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

United States

General Accounting Office

Washington, D.C. 20548 Letr

Page 1 GAO/NSIAD-99-58 Gender Issues

GAO

National Security and

International Affairs Division Letr

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 

1The 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.
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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.
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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 
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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.

5Few 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.
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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.
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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.)
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field settings, including advice about avoiding urinary tract infections and 

yeast infections; (3) female-specific health care services available intheater 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 
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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.”
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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.
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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
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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 ApeInxdi

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 

5One 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 respondents9

 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.

8Percentages 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 

10Of 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 

11Nine 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.

12Of 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.

13Of 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 ApIexndi

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).

4J.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 ApIexndi

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 Croatia2

 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 

1One 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 ApVenIxdi
Page 35 GAO/NSIAD-99-58 Gender ]Issues

Appendix V

Major Contributors to This Report ApVenxdi

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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