The number of women veterans utilizing

VA health care will likely double in the next

2 to 4 years. Given this growth, the VA

must evaluate current services and develop

an implementation plan to enhance services

for women veterans.

Women veterans have been chronically underserved by VA. The market penetration

for women from 2003 to 2007 increased

only from 11 percent to 14.6 percent, while

the market penetration for male veterans

during the same period was consistently at

22 percent.

1 In addition, we know that even

while utilizing VA services, women more

often have sought outside services than

have men, especially for women’s gynecological conditions.

2

Women Veterans’ View of

Health Care

A very worrisome outcome of our predominant models of primary care is fragmentation, with women seeing one provider for

primary care, and another in a separate clinic

visit for gender-specific care. VA recently

released data indicating poorer performance

for women vs. men on quality clinical indicators, raising questions about the overall

care provision to women and how examination of the various models of care might

inform quality improvement efforts.

Women’s view of health care varies on their

own particular experience and whether they

see a primary care internal medicine practitioner, a family medicine provider, or an

Ob/Gyn who meets most or all of their

health care needs. To a large extent, the

health care services delivered to women

veterans have grown up in a patchwork

fashion, with the delivery model based in

part on the academic leanings of the women’s

health champion onsite. In some facilities,

no particular model was developed and a

default system of heavy utilization of fee

basis care arose. Fortunately, a significant

body of research defining health care provision models now exists, and this research

provides data on the outcomes associated

with each model.

The face of women veterans is changing.

Even though the greatest proportion of

women veterans seen in VA is from the

Vietnam War era, there is a tremendous

influx of women recently deployed and discharged from service in OEF/OIF, where

the active duty military is 14 percent female.

Among new military recruits, the proportion

of females is growing, with women comprising 20 percent of the “freshman class.”

Cumulative data indicates that 42.2 percent

of all discharged women have utilized VA

health care at least once, and of that group,

45.6 percent have visited from 2 to 10

times.

3 While the number of male veterans

is steadily declining, the number of women

veterans is and will continue to be on a pronounced upward course. Given this trajectory, the proportion of women veterans

seeking VA health services will likely top 15

percent by 2020.

In FY 2006, the mean age of women veterans was 49.5 years; this compares with a

F

Translatin

O

g research i

R

nto quality

U

health care

M

for veterans

Commentary

The Evolution of Women’s Health Care

Services in VA

Patricia M. Hayes, Ph.D., Women Veterans Health Strategic Health Care Group

November 2008

Contents

Director’s Letter 2

Response to Commentary 3

Research Highlights

• Needs of Women Veterans 4

• PTSD in Women Veterans 5

• Ambulatory Care Among

Women Veterans 6

• Military Sexual Trauma 7

A publication of the VA Office of Research & Development,

Health Services Research & Development Service, Center

for Information Dissemination and Education Resources, in

conjunction with AcademyHealth.
mean age for male users of 61 years. However, it is important to realize that almost

all new women veterans entering VA care

are under age 40, and of childbearing age,

creating a need for a significant shift in provision of health care. A major project is

underway to involve patients and providers

in counseling about desire for conception,

informed consent, and use of teratogenic

medications. Some classes of medication

that are prescribed frequently to women and

that carry a high birth defect risk include

psychotropics and medications for some

dermatological conditions. In VA, we have

an opportunity to address intentions for becoming pregnant, utilizing CPRS VISTA

to address veterans’ sexual activity and risks,

and to reduce the potential risk of birth defects from some prescription medications.

A National Model for Women’s

Health Care Delivery

Leadership and policy have played an important role in driving change in care provision to women veterans. While in earlier

VHA Handbooks provision of gender related care onsite in VA was mandated, in

the 2003 VHA Handbook 1330.1 genderspecific care provision was relegated to

“preferred.” A decline in onsite offering of

gynecology has occurred in the interim.

4

In March 2008, the Under Secretary for

Health, Michael Kussman, M.D., charged a

workgroup to establish women’s health at

every VA, with a consensus definition:

That every women veteran has access to a VA

primary care provider who can meet all her primary

care needs, including gender-specific care, in the

context of an ongoing patient-clinician relationship.

