GAO 

United States Government Accountability Office

Report to Congressional Addressees

VA HEALTH CARE

VA Has Taken Steps to 

Make Services 

Available to Women 

Veterans, but Needs to 

Revise Key Policies 

and Improve 

Oversight Processes 

March 2010 

GAO-10-287 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

March 2010

VA HEALTH CARE

VA Has Taken Steps to Make Services Available to 

Women Veterans, but Needs to Revise Key Policies

Highlights of GAO-10-287, a report to and Improve Oversight Processes congressional addressees 

In 2008, VA provided health care to 

over 281,000 women veterans, a 

fast growing subgroup of veterans. 

Women veterans seeking VA health 

care need access to an array of 

services and Congress has raised 

concerns about how well VA is 

prepared to meet the physical and 

mental health care needs of 

women. GAO was asked to 

examine (1) the on-site availability 

of health care services at VA 

facilities for women veterans, 

(2) the extent to which VA facilities 

are following VA policies that apply 

to the delivery of health care to 

women veterans, and (3) key 

challenges that VA facilities face in 

providing health care to women 

veterans and how VA is addressing 

these challenges. GAO reviewed 

applicable laws and VA policies, 

interviewed officials, and visited a 

judgmental sample of 9 VA medical 

centers (VAMC) and 10 communitybased outpatient clinics (CBOC) 

chosen, in part, based on the 

number of women using services. 

GAO also visited 10 VA counseling 

centers (Vet Centers). 

What GAO Recommends

GAO recommends that VA provide 

complete information on its 

external Web sites about 

specialized residential programs 

for women; verify the information 

facilities report on compliance with 

privacy policies; expedite action to 

update VA’s design and 

construction policies; and clarify 

the roles and responsibilities of the 

Women Veterans Program Manager 

(WVPM). VA concurred with GAO’s 

recommendations. 

The VA facilities GAO visited provided basic gender-specific and outpatient 

mental health services to women veterans on site, and some facilities also 

provided specialized services for women. Seventeen of the 19 medical 

facilities GAO visited offered basic gender-specific services including pelvic 

examinations and cervical cancer screening on site, and 15 offered access to 

one or more female providers for gender-specific care. The availability of 

specialized gender-specific services—such as treatment of reproductive 

cancers—and mental health services for women varied by service and facility. 

While some VAMCs offered a broad array of specialized gender-specific care 

on site, smaller CBOCs referred women to other VA or non-VA facilities for 

many or most of these services. Nationally, 9 VAMCs have residential mental 

health programs that are for women only or have dedicated cohorts for 

women. However, information about all of these programs was not available 

on VA’s external Web sites. 

In July 2009, GAO reported in VA Health Care: Preliminary Findings on VA's 

Provision of Health Care Services to Women Veterans (GAO-09-884T), that 

none of the facilities GAO visited were fully compliant with VA policy 

requirements related to privacy for women veterans. In response, VA has 

required facilities to report more information on their compliance with these 

policies. However, facility reporting on privacy policies has, in the past, been 

inaccurate, and VA’s oversight process does not include a means to validate 

the information facilities report. The facilities GAO visited were in various 

stages of implementing a new VA initiative to provide comprehensive primary 

care—defined as complete primary care, including basic gender-specific 

services, and mental health care—to women veterans at all facilities. VA 

headquarters officials are working with Women Veterans Program Managers 

(WVPM) and facility leadership to help facilities implement this initiative. 

In locations GAO visited, VA identified a number of key challenges in 

providing health care services to women veterans. For example, officials at 

VA medical facilities reported that space constraints have raised issues 

affecting the provision of health care services to women veterans, particularly 

related to ensuring their privacy and safety. According to VA officials, most 

VAMCs have planned renovation, construction, or relocation projects as part 

of their efforts to expand services and implement comprehensive primary care 

for women veterans. However, VA’s design and construction policies have not 

been updated to reflect VA’s privacy policies for women veterans. Moreover, 

the VA memorandum which established the WVPM as a full-time position 

outlined broad authority for the WVPM in facilitating changes in the delivery 

of services to women veterans, but some facilities have not modified the 

WVPM position as envisioned in VA’s memorandum. For example, some 

WVPMs reported that they did not have sufficient authority and access to 

leadership to implement needed changes. Furthermore, VA’s WVPM 

handbook, which defines the roles and responsibilities of the WVPM, has not 

been updated since the WVPM position was made full-time. 

View GAO-10-287 or key components.

For more information, contact Randall B. 

Williamson at (202) 512-7114 or 

williamsonr@gao.gov. 
Page i GAO-10-287 

Contents 

Letter 1

Background 5 

VA Facilities Provided Basic and Specialized Gender-Specific 

Services and Mental Health Services to Women Veterans, though 

Not All Services Were Provided On Site at Each VA Facility 10 

VA Medical Facilities Had Not Fully Implemented VA Policies 

Pertaining to the Delivery of Health Care Services for Women 

Veterans 19 

VA Has Taken Steps to Alleviate Space Constraints, Hire Trained 

Providers, and Expand the Role of the WVPM, but Challenges 

Remain 28 

Conclusions 41 

Recommendations for Executive Action 42 

Agency Comments and Our Evaluation 43 

Appendix I Information on the Selection of Department 

of Veterans Affairs Facilities Examined in 

This Report 46 

Appendix II Comments from the Department of Veterans 

Affairs 49 

Appendix III GAO Contact and Staff Acknowledgments 54 

Tables 

Table 1: On-site Availability of Selected Basic Gender-Specific 

Services for Women Veterans at Selected Department of 

Veterans Affairs (VA) Facilities 11 

Table 2: On-site Availability of Selected Specialized GenderSpecific Services for Women Veterans at Selected 

Department of Veterans Affairs (VA) Facilities 13 

Table 3: Veterans Affairs Medical Centers (VAMC) with Specialized 

Residential Mental Health Treatment Programs for Women 

Who Have Experienced Military Sexual Trauma (MST) or 

Other Trauma, as of August 2009 16 

 VA Health Care for Women Veterans 
Table 4: Department of Veterans Affairs (VA) Facilities’ 

Compliance with VA Privacy Requirements 20 

Table 5: Women Veterans’ Health Care Utilization at Selected 

Veterans Affairs Medical Centers (VAMC) 47 

Table 6: Women Veterans’ Health Care Utilization at Selected 

Veterans Affairs (VA) Community-Based Outpatient 

Clinics (CBOC) 48 

Figures 

Figure 1: Correct and Incorrect Placement of Exam Tables in 

Gynecological Exam Rooms at Department of Veterans 

Affairs (VA) Medical Facilities 22 

Figure 2: Department of Veterans Affairs (VA) Outpatient Clinic 

Design Guide—Gynecologic Exam Room Guide Plate 32 

Abbreviations 

ACT Acceptance and Commitment Therapy 

CBOC community-based outpatient clinic 

CBT Cognitive Behavioral Therapy 

CPT Cognitive Processing Therapy 

HCS health care system 

MST military sexual trauma 

OEF Operation Enduring Freedom 

OIF Operation Iraqi Freedom 

PE Prolonged Exposure 

PTSD post-traumatic stress disorder 

VA Department of Veterans Affairs 

VAMC Veterans Affairs medical center 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

WVPM Women Veterans Program Manager 

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Page ii GAO-10-287 VA Health Care for Women Veterans
Page 1 GAO-10-287 

 

United States Government Accountability Office

Washington, DC 20548 

 

March 31, 2010 

Congressional Addressees 

Historically, the vast majority of patients who receive health care through 

the Department of Veterans Affairs (VA) have been men, but that is 

changing. As of September 2009, there were more than 1.8 million women 

veterans in the United States (representing almost 8 percent of the total 

veteran population). More than 102,000 of these women were veterans of 

the military operations in Afghanistan and Iraq, known as Operation 

Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). According 

to VA data, in fiscal year 2008, over 281,000 women veterans received 

health care services from VA—an increase of about 12 percent since 2006. 

Women veterans are younger, in the aggregate, than their male 

counterparts.1

 While almost all women veterans of OEF/OIF are under the 

age of 40—most between the ages of 20 and 29—VA also serves women 

veterans from other combat eras, who are typically over the age of 55. 

Looking ahead, VA estimates that while the total number of veterans will 

decline 37 percent by 2033, the number of women veterans will increase 

by more than 17 percent over the same period. 

As more women veterans are seeking care at VA facilities, Congress and 

others have raised concerns about how well VA’s health care system is 

prepared to meet the unique physical and mental health needs of these 

women, particularly women veterans of OEF/OIF. The health care services 

needed by women veterans are significantly different from those required 

by their male counterparts in several respects. Women veterans of all ages 

seeking care at VA medical facilities need access to a full range of physical 

health care services, including basic gender-specific services—such as 

breast examinations, cervical cancer screening, management of 

contraceptive medications, and menopause management—and specialized 

gender-specific services such as obstetric care (which includes prenatal, 

labor and delivery, and postpartum care) and treatment of reproductive 

cancers. Women veterans also need access to a range of mental health 

care services such as care for depression or post-traumatic stress disorder 

1

On the basis of an analysis VA conducted in 2007, the estimated median age of women 

veterans was 47, whereas the estimated median age of male veterans was 61. 

 VA Health Care for Women Veterans 
 

(PTSD).2 VA data show that almost 20 percent of women veterans of 

OEF/OIF have been diagnosed with PTSD. Moreover, an alarming number 

of women veterans have experienced military sexual trauma (MST).3

 VA 

data shows that in fiscal year 2008, 21 percent of women screened for 

MST, screened positive for having experienced MST.4

Women veterans also present unique challenges to VA. Traditionally, 

women veterans have utilized VA’s health care services less frequently 

than their male counterparts, even though VA has found that women 

veterans have health burdens comparable to or greater than that of male 

veterans. In fiscal year 2007, 15 percent of women veterans used VA’s 

health care services, compared to 22 percent of male veterans. VA believes 

that part of this difference may be attributable to barriers that the current 

care models at many VA medical facilities present to women veterans. For 

example, women veterans have often been required to make multiple visits 

to a VA medical facility in order to receive the full spectrum of primary 

care services, which includes such basic gender-specific care as cervical 

cancer screenings and breast examinations. Because many of these 

women work or have child care responsibilities, multiple visits can be 

problematic, especially when services are not available in the evenings or 

on weekends.5

 Research has also shown that women veterans often do not 

 

2

PTSD may develop following exposure to combat, natural disasters, terrorist incidents, 

serious accidents, or violent personal assaults like rape. People who experience stressful 

events often relive the experience through nightmares and flashbacks, have difficulty 

sleeping, and feel detached or estranged. These symptoms can occur within the first few 

days after exposure to the stressful event but may also be delayed for months or years. If 

symptoms continue for more than 30 days and significantly disrupt an individual’s daily 

activities, a diagnosis of PTSD is made. 

3

Federal law requires VA to provide services to help veterans overcome “psychological 

trauma, which in the judgment of a mental health professional employed by the 

Department, resulted from a physical assault of a sexual nature, battery of a sexual nature, 

or sexual harassment which occurred while the veteran was serving on active duty or 

active duty for training,” and further defines sexual harassment as “repeated, unsolicited 

verbal or physical contact of a sexual nature which is threatening in character.” See 

38 U.S.C. § 1720D. VA developed the term military sexual trauma (MST) to refer to the 

sexual assault or sexual harassment experiences described in the law. 

4

Although women are much more likely to experience MST than their male counterparts—

in fiscal year 2008, 1.1 percent of male veterans screened for MST screened positive—

almost half of all veterans who experience MST are men. 

5

VA has determined that under existing law, the agency is not authorized to provide child 

care, or operate childcare facilities for VA patients. 

Page 2 GAO-10-287 VA Health Care for Women Veterans
 

identify themselves as veterans and are unaware of their eligibility for VA 

services.6

VA has taken some steps to improve the availability of services for women 

veterans, including requiring that all VA medical facilities make the 

Women Veterans Program Manager (WVPM)—an advocate for the needs 

of women veterans—a full-time position and providing funding for 

equipment to help VA medical facilities improve health care services for 

women veterans. Additionally, in November 2008, VA began a systemwide 

initiative to make comprehensive primary care for women veterans 

available at every VA medical facility—VA medical centers (VAMC) and 

community-based outpatient clinics (CBOC). In announcing this initiative, 

VA established a policy defining comprehensive primary care for women 

veterans as the availability of complete primary care—including routine 

detection and management of acute and chronic illness, preventive care, 

gender-specific care, and mental health care—from one primary care 

provider at one site. 

You asked us to examine VA’s health care services for women veterans. In 

July 2009, we presented preliminary findings from our ongoing work to 

examine these services.7

 In this report we provide our complete findings, 

based on visits to selected VA facilities, on (1) the on-site availability of 

health care services at VA facilities for women veterans, (2) the extent to 

which VA facilities are following VA policies that apply to the delivery of 

health care services for women veterans, and (3) some key challenges that 

VA facilities are experiencing in providing health care services for women 

veterans, and how VA is addressing these challenges. 

