Erin Mulhall Deputy Policy Director for Research, IAVA 202 544 7692 | erin@iava.org

For all media inquiries, contact our Communications Department: 212 982 9699 | press@iava.org

table of contents1 ExecutiveSummary

2 ChangingRolesforWomen

3 BarriersFacingFemaleTroops 3 Career Progression Challenges 4 Balancing Family and Service 6 Inadequate Health Care for Women

6 Sexual Assault and Harassment

8 HomecomingChallenges 8 VA Health Care Stretched 11 Underemployment and Homelessness

12 SupportingShe‘WhoHasBornetheBattle’

13 RecommendedReading

13 Endnotes

1

issue report, october 2009

Women WarriorsSupporting She ‘Who Has Borne the Battle’

ErinMulhall

executive summary

During his Second Inaugural Address, President Abraham Lincoln pledgedAmerica’ssolemnobligation“Tocareforhimwhoshallhavebornethebattle,andforhiswidow,andhisorphan.”Morethan140yearslater,thespiritofLincoln’swordsareverymuchalive.However,womenhavejoinedthemilitary’sranks—servinginnewroles,ingreaternumbersthaneverbefore,andincombat.Liketheirmalepeers,womenveteranshaveshownenormousdedicationandcourageindefendingtheircountry.Buttoooften,theydonotreceivethesamesupport,withinthemilitaryandtheDepartmentofVeteransAffairs(VA).

Whilenewpositionsanddoorsofopportunityhavebeenopenedforwomenintheservices,theystillfacesignificant,uniquechallenges.Careerprogressionisoftenslowerforwomenandtheyareunderrepresentedinthemilitary’ssenior ranks.Challenges forwomenwithyoungchildrenandaperceivedlack of opportunity for advancement have ledmanywomen to leave theserviceearlyintheircareers.Inadequatemilitaryhealthcareforwomenandstaggeringratesofsexualassaultandharassmentarealsohinderingsomefemaletroopsfromcontinuingtheirmilitarycareers.Thesechallengesarenotonlybadforservicemembers’well-beingandreflectthemilitary’sfailuretoproperlyprotectitsown,buttheyhaveasubstantialimpactonthemissionreadinessoftheoverallforce.

Whentheycomehome,femaleveteransareconfrontedwithnewchallenges.Whileithasmadestridesinrecentyears,theVAisstillunderpreparedtopro-videadequatecaretothesurgeoffemaleveteranscomingtoitshospitalsandclinics. Inaddition,womenveteransfacesignificantbarrierswhenenteringthecivilianworkforce,andhomelessratesamongfemaleveteransareontherise.Giventhelackofsupportservicesforourwomenveterans,thiscomesasnosurprise.

Femaletroopsandveteransdeservethesameaccesstohigh-qualityhealthcare,transitionalresources,andbenefitsastheirmalecounterparts.Afterhonorablyfightingabroad,theyshouldnothavetowagenewbattleshereathome.Inor-dertofullyhonortheiroutstandingcontributionstothemilitaryandservicetothecountry,muchmoremustbedonetosupportourwomenwarriors.

2

changing roles for women

As early as theRevolutionaryWar, and in every othermajorAmericanconflictthereafter,womenhaveservedhonorablyandcourageouslyonbehalfof thecountry.In Iraq and Afghanistan especially, the health of ourforce relies heavily on a sustained and strong femalepopulation.More than212,000 female servicemembershavebeendeployedduringOperationIraqiFreedomandOperationEnduringFreedom,makingup11percentofour force there.1Over 120of thosewomenhave giventheir lives, andmore than 600have beenwounded inaction.2

However,womenhavenotalwayshadanofficiallyrecog-nizedroleinthemilitary.ItwasnotuntilJune12,1948,when President Harry Truman signed the Women’s

Armed Services Integration Act, that females were al-lowedtoserveapermanentroleintheactiveandreservebranches and were no longer relegated to serving in“women’scomponents”duringtimesofwar.3

During the Equal Rights Movement, many of the re-maining limitations on female participation in theArmedForcesdisappeared,particularlywiththeadventoftheAll-VolunteerForcein1973.Theneedtofilltheranks without a draft led to targeted recruitment ofwomen.4By1976,womenhadgainedadmittancetoalloftheserviceacademies.5Inthelasttwodecades,legisla-tiveandDODdirectiveshavecreatedevenmoreoptionsforwomen.Currently,morethan80percentofallDODpositionsarenowavailabletowomen,andtheseoppor-tunitiesvarybyservice.6Forexample,99.7percentofAirForcespecialtiesareopentowomen.7

General ann e. DunwooDy—Profile in Service

On Nov 14, 2008, General Ann E. Dunwoody became the first woman

to be promoted to the rank of four star general. Over the course of her

34-year career, Dunwoody has consistently proven to be an exceptional

leader with wide-ranging experience.

In 1975, Dunwoody graduated from the State University of New York

at Cortland and received her commission as a Second Lieutenant. Since

then, she has served in a variety of roles within the military, including

head of logistics for the storied 82nd Airborne Division during the Gulf

War. In addition to being an accomplished logistician, she is a former

battalion commander and master parachutist.

In her new role as Commander of the Materiel Command of the

Army, Dunwoody is in charge of supplying soldiers with military hard-

ware, repairing armored vehicles and sustaining combat operations in

Iraq and Afghanistan.

General Dunwoody is an example of the limitless potential of women

in the Armed Forces, and she is an inspiration to this generation of

warriors—male and female—and all Americans.

women warriors | october 2009

However,theDepartmentofDefensespecificallyprohibitswomenfromservinginassignments“whoseprimarymis-sionistoengageindirectcombatontheground.”8Whilethereisnolawactivelybarringwomenfromengagingincombat,womencannotbeassignedtopositionsthatarelikelytoengageindirectgroundcombat,suchasinfantry.9But,womencannowserveascombatpilotsinallservicebranchesandonnavalvessels,exceptforsubmarines.10

While restrictions remain on certain combat roles forwomen,themilitaryprovidesmanyopportunitiesforre-wardingcareers.Andunlikeinthecivilianworld,femaletroopsreceiveequalpayforequalservice.11

barriers facing female troops

Themilitary would not be able to perform itsmissionwithout the continued contributions of female troops.Althoughagrowingnumberofwomenareservinginthemilitary today, females are leaving themilitaryathigh-erratesthanmales,12andproportionatelyfewerwomenplantoserveuntilretirement.13Whilemanyfactorscannegativelyimpactthedecisionofwomentoremaininthemilitary,womenhaveexpressedconcernsabout theop-portunitiesforcareeradvancement,balancingamilitarycareerandfamilylife,inadequatemilitaryhealthcareforfemaletroops,andstaggeringratesofsexualassaultandharassment.

Career Progression ChallengesAccordingtothemilitary’sAdvisoryCommitteeonWomenintheServices(DACOWITS),womenareunderrepresent-ed in the higher ranks of themilitary,14 and have lowerpromotionratesthantheirmalecounterparts.15Accordingto the RAND Corporation, the Army’s ban on womenservingindirectgroundcombatmaybeonemajorfactoraffectingopportunitiesforpromotionsandselectionforcommand.16

Many female troopsdoubt their ownopportunities forcareeradvancementwithinthemilitary.17Accordingtoa2008DODsurvey:

•Only36percentoffemaleenlistedsoldiersagreedorstronglyagreedwiththestatement,“(Iwill)getassignmentsneededforpromotion,”comparedto44percentofmalesoldiers.18

•Only55percentoffemaleenlistedsoldiers(versus61 percent of theirmale counterparts) agreed orstronglyagreedwiththestatement,“(Iam)confi-dentIwillbepromotedashighaswarranted.”19

•Female soldiers,bothofficersandenlisted, con-sistentlyratetheirsuperiorsmorenegativelythantheirmalepeersoncategorieslike“qualityoflead-ership at place of duty” and “amount of respectreceivedfromsuperiors.”20

3 | issue report

“[the military is] a great opportunity to learn about yourself and what you are capable of.” — april, afghanistan veteran