And in July 2008, Secretary Peake and Dr.

Kussman announced that the position of

Women Veterans Program Manager would

be full-time at every facility by December 2008.

“While the number of male veterans

is steadily declining, the number of

women veterans is and will continue

to be on a pronounced upward

course. Given this trajectory, the

proportion of women veterans

seeking VA health services will likely

top 15 percent by 2020.”

The tides have changed, and VA is moving

quickly to implement clinic enhancements

and provision of care that will address the

needs of women veterans. In addition, a

major campaign is underway to involve

every service and every aspect of VA care in

the responsibility to provide the best care

anywhere. The goal is not simply to provide

a model for care of women in the VA, but

to provide a national model for delivery of

comprehensive women’s health care.

Research plays an important role in this

evolution. Not only do sufficient populations of women veterans now exist for

inclusion in research paradigms, research

is needed to inform specific health care

strategies and models. The time may be

here for additional focused supports for

research on the health of women veterans.

References

1. Market penetration: current year users divided by

projected living veteran population that year, VetPOP

2003-2007.

2. Bean-Mayberry BA et al. Comprehensive Care for

Women Veterans: Indicators of Dual Use of VA and

Non-VA Providers. Journal of the American Medical

Women’s Association 2005; 59(3):192-7.

3. Kang H. OEF/OIF Utilization Data FY 2008

1st Quarter. OPHEH.

4. Seelig, MD et al. Availability of Gynecologic Services

in the Department of Veterans Affairs. Women’s Health

Issues 2008; 18(3):167-73.

FORUM — Translating research into quality health care for veterans 2

Director’s Letter

Traumatic Brain Injury (TBI) is considered the signature injury

of the Operation Enduring Freedom/Operation Iraqi Freedom

(OEF/OIF) conflicts. Penetrating TBI is clearly observable and

receives immediate care. Closed TBIs are less apparent and

can go undiagnosed—this has been particularly true for mild

TBIs. Symptoms of mild TBI can include dizziness, nausea,

blurred vision, ringing in ears and depression—all of which

can be very debilitating. However, if properly diagnosed, mild TBIs can be

effectively treated. Of particular importance, therefore, are screening characteristics

and associations of the VA’s TBI screening instrument. Considerable research

efforts are necessary to evaluate and improve, if necessary, its performance.

While VA HSR&D now has a growing portfolio of TBI studies, we recently solicited

concept papers for Service Directed Research projects examining the quality,

usefulness, and potential improvement of VA’s screening for TBI. Of the 19

concept papers we received and reviewed, 8 were approved for full proposals

and many of the others were encouraged to submit Investigator Initiated Research

proposals to the VA ORD comprehensive TBI solicitation that included an

HSR&D component. HSR&D researchers are encouraged to consider investigations around operational definitions for TBI, TBI screening instruments, and

tools that measure the long-term outcomes for veterans with TBI.

I strongly encourage health services researchers, clinical researchers, and

epidemiologists to continue to consider this rapidly growing area of investigation.

It is a key concern for VA and for our OEF/OIF veterans and their families.

Seth A. Eisen, M.D., M.Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service November 2008
VA Office of Research & Development, Health Services Research & Development Service November 2008

Women have been an extreme numerical

minority in VA settings for many years,

settings that once reflected the historical

2 percent cap on their participation in

the military. These settings offered limited

acknowledgment of women veterans’ contributions and the risks they faced while

serving their country.

1 As a consequence,

few VA providers have much experience

seeing women patients, and few women veterans know much about their veteran benefits; fewer still are aware of the availability

of women’s health services in the VA.

2

Among those women who use VA care, many

now have the option of being seen in women’s

health clinics, their growth rate roughly paralleling increases in women veteran caseloads.

However, recent evidence suggests that, on

average, these clinics are open roughly halftime—reducing access—and that over 40

percent of these clinics focus on genderspecific exams only. While comprehensive

women’s primary care clinics exist, they are

the exception rather than the rule. As Dr.

Hayes points out, however, changes are

taking place at an unprecedented rate, and

VA researchers are in a unique position to

support and inform the transitions ahead.

