The Female Veteran
Unique Service and Needs
By Micaila Britto
As you walk down the streets of your town every day, you see her there – a woman who might be attired as a business manager, health care worker, or any number of other skilled professionals. You think that she probably is someone’s mother, daughter, sister, or girlfriend, and you would be right. But what you probably do not realize is that she also is, or has been, someone’s commanding officer, wingman, heavy equipment operator, or supply clerk. She is the female veteran. It’s no secret that America’s armed forces today are made up of men and women from all walks of life. And since they were fully integrated into the military, the number of women serving has increased to about 11 percent of the total force, including the various Reserve and National Guard components. With this increase in numbers, the Department of Veterans Affairs (VA) is being forced to rethink how it will be treating these women warriors once they leave the service. That they are among the first generation of career servicewomen from the 1970s and 1980s, and entering the prime of their retirement years, brings with it very specific medical needs unique to their gender. Along with the new generation of female veterans from the Global War on Terrorism (GWOT), this growing need for female-specific health care services is creating challenges that VA planners did not need to consider just a decade ago.
The reality is that the development of female-specific health care services is neither new nor even unusual. Women have long been clients of the VA, as both dependents and servicewomen. What is new is the growing numbers of female vets, and their inclusion into patient groups, which previously would have been limited to men. Like their male counterparts, women veterans are now obtaining treatment for service-related illnesses like Gulf War Syndrome, and with more common conditions like repetitive stress injuries. Add to these the everyday health needs of women everywhere, from gynecological services to mammography, and you
HISTORY
Like any other challenge, women’s health care in the VA requires research and definition. Especially when you consider the escalating costs of health care in America overall, the VA can ill-afford throwing scarce federal funds at the wrong kinds of female-specific services. So the past few years have seen the VA and the Department of Defense (DoD) closely watching health trends among women on active duty, as well as those in the inactive and retired communities. This task, along with many others specifically related to women’s health issues at the VA, is the responsibility of the Women’s Veteran Health Strategic Healthcare Group (WVHSHG), which was created in 1988. The mission of female vets’ health care became public law with the Veterans Health Care Act of 1992, which authorized a number of new and expanded medical services for women veterans.
This legislation made counseling for rape and other sexual trauma a priority, along with specific health services for women like Pap smears, mammography, and OB-GYN procedures at VA medical facilities.
Four years later, the Veterans’ Health Care Eligibility Reform Act of 1996 further expanded VA women’s health services to include maternity and infertility benefits, among others. Within months, with the start of FY 1997, the VA undersecretary for health appointed the first full-time director for the Women Veterans Health Program. Run with oversight from the WVHSHG, this program provides a cost-effective and comprehensive system of medical and psychosocial services for women veterans throughout the VA health care system.
Women’s services expanded through legislation again in 1999, with the Veterans Millennium Health Care and Benefits Act extending the provision of counseling and treatment services to veterans who have experienced military sexual trauma through Dec. 31, 2004. That same year (1999) also saw the expansion of the VA’s uniform benefits package, along with special initiatives creating Women Veterans Comprehensive Health Centers and Clinical Programs of Excellence.
THE DEMOGRAPHIC
The demographic for women in the VA health system today is well-documented and understood. The estimated number of U.S. women veterans as of 2001 was around 1.6 million, or about 7.2 percent of the 22.8 million total. This means that 10.26 percent of U.S. veterans who use the VA for health care are women. By comparison, women make up 14.8 percent of the current active duty military force, and approximately 22.8 percent of the National Guard and Reserve communities. Overall, 62 percent of women veterans are less than 45 years of age. In addition, by 2010, females are expected to represent over 14 percent of the total veteran population, with 56 percent of women who use VA health services being older than 45 years of age.
According to Dr. Patricia Hayes, acting chief consultant for WVHSHG, the DoD and VA have been tracking the health data of more than 70,000 women deployed in support of OIF and/or Operation Enduring Freedom (OEF), who have been discharged since 2003. According to the data collected on these veterans, 37 percent of the women have enrolled in the VA health care system, where previously only about 17 percent of women veterans enrolled following military service.
Also interesting are the conditions for which OEF/OIF women veterans have sought VA health services. Fully 50 percent have made between two and 10 visits to VA health care facilities, while 32.5 percent have made more than 11. The top five reasons for vets of both sexes to visit VA health care facilities are:
1. Diseases of the musculoskeletal (bones/joints) system (43 percent);
2. Symptoms, signs and ill-defined conditions (39 percent);
3. Mental disorders/Post-Traumatic Stress Disorder or PTSD (36 percent);
4. Diseases of the digestive system/dental hygiene (32 percent);
And
5. Disease of the genitourinary (reproductive/urinary) system (30 percent).
These percentages are somewhat higher for women vets who have served in the Persian Gulf region, due to various areas lacking proper water supplies, along with inadequate personal hygiene and bathing facilities. These factors, among others, tend to elevate infection rates of the liver, bladder, and kidneys in women.
In addition, the “mental disorders” category actually covers a whole group of symptoms, including difficulty adjusting to post-deployment life, along with depressive and neurotic disorders. There also is continuing tracking and research by the DoD and VA into the local water supplies, animal and insect bites where U.S. troops are deployed worldwide, and various rashes and skin conditions that tend to affect women warriors more than their male counterparts. All of this translates into a series of health considerations for women that tend to be layered on top of those of men: thus the need for continuing research and monitoring of women veterans in both the military and civilian life, as the VA continues to evolve health care policy for them.