To examine the availability of health care services at VA facilities for 

women veterans and to determine the extent to which VA facilities are 

 

6

See 38 U.S.C. § 1710(a), 38 C.F.R. § 17.38 (2009). Any veteran who has served in a combat 

theater after November 11, 1998, including OEF/OIF veterans, and who was discharged or 

released from active service on or after January 28, 2003, has up to 5 years from the date of 

the veteran’s most recent discharge or release from active duty service to enroll in VA’s 

health care system and receive VA health care services. See 38 U.S.C. § 1710(e)(1)(D), 

(e)(3)(C). Veterans who were discharged or released before January 28, 2003, and who did 

not enroll in VA’s health care system before that date are eligible for these VA health care 

services for 3 years after January 28, 2008. 

7

See: GAO, VA Health Care: Preliminary Findings on VA’s Provision of Health Care 

Services to Women Veterans, GAO-09-884T (Washington, D.C.: July 14, 2009); and VA 

Health Care: Preliminary Findings on VA’s Provision of Health Care Services to Women 

Veterans, GAO-09-899T (Washington, D.C.: July 16, 2009). 

Page 3 GAO-10-287 VA Health Care for Women Veterans
 

following VA policies that apply to the delivery of health care services for 

women veterans, we reviewed applicable laws, VA policies,8

 and available 

VA data and also interviewed officials from VA headquarters, Veterans 

Integrated Service Networks (VISN),9

 and VA facilities. In addition, we 

conducted site visits to a judgmental sample of 9 VAMCs located in Long 

Beach and San Diego, California; Atlanta and Dublin, Georgia; Minneapolis 

and St. Cloud, Minnesota; Sioux Falls, South Dakota; and Temple and 

Waco, Texas.10 We also visited 10 VA CBOCs affiliated with these 9 

VAMCs, and 8 Vet Centers, which are counseling centers that help combat 

veterans readjust from wartime military service to civilian life. We used VA

data to select these sites based on several factors, including the number of 

women veterans using health care services at each VAMC and whether 

facilities offered specific programs for women veterans, such as outpa

or residential treatment programs for women who have PTSD or hav

experienced MST. See appendix I for additional details on the selection 

criteria we used and information on the number of women veterans using 

health care services at each VAMC and CBOC we visited. To further 

examine the availability of services for women veterans, we obtained 

information from each VAMC and CBOC regarding the organization and 

availability of primary care services; basic gender-specific services; 

specialized gender-specific services; mental health services in outpatient, 

residential, and inpatient settings; and the availability of specific clinical 

services such as prenatal care, osteoporosis treatment, mammography, 

and counseling for MST. When services were not available on site, we 

determined whether they were available through fee-for-service 

arrangements (fee basis), contracts, or sharing agreements with non-VA 

facilities. During our site visits we also toured each facility and 

documented observations of the physical space in each care setting. We 

examined how facilities were implementing VA policies pertaining to 

tient 

e 

 

8

The scope of services VA requires to be provided to women veterans, including 

requirements for ensuring the privacy of women veterans, is outlined in Veterans Health 

Administration (VHA) Handbook 1330.1, and the requirements for WVPM are outlined in 

VHA Handbook 1330.02 and in a July 2008 VA directive titled Women Veteran Program 

Managers Full-Time FTEE Positions. 

9

The management of VAMCs and CBOCs is decentralized to 21 regional networks referred 

to as VISNs. 

10We selected locations for our site visits using VA data on the numbers of various 

categories of women veterans using services at each VAMC in the United States. To assess 

the reliability of these data, we reviewed relevant documentation and interviewed agency 

officials knowledgeable about the data and the methodologies used to collect them. We 

determined that the data were sufficiently reliable for the purposes of this report. 

Page 4 GAO-10-287 VA Health Care for Women Veterans
 

ensuring the privacy of women veterans in outpatient, residential, and 

inpatient care settings; and VA’s model of comprehensive primary care for 

women veterans. Finally, to identify key challenges that VA facilities are 

experiencing in providing health care services for women veterans, and 

what VA is doing to address these challenges, we reviewed relevant 

literature; reviewed relevant VA policies and procedures; interviewed VA 

officials in headquarters, medical facilities, and Vet Centers; interviewed 

VA experts in the area of women veterans’ health; and documented 

challenges observed during our site visits. The findings of our site visits to 

VA facilities cannot be generalized to other VA facilities. 

We conducted our performance audit from July 2008 through March 2010 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives. 

VA’s integrated health care delivery system is one of the largest in the 

United States and provides enrolled veterans, including women veterans, 

with a range of services including primary and preventive health care 

services, mental health services, inpatient hospital services, long-term 

care, and prescription drugs.11 VA’s health care system is organized into 21 

VISNs that include VAMCs and CBOCs. VAMCs offer outpatient, 

residential, and inpatient services. These services range from primary care 

to complex specialty care, such as cardiac and spinal cord injury care. 

VAMCs also offer a range of mental health services, including outpatient 

counseling services, residential programs—which provide intensive 

treatment and rehabilitation services, with supported housing, for 

treatment, for example, of PTSD, MST, or substance use disorders—and 

inpatient mental health treatment. CBOCs are an extension of VAMCs and 

provide outpatient primary care and general mental health services on site. 

VA also operates 232 Vet Centers, which offer readjustment and family 

counseling, employment services, bereavement counseling, and a range of 

Background 

 

11In general, veterans must enroll in VA’s health care system in order to receive most of 

VA’s medical services. 

Page 5 GAO-10-287 VA Health Care for Women Veterans
 

social services to assist combat veterans in readjusting from wartime 

military service to civilian life.12

When VA facilities are unable to efficiently provide certain health care 

services on site, they are authorized to enter into agreements with non-VA 

providers to ensure veterans have access to medically necessary 

services.13 Specifically, VA facilities can make services available through 

 

• referral of patients to other VA facilities or use of telehealth services,14

• sharing agreements with university affiliates or Department of Defense 

medical facilities, 

• contracts with providers in the local community, or 

• allowing veterans to receive care from providers in the community who 

will accept VA payment (commonly referred to as fee-basis care). 

VA Policies Pertaining to 

Women’s Health 

VA provides medically necessary health care services to eligible veterans, 

including women veterans, as authorized under federal law.15 VA provides 

health care services to veterans through its medical benefits package—

health care services required to be provided are broadly stated in a 

regulation16 and further specified in VA policies. Through policies, VA 

requires its medical health care facilities to make certain services, 

including basic and specialized gender-specific services and primary care 

services, available to eligible women veterans.17 Examples of basic gender12All veterans who have served in a combat theater, including OEF/OIF veterans, are 

eligible for Vet Center services. See 38 U.S.C. § 1712A(a). As of September 2009, 39 

additional Vet Centers had signed leases but had not formally begun operations. VA plans 

to open another 28 Vet Centers in fiscal year 2010. 

13See 38 U.S.C. § 1703. 

14Telehealth is the provision of health services from a distance using telecommunications 

technologies, such as videoconferencing. 

1538 U.S.C. § 1710. 

16See 38 C.F.R. § 17.38 (2009). 

17These services are defined in: VHA Handbook 1330.1, VHA Services for Women Veterans 

(revised July 16, 2004); VHA Directive 2005-015, Military Sexual Trauma Counseling 

(revised Mar. 25, 2005); VHA Handbook 1160.01, Uniform Mental Health Services in VA 

Medical Centers and Clinics (Sept. 11, 2008); and VHA Handbook 1162.02, Mental Health 

Residential Rehabilitation Treatment Program (MH RRTP) (revised May 26, 2009). 

Page 6 GAO-10-287 VA Health Care for Women Veterans
 

specific services that would be provided under VA’s medical benefits 

package include, for example, cervical cancer screening, breast 

examination, and management of menopause. Examples of specialized 

gender-specific services that would be provided under VA’s medical 

benefits package include, for example, treatment after abnormal cervical 

cancer screening, mammography, obstetric care, and infertility 

evaluation.18

In December 2008, VA directed all VA medical facilities to establish a 

planning process and begin implementing comprehensive primary care for 

women veterans.19 VA defines comprehensive primary care for women 

veterans as the availability of complete primary care—including routine 

detection and management of acute and chronic illness, preventive care, 

basic gender-specific care, and basic mental health care—from one 

primary care provider at one site. VA did not establish a deadline by which 

VAMCs and CBOCs must meet this requirement. 

VA policies also outline a number of requirements specific to ensuring the 

privacy of women veterans in all settings of care at VAMCs and CBOCs.20

These include requirements related to ensuring auditory and visual privacy 

at check-in and in interview areas; the location of exam rooms, presence 

of privacy curtains, and the orientation of exam tables; the availability of 

sanitary products in public restrooms at VA medical facilities; access to 

private restrooms in outpatient, residential, and inpatient settings of care; 

and access to separate and secured sleeping accommodations in 

residential and inpatient settings. 

In 1991, VA established the position of Women Veteran Coordinator—now 

the WVPM—to ensure that each VAMC had an individual responsible for 

assessing the needs of women veterans and assisting in the planning and 

delivery of services and programs to meet those needs. The WVPM 

position was outlined as a part-time collateral position in the Veterans 

 

18In reviewing the services provided at VA medical facilities, we distinguished between 

“basic” and “specialized” gender-specific services. This distinction is based on the 

definitions included in VHA Handbook 1330.1 and the 2003 article by Elizabeth Yano and 

Donna Washington, “Availability of Comprehensive Women’s Health Care Through 

Department of Veterans Affairs Medical Center,” published in Women’s Health Issues, v. 13 

(2003). 

19See December 5, 2008, Memorandum from VA’s Deputy Under Secretary for Health for 

Operations and Management. 

20See VHA Handbook 1330.1, VHA Handbook 1160.01, and VHA Handbook 1162.02. 

Page 7 GAO-10-287 VA Health Care for Women Veterans
 

Health Administration’s (VHA) Women Veterans Program Manager 

Position Handbook—last updated in March 200721—but in July 2008, VA 

required VAMCs to establish the WVPM as a full-time position (no longer a 

collateral duty) no later than December 1, 2008. Clinicians in the role of 

WVPM would be allowed to perform clinical duties to maintain their 

professional certification, licensure, or privileges, but must limit the time 

to the minimum required, typically no more than 5 hours per week. 

VA Policy on Mental 

Health Services 

In September 2008, VA issued its revised Uniform Mental Health Services 

in VA Medical Centers and Clinics handbook,22 which specifies VA 

policies on the mental health services that must be provided at each VAMC 

and CBOC.23 The purpose of these policies is to ensure that all veterans, 

wherever they obtain care in VA’s health care system, have access to 

needed mental health services. The handbook lists the mental health care 

services that must be delivered on site or made available by each medical 

facility. The policies further state that mental health services must be 

delivered by qualified, trained, and competent staff, and that care should 

be provided by those with an appropriate level of training and clinical 

privileging.24

Further, VA is required to provide mental health screening, counseling, 

and related treatment for eligible veterans who have experienced MST, 

which is much more common among women veterans than their male 

counterparts.25 Research has shown that veterans who have experienced 

MST are at a high risk for developing a range of mental health conditions 

such as PTSD, major depression, anxiety, and panic disorder. MST victims 

may also struggle with other problems, including low self-esteem, 

difficulties with interpersonal relationships, and sexual dysfunction. VA 

 

21VHA Handbook 1330.02. 

22VHA Handbook 1160.01. 

23The mental health services that must be provided in CBOCs differ according to the size of 

the clinics. 

24VA defines clinical privileging as the process by which a medical facility grants the 

practitioner permission to independently provide specified medical or other patient care 

services, within the scope of the practitioner’s license and/or an individual’s clinical 

competence. 

25Veterans who report experiencing MST, but who are otherwise deemed ineligible for VA 

health care benefits, may be eligible for free counseling and treatment for conditions 

related to MST. 

Page 8 GAO-10-287 VA Health Care for Women Veterans
 

research indicates that the psychological outcomes of sexual trauma that 

occurs in a military context are unique to the military and veteran 

population and may be more damaging than sexual trauma that occurs in 

civilian settings.26 Federal law specifically requires VA to establish a 

program to provide these MST-related services and to provide for 

appropriate training of mental health professionals and such other health 

care personnel as the Secretary determines necessary to carry out the 

program effectively.27

VA’s MST-related policies require that VAMC directors appoint an MST 

Coordinator and that necessary staff education and training be provided.28

The MST coordinators are responsible, among other things, for monitoring 

and ensuring that VA policies related to MST screening, education, 

training, and treatment are implemented at the facility. VA policy also 

requires that evidence-based29 mental health care be available to veterans 

diagnosed with mental health conditions resulting from MST. VA’s Office 

of Mental Health Services is responsible for oversight of MST-related 

services. 

Starting in 2007, VA began rolling out a national program that offers 

intensive training in evidence-based psychotherapies for VA staff who 

treat patients with PTSD, depression, and serious mental illness. These 

training programs cover five evidence-based psychotherapies: Cognitive 

Processing Therapy (CPT) and Prolonged Exposure (PE), which are 

recommended for PTSD; Cognitive Behavioral Therapy (CBT) and 

Acceptance and Commitment Therapy (ACT), which are recommended 

for depression; and Social Skills Training, which is recommended for 

serious mental illness. The training programs involve two components: 

(1) attendance at an in-person, experientially-based workshop (usually 

3–4 days long); and (2) ongoing, telephone-based, small-group consultation 

 

26According to VA researchers, sexual trauma in the military is unique, among other things, 

because the interpersonal trauma involves perpetrators that the victims know and are 

dependent on, such as a superior or someone they need to rely on for training or combat. 

