DOD HEALTH CARE

Domestic Health Care 

for Female 

Servicemembers

Report to Congressional Addressees

January 2013

GAO-13-205

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-205, a report to 

congressional addressees

January 2013

DOD HEALTH CARE

Domestic Health Care for Female Servicemembers 

Why GAO Did This Study

Female servicemembers are serving in 

more complex occupational specialties 

and are being deployed to combat 

operations, potentially leading to 

increased health risks. Similar to their 

male counterparts, female 

servicemembers must maintain their 

medical readiness; however, they have 

unique health care needs that require 

access to gender-specific services.

The National Defense Authorization 

Act for Fiscal Year 2012 directed GAO 

to review a variety of issues related to 

health care for female 

servicemembers. This report describes 

(1) the extent that DOD’s policies for 

assessing individual medical readiness 

include unique health care issues of 

female servicemembers; (2) the 

availability of health care services to 

meet the unique needs of female 

servicemembers at domestic Army 

installations; and (3) the extent that 

DOD’s research organizations have 

identified a need for research on the 

specific health care needs of female 

servicemembers who have served in 

combat. 

GAO reviewed DOD and militaryservice policies on individual medical 

readiness and surveyed senior health 

care officials about the availability of 

specific health services at the 27 

domestic Army installations with MTFs 

that report directly to the domestic 

regional medical commands. GAO 

focused on the Army because it has 

more female servicemembers than the 

other military services. GAO also 

visited six Army installations—two from 

each of the Army’s three domestic 

regional medical commands—and 

interviewed DOD officials who conduct 

research on health issues for 

servicemembers.

What GAO Found

The Department of Defense’s (DOD) policy for assessing the individual medical 

readiness of a servicemember to deploy establishes six elements to review, most 

of which are gender-neutral. Four of the six elements—immunization status, 

medical readiness laboratory tests, individual medical equipment, and dental 

readiness—apply equally to female and male servicemembers. The remaining 

elements of individual medical readiness—deployment-limiting conditions and 

periodic health assessments—include aspects that are specific to female 

servicemembers. For example, the Army, Navy, Air Force, and Marine Corps 

have policies that define pregnancy as a deployment-limiting condition.

Officials surveyed by GAO reported that female-specific health care services and 

behavioral health services were generally available through domestic Army 

installations. Specifically, according to GAO’s survey results: 

• Most routine female-specific health care services—pelvic examinations, 

clinical breast examinations, pap smears, prescription of contraceptives, and 

pregnancy tests—were available at the 27 surveyed domestic Army 

installations. 

• The availability of specialized health care services—treatment of abnormal 

pap smears, prenatal care, labor and delivery, benign gynecological 

disorders, postpartum care, and surgical, medical, and radiation treatment of 

breast, ovarian, cervical, and uterine cancers—at the 27 surveyed domestic 

Army installations varied. However, when these services were not available 

at the installation, they could be obtained through either another military 

treatment facility (MTF) or from a civilian network provider. 

• The availability of behavioral health services, such as psychotherapy or 

substance abuse treatment, which were not gender-specific, varied across 

the 27 domestic Army installations; however, similar to specialty care, these 

services could be obtained from other MTFs or civilian network providers. In 

addition, 18 of the 27 surveyed Army installations reported offering femalespecific programs or activities, such as a post-deployment group for female 

servicemembers or a postpartum group.

One DOD organization, the Women’s Health Research Interest Group, is 

currently in the process of identifying research gaps on health issues affecting 

female servicemembers. Interest group officials said that the goal is to develop a 

repository for peer-reviewed research articles related to health issues for female 

servicemembers, including those who served in combat, and to use this 

repository to identify research that could enhance the health care of female 

servicemembers, including those who have served in a combat zone. To ensure 

that researchers will have access to the results of their work, officials have plans 

to distribute their results in presentations at local and national conferences. In 

addition, officials told GAO that they will disseminate their findings through peerreviewed publications and post this information on the Internet to make it 

available to the public.

GAO provided a draft of this report to DOD for comment. DOD responded that it 

did not have any comments on the draft report.

View GAO-13-205. For more information, 

contact Randall B. Williamson, 202-512-7114, 

williamsonr@gao.gov.
Page i GAO-13-205 DOD Health Care

Letter 1 

Background 5

DOD’s Policies for Assessing Individual Medical Readiness Are 

Mainly Gender-Neutral but Include Some Aspects That Are 

Female-Specific 11

Health Care and Behavioral Health Services Were Generally 

Available to Female Servicemembers through Domestic Army 

Installations 13

One DOD Organization Is in the Process of Identifying Research 

Gaps on Health Care Needs for Female Servicemembers 19

Agency Comments 20

Appendix I List of Domestic Army Installations with a Primary 

Military Treatment Facility 23

Appendix II Scope and Methodology for the Survey Sent to Domestic 

Army Military Treatment Facilities 24

Appendix III GAO Survey Sent to Domestic Army Military Treatment 

Facilities 26

Appendix IV GAO Contact and Staff Acknowledgments 39

Tables

Table 1: Availability of Female-Specific Specialized Health Care 

Services at the 27 Domestic Army Installations, by Primary 

Military Treatment Facility Type 15

Table 2: Number of Domestic Army Installations with a Primary 

Military Treatment Facility That Offered Behavioral Health 

Services, by Type and Source of Service 17

Table 3: Number of Domestic Army Installations with a Primary 

Military Treatment Facility That Offered Behavioral Health 

Services for Substance Abuse, by Type and Source of 

Service 18

Contents 
Page ii GAO-13-205 DOD Health Care

Figures

Figure 1: Number of Active-Duty Female Servicemembers, by 

Military Service, Fiscal Year 2007 through 2012 5

Figure 2: Active-Duty Army Female Servicemembers by Age Group 6

Abbreviations

DOD Department of Defense

IMR individual medical readiness

MEDCOM Army Medical Command

MEDPROS Medical Protection System

MTF military treatment facility

NIH National Institutes of Health

PHA periodic health assessment

PTSD post-traumatic stress disorder

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Page 1 GAO-13-205 DOD Health Care

United States Government Accountability Office

Washington, DC 20548

January 29, 2013

Congressional Addressees

The role of women in the military is changing. Over the last four decades, 

the percentage of female servicemembers among enlisted ranks has 

increased seven-fold (from 2 to 14 percent) and the percentage of female 

servicemembers among commissioned officers has increased four-fold 

(from 4 to 16 percent). Currently, the largest total number of female 

servicemembers resides in the Army. Female servicemembers also are 

serving in more complex occupational specialties and are being deployed 

to combat operations, potentially leading to increased health risks.