History of VA Women’s Health

Research

VA women’s health research has had a relatively brief but highly dynamic and productive

evolution in recent years. In 2003, in response

to inquiries from policymakers, the VA

Office of Research & Development (ORD)

sponsored establishment of a VA women’s

health research agenda. A national planning

group combined an appraisal of VA’s research

portfolio with a systematic literature review

and secondary analyses of existing databases

to serve as the foundation for a national

consensus development conference designed

to set evidence-based research priorities.

3

Subsequently, following an unexpectedly

high number of submissions, HSR&D funded

a special issue of the Journal of General

Internal Medicine, which came out in 2006,

that focused on women veterans’ health and

health care. In the intervening years, the

virtual explosion of women veterans’ related

research literature has led to the funding by

VA HSR&D’s Evidence Synthesis Program

(ESP) of an updated systematic review,

which is now underway.

VA HSR&D Service has explicitly made

women’s health services research a priority

solicitation area for over a decade. While

only a handful of women’s health projects

were funded in the early years, this changed

significantly following the establishment of

the VA women’s health research agenda.

VA HSR&D has funded a broad range of

research related to this agenda, including:

assessing women veterans’ chronic physical

and mental illnesses (Sambamoorthi &

Findlay, East Orange VA); their unmet health

care needs and fragmentation (Washington,

West Los Angeles VA); the quality of breast

cancer care received in VA settings (Luther,

Gainesville VA); determinants of changes in

how VA care is organized (Yano, Sepulveda

VA); resource use and outcomes among

OEF/OIF women veterans compared to men

(Brandt, Haskell & Justice, West Haven VA);

sexual violence and gynecologic health

(Sadler, Iowa City VA); evaluation of MST

screening and treatment (Kimerling, Palo

Alto VA); MST effects of PTSD and behavior

among women Marines (Shipherd, Boston

VA); physical and sexual assault among deployed women (Sadler, Iowa City VA); and,

stigma and barriers to care (Vogt, Boston

VA), among others.

Spotlight on VA Women’s

Health Services Research

VA women’s health services research now

has the direct attention of national leaders

in VA Central Office, and beyond. While

the spotlight can be bright, this attention

brings with it an unprecedented opportunity

to conduct research that is highly policy relevant to a waiting audience. VA managers

and clinicians are facing enormous challenges ahead, as the numbers of women

veterans double. Almost all of the women

veterans’ research literature reflects descriptive or observational studies, leaving an

enormous hole—and opportunity—for

designing and conducting studies of quality

improvement interventions that can help

improve women’s health care and address

gender disparities.

Interventions for promoting provider skills,

proficiency, and comfort in treating women

veterans are needed, as are interventions for

improving women veterans’ knowledge and

awareness of their VA benefits, and their

entree to VA care. Given the substantial

amount of care that women veterans receive

in the community, via fee basis and contract

care, studies are needed that evaluate the

quality of care delivered. Coordination of

care among multiple providers, especially for

women with comorbid mental health conditions, is another important research area.

While the VA has mandated inclusion of

women in all VA studies since 1983, I believe that most “non-compliance” is unlikely

purposeful but instead a function of the difficulties inherent in recruiting available

women in sufficient numbers. Creation of a

women veterans’ practice-based research

network would help remedy this structural

limitation by setting up the infrastructure

for trials in VA medical centers with larger

volumes of female patients. As members of

the VA research community, it is incumbent

on all of us to be mindful of not only the

Response to Commentary

Achieving Equitable High-Quality Care

for Women Veterans

Elizabeth M. Yano, Ph.D., M.S.P.H., HSR&D Center for the Study of Healthcare

Provider Behavior, VA Greater Los Angeles Healthcare System, Los Angeles,

California

FORUM — Translating research into quality health care for veterans 3

continued on page 8
Women have served in the U.S. military since

our country’s birth. However, as a numeric

minority in VA, they received little special

attention until the 1990s, when multiple

clinical programs were launched. Research

on the health care needs of women veterans

grew during the same period, but did not

keep pace with this service expansion.