4 women warriors | october 2009

Balancing Family and ServiceIn addition to career concerns, both male and femaleservicemembers can experience challenges balancingmilitary and family life. According to the GovernmentAccountability Office (GAO), “Family satisfaction withmilitary life can influence a service member’s decisionwhethertoremaininthemilitary.”21

Forfemaleservicemembers,wholiketheirciviliancoun-terparts often assume the role of primary caretaker fortheir children, balancing a military career and a familycan be especially challenging. More than 40 percent ofwomenonactive-dutyhavechildren.22AccordingtoArmyofficials, “the constraints on reproduction, child-rearingandfamilyareakeyfactorleadingmanyfemalesoldierstoquittheArmy,andhavediscouragedmanycivilianwom-

en from consideringenlistment.”23 DODsurveyshavealsofoundthateventhoughmaletroops aremore likelyto be married andhave children than fe-male servicemembers,a larger percentage offemale soldiers cite“the amount of time

separatedfromfamily”asthemostimportantreasonforleavingthemilitarybeforeretirement.24Femaletroopsarealsolesslikelytoreceivesupportfromtheirfamilywhentheydecidetostayinthemilitary.”25

These work-life conflicts are compounded by the longandfrequentcombattoursinIraqandAfghanistan,andthelackofadequate“dwell-time”orrestbetweendeploy-ments. These long and repeated tours weigh especiallyheavyonfemaletroopsandtheirfamilies.Divorceratesforfemaleservicemembersarehighandrising(seeInsetonpage5),andarecentstudyfoundthatmilitarymoth-ers’deploymentscanhaveanegativeeffectonthehealthand behavior of both thewomen and their adolescentchildren.26 For single parents in themilitary, multipletourscanbeespeciallyhard.Femaleservicemembersaremuchmorelikelytobeasingleparentthanmaletroops,andmorethan30,000singlemothershavedeployedtoIraqandAfghanistanasofMarch2009.27

Thecurrentoperational tempohascreatedconsiderablepressure to change theDefenseDepartment’smaternitypolicy.AccordingtotheGAO,“about10percentofwom-eninthemilitarybecomepregnanteachyear,and75,000militaryoffspringareyoungerthanone,”asof2002.28Themilitarygivesnewmothers sixweeksofmaternity leavebeforetheyhavetoreturntoworkortraining.However,each service branch has its own post-birth deferment-from-deploymentpolicy.TheArmy,whichhasthelongesttoursofdutyat12months,giveswomenjust4monthsto stay stateside with their newborns before deployingtothewarzone,leavinglittletimetobondwithornursetheir infants.Othermilitarybranchesgrantlongerstaysand have shorter deployment lengths. For example, theMarinesoffer6monthdefermentsandtheirtoursaverage7months.29AccordingtoMaj.Gen.GaylePollock,formeractingArmysurgeongeneral,theArmyshouldincreaseitsmaternitydefermentstoatleast8months,with12monthsbeing themost ideal: “Weneed to look at the fact thatmanywomenwanttoservebuttheyalsowanttobemoth-ers. It’s amedical issue, it’s amentalhealth issue.Yourability tobondwithyourchildren is...very important.”30CongresshasalsoaskedthePentagontofixthedisparitythatexistsbetweentheservicebranches,31butnoofficialactionhasbeentakentodate.

“i was told that i could not be both a soldier and a mother at the same time.” — melissa, iraq veteran

more than 30,000 single mothers have deployed

to iraq and afghanistan.

4 women warriors | october 20094 women warriors | october 2009

Despite a spike in divorces at the start of the Iraq

War,32 today’s divorce rates in the active-duty mili-

tary are not dramatically higher than either the

national divorce rate or the peacetime military

divorce rate. A recent RAND study33 concluded

that rates of military divorce in 2005 had only risen

to the levels observed in 1996. In the past three

years, however, divorce rates have continued to

rise, reaching 3.5 percent in the Army in 2008 —

approximately the same as the national divorce

rate for 2005 (the last year for which national

data is available).34

When military divorce data is broken down by

gender, however, a very troubling pattern emerges.

Marriages of female troops are failing at almost

three times the rate of male servicemembers.35

Female servicemembers are bearing the brunt

of military divorces. In fact, the overall rise in

divorce rates between 2005 and 2008 primar-

ily reflects a significant rise in the female service-

members’ divorce rates. Between 2005 and 2008,

Army women saw an increase in their divorce rate

of 2 percent, compared to 0.1 percent for men.

In the Marines, the divorce rate has jumped

3 percent for women, compared with 0.5 percent

for men.36

Unfortunately, much of the data on military

divorce includes only troops who are still serv-

ing — not the more than one million Iraq and

Afghanistan veterans who have left the active-duty

military.37 In addition, there is little data about

the causes of marital strain and high divorce rates

among servicemembers and veterans. Further study

is needed to evaluate stressors such as multiple

deployments, mental health injuries, dual-military

marriages, and gaps in family support programs,

particularly for the families of female troops and

veterans.

HiGHer Divorce rate for female ServicememberS

Marriages of female troops are failing at almost three times the rate of male servicemembers.

Female Troops Face MuchHigher Divorce Rates

Source: Department of Defense data, FY2008, via the Associated Press

9.2%

8.5%

2.9%3.3%

Men Women

Marines

Men Women

Army

5 | issue report

6 women warriors | october 2009

Inadequate Health Care for WomenThemilitary’shealthcaresystem,TRICARE,providesafullrangeofhealthcarebenefitstofemaleservicemem-bers.AccordingtotheGAO,TRICAREisconsistentwiththenational clinical guidelines forwomen’shealthde-velopedbyTheAmericanCollege ofObstetricians andGynecologists and comparable to benefits for womenoffered by the widely-used Federal Employees HealthBenefits Programs.38 However, TRICARE’s capacity todeliver has been challengedby the growingnumber ofactive-duty and reservewomen in a system thathas inthepastprimarilyservedmaletroops.

AccordingtoaDODsurvey,maleandfemaleactive-dutyservicemembers who use TRICARE generally share thesamelevelofsatisfactionwiththehealthcareprovidedby the system.39However, youngermalesgenerally ratetheirdoctorsmorehighlythantheirfemalecounterparts,and females are “substantially less satisfied with theirability tofindapersonaldoctor thanaremaleperson-nel,adifferencethatispronouncedinallagegroups.”40Furthermore,itappearsthatactive-dutywomenaremorelikelytoreportthattheydonotgetenoughtimeorarenottreatedwiththeproperrespectbytheirdoctors.41

Female servicemembers may also experience limitedaccesstoroutinehealthcareorappropriatemedicalsup-plieswhiledeployed.Duetolimitedspace,somewomenhaveraisedconcernsoverprivacy,andadequateaccesstofeminine hygiene products or gender-specific prescrip-tionssuchasbirthcontrolpillswhileintheatre.42Femaleservicemembersalsoexpressdissatisfactionoveralackofaccesstoapreferredprovider,forexampleafemaledoctorthatspecializesinwomen’shealthissues.43

Theattitudeofsomecommanderstowardwomen’suniqueneeds can also have a negative impact on the health offemale servicemembers. According to theDOD, “somelinecommanders, includingofficersandseniorenlist-ed personnel,may not understand the importance ofwomen’s health care.”44Commandersmaynot readilyallowthemtimeawayfromtheirdutystationtoobtaingender-specifichealthcare,andfemaleservicemembersmay avoid seeking care rather than disclose a privatehealthconditiontoacommandingofficer,particularlyif that officer ismale.Others stay silent about physi-cal ailments in an effort to prove their toughness to

theirmalecomrades.Bothfemaleservicemembersandcommanderscouldbenefit frommore trainingontheimportanceofwomen’sbasichealthcareanditseffecton readiness. In addition, themilitarymust renew itscommitmenttoprovidingfull-servicehealthcaretofe-maleservicemembers.

