[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






                  U.S. GOVERNMENT PRINTING OFFICE
51-873                    WASHINGTON : 2010
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001









                     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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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).
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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/.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
            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?
---------------------------------------------------------------------------
    \2\ Yano, EM., Achieving equitable high-quality care for women 
veterans, VA HSR&D Forum. Nov 2008.
---------------------------------------------------------------------------
      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).
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.

                                 
