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S. HRG. 111–205 

VA HEALTH CARE SERVICES FOR WOMEN 

VETERANS: BRIDGING THE GAPS IN CARE 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

JULY 14, 2009 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

MARK BEGICH, Alaska 

ROLAND W. BURRIS, Illinois 

ARLEN SPECTER, Pennsylvania 

RICHARD BURR, North Carolina, Ranking 

Member 

LINDSEY O. GRAHAM, South Carolina 

JOHNNY ISAKSON, Georgia 

ROGER F. WICKER, Mississippi 

MIKE JOHANNS, Nebraska 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

JULY 14, 2009 

SENATORS 

Page 

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........................... 1 

Burr, Hon. Richard, Ranking Member, U.S. Senator from North Carolina ....... 2 

Burris, Hon. Roland W., U.S. Senator from Illinois ............................................. 3 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 4 

Brown, Hon. Sherrod, U.S. Senator from Ohio ..................................................... 5 

Begich, Hon. Mark, U.S. Senator from Alaska ..................................................... 53 

WITNESSES 

Hayes, Patricia M., Ph.D., Chief Consultant, Women Veterans Health Strategic Health Care Group, U.S. Department of Veterans Affairs; accompanied by Irene Trowell-Harris, M.Ed, Ed.D, Director, Center for Women 

Veterans, U.S. Department of Veterans Affairs ................................................ 6 

Prepared statement .......................................................................................... 7 

Response to requests arising during the hearing by: 

Hon. Daniel K. Akaka ............................................................................... 44 

Hon. Patty Murray .................................................................................... 51 

Hon. Mark Begich ..................................................................................... 54, 58, 64 

Response to post-hearing questions submitted by: 

Hon. Daniel K. Akaka ............................................................................... 65 

Hon. Richard Burr ..................................................................................... 68 

Williamson, Randall B., Director, Health Care Issues, Government Accountability Office ......................................................................................................... 12 

Prepared statement .......................................................................................... 14 

Ilem, Joy, Deputy National Legislative Director, Disabled American Veterans 70 

Prepared statement .......................................................................................... 71 

Christopher, Tia, U.S. Navy Veteran; Women Veterans Coordinator, Iraq 

Veteran, Project Associate, Swords to Plowshares ............................................ 78 

Prepared statement .......................................................................................... 79 

Chase, Genevieve, U.S. Army Reserve Veteran, Operation Enduring Freedom, 

Afghanistan; Founder and Executive Director, American Women Veterans .. 82 

Prepared statement .......................................................................................... 84 

Williams, Kayla M., U.S. Army Veteran; Board of Directors, Grace After 

Fire; Senior Adviser, VoteVets.org ..................................................................... 85 

Prepared statement .......................................................................................... 87 

Olds, Jennifer, U.S. Army Veteran on behalf of Veterans of Foreign Wars ....... 89 

Prepared statement .......................................................................................... 91 

APPENDIX 

Veterans Health Administration, U.S. Department of Veterans Affairs, Patient Satisfaction Scores by Gender Using CAHPS; report .............................. 103 

Four, Marsha (Tansey), RN, Chair, Woman Veterans Committee, Vietnam 

Veterans of America; prepared statement ......................................................... 109 

Bhagwati, Anuradha K., MPP, Executive Director, Service Women’s Action 

Network (SWAN); prepared statement .............................................................. 113 

(1) 

VA HEALTH CARE SERVICES FOR WOMEN 

VETERANS: BRIDGING THE GAPS IN CARE 

TUESDAY, JULY 14, 2009 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 9:33 A.M., in room 

418, Russell Senate Office Building, Hon. Daniel K. Akaka, Chairman of the Committee, presiding. 

Present: Senators Akaka, Murray, Brown, Begich, Burris, and 

Burr. 

OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 

U.S. SENATOR FROM HAWAII 

Chairman AKAKA. This hearing of the Senate Veterans’ Affairs 

Committee will come to order. 

Aloha and good morning to all of you. Welcome to this important 

hearing on VA’s Health Care Services for Women Veterans. We will 

be looking at programs already in the works to improve access to 

and the quality of care and other unique issues facing women veterans. 

Women veterans are the fastest-growing segment of veterans. In 

1988, when VA first began providing care to women, they were only 

4 percent of the veteran population. Today, the percentage of 

women veterans is nearing 8 percent and expected to rise substantially over the next two decades. So, it is appropriate that we ask 

now, ‘‘Is VA meeting the needs of women veterans?’’ 

Many women veterans in need of services fall through the cracks 

because VA does not have a thoroughly gender-focused range of 

care set up to catch them. There are many obstacles that veterans 

face. Access to health care and homelessness are two, and many 

veterans—women veterans in particular—are struggling to get the 

services they deserve. For too long, the approach to helping veterans avoid obstacles through veteran benefits and services has 

been predominantly focused on men. Today, the Committee will review these issues and how they affect women veterans. 

While I applaud VA for the progress it has made in recent years 

to ramp up services for the rapidly growing number of women veterans, there is much still to be done to bridge the gaps in access 

to care that women veterans face compared to their male counterparts. 

I am pleased that the Committee, with the leadership of Senator 

Murray, recently approved legislation designed to enhance the understanding of women veterans’ need for health care and to imVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
2 

prove the delivery of that care. I hope to bring this legislation before the full Senate during this work period. 

Today’s hearing gives us a chance to better understand the current situation with an eye toward fixing what is not working and 

expanding what is. 

And now I’d like to call on our Ranking Member for his opening 

statement. 

STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Mr. Chairman, thank you. I hope you’re doing 

well this morning. Aloha. 

Chairman AKAKA. Aloha. 

Senator BURR. Welcome to our witnesses. 

We’re here to look at the advocacy of health care services VA provides to a growing number of individuals who have proudly worn 

the Nation’s uniform: women veterans. The statistics do not lie. In 

1990, there were 1.2 million women veterans. Today, there are 1.8 

million, a number that continues to grow. In 1990, women represented 4 percent of the veterans’ population. Today, they represent 8 percent. 

North Carolina is no stranger to this growth. My State ranks 

sixth in the total number of women veterans, with just over 67,000 

residing there. Fourteen percent of the active duty force is comprised of women, many of whom have served in combat or war 

zones. They fly combat aircraft, man missile placements, serve on 

ships in dangerous waters, drive convoys in areas at risk of ambush. 

In short, our military and our country are heavily dependent on 

the service of women. We must honor their service by ensuring VA 

health care systems meet their unique needs. 

As we move forward to do that, there is one more statistic that 

I would like to call to the attention of everyone—one that suggests 

we have some work to do. According to the VA budget submissions, 

in 2007, just over 146,000 women veterans used gender-specific 

health care services at the Veterans Administration. 

In 2008, despite the growing number of women veterans that I 

talked about, there were over 141,000 users of the system, a decline of 3 percent from just 1 year ago. 

The question this Committee must ask is why? Why do women 

veterans feel uncomfortable coming to a hospital system largely 

comprised of male patients, or do they? Does the VA provide the 

unique services required by women veterans? Does it provide these 

services in enough locations to make travel convenient? 

When VA cannot provide quality care, does it use services that 

already exist in the community that are specific to the needs of 

women? These are all questions that I am hopeful our panelists 

will help us find the answers to. 

Mr. Chairman, just across the Potomac River stands the Women 

in Military Service for America Memorial. The memorial serves as 

the ceremonial entrance of Arlington National Cemetery. I think its 

placement at the front gate of American’s most hallowed military 

cemetery is symbolic. 

3 

For many years, the service of military women often went overlooked and unheralded. We now know better. As Former Senator 

Bob Dole said at its dedication 12 years ago, the memorial serves 

as ‘‘a lens through which we can better see and appreciate the 

dedication and sacrifice of American service women.’’ 

I look forward to hearing from our witnesses today, and I hope 

that this will serve as a lens through which this Committee can see 

where improvements need to be made for women who have served 

their country and their military. 

I thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Burr. 

Now I’d like to call on Senator Burris for his opening statement. 

STATEMENT OF HON. ROLAND W. BURRIS, 

U.S. SENATOR FROM ILLINOIS 

Senator BURRIS. Thank you very much, Mr. Chairman, Ranking 

Member Burr. 

Unfortunately, Members, I am scheduled to preside over the Senate in just a few moments. But, before I go, I would like to recognize the importance of this hearing. 

As someone who has fought for the quality and diversity 

throughout my career, I believe this hearing is long overdue. Too 

often the role of women in military has been misunderstood; their 

accomplishments and needs overlooked. 

In the VA health system, women’s status as a minority has lead 

to disjointed, gender-specific care that can be difficult to access and 

hard to navigate. There is no reason why a woman seeking basic, 

primary care should have to go to two or three different providers 

in order to meet their needs. 

Women make up the largest-growing segment of the veterans’ 

population, which is all the more reason for us to move forward toward integrated services, including mental health providers that 

recognize the unique needs of women, such as military sexual trauma. 

I commend the work of the VA thus far at addressing these 

issues. Tremendous progress has been made, but I am concerned 

that only one-third of the Veterans’ health facilities provide for the 

one-stop shop approach, an approach which shows the highest level 

of patient satisfaction. All of our female veterans deserve the highest quality of care, and we must work toward that day when every 

VA facility is fully equipped to address these needs. 

Mr. Chairman, I recall a presentation on the floor by Senator 

Kay Bailey Hutchison from Texas about these women who were in 

the Air Force in World War II—and there are a few of them still 

around—and what the trauma was from Senator Hutchison’s presentation, which she was trying to get resolution. 

I became a cosponsor, so I really want to know just where that 

is because women flew those missions while the men were fighting 

the wars. They flew the supply missions on those airplanes, and 

they paid their way to Texas. Then, when they were discharged— 

unbelievably, as Senator Hutchison said—they had to pay their 

way back home. Some of these women are still alive. And after 

hearing that speech, I told her to put me on that bill as a cosponsor, because we have to recognize those women, the same way we 

4 

recognize the Tuskegee Airmen for their dedicated service to this 

country. 

So, I am going to still try to follow-up on that, Mr. Chairman, 

find out what is really happening to that resolution that Senator 

Hutchison presented to the Senate because we need to recognize 

those women that are still alive and give respect to those who 

passed on for their service to this country. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Burris. 

And now we’ll hear from Senator Murray with an opening statement. 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Thank you very much, Chairman Akaka and 

Senator Burr for holding today’s hearing to have a chance to really 

examine the status of the VA’s health care services to women veterans. I want to thank today’s witnesses for all of their hard work 

to both improve the level of care provided to women veterans and 

to increase the public awareness of this important issue, as well. 

As has been said very well by my colleagues here, since the 

founding of our Nation, women have always played a role in our 

military, and that role, of course, has changed over time. In today’s 

conflicts, women are playing a far different and far greater role. 

And, while they have historically remained as a very small portion 

of the veteran population and a small minority at the VA, women 

veterans now total about 1.8 million, and they make up nearly 8 

percent of the total veteran population in the United States. 

That percentage, we all know, is expected to increase more than 

14 percent by 2033, and the number of women veterans enrolled 

in the VA System is expected to double in the next 2 to 4 years. 

That makes female veterans one of the fastest growing demographics of the veterans today, and I think it is really important 

at this hearing and always that we remember that behind those 

statistics are real women. These are women who sacrificed for their 

country, they have borne the burden of battle, and they now deserve the respect and the benefits that their service has earned. 

Earlier this year, as has been referenced, the Committee passed 

my bill, the Women Veterans Health Care Improvements Act of 

2009. More recently, the full House has passed similar legislation. 

I think this is very important progress. I hope we can pass this out 

of the Senate soon because that bill will encourage women to access 

the VA, increase the VA’s understanding of the needs of women 

veterans and, really, the practices that helped them get the best 

kind of care. 

But we cannot stop there and we are not stopping there. I know 

that the VA is recognizing the need to improve services to women 

veterans and are taking steps to ensure equal access to benefits 

and health care for them. 

So, I look forward to today’s hearing for the steps the VA is taking and what else we need to be doing to achieve that goal. 

I would say to Senator Burris, I believe that the bill that Senator 

Hutchison was talking about was a Congressional Gold Medal that 

5 

has been sent to committee. I appreciate you bringing that up and 

hope that it can move forward. 

Senator BURRIS. Mr. Chairman, my staff said the resolution was 

approved, but we need to get the Gold Medal part for the women. 

So, that is what is pending. That is correct, for the record. 

Thank you very much, Senator Murray. We must do that. 

Chairman AKAKA. Thank you very much, Senator Murray. 

I want to welcome our principal witness from VA, Dr. Patricia 

Hayes, Chief Consultant of the Women Veterans Health Strategic 

Health Care Group. She is accompanied by Dr. Irene Trowell-Harris, Director of the VA Center for Woman Veterans. 

Following Dr. Hayes, we have GAO’s Director of Health Care 

Issues, Mr. Randall Williamson. 

Thank you, all, for being here this morning. Both VA and GAO’s 

full testimony will appear in the record. 

Before I call on Dr. Hayes for her testimony, I call on Senator 

Brown for an opening statement. 

STATEMENT OF HON. SHERROD BROWN, 

U.S. SENATOR FROM OHIO 

Senator BROWN. Yes. Thank you, Mr. Chairman. I appreciate 

that. I appreciate the work that Senator Murray has done in the 

Women Veterans Health Care Improvement Act of 2009; and thank 

you, Mr. Chairman, for holding this meeting. 

I wanted to mentioned briefly, we know what the issue is, we 

know how important it is that there be more parity—if that is the 

right word—more equality in everything from the big VA Centers 

to the CBOCs to veterans’ health care generally, but I wanted to 

tell a real quick story. 

A woman by the name of Loretta Schimmoler of Crawford County, Ohio—a rural county halfway between Columbus and Cleveland—was one of the first woman to be inducted in the Ohio Veterans Hall of Fame, helped to lead the way in what was to become 

the Flight Nurses Corps. Her story mirrors in many ways what 

women have faced in the military dealing with VA care. 

She was a dedicated patriot, intent on making our Nation and 

our military better. Despite the hurdles she faced, she was able to 

change the way our military did business to the betterment of all 

those who served. She began flying in 1932 for her service. At that 

time, nurses, of course, were almost exclusively women, and would 

serve on planes and helicopters that provided care and evacuation 

to wounded servicemembers. It was not until World War II that the 

program became a reality, due in large part to her persistence and 

her vision. 

The VA of her day, of Loretta Schimmoler’s day, looked a lot different from the Department of Veterans Affairs today in meeting 

the needs of our women veterans, but much more needs to be done. 

This hearing is a major step in doing that. 

I thank the Chairman and thank Senator Murray for her work. 

Chairman AKAKA. Thank you very much, Senator Brown. 

Again, let me call on Dr. Hayes and ask for your testimony. 

6 

STATEMENT OF PATRICIA HAYES, PH.D., CHIEF CONSULTANT, 

WOMEN VETERANS HEALTH STRATEGIC HEALTH CARE 

GROUP; ACCOMPANIED BY IRENE TROWELL-HARRIS, M.ED, 

ED.D, DIRECTOR, CENTER FOR WOMEN VETERANS, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Ms. HAYES. Good morning, Mr. Chairman and Ranking Member. 

Thank you very much for the opportunity to discuss how VA has 

provided and will continue to improve the health care for women 

veterans. 

As you mentioned, I am accompanied by Dr. Irene Trowell-Harris, the Director of the Center for Women Veterans. Thank you for 

submitting my written testimony into the record. 

I also want to thank you, Chairman Akaka and Senator Murray 

specifically, again for your interest in working with VA to ensure 

that the quality of care for women veterans is improved and that 

they do get what they deserve for service to their country. 

Secretary Shinseki recently testified before this Committee that 

enhancing the primary care for women veterans is one of VA’s top 

priorities. Women who were deployed and served in the recent conflicts in Afghanistan and Iraq are enrolling in VA at record numbers. 

Of all the women veterans who are deployed and served in Afghanistan or Iraq, VA knows that 44 percent have enrolled in VA 

health care, which suggests that many of these newly-enrolled 

women veterans really rely on VA for their health care needs. 

Women veterans are entering VA’s health care system younger, 

and they have health care needs distinct from their male counterparts. The average age of women veterans is 48-years-old compared 

to 61-years-old among men. Nearly all newly-enrolled women veterans are under age 40 and they are of childbearing age. This obviously means a trend that will create a shift in how we provide their 

care. 

This shift will move primary care and gender-specific care needs 

of women veterans from the multi-visit, multi-provider model that 

has been mentioned here—which does not achieve the continuity of 

care that we desire—to a more comprehensive, primary care delivery model. VA recognizes many current challenges and has initiated new programs, including the implementation of comprehensive primary care, enhancing the health care environment for 

women veterans, creating a mini residency education program 

among women’s health, staffing every VA Medical Center with a 

Women Veterans Program Manager, and improving communication 

and outreach to women veterans. 

Most importantly, VA is implementing an innovative approach to 

women’s health care that will address the concerns about fragmented care, quality disparities, and lack of provider proficiency in 

women’s health by fundamentally changing the experience for 

women veterans in VA. 

To achieve the goal of providing comprehensive primary care, we 

have designed three models to promote the delivery of optimal primary care, and we recognize that more than one model might be 

needed even within various facilities in order to meet the needs to 

deliver comprehensive care to women veterans. 

7 

All three models ensure that every women veteran, wherever she 

comes to VA, has access to a VA primary care provider who is capable of meeting all of her primary care needs in the one-stop shop 

model that we have described. A site-level evaluation will also 

begin so that we can be certain that this program is effective. We 

are going to start that in fiscal year 2010. 

All women veterans need to feel welcomed in their VA setting. 

The health care environment directly and indirectly affects the 

quality of the care that is provided to women veterans, and a part 

of redefining our comprehensive care to be delivered means that we 

have to have improvements in the health care environment which 

are being made in order to support dignity, privacy, and sense of 

security. 

VA recognizes many primary care providers need to update their 

women-specific clinical experience. VA is offering many residencies 

in women’s health across the country. Early results from this program indicate success in increasing competencies in 12 areas of 

women’s health care. 

As of June 2009, 216 participants from 90 VA medical centers 

and 28 community-based outpatient clinics have completed the program. In order to ensure improved advocacy at the facility level, 

VA has mandated that all medical centers appoint a full-time 

Women Veterans Program Manager. These managers support increased outreach to women veterans, improve the quality of care, 

and develop best practices in the organizational delivery of women’s health care. 

Effective internal and external communication is also important 

in terms of outreach and our success of implementing comprehensive care. VA Center for Women Veterans will continue to expand 

its ongoing outreach and communications plan to ensure not only 

public awareness of women veterans’ service to our country, but 

making sure that women veterans are aware of their eligibilities 

and access to VA health care. 

Mr. Chairman, VA’s commitment to women veterans is unwavering, and while significant efforts are underway, we know that we 

have to do a lot more to improve the care. A lot more needs to be 

done. We stand at a really unique moment in time where our actions and plans today will build this system that will provide equal 

care for all of American veterans regardless of gender. 

Thank you once again for this opportunity to testify, and we now 

are very prepared to answer any addition questions that you may 

have of us. 

[The prepared statement of Ms. Hayes follows:] 

PREPARED STATEMENT OF PATRICIA HAYES, PH.D., CHIEF CONSULTANT, WOMEN VETERANS HEALTH STRATEGIC HEALTH CARE GROUP, VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

Good morning, Mr. Chairman and Ranking Member. Thank you for the opportunity to discuss how the Department of Veterans Affairs (VA) has provided, and 

will continue to improve, health care availability for women Veterans. I would like 

to thank the Chair, this Committee and Senator Murray specifically for your interest in working with VA to ensure women Veterans receive the care they have 

earned through service to their country. 

The Secretary has recently testified before this Committee that enhancing primary care for women Veterans is one of VA’s top priorities. VA recognizes that the 

number of women Veterans is growing with women becoming increasingly dependVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6621 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
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ent on VA for their health care. Of the 1.8 million women Veterans in the United 

States more than 450,000 have enrolled for care. This number is expected to grow 

by 30 percent in the next 5 years. Women currently comprise approximately 14 percent of the active duty military, 17.6 percent of Guard and Reserves and 5.9 percent 

of VA health care users. 

Women who were deployed and served in the recent conflicts in Afghanistan and 

Iraq are enrolling in VA at historical rates. Of all women who were deployed and 

served in Afghanistan or Iraq, 44 percent have enrolled and 43 percent have used 

VA between 2 and 11 times. This suggests that many of our newer women Veterans 

rely more heavily on VA to meet their health care needs. 

My testimony will describe how VA plans to continue to enhance the delivery of 

high quality health care to this fastest growing cohort of Veterans and ensure today’s heroes and tomorrow’s Veterans receive the care they need. Women Veterans 

served; they deserve the best care anywhere. 

CURRENT CHALLENGES

Women Veterans entering VA’s system are younger and have health care needs 

distinct from their male counterparts. The average age of women Veterans is 48 

years old, compared to 61 years old among men. Nearly all newly enrolled women 

Veterans accessing VA care are under 40 and of childbearing age. This trend creates 

a need to shift how we provide health care. 

General primary care and gender-specific care needs of women Veterans are currently provided through a multi-visit, multi-provider model that may not achieve the 

continuity of care desired. Additionally, some VA facilities rely on outside providers 

for gender- specific primary care and specialty gynecological care through the use 

of fee-basis care. This approach to women’s health delivery can provide challenges 

in providing continuity of care. 

Moving to a more comprehensive primary care delivery model could challenge VA 

clinicians, who may have dealt predominately with male Veterans and sometimes 

have little or no exposure to female patients. VA facilities may also need to increase 

both focus and resources on women’s health (e.g., space, staffing, appropriately 

equipped exam rooms) to ensure adequate privacy for women during examinations. 

Initiatives are underway and under development to address these and other changes 

brought on by the increasing number of women Veterans seeking care from VA. 

The quality of health care VA provides to women Veteran’s exceeds the care many 

would receive in other settings (including commercially managed care systems, 

Medicare and Medicaid). For example, VA’s system of quality management and preventive patient care, supported by technology like our electronic health record and 

clinical reminders, ensures women are screened for unique health concerns like cervical cancer or breast cancer at higher rates than non-VA health care programs. On 

the other hand, VA is aware of existing disparities between male and female Veterans in our system. The Department is particularly concerned with performance 

measures related to cardiovascular disease, the leading cause of death in women. 

Performance scores for several quality measures, including high blood pressure, 

high cholesterol and diabetes, all of which contribute to cardiovascular disease risk, 

show a consistent difference between men and women Veterans. Gender-neutral 

prevention measures such as colon cancer screening, depression screening and immunizations show a disparity between men and women Veterans as well. For example, although VA significantly outperforms Medicare on colorectal cancer screening, 

only 75 percent of women Veterans are screened compared with 83 percent of male 

Veterans. These issues and other quality issues are being addressed. 

Some women report that lack of newborn care and child care forces them to seek 

care elsewhere. VA recently supported section 309 of S. 252, which would authorize 

VA to furnish health care services up to 7 days after birth to a newborn child of 

a female Veteran who is receiving maternity care furnished by VA if the Veteran 

delivered the child in a VA health care facility or in another facility pursuant to 

a contract for service related to such delivery. We similarly supported a companion 

measure in the House. We believe benefits such as these will help improve women 

Veterans’ perception that VA welcomes them and will provide complete, effective 

and compassionate care. 

CURRENT INITIATIVES

VA recognizes the need to continually improve our services to women Veterans, 

and has initiated new programs including the implementation of comprehensive primary care throughout the Nation, enhancing mental health for women Veterans, 

staffing every VA medical center with a women Veterans program manager, creating a mini-residency education program on women’s health for primary care physiVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6621 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
9 

cians, supporting a multifaceted research program on women’s health, improving 

communication and outreach to women Veterans, and continuing the operation of 

organizations like the Center for Women Veterans and the Women Veterans Health 

Strategic Healthcare Group. 

Comprehensive Primary Care for Women Veterans 

VA is implementing an innovative approach to women’s health care that seeks to 

reduce the possibilities of fragmented care, quality disparities, and lack of provider 

proficiency in women’s health by fundamentally changing the experience of women 

Veterans in VA. 

In March 2008, the former Under Secretary for Health charged a workgroup to 

define necessary actions for ensuring every woman Veteran has access to a VA primary care provider capable of meeting all her primary care needs, including genderspecific and mental health care, in the context of a continuous patient-clinician relationship. This new definition places a strong emphasis on improved coordination of 

care for women Veterans, continuity, and patient-centeredness. In November 2008, 

the workgroup released its final report identifying recommendations for delivering 

comprehensive primary care. These recommendations included: (1) delivering coordinated, comprehensive primary women’s health care at every VA health care facility 

by recognizing best practices and developing systems and structure for care delivery 

appropriate to women Veterans; (2) integrating women’s mental health care as part 

of primary care, including co-locating mental health providers; (3) promoting and 

incentivizing innovation in care delivery by supporting local best practices; (4) cultivating and enhancing capabilities of all VA staff to meet the comprehensive health 

care needs of women Veterans; and (5) achieving gender equity in the provision of 

clinical care. 

To implement these goals and recommendations, the Women Veterans Health 

Strategic Health Care Group developed a women’s comprehensive health implementation planning (WCHIP) tool to assist facilities in analyzing its own current health 

care delivery for women Veterans and plans for primary care delivery enhancement. 

Every VA health care facility was requested to convene a multidisciplinary planning 

and implementation team to address comprehensive primary care for women Veterans. The WCHIP tool outlines an analysis of current services and projected use, 

a market analysis and a needs assessment, which facilitated the development of a 

business plan. This plan includes resource needs, goals, timelines, budgets, training 

needs and program evaluation metrics to deliver comprehensive health care to 

women Veterans. No later than August 1, 2009, facilities will finalize their analyses 

and action plans based on the WCHIP tool. These plans will be instrumental in decisions for directing resources for fiscal 2010 and 2011. 

To achieve the goal of providing comprehensive primary care for women Veterans, 

VA has designed three models to promote the delivery of optimal primary care. 

Under the first model, women Veterans are seen within a gender neutral primary 

care clinic. Under the second model, women Veterans are seen in a separate but 

shared space that may be located within or adjacent to a primary care clinic. Under 

the third model, women Veterans are seen in an exclusive separate space with a 

separate entrance into the clinical area and a distinct waiting room. In this scenario, gynecological, mental health and social work services are co-located in this 

space. Each of these models can be tailored to local needs and conditions to 

systemize the coordination, continuity, and integration of women Veterans’ care. 

One-third of VA facilities have already adopted the third model of comprehensive 

primary care delivery and found it to be very effective. Access and wait times are 

better at sites where gender-specific services are available in an integrated women’s 

primary care setting, regardless of whether the care was delivered in a separate 

space (such as a women’s clinic) or incorporated within general primary care clinics. 

VA facilities that have established a ‘‘one-stop’’ approach to primary care delivery 

have already reported higher patient satisfaction on care coordination for contraception, sexually transmitted disease screening, and menopausal management. 

