DOD Health Care: Domestic Health Care for Female Servicemembers
Published: 2013-01-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Female servicemembers are serving in more complex occupational specialties and are being deployed to combat operations, potentially leading to increased health risks. Similar to their male counterparts, female servicemembers must maintain their medical readiness; however, they have unique health care needs that require access to gender-specific services. The National Defense Authorization Act for Fiscal Year 2012 directed GAO to review a variety of issues related to health care for female servicemembers. This report describes (1) the extent that DOD's policies for assessing individual medical readiness include unique health care issues of female servicemembers; (2) the availability of health care services to meet the unique needs of female servicemembers at domestic Army installations; and (3) the extent that DOD's research organizations have identified a need for research on the specific health care needs of female servicemembers who have served in combat.
GAO reviewed DOD and military-service policies on individual medical readiness and surveyed senior health care officials about the availability of specific health services at the 27 domestic Army installations with MTFs that report directly to the domestic regional medical commands. GAO focused on the Army because it has more female servicemembers than the other military services. GAO also visited six Army installations--two from each of the Army's three domestic regional medical commands--and interviewed DOD officials who conduct research on health issues for servicemembers.
section_title: What GAO Found
paragraphs: The Department of Defense's (DOD) policy for assessing the individual medical readiness of a servicemember to deploy establishes six elements to review, most of which are gender-neutral. Four of the six elements--immunization status, medical readiness laboratory tests, individual medical equipment, and dental readiness--apply equally to female and male servicemembers. The remaining elements of individual medical readiness--deployment-limiting conditions and periodic health assessments--include aspects that are specific to female servicemembers. For example, the Army, Navy, Air Force, and Marine Corps have policies that define pregnancy as a deployment-limiting condition.
Officials surveyed by GAO reported that female-specific health care services and behavioral health services were generally available through domestic Army installations. Specifically, according to GAO's survey results:
Most routine female-specific health care services--pelvic examinations, clinical breast examinations, pap smears, prescription of contraceptives, and pregnancy tests--were available at the 27 surveyed domestic Army installations.
The availability of specialized health care services--treatment of abnormal pap smears, prenatal care, labor and delivery, benign gynecological disorders, postpartum care, and surgical, medical, and radiation treatment of breast, ovarian, cervical, and uterine cancers--at the 27 surveyed domestic Army installations varied. However, when these services were not available at the installation, they could be obtained through either another military treatment facility (MTF) or from a civilian network provider.
The availability of behavioral health services, such as psychotherapy or substance abuse treatment, which were not gender-specific, varied across the 27 domestic Army installations; however, similar to specialty care, these services could be obtained from other MTFs or civilian network providers. In addition, 18 of the 27 surveyed Army installations reported offering female-specific programs or activities, such as a post-deployment group for female servicemembers or a postpartum group.
One DOD organization, the Women's Health Research Interest Group, is currently in the process of identifying research gaps on health issues affecting female servicemembers. Interest group officials said that the goal is to develop a repository for peer-reviewed research articles related to health issues for female servicemembers, including those who served in combat, and to use this repository to identify research that could enhance the health care of female servicemembers, including those who have served in a combat zone. To ensure that researchers will have access to the results of their work, officials have plans to distribute their results in presentations at local and national conferences. In addition, officials told GAO that they will disseminate their findings through peer-reviewed publications and post this information on the Internet to make it available to the public.
GAO provided a draft of this report to DOD for comment. DOD responded that it did not have any comments on the draft report.

section_title: Letter
paragraphs: The role of women in the military is changing. Over the last four decades,  the percentage of female servicemembers among enlisted ranks has  increased seven-fold (from 2 to 14 percent) and the percentage of female  servicemembers among commissioned officers has increased four-fold  (from 4 to 16 percent). Currently, the largest total number of female  servicemembers resides in the Army. Female servicemembers also are  serving in more complex occupational specialties and are being deployed  to combat operations, potentially leading to increased health risks.
