson, Director, Health Care,
U.S. Government Accountability Office
VA Health Care
Preliminary Findings on VA's Provision of Health Care
Services to Women Veterans
GAO Highlights
Why GAO Did This Study
Historically, the vast majority of VA patients have been men, but
that is changing. VA provided health care to over 281,000 women
veterans in 2008--an increase of about 12 percent since 2006--and the
number of women veterans in the United States is projected to increase
by 17 percent between 2008 and 2033. Women veterans seeking care at VA
medical facilities need access to a full range of health care services,
including basic gender-specific services--such as cervical cancer
screening--and specialized gender-specific services--such as treatment
of reproductive cancers.
This testimony, based on ongoing work, discusses GAO's preliminary
findings on (1) the on-site availability of health care services for
women veterans at VA facilities, (2) the extent to which VA facilities
are following VA policies that apply to the delivery of health care
services for women veterans, and (3) some key challenges that VA
facilities are experiencing in providing health care services for women
veterans. GAO reviewed applicable VA policies, interviewed officials,
and visited 19 medical facilities--9 VA medical centers (VAMC) and 10
community-based outpatient clinics (CBOC)--and 10 Vet Centers. These
facilities were chosen based in part on the number of women using
services and whether facilities offered specific programs for women.
The results from these site visits cannot be generalized to all VA
facilities. GAO shared this statement with VA officials, and they
generally agreed with the information presented.
What GAO Found
The VA facilities GAO visited provided basic gender-specific and
outpatient mental health services to women veterans on-site, and some
facilities also provided specialized gender-specific or mental health
services specifically designed for women on-site. Basic gender-specific
services, including pelvic examinations, were available on-site at all
nine VAMCs and 8 of the 10 CBOCs GAO visited. Almost all of the medical
facilities GAO visited offered women veterans access to one or more
female providers for their gender-specific care. The availability of
specialized gender-specific services for women, including treatments
after abnormal cervical cancer screenings and breast cancer, varied by
service and facility. All VA medical facilities refer female patients
to non-VA providers for obstetric care. Some of the VAMCs GAO visited
offered a broad array of other specialized gender-specific services on
site, but all contracted or fee-based at least some services. Among
CBOCs, the two largest facilities GAO visited offered an array of
specialized gender-specific care on-site; the other eight referred
women to other VA or non-VA facilities for most of these services.
Outpatient mental health services for women were widely available at
the VAMCs and most Vet Centers GAO visited, but were more limited at
some CBOCs. While the two larger CBOCs offered group counseling for
women and services specifically for women who have experienced sexual
trauma in the military, the smaller CBOCs tended to rely on VAMC staff,
often through videoconferencing, to provide mental health services.
The extent to which the VA medical facilities GAO visited were
following VA policies that apply to the delivery of health care
services for women veterans varied, but none of the facilities had
fully implemented these policies. None of the VAMCs and CBOCs GAO
visited were fully compliant with VA policy requirements related to
privacy for women veterans in all clinical settings where those
requirements applied. For example, many of the medical facilities GAO
visited did not have adequate visual and auditory privacy in their
check-in areas. Further, the facilities GAO visited were in various
stages of implementing VA's new initiative to provide comprehensive
primary care for women veterans, but officials at some VAMCs and CBOCs
reported that they were unclear about the specific steps they would
need to take to meet the goals of the new policy.
Officials at facilities that GAO visited identified a number of
challenges they face in providing health care services to the
increasing numbers of women veterans seeking VA health care. One
challenge was that space constraints have raised issues affecting the
provision of health care services. For example, the number, size, or
configuration of exam rooms or bathrooms sometimes made it difficult
for facilities to comply with VA requirements related to privacy for
women veterans. Officials also reported challenges hiring providers
with specific training and experience in women's health care and in
mental health care, such as treatment for women veterans with post-
traumatic stress disorder or who had experienced military sexual
trauma.
__________
Mr. Chairmen and Members of the Subcommittees:
I am pleased to be here today as the Subcommittees consider issues
related to the Department of Veterans Affairs' (VA) delivery of health
care services to women veterans. Historically, the vast majority of VA
patients have been men, but that is changing. As of October 2008, there
were more than 1.8 million women veterans in the United States
(representing approximately 7.7 percent of the total veteran
population), and more than 102,000 of these women were veterans of the
military operations in Afghanistan and Iraq, known as Operation
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). According to
VA data, in fiscal year 2008, over 281,000 women veterans received
health care services from VA--an increase of about 12 percent since
2006. Looking ahead, VA estimates that while the total number of
veterans will decline by 37 percent between 2008 and 2033, the number
of women veterans will increase by more than 17 percent over the same
period.
The health care services needed by women veterans are significantly
different from those required by their male counterparts. Women
veterans are younger, in the aggregate, than their male counterparts.
Based on an analysis conducted by the VA in 2007, the estimated median
age of women veterans was 47, whereas the estimated median age of male
veterans was 61. Women veterans seeking care at VA medical facilities
need access to a full range of physical health care services, including
basic gender-specific services--such as breast examinations, cervical
cancer screening, and menopause management--and specialized gender-
specific services such as obstetric care (which includes prenatal,
labor and delivery, and postpartum care) and treatment of reproductive
cancers. Women veterans also need access to a range of mental health
care services, such as care for depression.
In addition, women veterans of OEF/OIF present new challenges for
VA's health care system. Almost all of these women are under the age of
40--58 percent are between the ages of 20 and 29. VA data show that
almost 20 percent of women veterans of OEF/OIF have been diagnosed with
post-traumatic stress disorder (PTSD).\1\ Additionally, an alarming
number of them have experienced sexual trauma while in the military.\2\
As a result, many women veterans of OEF/OIF have complex physical and
mental health care needs.
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\1\ PTSD may develop following exposure to combat, natural
disasters, terrorist incidents, serious accidents, or violent personal
assaults like rape. People who experience stressful events often relive
the experience through nightmares and flashbacks, have difficulty
sleeping, and feel detached or estranged. These symptoms can occur
within the first few days after exposure to the stressful event but may
also be delayed for months or years. If symptoms continue for more than
30 days and significantly disrupt an individual's daily activities, a
diagnosis of PTSD is made.
\2\ VA defines military sexual trauma (MST) as ``psychological
trauma, which in the judgment of a VA mental health professional
resulted from a physical assault of a sexual nature, battery of a
sexual nature, or sexual harassment which occurred while the veteran
was serving on active duty or active duty for training.'' VA reported
that in fiscal year 2008, 21 percent of women screened for MST,
screened positive for having experienced MST.
---------------------------------------------------------------------------
Congress and others have raised concerns about how well VA is
prepared to meet the physical and mental health care needs of the
growing number of women veterans, particularly veterans of OEF/OIF.
Traditionally, women veterans have utilized VA's health care services
less frequently than their male counterparts. In fiscal year 2007, 15
percent of women veterans used VA's health care services, compared to
22 percent of male veterans. VA believes that part of this difference
may be attributable to barriers that the current care models at many VA
medical facilities present to women veterans. For example, women
veterans have often been required to make multiple visits to a VA
facility in order to receive the full spectrum of primary care
services, which includes such basic gender-specific care as cervical
cancer screenings and breast examinations. Because many of these women
work or have child care responsibilities, multiple visits can be
problematic, especially when services are not available in the evenings
or on weekends.
VA has taken some steps to improve the availability of services for
women veterans, including requiring that all VA medical facilities make
the Women Veterans Program Manager (WVPM)--an advocate for the needs of
women veterans--a full-time position and providing funding for
equipment to help VA medical facilities improve health care services
for women veterans. Additionally, in November 2008, VA began a
systemwide initiative to make comprehensive primary care for women
veterans available at every VA medical facility--VA medical centers
(VAMC) and community-based outpatient clinics (CBOC). In announcing
this initiative, VA established a policy defining comprehensive primary
care for women veterans as the availability of complete primary care--
including routine detection and management of acute and chronic
illness, preventive care, gender-specific care, and mental health
care--from one primary care provider at one site.
You asked us to examine VA's health care services for women
veterans. In my testimony today, I will discuss our preliminary
findings, based on visits to selected VA facilities, regarding (1) the
on-site availability of health care services at VA facilities for women
veterans, (2) the extent to which VA facilities are following VA
policies that apply to the delivery of health care services for women
veterans, and (3) some key challenges that VA facilities are
experiencing in providing health care services for women veterans.\3\
---------------------------------------------------------------------------
\3\ See GAO, VA Health Care: Preliminary Findings on VA's Provision
of Health Care Services to Women Veterans, GAO-09-884T (Washington,
D.C.: July. 14, 2009).
---------------------------------------------------------------------------
To examine the availability of health care services at VA
facilities for women veterans and to determine the extent to which VA
facilities are following VA policies that apply to the delivery of
health care services for women veterans, we reviewed applicable VA
policies \4\ and available VA data, and interviewed officials from VA
headquarters, Veterans Integrated Service Networks (VISN),\5\ and VA
facilities. In addition, we conducted site visits to a judgmental
sample of nine VAMCs located in Atlanta and Dublin, Georgia; San Diego
and Long Beach, California; Minneapolis and St. Cloud, Minnesota; Sioux
Falls, South Dakota; and Temple and Waco, Texas. We also visited 10 VA
CBOCs affiliated with these nine VAMCs, and eight Vet Centers, which
are counseling centers that help combat veterans readjust from wartime
military service to civilian life. We used VA data to select these
sites based on several factors, including the number of women veterans
using health care services at each VAMC and whether facilities offered
specific programs for women veterans, such as outpatient or residential
treatment programs for women who have PTSD or have experienced military
sexual trauma (MST). See appendix I for additional details on the
selection criteria we used and information on the number of women
veterans using health care services at each VAMC and CBOC we visited.
To further examine the availability of services for women veterans, we
obtained information from each VAMC and CBOC regarding the organization
and availability of primary care services, basic gender-specific
services, specialized gender-specific services, and mental health
services in outpatient, residential, and inpatient settings; and the
availability of specific clinical services such as prenatal care,
osteoporosis treatment, mammography, and counseling for MST. When
services were not available on site, we determined whether they were
available through fee-for-service arrangements (fee basis), contracts,
or sharing agreements with non-VA facilities. During our site visits we
also toured each facility and documented observations of the physical
space in each care setting. We examined how facilities were
implementing VA policies pertaining to ensuring the privacy of women
veterans in outpatient, residential, and inpatient care settings; and
VA's model of comprehensive primary care for women veterans. Finally,
to identify key challenges that VA facilities are experiencing in
providing health care services for women veterans, we reviewed relevant
literature; interviewed VA officials in headquarters, medical
facilities, and Vet Centers; interviewed VA experts in the area of
women veterans' health; and documented challenges observed during our
site visits. The findings of our site visits to VA facilities cannot be
generalized to other VA facilities. We shared the information contained
in this statement with VA officials, and they generally agreed with the
information we presented.
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\4\ The scope of services VA requires to be provided to women
veterans, including requirements for ensuring the privacy of women
veterans, are outlined in Veterans Health Administration (VHA) Handbook
1330.1, and the requirements for WVPM are outlined in VHA Handbook
1330.02 and in a July 2008 VA directive titled ``Women Veteran Program
Managers Full-Time FTEE Positions.''
\5\ The management of VAMCs and CBOCs is decentralized to 21
regional networks referred to as VISNs.
---------------------------------------------------------------------------
We conducted our performance audit from July 2008 through July 2009
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
Health Care System
VA's integrated health care delivery system is one of the largest
in the United States and provides enrolled veterans, including women
veterans, with a range of services including primary and preventive
health care services, mental health services, inpatient hospital
services, long-term care, and prescription drugs.\6\ VA's health care
system is organized into 21 VISNs that include VAMCs and CBOCs. VAMCs
offer outpatient, residential, and inpatient services. These services
range from primary care to complex specialty care, such as cardiac and
spinal cord injury care. VAMCs also offer a range of mental health
services, including outpatient counseling services, residential
programs--which provide intensive treatment and rehabilitation
services, with supported housing, for treatment, for example, of PTSD,
MST, or substance use disorders--and inpatient psychiatric treatment.
CBOCs are an extension of VAMCs and provide outpatient primary care and
general mental health services on site. VA also operates 232 Vet
Centers, which offer readjustment and family counseling, employment
services, bereavement counseling, and a range of social services to
assist combat veterans in readjusting from wartime military service to
civilian life.\7\
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\6\ See 38 U.S.C. Sec. 1710(a), 38 CFR Sec. 17.38 (2008). Any
veteran who has served in a combat theater after November 11, 1998,
including OEF/OIF veterans, and who was discharged or released from
active service on or after January 28, 2003, has up to 5 years from the
date of the veteran's most recent discharge or release from active duty
service to enroll in VA's health care system and receive VA health care
services. See 38 U.S.C.Sec. 1710(e)(1)(D), (e)(3)(C). Veterans who
were discharged or released before January 28, 2003, and who did not
enroll in VA's health care system are eligible for these VA health care
services for 3 years after January 28, 2008.