VA FACILITIES: POINT OF DELIVERY
With the expansion of female veterans’ health services over the past two decades, the issue of delivery clearly comes down to available VA facilities, and the personnel who staff them. Currently, only 41 percent of all VA hospitals actually have a specialized women’s clinic, and of those only 30 percent have their facilities open on a daily basis. With the increase in numbers of women coming to the VA for health care since September 11, the VA has been working to expand the number and capacity of women’s clinical facilities across the country. As Hayes said of the work done by WVHSHG, “We’re hoping in the next 10 years to double the numbers for women veterans, per the projections of our group’s research on present-day deployment numbers.”
The challenge on expanding the number of VA facilities to deliver women’s health services is that many factors go into any opening, closing, or modification of any veteran’s hospital or office. The obvious factor, money, is carefully doled out by a Congress that sadly has fewer veterans in its membership with every new session. The living symbols of why the United States offers VA benefits, veterans like Senators John McCain, R-Ariz. and Daniel Inouye, D-Hawaii, are in their twilight years of public service. This means that the VA leadership must work harder than ever to get its message of America’s promise to its veterans to growing numbers of congressmen and senators who know nothing of military service and its sacrifices.
And then there are more local political considerations. A very real problem since the end of the Cold War has been the changes in population distribution throughout the United States. Many veterans, particularly those who are over 50, have chosen to move south and west to warmer climates, leaving the Northeast and Midwest where they worked and raised their families.
This has left a number of VA facilities with excess capacity in the Northeast and Midwest, while the Southern and Western states are suffering from shortages of both VA hospitals and personnel when they are needed most. And as much as the VA would like to close facilities in the Northeast and Midwest and transfer their personnel and equipment to more populated locations, there is often immense political pressure from Congress and local politicians to leave the legacy hospitals in place, despite the growing need in other areas.
One way that the VA is helping mitigate this is through consolidation of existing facilities, rather than total closure. This allows for continued service in the areas with declining populations, though with longer travel distances. One recent example is the closing of the women’s clinic at the Brockton VA facility in Massachusetts, whose patients and staff were absorbed into the VA hospitals in Boston and Providence, R.I. Brockton was one of the few facilities in the area with a women’s health clinic, and these services now must be accessed at the Boston and Providence VA facilities by female veterans in the area.
Ironically, there sometimes are other issues that determine where the VA may decide to open a women’s health clinic that involve unique female behavior following military service. Hayes explains: “Most discharged males tend to stay near the bases where they served, while women vets tend to move back to their hometowns or move on to career training at places like colleges and universities.”
This means that to know where it is best to open a new women’s health clinic, you sometimes need to know where female veterans are going after their service, as they move forward in their lives.
Along with the “where” in the decision to building a new women’s health clinic, there is also the question of “what” sorts of unique services women require. These include the establishment of specialized treatment facilities for women’s mental health services, which include:
• Inpatient and residential programs with cohort treatment;
• Women’s stress disorder treatment teams;
• Women veteran’s comprehensive health centers;
• Women’s homeless programs;
• Military sexual trauma treatment, support teams and coordinators; and
• National training initiatives in evidence-based practices for PTSD.
And while female-specific health services are a key concern of VA leaders and planners, they never forget the need to get the maximum return for every dollar invested in a building or program. Hayes explains: “One area where we are trying to stretch our dollars and resources is to create more programs and groups that serve all veterans, both men and women. These include mental health programs, which allow the veterans to develop their social skills back into the civilian world, and to assist with war injuries and poly-trauma centers.”
THE FUTURE: RESEARCH, SAMPLING, AND PROJECTIONS
Women veterans’ health care has made significant gains since the end of the first Gulf War in 1991, the first major American deployment into combat. But nobody at the VA is resting on their laurels, or pretending that the job of assessing the health needs of female veterans is anywhere near done. In fact, there is plenty of work still needing to be done to fully develop the VA benefits package for women, and then deliver it where it is needed.
One reality of today’s VA health benefits for women vets is that it is underutilized, with only 37 percent of present-day discharged/retired female warriors signing up for care. Given the growing perception that the VA is delivering a high quality of service at a time when it is becoming more difficult to acquire health care in the civilian sector, this number is likely to grow significantly in the years ahead.
To be better prepared for what is likely to be a rapid growth in claims for women’s health services, the VA is undertaking a study to better understand the likely numbers and needs of both male and female veterans in the years ahead. It will be composed of a series of special surveys, with extra questions on women’s health to provide VA planners with greater fidelity on female benefit requirements. The first year data will be available is FY 2009 and will continue going forward for up to 10 years. There are more than 30,000 vets involved in the study, which includes both genders. Included is a control group, so that the VA can see and show long-term effects of health risks that veterans have been exposed to.
This is just one of many such studies being conducted that take into account the special needs of women veterans. In fact, since May 1991, standard VA policy has required that all applicants for research funding and grants must consider and document the inclusion of women in their proposed studies. The full range of present-day women veterans’ research initiatives include studies on aging, breast and other cancers, chronic diseases, reproductive health and fertility, mental health and PTSD, substance abuse, and delivery of women’s health services and systems.
There can be no question that future female veterans’ health needs have to be more than just a consideration whenever VA leaders and planners are looking ahead. With women warriors becoming full partners in America’s total military force, their long-term health care needs will need to be a key consideration in VA policymaking. That more women vets are likely to make use of their benefits in the years ahead is almost inevitable, and Congress and the country need to be ready to fulfill the promise made to our soldiers, sailors, airmen, and Marines when they took the oath to serve America at the risk of their lives.
And America owes them no less, as women warriors take their places as full partners in the defense of the United States and its interests. As Hayes said in summary: “More and more women are being exposed to [traditional] combat injuries and illnesses, suffered from firefights and IEDs [improvised explosive devices]. In wars prior to OEF and OIF, women traditionally cared for the male warriors who were wounded in combat. Now both men and women require our care, and we need to be sensitive to the needs of both groups.”