Similar to their male counterparts, female servicemembers must maintain  their medical readiness by ensuring that they are free of health-related  conditions that would limit their ability to actively fulfill an assigned  mission. Female servicemembers also have unique health care needs  that require access to gender-specific services, including routine  gynecological care, such as breast and cervical examinations, as well as  specialized services, such as obstetric care (which includes prenatal,  labor and delivery, and postpartum care) and the treatment of  reproductive cancers. Additionally, while all servicemembers need access  to a range of behavioral health services, such as individual or group  therapy sessions, men and women may be affected by behavioral health   Servicemembers receive health care services  conditions differently.through the Department of Defense’s (DOD) Military Health System,  which has a dual health care mission of supporting wartime and other  deployments, known as the readiness mission, and providing peacetime  care, known as the benefits mission.
The National Defense Authorization Act for Fiscal Year 2012 directed us  to review a variety of issues related to health care for female  servicemembers, including the availability of female-specific health care  and behavioral health services, as well as the need for further clinical  research on the health care needs of female servicemembers who have  served in a combat zone, among other issues. In this report, we describe (1) the extent that DOD’s policies for assessing individual medical  readiness (IMR) include unique health care issues of female  servicemembers; (2) the availability of health care services to meet the  unique needs of female servicemembers at domestic Army installations;  and (3) the extent that DOD’s research organizations have identified a  need for research on the specific health care needs of female  servicemembers who have served in combat. While this report focuses on  domestic installations, a separate report will provide information on the  availability of health care for female servicemembers in deployed  environments and for servicemembers who are victims of sexual assault.
To describe the extent to which DOD’s policies for assessing IMR include  unique health care issues of female servicemembers, we reviewed IMR  policies for DOD and each of the military services—Army, Navy, Air  Force, and Marine Corps—to determine whether these assessments  include female-specific information and to identify any potential variations  among the military services.service officials about the IMR assessments that are conducted prior to  deployment to identify any specific health care issues related to female  servicemembers.
We also interviewed DOD and military  To describe the availability of health care services to meet the unique  needs of female servicemembers at domestic Army installations—the military service with the largest number of female servicemembers—we  surveyed senior health care officials at the 27 domestic Army   installations that had a primary military treatment facility (MTF). (To see  a list of the 27 domestic Army installations with a primary MTF, see   app. I.) Through this survey, we obtained information about the availability  of routine, specialized, and behavioral health services for female  servicemembers from all MTFs at these installations, including the  primary MTFs and other, smaller MTFs, such as clinics. (For more  details about the survey methodology and a copy of the survey, see   apps. II and III.) Additionally, we asked the officials to report on services  available for these female servicemembers from other sources, including  MTFs outside the installation and civilian network providers, and  challenges associated with ensuring physical privacy. Through this  survey, health care officials at the 27 domestic Army installations reported  on the availability of health care services at these installations, to which  more than two-thirds of the Army’s female servicemembers were attached  as of August 1, 2012. To supplement information collected in the survey,  we also conducted site visits to six domestic Army installations—two  installations in each of the medical regions and two of each type of MTF  that serves as the primary MTF—to interview officials in charge of  routine, specialized, and behavioral health services. We also spoke with  officials about policies related to physical privacy and observed the  physical space used for health care delivery for female servicemembers.  We visited MTFs at Fort Benning, Georgia; Fort Gordon, Georgia; Fort  Huachuca, Arizona; Fort Lee, Virginia; Fort Lewis, Washington; and Fort  Meade, Maryland. Additionally, during our site visits, we conducted  individual interviews with 39 female servicemembers about available  health care services, including questions about physical privacy.  Specifically, we interviewed six to eight women at each location who were either an enlisted servicemember or an officer; did not work at any of the MTFs on the installation; and had previously deployed.
The views expressed by these servicemembers cannot be generalized to  all female Army servicemembers.
To describe the extent to which DOD’s research organizations identified a  need for research on the specific health care needs of female  servicemembers who have served in combat, we interviewed officials  from specific DOD research organizations that fund or conduct research  involving individuals who have served in a combat zone. This includes the  Defense Health Program from the Office of the Assistant Secretary of  Defense for Health Affairs, as well as organizations for the three military  departments, such as the U.S. Army Medical Research and Materiel  Command. Additionally, we interviewed officials from other DOD research  organizations, including the TriService Nursing Research Program and its  Women’s Health Research Interest Group. We also reviewed  documentation about research currently underway and descriptions on  how these organizations determine what research to fund or conduct.
