The Department of Veteran Affairs (VA) has taken steps to make services available to women veterans, but needs to revise key policies and improve oversight, according to a new report released Wednesday by the Government Accountability Office (GAO).
The GAO conducted the study because women are a growing subgroup of veterans. In 2008, the VA provided health care to more than 281,000 women veterans. Also, women veterans seeking VA health care need access to an array of services and Congress has raised concerns about how well the VA is prepared to meet the physical and mental health care needs of women.
The GAO was asked to assess the on-site availability of health care services at the VA facilities for women veterans, the extent to which VA facilities are following VA policies that apply to the delivery of health care to women veterans and key challenges that VA facilities face in providing health care to women veterans and how the VA is addressing these challenges. The GAO reviewed related laws and VA policies, interviewed officials, visited nine VA medical centers (VAMC), ten community-based outpatient clinics (CBOC) and ten VA counseling centers (Vet Centers).
“The availability of specialized gender-specific services – such as treatment of reproductive cancers – and mental health services for women varied by service and facility,” the report stated. “While some VAMCs offered a broad array of specialized gender-specific care on site, smaller CBOCs referred women to other VA or non-VA facilities for many or most of these services.”
In July 2009, the GAO reported that none of the facilities it visited were fully compliant with VA policy requirements related to privacy for women veterans. In response, the VA has required facilities to report more information on their compliance with these policies. However, the report stated, “Facility reporting on privacy policies has, in the past, been inaccurate and VA’s oversight process does not include a means to validate the information facilities report.”
Also, the facilities that the GAO visited were in various stages of implementing a new VA initiative to provide comprehensive primary care, including mental health care, to women veterans at all facilities. VA headquarters officials are working with Women Veterans Program Managers (WVPM) and facility leadership to help facilities implement this initiative.
In the locations that the GAO visited, the VA identified many challenges in providing health care services to women veterans. For instance, officials at VA medical facilities reported that space constraints have raised issues affecting the provision of health care services to women veterans, especially related to privacy and safety. They also have said that most VAMCs have plans for renovation, construction or relocation projects to help expand services and create comprehensive primary care for women veterans.
According to the report, as of September 2009, there were more than 1.8 million women veterans in the United States (representing almost 8 percent of the total veterans’ population). Also, more than 102,000 of these women were veterans of the military operations in Afghanistan and Iraq.
Women veterans also tend to be younger than their male counterparts. While almost all women veterans returning from Iraq and Afghanistan are under 40 – most between the ages of 20 and 29 – the VA also serves women veterans from other combat eras who are typically over 55.
VA data show that almost 20 percent of women veterans from Iraq and Afghanistan have been diagnosed with post-traumatic stress disorder (PTSD). Also, many women veterans have experienced military sexual trauma (MST). The VA data shows that in fiscal year 2008, 21 percent of women screened positive for having experienced MST.
The report stated that women veterans present unique challenges to VA. “Traditionally, women veterans have utilized VA’s health care services less frequently than their male counterparts, even though VA has found that women veterans have health burdens comparable to or greater than that of male veterans,” the report stated.
In fiscal year 2007, 15 percent of women veterans used the VA’s health care services, compared to 22 percent of male veterans. “VA believes that part of this difference may be attributable to barriers that the current care models at many VA medical facilities present to women veterans,” the report stated.
For example, women veterans have often been required to make multiple visits to a VA medical facility to receive the full spectrum of primary care services, which includes such basic gender-specific care as cervical cancer screenings and breast examinations. “Because many of these women work or have child care responsibilities, multiple visits can be problematic, especially when services are not available in the evenings or on weekends,” the report stated.
VA policies outline many requirements that help to ensure the privacy of women veterans in all settings of care at VAMCs and CBOCs. These include requirements related to ensuring auditory and visual privacy at check-in and in interview areas; the location of exam rooms; presence of privacy curtains; the orientation of exam tables; the availability of sanitary products in public restrooms at VA medical facilities; access to private restrooms in outpatient, residential and inpatient settings of care; and access to separate and secured sleeping accommodations in residential and inpatient settings.
