Evidence-based Synthesis Program 

Systematic Review

of Women Veterans

Health Research 2004-2008 

Department of Veterans Affairs

Health Services Research & Development Service

October 2010

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

West Los Angeles VA Medical Center

Los Angeles, CA

Paul G. Shekelle, MD, PhD, Director

Investigators:

Principal Investigator: 

Bevanne Bean-Mayberry, MD, MHS

Co-Investigators: 

Christine Huang, MD

Fatma Batuman, MD

Caroline Goldzweig, MD, MSPH

Donna L. Washington, MD, MPH

Elizabeth M. Yano, PhD, MSPH

Research Associate:

Isomi M. Miake-Lye, BA
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

PREFACE

HSR&D’s Evidence-based Synthesis Program (ESP) was established to provide timely and 

accurate syntheses of targeted healthcare topics of particular importance to VA managers 

and policymakers, as they work to improve the health and healthcare of Veterans. The ESP 

disseminates these reports throughout VA. 

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help: 

• develop clinical policies informed by evidence, 

• the implementation of effective services to improve patient outcomes and to support VA 

clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, an ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and VISN Clinical Management 

Officers. The Steering Committee provides program oversight and guides strategic planning, 

coordinates dissemination activities, and develops collaborations with VA leadership to identify 

new ESP topics of importance to Veterans and the VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation:

Bean-Mayberry B, Batuman F, Huang C, Goldzweig CL, Washington DL, Yano EM, Miake-Lye 

I, Shekelle PG. Systematic Review of Women Veterans Health Research 2004-2008. VA-ESP 

Project #05-226; 2010

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the West Los Angeles VA Medical Center, Los Angeles, CA 

funded by the Department of Veterans Affairs, Veterans Health Administration, Office of 

Research and Development, Health Services Research and Development. The findings 

and conclusions in this document are those of the author(s) who are responsible for its 

contents; the findings and conclusions do not necessarily represent the views of the 

Department of Veterans Affairs or the United States government. Therefore, no statement 

in this article should be construed as an official position of the Department of Veterans 

Affairs. No investigators have any affiliations or financial involvement (e.g., employment, 

consultancies, honoraria, stock ownership or options, expert testimony, grants or patents 

received or pending, or royalties) that conflict with material presented in the report.
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

TABLE OF CONTENTS

Executive Summary............................................................................................................................................ iv

Background................................................................................................................................................... iv

Methods........................................................................................................................................................ iv

Results .......................................................................................................................................................... iv

Conclusions ................................................................................................................................................... v

Introduction .......................................................................................................................................................... 1

Background.................................................................................................................................................... 1

Methods................................................................................................................................................................... 1

Topic Development........................................................................................................................................ 1

Search Strategy.............................................................................................................................................. 1

Study Selection.............................................................................................................................................. 2

Data Abstraction ............................................................................................................................................ 2

Quality Assessment ....................................................................................................................................... 2

Data Synthesis............................................................................................................................................... 2

Cross Walk between Baseline Review and Updated Review........................................................................ 3

Peer Review................................................................................................................................................... 3

Results ..................................................................................................................................................................... 4

Literature Flow .............................................................................................................................................. 4

Description of Evidence ................................................................................................................................ 6

Deployment and Post-Deployment Health ............................................................................................... 6

Organizational Research......................................................................................................................... 10

Quality of Care ....................................................................................................................................... 11

Access and Utilization ............................................................................................................................ 20

Psychiatric Conditions............................................................................................................................ 23

Summary and Discussion.................................................................................................................................. 29

Building Knowledge: Notable Research Advances.................................................................................... 30

Ongoing Gaps: Future VA Research Targets.............................................................................................. 31

Conclusions ................................................................................................................................................. 32

Future Research........................................................................................................................................... 32

References............................................................................................................................................................ 33

Figures

Figure 1 Category Cross Walk....................................................................................................................... 3

Figure 2 Literature Flow................................................................................................................................ 5

Appendices

Appendix 1. Screener Form......................................................................................................................... 48

Appendix 2. Structured Abstract Form........................................................................................................ 49

Appendix 3. Screener Application Guidelines ............................................................................................ 50

Appendix 4. Search Strategy ....................................................................................................................... 51

Appendix 5. Deployment and Post-Deployment Health Evidence Table.................................................... 54

Appendix 6. Organizational Research Evidence Table ............................................................................... 68

Appendix 7. Quality of Care Evidence Table.............................................................................................. 71

Appendix 8. Access and Utilization Evidence Table................................................................................... 90

Appendix 9. Psychiatric/Mental Health Issues Evidence Table .................................................................111

Appendix 10. Peer Review Comments...................................................................................................... 141
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Introduction

Background

Women are playing an ever increasing role in the US military, representing about 15% of active 

military personnel, 17% of reserve and National Guard forces, and 20% of new military recruits. 

Concurrently, women are one of the fastest growing groups of new users in the Department 

of Veterans Affairs (VA) Healthcare System, with particularly high rates of utilization among 

veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Of the more 

than 100,000 OEF/OIF women veterans, over 44% have enrolled in the VA system for health 

care2. Thus, women veterans represent an integral part of the veteran community. 

Women’s military experiences and responses to their military experiences are often distinct from 

those of men, and these differences can affect both their health status and their health care needs 

as active duty personnel and as veterans. This, together with the rise in the number of women 

veterans in the VA system, calls for increased understanding of women veteran health issues and 

areas of potential knowledge deficit in order to guide VA care and VA research efforts. The body 

of research literature dedicated to women veterans and women’s military health and health care 

issues has significantly grown and expanded in size and scope since the publication of the first 

systematic review of women veterans research1. This project updated that review by examining 

the literature on women veterans’ health and health care from 2004 to 2008. 

METHODS

Topic Development

This project was nominated by Linda Lipson, HSR&D Equity Portfolio Manager, and the Office 

of Women’s Health. 

Because of the broad survey nature of this synthesis, no key questions were developed. 

Search Strategy

We searched MEDLINE/PubMed, PsycINFO, WorldCat and Web of Science for potentially 

relevant articles related to women veteran and military health published between January 2004 

and September 2008. For each database search, we used the medical subject heading (MeSH) 

terms women and veterans to search for relevant literature. We supplemented this search by 

contacting other sources with expertise in the area of women veteran and military health. The 

Department of Defense Health Affairs Division provided access to bibliographical reports on 

general deployment and mental health issues in Operation Enduring Freedom and Operation 

Iraqi Freedom (OEF/OIF) military personnel from 2002 through 20073. We received additional 

articles from a direct request to experts in the field via a VA research list service and personal 

contact with approximately 15 VA women’s health researchers. We also identified additional 

articles by reviewing bibliographies from articles identified through our search. The search 

strategy is listed in Appendix 4. 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Study Selection

All titles identified through our search were screened for relevance by the members of the 

team. Each article deemed potentially relevant was reviewed by two physician reviewers with 

backgrounds in women’s health working independently (BB, FB, CH) using a standardized, 

one page screening form (Appendix 1) and these assessments were compared and reconciled. 

Disagreements in ratings were resolved through consensus resolution with the help of at least 

one senior member of the review team. To be included, articles had to meet criteria (a), plus at 

least one of criteria (b), (c), or (d). The criteria were: (a) study relates to U.S. veterans or military 

personnel; (b) study includes women veterans, compares men and women, or analyzes women 

separately; (c) study involves active duty military and involves a health condition or functional 

status that requires medical intervention; and (d) topic is relevant to VA healthcare or to how VA 

care is delivered to women (Appendix 3). An article was excluded if it was defined as a nonsystematic review, editorial, commentary, or an unclear publication type. 

Data Abstraction

After the initial screening process, articles meeting inclusion criteria were further evaluated and 

abstracted using a structured abstract form (Appendix 2). The following data were abstracted: 

year(s) of study or sampling timeframe; purpose of study, outcomes reported; study population 

description; whether the article was women-focused or had women as a subset population, or 

neither; brief summary of methods; and main findings. Additional data collected covered basic 

information about each article: study design, sample size (both female and male), study setting 

(from where the study population was drawn), military period of service studied (if specified), 

women’s health research topic area, specific condition(s) studied and study funding.

Quality Assessment

For the few clinical trials identified, we used Jadad criteria for quality assessment4. For the 

descriptive studies, which are by far the largest number of studies, no simple standardized 

assessment of quality exists, and therefore, a quality assessment protocol is not included in this 

review. 

Data Synthesis

We identified 5 key focus areas for the Women’s Health Evidence Synthesis Project, using high 

priority areas identified by the 2004 review by Goldzweig and associates1, and the VA Health 

Services Research and Development Service (HSR&D) funding priorities. The areas were the 

following:

• Deployment and post-deployment health 

• Organizational research

• Quality of care

• Access to care and utilization

• Psychiatric conditions. 

Below we briefly describe the relationship between these categories and those in the baseline 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

review. We then summarize the findings of articles in each of area and highlight their 

significance. 

Cross walk between baseline review and updated review 

The baseline review grouped the available literature into four categories; the update review 

groups literature into 5 categories, reflecting the growth in the scientific literature in the areas of 

access, utilization, and quality of care. Figure 1 shows the cross walk between the categories for 

each review and provides explanatory notes.

Figure 1 Category Cross Walk 

Categories in updated review 

(2004 – 2008)

Categories in baseline 

review 

(1978 - 2004)

Comments

Deployment and post-deployment 

health

Stress of military life A substantial body of work now 

focuses on OEF/OIF veterans as well 

as on women’s health issues in the 

theatre

Organizational research Health services research Formerly included in the general 

health services research category. 

More focused literature has emerged 

examining how organizational 

factors affect women’s health care 

delivery environment and the overall 

practice environment 

Quality of care Health services research The literature on quality of care 

is now substantially expanded, 

including patient perceptions of 

quality and satisfaction and general 

quality of care processes and 

outcomes 

Access/utilization Health services research; 

Health and performance of 

military or VA women

The new category reflects the volume 

of work on determinants of access/

utilization especially for special 

cohorts of veterans

Psychiatric conditions Psychiatric conditions; 

Health and performance of 

military or VA women

New work describes prevalence of 

mental health conditions in different 

settings and for different subgroups 

and addresses non-trauma related 

health problems

Peer Review

A draft version of this report was sent to seven peer reviewers, of which five responded. Their 

comments and our responses are presented in Appendix 10.
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Results

Literature Flow

Our search identified 675 titles of potential relevance. Of these titles, 118 were duplicate 

references to a study, 151 were rejected as not being relevant to the topic, and 26 could not be 

retrieved. Of the remaining 380 articles that were evaluated as full-text articles by at least two 

physician reviewers independently, 154 were rejected because they did not meet our inclusion 

criteria; 48 did not relate to U.S. veterans or military personnel; and 106 failed to meet at least 

one of the following additional criteria. Thirty-one articles were excluded because the study 

design was not appropriate: 4 articles were non-systematic reviews, 22 were editorials or 

commentaries, and 5 articles had unclear design. 