Similar to their male counterparts, female servicemembers must maintain 

their medical readiness by ensuring that they are free of health-related 

conditions that would limit their ability to actively fulfill an assigned 

mission. Female servicemembers also have unique health care needs 

that require access to gender-specific services, including routine 

gynecological care, such as breast and cervical examinations, as well as 

specialized services, such as obstetric care (which includes prenatal, 

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

reproductive cancers. Additionally, while all servicemembers need access 

to a range of behavioral health services, such as individual or group 

therapy sessions, men and women may be affected by behavioral health 

conditions differently.1

The National Defense Authorization Act for Fiscal Year 2012 directed us 

to review a variety of issues related to health care for female 

servicemembers, including the availability of female-specific health care 

and behavioral health services, as well as the need for further clinical 

research on the health care needs of female servicemembers who have 

served in a combat zone, among other issues.

Servicemembers receive health care services 

through the Department of Defense’s (DOD) Military Health System, 

which has a dual health care mission of supporting wartime and other 

deployments, known as the readiness mission, and providing peacetime 

care, known as the benefits mission.

2

 

1

Behavioral health care includes services such as psychotherapy or treatment for 

substance abuse disorders.

In this report, we describe 

2

Pub. L. No. 112-81, § 725 (2011). 

 
 

Page 2 GAO-13-205 DOD Health Care

(1) the extent that DOD’s policies for assessing individual medical 

readiness (IMR) include unique health care issues of female 

servicemembers; (2) the availability of health care services to meet the 

unique needs of female servicemembers at domestic Army installations; 

and (3) the extent that DOD’s research organizations have identified a 

need for research on the specific health care needs of female 

servicemembers who have served in combat. While this report focuses on 

domestic installations, a separate report will provide information on the 

availability of health care for female servicemembers in deployed 

environments and for servicemembers who are victims of sexual assault.3

To describe the extent to which DOD’s policies for assessing IMR include 

unique health care issues of female servicemembers, we reviewed IMR 

policies for DOD and each of the military services—Army, Navy, Air 

Force, and Marine Corps—to determine whether these assessments 

include female-specific information and to identify any potential variations 

among the military services.4

To describe the availability of health care services to meet the unique 

needs of female servicemembers at domestic Army installations

We also interviewed DOD and military 

service officials about the IMR assessments that are conducted prior to 

deployment to identify any specific health care issues related to female 

servicemembers.

5

 

3

For information on the availability of health care for female servicemembers in deployed 

environments and for servicemembers who are victims of sexual assault, see GAO, 

Military Personnel: DOD Has Taken Actions to Meet the Needs of Deployed 

Servicewomen, but Actions Are Needed to Enhance Care for Sexual Assault Victims, 

—the 

military service with the largest number of female servicemembers—we 

surveyed senior health care officials at the 27 domestic Army 

GAO-13-182 (Washington, D.C.: Jan. 29, 2013).

4

The Navy is responsible for providing health care to members of the Marine Corps and 

their beneficiaries. The Marine Corps follows the Navy’s health care-related policies. 

However, in some cases, the Marine Corps has its own health care policies.

5

Section 2687 of Title 10 of the United States Code defines a military installation, for the 

purpose of certain base realignments and closures, as a base, camp, post, station, yard, 

center, homeport facility for any ship, or other activity under the jurisdiction of DOD, 

including any leased facility, located within a state, the District of Columbia, the 

Commonwealth of Puerto Rico, American Samoa, the Virgin Islands, the Commonwealth 

of the Northern Mariana Islands, or Guam. This term does not include any facility used 

primarily for civil works, rivers and harbors projects, or flood control. 
 

Page 3 GAO-13-205 DOD Health Care

installations6 that had a primary military treatment facility (MTF).7 (To see 

a list of the 27 domestic Army installations with a primary MTF, see 

app. I.) Through this survey, we obtained information about the availability 

of routine, specialized, and behavioral health services for female 

servicemembers from all MTFs at these installations, including the 

primary MTFs and other, smaller MTFs, such as clinics.8 (For more 

details about the survey methodology and a copy of the survey, see 

apps. II and III.) Additionally, we asked the officials to report on services 

available for these female servicemembers from other sources, including 

MTFs outside the installation and civilian network providers, and 

challenges associated with ensuring physical privacy. Through this 

survey, health care officials at the 27 domestic Army installations reported 

on the availability of health care services at these installations, to which 

more than two-thirds of the Army’s female servicemembers were attached 

as of August 1, 2012.9 To supplement information collected in the survey, 

we also conducted site visits to six domestic Army installations—two 

installations in each of the medical regions and two of each type of MTF 

that serves as the primary MTF10

 

6

The 27 domestic Army installations that had a primary MTF are located in the continental 

United States. 

—to interview officials in charge of 

routine, specialized, and behavioral health services. We also spoke with 

7

An MTF is a hospital or clinic owned and operated by DOD that provides medical or 

dental care or both to eligible individuals. For the Army, a primary MTF is a facility that 

reports directly to the regional medical command and is responsible for reporting 

information for other associated MTFs, which may include smaller MTFs, such as clinics, 

on the same installation, as well as MTFs on different Army installations or at installations 

operated by other military services. All domestic Army MTFs report to the Army Medical 

Command through the 27 primary MTFs that we surveyed. Our survey focused only on 

the services available for female servicemembers located at one of the installations with a 

primary MTF.

