Gender Issues: Medical Support for Female Soldiers Deployed to Bosnia
(Letter Report, 03/10/99, GAO/NSIAD-99-58).

Pursuant to a congressional request, GAO provided information on whether
adequate medical services were available to service members deployed to
the field, focusing on the: (1) availability of data collected on female
soldiers' health care needs in Bosnia; and (2) views of health care
officials and female soldiers on female-specific services and
health-related issues in Bosnia.

GAO noted that: (1) outpatient health care data is collected from
medical treatment facilities in Bosnia, but this data has limited value
for assessing the health care needs of deployed female soldiers; (2)
data collected on non-female-specific health problems is not broken out
by gender; (3) while data on gynecological visits is collected, this
data does not show the specific reasons for each visit; (4)
consequently, the types and extent of women's health care needs,
including female-specific needs, cannot be quantified; (5) collecting
this data would enable the Army to study the everyday aspects of the
gynecological health of military women, especially in field conditions,
and to identify and correct any shortfalls in medical services provided
to deployed women; (6) health care officials, including primary care
providers who staffed the base camp clinics and the hospital, told GAO
that the Army's health service support system in Bosnia was capable of
meeting the female-specific health care needs of women; (7) about
two-thirds of the women GAO surveyed who reported having gynecological
problems said all or most of their female-specific health care needs
were met while in Bosnia, while the other one-third said only a few or
none of their female-specific health care needs were met; (8) female
soldiers expressed some concerns about the Army's medical services and
other health-related issues in Bosnia; (9) a frequent complaint was the
lack of information on these subjects provided to women before they
deployed; (10) women said they would have benefited from more
information on how to prepare for an impending deployment, for example,
information on the availability of female-specific medications and
supplies, on the health care system that would serve them during the
deployment, and on best practices for staying healthy; and (11) women
also expressed concerns about the quality of medical support provided to
them and about the privacy and confidentiality of care at the clinics,
which were described as very small and lacking interior walls and doors
to shield individuals being examined.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  NSIAD-99-58
     TITLE:  Gender Issues: Medical Support for Female Soldiers Deployed 
             to Bosnia
      DATE:  03/10/99
   SUBJECT:  Women
             Health care services
             Military hospitals
             Army personnel
             Data collection
             Armed forces abroad
IDENTIFIER:  Bosnia
             Croatia
             Hungary
             
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cover-1.book GAO United States General Accounting Office

Report to the Ranking Minority Member, Subcommittee on Readiness
and Management Support, Committee on Armed Services, U. S. Senate

March 1999 GENDER ISSUES Medical Support for Female Soldiers
Deployed to Bosnia




GAO/NSIAD-99-58

  GAO/NSIAD-99-58

United States General Accounting Office Washington, D. C. 20548
Lett er

Page 1 GAO/NSIAD-99-58 Gender Issues

GAO

National Security and International Affairs Division Lett er

B-281815 March 10, 1999 The Honorable Charles S. Robb Ranking
Minority Member Subcommittee on Readiness

and Management Support Committee on Armed Services United States
Senate

Dear Senator Robb: At your request, we are reviewing various
issues pertaining to the treatment of men and women in the armed
services. This report addresses your question concerning whether
adequate medical services were available to servicemembers
deployed to the field. In this report, we have focused on female-
specific medical services and health- related issues for

Army personnel serving in the ongoing U. S. peace operation in
Bosnia. Specifically, we (1) determined the availability of data
collected on female soldiers' health care needs in Bosnia and (2)
obtained the views of health care officials and female soldiers on
female- specific medical services and

health- related issues in Bosnia. Background U. S. military forces
initially deployed to Bosnia in December 1995 as part of a
multinational effort to monitor and enforce implementation of the
Dayton

Agreement peace accords. 1 Most of the deployed soldiers live and
work in base camps in the vicinity of Tuzla. Each camp has a small
medical clinic, usually staffed by at least one doctor and other
medical personnel, that

provides health care services to the camp population. In addition,
an Army hospital has been established at one of the base camps to
provide a higher level of health care. 2 The hospital is better
equipped than the clinics and

has a relatively large medical staff. Soldiers who cannot be
treated in the theater of operations are evacuated to a military
hospital in Germany.

The size of the U. S. force in Bosnia and the proportion of female
soldiers there have fluctuated over time as units and individuals
rotate. As of 1 The agreement provided the structure and mandates
for an international operation intended to promote an enduring
peace in Bosnia and stability in the region. 2 At the time of our
review, the hospital was located in a site known as Blue Factory
at Guardian Base. In October 1998, Guardian Base was closed and
the hospital was moved to another base.

B-281815 Page 2 GAO/NSIAD-99-58 Gender Issues

October 1998, 6,871 U. S. soldiers were serving in Bosnia, with
female soldiers numbering 960 (14 percent). Another 1,318
soldiers, including 476 female soldiers (36 percent), were
deployed to Croatia and Hungary to support the Bosnia operation.

We obtained information on women's views primarily through a
questionnaire of 234 female soldiers who had recently served in
Bosnia. 3 We included a wide variety of women in our review. The
women were

assigned to eight different units and represented three pay grade
groups (E- 1s to E- 4s, E- 5s to E- 9s, and officers); they had
been deployed for varying lengths of time (almost all had served
sometime in 1998); and they had served in 12 different base camps.
To supplement the survey results and obtain a more complete
picture of female- specific health issues in

Bosnia, we conducted group interviews with 80 women who
participated in our survey. Because our survey participants were
not randomly selected, the survey results cannot be projected to a
larger population. Results in Brief Outpatient health care data is
collected from medical treatment facilities in Bosnia, but this
data has limited value for assessing the health care needs of
deployed female soldiers. First, data collected on non- female-
specific

health problems is not broken out by gender. Second, while data on
gynecological visits is collected, this data does not show the
specific reasons for each visit. Consequently, the types and
extent of women's health care needs, including female- specific
needs, cannot be quantified.

Collecting this data would enable the Army to study the everyday
aspects of the gynecological health of military women, especially
in field conditions, and to identify and correct any shortfalls in
medical services provided to deployed women.

Health care officials, including primary care providers who
staffed the base camp clinics and the hospital, told us that the
Army's health service support system in Bosnia was capable of
meeting the female- specific health care needs of women. For
example, they said very few women had been evacuated to the
military hospital in Germany for female- specific health problems.
About two- thirds of the women we surveyed who reported

3 A small number of these female soldiers had served in a base
camp across the border in Croatia. Army officials said the
soldiers at this base camp supported the U. S. operation in
Bosnia, served under similar deployment conditions, and were
provided medical care through the same health service support
system.