VA researchers also said that MST victims may have an increased sense of distress, 

hopelessness, and powerlessness because escape from the situation is often difficult or 

impossible and there is increased risk of revictimization. 

2738 U.S.C. § 1720D. 

28VHA Directive 2005-015 and VHA Handbook 1160.01. 

29Psychotherapies that have consistently been shown in controlled research to be effective 

for a particular condition or conditions are referred to as “evidence-based.” 

Page 9 GAO-10-287 VA Health Care for Women Veterans
 

on actual therapy cases with a consultant who is an expert in the 

psychotherapy. 

The VA facilities we visited generally provided basic gender-specific and 

outpatient mental health services to women veterans on site. All of the 

VAMCs we visited also offered at least some specialized gender-specific 

services on site, and six offered a broad array of these services. Among 

CBOCs we visited, most offered limited specialized gender-specific care on 

site. Women needing obstetric care were always referred to non-VA 

providers. Regarding mental health care, we found that outpatient services 

for women were widely available at the VAMCs and most Vet Centers we 

visited, but were more limited at some CBOCs. Eight of the VAMCs we 

visited offered mixed-gender inpatient or residential mental health 

services, and two VAMCs offered residential treatment programs 

specifically designed for women veterans. 

VA Facilities Provided 

Basic and Specialized 

Gender-Specific 

Services and Mental 

Health Services to 

Women Veterans, 

though Not All 

Services Were 

Provided On Site at 

Each VA Facility 

Basic Gender-Specific Care 

Services Were Generally 

Available On Site at VA 

Medical Facilities 

A full array of basic gender-specific services for women—such as pelvic 

examinations and osteoporosis treatment—were available on site at all 9 

of the VAMCs and 8 of the 10 CBOCs that we visited. (See table 1.) One of 

the CBOCs we visited did not offer any basic gender-specific services on 

site and another offered some of these services, but did not offer pelvic 

examinations or cervical cancer screening. These CBOCs that provided 

limited basic gender-specific services referred patients to other VA 

facilities for this care, but had plans under way to offer these services on 

site once providers received needed training. In general, women veterans 

had access to female providers for their gender-specific care: of the 19 

medical facilities we visited, all but 4 had one or more female providers 

available to deliver basic gender-specific care. 

Page 10 GAO-10-287 VA Health Care for Women Veterans
 

Table 1: On-site Availability of Selected Basic Gender-Specific Services for Women Veterans at Selected Department of 

Veterans Affairs (VA) Facilities 

Veterans Affairs Medical Center (VAMC), 

by number 

Community-Based Outpatient Clinic (CBOC), 

by number 

Service 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 10 

Pelvic exam and cervical cancer 

screening z z z z z z z z z z z z z z  a

z z z

Prescription of oral 

contraceptives z z z z z z z z z z z z z z z a z z z

Osteoporosis treatment z z z z z z z z z z z z z z z a z z z

Menopause management z z z z z z z z z z z z z z z a z z z

Source: GAO. 

Key: 

z Service available on site 

 Refer to another VA facility 

Notes: We collected this information using a data collection instrument during site visits to VA medical 

facilities from October 2008 through April 2009. Some VA facilities reported that serious or 

complicated cases may be referred to other VA medical facilities. 

a

This facility may also fee-base this service to an outside provider on a case-by-case basis. 

The facilities we visited delivered basic gender-specific services using a 

variety of clinical models. Seven of the nine VAMCs and the two large 

CBOCs we visited had women’s clinics. The physical setup of these clinics 

ranged from a physically separate dedicated clinical space (at five 

facilities) to one or more designated women’s health providers with 

designated exam rooms within a mixed-gender primary care clinic. 

Generally, when women’s clinics were available, facilities reported that 

most female patients received their basic gender-specific care in those 

clinics. When women’s clinics were not available, female patients either 

received their gender-specific care through their VA primary care provider 

or were referred to another VA or non-VA facility for these services. 

Basic gender-specific services were typically available between 8:00 a.m. 

and 4:30 p.m. on weekdays. At one CBOC and one VAMC, however, basic 

gender-specific care was only available during limited time frames. At the 

CBOC, a provider from the affiliated VAMC traveled to the CBOC 2 days 

each month to perform cervical cancer screenings and pelvic 

examinations for the clinic’s female patients. In general, medical facilities 

did not offer evening or weekend hours for basic gender-specific services. 

Page 11 GAO-10-287 VA Health Care for Women Veterans
 

While All VAMCs Offered 

at Least Some Specialized 

Gender-Specific Services 

On Site, CBOCs Typically 

Referred Patients Needing 

These Services to Other VA 

or Non-VA Medical 

Facilities 

The provision of specialized gender-specific services for women, including 

treatment after abnormal cervical cancer screenings and breast cancer 

treatment, varied by service and by facility. (See table 2.) All VA medical 

facilities referred female patients to outside providers for obstetric care. 

Some of the VAMCs we visited offered a broad array of other specialized 

gender-specific services on site, but all contracted or fee-based at least 

some services. In particular, most VAMCs provided screening and 

diagnostic mammography through contracts with local providers or feebased these services. In addition, less than half of the VAMCs provided 

reconstructive surgery after mastectomy on site, although six of the nine 

VAMCs we visited provided medical treatment for breast cancers and 

reproductive cancers on site. In general, the CBOCs we visited offered 

more limited specialized gender-specific services on site. For example, 

while most CBOCs offered pregnancy testing and sexually transmitted 

disease screening, counseling, and treatment, only the largest CBOCs 

offered intrauterine device placement on site. At both VAMCs and CBOCs, 

specialized gender-specific services were usually offered on site only 

during certain hours; for example, four medical facilities only offered 

these services 2 days per week or less. 

Page 12 GAO-10-287 VA Health Care for Women Veterans
 

Table 2: On-site Availability of Selected Specialized Gender-Specific Services for Women Veterans at Selected Department of 

Veterans Affairs (VA) Facilities 

Veterans Affairs Medical Center (VAMC), 

by number 

Community-Based Outpatient Clinic (CBOC), 

by number 

Service 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 10

Treatment of sexually 

transmitted diseases z z z z z z z z z z z z z z za  z z z

Treatment after abnormal 

cervical cancer screening z z b

z z zczaza,c zaz z   c c  

Intrauterine device 

placement z z b

z z z zaz z z z   c c  

Screening mammography z d z  z {   d  {     c   

Obstetric care { { { { { { { { { { { { { { { { { { {

Medical treatment of breast 

and reproductive cancers zc

zc,e zczcz c ze (Data about the availability of this service were 

not collected at CBOCs.) 

Reconstructive surgery after 

mastectomy { z zc

z z { {   (Data about the availability of this service were 

not collected at CBOCs.) 

Source: GAO. 

z Service available on site 

 Refer to another VA facility 

 Refer to a contract provider 

{ Refer to a fee-basis provider 

Note: We collected this information using data collection instruments during site visits to VA medical 

facilities from October 2008 through April 2009. 

a

This facility may refer this service to another VAMC. 

b

This facility referred this service to a large CBOC located approximately 13 miles from this facility. 

c

This facility may also fee-base this service to a non-VA provider on a case-by-case basis. 

d

This facility provided screening mammography services through a contract provider. That contract 

provider had a mobile unit that offers screening mammography services on site at the VAMC a few 

days a month. 

e

This facility contracted for associated stereotactic biopsies. 

Most CBOCs referred patients to VA medical facilities—sometimes as far 

as 130 miles away—for some specialized gender-specific services. For 

example, 8 of the 10 CBOCs we visited referred patients to another VA 

medical facility for treatment after abnormal cervical cancer screening test 

results. Four of these CBOCs typically referred their patients to a VAMC 

located 100 miles or more away for this care. Because the travel distance 

can be a barrier to treatment for some veterans, officials at some CBOCs 

said that they will fee-base services to local providers on a case-by-case 

basis. 

Page 13 GAO-10-287 VA Health Care for Women Veterans
 

Outpatient Mental Health 

Services Were Widely 

Available at Most VAMCs 

and Vet Centers, but More 

Limited at Smaller CBOCs 

A range of outpatient mental health services was readily available at the 

VAMCs we visited. These services included, for example, diagnosis and 

treatment of depression, substance use disorders, PTSD, and serious 

mental illness. All of the VAMCs we visited had one or more providers 

with training in evidence-based psychotherapies used to treat PTSD and 

depression and all had at least one female provider in outpatient mental 

health. All but one of the VAMCs we visited offered at least one womenonly counseling group, and four VAMCs offered an outpatient group with a 

specific focus on sexual trauma. Two VAMCs offered an outpatient 

treatment program specifically for women who have experienced MST or 

other traumas. In addition, six VAMCs offered services during evening 

hours at least 1 day a week. While most outpatient mental health services 

were available on site, facilities typically fee-based treatment to non-VA 

providers for a veteran with an active eating disorder. 

The eight Vet Centers we visited offered a variety of outpatient mental 

health services, including counseling services for PTSD and depression, as 

well as individual or group counseling for victims of sexual trauma. Five of 

the eight Vet Centers we visited offered women-only groups, and six had 

counselors with training or experience in treating patients who have 

suffered sexual trauma. Two of the Vet Centers with sexual trauma 

counselors offered groups specifically for women veterans who had 

experienced sexual trauma. Vet Centers generally offered some counseling 

services in the evenings. 

The outpatient mental health services available in CBOCs were, in some 

cases, more limited. The two larger CBOCs offered women-only group 

counseling as well as intensive treatment programs specifically for women 

who had experienced MST or other traumas. In general, we saw varying 

levels of mental health services and staffing in the smaller CBOCs. Only 

two of the eight smaller CBOCs offered women-only group counseling. 

Some had several mental health professionals, including staff with 

experience in working with victims of sexual trauma. Others relied upon 

one or two mental health providers and tended to rely on staff from the 

affiliated VAMC, often through telehealth, to provide mental health 

services. Five CBOCs provided some mental health services through 

telehealth or using mental health providers from the VAMC who traveled 

to the CBOCs on specific days. Two of the CBOCs we visited did not offer 

mental health services every day of the work week. One CBOC offered 

extended hours, on Saturday mornings, for mental health services. 

Page 14 GAO-10-287 VA Health Care for Women Veterans
 

Most VAMCs offered mixed-gender inpatient mental health services or 

residential mental health treatment programs, but few had specialized 

programs for women veterans. Eight of the nine VAMCs we visited served 

women veterans in mixed-gender inpatient mental health units, mixedgender residential treatment programs, or both. However, none of the 

VAMCs we visited had dedicated inpatient mental health units for 

women.30 Two VAMCs we visited had specialized residential treatment 

programs specifically for women who have experienced MST and other 

traumas. 

Most VAMCs Offered 

Residential or Inpatient 

Mental Health Services, 

but Few Had Specialized 

Women’s Programs and 

Information on These 

Programs Is Not Readily 

Available to Veterans 

The two VAMCs we visited that had specialized residential treatment 

programs for women are part of a group of nine VAMCs nationally that 

have residential mental health programs that are for women only or have 

dedicated cohorts for women.31 The specific focus and structure of each 

program varies, but all of them offer intensive treatment in a residential 

setting. Some of the programs only admit women, while others admit both 

men and women but have specific tracks or cohorts for women. Some of 

the programs are focused on MST and others offer treatment focused on 

other traumas or disorders. The programs offer a mix of group and 

individual treatment options, but the types of psychotherapy offered in the 

programs also varies. For example, some programs offer CPT, some focus 

more on exposure therapy, and some provide a mix of these therapies or 

other treatment options. (See table 3 for more information on the 

locations, structure, and focus of these programs.) In addition to these 

facilities, five other VAMCs offer MST or sexual-trauma-specific mental 

health treatment programs for both men and women in a residential or 

inpatient setting, but do not have separate women only tracks. 

 

30While none of the facilities we visited had a dedicated inpatient mental health unit for 

women, according to VA’s Office of Mental Health Services the Houston VAMC recently 

opened a physically separate, 10-bed inpatient mental health unit exclusively for women. 

As of December 2009, this was the only such unit in VA’s health care system. 

31One of these VAMCs offers two distinct programs. 

Page 15 GAO-10-287 VA Health Care for Women Veterans
 

Table 3: Veterans Affairs Medical Centers (VAMC) with Specialized Residential Mental Health Treatment Programs for Women 

Who Have Experienced Military Sexual Trauma (MST) or Other Trauma, as of August 2009 

Facility Program name Structure of programaProgram focus 

VA Boston Health 

Care System (HCS), 

Jamaica Plains 

Campus 

(Boston, Mass.) 

Women Veterans’ 

Therapeutic 

Transitional 

Residence Program 

Women only. Rolling admissions. 

Ask for commitment to stay for 

at least 3 months, though prefer 

1 year (18-month maximum). 

PTSD. 

MST-related therapy provided through 

associated outpatient team at medical 

center. 

VA Boston HCS, 

Brockton Campus 

(Brockton, Mass.) 

Women’s Integrated 

Treatment and 

Recovery Program 

Women only. Rolling admissions. 

8-week length of stay (can be extended). 

Integrated treatment of trauma and 

substance abuse. 