In addition to improving the primary care infrastructure for women Veterans, VA 

is committed to advancing the entire range of emergency, acute, and chronic health 

care services needed by women Veterans to develop an optimal continuum of health 

care. Such a continuum of health care includes: enhancing and integrating mental 

health care, medical and surgical specialty care, health promotion and disease prevention, diagnostic services and rehabilitation for catastrophic injuries. 

Enhancing Mental Health 

VA has identified that 37 percent of women Veterans who use VA health care 

have a mental health diagnosis; these rates are higher than those of male Veterans. 

Women Veterans also present with complex mental health needs, including depresVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6621 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
10 

sion, post- traumatic stress disorder (PTSD), military sexual trauma (MST), and 

parenting and family issues. 

In response, VA has instituted policy requirements, such as that outlined in its 

Handbook on Uniform Mental Health Services in VA medical centers and Clinics, 

to emphasize the importance of being aware of gender-specific issues when providing 

mental health care. In particular, the Handbook identifies services every health care 

facility must have available for women Veterans to ensure integrated mental health 

services as a part of comprehensive primary care for women Veterans. For example, 

the services provided optimally involve a designated, co-located, collaborative provider (psychologist, social worker, or psychiatrist) and care management with an 

emphasis on the need for safety, privacy, dignity, and respect to characterize all 

gender-specific services provided. Facilities are strongly encouraged to give patients 

treated for other mental health conditions the option of a consultation from a samesex provider regarding gender-specific issues. All inpatient and residential care facilities must provide separate and secured sleeping accommodations for women. 

Every VA facility has a designated MST coordinator who serves as a contact person 

for related issues. VA is ensuring a concerted effort to provide quality mental health 

care appropriate to the needs of women Veterans. 

Women Veterans Program Managers 

In order to ensure improved advocacy for women Veterans at the facility level, VA 

has mandated all VA medical centers appoint a full-time Women Veterans Program 

Manager. These Women Veterans Program Managers support increased outreach to 

women Veterans, improve quality of care provision, and develop best practices in organizational delivery of women’s health care. They serve as advisors to facility directors in identifying and expanding the availability and access of inpatient and outpatient services for women Veterans and provide counseling on a range of genderspecific care issues. Women Veterans Program Managers also coordinate and provide appropriate local outreach initiatives to women Veterans. As of June 2009, each 

of VA’s 144 health care systems has appointed a full-time Women Veterans Program 

Manager. 

Mini-Residency Training in Women’s Health 

As the number of women Veterans continues to grow, particularly women of childbearing age, VA recognizes many primary care providers need to update their 

women-specific clinical experience. VA is offering waves of mini-residencies in women’s health across the country in strategic geographic locations. Each mini- residency lasts two and a half days and is taught by national women’s health experts. 

Clinical staff receive presentations on contraception, cervical cancer screening and 

sexually transmitted infections, abnormal uterine bleeding, chronic abdominal and 

pelvic pain, post-deployment readjustment issues for women Veterans, and other 

womens’ health topics. Early results from this program indicate its success in increasing competencies in 12 areas of women’s health care. As of June 2009, 216 participants (119 physicians, 77 nurse practitioners, 10 physician assistants, 9 registered nurses and 1 therapist) from 90 VA medical centers and 28 communitybased outpatient clinics have either scheduled or completed this program. 

Research on Women Veteran’s Health Issues 

VA has clearly established women’s health as a research priority and intensified 

its efforts in the last decade. Currently, VA’s Office of Research and Development 

supports a broad research portfolio focused on women’s health issues, including 

studies on diseases prevalent solely or predominantly in women, hormonal effects 

on diseases in post-menopausal women, and health needs and health care of women 

Veterans. VA’s Office of Health Services Research and Development is funding 27 

research projects in this area. VA is also conducting a study that will survey 3,500 

women Veterans (both those who use VA health care and those who do not) to identify the changing health care needs of women Veterans and to understand the barriers they face in using VA health care. We anticipate receiving the results of this 

study within the next several months, and we will share these findings with the 

Committee. VA is also conducting risk assessments to track the effects of deployments on women Veterans and improve our epidemiological data on Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women Veterans through the 

National Health Study for a New Generation of U.S. Veterans (an OEF/OIF cohort 

study). We are enrolling 60,000 Veterans for this study—of these 12,000 are women. 

Outreach Initiatives 

Effective internal and external communication and outreach to women Veterans 

is critical to the success of implementing comprehensive care. Surveys and research 

show that women Veterans are often not aware of the services and benefits availVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6621 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
11 

able to them. VA is engaging in multiple efforts to correct this. For example, VA’s 

Center for Women Veterans and the Women Veterans Health Strategic Health Care 

Group will continue to expand its ongoing outreach and communications plan to ensure increased public awareness of women Veterans and their service to our country 

and increased awareness by women Veterans of VA health care. 

Center for Women Veterans 

The Center’s mission is to ensure that women Veterans have access to VA benefits 

and services on par with male Veterans; that VA programs are responsive to the 

gender- specific needs of women Veterans; that joint outreach is performed to improve women Veterans’ awareness of VA services, benefits, and eligibility criteria; 

and that women Veterans are treated with dignity and respect. The Center coordinates and collaborates with Federal, State and local agencies, Veterans service organizations and community- based organizations. 

Women Veterans Health Strategic Healthcare Group 

VA has developed a women Veterans health care ‘‘brand’’ within VA and among 

women Veterans. VA has made available upgraded communication resources, processes, and tools to Veterans Integrated Service Networks (VISN) and facilities. VA 

is building on the OEF/OIF call center to reach out to women Veterans. New scripts, 

new outreach materials and training are being developed to ensure women Veterans 

are aware of VA’s services and benefits. While these efforts have created an important foundation upon which to build, it will take sustained and coordinated planning 

to successfully reach out to women Veterans. 

FUTURE PLANS

While significant efforts are underway, we recognize that more must be done. VA 

must provide recurring funds to build adequate infrastructure for primary care and 

expand services to provide a full continuum of care for women Veterans at its secondary and tertiary care facilities. This investment of resources will contribute to 

the continuing goal of delivering quality health care focused on privacy, safety, sensitivity, dignity and continuity. 

Expanding Access to Gynecology 

Gynecologists are indispensable in providing care for women with abnormal findings on pelvic exams, such as abnormal pap smears, complicated cases of pelvic pain 

and abnormal vaginal bleeding in addition to specialized services in urology-gynecology, gynecology-oncology and obstetrics care. As VA primary care physicians increase their proficiency in women’s health care to meet the needs of the growing 

numbers of women Veterans, primary care physicians will need to have on-site gynecologists available to act as experts, consultants and teachers. VA plans to have 

a gynecologist available at each of VA’s 144 health care systems by 2012. 

Expanding Innovative Technology 

In the area of innovative technologies, VA is expanding its efforts to dramatically 

transform and improve care for women Veterans by enhancing its electronic health 

records system to provide more functionality related to women’s health, including 

clinical reminders, pharmacy alerts for teratogenic drugs, improved decision support, gender-specific health history and screening questionnaires, e-videos and other 

tools for shared decisionmaking, particularly with regard to preference-sensitive 

health care choices (e.g., breast cancer surgery and treatments). 

CONCLUSION

Mr. Chairman, VA’s commitment to women Veterans is unwavering. We stand 

now at a unique moment in time where our actions and plans today will build the 

system that will provide care equal to the health care needs of all of America’s Veterans, regardless of gender. Thank you once again for the opportunity to testify. My 

colleagues and I are prepared to address any additional questions you might have. 

Chairman AKAKA. Thank you very much, Dr. Hayes. 

Mr. Williamson, we will now begin with your testimony. 

12 

STATEMENT OF RANDALL B. WILLIAMSON, DIRECTOR OF 

HEALTH CARE ISSUES, GOVERNMENT ACCOUNTABILITY OFFICE 

Mr. WILLIAMSON. Good morning, Mr. Chairman and Members of 

the Committee. I am pleased to be here today as the Committee 

considers issues related to VA’s health delivery of service to women 

veterans. 

VA provided health services to over 281,000 women veterans in 

fiscal year 2008, an increase of 12 percent in just 2 years. Looking 

ahead, VA estimates that, while a total number of veterans will decline by 37 percent by the year 2033, the number of women veterans will increase by more than 17 percent over that period; 

thereby putting greater demands on VA’s health care system to 

meet the physical and mental health care needs of women veterans. 

Women veterans seeking care at VA medical facilities need access to a full range of physical health care services including: basic 

gender-specific services, such as cervical cancer screening and clinical breast examinations; specialized gender-specific services such 

as obstetric care and treatment of reproductive cancers; and mental 

health care services, such as care for depression and anxiety. 

In addition, women veterans from conflicts in Iraq and Afghanistan present new challenges for VA’s health care system. These 

women have experienced a greater exposure to combat than women 

participating in previous conflicts. VA data showed that as many 

as 20 percent of women veterans of Iraq and Afghanistan have 

been diagnosed with Post Traumatic Stress Disorder. An alarming 

number have also experienced sexual trauma while in the military. 

As a result, many have complex physical and mental health care 

needs. 

In my testimony today, which is based on ongoing work for the 

Committee, I will discuss three aspects based largely on the work 

we did at 19 VA medical facilities. 

First, the onsite availability of health care services for women 

veterans at VA facilities. Second, the extent to which VA facilities 

are following VA policies for delivering health care service for 

women veterans. And, third, some key challenges that VA facilities 

face in providing women’s health care. 

Dr. Hayes has outlined a number of steps VA is undertaking to 

fulfill its commitment to provide high-quality health care services 

for women veterans. VA has taken some bold steps in this regard. 

However, much remains to be done in some areas to fully implement the new initiatives. 

Regarding the availability of services, we found that basic gender-specific services, including pelvic and clinic breast examinations, were available onsite at all 9 VAMCs and 8 of the 10 CBOCs 

we visited. All of the VAMCs that we visited offered at least some 

other specialized gender-specific services, such as treatment for abnormal cervical screening test and breast cancer. 

Among the CBOCs, the two largest facilities we visited offered an 

array of specialized, gender-specific care onsite. The other eight referred women to other VA and non-VA facilities for most of these 

services. Outpatient mental health care services for women varied 

13 

widely among the VAMCs and the eight Vet Centers we visits, but 

were more limited at some of the CBOCs. 

Four CBOCs offered women-only counseling groups, and only the 

two larger CBOCs offered specific programs for women who had experienced sexual trauma in the military. Also, only two VAMCs offered residential treatment programs for women who experienced 

sexual trauma. None had dedicated inpatient psychiatric units for 

women. 

Regarding the extent to which VA facilities are following VA policies for delivering health care services for women veterans, we 

found that none of the VAMCs and CBOCs we visited was fully 

compliant with VA policy requirements related to privacy for 

women veterans in all clinical settings where those requirements 

applied. 

For example, many of the outpatient clinics we visited did not 

have adequate visual and auditory privacy in their check-in areas. 

Further, the facilities we visited were in various stages of implementing VA’s new initiative to provide comprehensive primary care 

for women veterans. 

Finally, officials at facilities that we visited identified challenges 

they face in providing health care services to the increasing numbers of women seeking VA health care. One challenge involves 

space constraints. 

For example, the number, size, and configuration of exam rooms, 

as well as limited space for women’s bathrooms, sometimes made 

it difficult for facilities to comply with VA’s privacy requirements. 

Officials also reported challenges in hiring providers with specific 

training and experience in women’s health care issues, including 

treatment for women veterans with Post Traumatic Stress Disorder 

and those who had experienced military sexual trauma. 

So, overall, Mr. Chairman, while VA has taken important steps 

in many areas to improve health care services for women veterans, 

some areas still require attention. 

Mr. Chairman, that concludes my remarks. 

[The prepared statement of Mr. Williamson follows:] 

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Chairman AKAKA. Thank you very much, Mr. Williamson. 

Dr. Hayes, thank you for your testimony. 

VA is poised to make some important changes to how care is delivered to women, but, in fairness, we seem to have a bit of a disconnect between mandates and what is actually happening. I am 

going to ask you a series of questions about this. 

First, VA has mandated that all VA medical centers appoint a 

full-time Women Veterans Program Manager. 

Does every VA medical center have one in place? 

Ms. HAYES. VA has reported, as you know, that there are 144 out 

of the 144 sites that have a full-time Women Veterans Program 

Manager. I am actively now in the process of verifying that. 

What we do know is that my office, over the last 3 months, has 

held three different trainings. We trained 142 Women Veterans 

Program Managers over the last 3 months. We think it is very important to train folks—to take these brand-new folks and make 

sure that they know what they are doing—in terms of this plan to 

develop health care for women. 

Chairman AKAKA. Dr. Hayes, hopefully, you have read the testimony of the second panel. 

Jennifer Olds details her battle with PTSD and specifically 

makes a case for cognitive therapy. Congress passed a law last year 

requiring that these state-of-the-art therapies be available to all 

veterans. 

I suppose this is something you need to take for the record, but 

are all veterans with PTSD able to receive this kind of treatment? 

Ms. HAYES. You’re right, Mr. Chairman, I will have to take that 

specifically for the record in terms of the issues about access to 

PTSD treatment. But I think that one of the things that was pointed out in the GAO report about where there is access, it is very 

important that we first ask veterans what they need, and that is 

why it is important to hear from veterans about what their struggles are and, I think, to make sure that we are addressing what 

that veteran needs in terms of her care. 

So, for example, there has been a lot of question about residential treatment. I think when we look at women veterans, we have 

to be aware that, for example, women with children are not necessarily interested in going off, leaving their children, and going to 


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a residential site. So that every time we look at what we have 

available, we have to make sure we have available for each veteran 

what she might need, whether it is intensive outpatient, residential, or telehealth-telemedicine. Some of our veterans have rated 

that as very highly successful for them to be in that type of treatment. 

So, we will take the question for the record in terms of the exact 

issue of where PTSD treatment is available, but I think that it 

needs to be a constant issue of asking the veteran what they need, 

and that particular issue for Ms. Olds, I think, is very important. 

Chairman AKAKA. Thank you. 

[The response to additional information requested during the 

hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. DANIEL K. AKAKA

TO PATRICIA HAYES, PH.D., CHIEF CONSULTANT, WOMEN VETERANS HEALTH STRATEGIC HEALTH CARE GROUP, U.S. DEPARTMENT OF VETERANS AFFAIRS

The Department of Veterans Affairs (VA) is strongly committed to making evidence-based psychotherapies for Post Traumatic Stress Disorder (PTSD) widely 

available to Veterans. VA is in the process of actively disseminating Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE), two specialized forms 

of Cognitive-Behavioral Therapy for PTSD. CPT and PE are recommended in the 

VA/Department of Defense (DOD) Clinical Practice Guidelines for PTSD stating that 

the intervention is always indicated and acceptable. Moreover, in 2008, the Institute 

of Medicine conducted a review of the literature of pharmacological and psychological treatments for PTSD and concluded in its report, Treatment of Post Traumatic Stress Disorder: An Assessment of the Evidence, that the evidence was greater 

for these treatments than for all other currently available treatments for PTSD. 

To date, 1,908 Veterans Health Administration staff have received training in 

CPT. The majority of these clinicians were trained as part of the national CPT rollout, with some staff also receiving training through similar, locally arranged training. In addition, 722 DOD clinicians have received CPT training through the national rollout or locally arranged VA training. Seven hundred and twenty-eight VHA 

providers have received training in PE, with the majority of staff being trained as 

part of the national PE rollout. One hundred and twenty-nine DOD clinicians have 

received PE training through the national rollout or other similar VA training. Additionally, VA is planning training in CPT and PE for the remainder of this Fiscal 

Year and beyond. Currently, 94 percent of VA medical centers provide CPT or PE; 

remaining sites are implementing plans to provide at least one of these therapies. 

Moreover, to promote the implementation and ongoing delivery of evidence-based 

psychotherapies for PTSD and other mental disorders, VA has designated a Local 

Evidence-Based Psychotherapy Coordinator at each medical center. 

Chairman AKAKA. Mr. Williamson, your testimony lays out that 

none of the facilities reviewed fully implemented VA’s policies for 

women’s health care. 

Could you determine the reasons behind this noncompliance? 

Was it funding, lack of training, or anything else? 

Mr. WILLIAMSON. Thank you, Mr. Chairman. 

It is very difficult sometimes to understand the reason. 

The area you referred, for example, in assuring privacy of women 

veterans, part of it is due to facilities in terms of the layout that 

currently exists and is trying to convert and modify that. But, also, 

I think part of it comes down to commitment at the local level. 

There is no doubt that the Secretary, Dr. Hayes, and others at 

the top are very committed to implementing VA policies and improving overall health care for women. Yet, as we visited the facilities, simple things that are easy to do like placing exam tables so 

the foot is away from the door, putting sanitary products in bathrooms for women—those things are easy—and if they’re not being 

45 

done, part of that reason may come back to is there a commitment 

at the local level to make sure these policies are done? 

Chairman AKAKA. Several witnesses on the second panel are 

quite critical of VA care for women. Let us take these one by one. 

DAV is most concerned that some service-connected women veterans are without access to VA health care. 

Ms. Williams detailed a lack of understanding on the part of VA 

providers. 

Ms. Christopher found that community care is easier to access 

than VA care. 

And Ms. Chase finds that, generally, VA is playing catch-up to 

meet the needs of women veterans. 

Dr. Hayes, what is at the root of all these issues, and how can 

we rectify them? 

Ms. HAYES. I think that what is at the root of these issues really 

is a system that has not been responsive to the needs of women 

veterans. 

I came a year ago and launched an initiative specifically to make 

VA more inclusive of women veterans: to establish primary care 

that meets their needs so they do not have to come for multiple visits; and to make sure that we reach out to those who do not have 

health care. 

One of the things that research has shown us over and over 

again is that women do not know that they have VA services available. And it is not good enough if we reach them yet we do not 

have the right care when they get in our front door. 

And, so, we have a very intensive effort going on, which started, 

as you saw last year, but is rolling up August 1 with every facility 

giving us an implementation plan for: how to fix primary care for 

women veterans; how to make the facilities respond to the environment of care issues; and to develop services going forward that will 

meet women veterans’ needs. I think that until we do that—until 

we make sure that it is right—then we should begin to reach out 

to our women veterans and welcome them back. We will have a 

specific initiative which we identified the need for service-connected 

women veterans to get their health care, and that is the first on 

our list. When we can be assured that there is primary care available for them when they walk in the door. 

Chairman AKAKA. Thank you. 

Senator Burr, your questions? 

Senator BURR. Thank you, Mr. Chairman. 

Dr. Hayes, I want to give you an opportunity to clarify something 

for me from a statement. 

In your testimony on page 7, you state, ‘‘As of June 2009, each 

of the VA’s 144 health care systems has appointed a full-time 

Women Veterans Program Manager,’’ but I thought I heard you say 

in the response to Senator Akaka that you were in the process of 

confirming if you had 144 Women Veterans Program Managers. 

Which one is accurate? Do we have them or are you in the process 

of verifying that we—— 

Ms. HAYES. I am personally in the process of verifying, and because I want to make sure that I can tell you that is accurate when 

we say that we have 144 in place. 

Senator BURR. How long does that take? 

46 

Ms. HAYES. We have a list out now. It is really a question sometimes of are they in place or not. The 144 was—— 

Senator BURR. But your testimony says, ‘‘As of June 2009, each 

of the VA’s 144 health care systems has appointed a full-time 

Women Veterans Program Manager.’’ 

Is that a correct statement or an incorrect statement? 

Ms. HAYES. That is a correct statement in terms of a person appointed to be in that job. We want to make sure that person is fulltime, they are able to do the job, they have been trained, and they 

are the person in place to do the work that we need them to do 

to advance this program. 

Senator BURR. But what—— 

Ms. HAYES. Some of them had just been hired—— 

Senator BURR. This is under an architecture put out by VA leadership that you are going to have 144 individuals in 144 facilities, 

and I would take for granted that listed in the dictate is permanent 

and full-time. It spells out exactly what these program managers 

are going to do. 

Ms. HAYES. That is correct. 

Senator BURR. So, I guess what I am having difficulty clarifying 

is if you say they are ‘‘in place,’’ but you have to verify they are 

in place because you want to make sure that they are full-time 

folks, et cetera. Does that mean that you have had individual facility managers who have hired somebody different than what the 

leaderships dictate was? 

Ms. HAYES. No, sir. I do not want to indicate that. 

For example, we had sites where a Women Veteran Program 

Manager was half-time, and—— 

Senator BURR. But is that allowable under—— 

Ms. HAYES. No, excuse me. I do not mean new, I meant that she 

was doing it half-time. She was performing duties serving women 

veterans in a clinic setting, and she has been appointed as a fulltime person. We want to make sure that veterans have been transferred appropriately to other people so that her full-time can be devoted to the Women Veteran Program Manager job. 

We are still in a transition phase. I’m making sure that we are 

fulfilling what we said we’re fulfilling, which is making sure those 

folks are available to do this work for us. 

Senator BURR. OK. You said on page 9, ‘‘The VA plans to have 

gynecologists available at each of the VA’s 144 health care systems 

by 2012.’’ 

Why is it 2012 and not 2009? 

Ms. HAYES. Maybe I should explain. We have gynecologists onsite in approximately 70 locations. And, again, I do not have an 

exact number for the record on that. At the other sites, we have 

gynecology services available largely by fee-basis. 

As we develop and the number of women veterans increases, we 

anticipate that we will need to bring those services in-house; and 

we want to move toward that by fiscal year 2012. 

Senator BURR. Well, do you agree with the statement that I 

made that we’ve actually had a decrease in the number of women 

seeking gender-specific health care services at the VA from last 

year to this year? 

47 

Ms. HAYES. I do not actually think that we have had a decrease. 

I think that the way that we were accounting for the numbers for 

gender-specific health care has changed, and that, in fact, masked 

some of the gender-specific care. We’ve changed from having 

women go just to pap clinics to having women go to comprehensive 

primary care clinics, and the costs of that were all rolled in together so that we actually, on paper, look like we decreased our 

gender-specific care, when, in fact, we believe that it has increased. 

Senator BURR. What percentage of gender-specific care does the 

VA purchase in the community? Has it increased or decreased? 

Ms. HAYES. I do not know the answer to that. 

Senator BURR. OK. In your testimony, you mentioned the disparity in quality between male and female veterans in the VA System. You specifically noted the disparity in prevention measures 

such as colon cancer screening, depression screening, and the immunizations. 

What are you doing to address these issues? 

Ms. HAYES. We are quite aware that there have been quality differences for women. The quality for performance measures for 

women has been significantly lower than that for men, and we 

have data now consistently showing that trend from 2006 forward. 

We have launched, with the Office of Quality and Performance, 

efforts which are identifying the quality measures at each site. 

That data was not available to facility directors until very recently, 

so, we knew there was a national problem, but we did not know 

exactly how people were doing. So, we have asked the facilities 

now—as we rolled out this data just this last week—to address specific areas at their facility where the gender performance scores are 

lower for women than men; and we are helping them as we develop 

mechanisms to look at patient factors, provider factors, and system 

factors. 

And, again, it goes back to the issues about are we providing care 

that women can access in a way that once we say, for example, 

come back for your fasting lipid test, that that is even possible for 

a woman to conveniently do. So, we need to look at all of it. We 

need to look at it from a facility-specific level, and we need to address these gender disparities very actively, and we are doing that. 

Senator BURR. You noted the recently-released report ‘‘Provisions 

of Primary Care to Women Veterans,’’ and you point to it as a roadmap for improving service to women veterans. The report’s recommendations, I think, have been well-received throughout the veterans’ community. 

Let me ask you, does the VA have a timetable for implementing 

the report’s recommendations? 

Ms. HAYES. We have a timetable for implementing comprehensive primary care to women veterans. The first part—the comprehensive plans—are due by the facilities in August, and that is 

a 5-year plan. Not to say they have 5 years to get it done, but they 

must take immediate actions, interim actions, and mid-term actions. 

Senator BURR. Does that plan encompass all of the recommendations in that report? 

48 

Ms. HAYES. That plan does not encompass all the recommendations in the report. There are many recommendations that are still 

being developed in terms of a timeline. 

Senator BURR. Whose responsibility will it be for implementing 

the recommendations in the report? 

Ms. HAYES. It is ultimately the responsibility of the Under Secretary for Health. The workgroup was set up by the Under Secretary for Health, but I consider the responsibility largely on my 

shoulders and my office. 

Senator BURR. Great. I thank you and thank you, Mr. Chairman. 

Chairman AKAKA. Thank you, Senator Burr. 

Senator Murray? 

Senator MURRAY. Thank you, Mr. Chairman. 

Let me follow-up on Senator Burr’s question on the report called 

‘‘Provision of Primary Care for Women Veterans.’’ 

I thought it was a good report, and it did a good job of detailing 

some of the most pressing challenges, but it was sent out as not 

mandatory. It was just sent out to the VA facilities. 

If it did not include any mandatory requirements or any accountability, how do we expect it to be implemented? 

Ms. HAYES. There are two factors that actually help us move forward immediately with the recommendations of the report. As I 

mentioned, there were these mandatory implementation plans 

which started in January; and there was a gap analysis that was 

mandatory and required in March; and a resource request that was 

submitted in May, which was also required. 

The other part of the policy, though, is that we have the policy 

for Women Veterans Program Health Services Handbook, formally 

known as handbook 1330.01, which has been revised and is now in 

the concurrence process. It details mandated policy changes, including the one-stop type model for Provision of Women’s Health Care 

and Primary Care. It also continues to mandate the privacy standards and the other environment issues that are required. 

Senator MURRAY. OK. Well, sometimes when things are sent out, 

it is informational; they’re not implemented. So, I am concerned 

that there is not any mandatory requirements, but we will continue 

to follow that. 

Dr. Hayes, as you know, the military currently bars women from 

serving in combat. We all know, however, in today’s wars that 

there is no frontline on the battlefield. We know that women are 

serving right alongside their male colleagues and they are engaging 

in combat with the enemy. Unfortunately, the new reality of this 

modern warfare is not well understood here at home, including by 

some in the VA. This knowledge gap obviously impacts the ability 

of women veterans to receive health care and disability benefits 

from the VA. 

What are you doing, Dr. Hayes, to ensure that all VA staff—both 

in the VHA and in the VBA—are aware that women are serving 

in combat and that they are getting the health care and benefits 

that they have earned? 

Ms. HAYES. We have initiated a number of efforts. In addition to 

training providers—we know that it is not enough just to train the 

providers in terms of women’s health—we need to train all of the 

staff. We have a staff module—a sensitivity module, which is under 

49 

development—in order to get across and make sure that everyone 

who comes into contact with women veterans appreciates the extensiveness of her service and some of the complex issues that she 

may face. 

As you know and are well aware that many of our women veterans have the effects of combat and are serving—there is not, I 

do not think, anyone who is serving today who is not under significant stress. 

Senator MURRAY. Right. But we have people who say well, you 

were not in combat. You are a woman. 

Ms. HAYES. I am distressed that those reports have come forward, and we are educating our mental health people and our 

other staff about the significance of women’s service. 

Senator MURRAY. Are you working with the Defense Department 

to make sure that the experience of women veterans is properly 

documented in their DD–214s? 