\7\ All veterans who have served in a combat theater, including
OEF/OIF veterans, are eligible for Vet Center services. See 38 U.S.C.
Sec. 1712A(a).
---------------------------------------------------------------------------
When VA facilities are unable to efficiently provide certain health
care services on site, they are authorized to enter into agreements
with non-VA providers to ensure veterans have access to medically
necessary services.\8\ Specifically, VA facilities can make services
available through:
---------------------------------------------------------------------------
\8\ See 38 U.S.C. Sec. 1703.
referral of patients to other VA facilities or use of
telehealth services,\9\
---------------------------------------------------------------------------
\9\ Telehealth is the provision of health services from a distance
using telecommunications technologies, such as videoconferencing.
---------------------------------------------------------------------------
sharing agreements with university affiliates or
Department of Defense medical facilities,
contracts with providers in the local community, or
allowing veterans to receive care from providers in the
community who will accept VA payment (commonly referred to as fee-basis
care).
VA Policies Pertaining to Women's Health
Federal law authorizes VA to provide medically necessary health
care services to eligible veterans, including women veterans.\10\
Federal law also specifically requires VA to provide mental health
screening, counseling, and treatment for eligible veterans who have
experienced MST.\11\ Although the MST law applies to all veterans, it
is of particular relevance to women veterans because among women
veterans screened by VA for MST, 21 percent screened positive for
experiencing MST. VA provides health care services to veterans through
its medical benefits package--health care services required to be
provided are broadly stated in a regulation and further specified in VA
policies. Through policies, VA requires its health care facilities to
make certain services, including gender-specific services and primary
care services, available to eligible women veterans.\12\ Gender-
specific services that are included in the VA medical benefits package
\13\ include, for example, cervical cancer screening, breast
examination, management of menopause, mammography, obstetric care, and
infertility evaluation. See table 1 for a list of selected basic and
specialized gender-specific services that VA is required to make
available and others that VA may make available to women veterans.
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\10\ 38 U.S.C. Sec. 1710.
\11\ 38 U.S.C. Sec. 1720D.
\12\ These services are defined in VHA Handbook 1330.1, VHA
Services for Women Veterans (revised July 16, 2004) and VHA Handbook
1160.01, Uniform Mental Health Services in VA Medical Centers and
Clinics (Sept. 11, 2008).
\13\ See 38 CFR Sec. 17.38 (2008).
Table 1: Selected Clinical Services That VA Is Required to Make
Available and Others That VA May Make Available to Women Veterans, by
Category
------------------------------------------------------------------------
Services that VA medical
facilities may make
available to women veterans
------------------------------------------------------------------------
Primary care/basic gender-specific Intake and initial
services a assessment, including
screening for military
sexual trauma (MST) b
Routine physical
exams
Intimate partner
violence screening
Smoking cessation
counseling
Smoking cessation
treatment
Nutrition
counseling
Weight management
and fitness
Urgent/emergent
gender-related care--normal
hours
Urgent/emergent
gender-related care--
evenings, weekends, and
holidays
Pelvic examination
b
Clinical breast
examination b
Education on
performing breast self-
examination b
Cervical cancer
screening b
Menopause
management b
Uncomplicated
vulvovaginitis treatment b
Osteoporosis
screening b
Osteoporosis
treatment b
Hormone replacement
therapy b
Prescription of
oral contraceptives b
------------------------------------------------------------------------
Specialized gender-specific services a Treatment after
abnormal cervical cancer
screening b
Surgical
sterilization--evaluation b
Surgical
sterilization
Sexually
transmitted disease (STD)
screening
STD counseling
STD treatment
Intrauterine device
(IUD) placement
Pregnancy test--
urine
Pregnancy test--
serum
Prenatal care
Labor and delivery
Postpartum care
Infertility
evaluation b
Endometriosis
treatment
Evaluation of
polycystic ovarian syndrome
b
Treatment of
polycystic ovarian syndrome
b
Screening
mammography b
Diagnostic
mammography
Surgical treatment
of breast cancer b
Surgical treatment
of reproductive cancer b
Medical treatment
of breast cancer b
Medical treatment
of reproductive cancer b
------------------------------------------------------------------------
Source: GAO review of VA data.
Notes: The data are from a review of VHA Handbook 1330.1 and VA's annual
Plan of Care and Clinical Inventory Survey.
a The distinction between ``basic'' and ``specialized'' gender-specific
services is based on the definitions included in VHA Handbook 1330.1
and the 2003 article by Yano and Washington. Elizabeth Yano and Donna
Washington, ``Availability of Comprehensive Women's Health Care
Through Department of Veterans Affairs Medical Center.'' Published by
Donna Washington, et al., in Women's Health Issues, v. 13 (2003).
b Denotes a service that VA medical facilities are required to make
available to women veterans, based on VHA Handbook 1330.1.
In November 2008, VA established a policy that requires all VAMCs
and CBOCs to move toward making comprehensive primary care available
for women veterans. VA defines comprehensive primary care for women
veterans as the availability of complete primary care--including
routine detection and management of acute and chronic illness,
preventive care, basic gender-specific care, and basic mental health
care--from one primary care provider at one site. VA did not establish
a deadline by which VAMCs and CBOCs must meet this requirement.
VA policies also outline a number of requirements specific to
ensuring the privacy of women veterans in all settings of care at VAMCs
and CBOCs.\14\ These include requirements related to ensuring auditory
and visual privacy at check-in and in interview areas; the location of
exam rooms, presence of privacy curtains, and the orientation of exam
tables; access to private restrooms in outpatient, inpatient, and
residential settings of care; and the availability of sanitary products
in public restrooms at VA facilities.
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\14\ VHA Handbook 1160.01 and VHA Handbook 1330.1.
---------------------------------------------------------------------------
In 1991, VA established the position of Women Veteran Coordinator--
now the WVPM--to ensure that each VAMC had an individual responsible
for assessing the needs of women veterans and assisting in the planning
and delivery of services and programs to meet those needs. Begun as a
part-time collateral position, the WVPM is now a full-time position at
all VAMCs. In July 2008, VA required VAMCs to establish the WVPM as a
full-time position (no longer a collateral duty) no later than December
1, 2008. Clinicians in the role of WVPM would be allowed to perform
clinical duties to maintain their professional certification,
licensure, or privileges, but must limit the time to the minimum
required, typically no more than 5 hours per week.
VA Mental Health Services
In September 2008, VA issued the Uniform Mental Health Services in
VA Medical Centers and Clinics,\15\ a policy that specifies the mental
health services that must be provided at each VAMC and CBOC.\16\ The
purpose of this policy is to ensure that all veterans, wherever they
obtain care in VA's health care system, have access to needed mental
health services. The policy lists the mental health care services that
must be delivered on site or made available by each facility. To help
ensure that mental health staff can provide these services, VA has
developed and rolled out evidence-based \17\ psychotherapy training
programs for VA staff that treat patients with PTSD, depression, and
serious mental illness. VA's training programs cover five evidence-
based psychotherapies: Cognitive Processing Therapy (CPT) and Prolonged
Exposure (PE), which are recommended for PTSD; Cognitive Behavioral
Therapy (CBT) and Acceptance and Commitment Therapy (ACT), which are
recommended for depression; and Social Skills Training (SST), which is
recommended for serious mental illness. The training programs involve
two components: (1) attendance at an in-person, experientially based,
workshop (usually 3-4 days long), and (2) ongoing telephone-based
small-group consultation on actual therapy cases with a consultant who
is an expert in the psychotherapy.
---------------------------------------------------------------------------
\15\ VHA Handbook 1160.01.
\16\ The mental health services that must be provided in CBOCs
differ according to the size of the clinics.
\17\ Psychotherapies that have consistently been shown in
controlled research to be effective for a particular condition or
conditions are referred to as ``evidence-based.''
---------------------------------------------------------------------------
VA Facilities Provided Basic and Specialized Gender-Specific Services
and Mental Health Services to Women Veterans, Though Not All
Services Were Provided On Site at Each VA Facility
The VA facilities we visited provided basic gender-specific and
outpatient mental health services to women veterans on site, and some
facilities also provided specialized gender-specific or mental health
services specifically designed for women on site. All of the VAMCs we
visited offered at least some specialized gender-specific services on
site, and six offered a broad array of these services. Among CBOCs,
other than the two largest facilities we visited, most offered limited
specialized gender-specific care on site. Women needing obstetric care
were always referred to non-VA providers. Regarding mental health care,
we found that outpatient services for women were widely available at
the VAMCs and most Vet Centers we visited, but were more limited at
some CBOCs. Eight of the VAMCs we visited offered mixed-gender
inpatient or residential mental health services, and two VAMCs offered
residential treatment programs specifically designed for women
veterans.
Basic Gender-Specific Care Services Were Generally Available On Site at
VA Medical Facilities
Basic gender-specific care services were available on site at all
nine of the VAMCs and 8 of the 10 CBOCs that we visited. (See table 2.)
These facilities offered a full array of basic gender-specific services
for women--such as pelvic examinations, and osteoporosis treatment--on
site. One of the CBOCs we visited did not offer any basic gender-
specific services on site and another offered a limited selection of
these services. These CBOCs that provided limited basic gender-specific
services referred patients to other VA facilities for this care, but
had plans underway to offer these services on site once providers
received needed training. In general, women veterans had access to
female providers for their gender-specific care: of the 19 medical
facilities we visited, all but 4 had one or more female providers
available to deliver basic gender-specific care.
[GRAPHIC] [TIFF OMITTED] T1873A.001
The facilities we visited delivered basic gender-specific services
in a variety of ways. Seven of the nine VAMCs and the two large CBOCs
we visited had women's clinics. The physical setup of these clinics
ranged from a physically separate dedicated clinical space (at five
facilities) to one or more designated women's health providers with
designated exam rooms within a mixed-gender primary care clinic.
Generally, when women's clinics were available, most female patients
received their basic gender-specific care in those clinics. When
women's clinics were not available, female patients either received
their gender-specific care through their primary care provider or were
referred to another VA or non-VA facility for these services.
Basic gender-specific services were typically available between
8:00 a.m. and 4:30 p.m. on weekdays. At one CBOC and one VAMC, however,
basic gender-specific care was only available during limited
timeframes. At the CBOC, a provider from the affiliated VAMC traveled
to the CBOC 2 days each month to perform cervical cancer screenings and
pelvic examinations for the clinic's female patients. In general,
medical facilities did not offer evening or weekend hours for basic
gender-specific services.
While All VAMCs Offered at Least Some Specialized Gender-Specific
Services On Site, CBOCs Typically Referred Patients Needing These
Services to Other VA or Non-VA Medical Facilities
The provision of specialized gender-specific services for women,
including treatment after abnormal cervical cancer screenings and
breast cancer treatment, varied by service and by facility. (See table
3.) All VA medical facilities referred female patients to outside
providers for obstetric care. Some of the VAMCs we visited offered a
broad array of other specialized gender-specific services on site, but
all contracted or fee-based at least some services. In particular, most
VAMCs provided screening and diagnostic mammography through contracts
with local providers or fee-based these services. In addition, less
than half of the VAMCs provided reconstructive surgery after mastectomy
on site, although six of the nine VAMCs we visited provided medical
treatment for breast cancers and reproductive cancers on site. In
general, the CBOCs we visited offered more limited specialized gender-
specific services on site. For example, while most CBOCs offered
pregnancy testing and sexually transmitted disease (STD) screening,
counseling, and treatment, only the largest CBOCs offered IUD placement
on site. Most CBOCs referred patients to VA medical facilities--
sometimes as far as 130 miles away--for some specialized gender-
specific services. Because the travel distance can be a barrier to
treatment for some veterans, officials at some CBOCs said that they
will fee-base services to local providers on a case-by-case basis. At
both VAMCs and CBOCs, specialized gender-specific services were usually
offered on site only during certain hours: for example, four medical
facilities only offered these services 2 days per week or less.
[GRAPHIC] [TIFF OMITTED] T1873A.002
Outpatient Mental Health Services Were Widely Available at Most VAMCs
and Vet Centers, but More Limited at Smaller CBOCs
A range of outpatient mental health services was readily available
at the VAMCs we visited. The types of outpatient mental health services
available at most VAMCs included, for example, diagnosis and treatment
of depression, substance use disorders, PTSD, and serious mental
illness. All of the VAMCs we visited had one or more providers with
training in evidence-based therapies for the treatment of PTSD and
depression. All but one of the VAMCs we visited offered at least one
women-only counseling group. Two VAMCs offered outpatient treatment
programs specifically for women who have experienced MST or other
traumas. In addition, several VAMCs offered services during evening
hours at least 1 day a week. While most outpatient mental health
services were available on site, facilities typically fee-based
treatment for a veteran with an active eating disorder to non-VA
providers.