VA Western New 

York HCS, Batavia 

Campus (Batavia, 

N.Y.) 

Women Veterans’ 

Residential Program 

Women only. 10-week mixed-trauma 

cohorts, with some flexibility. 

All traumas. 

VA New Jersey HCS 

(Lyons, N.J.) 

Women’s Residential 

MST Program 

Women only. 7-week cohorts. MST, with other traumas addressed as 

needed. 

Bay Pines VA HCS 

(Bay Pines, Fla.) 

Center for Sexual 

Trauma Services, 

Residential Program 

Women and men, with a women-only 

track. Rolling admission. Variable length of 

stay depending on treatment needs. 

MST, with other sexual trauma 

addressed as needed. 

Cincinnati VAMC 

(Cincinnati, Ohio) 

Residential PostTraumatic Stress 

Disorder (PTSD) 

Program 

Women and men, with a women-only 

track. 7-week cohorts. 

PTSD. 

Central Texas 

Veterans HCS 

(Temple, Tex.) 

Women’s Trauma 

Recovery Center 

Women only. 7-week cohorts. MST (sexual assault focused). 

VA Palo Alto HCS, 

Menlo Park Division 

(Menlo Park, Calif.) 

Women’s Trauma 

Recovery Program 

Women only. Rolling admissions. 

2- to 3-month length of stay. 

PTSD, but high prevalence of sexual 

trauma among veterans in program. 

VA Long Beach HCS 

(Long Beach, Calif.)b

“Renew” and 

“Bridges” 

Women only. Renew: 12-week cohorts. 

Bridges: rolling admission, 12-week 

residential and/or outpatient program. 

Renew is sexual trauma focused. 

Bridges is a sexual trauma focused 

aftercare program consisting of 

12 hours a week of community activity 

and support groups. 

Source: GAO review of VA documentation. 

a

Cohorts are a size-limited group of individuals who begin a program at the same time and commit to 

completing the program. 

b

This facility offers two distinct programs: “Renew” and “Bridges.” 

Although the specialized programs offered at these nine facilities are all 

national VA resources—meaning that they serve veterans living nearby as 

well as veterans who live in other states—several VA providers told us that 

many veterans and VA providers alike did not know about VA’s specialized 

programs for women and suggested that VA could do more to publicize the 

programs. One clinician running one of the programs noted that during the 

Page 16 GAO-10-287 VA Health Care for Women Veterans
 

first year of their program—which opened in July 2007 and has room for 

eight women in each cohort—they had space for additional patients in 

their cohorts but at the same time veterans in the region were being 

referred to programs across the country because VA providers in their 

region didn’t know about the program. These providers told us that, while 

their cohorts have usually been full since the middle of 2008, many 

veterans still do not know about VA’s specialized programs and other 

MST-related services that are available to them. 

VA has taken some steps internally to make information about these 

programs more readily available to VA providers. Specifically, VA has 

conducted monthly, nationwide MST conference calls which have 

included basic information on the structure and focus of the various 

residential and outpatient programs offering MST or sexual-traumaspecific treatment, as well as detailed presentations by key providers from 

several programs. VA also has a list of the various programs on its internal 

Web site, which is accessible by VA providers. 

However, VA has not made the same information accessible to veterans 

through VA’s external Web sites. As of November 2009, the Web pages we 

reviewed from VA’s national Web site did not provide complete lists of 

facilities that have MST-related treatment programs or specialized 

programs for women veterans. The sites that did list specific residential 

treatment programs usually listed a single program, while nine VAMCs 

have relevant programs.32 VA’s national Web sites directed veterans to 

their local facilities for questions about available treatment options, but 

did not provide relevant contact information, instead linking veterans to a 

Web page that allows them to search for VA facilities in their area. 

Moreover, only three of the nine VAMCs that have these specialized 

residential programs for women provided detailed information about the 

programs on their facility-specific Web sites. Three of the nine VAMCs’ 

 

32We found one VA Web page that linked to a “Frequently Asked Questions” document 

which listed four “special PTSD treatment centers,” but did not provide contact 

information for those facilities. In November 2009, VA added a link on one VA Web page to 

a spreadsheet titled “PTSD Program List.” This spreadsheet provided program names and 

contact information for over 160 programs or teams, 7 of which were labeled as “Women’s” 

programs. Four of these women’s programs corresponded to VAMCs that have specialized 

residential treatment programs for women veterans. The remaining 3 VAMCs in the 

spreadsheet were labeled as having a women’s “team.” The other 5 VAMCs that have 

specialized programs were not included in the spreadsheet. Separately, we found one 

Department of Defense site—within the agency’s Sexual Assault Prevention and Response 

Office Web site—that identified 4 VA facilities. 

Page 17 GAO-10-287 VA Health Care for Women Veterans
 

Web sites mentioned their residential program briefly and the remaining 

three VAMCs did not mention their program at all. Several facility-specific 

Web sites mentioned that they provide specialized health care services for 

women or related to MST, but did not provide additional information 

about their programs. 

This lack of accessible information on VA’s residential mental health 

programs for women veterans is not consistent with VA’s goals—

referenced in its fiscal year 2010 Budget Submission—related to 

transforming the agency to serve veterans more effectively, including the 

goal of allowing veterans to “reach VA on their own terms (phone, web, in 

person) and gain quick and convenient access to information about all VA 

services from a single point of contact.” Moreover, research has shown 

that women veterans’ lack of awareness about VA services available to 

them has been a barrier to their receiving care. 

Officials in VA’s Office of Mental Health Services acknowledged that the 

information on these residential programs on VA’s external Web site is 

limited. They said that, in general, they would prefer that a veteran contact 

the WVPM or MST Coordinator at their local facility to get help identifying 

their unique treatment needs, finding the right program to meet those 

needs, and navigating the sometimes complicated process of enrolling in 

the programs. However, we found that contact information for WVPMs 

and the MST Coordinators was either missing or hard to find on most of 

the facility-specific Web sites for the nine facilities that have these 

programs. Three of these facilities’ Web sites did not provide the WVPM’s 

or the MST coordinator’s contact information, and only two facilities 

provided contact information for both individuals. It is important that VA 

provide women veterans easy access to information about specialized VA 

programs for women as well as more complete information on key 

contacts at local facilities. Better access to this information could 

empower women veterans to have more informed conversations with VA 

staff about the available treatment options. 

Page 18 GAO-10-287 VA Health Care for Women Veterans
 

VA Medical Facilities 

Had Not Fully 

Implemented VA 

Policies Pertaining to 

the Delivery of Health 

Care Services for 

Women Veterans 

The extent to which VA medical facilities we visited were following VA 

policies that apply to the delivery of health care services for women 

veterans varied, but none of the facilities had fully implemented VA 

policies pertaining to women veterans’ health care. None of the facilities 

were fully compliant with VA policies on privacy for women veterans, but 

all of them complied with at least some of the policies. The medical 

facilities we visited were in various stages of implementing VA’s initiative 

to expand access to comprehensive primary care for women veterans. 

None of the Facilities Were 

Fully Compliant with VA 

Privacy Policies for 

Women Veterans, and VA’s 

Oversight Process Does 

Not Ensure Accurate 

Reporting on Compliance 

None of the VAMCs or CBOCs we visited were fully compliant with VA 

policy requirements related to privacy for women veterans. Since July 

2009, when we reported our preliminary findings on selected medical 

facilities’ compliance with VA policies, VA has taken steps to implement a 

process that requires facilities to report more information on their 

compliance with these policies. However, the process VA is using relies on 

information reported by facilities, and VA does not have a process for 

ensuring that this information is accurate. 

While none of the medical facilities we visited were fully compliant, all of 

the VAMCs and CBOCs we visited were compliant with at least some of 

VA’s policy requirements related to privacy for women veterans in all 

clinical settings where those requirements applied. Table 4 summarizes the 

extent to which the medical facilities we visited complied with VA policy 

requirements related to privacy for women veterans. 

Medical Facilities Were Not 

Fully Compliant with VA 

Privacy Policies for Women 

Veterans 

Page 19 GAO-10-287 VA Health Care for Women Veterans
 

Table 4: Department of Veterans Affairs (VA) Facilities’ Compliance with VA Privacy Requirements 

Compliance with requirement 

Veterans Affairs Medical Center (VAMC), 

by number 

Community-Based Outpatient Clinic (CBOC), 

by number 

Privacy requirement 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 10 

Adequate visual and auditory 

privacy at check-in 

◒ ◒ ◒ ◒ ◒ ◒ ◒ ◒ ◒ ◒ ◒ ◒ ◒ ◒ ○ ◒ ○ ◒ ○

Adequate visual and auditory 

privacy in the interview area ● ◒ ◒ ● ● ◒ ● ◒ ● ◒ ● ● ◒ ● ● ● ● ● ●

Exam rooms located so they do not 

open into a public waiting room or 

a high-traffic public corridor 

● ● ◒ ◒ ◒ ◒ ◒ ● ◒ ● ● ● ● ● ● ● ● ● ●

Privacy curtains present in exam 

rooms 

● ● ● ◒ ● ● ● ● ● ● ● ○ ● ● ● ● ○ ○ ●

Exam tables placed with the foot 

facing away from the door (if not 

possible, placed so they are fully 

shielded by privacy curtains)a

◒ ◒ ○ ○ ◒ ○ ● ○ ◒ ○ ● ○ ○ ○ N/A N/A ○ ● ○

Changing area provided behind 

privacy curtain ● ● ● ◒ ● ● ● ● ● ● ● ○ ● ● ● ● ○ ○ ●

Toilet facilities immediately 

adjacent to examination rooms 

where gynecological exams and 

procedures are performed 

◒ ● ○ ● ◒ ◒ ○ ○ ◒ ○ ○ ○ ○ ● N/A N/A ○ ○ ○

Sanitary napkin and/or tampon 

dispensers and disposal bins in at 

least one women’s public restroom 

●b○ ○ ○ ○ ○ ○ ○ ●b○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Privacy curtains in inpatient rooms 

(exception: psychiatry and mental 

health units) 

◒ ● ● ● ● ● N/A ● ○ (This requirement does not apply to CBOCs.) 

Access to a private bathroom 

facility (with toilet and shower) in 

close proximity to the patient’s 

room (inpatient and residential 

units) 

● ◒ ● ● ● ◒ ◒ ◒ ● (This requirement does not apply to CBOCs.) 

Source: GAO. 

● Facility was compliant with requirement in all clinical settings 

◒ Facility was compliant with requirement in at least one—but not all—clinical settings 

○ Facility was not compliant with requirement in any clinical settings 

N/A We did not tour any clinical settings at this facility where this requirement must be applied 

Note: We collected this information using data collection instruments during site visits to VA medical 

facilities from October 2008 through April 2009. 

a

We did not observe any clinical settings where it was not possible to orient exam tables with the foot 

facing away from the doorway. 

b

At this facility, sanitary napkins, tampons, or both were available free of charge in baskets that had 

been placed in public restrooms. 

Page 20 GAO-10-287 VA Health Care for Women Veterans
 

Some common areas of noncompliance included the following: 

• Visual and auditory privacy at check-in. None of the VAMCs or CBOCs 

we visited ensured adequate visual and auditory privacy at check-in in all 

clinical settings that were accessed by women veterans as required by VA 

policy. In most clinical settings, check-in desks or windows were located 

in a mixed-gender waiting room or on a high-traffic public corridor. In 

some locations, the check-in area was located far enough away from the 

waiting room chairs that patients checking in for appointments could not 

easily be heard. In a total of 12 outpatient clinical settings at six VAMCs 

and five CBOCs, however, check-in desks were located in close proximity 

to chairs where other patients waited for their appointments. At one 

CBOC, we observed a line forming at the check-in window, with several 

people waiting directly behind the patient checking in, demonstrating how 

privacy can be easily violated at check-in. 

• Orientation of exam tables. In exam rooms where gynecological exams 

are conducted, only one of the nine VAMCs and two of the eight CBOCs33

we visited were fully compliant with VA’s policy requiring exam tables to 

face away from the door.34 In many clinical settings that were not fully 

compliant at the remaining facilities, we observed that exam tables were 

oriented with the foot of the table facing the door, and in two CBOCs 

where exam tables were not properly oriented, there was no privacy 

curtain to help assure visual privacy during women veterans’ exams. At 

one of these CBOCs, a noncompliant exam room was also located within 

view of a mixed-gender waiting room. Figure 1 shows the correct and 

incorrect orientation of exam tables in two gynecological exam rooms at 

two VA medical facilities. 

 

33We visited 10 CBOCs, but 2 of the CBOCs we visited did not offer gynecological exams. 

34According to VA policy, if it is not possible for exam tables to be placed with the foot 

facing away from the door, they may be placed so that they are fully shielded by privacy 

curtains. However, we did not observe any clinical settings where it was not possible to 

orient exam tables with the foot facing away from the door. 

Page 21 GAO-10-287 VA Health Care for Women Veterans
 

Figure 1: Correct and Incorrect Placement of Exam Tables in Gynecological Exam Rooms at Department of Veterans Affairs 

(VA) Medical Facilities 

• Restrooms adjacent to exam rooms. Only two of the nine VAMCs and 

one of the eight CBOCs we visited were fully compliant with VA’s 

requirement that exam rooms where gynecological exams are conducted 

have immediately adjacent restrooms.35 In most of the outpatient clinics 

we toured, a woman veteran would have to walk down the hall to access a 

restroom, in some cases passing through a high-traffic public corridor or a 

mixed-gender waiting room. 