B-281815 Page 3 GAO/NSIAD-99-58 Gender Issues

having gynecological problems said all or most or their female-
specific health care needs were met while in Bosnia, while the
other one- third said only a few or none of their female- specific
health care needs were met.

Female soldiers expressed some concerns about the Army's medical
services and other health- related issues in Bosnia. A frequent
complaint was the lack of information on these subjects provided
to women before they deployed. Women said they would have
benefited from more information on how to prepare for an impending
deployment, for example, information on the availability of
female- specific medications and supplies, on the health care
system that would serve them during the deployment,

and on best practices for staying healthy. Women also expressed
concerns about the quality of medical support provided to them and
about the privacy and confidentiality of care at the clinics,
which were described as very small and lacking interior walls and
doors to shield individuals being

examined. Collected Outpatient Data Has Limitations for Assessing
Women's Health Care Needs

The great majority of health problems including female- specific
health problems are resolved on an outpatient basis and do not
require hospitalization. In Bosnia, information on soldiers'
outpatient visits is gathered through a data collection system
that countries participating in the peace operation have adopted.
Medical treatment facilities report

weekly on their number and types of new outpatient visits. Health
officials use the collected data to monitor trends in the
incidence of disease and non- battle- related injury.

The data collection system was not designed to capture the gender
of soldiers making outpatient visits. Thus, for non- female-
specific categories of disease and injury, the data does not show
how many men and women made outpatient visits. In the absence of
gender- specific data, the total number of outpatient visits by
women, the relative number of visits made by men and women, and
the proportion of gynecological visits to women's overall visits
cannot be determined. Studies from prior deployments showed that
female- specific health care needs accounted for a minimum of 14
percent and a maximum of 26 percent of women's health care needs.
(See app. II for discussion of this research.)

Gynecological problems are reported as one category of outpatient
visits. In 1997, according to an analysis conducted by Army health
officials, 1.9 percent of the 38, 786 reported outpatient visits
by soldiers deployed to Bosnia were for gynecological problems
equating to approximately

740 gynecological visits during the year, or a weekly average of
14. The

B-281815 Page 4 GAO/NSIAD-99-58 Gender Issues

data collected on gynecological outpatient visits, however, does
not indicate the specific reasons for each visit. For example, the
data does not indicate how many visits were for health services
such as obtaining birth control refill prescriptions or for
specific medical problems such as pelvic pain or menstrual
difficulties.

Health Care Officials Said Female Soldiers Received Satisfactory
Level of Care in Bosnia

Army officials have characterized the U. S. operation in Bosnia as
one of the healthiest deployments in recent history, with low
rates of disease and non- battle- related injury. A 1998 Army
health assessment attributed these low rates partly to an emphasis
on preventative medicine and the deployment of a healthy, fit
force. 4 Health officials we interviewed, including 14 doctors and
9 physician assistants who had served in Bosnia as primary care
medical providers, agreed with this overall assessment. In
addition, on the basis of their personal experience, these
officials did not

perceive an unusually high incidence of female- specific health
problems. At camps where combat units were primarily assigned, few
women were present and medical providers saw very small numbers of
female- specific health problems. 5 According to health care
officials, the combined capabilities of the base camp clinics and
the in- theater Army hospital provided a satisfactory level of
care to female soldiers. Almost all women who sought care for
femalespecific problems were treated either at the clinics or the
hospital, and very few had to be evacuated to Germany. The former
commander of the Army

hospital in Bosnia said only one such evacuation had been
necessary during her recent 6- month deployment. This case
involved a woman who needed a follow- up diagnostic procedure for
an abnormal Pap smear. The equipment for this procedure was not
available at the Army's hospital in Bosnia. Other health care
officials recalled similarly small numbers of evacuations for
female- specific problems. 6 Data provided by one Army

4 Other positive factors, according to the assessment, were (1) a
relatively friendly host nation populace, (2) mild environmental
conditions, (3) limited opportunity for transmission of food-
related pathogens, (4) almost exclusive use of bottled water for
drinking, and (5) limits on motor vehicle use and alcohol

consumption. 5 Few female soldiers were assigned to these camps
because women are barred from holding ground combat positions.

6 Not included in these anecdotes were women who were evacuated
because they tested positive for pregnancy. Such evacuations,
unless they involved an abnormal pregnancy, were accomplished
through administrative channels rather than through the medical
system.

B-281815 Page 5 GAO/NSIAD-99-58 Gender Issues

unit shows that of the 229 female soldiers it sent to Bosnia
during a 10- month time span, only 4 (1. 7 percent) were evacuated
for a femalespecific health problem and all 4 returned to duty in
Bosnia.

Medical providers who staffed the base camp clinics said their
mission was to stabilize and evacuate soldiers with acute
conditions and treat minor health problems. With respect to
female- specific conditions, the providers said they could treat
relatively simple problems such as yeast infections and urinary
tract infections. They could also test for pregnancy and dispense
birth control. The clinics, however, were not equipped to diagnose
and treat all female- specific conditions. For instance, providers

said they did not have microscopes or a laboratory. However, they
generally believed that the equipment they had at the clinics was
appropriate for the level of care they provided. They also said
they could obtain needed supplies, including medicine.

Medical providers at the base camp clinics described varying
approaches for treating female- specific problems. Some providers
said they had tried to treat certain conditions before deciding to
send women to the Army's intheater hospital for laboratory tests.
Other providers said they had referred women to the hospital if
laboratory tests were needed. Some providers said they had
performed pelvic exams at the clinics; others said they had not
(either because of the lack of privacy or laboratory support).
Providers said it was easy to refer a soldier to the Army's in-
theater hospital if necessary.

Soldiers referred to the hospital for nonurgent health care
problems were typically placed on a convoy leaving the base camp.
7 The soldiers would arrive at the hospital, receive treatment,
and then return to their base camp by convoy later that day.
Although a gynecologist was not on the hospital staff, a physician
certified in family medicine was available to treat femalespecific
health problems. For problems requiring pelvic exams, the hospital
had a private room with a door. It also had a laboratory and
ultrasound equipment (which is used to diagnose a wide variety of
pelvic problems). The hospital also performed Pap smears.