Ms. HAYES. Dr. Trowell-Harris? 

Ms. TROWELL-HARRIS. I serve as an ex-officio on the Defense Advisory Committee on Women in the Services, and the director for 

that committee also is an ex-officio on the VA Advisory Committee 

on Women Veterans. 

This issue does come up frequently, and we are attempting to 

educate everybody within DOD and VA; and currently we are exploring an option of working with DOD and VA through the White 

House Project called the Interagency Council on Women and Girls. 

But, in this case, we are looking at women veterans and servicemembers. 

We are interested in an outreach communications model for exploring that and which could help educate because the education 

is not just to women veterans, the women servicemembers—— 

Senator MURRAY. But you are talking about outreach in general. 

I am talking about the problem which women are finding on their 

DD–214s. It’s not that nobody wrote ‘‘combat’’ because nobody 

wanted to say they are in combat, but they come home and then 

they cannot get service. 

And Mr. Chairman and Members of the Committee should know 

that we do have the Defense Bill on the floor right now. I am going 

to be offering an amendment to make sure that the Defense Department properly notes the combat experience on the DD–214s so 

that when women come home, they are not fighting somebody 

when saying ‘‘but I was in combat.’’ And they reply, ‘‘Well, you 

can’t be.’’ 

Ms. TROWELL-HARRIS. Right. 

Senator MURRAY. So, I hope that I get the support of this Committee to do that. 

Ms. TROWELL-HARRIS. And that issue was raised in a roundtable 

we had recently, which we were told during that session that the 

military documents the location and they do not use the word of 

combat. So, we did take that back to the DACOWITS Committee, 

and they had somebody who is going to be looking at that. 

But this is probably an area where you all could really help us 

with that, because the documentation needs to be there. That 

would make it really easy for VA to deal with those particular 

cases. 

50 

Senator MURRAY. OK. Well, I plan on offering that. I will have 

more on the second round, but, for this round, I hear so often from 

women veterans that you can provide all the service you want, but 

I have got to take care of my kids. There is no childcare available. 

Are we looking at the issue of making sure women have childcare 

so that is not the obstacle to them getting the treatment they need? 

Ms. HAYES. As you mentioned, we are very much aware that 

women and men with children and grandparents with children 

need childcare in order to access VA services. The Secretary has us 

actively examining the issues, and we also are looking at the opinion of General Counsel. 

We may need Congress’s support on this in terms of authority to 

provide childcare, but we are actively exploring it with the task 

force. We do have some pilots—— 

Senator MURRAY. You need authority from Congress to be able 

to provide childcare? Did I hear—— 

Ms. HAYES. General Counsel may advise us. We will have to get 

back with you for the record because there is concern about the authority to provide childcare by VA. 

Senator MURRAY. Well, do you expect to have that soon? 

Ms. HAYES. Yes. Yes, ma’am, we do. 

[The response to additional information requested during the 

hearing follows:] 

51 

RESPONSE TO QUESTION ARISING DURING THE HEARING BY HON. PATTY MURRAY TO

PATRICIA M. HAYES, PH.D., CHIEF CONSULTANT, WOMEN VETERANS HEALTH STRATEGIC HEALTH CARE GROUP, U.S. DEPARTMENT OF VETERANS AFFAIRS


714qrVAm301.eps
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Senator MURRAY. OK. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you, Senator Murray. 

Senator Begich? 

STATEMENT OF HON. MARK BEGICH, 

U.S. SENATOR FROM ALASKA 

Senator BEGICH. Thank you, Mr. Chairman. Thank you very 

much for your testimony. 

I apologize I was not here when you gave your verbal testimony, 

but I have a few questions. I do want to follow-up on several of the 

questions by the Chairman and the Ranking Member in regards to 

the Women Veterans Program Managers. 

I have a friend in Alaska, Joelle Hall, who’s a female veteran 

with two kids and a husband in the Guard. She has given me kind 

of a shopping list the minute I told her that you all were coming 

in front of me. She quickly gave me a list of questions to ask and 

this is one of them. 

I know there is a lot of discussion of what the 144 is or is not, 

and I am going to ask you this question, then ask for a timeline. 

Can you provide the list of the positions that will be occupied 

and by whome full-time, part-time, and when they will actually be 

working full-time? 

Ms. HAYES. We can provide that for the record. 

Senator BEGICH. And your timetable to do that? 

Ms. HAYES. We can provide that very soon for the record. 

[The response to additional information requested during the 

hearing follows:] 


714qrVAm303.eps
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W5112101.eps
55 


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W5112103.eps
57 

Senator BEGICH. OK, I think that will specifically answer the 

questions that we are all asking around this topic and, in that 

process, make sure that we know where they are going to be assigned, which would help us understand the 144, and what they 

mean, and what they are going to be doing. 

Also, in regards to the Women Veterans Program Manager, is 

there discussion of expanding this requirement to the CBOCs? 

Ms. HAYES. We currently require that there be a liaison named 

at each CBOC—a VA employee who is the liaison to the Women 

Veterans Program Manager. We are not requiring that at the 

CBOCs. They are facilities that we are looking at, particularly at 

the very large CBOCs, as to whether that would be an appropriate 

placement. But, no, we do not have a requirement for that at the 

CBOCs. 

Senator BEGICH. Let me ask you personally. Do you think that 

is something that we should strive to do? I mean, it is easy to have 

a task force and a group, but what do you think? You are running 

the program. 

Ms. HAYES. I think that if the person is full-time at the facility 

and they are doing their job to involve everyone in taking care of 

women veterans, then we do not necessarily need one at a CBOC. 

I think the person has the ability to go out to that CBOC, to make 

sure what is going there, and to provide active coordination 

through other means—telephone and other means—with that site. 

So, I think if we make it so they are able to do their job, then 

the CBOCs do not necessarily have to have one onsite. 

Senator BEGICH. OK. Let me ask, and I do not know who would 

answer this—Dr. Hayes or Dr. Harris. In regards to the design of 

the facilities, we know—based on some of the other facilities—the 

design is not there really to take into account women veterans. 

What is the process now to expand the facilities for that purpose? 

And then I have a couple of additional questions. 

Ms. HAYES. In part of the implementation plan, which, as I said, 

could expand as far as 5 years, we have asked facilities to name 

where they need space, where they need construction monies to be 


W5112104.eps
58 

able to fix the situation in terms of women veterans. And, so, they 

are able to submit those longer-term requests right now. 

Also, my office is working with the Office of Construction and Design so that new construction appropriately has designs for women 

veterans’ exam rooms, appropriately has requirements for bathrooms, et cetera, in the new design process. 

Senator BEGICH. In the Office of Construction Design, other than 

your office, do they actually have clients that sit down with them 

on a regular basis reviewing the designs? Do people actually use 

the facilities? 

Ms. HAYES. I do not know. We would have to get back with you 

on that. 

[The response to additional information requested during the 

hearing follows:] 

WOMEN VETERANS FACILITY DESIGN GUIDANCE

VA’s Office of Construction & Facilities Management’s (CFM) guiding principles 

for the development of design and construction standards for state-of-the-art 21st 

century VA facilities include a variety of approaches to ensure they address the 

needs of Veterans, their families, and VA health care providers in the most efficient 

and cost-effective manner. 

• Advocating evidence-based design, with involvement and awareness of latest 

issues in healing environment forums including Planetree, Greenhouse, AIA Academy of Architecture for Health, American Society of Healthcare Engineers, Center 

for Health Environments Research, and others. Example: VAMC Martinsburg ’07 

Patient Single Rooms Mock-up Study with results published in Health Environments Research and Design (HERD) Journal, a leading peer reviewed evidencebased design publication. 

• Basing Space Planning Criteria and Design Guide programs on applicable evidence-based design research, active participation of VA healthcare providers, administrators, and staff. Surveying best-practice in private sector and other agencies, 

with Veterans’ input. All CFM efforts are focused on providing Veteran- and familycentric healing environments supporting world class health care. Design Guides depict functional relationships and design considerations in addition to space planning 

criteria for heath care functions. They include comprehensive information including 

an overview of design principles and concepts, narrative text descriptions, and guide 

plates for reference. 

• Extensively involving state-of-the-art experienced national health care consultants together with field input in regular VA Design and Construction Standards upgrades. CFM also follows the principles in 2010 Guidelines for the Design and Construction of Healthcare Facilities used by HHS, most state and local Authorities 

Having Jurisdiction, and the Joint Commission for Accreditation of Health Care Facilities as codes, regulations, or guidelines for design and inspection. This process 

provides the experience of a wide range of technical consultants and users. 

• Coordinating with over 70 VA advisory groups who collaborate in the development and updating of VA Design Guides, Space Planning Criteria, and Construction 

Standards and Specifications for life-cycle operations. Examples: VA Community 

Living Centers; VA Mental Health Facilities; Polytrauma Rehabilitation Centers; 

etc. 

Many of the Veteran- and family-centric environments included in our updated 

criteria reflect women’s needs; these include the privacy afforded by single bedrooms 

with bathrooms in hospitals and VA’s patient-centered design for Community Living 

Centers, replacing older design concepts of traditional nursing home care facilities, 

again with single bedrooms with bathrooms, organized in small community familylike living units. 

The Space Planning Criteria and Design Guides, completed in the recent past, 

have addressed numerous specific changes reflecting women’s issues. These include 

Design Guides for Ambulatory Care, Outpatient Clinic, and Leased-Based Clinic Design Guide, MRI, Radiology, Nuclear Medicine, Radiation Therapy, etc. Changes include increased importance of Mammography spaces, adjustment of workload criteria to ensure the appropriate generation of women’s health spaces, larger more 

private dressing rooms areas, women’s specialty exam/procedure rooms larger than 

standard spaces, more bathrooms in targeted treatment and diagnostic areas, sepaVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00062 Fmt 6633 Sfmt 6621 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
59 

rate male and female bathrooms in small pubic areas and waiting rooms where one 

unisex bathroom would technically suffice. On going recent efforts include: 

• February 5, 2010 finalization of interim space criteria for Women’s clinic, working with CFM staff and the Chief, Consultant Women’s Health Office. This interim 

space criteria will be utilized either as part of a larger ambulatory care clinic or a 

stand alone women’s clinic. 

• Chief, Consultant Women’s Health Office and members of her staff have been 

regular members of advisory committee reviewing CFM Standard updates. 

• 00CFM has been meeting regularly with Women’s Health Office since early 

2009 to review standards and discuss comments 

• Ongoing updates of Mental Health Design Guide, Community Living Center Design Guide, Inpatient Units—Medical, Surgical Patient Care Units Design Guide, 

and Procedure Suites Design Guides will include updated criteria specifically addressing women’s issues, related to waiting rooms, privacy, check in areas, bathroom 

facilities etc. These will be completed later this year. 

• Current IDQA/E task order is complete and soon to be contracted for the updating or development of 6 priority Design Guides, one of which is the Women’s Clinic 

Design Guide which will include the interim space criteria for women’s clinic noted 

above and additional guidance, to be completed later this year. 

Project Examples: 

• VAMC Las Vegas New Hospital—Under Construction: 

Women’s Ambulatory Care Clinic located at the 3rd floor level of the tower. 

The clinic area is 5600 sq. ft. and includes 9 exams rooms, 2 procedure 

rooms, a reception/waiting area, a nurse station, utility rooms (clean and 

soiled), patient toilet, staff lounge, staff toilet and offices. 

• VAMC Walla Walla OPC: 

Women’s Exam Rooms and physician offices grouped in a ‘‘mini’’ pod type 

arrangement (800 sq. ft.) along a dedicated clinic corridor affording privacy, 

two dedicated exam rooms with dedicated women’s toilet provided between 

the exam rooms, private dressing cubicle within the room and exam table 

out of the line-of-sight from the door, and separate family waiting and toilet 

rooms room to accommodate women and families. 

08 February 2010 

Senator BEGICH. I would suggest, as a former mayor who dealt 

with many designs of buildings, that the users need to be part of 

the equation. If they are not involved, they should be, to be very 

frank with you, because—no offense to your office and anyone 

else—but I know construction people; I used to be in the business. 

They build to facilitate, they work off of budget, and then they are 

done. I highly recommend that you establish your work with the 

Office of Construction including an advisory of actual clients who 

utilize those facilities currently or have utilized their facilities to 

give advice on how those should be constructed. 

Some of the issues that you brought up, Mr. Williamson, are 

small, yet they are significant. And design is part of it because I 

can tell you if you do not design the bathroom the right size, those 

extra items that you want in there are not going to fit. Just if you 

would take that under at least some advisement, I would appreciate that. 

Mr. WILLIAMSON. If I may add also—— 

Senator BEGICH. Sure. 

Mr. WILLIAMSON. We have heard the same thing in terms of 

needing to have good communication between Dr. Hayes’ office and 

others with the construction people because, again, we are dealing 

with a cultural change here. And it is really important that the design people and the people who do specifications have incorporated 

the needs of women veterans in terms of the facilities. 

60 

Senator BEGICH. Well, thank you very much for echoing that. 

Again, if you could report back to the Committee what your plans 

are. I cannot stress enough, I have seen projects turn from good 

projects to excellent projects because of the client involvement. It 

does not matter if it is health care facilities or anything, but, in 

this case, health care. 

I will just end on this one question. 

To follow-up on Senator Murray’s comments in regards to how 

women veterans understand what care is available, you had mentioned there were veterans that are not necessarily aware of the 

benefits. 

How big would you say that universe is if you could measure it 

in volume of people? Is it a few thousand? Is it tens of thousands? 

Ms. HAYES. I think it might be on the level of about 1 million 

women veterans. 

Senator BEGICH. One million women. 

Ms. HAYES. We have an active plan now to utilize the VA call 

centers to reach out to women veterans and advise women veterans 

about the benefits and the access. Again, that is going to be phased 

in. We will start with the service-connected women veterans, but 

we want to make sure that that does not start until at least this 

fall because we want to make sure the clinics are available. 

Senator BEGICH. OK. 

Ms. HAYES. And we have been told that there may be in the 

neighborhood of 1.5 million women veterans altogether, including 

those who use us. 

There are about 450,000 enrolled women veterans right now. So, 

there are about 1 million women veterans who have not enrolled 

in VA. To the extent that they do not know about us, we can only 

hope that we can reach out and tell them. 

Senator BEGICH. And where do you think they get health care 

coverage now? 

Ms. HAYES. We don’t know that. 

Senator BEGICH. Or do they? 

Ms. HAYES. We do have a study underway by Dr. Donna Washington, and the results of that study will be available approximately September. She has done research on this for us—a stratified random sample of women—women who use VA, women who do 

not use VA who are veterans, and those who use this and don’t 

come back. That study is going to help us understand how women 

veterans who do not use VA access health care. 

Senator BEGICH. Great. If you could share that with us, that 

would be great. 

[Note: This study was not completed in the anticipated timeframe and the target for completion and release is spring of 2010.] 

Senator BEGICH. Mr. Chairman, I apologize for going over, and 

thank you very much. 

Chairman AKAKA. Thank you very much, Senator Begich. 

I have one remaining question for you, Dr. Hayes. 

As part of my oversight responsibility, I learned that some veterans at the Austin, Texas, clinic were inappropriately being 

charged for services related to military sexual trauma. As you well 

know, such care is provided at no charge. It is quite difficult for 

women to seek such care to begin with, let alone to be presented 

61 

with a bill for it. One woman told me she found this emotionally 

draining and an insult to all women who served. 

Is it your belief that this situation at Austin is an isolated incident or are veterans nationwide being charged for care for military 

sexual trauma? 

Ms. HAYES. I can only let you know that personally having been 

in the field for 25 years, I was actually involved in the initial attempts to roll out the eligibility for military sexual trauma for free 

counseling. It should not be ‘‘free;’’ it is without-charge counseling 

for veterans who have undergone such trauma. So, it is personally 

distressing when I see all these years later that there are veterans 

who have, I think, inadvertently been charged, but, nevertheless, 

been charged for their counseling services. 

After the incident in Austin, a mental health group that oversees 

the Military Sexual Trauma Program not only educated the persons there at Austin regarding eligibility, but have done a nationwide search and should have a report very soon about any other 

cases that were uncovered. But we believe it is an isolated type of 

occurrence. 

They made an effort to retrain the eligibility clerks through some 

online information that has gone out, and they will have a report 

as to whether they discovered any other sites where veterans were 

being charged for these services. 

Chairman AKAKA. Thank you very much. 

Let me call on Senator Murray for any second round questions. 

Senator MURRAY. Thank you, Senator Akaka. I just have two additional questions. 

One is about homeless female veterans. The number of women 

veterans who are ending up homeless has nearly doubled over the 

last decade. One out of every 10 homeless veterans under the age 

of 45 is now a woman. Many of these homeless female veterans 

have kids. 

According to Pete Dougherty, who is the Director of VA’s Homeless Veteran Programs, he said, ‘‘While the overall numbers of 

homeless vets have been going down, the number of women veterans who are homeless is going up.’’ 

I have introduced legislation to expand and improve the services 

and care for homeless female veterans and their children through 

the VA Grant and Per Diem Program in the Labor Department’s 

Homeless Veteran’s Reintegration Program. 

Dr. Hayes, tell me what else you think we should be doing currently; and are you aware of this challenge that we have? 

Ms. HAYES. Yes, I am very aware of the challenge. And I think 

it is in part an unfortunate side effect of what is going on in terms 

of the number of new women veterans, but it is a particular challenge in a system that we have not done what I think we need to 

do with screening for the things that underlie the problems of 

homelessness. 

I think—again, women veterans are largely invisible, so we need 

to do more to screen for risks of homelessness in our primary care 

setting. We need to do a better job of screening women for substance use, asking women about whether they have enough to get 

by, and having earlier interventions to avoid the final decline into 

homelessness. 

62 

So, that is what I think we need to do in our system; and, again, 

when we organize the primary care better to comprehensively serve 

women and not just say, well, we will take care of your pap smear 

and we will take care of your mammogram, but to say instead, we 

will take care of you as a whole person. Part of our goal is to make 

sure that we have adequate mental health and social work in our 

primary care setting for women. 

I applaud and thank you for your efforts to put more into the 

Grant and Per Diem Program. As you know, there have been barriers because of the issues of children, and women with children 

have been the most difficult group to place—whether they are veterans or non-veterans—and, so, I certainly applaud that effort because that is clearly what we need in expanding the services that 

are available to women. 

And I think it is another area where we have to continue to provide education to our homeless outreach workers and our homeless 

placement folks in areas where we may underserve the women 

homeless so that they clearly ask a homeless person whether they 

are a veteran and ask a homeless women whether she is a veteran 

to make sure she gets in the VA services. 

Senator MURRAY. Which goes to my last question. When a man 

tells you they are a veteran, folks immediately say yes. Women do 

not perceive themselves to be veterans. The general public does not 

perceive women to be veterans, even if the woman says she served 

in the military. 

How are we going to overcome that sentiment and make the VA 

and the general public really respect the service of women and for 

women to perceive themselves as veterans? I mean, may we should 

not call them ‘‘veterans.’’ I do not know. It is just a real problem. 

Have you thought about that? Do you have any advice for us? 

What can we do to change that? 

Ms. HAYES. I may turn to Dr. Trowell-Harris. A major effort of 

her office is to tackle this problem. 

I, myself, believe that the kind of effort that you are putting in 

to raise the awareness goes very far in helping to identify that 

women proudly served, and women have always served as volunteers. I think we have to continue to get that message out in the 

media, in the Internet, any way that we can, and turn to our partners who are here—the veterans who are here—to help us with 

that message. 

But Dr. Trowell-Harris’ office is dedicated also to this outreach 

effort. 

Ms. TROWELL-HARRIS. We participate in all of the major women’s 

policy groups, the Veteran Service Organizations Convention, minority groups, roundtable groups, hearings, and we work with 

DOD. So, we try to get the education out there. But my opinion is 

it is a matter of changing the culture, getting everybody to understand that women are veterans. 

So, you may recall that, years ago, the census used to ask women 

are you a veteran? They would say, ‘‘no.’’ But the census question 

changed to ask, ‘‘Have they ever served in the Armed Forces?’’ 

Then women would say, ‘‘yes.’’ 

But, still, the education is needed for everybody, as Dr. Hayes, 

said: the media, the women veterans, VA staff, and Congressional 

63 

members. It takes all of us. And, again, this is one way that you 

can help us. 

We are doing extensive outreach with the State Departments of 

Veterans Affairs. Each State Department of Veterans Affairs has 

a designated female assigned to work with women veterans, and 

we do have conferences and send them tons of educational material. Again, we work with various committees, such as the Homeless Committee, the Minorities Affairs Committee, and the Research Committee. 

I have a report which some of you have seen. I had 20 recommendations for women veterans, and, as part of that, the program managers who were part of that committee got Dr. Hayes’ office raised on the VA organizational chart, which was one of the 

recommendations, and that has been done. 

So, all of these things we are trying to do to improve outreach. 

We are also working with the Honorable Tammy Duckworth, who 

was just employed with VA. She heads a major outreach effort, so 

we are meeting with her staff, looking at some creative ways of getting the message out—not just to the women veterans, but to everybody. 

Senator MURRAY. I appreciate that. I think we really have to 

focus on that as communities, as the media, as everybody so that 

we, as a country, recognize that women who serve in the military 

are veterans, deserve the benefits that they have earned, and the 

respect of this country. 

Ms. TROWELL-HARRIS. Thank you. 

Chairman AKAKA. Thank you very much, Senator Murray. 

Senator Begich? 

Senator BEGICH. Mr. Chairman, if I can just ask a couple more 

quick questions. I know I went over time last time. 

Can you give me a sense of—making people aware as women 

who are getting into the military—what kind of relationship does 

the VA have with the DOD in ensuring that knowledge of what is 

available specifically for women is available once they become a 

veteran? 

Who could answer that? Just what kind of relationship is there? 

Ms. TROWELL-HARRIS. Our Secretary works with the Secretary of 

Defense, and, also, there is a designated person at DOD that works 

on benefit issues and also on health care issues. And I did mention 

before about being on the DACOWITS Committee. 

We do have some printed material that we use at all major conventions and forums for women veterans. We have open forums. 

Women do site visits to the field with our Advisory Committee. So, 

we’re trying multiple ways of getting the word out. 

We have numerous media interviews, also; and we really appreciate those because they help us get the word out to the veterans 

nationally. 

Senator BEGICH. And recruitment centers? Is there information 

available at the recruitment centers? 

Ms. TROWELL-HARRIS. You mean military? 

Senator BEGICH. Yes. 

Ms. TROWELL-HARRIS. I am not sure about that. We can get back 

to you on that. 

64 

Senator BEGICH. I mean, the recruitment centers are the first opportunity to educate on what the benefits are on the back-end. So, 

if you could let me know how the recruitment centers are operating 

and people are doing the recruitment, what is there also? Is there 

any special effort, especially for women on what is available and 

what could be available to them? 

So, whichever of you could answer that, that would be great. 

Ms. TROWELL-HARRIS. Sure, we will get back to you on that. 

Senator BEGICH. And please, whoever would be the right person 

to answer this, please do so. 

From a funding level, is there enough resources for what you 

need in some of the leasing of the space that is occurring as well 

as future construction, and what will be necessary to expand these 

facilities to meet the women veterans’ needs? And, if not, is that 

part of the 5-year plan, and tell me how that all works. 

Ms. HAYES. We have been working very closely with the Office 

of Budget and with the Secretary’s office to help define the resource 

needs for this infusion of infrastructure, and we understand that 

with the support of the Secretary, VA will have the resources needed to enhance the care to women veterans. 

Senator BEGICH. That is good. Very good. 

At what point will you have kind of the strategic plan of expansion of facilities that this Committee could at least see? In other 

words, a plan that would kind of say, here is our game plan for the 

next five or so years and here are the highest priorities based on 

demand, based on facility structure, and so forth. 

Ms. HAYES. OK, that will not be my office specifically, although, 

the plans are coming back through the VISN level office and the 

Offices of Construction, but we can get back to you regarding the 

Secretary’s response on how the Secretary’s office would see these 

priorities. 

[The response to additional information requested during the 

hearing follows:] 

RESPONSES TO QUESTIONS ARISING DURING THE HEARING BY HON. MARK BEGICH TO

THE DEPARTMENT OF VETERANS AFFAIRS

Question. Please provide a priority list of VA’s plans to have the facilities identified in the GAO’s preliminary findings on VA’s Provision of Health Care Services 

to Women Veterans. 

Response. VHA has identified the following as top privacy and security priorities 

based on the preliminary findings of the GAO’s Report on VA’s Provision of Health 

Care Services to Women Veterans: 

• Adequate visual and auditory privacy at check-in; 

• Adequate visual and auditory privacy in the interview area; 

• Exam rooms located so they do not open into a public waiting room or a hightraffic public corridor; 

• Privacy curtains present in exam rooms; 

• Exam tables placed with the foot facing away from the door (if not possible, 

placed so they are fully shielded by privacy curtains); 

• Changing area provided behind privacy curtain; 

• Toilet facilities immediately adjacent to examination rooms where gynecological 

exams and procedures are performed; 

• Sanitary napkin and/or tampon dispensers and disposal bins in at least one 

women’s public restroom; 

• Privacy curtains in inpatient rooms (with exception of psychiatry and/or mental 

health units); 

• Access to a private bathroom facility (with toilet and shower) in close proximity 

to the patient’s room (inpatient and residential units). 

65 

Senator BEGICH. That would be great. And that is just so I can 

get a sense of where and what in preparation priorities. You see, 

when I sat on the Armed Services Committee we sometimes focused just on the year. The problem with that is one year will have 

ramifications for the next and following years. So, it just kind of 

helps. 

Ms. HAYES. Yes. 

Senator BEGICH. I know there is a big commitment from the 

president in regards to dollars for the Veterans Administration, 

which is great. I just want to make sure we are in the right tow 

here. 

Ms. HAYES. I also want to clarify, a lot of the issues, as Mr. 

Williamson said, are really issues of being able to put some renovation costs and would be on the priority list for construction, but 

rather needing the ability to plan and put together a space that 

would really involve renovation costs and local costs. 

Senator BEGICH. If I can ask, so, will the renovation costs then 

not be in the long-term capital improvement? 

Ms. HAYES. Oh, no, I did not mean to confuse that. 

Senator BEGICH. Oh, OK. 

Ms. HAYES. I am just telling you that the process is one in which 

we are looking at both short-terms in terms of some renovation 

where places are putting in new projects. That is already part of 

other processes that you would be aware of. 

Senator BEGICH. OK. Very good. 

Mr. Chairman, I am going to end there. I do have some additional questions, but I know I exceeded my time the last time and 

I have a feeling with about 30 seconds left, I’ll burn that up very 

quickly. So, let me end here. 

Thank you. 

Chairman AKAKA. Thank you very much, Senator Begich. 

I want to thank the first panel for your testimony and your responses. 

As we know, we are facing a huge surge of an issue here that 

has been important to our country, and some of the problems have 

been noted. We want to work together as closely as we can to move 

it and provide the health care services that our women veterans expect and will have. 

