Military Personnel: DOD Has Taken Steps to Meet the Health Needs of Deployed Servicewomen, but Actions Are Needed to Enhance Care for Sexual Assault Victims
Published: 2013-01-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The roles for women in the military have been expanding and evolving. Servicewomen today are integral to combat, combat support, and counterinsurgency operations, and serve in many roles they previously did not hold. Pub. L. No. 112-81, 725 (2011) mandated that GAO conduct a review of the female-specific health care services provided by DOD to female servicemembers, including the treatment of servicewomen who are victims of sexual assault. In this report, GAO evaluates the extent to which (1) DOD is addressing the health care needs of deployed servicewomen; (2) female-specific health care services are available to deployed servicewomen; and (3) medical and mental health care are available to servicewomen who are victims of sexual assault. GAO reviewed pertinent DOD policies, guidance, and data. GAO also met with health care providers, servicewomen, and others during site visits to 18 locations where servicewomen are currently serving or deployed, including 15 installations in Afghanistan and Navy vessels.
section_title: What GAO Found
paragraphs: The Department of Defense (DOD) is taking steps to address the health care needs of deployed servicewomen. For example, DOD has put in place policies and guidance that include female-specific aspects to help address the health care needs of servicewomen during deployment. Also, as part of pre-deployment preparations, servicewomen are screened for potentially deployment-limiting conditions, such as pregnancy, and DOD officials and health care providers with whom GAO met noted that such screening helps ensure that many female-specific health care needs are addressed prior to deployment. GAO also found that DOD components have conducted reviews of the health care needs of servicewomen during deployments and are collecting data on the medical services provided to deployed servicewomen.
At the 15 selected locations GAO visited in Afghanistan and aboard Navy vessels, health care providers and most servicewomen indicated that the available health care services generally met deployed servicewomen's needs. In Afghanistan and aboard Navy vessels, health care providers said they were capable of providing a wide range of the female-specific health care services that deployed servicewomen might seek, and servicewomen GAO spoke with indicated that deployed women's needs were generally being met. Specifically, based on information provided by the 92 servicewomen GAO interviewed, 60 indicated that they felt the medical and mental health needs of women were generally being met during deployments; 8 indicated they did not feel those needs were generally being met during deployments; an additional 8 indicated a mixed opinion; and 16 said they did not have an opinion. For example, some servicewomen told GAO that they were satisfied with their military health care, given the operating environment. Among those who expressed dissatisfaction with their military heath care, GAO heard a concern about difficulty in obtaining medications. Among those who expressed mixed views, a comment was raised that junior health care providers were limited in the types of procedures they could perform and lacked practical experience.
DOD has taken steps to provide medical and mental health care to victims of sexual assault, but several factors affect the availability of care. For example, this care can vary by service and can be impacted by operational factors, such as transportation and communication challenges, that are inherent to the deployed environment. Further, military health care providers do not have a consistent understanding of their responsibilities in caring for sexual assault victims because the department has not established guidance for the treatment of injuries stemming from sexual assault--which requires that specific steps are taken while providing care to help ensure a victim's right to confidentiality. Additionally, while the services provide required annual refresher training to first responders, GAO found that some of these responders were not always aware of the health care services available to sexual assault victims because not all of them are completing the required training. Without having a clearer understanding of their responsibilities, health care providers and first responders will be impeded in their ability to provide effective support for servicewomen who are victims of sexual assault.
section_title: What GAO Recommends
paragraphs: To enhance the medical and mental health care for servicewomen who are victims of sexual assault, GAO recommends that DOD (1) develop department-level guidance on the provision of care to victims of sexual assault; and (2) take steps to improve first responders' compliance with the department's requirements for annual refresher training. DOD did not concur with the first recommendation, but cited steps it is taking that appear consistent with the recommendation. DOD concurred with the second recommendation.

section_title: Letter
paragraphs: The roles for women in the military have been expanding and evolving,  particularly since the Persian Gulf War more than 2 decades ago.  Formerly, servicewomen served primarily in supportive roles in overseas  U.S. military operations. Today, servicewomen are integral to combat  support and counterinsurgency operations, and they serve in many roles  they previously did not hold. In late 2011, for example, women began  serving aboard Navy submarines. In early 2012, the Department of  Defense (DOD) announced that changes to its assignment policies would  result in more than 14,000 additional positions being opened to women,  including positions in select direct ground combat units. Further, while  sexual assault victimization is not unique to women, the presence of  women in new roles suggests that continued vigilance with respect to this  issue is needed. Given the expanding and evolving role of women in the  military, the health and wellness of servicewomen plays an important role  in overall military readiness.
The National Defense Authorization Act for Fiscal Year 2012 required  GAO to conduct a review of various aspects of the female-specific health  care services provided by DOD to female servicemembers. In response  to the act, this report focuses on female-specific health care services  provided by DOD to deployed servicewomen, as well as the medical and  mental health care available to servicewomen who are victims of sexual  assault. Specifically, it evaluates the extent to which (1) DOD is  addressing the health care needs of deployed servicewomen; (2) female- specific health care services are available to deployed servicewomen;  and (3) medical and mental health care are available to servicewomen  who are victims of sexual assault. In a separate report,on the availability of female-specific health care services provided to  female servicemembers in the United States.