Further data abstraction was performed on the remaining 195 articles, and all were categorized 

into the following 5 areas, which were not mutually exclusive: deployment and post-deployment 

health issues (n=33); organizational research (n=7); quality of care (n=54); access and utilization 

(n=48); and psychiatric conditions (n=85) (See Figure 2).
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Figure 2 Literature Flow

Literature Searches

(n= 326)

VA and other non-DoD Experts 

(n= 97)

Dept. of Defense Experts

(n= 252)

675 Articles Requested

380 Articles Screened

295 Rejected

118 Duplicates

151 Abstract/title rejections

26 Articles not found

185 Rejected:

154 Inclusion criteria not met*

48 Did not meet criteria A

106 Did not meet B, C, or D

31 Study design not appropriate

4 Non systematic reviews

22 Editorial/commentaries

5 Unclear study design

195 Articles Assessed*

Deployment and Post-Deployment Health (n= 33) 

Organizational Research (n= 7)

Quality of Care (n= 54)

Access and Utilization (n= 48)

Psychiatric/Mental Health Issues (n= 85)

*Categories are not mutually exclusive; articles may be categorized under multiple headings
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Description of Evidence

As in the baseline systematic review1, the majority of articles discussed observational or 

descriptive studies. Nearly half of the research articles focused on psychiatric issues (e.g., 

screening for mental health conditions or for post traumatic stress disorder (PTSD). 

Only five studies were identified as experimental studies or clinical trials. Of these, three focused 

on women veterans or military personnel with PTSD diagnosis or symptoms5-7, one on VA 

employees’ perceptions about women veterans8 and one on improving mammography screening 

among women veterans9. Compared to the initial systematic review, these trials highlight a few 

key advances in methods by including the first VA multi-site randomized controlled trial on 

women veterans using the cooperative study program, and a moderately large sized mental health 

patient sample (N=284)6. 

Due to the broad scope of research contained in this report, each study has to be interpreted 

subject to its own limitations, and it is not feasible to include all the caveats and constraints 

within this document. Before citing specific findings, the reader should refer to the source article 

to understand the context of the research methods and findings. 

Deployment and Post-Deployment Health

Thirty-three articles covered deployment and post deployment-health issues, with the majority 

of studies (n=23) addressing health issues specific to OEF/OIF veterans10-32. The OEF/OIF topics 

focused on mental health screenings, general women’s deployment health issues, validation of 

the deployment risk and resilience inventory (DRRI), and psychiatric diagnoses associated with 

medical evacuation from the combat theatre. The remaining articles consisted of deployment 

studies in non-OEF/OIF cohorts (n=10)33-42.

Studies Specific to OEF/OIF

Twenty-three studies addressed post-deployment health issues specific to OEF/OIF veterans; most focused on general mental health screening/utilization, PTSD symptoms, or access to services while deployed or upon return post-deployment. 

 Mental Health Screening and Utilization 

The bulk of articles focused on mental health issues and OEF/OIF deployment. In this 

group (n=14), the majority of studies focused on mental health screening before, during, 

or after deployment among military personnel or recently returning veterans10-13, 15, 17, 20-25, 

27, 28. Four themes are prominent in these studies: (1) high rates of screen positive PTSD 

symptoms (range 10-19%)10, 11, 13, 15, 23, 28 or other mental health disorders11, 12, 15, 17, 20-22, 24, 28

occur among OEF/OIF returning military women; (2) women in the military who recently 

returned from OEF/OIF deployments are disproportionately or more affected by symptoms 

of PTSD, symptoms of depression, other mental health issues or more likely referred for 

mental health care compared with men in the military who were recently deployed11, 20, 22, 28; 

(3) younger age and separated or divorced marital status tend to place military members at 

risk for more mental health symptoms21, 22, 25; and (4) a greater number of OIF deployments 

appears to be associated with screening positive for mental health problems17, 20, 22. 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

PTSD Symptoms in OEF/OIF 

Two studies assessed general assault history or Military Sexual Trauma (MST) history10, 

16. The first by Smith and associates identified a doubled rate of new onset PTSD symptoms among combat military women (22% vs 10%) who had been exposed to assault 

prior to combat vs not, and also among military men (12% vs 6%)10. The second by Katz 

et al evaluated a small group of women (n=18) previously deployed who were referred 

for mental health care and compared their readjustments to civilian life and experiences 

in war compared with men. Over half the group (56%) were identified as having a MST 

history, based on a 3-item screen16. The two major study findings were that (1) of three 

types of events (MST, being injured, and witnessing others injured or killed), only MST 

was significantly related to the severity of clinical symptoms and difficulty with readjustment to civilian life, and (2) women who had MST had more symptoms and more difficulties with readjustment to civilian life than those without MST.

Access to Services 

A salient finding by Seal and associates related to managing mental health symptoms 

and diagnoses was that mental health visits occurring within 90 days of screening were 

more likely to occur in veterans seen in VA community clinics versus the medical center (aOR 6.08; 95%CI 1.56, 23.6) or seen in any VA primary care clinic compared with 

other VA outpatient settings (aOR 19.4; 95%CI 1.30, 290)24. One small study captured 

potential barriers to mental health treatment reported by OIF National Guard soldiers, 

including stigma associated with seeking mental health treatment, pride, not being able 

to ask for help, and not being able to admit to having a problem27.

Two additional studies analyzed the psychiatric diagnoses associated with medical evacuation from the theatre of combat18, 19. Stetz et al. analyzed the characteristics and diagnoses of medical evacuees from combat theatres during 2001-200318. Women represented 

16 and 18% of OIF and OEF evacuees respectively, and psychiatric diagnoses were the 

2nd most common reason for evacuation from OEF and the 4th most common reason in 

OIF for the group overall. Rundell et al. found that psychiatric evacuees were more likely 

to be women, African-American or Hispanic, under the age of 31, and enlisted in the National Guard Reserve, as opposed to active duty military19. The most compelling finding 

was that women were overrepresented as psychiatric evacuees by a factor of 2.

A single study by Pierce on pregnant women32 with recently deployed partners showed 

that these women often reported higher stress levels than those with homeland partners 

(39.6% and 24.2%; p<0.01). Regression analyses revealed that having a partner deployed, being active duty, advanced gestational age, and having >1child at home (OR 

2.30, 95% CI 1.12-4.73) all predicted higher stress reporting. However, having a support person present was protective against stress (OR 0.40, 95% CI 0.20-0.78). These 

data included both military and nonmilitary pregnant women living on base and obtaining obstetric care at Naval Hospital. 

General Deployment Health Issues 

Two studies focused on military women in the field of duty29, 30. The Farley and colleagues document the number of gynecologic visits to a far forward combat support 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

hospital at Bagram Air Force Base in Afghanistan compared with transport out of the 

regional area to Germany and the average number of work hours lost29. Over 90% 

of women (57 of 62) were seen in theatre at the Air Force Combat Support Hospital 

(CSH). Most patients had abnormal cervical cytology and colposcopies; other diagnoses included pregnancy, dysfunctional uterine bleeding and pelvic pain. The average 

work time loss during in theatre treatment was 6 woman-hours per patient compared 

with 216 hours per patient with travel to Germany. This paper underscores the benefits 

of providing far forward gynecology care (or gender-specific care) in the theatre of 

operations in order to maintain military readiness. 

The second study by Thomson and colleagues anonymously surveyed women in the 

military deployed to Iraq or Kuwait for at least 3 months to assess their perceptions of 

health care delivery in OIF at the front line and aid stations30. Irregular bleeding (26%) 

and changes in hormonal contraception (23%) were the most common complaints 

among soldiers. Additionally, 21% of soldiers experienced some type of gynecological problem, and nearly one-half of patients (44%) did not meet the cervical cytology 

screening practice guidelines. 

These studies highlighted the need to (1) complete routine gynecological screening at 

least 6 months before deployment to account for any abnormal results and allow for 

follow up, (2) educate non-gynecologic medical personnel on gender-specific issues, 

especially related to cycle control and contraception, and (3) provide at least a 3 month 

and preferably 6-12 month supply of hormonal contraception for women deployed. 

Each of these issues affects the military readiness of women soldiers.

Deployment Risk and Resilience Inventory 

A single study by Vogt and associates validated 9 scales of the Deployment Risk and 

Resilience Inventory (DRRI) among a sample of OIF active duty soldiers who participated both before and after deployment31. In general, all DRRI scales demonstrated 

reasonable to excellent values for internal consistency and reliability (coefficient alpha 

or cronbach’s alpha ranged from 0.77 to 0.90) suggesting that the item sets converged 

on a common construct. Only one construct had a lower cronbach’s alpha (alpha = 

0.55), and it was related to post deployment life stressors. Significant gender differences emerged for 5 of the DRRI scales. Men reported greater exposure to combat and 

aftermath of battle and more often reported being well prepared for deployment, and 

women reported greater perceived threat and less preparedness for battle compared 

with the men.

Other Studies

The remaining studies covered a sundry of topics ranging from environmental and 

physical health exposures reported by veterans (e.g., burning of trash and feces in OIF, 

genito-urinary concerns)14, to case reports on the use of aripiprazole with sertraline or 

cognitive behavioral therapy for the treatment of PTSD symptoms such as sleep disorders in returning combat veterans26. 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

General Deployment Issues - Non OEF/OIF 

OEF/OIF deployment and mental health findings are described above in Studies Specific 

to OEF/OIF. The remaining ten deployment and mental health articles are not specific to 

the OEF/OIF cohorts33-42. A study on Bosnian peacekeeping veterans showed that longer 

deployments and first time deployments were associated with increased distress scores for 

male soldiers specifically; longer deployments did not show this effect in women veterans33. 

Among a sample of Vietnam veteran females, those who had a history of PTSD symptoms 

were susceptible to greater distress after the onset of Operation Desert Storm across all 

PTSD symptoms of re-experiencing, avoidance/numbing, and hyperarousal37. In contrast, 

risk of a mental health related hospitalization was lower among women in combat support 

occupations compared to women in non-combat support (HR0.64, 95% CI 0.53, 0.77) in a 

study occurring prior to the onset of OEF/OIF35. Among a mixed gender group of Gulf War 

I veterans, lower levels of social support resulted in increased depression symptoms for 

women, and increased levels of sexual harassment resulted in increased depression symptoms for men but not women suggesting that social support was a greater risk factor for 

depression in women and sexual harassment was a stronger risk factor for men34. Even in a 

small mixed gender case series of World War II veterans, 25% still had some PTSD symptoms 50 years after war36. The authors of this study suggest that studies of high functioning 

female and male veterans who have survived combat experiences and other trauma may be 

needed to provide more insight to veteran experiences and resiliency. 

The baseline health status (physical and mental health component scores) of a large population-based military cohort is slightly more favorable than that of the same-age, same-sex 

U.S. general population, especially among older age groups, and also much higher than levels 

reported in VA populations presenting for care38. Deployment experiences were not associated 

with either decreased overall health status or mental well being38, 39. However, after adjustments for socio-demographics, deployment experience in SW Asia, Bosnia, or Kosovo (from 

1998-2000), and deployment to the 1991 Gulf War, active-duty women health care specialists 

were significantly more likely to report witnessing death or trauma when compared to combat 

specialists40. In addition, Air Force women deployed to theatre during the Gulf War reported 

significantly more general as well as gender-specific health problems than did women deployed elsewhere39. Common health problems included: skin rash; cough; depression; unintentional weight loss; insomnia; and memory problems and a significant increase in gender-specific problems compared to women deployed elsewhere (e.g., abnormal pap, breast problems). 