Also, the VA is required to provide mental health screening, counseling and related treatment for eligible veterans who have experienced MST, which is much more common among women veterans than their male counterparts.
“Research has shown that veterans who have experienced MST are at a high risk for developing a range of mental health conditions such as PTSD, major depression, anxiety and panic disorder,” the report stated. “MST victims may also struggle with other problems, including low self-esteem, difficulties with interpersonal relationships and sexual dysfunction.”
The VA has taken some steps to make information about mental health programs more readily available to VA providers. Specifically, the VA has conducted monthly, nationwide MST conference calls, which have included basic information on the structure and focus of the various residential and outpatient programs offering MST or sexual-trauma-specific treatment, as well as detailed presentations by key providers from several programs. The VA also has a list of the various programs on its internal web site, which is accessible by VA providers.
However, the report stated, “As of November 2009, the web pages we reviewed from VA’s national website did not provide complete lists of facilities that have MST-related treatment programs or specialized programs for women veterans. The sites that did list specific residential treatment programs usually listed a single program, while nine VAMCs have relevant programs.”
In addition, the report stated that none of the VAMCs or CBOCs visited were fully compliant with VA policy requirements related to privacy for women veterans.
For example, in exam rooms where gynecological exams are conducted, only one of the nine VAMCs and two of the eight CBOCs visited were fully compliant with VA’s policy requiring exam tables to face away from the door. Also, at one of these CBOCs, a noncompliant exam room was also located within view of a mixed-gender waiting room.
Even though the VA has strengthened its oversight of privacy policies, the report stated that because it is still relying on a self-reporting process, the VA lacks independent validation that VA medical facilities are complying with VA privacy policies for women veterans. “While the online checklist and facility action plans will allow VA headquarters officials to review deficiencies reported by facilities, the process relies on self-reported information that may not always be accurate,” the report stated.
Also, VA medical facility and Vet Center officials interviewed reported challenges attracting and hiring psychiatrists, psychologists, and other mental health staff with specialized training or experience in treating PTSD and other MST-related conditions.
“Two officials, who both have experience as an MST coordinator, told us that many mental health providers at their facilities could use additional training in MST screening,” the report stated. “In addition, two VA mental health officials reported that because it is difficult to attract and hire mental health professionals with experience in treating the veteran population, some medical facilities have hired younger, less experienced providers.”
While the VA is taking positive steps to provide MST training for its providers, it has not yet defined the appropriate training needed for treating victims of MST, the report concluded. However, VA officials said that all VA mental health providers who are licensed in their field and have appropriate clinical privileges are considered VA-qualified mental health providers and are qualified to work with victims of MST.
The report concluded that the number of women veterans using VA health care services has increased substantially in recent years and this trend is going to continue over the coming decades. Also, the report stated, “The VA has taken important steps to address the needs of women veterans, including efforts to expand comprehensive primary care for women veterans.
“However, our review also identified some gaps in services available to women, including several medical facilities that did not routinely offer basic gender-specific services on site.”
While most facilities visited offered a variety of mental health services, the VA has not made information accessible on its external web sites about all VA specialized residential mental health programs for women veterans who have experienced MST or other traumas. And without ready access to such information, women veterans who need treatment may face unnecessary challenges to accessing VA programs, the report concluded.
The report also recommended the following:
- Provide complete information on the VA’s external websites on the specialized residential mental health treatment programs that the VA offers for women veterans who have experienced MST or other traumas;
- Establish a process to independently validate self-reported information by VA medical facilities’ on compliance with privacy policies that pertain to women veterans;
- Expedite action to ensure that the VA’s design and construction policies address the needs of women veterans in all health care delivery settings in VA medical facilities; and
- Clarify VA’s policies by describing specifically what constitutes “appropriate and necessary training” for mental health professionals who provide services to veterans who have experienced MST.