7 Emergency cases could be evacuated by ground ambulance or
helicopter.

B-281815 Page 6 GAO/NSIAD-99-58 Gender Issues

Women Expressed Some Concerns About Female- Specific Medical
Services and Other Health- Related Issues

Our survey of female soldiers indicated that gynecological
problems were common for this group of women. Of the 234 women
taking our survey, 121 (52 percent) reported they had at least one
such problem while deployed, 8 though many of these women had not
sought medical care for their problems. Of the 121 women reporting
that they had gynecological

problems, almost two- thirds said all or most of their female-
specific health care needs had been met in Bosnia, and one- third
said only a few or none of their needs had been met. In our survey
and group interviews, several common themes emerged as concerns
women had about female- specific medical services and other
health- related issues related to deployment in Bosnia. Particular
concerns were expressed about predeployment information provided
to women on female health and hygiene, the quality of medical
support provided for women, and the privacy and confidentiality of
care at the base camp clinics. In is unclear to what extent some
of the concerns were unique to female- specific health care or
were symptomatic of the medical care overall in Bosnia. (See app.
I for more detailed information on the views expressed to us by
these women.)

Predeployment Information on Female Health and Hygiene

Women in our group interviews emphasized the lack of unit
predeployment training on female health and hygiene more than any
other issue. They told us they would have benefited from having
been better informed about how to prepare for an impending
deployment. Some emphasized the need to prepare younger female
soldiers with no previous deployment experience. About one- fourth
of our survey respondents reported that their unit had

been their primary source of information on female- specific
health care and hygiene practices in the field. In contrast, about
half said they either had not received this type of information
prior to deployment or had obtained it through informal
conversation with their peers. One unit we visited had deployed
more than 200 women, but unit medical officials said information
on female- specific health care and hygiene was not part of
soldier readiness preparations.

Participants in our group interviews suggested that women with
previous deployment experience and medical credentials conduct
unit predeployment briefings. Some suggested topics for these
briefings were (1) birth control and sexually transmitted
diseases; (2) female hygiene in 8 Not all 234 women taking our
survey responded to our questions about whether they experienced

gynecological problems while in Bosnia. The proportion of
respondents who reported experiencing these problems was higher
than 52 percent. (See app. I for further discussion of these
survey results.)

B-281815 Page 7 GAO/NSIAD-99-58 Gender Issues

field settings, including advice about avoiding urinary tract
infections and yeast infections; (3) female- specific health care
services available in- theater and ways to obtain these services;
(4) guidance on packing

sufficient supplies of medications and feminine hygiene products;
and (5) tips for staying healthy.

Strategies for preparing female soldiers for deployment also are
suggested in an Army handbook developed for military leaders.
While the handbook states that responsibility for personal
readiness ultimately falls on the soldiers themselves, it suggests
that units coordinate a training session for female soldiers with
a community health nurse or a representative of the local
hospital's department of obstetrics and gynecology. According to
the handbook, these health officials can teach women how to
prepare themselves for the field and how to maintain their health
during deployment.

Quality of Medical Support The types of gynecological problems
women reported experiencing were common problems, such as pelvic
cramping or pain and menstrual difficulties. Those who had sought
care for gynecological problems typically went to the medical
treatment facility serving their base camp. Although some women
had positive experiences when seeking care there, others expressed
various concerns about the medical support. For instance, about
half of the survey respondents who had sought gynecological care
while in Bosnia were only mildly confident or not confident at all
in the medical provider's abilities.

Women cited various reasons for not seeking care for gynecological
problems. The most common reason was that the women had not
considered the problems severe or important enough to warrant
medical care. Others cited a lack of confidence in the medical
providers. When we explored this lack of confidence issue during
group interviews, some participants said the medical providers at
their base camp did not appear to be well- qualified to provide
female- specific care and did not take their health concerns
seriously. One woman, for instance, said her company commander had
to intervene with the medical provider at the clinic to secure a
referral to the Army hospital. Some women noted on their surveys
that they would prefer to see a gynecologist for their female-
specific problems but that a gynecologist was not available.

The Army has recently taken some steps aimed at evaluating and
improving medical support for deployed women. In 1997, a team was
chartered to

B-281815 Page 8 GAO/NSIAD-99-58 Gender Issues

identify the quantity and quality of well women's services
available to active duty women in garrison, prior to deployment,
and during deployment. The team is to recommend standards of care
necessary to ensure medical readiness for deployment. The results
of that effort were undergoing review within the Army.
Additionally, the Army has designed a new medical equipment set
for providing primary care to female soldiers. The set, to be
provided to deployable medical companies, includes the

capability of providing gynecological exams and related laboratory
tests and provides common medications such as birth control pills
and antibiotics. The set is to be tested in 1999 and fielded in
2000.

Privacy and Confidentiality In the view of many women we
interviewed, the small base camp clinics did not offer sufficient
privacy to soldiers being examined. Women also had concerns that
their medical problems would not be kept confidential by staff at
the clinics. Our survey showed that one- fourth of respondents who
had sought care were moderately dissatisfied or very dissatisfied
with

the level of privacy afforded them while receiving care; almost
one- third of respondents who had sought care were moderately
uncomfortable or very uncomfortable talking with the medical
provider about private matters. During the group interviews, some
women told us they had been concerned

that if they sought care at the clinic, word of their visit would
leak out and spread around camp.

Other Health- Related Issues Some aspects of the deployment
received favorable comment regarding their contribution to
personal health and hygiene. For example, all but one of the
survey respondents reported that a shower or clean water for
bathing had been available daily. In addition, more than half of
the respondents cited military stores located at the base camps as
their primary source of feminine hygiene products.

However, one- fifth of the respondents reported that they had
problems obtaining adequate supplies of feminine hygiene products
at some time during their deployment. Several respondents, in
their write- in comments to the survey, criticized the limited
selection of feminine hygiene products at the base camp stores.
One wrote, There was a lack of feminine hygiene

products. They always ran out. They had no variety. Another wrote,
Many times a form of feminine hygiene product was available, but
it was . . . most often a generic brand unfamiliar to the soldier.