Therefore, in 2004, as part of a VA-wide

initiative of the VA Office of Research &

Development, experts from around the

country participated in development of a

women veterans’ health research agenda,

designed to ensure that VA is positioned to

provide high quality, evidence-based care to

this rapidly growing population.

1 The

agenda identified an important next step:

taking stock of the health care needs of

women veterans, benchmarked against male

veterans. In response, the research described here used VA’s 2002 National Patient Care Database to characterize gender

differences in diagnoses, utilization, and

cost of VA care at a macro level.

Not All Women VA Patients

are Veterans

Surprisingly, this analysis found that half the

women who use VA are not veterans.

2 Employees constitute the biggest group of

non-veterans. Other non-veteran women

who use VA include those eligible under

Tricare or CHAMPVA. Since non-veteran

status is far more common in women than

in men, it is important to account for veteran status in gender disparities research; if

non-veterans are included, the female sample is disproportionately enriched with a

healthy group of low utilizers (e.g., employees). VA investigators doing gender research

need to decide up front whether their research question calls for inclusion of nonveterans, and ensure their methods account

for this issue. As a result, the researchers decided to limit the focus of their work to veteran VA patients.

Characteristics of Women

Veteran VA Patients

Since women are joining the military in

increasing numbers, it made sense that

women veteran VA patients were on average

younger than their male counterparts: 43

percent of women versus 9 percent of

men were under age 45.

3 Despite their

younger age, the majority of women

veteran VA patients, like male veterans,

suffer from at least one chronic medical

condition (74 percent of women, 79 percent

of men). More women veterans than male

veterans, however, had a mental health

condition (38 percent vs. 30 percent).

Within every age stratum, women used VA

outpatient services more heavily than did

men, and at higher cost, although the

magnitude of difference was small after

adjusting for age and medical conditions.

The 31 percent of women who had both

medical and mental health conditions had

the highest health care utilization and costs

of care. Indeed, while women overall averaged 17 outpatient encounters per year,

the subgroup with comorbid medical and

mental illness averaged 31.

Using broad strokes, this research paints a

picture of women veteran VA patients as a

group with a heavy illness burden, frequent

outpatient utilization, and substantial costs

of care. Male veteran VA patients are

known to be sicker than men in the general

population. These findings suggest that

the women veterans we serve are likely to

require a comparable intensity of care.

Research Gaps Remain

Subsequent work will need to fill in the

finer details of this picture, such as: Where

should we focus efforts to improve quality

of care, so as to have the greatest impact?

What health care delivery systems most

effectively address the health care needs

of women veterans? Do findings apply to

women veterans who do not use VA?

Investigators will be able to pursue these

questions because VA HSR&D has made

women veterans’ health a major focus.

For example, HSR&D partnered with the

Journal of General Internal Medicine to create a

special women veterans issue in 2006. VA

HSR&D has distributed special solicitations

in women’s health, and encourages grant reviewers to note whether even projects without a women’s health focus include women

and, if feasible, characterize findings by

gender. Women’s health is one of the 11

special focus areas overseen by a specific

portfolio manager.

All of these initiatives point to VA

HSR&D’s commitment to expanding the

knowledge base upon which our clinical

care of women veterans rests. Women are

joining VA in rapidly increasing numbers.

There is a pressing demand for VA investigators to address gaps in this field so as to

respond to women’s needs today and better

prepare for the VA of tomorrow.

References

1. Yano EM, et al. Toward a VA Women’s Health

Research Agenda: Setting Evidence-based Priorities to

Improve the Health and Health Care of Women

Veterans. Journal of General Internal Medicine

2006; 21(s3):S93-S101.

2. Frayne SM, et al. Gender Disparities in Veterans Health

Administration Care: Importance of Accounting for

Veteran Status. Medical Care 2008; 46(5):549-53.

3. Frayne SM, et al. Gender and Use of Care: Planning for

Tomorrow’s Veterans Health Administration. Journal

of Women’s Health 2007; 16(8):1188-99.