So, we look forward to working with you. Thank you very much. 

Ms. TROWELL-HARRIS. Thank you. 

Ms. HAYES. Thank you. 

RESPONSE TO POST-HEARING QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO

PATRICIA HAYES, PH.D., CHIEF CONSULTANT, WOMEN VETERANS HEALTH STRATEGIC HEALTH CARE GROUP, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 1. VA’s written testimony discusses how the ‘‘women’s comprehensive 

health implementation planning (WCHIP) tool’’ is used to ‘‘assist facilities in analyzing its own current health care deliver for women veterans.’’ After the initial 

analysis is completed by each facility, is there a process to repeat the analysis periodically to account for the expected growth in the women veteran population and 

how that may affect the model a facility uses to provide care for its women 

veterans? 

Response. The Veterans Health Administration (VHA) continues to incorporate 

WCHIP to assess the current status of primary care delivery to women Veterans 

across VHA, and recommend enhancements as required. 

For every VA health care facility, VHA will create a benchmarking tool to evaluate WCHIP. The tool will help define and develop recommendations regarding the 

66 

essential components and critical capabilities of comprehensive primary care delivery models. In addition, metrics will be developed that evaluate the implementation 

of comprehensive care for women Veterans. The tool is currently being developed 

with an expected completion of February 2010. A plan to pilot the tool is expected 

in March 2010, and validation is expected May-August 2010. Once the tool has been 

validated, an annual reporting process will be established for ongoing evaluation 

and resource monitoring and tracking so that facilities can plan for the expected 

growth in the women Veteran population in their areas. 

Question 2. During the hearing, there was discussion regarding VA’s plans for expanding and remodeling clinical areas that provide women’s health care and the 

need to maintain close coordination with VA’s Office of Construction and Facilities 

Management when implementing these plans. In addition to evaluating the space 

used to provide women’s health care, is VA evaluating the equipment, such as exam 

tables, used in these spaces to ensure it is appropriate for all women veterans, particularly those with catastrophic disabilities? 

Response. VA’s design criteria moved aggressively to improve space and logistics 

issues related to women’s health this past year. The design criteria incorporated 

many women-specific requirements, such as ensuring adequate space for women 

specific equipment, ensuring 100% private patient rooms and ensuring adequate 

space for dependents accompanying the women Veterans. These design criteria have 

been incorporated into both, our existing facilities, as well as new Women’s Centers. 

More specifically for high-tech/high-cost equipment, equipment needs are assessed 

and evaluated for performance continually. Prior to a new acquisition, an intensive 

review occurs to optimize the selection to best suit VA’s needs. This new equipment 

then becomes the basis for designing the room to ensure adequate space and 

privacy. 

Regarding the space designs for women’s areas in general, VA’s standards development efforts have increased addressing the physical and mental health care needs 

of the growing number of women Veterans. Most efforts related to updating VA’s 

Space Planning Criteria and Design Guides for specific functional areas. Space Planning Criteria provides space requirements and guidance for development of space 

programs for specific VA Facility Project development and leasing agreements. It 

contains functional relationships and design considerations in addition to space 

planning criteria for heath care functions. Design Guides provide comprehensive information, including an overview of design principles and concepts, narrative text 

descriptions, and guide plates for reference. 

These Space Planning Criteria and Design Guides, particularly over the recent 

past, have addressed numerous specific changes reflecting women’s issues. In the 

most recent Design Guides for Ambulatory Care, Outpatient Clinic, MRI, Radiology, 

Nuclear Medicine, Radiation Therapy, etc., changes include increased importance of 

Mammography spaces, adjustment of workload criteria to ensure the appropriate 

generation of women’s health spaces, larger more private dressing room areas, women’s specialty exam/procedure rooms (10% larger than standard spaces), more bathrooms in targeted treatment and diagnostic areas, separate male and female bathrooms in small public areas, and waiting rooms where one unisex bathroom would 

technically suffice. 

The Office of Construction and Facility Management (CFM) is partnering with 

and including the Chief Consultant Women’s Health Office, on the Advisory Teams 

established to update Space Planning Criteria and Design Guides along with consultants and other VHA health care providers. Design Guide and Space Planning 

Criteria recently completed or major updates are underway: Mental Health; Inpatient Units—Medical, Surgical, and Neurological Patient Care Units; Intensive Care 

Units; Procedure Suites; and Leased-Based Clinic Design Guide. 

Question 3. Much attention is given to providing gender-specific care to women 

Veterans from OIF/OEF. Besides the research mentioned in written testimony regarding hormonal effects on diseases in post-menopausal women, what is VA doing 

to ensure there are adequate gender-specific services for our older generations of 

women veterans? 

Response. The gender-specific services VA provides takes into account the changing needs of women at each stage of their lives. VA’s comprehensive health services 

for older women Veterans include: 

• Continued access to gender-specific screening for breast and cervical cancer to 

detect early malignancies and improve survival. VA also notes that postmenopausal 

women are at increased risk of having cardiovascular disease, the number one killer 

of women. Thus our comprehensive primary care initiatives take into account the 

needs of our aging women Veterans and focus on breast health and heart health, 

diabetes and weight management, and smoking and lung cancer. 

67 

• Education initiatives for women’s health providers include modules on prevention and management of osteoporosis in addition to evaluation and basic assessment 

of reproductive issues in older women. In addition to hormonal replacement therapy, 

these issues include urinary incontinence, pelvic floor disorders, and reproductive 

cancers. Women Veterans with are appropriately and expeditiously referred to subspecialty care services as needed. 

Question 4. VA’s testimony referred to the mini-residency training in women’s 

health which is taught by national women’s health experts. During the hearing it 

was suggested numerous times that it would be beneficial for someone to learn 

about women veterans’ experiences in the military from actual women veterans. 

What is your view about having women veterans provide education and insight to 

VA health care providers in order to help them understand their patients better? 

Response. VA understands and agrees that it is essential to have women Veterans 

participate in providing insight to VA health care providers. In September 2009, VA 

held a conference entitled, ‘‘OEF/OIF Evolving Paradigms II: The Journey Home,’’ 

that was aimed at preparing approximately 3,000 VA providers of care to Veterans 

returning from the current conflicts. This conference included several plenary sessions featuring men and women Veteran patients sharing their stories. 

VHA also created a staff training CD-Rom which includes numerous images of 

women Veterans, aimed at increasing awareness and sensitivity about women Veterans. This presentation also includes a video of a woman Veteran describing her 

military experiences, and her perspectives on care in a VA primary care women’s 

clinic. VA will include women Veterans in person and videos when possible in future 

educational events. In addition, future educational programs will include techniques 

and tools for providers such as the military service history pocket card (http:// 

vaww.va.gov/oaa/pocketcard/default.asp) to help providers discuss a better military 

history and to begin to engage their own patients in the dialog to better understand 

the experiences of their patients. 

All of these things are essential as VA moves toward providing health care that 

is more patient-centered. 

Question 5. What can this Committee do to assist the CWV in its efforts to increase awareness about the women veterans’ programs? 

Response. The Center for Women Veterans continues to encounter women Veterans who do not self-identify as Veterans, or who are unsure of their entitlement 

to VA benefits and services. The Senate Committee on Veterans’ Affairs could complement the Center’s efforts to educate women Veterans about VA’s programs for 

women Veterans as it interacts with constituents, especially those who are women 

Veterans. Examples of actions the Committee and its members can consider include: 

• Including information about women Veterans programs in outreach literature 

targeting Veterans in general. 

• Noting the contributions of women in the military and women Veterans in remarks and speeches, as appropriate. 

• Establishing forums for women Veterans in their respective states that would 

provide opportunities to learn about these programs and how to access them. 

• Sharing initiatives and ideas with non-Committee lawmakers regarding VA’s 

programs and efforts for women Veterans in order to expand opportunities for 

outreach. 

Question 6. What happens if a female veteran asks for a female provider and one 

is not available? 

Response. It is VHA’s goal that women Veterans be given the option to designate 

their preference for a female provider. Overall, 62% of VHA providers are female. 

More than 80% of all nurse practitioners are women and up to one third of all VA 

physicians are women. Facilities are strongly encouraged to make the necessary accommodations for a female provider (if one is requested) so that services are provided in-house to the greatest extent possible. If a female provider is not available 

in-house, services are to be provided through fee-basis arrangements or sharing contracts to the extent the Veteran is eligible. 

Question 7. When will the new handbook for VHA services for women veterans 

be issued? 

Response. The revised handbook for VHA services for women Veterans incorporates the new standard requirements and delineates the essential components 

necessary to ensure that all enrolled women Veterans have access to appropriate 

services, regardless of their VHA site of care. The handbook has recently been revised to reflect comments made in the review process and is going back through internal concurrence. The handbook is expected to be issued during the second quarter 

of FY 2010. 

68 

RESPONSE TO POST-HEARING QUESTIONS SUBMITTED BY SENATOR BURR TO PATRICIA

HAYES, PH.D., CHIEF CONSULTANT, WOMEN VETERANS HEALTH STRATEGIC HEALTH

CARE GROUP, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 1.a. As we discussed at the hearing, on page 7 of your written testimony 

there is a statement that ‘‘As of June 2009, each of VA’s 144 health care systems 

has appointed a full-time Women Veterans Program Manager.’’ On page 9 of GAO’s 

testimony there is a statement that ‘‘In July 2008, VA required VAMCs to establish 

the WVPM as a full-time position (no longer a collateral duty) no later than December 1, 2008. So, it appears that according to both VA’s internal directives and your 

own testimony that each health care system should have appointed a full-time 

WVPM long ago. 

In response to questions from the Chairman, however, you stated that you were 

‘‘actively in the process of verifying’’ whether that is, in fact, the case. In response 

to my questions you stated, in essence, that just because each system has appointed 

a full time WVPM that it doesn’t necessarily mean that it’s happening, and that you 

wanted to make sure it was because VA was in a ‘‘transition phase’’ on this matter. 

For the record: 

Please clarify these statements. Is there a distinction between the ‘‘appointment’’ 

of a WVPM and the actual placement of an individual to fill that job? 

Response. Occasionally during the hiring process, when bringing on board a new 

person to fill a vacant slot, there may be a lag from appointment to actual on-site 

placement. In those cases, the Department of Veterans Affairs (VA) names an acting 

women Veterans program manager (WVPM) until the appointed individual is officially on board. Additionally, many of the WVPMs who held the position prior to 

its becoming a full-time position have had to greatly reduce their clinical time to 

fill the role of a full-time WVPM. For some, the transition from clinical duties had 

taken longer than expected. This process is still underway. VA currently employs 

137 full-time WVPMs; 7 sites have individuals acting in these roles with recruitment for full-time employees underway. 

Question 1.b. Is it typical for VA to appoint someone to a position who is unable 

to perform the job to which they are appointed? 

Response. VA does not appoint anyone to a position who is unable to perform that 

position. Mandatory training of new hires does not suggest they are unqualified or 

unable to perform the job to which they are appointed. The role of the WVPM is 

quite complex with regard to understanding the population of women Veteran and 

their unique needs. Therefore, significant training of new WVPMs and ongoing 

training for all existing WVPMs is required. 

Every new WVPM is required to complete a Web-based, 40-hour certificate training course, which is monitored through the employee education system. In addition, 

VA women Veterans health strategic health care group (SHG) has provided training 

for all WVPMs. The eastern region 1 training was held in Baltimore, MD, in April 

2009; the mid-western/south region 2 in Chicago, IL, in May 2009l and the western 

region 3 in San Francisco, CA, in June 2009. Through the course of these three sessions, VA trained all existing, acting and new WVPMs in additional program-specific skills areas. A follow-on training meeting for all current WVPMs was held on 

September 20, 2009. This training focused on a variety of relevant topics including: 

• Follow-up on the Women’s Comprehensive Health Care Implementation Plan 

(WCHIP) 

• Issues related to the newly developing Veteran-centered patient care model 

• Building a successful women’s health center with full backing of leadership 

• Writing successful request for proposal responses 

• Issues associated with military sexual trauma 

Question 1.c. How long before you have verified that each of the 144 WVPMs is 

in place, trained, and performing the duties for which they were appointed? Please 

report that to me as soon as possible. 

Response. Attached is a comprehensive list of the 144 WVPMs, where they are 

posted and when they began working full time in that position; 2 WVPMs are currently part-time, and 3 sites have acting WVPMs, while recruitment for the 5 permanent positions are being advertised. All have received the WVPM training referred to in response to question 1b. 

Question 2.a. At the hearing I noted that VA budget submissions show a decline, 

from 2007 to 2008, in the number of unique users seeking gender-specific care at 

VA. In response you stated that ‘‘on paper it looks like we’ve decreased our gender 

specific care when, in fact, we believe that it’s increased.’’ Please clarify this for me 

If from one year to the next the number of unique users seeking gender-specific care 

69 

has declined, doesn’t that indicate that those who were once users of the system for 

gender-specific purposes are seeking that care elsewhere? 

Response. In the fiscal year (FY) 2010 President’s Budget submission the reported 

number of the female Veterans being treated for gender specific conditions (FY 2008 

actual) was lower than the number that was reported in the FY 2009 President’s 

Budget (FY 2007 actual). The reason the FY 2007 (actual) number was higher is 

because non- Veteran women were mistakenly counted in the FY 2007 number; that 

cohort should have been deleted from the equation before the budget submission 

was finalized. 

In addition to identifying the non-Veteran inconsistency, the VA review process 

produced insight on what is identified as gender-specific care for women. In that review, 172 additional diagnosis codes that represent gender specific were added to 

the former list of 441 codes to more accurately identify care that is gender-specific. 

These additional codes were applied to historical data for use in the FY 2011 budget 

process. 

Question 2.b. If you believe that the number of women seeking gender-specific 

care has actually gone up instead of down, then, what are the true numbers? What 

do the numbers look like for 2009 and do they track what was estimated for 2009? 

Response. The table below shows the revised historical data for female Veterans 

who come to VA for gender-specific care using the expanded list of diagnosis and 

clinics. 

In FY 2008, actual data through mid-year reflected 61 percent of the annual total 

unique female Veteran patients in FY 2008 had already received care and 43 percent of the annual total costs had been expended by mid-year FY 2008. At mid-year 

FY 2009, actual unique patients are 68 percent of the estimated annual total and 

actual costs are 50 percent of the estimated annual total, so actual experience thus 

far indicates that the estimate may have been low if second half expenditures occur 

at the same pace as happened in FY 2008. As compared to mid-year FY 2008, FY 

2009 actual data shows a 14 percent increase in female Veteran patients and a 26 

percent increase in cost. 

The following table shows historical data for female Veterans who come to VA for 

gender-specific care using the expanded list of diagnosis and clinics. The response 

to question 2a discusses the expansion of the scope of gender-specific care. 

FY 2008 

Actual 

FY 2009 

Budget 

FY 2008 

Mid-Year 

FY 2009 

Mid-Year 

Female Veteran Patients ............................. 141,698 145,647 87,128 99,500 

Obligations (000s) ....................................... $153,315 $167,330 $65,758 $82,860 

Question 3. What percentage of the gender-specific care (as a percentage of obligations) VA provides was purchased from a non-VA provider? Has this number increased or decreased in the last decade? 

Response. The data below shows the percentage spent in VA and the percentage 

spent on non-VA providers. Data are not available prior to FY 2005. Since FY 2005 

the percent spent on gender-specific care increased between 12.18 percent in FY 

2005 to 14.2 percent in FY 2009. The data over this short period is narrow in variance and does not allow for reliable trending. 

Fiscal Year VA Non-VA 

2009, 2nd quarter ....................................... 85.80 percent 14.20 percent 

2008 ............................................................. 86.90 percent 13.10 percent 

2007 ............................................................. 87.92 percent 12.08 percent 

2006 ............................................................. 88.49 percent 11.51 percent 

2005 ............................................................. 87.82 percent 12.18 percent 

Chairman AKAKA. I welcome now a second panel this morning. 

Members of this panel are five women veterans, each working in 

the field of advocacy in its various forms. 

First, I welcome Joy Ilem, Deputy National Legislative Director 

for Disabled American Veterans. 

Next, we have Tia Christopher, who is an Iraq Veteran and 

Project Associate and Women Veteran Coordinator for Swords to 

Plowshares. 

70 

Next, welcome to Genevieve Chase, Executive Director for American Women Veterans. 

We will hear testimony also from Kayla Williams, a veteran of 

the U.S. Army. 

And, finally, we have Jennifer Olds, also a U.S. Army veteran. 

I am grateful to VFW for making it possible for Ms. Olds to join 

us today. 

Ms. Ilem, we will begin with you and then move down the table 

in order. 

Ms. Ilem? 

STATEMENT OF JOY ILEM, DEPUTY NATIONAL LEGISLATIVE 

DIRECTOR, DISABLED AMERICAN VETERANS 

Ms. ILEM. Thank you, Mr. Chairman and Ranking Member Burr. 

Thank you for inviting the Disabled American Veterans to participate in this timely hearing on women veterans. 

The changing roles of women in the military, increasing numbers 

of women coming to VA for care, and the impact of war on women’s 

health present a number of new challenges for VA in meeting the 

unique needs of women veterans today. 

Ensuring equal access to benefits and high-quality health care 

services for women veterans is a top priority for DAV. We have a 

longstanding resolution that calls for review of VA’s health program for women to ensure they have access to the same high-quality health care and specialized services that male veterans receive. 

It is apparent from the recently-released Report of the Under 

Secretary for Health Workgroup on Women Veterans that VA is 

aware of the shortcomings in its women’s health program and is 

making a concerted effort to systematically address the significant 

challenges it faces to bring care provided to women veterans on par 

with male veterans. 

The report outlines the most critical challenges VA faces in caring for women veterans, and, more importantly, provides a roadmap for change. Some of the most critical issues identified in the 

report include: significantly increasing utilization rates of younger 

women accessing VA care; the systemic fragmentation of primary 

care delivery for women; too few proficient, knowledgeable providers with expertise in women’s health; and a number of identified 

outpatient quality disparities for women veterans. 

Additionally, VA researchers report a number of access barriers 

for women veterans, including lack of childcare services, privacy, 

safety, and comfort concerns, and unique post-deployment mental 

health reintegration issues for newly-discharged women veterans 

who have served in Operations Iraqi and Enduring Freedom. 

The workgroup states its primary objective is to ensure every 

woman veteran has access to a qualified health care provider who 

can deliver coordinated, comprehensive, primary, women’s health 

care inclusive of gender-specific care, preventive, and mental health 

services. 

It plans to achieve these goals through a number of key policy 

recommendations to reform and enhance women’s health delivery 

in VA. These recommendations thoroughly address quality, efficiency, access, and equity of care for women who use VA services. 

71 

And we congratulate the Women Veterans Health Strategic 

Health Care Group for an extraordinarily forthcoming report in a 

highly-detailed series of goal-orientated recommendations and action items. These recommendations are fully consistent with a series of recommendations that have been made in recent years by 

VA researchers, experts in women health, VA’s Advisory Committee on Women Veterans, and the Independent Budget. 

If implemented, these reforms will change the face of health care 

delivery for women veterans in the VA health care system, and, in 

turn, improve the health of women veterans. 

Without question, VA has a lot of hard work ahead to achieve 

these goals it has set out for itself, but we are hopeful with the attention, oversight, and collaboration of this Committee, that an implementation plan can be expeditiously carried out. 

A number of events focused on women veterans have been held 

in recent months and all are essential to process of change. However, nothing is more important than taking action. For these reasons, DAV urges the Committee to carefully consider the recommendations outlined in the report on women’s health and to 

support VA’s efforts for change. 

Although this groundbreaking report represents progress, we 

question if the women’s health program directors have the resources to build adequate infrastructure and program capacity and 

the internal support necessary at the very highest levels to make 

the reforms it says are necessary. 

One final concern we bring to the Committee’s attention, although it appears VA has been making a good faith effort to move 

forward on its plans for improving women’s health care services 

and implement the principles outlined in the report, it does not appear VA has issued a formal policy or directive to the field to address the gaps identified in the report. Therefore, we seek assurance from VA that its implementation will be, in fact, faithfully executed. 

Mr. Chairman, again, we thank you and other Members of the 

Committee for your leadership and continued support on women 

veteran’s issues, and we appreciate the opportunity to participate 

in this important hearing. 

Thank you. 

[The prepared statement of Ms. Ilem follows:] 

PREPARED STATEMENT OF JOY J. ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, 

DISABLED AMERICAN VETERANS

Mr. Chairman and Members of the Committee: Thank you for inviting the Disabled American Veterans (DAV) to testify at this hearing that is focused on women 

veterans, entitled ‘‘Bridging the Gaps in Care.’’ This hearing is extremely timely 

given the changing roles of women serving in our Armed Forces today, the 1.7 million women veterans who served previously, and the dramatically growing number 

of women seeking health care and other benefits from the Department of Veterans 

Affairs (VA). 

Ensuring equal access to benefits and high quality health care services for women 

veterans is a top priority for DAV. We have a long-standing resolution from our 

membership of 1.2 million disabled war veterans that seeks to ensure VA health 

care services for women veterans, including gender-specific care, are provided to the 

same degree and extent that services are provided to male veterans. Also, given the 

undoubted greater exposure of servicewomen to combat, we believe they should have 

equal access to supportive counseling and psychological services incident to combat 

exposure. Military sexual trauma, while not exclusively a women’s issue, is also of 

72 

1 U.S. Dept of Veterans Affairs, Office of Public Health and Environmental Hazards, Women 

Veterans Health Strategic Health Care Group; Report of the Under Secretary for Health 

Workgroup: Provision of Primary Care to Women Veterans. Washington, DC: November 2008. 2Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health, Strategic Health Care 

Group, Department of Veterans Affairs; Women Veterans Health Care, Evolution of Women’s 

Health Care in the Veterans Administration, Page 1. June 2009. www.amsus.org/sm/presentations/Jun09-B.ppt 3 Ibid. 

special concern to DAV. Additionally, we urge VA to strictly adhere to their stated 

policies regarding privacy and safety issues related to the treatment of women veterans and to proactively conduct research and health studies as appropriate, periodically review its women’s health programs, and seek innovative methods to address women’s barriers to VA health care and services, thereby better ensuring 

women veterans receive the treatment and specialized services they rightly earned 

through military service to America. 

Likewise, for many years, the organizations that make up the Independent Budget 

(IB)—AMVETS, DAV, Paralyzed Veterans of America (PVA) and Veterans of Foreign Wars of the United States (VFW)—have included a special section in the IB 

emphasizing women veterans, in an effort to call attention to the need to address 

many of the challenges VA faces in providing high quality health services to women 

veterans in a predominantly male-oriented health care system. We are pleased to 

see that many of the recommendations made in this section of the fiscal year 2010 

IB have been addressed by VA in a recent ground-breaking publication—Report of 

the Under Secretary for Health Workgroup: Provision of Primary Care to Women Veterans (Report), published in November 2008 but released only very recently. Additionally, DAV included a special focus on women veterans as part of our ongoing 

Stand Up For Veterans campaign—focusing public attention on the unique needs of 

women veterans—with a special emphasis on women who became disabled during 

their wartime service. 

VA’s 2008 Report 1 reflects the most pressing challenges VA faces: specifically, developing the appropriate health care model for women in a system that is disproportionately male focused, the increasing numbers of women coming to VA for care, the 

impact of changing demographics in the women veteran population, and impact on 

VA health care delivery as well as the already-identified gender disparities in quality of care for women veterans. 

Women veterans are the fastest growing segment of the veteran population—and 

according to the Veterans Health Administration (VHA), women are projected to account for one in every seven enrollees within the next fifteen years, compared to 

the one in every sixteen enrollees today. Because of the large and growing number 

of women serving in the military today, the percentage of women veterans is projected to rise proportionately from 7.7 percent of the total veteran population in 

2008, to 10 percent in 2018. Additionally, VA notes that women who served in Operations Iraqi and Enduring Freedom (OIF/OEF) utilize VA services at a higher rate 

than other veterans, including other women veterans and male OIF/OEF veterans— 

with 42.5 percent of the 102,000 OIF/OEF women veterans having enrolled in VA, 

and nearly 43.8 percent who are consuming between two and ten VHA visits per 

year on average. Earlier generations of women veterans enrolled in VA health care 

at a 15 percent average rate.2

As reported by VA, historically, women have underutilized VA health in comparison to male veterans. In the past five years, on average, 22 percent of men versus 

15 percent of women have accessed VA health care. Women veterans using VA 

health care are also younger—with an average age of 48 compared to male veterans’ 

average age of 61. Among women users from OIF/OEF, more than 85 percent are 

under age 40 and of child-bearing age, and nearly 60 percent are between the ages 

of 20–29.3 In addition, women veterans have been shown to have unique and more 

complex health needs with a higher rate of comorbid physical health and mental 

health conditions, i.e., 31 percent of women have such comorbidities versus 24 percent of men. Even with this high rate of comorbidity, women veterans receive their 

primary and mental health care in a fragmented model of VA health care delivery 

that complicates continuity of care. In fact, according to the VHA Plan of Care Survey for fiscal year 2007, 67 percent of sites provide primary care in a multi-site/ 

multi-provider model (i.e., with primary care at one visit and gender-specific primary care at another visit), with only 33 percent of facilities offering care to women 

in a one-visit model. The Under Secretary’s workgroup concluded given these facts 

that there are now sufficient numbers of women veterans to support coordinated 

models of service delivery to meet their needs, and that while women will always 

comprise a minority of veterans in the VA system, they represent a critical mass 

73 

4Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health, Strategic Health Care 

Group, Department of Veterans Affairs; Women Veterans Health Care, Evolution of Women’s 

Health Care in the Veterans Administration, Page 15. June 2009. www.amsus.org/sm/presentations/Jun09-B.ppt 5 Ibid. 

as a group and should therefore be factored into plans for focused service delivery 

and improved quality of care. 

As indicated above, we have read with great interest a recently released VA publication titled: Report of the Under Secretary for Health Workgroup: Provision of Primary Care to Women Veterans, dated November 2008. We are impressed with the 

thoroughness of the review of women’s care in VHA, and also with the optimism 

of its recommendations to improve women’s health. If implemented nationally its 

recommendations could assure that women veterans receive coordinated, comprehensive, primary care at every VA facility from clinical providers who are trained 

to meet their needs; an integration of women’s mental health with primary care in 

each clinic treating women veterans; the promotion of innovation in women’s health 

delivery; enhanced capabilities of all staff interacting with women veterans in VA 

health care facilities; and an achievement of gender equity in the provision of clinical care within VA facilities. 

As directed by the VA Under Secretary for Health, the workgroup was charged 

with defining the actions necessary to ensure that every woman veteran has access 

to a VA primary care provider who can meet all her primary care needs. The 

workgroup reviewed the current organizational structure of VHA’s women’s health 

care delivery system, addressed impediments to delivering their care in VHA, identified current and projected future needs, and proposed a series of recommendations 

and actions for the most appropriate organizational initiatives to achieve the Under 

Secretary’s goals. 

CURRENT CHALLENGES

VA noted in its Report that only recently had it begun to address development 

of the most appropriate health care services for women veterans at each VA facility. 