B-281815 Page 9 GAO/NSIAD-99-58 Gender Issues

More than half of the survey respondents reported that there were
times during the deployment when they had encountered obstacles to
urinating. Of the women encountering obstacles, about 20 percent
said this problem had occurred on a daily basis. The most
frequently cited cause was extended travel time on convoys. When
leaving their base camp, U. S. soldiers in Bosnia are required to
travel by convoy to enhance force protection. During our group
interviews, women said these convoys could last several hours
without a stop to urinate. In a write- in comment to the

survey, one soldier stated, The drive from Taszar [Hungary] to
Bosnia was 12 hours without urinating and very painful. Real or
perceived obstacles to urinating can become a medical problem for
women if they decrease their fluid intake and dehydrate
themselves. Overall, more than four- fifths of our survey
respondents said they had access to their preferred method of
birth control during the deployment. However, a number of women
taking birth control pills were concerned about the limited
selection available for refill prescriptions at the base camp
clinics and were troubled because they had to change to another
brand. One woman, for instance, said she had to change
prescriptions three times while in Bosnia. Another said she had
switched prescriptions while deployed, then switched back when she
returned home. Birth

control pills, in addition to preventing pregnancy, may be used to
regulate a woman's menstrual cycle.

Conclusions The biggest concern raised by many women we
interviewed was the lack of predeployment information provided to
deploying women on female health and hygiene. Our survey data
indicates that about half the respondents either had not received
this type of information prior to deploying to Bosnia or had
obtained it on their own through informal conversations with their
peers. Female soldiers told us it would have been helpful to
receive a

briefing on these issues before they deployed. Some women were
particularly concerned that younger soldiers with no deployment
experience did not receive the information they needed from their
unit.

Recommendation We recommend that the Secretary of the Army take
steps to improve the preparation of female soldiers for deployment
by requiring units to provide

information on female- specific health care and hygiene. Included
should be information on the health services available to them
once deployed.

B-281815 Page 10 GAO/NSIAD-99-58 Gender Issues

Agency Comments In written comments on a draft of this report, the
Department of Defense agreed with our findings and recommendation.
The Department stated that adequate preparation of all
servicemembers for deployment is a critical element in
successfully completing the assigned mission. It further noted

that our recommendation to improve preparation of female soldiers
for deployment will be adopted. Specifically, the Department said
military units will provide information to their female members on
female- specific field health care and hygiene issues as well as
information on scope and access to deployed health services as
part of routine deployment preparations. The Department's comments
are reprinted in their entirety in appendix IV.

Our scope and methodology are discussed in appendix III. We are
sending copies of this report to interested congressional
committees, the Secretaries of Defense and the Army, and the
Director of the Office of Management and Budget. We will make
copies available to other parties on request.

If you or your staff have questions concerning this report, please
call me at (202) 512- 5140. The major contributors to this report
are listed in appendix V.

Sincerely yours, Mark E. Gebicke Director, Military Operations

and Capabilities Issues

B-281815 Page 11 GAO/NSIAD-99-58 Gender Issues

Page 12 GAO/NSIAD-99-58 Gender Issues

Contents Letter 1 Appendix I Views of Female Soldiers Deployed to
Bosnia

14 Appendix II Prior Research on Health Care Needs of Deployed
Women

26 Appendix III Scope and Methodology

31 Appendix IV Comments From the Department of Defense

34 Appendix V Major Contributors to This Report

35 Figures Figure I. 1: In the 3 months prior to deployment, what
was your primary

source of information on female- specific health care and hygiene
practices in field conditions? 15 Figure I. 2: Which topics on
female- specific health and hygiene were

addressed in the information you received prior to deployment? 16
Figure I. 3: Which of the following gynecological problems did you

experience while deployed to Bosnia? 18

Page 13 GAO/NSIAD-99-58 Gender Issues

Figure I. 4: To what extent did the health services in Bosnia meet
your overall female- specific health care needs? 19 Figure I. 5:
What were the reasons you did not seek care for

gynecological problems? 21 Figure I. 6: While you were deployed to
Bosnia, what was your

primary source of feminine hygiene products? 23 Figure I. 7: What
caused you to postpone urinating or prevented

you from urinating? 24

Contents

Page 14 GAO/NSIAD-99-58 Gender Issues

Appendix I Views of Female Soldiers Deployed to Bosnia Appendi x I

This appendix discusses women's views of female- specific medical
services and other health- related issues in Bosnia. We obtained
information on women's views primarily through a questionnaire of
234 female soldiers who had recently served in Bosnia. 1 The
number of respondents to each question varied because (1) some
survey respondents were told to skip certain questions based on
their answers to other questions and (2) some participants chose
not to answer certain questions. The women were assigned to eight
different units and represented three pay grade groups

(E- 1s to E- 4s, E- 5s to E- 9s, and officers); they had been
deployed for varying lengths of time (almost all had served
sometime in 1998); and they had served in 12 different base camps.
To supplement the survey results and obtain a more complete
picture of female- specific health issues related

to deployment in Bosnia, we conducted group interviews with 80
women who participated in our survey. Because our survey
participants were not randomly selected, the survey results cannot
be projected to a larger population.

During our review, women expressed some concerns about female-
specific medical services and other health- related issues.
Particular concerns were expressed about predeployment information
on female health and hygiene, the quality of medical support
provided for women, and the privacy and confidentiality of care at
the base camps. In addition, women expressed concerns about
feminine hygiene supplies, obstacles to urinating, and the
unavailability of birth control pill prescriptions.

Predeployment Information on Female Health and Hygiene

More than three- fourths of the survey respondents felt they were
either very prepared (43 percent) or moderately prepared (35
percent) for the Bosnia deployment with respect to female-
specific health care and hygiene. Other women said they were only
mildly prepared (15 percent) or not prepared at all (7 percent).
Nevertheless, many women expressed

concerns about their units' efforts to prepare female soldiers for
this aspect of deployment

In our survey, we asked women to review the preparations they made
prior to deploying to Bosnia and to recall their primary source of
information on

1 A small number of these female soldiers had served in a base
camp across the border in Croatia. Army officials said the
soldiers at this base camp supported the U. S. operation in
Bosnia, served under similar deployment conditions, and were
provided medical care through the same health service support
system.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 15 GAO/NSIAD-99-58 Gender Issues

female- specific health care and hygiene practices in field
conditions. While 61 (27 percent) women said they had received
this information primarily through unit training or information
sessions, 2 115 (51 percent) said they either had not received
this type of information from any source prior to

deployment or had obtained information through informal
conversations with peers (see fig. I. 1).

Figure I. 1: In the 3 months prior to deployment, what was your
primary source of information on female- specific health care and
hygiene practices in field conditions?

Note: This question was asked to all survey participants and was
answered by 226 respondents. Source: Our analysis of survey
responses.