8

We developed lists of female-specific routine and specialized health care services, as 

well as a list of behavioral health services. We then refined and validated these lists of 

services as those services that should be available to female servicemembers through 

discussions with Army health care providers.

9

For example, the survey would not account for services available to female 

servicemembers who may be attached to 1 of the 27 domestic installations but are 

temporarily located at another location, such as those who are off the installation for 

training.

10Within the continental United States, the Army is organized into three medical regions—

Northern, Southern, and Western. Additionally, all primary Army MTFs are classified as an 

Army Health Center/Clinic, Army Community Hospital, or an Army Medical Center.
 

Page 4 GAO-13-205 DOD Health Care

officials about policies related to physical privacy and observed the 

physical space used for health care delivery for female servicemembers. 

We visited MTFs at Fort Benning, Georgia; Fort Gordon, Georgia; Fort 

Huachuca, Arizona; Fort Lee, Virginia; Fort Lewis, Washington; and Fort 

Meade, Maryland. Additionally, during our site visits, we conducted 

individual interviews with 39 female servicemembers about available 

health care services, including questions about physical privacy. 

Specifically, we interviewed six to eight women at each location who

• were either an enlisted servicemember or an officer;

• did not work at any of the MTFs on the installation; and

• had previously deployed.

The views expressed by these servicemembers cannot be generalized to 

all female Army servicemembers.

To describe the extent to which DOD’s research organizations identified a 

need for research on the specific health care needs of female 

servicemembers who have served in combat, we interviewed officials 

from specific DOD research organizations that fund or conduct research 

involving individuals who have served in a combat zone. This includes the 

Defense Health Program from the Office of the Assistant Secretary of 

Defense for Health Affairs, as well as organizations for the three military 

departments, such as the U.S. Army Medical Research and Materiel 

Command. Additionally, we interviewed officials from other DOD research 

organizations, including the TriService Nursing Research Program and its 

Women’s Health Research Interest Group. We also reviewed 

documentation about research currently underway and descriptions on 

how these organizations determine what research to fund or conduct.

We conducted this performance audit from April 2012 through January

2013 in accordance with generally accepted government auditing 

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

obtain sufficient, appropriate evidence to provide a reasonable basis for 

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

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.
 

Page 5 GAO-13-205 DOD Health Care

From fiscal year 2007 through 2012, the total number of female 

servicemembers has grown from 200,941 to 208,905, with female 

servicemembers comprising about 14 percent of the total active duty 

force. During this time, the largest number of active-duty female 

servicemembers resided in the Army.11

Figure 1: Number of Active-Duty Female Servicemembers, by Military Service, 

Fiscal Year 2007 through 2012

(See fig. 1.)

Note: The Coast Guard is not included in this figure. Data are as of September 30, 2012.

In fiscal year 2012, more than three-quarters of the Army’s female 

servicemember population was age 35 and under, with the largest group 

being between 18 and 24 years old. Recommendations for femalespecific preventative health screenings are based on age, such as 

cervical cancer screening, which would be applicable for female 

 

11This information does not include the Coast Guard.

Background 
 

Page 6 GAO-13-205 DOD Health Care

servicemembers from an early age, while others, such as mammograms, 

are currently not recommended until age 50, absent any personal history 

of health problems of this nature.12

Figure 2: Active-Duty Army Female Servicemembers by Age Group

(See fig. 2.)

Note: Due to rounding, the percentages do not add up to 100. Data are as of September 30, 2012.

 

12The Guide to Clinical Preventive Services 2012, Recommendations of the U.S. 

Preventive Services Task Force. 
 

Page 7 GAO-13-205 DOD Health Care

DOD operates its own large, complex health system—the Military Health 

System—that provides health care to approximately 9.7 million 

beneficiaries across a range of venues, from MTFs located on military 

installations to the battlefield.13

The care of the eligible beneficiary population is spread across the 

military departments—Army, Navy, and Air Force. Each military 

department delivers care directly through its own MTFs, which are 

managed by their medical departments, including

These beneficiaries include active-duty 

servicemembers and their dependents, eligible National Guard and 

Reserve servicemembers and their dependents, and retirees and their 

dependents or survivors. The Military Health System has a dual health 

care mission: supporting wartime and other deployments, known as the 

readiness mission, and providing peacetime care, known as the benefits 

mission. The readiness mission provides medical services and support to 

the armed forces during military operations and involves deploying 

medical personnel and equipment, as needed, around the world to 

support military forces. The benefits mission provides medical services 

and support to members of the armed forces, their family members, and 

others eligible for DOD health care.

• the Army’s Medical Command (MEDCOM);

• the Navy’s Bureau of Medicine and Surgery, which is also responsible 

for providing health care to members of the Marine Corps and their 

beneficiaries; and

• the Air Force Medical Service.

Servicemembers obtain health care through the military services’ system 

of MTFs, which is supplemented by participating civilian health care 

providers, institutions, and pharmacies to facilitate access to health care 

services when necessary. Active-duty servicemembers receive most of 

their care from MTFs, where they receive priority access over other 

beneficiaries.

 

13In addition to approximately 9.7 million beneficiaries, DOD also provides care and, in 

some cases, rehabilitation for veterans as part of its coordination with the Department of 

Veterans Affairs on health care services.

The Military Health System
 

Page 8 GAO-13-205 DOD Health Care

Within the continental United States, the Army is organized into three 

medical regions—Northern, Southern, and Western—each headed by a 

subordinate regional medical command, which exercises authority over 

the MTFs in its region. Across the three regions, there are 27 domestic 

Army installations with a primary MTF, which report directly to the 

regional medical commands and are responsible for reporting information 

for other associated MTFs, which may include smaller MTFs, such as 

clinics, on the same installation, as well as MTFs on different Army 

installations or at installations operated by other military services. For 

example, at Fort Benning, there are multiple facilities located on the 

installation, including Martin Army Community Hospital—the primary 

MTF—as well as several clinics. In addition to reporting for all of those 

facilities, Martin Army Community Hospital also reports to the regional 

medical command for other Army facilities located off the installation, 

including an Army clinic at Eglin Air Force Base in Florida.