Sexual Assault and HarassmentInthemilitary,womenhavebeencopingwithsignificantand underreported sexual assault and harassment fordecades. In FY2008, therewere 2,908 reports of sexualassault involving servicemembers.45 Overall, reports ofsexualassaultswereup9percentfromtheyearbefore.46Eveninthewarzone,troopscannotescapethethreatofsexual assault; in Iraq andAfghanistan, 163 sexual as-saultswerereportedin2008.47Whilethesenumbersarealarming,theymaybeonlythetipoftheiceberg.Expertsestimatethathalfofallsexualassaultsgounreported.48Inaddition,almostone-thirdoffemaleservicemembers,and six percent of male servicemembers, have experi-enced sexual harassment while serving, which can bedevastatingtotroops’healthandmorale.49

Sexualassaultandharassmentthreatennotonlytheindi-vidualvictim;theyunderminemilitarycohesion,morale,and overall effectiveness. Themajority of assailants areolderandofhigherrankthantheirvictims,50andabusenot only their authority but the trust of those they areresponsibleforprotecting.Whenreportinganincidentofsexualassaultorharassment,somewomenfearunauthor-izedrepercussionsfromtheirchainofcommandorfromwithintheirunit.Othervictimsareconcernedthatinaneffort to protect their safety, a commanderwill remove

“it was always difficult to get to medical facilities, especially for more sensitive issues that you didn’t want a male medic to treat.” — sarah, iraq and afghanistan veteran

7 | issue report

themfromtheirunit,ratherthanremovingtheperpetra-tor. Evenworse, if they are too scared to come forwardor ifnoadministrativeaction is taken,victimscouldbeforcedtoservealongsidetheirattacker.

In an effort to increase thenumberof victimswho re-portassaults, theDODrecently introduced theoptionofrestrictedreportingforservicememberswhowishtoseekmedicaltreatmentfromthemilitarybutnotpursueactionagainsttheattacker.However,evenforrestrictedreporting,thevictimmustreporttheirrank,gender,age,race,branchofservice,andinformationabouttheassault,includingdate, time, and location.51 Inmanycases, thismakesactualanonymityimpossible.Moreover,althoughvictimscanopttopreserveevidenceincasetheydecidetochangetheirreportfromrestrictedtounrestricted,52evi-dencekitswillonlybestoredbythemilitaryforoneyear.Unfortunately,itmaytakelongerthanthatforvictimstodecidetochangetheirreportingoption.

Despite congressionalhearings,mediaattention, and theincreasing number of women coming forward publiclyabout their trauma, themilitary has been slow to estab-lish programs to prevent and respond to sexual assault.AccordingtotheGAO,themilitary’smandatorysexualas-saultpreventionand response trainingprogramsarenot

“consistently effec-tive”; shortages ofmental health careproviders are limit-ing victims’ access tomental health servic-es;thereisnodirectivefrom the DOD on

howtooperatetheprogramsinadeployedenvironment;andnooversightframeworktoevaluatewhetherthepro-gramsareworking.53

Theprosecutionratesofsexualassaultarealsoalarminglylow.In2007,only8percentofsexualassailantswerere-ferredtocourtsmartial,ormilitarycourt,comparedwith40 percent of similar offenders prosecuted in the civil-iancourtsystem.54 In2004,CongressdirectedtheDODtoformaspecialtaskforceonsexualassault,butittookmorethan4yearsforthecommitteetobeginitsreview,andnofindingshadbeenreleasedasofJuly2009.55

Manyfemaletroopswaituntilaftertheyleaveactive-dutytoreceivecareandcounselingforinjuriesstemmingfromsexualassaultorharassment.Since1999,theVAhasbeenscreeningallveteransseekingcareattheVAforMilitarySexualTrauma(MST),atermtheVAusestoencompasssexualharassmentandassault.56AsofMay2007,almost15percentoffemaleIraqandAfghanistanveteranswhohavegonetotheVAforcarehavescreenedpositiveforMST.57

Source: Department of Veterans Affairs.

Veterans of previous generations have reported evenhigher rates of MST: almost one-third of female vet-erans of all generations say they have been sexuallyassaultedorrapedwhileinthemilitary,andmorethan70percentsaytheyexperiencedsexualharassmentwhileserving.58

MSTcanleadtothedevelopmentofmajorhealthprob-lems, such as depression, eatingdisorders,miscarriages,andhypertension.59Foritspart,theVAprovidescaretoanyveteranthathasexperiencedMST.60However,theVA’sInspectorGeneraliscurrentlyreviewingthebillingprac-ticesofVAhealthfacilitiesandclinicsafteritwasrevealedthat patients at oneTexas clinicwere being improperlychargedforMST-relatedcare.61

half of all sexual assaults go unreported.

0.0%2.0%4.0%6.0%

10.0%12.0%14.0%16.0%

Iraq and Afghanistan Veterans Screening Positive for MST at the VA

Source: Department of Veterans Affairs.

Males Females

0.7%

14.5%

8 women warriors | october 2009

homecoming challenges

VA Health Care StretchedWhile experts agree that the VA health care system is“equivalentto,orbetterthan,careinanyprivateorpub-lichealth-caresystem,”intheUnitedStates,62theVAhasbeenchallengedinrecentyearstocareforfemaleveter-ans,whomakeup12percent of Iraq andAfghanistanveteransseekingVAhealthcare.63

Whiletheycurrentlyrepresent8percentoftheveteranpop-ulation,womenhavehistoricallymadeupanevensmaller

portionofveteranswhousetheVAforhealthcare.64Asaresult,VAfacilitieshavebeendesignedprimarilytoservemale patients. But with the changing demographics ofthe military, female Iraq and Afghanistan veterans areenrollinginVAhealthcareinhistoricnumbers.Already,44.2 percent of eligible women veterans from Iraq andAfghanistanhaveturnedtotheVAforhealthcare,utiliz-ingVAservicesatamuchhigherratethanotherveterans,includingtheirmalecounterpartsandoldergenerationsofwomenveterans.65Andtheyareremaininginthesys-tem;almost85percentof thesewomenhavevisitedtheVAmorethanonceforoutpatienttreatment.66

tammy DucKwortH—Profile in Service

As Battle Captain and Assistant Operations Officer, Tammy Duckworth helped

with planning, assigning and tracking combat missions of a 500-soldier avia-

tion taskforce in Iraq, and flew over 200 combat hours as a Blackhawk pilot.

In November 2004, she was flying a mission when a rocket-propelled grenade

struck the cockpit of her helicopter and exploded. She suffered grave injuries,

losing both legs.

Since coming home from Iraq, Tammy has remained active in the public

arena, speaking to veterans’ groups, running for a U.S. Congressional seat, and

continuing to serve her country as a Major in the Illinois National Guard. She

has also testified several times before Congress on issues of medical care and

seamless transition from the military to the VA for wounded warriors.

From 2006-2008, she served as Director of the Illinois Department of Veterans’

Affairs where she established her reputation as a tireless advocate for reform

and modernization of veterans’ care. During her time in Illinois, Tammy revolu-

tionized the state’s approach to issues such as mental health and access to care

for rural veterans.

In March 2009, her leadership on veterans’ issues reached national atten-

tion. Tammy Duckworth was selected to serve as the Assistant Secretary for

Public and Intergovernmental Affairs at the Department of Veterans Affairs in

Washington DC, where she directs VA’s public affairs, internal communica-

tions and intergovernmental relations.

8 women warriors | october 2009

9 | issue report

Womenveteransarethefastestgrowingsegmentofthevet-eranpopulation,andtheirenrollmentinVAhealthcareisexpectedtomorethandoubleinthenext15years.67Withthisgrowthcomesanevenhigherdemandonexistingservic-esforfemaleveterans.Moreover,becausethevastmajorityof femaleveteransreturning fromIraqandAfghanistanareofchild-bearingage,respondingtothesepatientswillrequirea“significantshiftinprovisionofhealthcare.”68

Distinct Health Care Needs of Women VeteransWomenveteransfaceuniquehealthcareissues.Despitethefactthattheyare,onaverage,youngerthanmalepatients,6974percentofwomenveteranswhousetheVAsufferfromatleastonechronicmedicalcondition.70TheyarealsomorelikelytohavepoorhealthstatuscomparedtomaleveteranswhousetheVA.71

Asaresultoftheirservice,womenveteransalsohavediffer-enthealthcareneedsthentheirnonveteranpeers.However,thehealthconsequencesforwomendeployedtoacombattheatrearestilllargelyunknown,asnolong-termstudiesonthistopichavebeencompleted.Toaddressthisknowledgegap,theVAcurrentlyhasseveralstudiesunderwayregard-ingwomenveterans,theirVAusage,andhealthconcerns.