The 61 women who said they had received information from their
units prior to deployment indicated that the most common topics
covered were sexually transmitted diseases, guidance on packing
feminine hygiene supplies and medications, and birth control.
Fewer women said their units 2 Three of these 61 respondents
marked more than one answer to this question, indicating that they
had

important sources of information other than unit training or
information sessions.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 16 GAO/NSIAD-99-58 Gender Issues

had provided information on preventing urinary tract infections
and vaginal infections (see fig I. 2).

Figure I. 2: Which topics on female- specific health and hygiene
were addressed in the information you received prior to
deployment?

Note: This figure shows responses from the 61 women in our survey
who reported that their units had been their primary source of
predeployment information on female health and hygiene.

Source: Our analysis of survey responses.

We also asked all survey participants about any female- specific
medical conditions that were not resolved prior to deployment. A
small group of women 25 (11 percent) respondents reported they had
an unresolved female- specific medical problem. Of these 25 women,
11 said the problem concerned an abnormal Pap smear. We do not
know what the other unresolved problems were.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 17 GAO/NSIAD-99-58 Gender Issues

Medical Support We asked all survey participants what types of
female- specific health problems they had experienced while
deployed to Bosnia and whether they had sought medical care for
these problems. We listed seven possible gynecological problems
and asked the women to indicate, for each, whether they (1) did
not have the problem, (2) had the problem but did not seek care,
or (3) had the problem and sought care. 3 The most commonly
experienced problems were pelvic cramping or pain and menstrual
difficulties (see fig. I. 3).

3 Respondents were also asked if they experienced other
gynecological problems that were not among the seven listed.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 18 GAO/NSIAD-99-58 Gender Issues

Figure I. 3: Which of the following gynecological problems did you
experience while deployed to Bosnia?

Note: The items in this question were asked to all survey
participants and were answered by 211 to 217 respondents.

Source: Our analysis of survey responses.

In a subsequent question about what they did to correct such
problems, 95 (44 percent) respondents said they had none of the
problems, 71 (33 percent) had one or more problems but had not
sought care, and 49 (23 percent) had sought care for at least one
of these problems. 4 Thus, more than half of the respondents 120
(56 percent) of 215 women

4 Another 14 women indicated in the previous question that they
had sought care for one of the specific gynecological problems
listed but were not consistent in their answers to this question.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 19 GAO/NSIAD-99-58 Gender Issues

reported that they had experienced a gynecological problem in
Bosnia. 5 For women who said they had at least one gynecological
problem, almost two- thirds said that all or most of their female-
specific health care needs had been met in Bosnia, and one- third
said only a few or none of their needs had been met (see fig. I.
4).

Figure I. 4: To what extent did the health services in Bosnia meet
your overall femalespecific health care needs?

Note: This question was answered by 121 survey respondents who
reported experiencing a gynecological problem while in Bosnia.

Source: Our analysis of survey responses.

Of the approximately 60 women who said they had sought care for at
least one gynecological problem, 6 more than 80 percent went to
the medical treatment facility serving their base camp. We asked
the women who had sought care to rate five aspects of that care:
(1) confidence in the medical 5 One respondent indicated in the
previous question that she had experienced a gynecological
problem, but in this question she did not report having a problem.
When this respondent is added, a total of 121

women reported experiencing gynecological problems. 6 These survey
respondents included the 49 women who said they sought care for at
least one gynecological problem while in Bosnia as well as 14
other women who indicated in the previous question that they
sought care for one of the specific problems listed. Between 55
and 57 of these

women answered each of our survey questions concerning the medical
care they received.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 20 GAO/NSIAD-99-58 Gender Issues

provider, (2) appropriateness of the gynecological services
received, (3) timeliness of care, (4) comfort level talking about
private matters, and (5) satisfaction with privacy while receiving
care. The last two aspects comfort level talking about private
matters and satisfaction with privacy

are discussed in the next section of this appendix. The survey
responses for the other three aspects showed the following:  Half
the respondents were only mildly confident (32 percent) or not
confident at all (18 percent) in the medical provider's abilities,
and half were very confident (16 percent) or moderately confident
(35 percent) in the provider's abilities. 7

 Considering their particular needs, 61 percent thought the
gynecological services they had received were either highly or
generally appropriate, 23 percent thought the services were
neither appropriate nor inappropriate, and 16 percent thought the
services were either generally or highly inappropriate.

 With respect to timeliness of care received, 73 percent said they
had received prompt or very prompt care, 22 percent said there had
been some delay, and 6 percent said it had taken much too long to
receive care. 8

Women who reported in the survey that they had not sought care for
one or more gynecological problems were asked to provide reasons.
The most prevalent reason cited by the 93 respondents 9 was they
did not feel the problems had been severe or important enough to
warrant medical attention, and the second most prevalent reason
was that the respondent had lacked confidence in the medical
provider (see fig. I. 5).

7 Percentages do not add to 100 due to rounding. 8 Percentages do
not add to 100 due to rounding. 9 The 93 respondents included
women who did not seek care for any gynecological problems, as
discussed earlier in the appendix, as well as women who sought
care for some problems but not for

other problems.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 21 GAO/NSIAD-99-58 Gender Issues

Figure I. 5: What were the reasons you did not seek care for
gynecological problems?

Note: This figure shows responses from the 93 women in our survey
who reported that they had not sought care for one or more of the
gynecological problems they experienced. Source: Our analysis of
survey responses.

When asked whether they would have sought care if stationed at
their home installation, 56 (60 percent) of these 93 respondents
said they would have sought care, and 37 (40 percent) said they
would not have. Isolating those respondents who reported that they
did not seek care for any of the gynecological problems they had
in Bosnia, we found that 36 (54 percent)

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 22 GAO/NSIAD-99-58 Gender Issues

of 67 respondents would have sought care if they were back home,
and 31 (46 percent) would not have sought care. 10

Privacy and Confidentiality

Women cited concerns about the privacy and confidentiality of care
provided at the base camp clinics. Our survey showed that of the
approximately 60 women who said they had sought medical care for
one or more gynecological problems, 44 percent were very
comfortable or moderately comfortable talking with their medical
provider about private

matters, 23 percent were neither comfortable nor uncomfortable,
and 33 percent were moderately uncomfortable or very
uncomfortable. In addition, 51 percent were very satisfied or
moderately satisfied with their level of privacy while receiving
care, 21 percent were neither satisfied nor

dissatisfied, and 28 percent were moderately dissatisfied or very
dissatisfied.