All Army MTFs, both primary and associated, can be classified under one 

of three categories on the basis of their size:

• Army Health Centers/Clinics are generally the smallest facilities only 

offering outpatient primary care.14

• Army Community Hospitals are larger than clinics and offer primary 

and secondary care, such as inpatient care and surgery under 

anesthesia.

• Army Medical Centers are generally the largest facilities offering 

primary and secondary care as well as other care, such as cancer 

treatments, neonatal care, and specialty diagnostics.

Each of the military services is responsible for maintaining the medical 

readiness of its active-duty force. DOD’s IMR policy establishes six 

elements for the military services to assess in order to determine a 

servicemember’s medical readiness to deploy:

 

14Primary care is basic or general health care traditionally provided by doctors trained in 

family practice, pediatrics, and internal medicine. It may also include care provided by 

doctors trained in gynecology. 

Army MTFs

Individual Medical 

Readiness
 

Page 9 GAO-13-205 DOD Health Care

1. dental readiness,

2. deployment-limiting conditions, 

3. immunization status,

4. individual medical equipment,15

5. medical readiness laboratory tests, and

6. periodic health assessments (PHA).

DOD’s policy establishes a baseline of standards for continuously 

assessing each of the IMR elements. In addition to this, each of the 

military services establishes its own policy that may include more specific 

criteria. Each military service is responsible for assessing and 

categorizing a servicemember’s IMR as follows:

• Fully medically ready, current in all categories.

• Partially medically ready, lacking one or more immunizations, 

readiness laboratory tests, or medical equipment.

• Not medically ready, existence of a chronic or prolonged 

deployment-limiting condition, including servicemembers who are 

hospitalized or convalescing from serious illness or injury, or 

individuals who require urgent dental care.

• Medical readiness indeterminate, inability to determine the 

servicemember’s current health status because of missing health 

information such as a lost medical record, an overdue PHA, or an 

overdue dental exam.

 

15The core requirement for individual medical equipment is one pair of gas mask inserts 

for all personnel needing visual correction. Service-specific policies, such as those for the 

Navy, may identify additional items of medical equipment, such as two pair of prescription 

spectacles and hearing aid batteries.
 

Page 10 GAO-13-205 DOD Health Care

All of the military services use different systems to collect information 

about IMR status.16 In addition, DOD requires that each of the services 

provide quarterly reports about the IMR status of their servicemembers.

DOD and the military services have a number of organizations that fund 

or conduct research, including research on health care issues that affect 

those who have served in a combat zone. The Defense Health Program 

within DOD’s Office of the Assistant Secretary of Defense for Health 

Affairs receives significant funding for this research through its annual 

appropriation.17 Through an interagency agreement, the Army Medical 

Research and Materiel Command manages the day-to-day execution of

this funding through joint program committees. There are several joint 

program committees that focus on specific research areas, including 

clinical and rehabilitative medicine and military operational medicine.18

Officials from the other military services participate in these committees. 

Research organizations from the military services, such as the Naval 

Medical Research Center, the Office of Naval Research, and the Air 

Force Medical Support Agency, also manage funds from the Defense 

Health Program for research. In addition to the military services, other 

organizations within DOD also fund or conduct research, including the 

TriService Nursing Research Program, which funds and supports 

research on military nursing.

 

16For example, for the Army, the Medical Protection System (MEDPROS) was developed 

to track all immunization, medical readiness, and deployability data for all active and 

reserve components of the Army as well as civilians, contractors, and others. It is a tool 

allowing the chain of command to determine the medical and dental readiness of 

individuals, units, and task forces. Commanders and medical leaders at various echelons 

are responsible for the use and implementation of MEDPROS to measure their 

unit/individual medical readiness status.

17The Department of Defense Appropriations Act, 2012, provided $1,267,306,000 for 

research, development, testing, and evaluation for the Defense Health Program for fiscal 

year 2012. Pub. L. No. 112-74, div. A, tit. VI, 125 Stat. 786, 802 (2011).

18Military operational medicine includes research on psychological health. 

Research Organizations
 

Page 11 GAO-13-205 DOD Health Care

DOD’s policy establishes six elements for assessing the IMR of a 

servicemember to deploy, most of which are gender-neutral. Four of the 

six elements—immunization status, medical readiness laboratory tests, 

individual medical equipment, and dental readiness—are gender-neutral; 

they apply equally to female and male servicemembers. In order to pass 

these elements of the IMR assessment, servicemembers must be current 

for each element, by having

• immunizations, including MMR (measles, mumps, and rubella);

• medical readiness laboratory tests, such as a human 

immunodeficiency virus test and results current within the past 

24 months; 

• individual medical equipment, such as gas mask inserts for all 

personnel needing visual correction; and

• an annual dental exam.19

The remaining elements of IMR—deployment-limiting conditions and 

PHAs—include some aspects that are specific to female 

servicemembers. The Army, Navy, Air Force, and Marine Corps have 

policies that define pregnancy as a deployment-limiting condition. In 

addition, they also have policies that establish a postpartum deferment 

period—generally 6 months after delivery20

 

19The results of the dental exam must fall into class 1 or 2 in order to pass this element. 

Class 1 results do not require dental treatment or reevaluation. For class 2, the results 

require nonurgent dental treatment or reevaluation of conditions that are unlikely to result 

in dental emergencies within the next 12 months.

—when a female 

servicemember is not required to deploy. The deferment period was 

established in order to provide for medical recovery from childbirth and to 

allow additional time to prepare family care plans and child care. 

However, each of the military services has a policy that allows the 

servicemember to voluntarily deploy before the period has expired. In 

addition, cancer that requires continuing treatment and specialty 

evaluations can also be a deployment-limiting condition. Although cancer 

treatment could affect both male and female servicemembers, there are 

some cancers that would be specific to female servicemembers, such as 

20The Navy has a 12-month postpartum deferment period.