GAO is focusing  To determine the extent to which DOD is addressing the health care  needs of deployed servicewomen, we reviewed pertinent DOD and  service-specific policies and guidance and interviewed knowledgeable  officials within the Office of the Assistant Secretary of Defense for Health  Affairs and the medical commands of the Army, the Navy, and the Air  Force. We also reviewed relevant guidelines, such as those issued by the  American College of Obstetricians and Gynecologists, and prior related  GAO reports. We also obtained information on reported patient  encounters for deployed servicemembers for fiscal year 2012. To assess  the reliability of these data, we contacted cognizant DOD officials in order  to understand the processes used to collect these data and any known  limitations of the data. We determined that these data were sufficiently  reliable for the purposes of our report—that is, to provide context for the  approximate number of reported patient encounters for servicewomen  during fiscal year 2012 and the frequency with which such encounters  specifically concerned women’s health by summarizing the top 25  diagnoses. In addition, we visited seven military installations in  Afghanistan and eight Navy vessels at their home ports in the United  States. The locations we visited in Afghanistan included forward operating  bases and military installations with more robust infrastructures, and were  selected because they allowed us to visit each of the levels of health  service support in Afghanistan. The Navy vessels we visited were  selected because they allowed us to visit different types of vessels within  both the U.S. Atlantic and U.S. Pacific Fleets where women are an  integrated part of the crew. During our site visits we met with health care  providers, military commanders, and a total of 92 female servicemembers  from various pay grades and from all services. Although the results of our  discussions with servicewomen cannot be generalized across DOD, a  service, or any single location we visited, the results do provide insight  into the perspectives of servicewomen regarding DOD’s efforts to address  the health care needs of deployed servicewomen.
To determine the extent to which female-specific health care services are  available to deployed servicewomen, we reviewed DOD and service- specific requirements and obtained information from health care providers  during our site visits regarding the availability of select female-specific  health care services at each location. Specifically, these female-specific  health care services included clinical breast examination; screening  mammography; diagnostic mammography; pelvic examination; PAP  smear; treatment of patients with abnormal PAP smear; treatment for  disorders of the female genitals; treatment for disorders of menstruation;  pregnancy test; and contraceptives, or contraceptive counseling. We  also focused on female-specific behavioral health care services, to  include mental health and substance abuse counseling. If female-specific  health care services were not available, we sought to understand how  situations requiring the need for such services would be handled during  deployments.
To determine the extent to which medical and mental health care are  available to servicewomen who are victims of sexual assault, we obtained  and analyzed various documents, including legislative requirements and  DOD’s policies and guidance for the prevention of and response to sexual  assault, and interviewed knowledgeable officials from DOD’s Sexual  Assault Prevention and Response office. We also reviewed DOD’s  Annual Report on Sexual Assault in the Military Services to identify the  department’s efforts to provide medical and mental health services to the  2,420 females who in fiscal year 2011 reported to DOD that they had  been victims of sexual assault. We conducted site visits to three military  installations in the United States in addition to the seven military  installations in Afghanistan and eight Navy vessels we visited for our  larger review, in order to assess the availability of medical and mental  health care services for victims of sexual assault in the military. The three  locations we visited in the United States were selected because they  enabled us to meet with military personnel who have served as Sexual  Assault Response Coordinators both while deployed and while at a  military installation in the United States. During our site visits we met with  Sexual Assault Response Coordinators, Victim Advocates, and health  care providers.
We conducted this performance audit from April 2012 through January  2013 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives. Further details about our  scope and methodology can be found in appendix I.
subsections: section_title: Background
subsections: section_title: DOD’s Military Health System
paragraphs: DOD’s health care system, known as the Military Health System, is one of  the largest and most complex health care systems in the nation.  Operationally, DOD’s Military Health System has two missions:  supporting wartime and other deployments, known as the readiness  mission, and providing peacetime care, known as the benefits mission.  The readiness mission provides medical services and support to the  armed forces during military operations and deployments, including  deploying medical personnel and equipment throughout the world, and  ensures the medical readiness of personnel prior to deployment. Within  DOD’s Office of the Under Secretary of Defense for Personnel and  Readiness, the Office of the Assistant Secretary of Defense for Health  Affairs oversees the Military Health System and also issues guidance to  DOD components on medical matters. The Departments of the Army and  the Navy each have a medical command, headed by a Surgeon General,  who manages each department’s respective military treatment facilities  and medical personnel. The Navy’s Bureau of Medicine and Surgery  supports both the Navy and the Marine Corps. The Air Force Surgeon  General, through the role of medical advisor to the Air Force Chief of  Staff, exercises similar authority to that of the other Surgeons General.
section_title: DOD’s Sexual Assault Prevention and Response Program
paragraphs: The Under Secretary of Defense for Personnel and Readiness also has  the responsibility for developing the overall policy and guidance for the  department’s sexual assault prevention and response program except for  criminal investigative policy matters assigned to the DOD Inspector  General and legal processes in the Uniform Code of Military Justice. DOD  Directive 6495.01 defines sexual assault as “intentional sexual contact  characterized by use of force, threats, intimidation, or abuse of authority,  or when the victim does not or cannot consent. Sexual assault includes  rape, forcible sodomy (oral or anal sex), and other unwanted sexual  contact that is aggravated, abusive, or wrongful (including unwanted and  inappropriate sexual contact), or attempts to commit these acts.”
DOD’s directive provides active duty servicemembers with two options for  reporting a sexual assault: (1) restricted and (2) unrestricted. DOD’s  restricted reporting option allows sexual assault victims to confidentially  disclose an alleged sexual assault to select individuals, including health  care personnel, and receive medical treatment without initiating an official  investigation. In cases where a victim elects restricted reporting, first  responders—including health care providers—may not disclose  confidential communications or information on the forensic examination to  law enforcement or command authorities unless certain exceptions apply,  and improper disclosure of confidential communications and medical  information may result in discipline pursuant to the Uniform Code of  Military Justice or other adverse personnel or administrative actions. In  contrast, DOD’s unrestricted reporting option allows sexual assault  victims to receive medical treatment and request an official investigation  of the allegation using existing reporting channels, such as their chain of  command or law enforcement.
DOD’s directive also identifies the various types of support, to include the  coordination of medical and mental health care services, that shall be  provided to victims of sexual assault. Specifically, the directive specifies  that sexual assault victims shall receive timely access to comprehensive  medical treatment, including emergency care that shall consist of  emergency medical care and the offer of a sexual assault forensic  examination consistent with Department of Justice protocols.sexual assault victims shall be advised that even if a forensic examination  is declined, the victim is encouraged (but not required) to receive medical  care, psychological care, and victim advocacy.