We conducted this performance audit from April 2012 through January  2013 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: From fiscal year 2007 through 2012, the total number of female  servicemembers has grown from 200,941 to 208,905, with female  servicemembers comprising about 14 percent of the total active duty  force. During this time, the largest number of active-duty female  servicemembers resided in the Army. (See fig. 1.)
In fiscal year 2012, more than three-quarters of the Army’s female  servicemember population was age 35 and under, with the largest group  being between 18 and 24 years old. Recommendations for female- specific preventative health screenings are based on age, such as  cervical cancer screening, which would be applicable for female  servicemembers from an early age, while others, such as mammograms,  are currently not recommended until age 50, absent any personal history  of health problems of this nature. (See fig. 2.)
DOD operates its own large, complex health system—the Military Health  System—that provides health care to approximately 9.7 million  beneficiaries across a range of venues, from MTFs located on military  installations to the battlefield. These beneficiaries include active-duty  servicemembers and their dependents, eligible National Guard and  Reserve servicemembers and their dependents, and retirees and their  dependents or survivors. The Military Health System has a dual health  care mission: supporting wartime and other deployments, known as the  readiness mission, and providing peacetime care, known as the benefits  mission. The readiness mission provides medical services and support to  the armed forces during military operations and involves deploying  medical personnel and equipment, as needed, around the world to  support military forces. The benefits mission provides medical services  and support to members of the armed forces, their family members, and  others eligible for DOD health care.
The care of the eligible beneficiary population is spread across the  military departments—Army, Navy, and Air Force. Each military  department delivers care directly through its own MTFs, which are  managed by their medical departments, including  the Army’s Medical Command (MEDCOM);  the Navy’s Bureau of Medicine and Surgery, which is also responsible  for providing health care to members of the Marine Corps and their  beneficiaries; and the Air Force Medical Service.
Servicemembers obtain health care through the military services’ system  of MTFs, which is supplemented by participating civilian health care  providers, institutions, and pharmacies to facilitate access to health care  services when necessary. Active-duty servicemembers receive most of  their care from MTFs, where they receive priority access over other  beneficiaries.
subsections: section_title: Army MTFs
paragraphs: Within the continental United States, the Army is organized into three  medical regions—Northern, Southern, and Western—each headed by a  subordinate regional medical command, which exercises authority over  the MTFs in its region. Across the three regions, there are 27 domestic  Army installations with a primary MTF, which report directly to the  regional medical commands and are responsible for reporting information  for other associated MTFs, which may include smaller MTFs, such as  clinics, on the same installation, as well as MTFs on different Army  installations or at installations operated by other military services. For  example, at Fort Benning, there are multiple facilities located on the  installation, including Martin Army Community Hospital—the primary  MTF—as well as several clinics. In addition to reporting for all of those  facilities, Martin Army Community Hospital also reports to the regional  medical command for other Army facilities located off the installation,  including an Army clinic at Eglin Air Force Base in Florida.
All Army MTFs, both primary and associated, can be classified under one  of three categories on the basis of their size:
Army Health Centers/Clinics are generally the smallest facilities only  offering outpatient primary care.
Army Community Hospitals are larger than clinics and offer primary  and secondary care, such as inpatient care and surgery under  anesthesia.
Army Medical Centers are generally the largest facilities offering  primary and secondary care as well as other care, such as cancer  treatments, neonatal care, and specialty diagnostics.
section_title: Individual Medical Readiness
paragraphs: Each of the military services is responsible for maintaining the medical  readiness of its active-duty force. DOD’s IMR policy establishes six  elements for the military services to assess in order to determine a  servicemember’s medical readiness to deploy:  4.  individual medical equipment,5.  medical readiness laboratory tests, and  6.  periodic health assessments (PHA).