DOD’s Policies for 

Assessing Individual 

Medical Readiness 

Are Mainly GenderNeutral but Include 

Some Aspects That 

Are Female-Specific 
 

Page 12 GAO-13-205 DOD Health Care

ovarian cancer, while other cancers are specific to male servicemembers, 

such as prostate cancer.

The PHA includes a review of information about preventative screenings 

and counseling for each servicemember. Some of the preventative 

screenings that are reviewed as part of the PHA are female-specific, such 

as mammograms and pap smears. To satisfy this element of IMR, a 

servicemember’s PHA must be current—the assessment of any changes 

in health status must have occurred within the past year—for both female 

and male servicemembers.21 The results of these preventative screenings 

do not negatively affect this element of a servicemember’s readiness 

assessment even when follow-on studies, labs, referrals or additional 

visits may be pending or planned.22 Nonetheless, these screenings could 

identify a health issue that would be considered a deployment-limiting 

condition—a separate element of IMR—and could therefore limit 

readiness. For example, the results of a mammogram may identify cancer 

that requires treatment or specialized medical evaluations that could be 

determined to be a deployment-limiting condition.

 

21DOD’s instruction allows for a 90-day grace period to conduct this assessment. 

22The frequency of these screenings is based on national standards, such as 

recommendations by the U.S. Preventive Services Task Force and may not be conducted 

annually.
 

Page 13 GAO-13-205 DOD Health Care

On the basis of our survey, we found that most routine female-specific 

health care services—including pelvic examinations, clinical breast 

examinations, pap smears, screening mammographies, prescription of 

contraceptives, and pregnancy tests—were available through the MTFs at 

the 27 domestic Army installations with a primary MTF.23

Senior health care officials at all of the 27 domestic installations we 

surveyed reported that both male and female providers were available to 

perform routine services for female servicemembers with the exception of 

mammography, which varied; however, all of the installations that made 

this service available (25 of 27) had female technicians.

Screening 

mammography services were not available at two of these installations; 

however, in those instances, this service was available from a civilian 

network provider.

24

 

23We surveyed senior health care officials at the 27 domestic Army installations with a 

primary MTF to obtain information about the availability of routine, specialized, and 

behavioral health services for female servicemembers. A copy of the survey and the 

specific types of health care services are included in app. III.

At the 

6 installations that we visited, 21 of the 39 female servicemembers we 

interviewed told us that they did not have a gender preference for their 

providers, while 14 said that they did have a preference that was 

accommodated. The remaining 4 female servicemembers we interviewed 

stated that they had asked for a female provider, but the request could 

not be immediately accommodated. One female servicemember was told 

24We did not survey about the availability of male and female providers to provide 

pregnancy tests as senior health care officials stated that this health care service is not 

one that is necessarily administered by health care providers.

Health Care and 

Behavioral Health 

Services Were 

Generally Available to 

Female 

Servicemembers 

through Domestic 

Army Installations

Routine and Specialized 

Female-Specific Health 

Care Services Were 

Generally Available at the 

Domestic Army 

Installations We Reviewed 

or from Other Sources
 

Page 14 GAO-13-205 DOD Health Care

that she would have to wait 3 months to see a female provider, so she 

opted to see a male provider.

On the basis of our survey, the availability of specialized health care 

services varied by the type of primary MTF on the domestic Army 

installation; however, when services were not available at the installation, 

they were available through other MTFs or from a civilian network 

provider.25 Specifically, more types of specialized health care services 

were available on installations with a larger Army Medical Center as the 

primary MTF than at installations with a smaller Army Health 

Center/Clinic. For example, none of the installations where the primary 

MTF was an Army Health Center/Clinic offered surgical, medical, or 

radiation treatments for breast, ovarian, cervical, and uterine cancers, 

whereas some installations where the primary MTFs were Army 

Community Hospitals and Army Medical Centers did make these 

treatments available. (See table 1.) Additionally, both male and female 

providers were available to provide specialized female-specific services—

such as treatment of abnormal pap smear, prenatal care, labor and 

delivery, benign gynecological disorders, and postpartum care—that were 

offered at the 27 domestic Army installations.

 

25Other MTFs could include Army MTFs located on a different installation or an MTF 

operated by another military service.
 

Page 15 GAO-13-205 DOD Health Care

Table 1: Availability of Female-Specific Specialized Health Care Services at the 27 Domestic Army Installations, by Primary 

Military Treatment Facility Type

Type of primary military treatment facility on the installation

Specialized health care service

Army Health 

Center/Clinic (n=7)

Army Community 

Hospital (n=14)

Army Medical 

Center (n=6)

Treatment of abnormal pap smear 5 (71 %) 14 (100 %) 6 (100 %)

Prenatal care 1 (14) 13 (93) 6 (100)

Labor and delivery 1 (14) 12 (86) 5 (83)

Benign gynecological disorders 7 (100) 14 (100) 6 (100)

Postpartum care 5 (71) 13 (93) 6 (100)

Diagnostic mammography 2 (29) 14 (100) 6 (100)

Surgical treatment of breast cancer 0 (0) 11 (79) 6 (100)

Medical treatment of breast cancer 0 (0) 3 (21) 5 (83)

Radiation treatment of breast cancer 0 (0) 0 (0) 2 (33)

Surgical treatment of ovarian, cervical, uterine cancer 0 (0) 7 (50) 3 (50)

Medical treatment of ovarian, cervical, uterine cancer 0 (0) 2 (14) 4 (67)

Radiation treatment of ovarian, cervical, uterine cancer 0 (0) 0 (0) 3 (50)

Source: GAO.

Note: Data are from GAO’s survey of the 27 domestic Army installations with a primary military 

treatment facility.

In addition, when asked about the availability of other programs, officials 

from 25 of the 27 domestic Army installations we surveyed reported 

offering female-specific health care programs or activities, including 

female-specific groups for breast cancer, pregnancy education, 

pregnancy physical training, postpartum care, women’s clinics, and health 

care fairs. Five of the six installations that we visited reported having 

female-specific programs, such as breast cancer awareness activities, 

lactation consultants, a women’s clinic or health care team, annual 

women’s health care fair, and a pregnancy physical training program.