Since 2008 we have issued a series of reports examining DOD’s  implementation of its Sexual Assault Prevention and Response Program  and made a total of 25 recommendations with which DOD has generally  concurred and taken actions to implement to varying degrees. These  reports include reviews of DOD’s sexual assault prevention and response  programs for the military academies; programs for the active components  of DOD, including during deployments; and processes for investigating  and adjudicating allegations of sexual assault. For further information on  these reports as well as our prior recommendations, see the summary we  issued in March 2012.
section_title: DOD Is Taking Steps to Help Address the Health Care Needs of Deployed Servicewomen
paragraphs: DOD has developed policies and guidance that include female-specific  aspects to help address the health care needs of female servicemembers  during deployment. Prior to deploying, servicewomen are screened for  potentially deployment-limiting conditions. According to DOD officials and  health care providers with whom we met, such pre-screening helps  ensure that many female-specific health care needs are addressed prior  to deployment. Further, DOD components have conducted reviews of the  health care needs of servicewomen during deployments. DOD also  collects health care data on the medical services provided to deployed  servicewomen in Afghanistan and aboard Navy vessels.
subsections: section_title: DOD Policies Addressing the Health Care Needs of Deployed Servicemembers Include Female-specific Aspects
paragraphs: DOD components have put in place policies and guidance that include  female-specific aspects to help address the health care needs of  servicewomen during deployment. DOD and service officials told us that  while the department’s policies are generally gender-neutral and focus on  addressing the health care needs of all servicemembers, some of the  policies and guidance include female-specific aspects such as pregnancy,  pelvic examinations, and screening mammography. In certain instances,  the services’ policies reflect clinical practice guidelines that come from  outside the department, such as those from the American College of  Obstetricians and Gynecologists. For example, we found that the Army  changed its pre-deployment screening requirements due to a change in  American College of Obstetricians and Gynecologists guidelines for  cervical cytology screening. Additionally, we found that Navy guidelines  require the provision of standbys—individuals who could be present  during sensitive or potentially compromising physical examinations— during medical examinations when female genitalia or breasts are  exposed or examined by a medical provider, in accordance with Joint  Commission guidelines.
According to DOD and service officials, although there may be some  gender differences for particular diagnoses, behavioral health care  services—that is, mental health care and substance abuse counseling— are not gender-specific. The treatment of servicemembers’ behavioral  health care needs and the availability of services to treat those needs,  therefore, do not vary based on gender.
section_title: Pre-deployment Screening Processes Help Ensure That Many Female-specific Needs Are Addressed Prior to Deploying
paragraphs: DOD has established a medical tracking system for assessing the  medical condition of servicemembers to help ensure that only those who  are medically and mentally fit are deployed outside of the United States.  According to service officials and health care providers with whom we  met, pre-deployment screenings help ensure that many women’s health  care needs are addressed prior to deployment. As part of DOD’s pre- deployment screening process, servicemembers of both sexes are  screened for potentially deployment-limiting medical conditions that would  render them unsuitable to perform their duties during deployment.  Servicemembers of both sexes are also required to complete a pre- deployment health assessment questionnaire. DOD requires that  servicemembers’ questionnaires be reviewed by a health care provider to  determine whether the servicemember is fit to deploy. Service officials we  spoke with told us that this screening also provides servicemembers an  opportunity to discuss and address with a health care provider any health  concerns they may have prior to deploying. The officials said they rely on  the questionnaires, reviews of servicemembers’ medical records, and  physical examinations to identify an individual’s health care needs prior to  deployments.
Some deployment-limiting conditions are female-specific: for example,  each of the military services defines pregnancy as a deployment-limiting  condition. Each of the services has also established a postpartum  deferment period—6 months for the Army, the Air Force, and the Marine  Corps, and 12 months for the Navy. During this period, servicewomen are  not required to deploy or redeploy, so as to enable mothers to recover from  childbirth and to bond with their children. However, each of the military  services has a policy that allows servicewomen to voluntarily deploy before  the period has expired. Typically, during deployment servicewomen who  are confirmed to be pregnant may not remain deployed. For example,  servicewomen who are confirmed to be pregnant in Afghanistan may not  remain in theater and must notify their military chain of command or  supervisor immediately. They are required to be redeployed within 14 days  of receipt of notification. Navy guidance prohibits a pregnant servicewoman  from remaining aboard a vessel if the time required to transport her to  emergency obstetric and gynecological care exceeds 6 hours.  Servicewomen who are confirmed to be pregnant at sea are to be sent at  the earliest opportunity to the closest shore-based U.S. military facility that  can provide obstetric and gynecological care. Navy medical providers we  met with during our site visits stated that pregnant servicewomen are  typically transferred off the vessel within days of confirmation of their  pregnancy. Further, we found that female-specific deployment-limiting  conditions sometimes depend on the deployed environment: for example,  women with conditions such as recurrent pelvic pain or abnormal vaginal  bleeding are disqualified from submarine service.
section_title: DOD Has Also Conducted Some Reviews of the Health Care Needs of Servicewomen during Deployments
paragraphs: DOD components have conducted reviews of the health care needs of  servicewomen while they are deployed. For example:
As part of a review the Army Surgeon General’s office initiated in  2011, the Army issued a white paper entitled “The Concerns of  Women Currently Serving in the Afghanistan Theater of Operations.”