Inaddition,theVAisintheearlystagesofalongitudinalstudyofIraqandAfghanistanveterans;thefirstresultsaretentativelydueby2012.TheVAhopestodevelopabetterunderstandingofnewveterans’issues,includingthehighratesofmentalhealthinjuries.

High Rate of Mental Health Injuries among Women VeteransAlthough they are technically excluded from groundcombat positions, many female troops have regularlyseen combat while serving in Iraq and Afghanistan. Asa result, female servicemembers and veterans, like theirmale peers, are suffering from mental health injuries,suchasPostTraumaticStressDisorderandmajordepres-sion.Accordingtoalandmark2008studybytheRANDCorporation,nearly 20percentof Iraq andAfghanistanveterans,orabout300,000people,reportsymptomscon-sistentwithadiagnosisofPostTraumaticStressDisorderordepression.72

Although in the general population, women developPTSDasa resultof traumaticexperiencesatmore thantwicetherateofmen,73itisnotyetknownwhetherfemaleIraq and Afghanistan veterans are experiencing higherratesofcombatstressthantheirmalepeers.Somestudiessuggestthat,historically,femaleservicemembersaremorepronetomental injuries thantheirmalecounterparts.74However,theArmy’sMentalHealthAdvisoryTeam,whichhasbeenmonitoringthemoraleandmentalhealthofsol-diersinIraqsince2003,foundthat:“Femalesoldiersarenomorevulnerablethanmalesoldiersinhowcombatcanaffecttheirmentalhealthandwell-being.”75

The recent studybyRANDoffered thefirst lookat thedifferences between genders in Iraq and Afghanistanveterans,findingthatwomenwereatahigherriskforre-portingsymptomsconsistentwithadiagnosisforPTSDandmajordepression.76However,RANDresearcherswerenotabletodetermineifothertypesoftraumasorstressorsaside from exposure to combat, such asmilitary sexualtrauma, could have contributed to the increased risk.According to theVA,MST leads to a59percenthigherriskformentalhealthinjuries.77Furtherstudyisneededtoexploretheseinitialfindings.

Within the VA, female patients aremore likely to havementalhealth issues thanmalepatients,78but thatmaybebecausefemaleveteransaremore likelytoseektreat-ment for their psychological injuries than their malecounterparts.

Oneof thebiggest challenges facing theVA in the com-ingyearsishowtoaddressthedistincthealthcareneedsof

| issue report 9

“the va hospitals are used to dealing with male vietnam, korea and wwii vets — the quality of care for a female at a va hospital is very low.” — larae, iraq veteran

10 women warriors | october 2009

womenveterans.Unfortunately,theVAiscurrentlyunder-preparedtomeetthisdemand,andmanyfemaleveteransareexperiencingsignificantbarrierstocare.

Significant Barriers to Care The VA acknowledges that women veterans have beenchronicallyunderserved.79Despitethefacttheyaremorelikely to have lower incomes and poor health, and arelesslikelytohaveprivatehealthinsurance,womenveter-ansfulfilltheirhealthcareneedsoutsideoftheVAmoreoftenthanmendo.80ThekeybarrierthatwomenfaceattheVAisthefragmentationofwomen’sservices.Otherbarriersincludelackofknowledgeabouteligibilityandbenefits,theperceptionthattheVAis“unwelcoming”towomenordoesnotprovideadequatesafetyandprivacystandards, and access to childcare. These impedimentswilllikelyworsen,asthenumberofwomenveteransuti-lizingVAhealthcarecontinuestogrow.

The VA has taken some critical steps in recent years.As of June 2009, every VAhospital nowhas a full-timeWomenVeteransProgramManagertocoordinateservicesforwomenveterans. Inaddition,Dr.MichaelKussman,formerVAUnderSecretaryforHealth,institutedawork-groupinMarch2008toestablishwomen’shealthateveryfacilityaccordingtothefollowingguidelines:“ThateverywomenveteranhasaccesstoaVAprimarycareproviderwhocanmeetallherprimarycareneeds,includinggender-specificcare,inthecontextofanongoingpatient-clinicianrelationship.”81However,despiteitscommitment,theVAhasstillnotestablishedadeadlineforitsfacilitiestomeettherequirementofcomprehensiveprimarycareforwom-en veterans, and some VA officials are even unclear onthestepsneededtoimplementthisnewplan.82Evenwiththesemeasures,muchmoreremainstobedonetoensurethat women veterans receive equitable, high-quality VAhealthcare.

Fragmentation of Women Veterans’ Health CareIn2003,theVAmadeitmandatoryforallVAhospitalsandclinicstoprovideaminimumlevelofwomen’shealthservices,butonly“wherefeasible.”83Inaddition,accordingtoDr.PatriciaHayesoftheVA’sWomenVeteransHealthStrategicHealthCareGroup,“thehealthcareservicesde-liveredtowomenveteranshavegrownupinapatchworkfashion, with the delivery model based in part on theacademic leaningsof thewomen’shealth championon

site.”84Asaresult,theavailabilityandqualityofVAcareforfemaleveteransvarieswidelyacrossthesystem.

Onsite offering of gender-specific care has actuallydeclined since 2003.85 Female veteransmay be forced totravelmore than2hours to receive routinegynecologi-cal care, suchasapapsmearorabreastexam.86Wheregender-specific care is available, it is often in multiplesettingsandperformedbymultipleproviders,leadingtofragmentedcare.87Formostwomen,thistranslatesintohaving a primary care physician handle general healthcarewhileasecondclinicianmayhandlegender-specificneeds, and in some cases, a thirdprovidermay addressmentalhealth issues.Unfortunatelyat theVA, compre-hensivewomen’sprimarycareclinicsare“theexceptionrather than the rule.”88Only14percentofVA facilitiesoffer specialized, comprehensivewomen’shealth clinicsthatserveasone-stopshopsforprimarycare,gender-spe-cificcare,mentalhealthservices,andsurgicalservices.89

Ingeneral,women’sclinicstypicallyoperatehalf-time,andmorethan40percentofferonlygender-specificexams.90

TypesofWomen’sHealthClinicsatVAFacilities

Females

14.5%

Women’shealthclinicsofferingonlygender-specificcare

43%

Nospecializedwomen’shealthclinicon-site

16%

Women’shealthclinicsprovidingfullspectrumofcareincluding

mentalhealthandsurgical

14%

Women’shealthclinicsofferingonlygender-specificandprimarycare

19%

Source: FY2010 Independent Budget.

11 | issue report

In addition, women veterans often lack access to skilledprovidersinwomen’s health,atermwhichencompassesgen-der-specificreproductivehealthcare,careforhealthproblemsthataremorecommoninwomen(likeosteoporosisandde-pression),andcare forhealthproblems thataffectwomendifferently(likeheartdisease).91AccordingtotheGAO,theVA’sabilitytoprovideconsistentandtimelycaretofemaleveterans is being compromised by shortages of qualifiedwomen’s health and mental health providers.92 Researchshowsthatwomenveteransaresignificantlymoresatisfiedwith VA health care when they have access to a women’shealthprovider,especiallyiftheproviderisfemaleandwhenthecarecanbeprovidedbyagender-specificclinic.93

Overall,womenwhohadreceivedtreatmentinwomen’shealthclinicswere“more likelytorelysolelyontheVAfortheirhealthcare,weremorelikelytohaveseenotherVA-providers,andwerelesslikelytoreportusingnon-VAphysicians.”94 They also aremore likely to report excel-lent satisfaction than those seen in traditional primarycareclinics.95Additionalresearchshouldbeundertakentodeterminetheoptimummodelofhealthcaredeliveryforfemaleveterans.