 

35We visited 10 CBOCs, but 2 of the CBOCs we visited did not offer gynecological exams, so 

this requirement was not applicable at those 2 CBOCs. 

Page 22 GAO-10-287 VA Health Care for Women Veterans
 

• Access to private restrooms in inpatient and residential units. At 

four of the nine VAMCs we visited, proximity of private restrooms to 

women’s rooms on inpatient or residential units was a concern. In one 

mixed-gender inpatient medical/surgical unit, two mixed-gender 

residential units, and one all-female residential unit, women veterans were 

not guaranteed access to a private bathing facility and may have had to use 

a shared or communal facility. In two of these four settings, access to the 

shared restroom was not restricted by a lock or a keycard system, raising 

concerns about the possibility of intrusion by male patients or staff while a 

woman veteran is showering or using the restroom. 

• Availability of sanitary products in public restrooms. At 7 of the 9 

VAMCs and all 10 of the CBOCs we visited, we did not find sanitary 

napkins or tampons available in dispensers in any of the public restrooms. 

In response to preliminary findings we issued in July 2009 regarding VA 

medical facilities’ lack of compliance with selected VA privacy policies,36

VA took steps to increase how often facilities review and report on their 

compliance with these policies. Specifically, VA’s Acting Deputy Under 

Secretary for Health directed all VA medical facilities to incorporate 

specific considerations related to the privacy, dignity, sense of security, 

and safety of all veterans into their facilities’ environmental rounds 

processes, which are regular internal reviews of clinical spaces conducted 

to evaluate compliance with a range of VA policies.37 The Acting Deputy 

Under Secretary also recommended that the WVPM should participate in 

the environmental rounds process. As part of environmental rounds 

processes, staff members at each facility assess whether the clinical 

spaces being reviewed are in compliance with the specified privacy, 

dignity, sense of security, and safety considerations and record their 

assessments in an online checklist. 

VA’s Steps to Update Oversight 

of Medical Facilities’ 

Compliance with VA Privacy 

Policies Lacks a Process to 

Ensure the Accuracy of 

Facilities’ Reporting 

 

36See GAO-09-884T and GAO-09-899T. 

37Environmental rounds are part of each facility’s regular internal oversight responsibilities. 

On a monthly basis, the environmental rounds team, which includes representatives of 

facility leadership along with key clinical and operational staff, reviews a sample of clinical 

spaces in every VA medical facility to determine compliance with a range of VA policies—

such as infection control, cleanliness of the environment, and staffing levels—and to 

identify deficiencies. VA’s Office of the Deputy Under Secretary for Health for Operations 

and Management has oversight authority for the environmental rounds process, and for 

implementing any national changes to the process. 

Page 23 GAO-10-287 VA Health Care for Women Veterans
 

VA required that all VAMCs and CBOCs assess their compliance in all 

clinical settings with these considerations and submit the results from 

their reviews to VA’s Office of the Deputy Under Secretary for Health for 

Operations and Management by August 31, 2009. According to VA, the 

initial round of these reviews identified some issues related to facilities’ 

compliance with privacy policies for women, including finding exam 

rooms that lacked privacy curtains, limited availability of sanitary napkins, 

and improper orientation of exam tables. VA directed facilities to 

immediately address any compliance gaps that could be corrected 

immediately and submit a written action plan with a target completion 

date for addressing other deficiencies. VA’s Office of the Deputy Under 

Secretary for Health for Operations and Management directed that 

facilities provide an update on the status of their efforts to address the 

identified deficiencies by October 30, 2009, with weekly updates thereafter 

until the deficiencies are addressed. 

While incorporating privacy policies into VA’s environmental rounds 

establishes a process for local oversight of compliance with these policies, 

it may not be enough, especially given that we identified inaccuracies in 

data that medical facilities had reported on their compliance with privacy 

policies under a prior system of self-reporting. Prior to the expansion of 

the environmental rounds process to include privacy issues, individual 

VAMCs reported, on an annual VA survey, whether their clinical spaces 

were in compliance with VA policies related to ensuring privacy for 

women veterans.38 But at the facilities we visited, the information facilities 

had reported in their surveys for fiscal year 2008 often did not accurately 

reflect the conditions we observed during our site visits. For example, 

medical facilities consistently reported that they were in compliance with 

the privacy policy that requires that exam tables are oriented with the foot 

of the table facing away from the door. However, in most clinical settings 

we visited where gender-specific physical exams might be conducted, 

examination tables were not oriented correctly. At several facilities we 

visited, staff specifically pointed out that exam tables were not oriented 

 

38Each fiscal year, WVPMs at each VAMC submit responses to this survey to VA’s Women 

Veterans Health Strategic Health Care Group. Officials in this office are responsible for 

providing strategic and programmatic support to facilities as they implement programs for 

women veterans, particularly VA’s initiative to provide comprehensive primary care for 

women veterans. In addition to collecting information on whether clinical settings are 

meeting VA’s privacy standards for women veterans, the survey collects information on a 

range of topics related to the delivery of health care services to women veterans, such as 

the types of services available at each facility. 

Page 24 GAO-10-287 VA Health Care for Women Veterans
 

correctly, but in only one facility we visited did we observe that staff took 

action to address the issue. 

Even though VA has strengthened its oversight of privacy policies, because 

it is still relying on a self-reporting process VA lacks independent 

validation that VA medical facilities are complying with VA policies related 

to ensuring privacy for women veterans. While the online checklist and 

facility action plans will allow VA headquarters officials to review 

deficiencies reported by facilities, the process relies on self-reported 

information that may not always be accurate. 

Medical Facilities Were in 

Various Stages of 

Implementing VA’s 

Initiative on 

Comprehensive Primary 

Care for Women Veterans, 

but Officials at Some 

Facilities Were Unclear 

about the Steps Needed to 

Implement VA’s New 

Initiative 

VA’s initiative to expand access to comprehensive primary care for women 

veterans is a key element of the agency’s efforts to address the needs of 

this population. In establishing the initiative, VA adopted as a fundamental 

goal that each woman veteran would have access to a VA primary care 

provider who is proficient, interested, and engaged and who meets all of 

her primary care needs, including gender-specific and mental health care, 

in the context of an ongoing patient-provider relationship. VA also 

expressly defined comprehensive primary care for women as the 

availability of these services through one provider at one site. Part of the 

intent of these goals is to address the fact that many VA medical facilities 

deliver general primary care services and basic gender-specific services to 

women veterans using different providers, in different settings, over 

multiple appointments. This shift towards providing comprehensive 

primary care for women veterans in this one visit model requires 

significant changes for many VA medical facilities, but VA believes it is 

important because this fragmented delivery of care interferes with 

continuity of care and increases barriers to accessing care. While VA has 

asked that all VAMCs and CBOCs implement this initiative, VA has not set 

a deadline by which facilities are required to have fully implemented it. 

The VA medical facilities we visited reported that they were at various 

stages of implementing VA’s new policy on comprehensive primary care 

for women veterans, but we also found that officials at some medical 

facilities were unclear about the steps needed to implement the initiative. 

Officials at six of the seven VAMCs and six of the eight CBOCs we visited 

after November 2008—when VA adopted the initiative—reported that they 

had at least one provider who could deliver comprehensive primary care 

services to women veterans. The models that facilities used to deliver 

comprehensive primary care varied. Some VAMCs and CBOCs we visited 

already offered comprehensive primary care services through designated 

women’s health providers during a single visit, consistent with VA’s vision 

Page 25 GAO-10-287 VA Health Care for Women Veterans
 

for a one-visit model of care. In contrast, some facilities were still working 

to adapt their existing model of care, as the following examples illustrate. 

• At one VAMC, primary care was offered in a mixed-gender primary care 

clinic and basic gender-specific services were offered by a separate 

appointment in the gynecology clinic, sometimes on the same day. 

Officials at this facility said that they were in the process of determining 

whether they can meet VA’s comprehensive primary care standard by 

placing additional primary care providers in the gynecology clinic so that 

both primary care services and basic gender-specific services could be 

offered during the same appointment, in one location. Facility officials 

were uncertain about whether they would meet the new standard if 

primary care and basic gender-specific services were still delivered by two 

different providers. However, VA’s comprehensive primary care policy is 

clear that the care is to be delivered by the same provider. 

• Some of the medical facilities we visited reported that they still were not 

routinely assigning all new women veteran patients to providers who 

could deliver comprehensive primary care in one visit. Even facilities that 

had implemented the one-visit model reported that they still had female 

patients who had established relationships with their primary care 

providers and had elected to continue to receive their primary and genderspecific care in two different settings.39

Another area of uncertainty facility officials highlighted was how to ensure 

that providers have and maintain the broad set of skills and knowledge 

that a provider would need to meet VA’s comprehensive primary care 

standard, particularly at facilities that see relatively few women patients. 

Officials from VA headquarters have made it clear that it is their 

expectation that comprehensive primary care providers have a broad 

understanding of basic women’s health issues—including initial evaluation 

and treatment of pelvic and abdominal pain, menopause management, and 

the risks associated with prescribing certain drugs to pregnant or lactating 

women. However, some VA medical facilities serve a low volume of 

women veterans. For example, three of the CBOCs we visited served 

fewer than 100 women veterans in fiscal year 2008, and each of these 

CBOCs had two or more providers who were delivering or were scheduled 

to be trained in delivering gender-specific care. Another CBOC that served 

 

39Facilities we visited reported that while they would offer established patients the option 

to be reassigned to a provider who could deliver comprehensive primary care services, 

they would not require these patients to switch if they preferred to stay with a provider 

with whom they had a relationship. 

Page 26 GAO-10-287 VA Health Care for Women Veterans
 

just over 100 women veterans in fiscal year 2008 did not offer genderspecific care at the time we visited the facility, but one provider had plans 

to obtain needed training in delivering gender-specific care. Some VA 

medical facility officials and providers told us they were unsure how 

providers, even those who already possessed the relevant skills, could 

maintain their competence in delivering the broad range of primary care 

and gender-specific services that VA envisions in facilities with a low 

volume of female patients given that opportunities to practice delivering 

these services are limited. 

VA headquarters officials report that they are taking several steps to help 

VA medical facilities implement comprehensive primary care for women 

veterans, including the following: 

• VA has established an internal work group that, among other things, has 

developed draft written recommendations to more clearly define the 

professional competencies that a proficient women’s health provider 

should have. This effort is being directed by leaders in VA’s Office of 

Primary Care. According to officials from VA’s Women Veterans Health 

Strategic Health Care Group, part of the work group’s efforts involve 

looking at strategies to help address challenges associated with 

maintaining providers’ competency at facilities with a low volume of 

female patients. 

• All VAMCs were required to submit to VA headquarters by August 1, 2009, 

final implementation plans for providing comprehensive primary care for 

women veterans. These plans identify strategic goals and staffing, 

equipment, and other capital needs (such as resources for renovation or 

construction projects) to address gaps in services for women veterans at 

each VAMC. VA’s Women Veterans Health Strategic Health Care Group is 

reviewing these plans to assess the status of medical facilities’ efforts to 

implement the comprehensive primary care initiative. They are also 

reviewing the plans to identify the short- and long-term planning and 

budgetary needs identified by each facility, and to assess resource needs 

across VA’s health care system. Officials from this group said that 

implementing comprehensive primary care for women veterans is an 

ongoing process that VA medical facilities should revisit during their 

annual strategic planning processes. 

Page 27 GAO-10-287 VA Health Care for Women Veterans
 

• Officials from VA’s Women Veterans Health Strategic Health Care Group 

are working closely with individual WVPMs to help them gain access to 

and work with medical facility leadership to move facilities’ 

implementation plans forward.40

VA facilities face challenges in providing health care services to women 

veterans, including alleviating space constraints that affect the provision 

of care, hiring providers who have specific experience and training in 

women’s health, and expanding the role of the WVPM. VA has taken steps 

to address some of these challenges, for example by implementing 

programs to educate VA providers in women’s health and evidence-based 

psychotherapies, creating a team to coordinate training and knowledge 

sharing on MST-related services, and working to educate facility 

leadership about the importance of ensuring that WVPMs have the ability 

to affect change at their facilities. However, these challenges have not 

been fully addressed. VA has not yet integrated its privacy policies for 

women into the agency’s design and construction standards, provided 

guidance on training that mental health providers working with MST 

patients should have, or updated its WVPM handbook to reflect the 

expanded full-time role it envisions for the position. 