The workgroup identified seven challenges that VA must overcome in order to deliver quality, comprehensive primary care to women veterans. 

Challenge 1: VA recognizes that women have been under-served in the veterans 

health care system. Utilization rates for men have held at approximately 22 percent 

for many years—while utilization rates for women range between 11–19 percent. 

Research shows that women veterans do not self-identify as bona fide veterans, and 

are more unlikely to be unaware of their enrollment eligibility. Of special note to 

DAV—and greatest concern is that among women veterans in this study who had 

not had access to health care in the past 12 months, 18.7 percent of this group is 

service-connected for disability incurred in the line of duty.4 This finding—that service-connected women veterans are without access to health care, are not enrolled in 

nor using VHA services—is especially distressing to DAV. 

Challenge 2: VA acknowledged there is a clear and growing need for improved 

service delivery to women veterans in VHA. Given the significantly higher VA utilization rates among women returning from OIF/OEF as indicated above, VA expects 

the number of women veterans coming to VA for care will likely double within the 

next four years. The workgroup noted there are now sufficient numbers of women 

to justify a VA effort to produce coordinated models of service delivery to meet their 

needs—and that as a group women veterans should be factored in as a special population cohort in any new strategic plans for service delivery.5

Challenge 3: In recent years, VA reports have shown a significant demographic 

shift related to women VA-users and notes the impact of age-related health concerns. Given the fact that almost all new users of the system are under age 40— 

and of child-bearing age—there is a need for a focused shift in the provision of 

health care services. The Under Secretary’s workgroup also noted VA must continue 

to be sensitive to the needs of older women veterans as well, since women over 55 

years of age face high risks for cardiac disease, cancers and the consequences of obesity (such as Type 2 diabetes). 

Challenge 4: The workgroup identified and acknowledged gender disparities in 

quality of care in VHA. Despite positive results on gender-specific measures such 

as screening for cervical and breast cancer, significant differences are recorded in 

VHA performance scores between men and women on certain outpatient quality 

measures that are common to both men and women. Specifically, depression and 

PTSD screening, colorectal cancer screening and vaccinations were reported as less 

favorable for women. 

74 

6Patty Hayes, Ph.D., Chief Consultant, Women Veterans Health, Strategic Health Care 

Group, Department of Veterans Affairs; Women Veterans Health Care, Evolution of Women’s 

Health Care in the Veterans Administration, Page 16. June 2009. www.amsus.org/sm/presentations/Jun09-B.ppt 

Challenge 5: The workgroup identified routine fragmentation of health care delivery to women veterans that poses possible negative health outcomes. According to 

the report, to a large extent, health care services offered to women veterans have 

evolved in a patchwork fashion. Some facilities have strong champions with expertise in women’s health and offer comprehensive services in one location; other facilities, however, require women to see several providers for basic primary care services, and some VA facilities rely heavily on fee-basis providers to care for enrolled 

women veterans. 

Challenge 6: One of the most significant challenges VHA faces according to this 

workgroup report is an insufficient number of clinicians with specific training and 

experience in women’s health. The report acknowledges that the historical predominance of male veterans in the VA setting has resulted in many providers lacking 

or having limited exposure to women patients.6 According to the workgroup, women 

veterans’ numerical minority in VHA has created logistical challenges in creating 

and sustaining delivery systems that assure VA’s goal of equitable access to high 

quality comprehensive services that include gender-specific care. 

Challenge 7: Finally, the workgroup identified that there is inconsistent policy in 

place for women’s health in VHA. The group noted that, in previous directives 

issued by VA Central Office, VA clinical staff were required to provide gender-specific care on-site in VA facilities, but, that more recent versions of the directives 

shifted the emphasis to ‘‘preferred’’ rather than ‘‘required.’’ As a result, a decline in 

on-site gynecological services occurred with an increase in fee-basis referral for 

those key women’s health care services. The workgroup noted that in contrast, gender-related care always has been recognized as an integral part of primary care delivery for men in VA health care. 

To aid in the implementation of comprehensive health care for women veterans 

at every VA facility, the Women Veterans Health Strategic Health Care Group developed a Women’s Comprehensive Health Implementation Planning (WCHIP) tool. 

The tool, which outlines a care gap analysis, market analysis and needs assessment, 

was designed to help VA facilities and VISNs assess and make decisions about 

which services need to be developed and what resources were necessary to carry out 

those plans. The stated goal was to then have Women Veterans Program Managers 

(WVPM) work directly with strategic planners at their VA facilities to incorporate 

the results of the WCHIP into the health care planning model for those facilities. 

We are pleased the WVPM position was made full time in July 2008, since these 

managers are clearly integral to providing increased outreach to women veterans, 

improving quality of care and developing best practices in the delivery of care to 

women veterans throughout the VA health care system. 

WORKGROUP REPORT RECOMMENDATIONS

The workgroup made a series of key recommendations with accompanying action 

items, as follows: 

Recommendation 1 focuses on the delivery of coordinated, comprehensive primary women’s health care at all VA facilities, including the development of systems and structures for care delivery that ensure every woman veteran has access to a qualified primary care physician who can provide care for acute and 

chronic illnesses, gender specific care, and preventative and mental health services. 

Actions items necessary to achieve this goal include using the WCHIP tool to 

provide an assessment of the current status of care delivery and resources at 

each facility; identify steps needed to achieve coordinated comprehensive primary women’s health care and implement a practice plan for each facility and 

women’s population in a particular catchment area; provide appropriate funding 

to build adequate infrastructure and program capacity; increase utilization 

rates for women and provide staff and resources to conduct outreach and education to women veterans; collect, analyze and report on data related to access, 

staffing flexibility, and cost to carry out plan; and, coordinate with VA academic 

affiliates for delivery of comprehensive primary care services to women. 

The workgroup noted that current research evidence, clinical data and the 

adoption of models of patient-centered care support the advancement of comprehensive primary women’s health care and are further supported by existing 

policies in VHA Handbook 1330.1 and Standards of Primary Care Directive 

75 

2006–031. These directives state that primary care includes gender-specific care 

services. 

Recommendation 2 seeks to ensure integration of women’s mental health care 

as a part of primary care. The workgroup identified that women veterans using 

the VA health care system carry a heavy burden of mental illness diagnosis— 

with depression being the most frequent condition in women seeking care in 

2007. PTSD was the fourth most frequent diagnosis reported, above diabetes 

and hypertension. (page 52 Rec. 2) The workgroup concluded the adoption of the 

combined provision of primary and mental health care services would help 

women veterans overcome barriers to access needed mental health care. 

Action items for Recommendation 2 include: assignment of mental health providers in primary care clinics who can provide assessment and psychosocial 

treatment for a variety of mental health problems, including depression and 

problem drinking with associated sexual behavior risk factors; facilitating collaboration of behavioral health with primary care to provide ancillary services 

such as pain management, weight management, and smoking cessation programs designed to meet the needs of women veterans. 

Recommendation 3 focuses on promoting new ways of providing care delivery 

for women through support of best practices fitted to a particular facility or 

VISN configuration and the women veteran population in that location or region. The workgroup opined that individual VA facilities are best positioned to 

develop innovative programs to meet the needs of women veterans, especially 

sub-populations of minority groups and women veterans from rural areas. We 

concur with VA that best practices can help address variation in geographic and 

demographic challenges across the system, and that innovative technologies 

should be utilized to enhance delivery of care for this population. 

Action items to achieve this goal include: sharing best practice models for 

comprehensive women’s health care through an improved web portal, conferences and other appropriate information transfer methods; developing requests for proposals from VA field facilities for pilot project initiatives using 

new technology; collaboration between the Offices of Care Coordination and Information to explore new opportunities in telehealth, inclusive of women veterans; recognize and promote local achievements in creating environments of 

care that support privacy, safety and comfort for women veterans who seek VA 

care. Recognizing that VHA has a longstanding history and focus on male patients, 

Recommendation 4 addresses the need to cultivate and enhance the capabilities 

of all VHA staff—including medical providers, clinical support, non-clinical, and 

administrative staff, to meet the comprehensive health care needs of women 

veterans. The workgroup acknowledged that despite increasing numbers of 

women enrolling for VA care, women users of the system continue to be relatively ‘‘invisible.’’ We fully concur that a paradigm shift is necessary and that 

a coordinated training and cultural sensitivity program will be essential to creating an atmosphere of equity and welcome for women veterans in VA health 

care facilities. 

According to the workgroup, many VA clinical providers have acquired skills 

during health professions internships or residencies but have subsequently lost 

those proficiencies in their intervening years working in VA facilities therefore, 

a concerted effort must be made to cultivate and enhance the capabilities of all 

VA staff to meet the needs of women veterans. Action items to achieve this goal 

include: recruitment and training of practitioners to be proficient, knowledgeable, and engaged providers in women’s health; funding mini-residency programs in women’s primary care programs for current VA providers; continue to 

strengthen VA-based women’s health fellowships; develop recruitment and retention strategies to increase the number of trained staff in women’s health; 

train and sensitize all VA staff on issues specific to women’s health care. 

Recommendation 5 seeks to achieve parity in clinical performance measures 

and gender equity in clinical quality of care issues by addressing the systemic 

reasons for the identified disparities in outcomes for women using VA in order 

to effect change in clinical practice. 

Although overall quality of care is high compared to the private sector and 

despite positive results on gender-specific measures such as screening for cervical and breast cancer, VA acknowledges that clinical quality performance disparities exist in the provision of care to women for certain prevention measures. 

We are pleased the workgroup states its goal is to be a ‘‘national model for 

women’s health care’’ and challenges VA to stand by its principles of providing 

the highest quality of care—the best care anywhere—and to ensure gender parity in the delivery of VA health care. 

76 

Actions necessary to achieve this goal include: assuring continual measurement of women veterans’ health outcomes for gender-specific and gender-neutral care; continuing research that addresses best practice models for delivery 

of care to women veterans; working closely with the VA Office of Research and 

Development to better understand the unique health concerns of post-deployed 

women veterans; developing and implementing a validated tool for routine clinical assessment of sexual activity, risk behaviors, and anticipation of pregnancy. 

These recommendations thoroughly address quality, efficiency, access and equity 

of VA care for women who use VA services. The workgroup found the need to improve all these areas in today’s VA health care programs for women veterans, and 

to better prepare these programs for tomorrow’s women veterans. We commend the 

members of the workgroup who contributed so much to what appears to us to be 

a comprehensive roadmap that could lead VA to make great strides in improving 

health programs and services for women veterans. 

RESEARCH

Research plays an integral role in developing the most appropriate health care delivery model for women veterans and providing access to high quality health care 

services. 

Over the years, VA researchers have brought to light a number of important facts 

that, if acted upon, would greatly improve the care that women veterans receive at 

VA health care facilities. Among these facts, it was shown that access and waiting 

time scores were better at sites where primary care and gender-specific services 

were available in a one-stop setting. VA facilities that have established this type of 

primary care delivery, whether in women’s clinics or in general primary care, have 

better patient satisfaction scores on care coordination for contraception, sexually 

transmitted disease screening and menopausal management than facilities that separate these services across multiple clinics. 

DAV is pleased that VA’s Office of Research and Development (ORD) supports a 

comprehensive women’s health research agenda, and VA has intensified its research 

on women’s health in the last decade. The first comprehensive VA women’s health 

research agenda, which covered biomedical, clinical, rehabilitative and health services research, was directed by ORD in 2004 with the goal of positioning VA as a 

national leader in women’s health research. ORD successfully mapped research priorities based on the needs of women veterans and capitalized on VA’s significant 

and productive research enterprise while using evidence-based data on the health 

status and health care needs of women veterans to include a systemic literature review on health care research related to women veterans and women in the military. 

Within ORD, VA’s Health Services Research and Development Service (HSR&D) is 

at the forefront of research focused on understanding and improving the health and 

health care of women veterans. 

ORD currently supports a broad research portfolio that includes: studies on diseases prevalent solely or primarily in women; hormonal effects on diseases in postmenopausal women; PTSD and other post-deployment mental health concerns 

among women; and, osteoporosis and multiple sclerosis in women. Gender disparities have also been analyzed and highlighted in addition to the disparities in some 

types of preventative care among spinal cord injured women veterans that include 

the need of special equipment and body adjustments required to perform care. 

HSR&D is also currently funding 27 research projects that examine the health and 

health care of women veterans; the consequences of military sexual trauma and 

other military traumas; PTSD treatment in women; screening and utilization as 

well as post-deployment access and reintegration issues; utilization; outcomes and 

quality of care for women veterans related to ambulatory care; chronic mental and 

physical illness, alcohol misuse, breast cancer and pregnancy outcomes. HSR&D is 

also in Phase II of a study examining VA’s approaches for delivering care to women 

veterans while another is assessing the implementation and sustainability of VA 

women’s mental health clinics. These studies include OIF/OEF populations. 

We look forward to the results of these 27 research projects, and applaud VA for 

standing in the forefront and leading the way in assuring our women veterans that 

they will secure the same access to and quality of care that their male counterparts 

receive in the VA health care system. 

SUMMARY

We congratulate the Women Veterans Health Strategic Health Care Group for an 

extraordinarily forthcoming report and highly relevant series of goal-oriented recommendations and action items. These recommendations are fully consistent with 

a series of recommendations that have been made in recent years by VA researchVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00080 Fmt 6633 Sfmt 6621 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
77 

ers, experts in women’s health, VA’s Advisory Committee on Women Veterans, the 

Independent Budget, and DAV. DAV Resolution 238 seeks to ensure high quality 

comprehensive VA health services for all women veterans, with a special focus on 

the unique post-deployment needs of women veterans returning from OIF/OEF. 

DAV’s resolution notes that VA needs to undertake a comprehensive review of its 

women’s health programs, and to seek innovative methods to address barriers to 

care for women veterans to ensure they receive the treatment and specialized services they need and deserve. Therefore, we fully support the recommendations made 

in the Report and urge their speedy implementation. 

We are pleased that VA Secretary Shinseki has testified previously that the delivery of enhanced primary care for women veterans is one of VA’s top priorities. Likewise, the Women Veterans Health Strategic Health Care Group’s commitment to assuring all eligible women veterans will receive gender-specific primary care by proficient and interested primary care providers; privacy, dignity, and sensitivity to 

gender-specific needs; state-of-the-art health equipment and technology; gender parity in performance measures; and, the right care in the right place and time are 

all laudable goals. We fully concur with the workgroup’s conclusion that ‘‘the debt 

owed to all our veterans and to women in particular demands nothing less than our 

full attention.’’ 

However, making these goals a reality will require VA’s building the proper resources and adequate infrastructure and program capacity and developing the internal support necessary at the highest levels to make the changes it says are needed. 

Without question, this is a significant undertaking by VA and there is a lot of hard 

work ahead to achieve the goals it has set out for itself, but we are hopeful with 

the attention, oversight and collaboration of this Committee that VA can achieve implementation of the recommendations in this report. 

Mr. Chairman, a number of public events focused on women veterans have been 

held in recent months. All are essential to the process of change; however, nothing 

is more important than taking action. For these reasons DAV urges the Committee 

to carefully consider the recommendations outlined in the Provision of Primary Care 

to Women Veterans Report and to support VA’s efforts to achieve these reforms. 

We would like to point out, Mr. Chairman, that as of March 11, 2009, this landmark report on women veterans was distributed to VA field facilities and to regional 

network management offices within VHA. However, its transmittal to the field by 

VA Central Office did not take the form of a VHA directive; nor did it convey any 

mandatory implementation requirements or accountability on the part of local or regional officials. It was simply transmitted to VA field elements as an informational 

device, apparently for their discretionary use in planning. We recognize that VA has 

been making a good faith effort to move forward on its plans for improving women 

veterans’ health services, and it is clear from VA correspondence included at the end 

of the workgroup report that at multiple levels work is underway to assess and implement principles outlined in the report. However, we note there is no formal expression of policy or directive to fill the gaps that this report identified. 

For these reasons we ask the Committee to oversee and seek VA’s commitment 

to issue instructions to all VA health care personnel who will be held accountable 

for implementation of this comprehensive policy. The implementation phase should 

include establishing performance measures for facility and network executive staffs, 

submission of appropriate reports and provision of other oversight to ensure these 

reforms are implemented and sustained at every VA facility caring for women veterans. Additionally, we ask that Congress ensure VA is provided sufficient resources 

to accomplish these essential reforms. 

As you know, women are a growing population within the ranks of the active, 

Guard and Reserve forces of our Armed Services, and women veterans are streaming into VA health care by the thousands. Soon women veterans will share ranks 

nearly two million strong and will constitute one of every seven veterans enrolled 

in VA health care. Expectations for VA to step up to this challenge are high, and 

this report by VHA’s own workgroup clearly reveals the necessity for VA to make 

significant changes in the short term to begin better addressing women’s needs in 

the long term. This workgroup report is an excellent beacon to show them the way, 

but we must have, and seek assurance that its implementation will be faithfully executed. 

Mr. Chairman, again we thank you for the opportunity to share our views at this 

important hearing focused on women veterans—and bridging the gaps in their care. 

We will appreciate your consideration of our views on this pressing and important 

matter to America’s women veterans. I would be pleased to address your questions, 

or those of other Committee Members. 

78 

Chairman AKAKA. Thank you very much for your testimony. I 

want you to know that your prepared remarks will be, of course, 

made part of the hearing record. 

So, now, let me call on Ms. Christopher. 

STATEMENT OF TIA CHRISTOPHER, U.S. NAVY VETERAN; IRAQ 

VETERAN PROJECT PROGRAM ASSOCIATE, WOMEN VETERAN COORDINATOR FOR SWORDS TO PLOWSHARES 

Ms. CHRISTOPHER. Thank you, Mr. Chairman and Members of 

the Committee for allowing me to speak. 

My name is Tia Christopher. I’m a U.S. Navy veteran, and 

Woman Veterans Coordinator for the veteran non-profit Swords to 

Plowshares. I speak before you today both in my professional capacity and from my personal experience as a woman veteran. 

I am 70 percent VA-rated disabled veteran for PTSD and military sexual trauma. My experiences have given me the passion and 

perseverance to do advocacy work on behalf of Swords to Plowshares. I mention this to illustrate that I am a VA consumer, as 

well as a community avenue for my peers to seek and access care. 

The VA has made notable strides in the care of our Nation’s 

women veterans. I would not be the person I am today without the 

young woman veteran PTSD groups established at some VA medical centers. 

Even as we acknowledge the amazing strides that have been 

made, it must be noted that services and support for women remain insufficient both in quality and accessibility. More women are 

serving in the military than ever before. 

No one entity should be expected to provide the breadth of services and support needed for female veterans. There needs to be a 

coordination and collaboration between the DOD, VA, and community providers in order to delivery adequate care. 

Community providers, such as Swords to Plowshares, are on the 

frontlines everyday serving veterans from all our Nation’s conflicts. 

Because of the historical lack of gender-appropriate services, it is 

critical that no door be the wrong door to accessing care. 

Resources are stretched—we all know that—both for the government and non-profits. Women veterans may seek assistance in the 

community, which do not address their underlying health issues, 

but address their pragmatic needs in the moment. 

For example, I had a young woman Air Force veteran come in 

initially asking for help finding a job, but, at the end of our conversation, it became evident she was homeless. This young women 

who honorably served her country divulged that she was now selling her body just to get by. It broke my heart that this sister veteran of mine had been reduced to this. 

Because of the specific employment and training services that 

Swords provides and the fact that she was able to speak with a fellow female veteran, she felt comfortable asking for help. In this 

case, she needed mental health attention, as well. Services need to 

reflect the myriad, co-occurring issues surrounding our female veterans and care providers need to be versed in how to appropriately 

and comprehensively address these issues. 

This veteran is not unique in her experience. Female veterans 

frequently access community care rather than VA care, which is 

79 

often times less of a hurdle to navigate, as well as less intimidating. Swords to Plowshares conducted focus groups of female veterans in San Francisco, during which many participants noted barriers to VA services. 

One stated, ‘‘If you do have benefits available through the VA, 

you have to be very persistent, you have to want to get your benefits, and you have to fight for them. If the benefits are there, you’re 

entitled to them, and you just have to find the right person in the 

office that’s going to help you fight for them.’’ 

Women need not only more gender-specific care, but also care 

that is appropriate for their needs. The gender of a mental health 

provider does not necessarily qualify them to treat that woman veteran. It is essential that women who do need inpatient treatment 

for PTSD, whether combat or sexual assault-related, receive care in 

a safe treatment space. A coed environment can truly be the worst 

thing for a woman suffering from military sexual trauma and 

PTSD. We need more woman-veteran-only inpatient VA programs. 

Just having the resources is not enough. Again, the quality, 

quantity, and accessibility of that care is vital. For those who are 

uncomfortable receiving treatment at a VA facility for whatever 

reason, funding needs to be allotted for culturally-competent care 

within the community. 

Both government and community entities need to be educated on 

the specific needs of women veterans. I regularly speak during the 

community panel portion of the National Center for PTSD’s Clinical Training Program. Sharing my story and experience navigating 

the VA system and receiving treatment has helped these clinicians 

better understand their patients. 

The Iraq Veteran Project of Swords to Plowshares is primarily 

composed of staff who are veterans. We provide foundation-funded 

free panel representations for VA clinicians and community behavioral health providers on issues such as prevalence of PTSD, TBI, 

MST, military terminology clarification, triggers, cultural obstacles 

to care, and effective outreach approaches. This has led to greater 

dialog and collaboration among community and government entities treating veterans, as well as help the veterans themselves feel 

that they are understood by their caregivers. 

Thank you very much for your time. 

[The prepared statement of Ms. Christopher follows:] 

PREPARED STATEMENT OF TIA CHRISTOPHER, U.S. NAVY VETERAN AND WOMEN

VETERAN COORDINATOR—IRAQ VETERAN PROJECT, SWORDS TO PLOWSHARES

Good morning. Thank you, Senators, for allowing me to speak. My name is Tia 

Christopher. I am a U.S. Navy veteran and Women Veterans Coordinator for the 

veteran nonprofit Swords to Plowshares. Our organization has been helping veterans since 1974. 

In response to the wars in Iraq and Afghanistan, we established the Iraq Veteran 

Project to specifically address the needs of the newest generation of veterans. Following the formation of the Iraq Veteran Project, Swords created my position to respond to the specific needs of the fastest growing cohort of the U.S. veteran population: Women. I speak before you today both in my professional capacity and from 

my personal experience as a woman veteran. I am a 70% VA-rated, disabled veteran 

for PTSD and Military Sexual Trauma. My experiences have given me the passion 

and perseverance to do advocacy work on behalf of Swords to Plowshares. I mention 

this to illustrate that I am a VA consumer as well as a community avenue for my 

peers to seek and access care. 

80 

The Department of Defense has made considerable progress in the eight years 

since I served. Significant steps have been made in the area of sexual assault prevention; (i.e.: the establishment of the SAPR program). In the same spirit, the VA 

has made notable strides in the care of our Nation’s women veterans. I would not 

be the person I am today without the young women veteran PTSD groups established at some VA medical centers. Even as we acknowledge the amazing strides 

that have been made, it must be acknowledged that services and support for women 

remain insufficient both in quality and accessibility. More women are serving in the 

military than ever before. No one entity should be expected to provide the breadth 

of services and support needed for female veterans. There needs to be coordination 

and collaboration between the DOD, VA, and community providers in order to deliver adequate care. 

Community providers such as Swords to Plowshares are on the front lines every 

day serving veterans from all our Nation’s conflicts. Because of the historical lack 

of gender appropriate services it is critical that no door be the wrong door to accessing care. Resources are stretched; we all know that, both for the government and 

nonprofits. I am scrambling every day to find resources for the women veterans who 

come through our door. 

Whether it is housing, inpatient programs, or resources for their families, services 

are insufficient for women veterans. Women veterans may seek out services in the 

community which don’t address their underlying health needs but address their 

pragmatic needs in the moment. For example, I had a young woman Air Force veteran come in initially asking for help finding a job, but at the end of our conversation it became evident she was homeless. This young woman who honorably served 

her country divulged that she was now selling her body just to get by. It broke my 

heart that this sister veteran of mine had been reduced to this. 

Because of the specific employment and training services that Swords provides, 

and the fact that she was able to speak with a fellow woman veteran, she felt comfortable asking for help. In this case, she needed mental health attention as well. 

Services need to reflect the myriad co-occurring issues surrounding our female veterans; and care providers need to be versed in how to appropriately and comprehensively address these issues. 

This veteran is not unique in her experience; female veterans frequently access 

community care rather than VA care, which is oftentimes less of a hurdle to navigate, as well as less intimidating. Swords to Plowshares conducted focus groups 

with female veterans in San Francisco, during which many participants noted barriers to VA services. One participant stated, ‘‘If you do have benefits available 

through the VA, you have to be very persistent. You have to want to get your benefits, and you have to fight them for it. The benefits are there, you’re entitled to 

them, and you just have to find the right person in the office that’s going to help 

you fight for them.’’ 

Women need not only more gender specific care, but also care that is appropriate 

for their needs. It is essential that women who do need inpatient treatment for 

PTSD, whether combat or sexual assault related, receive care in a safe treatment 

space. A coed environment can truly be the worst thing for a woman suffering from 

Military Sexual Trauma (MST) and PTSD. Just having the resources is not enough, 

again, the quality, quantity, and accessibility of that care is vital. For those who 

are uncomfortable receiving treatment at a VA facility, for whatever reason, funding 

needs to be allotted for culturally competent care within the community. 

Both government and community entities need to be educated on the specific 

needs of women veterans. I regularly speak during the community panel portion of 

the National Center for PTSD’s clinical training program. Sharing my story and experience navigating the VA system and receiving treatment has helped these clinicians better understand their patients. The Iraq Veteran Project is primarily composed of staff who are veterans. We provide free panel presentations for clinicians 

and community behavioral health providers on issues such as prevalence of PTSD, 

TBI and MST, military terminology clarification, triggers, language, cultural obstacles to care, and effective outreach and treatment approaches. Sessions such as 

these are a foundation-funded free service provided by our nonprofit to government 

and community entities. This has led to greater dialog and collaboration among the 

various entities treating veterans, as well as helping the veterans themselves feel 

that they are understood by their caregivers. 

Another area of great concern is an understanding of the resources available to 

them, and an understanding of what to expect during transition. I encountered dry, 

outdated materials that were difficult to digest and did not speak to me as a young 

veteran. As a result, Swords to Plowshares published our OIF/OEF transition manual written in familiar language from one veteran to another. The concept behind 

this manual is not profound- however- it is unique in its approach and has been 

81 

met with extremely positive feedback from DOD, VA, and community entities, as 

well as from the veterans themselves. Materials such as this could considerably augment and aid accessibility to VA services on a nationwide scale. This is one example 

of how the community and the VA can work together. Based on the success of this 

manual written for both genders, it is my dream to write one specifically for women 

veterans, working in partnership with the DOD and VA. 

Finally, women veterans have expressed their need for resources strictly for them. 