Anotherchallengethatwomenveteransfaceisensuringthe continuity of their care acrossmultiple health caresystems.51percentofwomenVAusersaresplittingtheircarebetweentheVAandanoutsidehealthcaresystem.96Formanyofthesewomen,especiallythoseinruralareas,therehasbeen little evaluationof theoverallqualityoftheircare.EvenlessisknownaboutthecarethatwomenveteransreceivewhentheyoptnottousetheVAsystem.

Other Barriers to CareWhile access to care is the primary obstacle for femaleveterans, theycanalsoexperienceotherbarriers.TheVAhastraditionallybeenapassivesystem,andveteransmustovercometremendousbureaucratichurdlestogettheben-efits and services that theVAprovides. Female veterans,inparticular,oftendonotknowwhattheyareeligiblefor.

SomewomenalsoperceivetheVAasunwelcomingtothem,asitrelatestoprivacyandsafetyissuesandqualityofgender-specificservices.InoneVAstudyoffemaleveteranswhodonotusetheVA,researchersfoundthatnon-usersdescribedtheVAas“datedHollywoodimagesofoldsoldiersinwardbeds, antiquated facilities, and less qualified doctors.”97

Otherfemaleshaveexpressedconcernaboutreceivingcareintheoverlymale-dominatedVAenvironment.

Inaddition,despiteitsassurances,theVAisstillnotmeet-ingprivacystandardsforwomenveteransatitsfacilities.In July 2009, the GAO found instances where women’sexamroomtablesfaceddoorsinsteadofwalls,andwherewomenpatientshadtowalkthroughwaitingroomstouserestrooms,asopposedtohavingthemlocatednexttoexamrooms as required byVApolicy.98 Somehospitals underreviewalsodidnotguaranteeaccesstoprivateandsecurebathingareasorvisualandauditoryprivacyatcheck-in.

Underemployment and HomelessnessAfter they leave themilitary,womenveteranshavedra-matically different employment experiences than men.Onaverage,femaleveteransearnstatisticallymorethantheirnon-veteranpeers,unliketheirmalecounterparts.99

AccordingtotheU.S.CensusBureau,thismaybebecause“militaryeducationandworkexperiencemaytranslateintohigherpayingcivilianjobsthanwomenwith a high school de-greewouldnormallyexpect.”100In addition, since women can-not hold ground combat jobs,their military skills may bemore readily transferable tothe civilian world than thoseofmale veterans.101 Inorder toenjoy this earnings advantage,however,womenveteransworklongerhoursandmoreweeksayearthanwomenwhohavenotservedinthemilitary.102Additionally,femaleveteransonaverageearnalmost$10,000lessayearthanmaleveterans,103andtheyoftenstruggletofindjobsthatpaywhattheirmili-tarycareerdid.104

Theselowerincomesmaybeafactorinwhywomenvet-eransaremore likely toexperienceaseverehousingcostburden thanmaleveterans,105placingthematsignificantriskforhomelessness.

As of September 2009, the VA estimated that there are13,100homelessfemaleveterans.106Womenveteransareuptofourtimesmorelikelytobehomelessthannonveteran

female veterans on average earn almost $10,000 less a year than male veterans.

12 women warriors | october 2009

women.107Unfortunately,asmorewomenjointheArmedForces, they are also swelling the ranks of the homeless.According to Pete Dougherty, director of homeless pro-gramsattheVA,“whiletheoverallnumbers[ofhomelessvets]havebeengoingdown,thenumberofwomenveteranswhoarehomelessisgoingup.”108

ThousandsofIraqandAfghanistanveteransarejoiningover100,000veteransofothergenerationslivingonthestreetsandinshelters.PreliminarydatafromtheVAsug-gests that Iraq andAfghanistan veteransmakeup1.8%of thehomeless veteranpopulation.109AsofSeptember2009, more than 3,700 Iraq and Afghanistan veteranshave already been seen in the Department of VeteransAffairs’homelessoutreachprogram.110OfhomelessIraqandAfghanistanveterans,morethan10percentarewom-en.111NotallhomelessIraqandAfghanistanveteransuseVAserviceshowever,sotherealnumberofhomelessIraqandAfghanistanveteransmaybeconsiderablyhigher.Inaddition, because thehomelesspopulation is transient,andbecausemanypeoplemay experiencehomelessnessoff-and-onovermonthsorevenyears,correctlymeasur-ingthehomelesspopulationisdifficult.112

Femalehomelessveteranstendtohavemoreseveremen-tal health problems than homelessmale veterans,113 inpart because they are more likely to experience sexualtraumawhile serving in themilitary.114 TheVA reportsthatabout40percentofthehomelessfemaleveteransofrecentwars say theywere sexuallyassaultedbya fellowservicememberwhileinthemilitary.115

Butprogramsforhomelessfemaleveterans,andespeciallyfor those with children, have been “slow tomaterialize,”

according to the VA Advisory Committee on HomelessVeterans.116 Even the VAacknowledgesthatexistingpro-grams for women veterans are“probablynotyet sufficient.”117Withonlyaboutadozenfemale-only facilities nationwide,118women veterans often have totravellongdistancesoroutsidetheir state in order tohave ac-cesstotheseoptions.WithintheVA’s homeless shelter system,only60percentof shelters canacceptwomen, and less than5percenthaveprogramsthattar-get female veterans specifically or offer separate housingfrommen.119

Addingtothechallengeistheincreasingnumberoffemaleveteranswithfamiliesinneedofhomelessservices;23per-centoffemaleveteransintheVA’shomelessnessprogramshavechildrenunder18yearsold.120SincetheVAcannotprovide direct care to children or spouses of veterans,121providing suitable housing for homeless veterans withfamiliesfallsundertheresponsibilityofmultipleagencies,andcoordinatingthiscarecanbeextremelychallenging.122Homeless veterans have continually cited child care astheirnumberoneunmetneed.123

supporting she ‘who has borne the battle’

ThroughoutAmerica’shistory,womenhaveservedhonor-ablyandsacrificedtremendously.AndtheycontinuethiseffortinIraqandAfghanistantoday.Yet,thenationisnotdoingenoughtosupportthemhereathome.

Collectively,boldstepsmustbetakentoimprovehealthcareforfemaletroopsandveterans—takingtheiruniquehealthcareneedsintoaccount—andexpandexistingsupportser-vicesandtransitionalresources.Femaleveteransshouldnolongerhavetochoosebetweenahomelessshelterandthestreets atnight.Themilitarymust alsowork aggressivelytoeliminatesexualassaultandharassmentfromwithinitsranks,andwidencareeropportunitiesforwomen.Thiswillmakeourmilitarystrongerandourcountrymoresecure.

“i came back to a crushed small business, therefore no job and no income, nowhere to live. i didn’t expect to have this much struggle getting back on track.” — jennifer, iraq veteran

Women veterans are up to four times more likely to be homeless than nonveteran women.

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Withmore female troops enlisting and returning homefromcombateveryday,thereisnotamoreurgenttimetoheedthewordsofLincolnandcareforshe‘whohasbornethe battle’. The bravewomenwho answer our country’scalldeservenothingless.

For IAVA’s recommendations on women veterans’ issues , see our Legislative Agenda available at www.iava.org/dc.

recommended reading and online resources

To learnmore about troops’ and veterans’ psychologicalinjuries,please see the2009 IAVA IssueReport, “InvisibleWounds:PsychologicalandNeurologicalInjuriesConfronta New Generation of Veterans.” For more informationaboutthehousingandemploymentissuesthatnewveter-ansarefacing,seethe2009IAVAIssueReports,“ComingHome:TheHousingCrisisandHomelessnessThreatenNewVeterans” and “Careers After Combat: Employment andEducationalChallengesforIraqandAfghanistanVeterans.”All IAVA reports are available for download atwww.iava.org/reports.

Youcanalsolearnmoreaboutfemaletroopsandveter-ans’issuesfromthefollowingsources:

• DefenseDepartmentAdvisoryCommitteeonWomenintheServices,2008Report,SecondDraft,November14,2008.