Similarly, the eight Vet Centers we visited offered a variety of
outpatient mental health services, including counseling services for
PTSD and depression, as well as individual or group counseling for
victims of sexual trauma. Five of the eight Vet Centers we visited
offered women-only groups, and six had counselors with training or
experience in treating patients who have suffered sexual trauma. Vet
Centers generally offered some counseling services in the evenings.
The outpatient mental health services available in CBOCs were, in
some cases, more limited. The two larger CBOCs offered women-only group
counseling as well as intensive treatment programs specifically for
women who had experienced MST or other traumas, and two other CBOCs
offered women-only group counseling. The smaller CBOCs, however, tended
to rely on staff from the affiliated VAMC, often through telehealth, to
provide mental health services. Five CBOCs provided some mental health
services through telehealth or using mental health providers from the
VAMC that traveled to the CBOCs on specific days.
While Most VAMCs Offer Mixed-Gender Residential or Inpatient Mental
Health Services, Few Have Specialized Programs for Women
Veterans
While most VAMCs offer mixed-gender residential mental health
treatment programs or inpatient psychiatric services, few have
specialized programs for women veterans. Eight of the nine VAMCs we
visited served women veterans in mixed-gender inpatient psychiatric
units, mixed-gender residential treatment programs, or both. Two VAMCs
had residential treatment programs specifically for women who have
experienced MST and other traumas. (VA has ten of these programs
nationally.) None of the VAMCs had dedicated inpatient psychiatric
units for women. VA providers at some facilities expressed concerns
about the privacy and safety of women veterans in mixed-gender
inpatient and residential environments. For example, in the residential
treatment programs, beds for women veterans were separated from other
areas of the building by keyless entry systems. However, female
residents in some of these programs shared common areas, such as the
dining room, with male residents, and providers expressed concerns that
women who were victims of sexual trauma might not feel comfortable in
such an environment.
Medical Facilities Had Not Fully Implemented VA Policies Pertaining to
the Delivery of Health Care Services for Women Veterans
The extent to which VA medical facilities we visited were following
VA policies that apply to the delivery of health care services for
women veterans varied, but none of the facilities had fully implemented
VA policies pertaining to women veterans' health care. In particular,
none of the VAMCs or CBOCs we visited were fully compliant with VA
policy requirements related to privacy for women veterans. In addition,
the facilities we visited were in various stages of implementing VA's
new initiative on comprehensive primary care: most medical facilities
had at least one provider that could deliver comprehensive primary care
services to women veterans, although not all of these facilities were
routinely assigning women veterans to these providers. Officials at
some VA facilities reported that they were unclear about the specific
steps they would need to take to meet VA's definition of comprehensive
primary care for women veterans.
None of the Facilities Were Fully Compliant with VA Policies Related to
Ensuring the Privacy of Women Veterans
None of the VAMCs and CBOCs we visited were fully compliant with VA
policy requirements related to privacy for women veterans in all
clinical settings where those requirements applied. Table 4 summarizes
the extent to which the facilities we visited complied with VA policy
requirements related to privacy for women veterans.
[GRAPHIC] [TIFF OMITTED] T1873A.003
All facilities were fully compliant with at least some of VA's
privacy requirements; however, we documented observations in many
clinical settings where facilities were not following one or more
requirements. Some common areas of noncompliance included the
following:
Visual and auditory privacy at check-in. None of the
VAMCs or CBOCs we visited ensured adequate visual and auditory privacy
at check-in in all clinical settings that are accessed by women
veterans. In most clinical settings, check-in desks or windows were
located in a mixed-gender waiting room or on a high-traffic public
corridor. In some locations, the check-in area was located far enough
away from the waiting room chairs that patients checking in for
appointments could not easily be overheard. In a total of 12 outpatient
clinical settings at six VAMCs and five CBOCs, however, check-in desks
were located in close proximity to chairs where other patients waited
for their appointments. At one CBOC, we observed a line forming at the
check-in window, with several people waiting directly behind the
patient checking in, demonstrating how privacy can be easily violated
at check-in.
Orientation of exam tables. In exam rooms where
gynecological exams are conducted, only one of the nine VAMCs and two
of the eight CBOCs \18\ we visited were fully compliant with VA's
policy requiring exam tables to face away from the door.\19\ In many
clinical settings that were not fully compliant at the remaining
facilities, we observed that exam tables were oriented with the foot of
the table facing the door, and in two CBOCs where exam tables were not
properly oriented, there was no privacy curtain to help assure visual
privacy during women veterans' exams. At one of these CBOCs, a
noncompliant exam room was also located within view of a mixed-gender
waiting room. Figure 1 shows the correct and incorrect orientation of
exam tables in two gynecological exam rooms at two VA medical
facilities.
---------------------------------------------------------------------------
\18\ We visited 10 CBOCs, but 2 of the CBOCs we visited did not
offer gynecological exams.
\19\ According to VA policy, if it is not possible for exam tables
to be placed with the foot facing away from the door, they may be
placed so that they are fully shielded by privacy curtains. However, we
did not observe any clinical settings where it was not possible to
orient exam tables with the foot facing away from the door.
---------------------------------------------------------------------------
Figure 1: Correct and Incorrect Placement of Exam Tables in
Gynecological Exam Rooms at VA Medical Facilities
[GRAPHIC] [TIFF OMITTED] T1873A.004
Restrooms adjacent to exam rooms. Only two of the nine
VAMCs and one of the eight CBOCs we visited were fully compliant with
VA's requirement that exam rooms where gynecological exams are
conducted have immediately adjacent restrooms.\20\ In most of the
outpatient clinics we toured, a woman veteran would have to walk down
the hall to access a restroom, in some cases passing through a high-
traffic public corridor or a mixed-gender waiting room.
---------------------------------------------------------------------------
\20\ We visited 10 CBOCs, but 2 of the CBOCs we visited did not
offer gynecological exams, so this requirement was not applicable at
those 2 CBOCs.
---------------------------------------------------------------------------
Access to private restrooms in inpatient and residential
units. At four of the nine VAMCs we visited, proximity of private
restrooms to women's rooms on inpatient or residential units was a
concern. In one mixed-gender inpatient medical/surgical unit, two
mixed-gender residential units, and one all-female residential unit,
women veterans were not guaranteed access to a private bathing facility
and may have had to use a shared or congregate facility. In two of
these four settings, access to the shared restroom was not restricted
by a lock or a keycard system, raising concerns about the possibility
of intrusion by male patients or staff while a woman veteran is
showering or using the restroom.
Availability of sanitary products in public restrooms. At
seven of the nine VAMCs and all 10 of the CBOCs we visited, we did not
find sanitary napkins or tampons available in dispensers in any of the
public restrooms.
Medical Facilities Were in Various Stages of Implementing VA's
Initiative on Comprehensive Primary Care for Women Veterans, but
Officials at Some Facilities Were Unclear about the Steps Needed to
Implement VA's New Initiative
VA has not set a deadline by which all VAMCs and CBOCs are required
to implement VA's new comprehensive primary care initiative for women
veterans, which would allow women veterans to obtain both primary care
and basic gender-specific services from one provider at one site.
Officials at the VA medical facilities we visited since the
comprehensive primary care for women veterans initiative was introduced
reported that they were at various stages of implementing the new
initiative. Officials at 6 of the 7 VAMCs and 6 of the 8 CBOCs we
visited since November 2008--when VA adopted this initiative--reported
that they had at least one provider who could deliver comprehensive
primary care services to women veterans. However, some of the medical
facilities we visited reported that they were not routinely assigning
women veterans to comprehensive primary care providers.
Officials at some medical facilities we visited were unclear about
the steps needed to implement VA's new policy on comprehensive primary
care for women veterans. For example, at one VAMC, primary care was
offered in a mixed-gender primary care clinic and basic gender-specific
services were offered by a separate appointment in the gynecology
clinic, sometimes on the same day. The new comprehensive primary care
initiative would require both primary care and basic gender specific
services to be available on the same day, during the same appointment.
Officials at this facility said that they were in the process of
determining whether they can adapt their current model to meet VA's
comprehensive primary care standard by placing additional primary care
providers in the gynecology clinic so that both primary care services
and basic gender-specific services could be offered during the same
appointment, in one location. Facility officials were uncertain about
whether it would meet VA's comprehensive primary care standard if
primary care and basic gender-specific services were still delivered by
two different providers. However, VA's comprehensive primary care
policy is clear that the care is to be delivered by the same provider.
Another area of uncertainty is the breadth of experience a provider
would need to meet VA's comprehensive primary care standard. Officials
from VA headquarters have made it clear that it is their expectation
that comprehensive primary care providers have a broad understanding of
basic women's health issues--including initial evaluation and treatment
of pelvic and abdominal pain, menopause management, and the risks
associated with prescribing certain drugs to pregnant or lactating
women. However, in one location, we found that the only provider who
was available to deliver comprehensive primary care may not have had
the proficiency to deliver the broad array of services that are
included in VA's definition, because the facility serves a very low
volume of women veterans and opportunities to practice delivering some
basic gender-specific services are limited.
VA Officials Identified Key Challenges Related to Space,
Hiring Staff with Specific Experience and Training,
and Establishing the WVPM as a Full-time Position
VA officials at medical facilities we visited identified a number
of key challenges in providing health care services to women veterans.
These challenges include physical space constraints that affect the
provision of care, including problems complying with patient privacy
requirements, and difficulties hiring providers that have specific
experience and training in women's health, as well as hiring mental
health providers with expertise in treating veterans with PTSD and who
have experienced MST. Officials at some VA medical facilities also
reported implementation issues in establishing the WVPM as a full-time
position.
VA Facility Officials Identified Space Constraints as a Challenge
Affecting the Provision of Health Care Services to Women
Veterans
Officials at VA medical facilities we visited reported that space
constraints have raised issues affecting the provision of health care
services to women veterans. In particular, officials at 7 of 9 VAMCs
and 5 of 10 CBOCs we visited said that space issues, such as the
number, size, or configuration of exam rooms or bathrooms at their
facilities sometimes made it difficult for them to comply with some VA
requirements related to privacy for women veterans. At some of the
medical facilities we visited, officials raised concerns about busy
waiting rooms and the limited space available to provide separate
waiting rooms for patients who may not feel comfortable in a mixed-
gender waiting room, particularly women veterans who have experienced
MST. Officials at one CBOC said they received complaints from women
veterans who preferred a separate waiting room. At this facility, space
challenges that affected privacy were among the factors that led to the
relocation of mental health services to a separate offsite clinic. VA
facility officials told us that some of the patient bedrooms at two
VAMC mixed-gender inpatient psychiatric units that were usually
designated for female patients were located in space that could not be
adequately monitored from the nursing station. VA policy requires that
all inpatient care facilities provide separate and secured sleeping
accommodations for women and that mixed-gender units must ensure safe
and secure sleeping arrangements, including, but not limited to, the
ability to monitor the patient bedrooms from the nursing station.
VA facility officials also told us they have struggled with space
constraints as they work to comply with VA's new policy on
comprehensive primary care for women and the requirements in the
September 2008 Uniform Mental Health Services in VA Medical Centers and
Clinics, as well as the increasing numbers of women veterans requesting
these services. For example, officials at a VAMC said that limitations
in the number of primary care exam rooms at their facilities made it
difficult for providers to deliver comprehensive primary care services
in an efficient and timely manner. Providers explained that having only
one exam room per primary care provider prevents them from
``multitasking,'' or moving back and forth between exam rooms while
patients are changing or completing intake interviews with nursing
staff. Similarly, mental health providers at a medical facility said
that they often shared offices, which limits the number of counseling
appointments they could schedule, and primary care providers sometimes
have two patients in a room at the same time separated by a curtain
during the intake or screening process. In addition, at one VAMC,
officials reported that the facility needed to be two to three times
its current size to accommodate increasing patient demand.
VA officials are aware of these challenges and VA is taking steps
to address them, such as funding construction projects, moving to
larger buildings, and opening additional CBOCs. However, some of these
projects will not be finished for a few years. In the interim,
officials said, some facilities are leasing additional space or
contracting some services to community providers.
VA Facility Officials Identified Difficulties Hiring Primary Care
Providers with the Specific Training and Experience Needed to Provide
Services to Women Veterans
VA facility officials reported difficulties hiring primary care
providers with specific training and experience in women's health. VA's
comprehensive primary care initiative requires that women veterans have
access to a designated women's health primary care provider that is
``proficient, interested, and engaged'' in delivering services to women
veterans. The new policy requires that this primary care provider
fulfill a broad array of health care services including, but not
limited to:
detection and management of acute and chronic illness,
such as osteoporosis, thyroid disease, and cancer of the breast,
cervix, and lung;
gender-specific primary care such as sexuality,
pharmacologic issues related to pregnancy and lactation, and vaginal
infections;
preventive care, such as cancer screening and weight
management;
mental health services such as screening and referrals
for MST, as well as evaluation and treatment of uncomplicated mental
health disorders and substance use disorders; and
coordination of specialty care.