During the focus groups with Swords to Plowshares many expressed the need for 

peer-based emotional support. One participant stated, ‘‘Getting support from other 

military veterans definitely helps. We have something in common.’’ One answer to 

this has been weekend retreats. In October 2008 several veteran nonprofits came 

together with the support of several VAs, Vet Centers, and active duty bases. This 

retreat was attended by OIF/OEF women veterans, reservists, and active duty. The 

overwhelming response from the 25 participants was how important it was for them 

to have a space to call their own. Being surrounded by their peers was integral for 

their healing; they heard and saw that they were not alone. This experience not 

only aided in their healing and transition process into the civilian world, but also 

functioned as a successful augmentation to the post-deployment process. In the 

words of one participant, ‘‘Thank you for recognizing this aching need for women 

veterans to meet and bond with other women veterans. Military service as a 

female... has been a very lonely and isolated experience, and I wish that I had 

been able to attend a workshop/retreat like this much earlier in my military career. 

Perhaps if such a support group/network had been established for me early on, I 

would not have struggled so much (or at least, not alone) through the dark valleys 

of depression and self-doubt that I traversed as a young female in the military.’’ 

The following are a list of recommendations for greater access to care for women 

veterans: 

• Mandatory and routine training for VA clinicians on the specific issues facing 

women veterans. 

• Resources available for VA providers to include: issues facing female combat 

veterans; military era specific information (i.e., OIF/OEF versus the Vietnam era); 

military terminology; the differences between Military Sexual Trauma and sexual 

trauma in a civilian setting; co-occurring combat and sexual trauma based PTSD, 

sometimes referred to as ‘‘The Double Whammy;’’ etc. 

• Escorts at VA facilities for women veterans not comfortable going alone. This 

‘‘battle buddy’’ system could be implemented at no cost to the VA through use of 

volunteers, the Chaplain Service, and veteran peers. This simple gesture could 

eliminate a huge barrier to care. 

• Development of permanent women-only clinics at VA facilities, and improved 

signage at all VA facilities designating where the women’s clinic is. 

• Separate entrances or waiting areas that are safe and monitored. 

• Childcare and extended clinic hours, at least for mental health. Some VA facilities do have extended hours, however this option needs to be universal regardless 

which community women veterans return to. 

• More female only inpatient PTSD and MST programs. For veteran nonprofits 

providing these programs, greater collaboration between the VA and these entities 

needs to occur. 

• Greater outreach concerning the eligibility for veterans with MST. 

• Utilization of peer based approaches and the retreat model to supplement care 

received at the VA. 

• More collaboration with community entities and the DOD to truly make transition seamless. 

• VA to track rates of MST and subsequent early discharge from military service 

to provide evidence that rates of MST are a retention issue for the DOD. 

ABOUT SWORDS TO PLOWSHARES

War causes wounds and suffering that last beyond the battlefield. Swords to Plowshares mission is to heal the wounds, to restore dignity, hope and self-sufficiency 

to all veterans in need, and to significantly reduce homelessness and poverty among 

veterans. 

Founded in 1974, Swords to Plowshares is a community-based not-for-profit organization that provides counseling and case management, employment and training, 

housing and legal assistance to homeless and low-income veterans in the San Francisco Bay Area. 

We promote and protect the rights of veterans through advocacy, public education, 

and partnerships with local, state and national entities. Over the years the name 

Swords to Plowshares has become synonymous with excellence in serving veterans 

82 

in need, a highly visible yet dramatically underserved population. We developed a 

model of coordinated care based on the philosophy that the many obstacles veterans 

face-including homelessness, unemployment and disability-are interrelated and require an integrated network of support. 

Frontline Drop-In Center 

Provides mental health services, including counseling for drug and alcohol problems and PTSD, as well as case management, income advocacy and referrals. 

Supportive Housing 

We offer permanent supportive housing combined with options for counseling, academic instruction and vocational training for 102 formerly homeless disabled veterans. Additionally, we provide transitional housing for 75 veterans at a time for 

intensive individual, group and peer counseling and a variety of recreational, cultural and community-building activities. Both housing programs provide daily hot 

meals to residents. 

Employment Support 

Swords to Plowshares helps veterans make the transition to gainful employment 

by offering vocational counseling, life-skills training, resume preparation and job referrals. 

Legal Services 

Many of our country’s veterans never apply for or receive the benefits they deserve. Swords to Plowshares is one of the few organizations in the country that provides free attorney representation, case management and advocacy to indigent veterans seeking benefits. 

The Iraq Veteran Project 

Launched in 2005 to make sure systems of care are appropriate, sufficient and 

accessible to meet the needs of veterans returning from the wars in Iraq and Afghanistan, and the needs of their families as well. 

Chairman AKAKA. Thank you, Ms. Christopher. 

Now Ms. Chase. 

STATEMENT OF GENEVIEVE CHASE, U.S. ARMY RESERVE VETERAN; EXECUTIVE DIRECTOR, AMERICAN WOMEN VETERANS 

Ms. CHASE. Mr. Chairman and Members of the Subcommittee, 

thank you for inviting us to testify today. 

My name is Genevieve Chase, and I am a Founder and Executive 

Director of American Women Veterans. On behalf of my peers, I 

would like to thank you for your commitment and dedication to 

serving the growing number of women veterans. 

I am a veteran of combat operations in Afghanistan. While serving in the Army Reserve, I volunteered for a 32-month active-duty 

tour, which included deployment in support of Operation Enduring 

Freedom. 

On April 7, 2006, our vehicle was attacked by a suicide vehicleborne, improvised explosive device. The car that hit our truck nearly disintegrated. Although I suffered minor external injuries, the 

impact of that explosion has continued to this day, and I now know 

that we were not adequately informed of the services available to 

us after our service. 

The Reserve soldiers I served with were discharged from active 

service with a 5-minute out-briefing. A single sheet of paper listing 

Web sites to access for VA health care and services. What I recall 

from that time was that being focused on overwhelming issues, like 

finding a job and figuring out how I was going to make it in a civilian world that had become somewhat foreign to me, not on servicerelated health issues I would face in the months to come or how 

83 

I would seek care for those issues. I was not and am not alone in 

this. 

Weeks after returning home, I began to experience additional 

symptoms that I now know to be characteristic of Post Traumatic 

Stress and mild Traumatic Brain Injury, such as extreme guilt, 

anxiety, panic attacks, memory loss, hyperactivity, and bouts of 

deep depression, in addition to periods of consecutive days where 

I suffered exhaustion from insomnia and lacked the energy to leave 

my apartment or speak to anyone. 

During the past 2 years, I have gone to the VA Web site repeatedly and called the VA to pursue an assessment and screening for 

TBI and other related issues. After attempting to navigate through 

the bureaucracy, I gave up, frustrated by an unclear Web site and 

unfriendly service on the other end of the phone. 

I looked to the VA for help when I most needed it, but never succeeded in completing my enrollment, let alone actually receiving 

the care that I needed. In communicating with other veterans, I 

have found that I am hardly alone in this, as well. 

While the VA struggles to catch up and provide adequate, gender-specific care to previous generations of women veterans, the 

total number of women veterans is projected to double in the next 

10 years. It is vital that this Nation proactively and immediately 

address the broad spectrum of treatment needs for this significant 

increase in the women veteran population. 

VA resources for women must expand to meet the growing number of combat-experienced women; and women dealing with PTS, 

military sexual trauma, and TBI must be able to find easily-accessible and concise information and guidance about these vital services when needed. Veterans should not need a third party to help 

them navigate the VA system. 

AWV believes that women veterans of all generations are entitled to VA services that include women-only clinics, women providers, holistic care, extended service hours, offsite care, PTSD and 

MST peer support groups, and the availability of childcare during 

clinic visits. But even with all of these services, women must know 

they are eligible, they must be enrolled, and they must have access 

to the VA. 

Despite the VA’s efforts and claims of educating and reaching out 

to today’s veterans, the message is not getting through. Even minor 

changes in the delivery of this message can have a huge impact. 

As just one example, women veterans from all eras have expressed to me that they would prefer to receive immediate e-mail 

updates on VA benefits and services rather than periodic, automatic mailings, which do not always get forwarded through the 

postal system. AWV believes the best way to improve access to the 

VA is for servicemembers to be educated and enrolled into VA services while they are still on active-duty. 

Briefings, workshops, and enrollment for VA benefits must be 

mandatory and should be conducted by knowledgeable representatives from the VA. Reaching out to all veterans prior to their discharge from active-duty would address several issues to include 

raising awareness and knowledge of eligibility for benefits and 

care; allowing continuity of care and eligibility from hospital to hospital; and offering immediate availability of physical and mental 

84 

health care when needed rather than after lengthy and unknown 

waiting periods. 

Veterans getting the care they need when they need it can help 

prevent a number of extended issues which includes extreme depression, which contributes significantly to the risk of homelessness, substance abuse, and suicide. 

In closing, our Nation’s veterans from all eras answer this country’s call to service, and the VA has the unique and rapidly-growing 

challenge of ensuring easily-accessible, quality services for women 

veterans across the spectrum from childbearing years to well beyond retirement. 

On behalf of American Women Veterans, thank you for working 

to honor and repay the service of all veterans through this inclusive dialog, and we thank you for your commitment to ensure the 

quality and scope of physical and mental health care that today’s 

American women veterans have earned by their service. 

Ladies, gentlemen, and Mr. Chairman, I thank you for your time 

and consideration and welcome your questions. 

[The prepared statement of Ms. Chase follows:] 

PREPARED STATEMENT OF GENEVIEVE CHASE, U.S. ARMY RESERVE VETERAN, OPERATION ENDURING FREEDOM; FOUNDER AND EXECUTIVE DIRECTOR, AMERICAN

WOMEN VETERANS

Mr. Chairman and members of the Subcommittee, Thank you for inviting us to 

testify today. My name is Genevieve Chase and I am the Founder and Executive 

Director of American Women Veterans (AWV). On behalf of my peers, I would like 

to thank you for your commitment and dedication to serving the growing number 

of women veterans. 

I am a veteran of combat operations in Afghanistan. While serving in the Army 

Reserve, I volunteered for a 32-month active duty tour, which included a deployment in support of Operation Enduring Freedom. On April 7, 2006, our vehicle was 

attacked by a suicide vehicle-borne, improvised explosive device. The car that hit 

our truck nearly disintegrated. Although I suffered minor external injuries, the impact of that explosion has continued to this day and I now know that we were not 

adequately informed of the services available to us. 

The reserve soldiers I served with were discharged from active service with a fiveminute out-briefing and a single sheet of paper listing Web sites to access for VA 

services. What I recall from that time was being focused on overwhelming issues 

like finding a job and figuring out how I was going to make it in a civilian world 

that had become somewhat foreign to me—not on the service related health issues 

I would face in the months to come or how I would seek care for those issues. 

Weeks after returning home, I began to experience additional symptoms that I 

now know to be characteristic of Post Traumatic Stress (PTS) and mild Traumatic 

Brain Injury (TBI), such as: extreme guilt, anxiety, panic attacks, and bouts of deep 

depression—in addition to periods of consecutive days where I suffered exhaustion 

from insomnia and lacked the energy to leave my apartment or speak to anyone. 

During the past two years, I have gone to the VA Web site repeatedly and called 

the VA to pursue an assessment and screening for TBI and other related issues. 

After attempting to navigate through the bureaucracy, I gave up, frustrated by an 

unclear Web site and unfriendly service on the other end of the phone. I looked to 

the VA for help when I most needed it, but never succeeded in completing my enrollment, let alone actually receiving the care I needed. In communicating with other 

veterans, I have found that I am hardly alone in this. 

While the VA struggles to catch up and provide adequate, gender specific care to 

previous generations of women veterans, the total number of women veterans is projected to double in the next 10 years. It is vital that this Nation proactively address—immediately—the broad spectrum of treatment needs for this significant increase in the women veterans population. VA resources for women must expand to 

meet the growing number of combat-experienced women; and women dealing with 

PTS, Military Sexual Trauma (MST) and TBI must be able to find easily-accessible 

and concise information and guidance about these vital services when needed. Veterans should not need a third party to help them navigate the VA system. 

85 

AWV believes that women veterans of all generations are entitled to VA services 

that include women-only clinics, women providers, holistic care, extended service 

hours, offsite care, PTSD and MST peer support groups, and availability of childcare 

during clinic visits. But even with all of these services; women must know they are 

eligible, must be enrolled and must have access to the VA. 

Despite the VA’s efforts and claims of educating and reaching out to today’s new 

veterans, the message is not getting through. Even minor changes in the delivery 

of this message can have a huge impact. As just one example, many women veterans have expressed to me that they would prefer to receive immediate email updates on VA benefits and services rather than periodic automatic mailings which 

don’t always get forwarded through the postal system. 

AWV beleives the best way to improve access to the VA is for servicemembers to 

be educated and enrolled into VA services while they are still on active duty. 

Briefings, workshops and enrollment for VA benefits must be mandatory, and 

should be conducted by knowledgeable representatives from the VA. Reaching out 

to all veterans prior to their discharge would address several issues to include: 

• Raising awareness and knowledge of eligibility of benefits and care, • Allowing continuity of care and eligibility from hospital to hospital, and • Offering immediate availability of physical and mental health care when needed, rather than after lengthy and unknown waiting periods. 

Veterans getting the care they need, when they need it, can help to prevent a 

number of extended issues to include extreme depression which contributes significantly to the risk of homelessness, substance abuse and suicide. 

In closing, our Nation’s veterans from all eras answered this country’s call to service and the VA has the unique and rapidly growing challenge of ensuring easily accessible, quality services for women veterans across the spectrum, from child-bearing years to those well beyond retirement. On behalf of American Women Veterans, 

thank you for working to honor and repay the service of all veterans through this 

inclusive dialog, and we thank you for your commitment to ensure the quality and 

scope of physical and mental healthcare that today’s women veterans have earned 

by their service. 

Ladies, gentlemen and Mr. Chairman, I thank you for your time and consideration and welcome your questions. 

Chairman AKAKA. Thank you very much, Ms. Chase. 

Now we’ll hear from Ms. Williams. 

STATEMENT OF KAYLA M. WILLIAMS, U.S. ARMY VETERAN; 

BOARD MEMBER, GRACE AFTER FIRE 

Ms. WILLIAMS. Mr. Chairman and Members of the Committee, 

thank you for hearing me speak today. On behalf of women veterans, I would like to thank you all for your commitment to meeting the changing needs of our Nation’s veterans. 

My name is Kayla Williams. I sit on the Board of Directors of 

Grace After Fire, a non-profit dedicated to helping women veterans. 

As a soldier with the 101st Airborne Division, Air Assault, I took 

part in the initial invasion of Iraq in 2003, and was there for approximately 1 year. As an Arabic linguist, I went out on combat 

foot patrols with the infantry in Baghdad. 

During the initial invasion, my team came under small arms fire. 

Later, in Mosul, we were mortared regularly. I served right alongside my male peers. With our flak vests on during missions, we 

were all truly Soldiers first. 

However, it became clear upon our return that, as Senator Murray noted, most people do not understand what women in today’s 

military experience. I was asked whether, as a woman, I was even 

allowed to carry a gun; and I was also asked whether I was in the 

infantry. This confusion about what role women play in war today 

extends beyond the general public. Even VA employees are still 

sometimes unclear on the nature of modern warfare, which presents challenges for women seeking care. 

86 

For example, since women are supposedly barred from combat, 

they may face challenges proving that their PTSD is service-connected. It is vital that all VA employees, particularly health care 

providers, fully understand that women do see combat in Operations Iraqi Freedom and Enduring Freedom, so that they can better serve women veterans. 

Many of the other problems that women face when seeking 

health care through the VA are by no means exclusive to women. 

The transition from DOD to VA remains imperfect, despite efforts 

to improve the process—lost records and missing paperwork are 

frequent complaints. Despite a growing number of community clinics and Vet Centers, many veterans face lengthy travel times to 

reach a VA facility, which is a particular burden during these 

tough, economic times. Often, other barriers may disproportionately affect women. 

For example, since women are more likely to be the primary 

caregivers of small children, they may require help in getting 

childcare to attend appointments at the VA. Currently, many VA 

facilities are not prepared to accommodate the presence of small 

children. Several friends have described having to change babies’ 

diapers on the floors of VA facilities because the restrooms lacked 

even the most basic changing tables. 

Another friend, whose babysitter canceled at the last minute, 

brought her infant and toddler to a VA appointment. The provider 

told her that it was not appropriate, and that if she could not find 

childcare, she should not even bother to come in. 

Facilities in which to nurse and change babies, increased availability of telehealth or telemedicine, and/or childcare assistance, or 

at least patience with the presence of small children, would ease 

the burdens on all veterans with small children, especially women. 

Women in the military are also far more likely to be married to 

other servicemembers. These women veterans must worry not only 

about their own readjustments to civilian life, but also the challenges their husbands may be facing. The VA must consider the 

dual role that women veterans may be balancing as both givers 

and seekers of care. 

My husband, for example, sustained a penetrating Traumatic 

Brain Injury in Iraq, and was medically retired from the military. 

This impacted my decision not to reenlist because he needed assistance that he simply was not getting. It was years before I realized 

that, as both a caregiver and a veteran, I needed to not simply suck 

it up and drive on as the military taught, but rather had to reach 

out for help and support. 

When struggling to cope with invisible wounds of war, such as 

PTSD or in simply facing challenges readjusting post-combat, peer 

support can be vital. However, there are things about women’s experiences in war zones that our male peers simply do not understand. 

They cannot truly know what it is like to fear not only the 

enemy, but also sexual assault from your brothers in arms. They 

may be aware of, but not fully able to empathize with the challenges of facing regular sexual harassment, and they certainly do 

not understand what it is like to feel invisible as a veteran, as 

many women veterans do. It is, therefore, vital that the VA provide 

87 

times and/or places where women veterans—especially those who 

may have experienced military sexual trauma—can feel safe and 

comfortable in seeking help in a community of their peers. These 

are all challenges that I am confident every VA hospital can meet 

and overcome. 

In 2006, I went to the VA Medical Center in Washington, DC. 

My visit was uncoordinated, stressful, and confusing. The facility 

did not smell clean and was crowded with veterans who seemed to 

have poorly-managed mental health concerns. I was not given clear 

information about what services were available to me. 

My husband also went to that VA in 2006. He was regularly told 

that he was at the wrong clinic and sent from one office to the 

other. Doctors gave him the impression that he and his issues were 

an inconvenience at best. My husband’s inability to schedule timely, well-coordinated appointments eventually made him give up on 

getting care from the VA at all. 

We both began relying exclusively on TRICARE for all of our 

medical and mental health needs, even though civilian providers 

we see are less familiar with combat injuries and Post Traumatic 

Stress. 

My visit to the VA Medical Center in Martinsburg, West Virginia, last month, however, was a stark contrast to both my previous experience and the experiences that I have heard about from 

other women veterans at some facilities. 

There was a women’s restroom clearly visible in the lobby. It was 

clean. There was a changing table available. I was treated as a veteran at all times, asked about my combat experiences, and sensitively asked if I had experienced sexual harassment or assault in 

the military. Providers carefully coordinated my visit, ensured that 

I was aware of all available resources, and followed-up promptly 

and thoroughly. 

Their OEF/OIF integrated care clinic and newly-opened women’s 

clinic are models worthy of emulation, and I truly believe that with 

continued advocacy and oversight, all VA facilities can provide that 

same standard of care. 

In order to best meet the needs of all veterans, I also urge the 

development of enhanced relationships not only between the DOD 

and VA, but also with those community organizations that are 

ready and willing to fill gaps in services. Public-private partnerships can allow all of us to come together to meet the needs of our 

veterans in innovative and exciting ways. I strongly urge that all 

legislators support S. 597, which will help better meet the needs of 

women veterans. 

Thank you all so much for working to assess VA’s health care 

services for women veterans and for your efforts to improve care 

for all of our Nation’s veterans. 

[The prepared statement of Ms. Williams follows:] 

PREPARED STATEMENT OF KAYLA M. WILLIAMS, AUTHOR: LOVE MY RIFLE MORE

THAN YOU: YOUNG AND FEMALE IN THE U.S. ARMY; BOARD OF DIRECTORS, GRACE

AFTER FIRE; SENIOR ADVISER, VOTEVETS.ORG

Mr. Chairman and Members of the Committee, thank you for hearing me speak 

today. On behalf of women veterans, I would like to thank you all for your commitment to meeting the changing needs of our Nation’s veterans. 

88 

1 ‘‘Population Representation in the Military Services,’’ Table 3.7, FY2004, available at: http:// 

www.defenselink.mil/prhome/poprep2004/enlisted—force/marital—status.html 

My name is Kayla Williams. As a Soldier with the 101st Airborne Division (Air 

Assault), I took part in the initial invasion of Iraq in 2003, and was there for approximately one year. As an Arabic linguist, I went on combat foot patrols with the 

Infantry in Baghdad. During the initial invasion, my team came under small arms 

fire. Later, in Mosul, we were mortared regularly. I served right alongside my male 

peers: with our flak vests on during missions, we were all truly Soldiers first. 

However, it became was clear upon our return that most people did not understand what women in today’s military experience. I was asked whether as a woman 

I was allowed to carry a gun, and was also asked if I was in the Infantry. This confusion about what role women play in war today extends beyond the general public; 

even Veterans Affairs (VA) employees are still sometimes unclear on the nature of 

modern warfare, which presents challenges for women seeking care. For example, 

being in combat is linked to Post Traumatic Stress Disorder (PTSD), but since 

women are supposedly barred from combat, they may face challenges proving that 

their PTSD is service-connected. One of my closest friends was told by a VA doctor 

that she could not possibly have PTSD for just this reason: he did not believe that 

she, as a woman, could have been in combat. It is vital that all VA employees, particularly health care providers, fully understand that women do see combat in Operations Iraqi Freedom and Enduring Freedom so that they can better serve women 

veterans. 

Many of the other problems that women face when seeking to get health care 

through the VA are by no means exclusive to women: the transition from DOD to 

VA remains imperfect, despite efforts to improve the process. Lost records and missing paperwork are frequent complaints. A woman I know who spent over twenty 

years in the Army Reserves was turned away from her local VA hospital because 

she never deployed to a combat zone; her paperwork was never even examined to 

determine if she is indeed eligible for care. Despite a growing number of community 

clinics and Vet Centers, many veterans face lengthy travel times to reach a VA facility—a particular burden during tough economic times. 

Other barriers may disproportionately affect women. For example, since women 

are more likely to be the primary caregivers of small children, they may require 

help getting childcare in order to attend appointments at the VA. Currently, many 

VA facilities are not prepared to accommodate the presence of children; several 

friends have described having to change babies’ diapers on the floors of VA hospitals 

because the restrooms lacked changing facilities. Another friend, whose babysitter 

canceled at the last minute, brought her infant and toddler to a VA appointment; 

the provider told her that was ‘‘not appropriate’’ and that she should not come in 

if she could not find childcare. Facilities in which to nurse and change babies, as 

well as childcare assistance or at least patience with the presence of small children, 

would ease burdens on all veterans with small children. 

Women in the military are also far more likely to be married to other servicemembers; throughout the Department of Defense (DOD), 51.3% of married female 

enlisted active duty personnel reported being in dual-service marriages, compared 

to only 8.1% of their male counterparts.1 These women veterans must worry not 

only about their own readjustments, but also their husbands’ challenges. The VA 

must consider the dual role women veterans may be balancing as both givers and 

seekers of care. My husband sustained a penetrating Traumatic Brain Injury (TBI) 

in Iraq and was medically retired from the military. This impacted my decision not 

to reenlist, because he needed assistance that he simply was not getting. In addition, I was so focused on his recovery that I barely considered my own needs. It was 

years before I realized that as both a caregiver and a veteran I needed to not simply 

‘‘suck it up and drive on,’’ as the Army taught, but rather had to reach out for help 

and support. 

When struggling to cope with invisible wounds of war such as PTSD, or when 

simply facing challenges readjusting post-combat, peer support can be vital. However, there are things about my experience as a woman in a war zone that my male 

peers do not understand. They cannot truly know what it is like to fear not only 

the enemy, but also sexual assault from your brothers in arms. They may be aware 

of, but not be able to fully empathize with, the challenges of facing regular sexual 

harassment. And they certainly do not understand what it is like to feel invisible 

as a veteran, as many women veterans do. It is therefore vital that the VA provide 

times or places where women veterans, especially those who may have experienced 

military sexual trauma, can feel safe and comfortable seeking help in a community 

of their peers. 

89 

These are all challenges that I am confident every VA hospital can meet and overcome. In 2006, I went to the VA Medical Center in Washington, DC. My visit was 

uncoordinated, stressful, and confusing. The facility did not smell clean and was 

crowded with veterans who seemed to have poorly managed mental health concerns. 

I was not given clear information about what services were available to me. My husband also went to that VA in 2006; he was regularly told that he was in the ‘‘wrong 

clinic’’ and sent back and forth between multiple offices. Doctors gave him the impression that he and his issues were an inconvenience at best. My husband’s inability to schedule timely appointments that fit in with his schedule eventually made 

him give up on getting care from the VA at all. We both began relying exclusively 

on TRICARE for all our medical and mental health needs, even though the civilian 

providers we saw were less familiar with combat injuries and post-traumatic stress. 

My visit to the VA medical center in Martinsburg, West Virginia in June 2008, 

however, was a stark contrast to my own previous experience and the stories I have 

heard from veterans about some other facilities. There was a women’s restroom 

clearly visible in the lobby; it had a changing table. I was treated as a veteran at 

all times, asked about my combat experiences, and sensitively asked if I had experienced sexual harassment or assault in the military. Providers carefully coordinated 

my visit, ensured that I was aware of all available resources, and followed up both 

promptly and thoroughly. Their OEF/OIF Integrated Care Clinic and newly-opened 

Women’s Clinic are models worthy of emulation, and I truly believe that with continued advocacy and oversight, all facilities can provide the same standard of care. 

In order to best meet the needs of all veterans, I also urge the development of 

enhanced relationships not only between the DOD and VA but also with those community organizations that are ready and willing to fill gaps in services. Public-private partnerships can allow all of us to come together to meet the needs of our veterans in innovative and exciting ways. 

Thank you for working to assess the VA’s health care services for women veterans, and for your efforts to improve care for all our Nation’s veterans. 

Chairman AKAKA. Thank you very much, Ms. Williams. 

Ms. Olds? 

STATEMENT OF JENNIFER OLDS, U.S. ARMY VETERAN ON 

BEHALF OF VETERANS OF FOREIGN WARS 

Ms. OLDS. Mr. Chairman and Members of the Committee, I 

would like to thank you and the VFW for the opportunity to testify 

today. 

My name is Jennifer Olds, and I served in the U.S. Army during 

the first Gulf War from 1990 to 1992. 

During my time in the military, I experienced multiple 

incidences of military sexual trauma. As a result of my experiences 

in the military, I suffer from severe and chronic PTSD. 

Some of the health conditions that resulted from that severe and 

chronic PTSD involved both physiological and psychological effects. 