The TriService Nursing Research Program funds and supports scientific research in the  field of military nursing in order to advance military nursing science and optimize the  health of military members and their families. military women’s health. The program is also funding research efforts  focused on deployed women’s health issues, including the use of  female urinary diversion devices and a review of the health education  provided to servicewomen before they deploy.
section_title: DOD Is Capturing Data on the Medical Services Provided to Deployed Servicewomen
paragraphs: DOD is collecting health care data on the medical services provided to  deployed servicewomen, as well as servicemen, in Afghanistan and  aboard Navy vessels. According to service officials, data that health care  personnel enter into electronic systems on servicemen and women’s  encounters with providers are accessible by commanders in order to  allow them to track the medical status of units and individuals.  According to information provided by service officials in Afghanistan, the  total number of reported patient encounters in U.S. Central Command’s  area of operations during fiscal year 2012 was around 460,000. Of  these, servicewomen accounted for about 62,000 patient encounters. For  U.S. Central Command’s area of operations, DOD’s fiscal year 2012 data  show that the most frequent diagnosis for servicemembers, based on  International Classification of Diseases codes, was lumbago, or, lower  back pain. Of the top 25 diagnoses, none were related specifically to  women’s health issues. According to information provided by the Office of  the Navy Surgeon General, the total number of reported patient  encounters aboard Navy vessels during fiscal year 2012 was  approximately 69,000, of which servicewomen accounted for about  21,000. For Navy vessels, based on International Classification of  Diseases codes the Navy’s data show that the most frequent diagnosis  during fiscal year 2012 for servicemembers was lumbago. Of the top 25  diagnoses, only one―urinary tract infection―was commonly associated  with women’s health.
The department also uses the data to develop reports that address  broader health issues. For example, the Armed Forces Health  Surveillance Center has issued reports that provide, by service, data on  deployment-related conditions of special interest, such as traumatic brain  injury, amputations, and severe acute pneumonia, among other data.  While these reports generally do not separate data by gender, the Armed  Forces Health Surveillance Center has issued two reports since  December 2011 focusing on women’s health issues. For example, a July  2012 report presented data on the incidence of acute pelvic inflammatory  disease, ectopic pregnancies, and iron deficiency among active duty  women, as well as data on selected conditions among women after initial  and repeated deployments to Afghanistan and Iraq. According to these  reports, from January 2003 through December 2011, based on  International Classification of Diseases codes, 50,634 servicemembers— comprising 6,376 females and 44,258 males—were evacuated from Iraq  and Afghanistan for medical reasons. The most frequent causes of  medical evacuations for females were mental disorders, musculoskeletal  disorders, “signs, symptoms, and ill-defined conditions,” and non-battle- injuries, whereas the most frequent causes of such evacuations for males  were battle injuries, musculoskeletal disorders, non-battle injuries, and  mental disorders.
section_title: Servicewomen’s Perceptions Suggest that Health Care Services Available to Deployed Servicewomen Generally Meet Needs
subsections: section_title: A Variety of Health Care Services Are Available to Servicemembers Deployed to Afghanistan and at Sea
paragraphs: The health care services, and in turn the female-specific health care  services available to deployed servicewomen, vary depending on the  deployed environment. DOD provides three levels of health service  support to servicemembers deployed to Afghanistan. The most basic  level of care is provided at “Role 1” facilities, which include primary care  facilities and outpatient clinics. “Role 2” facilities provide advanced trauma  management and emergency medical treatment. The highest level of care  that DOD provides in Afghanistan is at “Role 3” facilities. These facilities  are equivalent to full-spectrum hospitals and are staffed and equipped to  provide resuscitation, initial wound surgery, and post-operative treatment.  As of November 2012, there were 143 facilities in Afghanistan providing  Role-1 level care, 24 facilities providing Role-2 level care, and 5 facilities  providing Role-3 level care. According to senior medical officials with  U.S. Forces Afghanistan and the International Security Assistance Force  Joint Command, most gynecological care is provided at Role 1 facilities,  and infantry battalions and most forward operating bases and combat  outposts in Afghanistan can at a minimum provide Role 1-level care.
We found that servicewomen while deployed at sea have access to  providers of primary care, although the health care services that are  available aboard Navy vessels largely depend on the type and class of  vessel. Larger vessels generally offer a wider range of services—including  specialized services—than do smaller vessels, due largely to their more  robust crew levels and capabilities. The medical department of an aircraft  carrier, for example, typically consists of more than 40 billets, including a  family practitioner, a physician’s assistant, and a clinical psychologist.  Similarly, the medical department of a WASP-class amphibious assault  ship consists of more than 20 billets, including a medical officer. For  cruisers, destroyers, and frigates, the medical department typically consists  of only a handful of billets, including an Independent Duty Hospital  Corpsman, but no medical officer. For Ohio-class submarines, the sole  source of medical care aboard is an Independent Duty Hospital Corpsman.  Each of these classes of vessels is capable of providing health care  services to servicemembers of both sexes.
section_title: Health Care Providers and Servicewomen Said DOD Generally Meets Women’s Health Care Needs during Deployments
paragraphs: At the 15 selected locations we visited in Afghanistan and Navy vessels,  health care providers and servicewomen told us that the health care  services available to deployed servicemembers generally meet the needs  of servicewomen. Health care providers we spoke with in Afghanistan and  aboard Navy vessels told us they were capable of providing a wide range  of female-specific health care services—including treating certain  gynecological conditions such as urinary tract infections and conducting  clinical breast examinations—that women might seek while deployed.
They also told us that servicemembers had access at least to basic  mental health care services. Some female-specific services—such as  treatment for an abnormal PAP smear result, or mammography  services—were not always available, but providers told us that conditions  resulting in the need for more specialized services were routinely  addressed prior to deployment. For example, providers with an  expeditionary medical group we met in Afghanistan told us that in their  experience PAP smears are rarely performed in theater except for women  who had received abnormal PAP smear results prior to deploying and  needed follow-up checks after 6 months. Those providers also told us that  screening mammography is not provided in theater because screening  mammography is generally preventative care, which is conducted as part  of a woman’s annual exam prior to deployment. Health care providers  from multiple Navy vessels we visited also told us that a number of  female-specific health care services—from performing PAP smears to  treating patients with abnormal PAP smear results to mammography  services—were not needed during deployments at sea because such  services were provided prior to deploying.