Officials at some facilities we visited told us that they would
like to hire more providers with the required knowledge and experience
in women's health, but struggle to do so. For example, at one VAMC,
officials reported that they had difficulty filling three vacancies for
primary care providers, which they needed to meet the increasing demand
for services and to replace staff who had retired. They said it took
them a long time to find providers with the skills required to serve
the needs of women veterans. Similarly, at one CBOC, officials reported
that it takes them about 8 to 9 months to hire interested primary care
physicians. Further, officials at some facilities we visited said that
they rely on just one or two providers to deliver comprehensive primary
care to women veterans. This is a concern to the officials because,
should the provider retire or leave VA, the facility might not be able
to replace them relatively quickly in order to continue to provide
comprehensive primary care services to women veterans on site.
VA officials have acknowledged some of the challenges involved in
training additional primary care providers to meet their vision of
delivering comprehensive primary care to women veterans. A November
2008 report on the provision of primary care to women veterans cites
insufficient numbers of clinicians with specific training and
experience in women's health issues among the challenges VA faces in
implementing comprehensive primary care.\21\ To help address the
knowledge gap, VA is using ``mini-residency'' training sessions on
women's health. These training sessions--which VA designed to enhance
the knowledge and skills of primary care providers--consist of two and
one-half days of case-based learning and hands-on training in gender-
specific health care for women. During the mini-residency, providers
receive specific training in performing pelvic examinations, cervical
cancer screenings, clinical breast examinations, and other relevant
skills.
---------------------------------------------------------------------------
\21\ Department of Veterans Affairs, Report of the Under Secretary
for Health Workgroup, Provision of Primary Care to Women Veterans,
Office of Public Health and Environmental Hazards, Women Veterans
Health Strategic Health Care Group (Washington, D.C.: November 2008).
---------------------------------------------------------------------------
VA Medical Facility and Vet Center Officials Identified Challenges
Hiring Mental Health Providers with Training and Experience in Treating
PTSD and MST
VA medical facility and Vet Center officials reported challenges
hiring psychiatrists, psychologists, and other mental health staff with
specialized training or experience in treating PTSD and MST. Medical
facility officials often noted that there is a limited pool of
qualified psychiatrists and psychologists, and a high demand for these
professionals both in the private sector and within VA. In addition,
two officials reported that because it is difficult to attract and hire
mental health professionals with experience in treating the veteran
population, some medical facilities have hired younger, less
experienced providers. These officials noted that while younger
providers may have the appropriate education and training in some
evidence-based psychotherapy treatment methods that are recommended for
treating PTSD and MST, they often lack practical experience treating a
challenging patient population.
Some officials reported that staffing and training challenges limit
the types of group or individual mental health treatment services that
VA medical facilities and Vet Centers can offer. For example, officials
at one VAMC said that they had problems attracting qualified mental
health providers to work at its affiliated CBOCs. The facility posted
announcements for psychiatrist and psychologist positions, but
sometimes received no applications. Because the facility has not been
able to recruit mental health providers, it relies on contract
providers and fee-basing to deliver mental health services to veterans
in its service area. At one Vet Center, officials told us that because
none of their counselors have been trained to counsel veterans who have
experienced MST, patients seeking counseling for MST are usually
referred to the nearby CBOC or VAMC. At one CBOC, a licensed social
worker reported that he provides individual counseling for about seven
women who have experienced MST, even though he has limited training in
this area. He said that this situation was not ideal, but said that he
consults with mental health providers at the associated VAMC on some of
these cases, and that without his services some of these women might
not receive any counseling.
VA officials told us that they are aware of the challenges involved
in finding clinical staff with specialized training and experience in
working with veterans who have PTSD or have experienced MST. A VA
official told us that as part of a national effort to enhance mental
health providers' knowledge of clinically effective treatment methods
and make these methods available to veterans, VA has developed
evidenced-based psychotherapy training for VA mental health staff. In
particular, CPT, PE, and ACT are evidence-based treatment therapies for
PTSD and also commonly used by providers who work with patients who
have experienced MST.\22\ A VA headquarters official who is responsible
for these training programs told us that as of May 4, 2009, 1,670 VA
clinicians had completed VA-provided training in evidence-based
therapies. Although VA is providing training in these evidence-based
therapies, VA officials stated that this training is not mandatory for
VA mental health providers who work with patients who have PTSD or have
experienced MST.
---------------------------------------------------------------------------
\22\ According to VA officials, these therapies address the PTSD
diagnosis commonly associated with sexual trauma. Other diagnoses
commonly associated with MST are depression and generalized anxiety.
---------------------------------------------------------------------------
Some VAMC Officials Reported That Establishing the WVPM as a Full-time
Position Has Raised Implementation Issues
Some VA officials expressed concerns that certain aspects of the
new policymaking the WVPM a full-time position may have the unintended
consequence of discouraging clinicians from applying for or staying in
the position, potentially leading to the loss of experienced WVPMs. One
concern that some WVPMs raised during our interviews was that they were
interested in performing clinical duties beyond the minimum required to
maintain their professional certification, but would not be able to do
so under the new policy. The new policy limits a WVPM's clinical duties
to the minimum required to maintain professional certification,
licensure, or privileges, typically no more than 5 hours per week.
Another concern was that the change to full-time status could result in
a reduction in salary for some clinicians because the position could be
classified as an administrative position, depending on how the policy
is implemented at the VAMC. At two VAMCs we visited, such concerns had
discouraged the incumbent WVPM from accepting the full-time position.
VA headquarters officials told us that they are aware of and have
expressed their concerns to VA senior headquarters officials about
unintended consequences of the new policy. VA headquarters officials
provided VISN and VAMC leadership with some options that they could use
to help avoid or minimize the potential loss of experienced WVPMs. For
example, one option that could be approved on a case-by-case basis is
to use a job-sharing arrangement that would allow the incumbent WVPM
and another person to each dedicate 50 percent of their time to the
WVPM position, performing clinical duties the other 50 percent, in
order to transition staff into the full-time position or as a
succession planning effort. VA headquarters officials said that action
on this issue was important because VA does not have the time or
resources to train new staff to replace experienced WVPMs who may leave
their positions.
Mr. Chairmen, this completes my prepared remarks. I would be happy
to respond to any questions either of you or other Members of the
Subcommittees have at this time.
For further information about this testimony, please contact
Randall Williamson at (202) 512-7114 or [email protected]. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this statement. GAO staff who made
major contributions to this testimony are listed in appendix II.
Appendix I: Information on the Selection of
VA Facilities Examined in This Report
We selected locations for our site visits using VA data on each VA
medical center (VAMC) in the United States. Our goal was to identify a
geographically diverse mix of facilities, including some facilities
that provide services to a high volume of women veterans, particularly
women veterans of Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF); some facilities that serve a high proportion of National
Guard or Reserve veterans; and some facilities that serve rural
veterans. We also considered whether VAMCs had programs specifically
for women veterans, particularly treatment programs for post-traumatic
stress disorder (PTSD) and for women who have experienced military
sexual trauma (MST). For each of the factors listed below, we examined
available facility- or market-level data to identify facilities of
interest:
total number of unique women veteran patients using the
VAMC;
total number of unique OEF/OIF women veteran patients
using the VAMC;
proportion of unique women veterans using the VAMC who
are OEF/OIF veterans;
proportion of unique OEF/OIF women veterans using the
VAMC who were discharged from the National Guard or Reserves;
within the VA-defined market area for the VAMC, the
proportion of women veterans who use VA health care and live in rural
or highly rural areas; and
availability of on-site programs specific to women
veterans, such as inpatient or residential treatment programs that
offer specialized treatment for women veterans with PTSD or who have
experienced MST, including programs that are for women only or have an
admission cycle that includes only women; and outpatient treatment
teams with a specialized focus on MST.
We selected a judgmental sample of the VAMCs that fell into the top
25 facilities for at least two of these factors. Once we had selected
these VAMCs, we also selected at least one community-based outpatient
clinic (CBOC) affiliated with each of the VAMCs and one nearby Vet
Center, which we also visited during our site visits. In selecting
these CBOCs and Vet Centers, we focused on selecting facilities that
represented a range of sizes, in terms of the number of women veterans
they served.
Tables 5 and 6 provide information on the unique number of women
veterans served by each of the VAMCs and CBOCs we selected for site
visits.
Table 5: Women Veterans' Health Care Utilization at Selected VA Medical Centers (VAMC)
----------------------------------------------------------------------------------------------------------------
Percentage increase
Percentage increase between fiscal year
Number of unique women between fiscal year 2006 and fiscal year
VAMC, by number veterans served in 2006 and fiscal year 2008 in the total
fiscal year 2008 2008 in the number of number of veterans
women veterans served served (both men and
women)
----------------------------------------------------------------------------------------------------------------
VAMC 1 6,464 19.5 8.5
VAMC 2 6,360 22.4 12.8
VAMC 3 4,497 8.2 7.3
VAMC 4 3,588 19.4 10.2
VAMC 5 2,324 11.7 4.8
VAMC 6 1,846 20.2 3.9
VAMC 7 1,841a 19.8 5.1a
VAMC 8 999 12.5 1.0
VAMC 9 995 22.5 6.9
----------------------------------------------------------------------------------------------------------------
Source: VA data and GAO analysis.
a This VAMC is part of the same health care system as VAMC 1. Some of these veterans may also have received
services at VAMC 1.
Table 6: Women Veterans' Health Care Utilization at Selected Community-Based Outpatient Clinics (CBOC)
----------------------------------------------------------------------------------------------------------------
Percentage increase
between fiscal year
Number of unique women 2006 and fiscal year
CBOC, by number veterans served in 2008 in the number of
fiscal year 2008 unique women veterans
served
----------------------------------------------------------------------------------------------------------------
CBOC 1 2,926 12.5
CBOC 2 1,750 27.0
CBOC 3 599 90.2
CBOC 4 554 51.0
CBOC 5 224 13.1
CBOC 6 115 8.5
CBOC 7 103 21.2
CBOC 8 88 54.4
CBOC 9 48 9.1
CBOC 10 a 42 not applicable a
----------------------------------------------------------------------------------------------------------------
Source: VA data and GAO analysis.
a This facility opened in 2007, so percentage increase since fiscal year 2006 does not apply.
Appendix II: GAO Contact and Staff Acknowledgments
GAO Contact
Randall B. Williamson, (202) 512-7114 or [email protected]
Staff Acknowledgments
In addition to the contact named above, Marcia A. Mann, Assistant
Director; Susannah Bloch; Chad Davenport; Alexis MacDonald; and Carmen
Rivera-Lowitt made key contributions to this testimony.
Prepared Statement of Phyllis E. Greenberger, M.S.W, President and
Chief Executive Officer, Society for Women's Health Research
Thank you for the invitation to address the Subcommittee on
Disability Assistance and Memorial Affairs and the Subcommittee on
Health of the U.S. House of Representatives Committee on Veterans'
Affairs on the important topic of eliminating the gaps in women
veterans' health care. I am Phyllis Greenberger, the CEO and President
of the Society for Women's Health Research (SWHR), an advocacy
organization dedicated to improving women's health and their health
care. The Society encourages the study of differences between men and
women that affect the prevention, diagnosis, and treatment of disease
and conditions.
At our inception, the Society fought for legislation to require the
inclusion of women in federally funded clinical research and for
guideline changes at the Food and Drug Administration to regulate
women's participation in pre-market clinical trials. As a result of
these successes--and our efforts to encourage women to participate in
research--we learned that sex matters in health care. A 2001 report of
the Institute of Medicine (IOM), ``Exploring the Biological
Contributions to Human Health: Does Sex Matter?'' validated our
thinking that sex differences important to health and human disease
occur in the womb and throughout the lifespan, affecting behavior,
perception, and health. With the Society's support, the field of sex
and gender differences research is flourishing, and through our
advocacy we are ensuring that what we learn about health care
differences between the sexes becomes translated into clinical
practices to benefit both women and men.
The Society strongly believes that the Department of Veterans
Affairs (VA) is in a unique position to lead the Nation in furthering
essential sex differences research and in translating that research
into clinical practice. Lessons learned at the VA can be applied to the
private sector. The Society recommends that Congress request an update
on the research conducted by the Veterans Health Administration (VHA)
since the establishment of its women's health research agenda in
November 2004 \1\ and further recommends that Congress provide the VA
with the funding necessary to conduct research that will result in
improved care for women veterans.
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\1\ Yano, EM., Bastian, LA., Frayne, SM., et al. Toward a VA
women's health research agenda: Setting evidence-based priorities to
improve the health and health care of women veterans, Journal of
General Internal Medicine, 2006; 21(Suppl 3); S93-S101, S96.