FORUM — Translating research into quality health care for veterans 4

VA Office of Research & Development, Health Services Research & Development Service November 2008

Research Highlights

Needs of Women Veterans Must

be Carefully Considered in Building

Tomorrow’s VHA

Susan M. Frayne, M.D., M.P.H., Center for Health Care Evaluation (CHCE),

VA Palo Alto Health Care System, Palo Alto, California
VA Office of Research & Development, Health Services Research & Development Service November 2008

The wars in Iraq and Afghanistan have

focused attention on the issue of posttraumatic stress disorder (PTSD) in women

veterans. Many people, including those in

the media, have questioned whether PTSD

prevalence is elevated in female OEF/OIF

personnel because of the unique roles performed by these women—specifically the

greater direct exposure to combat relative

to the exposure women had in prior wars.

The question is especially important given

the high prevalence of women among

OEF/OIF veterans who use the VA:

according to a May 2008 report by VHA’s

Office of Public Health and Environmental

Hazards, women comprise 12 percent of

the OEF/OIF veterans who have sought

VA health care.

Prevalence of PTSD Among

Women

Among civilians, PTSD prevalence is higher

in women than in men. According to the

National Comorbidity Survey Replication,

9.7 percent versus 3.6 percent have lifetime

PTSD. The gender difference in PTSD is

partially explained by a gender difference in

traumatic exposure. A recent meta-analysis

found that women are more likely than men

to experience the kind of traumas, such as

rape and sexual assault, that carry a high risk

of PTSD in both men and women.

1 Differential exposure also occurs in veterans.

Investigators in an ongoing HSR&D-funded

study recently reported that the prevalence

of military sexual trauma (MST) in VA patients was 21.8 percent in women and 1.1

percent in men.

2 However, the meta-analysis

found that the odds ratio for PTSD following MST was much higher in the women

(8.8) than in the men (3.0), paralleling findings that women are also more likely than

men to develop PTSD in response to other

events, including nonsexual assault or disasters. Warzone exposure may be unique. In

the meta-analysis, there was no gender difference in the prevalence of PTSD due to

warzone exposure among veterans.

To understand these findings, it is helpful to

look back to the National Vietnam Veterans

Readjustment Study, which was based on a

nationally representative sample of veterans

that included an oversampling of women.

Lifetime PTSD prevalence was 26.9 percent

in women and 30.9 percent in men, and

current PTSD prevalence (in the mid-1980s)

was 8.5 percent in women and 15.2 percent

in men. The likely explanation for the gender difference is that the men and women

who served in Vietnam differed on numerous risk and protective factors, e.g., the

women were older, more educated, more

likely to be officers and to serve in medical

roles, and less likely to experience combat.

Fast forwarding to the present, a recent

report by the Rand Corporation on

OEF/OIF veterans illustrates the importance of accounting for differences in individual characteristics and type of warzone

exposure when comparing PTSD prevalence in male and female veterans.

3 In unadjusted analysis, the relative risk of PTSD

was 1.03 among women (vs. men), but in

analyses that adjusted for demographic and

exposure variables, the relative risk was

1.69—significantly higher among women

than men.

Range of PTSD Studies

But prevalence is only the tip of the iceberg.

PTSD is associated with psychiatric and

physical comorbidity, impaired functional

status, reduced quality of life, health risk behaviors, and increased service utilization.

HSR&D has supported a number of studies

to facilitate greater understanding about

these aspects of PTSD in women veterans.

Past studies have examined the physical

health burden associated with PTSD,

the antecedents and consequences of military sexual harassment, and gender differences in compensation and pension claims

approval process.

The portfolio of current studies addresses

a wide range of topics too. In the Women

Veterans Cohort Study, Brandt and colleagues are assembling a longitudinal

cohort of male and female OEF/OIF

veterans to examine gender disparities in

utilization and outcomes, including PTSD.

Another longitudinal cohort study is a

follow-up of male and female Marines who

were initially assessed at Parris Island

between 1997 and 1999; this study will

examine the effects of MST on PTSD and

health behaviors. One study is focusing on

the effects of physical and sexual assault

on women who served in the Reserves or

National Guard, who may have increased

risk of PTSD and poor outcomes.

Studies like these are complemented by

HSR&D-funded projects of ways to

enhance the treatment of PTSD in both

male and female veterans, including telehealth delivery, the use of decision aids,

integrated primary care, and combined

treatment for PTSD and substance abuse.