According to health care officials and providers with whom we met,  women who developed acutely urgent conditions during deployments, to  include female-specific conditions, would typically be transferred to a  locale offering access to more specialized services. Health care providers  with whom we met were able to identify their available options for  referring individuals with acutely urgent conditions for specialized care  elsewhere if necessary—in Afghanistan, typically, to a higher level of  care; during deployments at sea, to another vessel or a shore-based  facility. Providers also noted that in some cases they could consult with  other health care providers if necessary, including providers specializing  in women’s health care. For example, at one Role 1 facility we visited in  Afghanistan, health care providers noted that their Deputy Command  Surgeon specialized in obstetrics and gynecology and was available to  consult on cases if they needed assistance. As another example, Navy  Independent Duty Hospital Corpsmen told us that they could consult with  their physician supervisor if necessary during deployments at sea.
At each of the locations we visited we found that a variety of steps were  being taken to help ensure that servicewomen had a reasonable amount  of privacy during examinations as well. For example, each of the locations  we visited offered at a minimum a medical examination room with privacy  curtains that could be drawn. In most instances, doors with locks were  available as well. We also observed that signs could be posted indicating  that an examination was in process. Further, health care providers told us  that a standby—individuals who could be present during sensitive or  potentially compromising physical examinations—was available at each  location we visited. Figures 1 through 3 show photographs of the medical  examination rooms at selected locations we visited.
Based on information provided by the 92 servicewomen we interviewed at  selected locations in Afghanistan and aboard Navy vessels, the responses  from 60 indicated that they felt the medical and mental health needs of  women were generally being met during deployments, whereas the  responses from 8 indicated they did not feel the medical and mental health  needs of women were generally being met during deployments. The  responses from an additional 8 servicewomen suggested that they had a  mixed opinion as to whether the medical and mental health needs of  women were being met during deployments, and 16 told us they did not  know or did not have an opinion. Servicewomen who indicated during our  interviews that the medical and mental health needs of women were  generally being met during deployments offered a variety of reasons for  their responses. At one location we visited in Afghanistan, a female Airman  told us that if she had a health problem, the medical facility at her location  could treat her or send her elsewhere if needed. She further noted that if  the problem were serious enough she could be evacuated. Similarly, a  female Army soldier we met at another location told us she felt some of the  best care that she has received in her life has been military health care. At  another location, a female Marine told us that the care provided to her was  as good as she could imagine, given the operating environment. Aboard  one Navy vessel we visited, a female sailor told us that even though mental  health care was not available aboard her ship, it was available ashore, and  the ship could handle emergencies at sea.
Servicewomen we interviewed who indicated that they felt the medical  and mental health needs of women were generally not being met during  deployments offered a variety of reasons for their responses as well. At  one location we visited in Afghanistan, a female airman told us that she  believed the military was trying to meet the health needs of women, but  still had work to do—noting, for example, that a medication she was  prescribed had given her yeast infections. At another, a female Army  soldier told us that she had experienced difficulty obtaining sleep  medication. In the case of deployments at sea, one female sailor  expressed concern that a mental health provider was not aboard. Of  servicewomen who offered a mixed opinion, one female sailor told us that  she felt junior health care providers were limited in the types of  procedures they could perform and lacked practical experience.
section_title: Several Factors Affect the Availability of Medical and Mental Health Care to Sexual Assault Victims
paragraphs: DOD has taken steps to address the provision of medical and mental  health care for servicemembers who are sexually assaulted, but several  factors affect the extent to which this care is available. Specifically, the  branch of military service and the operational uncertainties of a deployed  environment can affect the ready availability of medical and mental health  care services for victims of sexual assault. Additionally, care is in some  cases affected because military health care providers do not have a  consistent understanding of their responsibilities in caring for sexual  assault victims who make restricted reports of sexual assault. Further,  first responders such as Sexual Assault Response Coordinators and  Victim Advocates are not always aware of the specific health care  services available to sexual assault victims at their respective locations.
subsections: section_title: Availability of Medical and Mental Health Care for Sexual Assault Victims Can Vary by Service and Operational Uncertainties
paragraphs: Each military service offers medical and mental health care resources to  servicemembers who have been sexually assaulted, including those  serving in a deployed environment. However, as we have noted in our  prior work, the availability of such resources for victims can vary based on  a number of factors, including branch of military service and the  operational uncertainties associated with serving in a deployed  environment. For example, the availability of deployed medical  providers who are trained to conduct a sexual assault forensic  examination varies across the military services because each service has  a different process for deploying personnel. Specifically, we spoke with  Army officials who told us that the Army requires each brigade to deploy  with a health care provider who is trained to conduct a forensic  examination, whereas the Air Force deploys trained health care providers  based on the medical needs at specific locations. Navy medical providers  we spoke with told us that the Navy does not require that its vessels  deploy with a provider trained to conduct a forensic examination, and will  instead transfer a victim to the nearest trained provider, whether at sea or  ashore. Navy medical providers also told us that if a transfer is not  possible they would do their best to conduct the forensic examination  using the instructions provided with examination kits.
Department of Defense, Fiscal Year 2011 Annual Report on Sexual Assault in the  Military (April 2012). treatment. To mitigate these limitations, the Army included a primary and  alternate evacuation protocol in its standardized operating procedures, to  help ensure that servicemembers who are sexually assaulted during  deployment have access to care.
section_title: Guidance Has Not Been Developed for the Provision of Specialized Medical and Mental Health Care for Sexual Assault Victims
paragraphs: DOD has established policies and procedures for its sexual assault  prevention and response program that address, among other things, the  provision of medical and mental health care for servicemembers who are  sexually assaulted. Specifically, in October 2005 DOD published a  directive that contains its comprehensive policy for the prevention of and  response to sexual assault. While generally applicable to all  servicemembers and locations, DOD’s directive calls for the sexual  assault prevention and response program to be gender-responsive,  culturally competent, and recovery-oriented; and for an immediate,  trained sexual assault response capability to be available in deployed  locations. For example, DOD requires care for sexual assault victims to  be linguistically appropriate; sensitive to gender-specific issues such as  pregnancy; and supportive of a victim’s ability to be fully mission-capable  and engaged.