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STATUS OF THE VA WOMEN'S HEALTH RESEARCH AGENDA
The Society applauds the VA Office of Research and Development
(ORD) for its determination that women's health services research is a
high priority and for establishing evidence-based research priorities
that, if implemented, will help improve women veterans' health and
health care. We are pleased that the agenda-setting process included
identification of conditions that affect women disproportionately and
those that affect women differently than they affect men. We are
particularly pleased that the Biomedical Workgroup established as its
``overarching focus,'' ``sex-based influences on prevention, induction,
and progression of diseases relevant to women veterans.''
The Society advises that a status report is needed on the progress
the VA has made in initiating research in these critical areas. This
report should address the following questions:
Has the VA's Health Services Research & Development
(HSR&D) completed its ``Evidence Synthesis Program'' on women veterans'
health and health care?
What are some important sex differences that have come
out of VA research that are likely to be translated into improved
health care for women?
Currently, what percentage of clinical trials conducted
by the VA are populated by women? What percent of the trials that
include women have appropriate representation of women in proportion to
burden of disease?
What is the status of a ``women veterans' practice-based
research network'' that could set up an infrastructure for clinical
trials with larger volumes of female patients recently described by
HSR&D investigator Elizabeth Yano, PhD, MSPH.\2\ What other systems are
currently in place with regards to the recruitment of women to
participate in clinical trials?
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\2\ Yano, EM., Achieving equitable high-quality care for women
veterans, VA HSR&D Forum. Nov 2008.
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What are the success rates of these efforts?
What are the barriers to effective recruitment and
retention of women in VA clinical trials?
What steps has the VA taken to ameliorate these barriers?
The Society notes that the VA ORD ``needs to build research
capacity, solve methodologic issues that limit participation of women
in research, and increase the awareness and visibility of women's
health research.'' \3\ The Society is the pioneer in encouraging
women's participation in clinical trials and in encouraging clinical
trial design that allows for subsequent analysis by subgroups
(including women).
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\3\ Yano, EM., Bastian, LA., Frayne, SM., et al. Toward a VA
women's health research agenda: Setting evidence-based priorities to
improve the health and health care of women veterans, Journal of
General Internal Medicine, 2006; 21(Suppl 3); S93-S101, S100.
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The Society sponsors small, interdisciplinary research networks
that focus on understanding sex differences in various critical areas
of research, including neuroscience, metabolism, musculoskeletal
health, and cardiovascular disease. These networks are composed of
scientists and clinicians within various fields who identify gaps of
knowledge in each subject area and develop strategies and methods to
fill those gaps. Members of the first of these networks edited a text
book, Sex Differences in the Brain: From Genes to Behavior,\4\
described in a review in the New England Journal of Medicine as ``an
excellent overview of the latest research in basic and health-related
science in an important area.'' A review in Science stated that
``information content is high, references are ample, and the continuity
between different chapters has been skillfully coordinated. . . .''
Nancy Yanes-Hoffman, from the Writing Doctor blog, called the text ``a
brilliant, long-overdue guidebook leading us to better understanding,
treatment, and care of men and women.''
---------------------------------------------------------------------------
\4\ Becker JB., Berkley KJ., Geary N., Hampson E., Herman JP.,
Young EA. (eds). Sex Differences in the Brain: From Genes to Behavior.
(New York: Oxford University Press, 2008), 185.
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In addition, the Society is the founding partner of the
Organization for the Study of Sex Differences (OSSD), a professional
membership society for researchers and clinicians who have adopted a
transdisciplinary approach to understanding the basic mechanisms of
biological sex differences and how those can be translated into better
clinical practice. In the first three annual meetings, OSSD members
have reported on sex differences in a wide array of areas, including
immunity and infection; drug abuse; stress; sleep disorders; vascular
and renal disease; obesity; autoimmunity; tissue injury, repair and
regeneration; stroke; and osteoarthritis.
Both prior to and after the establishment of the OSSD, the Society
has sponsored scientific conferences that explore cutting-edge research
in women's health and sex differences. Topics covered include
neurology, immunity, pharmacology, digestive diseases, sexually
transmitted diseases, and pain. One recent conference (December 2008)
was on sex differences in post-traumatic stress disorder (PTSD),
cosponsored by the VA (among others). Researchers from academia and
Federal health agencies, including the Department of Defense, National
Institutes of Health, and VA, presented the latest findings about
differences in diagnosis and treatment of PTSD in men and women.
Attached to this testimony is the conference summary, which includes
recommendations for future research.
The Society publishes many conference reports and other information
for both researchers and the general public on how sex and gender
differences can affect a person's health. At
www.womenshealthresearch.org are two electronic resources: ``Just the
Facts: What Women Need to Know About Sex Differences in Health'' and
``Just the Facts: Sex-Based Biology.'' Along with Jennifer Wider, MD, I
edited the only patient reference book on sex differences, The Savvy
Woman Patient: How and Why Sex Differences Affect Your Health.
With such expertise and resources, the Society stands ready to
assist the VA in building its research capacity, increasing
participation of women in research, and increasing the visibility of
its women's health research.
VA WOMEN'S HEALTH RESEARCH FUNDING
The Society has long advocated for the ``Women's Health Office
Act,'' which would ensure that the women's health offices at Federal
health agencies--the Department of Health and Human Services (HHS), the
Agency for Health care Research and Quality (AHRQ), the Health
Resources and Services Administration (HRSA), the Centers for Disease
Control and Prevention (CDC), and the Food and Drug Administration
(FDA)--be made permanent in statute. Without permanent authorization,
these offices face underfunding, understaffing, or elimination in the
future. These offices are of critical importance to health and health
care services for all women, providing leadership on research,
dissemination of information, education, and health care service
delivery.
The Society recommends that Congress authorize the VA to establish
an office within its ORD, similar to those in other Federal agencies,
with the appropriate powers and authority, including grant-making and
provision of contracts, to direct the women's health and the sex
differences research agenda for the VA.
The VA's health research budget for FY2009 is $510 million. In
moving forward the efforts on women's health at the VA, it is important
that we understand how much of this funding is directed toward women's
health research and how much is applied to sex differences research
that benefits both men and women. The Society encourages Congress to
provide sufficient appropriations to the Department of Veterans Affairs
to ensure that the VA will be able to fulfill its women's health
research agenda. Further, if an office to direct women's health
research is established within ORD, the Society recommends that it be
appropriately funded to carry out its duties, including entering into
grants, contracts, and other cooperative agreements directing the
women's health and the sex differences research agenda for the VA.
CONCLUSION
I want to thank you again for this opportunity to discuss the
important topic of women's health research at the VA. The Society looks
forward to continuing to work on this important matter with the
Subcommittee on Disability Assistance and Memorial Affairs and the
Subcommittee on Health of the U.S. House Committee on Veterans'
Affairs.
[The attached report entitled, ``PTSD in Women Returning from
Combat: Future Directions in Research and Service Delivery'' a Report
by the Society for Women's Health Research, is being retained in the
Committee files. The Report can also be accessed online at http://
www.womenshealthresearch.org/site/DocServer/PTSD_in_
Women_Returning_From_Combat--reduced_file_size.pdf?docID=2661.]
Prepared Statement of Janice L. Krupnick, Ph.D., Professor,
Department of Psychiatry, Director, Trauma and Loss Program,
Georgetown University Medical Center, on behalf of Committee on
Veterans' Compensation for Post Traumatic Stress Disorder, Institute of
Medicine and National Research Council, The National Academies
Good morning, Mr. Chairman, Mr. Ranking Member, and Members of the
Committee. My name is Janice Krupnick and I am a Professor in the
Department of Psychiatry at the Georgetown University Medical Center
and Director of the Center's Trauma and Loss Program. Thank you for the
opportunity to testify on the content of the National Academies report
PTSD Compensation and Military Service. The committee's work--which was
conducted between March 2006 and July 2007--was requested by the
Department of Veterans Affairs, which provided funding for the effort.
I provided input to this committee while serving as a member of the
Institute of Medicine Committee on Gulf War and Health--Physiologic,
Psychologic, and Psychosocial Effects of Deployment-Related Stress and
its Subcommittee on post-traumatic stress disorder (PTSD).
I'm pleased to be here today to share with you some of the results
of the PTSD Compensation . . . report and the knowledge I've gained as
a clinical psychologist and researcher on traumatic stress. I will
briefly address five issues in this testimony:
the prevalence of military sexual assault,
the relationship between sexual assault and PTSD,
PTSD comorbidities and recovery for women,
PTSD compensation and women veterans, and
the PTSD Compensation . . . report's conclusions and
recommendations regarding women veterans.
The prevalence of military sexual assault
It is recognized that the circumstances of military service may
create barriers to reporting sexual assault above and beyond those
extant in other sectors of the population. That said, the prevalence of
reported sexual assault in the military is alarming. A synthesis of 21
studies by Goldzweigh and colleagues found that 4.2 to 7.3 percent of
active duty military females had experienced a military sexual assault
(MSA), while 11 to 48 percent of female veterans reported having
experienced a sexual assault during their time in the military. A
survey by Campbell and Raja (2005) found that among 104 female veterans
and reservists who disclosed that they were sexually assaulted while in
military service, 13 percent reported sexual assault from a marital
partner and 8 percent from a date. Eighty-two percent of the
perpetrators in these MSAs were military peers or supervisors. The
women in this sample also reported a great deal of secondary
victimization by the military and by the VA system, an experience that
is known to make the PTSD symptoms worse. Other studies have found
subsequent secondary victimization and sexual harassment, exposing the
women to additional trauma over and above rape and combat.
The relationship between gender, sexual assault and PTSD
A substantial body of literature documents measurable gender
differences in PTSD frequency and severity. A well-conducted meta-
analysis published in 2006 by Tolin and Foa found that PTSD was twice
as prevalent in females as in males after controlling for potential
confounders. There are several possible reasons for this, including sex
differences in the cognitive response to the traumatic event, immediate
coping strategies, and the willingness to admit symptoms. Women are
more likely to experience chronic trauma, such as repeated childhood
sexual assault by a family member or recurring intimate partner
violence. Women are also more commonly the victim in cases of multiple
traumas. Research indicates that sexual-assault experiences are
strongly associated with PTSD in both civilian and military
populations.
PTSD comorbidities and recovery for female veterans
Studies of female veterans indicate that PTSD symptoms and PTSD
diagnoses are associated with comorbidities such as depression,
substance abuse, smoking, and physical health problems as well as with
increased medical utilization. Females are more likely than males to
have major depressive disorder along with PTSD and tend to experience
symptoms for a longer duration and have more associated physical health
problems than do males.
For female veterans, post-military social support from family and
friends both reduces the risk of developing PTSD and aids in recovery
from the disorder, according to the few studies of PTSD recovery in
this population. Female veterans were more comfortable in a specialized
treatment program for women; it increased their participation as
measured by attendance and commitment, but had no effect on outcomes.
The PTSD Compensation . . . committee observed that studies of PTSD
treatment for female veterans are badly needed, and noted that it was
important to ensure that the study samples were sufficiently large to
disentangle the differential treatment effects for women whose trauma
is primarily MSA versus those whose trauma is primarily combat or to
determine if multiple traumas are part of the etiology of the PTSD
experience.
PTSD compensation and female veterans
Very little research exists on the subject of PTSD compensation and
female veterans. A 2003 study by Murdock and colleagues did determine
that a significantly smaller percentage of females had their PTSD
deemed to be service connected as compared to males, and that this was
primarily related to the lower rates of combat exposure among females.
Subsequent research by Murdock (2006) found that, when MSA was
substantiated in a Veterans Benefits Administration (VBA) claim file,
service-connected PTSD determinations increased substantially.
Unfortunately, there are huge barriers to women being able to
independently substantiate their experiences of MSA, especially in a
combat arena. A 2004 U.S. Air Force report cited by the committee noted
that these barriers included:
lack of privacy/confidentiality[,] . . . stigma, fear, or
shame; fear of disciplinary action because of a victim's
misconduct; fear of being reduced in the eyes of one's
commander/colleagues; fear of re-victimization; and fear of
perceived operational impacts, including loss of security
clearances, effect on training, and impact on overseas
deployments (U.S. Air Force, 2004; p. 10).
Available information suggests that female veterans are less likely
to receive service related compensation for PTSD and that this is, at
least in part, a consequence of the relative difficulty of
substantiating exposure to noncombat traumatic stressors--notably, MSA.
The committee noted that PTSD training and reference materials for VBA
raters address MSA, but scant attention is paid either to the
challenges of documenting it as an in-service stressor or to approaches
to addressing this problem.
The PTSD Compensation . . . report's conclusions and recommendations
regarding women veterans
The committee responsible for the PTSD Compensation . . . report
reached several conclusions and recommendations related to women
veterans on the basis of their review of papers, reports, and other
scientific information. It also identified research needs.