VA Has Taken Steps 

to Alleviate Space 

Constraints, Hire 

Trained Providers, 

and Expand the Role 

of the WVPM, but 

Challenges Remain 

VA Facilities Plan 

Construction Projects to 

Alleviate Space 

Constraints That Affect the 

Provision of Services to 

Women Veterans, but VA’s 

Design Policies Do Not 

Address VA’s Privacy 

Policies Pertaining to 

Women Veterans 

Officials at VA medical facilities we visited reported that space constraints 

have affected both their ability to provide comprehensive primary care 

services to women veterans and their ability to comply with VA’s privacy 

policies that pertain to women veterans. VA facility officials told us that 

space constraints have created challenges as they work to comply with 

VA’s new policy on comprehensive primary care for women and the policy 

requirements in the September 2008 Uniform Mental Health Services in 

VA Medical Centers and Clinics handbook. For example, officials at one 

VAMC said that the limited numbers of primary care exam rooms at the 

facilities in their system—including CBOCs—made it difficult for 

providers to deliver comprehensive primary care services in an efficient 

and timely manner. Providers in this VAMC and at a large CBOC explained 

that they had only one exam room per primary care provider, and this 

 

40In addition, officials from the Women Veterans Health Strategic Health Care Group are 

conducting “coaching visits” for medical facilities that request their assistance. According 

to officials from the Women Veterans Health Strategic Health Care Group, these visits 

provide an opportunity for them to work directly with local WVPMs and facility leadership 

on how best to address the elements of their facility’s implementation plan and the 

potential challenges, and also to highlight the importance of supporting the plans. 

Page 28 GAO-10-287 VA Health Care for Women Veterans
 

prevented them from “multitasking,” or moving back and forth between 

exam rooms while patients are changing or completing intake interviews 

with nursing staff. Similarly, mental health providers at a large CBOC said 

that they often shared offices, which limited the number of counseling 

appointments they could schedule. At another VAMC, officials reported 

that because of substantial increases in demand for services, they no 

longer have adequate space in their women’s clinic and they have limited 

options for expanding the clinic. 

Regarding the impact of space constraints on facilities’ implementation of 

privacy policies, officials at 7 of 9 VAMCs and 5 of 10 CBOCs we visited 

said that space issues, such as the number, size, or configuration of exam 

rooms at their facilities, sometimes made it difficult for them to comply 

with some VA requirements related to privacy for women veterans. At 

some of the medical facilities we visited, officials raised concerns about 

busy check-in stations, waiting rooms, and patient intake rooms limiting 

their ability to ensure the privacy of women, particularly those who have 

experienced MST and may not feel comfortable in a mixed-gender 

environment. For example, at one VAMC we visited the check-in station 

for the mixed-gender primary care clinic was located in a major hallway 

and near the medical center’s main elevator bank. At one large CBOC we 

visited—which saw almost 3,000 female patients in fiscal year 2008—the 

primary care clinic had only one patient intake room and providers 

sometimes had two patients separated by a curtain in that room during 

intake or screening processes, which involve sensitive questions about a 

patient’s medical history, including problems with substance use and 

whether a patient has experienced MST. Officials at another large CBOC 

said that space challenges that limited their ability to ensure privacy for 

women were among the factors that led to the relocation of mental health 

services to a separate off-site clinic. 

VA providers at some facilities also expressed concerns about the privacy 

and safety of women veterans in mixed-gender residential programs, and 

cited space constraints as limiting their ability to address some of these 

issues. In May 2009, VA issued revised policies for residential mental 

health programs that require facilities with such programs to provide 

separate and secure sleeping arrangements for women veterans, including 

locks on bathroom and bedroom doors. In the residential treatment 

programs we visited, women veterans were placed either in a private room 

or a multibed room with other women, with bedrooms accessible using 

electronic keycards. Some residential programs placed women in secured 

bedrooms located at one end of a hallway, or near a nurses’ station. Other 

facilities had created a separate section of bedrooms for women only, 

Page 29 GAO-10-287 VA Health Care for Women Veterans
 

physically separated from other areas of the building and secured with a 

keyless entry system. However, given the available space in the buildings 

that house these programs, female residents shared common areas, such 

as the dining room, with male residents. Some providers expressed 

concerns that women who were victims of sexual trauma might not feel 

comfortable in such an environment. Further at one facility, a unit that 

housed a residential PTSD program had only one dormitory-style 

communal bathroom. Because it was a mixed-gender program, and 

although the bathroom was secured with a keycard entry system, staff had 

to allocate specific times of the day when women residents could use the 

showers and also had to stand guard at the door of the bathroom during 

the allocated time. 

Finally, some VA providers highlighted space challenges that affected their 

ability to ensure the privacy and safety for women in inpatient 

environments. VA policy requires that all inpatient care facilities provide 

separate and secured sleeping accommodations for women and that 

mixed-gender units must ensure safe and secure sleeping arrangements, 

including, but not limited to, placing female patients in bedrooms that can 

be readily monitored from the nursing station. All of the inpatient mental 

health units we visited were mixed-gender units that had predominantly 

two- or four-bed bedrooms, with a limited number of private rooms. 

Providers told us they try to place women in private rooms, or if more than 

one woman is on the unit, they sometimes place these women in a two- or 

four-bed room near a nursing station. However, VA providers in two VAMC 

mixed-gender inpatient mental health units told us that some of the 

bedrooms that they usually designate for female patients were located 

where they could not be adequately monitored from the nursing station. 

Providers at several facilities told us that they had at times referred female 

patients to other VA or non-VA facilities when they felt they could not 

ensure the safety of those patients on their units. In one facility we visited, 

staff in the inpatient mental health intensive care unit had temporarily 

removed the doors to patient rooms and bathrooms as part of the facility’s 

ongoing renovations to address updates in VA’s suicide prevention and 

safety policies. However, this made it difficult to ensure safe and secure 

sleeping arrangements for women on the unit. 

VA officials are aware of the space challenges that facilities face and VA is 

taking steps to address them, but the agency lacks a formal process to 

ensure that construction projects take into account the privacy needs of 

women veterans. According to VA headquarters officials, the majority of 

VAMCs have planned to undertake renovation, construction, or relocation 

projects as part of their efforts to implement comprehensive primary care 

Page 30 GAO-10-287 VA Health Care for Women Veterans
 

for women veterans. However, VA design policy documents—in particular 

VA’s Design and Construction Procedures and Design Guides—which lay 

out the detailed requirements that facilities will need to adhere to in 

undertaking these projects, do not explicitly address the policy 

requirements VA has outlined for ensuring the privacy of women 

veterans.41 For example, the Outpatient Clinic Design Guide, which 

includes detailed floor plans for a wide range of clinical spaces, does not 

note the need to ensure visual or auditory privacy at check-in, access to 

gender-specific restrooms, or the availability of a dispenser for sanitary 

products in at least one public restroom. Further, this Design Guide 

contains a detailed floor plan for an outpatient gynecological exam room 

that illustrates an incorrect placement of the examination table—the foot 

of the table is not facing away from the door, as VA’s privacy policies for 

women require. (See fig. 2.) 

 

41VA’s Design and Construction Procedures specify the requirements that facilities must 

adhere to in designing new or renovated spaces, and state that these requirements “shall be 

utilized to the maximum extent practicable, commensurate with cost considerations.” 

Additionally, some of the design standards are required by laws or regulations. 

Page 31 GAO-10-287 VA Health Care for Women Veterans
 

Figure 2: Department of Veterans Affairs (VA) Outpatient Clinic Design Guide—

Gynecologic Exam Room Guide Plate 

Page 32 GAO-10-287 VA Health Care for Women Veterans
 

Note: This VA Guide Plate for a gynecological examination room is one of many in VA’s Outpatient 

Clinic Design Guide, which lays out detailed specifications for a range of outpatient clinic spaces. The 

technical and medical terminology used in these Guide Plates is not directly relevant to this report. 

However, this Guide Plate contains several elements that are relevant to privacy for women veterans. 

Specifically, it specifies the need for a privacy curtain (labeled “cubicle curtain”) and depicts a 

restroom immediately adjacent to the examination room, both of which comply with VA’s privacy 

policies. However, the Design Guide also depicts the exam table with the foot of the table facing 

toward the door, which is contrary to VA’s privacy policies. In addition the bathroom does not include 

a dispenser for sanitary products, which is required to be available in at least one public women’s 

restroom, and would be expected to be available in a restroom attached to a gynecological 

examination room. 

Although VA revised some of its design policy documents in April 2009, 

including Design Guides for outpatient clinics, those revisions did not 

include changes to explicitly address the privacy needs of women. At the 

time of the revisions, VA’s Office of Construction and Facilities 

Management—which is responsible for developing VA’s design and 

construction standards—was unaware of VA’s privacy policies pertaining 

to women veterans. Consequently, officials from VA’s Women Veterans 

Health Strategic Health Care Group were not consulted during the process 

of revising the design documents. Officials from both offices reported in 

November 2009 that they were working closely together to revise the 

current design policies to address VA’s privacy policies and other needs of 

women. However, according to these officials, because of the many 

different types of clinical spaces in VA medical facilities, the process of 

making formal revisions to the design guides is a long and complex 

process that is conducted on a 3- to 5-year cycle, depending on the 

document. In order to get updated guidance to the responsible staff at the 

facility level as soon as possible, these offices are working together to 

develop “interim” design standards that better address the privacy needs 

of women veterans. According to these officials, the interim document 

covers the standards for women veteran’s clinical services in an outpatient 

clinic setting. This document will be disseminated to facilities using VA’s 

standard processes, which include online access to all current standards 

and a monthly report to engineering staff at VA facilities identifying that 

new standards have been released. Facilities will be asked to rely on the 

interim standards while the formal process of revising the design 

standards takes place. VA’s Office of Construction and Facilities 

Management also said that they plan to work with the Women Veterans 

Health Strategic Health Care Group to help disseminate the interim 

standards through the Group’s network of facility contacts. This office 

also reported that recent updates to the Design Guide for mental health 

services addressed the privacy and safety of women veterans, and that 

updates to Design Guides for certain other clinical settings—including 

medical/surgical units—were under way as of November 2009. 

Page 33 GAO-10-287 VA Health Care for Women Veterans
 

VA Facilities Face 

Challenges Hiring 

Providers with the 

Specialized Training and 

Experience Needed to 

Provide Services to 

Women Veterans, and VA 

Lacks Clear Guidance on 

the Training Appropriate 

for Providers Who Treat 

Victims of MST 

VA facility officials reported difficulties hiring primary care and mental 

health providers with specialized training and experience in women’s 

health and MST-related conditions. In addition, while VA is providing 

mental health training for many of its existing providers, VA has not 

developed clear guidance on appropriate training for those mental health 

providers who treat victims of MST. 

VA’s comprehensive primary care initiative requires that women veterans 

have access to a designated women’s health primary care provider that is 

“proficient, interested, and engaged” in delivering a range of services to 

women veterans. This new policy requires that the primary care provider 

fulfill a broad array of health care services including, but not limited to, 

VA Medical Facilities Face 

Challenges Hiring Trained 

Primary Care Providers 

• detection and management of acute and chronic illness, such as 

osteoporosis; thyroid disease; and cancer of the breast, cervix, and lung; 

• gender-specific primary care such as sexuality, pharmacologic issues 

related to pregnancy and lactation, and vaginal infections; 

• preventive care, such as cancer screening and weight management; 

• mental health services, such as screening and referrals for MST, as well as 

evaluation and treatment of uncomplicated mental health disorders and 

substance use disorders; and 

• coordination of specialty care. 

However, a November 2008 VA report on the provision of primary care to 

women veterans cites insufficient numbers of clinicians with specific 

training and experience in women’s health issues among the challenges VA 

Page 34 GAO-10-287 VA Health Care for Women Veterans
 

faces in implementing comprehensive primary care.42 During our site 

visits, some VA medical facility officials discussed similar issues. For 

example, officials at some facilities we visited told us that they would lik

to hire more providers with the required knowledge and experience in 

women’s health, but struggle to do so. At one VAMC, officials reported that 

they had difficulty filling three vacancies for primary care providers, wh

they needed to meet the increasing demand for services and to replace 

staff who had retired. They said it took them months to find providers with

the skills required to serve the needs of women veterans. Similarly, at o

CBOC, officials reported that it takes them about 8 to 9 months to hire 

interested primary care physicians. Further, officials at some medical 

facilities we visited said that they rely on just one or two providers to 

deliver comprehensive primary care to women veterans. This is a concern 

to the officials because, should the provider retire or leave VA, the facility 

might not be able to replace them relatively quickly in order to continue to 

provide comprehensive primary care services to women veterans on site. 

e 

ich 

ne 

 

VA officials have acknowledged some of the challenges involved in hiring 

primary care providers with the required knowledge to meet their vision of 

delivering comprehensive primary care to women veterans. To help ensure 

they have sufficient primary care providers with knowledge of women’s 

health issues, VA is using “mini-residency” training sessions on women’s 

health. These training sessions—which VA designed to enhance the 

knowledge and skills of primary care providers—consist of 2-1⁄2 days of 

case-based learning and hands-on training in gender-specific health care 

for women. During the mini-residency, providers receive specific training 

in performing pelvic examinations, cervical cancer screenings, clinical 

breast examinations, and other relevant skills. VA officials reported that as 

of November 20, 2009, a total of 301 providers from 87 VAMCs and 100 

CBOCs have attended the mini-residency training. 

42VA, Office of Public Health and Environmental Hazards, Women Veterans Health Strategic 

Health Care Group, Report of the Under Secretary for Health Workgroup, Provision of 

Primary Care to Women Veterans (Washington, D.C.: November 2008). This report 

attributed the insufficient number of primary care providers to the historical prevalence of 

male veterans in VA health care settings, which led to many providers having limited or no 

experience treating women veterans. 