During our group interviews, some women expressed concerns about a
lack of both visual and auditory privacy in the small base camp
clinics. For instance, they said that examining rooms lacked doors
and that curtains or

other dividers used to screen off the examining rooms did not
always close completely. Furthermore, discussions in the clinics
could easily be overheard by others. Women also were concerned
about what they perceived to be a lack of patient confidentiality.
They told us that word would leak out if they sought care and that
the information about their problem, or an exaggerated version of
the problem, would soon spread

around camp. Medic staff, rather than doctors or physician
assistants, were more often blamed for these breaches of
confidentiality.

Feminine Hygiene Supplies Some aspects of the Bosnia deployment
received favorable comment regarding their contribution to good
personal health and hygiene. For

example, all but one of the survey respondents (more than 99
percent) said they had daily access to showers or clean water for
bathing. The survey indicated, however, that some women had
experienced problems obtaining

feminine hygiene products such as tampons and sanitary pads. Of
the survey respondents, 45 (20 percent) said there had been times
during the deployment when they had not been able to obtain
adequate supplies of

10 Of the 71 respondents who reported earlier in the survey that
they had not sought care for any gynecological problems, 2 did not
answer this question and 2 answered that this question was not
applicable to them, leaving a total of 67 respondents.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 23 GAO/NSIAD-99-58 Gender Issues

these products, while 182 (80 percent) said they had not had such
problems. When asked about their primary source of feminine
hygiene products, 124 (56 percent) respondents cited base camp
stores see fig. I. 6). 11 A number of women indicated in the
survey that they had

been dissatisfied with the limited selection of feminine hygiene
products at the base camp stores and complained that the stores
had run out of supplies of these products.

Figure I. 6: While you were deployed to Bosnia, what was your
primary source of feminine hygiene products?

Notes: This question was asked to all survey participants and
answered by 222 respondents. Percentages do not add to 100 due to
rounding. Source: Our analysis of survey responses.

Obstacles to Urinating A majority of women taking our survey said
there were times during the deployment when they had encountered
obstacles to urinating. Specifically, 126 (55 percent) of 230
respondents said this had happened to 11 Nine of these 124
respondents entered more than one response to this question,
indicating that they

had important sources of feminine hygiene products in addition to
base camp stores.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 24 GAO/NSIAD-99-58 Gender Issues

them, and 104 (45 percent) said it had not happened. Of those
women who experienced this problem, 61 (50 percent) of 123
respondents said it had occurred at least 2 to 3 days a week,
including 25 women (20 percent) who had experienced the problem
daily. 12 By a large margin, the top obstacle to

urinating was extended travel time on convoys (see fig. I. 7).
When leaving their base camp, U. S. soldiers in Bosnia are
required to travel by convoy to enhance force protection. During
our group interviews, women said these

convoys could last several hours without a stop to urinate.

Figure I. 7: What caused you to postpone urinating or prevented
you from urinating?

Note: This figure shows responses from 123 women in our survey who
reported that they had encountered obstacles to urinating during
their deployment.

Source: Our analysis of survey responses.

12 Of the 126 respondents who reported that that were times when
they felt they had to postpone urinating, 3 did not answer this
question, leaving a total of 123 respondents.

Appendix I Views of Female Soldiers Deployed to Bosnia

Page 25 GAO/NSIAD-99-58 Gender Issues

Unavailability of Birth Control Pills Of 189 survey respondents,
156 (83 percent) said they had access to their

preferred method of birth control during deployment, and 33 (17
percent) said they had not. Of those who said they had not had
access, the most frequent form of birth control not available was
birth control pills. Specifically, 13 (62 percent) of 21
respondents said birth control pills had not been available to
them. 13 According to women we surveyed and interviewed, the
primary problem concerning birth control pills was the limited
selection for refill prescriptions at their base camp clinics.
Several women said their brand had not been available and that
they had to change

prescriptions, sometimes more than once, after they deployed.
Other women avoided this problem by bringing a long- term supply
of pills with them. 13 Of the 33 respondents who reported that
they had not had access to their preferred birth control method
during deployment, 12 did not answer this question, leaving a
total of 21 respondents.

Page 26 GAO/NSIAD-99-58 Gender Issues

Appendix II Prior Research on Health Care Needs of Deployed Women
Appendi x I I

Prior to the Persian Gulf War, very little research was published
on women's health experiences while deployed or on the
effectiveness of the health service support system in meeting
women's medical needs. The Gulf War generated greater interest in
these issues because of the large number of women more than 40,000
who deployed. In three separate studies,

Army doctors reviewed patient records from the war to assess
women's health care needs. 1 In at least one study, Air Force
women were surveyed about their health experiences during the Gulf
War, including gynecological health care needs. 2 In addition, our
office studied the deployment of women to the Persian Gulf and
addressed concerns that had been raised about the impact of
austere deployment conditions on women's health. 3 Some research
has been conducted on other deployments as well. An

Army study, for instance, reviewed the morbidity of women deployed
to Korea and at a U. S. installation, 4 and Navy researchers have
studied women's health experiences while deployed aboard ships. 5
In fiscal years 1994 and 1995, Congress appropriated a total of
$80 million for additional research on defense women's health
issues. More than 100 studies were funded under this program,
covering a broad array of subjects. The Institute of Medicine
prepared a report in 1995 that served as

guidance for the research program. The Institute's report noted
very little is being done to study the everyday aspects of
gynecologic or reproductive health of military women, especially
in field conditions and health services research should be
conducted to study the accessibility and availability of women's
health services in field operations and ways that 1 J. F. Hines,
Ambulatory Health Care Needs of Women Deployed With a Heavy
Armored Division During

the Persian Gulf War, Military Medicine, 157, 5: 219, 1992; G.
Markenson, Female Health Care During Operation Desert Storm: The
Eighth Evacuation Hospital Experience, Military Medicine, 157, 11:
610, 1992; and J. T. Hanna, An Analysis of Gynecological Problems
Presented to an Evacuation Hospital During Operation Desert Storm,
Military Medicine, 157, 5: 222, 1992.

2 A. S. Robbins, Availability, Accessibility, and Adequacy of
Health Care Provided to USAF Active Duty Women In- Theater During
Operation Desert Shield/ Storm, Armstrong Lab, Brooks Air Force
Base, Texas (Oct. 1995).