The committee concluded that ``the most effective strategy for
dealing with problems with self reports of traumatic exposure is to
ensure that a comprehensive, consistent, and rigorous process is used
throughout the VA to verify veteran-reported evidence.'' It therefore
recommended that the Veterans Benefits Administration ``conduct more
detailed data gathering on the determinants of service connection and
ratings level for MSA-related PTSD claims, including the gender-
specific coding of MSA-related traumas for analysis purposes.''
The committee observed that appropriate management of MSA-related
claims begins with the proper documentation of incidents that occur
during active service. Therefore, improved training of military medical
and nursing personnel on how to document and collect evidence regarding
sexual assault is needed. The committee thus recommended that VBA
``develop and disseminate reference materials for raters that more
thoroughly address the management of MSA-related claims'' and that
``training and testing on MSA-related claims should be a part of [a]
certification program . . . for raters who deal with PTSD claims.''
Citing the gaps it found in the information base, the committee
noted that ``more research is needed on the as yet unexplained gender
differences in vulnerability to PTSD, which could help identify useful
sex-specific approaches to prevention and treatment, and on more
effective means for preventing military sexual assault and sexual
harassment.''
The PTSD Compensation . . . committee also reached a series of
other findings and recommendations regarding the conduct of VA's
compensation and pension system for PTSD that are detailed in the body
of our report. The National Academies previously provided the
Subcommittee with copies of this report and would happy to fulfill any
additional requests for it.
Thank you for your attention. I'm happy to answer your questions.
Publications referenced in this testimony
Campbell R, Raja S. 2005. The sexual assault and secondary
victimization of female veterans: help-seeking experiences with
military and civilian social systems. Psychology of Women Quarterly
29(1):97-106.
Goldzweig CL, Balekian TM, Rolon C, Yano EM, Shekelle PG. 2006. The
state of women veterans' health research: results of a systematic
literature review. Journal of General Internal Medicine (Suppl. 3):S82-
S92.
Institute of Medicine. 2007. PTSD Compensation and Military
Service. Washington, DC: National Academies Press. [Online]. Available:
http://www.nap.edu/
catalog.php?record_id=11870 [accessed July 13, 2009].
Murdoch M. 2006. PTSD Disability Benefits: A Focus on Gender.
Presentation to the Committee on Veterans' Compensation for
Posttraumatic Stress Disorder, July 6, 2006. Washington, DC.
Murdoch M, Hodges J, Hunt C, Cowper D, Kressin N, O'Brien N. 2003.
Gender differences in service connection for PTSD. Medical Care
41(8):950-961.
U.S. Air Force. 2004. Report concerning the assessment of USAF
sexual
assault prevention and response--August 2004. Office of the Assistant
Secretary of the Air Force (Manpower and Reserve Affairs). [Online].
Available: http://www.defenselink.mil/dacowits/agendadoc/
USAF_Sexual_Assault_p_r.pdf [accessed July 13, 2009].
Prepared Statement of Bradley G. Mayes, Director, Compensation and
Pension Service, Veterans Benefits Administration,
U.S. Department of Veterans Affairs
Chairman Hall, Chairman Michaud, and Members of the Subcommittees,
thank you for providing me an opportunity to speak today on the
important topic of assisting women veterans.
I. Changing Demographics of Women Veterans
Although women have been associated with military activity since
the founding of our Nation, their role has increased dramatically in
recent years. From the time of the American Revolution, women have
supported the military service of their male counterparts and sometimes
took up arms themselves. Their work and sacrifice as military nurses
saved innumerable lives and contributed immeasurably to the efforts of
all military campaigns. These medical efforts were especially valuable
during World War II and the wars in Korea and Vietnam. However, despite
their major contributions, the percentage of servicemembers in these
conflicts who were women was relatively small. According to U.S. Census
Bureau statistics, 5 percent of veterans who served in World War II
were women veterans, 2 percent who served in Korea were women veterans,
and 3 percent who served in Vietnam were women veterans. However,
during the Gulf War 1991-1992, the percentage of women veterans
increased to 16 percent. This reflects a significantly expanded role
for women in the military. As a result, the Department of Veterans
Affairs (VA) has adjusted its programs accordingly.
The expanded role of women in the military has also brought about
increased responsibilities and risk taking. Women serving in Iraq and
Afghanistan face combat activity similar to their male counterparts. As
aircraft pilots, convoy transportation specialists, military police
officers, and members of civilian pacification teams, women have
increasingly been in harm's way and have incurred more service-related
physical and mental disabilities as a result.
The following VA statistics illustrate the significance these
changing roles have had on VA. America has approximately 1.8 million
women veterans. They make up approximately 7.7 percent of the total
number of veterans awarded service connection. The number of women
receiving VA compensation and pension increased from 203,000 in 2006,
to over 250,000 in June of 2009. This represents a 23-percent increase
in less than 3 years. So far this fiscal year, the number of women
veterans receiving benefits who served in the current overseas
contingency operations has increased by nearly 10,000. Although women
veterans represent 12 percent of those who served in these operations,
they represent 15 percent of those awarded service connection for a
disability.
II. VA Efforts to Assist Women Veterans
VA established the Advisory Committee on Women Veterans in 1983 as
a panel of experts on issues and programs affecting women veterans.
Since then, we have worked to implement its recommendations for
improving services to women veterans. A major issue of current concern
for this Committee is the occurrence of military sexual trauma (MST)
among women on active duty and the disabilities that may result. The
Committee has recommended that VA address this issue to the greatest
extent possible.
The claims of women veterans who seek disability compensation for
post-traumatic stress disorder (PTSD) based on MST are specifically
addressed in VA's regulations at 38 CFR Sec. 3.304(f)(4). In 2002, VA
amended its PTSD regulations to emphasize that, if a PTSD claim is
based on in-service personal assault, which include MST claims,
evidence from sources other than the veteran's military records may be
used to corroborate the in-service traumatic event. Such evidence may
include, but is not limited to, records from law enforcement
authorities, rape crisis centers, mental health counseling centers, and
hospitals, as well as statements from family Members, associates, or
clergy. Service medical and personnel records are also reviewed in
order to discover evidence of behavior changes that may support the
occurrence of the traumatic event. In addition, prior to a decision on
the claim, VA provides an appropriate medical or mental health
professional with the available evidence and asks for an opinion as to
whether the traumatic event occurred. These procedures take into
account the sensitive nature of MST and the difficulty in obtaining
supporting evidence.
Another general recommendation from the Advisory Committee on Women
Veterans is that proper health care and compensation should be provided
for service-connected disabilities that are unique to women veterans.
Unique disability compensation evaluation criteria for women veterans
are provided in the VA Schedule for Rating Disabilities under the
section for gynecological conditions and disorders of the breast. An
additional monetary benefit, referred to as special monthly
compensation, is also available for loss, or loss of use, of a creative
organ as the result of a service-connected disability. This applies to
the male and female reproductive systems. In 2000, VA amended 38 CFR
Sec. 3.350(a) to authorize special monthly compensation for women
veterans who suffer a service-connected loss of 25 percent or more of
breast tissue from a mastectomy or radiation treatment.
Congress has acknowledged the effects of herbicide exposure on
women veterans who served in Vietnam and the potential for birth
defects that may occur in their children as a result. Chapter 18 of
title 38, United States Code, authorizes a monetary allowance for the
children of any Vietnam veteran for disability attributable to spina
bifida and for the children of women veterans who served in Vietnam for
disability due to a covered birth defect. A long list of birth defects
that qualify a child for a monetary allowance are described in VA
regulations. This list reflects the findings of a VA study that
indicated an association between numerous birth defects among the
children of females, but not males, who were exposed to herbicides.
As a further means to implement recommendations of the Advisory
Committee on Women Veterans, the Veterans Benefits Administration (VBA)
has engaged in outreach efforts. When active duty military personnel
are separated from service or National Guard and Reserve Members are
demobilized, VBA provides information to them under the Transitional
Assistance Program (TAP) at their military base. This pre-discharge
program explains the array of benefits available from VA and assists
individuals with filing disability claims. One mandatory section of TAP
is a PowerPoint slide presentation on ``military sexual and other
personal trauma.'' This is intended to alert separating servicemembers
that VA is aware of the MST problem and inform them that counseling,
treatment, and disability compensation are available.
Outreach efforts are also conducted at all VA regional offices on a
continuing basis. Each regional office employs a Women Veterans
Coordinator who is well versed in personal trauma issues, including
those of MST, as well as gender specific disability issues, and who
acts as a liaison with the Women Veterans Program Manager at the local
VA health care facility. These coordinators also work with the regional
office Homeless Veterans Coordinators to address the problems of
homeless women veterans. A nationwide VA Women Veterans Coordinator
Training Conference is scheduled for August 2009 in St. Paul,
Minnesota. At the conference, VA will present updated information and
skill training to the coordinators. Topics will include: outreach
methods, clinical perspectives on personal trauma, and women veterans
health issues. In addition to these personal outreach efforts, VBA
maintains a public Internet Web site devoted to the unique issues
associated with women veterans. This VBA Web site is in addition to Web
sites maintained by the VA Center for Women Veterans and the Veterans
Health Administration (VHA) on women veterans health care.
III. Conclusion
VA has recognized the service provided to our Nation by women
veterans and the importance of providing them with the assistance they
deserve. VBA has moved forward, along with VHA, to address the issues
that are unique to women veterans. We have developed special
regulations for adjudication of PTSD claims based on MST. Regarding
compensation for gender specific disabilities, we provide special
monthly compensation for breast tissue loss and monetary assistance for
the children of women Vietnam veterans who develop birth defects. We
have also engaged in nationwide outreach to facilitate women veterans'
access to VA benefits. We realize that VA needs to keep pace with the
changing needs of women who served in the military, and we are ready to
take whatever steps are necessary in the future to properly assist
women veterans.
Prepared Statement of Irene Trowell-Harris, RN, Ed.D., Director,
Center for Women Veterans, U.S. Department of Veterans Affairs
Chairman Hall, Chairman Michaud and Members of the Subcommittees, I
am pleased to testify today on behalf of the Department of Veterans
Affairs (VA) regarding women veterans' issues. Through recommendations
made by the Secretary's Advisory Committee on Women Veterans,
collaborations between the Center for Women Veterans and VA's
Administrations, and proactive measures taken by the Veterans Health
Administration (VHA), Veterans Benefits Administration (VBA), and
National Cemetery Administration (NCA), VA continues to transform to
meet the anticipated needs of women veterans. I greatly appreciate the
Committee's diligence in bringing forth discussion on this very
important and timely issue.
Center for Women Veterans
The Center was created by Public Law 103-446 in November 1994. As
Director, I serve as chief advisor to the Secretary on all issues
related to women veterans and serve as the Designated Federal Officer
to the Secretary's Advisory Committee on Women Veterans.
The Center's mission is to ensure that women veterans have access
to VA benefits and services on par with male veterans; that VA programs
are responsive to the gender-specific needs of women veterans; that
joint outreach is performed to improve women veterans' awareness of VA
services, benefits and eligibility criteria; and that women veterans
are treated with dignity and respect.
The Center accomplishes its mission by monitoring the Department's
programs and policies to ensure that they are responsive to the needs
of women veterans by:
recommending policy and legislative proposals to the
Secretary and analyzing the impact of these proposals on women
veterans;
collaborating with VA's Administrations to make women
veterans more knowledgeable about changes in VA policies;
ensuring that the Advisory Committee on Women Veterans is
educated about VA to ensure clear, meaningful recommendations;
coordinating the development, distribution, and
processing of the Committee reports; and
coordinating an annual Committee site visit to VA health
care facilities, regional offices, Vet Centers, national cemeteries,
and other related programs such as homeless and transitional housing.
Caring for our women veterans does not stop within the confines of
the Department. We conduct extensive outreach, coordination and
collaboration with other agencies (Federal, state, and local), as well
as with Veterans Service Organizations (VSO) and community-based
organizations concerned with women veterans issues.
Advisory Committee on Women Veterans
The Advisory Committee was established in 1983 pursuant to Public
Law 98-160. The committee is charged with advising the Secretary on VA
benefits and health services for women veterans, assessing the needs of
women veterans, reviewing VA programs and activities designed to meet
those needs, and developing recommendations addressing unmet needs. The
Advisory Committee is required to submit a biennial report to the
Secretary incorporating its findings and recommendations. There are
currently 13 committee members, including two Operation Enduring
Freedom and Operation Iraqi Freedom Veterans.
Committee Meetings and Site Visits
The Advisory Committee meets twice a year at VA Central Office
(VACO) and receives briefings from VHA, VBA, NCA and from staff
offices. These briefings update the Advisory Committee on the status of
VA programs and progress on recommendations, and respond to concerns
raised during the site visits. The Advisory Committee uses information
from the site visits and briefings to formulate its recommendations to
the Secretary in biennial reports.
To obtain information regarding the delivery of health care and
services to women veterans, the Advisory Committee conducts annual site
visits to VA facilities throughout the country. During these site
visits, the Committee tours the facilities and meets with senior
officials to discuss services and programs available to women veterans.
