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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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.