Two additional studies covered deployment related reproductive and pregnancy issues41, 42. 

The most prevalent gender-specific problems among an active duty sample (from Persian 

Gulf War) were problems during pregnancy (41%), urinary tract infection (34%), headache 

(33%), menstrual irregularities (32%) and abnormal Pap smear (27%)42. In this group, 76% 

reported using military health care, 41% used civilian health care, and only 3% reported 

using the VA. Overall, satisfaction ratings were higher for civilian care, and too few patients 

attended the VA to provide satisfaction ratings.

Another study41 compared conceptions and pregnancy loss among Gulf War exposed conceptions and non-deployed conceptions among veterans and found similar outcomes. Sepa-
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

rately, GW veteran postwar conceptions were at increased risk for ectopic pregnancies and 

spontaneous abortions, but the study was limited due to lack of information on risk factors 

for and documentation of fetal loss. 

Summary 

The large number of studies focused on the health issues of OEF/OIF soldiers reflects the 

growing participation of women in these conflicts. More than half of the OEF/OIF articles 

underscore the need to screen for PTSD and other mental health symptoms among recently 

returning soldiers who might have multiple risk factors. A key finding is that psychiatric 

diagnoses were common for both OEF and OIF evacuations, suggesting the need for DOD 

and VA to ensure that military personnel evacuated from the field for mental health issues 

receive ongoing care. 

Two other salient issues arose in this section. First, both women and men with assault histories prior to combat had double the rates of new onset PTSD symptoms. Second, military 

readiness for women includes field access to gynecological services. These issues will be 

key for both DOD and VA in post-deployment health care settings. 

Organizational Research

The seven studies in this category all examined organizational characteristics of clinics delivering services to women in a national or regional sample of VA sites for primary care 43-49. 

Services Available to Women 

A national survey of VA facilities delivering primary care documented that 61% had established women’s health clinics (WHC) for primary care; the main factor significantly related 

to the presence of WHCs was separate primary care leadership (OR 3.62, 95% CI 1.45-

9.05)43. Three papers evaluating VA sites across the country serving 400 or more women 

veterans defined the presence of emergency services for women and the breadth and depth 

of gynecological services in the VA. Washington and colleagues assessed whether women’s 

health care specialists for emergency gynecological problems or for emergency mental 

health conditions were available during and after clinic hours46. They found that while most 

sites had a specialist available for gynecologic and mental health emergencies during clinic 

hours, rates dropped for after-hour emergencies. Predictors of specialist availability were 

presence of a separate WHC for gynecological emergencies and lower local managed care 

penetration for mental health emergencies. 

Cope and colleagues evaluated the availability of different forms of contraception in VA47. 

While 97% of VA sites provided hormonal contraception, only 60% of offered intrauterine 

devices (IUDs). Factors related to IUD service availability were hospital-based facility (in 

contrast to community-based outpatient clinic), on site gynecologist, and availability of a 

women’s health clinician who trained other clinicians. Seelig and colleagues built on this 

work by assessing availability of gynecologic services across VA44. They found that availability of endometrial biopsy, IUD, infertility evaluation, infertility treatment, and general 

gynecologic surgery were directly related to routine availability of an Ob/Gyn physician. 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Practice Environment 

Hall et al. presented an assessment of organizational factors impacting the MST practice environment and perceived organizational support using key surveys of MST health providers 

in a VA geographical region48. Wide variability in the perception of organizational support 

existed among facilities even with a small sample size. Ethical conflicts, burnout, vicarious 

trauma experiences (i.e., from counseling), and isolation had negative correlations with perceived organizational support while workload, organizational culture, leadership, and MST 

resources were positively correlated with perceived organizational support. 

Two studies focused on the organizational features associated with the adoption of women’s 

health centers into VA sites43, 49. The first43 examined primary care organizational features 

influencing the development of women’s clinics in primary care (VAMCs or CBOCs) and 

found that nearly two-thirds of VAMCs had women’s clinics (64%), but the only factor 

significantly associated with their presence was separate strong primary care leadership (OR 

3.62, 95% CI 1.45, 9.05). Separately, Yano and colleagues49 identified the degree to which 

VA medical centers had adopted women’s clinics as an organizational innovation by comparing their structure and services to the 8 original Comprehensive Women’s Health Centers 

(CWHCs) in VA. Gender specific service availability was comparable to the CWHCs with 

the exception of onsite mammography, osteoporosis assessment, and availability of separate mental health clinics49. While the general WHCs were less likely to have same gender 

providers, women’s health training programs, separate space, or adequate privacy, they also 

were less likely to experience educational program closures or staffing losses.

The final study compared the original 8 VA Comprehensive Women’s Health Centers with 

the Department of Health and Human Services (DHHS) National Centers of Excellence in 

Women’s Health45. These prototype women’s health centers had many parallel organizational characteristics (e.g., training or fellowship programs, quality monitoring activities, 

and extended hours or same gender providers) and uniformally provided preventive cancer 

screening, and general reproductive services. However, DHHS sites had more extensive 

reproductive care on site, and VA centers had more on-site mental health care. 

Summary 

Two issues are salient in this area. Presence of an Ob/Gyn physician in the VA or a separate 

gynecology or women’s clinic in the VA improves the availability of IUD contraception, 

advanced gynecologic services, and emergency gynecologic services after hours. Separately, organizational culture and leadership showed positive associations with the practice 

environment for MST providers and with sites reporting separate women’s clinics delivering 

primary care, indicating that key role of VA local leadership in women veteran care. 

Quality of Care

Our summary of the quality of care literature on women veterans included fifty one studies that 

covered the following areas: patient perceptions of quality and ratings of satisfaction50-58, general quality of care processes and outcomes59-68, surgical outcomes69-72, prescription medication 

issues73-77, cardiovascular risk factors and health disparities59, 60, 62, 63, 69, 70, 78-80, gender-specific and 

reproductive care32, 41, 42, 81-91, other quality of care issues92-98, and two clinical trials8, 9.
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Patient Perceptions of Quality and Satisfaction 

Patient preferences in VA care among women veteran users and non-users were explored 

through a qualitative study by Washington and colleagues, which demonstrated knowledge 

gaps about VA eligibility and services51. These gaps included a general lack of information 

about VA eligibility and available services; nonusers often assumed that the VA did not provide women’s health care. Separately, both users and nonusers identified the availability and 

accessibility of physicians and treatments, gender specific knowledge and sensitivity, and 

quality expertise and knowledge among the physicians/providers as expectations for their 

care. However, users and nonusers differed in perceptions of VA quality, and VA environment and quality concerns led many women to limit their VA use to women’s clinics.

In a regional study of women veterans, Bean-Mayberry and associates examined patient 

race and primary care ratings in VA50. Race had no association with any of four primary care 

domains or with overall satisfaction with VA care. Separately, patients who reported that 

they received routine gynecological care from VA providers gave high ratings on preference 

for provider (OR 2.0, 95% CI 1.3, 3.1) and satisfaction (OR 1.6, 95% CI 1.2, 2.3). 

Women’s Clinics Versus Traditional Clinics 

In a comparison of women veterans using women’s clinics versus traditional primary 

care clinics, Bean-Mayberry et al. found that female veterans who were seen in the 

women’s clinics were more likely to report excellent satisfaction compared with those 

seen in traditional clinics (p<.05, OR 1.42, 95% CI 1.00, 2.02)52. Similarly, for every 

domain in the original version of the Primary Care Satisfaction Survey for Women, 

patients seen in women’s clinics were significantly more likely to report the highest 

satisfaction rating: getting care (OR 1.69, 95% CI 1.14, 2.49); privacy and comfort 

(OR 1.63, 95% CI 1.11, 2.39); communication (OR 1.66, 95% CI 1.16, 2.37); complete 

care (OR 1.69, 95% CI 1.17, 2.43); and follow up care (OR 1.70, 95% CI 1.16, 2.47). 

Inpatient/Outpatient Satisfaction 

Wright and associates compared patient satisfaction among male and female veterans 

in inpatient and outpatient settings in the VA nationally53. They found that in adjusted 

analyses, overall quality perceptions and most dimensions of satisfaction with outpatient care were not different for females compared with males. However, women were 

less satisfied than men for inpatient settings in multiple domains. Men reported higher 

scores for inpatient quality, after adjustment for transitions (68 vs. 65, p=0.0009), 

physical comfort (82 vs. 80, p=0.0003), involvement of family and friends (74 vs. 71, 

p=0.0024), courtesy (88 vs. 86, p=0.0001), coordination (77 vs. 74, p=0.0000), and access (80 vs. 76, p=0.0000). 

Gender and Gynecological Services

Bean-Mayberry and colleagues determined whether the separate or combined effects 

of provider gender, gynecologic services from the provider, and women’s clinic setting 

improved patient ratings of primary care54. Each combination was compared to a baseline of male provider, no gynecologic care from provider and no women’s clinic setting. Having a female provider was significantly associated with the highest ratings for 
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communication (OR 2.9, 95% CI 1.4, 5.8) and coordination (OR 3.7, 95% CI 1.5, 9.0). 

Male providers who provided gynecologic care or had patients enrolled in women’s 

clinic had a higher rating of coordination (OR 3.0, 95% CI 1.2, 7.0) (compared with 

male providers who did not). Female providers who performed gynecological services 

also had significant positive associations in 3 of 4 domains: continuity (OR 4.0, 95% 

CI 1.8, 8.7); communication (OR 2.7, 95% CI 1.3, 5.5); and coordination (OR 2.8, 

95% CI 1.1, 7.1). Similar findings occurred for patients who had all 3 factors (female 

provider, received gynecologic services, and used a women’s clinic setting). 

Fan and associates evaluated the relationship between continuity of care and satisfaction among women and men veterans in primary care at 7 medical centers using the 

Seattle-based Outpatient Satisfaction Questionnaire which has both a humanistic and 

organizational scale57. The humanistic scale measures satisfaction with communication 

skills and humanistic qualities of the providers, and the organizational scale measures 

satisfaction with the delivery of health care services. Higher patient reports of continuity of care were associated with higher patient satisfaction. Patients who reported 

always seeing the same provider had higher mean humanistic scores and mean satisfaction scores than those who rarely or never saw the same provider. Additionally, female 

patient gender and increasing age was associated with improved satisfaction and higher 

humanistic scores.

Mental Health 

Two studies assessed the association of mental health with satisfaction in primary 

care55, 58. The first surveyed women in one VA healthcare system to identify the associations between satisfaction in general medical clinics and trauma-related mental health 

symptoms. The study found that women with more PTSD symptoms appeared to be 

more satisfied with their overall care and with their provider55. Separately, Desai and 

colleagues, evaluating VA patients with and without psychiatric illnesses who responded to a national VA satisfaction survey, found that patients with mental health diagnoses had lower satisfaction in outpatient primary care58. Dissatisfaction was associated 

with poorer perceptions of access to care and overall coordination of care.