Through their efforts, VA researchers are

helping to meet the needs of our newest

veterans as well as those with chronic

PTSD—and the unique needs of women

remain at the forefront of these efforts.

References

1. Tolin DF, Foa EB. Sex Differences in Trauma and

Posttraumatic Stress Disorder: A Quantitative Review

of 25 Years of Research. Psychological Bulletin

2006; 132:959-92.

2. Kimerling R, et al. The Veterans Health Administration

and Military Sexual Trauma. American Journal of Public

Health 2007; 97:2160-6.

3. Tanielian T, Jaycox LH. Invisible Wounds of War:

Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica,

CA: Rand, 2008.

Research Highlights

Posttraumatic Stress Disorder in

Women Veterans

Paula P. Schnurr, Ph.D., VA National Center for PTSD, VA Medical Center,

White River Junction, Vermont

FORUM — Translating research into quality health care for veterans 5
Women are one of the fastest growing segments of the veteran population, projected

to comprise 14 percent of VA health care

users by 2010. However, their numerical

minority within the VA has created challenges to designing delivery systems that

ensure their equitable access to high quality,

gender-appropriate care. Determining current patterns of VA and non-VA ambulatory care use by women veterans is

important in gauging how well the VA is

meeting its access and patient satisfaction

goals. These patterns also have implications

for the organization and scope of services

that the VA should provide to women

veterans to improve their access to care.

In numerous veteran studies, sociodemographic and health-related predictors

of VA use included: being low income,

lacking private medical insurance, having

poor health status, having a serviceconnected disability, and being an ethnic

minority group member. Compared with

male veterans, women veterans are more

likely to have low income, lack insurance,

have poor health status, and be an ethnic

minority group member. However, women

veterans’ proportionate use of VA ambulatory care and inpatient services is less than

that of male veterans. This finding suggests

that additional gender-related influences on

VA use remain.

Perceptions Among Women

Veterans

A population-based VISN22 regional study

of women veterans’ ambulatory care use

identified several additional influences on

VA use. This study identified numerous barriers to women veterans’ VA use, including

lack of information about VA eligibility and

services, perceptions of limited availability

of gender-appropriate services, concerns

about the VA environment, privacy and

quality of care, and inconvenient VA locations and hours.

1, 2 In contrast, reasons cited

for VA use included affordability, women’s

health clinic availability, quality of care, and

convenience. Interestingly, the study identified several factors that serve as both barriers and facilitators to VA use, highlighting a

VA user/nonuser paradox in perceptions

about VA accessibility, service availability,

and health care quality.

In qualitative research, conducted to gain

greater insight into the factors underlying

women veterans’ perceptions about and

experiences with VA care, VA nonusers

described dated Hollywood images of old

soldiers in ward beds, antiquated facilities,

and less qualified doctors.

2 A few women

veterans based their perceptions on remote

VA contact that occurred prior to the VA

quality transformation and expansion of

women’s health care services. However,

most VA nonusers based their perceptions

on non-VA sources—primarily media portrayals of VA health care or word-of-mouth.

Some women who had used VA health care

services refuted these perceptions. But only

an actual visit dispelled this image for both

VA users and VA nonusers. Women veterans often started using VA health care after

losing health insurance or other access to

non-VA care, but remained VA users after

becoming familiar with available health care

services and their quality.

At VA medical centers and larger community-based outpatient clinics (i.e., those serving 400 or more women), basic women’s

health care services—those deliverable by a

primary care provider—are almost universally available onsite. Delivery arrangements

include designated providers in general

primary care clinics, women’s health clinics

for gender-specific examinations only, and

comprehensive women’s health clinics. By

contrast, to ensure availability of lower

volume specialized women’s health services,

VA sites have adopted varied onsite and

off-site arrangements, including referral to

larger VA sites, contract care, fee-basis care,

or onsite delivery in gynecology clinics.

Internal marketing to VA clinicians and

other staff, about the scope and referral

mechanisms for women’s health services,

may improve women veterans’ access to

and use of these services.