In addition, the Committee also hosts open forums at site visits with
the women veterans' community, encouraging women veterans to discuss
issues and ask questions related to VA benefits and services. Copies of
the ``25 Most Frequently Asked Questions'' are distributed at the
townhall meeting.
The Advisory Committee completed a site visit in June 2009 to the
Veterans Affairs North Texas Health Care System facilities in Dallas
and Bonham, Texas. The purpose of site visits are to provide an
opportunity for Committee Members to compare the information they
received from briefings, provided by the administrations with the
activity in the field. This effort is to ensure that policies
established in VACO are implemented in VA medical centers and other
facilities that serve and impact women veterans which are people-
centric, results driven, and forward looking.
VA is grateful for the work of the Advisory Committee because its
activities and reports play a vital role in helping the VA assess and
address the needs of women veterans.
Advisory Committee on Women Veterans 2008 Report
In the 2008 Report of the Advisory Committee on Women Veterans, the
Committee made 20 recommendations--with supporting rationale--
addressing 10 topical areas. The Center collaborates frequently with
Administrations and staff offices to ensure that the Department
thoroughly addresses the Committee's recommendations. The 2008 Report,
including VA's responses, was provided to the House and Senate Veterans
Affairs' Committees on September 26, 2008.
Recommendations stem from data and information gathered in
briefings from VA officials, Departments of Labor (DOL) and Defense
(DoD) officials, Members of House and Senate Congressional Committee
staff offices, women veterans, researchers, VSOs, internal VA reports,
and site visits to VHA, VBA, and NCA facilities. The Committee is
confident that the 20 recommendations and supporting rationale reflect
value-added ways for VA to strategically and efficiently address many
needs of women veterans.
What Women Veterans Tell Us They Want and Need
Anecdotally and in research, women veterans tell us they want and
need recognition and respect, employment, suitable housing, access to
and receipt of high quality health care, childcare options,
opportunities for social interaction, and that they want to make a
difference.
Summit on Women Veterans' Issues
Every 4 years, VA sponsors a Summit on Women Veterans' Issues. The
fourth quadrennial Summit was held on June 20-22, 2008, in Washington,
DC. The purpose of the Summit was to look at the issues and
recommendations from the 2004 Summit, review VA's progress on these
issues, provide information on current issues, and develop
recommendations and a plan for continuous progress on women veterans'
issues.
More than 400 individuals attended, including women veterans, women
veterans' program managers and coordinators, Congresswoman Susan Davis
and Congressional staff from the Senate and House Committees on
Veterans' Affairs, women veterans' organizations, representatives from
other collaborating Federal, state and local agencies, VSOs, and
members of the active duty military, Guard, and Reserve. The program
consisted of 11 breakout sessions plus VA Updates since 2004. For the
first time, we held a townhall meeting to discuss national issues
affecting women veterans, viewed the Public Broadcasting Service
Lioness documentary (Lioness looks at five women from an Army engineer
battalion in Iraq who were drawn into battle and the fallout from their
experiences), and had an open discussion with the directors and
soldiers featured in the film. Based on feedback received from Summit
participants, the Center is posting updates on women veterans' issues
to its Web site.
Progress on Women Veterans' Issues
Many of the recommendations made by the Advisory Committee have
been instrumental in transforming VA to assist in meeting the needs of
women veterans and to help bridge the gaps in services and benefits. To
address the challenges of enhancing primary care for women veterans, VA
has done the following:
Elevated the Women's Veterans Health Program Office on
VA's organizational chart to the Women Veterans Health Strategic Health
Care Group, as part of VA's readiness for the influx of new women
veterans. This group provides programmatic and strategic support to
implement positive changes in the provision of care for all women
veterans.
Employed a full-time Women Veterans Program Manager at
every VA health care facility.
Initiated implementation of comprehensive primary care
(including gender specific care) at every VA site.
Ensured accurate representation of the women veterans
population through analysis and data.
Expanded the women's health knowledge base among VA
providers.
Sought to recruit primary care physicians who have
knowledge and interest in women's health.
Started to integrate mental health with primary care to
enable a comprehensive women's health care program.
Started to change the overall culture of VA to be more
inclusive of women veterans, and recognize their military service and
contribution to this Nation.
Conducting Joint and Collaborative Outreach Efforts
The Center takes every opportunity to collaborate with VSO, policy,
women and minority groups, other Federal and state agencies, and
community organizations to outreach to women veterans by:
Providing keynote speeches at national conventions and
women veterans forums;
Participating in Congressional round table discussions on
the needs of women veterans;
Collaborating with VA Administrations, staff offices, and
other advisory Committees;
Providing information to minority women, including those
who live on reservations through the Center for Minority Veterans;
Participating on the homeless veterans workgroup to
ensure that needs of homeless women veterans with children are
addressed;
Working with the Congressional Caucus for Women's Issues
to recognize and honor our Nation's service women and women veterans at
an annual wreath laying ceremony at the Women in Service for America
Memorial; and
Representing the Secretary at the monthly White House
Interagency Council Meeting on Women and Girls, addressing the needs of
women veterans nationally in collaboration with the Department of
Defense.
This concludes my formal testimony. I will be pleased to answer any
questions.
Prepared Statement of Lawrence Deyton, M.D., MSPH, Chief Public
Health and Environmental Hazards Officer, Veterans Health
Administration, U.S. Department of Veterans Affairs
Good morning, Mr. Chairman and Ranking Member. Thank you for the
opportunity to discuss how the Department of Veterans Affairs (VA) has
provided, and will continue to improve, health care availability for
women veterans. I would like to thank the Chair and this Committee for
your interest in working with VA to ensure women veterans receive the
care they have earned through service to their country.
The Secretary recently testified before this Committee that
enhancing primary care for women veterans is one of VA's top
priorities. VA recognizes that a growing number of women veterans are
choosing VA for their health care. Of the 1.8 million women veterans in
the United States more than 450,000 have enrolled for care. This number
is expected to grow by 30 percent in the next 5 years. Women currently
comprise approximately 14 percent of the active duty military, 17.6
percent of Guard and Reserves and 5.9 percent of VA health care users.
Women who were deployed and served in the recent conflicts in
Afghanistan and Iraq are enrolling in VA at historic rates. Of all
women who were deployed and served in Afghanistan or Iraq, 44 percent
have enrolled and 43 percent have used VA between 2 and 11 times. This
suggests that many of our newer women veterans are and will rely more
heavily on VA to meet their health care needs than women veterans of
earlier eras.
My testimony will describe how VA plans to continue to enhance the
delivery of high quality health care to this fastest growing cohort of
veterans and ensure today's heroes and tomorrow's veterans receive the
care they need. Women veterans served; they deserve the very best care
we can provide.
Current Challenges
Women veterans entering VA's system are younger and have health
care needs distinct from their male counterparts. The average age of
women veterans is 48 years old, compared to 61 years old among men.
Nearly all newly enrolled women veterans accessing VA care are under 40
and of childbearing age. This trend creates a need to shift how we
provide health care.
General primary care and gender-specific care needs of women
veterans are currently provided through a multi-visit, multi-provider
model that may not achieve the continuity of care desired.
Additionally, some VA facilities rely on outside providers for gender-
specific primary care and specialty gynecological care through the use
of fee-basis care. This approach to women's health delivery can create
challenges in maintaining continuity of care.
Moving to a more comprehensive primary care delivery model could
challenge VA clinicians, who may have dealt predominately with male
veterans and sometimes have little or no exposure to female patients.
VA facilities may also need to increase both focus and resources on
women's health (e.g., space, staffing, appropriately equipped exam
rooms) to ensure adequate privacy for women during examinations.
Initiatives are underway and under development to address these and
other changes brought on by the increasing number of women veterans
seeking care from VA.
The quality of health care VA provides to women veteran's exceeds
the care many would receive in other settings (including commercially
managed care systems, Medicare and Medicaid). For example, VA's system
of quality management and preventive patient care, supported by
technology like its electronic health record and clinical reminders,
ensures women are screened for unique health concerns such as cervical
cancer or breast cancer at higher rates than non-VA health care
programs. On the other hand, VA is aware of existing disparities
between male and female veterans in its system. The Department is
particularly concerned with performance measures related to
cardiovascular disease, the leading cause of death in women.
Performance scores for several quality measures, including high blood
pressure, high cholesterol and diabetes, all of which contribute to
cardiovascular disease risk, show a consistent difference between men
and women veterans. Gender-neutral prevention measures such as colon
cancer screening, depression screening and immunizations show a
disparity between men and women veterans as well. For example, although
VA significantly outperforms Medicare on colorectal cancer screening,
only 75 percent of women veterans are screened compared with 83 percent
of male veterans. These issues and other quality issues are being
addressed.
VA recently supported section 309 of S. 252, which would authorize
VA to furnish health care services up to 7 days after birth to a
newborn child of a female veteran who is receiving maternity care
furnished by VA if the veteran delivered the child in a VA health care
facility or in another facility pursuant to a contract for service
related to such delivery. We believe benefits such as these will help
improve women veterans' perception that VA welcomes them and will
provide complete, effective and compassionate care.
Current Initiatives
VA recognizes the need to continually improve its services to women
veterans, and has initiated new programs including the implementation
of comprehensive primary care throughout the Nation; enhancing mental
health for women veterans; staffing every VA medical center with a
women veterans program manager; creating a mini-residency education
program on women's health for primary care physicians; supporting a
multifaceted research program on women's health; improving
communication and outreach to women veterans; and continuing the
operation of organizations like the Center for Women Veterans and the
Women Veterans Health Strategic Health Care Group.
Comprehensive Primary Care for Women Veterans
VA is implementing an innovative approach to women's health care
that seeks to reduce the possibilities of fragmented care, quality
disparities, and lack of provider proficiency in women's health by
fundamentally changing the experience of women veterans in VA.
In March 2008, the former Under Secretary for Health charged a
workgroup to define necessary actions for ensuring every woman veteran
has access to a VA primary care provider capable of meeting all her
primary care needs, including gender-specific and mental health care,
in the context of a continuous patient-clinician relationship. This new
definition places a strong emphasis on improved coordination of care
for women veterans, continuity, and patient-centeredness. In November
2008, the workgroup released its final report identifying
recommendations for delivering comprehensive primary care. These
recommendations included: (1) delivering coordinated, comprehensive
primary women's health care at every VA health care facility by
recognizing best practices and developing systems and structure for
care delivery appropriate to women veterans; (2) integrating women's
mental health care as part of primary care, including co-locating
mental health providers; (3) promoting and incentivizing innovation in
care delivery by supporting local best practices; (4) cultivating and
enhancing capabilities of all VA staff to meet the comprehensive health
care needs of women veterans; and (5) achieving gender equity in the
provision of clinical care.
To implement these goals and recommendations, the Women Veterans
Health Strategic Health Care Group developed a women's comprehensive
health implementation planning (WCHIP) tool to assist facilities in
analyzing their own current health care delivery for women veterans and
plans for primary care delivery enhancement. Every VA health care
facility was requested to convene a multidisciplinary planning and
implementation team to address comprehensive primary care for women
veterans. The WCHIP tool outlines an analysis of current services and
projected use, a market analysis and a needs assessment, which
facilitated the development of a business plan. This plan includes
resource needs, goals, timelines, budgets, training needs and program
evaluation metrics to deliver comprehensive health care to women
veterans.
No later than August 1, 2009, facilities will finalize their
analyses and action plans based on the WCHIP tool. These plans will be
instrumental in decisions for directing resources for fiscal years 2010
and 2011.
To achieve the goal of providing comprehensive primary care for
women veterans, VA has designed three models to promote the delivery of
optimal primary care. Under the first model, women veterans are seen
within a gender neutral primary care clinic. Under the second model,
women veterans are seen in a separate but shared space that may be
located within or adjacent to a primary care clinic. Under the third
model, women veterans are seen in an exclusive separate space with a
separate entrance into the clinical area and a distinct waiting room.
In this scenario, gynecological, mental health and social work services
are co-located in this space. Each of these models can be tailored to
local needs and conditions to systemize the coordination, continuity,
and integration of women veterans' care. One-third of VA facilities
have already adopted the third model of comprehensive primary care
delivery and found it to be very effective. Access and wait times are
better at sites where gender-specific services are available in an
integrated women's primary care setting, regardless of whether the care
was delivered in a separate space (such as a women's clinic) or
incorporated within general primary care clinics. VA facilities that
have established a ``one-stop'' approach to primary care delivery have
already reported higher patient satisfaction on care coordination for
contraception, sexually transmitted disease screening, and menopausal
management.
In addition to improving the primary care infrastructure for women
veterans, VA is committed to advancing the entire range of emergency,
acute, and chronic health care services needed by women veterans to
develop an optimal continuum of health care. Such a continuum of health
care includes: enhancing and integrating mental health care, medical
and surgical specialty care, health promotion and disease prevention,
diagnostic services and rehabilitation for catastrophic injuries.