In June 2006, DOD’s Office of the Under Secretary of Defense for  Personnel and Readiness issued an instruction that provides guidance for  implementing its policy and specifies roles, responsibilities, and required  training for program personnel such as health care providers who may be   For example, DOD’s  involved in responding to victims of sexual assault. instruction identifies various types of health care providers who,  depending on their training, may be eligible to conduct sexual assault  forensic examinations; and directs the military services to establish a  multi-disciplinary case management group and include provisions for  continuity of victim care when a victim has a temporary or permanent  change of station, or is deployed. Additionally, DOD’s instruction identifies  required categories of training for program personnel on topics that  include victim advocacy and medical treatment resources, sexual assault  response policies, and the sexual assault examination process.
Department of Defense Instruction 6495.02, Sexual Assault Prevention and Response  Program Procedures (June 23, 2006).
Although DOD issued this overarching instruction that provides guidance  for implementing its sexual assault prevention and response policies to  personnel such as health care providers, we found that the Office of the  Assistant Secretary of Defense for Health Affairs—the organization  responsible for ensuring the effective execution of the department’s  medical mission—has not, in turn, developed more specified guidance to  address the military services’ responsibility to provide specialized medical  and mental health care to victims of sexual assault. According to DOD  Directive 5136.01, the Assistant Secretary of Defense for Health Affairs is  required to, among other things, exercise authority, direction, and control  over DOD medical policy, and to establish policies, procedures, and  standards that govern the management of DOD health and medical  programs. The Office of the Assistant Secretary of Defense for Health  Affairs has performed these responsibilities for some medical issues in  DOD, but it has not established guidance for the treatment of injuries  stemming from sexual assault—a crime that requires a specialized level  of care to help ensure that forensic evidence is properly collected,  medical care is provided in a way that minimizes the risk of  revictimization, and a victim retains the right to disclose the assault with  confidentiality.
Absent department-level guidance from DOD’s Office of the Assistant  Secretary of Defense for Health Affairs, the services have, to varying  degrees, revised their respective medical guidance to address care for  victims of sexual assault. For example, at one location we visited we  reviewed a command’s medical policy and found that while the policy  addressed some responsibilities of health care providers in responding to  sexual assault incidents, it had not been updated to identify how care  should be modified for restricted reports of sexual assault. For example,  the policy addressed topics such as when and where forensic  examinations should be conducted, and health care provider  responsibilities for transferring evidence to law enforcement. However, it  did not mention DOD’s policy on restricted reporting or provide guidance,  for example, on the use of non-identifying information to label and store  evidence collected from restricted reports of sexual assault. At another  location, we found that a command’s medical policy contained  requirements for health care personnel that conflicted with their  responsibilities under restricted reporting. The policy required the  command’s medical department representatives to document all injuries  and referrals of personnel for care, and to keep the commanding officer  and chain of command informed of medical conditions that affect the  health, safety, and readiness of all command personnel. However, the  policy was silent on the issue of sexual assault and did not identify  exceptions to these requirements or offer health care providers alternative  procedures for documenting and reporting medical issues associated with  restricted reports of sexual assault. Accordingly, we found that military  health care providers do not have a consistent understanding of their  responsibilities in caring for sexual assault victims. We met with senior  medical personnel from the command who confirmed that provisions in  their medical policy conflicted with other command policy and had created  confusion for health care providers regarding the extent of their  responsibility to maintain the confidentiality of victims who choose to  make a restricted report of sexual assault. These inconsistencies can put  DOD’s restricted reporting option at risk, undermine DOD’s efforts to  address sexual assault issues, and erode servicemembers’ confidence.  As a consequence, sexual assault victims who want to keep their case  confidential may be reluctant to seek medical care.
section_title: First Responders Are Not Always Aware of the Health Care Services Available to Sexual Assault Victims
paragraphs: DOD requires that personnel designated as first responders to sexual  assault incidents, whether in the United States or in deployed  environments, receive initial and annual refresher training on topics that  include available medical and mental health treatment options. Although  DOD provides this required training, we found that first responders we  met with were still unsure of the health care services available to sexual  assault victims at their respective locations. This was particularly the case  among first responders we met with during visits to selected locations in  the United States, in part because of the increased medical and mental  health care options that were available to them. For example, we  regularly found that Sexual Assault Response Coordinators, Victim  Advocates, and health care personnel differed in their understanding as  to where to take a sexual assault victim for a forensic examination—a  potentially problematic issue, given that the quality of forensic evidence  diminishes the later it is collected following a sexual assault. The  Department of Justice’s National Protocol for Sexual Assault Medical  Forensic Examinations identifies 72 hours after an assault occurs as the  standard cutoff time in many jurisdictions for collecting evidence (except  for blood alcohol determinations, which should be done within 24 hours of  ingestion of alcohol), but notes that evidence collection beyond that point  is conceivable. Additionally, we found that not all first responders fulfill the  requirement to annually complete refresher training on tasks DOD deems  essential to their role in responding to incidents of sexual assault.  According to DOD’s instruction, first responders are required to complete  periodic refresher training on a variety of topics that include management  of restricted and unrestricted reports of sexual assault and local protocols  and procedures. DOD reported in its fiscal year 2011 Annual Report on  Sexual Assault in the Military that while each of the military services  continued to implement sexual assault prevention and response training  for first responders, not all first responders had completed the required  training. For example, DOD reported that for fiscal year 2011, the Army  trained only about 6,000 of the more than 17,000 personnel who served  as Sexual Assault Response Coordinators or Victim Advocates. Further,  DOD’s report noted that only 69 percent of Department of Navy Victim  Advocates—which include Navy and Marine Corps personnel— completed the required training, and the report also noted that some of  the training for Air Force first responders was overdue.