Maternity Care 

One study evaluated women’s satisfaction with maternity care in 44 military hospitals 

and found that less than 50% of the respondents would recommend their hospital of 

care to family or friends due to a higher-than-average rate of problems with care56. 

Although this study had a fairly low response rate (41%), the data identify multiple 

quality and satisfaction issues: problem rates were significantly higher for these women compared with average Picker scores from patients nationwide. Military women 

reported worse ratings on satisfaction domains or items covering confidence and trust 

in provider, treatment with respect and dignity, involvement with medical decisionmaking, and coordination of care (p<.0001 for each). These experiences are directly 

related to maternity care in military hospitals; however, such experiences may affect 

expectations about potential VA health care after active duty.
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General Quality of Care Prevention, Processes and Outcomes 

Ten quality of care studies focused on general prevention and chronic disease processes59-68. 

One study, which focused on patterns of colorectal cancer screening in fiscal year 2002, 

noted that screening was most likely in patients aged 70-80 years. Factors associated with 

lower screening included: female gender; black race; lower income; infrequent primary care 

visits; and recent admission to a nursing home setting61. One salient clinical finding was that 

41% of patients with a positive fecal occult blood test were not offered any type of colon 

examination within a 6-month window. Another study66 explored the barriers, attitudes and 

preferences for colorectal cancer (CRC) screening by gender and found that female and 

male participants reported similar preferences for CRC screening mode, but women viewed 

the preparation for endoscopic procedures as a major barrier to screening while men did 

not. Women also expressed different fears from men (vulnerability vs. pain) and perceived 

CRC as a male disease thus feeling less vulnerable to CRC. These gender-specific barriers 

may help explain women’s lower rate of screening for CRC. In a separate analyses examining flu vaccination by race among outpatient veterans age 50 and older (in 2003-04) in the 

VA, gender did not have any effect on vaccination for the 121,738 veterans surveyed67. Jha 

and coworkers evaluated multiple prevention and chronic disease measures in fiscal year 

2000 and documented comparable overall care for both men and women overall in VA, 

although a few quality measures varied by age and sex62. Among those less than 65 years, 

women were more likely to receive hemoglobin A1c testing (OR 1.13, 95% CI 1.03-1.25) 

and adequate hypertension control (OR 1.09, 95% CI 1.00-1.18) but less likely to receive 

pneumococcal vaccine (OR 0.78, 95% CI 0.73-0.83). For patients age 65 and older, women 

were less likely to receive adequate hypertension control (OR 0.82, 95% CI 0.75-0.90) or 

pneumococcal vaccine (OR 0.92, 95% CI 0.86-0.99). 

Tseng and colleagues performed 2 studies with veteran populations with diabetes. The first, 

which compared older male and female veterans with non-veterans enrolled in Medicare to 

examine gender differences in process of care measures, found no differences in glycosylated hemoglobin (HbA1c), or low density lipoprotein cholesterol (LDL-C) testing59. Women 

were more likely to have completed eye exams but less likely to have LDL-C under 130mg/

dl compared with men. 

In a separate diabetes study comparing female veterans with and without service connected 

disability status, women veterans with service connection were more likely to receive recommended diabetes tests compared with women veterans without service connection, but 

were less likely to have LDL-C controlled even though they were more likely to be tested60. 

The last study in this section focused on cardiovascular risks in veterans with HIV. Among 

HIV positive veterans started on protease inhibitors for disease control, 60% achieved the 

recommended lipid screening guidelines63. Notably, female gender was not a factor associated with receipt of lipid screening in either unadjusted or adjusted analyses. 

The remaining three articles64, 65, 68 described tobacco use and development of a tobacco 

cessation program for women veterans. Vander Weg68 evaluated use of various tobacco 
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products among the military by gender and noted use of any type of alternative tobacco 

products (e.g., bidics, cigars, kretekcs, pipes, and smokeless tobacco) was greater among 

cigarette smokers compared to non-cigarette smokers, and use of alternative products was 

consistently higher for males than for females. The qualitative articles described the development process for selecting ideal components of a smoking cessation program for women 

veterans and uncovered the finding that women veterans wanted both formal and informal 

support mechanisms (professional and peer support) in addition to choice for a smoking 

cessation program (new vs. traditional alcoholics anonymous style)64. When women in these 

focused groups were given a VA tailored smoking cessation booklet to choose options from, 

most women selected multiple options for cessation and least often chose the traditional VA 

program65.

Surgical Outcomes

Four research studies focused on surgical outcomes in women patients or diseases predominant in women (e.g., breast cancer surgery)69-72. Johnson and colleagues evaluated postoperative morbidity and mortality among women patients (n=458 VA patients and n=3535 

non-VA patients) undergoing vascular surgery at multiple VA and private hospitals69. In the 

stepwise logistic regression models adjusted for clinical and operative characteristics, VA 

and private sector hospitals showed no difference in mortality; however, VA care was associated with significantly lower morbidity (OR 0.60, 95% CI 0.44-0.81).

Fink and colleagues also evaluated post-operative morbidity and mortality among female 

surgical patients (n=5157 VA patients and n=27,467 non-VA patients) undergoing general 

surgery procedures in VA and private sector hospitals71. They found that risk adjusted morbidity was significantly lower in the VA compared with the private sector (OR 0.80, 95% CI 

0.71-0.90), however, risk-adjusted mortality did not differ. The next study focused on surgical morbidity and mortality outcomes for breast surgery (n=1333) performed at VA hospitals 

over a 6-year period (1991-1997)72. Of those diagnosed with breast cancer (n=478), 75% 

were women. Thirty-day morbidity rates (12%), 30-day mortality rates (1%), and 1-year 

operation related readmission rates (<1%) were all low for both the women and men in VA. 

The most common post-operative complications were wound infections for both women and 

men, and urinary tract infections in women. Women breast cancer patients were more likely 

to be younger, unmarried, and low income compared with men. 

The last study focused on surgical outcomes in VA and non-VA patients of both genders 

undergoing gastric bypass70. This surgical study evaluated 30-day post operative morbidity 

outcomes and predictors of morbidity in VA and non-VA male and female patients (veterans 

and non-veterans) undergoing Roux-en-Y gastric bypass surgery. The adjusted odds of postoperative morbidity for the VA versus non-VA female patients was 1.14 (95% CI 0.63-2.05), 

and for male patients was 2.29 (95%CI 1.28-4.10). Although the VA male subset showed 

high risk-adjusted postoperative morbidity, both the unadjusted or adjusted findings for VA 

females were equivalent to those of non-veteran females. 

Prescribing Outcomes 

We reviewed five studies that focused on prescribing outcomes73-77. In a VA and Medicare 
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comparison paper, Barnett and colleagues found that VA users had lower rates of any inappropriate medication prescribed overall (21% vs. 29%, p<0.001), and the rate of inappropriate drug use was lower in VA compared with the private sector for males (21% vs. 24%, 

p<0.001) and females (28% vs. 32%, p<0.001)75. 

Three studies focusing only on VA populations showed that inappropriate prescribing was 

more likely to occur in VA women whether using Beers criteria73, HEDIS 2006 criteria74, or 

Zhan criteria76. In addition, gender-stratified analyses found that only geriatric care was protective against inappropriate prescribing for women. An additional study compared antidepressant treatment between the VA and private sector patients and found more than 80% of 

patients achieved guideline acute phase treatment (i.e., effective antidepressant medication 

therapy during the first 84 days after depression diagnosis) with little differences between 

VA and private sector77. Predictors of quality treatment included female gender, and comorbid substance abuse or other mental health diagnoses.

Pugh and colleagues identified inappropriate prescribing using multiple criteria (AHRQ, 

Beers, and Zhan)76. The Agency for Healthcare research and Quality (AHRQ) criteria included documentation of certain drugs by the categories of always avoid, rarely appropriate, 

or some indications while the Beers criteria involved the medications that should be avoided 

in persons aged 65 and older due to ineffectiveness or high risk to safety and medications 

that should not be used in older persons with specific conditions99. The AHRQ panel further identified situations in which use of rarely appropriate and some-indications drugs are 

proper (i.e., Zhan criteria). The study found that adjustment for clinical diagnoses decreased 

inappropriate prescribing practices from 33 to 23% of all veterans and showed that inappropriate drug exposure was prolonged (means not given). Multivariate analyses revealed that 

women were more likely than men to be prescribed inappropriate drugs using Zhan criteria 

(OR 1.3, 95% CI 1.2-1.3), and were less likely to receive dose-limited drugs (OR 0.6, 95% 

CI 0.6-0.7). Other factors associated with either inappropriate drugs or dose limited drugs 

were white race, psychiatric comorbidity, or receipt of an increasing number of medications. 

Busch and colleagues, comparing the quality of pharmacotherapy for patients with major 

depression in the VA (n=27,713) and private sector (n=4852), found that over 80% of patients received guideline-level acute phase treatment (antidepressant therapy in first 84 days) 

in either system77. Raw scores showed that VA slightly outperformed the private sector 

with prescriptions for antidepressants in the initial 84 days (84.7% vs. 81.0%, p<.001) and 

maintenance phase treatment for 181 days (53.9% vs. 50.9%, p<.001). In the fully adjusted 

regression models, women patients were more likely to receive guideline level treatment 

at both 84 (OR 1.18, 95% CI 1.08-1.29) and 181 days (OR 1.14, 95% CI 1.07-1.22). The 

association of VA care with initial guideline treatment was lost after inclusion of co-morbid 

diagnoses. No difference was found between VA and private depression care quality in the 

fully adjusted model.

Cardiovascular Risk Reduction and Health Disparities 

Nine studies possessed data on cardiovascular risk factors for women veterans, most in the 

form of prevalence of risk behaviors/conditions or comparisons of process and outcome 
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measures as mentioned above59, 60, 62, 63, 69, 70, 78-80. Frayne et al assessed prevalence of known 

cardiac risk factors among women veterans who sustained a sexual assault while in the 

military, and identified obesity, smoking, hazardous alcohol use, sedentary lifestyle, and 

hysterectomy before age 40 as more common events in women reporting a history of sexual 

assault in the military compared with women without such as history79. Johnson et al identified watching television more than 2 hours per day and snacking/eating as significantly associated with obesity among women veterans after adjusting for patient characteristics and 

screening positive for depression or PTSD78. A study by Cypel and colleagues compared a 

national population based sample of female Vietnam veterans with non-Vietnam veteran cohorts, and found that women Vietnam veterans showed a significant deficit (ARR 0.78, 95% 

CI 0.62, 0.98) in circulatory system disease relative to non-Vietnam veterans, but significant deficits were also observed when both cohorts were compared with women in the U.S. 

population (SMR 0.65, 95% CI 0.54, 0.77; SMR 0.82, 95% CI 0.73, 0.93, respectively)80. 

Additionally, Vietnam veterans were at significantly greater risk of mortality from motor vehicle accidents than non-Vietnam veterans (ARR 2.60, 95% CI 1.22, 5.55) and this appeared 

to be specific to service in Vietnam based upon comparisons to the U.S. population. While 

each cardiovascular risk reduction and health disparities study evaluated cardiovascular risk 

factors or mortality in women veterans, none assessed risk reduction over time or due to 

specific therapy. The other six articles were mentioned in the sections on general quality of 

care prevention, processes and outcomes59, 60, 62, 63 and surgical outcomes69, 70.