• GAO-02-602, “Defense Health Care: Health CareBenefitforWomenComparabletoOtherPlans,”May2002:http://www.gao.gov/new.items/d02602.pdf.

• Department of Defense, “FY08 Report on SexualAssault in the Military,” March 2009: http://www.sapr.mil/contents/references/2007%20Annual%20Report.pdf.

• Patricia M. Hayes, Ph.D., Women Veterans HealthStrategic Health Care Group, “The Evolution ofWomen’sHealthCareServicesinVA,”VAOfficeofResearch&Development,November 2008:http://www.hsrd.research.va.gov/publications/forum/nov08/Nov08-1.cfm.

• SusanM. Frayne,M.D.,M.P.H., Center for HealthCareEvaluation,VAPaloAltoHealthCareSystem,“Needs of Women Veterans Must be CarefullyConsidered in Building Tomorrow’s VHA,” VAOfficeofResearch&Development,November2008:http://www.hsrd.research.va.gov/publications/forum/nov08/Nov08-1.cfm.

• Lioness. Dirs. Meg McLagan and Daria Sommers.Room11Productions,2008.Learnmoreat:http://www.lionessthefilm.com/.

• When I Came Home.Dir.DanLohaus.LohausFilmsLLC,2006.Learnmoreat:http://whenicamehome.com/.

endnotes1 DepartmentofDefense,ContingencyTrackingSystemDeploymentFileforOperationsEnduringFreedom and Iraqi Freedom, as of January 31,2009.2 Statistical Information Analysis Division,“DODPersonnelandMilitaryCasualtyStatistics,”Asof June6,2009:http://siadapp.dmdc.osd.mil/personnel/CASUALTY/castop.htm.3 David F. Burrelli, “Women in the ArmedForces,” Congressional Research Service IssueBrief,updatedDecember12,1996:http://www.fas.org/man/crs/92-008.htm.4 Ibid.5 Ibid.6 RANDCorporation,ResearchBrief, “MilitaryReadiness: Women Are Not a Problem,” p. 2:http://www.rand.org/pubs/research_briefs/RB7515/index1.html.7 Ibid.

8 Margaret C. Harrell et al., “Assessing theAssignment Policy for Army Women,” RANDCorporation, August 7, 2007: http://www.rand.org/pubs/monographs/MG590-1/.9 “Women In Land Combat,” The Centerfor Military Readiness, November 18, 2004:http://www.cmrlink.org/WomenInCombat.asp?docID=233.10 David F. Burrelli, “Women in the ArmedForces,” Congressional Research Service IssueBrief,updatedDecember12,1996:http://www.fas.org/man/crs/92-008.htm.11 Institute for Women’s Policy Research, “TheGender Wage Gap: 2008,” Fact Sheet, UpdatedApril2009:http://www.iwpr.org/pdf/C350.pdf.12 Defense Department Advisory Committeeon Women in the Services (DACOWITS), 2008Report,SecondDraft,November14,2008,p.4-5.

13 According to the fall 2007 Sample Survey ofMilitary Personnel (SSMP) 66 percent of males,comparedto49percentoffemales,reportedthatthey“plantostayuntilretirement.”DACOWITS,p.5.14 Ibid.,at4-5.15 AccordingtotheDefenseDepartmentAdvisoryCommitteeonWomen in theServices, “ahigherpercentage of men were promoted among bothenlisted personnel and officers in FY04-FY06.”Ibid.,at7.16 RAND,p.2.17 DACOWITS,p.718 Ibid.,at10.19 Ibid.,at11.20 Ibid.

14 women warriors | october 2009

21 GAO-02-935,“MilitaryPersonnel:ActiveDutyBenefits Reflect Changing Demographics, butOpportunitiesExisttoImprove,”September2002,p.7:http://www.gao.gov/new.items/d02935.pdf.22 AnnScottTyson,“ShortMaternityLeaves,LongDeployments,”TheWashingtonPost,February18,2008: http://www.washingtonpost.com/wp-dyn/content/article/2008/02/17/AR2008021702324.html.23 Ibid.24 DACOWITS,p.14.25 DACOWITS,p.13.26 “Study finds that mothers’ military deploy-ment affects the health of women and teens,”April 2, 2009: http://www.eurekalert.org/pub_releases/2009-04/gmu-sft040209.php.27 Department of Defense, “Marital and ChildStatusofActiveDutyWomen,”DefenseManpowerDataCenter,December2006andDepartmentofDefense,“ProfileoftheMilitary:2005DemographicReport.” Defense Manpower Data Center, CTSDeployments“DeployedDemographicsofSingleServicemembers,”March2009.28 AnnScottTyson,“ShortMaternityLeaves,LongDeployments,”TheWashingtonPost,February18,2008: http://www.washingtonpost.com/wp-dyn/content/article/2008/02/17/AR2008021702324.html.29 “TheNavy exemption is 12months, and theMarine Corps’s is six months, and deploymentsaveragesevenmonthsforboth.TheAirForcehasafour-monthexemption,butitsdeploymentsaver-ageonlyfourtosixmonth.”Ibid.30 Ibid.31 WilliamH.McMichael,“Senator:Armymomsneed more maternity leave,” February 22, 2008:http://www.militarytimes.com/news/2008/02/military_maternityleave_080221w/.32 Gregg Zoroya, “Soldiers’ divorce rate dropsafter2004 increase,”USA Today, January1,2006:http://www.usatoday.com/news/nation/2006-01-09-soldier-divorce-rate_x.htm.33 BenjaminKarneyandJohnS.Crown,“FamiliesUnderStress:AnAssessmentofData,Theory,andResearchonMarriageandDivorceintheMilitary,”RAND, 2007: http://www.Rand.org/pubs/mono-graphs/MG599/.34 Pauline Jelinek, “Divorce rate increases InMarineCorps,Army,”AssociatedPress,December2, 2008: http://news.yahoo.com/s/ap/20081203/ap_on_go_ca_st_pe/military_divorces.35 Ibid.36 BenjaminKarneyandJohnS.Crown,“FamiliesUnder Stress: An Assessment of Data, Theory,and Research on Marriage and Divorce in theMilitary,” RAND, 2007: http://www.Rand.org/pubs/monographs/MG599/. Pauline Jelinek,“Divorce rate increases InMarine Corps, Army,”AssociatedPress,December2, 2008:http://news.yahoo.com/s/ap/20081203/ap_on_go_ca_st_pe/military_divorces.37 VHAOfficeofPublicHealthandEnvironmentalHazards,“AnalysisofVAHealthCareUtilizationAmong US Global War on Terrorism (GWOT)VeteransOperationEnduringFreedomOperationIraqiFreedom,”October2009.38 GAO-02-602, “Defense Health Care: HealthCare Benefit for Women Comparable to OtherPlans,”May 2002, p. 7: http://www.gao.gov/new.items/d02602.pdf.39 Kristin Andrews et al., “2008 Health CareSurvey of DOD Beneficiaries Annual Report,”