section_title: Conclusions
paragraphs: As women continue to assume an expanding and evolving role in the  military it is important that DOD be well positioned to meet the health care  needs of deployed servicewomen and ensure their readiness. To the  department’s credit, DOD components have taken positive steps toward  addressing the female-specific health care needs of deployed  servicewomen, and we note that at the selected locations we visited  during the course of our review the responses from most servicewomen  we spoke with indicated that they felt the medical and mental health  needs of women were generally being met during deployments. DOD also  has taken positive steps in making medical and mental health care  services available to sexual assault victims of both sexes. However,  DOD’s limited health care guidance on the restricted sexual assault  reporting option and first responders’ inconsistent knowledge about  available resources are factors that affect the quality and availability of  that care. Left unaddressed, such factors can undermine DOD’s efforts to  address the problem of sexual assault in the military by eroding  servicemembers’ confidence in the department’s programs and  decreasing the likelihood that victims of sexual assault will turn to the  programs or seek care and treatment when needed.
section_title: Recommendations for Executive Action
paragraphs: To help ensure that sexual assault victims have consistent access to  health care services and the reporting options specified in DOD’s sexual  assault prevention and response policies, we recommend that the  Secretary of Defense direct the Under Secretary of Defense for Personnel  and Readiness to direct the Assistant Secretary of Defense for Health  Affairs to develop and implement department-level guidance on the  provision of medical and mental health care to victims of sexual assault  that specifies health care providers’ responsibilities to respond to and  care for sexual assault victims, whether in the United States or in  deployed environments.
To help ensure that Sexual Assault Response Coordinators, Victim  Advocates, and health care personnel have a consistent understanding of  the medical and mental health resources available at their respective  locations for sexual assault victims, we recommend that the Secretary of  Defense direct the Under Secretary of Defense for Personnel and  Readiness, in collaboration with the military departments, to take steps to  improve compliance regarding the completion of annual refresher training  on sexual assault prevention and response.
section_title: Agency Comments and Our Evaluation
paragraphs: In written comments on a draft of this report, DOD stated in its cover letter  that, overall, the department did not concur with the report’s findings and  conclusions. However, DOD’s cover letter did not provide an explanation  for this comment. In an enclosure to its letter, DOD stated that it did not  concur with our first recommendation that the Assistant Secretary of  Defense for Health Affairs develop and implement department-level  guidance on the provision of medical and mental health care to victims of  sexual assault that would specify health care providers’ responsibilities to  respond to and care for sexual assault victims, whether in the United  States or in deployed environments. DOD’s justification of its assessment,  however, did not make clear why the department did not concur. Instead,  DOD provided examples of steps it has been taking that may help to  address the findings in this report. Specifically, DOD stated that, while the  second version of DOD Instruction 6495.02, entitled “Sexual Assault  Prevention and Response (SAPR) Program Procedures” has been in  coordination for nearly 2 years and is not yet published, the revised  instruction will be comprehensive and will contain two medical  enclosures. According to DOD, the first medical enclosure will address  health care provider procedures and direct the Surgeons General of the  military services to carry out responsibilities related to the coordination,  evaluation, and implementation of care, while the second medical  enclosure will address health care providers’ responsibilities related to  Sexual Assault Forensic Examination kits. During the course of this  review, we met with DOD officials who had knowledge of and were  involved in the instruction’s revision, but these officials did not discuss or  share their draft revisions with us when we presented our findings to  them. We cannot verify, therefore, whether the enclosures referenced in  DOD’s comments will address our recommendation. However, we plan to  review the instruction when DOD finalizes it to determine whether it meets  the intent of our recommendation. Finally, DOD stated that the  department meets its oversight responsibilities with regard to sexual  assault response through training in graduate medical education and  through monitoring and oversight of the process that governs  credentialing and privileging of providers. However, it is not clear why this  statement is applicable to our recommendation. We did not address these  points in the finding that led to this recommendation, and our  recommendation is focused on the need for additional guidance.
DOD concurred, without comment, on our second recommendation that  the Under Secretary of Defense for Personnel and Readiness, in  collaboration with the military departments, take steps to improve  compliance with completing annual refresher training on sexual assault  prevention and response. DOD’s comments are reprinted in appendix II.
We are sending copies of this report to the Secretary of Defense, the  Under Secretary of Defense for Personnel and Readiness, the Assistant  Secretary of Defense for Health Affairs, and appropriate congressional  committees. In addition, this report will also be available at no charge on  the GAO Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-3604 or farrellb@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made major contributions to this report  are listed in appendix III.
section_title: Appendix I: Scope and Methodology
subsections: section_title: Determining the Extent to Which the Health Care Needs of Deployed Servicewomen Are Being Addressed and Female- specific Health Care Services Are Available
paragraphs: In our review of female-specific health care services provided by DOD to  deployed servicewomen, our scope included each of the military services.  We focused our work in conducting this review on the health care  services available to servicewomen deployed to Afghanistan or aboard  Navy vessels at sea.
To determine the extent to which DOD is addressing the health care  needs of deployed servicewomen, we reviewed legislative requirements  and pertinent DOD and service-specific policies and guidance. We also  interviewed responsible officials within the Office of the Assistant  Secretary of Defense for Health Affairs, each of the services’ medical  commands, and the TriService Nursing Research Program and its  Women’s Health Research Interest Group. We reviewed guidelines  specifically applicable to women, such as guidelines issued by the  American College of Obstetricians and Gynecologists, and prior GAO  reports. We also obtained information on reported patient encounters for  deployed servicemembers for fiscal year 2012 collected by U.S. Central  Command and the Navy’s Office of the Surgeon General. To assess the  reliability of these data, we contacted cognizant DOD officials in order to  understand the processes used to collect these data and any known  limitations of the data. We found that while the data likely underreported  the total number of patient encounters, these data were sufficiently  reliable for the purposes of our report—that is, to provide context for the  approximate number of reported patient encounters for servicewomen  during fiscal year 2012 and the frequency with which such encounters  specifically concerned women’s health by summarizing the top 25  diagnoses. In addition, we conducted a total of 15 site visits where we  met with health care providers, military commanders, and female  servicemembers to obtain their perspectives on DOD’s efforts to address  the health care needs of deployed servicewomen. In Afghanistan we  visited 7 military installations, selected so as to enable us to visit each of  the three levels of health service support across Afghanistan. Figure 4  shows the locations in Afghanistan we visited during the course of our  review, which included Bagram Air Field, Camp Eggers, Camp  Leatherneck/Bastion, Camp Phoenix, Camp Stone, Forward Operating  Base Fenty, and Forward Operating Base Gardez.