With respect to privacy for individuals, including female servicemembers, 

who seek care at domestic Army MTFs, Army MEDCOM officials noted 

that reasonable safeguards should be in place to limit incidental, and 
 

Page 16 GAO-13-205 DOD Health Care

avoid prohibited, uses and disclosures of information.26

When asked to report on the challenges MTFs face in ensuring the 

physical privacy of female servicemembers, senior health care officials at 

most domestic Army installations (18 of 27) we surveyed did not report 

examples of any challenges. However, officials from the remaining nine 

installations cited two privacy-related challenges—physical layout of the 

exam rooms and auditory issues. For example, officials from three 

installations reported that some exam rooms were configured such that 

some examination tables face the door. Officials from two of these 

installations reported the use of a privacy curtain to overcome this room 

limitation. Nonetheless, all of the female servicemembers that we 

interviewed at the six sites that we visited felt that adequate steps were 

taken to ensure their physical privacy during health care visits. Officials 

from another installation reported on the survey that the layout of a 

waiting room may allow for conversations at the reception desk to be 

overheard, which may compromise patient privacy. Additionally, 3 of the 

39 female servicemembers that we interviewed stated that they had 

concerns regarding auditory privacy in the waiting or exam rooms. At 

three of the six installations that we visited, we observed clinics that had 

waiting areas with separate check-in bays, such as those for walk-in 

appointments, pharmacy, and laboratory tests. The separation of these 

check-in areas spread people out and provided more distance between 

those checking in and those sitting in the waiting rooms.

For example, 

cubicles, dividers, shields, curtains, or similar barriers should be utilized in 

an area where multiple patient-staff communications routinely occur. DOD 

provides space-planning criteria for health facilities that assert that private 

space be made available to counsel patients, including facilities for 

outpatient women’s health services.

 

26The Health Insurance Portability and Accountability Act Privacy Rule requires covered 

entities to have in place appropriate administrative, technical, and physical safeguards to 

protect the privacy of protected health information and to make reasonable efforts to 

prevent uses and disclosures not permitted by the rule. See 45 C.F.R. § 164.530(c). The 

Department of Health and Human Services does not consider restructuring of hospitals 

and doctors’ offices, such as providing private rooms and soundproof walls, to be a 

requirement under this standard.
 

Page 17 GAO-13-205 DOD Health Care

Behavioral health illnesses affect both men and women, and with the 

exception of postpartum depression, are not easily distinguished by 

gender. Consequently, behavioral health services are not inherently 

gender-specific.

Behavioral health services were provided in a variety of settings, such as 

through outpatient, inpatient, residential, and telebehavioral settings. We 

found in our survey that the availability of behavioral health services at 

domestic Army installations varied; however, when these services were 

not available at the installation, they were available from other sources, 

including from other MTFs or from civilian network providers. (See 

table 2.) All of the 27 domestic Army installations we surveyed offered 

individual and group outpatient treatments, and most (23 of 27) offered 

family outpatient treatment. If treatments were not available at the 

installation, they were offered from another MTF or a civilian network 

provider. About one-third (10 of 27) of domestic Army installations offered 

inpatient treatment, and fewer offered residential treatment (5 of 27).

Table 2: Number of Domestic Army Installations with a Primary Military Treatment Facility That Offered Behavioral Health 

Services, by Type and Source of Service

Behavioral health service

Available at the 

installation

Available from another military 

treatment facility 

(off the installation)

Available from a civilian 

network provider

Individual outpatient treatment 27 18 25

Family outpatient treatment 23 12 25

Group outpatient treatment 27 16 24

Inpatient treatment 10 15 25

Residential treatment 5 14 24

Source: GAO.

Note: Data are from GAO’s survey of the 27 Army domestic installations with a primary military 

treatment facility, 2012. Survey respondents were asked to report on the availability of a behavioral 

health service from each of these sources for female servicemembers at their installation. Services 

may be available from more than one source, so the totals are not mutually exclusive.

In addition to general behavioral health services, all of the domestic Army 

installations included in our survey offered some type of behavioral health 

services for substance abuse. (See table 3.) With regard to the availability 

of substance abuse treatment options, all 27 domestic Army installations 

we surveyed offered individual outpatient treatment. All but one domestic 

Army installation offered group outpatient treatment and more than a third 

(11 of 27) offered family outpatient treatment. Few domestic Army 

installations offered inpatient treatment (5 of 27) or residential treatment 

(4 of 27) for substance abuse. If these treatments were not available on 

While Not Inherently 

Gender-Specific, 

Availability of Behavioral 

Health Services at 

Domestic Army 

Installations Varied but 

Was Offered from Other 

Sources 
 

Page 18 GAO-13-205 DOD Health Care

the installations, they were available from another MTF, a civilian network 

provider, or both.

Table 3: Number of Domestic Army Installations with a Primary Military Treatment Facility That Offered Behavioral Health 

Services for Substance Abuse, by Type and Source of Service

Behavioral health service for substance abuse

Available at the 

installation

Available from 

another military 

treatment facility 

(off the installation)

Available from a 

civilian network 

provider

Individual outpatient treatment for substance abuse 27 18 23

Family outpatient treatment for substance abuse 11 12 24

Group outpatient treatment for substance abuse 26 19 23

Inpatient treatment for substance abuse 5 15 26

Residential treatment for substance abuse 4 15 25

Source: GAO.

Note: Data are from GAO’s survey of the 27 Army domestic installations with a primary military 

treatment facility, 2012. Survey respondents were asked to report on the availability of a behavioral 

health service for substance abuse from each of these sources for female servicemembers at their 

installation. Services may be available from more than one source, so the totals are not mutually 

exclusive.

As a way to increase access to behavioral health services, telebehavioral 

health services—medically supervised behavioral health treatment using 

secured two-way telecommunications technology to link patients from an 

originating site for treatment with providers who are at another site—can 

be used to connect servicemembers and behavioral health providers. 

This service was available at 22 of the 27 domestic installations we 

surveyed. Telebehavioral health services can be used to provide 

treatment to servicemembers in remote locations, where providers may 

not be readily available, and to ensure continuity of care for 

servicemembers who change duty stations.