3 Women in the Military: Deployment in the Persian Gulf War
(GAO/NSIAD-93-93, July 13, 1993). 4 J. D. Gunzenhauser,
Comparative Morbidity Study of Active Duty Women Serving in Korea
and Fort Lewis, Madigan Army Medical Center, Tacoma, Washington
(May 1997). 5 S. Nice, Sex Differences in Health Care Requirements
Aboard U. S. Navy Ships, Naval Health Research Center (Report No.
90- 2, Mar. 20, 1990); S. Nice, Sex Differences and Occupational
Influences on Health

Care Utilization Aboard U. S. Navy Ships, Military Psychology, 6(
2), 109- 123, 1994; R. G. Burr, Health Care Satisfaction: A
Comparison of U. S. Navy Women With Men Aboard Ships, Naval Health
Research Center (Report No. 96- 28, Oct. 1996); and M. J.
Schwerin, Shipboard Women's Health Care: Provider Perceptions,
Military Medicine, 162, 10: 666, 1997.

Appendix II Prior Research on Health Care Needs of Deployed Women

Page 27 GAO/NSIAD-99-58 Gender Issues

these might be improved. In 1998, the Department of Defense hired
a contractor to assess the overall results of the research program
and determine what research gaps remain.

According to the various published studies, men and women tend to
experience similar types of illnesses and disorders while
deployed, although there may be some gender differences for
particular diagnoses. A study of sick call data at an Army
division deployed to the Persian Gulf War evaluated gender
disparities for seven major clinical diagnoses, which together
accounted for 67 percent of all the sick call visits. 6 The study

found that women and men were statistically similar for three
diagnoses acute gastrointestinal, respiratory, and dental
disorders. Men were more likely to be diagnosed with
dermatological and orthopedic disorders, and

women were more likely to be diagnosed with psychiatric and
optometry disorders. A study comparing the morbidity of male and
female servicemembers deployed to Korea did not reproduce these
results. This study found that women had higher rates of
dermatological disorders than men did and that psychiatric and
ophthalmic conditions represented only a small proportion of all
clinic visits. A study of women's health aboard Navy ships found
that, for both genders, about half of all sick call visits were
for illnesses or disorders, another one- fourth were for injuries,
and the remaining one- fourth were for health services (such as
physical examinations).

The studies have consistently shown that, following patterns in
the civilian sector and at peacetime garrisons, deployed women
tend to visit medical providers for sick call more often than men.
A Navy researcher concluded

that it is the frequency, not the types, of health problems that
distinguishes the health of men and women. That study found that
the monthly sick call rate for women aboard ships was 1.79 times
greater than for men. A subsequent study found a similar female-
to- male ratio of shipboard sick- call rates 1.66 to 1. When the
data was adjusted for age, however, the ratio decreased to 1.44 to
1 because the women aboard the ships were younger on average than
the men and younger people tend to make sick call visits more
often. Additionally, when visits for female- specific

conditions were excluded, the female- to- male ratio decreased to
1.21 to 1. The study of servicemembers deployed to Korea and at a
U. S. installation found that gender was a much more significant
factor on morbidity than

6 J. f. Hines, A Comparison of Clinical Diagnoses Among Male and
Female Soldiers Deployed During the Persian Gulf War, Military
Medicine, 158, 2: 099, 1993.

Appendix II Prior Research on Health Care Needs of Deployed Women

Page 28 GAO/NSIAD-99-58 Gender Issues

were the effects of deployment. Women in Korea visited clinics at
twice the rate of men and self- reported significantly worse
health status. In an Army combat division deployed to the Persian
Gulf, women made up approximately 6 percent of the total force but
accounted for nearly 18 percent of all sick call visits to five
support battalion medical units. These medical units, however,
were located in areas behind the front lines where most women
served (women are excluded from front- line ground

combat positions). Thus, the analysis may have been skewed because
the female- to- male ratio was higher in the rear, giving women
comparatively greater access to health care. Several reasons for
women's higher health care usage have been postulated, but there
does not yet appear to be a consensus among researchers.

A number of the published studies calculated the proportion of
female- specific health care needs as a percentage of women's
overall health needs during deployment. In these studies, female-
specific needs

accounted for a minimum of 14 percent and a maximum of 26 percent
of women's health needs. According to Army studies of the Gulf
War, the most common gynecological diagnoses were vaginitis
(mostly yeast infections), abnormal bleeding, pelvic pain, desire
for birth control pills, and pregnancy. A gynecologist who
reviewed these studies stated that the

most common gynecological complaints women experienced during the
Gulf War are also the most common seen in private practice. 7 A
Navy study on gynecological care aboard one ship found that
routine care, including Pap smears and birth control pill refills,
accounted for 30 percent of visits, followed by sexually
transmitted diseases (14 percent), menstrual abnormality (13
percent), vaginitis (10 percent), urinary tract problems (9
percent), and pregnancy- related issues (9 percent).

Female- specific health needs, while common, do not generally
represent severe problems during deployments. Most gynecological
conditions have been handled on an outpatient basis. During the
Gulf War, gynecological

hospital admissions accounted for a small percentage of total
hospital admissions. (This percentage would have been even smaller
had U. S. forces experienced the combat casualties that were
predicted prior to the start of hostilities.) For instance, of 577
gynecological patient visits to one Army hospital in the Persian
Gulf, only 9 patients were admitted. Of

86 women admitted to another Army hospital, 10 (12 percent) had 7
D. S. Lyon, Medical Care of Women Deployed During Desert Storm,
Southern Medical Journal, Vol. 89, No. 2 (Feb. 1996).

Appendix II Prior Research on Health Care Needs of Deployed Women

Page 29 GAO/NSIAD-99-58 Gender Issues

gynecological- related diagnoses. A third Army hospital recorded
17 gynecological- related admissions, accounting for 3 percent of
all admissions. Various studies also have found that the great
majority of female- specific health needs can be addressed by a
medical provider other than a obstetrical/ gynecological
specialist. One researcher stated that a provider armed with a
basic knowledge of gynecology and a modicum of equipment,

laboratory, and pharmacy support would be sufficient to evaluate
most female- specific complaints. The published research indicates
that most women surveyed report that they get the health care they
need. An Air Force survey of women deployed to the Persian Gulf
showed that women gave high overall ratings for availability,
accessibility, and adequacy of health care during the deployment.
However, there have been some troubling survey findings with
respect to gynecological care. The Air Force survey showed the

following:  A substantial percentage (66 percent) of those with
gynecological conditions during deployment said their illnesses
persisted after the deployment.