DOD’s policy establishes a baseline of standards for continuously  assessing each of the IMR elements. In addition to this, each of the  military services establishes its own policy that may include more specific  criteria. Each military service is responsible for assessing and  categorizing a servicemember’s IMR as follows:
Fully medically ready, current in all categories.
Partially medically ready, lacking one or more immunizations,  readiness laboratory tests, or medical equipment.
Not medically ready, existence of a chronic or prolonged  deployment-limiting condition, including servicemembers who are  hospitalized or convalescing from serious illness or injury, or  individuals who require urgent dental care.
Medical readiness indeterminate, inability to determine the  servicemember’s current health status because of missing health  information such as a lost medical record, an overdue PHA, or an  overdue dental exam.
All of the military services use different systems to collect information  about IMR status. In addition, DOD requires that each of the services  provide quarterly reports about the IMR status of their servicemembers.
section_title: Research Organizations
paragraphs: DOD and the military services have a number of organizations that fund  or conduct research, including research on health care issues that affect  those who have served in a combat zone. The Defense Health Program  within DOD’s Office of the Assistant Secretary of Defense for Health  Affairs receives significant funding for this research through its annual  appropriation. Through an interagency agreement, the Army Medical  Research and Materiel Command manages the day-to-day execution of  this funding through joint program committees. There are several joint  program committees that focus on specific research areas, including  clinical and rehabilitative medicine and military operational medicine.Officials from the other military services participate in these committees.  Research organizations from the military services, such as the Naval  Medical Research Center, the Office of Naval Research, and the Air  Force Medical Support Agency, also manage funds from the Defense  Health Program for research. In addition to the military services, other  organizations within DOD also fund or conduct research, including the  TriService Nursing Research Program, which funds and supports  research on military nursing.
section_title: DOD’s Policies for Assessing Individual Medical Readiness Are Mainly Gender- Neutral but Include Some Aspects That Are Female-Specific
paragraphs: DOD’s policy establishes six elements for assessing the IMR of a  servicemember to deploy, most of which are gender-neutral. Four of the  six elements—immunization status, medical readiness laboratory tests,  individual medical equipment, and dental readiness—are gender-neutral;  they apply equally to female and male servicemembers. In order to pass  these elements of the IMR assessment, servicemembers must be current  for each element, by having  immunizations, including MMR (measles, mumps, and rubella); medical readiness laboratory tests, such as a human  immunodeficiency virus test and results current within the past   24 months;  individual medical equipment, such as gas mask inserts for all  personnel needing visual correction; and an annual dental exam.
The remaining elements of IMR—deployment-limiting conditions and  PHAs—include some aspects that are specific to female  servicemembers. The Army, Navy, Air Force, and Marine Corps have  policies that define pregnancy as a deployment-limiting condition. In  addition, they also have policies that establish a postpartum deferment  period—generally 6 months after delivery—when a female  servicemember is not required to deploy. The deferment period was  established in order to provide for medical recovery from childbirth and to  allow additional time to prepare family care plans and child care.  However, each of the military services has a policy that allows the  servicemember to voluntarily deploy before the period has expired. In  addition, cancer that requires continuing treatment and specialty  evaluations can also be a deployment-limiting condition. Although cancer  treatment could affect both male and female servicemembers, there are  some cancers that would be specific to female servicemembers, such as  ovarian cancer, while other cancers are specific to male servicemembers,  such as prostate cancer.
The PHA includes a review of information about preventative screenings  and counseling for each servicemember. Some of the preventative  screenings that are reviewed as part of the PHA are female-specific, such  as mammograms and pap smears. To satisfy this element of IMR, a  servicemember’s PHA must be current—the assessment of any changes  in health status must have occurred within the past year—for both female  and male servicemembers. The results of these preventative screenings  do not negatively affect this element of a servicemember’s readiness  assessment even when follow-on studies, labs, referrals or additional  visits may be pending or planned. Nonetheless, these screenings could  identify a health issue that would be considered a deployment-limiting  condition—a separate element of IMR—and could therefore limit  readiness. For example, the results of a mammogram may identify cancer  that requires treatment or specialized medical evaluations that could be  determined to be a deployment-limiting condition.
section_title: Health Care and Behavioral Health Services Were Generally Available to Female Servicemembers through Domestic Army Installations
subsections: section_title: Routine and Specialized Female-Specific Health Care Services Were Generally Available at the Domestic Army Installations We Reviewed or from Other Sources
paragraphs: On the basis of our survey, we found that most routine female-specific  health care services—including pelvic examinations, clinical breast  examinations, pap smears, screening mammographies, prescription of  contraceptives, and pregnancy tests—were available through the MTFs at  the 27 domestic Army installations with a primary MTF. Screening  mammography services were not available at two of these installations;  however, in those instances, this service was available from a civilian  network provider.