Gender-specific and Reproductive Care 

A range of articles of varying quality covered gender-specific and reproductive care issues32, 

41, 42, 81-91. Three studies covered deployment related reproductive and pregnancy issues32, 41, 42

and are discussed previously. 

One narrative report83 of a VA cognitive behavioral therapy program for transgender women 

veterans (male to female) showed improvement on measures of anxiety and depression 

from pre- to post-treatment and appeared to reduce transgender related isolation and stigma. 

Locating the group in the VA system felt supportive to the veterans who had conceptualized 

being rejected at a systemic level (e.g., by a government organization). Many transgender 

specific issues were addressed in this CBT framework, and the work may serve as a roadmap for future group and individual therapy.

Two studies involved urological issues in military or veteran patients84, 87. The first study 

reported that more active duty women with dysuria postponed voiding; reported fluid restriction; were treated for dysuria in the field or after field duty; and used tampons, pads or 

devices to control urinary incontinence during field duty84. The second study87 described the 

prevalence of eight high priority urologic diseases among patients in the VA. While no major findings are reported by gender, interstitial cystitis was almost twice as prevalent among 

female compared to male VA users (2205 vs. 1311 per 100,000 persons). The etiology or 

context for this finding was not described. 

One retrospective pilot study described pregnancy costs and outcomes at a single VA medical center 91. These investigators found that among the 33 pregnancies reviewed, 31% were 
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to women with at least one chronic condition (mainly hypertension and asthma), 39% had 

at least one psychiatric condition, and 36% had an adverse pregnancy outcome (e.g., premature birth, gestational diabetes, etc). The estimated mean total cost of pregnancy care for the 

entire sample was $9,359 (range $5,466 to $20,279).

A few studies provided information on sexual health, contraception and hormone therapy81, 

86, 88, 90. Among a small group of active duty women completing an anonymous survey on 

sexual health information, responses yielded little desire for information regarding safer 

sexual practices86. However, information requested during normal duty differed from information requested for deployment. Information most frequently requested during deployment 

included how to abstain or say no to sex (23.5%), how to use safer sex or condoms (10.2%), 

and how to keep oneself clean or personal hygiene (9.2%), whereas no information (14.4%), 

how to use safer sex or condoms (9.3%), and how to abstain or say no to sex (9.3%) were 

the top choices for information requested during normal duty. 

During 2004-2006, military facilities filled hormonal contraceptive prescriptions for more 

than half (54.2%) of all females who served in an active component of the US military90. 

The majority of females who were prescribed hormonal contraceptives were younger than 

25 years old (51.2%), white (55%), and not married (56.7%). Females in their twenties were 

more likely than those younger or older to receive prescriptions for hormonal contraceptives 

of all types except the IUD with progestin. For latter reproductive years, two studies were 

present. In a very small study of women at one VA site, over three-quarters stopped taking 

hormone replacement therapy after the WHI trial reports in 2002, and recurrent vasomotor symptoms were common in those who quit abruptly compared to those who tapered88. 

Tapering did not appear to reduce the recurrence of vasomotor symptoms. A larger national 

study completed after the pilot, indicated similar findings with nearly two-thirds of women 

nationally in VA stopping their hormone therapy within two-years after the WHI trial81.

Women with gender-specific and non-gender specific pain reported had high correlations 

with psychological stress, lower health status and sometimes trauma. For breast pain, women reporting frequent mastalgia, compared to those without mastalgia, were more likely to 

screen positive for PTSD, major depression, panic disorder, eating disorders, alcohol misuse, or domestic violence, and often reported fibromyalgia, chronic pelvic pain, or irritable 

bowel syndrome89. In a study of women veterans with and without menstrual symptoms, 

data revealed significantly lower scores for nearly all domains of the SF-36 (p<.01), both 

before and after adjustment for sociodemographic, psychosocial, and comorbidity variables82. Results remained unchanged when analyses were limited only to women without a 

depression or a sexual trauma history.

Finally, a mammogram intervention trial was evaluated for external and internal validity85. 

For internal validity, the five study groups did not differ with respect to any of the covariates. Groups not receiving the intervention showed similar rates of mammogram screening 

during the 1 or 2 years before or after the baseline survey, indicating that cueing had not 

occurred. Mammogram screening rates during the 30 months prior to the baseline evaluation for 5 different randomized groups of women showed mildly lower screening in group 
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5 compared to all other groups combined (82.3% vs 85.1%) which was consistent with 

changes occurring nationally. (The specific trial is discussed at the end of this quality section within the clinical trials subgroup.)

Other 

Seven articles could not be clustered in the categories above92-98. One study focused on 

patient perceptions of breast cancer risk susceptibility and found that only breast symptoms 

and cancer worry predicted greater perceived susceptibility. The models only explained a 

small amount of variance for each susceptibility measure98. For VA patients on ace inhibitor medications, independent of other factors, risk of angioedema among VA patients was 

higher for blacks, females, and patients with chronic heart failure or coronary artery disease, 

but substantially lower for diabetics92. The five following studies had women in their samples and analyses and had no difference identified by gender93, 95-97 and/or did not comment 

on results or discussions on implications of women in their sample for health status/quality 

of life comparisons94, 95 or cost comparisons93, 97.

Clinical Trials

The last two studies in this section are trials8, 9. One is an educational intervention to improve VA employee perceptions of women veterans. The other is an intervention to increase 

mammography screening among women veterans.

VA Employee Study 

The VA employee study by Vogt8 was an educational intervention which evaluated 

gender role ideology (i.e., “the extent to which a health-care worker does or does not 

rely on negative stereotypes about women, as they compare to men, to make judgments 

about different aspects of care”), knowledge, and sensitivity among male and female 

employees randomly given the educational training then compared with a control 

group8. Initial findings indicated that older age, direct patient contact, and years of VA 

employment predicted higher gender awareness and suggested a meaningful role for 

”hands-on” experience with veterans. Analyses revealed significantly greater improvement in sensitivity and knowledge for participants in intervention relative to control 

setting. Contrary to expectations, the program did not significantly improve genderrole ideology. 

Mammography Intervention 

This study by Vernon et al9 was a randomized controlled trial of two interventions in a 

population-based, nationally representative sample of women veterans that compared 

rates of completion of two or more mammograms among women assigned to two types 

of interventions versus a survey only control group. While the absolute between group 

differences ranges from 3-6%, depending on analyses, neither was superior to the control group.

Summary 

The satisfaction data are mixed. Women veterans who do not use the VA lack understanding 

of VA care and services. Among VA users, women and men had similar outpatient satisfac-
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tion ratings; however, women had consistently lower ratings for inpatient care. Additionally, 

women veteran satisfaction was affected by access to women’s clinics, gynecological care, 

and overall continuity of care. The VA quality assessment indicated that women in VA may 

have some comparable outcomes with men; however, overall improvement is needed for 

lipid and hypertension control and preventive immunizations. Surgical data indicate that 

women in VA settings have equal or lower surgical morbidity and mortality outcomes compared with the private sector for general and vascular procedures. Pharmacy data indicate 

that while VA has consistently lower or comparable rates of inappropriate prescription drugs 

in the elderly, and women in the VA (compared to men) are consistently more likely to be 

prescribed inappropriate drugs by regardless of the criteria used73-76. 

Separately, the literature on quality of care and cardiovascular risks in women veterans is 

salient but small. Women appear to have obesity related surgical outcomes equivalent or 

better than the non-veteran women, but have higher levels of cardiovascular disorders compared to civilian women and lower level of ambulatory care intermediate outcomes (LDLcholesterol control) compared to men veterans. None of the epidemiologic or quality of 

care studies focused on cardiac risk reduction over time or with specific therapies. Studies 

with intermediate outcomes (e.g., controlled lipids or other process measures) and disease 

outcomes (lower disease-specific morbidity and mortality rates) are desperately needed to 

understand what improves cardiovascular care for women veterans alone or in mixed populations with men. 

Finally, women veterans with a history of MST and PTSD have increased obesity associated 

risk factors. This subgroup of studies indicates that cardiovascular risk reduction will be a 

growing and ongoing need in VA with the growing population of women veterans who will 

age in our system.

Access and Utilization

Forty-eight articles focused on access and utilization addressed determinants of access, gender 

and utilization, and utilization among special populations – sexual trauma patients, mental health/

PTSD patients, and veterans from different periods of military service. Twelve articles focused 

on determinants of access51, 100-110; fourteen focused on gender-specific care or gender differences 

and access46, 81, 111-122. Six articles focused on sexual trauma patients and utilization123-128; and 

eleven focused on PTSD or other mental health patients and utilization15, 129-138. Five additional 

studies focused on access and utilization among specific cohorts of veterans20, 25, 139-141. 

General Determinants of Access 

The studies on determinants of access to VA care identified knowledge gaps about VA care, 

incorrect assumptions about services available to women, and difficulty with using VA care 

as major barriers to women’s using the VA51, 101, 102. Other factors influencing women not 

to use the VA or to use both the VA and private sector care included availability of private 

insurance or higher income102-104. Patient and organizational factors related to low VA and 

non-VA dual use were no insurance, receipt of general gynecological care from the VA 

provider or use of women’s clinics100, 107. For patients older than 65, availability of Medicare 

HMOs predicted healthcare use outside the VA110. Among veterans with dual VA-Medicare 
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eligibility, veteran women were more likely than veteran men to rely solely on VA care108, 

109. Additionally, one qualitative study found that veterans reported using VA due to cost 

issues in addition to more access to services (compared to local community) and quality of 

care available at VA106. These veterans voiced similar concerns about cost, access and quality in other settings if VA outsourced care, with the greatest concerns being whether they 

would be negative effects (e.g., lower quality, harder to obtain appointments or wait time)106. 

One last study on utilization after increases in medication copayments among male and female veterans with schizophrenia noted that outpatient visits remained stable, but inpatient 

admissions increased slightly105.

Gender-Specific Differences in Access 

Compared with male VA users, women who used VA care had more outpatient encounters111

and also used more outpatient services if they had medical, mental health, or pain conditions in comparison to men111, 112, 115. Women veterans in a Midwestern regional sample were 

found to have higher health related quality of life compared with men; however, younger 

women who had poor mental or physical health functioning had fewer primary care visits compared with men with the same characteristics114. A study of total knee replacement 

or hip arthroplasty in the VA found no gender difference in rates of these surgical procedures117. A smoking cessation study documented that while women and men were equally 

likely to be advised to quit smoking and be referred to a cessation program, women less 

often received nicotine patches (OR 0.50, 95% CI 0.3, 0.9) and were less likely to have 

successfully quit smoking one year later118. For women veterans requiring emergency gynecological or mental health care, VA sites reported high availability during general clinic 

hours (64.4% and 82.7% respectively had specialty emergency care); however, this access 

dropped to half or fewer sites offering after hours emergency care for women46. The main 

predictors for access for a VA site were the presence of a separate women’s health clinic or 

lower local managed care penetration for emergency mental health.