Page 35 GAO-10-287 VA Health Care for Women Veterans
 

VA medical facility and Vet Center officials we interviewed reported 

challenges attracting and hiring psychiatrists, psychologists, and other 

mental health staff with specialized training or experience in treating 

PTSD and other MST-related conditions. Medical facility officials often 

noted that there is a limited pool of qualified psychiatrists and 

psychologists, and a high demand for these professionals both in the 

private sector and within VA. For example, one VA medical facility official, 

who was responsible for training other mental health providers, both 

regionally and nationally, said that some VAMCs did not have staff with 

sufficient knowledge or training to provide adequate MST-related 

counseling services. Two officials, who both have experience as an MST 

coordinator, told us that many mental health providers at their facilities 

could use additional training in MST screening. In addition, two VA mental 

health officials reported that because it is difficult to attract and hire 

mental health professionals with experience in treating the veteran 

population, some medical facilities have hired younger, less experienced 

providers. These officials noted that while younger providers may have the 

appropriate education and training in some evidence-based 

psychotherapies that are recommended for treating PTSD and other MSTrelated conditions, they often lack practical experience treating a 

challenging patient population. Some officials reported that shortages of 

trained and experienced providers limit the types of group or individual 

mental health treatment services that VA medical facilities and Vet Centers 

can offer. 

VA Facilities Face Challenges 

Hiring Mental Health Providers 

with Training and Experience 

in Treating MST-Related 

Conditions 

Some CBOCs and one Vet Center we visited reported similar challenges. 

Officials at one VAMC, for example, said that they had problems attracting 

qualified mental health providers to work at its affiliated CBOCs. The 

facility posted announcements for psychiatrist and psychologist positions, 

but sometimes received no applications. Because the facility has not been 

able to recruit mental health providers, it relies on contract providers and 

fee-basing to deliver mental health services to veterans in its service area. 

At another CBOC, a licensed social worker reported providing individual 

counseling for about seven women who have experienced MST, but 

acknowledged having limited training in this area. The provider said that 

this situation was not ideal, and reported consulting with mental health 

providers at the associated VAMC on some of these cases. The provider 

also said that without these services some of these seven women might 

not receive any counseling. At one Vet Center, officials told us that 

because none of their counselors have been trained to counsel veterans 

who have experienced MST, patients seeking counseling for MST are 

usually referred to the nearby CBOC or VAMC. 

Page 36 GAO-10-287 VA Health Care for Women Veterans
 

VA has taken steps to provide mental health training to its existing 

providers, including an agencywide training program to enhance its mental 

health providers’ knowledge of clinically effective treatment methods. 

Specifically, VA is providing intensive training in CPT, PE, CBT, and ACT, 

which are evidence-based psychotherapies for treatment of PTSD and 

other conditions that are associated with MST.43 According to VA, as of 

November 18, 2009, 3,426 VA providers had completed VA-provided 

training in evidence-based psychotherapies. 

In addition to the broad mental health training efforts, VA has taken steps 

to provide specific MST-related training. VA’s MST Support Team was 

created within VA’s Office of Mental Health Services in fiscal year 2007, in 

part, to enhance MST-related training opportunities nationwide. According 

to VA officials, the team conducts monthly teleconference training for 

about 1-1⁄2 hours on a variety of MST-related topics, such as VA residential 

mental health treatment programs with specialized MST-related care, and 

how MST can affect veterans who served during different eras. The team is 

also responsible for an annual MST training conference on issues related 

to clinical care and program development and the development of a VA 

intranet Web site that contains MST-related resources.44 VA officials also 

said that the MST Support Team provided MST-related materials for 

inclusion in the evidence-based psychotherapy training program. 

While VA is taking positive steps to provide MST training for its providers, 

it has not yet defined the appropriate training needed for treating victims 

of MST. MST-related law requires that VA provide for “appropriate training 

of mental health professionals and such other health care personnel” who 

deliver MST-related services.45 VA policies require that all VA mental 

VA Lacks Clear Guidance on 

the Training Appropriate for 

Mental Health Providers Who 

Treat Victims of MST 

 

43VA officials told us that these therapies address the PTSD, depression, and generalized 

anxiety diagnoses commonly associated with sexual trauma. 

44The intranet Web site includes resources such as educational handouts, an independent 

study course on MST, providers’ forums, veteran outreach materials, and sample treatment 

protocols. 

4538 U.S.C. § 1720D(b)(2)(A). On November 19, 2009, the Senate passed a bill that, among 

other things, would address training and certification requirements for mental health care 

providers who provide care to veterans suffering from MST. S. 1963, 111th Cong. § 204 

(2009). The bill would amend the law to require VA to implement a program for education, 

training, certification, and continuing medical education for mental health professionals to 

specialize in the provision of counseling and care to eligible veterans; determine the 

minimum qualifications necessary for mental health professionals certified by the program 

to provide evidence-based treatment to veterans in VA facilities; and establish education, 

training, certification, and staffing standards for VA health-care facilities for full-time 

employees who are trained to provide treatment and care to veterans for sexual trauma. 

Page 37 GAO-10-287 VA Health Care for Women Veterans
 

health providers have appropriate training and that necessary staff 

education and training for treatment of MST-related conditions be 

provided, but do not specify what constitutes “appropriate or necess

training for VA providers who work with victims of MST. VHA’s Uniform 

Mental Health Services in VA Medical Centers and Clinics handbook 

states that VA should ensure that mental health services be provided by

staff with an “appropriate level of training and clinical privileging” and t

medical center directors should ensure that “necessary staff education and 

training is provided.” However, this handbook does not further specify the 

types of training that would meet this standard for mental health provide

who treat MST-related conditio

ary” 

hat 

rs 

ns. 

VA officials in headquarters told us that they have no plans to develop 

criteria that spell out in policy the specific training and experience needed 

for mental health providers that treat victims of MST. They said that all VA 

mental health providers who are licensed in their field and have 

appropriate clinical privileges are considered VA-qualified mental health 

providers and are qualified to work with victims of MST. They also 

confirmed that, beyond these standards, VA does not have specific training 

or experience requirements for providers who work with veterans who 

have experienced MST or other sexual trauma. However, some VA mental 

health providers told us there is a need for additional guidance on the 

types of training mental health providers should have to work effectively 

with veterans who have experienced MST. For example, two providers 

who have served as MST coordinators said that some minimum 

requirements for training on evidence-based psychotherapies for traumarelated conditions would be helpful for working with veterans who 

experienced MST. 

In the absence of VA criteria on MST-specific training required for its 

providers, we found that some facilities were applying their own criteria 

or judgment on what constitutes appropriate training for mental health 

providers who deliver MST-related treatment. For example, at one VAMC, 

the Director of Mental Health Services told us the facility only allows 

providers who have received training and supervision in a relevant 

evidence-based psychotherapy, such as CPT or ACT, to work with victims 

of MST. MST coordinators at several other VAMCs told us that they try to 

ensure that providers who work with victims of MST have had some 

formal training in evidence-based psychotherapy. Similarly, VA’s 

Readjustment Counseling Service, which oversees the Vet Centers, has 

established specific training and experience requirements that its 

counselors must meet before being permitted to provide unsupervised 

counseling services to victims of sexual trauma. Vet Center policy 

Page 38 GAO-10-287 VA Health Care for Women Veterans
 

specifies, among other things, that sexual trauma counselors must have 

120 hours of specialized training and 50 supervised hours of treatment 

experience with a minimum of five sexual trauma cases. According to Vet 

Center officials, these requirements were established to ensure that 

providers are adequately trained to meet the unique needs of veterans who 

have experienced MST or other sexual trauma. 

Some Facilities Have Not 

Implemented the Full-time 

WVPM Position as VA 

Envisioned, and VA Has 

Not Updated Its Policy to 

Clarify the WVPM’s Roles 

and Responsibilities 

Some medical facilities have not implemented the full-time WVPM position 

with the broad responsibilities, authority, and access to senior facility 

leadership that VA envisioned in creating the position. VA’s July 8, 2008, 

memorandum that directed all VAMCs to establish the full-time WVPM 

position broadened the role and responsibilities of the position with the 

intent that WVPMs be empowered to work across a facility’s various 

clinical services in order to implement needed changes, particularly 

related to VA’s efforts to expand comprehensive primary care for women 

veterans. The memorandum further directed facilities to “ensure that the 

WVPM has full access to facility leadership.” The memorandum specified 

that the role of the full-time WVPM was to strategically plan, coordinate 

quality of care, evaluate delivery of care, and increase outreach to women 

veterans. 

While VA’s July 2008 memorandum establishes the key aspects of VA’s 

vision for the full-time WVPM position, it also cites VHA’s WVPM 

handbook—which has not been revised since March 28, 2007, when the 

WVPM was still a collateral duty—for additional guidance on the duties 

and responsibilities of the WVPM.46 We found that although the handbook 

addresses many responsibilities encompassed in VA’s July 2008 

memorandum, it is not fully consistent with VA’s new vision for the fulltime WVPM position. For example, the handbook discusses a range of 

responsibilities for the WVPMs including evaluating delivery of care 

(involving reviews of the physical environment, construction plans, and 

privacy and safety policies), and increasing outreach to women veterans, 

among others. However, the handbook does not explicitly mention or fully 

discuss other key responsibilities cited in VA’s July 2008 memorandum 

related to strategic planning and coordination of quality of care. In 

addition, the handbook states that facility directors should ensure that 

WVPMs have direct access to top management in the facility and serve on 

appropriate clinical and administrative committees, but does not give clear 

 

46VHA Handbook 1330.02. 

Page 39 GAO-10-287 VA Health Care for Women Veterans
 

guidance about the level of reporting authority that the position should 

have. Instead, the handbook states that the responsibilities of the WVPM 

must be negotiated between the WVPM and the WVPM’s supervisor and be 

tailored to the local circumstances. 

During our site visits and reviews of position descriptions for the WVPMs 

at the facilities we visited, we found differences between the 

responsibilities some facilities had assigned to the full-time WVPM and 

those envisioned in VA’s July 2008 memorandum. The differences we 

found related primarily to responsibilities for strategic planning, reviews 

of compliance with privacy policies, and reporting authority. For example, 

five of six position descriptions we reviewed47 did not explicitly mention 

strategic planning as one of the WVPM key responsibilities. We also found 

that two position descriptions did not discuss the WVPM’s responsibilities 

for monitoring or participating in reviews of facility compliance with 

privacy policies that affect women veterans. Similarly, while VA’s July 

2008 memorandum urged facilities to make certain the WVPM “has the 

support and reporting chain necessary to effectively carry out the rapid 

changes required at the facility level,” none of the WVPMs at the facilities 

we visited reported directly to a member of the facility’s senior 

leadership.48

The inconsistencies we observed between VA’s vision for the WVPM and 

how facilities are implementing the position can limit individual WVPMs’ 

effectiveness in implementing changes needed at the facility level to 

improve care for women veterans. Some WVPMs told us about situations 

where their ability to affect changes to improve care for women veterans 

sometimes had been limited by a lack of authority to directly exercise their 

judgment or report directly to senior facility leadership to discuss issues 

that affected women veterans. For example, one WVPM reported not being 

included in key initiatives, such as the environmental rounds or reviewing 

construction plans. Another WVPM told us that efforts to expand genderspecific services for women at a CBOC were rebuffed by her supervisor, 

and did not move forward until someone else who was committed to 

addressing the needs of women veterans took over the supervisory 

position. Officials from VA’s Women Veterans Health Strategic Health Care 

 

47One VAMC did not provide a position description and one VAMC provided a sample 

position description from a different facility. 

48The WVPMs that we reviewed reported to various other officials, such as the Chief of 

Primary Care, Service Line Medical Director, or the Chief of Social Work Service. 

Page 40 GAO-10-287 VA Health Care for Women Veterans
 

Group also told us they have heard from WVPMs that their supervisors 

have sometimes prevented them from communicating with facility 

leadership about steps they believe are needed to implement changes to 

improve services for women veterans. Officials from this group said that 

they are working to educate facility leadership on the importance of 

ensuring that WVPMs have the ability to affect changes across the 

spectrum of services and clinical settings in their facilities, and are also 

working with WVPMs to help them be proactive in gaining access to 

facility leadership. These officials acknowledged that VA could update the 

WVPM handbook to better reflect the agency’s current vision for the roles, 

responsibility, and authority of the WVPM position. 

The number of women veterans using VA health care services has 

increased substantially in recent years and this trend is going to continue 

over the coming decades. VA has taken important steps to address the 

needs of women veterans, including efforts to expand comprehensive 

primary care for women veterans. However, our review also identified 

some gaps in services available to women, including several medical 

facilities that did not routinely offer basic gender-specific services on site. 

While most facilities we visited offered a variety of mental health services, 

VA has not made information accessible on its external Web sites about all 

VA specialized residential mental health programs for women veterans 

who have experienced MST or other traumas. Without ready access to 

such information, women veterans who need treatment may face 

unnecessary challenges to accessing VA programs. 

Conclusions 

To address our preliminary findings that medical facilities were often not 

complying with VA’s privacy policies for women veterans, VA has 

increased its oversight of compliance with these policies by incorporating 

privacy, dignity, sense of security, and safety considerations into facilities’ 

existing environmental rounds processes. However, we found that 

facilities’ prior reporting on their compliance with privacy policies often 

did not accurately reflect the conditions that we found on site, and as a 

result continuing to rely solely on self-reported information may not 

provide sufficient assurance that facilities are complying with these 

policies. 