August2008,p.13:http://www.tricare.mil/survey/hcsurvey/downloads/hcsdb_2008_final.pdf.40 Ibid.,at15.41 Ibid.42 GAO-02-602,p.7.43 Ibid.,at13.44 Ibid.,at7.45 Department of Defense, “FY08 Report onSexualAssaultintheMilitary,”March2009:http://www.sapr.mil/contents/references/2007%20Annual%20Report.pdf.46 Ibid.47 KimberlyHefling,“Femalesoldiersraisealarmsonsexualassaults,”AssociatedPress,July21,2008:http://www.msnbc.msn.com/id/25784465/.48 Between 22 to 41.6% of the sexual assaultsthat occur in the U.S. are reported to police.U.S. Department of Justice (2008). CriminalVictimization, 2007. Washington,DC: Rand,Michael andU.S. Department of Justice. (2002).RapeandSexualAssault:ReportingtoPoliceandMedical Attention, 1992-2000.Washington, DC:Rennison,CallieMarie.49 The Department of Defense defines sexualharassment as “a form of sex discriminationthat involves unwelcome sexualadvances.”DepartmentofDefense,“2006GenderRelations Survey of Active Duty Members,”DefenseManpower Data Center, p. viii: http://www.sapr.mil/contents/references/WGRA_OverviewReport.pdf.50 HelenBenedict, Testimony before theHouseCommitteeonOversightandGovernmentReformSubcommitteeonNationalSecurityandForeignAffairs,June25,2009:http://nationalsecurity.over-sight.house.gov/documents/20090625172502.pdf.51 Colonel John Pollock, U.S. Marine Corps,CommandingOfficerChemical Biology IncidentResponse Force, “Policy Statement on SexualAssault”: http://www.marines.mil/units/mar-forcom/iimef/cbirf/Pages/Front%20Page/SAPR.aspx#restricted-reporting.52 For more on the reporting options for vic-tims of sexual assault, please see: http://www.sapr.mil/HomePage.aspx?Topic=Sexual%20Assault&PageName=reporting.htm.53 GAO-08-1013T, “Military Personnel:PreliminaryObservationsonDOD’sandtheCoastGuard’sSexualAssaultPreventionandResponseProgram,”July31,2008:http://www.gao.gov/new.items/d081013t.pdf.54 CNN, “Sexual assault in military ‘jaw-drop-ping,’ lawmakersays,”July31,2008:http://www.cnn.com/2008/US/07/31/military.sexabuse/index.html?eref=rss_topstories.55 GAO-08-1013T, “Military Personnel:PreliminaryObservationsonDOD’sandtheCoastGuard’sSexualAssaultPreventionandResponseProgram,”July31,2008:http://www.gao.gov/new.items/d081013t.pdf.56 MilitarySexualTraumaistheDepartmentofVeteransAffairs’termforsexualassaultorsexualharassment occurring during military service.According to U.S. Public Law 102-585 and 108-422,MilitarySexualTraumaisdefinedas“physi-calassaultofa sexualnature,batteryofa sexualnature,orsexualharassment”[“repeated,unsolic-itedverbalorphysicalcontactofasexualnaturewhich is threatening incharacter”] thatoccurredwhileaveteranwasservingonactivedutyoractivedutyfortraining.SusanMcCutcheon,RN,Ed.D.and Rachel Kimerling, Ph.D., “Military Sexual

Trauma,”PresentationattheNationalSummitonWomenVeterans,Washington,DC,June20,2008,p.4.57 KimberlyHefling,“Militaryassaultvictimsfacetoughrecovery,”Associated Press,July23,200858 HelenBenedict,“ForWomenWarriors,DeepWounds, Little Care,” New York Times, May 26,2008: http://www.nytimes.com/2008/05/26/opinion/26benedict.html.59 Asaresult,victimsmayalsobeeligiblefordis-abilitycompensationfromtheVA.HelenBenedict,“ForWomenWarriors,DeepWounds,LittleCare,”New York Times, May 26, 2008: http://www.nytimes.com/2008/05/26/opinion/26benedict.html.60 Susan McCutcheon, RN, Ed.D. and RachelKimerling, Ph.D., “Military Sexual Trauma,”PresentationattheNationalSummitonWomenVeterans,Washington,DC,June20,2008,p.4.61 JamesDao, “V.A. Plans Review of Billing forCare inSexualAssaults,”New York Times,May7,2008.62 FY2008 Independent Budget, p. 35: www.inde-pendentbudget.org.63 Paula P. Schnurr, Ph.D., VANational Centerfor PTSD, VA Medical Center, White RiverJunction,Vermont,“PosttraumaticStressDisorderin Women Veterans,” VA Office of Research &Development,November2008,p, 5:http://www.hsrd.research.va.gov/publications/forum/nov08/Nov08-1.cfm.64 DepartmentofVeteransAffairs,“VABenefits&HealthCareUtilization,”October27,2008:http://www1.va.gov/vetdata/docs/4X6_fall08_share-point.pdf.65 Earliergenerationsofwomenveteransenrolledin VA health care at a 15 percent average rate.Through 3rd Quarter 2008. Email Conversationwith Laura Herrera, MD, MPH, Director,Comprehensive Women’s Health, WVHSHG,DepartmentofVeteransAffairs, on July 6, 2009.See also: Joy J. Ilem,DeputyNationalLegislativeDirector,DisabledAmericanVeterans,TestimonybeforetheSenateCommitteeonVeteransAffairs,“Women Veterans, Bridging the Gaps in Care,”July14,2009:http://veterans.senate.gov/hearings.cfm?action=release.display&release_id=aa74a8ba-c163-4d80-a349-1ed85d46f211.66 DepartmentofVeteransAffairs,EnvironmentalEpidemiologyService,“VAHealthcareUtilizationAmong97,658FemaleOIF/OEFveteransThrough2ndQuarterFY2008,”June27,2008.67 Women are projected to account for one ineverysevenenrolleeswithinthenextfifteenyears,compared to the one in every sixteen enrolleestoday.” Joy J. Ilem, Deputy National LegislativeDirector,DisabledAmericanVeterans,TestimonybeforetheSenateCommitteeonVeteransAffairs,“Women Veterans, Bridging the Gaps in Care,”July14,2009:http://veterans.senate.gov/hearings.cfm?action=release.display&release_id=aa74a8ba-c163-4d80-a349-1ed85d46f211.68 More than 85 percent of female Iraq andAfghanistanveteranswhoturntotheVAforcareareundertheageof40.DepartmentofVeteransAffairs,EnvironmentalEpidemiologyService,“VAHealthcareUtilizationAmong97,658FemaleOIF/OEFveteransThrough2ndQuarterFY2008,”June27,2008.Currently,theVAcoverspre-natalcare,delivery, and postnatal care for women veteransthrougharrangementswithcommunityproviders,butitisnotauthorizedtocarefornewborninfants.DepartmentofVeteransAffairs,WomenVeteransHealthCare,“FrequentlyAskedQuestions,”April22,2009:http://www.publichealth.va.gov/women-shealth/faqs.asp.

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69 “InFY2006,themeanageofwomenveteranswas 49.5 years; this compares with a mean agefor male users of 61 years.” Hayes, http://www.hsrd.research.va.gov/publications/forum/nov08/Nov08-1.cfm.70 Susan M. Frayne, M.D., M.P.H., Center forHealth Care Evaluation, VA Palo Alto HealthCare System, “Needs of Women Veterans MustbeCarefullyConsidered inBuildingTomorrow’sVHA,” VA Office of Research & Development,November2008:http://www.hsrd.research.va.gov/publications/forum/nov08/Nov08-1.cfm.71 FY2010 Independent Budget, p. 111:www.inde-pendentbudget.org72 Terri Tanielian and Lisa H. Jaycox, Eds.,“Invisible Wounds of War: Psychological andCognitive Injuries, Their Consequences, andServices toAssistRecovery,”RAND, 2008: http:/www.rand.org/pubs/monographs/MG720/.73 “According to the National ComorbiditySurveyReplication,9.7percent[ofwomen]versus3.6percent[ofmen]havelifetimePTSD.”Schnurr,p.5.74 “TwoyearsafterdeploymenttotheGulfWar,where combat exposurewas relatively low,Armydatashowedthat16percentofasampleoffemalesoldiersstudiedmetdiagnosticcriteriaforPTSD,asopposedto8percentoftheirmalecounterparts.Thedatareflectalargerfindingsupportedbyotherresearch, thatwomenaremore likely tobegivendiagnosesofPTSD,insomecasesattwicetherateofmen.”SaraCorbett,“TheWomen’sWar,”The New York Times Magazine,March18,2007.Departmentof Defense Task Force on Mental Health, “AnAchievable Vision: Report of the Department ofDefenseTaskForceonmentalHealth,”June2007,p.59.Conversely,Brewinetal.foundthatfemalegenderwasnotasignificantriskfactorforPTSDinmilitarysamples.ChrisR.Brewinetal.,“Meta-AnalysisofRiskFactors forPosttraumaticStressDisorder in Trauma-Exposed Adults,” Journal of Consulting and Clinical Psychology, 68(5) 2000, p.752.Matthew J. Friedman,MD,PhD, andPaulaP.Schnurr,PhD,“PTSDTreatment:ResearchandDissemination,”NationalCenterforPTSD,p.9.75 Lisa Chedekel, “Sexes’ War Stress Same;WomeninCombatCopeasWellAsMen,MilitaryFinds,”Hartford Courant,May17,2007.76 “Inadjustedanalysis,therelativeriskofPTSDwas 1.03 amongwomen (vs.men), but in analy-ses that adjusted for demographic and exposurevariables, the relative risk was 1.69—significantlyhigheramongwomenthanmen.”Schnurr,p.5.77 “VA screenings yield data on military sexualtrauma,”’VA Research Currents,Nov-Dec2008.78 Womenarealsomorelikelytohaveasubstan-tial mental health comorbidity, or the presenceof anothermedical condition alongwith amen-tal health illness. Frayne, p. 4. See also: FY2010Independent Budget, p. 111:www.independentbud-get.org.79 “Themarketpenetrationforwomenfrom2003to 2007 increased only from 11 percent to 14.6percent, while the market penetration for maleveteransduringthesameperiodwasconsistentlyat 22 percent.” Hayes, http://www.hsrd.research.va.gov/publications/forum/nov08/Nov08-1.cfm.Inits2008“HospitalReportCard,”theVAfoundthathealth care forwomenveterans lagsbehindcare formales. Department of Veterans Affairs,“HealthCare‘ReportCard’GiveVAHighMarks,”June 13, 2008: http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1515.80 “In numerous veteran studies, socio-demo-graphic and health-related predictors of VA useincluded:beinglowincome,lackingprivatemedi-calinsurance,havingpoorhealthstatus,havinga