While behavioral health services are not inherently gender-specific, a 

number of Army installations we surveyed reported offering programs or 

activities that were specific to women. Officials from 18 of 27 domestic 

Army installations provided examples of female-specific behavioral health 

programs or activities, including a post-deployment group for female 

servicemembers, postpartum groups, and specific therapy groups for 

female servicemembers. Four of the six installations we visited reported 

having female-specific behavioral health programs or activities, such as 

postpartum, post-deployment, and general women’s support groups. The 

importance of female-specific groups was echoed by most (34 of 39) of 

the female servicemembers that we interviewed. These female 
 

Page 19 GAO-13-205 DOD Health Care

servicemembers told us that there was a need for female-specific groups 

for certain topics, such as post-traumatic stress disorder (PTSD), 

postpartum depression, parenting, and general female servicemember 

issues. 

With respect to privacy when providing behavioral health services, 

officials from 17 of the 27 domestic Army installations that we surveyed 

did not report any challenges to ensuring physical privacy when providing 

behavioral health services to female servicemembers when asked to 

report on the challenges MTFs face in ensuring the physical privacy of 

female servicemembers. Officials from the other 10 installations reported 

two main challenges to ensuring physical privacy—having mixed gender 

waiting rooms and concerns regarding auditory privacy in the waiting or 

exam rooms. Three of the 27 installations reported using white noise 

machines in an effort to help mask noise and address any potential 

auditory concerns. All of the female servicemembers we interviewed at 

the six installations that we visited felt that adequate steps were taken to 

ensure their physical privacy during behavioral health visits.

The Women’s Health Research Interest Group, which is supported by the 

TriService Nursing Research Program, is currently in the process of 

identifying research gaps on health issues affecting female 

servicemembers. As part of this effort, they are comparing a compiled list 

of existing research with data on health care issues for female 

servicemembers to determine if there are any existing gaps in research. 

Interest group officials said that the goal is to develop a repository for 

peer-reviewed research articles related to health issues for female 

servicemembers, including those who served in combat, and to use this 

repository to identify research that could enhance the health care of 

female servicemembers, including those who have served in a combat 

zone. To ensure that researchers will have access to the results of their 

work, officials have plans to distribute their results in presentations at 

local and national conferences. In addition, officials told us that they will 

disseminate their findings through peer-reviewed publications and post 

this information on the TriService Nursing Research Program website, 

which is available to the public. However at the time of our review, only 

one DOD research organization that we spoke with was aware of their 

work. Specifically, an official from the Air Force Medical Support Agency 

told us that it was aware of the efforts by the Women’s Health Research 

Interest Group. In addition, other DOD research organizations told us that 

they would be interested in the results of this work even though they were 

not aware of it at the time of our discussion.

One DOD 

Organization Is in the 

Process of Identifying 

Research Gaps on 

Health Care Needs for 

Female 

Servicemembers 
 

Page 20 GAO-13-205 DOD Health Care

While none of the other DOD research organizations that we spoke with 

are trying to identify gaps in research on female servicemembers, officials 

from each organization told us that they conduct research based on 

needs and capabilities. For example, one organization said that it reviews 

health care issues experienced during deployments and speaks with 

health care providers to determine what research is needed to better 

restore a servicemember’s ability to function. DOD research organizations 

said that while they focus their research on needs or capabilities, they 

consider gender in their research efforts. For example, officials from one 

division of the Army Medical Research and Materiel Command told us 

that when developing a research announcement based on genitourinary 

injuries sustained during deployments, they contacted the services to 

determine the type and extent of injuries encountered. At the time of the 

inquiry, only one female was reported by the services as having a 

significant genitourinary injury and this led to the development of an 

announcement that did not specifically mention females or males. While 

this announcement was not gender-specific, officials said that research 

proposals could include female servicemembers. In addition, officials from 

another division of the Army Medical Research and Materiel Command 

told us that when discussing proposed research to examine blood 

markers for PTSD, the original proposal did not include female 

servicemembers because researchers believed that female hormones 

would make detecting blood biomarkers for PTSD more difficult. Officials 

from Army Medical Research and Materiel Command found this 

justification for leaving out female servicemembers unsatisfactory so they 

required researchers to include both genders in this study.27

We provided a draft of this report to DOD for comment. DOD responded 

that it did not have any comments on the draft report.

 

27DOD’s approach to considering gender when conducting research is similar to that of 

the National Institutes of Health (NIH), another federal agency that conducts research. 

NIH notes that women, as well as others, must be considered in all NIH-funded research, 

but may be excluded from the research with a clear and compelling rationale. See NIH 

Policy and Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical 

Research, accessed October 24, 2012, 

http://grants.nih.gov/grants/funding/women_min/guidelines_amended_10_2001.htm. 

Agency Comments
 

Page 21 GAO-13-205 DOD Health Care

We are sending copies of this report to the Secretary of Defense, 

appropriate congressional committees, and other interested parties. In 

addition, the report will be available at no charge on GAO’s website at 

http://www.gao.gov. 

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or at williamsonr@gao.gov. Contact points for our 

Office of Congressional Relations and Office of Public Affairs can be 

found on the last page of this report. Other major contributors to this 

report are listed in appendix IV. 