Gender-Specific Differences in Utilization 

The gender-specific data covered a broad range of topics. After the Women’s Health Initiative data were reported in 2002 and 2004, women veterans nationally discontinued hormone therapy at about the same rate as non-veteran women. However women utilizing VA 

women’s clinics more often stayed on hormone therapy compared with women cared for in 

other VA settings81. Women veterans with spinal cord disorders compared with those without showed higher rates of cardiovascular disease, lower health status, and fewer reports of 

preventive dental care, colon screening, and mammogram screening, indicating areas for 

improvement. Rates of vaccinations and lipid screening were similar for these two groups113. 

With regard to breast disease, image-guided breast biopsies were shown to be more costeffective compared with traditional open biopsy surgical techniques at one VA site116, and 

factors inversely affecting demand for mammograms included patient characteristics of 

older age, poor health and smoking status, and the system factor of increased waiting time 

for the mammogram119.

LaVela122 also described utilization of services by veterans with spinal cord disorders. Females, older, and non-white veterans (p<.0.000 each), and veterans with a history of medical 
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problems such as respiratory, kidney/urinary tract, circulatory, or digestive system diseases 

(p<0.005 for each) were more likely to use outpatient care, and farther distance from VA 

facilities indicated infrequent use (p<0.000). Homeless female veterans were more likely 

to receive compensation benefits rather than pension benefits120. In the limited number of 

veterans (15%) who were subsequently awarded benefits; they were more likely to have reported recent use of VA services and a greater number of medical and psychiatric problems 

at the time of outreach120. Finally, a convenience sample of women veterans at one VA site121

showed that women veterans with pain (vs. without) were more than 6 times as likely to 

report ≥12 medical visits in the past year and twice as likely to report ≥12 visits to a mental 

health provider.

Sexual Trauma and Utilization

The research on sexual trauma and utilization revealed patient difficulties with identifying 

their emotions124, more use of VA services among those with sexual trauma histories125, 128, 

and more psychological impairment compared with veterans with other forms of trauma126, 

128. In addition, women who had experienced more severe forms of sexual violence in the 

military (i.e., repeated rapes or gang rapes) were severely impaired physically and emotionally compared with women who had no or one such event, and were more likely to use both 

inpatient and outpatient mental health services127. A national study of veterans screened for 

military sexual trauma showed that both men and women who had a positive screen were 

more than twice as likely to have a post-screen mental health visit compared with those who 

screened negative123, a benefit for both genders in the VA. 

PTSD and Other Mental Health Issues

Among the eleven PTSD and mental health studies focused on utilization15, 129-138, women 

with PTSD symptoms and women with other mental health issues were more likely to use 

VA services compared with women without PTSD symptoms or men, respectively129, 138. 

Other gender-related findings were that being mistreated as a child did not appear to be 

associated with increased utilization among women with PTSD133. Both women veterans 

with PTSD and female partners of Vietnam Veterans with PTSD preferred treatment or 

support services that were female-only135, 136. One study examined continuity of care and 

treatment outcomes but was not able to find a significant association between continuity of 

care factors and PTSD outcomes when analyses were adjusted for multiple comparisons137. 

Compared to men with mental illness, women with mental health issues were less likely to 

be placed in nursing home settings132. Identification of patients by psychiatric criteria on 

interview indicated that up to 44% of women veterans in primary care may have at least 

1 mental health diagnosis130, and middle age adults are more likely to have a psychiatric 

diagnosis compared with younger and older veterans131. One article noted that patients with 

mental health diagnoses (compared to those without mental illness) are less likely to be 

screened for lipid disorders unless they have increased outpatient utilization at the VA134. A 

last study focusing on OEF/OIF veterans with PTSD is discussed in a previous section15.

Access and Utilization Among Specific Cohorts 

Several access and utilization studies focused on specific cohorts of military personnel. One 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

study noted that active duty Air Force personnel who self-refer for mental health services 

compared with those referred by supervisors are less likely to have a significant diagnosis, 

have confidentiality broken, or have career-affecting recommendations made140. For women 

Vietnam veterans, physical health problems mediated the relationship between combat 

exposure and outpatient utilization for physical health, whereas combat exposure only indirectly predicted men’s mental healthcare use 139. The Iowa Gulf War Study identified similar 

combat and noncombat exposures among men and women but noted that women were more 

likely to report more than 5 outpatient visits in the prior year, and inpatient hospitalization, 

and receive VA compensation141. Two other studies focused on OEF/OIF personnel and were 

discussed previously20, 25.

Summary 

Women with positive screens for mental health disorders, trauma, or diagnoses tend to use 

more healthcare services than women without positive screens or than men veterans. In a 

few areas, findings are mixed, cautioning us to remain aware of patients who may reduce 

utilization because of specific mental health issues.

Psychiatric Conditions

The 85 publications covering mental health and psychiatric issues fell into five broad categories: 

PTSD5-7, 13, 15, 22, 23, 26, 28, 55, 58, 129, 131, 133, 135-137, 142-166; substance abuse and treatment167-171; general 

mental health130, 132, 134, 138, 140, 172-179; Trauma10, 124, 128, 180-194; and other77, 105, 195-199. The PTSD focused 

articles included screening and treatment, descriptors and determinants of diagnosis, quality of 

life and utilization impacts, and comorbid disorders. General mental health articles included 

prevention and screening, deployment issues, quality of life, and utilization. 

PTSD 

Clinical Trials 

Three PTSD clinical trials focused on treatment occurred during this period5-7. David 

evaluated a 12-week open behavioral intervention for PTSD patients5. The intervention focused on structured group psychotherapy and self-defense training and measured 

patient risk perceptions among women veterans with PTSD. Women veterans showed 

significant and sustained improvement at both 3 and 6 months after completing the program with respect to PTSD avoidance behavior and hyperarousal symptoms. Patients 

also had decreased depression scores, and increased interpersonal self-efficacy, self 

defense self-efficacy and willingness to participate in community activities. Schnurr et 

al. was a multi-site trial that randomized women veterans and female military personnel with PTSD to either prolonged exposure therapy or present-centered therapy by 

standard protocol for 10 weeks6. This study indicated that prolonged exposure therapy 

was significantly associated with a greater reduction of PTSD symptoms and a lower 

likelihood of meeting PTSD diagnostic criteria after therapy was completed. A final 

pilot trial by Butterfield et al. evaluated olanzapine therapy over 10 weeks in a small, 

double blind, placebo controlled group of patients (predominantly female) with noncombat related PTSD and reported no between-group difference in treatment responses 

but noted a large placebo effect7. 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Screening and Symptoms

PTSD screening and treatment included seven articles covering a variety of topics26, 

28, 135, 137, 142-144. One study found that a small subset of veterans (2.7%) filing disability 

benefits for PTSD reported being spontaneously distressed by a survey142. However, in 

a Persian Gulf War I cohort, gender analyses revealed that perceived threat was associated with more PTSD type symptoms for National Guard/Reserve men compared 

with active duty men, but the PTSD symptom associations were greater for active duty 

women compared with women in guard/reserve units143. Another gender related finding 

was that the most important factor for women veterans and partners of disabled veterans coming to the VA for PTSD treatment was the availability of specialized treatment 

programs for women135. 

Women veterans treated for PTSD with group psychoeducation and self-defense training showed (similar to the David 2006 study5

) improved use of personal safety skills144. 

Lambert’s case series on the use of aripiprazole with either sertraline or cognitive –behavior therapy shows some promise in improving symptoms in some patients26. Corrections for multiple comparisons eliminated the relationships between clinical status 

outcomes and continuity of care in a small sample of women receiving outpatient VA 

treatment for PTSD137. Future clinical trials will be needed to produce clinical evidence 

for improving PTSD symptoms in women through medication and therapy. 

Finally, the findings of the repeat post-deployment screens for PTSD and other symptoms among OEF/OIF veterans are discussed in an earlier section28.

Determinants of Diagnosis 

Twelve articles focused on determinants of a diagnosis22, 23, 133, 145-153. In a study of stress 

and social support among male and female Marine recruits, the negative impact of 

stress reactions on hardiness (i.e., courage and motivation to cope with stressors in 

daily life) was strongest when social support was low; however, in women stress reactions predicted enhanced hardiness when social support was high145. Women who have 

strong social supports may endure more stressors without negative consequences. In a 

similar fashion, life experiences and unit cohesion predicted PTSD symptoms in active 

duty soldiers, with unit cohesion appearing to ameliorate some life experiences and 

symptoms153. A few studies focused on the determinants of PTSD found the following associations: 1) poorer perceptions of health and well being were correlated with 

increased depression or PTSD symptoms146; 2) PTSD diagnosis and symptoms were 

associated with more medical conditions and poorer health related quality of life151, 

and gender did not moderate the relationship between PTSD and poorer health related 

quality of life147; 3) one VA primary care clinic identified PTSD as the best predictor 

for somatization in women patients148; and 4) pain related factors149, childhood nonsexual/physical maltreatment, childhood sexual assault152 or adult sexual assault133, 150

were significant predictors of PTSD symptom clusters among women veterans. Two 

other studies are discussed previously in the deployment and post-deployment health 

section22, 23.
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Quality of Life and PTSD 

Fifteen articles focused on quality of life and mental health13, 15, 55, 58, 129, 131, 136, 154-161. Findings varied in mixed gender versus single gender studies. Among male and female veterans treated for PTSD in the VA, overall quality of life was poor and did not differ between 

genders, and numbing was uniquely associated with reduced quality of life154. In contrast, 

women screening positive for PTSD symptoms (compared to those screening negative) 

had more mental and physical problems, and poorer health related quality of life160. 

Two studies examined how PTSD-related stress affects the family of veterans155, 156. 

Severity of PTSD symptoms was negatively correlated with marital adjustment (r=-

.38), family adaptability (r=-.40), cohesion (r=-.34) and parenting satisfaction (r=-

.31)155. Among women Vietnam veterans, hyperarousal symptoms negatively impacted 

parenting satisfaction156. Gahm et al. identified family experiences that may contribute 

to PTSD risk161. Experiencing combat (OR 2.04), witnessing someone being assaulted 

or killed (OR 1.88), and number of adverse childhood events (OR 1.25) all emerged 

as significant risk factors for PTSD symptoms161. In a PTSD disability benefits study, 

regional differences in PTSD awards are not explained by different PTSD symptom severity or level of disability159. Separately, no difference in the reporting of low income 

occurs among women compared to men applying for PTSD disability benefits157. In 

addition, a disparity in estimated rates of service connection for PTSD by gender was 

partially explained by differences in combat exposure158. A number of related articles 

were discussed under postdeployment OEF/OIF health13, 15 and PTSD symptoms related to access and utilization129, 131, 136.

Satisfaction had mixed associations with PTSD symptoms55, 58. Women veterans with 

trauma related mental health symptoms reported more satisfaction with overall primary 

care and their provider55. However, in another study patients with PTSD and other 

co-morbid diagnoses reported lower overall satisfaction with primary care (see Desai 

(2005) discussion under quality of care and patient satisfaction)58.