We did not survey about the availability of male and female providers to provide  pregnancy tests as senior health care officials stated that this health care service is not  one that is necessarily administered by health care providers. that she would have to wait 3 months to see a female provider, so she  opted to see a male provider.
On the basis of our survey, the availability of specialized health care  services varied by the type of primary MTF on the domestic Army  installation; however, when services were not available at the installation,  they were available through other MTFs or from a civilian network  provider. Specifically, more types of specialized health care services  were available on installations with a larger Army Medical Center as the  primary MTF than at installations with a smaller Army Health  Center/Clinic. For example, none of the installations where the primary  MTF was an Army Health Center/Clinic offered surgical, medical, or  radiation treatments for breast, ovarian, cervical, and uterine cancers,  whereas some installations where the primary MTFs were Army  Community Hospitals and Army Medical Centers did make these  treatments available. (See table 1.) Additionally, both male and female  providers were available to provide specialized female-specific services— such as treatment of abnormal pap smear, prenatal care, labor and  delivery, benign gynecological disorders, and postpartum care—that were  offered at the 27 domestic Army installations.
In addition, when asked about the availability of other programs, officials  from 25 of the 27 domestic Army installations we surveyed reported  offering female-specific health care programs or activities, including  female-specific groups for breast cancer, pregnancy education,  pregnancy physical training, postpartum care, women’s clinics, and health  care fairs. Five of the six installations that we visited reported having  female-specific programs, such as breast cancer awareness activities,  lactation consultants, a women’s clinic or health care team, annual  women’s health care fair, and a pregnancy physical training program.
With respect to privacy for individuals, including female servicemembers,  who seek care at domestic Army MTFs, Army MEDCOM officials noted  that reasonable safeguards should be in place to limit incidental, and  avoid prohibited, uses and disclosures of information.cubicles, dividers, shields, curtains, or similar barriers should be utilized in  an area where multiple patient-staff communications routinely occur. DOD  provides space-planning criteria for health facilities that assert that private  space be made available to counsel patients, including facilities for  outpatient women’s health services.
When asked to report on the challenges MTFs face in ensuring the  physical privacy of female servicemembers, senior health care officials at  most domestic Army installations (18 of 27) we surveyed did not report  examples of any challenges. However, officials from the remaining nine  installations cited two privacy-related challenges—physical layout of the  exam rooms and auditory issues. For example, officials from three  installations reported that some exam rooms were configured such that  some examination tables face the door. Officials from two of these  installations reported the use of a privacy curtain to overcome this room  limitation. Nonetheless, all of the female servicemembers that we  interviewed at the six sites that we visited felt that adequate steps were  taken to ensure their physical privacy during health care visits. Officials  from another installation reported on the survey that the layout of a  waiting room may allow for conversations at the reception desk to be  overheard, which may compromise patient privacy. Additionally, 3 of the  39 female servicemembers that we interviewed stated that they had  concerns regarding auditory privacy in the waiting or exam rooms. At  three of the six installations that we visited, we observed clinics that had  waiting areas with separate check-in bays, such as those for walk-in  appointments, pharmacy, and laboratory tests. The separation of these  check-in areas spread people out and provided more distance between  those checking in and those sitting in the waiting rooms.
section_title: While Not Inherently Gender-Specific, Availability of Behavioral Health Services at Domestic Army Installations Varied but Was Offered from Other Sources
paragraphs: Behavioral health illnesses affect both men and women, and with the  exception of postpartum depression, are not easily distinguished by  gender. Consequently, behavioral health services are not inherently  gender-specific.