Randall B. Williamson

Director, Health Care
Page 22 GAO-13-205 DOD Health Care

List of Addressees

The Honorable Carl Levin

Chairman

The Honorable James Inhofe

Ranking Member

Committee on Armed Services

United States Senate

The Honorable Chairman

The Honorable Thad Cochran

Ranking Member

Subcommittee on Defense

Committee on Appropriations

United States Senate

The Honorable Howard P. “Buck” McKeon

Chairman

The Honorable Adam Smith

Ranking Member

Committee on Armed Services

House of Representatives

The Honorable C.W. Bill Young

Chairman

The Honorable Pete Visclosky

Ranking Member

Subcommittee on Defense

Committee on Appropriations

House of Representatives
Appendix I: List of Domestic Army Installations 

with a Primary Military Treatment Facility

Page 23 GAO-13-205 DOD Health Care

Facility type Installation Primary military treatment facility 

Army Regional 

Medical Command 

Army Health Center/ 

Clinic

Fort Drum, NY Guthrie Army Health Center Northern

Fort Eustis, VA McDonald Army Health Center Northern

Fort Huachuca, AZ* Bliss Army Health Center Western

Fort Leavenworth, KS Munson Army Health Center Western

Fort Lee, VA* Kenner Army Health Clinic Northern

Fort Rucker, AL Lyster Army Health Clinic Southern

Redstone Arsenal, AL Fox Army Health Center Southern

Army Community 

Hospital

Fort Benning, GA* Martin Army Community Hospital Southern

Fort Campbell, KY Blanchfield Army Community Hospital Southern

Fort Carson, CO Evans Army Community Hospital Western

Fort Irwin, CA Weed Army Community Hospital Western

Fort Jackson, SC Moncrief Army Community Hospital Southern

Fort Knox, KY Ireland Army Community Hospital Northern

Fort Leonard Wood, MO General Leonard Wood Army Community Hospital Western

Fort Meade, MD* Kimbrough Ambulatory Care Center Northern

Fort Polk, LA Bayne Jones Army Community Hospital Southern

Fort Riley, KS Irwin Army Community Hospital Western

Fort Sill, OK Reynolds Army Community Hospital Southern

Fort Stewart, GA Winn Army Community Hospital Southern

Fort Wainwright, AK Bassett Army Community Hospital Western

West Point, NY Keller Army Community Hospital Northern

Army Medical Center Fort Bliss, TX William Beaumont Army Medical Center Western

Fort Bragg, NC Womack Army Medical Center Northern

Fort Gordon, GA* Dwight D. Eisenhower AMC Southern

Fort Hood, TX Carl R. Darnall Army Medical Center Southern

Fort Lewis, WA* Madigan Army Medical Center Western

Fort Sam Houston, TX Brooke Army Medical Center Southern

Source: Department of the Army.

Note: An asterisk (*) Indicates that the installation was selected for a site visit.

Appendix I: List of Domestic Army 

Installations with a Primary Military 

Treatment Facility 
Appendix II: Scope and Methodology for the 

Survey Sent to Domestic Army Military 

Treatment Facilities

Page 24 GAO-13-205 DOD Health Care

To describe the availability of routine, specialized, and behavioral health 

care services to female servicemembers at domestic Army installations1

and from other sources, we surveyed senior health care officials at the 

27 domestic Army installations that had a primary military treatment 

facility (MTF).2

In developing the survey, we conducted pre-tests to refine and validate 

the specific health care services as those services available to female 

servicemembers in the Army and checked that (1) the terminology was 

used correctly; (2) the questionnaire did not place undue burden on 

agency officials; (3) the information could be feasibly obtained; and 

(4) the survey was complete and unbiased. We chose the four pretest 

sites to include at least one installation with a primary MTF that was a 

medical center, a community hospital, and a health center/clinic. We 

conducted one of the pretests where all GAO participants were present 

and three pretests with some GAO participants in person and others 

participated by telephone. We made changes to the content and format of 

the survey on the basis of the feedback we received during the pretests.

Through this survey, we collected information on the 

availability of these services to female servicemembers at installations to 

which more than two-thirds of the Army’s female servicemembers were 

attached as of August 1, 2012.

On August 20, 2012, Army Medical Command (MEDCOM) officials sent 

the survey to senior health care officials at the 27 domestic Army 

installations as a Word document by email that the respondents were 

requested to return after marking checkboxes or entering responses to 

 

1

For purposes of our report, the 27 domestic Army installations that had a primary military 

treatment facility (MTF) are those located in the continental United States. Section 2687 of 

Title 10 of the United States Code defines a military installation, for the purpose of certain 

base realignments and closures, as a base, camp, post, station, yard, center, homeport 

facility for any ship, or other activity under the jurisdiction of the Department of Defense 

(DOD), including any leased facility, located within a state, the District of Columbia, the 

Commonwealth of Puerto Rico, American Samoa, the Virgin Islands, the Commonwealth 

of the Northern Mariana Islands, or Guam. This term does not include any facility used 

primarily for civil works, rivers and harbors projects, or flood control. 

2

An MTF is a hospital or clinic owned and operated by DOD that provides medical or 

dental care or both to eligible individuals. For the Army, a primary MTF is a facility that 

reports directly to the regional medical command and is responsible for reporting 

information for other associated MTFs, which may include smaller MTFs, such as clinics, 

on the same installation, as well as MTFs on different Army installations or at installations 

operated by other military services. All domestic Army MTFs report to the Army Medical 

Command through the 27 primary MTFs that we surveyed. 

Appendix II: Scope and Methodology for the 

Survey Sent to Domestic Army Military 

Treatment Facilities
Appendix II: Scope and Methodology for the 

Survey Sent to Domestic Army Military 

Treatment Facilities

Page 25 GAO-13-205 DOD Health Care

open-answer boxes. All surveys were returned by September 26, 2012, 

for a 100 percent response rate. We conducted follow-up with senior 

health care officials about missing or inconsistent responses, through 

Army MEDCOM officials, between September 2012 and December 2012. 

The survey is presented in appendix III. 
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 26 GAO-13-205 DOD Health Care

Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 27 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 28 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 29 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 30 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 31 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 32 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 33 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 34 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 35 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 36 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 37 GAO-13-205 DOD Health Care
Appendix III: GAO Survey Sent to Domestic 

Army Military Treatment Facilities

Page 38 GAO-13-205 DOD Health Care
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 39 GAO-13-205 DOD Health Care

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov

In addition to the contact named above, Bonnie Anderson, 

Assistant Director; Jennie Apter; Danielle Bernstein; Natalie Herzog; 

Ron La Due Lake; Amanda K. Miller; Lisa Motley; Mario Ramsey; and 

Laurie F. Thurber made key contributions to this report.

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(291029)
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