Comorbid Disorders 

A few articles covered co-morbid disorders162-166. Women with PTSD had more medical 

conditions and worse health status than women with only depression or neither diagnosis162. Among a male and female cohort of Persian Gulf military followed longitudinally, 

a drug problem or PTSD symptoms at time point 2 was predictive of a positive drug use 

screen at time point 3 but not predictive of alcohol use163. African American female veterans at one VA site had a greater prevalence of prior exposure to violence (childhood or 

adult sexual abuse, intimate partner violence or sexual harassment) than their Caucasian 

counterparts, but these levels were not markedly different from other low-income African 

American women164. In another single site VA study of women veterans, women with a 

history of MST had a greater odds of PTSD (OR 4.4, 95% CI 2.4, 8.2), but prior experience of other trauma was not a significant predictor of PTSD (OR 1.3, 95% CI 0.63, 

2.5)165. A similar analysis revealed that the relative risk of women with MST developing 

PTSD was nearly 2.5 times that of patients without MST (RR 2.40)166. 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Substance Abuse and Treatment 

Five studies explored substance abuse issues in military and veteran populations167-171. 

Two169, 170 describe military and veteran characteristics associated with alcohol use, while the 

others describe predictors for participating in substance abuse treatment programs167, 168, 171. 

Gutierrez and researchers169 assessed alcohol behaviors among deployed soldiers (within 

and outside of the United States) in 2003 and found that significant predictors of greater 

alcohol-related consequences, as assessed with the CAGE questionnaire, included less formal education, male gender, not being in an intimate relationship, racial/ethnic minority status, enlisted rank, having been deployed to the continental United States, and greater stress 

[χ2(8,5,458) = 235.991; p < 0.001]. Lande et al170 determined gender based differences in alcohol use among Army soldiers and noted that although men were more likely to engage in 

“bolus” (binge) drinking, women exceeded established guidelines for safe alcohol consumption (i.e., 7 drinks per week) at a risk-adjusted rate nearly twice that of men. In addition, 

for individuals whose behaviors were considered unsafe, the severity of reported negative 

consequences was influenced by gender. Women initially experience greater psychosocial 

impairment, and—should harmful drinking patterns progress to alcohol dependency – they 

are at greater risk of injury, morbidity, and mortality than men. 

Predictors of admission into a substance abuse treatment program for active duty women 

include coexisting psychiatric conditions171, primarily concurrent use of alcohol171 and for 

veteran women in intensive outpatient treatment include cocaine abuse/dependence, greater 

burden of medical and psychiatric co-morbidities compared to men in intensive treatment 

and compared to other women veterans not in treatment167. For homeless veterans, the situation is more complicated. Benda168 compared readmission rates for substance abuse program 

by gender among homeless veterans and identified abuse in childhood, during military status or in the recent 2 year period prior to admission were all potent factors for women compared to men. Readmission for women was heightened by increases in depression, suicidal 

thoughts or traumatic events, while for men it was increased by elevated substance abuse, 

aggression and cognitive impairment. However, social supports through family, friends, 

church or other mechanism all lessened readmission rates for women, while employment 

stability and job satisfaction reduced the readmissions for men. 

General Mental Health 

The general mental health prevention and screening articles indicated that women in the 

military had a higher prevalence of mental health disorders such as panic, anxiety and depression compared with men in the military175, 176. The exception is alcohol abuse, where the 

prevalence among men in active duty cohorts was higher than that of military women175. 

Quality of Life

For veterans responding to the Large Health Survey of Veteran Enrollees in 1999, 

Physical and mental component scores were similar by gender except among those 

age 65 or older, where mean MCS was better for women than men (49.3 vs 45.9, 

p<.001)179. Among women veterans, health related quality of life physical component 

scores were lower, with more limitations in activities of daily living and more reported 
27

Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

pain than the men172, and among psychiatric patients, rural veterans had worse physical 

component scores and mental component scores compared to urban-dwelling veterans173. Those with mental health comorbidities also had lower health related quality of 

life scores174. Women in the Air Force showed increased levels of family stress, work 

family conflicts and job distress compared with community samples of women177, and 

children of deployed Air Force mothers in Operation Desert Storm were at risk for 

multiple behavioral and emotional adjustments problems178.

Utilization 

Within VA primary care clinics, a large proportion of women (44%) had at least one 

mental health diagnosis, and about 40% of these women with a mental health condition 

received care in a VA specialized mental health clinic130. Service members discharged 

from the military for mental health reasons were more likely to use VA mental health 

services if they were women, older, or had schizophrenia or bipolar disorder. The 

women were more likely to contact VA and use VA services compared with the men138. 

Within the military, service members who self-referred for mental health care had better outcomes than those members who had been referred to mental health care by their 

supervisor140. Other articles discussed previously included nursing home users were 

likely to be men, recently hospitalized and with dementia132, and lipid screening was 

low for veterans who used VA mental health services infrequently but increased screening occurred with increased levels of outpatient use134. 

Trauma 

General Sexual Trauma or MST

Key findings from the nine articles on general sexual trauma or MST10, 124, 128, 180-185

include the following: Positive MST screens among women and men were associated 

with greater odds of nearly all mental health comorbidities, including PTSD in women 

(OR 8.83, 99% CI 8.34, 9.35) and men (OR 3.00, 99% CI 2.89, 3.12), but were almost 

three times stronger among women180. These findings were reinforced in an additional 

study evaluating the various forms of sexual assault and PTSD diagnosis183 and in one 

of the OEF/OIF deployment studies discussed previously10. In-service sexual harassment severity was also associated with PTSD symptom severity in women, after adjusting for other reported traumas185. Many active duty women (80%) and men (45%) 

reported at least one type of sexual stressor in the previous year (i.e., sexual identity 

challenges, sexual harassment, or sexual assault)181. In addition, women with a history 

of sexual trauma report significantly higher levels of anxiety for any gender-specific 

or invasive exams (breast, pelvic, rectal) when the clinician is male (p<.001 for each 

exam)182. Moreover, women with sexual trauma histories showed evidence of alexithymia (i.e., difficulty identifying one’s emotions), and this factor explained variance 

in both physical health and urgent care utilization among these women124. Notably, a 

small study of women with physical and/or sexual assault histories reported that selfdefense training would be an effective addition to traditional treatments for PTSD184. 

An additional relevant article is discussed in the access and utilization section128.
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Trauma from Multiple Sources 

Women experiencing multiple traumatic events (sexual, physical or both) during 

military service, had more severely impacted health status190, 194 and more outpatient 

visits190. Some women had repeated violent experiences from childhood which were 

also associated with worse physical and mental quality of life compared to women 

without the history189; other childhood events were more frequently perpetrated by 

parental figures, occurred over longer durations or involved more severe experiences 

of abuse186. Prior to entering the military, one-fourth of recruits reported pre-military 

physical intimate partner violence (IPV) events191 and both physical IPV and history of 

interpersonal trauma predicted attrition from the military187, 191. Separately, active duty 

women’s perceptions of screening for domestic violence (now called intimate partner 

violence) in the military was generally supportive, but fewer women thought abuse 

should be reported to the commanding officer192.

Multiple workplace factors increased the likelihood of physical assault for women in 

the military: experiencing unwanted sexual advances or pressure for dates in sleeping 

quarters (7 fold); experiencing hostile work environments (5 fold); observing heterosexual activities in sleeping quarters (4 fold); and ranking officers making sexually demeaning comments or behaviors (3 fold)193. Of note, being quartered in mixed 

gender barracks was not significantly associated with physical assault. Combat and 

non-combat exposed veterans had different levels of sexual assault in-service; higher 

levels occurred among non-combat males (13% vs 6%) and non-combat females (75% 

vs 63%) for unclear reasons188.

Other 

The other mental health articles focused on other psychiatric conditions not discussed previously. Three articles focused on depression treatment77, 197, 199. The first showed no difference 

in depression therapy between VA and the private sector77, the second identified depression 

screening rates of nearly 85% in 2002, but only about half the patients received follow up if 

they screened positive and male gender was a factor197. The third article found that among 

depressed veterans, being young, male, and white were the demographic factors associated 

with higher suicide risks199. However, the relative risk ratio for suicide among men compared with women was smaller than in the general population. The remaining four articles 

identified that 60% of veterans with serious mental illness had overwhelmingly poor dental 

health195; bipolar disorder patients who were nonadherent to medication were likely to have 

an active substance use disorder such as alcohol abuse196, with women showing higher odds 

of nonadherence198; and lastly, psychiatric drug refills dropped nearly 25% among schizophrenia patients after copayments for medications increased105. 

The remaining articles from on psychiatric conditions were included in the access and 

utilization section covering mental health issues, deployment and post-deployment health 

section for OEF/OIF veterans and non OEF/OIF veterans.
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

Summary

The section on psychiatric conditions covers a broad spectrum of literature describing issues 

for women and men veterans. This literature should provide a stable foundation for increasing treatment and outcome pilot and multi-center trial studies among women veterans. 

Three points should be emphasized. 

• More clinical trials like those of David, Schnurr, and Butterfield are needed to help direct 

VA providers toward treatment options that are best suited for the female veteran patient. 

• The literature confirms the positive relationship between MST and PTSD, and both of 

these diagnoses have multiple negative health-related associations that both providers 

and policymakers need to understand. In particular, women with a sexual trauma history 

reported significant anxiety for any invasive exam and male providers. Such data are critical for managing patients in primary care where repeated invasive exams (breast, pelvic, 

rectal) will be required to provide evidence-based quality care over the life span; the role 

of provider type and practice setting (women’s clinics) may be a long-term issue. 

• A small cluster of studies show that social support (in military or in civilian life) may 

be a factor for resiliency and quality of life among women and (possibly their children) 

while performing in the military and when they transition home from deployment.

Summary and Discussion

The growth in the number of women in the military is reshaping the veteran population, with 

women now constituting one of the fastest growing segments of eligible VA healthcare users. 

This trend has been accelerated by the unexpectedly high VA enrollment of women veterans 

from recent wars in Iraq and Afghanistan. As women veterans have entered the VA healthcare 

system in increasing numbers, VA managers and providers have been challenged to organize and 

deliver gender-specific and gender-sensitive services in a system that has otherwise historically 

focused on treating men. Gender-specific care also imposes considerable training and experience 

requirements on a VA workforce with limited exposure to female patients. 

VA’s health services research enterprise has been designed to map to high priority topics, women 

veterans’ health and health care among them. Yano and colleagues led the leadership efforts for 

the first mapping of VA research priorities to the needs of women veterans with the VA Women’s 

Health Research Agenda Setting Conference in late 2004200. This initial women’s health research 

agenda was the product of a national consensus development meeting, which (a) brought together 

researchers from various fields (laboratory, clinical science, rehabilitation and health services) to 

focus on establishing an evidence base for a women’s health agenda and (b) to incorporate results 

of the first VA systematic review of the literature on women veterans1. That review identified 

182 relevant articles published between 1978 and 2004. Most were descriptive in nature, using 

observational study designs; only 2 were randomized controlled trials. About 45% of the studies 

were VA funded, with the majority of the literature focusing on women veterans’ mental health 

(mostly risk, prevalence and treatment of PTSD) and general health services research (8 on 

quality of care, 5 on patient satisfaction, 25 on use and organization of care). 