Behavioral health services were provided in a variety of settings, such as  through outpatient, inpatient, residential, and telebehavioral settings. We  found in our survey that the availability of behavioral health services at  domestic Army installations varied; however, when these services were  not available at the installation, they were available from other sources,  including from other MTFs or from civilian network providers. (See   table 2.) All of the 27 domestic Army installations we surveyed offered  individual and group outpatient treatments, and most (23 of 27) offered  family outpatient treatment. If treatments were not available at the  installation, they were offered from another MTF or a civilian network  provider. About one-third (10 of 27) of domestic Army installations offered  inpatient treatment, and fewer offered residential treatment (5 of 27).
In addition to general behavioral health services, all of the domestic Army  installations included in our survey offered some type of behavioral health  services for substance abuse. (See table 3.) With regard to the availability  of substance abuse treatment options, all 27 domestic Army installations  we surveyed offered individual outpatient treatment. All but one domestic  Army installation offered group outpatient treatment and more than a third  (11 of 27) offered family outpatient treatment. Few domestic Army  installations offered inpatient treatment (5 of 27) or residential treatment  (4 of 27) for substance abuse. If these treatments were not available on  the installations, they were available from another MTF, a civilian network  provider, or both.
As a way to increase access to behavioral health services, telebehavioral  health services—medically supervised behavioral health treatment using  secured two-way telecommunications technology to link patients from an  originating site for treatment with providers who are at another site—can  be used to connect servicemembers and behavioral health providers.  This service was available at 22 of the 27 domestic installations we  surveyed. Telebehavioral health services can be used to provide  treatment to servicemembers in remote locations, where providers may  not be readily available, and to ensure continuity of care for  servicemembers who change duty stations.
While behavioral health services are not inherently gender-specific, a  number of Army installations we surveyed reported offering programs or  activities that were specific to women. Officials from 18 of 27 domestic  Army installations provided examples of female-specific behavioral health  programs or activities, including a post-deployment group for female  servicemembers, postpartum groups, and specific therapy groups for  female servicemembers. Four of the six installations we visited reported  having female-specific behavioral health programs or activities, such as  postpartum, post-deployment, and general women’s support groups. The  importance of female-specific groups was echoed by most (34 of 39) of  the female servicemembers that we interviewed. These female  servicemembers told us that there was a need for female-specific groups  for certain topics, such as post-traumatic stress disorder (PTSD),  postpartum depression, parenting, and general female servicemember  issues.
With respect to privacy when providing behavioral health services,  officials from 17 of the 27 domestic Army installations that we surveyed  did not report any challenges to ensuring physical privacy when providing  behavioral health services to female servicemembers when asked to  report on the challenges MTFs face in ensuring the physical privacy of  female servicemembers. Officials from the other 10 installations reported  two main challenges to ensuring physical privacy—having mixed gender  waiting rooms and concerns regarding auditory privacy in the waiting or  exam rooms. Three of the 27 installations reported using white noise  machines in an effort to help mask noise and address any potential  auditory concerns. All of the female servicemembers we interviewed at  the six installations that we visited felt that adequate steps were taken to  ensure their physical privacy during behavioral health visits.
section_title: One DOD Organization Is in the Process of Identifying Research Gaps on Health Care Needs for Female Servicemembers
paragraphs: The Women’s Health Research Interest Group, which is supported by the  TriService Nursing Research Program, is currently in the process of  identifying research gaps on health issues affecting female  servicemembers. As part of this effort, they are comparing a compiled list  of existing research with data on health care issues for female  servicemembers to determine if there are any existing gaps in research.  Interest group officials said that the goal is to develop a repository for  peer-reviewed research articles related to health issues for female  servicemembers, including those who served in combat, and to use this  repository to identify research that could enhance the health care of  female servicemembers, including those who have served in a combat  zone. To ensure that researchers will have access to the results of their  work, officials have plans to distribute their results in presentations at  local and national conferences. In addition, officials told us that they will  disseminate their findings through peer-reviewed publications and post  this information on the TriService Nursing Research Program website,  which is available to the public. However at the time of our review, only  one DOD research organization that we spoke with was aware of their  work. Specifically, an official from the Air Force Medical Support Agency  told us that it was aware of the efforts by the Women’s Health Research  Interest Group. In addition, other DOD research organizations told us that  they would be interested in the results of this work even though they were  not aware of it at the time of our discussion.