We also visited 8 Navy vessels at their home ports in the United States,  selected so as to enable us to visit different types of vessels on which  women are an integrated part of the crew, for both the U.S. Atlantic and  U.S. Pacific Fleets. The Navy vessels we visited included the USS  George H.W. Bush (CVN 77), USS Boxer (LHD 4), USS Carl Vinson  (CVN 70), USS Chancellorsville (CG 62), USS Georgia (SSGN 729), USS  McClusky (FFG 41), USS Mesa Verde (LPD 19), and USS Truxtun (DDG  103). Table 1 provides information on the composition of the crew for  each of the Navy vessels we visited.
To determine the extent to which female-specific health care services are  available to deployed servicewomen, we focused on the following female- specific health care services: clinical breast examination; screening  mammography; diagnostic mammography; pelvic examination; PAP  smear; treatment of patients having abnormal PAP smear results;  treatment for disorders of the female genitals; treatment for disorders of  menstruation; pregnancy test; and contraceptives, or contraceptive  counseling. We also focused on female-specific behavioral health care  services, to include mental health and substance abuse counseling. To  determine availability of the services, we obtained information from health  care providers during our site visits regarding the availability of these  services at that location. If female-specific health care services were not  available, we sought to understand how situations requiring the need for  such services would be handled during deployments. In the case of the  Navy, we also obtained information from senior officials from the Navy  Type Commands responsible for overseeing health care units supporting  air craft carriers, surface ships, and submarines.
To obtain female servicemembers’ perspectives on women’s health and  wellness issues, we conducted 92 one-on-one structured interviews with  servicewomen from various pay grades and from all services during our  site visits to 7 military installations in Afghanistan and 8 Navy vessels.  Our objective in using this approach was to obtain female  servicemembers’ perspective on a range of women’s health and wellness  issues, such as specific health issues and challenges women might face  in seeking medical care while deployed. Although the results of our  discussions are not generalizable and therefore cannot be projected  across DOD, a service, or any single location we visited, the results of our  discussions provide insight into the perspectives of servicewomen  regarding DOD’s efforts to address the health care needs of deployed  servicewomen. Because of the sensitivity of some of the information we  were seeking, we took steps to assure a confidential environment and  encourage an open discussion during these interviews. Only female GAO  analysts conducted these interviews.
section_title: Determining the Availability of Medical and Mental Health Care to Servicewomen Who Are Victims of Sexual Assault
paragraphs: To determine the extent to which medical and mental health care are  available to servicewomen who are victims of sexual assault, we obtained  and reviewed various documents, including legislative requirements and  DOD’s and the military services’ policies and guidance establishing  requirements for the prevention of and response to sexual assault. We  also interviewed knowledgeable officials, including officials from DOD’s  Sexual Assault Prevention and Response office. We also reviewed  DOD’s Annual Report on Sexual Assault in the Military Services to  identify the department’s efforts to provide medical and mental health  services to the 2,420 females who in fiscal year 2011 reported to DOD  that they had been victims of sexual assault. We conducted site visits to   3 other military installations in the United States in addition to the 7  military installations in Afghanistan and the 8 Navy vessels we visited for  our review, in order to assess the availability of medical and mental health  care services for servicewomen who are victims of sexual assault in the  military. To select the additional locations, we requested the military  services’ respective Sexual Assault Prevention and Response offices to  identify locations that met select criteria. The locations we visited included  Camp Pendleton, California; Davis-Monthan Air Force Base, Arizona; and  Joint Base San Antonio, Texas. These locations were selected because  they enabled us to meet with military personnel who have served as  Sexual Assault Response Coordinators both while deployed and while at  a military installation in the United States. During our site visits we met  with Sexual Assault Response Coordinators, Victim Advocates, and  health care providers.
Office of the Secretary of the Air Force
Office of the Assistant Secretary of the Air Force for Manpower  and Reserve Affairs, Washington, D.C.
Office of the Air Force Surgeon General
Air Force Medical Support Agency, Falls Church, Virginia
Office of the Surgeon General, Washington, D.C.
Bureau of Medicine and Surgery, Office of Women’s Health,  Washington, D.C.
Bureau of Naval Personnel
Office of Women’s Policy, Washington, D.C.
Commander Naval Air Force, U.S. Atlantic Fleet, Norfolk, Virginia
Commander Naval Air Force, U.S. Pacific Fleet, San Diego, California
Commander Naval Surface Force, U.S. Atlantic Fleet, Norfolk, Virginia
Commander Naval Surface Force, U.S. Pacific Fleet, San Diego,
Commander Submarine Force, U.S. Atlantic Fleet, Norfolk, Virginia
Commander Submarine Force, U.S. Pacific Fleet, Pearl Harbor,
Navy and Marine Corps Public Health Center, Portsmouth, Virginia
Sexual Assault Prevention and Response Office, Washington, D.C.
Headquarters, U.S. Marine Corps (Health Services), Arlington,
U.S. Marine Corps Sexual Assault Prevention and Response Office,  In Afghanistan, we visited or contacted the following organizations:  International Security Assistance Force Joint Command, Afghanistan
Task Force Medical-Afghanistan, Afghanistan
U.S. Forces Afghanistan, Afghanistan  We conducted this performance audit from April 2012 through January  2013 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, key contributors to this report  include David E. Moser (Assistant Director), Wesley A. Johnson,   Ronald La Due Lake, Kim Mayo, Amanda Miller, Sharon Reid,   Cheryl A. Weissman, and K. Nicole Willems. In addition, Carole F. Coffey,  Kasea Hamar, David W. Hancock, and Tamiya R. Lunsford provided  assistance during site visits.