In the current updated systematic review, we identified 195 articles from 2004-2008–more 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

articles in 5 years than we identified in the previous 25 years. This sharp increase in volume is 

likely due to VA’s increased focus on research funding in these priority areas. Consistent with 

the previous systematic review, most VA women’s health research continues to be observational; 

however, more articles are shifting from a descriptive to an analytical focus (i.e., determinants of 

care or health), and there were 5 clinical trials, a modest increase from the first review. 

While the focus on mental health among women in the military and women veterans remains 

high, with a continuing emphasis on PTSD and MST, important new work has been published 

on prevalence of mental health conditions in different settings and for different subgroups 

and on non-trauma-related mental health problems (e.g., depression, serious mental illness). 

Emphasis on access, utilization and quality of care for women veterans has also increased, with 

a rapidly emerging focus on post-deployment health. These topic areas clearly map to ongoing 

VA research priorities, demonstrated in part by the fact that about 60% of the articles were VA 

funded in whole or in part, up from 45% in the review published in 2006. 

Building Knowledge: Notable Research Advances

To what extent has the more recent literature closed the gaps identified in the previous review? 

Previous notable gaps included very limited information on the prevalence of chronic diseases, 

women veterans’ preferences and self-reported care needs, research on utilization patterns within 

and outside the VA health care system, transitions from military to veteran status, studies of the 

quality of care women veterans receive, and studies on how to improve their quality of care. 

These gaps served as the basis for more targeted solicitations for new research. 

We highlight 3 areas with the noteworthy impact: 

1) Treatment outcomes in PTSD: The Schnurr study is the first multi-centered, VA funded 

cooperative trial focused on outcomes of women veterans with PTSD using a comparison 

of prolonged exposure therapy to a previous standard of care. Due to the quality of the 

research and significant clinical findings, prolonged exposure therapy is being considered 

by VA administration as part of the revised guidelines for PTSD standards of care due out 

later this year, used to train clinical providers, and implemented across the field nationally6 .

2) Access to care: We now know more about barriers, perceptions and utilization of VA 

care among women veterans, and this information should be used as a foundation to 

remove barriers and consider methods for restructuring care to meet healthcare needs. 

Chief barriers include knowledge gaps and incorrect assumptions about VA services 

among women veterans outside the VA and high use of care once enrolled in VA among 

women with various co-morbidities. This knowledge should direct us toward potential 

interventions among subgroups of women veterans to decrease barriers and documented 

and improved care outcomes among women in VA with significant co-morbidities. 

3) Organizational determinants of quality care: Advances in research describing how care 

is organized for women in VA demonstrate variations in service availability and their 

determinants as well as the importance of practice environment for women veterans care. 

Better attention to gynecologic access (staff, clinic, services) appears to be important 

for types of services a woman has access to and a key area for future research in VA. 

The impact of local leadership on women veteran services also appears essential. Future 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

quality improvement interventions need to consider the integration of leadership or other 

diverse stakeholders in care of women. 

Separately, the PTSD trial impacts the literature on women veterans in another manner. Few 

studies had an adequate sample for comparing women to men or VA users to non-users and 

evaluating outcomes. The Schnurr trial overcame this challenge and future studies should use 

similar methods (multi-site approach, cooperative study, practice based research network) to 

achieve adequate patient samples for clinical and health services research Schnurr trial6. The 

Schnurr trial tackles the historical research dilemma of insufficient sampling strategies for 

performing primary or subgroup analyses of women in VA and demonstrates that it is feasible to 

conduct robust clinical trials in women veterans201.

With the current systematic review, we found increases in the number of articles on access, 

utilization and quality of care studies. Collectively, this research provides an evidence base for 

detecting barriers to VA care that women soldiers may encounter, defining optimal women’s 

healthcare delivery arrangements, and adopting best practices. In these areas, the field as a 

whole is now ready to move toward identifying and implementing interventions to promote 

best practices. This identification of interventions and promotion of best practices fits within 

the VA Quality Enhancement Research Initiative (QUERI) model for translational research and 

quality improvement202. The VA QUERI program promotes the linking of research and clinical 

practice to improve the quality and outcomes of care among veterans across the VA system by 

a series of quality improvement steps and interventions that involve researchers, providers, and 

clinical managers203. These steps include: (1) identifying high-risk or high burden conditions 

or problems; (2) identify best practices or clinical guidelines; (3)define variations from best 

practices and their determinants; (4) identify and implement interventions to promote best 

practices; (5) assess intervention program feasibility, outcomes and impacts on patient, provider, 

and system; and (6) assess intervention program impacts on health releated quality of life 

outcomes203, 204. VA women veterans’ health research now stands solidly within the VA QUERI 

framework at steps 3 and 4, where variations can be identified and explicitly understood so that 

appropriate interventions will be designed for women veterans.

Ongoing Gaps: Future VA Research Targets

In contrast to the growth in the scientific literature on access, utilization and quality, recently 

funded VA studies have not yet made their mark in the published literature on prevalence of 

chronic diseases or on transitions from military to veteran status. Additional areas that stand as 

new or ongoing gaps in the literature for our women veteran population are included below: 

1) Limited clinical and intervention outcome data for chronic physical or mental health 

conditions and complex combinations of diseases

2) Limited information on transitions from military to civilian life

3) Minimal information of military duty and transitions on families 

4) Health issues for women veterans across the life span (e.g., pregnancy, aging) 

5) New information on general care or gender differences for veterans with polytrauma or 

traumatic brain injury

6) Challenges and strategies for comanaging mental health and general preventive health 
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

We anticipate that the increases in VA women’s health services research funding over the past 

5 years will continue to affect the topical coverage and methodological diversity and rigor 

seen in the coming 5 years. Ongoing efforts to continually update the literature, augmented by 

interactive search capabilities, will enhance the value and application of this growing evidence 

base to ongoing care improvements in health care settings within and outside the VA. Separately, 

we suggest that internal final reports of VA supported research should document if the study 

contained findings reportable by gender (whether the same or different) even if that was not one

of the research aims of the study. Such detailing offers insight to unknown areas of disparity or 

equity in veteran health and healthcare. 

The primary limitation of this systematic review, as with any review, is the potential for having 

missed salient articles. Search terms for our topic area of women veterans’ health and health care 

have not been standardized in such as way that authors routinely select consistent terms. We thus 

augmented traditional computerized search strategies with contacts among leading researchers in 

the field in the hopes of enhancing our yield. Now that we have a significant database of relevant 

articles, we hope that authors not represented herein will forward their articles for inclusion. As 

with any systematic review, we are also limited by publication bias.

Conclusions

The areas more fully developed in women veterans’ research (access, utilization, and quality 

of care) will serve as a foundation for future intervention and implementation research in VA. 

In addition, the already substantial scope of women veteran mental health literature should be 

expanded with future VA studies on treatment modalities and outcomes and should explore ways 

in which veteran, provider, or practice settings can incorporate potential treatments. 

Future Research

Continued need exists for clinical trials data involving women veteran health issues and women 

veteran populations.
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Systematic Review of Women Veterans Health Research 2004-2008 Evidence-based Synthesis Program

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91. Chireau, M. V., et al., Outcomes, costs, and utilization of pregnancy related care. Federal 

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95. Mrus, J. M., et al., Health-related quality of life in veterans and nonveterans with HIV/

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98. McQueen, A., et al., Predictors of perceived susceptibility of breast cancer and changes 

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100. Bean-Mayberry, B., et al., Comprehensive Care for Women Veterans: Indicators of Dual 

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102. Washington, D. L., et al., To Use or Not to Use: What Influences Why Women Veterans 

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111. Frayne, S. M., et al., Gender and Use of Care: Planning for Tomorrow’s Veterans Health 

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115. Kaur, S., et al., Gender differences in health care utilization among veterans with chronic 

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116. Hatmaker, A. R., et al., Cost-effective use of breast biopsy techniques in a Veterans health 

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118. Sherman, S. E., et al., Gender differences in smoking cessation services received among 

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119. Lairson, D. R., W. Chan and G. R. Newmark, Determinants of the demand for breast 

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120. Chen, J. H., et al., Receipt of disability through an outreach program for homeless veterans. Mil Med, 2007. 172(5): p. 461-5.

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125. Kelly, M. M., et al., Effects of Military Trauma Exposure on Women Veterans’ Use and 

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126. Zinzow, H. M., et al., Sexual assault, mental health, and service use among male and female veterans seen in Veterans Affairs primary care clinics: a multi-site study. Psychiatry 

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130. Grubaugh, A., et al., Female Veterans Seeking Medical Care at Veterans Affairs Primary 

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131. Frueh, B. C., et al., Age differences in posttraumatic stress disorder, psychiatric disorders, 

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132. Miller, E. A. and R. A. Rosenheck, Risk of nursing home admission in association with 

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133. Lang, A. J., et al., Relationships among childhood maltreatment, PTSD, and health in 

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138. Mojtabai, R., et al., Use of VA aftercare following military discharge among patients with 

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139. Maguen, S., et al., Predictors of mental and physical health service utilization among 

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143. Vogt, D. S., et al., Deployment Stressors and Posttraumatic Stress Symptomatology: 

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147. Ouimette, P., et al., Posttraumatic stress disorder and health status among female and 

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148. Escalona, R., et al., PTSD and somatization in women treated at a VA primary care clinic.

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149. Asmundson, G. J., K. D. Wright and M. B. Stein, Pain and PTSD symptoms in female 

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150. Lang, A. J., et al., Direct and indirect links between childhood maltreatment, posttraumatic stress disorder, and women’s health. Behavioral Medicine, 2008. 33(4): p. 125-135.

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152. Becker, M., The impact of childhood adversity factors on posttraumatic stress and other 

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154. Schnurr, P. S. and C. A. Lunney, Exploration of how gender differences in quality of life 

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156. Berz, J. B., et al., Associations Between PTSD Symptoms and Parenting Satisfaction in a 

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157. Murdoch, M., et al., Mitigating Effect of Department of Veterans Affairs Disability Benefits for Post-Traumatic Stress Disorder on Low Income. Military Medicine, 2005. 170(2): 

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158. Murdoch, M., et al., Gender Differences in Service Connection for PTSD. Medical Care, 

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159. Murdoch, M., et al., Regional variation and other correlates of Department of Veterans 

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160. Dobie, D. J., et al., Posttraumatic stress disorder in female veterans: association with selfreported health problems and functional impairment. Arch Intern Med, 2004. 164(4): p. 

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161. Gahm, G. A., et al., Relative impact of adverse events and screened symptoms of posttraumatic stress disorder and depression among active duty soldiers seeking mental health 

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162. Frayne, S. M., et al., The burden of medical illness in women with depression and PTSD.

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164. Campbell, R., et al., The co-occurrence of childhood sexual abuse, adult sexual assault, 

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165. Yaeger, D., et al., DSM-IV diagnosed posttraumatic stress disorder in women veterans 

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166. Himmelfarb, N., D. Yaeger and J. Mintz, Posttraumatic stress disorder in female veterans 

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