While none of the other DOD research organizations that we spoke with  are trying to identify gaps in research on female servicemembers, officials  from each organization told us that they conduct research based on  needs and capabilities. For example, one organization said that it reviews  health care issues experienced during deployments and speaks with  health care providers to determine what research is needed to better  restore a servicemember’s ability to function. DOD research organizations  said that while they focus their research on needs or capabilities, they  consider gender in their research efforts. For example, officials from one  division of the Army Medical Research and Materiel Command told us  that when developing a research announcement based on genitourinary  injuries sustained during deployments, they contacted the services to  determine the type and extent of injuries encountered. At the time of the  inquiry, only one female was reported by the services as having a  significant genitourinary injury and this led to the development of an  announcement that did not specifically mention females or males. While  this announcement was not gender-specific, officials said that research  proposals could include female servicemembers. In addition, officials from  another division of the Army Medical Research and Materiel Command  told us that when discussing proposed research to examine blood  markers for PTSD, the original proposal did not include female  servicemembers because researchers believed that female hormones  would make detecting blood biomarkers for PTSD more difficult. Officials  from Army Medical Research and Materiel Command found this  justification for leaving out female servicemembers unsatisfactory so they  required researchers to include both genders in this study.
section_title: Agency Comments
paragraphs: We provided a draft of this report to DOD for comment. DOD responded  that it did not have any comments on the draft report.
We are sending copies of this report to the Secretary of Defense,  appropriate congressional committees, and other interested parties. In  addition, the report will be available at no charge on GAO’s website at  http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or at williamsonr@gao.gov. Contact points for our  Office of Congressional Relations and Office of Public Affairs can be  found on the last page of this report. Other major contributors to this  report are listed in appendix IV.
section_title: Appendix I: List of Domestic Army Installations with a Primary Military Treatment Facility
section_title: Appendix II: Scope and Methodology for the Survey Sent to Domestic Army Military Treatment Facilities
paragraphs: To describe the availability of routine, specialized, and behavioral health  care services to female servicemembers at domestic Army installations  and from other sources, we surveyed senior health care officials at the   27 domestic Army installations that had a primary military treatment  facility (MTF). Through this survey, we collected information on the  availability of these services to female servicemembers at installations to  which more than two-thirds of the Army’s female servicemembers were  attached as of August 1, 2012.
In developing the survey, we conducted pre-tests to refine and validate  the specific health care services as those services available to female  servicemembers in the Army and checked that (1) the terminology was  used correctly; (2) the questionnaire did not place undue burden on  agency officials; (3) the information could be feasibly obtained; and   (4) the survey was complete and unbiased. We chose the four pretest  sites to include at least one installation with a primary MTF that was a  medical center, a community hospital, and a health center/clinic. We  conducted one of the pretests where all GAO participants were present  and three pretests with some GAO participants in person and others  participated by telephone. We made changes to the content and format of  the survey on the basis of the feedback we received during the pretests.
On August 20, 2012, Army Medical Command (MEDCOM) officials sent  the survey to senior health care officials at the 27 domestic Army  installations as a Word document by email that the respondents were  requested to return after marking checkboxes or entering responses to  open-answer boxes. All surveys were returned by September 26, 2012,  for a 100 percent response rate. We conducted follow-up with senior  health care officials about missing or inconsistent responses, through  Army MEDCOM officials, between September 2012 and December 2012.  The survey is presented in appendix III.
section_title: Appendix III: GAO Survey Sent to Domestic Army Military Treatment Facilities
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Bonnie Anderson,   Assistant Director; Jennie Apter; Danielle Bernstein; Natalie Herzog;   Ron La Due Lake; Amanda K. Miller; Lisa Motley; Mario Ramsey; and  Laurie F. Thurber made key contributions to this report.