Some common psychological effects that have been stated before 

are flashbacks, nightmares, insomnia, distrust of society, constant 

fear, depression, and becoming suicidal. I also suffered from physical ailments because of the PTSD, which include things like nervous issues, anxiety attacks, panic disorders, dizzy spells, ulcers, 

and I had shingles twice in my 20s. 

As I look back over the treatment that I have received from the 

VA, I find a list of things that I think has comprehensively helped 

me to recover to the place that I am today, which is significantly 

much better than I was 15 years ago. Among this list include the 

availability of counseling from the Vet Centers in the Portland, Oregon, VA; and, also, being assigned a psychiatric nurse practitioner 

who tried to provide medications to help me with sleeping because 

getting sleep can help improve your ability to handle all the other 

effects of PTSD. 

90 

Eventually, about 10 years after my initial start in the VA system, I finally allowed them to provide anti-anxiety medications, 

which, in combination with other things, seemed to help me improve quite a bit. 

One of the things I believe that had a severe impact on turning 

my life around was my admittance into the vocational rehabilitation program. That gave me a reason to stop being suicidal or at 

least to start fighting my suicidal ideations and allowed me to look 

forward to my future. 

Not long after, a few years later, I was given the opportunity to 

participate in some PTSD research. It was a research study at the 

VA comparing cognitive studies—cognitive therapy—against exposure therapy. I was randomized into the exposure therapy program 

and participated in it. It was a 10-week, intense, grueling program 

that asked me to recollect and discuss a traumatic event. 

So, it is not a program that is easy for people to get through, but, 

if you can, and you are like me, you benefit significantly. 

As I also look back, I realize the importance of having holistic 

care. Because I suffered not only psychological issues, but physical 

issues, being able to get the support from both sides of the coin was 

very helpful, as well. 

Finally, and I think most importantly, as we look at providing 

care for vets or women vets in particular—with the kinds of backgrounds that we tend to have, I think with PTSD and military sexual trauma—having very patient, understanding, good-fit providers 

is key. If we have someone that we are unhappy with or we feel 

does not understand us, we are not going to go. So, finding people 

that have the patience and endurance to stick with us until we are 

able to sort of work for ourselves, I think, is very important. 

As I look forward to the future for things that I think would be 

helpful for the VA system to implement, the first thing that comes 

to my mind is location. 

I spent an hour-and-one-half driving each way to my counseling 

appointments, not to mention the amount of time I spent in my 

counseling appointments, and those combined ended up being at 

least 4 hours per day, 3–5 days per week. That does not bode well 

for working. 

Also, as I think back on my original discharge, I, again, was not 

given any information. I had no idea that there was stuff available 

for me; and really, there was not, as I look back for PTSD and 

women specifically. 

But I had gotten so suicidal that I sought my own care from a 

private institution where I utilized my own private insurance. That 

only covered 2 weeks at the most. It only covers a portion of that 

amount, so, my family had to take on the burden of the additional 

costs. So, my point of this is: getting acceptance right into the VA 

system immediately is important. 

I also think that we need to think about women veterans as individuals. I do not think there is a one-size-fits-all. I have listed a 

number of things that I felt were extremely beneficial to me, but 

there were other options that came up that were available to me 

that I did not take advantage of because they were not good fits 

for me. 

91 

An example of this is a counselor that tried to provide EMDR, 

another type of therapy for PTSD. While it has been proven to be 

very effective, it was not a type of therapy that I felt was fitting 

for me at the time. 

So, being able to look at the individual and examine what they 

themself need, then providing a variety of options to pick from, I 

think, is important, as well. 

One of the other things I think that we need to provide is education for everyone—for providers, for women vets, and for the public—on what the VA can offer and how the VA provides care for 

the women, sort of an around the world picture for everyone. 

As I have looked at the care that has been offered for women 

vets, I have come up with a conclusion like what some of the other 

people have said. I believe that if we have some of what I call ‘‘information sessions’’ for women or ‘‘for vets by vets’’ sessions in 

helping them understand how to navigate the system and to move 

forward with the different kinds of options, which is important, as 

well. If I had had that, I may have started some things earlier in 

my treatment plan. And I would be one to volunteer to do that for 

other vets because I feel it is important to help others get their life 

back sooner than some of us have. 

And, finally, I think we need to reduce the stigma that the VA 

has in the system in general. While I go out and speak positively 

about my experiences from the VA—because I have had numerous, 

wonderful experiences from the Portland, Oregon, VA—there are 

other people who do not, and we need to reduce the amount of 

incidences like this that prevent the VA system from getting the 

good reputation that it can deserve. 

I understand there are differences from VA to VA, but, in general, reducing that stigma, I think, will help encourage vets to use 

the system. 

So, Mr. Chairman, this concludes my statement. I would be 

happy to answer any questions you or the other Members of the 

Committee may have. Thank you for your time. 

[The prepared statement of Ms. Olds follows:] 

PREPARED STATEMENT OF JENNIFER OLDS, B.S., M.B.A., U.S. ARMY VETERAN ON

BEHALF OF VETERANS OF FOREIGN WARS OF THE UNITED STATES

Mr. Chairman and Members of the Committee: I would like to thank you and the 

Veterans of Foreign Wars of the United States (VFW) for the opportunity to testify 

today. 

My name is Jennifer Olds, B.S., M.B.A., and I am from Forest Grove, Oregon. 

When I enlisted at 18 years old, I was voraciously positive about what life could 

offer and had much to look forward to. I was college oriented in high school taking 

college prep classes like physics, chemistry, college writing, etc., as well as athletic, 

engaged to be married and strong in my faith. I served on active duty in the U.S. 

Army during the first Gulf War, from 1990–1992. While in the Army I was exposed 

to Military Sexual Assault situations numerous times, either trying to protect myself, or the other female soldiers around me. This was my own ‘‘battle field.’’ Once 

discharged, I became increasingly aware of my new symptoms of PTSD. 

Some examples of my PTSD involved the following: 

1) While I was driving, I was constantly in belief that someone was out to harm 

me, constantly watching to see who was following me home, driving out of the way 

to make sure no one was following me, thus experienced intense fear and anxiety 

attacks while driving, 

2) While at restaurants I needed to sit in the corner, or against the wall and 

would be on constant guard evaluating who was out to harm me or my family. If 

one of them needed to run to the bathroom I would be extremely on edge until their 

92 

return. If anyone asked me what was discussed during dinner at the restaurant, I 

couldn’t tell you since I was so busy paying attention to the potential bad guys 

around us. 

3) I was no longer engaged upon my return from the military and had not dated 

for over 10-years since my discharge. Finally, When in my home I had to have every 

curtain closed, window and door locked, and was constantly freaked out about who 

was driving by or walking by because I truly believed they were scouting me out 

and would eventually be back to harm me. 

After a year of continued daily battles with insomnia, nightmares, flashbacks, 

anxiety attacks, depression, with situations described in the previous paragraph, it 

became clear to me that this way of living was something I no longer wished to deal 

with. I no longer felt that life would be worth living if that is all I had to look forward to. I became extremely depressed and suicidal, and had no knowledge of how 

to help myself. 

When I became suicidal I met with my family and asked them for help, since I 

had no idea what needed to be done and frankly was in no position to help myself. 

They suggested I enter a program at a hospital facility where I was admitted but 

the insurance coverage ran out within two weeks and I was discharged owing thousands of dollars to them, which my family had to take on. Within a week or so, I 

was desperate for help, as I knew I was still suicidal and finally was admitted to 

the Portland VAMC where again I was discharged within two weeks. I was told I 

didn’t belong there and that staying any longer would force them to send me to the 

Salem ‘‘crazy ward,’’ a place I was sure would ruin my future. Again I was sent 

home with nowhere to go or seemingly any help. 

Fortunately I was assigned a psychiatric NP who patiently saw me over the next 

several years with little improvement from me. You see, our visits went something 

like this, I would be unable to continue a stream of thought, as the anxiety increased and I would become blank and unable to figure out my thoughts or feelings. 

This made the process very difficult, but so did making the appointments given the 

stigma. I didn’t want others to know about, or me to actually realize about myself. 

I met with a representative of Paralyzed Veterans of America (PVA) who asked 

the right questions and helped me realize and seek help from the VA for the treatment of PTSD. Initially, I was sent to the Vet Center that was located over an hour 

drive away from my home. Eventually that therapist moved on, and I was assigned 

a new one who wanted to do EMDR. I was in no position to do EMDR and told the 

new therapist this many times and it seemed an endless conversation so I stopped 

going altogether. At this point I only maintained a working relationship with my 

Psychiatric NP who had the strength of a horse with enduring patience with my 

slow progress. 

Over the course of my treatment with the VA, I was given the opportunity to go 

to college under the VOC REHAB program, which was a turning point for me. This 

opportunity inspired me to want to live, and to fight the constant suicidal ideations. 

Getting over this hurdle took time, but college was certainly one of the many steps 

that have eventually given me some solace on life. By the time I was finishing up 

my undergraduate degree, a serious life event forced me to begin looking at old 

trauma wounds and I began to focus efforts with my NP. Eventually, after a few 

more years in treatment, my fabulous NP suggested I participate in the research 

study comparing cognitive therapy with exposure-based therapy. I said I would, because I wanted my life back, that is, the voracity and charge to live life and be 

happy. 

I participated in this grueling 10-week program that asked me to repeatedly discuss one of my traumatic events. I had intense anxiety attacks, dizzy spells, nausea, 

etc., while I was undergoing this therapy. It was not long after the completion of 

this treatment, that my family and friends became aware of the changes I was making, little known to me at the time. Eventually I came to see that I now could partake in conversations with others and actually hear what they were talking about 

and know what was going on in their lives. Within a few years I was dating again 

after quite some time. I have decreased nightmares, no longer watch who’s following 

or walking by my house, and even enjoy a night full of sleep more often. I am extremely delighted with the caregivers at the Portland VA and think if not for them, 

I would not be where I am today. 

To say I had PTSD should not be summarized by mental capacities only. I made 

several visits to the doctors for dizzy spells, chest pains, skin issues, nervous ticks, 

ulcers, stomach/bowel issues and the shingles x2, all while in my 20’s. Most of the 

time these things were ‘‘undiagnosable,’’ but I have come to realize over the last 15 

years that much of these were stress related. That is, I believe PTSD caused not 

only mental issues, but numerous physical issues as well. A person, like me, can 

93 

become overwhelmed with the array of issues one can experience simply from PTSD, 

and become quite discouraged on how to tackle it all. 

I have a few suggestions on how I think we can encourage others to get help and 

improve their PTSD symptoms: 

1) encourage support groups and speakers from others like themselves who have 

actually improved from PTSD. 

2) Provide them with names of providers who have enormous patience. 

3) Provide holistic approaches, and specific focused treatment: I truly believe that 

one size does not fit all. 

For example, Eye Movement Desensitization and Reprocessing Therapy (EMDR) is 

a comprehensive, integrative psychotherapy approach often used for MST. Although 

I did not feel comfortable with this type of treatment, it may work for some and 

exposure-based therapy may work for others, or perhaps medications in addition or 

on their own may also be the best way. 

Today I am able to do things that I have not been able to do in a long time, and 

I also find myself void of other previous behaviors, which were not positively affecting my life. All these changes are not only very encouraging, but seem to continue 

to yield way to yet more and more ‘‘platforms’’ on which to continue with more positive changes. I have seen these abilities and actions of change as extremely exciting 

and very positive, and so have my family and friends who have known the struggles 

I have had to deal with since my time in the Army. My life is continuing to improve. 

I have watched PVA make significant changes that have improved the care to all 

veterans and am extremely pleased with my care. This process of dealing with 

PTSD has been a learning experience for me as well as many at the VA. 

Mr. Chairman this concludes my statement, I would be happy to answer any 

questions you or the other Members of the Committee may have. 

Chairman AKAKA. Thank you very much, Ms. Olds, for your testimony, and all of you here. 

Several of you mentioned the importance of VA providers to understand and acknowledge that women can experience combat 

while serving in the military. 

How would you recommend VA and women veterans educate 

their providers about this in order to help them provide better care 

for women veterans? 

Ms. CHASE. Senator, I think—— 

Chairman AKAKA. Ms. Chase? 

Ms. CHASE [continuing]. In terms of recognizing combat and raising awareness about that, there are several military occupational 

specialties within the Army and across the services that have 

women who are engaging in activities outside of the wire. Some of 

these include our intelligence teams, our medics, our truck drivers, 

our civil affair soldiers, our military police, and even sometimes our 

finance and supply sergeants and NCOs, and officers. 

I think the best way to get people to understand and to pay attention is to connect the two. I think if we could provide or somehow get together statements and maybe even personal testimony or 

a team of people that address the Veterans Affairs directly—to 

some of these service providers and some of these clinics in their 

local areas—and say, ‘‘I am a real person and I am standing in 

front of you to tell you that I served in combat, and I need you to 

hear me.’’ I think that would be more impactful than anything else 

that we could give them on a memo or an e-mail. 

Chairman AKAKA. Yes, Ms. Williams? 

Ms. WILLIAMS. Another option that may help people understand 

a little more viscerally would be to have viewings of the Lioness 

documentary about women serving in combat available at VA facilities perhaps over lunch hour or in some way that providers would 

have a chance to watch it. 

94 

Chairman AKAKA. Ms. Ilem? 

Ms. ILEM. I would just note that I think the Lioness documentary 

probably most exemplifies a great opportunity for them to really 

see and hear female veterans in their own voices. Either that or 

other short videos that VA has done on a number of issues related 

to TBI and OEF/OIF population and mental heath issues—reintegration issues. A video on women veterans specifically would be 

an excellent opportunity for providers to see something short, and 

told in women veterans’ own words for them to be able to connect. 

Ms. CHASE. And, Senator, I would like—— 

Chairman AKAKA. Ms. Chase? 

Ms. CHASE [continuing]. To caveat that. Sorry. 

The Lioness documentary is a phenomenal and fantastic documentary. However, it is specifically about a particular team of 

women called the Lionesses who were embedded with combat 

teams and infantry teams. We also need to recognize and make 

sure that they are aware that there are very many jobs out there— 

there are a lot of women every day on different jobs in different capacities, in different branches of service—that are serving outside 

the wire in combat every day, and not just that one specific team 

specific to that movie or documentary. 

Ms. CHRISTOPHER. Mr. Chairman? 

Chairman AKAKA. Ms. Christopher? 

Ms. CHRISTOPHER. I agree with the fellow panelists on what 

they’re suggesting. The one thing that I would like to note though, 

to be quite frank, is trainings can be very boring. I mean, whether 

you are watching a PowerPoint or a video or listening to someone 

talk, I mean, I think that in order for it to be truly effective, there 

needs to be dialog, and it needs to be interactive. 

And I think there should be a Q and A portion. When we do our 

trainings through Swords to Plowshares, we open ourselves up for 

questions. We actually refer to it as ‘‘an uncomfortable questions 

panel,’’ and we encourage the clinicians to ask us—to clarify MOSs 

and military terminology—and to ask us our opinion on treatment 

that has worked for us and that has not; and we make it extremely 

candid, and I think that it has helped immensely. The feedback has 

been so positive. 

So, I just definitely stress the interactive component for a successful training. 

Chairman AKAKA. Thank you. 

We will have a second round of questions. So, let me call on Senator Murray for her questions. 

Senator MURRAY. Thank you very much, Mr. Chairman. 

First of all, thank you all for your service to the country. I really 

appreciate what all of you have done, and going beyond the service 

now to come and talk with us about the important issue that we 

are discussing today. I just want to reiterate that I really do appreciate that. 

While it is the official policy of the military that women can not 

serve in combat, many of you talked about your experiences, 

whether it is Traumatic Stress Syndrome, being close to IED explosions, or being injured. 

Given the fact that women are serving in combat roles, have you 

found that this combat experience is reflected in DD–214ss? 

95 

Ms. WILLIAMS. My own certainly was reflected on my DD–214s. 

It shows that I was awarded the service medal for my time in Operation Iraqi Freedom; and, also, if it ever were to become a question, I also received Army medals and the paperwork that support 

those details of what experiences they were earned for, which is another way people can show their experience. But I know that is not 

universally the case. I was just lucky enough that that was true 

for me. 

Senator MURRAY. How about others of you? 

Ms. Chase? 

Ms. CHASE. When we get our DD–214ss, it states in there whether or not you served and in what theater, and it also states your 

job. I was also awarded the combat action badge. However, that is 

not an automatic award. It’s not an automatic entitlement. It is 

something that is submitted by your chain of command, and if it 

is not submitted or the paperwork gets lost or it does not go 

through, then you do not have that, as well. 

And it also is not a qualifier. A lot of people do not perceive it 

to mean that you were actually in combat or directly engaging the 

enemy. So, that policy needs to be changed or reworded to reflect 

that women are, in fact, serving in combat and they are, in fact, 

on missions outside of the wire. Regardless of whether or not they 

are going outside the wire and they are inside an FOB or a PRT, 

when you have mortars that are incoming daily and you have no 

idea where they are coming from, that is combat; and the perception, I think, needs to be changed. I think the perception would be 

helped if the wording in the policy was changed, as well. 

Senator MURRAY. Ms. Williams, you mentioned that you were 

both a caregiver and a care seeker. Your husband was in the military. I assume that it is fairly common for a woman to be married 

to a fellow military officer and be in the same position. 

What can be done to help us better care for women veterans who 

are not only dealing with their own readjustment issues, but are 

dealing with spouse or children, as well? 

Ms. WILLIAMS. You are right, the percentages are very high. I 

think that it is important that care be more comprehensive. Among 

active-duty, enlisted, married, female servicemembers, over 50 percent are married to other servicemembers, compared to only 8 percent of their male peers. My husband and I were both enlisted. 

I know the VA is trying very hard to do outreach. I once got a 

call, for example, asking if I had sustained a Traumatic Brain Injury as part of their outreach effort to make sure that they are 

catching everybody. And I said, no, I did not; but I am glad you 

called because my husband did and our family is in shambles right 

now. I do not know how to hold myself together and my family together and keep my job, and I am struggling really hard here. And 

he said, well, I cannot really help you with that; I am calling to 

ask if you have suffered a brain injury. 

And that is the way that I think we can try to make sure that 

we are addressing entire family needs. If you have a servicemember who has sustained an injury making sure that their family 

is being taken care of both while they are in the DOD and once 

they have transitioned to VA care, is an important step. 

96 

I know the VA does not cover care for family members, but if 

they learn that the spouse is also a veteran, it is important that 

they take an extra step, reach out and contact them proactively, 

and ask if they need help as a caregiver. Of course, this does apply 

to both male and female spouses; its just that the number of female 

spouses giving care is much higher. 

Senator MURRAY. I hear a lot from women about the access of 

childcare being a barrier to go to the VA. Several of you mentioned 

this in your testimony, and I do not think a lot of people realize 

that if you tell a woman that there is no childcare, they just simply 

do not go. That is it. They do not get their health care. 

For all of the panelists, do you think that the VA providing 

childcare services would increase the number of women who go to 

the VA and get the care that they need? 

Ms. ILEM. I would say definitely. I think researchers have repeatedly shown this as a barrier for women veterans, and that is the 

frustration. How many research surveys do you have to do when 

women keep repeatedly saying this is a barrier for them to access 

care? And I think it was Kayla who mentioned an experience of 

someone who was told it is inappropriate for them to bring their 

child with them. At some of these very personalized appointments 

for mental health or other things, it may be very difficult, but they 

have no other choice. 

So, I think it would definitely be a benefit and we would see an 

increase in the number of women veterans who would probably 

come to VA. 

Senator MURRAY. Ms. Williams? 

Ms. WILLIAMS. I definitely think that user traits of the VA would 

increase if women knew that they had childcare available. There 

are a variety of innovative ways that we could try to address the 

problem of women having to balance their needs for childcare with 

their needs to get services. Among them would be increasing the 

availability of telehealth or telemedicine, where women do not have 

to necessarily go all the way to a remote facility, spending 4 hours 

trying to get to and from and then be in care. 

There are also opportunities for innovative programs. 

For example, the VA has small business loans available. If they 

could provide loans to women veterans who want to provide 

childcare at facilities near VA facilities, that would be a great way 

to try to marry these two needs. 

There are also a lot of community organizations that stand ready 

and waiting to help that would be happy just given a small office 

to staff it with volunteers and be able to help provide that care for 

the time that a women has to be in an appointment. 

And I think as many others have said, the specific solutions may 

vary by location, but there are a lot of innovative ways that we 

could forge public-private partnerships to try to meet these needs. 

Senator MURRAY. OK. Excellent. 

Mr. Chairman, I have gone way over my time. I need to get to 

another committee for mark-up, but I love the video idea of showing the Lioness documentary at VA facilities. I think it, at the very 

least, opens peoples’ eyes to the fact that women have served in 

very important roles and will maybe open that little door in their 

head to think oh, wow, women really have served our country in 

97 

amazing ways and they do need the care and the respect and the 

services that they have earned. 

I would love to see another documentary about all the other 

things that women have done and start helping people everywhere 

really recognize the important service that women are providing. 

So, I thank all of you. And, Mr. Chairman, thank you so much 

for having this hearing today. 

Chairman AKAKA. Thank you very much, Senator Murray. 

Senator Begich? 

Senator BEGICH. Thank you very much, Mr. Chairman. 

Like Senator Murray, at around 11:30, I am going to have to depart for a meeting. This is a very interesting panel, and I want to 

thank you for your service, and also for your insight in the day-today utilization of the VA services and what can be done. I have a 

couple of questions. 

I am going to look through my notes here and try to reread my 

handwriting, as each one of you were speaking, and I am going to 

make a couple of comments. It is not necessary for you to respond. 

I am kind of looking to Dr. Hayes. If you could follow-up with 

at least me and if the Committee so desires on a couple of things— 

one being the childcare issue. 

I remember a circumstance in Anchorage, Alaska. My wife and 

I had our first child, who was 1 year old when I got elected. In my 

office we had at least a crib in there at any given time and there 

were probably toys scattered throughout. I can remember a colonel 

from the Army coming over and introducing himself to me with his 

spouse and their 2-year-old, who also came into my office; and I 

think because I created an environment that showed it was OK, it 

made a big difference. I would not ever imagine that 5 years ago 

a colonel from the Army would bring his 2-year-old to the mayor 

of the city where they were being stationed. That would never 

probably have happened, but we created an environment for that. 

So, you had mentioned the childcare, each one of you, as critical. 

The question I would have, Dr. Hayes, you had mentioned legal 

counsel may have some issues with this. I would like to get whatever they write up, if they do, on childcare. I would like to see that 

because the one thing I know about attorneys—and, no offense, I 

am not one—but they will always tell you why something cannot 

happen versus why something should happen. And, so, if you approach them in a way that when they give you the answer why it 

cannot happen, which is probably the likelihood, can you ask them 

what can change to make it happen? 

That is what I think many of us are talking about or are going 

to be interested in because I agree with you, if the facility does not 

have childcare—facilities for both women and men—it is a problem. 

And, so, if you could do that, that would be fantastic. 

A couple of you mentioned training and successful training, and 

I agree with you, it is ‘‘boring.’’ The trainings I have had to go to 

when they are not interactive are boring. 

I’ll look to you first, Ms. Christopher. 

In your interactions, how do the clinic folks come to you? In other 

words, do they volunteer to come to your training? What happens? 

How does that work? Does the VA require it? I would say no to 

98 

that, but it is a set up question. But how does it work? How do you 

get folks to participate from the clinical side, the professionals? 

Ms. CHRISTOPHER. Honestly, we have been very lucky. Actually, 

the DOD liaison to the Palo Alto Polytrauma Center actually invited me and my colleagues to join the National Center PTSD Clinical Training Program. He actually cut his time in half to develop 

a community panel because he thought it was important. And, honestly, I found that the DOD liaisons have been extremely instrumental in bridging the gap between the VA and the community, 

which I think is fantastic. 

When it comes to the VA clinician trainings that we have done, 

honestly, we have approached them and we have gotten really good 

feedback, and I think in the Bay Area, there is some really good 

dialog. But, no, we—— 

Senator BEGICH. No outcome yet? 

Ms. CHRISTOPHER. To suggest it. 

Senator BEGICH. OK. Do you have something, again, you could 

share at least with me in any written document that is specifying 

what you would like to propose to the VA? 

For example, we did this with community police training in Anchorage when we saw an opportunity because we had a lack of understanding within our police department in regards to the cultural 

diversity of our city. We have 90-plus languages spoken in our 

school district—a very diverse community—so, we integrated that 

into our training. We kind of forced it at first because it was a 

structure, and police are paramilitary, so they have similar structures, procedures, and processes; and change is not necessarily 

high on the list. 

I would be interested in, Ms. Christopher—and I think it was 

Ms. Williams who also talked about training—any of you that have 

some suggestions of how to then have a discussion with the VA on 

how they can make that a little better. I would be very interested 

in that, if you could. 

Ms. CHRISTOPHER. Yes, Senator. 

Senator BEGICH. And whoever else would be willing to do that. 

In connection to that, again, I am going to kind of veer through 

you to Dr. Hayes. 

I would be very interested if the VA actually surveys their clients 

for results of VA clinics because—I am just guessing—even though 

in theory they are all same, they operate differently. 

The example you gave, Ms. Williams, was your positive experience in the last clinic you had gone to. It was very positive and 

there are some good things that occurred there. But that varies 

clinic to clinic. I would be curious if, Dr. Hayes, you could provide 

that. Ms. Williams, if you could tell me again where that was. I did 

not write it down quick enough. The one you had a very good experience in. 

Ms. WILLIAMS. Yes, sir. I have had negative experiences at the 

DC VA. And, just on my way here this morning, I shared with a 

woman in uniform that I was coming here, and she said she is in 

the process of retiring. She just went to the DC VA, and had the 

same experience that I did. She said that it seemed unclean to her 

and very disorganized, and there were people there clearly struggling to cope. It can be nerve-racking when you are seeking care 

99 

to worry that that is your future. So I said, go to the one in Martinsburg, West Virginia. 

We live out near Dulles airport, and from there, it takes just as 

long to get into D.C. as it does to go all the way out to West Virginia based on the lovely traffic we all face. And the Martinsburg 

facility is doing great. 

There are obviously areas that they could improve on, as well. 

They are undergoing construction. So, currently, the OEF/OIF clinic is collocated with the mental health outpatient clinic, which at 

first I found a little off-putting, but when they said that was because of the ongoing construction to improve the facility, I thought 

that was great and it is really a wonderful model. 

Senator BEGICH. That is great. Thanks for telling me which clinic 

that was which helps me get a little better understanding. 

The last think I will just mention, triggered by the discussion of 

telemedicine, that Alaska, because of our ruralness and remoteness, telemedicine is a very powerful tool, and it is very valuable 

in a lot of ways. So, I know we have had very positive comments 

and conversations with the VA about telemedicine and their interest in expanding that. 

I know from my State, it is a critical path to delivery because we 

do not have a VA hospital, for one. We have clinics. And then, in 

remote areas, we have nothing. And it is very difficult because 

there are no roads to get from one place to the next. So, I appreciate your comments on telemedicine from another perspective. You 

know, I see it from a rural perspective. I appreciate your comments 

from women veterans’ perspective, is another access point that is 

a positive one. So thank you for that. 