VA has also taken steps to address some of the challenges that facilities 

have identified in delivering services to women veterans, but has not 

updated some key policies. Many medical facilities have planned 

renovation, construction, or relocation projects to help expand 

comprehensive primary care for women veterans. However, VA’s recently 

Page 41 GAO-10-287 VA Health Care for Women Veterans
 

revised design and construction policies do not accurately reflect VA’s 

privacy policies for women. Given that facilities are actively planning 

construction projects, it is important that facilities have access to design 

policy documents that reflect VA’s privacy policies so that plans for new 

and renovated clinical spaces do not fall short of addressing the needs of 

women. VA would also benefit from utilizing the expertise of the staff from 

the Women Veterans Health Strategic Health Care Group to help ensure 

that any revisions to VA’s policies take into consideration other unique 

needs of women veterans. To address challenges related to training of 

mental health providers, VA has taken decisive action to expand its 

national training program in evidenced-based psychotherapies. However, 

VA policies require appropriate training for mental health professionals in 

general, but have not clearly specified what constitutes appropriate or 

necessary training for VA mental health professionals who work with 

victims of MST or other sexual trauma. In the absence of clear guidance 

from VA, some medical facilities we visited had established their own 

criteria on the training and experience their providers needed to have in 

order to work with this population. Finally, VA has directed that VAMCs 

make the WVPM a full-time position with broad responsibilities and 

authority to transform the delivery of health care to women veterans. 

However, VA has not revised its WVPM handbook since the time that the 

position was a collateral duty, and we found some inconsistencies 

between VA’s expressed vision for the position and the responsibilities, 

level of authority, and access to leadership that facilities were assigning to 

individual WVPMs. The lack of clear and consistent policies at the national 

level about the role of the WVPM position may hamper the effectiveness of 

individual WVPMs in taking a leadership role in facility efforts to improve 

and expand the services offered to women veterans. 

To better ensure that women veterans have access to health care services 

that meet their unique needs and to strengthen oversight of the services 

delivered to women veterans at VA facilities, we recommend that the 

Secretary of Veterans Affairs direct the Under Secretary of Health to 

implement the following five recommendations: 

Recommendations for 

Executive Action 

• provide complete information on VA’s external Web sites on the 

specialized residential mental health treatment programs VA offers for 

women veterans who have experienced MST or other traumas; 

• establish a process to independently validate self-reported information by 

VA medical facilities’ on compliance with privacy policies that pertain to 

women veterans; 

Page 42 GAO-10-287 VA Health Care for Women Veterans
 

• expedite action to ensure that VA’s design and construction policies 

explicitly address the needs of women veterans in all health care delivery 

settings in VA medical facilities; 

• clarify VA’s policies by describing specifically what constitutes 

“appropriate and necessary training” for mental health professionals who 

provide services to veterans who have experienced MST; and 

• update VA’s policies to clarify the roles and responsibilities of the full-time 

WVPM position, in particular with respect to the level of reporting 

authority and access to senior facility management. 

VA provided written comments on a draft of this report, which we have 

reprinted in appendix II. In its comments, VA generally agreed with our 

conclusions and concurred with our recommendations, and also described 

the agency’s planned actions to implement each of the recommendations. 

VA did not provide separate technical comments on the draft report. 

Agency Comments 

and Our Evaluation 

Specifically, VA agreed that it is important that the agency’s external Web 

sites provide appropriate information about specialized residential mental 

health treatment programs for women veterans, and stated that the agency 

is conducting a systematic review of VA’s national Web sites to identify 

sites that contain limited or inadequate information. However, it is unclear 

from VA’s comments whether this review will include VA’s facility-specific 

Web sites. Given our finding that only three of the nine VAMCs that have 

specialized residential programs for women provided detailed information 

about those programs on their Web sites, we believe it is important that VA 

include facilities’ Web sites in its review. VA also plans to emphasize with 

facilities the importance of ensuring that local MST coordinators’ contact 

information is readily available at key entry points to the VA system. We 

commend this effort and encourage VA to include WVPMs’ contact 

information in its plans, given the agency’s stated goal that women 

veterans work with their local WVPMs or MST coordinators to identify 

programs to best meet their unique treatment needs. Separately, VA plans 

a collaborative effort to develop, by March 30, 2010, a process to validate 

facilities’ self-reported information on compliance with privacy policies. 

In its comments, VA further concurred with the need to expedite action to 

update VA’s design and construction standards to explicitly address the 

needs of women veterans in all health care delivery settings. VA said that 

these standards have been upgraded for some clinical settings, and cited 

the design guides and standards for ambulatory care and outpatient 

Page 43 GAO-10-287 VA Health Care for Women Veterans
 

clinics, among others, as examples. However, as of March 25, 2010, the 

current Ambulatory Care and Outpatient Clinic Design Guides—last 

updated in April 2009—were the same documents that we reviewed in our 

draft report and found to be inadequate. VA also commented that an 

interim document focusing on “women’s issues” is scheduled to be issued 

in late spring 2010, which our draft report mentioned VA was working on 

in November 2009. We urge VA to expedite updating of design and 

construction standard documents—which are typically updated on a 3- to 

5-year cycle—for all clinical settings to ensure that the renovation, 

construction, or relocation projects that many VA facilities are planning 

adequately address the needs of women veterans. 

VA concurred that mental health professionals must be skilled to provide 

MST-related care, and said that the agency will specify what constitutes 

adequate training for these clinicians in an action plan to be delivered by 

March 30, 2010. Finally, VA has tasked a work group to revise the current 

WVPM handbook to ensure that it aligns with the expanded mission of the 

full-time WVPM position. VA noted that the work group will examine and 

define the reporting authority, access to senior facility management, and 

the program management responsibilities of the position. VA anticipates 

the handbook will be revised and submitted for internal review within VA 

by June 1, 2010. 

We are sending copies of this report to the Secretary of Veterans Affairs, 

appropriate congressional committees, and other interested parties. In 

addition, the report is available at no charge on the GAO Web site at 

http://www.gao.gov. 

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or at williamsonr@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on the 

last page of this report. GAO staff who made major contributions to this 

Randall B. Williamson 

report are listed in appendix III. 

Director, Health Care 

Page 44 GAO-10-287 VA Health Care for Women Veterans
Page 45 GAO-10-287 

List of Congressional Addressees 

The Honorable Daniel K. Akaka 

Chairman 

Committee on Veterans’ Affairs 

United States Senate 

The Honorable Tim Johnson 

Chairman 

The Honorable Kay Bailey Hutchison 

Ranking Member 

Subcommittee on Military Construction, Veterans Affairs, 

 and Related Agencies 

Committee on Appropriations 

United States Senate 

The Honorable Chet Edwards 

Chairman 

The Honorable Zach Wamp 

Ranking Member 

Subcommittee on Military Construction, Veterans Affairs, 

 and Related Agencies 

Committee on Appropriations 

House of Representatives 

The Honorable Michael H. Michaud 

Chairman 

Subcommittee on Health 

Committee on Veterans’ Affairs 

House of Representatives 

The Honorable Russell D. Feingold 

United States Senate 

 VA Health Care for Women Veterans 
Appendix I: Information on the Selection of 

Department of Veterans Affairs Facilities Appendix I: Information on the Selection of Examined in This Report 

Department of Veterans Affairs Facilities 

Examined in This Report 

We selected locations for our site visits using Department of Veterans 

Affairs (VA) data on each VA medical center (VAMC) in the United States. 

Our goal was to identify a geographically diverse mix of facilities, 

including some facilities that provide services to a high volume of women 

veterans, particularly women veterans of Operation Enduring Freedom 

(OEF) and Operation Iraqi Freedom (OIF); some facilities that serve a high 

proportion of National Guard or Reserve veterans; and some facilities that 

serve rural veterans. To assess the reliability of these data, we reviewed 

relevant documentation and interviewed agency officials knowledgeable 

about the data and the methodologies used to collect them. We 

determined that the data were sufficiently reliable for the purposes of this 

report. In addition to these data, we also considered whether VAMCs had 

programs specifically for women veterans, particularly treatment 

programs for post-traumatic stress disorder (PTSD) and for women who 

have experienced military sexual trauma (MST). For each of the factors 

listed below, we examined available facility- or market-level data to 

identify medical facilities of interest: 

• total number of unique women veteran patients who used the VAMC; 

• total number of unique OEF/OIF women veteran patients who used the 

VAMC; 

• proportion of unique women veterans who used the VAMC who were 

OEF/OIF veterans; 

• proportion of unique OEF/OIF women veterans who used the VAMC who 

were discharged from the National Guard or Reserves; 

• within the VA-defined market area for the VAMC, the proportion of women 

veterans who used VA health care and lived in rural or highly rural areas; 

and 

• availability of on-site programs specific to women veterans, such as 

inpatient or residential treatment programs that offered specialized 

treatment for women veterans with PTSD or who have experienced MST, 

including programs that were for women only or that had an admission 

cycle that included only women; and outpatient treatment teams with a 

specialized focus on MST. 

We selected a judgmental sample of the VAMCs that fell into the top 25 

facilities for at least two of these factors. Once we had selected these 

VAMCs, we also selected at least one community-based outpatient clinic 

(CBOC) affiliated with each of the VAMCs and one nearby Vet Center, 

which we also visited during our site visits. In selecting these CBOCs and 

Page 46 GAO-10-287 VA Health Care for Women Veterans
Appendix I: Information on the Selection of 

Department of Veterans Affairs Facilities 

Examined in This Report 

Vet Centers, we focused on selecting facilities that represented a range of 

sizes, in terms of the number of women veterans they served. Tables 5 and 

6 provide information on the unique number of women veterans served by 

each of the VAMCs and CBOCs we selected for site visits. 

Table 5: Women Veterans’ Health Care Utilization at Selected Veterans Affairs 

Medical Centers (VAMC) 

VAMC, by 

number 

Number of unique 

women veterans 

served in 

fiscal year 2008

Percentage increase 

between fiscal year 

2006 and fiscal year 

2008 in the 

number of women 

veterans served 

Percentage increase 

between fiscal year 

2006 and fiscal year 

2008 in the total 

number of veterans 

served (both men 

and women)

VAMC 1a6,464 19.5 8.5

VAMC 2 6,360 22.4 12.8

VAMC 3 4,497 8.2 7.3

VAMC 4 3,588 19.4 10.2

VAMC 5 2,324 11.7 4.8

VAMC 6 1,846 20.2 3.9

VAMC 7 1,841 19.8 5.1

VAMC 8 999 12.5 1.0

VAMC 9 995 22.5 6.9

Source: VA data and GAO analysis. 

a

Because VAMC 1 is part of the same health care system as VAMC 7, some of these veterans may 

also have received services at VAMC 7, and vice versa. 

Page 47 GAO-10-287 VA Health Care for Women Veterans
Appendix I: Information on the Selection of 

Department of Veterans Affairs Facilities 

Examined in This Report 

Table 6: Women Veterans’ Health Care Utilization at Selected Veterans Affairs (VA) 

Community-Based Outpatient Clinics (CBOC) 

CBOC, by number

Number of unique 

women veterans served in 

fiscal year 2008 

Percentage increase between 

fiscal year 2006 and fiscal year 

2008 in the number of unique 

women veterans served

CBOC 1 2,926 12.5

CBOC 2 1,750 27.0

CBOC 3 599 90.2

CBOC 4 554 51.0

CBOC 5 224 13.1

CBOC 6 115 8.5

CBOC 7 103 21.2

CBOC 8 88 54.4

CBOC 9 48 9.1

CBOC 10a 42 not applicablea

Source: VA data and GAO analysis. 

a

This facility opened in 2007, so percentage increase since fiscal year 2006 does not apply. 

Page 48 GAO-10-287 VA Health Care for Women Veterans
Appendix II: Comments from the Department Appendix II: Comments from the Department of Veterans Affairs 

of Veterans Affairs 

Page 49 GAO-10-287 VA Health Care for Women Veterans 
Appendix II: Comments from the Department 

of Veterans Affairs 

Page 50 GAO-10-287 VA Health Care for Women Veterans
Appendix II: Comments from the Department 

of Veterans Affairs 

Page 51 GAO-10-287 VA Health Care for Women Veterans
Appendix II: Comments from the Department 

of Veterans Affairs 

Page 52 GAO-10-287 VA Health Care for Women Veterans
Appendix II: Comments from the Department 

of Veterans Affairs 

Page 53 GAO-10-287 VA Health Care for Women Veterans
Appendix III: GAO

A

 Contact and Staff 

cknowledgments 

Page 54 GAO-10-287 

Appendix III: GAO Contact and Staff 

Acknowledgments 

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov 

In addition to the contact named above, Marcia A. Mann, Assistant 

Director; Susannah Bloch; Chad Davenport; Alexis MacDonald; Kaitlin 

McConnell; Carmen Rivera-Lowitt; and Michael Zose made key 

contributions to this report. 

 VA Health Care for Women Veterans 

GAO Contact 

Staff 

Acknowledgments 

(290789) 
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