Barriers for Women Veterans

Merit Further Study

Women veterans prefer to receive both

women’s health care and other primary care

from the same provider or clinic.

1 However,

women veterans often received fragmented

care. Fragmentation means that different

components of women’s basic health care

are provided by different types of providers

and in different settings, with varying

degrees of coordination of care. In addition

to the fragmentation inherent in the VA

women’s health service delivery arrangements, we found that 51 percent of women

veteran VA users also split their care across

VA and non-VA systems of care. Barriers

to VA use that lead some women veterans

to go outside the VA for selected health

care services, and others to forego VA care

altogether, are foci for interventions to

improve women veterans’ equitable access

to coordinated comprehensive care.

References

1. Washington DL, et al. To Use or Not to Use—What

Influences Why Women Veterans Choose VA Health

Care? Journal of General Internal Medicine 2006; 21 Supplement 3:S11-8.

2. Washington DL, et al. Women Veterans’ Perceptions

and Decision-making about VA Health Care. Military

Medicine 2007; 172(8):812-7.

FORUM — Translating research into quality health care for veterans 6

VA Office of Research & Development, Health Services Research & Development Service November 2008

Research Highlights

Ambulatory Care Among Women

Veterans: Access and Utilization

Donna L. Washington, M.D., M.P.H., VA Greater Los Angeles Healthcare

System, Los Angeles, California
VA Office of Research & Development, Health Services Research & Development Service November 2008

Attention to women’s health issues in VA

has led to increased recognition and treatment resources for military-related sexual

assault and harassment, referred to as Military Sexual Trauma (MST). Evaluation of

these programs suggests important genderspecific health care needs for both women

and men.

Beginning in 1992, public law authorized

VA to provide up to one year of treatment

to women veterans for psychological trauma

resulting from “physical assault of a sexual

nature, battery of a sexual nature, or sexual

harassment” occurring during military

service. Sexual harassment was defined as

“repeated, unsolicited verbal or physical

contact of a sexual nature which is threatening

in character.” Since then, a series of public

laws and VA directives reflected the growing

knowledge that these issues, referred to by

VA as ‘military sexual trauma’ affect both

women and men and are associated with

lasting health consequences. VA has now

implemented training for all staff, universal

screening, and unlimited care for all MSTrelated conditions for all veteran patients.

Screening Uncovers Mental

Health, Chronic Conditions

In FY 2007, 22.2 percent of females and 1.3

percent of males seen in VA outpatient care

reported MST when screened.

1 Because VA

patients are predominantly male, the size of

each clinical population that reports MST is

actually similar: 45,570 women and 47,764

men. Screening is important in the detection

of MST because individuals seldom disclose

such stigmatizing experiences unless asked.

Standardized universal screening frames this

as a mainstream health care issue, which

helps many veterans cope with feelings of

isolation and self-blame.

“Treatment of MST among OEF/OIF

veterans presents new challenges

for VA providers. We will be able to

detect and treat sexual trauma more

closely following separation from

military service, allowing new

opportunities to prevent potentially

chronic health and mental health

consequences.”

Researchers at the Center for Health Care

Evaluation and the National Center for

PTSD examined the gender-specific burden

of illness associated with positive MST

screens in an effort to guide the health

care services authorized for MST-related

conditions.

2 The study found that MST

was associated with a broad range of mental

health conditions. Diagnoses of PTSD,

other anxiety disorders, and alcohol use

disorders were overrepresented among all

patients with MST, but effect sizes were

significantly stronger for women than men.

In contrast, effects for adjustment disorders

were significantly stronger among men

compared to women.

While fewer associations with physical

health conditions were observed, a number

of behaviorally-linked chronic medical

conditions, such as liver disease and pulmonary disease, were associated with MST

for both men and women. Associations of

obesity and hypothyroidism were unique to

women and an association of MST with

HIV/AIDS was unique to men. MST

screening, therefore, detects a significant

burden of illness and calls for a genderspecific approach to treatment.