 Of the women with gynecological conditions, 74 percent reported
seeking medical care during the deployment. However, 89 percent
said they would have sought care had they been back in the United
States. Reasons for not seeking care included (1) they did not
think their conditions were serious enough, (2) they had no
confidence in the

medical providers, or (3) they would have had to wait too long to
receive care. Nearly half the women were embarrassed about their
gynecological problems.  Nearly 40 percent of the respondents had
to see a medical provider two

or three times for a condition.  Women gave their highest negative
rankings to providers' efforts to explain the women's symptoms.

A Navy survey of women and men aboard ships found that a majority
of women were satisfied with their health care during sick call
visits, but they reported less satisfaction than men with their
general health care, health care providers or consultations, the
quality of service at sick call visits, and

the extent to which sick call visits met their needs. Women also
reported lower distress relief and lower levels of rapport with
health care providers.

Appendix II Prior Research on Health Care Needs of Deployed Women

Page 30 GAO/NSIAD-99-58 Gender Issues

While they did not describe their general health less favorably
than men, women reported significantly more symptoms of distress.

Page 31 GAO/NSIAD-99-58 Gender Issues

Appendix III Scope and Methodology Appendi x I I I

To review medical services available to servicemembers deployed to
the field, we focused on female- specific medical services and
health- related issues for Army personnel who had deployed
recently to Bosnia. We focused on female- specific health care
because it constituted up to

one- fourth of women's health care needs in prior deployments. We
selected the U. S. deployment to Bosnia because it is a major,
ongoing operation. At more than 3 years old, it is also a
relatively mature operation and no longer can be said to represent
austere field conditions. During the course of our review, we were
told that the health and hygiene conditions today are greatly
improved from the first months of the operation when there was
very little infrastructure support. Currently, a contractor
provides base support, and amenities have been added to increase
the comfort level of U. S. forces deployed there.

To determine the availability of data collected on female
soldiers' health care needs in Bosnia, we met with or contacted
cognizant Army officials to discuss the outpatient data collection
system. We obtained an analysis of disease and non- battle-
related injury data that was conducted by Army

health officials responsible for gathering the data. We also
obtained a 1998 Army health assessment of the Bosnia deployment
that considered various health measures and a briefing on a mental
health study of soldiers in Bosnia that was conducted by Army
officials in Germany.

To obtain the views of health care officials on female- specific
medical services, we interviewed health officials and medical
staff responsible for providing care to soldiers deployed to
Bosnia. Among those interviewed were the Commander and Deputy
Chief for Clinical Services, 67th Combat Support Hospital,
Wurzburg, Germany; Commander, 396th Combat Support

Hospital, U. S. Army Reserve; Command Surgeon, 1st Armored
Division, Bad Kreuznach, Germany; and Commander, 261st Area
Support Medical Battalion, Fort Hood, Texas. We also interviewed
officials in the Office of the Command Surgeon, U. S. Army Europe;
the Europe Regional Medical Command; and the Office of the Command
Surgeon, V Corps, Heidelberg,

Germany; the 2nd Armored Cavalry Regiment, Fort Polk, Louisiana;
the U. S. Army Surgeon General's Office, Baileys Crossroads,
Virginia; and the U. S. Army Medical Command, Fort Sam Houston,
Texas. We interviewed 23 medical providers who served in Bosnia 14
doctors and 9 physician assistants. Almost all of these medical
personnel served in primary care positions, either at the base
camps or in the hospital. We also met with a small number of
combat medics who staffed the base camp clinics.

Appendix III Scope and Methodology

Page 32 GAO/NSIAD-99-58 Gender Issues

To obtain the perspective of women who deployed to Bosnia, we
conducted a survey of 234 female soldiers. Of the 234 soldiers
surveyed, 144 (62 percent) were assigned to the 2nd Armored
Cavalry Regiment, Fort Polk, Louisiana, and 90 (38 percent) were
assigned to the following units in Germany: 130th Engineering
Brigade, Hanau; 22nd Signal Brigade,

Darmstadt; 18th Corps Support Battalion (3rd Corps Support
Command), Hanau; 127th Maintenance Support Battalion, Hanau; 501st
Military Intelligence Battalion, Dexheim; Headquarters, 1st
Armored Division, Bad Kreuznach; and 527th Military Police
Company, Wiesbaden. In Germany, the U. S. Army's V Corps selected
units for us to visit. The units identified and provided female
soldiers to participate in our survey. We visited each

of the selected units to administer the survey. Because our survey
participants were not randomly selected, the results cannot be
projected to a larger population. Of the 234 survey participants,
158 (68 percent) were in the E- 1 to E- 4 pay grade group, 54 (23
percent) were in the E- 5 to E- 9 pay grade group, and 21 (9
percent) were officers. 1 The average length of deployment for the

survey participants was 7.3 months, and their average age was 25.
6 years. Most of the women served sometime in 1998, although a few
served earlier tours. We asked those who had deployed more than
once to provide information concerning their most recent
deployment. We did not determine how many of the survey
participants were on their first

deployment when they served in Bosnia. The great majority of
survey participants served at one of the three following base
camps: Tuzla Main, 74 (32 percent); Guardian Base/ Blue Factory,
64 (28 percent); and Comanche, 34 (15 percent). Another 44
participants (19 percent) served at nine other base camps in
Bosnia, and 16 (7 percent) served in Croatia 2 in support of the
U. S. peace operation in Bosnia. To obtain a more complete picture
of female soldiers' views, we interviewed 80 of the 234 soldiers
surveyed. These interviews were conducted in small groups of 2 to
13 people. For each interview, we grouped the comments into
overall themes. Likewise, we grouped the

write- in comments to the survey into overall themes. To
supplement our work in Bosnia, we conducted a literature search
for research on women's health issues during deployments. We also
reviewed 1 One woman did not identify her pay grade group.

2 Two women did not identify their primary base camp.

Appendix III Scope and Methodology

Page 33 GAO/NSIAD-99-58 Gender Issues

Department of Defense research programs, contacted officials
responsible for overseeing defense women's health research, and
interviewed selected researchers.

We performed our work between May and December 1998 in accordance
with generally accepted government auditing standards.

Page 34 GAO/NSIAD-99-58 Gender Issues

Appendix IV Comments From the Department of Defense Appe ndi x I V

Page 35 GAO/NSIAD-99-58 Gender ]Issues

Appendix V Major Contributors to This Report Appe ndi x V

National Security and International Affairs Division, Washington,
D. C.

Carol Schuster Bill Beusse Thomas Gosling Carole Coffey

Suzanne Lofhjelm Jack Edwards

Los Angeles Field Office

Cheryl Gordon

(703268)

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