Enhancing Mental Health
VA has identified that 37 percent of women veterans who use VA
health care have a mental health diagnosis; these rates are higher than
those of male veterans. Women veterans also present with complex mental
health needs, including depression, post-traumatic stress disorder
(PTSD), military sexual trauma (MST), and parenting and family issues.
In response, VA has instituted policy requirements, such as that
outlined in its Handbook on Uniform Mental Health Services in VA
Medical Centers and Clinics, to emphasize the importance of being aware
of gender-specific issues when providing mental health care. In
particular, the Handbook identifies services every health care facility
must have available for women veterans to ensure integrated mental
health services as a part of comprehensive primary care for women
veterans. For example, the services provided optimally involve a
designated, co-located, collaborative provider (psychologist, social
worker, or psychiatrist) and care management with an emphasis on the
need for safety, privacy, dignity, and respect to characterize all
gender-specific services provided. Facilities are strongly encouraged
to give patients treated for other mental health conditions the option
of a consultation from a same-sex provider regarding gender-specific
issues. All inpatient and residential care facilities must provide
separate and secured sleeping accommodations for women. Every VA
facility has a designated MST coordinator who serves as a contact
person for related issues. VA is ensuring a concerted effort to provide
quality mental health care appropriate to the needs of women veterans.
Women Veterans Program Managers
In order to ensure improved advocacy for women veterans at the
facility level, VA has mandated all VA medical centers appoint a full-
time Women Veterans Program Manager. These Women Veterans Program
Managers support increased outreach to women veterans, improve quality
of care provision, and develop best practices in organizational
delivery of women's health care. They serve as advisors to facility
directors in identifying and expanding the availability and access of
inpatient and outpatient services for women veterans and provide
counseling on a range of gender specific care issues. Women Veterans
Program Managers also coordinate and provide appropriate local outreach
initiatives to women veterans. As of June 2009, each of VA's 144 health
care systems has appointed a full-time Women Veterans Program Manager.
Mini-Residency Training in Women's Health
As the number of women veterans continues to grow, particularly
women of childbearing age, VA recognizes many primary care providers
need to update their women-specific clinical experience. VA is offering
waves of mini-residencies in women's health across the country in
strategic geographic locations. Each mini-residency lasts 2\1/2\ days
and is taught by national women's health experts. Clinical staff
receive presentations on contraception, cervical cancer screening and
sexually transmitted infections, abnormal uterine bleeding, chronic
abdominal and pelvic pain, post-deployment readjustment issues for
women veterans, and other women's health topics. Early results from
this program indicate its success in increasing competencies in 12
areas of women's health care. As of June 2009, 216 participants (119
physicians, 77 nurse practitioners, 10 physician assistants, 9
registered nurses and one therapist) from 90 VA medical centers and 28
community-based outpatient clinics have either scheduled or completed
this program.
Research on Women Veterans' Health Issues
VA has clearly established women's health as a research priority
and intensified its efforts in the last decade. Currently, VA's Office
of Research and Development supports a broad research portfolio focused
on women's health issues, including studies on diseases prevalent
solely or predominantly in women, hormonal effects on diseases in post-
menopausal women, and health needs and health care of women veterans.
VA's Office of Health Services Research and Development is funding 27
research projects in this area. VA is also conducting a study that will
survey 3,500 women veterans (both those who use VA health care and
those who do not) to identify the changing health care needs of women
veterans and to understand the barriers they face in using VA health
care. We anticipate receiving the results of this study within the next
several months, and we will share these findings with the Committee. VA
is also conducting risk assessments to track the effects of deployments
on women veterans and improve its epidemiological data on Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) women veterans
through the National Health Study for a New Generation of U.S. veterans
(an OEF/OIF cohort study). We are enrolling 60,000 veterans for this
study--of these 12,000 are women.
Outreach Initiatives
Effective internal and external communication and outreach to women
veterans is critical to the success of implementing comprehensive care.
Surveys and research show that women veterans are often not aware of
the services and benefits available to them. VA is engaging in multiple
efforts to correct this. For example, VA's Center for Women Veterans
and the Women Veterans Health Strategic Health Care Group will continue
to expand its ongoing outreach and communications plan to ensure
increased public awareness of women veterans and their service to our
country and increased awareness by women veterans of VA health care.
Center for Women Veterans
The Center's mission is to ensure that women veterans have access
to VA benefits and services on par with male veterans; that VA programs
are responsive to the gender-specific needs of women veterans; that
joint outreach is performed to improve women veterans' awareness of VA
services, benefits, and eligibility criteria; and that women veterans
are treated with dignity and respect. The Center coordinates and
collaborates with Federal, State and local agencies, Veterans Service
Organizations and community-based organizations.
Women Veterans Health Strategic Health Care Group
VA is developing new strategies to improve both communications
with, and services to, women veterans. VA has made available upgraded
communication resources, processes, and tools to Veterans Integrated
Service Networks (VISN) and facilities. VA is building on the OEF/OIF
call center to reach out to women veterans. New scripts, new outreach
materials and training are being developed to ensure women veterans are
aware of VA's services and benefits. While these efforts have created
an important foundation upon which to build, it will take sustained and
coordinated planning to successfully reach out to women veterans.
Future Plans
While significant efforts are underway, we recognize that more
still needs to be accomplished. VA must provide women veterans with
adequate infrastructure for primary care and expand services to provide
a full continuum of care for women veterans at its secondary and
tertiary care facilities. This investment of resources will contribute
to the continuing goal of delivering quality health care focused on
privacy, safety, sensitivity, dignity and continuity.
Expanding Access to Gynecology
Gynecologists are indispensable in providing care for women with
abnormal findings on pelvic exams, such as abnormal pap smears,
complicated cases of pelvic pain and abnormal vaginal bleeding in
addition to specialized services in urology-gynecology, gynecology-
oncology and obstetrics care. As VA primary care physicians increase
their proficiency in women's health care to meet the needs of the
growing numbers of women veterans, primary care physicians will need to
have on-site gynecologists available to act as experts, consultants and
teachers.
Expanding Innovative Technology
In the area of innovative technologies, VA is expanding its efforts
to dramatically transform and improve care for women veterans by
enhancing its electronic health records system to provide more
functionality related to women's health, including clinical reminders,
pharmacy alerts for teratogenic drugs, improved decision support,
gender-specific health history and screening questionnaires, e-videos
and other tools for shared decision-making, particularly with regard to
preference-sensitive health care choices (e.g., breast cancer surgery
and treatments).
Conclusion
Mr. Chairman, VA's commitment to women veterans is unwavering. We
stand now at a unique moment in time where our actions and plans today
will build the system that will provide care equal to the health care
needs of all of America's veterans, regardless of gender. Thank you
once again for the opportunity to testify. My colleagues and I are
prepared to address any additional questions you might have.
Statement of Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
and a Representative in Congress from the State of Maine
Good morning. I would like to thank everyone for attending today's
hearing on women veterans.
I am happy to join my colleagues, DAMA Subcommittee Chairman Hall
and our Ranking Members Mr. Brown and Mr. Lamborn, in holding this
joint hearing. Together, we have a shared interest in ensuring that
women veterans receive the health care and benefits that they deserve.
Today's hearing will help us further explore the issues and gaps
facing women veterans, as we work toward a VA for the 21st Century, a
VA, that must fully embrace the growing and unique needs of women
veterans.
Women have answered the call and today serve our country alongside
their male counterparts. The changing role of women who serve in the
armed forces demands a thorough and comprehensive look at what needs to
be done to better serve them after they separate from service. I am
sure we would all agree that women veterans must have equal access to
gender-specific and comprehensive health care and benefits as their
male counterparts. As a Committee, we have taken key steps toward
realizing this goal of equal health care and benefits for women
benefits.
First, under the leadership of Chairman Filner, we held a
roundtable discussion on May 20, 2009 when we heard from women veterans
representing veteran service organizations and their auxiliary
organizations. The roundtable participants identified many issues,
which included military sexual trauma, combat post-traumatic stress
disorder, denied benefits claims and lengthy appeals, barriers to
health care utilization, and health care research on women veterans.
Another example of this Committee's commitment to women veterans is
our work on H.R. 1211, the Women Veterans Health Care Improvement Act,
which was introduced by Ms. Stephanie Herseth Sandlin. My Subcommittee
favorably reported this bill to the Full Committee in early June and
this important legislation passed the House recently on June 23, 2009.
Specifically, H.R. 1211 requires key studies assessing the VA health
care services provided to women veterans, including an assessment of
barriers. The bill also provides 7 days of medical care for newborn
children of women veterans receiving maternity care, authorizes a child
care pilot program, requires mental health professionals to receive
training on caring for veterans suffering from military sexual trauma
and PTSD, and empowers OEF/OIF women veterans to serve on the VA's
Advisory Committee on Women Veterans and the Advisory Committee on
Minority Veterans.
While we have made some progress on the issues facing women
veterans, it is clear that more needs to be done. Just earlier this
week, there was an article in MSNBC about the VA inadequately serving
women veterans. This article described the key findings of a GAO report
which revealed that no VA hospital or outpatient clinic is complying
fully with Federal privacy requirements. In other words, many VA
facilities had gynecological tables that faced the door, including one
door that opened to a waiting room. Beyond these privacy concerns, VA
facilities were built to serve male veterans and therefore, do not
accommodate the presence of children. This means that some women
veterans have had to resort to changing babies' diapers on the floors
of VA hospitals due to the absence of changing tables in the women's
bathrooms. In light of these challenges which continue to face women
veterans, it is important that we do more to address these issues.
I look forward to hearing from our witnesses today and learning
more about the potential barriers facing women veterans, including the
detailed findings of the GAO report entitled ``Preliminary Findings on
VA's Provision of Health Care Services to Women Veterans''.
MATERIAL SUBMITTED FOR THE RECORD
U.S. House of Representatives
Washington, DC.
July 24, 2009
Judith Sterne
Director
Office of Congressional and Legislative Affairs
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Ms. Sterne:
Thank you for the Department of Veterans Affairs testimony at the
joint Disability and Memorial Affairs and Health Subcommittees hearing
on Tuesday, July 14, 2009. Review of the testimony for this hearing
yielded three questions I ask for the record.
1. Can you please explain how the Director of the Center for Women
Veterans fits into the leadership structure of the Department of
Veterans Affairs?
2. Who is responsible for reporting to the Secretary on the
Department of Veterans Affairs health care facilities' implementation
of policies for improved women veterans' services?
3. Has there been a consideration of creating a position in the
secretariat for women's affairs?
I appreciate your response to these questions for the record and
look forward to working with you and the Department of Veterans Affairs
in the future. If you have any questions, please feel free to contact
Tim Leahy on my staff at (202) 225-3635.
Sincerely,
Debbie Halvorson
Member of Congress
__________
Questions for the Record
Hon. Debbie Halvorson
Subcommittee on Health
House Committee on Veterans' Affairs
July 16, 2009
Eliminating the Gaps: Examining Women Veterans' Issues
Question 1: Can you please explain how the Director of the Center
for Women Veterans fits into the leadership structure of the Department
of Veterans Affairs?
Response: The Center for Women Veterans is located within the
Office of the Secretary, Department of Veterans Affairs (VA). The
Director reports to the VA Chief of Staff. The Director serves as the
primary advisor to the Secretary on all matters related to policies,
legislation, programs, issues, and initiatives affecting women
veterans. The Director's duties include:
Monitoring VA's programs for women veterans and working
closely with VA's staff offices and three administrations--Veterans
Health Administration, Veterans Benefits Administration, and National
Cemetery Administration--to identify policies, practices, programs, and
related activities that may need enhancements or revisions to
accommodate the needs of women veterans; may be disparaging to women
veterans or hinder the receipt of services; or may need to be
established to facilitate access to care and benefits.
Fostering communication among all elements of VA on
research findings and ensuring that women veterans' issues are
incorporated into VA's strategic plan.
Recommending policy and legislative proposals to the
Secretary.
Providing support to the Advisory Committee on Women
Veterans (ACWV) which provides advice to the Secretary on the needs of
women veterans with respect to health care, rehabilitation benefits,
compensation, outreach, and other relevant programs administered by VA.
Question 2: Who is responsible for reporting to the Secretary on
the Department of Veterans Affairs health care facilities'
implementation of policies for improved women veterans' services?
Response: The Under Secretary for Health is responsible for
reporting to the Secretary and for overseeing the implementation of
policies on women's health care needs at VA health care facilities
involving over 1,400 sites, including hospitals, clinics, nursing
homes, domiciliaries, and readjustment counseling centers.
Question 3: Has there been a consideration of creating a position
in the secretariat for women's affairs?
Response: The Center for Women Veterans is organizationally
positioned in the Office of the Secretary.