This is the accessible text file for GAO report number GAO-13-182 
entitled 'Military Personnel: DOD Has Taken Steps to Meet the Health 
Needs of Deployed Servicewomen, but Actions Are Needed to Enhance Care 
for Sexual Assault Victims' which was released on January 29, 2013. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as 
part of a longer term project to improve GAO products' accessibility. 
Every attempt has been made to maintain the structural and data 
integrity of the original printed product. Accessibility features, 
such as text descriptions of tables, consecutively numbered footnotes 
placed at the end of the file, and the text of agency comment letters, 
are provided but may not exactly duplicate the presentation or format 
of the printed version. The portable document format (PDF) file is an 
exact electronic replica of the printed version. We welcome your 
feedback. Please E-mail your comments regarding the contents or 
accessibility features of this document to Webmaster@gao.gov. 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

United States Government Accountability Office: 
GAO: 

Report to Congressional Addressees: 

January 2013: 

Military Personnel: 

DOD Has Taken Steps to Meet the Health Needs of Deployed Servicewomen, 
but Actions Are Needed to Enhance Care for Sexual Assault Victims: 

GAO-13-182: 

GAO Highlights: 

Highlights of GAO-13-182, a report to congressional addressees. 

Why GAO Did This Study: 

The roles for women in the military have been expanding and evolving. 
Servicewomen today are integral to combat, combat support, and 
counterinsurgency operations, and serve in many roles they previously 
did not hold. Pub. L. No. 112-81, § 725 (2011) mandated that GAO 
conduct a review of the female-specific health care services provided 
by DOD to female servicemembers, including the treatment of 
servicewomen who are victims of sexual assault. In this report, GAO 
evaluates the extent to which (1) DOD is addressing the health care 
needs of deployed servicewomen; (2) female-specific health care 
services are available to deployed servicewomen; and (3) medical and 
mental health care are available to servicewomen who are victims of 
sexual assault. GAO reviewed pertinent DOD policies, guidance, and 
data. GAO also met with health care providers, servicewomen, and 
others during site visits to 18 locations where servicewomen are 
currently serving or deployed, including 15 installations in 
Afghanistan and Navy vessels. 

What GAO Found: 

The Department of Defense (DOD) is taking steps to address the health 
care needs of deployed servicewomen. For example, DOD has put in place 
policies and guidance that include female-specific aspects to help 
address the health care needs of servicewomen during deployment. Also, 
as part of pre-deployment preparations, servicewomen are screened for 
potentially deployment-limiting conditions, such as pregnancy, and DOD 
officials and health care providers with whom GAO met noted that such 
screening helps ensure that many female-specific health care needs are 
addressed prior to deployment. GAO also found that DOD components have 
conducted reviews of the health care needs of servicewomen during 
deployments and are collecting data on the medical services provided 
to deployed servicewomen. 

At the 15 selected locations GAO visited in Afghanistan and aboard 
Navy vessels, health care providers and most servicewomen indicated 
that the available health care services generally met deployed 
servicewomen’s needs. In Afghanistan and aboard Navy vessels, health 
care providers said they were capable of providing a wide range of the 
female-specific health care services that deployed servicewomen might 
seek, and servicewomen GAO spoke with indicated that deployed women’s 
needs were generally being met. Specifically, based on information 
provided by the 92 servicewomen GAO interviewed, 60 indicated that 
they felt the medical and mental health needs of women were generally 
being met during deployments; 8 indicated they did not feel those 
needs were generally being met during deployments; an additional 8 
indicated a mixed opinion; and 16 said they did not have an opinion. 
For example, some servicewomen told GAO that they were satisfied with 
their military health care, given the operating environment. Among 
those who expressed dissatisfaction with their military heath care, 
GAO heard a concern about difficulty in obtaining medications. Among 
those who expressed mixed views, a comment was raised that junior 
health care providers were limited in the types of procedures they 
could perform and lacked practical experience. 