service-connected disability, and being an ethnicminoritygroupmember.”DonnaL.Washington,M.D.,M.P.H.,VAGreaterLosAngelesHealthcareSystem,LosAngeles,California,“AmbulatoryCareAmongWomenVeterans:AccessandUtilization,”VAOfficeofResearch&Development,November2008,p.6:http://www.hsrd.research.va.gov/publi-cations/forum/nov08/Nov08-1.cfm.81 Ibid.82 GAO-09-884T, “VA Health Care: PreliminaryFindingsonVA’sProvisionofHealthCareServicestoWomenVeterans,” July 14, 2009: http://www.gao.gov/new.items/d09884t.pdf.83 FY2010 Independent Budget, p. 112:www.inde-pendentbudget.org.84 Hayes, http://www.hsrd.research.va.gov/publi-cations/forum/nov08/Nov08-1.cfm.85 Ibid.86 Department of Veterans Affairs, “WomenVeterans Health Fact Sheet,” August 2008:http://www.visn12.va.gov/docs/VA_Factsht_HIRES_81208_LKO.pdf.87 Washington,p.6.88 ElizabethM. Yano, Ph.D.,M.S.P.H., HSR&DCenter for the Study of Healthcare ProviderBehavior, VA Greater Los Angeles HealthcareSystem, Los Angeles, California, “AchievingEquitableHigh-QualityCareforWomenVeterans,”VAOfficeofResearch&Development,November2008,p.3:http://www.hsrd.research.va.gov/publi-cations/forum/nov08/Nov08-1.cfm.89 FY2010 Independent Budget, p. 112:www.inde-pendentbudget.org.90 90.Yano,p.3.91 “Women’s Health,” U.S. National Library ofMedicine and the National Institutes of Health,February26,2009:http://www.nlm.nih.gov/med-lineplus/womenshealth.html.92 GAO-09-884T, “VA Health Care: PreliminaryFindingsonVA’sProvisionofHealthCareServicestoWomenVeterans,” July 14, 2009: http://www.gao.gov/new.items/d09884t.pdf.93 FY2010 Independent Budget, p. 112: www.independentbudget.org.94 Dr.BevanneBean-Mayberry,CenterforHealthEquity Research and Promotion, “OptimizingHealthCareforWomenVeterans,”Volume2,Issue1:September2004,p.2.95 Ibid.96 Washington,p.6.97 Washington DL, et al., Women Veterans’Perceptions and Decision-making about VAHealthCare.Military Medicine2007;172(8):812-7.98 GAO-09-884T, “VA Health Care: PreliminaryFindingsonVA’sProvisionofHealthCareServicestoWomenVeterans,” July 14, 2009: http://www.gao.gov/new.items/d09884t.pdf.99 UnitedStatesCensusBureau, “CensusStudyShows Women Veterans Earn More and WorkLonger Hours,” June 17, 2008: http://www.cen-sus.gov/Press-Release/www/releases/archives/women/012062.html.100 Ibid.101 Ibid.102 Ibid.103 Onereasonforthismaybethatthemalessur-veyed averaged 51 years compared to an averageageof43forthefemaleveterans.Ibid.

104 AmericanLegion,“WomenVeterans:IdentifyingRisks, Services andPrevention,”p. 3:http://www.legion.org/documents/pdf/womensguide.pdf.105 Mary Rooney, Program Specialist, HomelessVeterans Programs, and Deborah Lee, VISN 6NetworkHomelessCoordinator,U.S.Departmentof Veterans Affairs, presentation at theNationalSummitonWomenVeteransAnnualConference,June20-22,2008,p.14.106 Thom Patterson, “U.S. seeing more femalehomeless veterans,” CNN, September 25, 2009:http://www.cnn.com/2009/LIVING/09/25/home-less.veterans/index.html.107 Male veteransare twiceas likely tobehome-lessastheirnonveteranpeers.GailGamache,PhD,RobertRosenheck,MD,andRichardTessler,PhD,“Overrepresentation ofWomen Veterans AmongHomeless Women,” American Journal of Public Health93(7),July2003,p.1132-1136.108 108.BryanBender,“Morefemaleveteransarewindinguphomeless,”Boston Globe,July6,2009.109 DepartmentofVeteransAffairs,“CommunityHomelessness Assessment, Local Education, andNetworking Group (CHALENG) for Veterans:FourteenthAnnualProgressReport,”p.2.110 Thom Patterson, “U.S. seeing more femalehomeless veterans,” CNN, September 25, 2009:http://www.cnn.com/2009/LIVING/09/25/home-less.veterans/index.html.111 This number is almost 2.5 times the rate ofhomeless women veterans of all generations.EmailconversationwithPeteDougherty,Director,Homeless Veterans Programs, Department ofVeteransAffairs,February19,2009.112 For more information on the methods usedtocountthehomeless,seeLibbyPerl,“CountingHomeless Persons: Homeless ManagementInformation System,” Congressional ResearchService,April3,2008.113 Erin Edwards andHallieMartin, “Willmorewomenvetsbehomeless?”MedillReports,March12, 2008: news.medill.northwestern.edu/chicago/news.aspx?id=83199.114 Erik Eckholm, “Surge Seen in Number ofHomelessVeterans,”The New York Times,November8, 2007:www.nytimes.com/2007/11/08/us/08vets.html?ex=1352178000&en=0a95aa78b612ae16&ei=5088&partner=rssnyt&emc=rss.115 Ibid.116 Perl,p.28.117 Bina Venkataraman, “Help lags for homelessfemaleveterans,”Christian Science Monitor,July18,2007: www.csmonitor.com/2007/0718/p02s01-usmi.html.118 James Hannah, “New Housing ServesHomeless Female Veterans,” Associated Press,October 20, 2008: www.portclintonnewsherald.com/apps/pbcs.dll/article?AID=/20081020/UPDATES01/81020008.119 Ibid.120 Rooney and Lee, p. 23. See also: NationalAlliance to End Homelessness, “Vital Mission:Ending Homelessness Among Veterans,” p. 27.AmericanLegion,p.3.121 AmericanLegion,p.3.122 DepartmentofVeteransAffairs,“CommunityHomelessness Assessment, Local Education andNetworking Group (CHALENG) for Veterans:FourteenthAnnualProgressReport,”p.9.123 Ibid.,at12.

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