MST Screening Promotes Use

of Mental Health Services

Since MST was most strongly associated

with mental health conditions, a key outcome by which to evaluate universal

screening is utilization of mental health

treatment. We compared utilization before

and after screening, to assess whether

patients with positive screens were more

likely to initiate or continue mental health

treatment. We found that the majority of

patients who reported MST had not

received mental health treatment prior to

screening. However, for both women and

men, a positive MST screen was associated

with a significantly increased likelihood of

post-screen mental health care, as compared

to patients with negative screens. We found

that one additional patient receives mental

health care for every five women and seven

men with positive MST screens. While

screening appears to be somewhat more

effective in promoting treatment for

women as compared to men, these low

numbers indicate that universal screening

is an efficient way to help both women and

men with MST access mental health care.

3

MST Care for the Newest

Generation of Veterans

Treatment of MST among OEF/OIF

veterans presents new challenges for VA

providers. We will be able to detect and

treat sexual trauma more closely following

separation from military service, allowing

new opportunities to prevent potentially

chronic health and mental health consequences. Access to mental health care

should be a key focus, especially with VA’s

dissemination of evidence-based treatments for PTSD, which have demonstrated

effectiveness for sexual trauma. Coupled

with the younger age of these patients,

we may also need research into broader

foci of treatment, such as preventing revictimization and treating reproductive

health issues among women. VA has implemented one of the most comprehensive

programs to detect and treat interpersonal

violence of any health care setting. Continued focus in this area will help to provide a

strong basis for treating the full range of

Research Highlights

Military Sexual Trauma

Rachel Kimmerling, Ph.D., National Center for PTSD, and Center for Health

Care Evaluation, VA Palo Alto Health Care System

FORUM — Translating research into quality health care for veterans 7

continued on page 8
requirements but also the value of including

women veterans in our research.

The time is ripe for advancing VA women’s

health research in ways that we did not even

envision during the agenda-setting process a

few short years ago. I invite you to join the

growing consortium of researchers working

in this arena, and challenge you to consider

innovative ways to integrate women veterans into your current research.

References

1. Murdoch M, et al. Women and War: What Physicians

Should Know. Journal of General Internal Medicine

2006; 21(Suppl 3):S5-10.

2. Washington DL, et al. To Use or Not to Use–Women

Veterans’ Choices About VA Health Care Use. Journal

of General Internal Medicine 2006; 21(Suppl 3):S11-18.

3. Yano EM, et al. Toward a VA Women’s Health Research

Agenda: Setting Evidence-Based Priorities to Improve

the Health and Health Care of Women Veterans.

Journal of General Internal Medicine 2006;

21(Suppl 3):S93-101.

FORUM — Translating research into quality health care for veterans 8

Response to Commentary

continued from page 3

Peter Almenoff, M.D.,

Director, VA Network #15,

Kansas City, MO

Martin P. Charns, D.B.A., PI,

VA HSR&D Center

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc.,

Director, HSR&D

Joseph Francis, M.D., M.P.H.,

Deputy Chief Quality and

Performance Officer,

Central Office

Rodney A. Hayward, M.D.,

PI, VA HSR&D Center

of Excellence, Ann Arbor, MI

Shirley Meehan, M.B.A.,

Ph.D., Deputy Director, VA

HSR&D, Central Office

Michael J. Miller, M.D., Ph.D.,

Chief Medical Officer, VA

Network #1, Bedford, MA

Eugene Z. Oddone, M.D.,

M.H.Sc., PI, VA HSR&D

Center of Excellence,

Durham, NC

Alan S. Perry, M.H.A.,

FACHE, Director, VA

Central California Health

Care System

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

deployment-related stressors among

OEF/OIF veterans in VA care.

References

1. Military Sexual Trauma Support Team. Military Sexual

Trauma Screening Report: Fiscal Year 2006. Washington, DC: Department of Veterans Affairs, Office of

Mental Health Services, MST Support Team; 2007.

2. Kimerling R, et al. The Veterans Health Administration

and Military Sexual Trauma, American Journal of Public

Health 2007; 97:2160-6.

3. Kimerling R, et al. Evaluation of Universal Screening

for Military-Related Sexual Trauma. Psychiatric Services

2008; 59:635-40.

Research Highlight

continued from page 7