Mr. Chairman, I will end there. It is a very enlightening panel 

in a lot of ways because of your direct contact, utilization, and work 

with other folks. So, thank you very much for this insight. 

Chairman AKAKA. Thank you very much, Senator Begich. 

Hearing what has gone on here, I just want to inform everyone 

that the Committee’s legislation S. 252 has provisions making 

childcare more available by using an existing childcare program 

and providing reimbursement to those getting care. So, that is in 

that bill and this is something, of course, as we have discussed, 

that certainly can be used here with helping all women. 

One of my major goals is to create a seamless transition for 

servicemembers as they leave the military and become veterans. 

As women veterans, what do you perceive as a major gap in this 

transition process, and how would you recommend we fix it? 

Ms. Williams? 

Ms. WILLIAMS. Sir, I think one thing that will go a long way toward fixing some of the problems—and it is my understanding it 

is at least in the trial process now in some locations—would be 

electronic medical records. 

Having to hand-carry your own medical records when you leave 

the DOD system and take them to the VA system, and the fear 

that some piece of paper will get lost—a vital piece of paper proving what has happened to you in the past—is very difficult and 

stressful, and may be even more of a challenge for veterans who 

may have sustained a Traumatic Brain Injury or be struggling with 

mental health concerns. So, I think that the implementation of uniVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00103 Fmt 6633 Sfmt 6601 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
100 

versal electronic medical records will go a long way toward fixing 

that problem. 

Also, there can be big challenges in terms of benefits. 

When my husband was medically retired from the military, there 

was a gap between that time and when he started getting his VA 

benefits. During that time, we were so financially insecure that 

both of us ended up going on unemployment, which was a deeply 

humiliating experience for two proud and honorable combat veterans—to be reduced to that while we were waiting for his VA benefits to start coming in, and I was waiting for my job to get started. 

So, trying anything that can help smooth and ease that transition would help. I think efforts to get VA exams done for those 

servicemembers who have been injured in the military so that they 

can have a more seamless transition in terms of benefits is another 

step in the right direction. 

Chairman AKAKA. Thank you. 

Ms. Chase? 

Ms. CHASE. Senator, as a Reservist, when you come off of activeduty, which can be multiple times during your military career—especially if you have been activated several times—one of the biggest issues is that we are handed our records, and then it comes 

on you to keep and maintain those records throughout the duration 

for however long you will need them. 

Once you are handed your medical records, that is it. That documentation does not flow from what is or may have been put into 

a computer system at a care facility that you were at even to another care facility while on active-duty orders from base to base, 

much less from when you are on DOD and then into the VA System. 

So, that enrollment period where the records directly transfer 

from your active military service and they follow you throughout 

your VA service or throughout your VA eligibility time, it is important, it is significant, and I cannot stress and say enough about 

how vital it is to have that to also prove combat service. If a 

woman or any veteran has served in combat and has been seen or 

treated by a physician or a physician’s assistant while on activeduty, then it would flow right into their VA eligibility and into the 

computer system. So, it will alleviate so many of the other issues 

that we are seeing. 

Chairman AKAKA. Thank you very much. 

Are there any other—Ms. Olds? 

Ms. OLDS. Mr. Chairman, thank you. 

I want to follow-up with the medical records topic. 

That was one of the biggest problems with me getting care when 

I first got out back in 1992. To this day, no one has found my 

records, and, of course, that caused a significant delay in getting 

benefits from the VA. It took almost 3 years and Councilwoman 

Furse to get involved. So, having access to our medical records, 

having them transferred without anyone having an opportunity to 

lose them, I think, is significantly important. 

And, also, giving information to people about what benefits they 

can get, I was not given any. I had no idea I had benefits coming 

until I met with someone at the PVA and they asked the right 

questions. 

101 

So, information and medical record availability, I think, are probably the two big ones as far as us getting our access into the VA 

system when we get out. 

So, thank you. 

Chairman AKAKA. Thank you. 

Ms. Christopher? 

Ms. CHRISTOPHER. Mr. Chairman, when I got out of the military, 

I did not think that I had any benefits. It was due to a volunteer 

writing an op-ed in the Seattle Times that I found out about the 

Military Sexual Trauma Program, and that I might be eligible. 

Needless to say, when I arrived, I had to fight for my eligibility. 

I have an honorable discharge, but the circumstances are a bit 

more complicated, so, it was the clerks that I really had to fight 

with to get seen to get treatment. 

Once I did finally prove that I was a veteran and that I was entitled to treatment for MST, I got great care by the doctors that I 

got there. But it was an uphill battle, and having to prove again 

and again my trauma and that I am a veteran has definitely affected me. And, let me tell you, it was very validating to finally be 

rated by the VA. 

I have witnessed having OEF/OIF advocates and case managers 

nowadays since the process is so much easier for new veterans, and 

I am so glad that the VA has those. However, most veterans— 

newly-separated servicemembers—are not always aware that these 

positions exist. 

So, again, referring back to the community: when veterans come 

into my clinic or when we are doing briefings, I ask them, hey, do 

you know about this office in the VA; or I hand out a business card 

and personally introduce them to my VA counterparts. So, my 

point is that the community is still a really integral tool in accessing VA health care. 

Chairman AKAKA. Ms. Ilem? 

Ms. ILEM. I would say that things have changed a lot since I got 

out of the military in the mid-80s when there was little-to-know information. I definitely did not recognize myself as a veteran; did 

not know that I had access to the VA; and did not even recognize 

that I was entitled to service-connected benefits for disabilities incurred during service until I met DAV folks. 

So, I think VA is on the right track now in terms of a number 

of outreach efforts when people are coming back from deployments—trying to outreach with them then, get them enrolled in VA 

care at that point, and giving them information—but also then 

doing follow-up letters and follow-up phone calls. 

The unfortunate thing is, as we heard from Ms. Williams, when 

somebody from VA does call, if they would have the ability to just 

adapt a little bit and take into account that, yes, they were calling 

on this particular veteran, but others need help—to be able to refer 

them and simply go ahead and take care of these people. That is 

going to be key in terms of continued follow-up until the time when 

that veteran is ready; and maybe catch them at a point when they 

realize they have access to these benefits and are in need of them. 

Chairman AKAKA. Thank you very much, Ms. Ilem. 

First, I want to thank you for the sacrifice you have made for our 

country; and for the kind of help you are giving us in trying to supVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00105 Fmt 6633 Sfmt 6601 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
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port our women veterans, I want to thank all of you for being here 

today. 

We have heard about a lot of good initiatives VA is undertaking 

to increase the quality and access to care for women veterans. 

However, we also heard that there is much more that could be 

done, especially in the areas of outreach and education about these 

services; and you mentioned medical records and also the electronic 

shift that needs to come. 

All our Nation’s veterans, both men and women, deserve the best 

quality of health care, and I will continue to work to make sure 

that they receive it. 

I look forward to working with VA and others to find solutions 

to the gaps in care for our women veterans. 

Thank you all, again, for being here today. You have been very 

helpful. 

This hearing is now adjourned. 

[Whereupon, at 11:10 a.m., the hearing was adjourned.] 

(103) 

A P P E N D I X 

PATIENT SATISFACTION SCORES BY GENDER USING CAHPS REPORT PROVIDED BY

VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS


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PREPARED STATEMENT OF MARSHA (TANSEY) FOUR, RN, CHAIR, 

WOMAN VETERANS COMMITTEE, VIETNAM VETERANS OF AMERICA

Good morning Mr. Chairman, Ranking Member Burr, and distinguished Members 

of the Senate Veterans’ Affairs Committee. Thank you for giving Vietnam Veterans 

of America (VVA) the opportunity to submit our statement for the record regarding 

VA Health Care Services for Woman Veterans. VVA supports swift passage of 

S. 252, ‘‘The Veterans Health Care Authorization Act of 2009;’’ however, we would 

like for additional language to be included in Section III, regarding woman veterans 

health care which was missing from H.R. 1211, the Women Veterans Health Care 

Improvement Act that was passed by the House. 

It is indisputable that the number of women in the military has risen consistently 

since the 2 percent cap on their enlistment in the Armed Forces was removed in 

the early 1970s. This has resulted in an increased number of women we can now 

call ‘‘veterans’’, and most assuredly, will have a direct bearing on the number of 

women who will be knocking on the door of the VA in the very near future. A focus 

on the capacity and capability of the VA to equitably and effectively provide care 

and services must be a priority today. Planning and readiness is essential for the 

future. These responsibilities also require oversight and accountability in order to 

meet VA and veteran goals, objectives, requirements, standards, and satisfaction, 

along with agency advancement. 

While much has been done over the past few years to advance and ensure greater 

equity, safety, and provision of services for the growing number of women veterans 

in the VA system, these changes and improvements have not been completely implemented throughout the entire VA system. In some locations, women veterans still 

experience significant barriers to adequate health care. Thus, VVA asks Secretary 

Shinseki to ensure senior leadership at all VA facilities and in each VISN to be held 

accountable for ensuring that women veterans receive appropriate care in an appropriate environment by appropriate staff. 

There is much to learn about women veterans as a separate patient cohort within 

the VA. Women’s Health is now studied as a specialty in every medical school in 

the country. It has moved far beyond that of obstetrics and gynecology. Gender has 

an impact on nearly every system of the body and mind. This has great significance 

in the ability of any health care system to provide the most appropriate, comprehensive, and evidence-based scientific treatment and care. This also has a direct effect 

on the delivery system along with staff requirements to meet the needs of women 

now utilizing the VA health care system, as well as for those new women veterans 

who will soon be accessing the system in the days and years to come. 

The VA has already identified that our country’s new women veterans are younger and that they expect to use the system more consistently. For example, in December 2008, the VA reported that of the total 102,126 female OIF-OEF veterans, 42.2 

percent of them have already enrolled in the VA system, with 43.8 percent using 

the system for 2–10 visits. Among these returning veterans, 85.9 percent are below 

the age of 40 and 58.9 percent are between 20 and 29. In fact, the average age of 

female veterans using the VA system is 48 compared with 61 for men. The needs 

of women veterans have yet to be fully identified or recognized*** these needs 

are growing and already taxing the VA system, which historically has focused on 

an older male population. 

As time, social environments, and veterans’ population demographics change, 

there are also cultural expectations based on scientific advancements in health care 

that elicit a re-definition of women veterans’ needs in the VA system. Knowing the 

needs is vital to understanding and meeting them. The VA has recognized many of 

the needs of women veterans by actually creating interest groups comprised of not 

only VA staff, but veterans as well. For example, there is recognition that younger 

women veterans are also working women who need flexible clinic and appointment 

hours in order to also meet their employment and child-care obligations. They also 

need to have sexual health and family planning issues addressed, along with the 

needs of infertility and pre-natal maternity. And there are unanswered questions 

and concerns about the role of exposures to toxic substances and women’s reproductive health. 

VVA requests that this Committee continue to focus on treating women veterans 

who are homeless with children, victims of sexual trauma, and provide funding for 

additional caseworkers and mental health counselors, a women’s mental health 

treatment program, and a comprehensive mental health study of returning female 

soldiers. 

110 

Studies and Assessments of Department of Veterans Affairs Health Services for 

Women Veterans 

VVA believes that this study is vital to understanding today’s women veterans 

and that building on the ‘‘National Survey of Women Veterans in Fiscal Year 2007– 

2008’’ is a referenced starting point and this study should be included as language 

in the bill as similar to H.R. 1211 to expand a survey of sufficient size and diversity 

to be statistically significant for women of all ethnic groups and service periods. 

VVA believes that this study should identify the ‘‘best practices’’ that facilities utilize to overcome identified barriers. 

VVA believes that with the fragmentation of women’s health care services there 

needs to be consideration for driving time/transportation to medical facilities that 

offer specialty care as well as primary care. 

While VVA holds great respect for and recognizes the important work of both the 

Office of the Center for Women Veterans and that of the Advisory Committee on 

Women Veterans, this section as written would limit the initial review, creating unnecessary delays. Rather, VVA believes that this study should also go immediately 

to these two entities, plus the VA Undersecretary for Health, the Deputy Undersecretary for Quality and Performance, the Deputy Undersecretary for Operations, the 

Office of Patient Care Services, and the Chief Consultant for the Women Veterans 

Health Program for review and recommendations, which in turn are then forwarded 

to the Deputy Undersecretary for action to remove or ameliorate the identified 

barriers. 

VVA recognizes that this requires 30 months after the VA publishes the 2007– 

08 National Survey of Women Veterans that the VA Secretary in turn is required 

to report to Congress on the barriers study and what actions the VA is planning. 

However, in reality, this means that the information/directions contained in the 

1907–08 report is/are put ‘‘on hold’’ for two and a half years. Therefore VVA believes 

that the Secretary’s report to Congress should also include what actions—if any— 

have transpired both during the survey and the 30 month hiatus. 

Independent Study on Health Consequences of Women Veterans of Military Service 

in Operation Iraqi Freedom and Operation Enduring Freedom 

VVA believes this section should include appropriate language directing the study 

format to include the use of evidence-based ‘‘best practices in care delivery.’’ 

During the 110th Congress, VVA was heartened to see that the S. 2799 legislation 

included a ‘‘Long Term Study of Health of Women Veterans of the Armed Forces 

Serving Operation Iraq Freedom and Operation Enduring Freedom.’’ However, VVA 

is extremely disappointed to see that while calling for ‘‘a study on health consequences for women veterans of service on active duty in the Armed Forces in deployment in Operation Iraqi Freedom and Operation Enduring Freedom;’’ it eliminates the longitudinal aspect contained in S. 2799 of the 110th Congress. 

As you know, the second round of the National Vietnam Veterans Readjustment 

Study was never completed by the VA, even though it was mandated by Congress 

to do so. VVA urges you not to let this opportunity be lost again on a statistically 

significant and diverse population of veterans. It is an important element to a study 

that will bring long term identification and understanding and of the long term implication of military service during this period of history when the role and duties 

of women veterans has far expanding the service of women in the past. 

Report on Full-Time Program Managers for Women Veterans Programs at Medical 

Centers 

VVA applauds the VA for recognizing the need and importance of the requirement 

for a full time Woman Veteran Program Manager at all VA medical center. However, VVA feels this action falls short of providing these managers with the reporting process that is commensurate with their full duties and responsibilities. Consistency is vital in recognizing the true tracking of the work they perform and in evaluating the issues of their mission. VVA believes this position is most significant and 

demands that this position’s reporting line should also be significant and not determined by individual medical centers. It is known that reporting lines are varied 

from medical center to medical center. In some instances the reporting of identified 

items of the Woman Veteran Program Manager is moved forward through the medical center hierarchy based, not on the desire of the Woman Veteran Program Manager, but of other staff who are selective on what is actually ‘‘moved up the chain 

of command’’ at the medical centers. VVA calls for the Undersecretary of Health to 

define the reporting line for the Woman Veteran Program Managers as that of the 

Chief of Staff at each medical center. This action backs up the initial significance 

that the VA recognized when elevating the position to full time. It brings significant 

investment in the importance of meting the needs of women veterans in its vast 

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health system. If not, a true reporting of the work of the Woman Veteran Program 

Managers and the issues of women veterans could fall into the vast dark pit of the 

unknown. The work of the Woman Veteran Program Managers is vital to recognizing not only the needs but also providing clear information for program and process formation but also on establishing even possible research opportunities. 

Improvement of Health Care Programs of the Department of Veterans Affairs for 

Women Veterans 

VVA asks that particular reflective consideration be given to the following—VVA 

seeks a change in this section of the proposed legislation that would increase the 

time for the provision of neonatal care from 14 to 30 days, as needed for the newborn children of women veterans receiving maternity/delivery care through the VA. 

Certainly, only newborns with extreme medical conditions would require this time 

extension. VVA believes that there may be extraordinary circumstances wherein it 

would be detrimental to the proper care and treatment of the newborn if this provision of service was limited to solely 14 days. If the infant must have extended hospitalization, it would allow time for the case manager to make the necessary arrangements to arrange necessary medical and social services assistance for the 

women veteran and her child. This has important implications for our rural woman 

veterans in particular. And this is not to mention cases where there needs to be consideration of a woman veteran’s service-connected disabilities, including toxic exposures and mental health issues, especially during the pre-natal period. 

Training and Certification for Mental Health Care Providers on Care for Veterans 

Suffering from Sexual Trauma 

VVA has concerns about the VA establishing a ‘‘certification’’ program. In order 

to be valid, VVA believes that such a certification program be based upon and modeled after those already utilized by many professional organizations. Such a certification program would lend itself well to oversight and accountability. Too many VA 

certification programs now consist of only a 1-hour training class or reading 

materials. 

Although this section calls for reporting the number of women veterans who have 

received counseling, care and services under subsection (a) from ‘‘professionals and 

providers who received training under subsection (4)’’, VVA asks ‘‘Who in the VA 

is already trained and holds professional qualifications under these subsections’’? 

Care for Newborn Children of Women Veterans Receiving Maternity Care 

VVA asks that particular reflective consideration be given to the following—VVA 

seeks a change in this section of the proposed legislation that would increase the 

time for the provision of neonatal care to 30 days, as needed for the newborn children of women veterans receiving maternity/delivery care through the VA. Certainly, only newborns with extreme medical conditions would require this time extension. VVA believes that there may be extraordinary circumstances wherein it 

would be detrimental to the proper care and treatment of the newborn if this provision of service was limited to less than 30 days. The decision for extended would 

require professional justification. If the infant must have extended hospitalization, 

it would allow time for the case manager to make the necessary arrangements to 

arrange necessary medical and social services assistance for the women veteran and 

her child. This has important implications for our rural woman veterans in particular. And this is not to mention cases where there needs to be consideration of 

a woman veteran’s service-connected disabilities, including toxic exposures and mental health issues, especially during the pre-natal period, multiple births and pre-mature births. Prenatal and neonatal birthrate demographics (including miscarriage 

and stillborn data) would seem to be an important element herein. 

Delivery of Services 

Considering the ever increasing percentage of women veterans in the homeless 

veteran population and the extraordinary occurrence of this in the OEF/OIF homeless veteran population, one can see that their presence in the VA system will affect 

all levels of service, delivery, treatment, and care. Advocacy for them within the VA 

will be paramount. 

Vietnam Veterans of America believes women’s health care is not evenly distributed or available throughout the VA system. Although women veterans are the fastest growing population within the VA, there seems to remain a need for increased 

focus on women health and its delivery. It seems clear that although VACO may 

interpret women’s health as preventative, primary and gender specific care, this 

comprehensive concept remains ambiguous and splintered in its delivery throughout 

all the VA medical centers. Many view women’s health as only a GYN clinic. As you 

are aware, throughout medical schools across the country and in the current health 

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care environment, women’s health is viewed as a specialty onto itself and involves 

more that gender specific GYN care. 

The new woman veterans also need increased mental health services related to 

re-adjustment, depression, and re-integration, along with recognition of differences 

among active duty, Guard, and reserve women. The VA already acknowledges the 

issue of fragmented primary care, noting that in 67 percent of VA sites, primary 

care is delivered separately from gender specific health care—in other words, two 

different services at two different times, and in some cases, two different services, 

two different times, and two different delivery sites. The VA also notes that there 

are too few primary care physicians trained in women’s health, and at a time when 

medicine recognizes the link between mental and medical health, most mental 

health is separate from primary care. VVA seeks to ensure that every woman veteran has access to a primary care provider who meets all her primary care needs, 

including gender specific and mental health care in the context of an on-going patient-clinician relationship; and that general mental health providers are located 

within the women’s and primary care clinics in order to facilitate the delivery of 

mental health services. 

Providing care and treatment to women veterans by professional staff that have 

a proven level of expertise is vital in delivering appropriate and competent genderspecific care. It is not sufficient to simply have training in internal medicine. Women’s health care is a specialty recognized by medical schools throughout the country. 

Providers who have both a knowledge base and training in women’s health are able 

to keep current on health care and its delivery as it relates to gender. In order to 

maintain proficiency in delivering care and performing procedures, these providers 

must meet experience standards and maintain an appropriate panel size. This cannot occur if women veterans are lost in the general primary care setting. It is critical that women receive care from a professional who is experienced in women’s 

health. If attention is not given to defining qualified providers, it will be a detriment 

to the quality of care provided to women veterans. 

VVA does, however, feel comprehensive women’s health care clinics are most desirable where the medical center populations indicate because comprehensive consolidated delivery systems present increased advantage to the patients they serve.

Research 

Vietnam Veterans of America applauds the VA for elevating its Office of Women’s 

Health to the Strategic Health Care Group level. With this action, the VA has 

‘‘pumped up’’ the volume on the attention and direction of the VA regarding woman 

veterans. But there remains much to be learned about women veterans as a health 

care cohort. Data collection and analytical studies will provide increased opportunities for research and health care advancement in the field of women’s health, as 

well as offer evidence-based ‘‘best practices’’ models and innovative treatments. 

As discussed by Phyllis Greenberger, President and CEO of the Society for Women’s Health Research, at a recent Roundtable on Women Veterans before the House 

Committee on Veterans’ Affairs, Ms. Greenberger stated that the focus of The Society clearly demonstrated that sex and gender differences exist throughout all conditions that affect women differently, disproportionately or exclusively and research 

needs to be done to identify those differences and understand their implications for 

diagnosis and treatment. She discussed the unknown in regard to the influence of 

hormones on not only the bodily process of the women’s medical and mental care 

but also its influence on the regime of medication prescribed by the care providers 

and utilized by women veterans. This is especially true with medications in the 

mental health arena. 

It is well recognized that biological differences related to hormones affect mental 

health risks, rates of disorders and course of those disorders. Research had indicated that estrogen and progesterone influence brain function and stress response. 

Some women experience increased vulnerability to depression during times of reproductive endocrine changes such as premenstrual, postpartum and perimenopausal 

periods. VVA believes more funding needs to be available for research into sex differences and better coordination is needed among VA centers throughout the country to increase the number of women in clinical trials to understand the differences 

and their implication for treatment. 

Suicide Risk 

Last, but just as important, VVA is deeply concerned about the high suicide risk 

among women veterans as reported at the American Psychiatric Association’s May 

2009 meetings in San Francisco. A 2007 longitudinal study of women veterans, 

which followed individuals for a period of 12 years, suggests that women who have 

been in the military have a 3fold increased risk for suicide compared with nonVerDate Nov 24 2008 19:42 Feb 25, 2010 Jkt 000000 PO 00000 Frm 00116 Fmt 6601 Sfmt 6621 H:\ACTIVE\071409.TXT SVETS PsN: PAULIN
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military women. Furthermore, female veterans are more likely to be young and use 

firearms to commit suicide compared with their civilian counterparts, who tend to 

choose other methods—commonly drug overdose. Data for this study came from the 

National Health Interview Study and was then linked with data from the National 

Death Index. It is important to note that this study was population-based and therefore, the findings are applicable to all military personnel and not just those in the 

Veterans Affairs (VA) health system. 

The VA is a massive health care system that possesses challenges for woman veterans, who are encouraged to seek treatment at VA facilities; but not many do. 

Treatment of women veterans at various facilities throughout the country are not 

‘‘women’’ friendly. We are hopeful that any shortfalls can be turned into positive action for our so woman veterans who deserve the same care and treatment because 

of their service and sacrifice to this country. 

In closing, VVA would like to personally thank Senator Patty Murray, for her 

hard work and dedication to our woman veterans, for without Senator Murray, VVA 

believes that this hearing today would not be possible. We thank this Committee 

for the opportunity to submit testimony for the record. 

PREPARED STATEMENT FROM ANURADHA K. BHAGWATI, MPP, EXECUTIVE DIRECTOR, 

SERVICE WOMEN’S ACTION NETWORK (SWAN) 

My name is Anuradha Bhagwati. I am a former Captain in the U.S. Marine 

Corps. I currently serve as Executive Director of the Service Women’s Action Network (SWAN), a non-partisan, non-profit organization founded by female veterans, 

based out of New York City. SWAN specializes in policy analysis, advocacy, and 

legal services for all servicewomen, women veterans, and their families. 

Despite the progress the Veterans’ Health Administration has made in addressing 

the recent influx of women veterans into the VA system, the challenges in delivering 

adequate health care services to women veterans remain numerous and daunting. 

Every day, SWAN receives calls from frustrated, disappointed, and traumatized 

women veterans looking for legal assistance or personal support due to inadequate 

health care, or mistreatment and harassment by staff or male patients at VA hospitals. Many women justifiably give up on the VA, as their traumas and conditions 

rapidly deteriorate into drug and alcohol abuse, homelessness, or suicide. 

The epidemic of Military Sexual Trauma (MST)—sexual harassment, assault and 

rape—which has yet to be fully recognized by the Armed Forces, has also yet to be 

adequately integrated into the daily operations of VA hospitals. 

MST screening at hospitals around the Nation appears to be inconsistent, at best. 

A shortage of female physicians and counselors, a rapid turn-over of inexperienced 

residents, a preponderance of culturally conservative administrative staff, and poorly trained or unprofessional medical staff contributes to a lack of understanding 

about how to treat veterans who suffer from symptoms related to MST. 

However, I must emphasize that regardless of medical condition, women veterans, 

when compared to their male counterparts, are largely subjected to unequal treatment at VA facilities nationwide. The following anecdotes illustrate just a few of the 

VA’s institutional failures to deliver proper health care to women veterans: 

• One Iraq veteran who checked herself into inpatient psychiatric care during a 

particularly bad PTSD episode, was forced to share a bathroom with male veterans, 

including a peeping tom. When she told her nurse she felt uncomfortable eating her 

meals with male veterans, the nurse threatened that she would not be fed at all. 

• An Afghanistan veteran—a single mother—who was raped in theater by a fellow servicemember, cannot bear to enter a VA facility out of sheer terror of re-triggering the trauma from her assault. Like many other women veterans, she pays for 

counseling out of pocket so as not to subject herself to further trauma. 

• One veteran recently received her annual pap smear with a male gynecologist 

who did not enforce the requirement to have a female staff member present during 

the examination. When this veteran mentioned to the gynecologist that she had experienced MST, he left the room and barked down the hall, ‘‘We’ve got another one!’’ 

Many of these examples illustrate a larger point: that the VA requires an enormous cultural shift recognizing the sacrifices and specific needs of women veterans. 

RECOMMENDATIONS TO BRIDGE THE GAPS IN CARE FOR WOMEN VETERANS

1. Require that the VA remedy the shortage of female physicians, female mental 

health providers and MST counselors at VA hospitals nationwide. Also require that 

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114 

erans, and female- as well as male-only counseling groups for female and male survivors of MST. 

2. Require the VA to implement a program to train, educate, and certify all staff, 

including administrative and medical, in Federal Equal Opportunity regulations and 

MST, to reduce a discriminatory and unwelcoming atmosphere toward women veterans. 

3. Require the VA to increase accessibility of fee-based care for veterans (both 

male and female) who have been diagnosed with Military Sexual Trauma. 

4. Require day-care facilities for veterans who are parents, as well as more flexible evening hours for working veterans, at every VA hospital. 

Æ