DOD has taken steps to provide medical and mental health care to 
victims of sexual assault, but several factors affect the availability 
of care. For example, this care can vary by service and can be 
impacted by operational factors, such as transportation and 
communication challenges, that are inherent to the deployed 
environment. Further, military health care providers do not have a 
consistent understanding of their responsibilities in caring for 
sexual assault victims because the department has not established 
guidance for the treatment of injuries stemming from sexual assault—
which requires that specific steps are taken while providing care to 
help ensure a victim’s right to confidentiality. Additionally, while 
the services provide required annual refresher training to first 
responders, GAO found that some of these responders were not always 
aware of the health care services available to sexual assault victims 
because not all of them are completing the required training. Without 
having a clearer understanding of their responsibilities, health care 
providers and first responders will be impeded in their ability to 
provide effective support for servicewomen who are victims of sexual 
assault. 

What GAO Recommends: 

To enhance the medical and mental health care for servicewomen who are 
victims of sexual assault, GAO recommends that DOD (1) develop 
department-level guidance on the provision of care to victims of 
sexual assault; and (2) take steps to improve first responders’ 
compliance with the department’s requirements for annual refresher 
training. DOD did not concur with the first recommendation, but cited 
steps it is taking that appear consistent with the recommendation. DOD 
concurred with the second recommendation. 

View [hyperlink, http://www.gao.gov/products/GAO-13-182]. For more 
information, contact Brenda S. Farrell at (202) 512-3604 or 
farrellb@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

DOD Is Taking Steps to Help Address the Health Care Needs of Deployed 
Servicewomen: 

Servicewomen's Perceptions Suggest that Health Care Services Available 
to Deployed Servicewomen Generally Meet Needs: 

Several Factors Affect the Availability of Medical and Mental Health 
Care to Sexual Assault Victims: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Comments from the Department of Defense: 

Appendix III: GAO Contact and Staff Acknowledgments: 

Table: 

Table 1: Crew Composition for Navy Vessels Visited: 

Figures: 

Figure 1: Medical Examination Rooms at Selected Facilities A and B in 
Afghanistan: 

Figure 2: Medical Examination Rooms at Selected Facilities C and D in 
Afghanistan: 

Figure 3: Medical Examination Rooms Aboard Selected Navy Vessels A and 
B: 

Figure 4: Locations in Afghanistan Visited during GAO's Review: 

Abbreviations: 

DACOWITS: Defense Advisory Committee on Women in the Services: 

DOD: Department of Defense: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

January 29, 2013: 

Congressional Addressees: 

The roles for women in the military have been expanding and evolving, 
particularly since the Persian Gulf War more than 2 decades ago. 
Formerly, servicewomen served primarily in supportive roles in 
overseas U.S. military operations. Today, servicewomen are integral to 
combat support and counterinsurgency operations, and they serve in 
many roles they previously did not hold. In late 2011, for example, 
women began serving aboard Navy submarines. In early 2012, the 
Department of Defense (DOD) announced that changes to its assignment 
policies would result in more than 14,000 additional positions being 
opened to women, including positions in select direct ground combat 
units. Further, while sexual assault victimization is not unique to 
women, the presence of women in new roles suggests that continued 
vigilance with respect to this issue is needed. Given the expanding 
and evolving role of women in the military, the health and wellness of 
servicewomen plays an important role in overall military readiness. 

The National Defense Authorization Act for Fiscal Year 2012[Footnote 
1] required GAO to conduct a review of various aspects of the female-
specific health care services provided by DOD to female 
servicemembers. In response to the act, this report focuses on female-
specific health care services provided by DOD to deployed 
servicewomen, as well as the medical and mental health care available 
to servicewomen who are victims of sexual assault. Specifically, it 
evaluates the extent to which (1) DOD is addressing the health care 
needs of deployed servicewomen; (2) female-specific health care 
services are available to deployed servicewomen; and (3) medical and 
mental health care are available to servicewomen who are victims of 
sexual assault. In a separate report,[Footnote 2] GAO is focusing on 
the availability of female-specific health care services provided to 
female servicemembers in the United States. 

To determine the extent to which DOD is addressing the health care 
needs of deployed servicewomen, we reviewed pertinent DOD and service-
specific policies and guidance and interviewed knowledgeable officials 
within the Office of the Assistant Secretary of Defense for Health 
Affairs and the medical commands of the Army, the Navy, and the Air 
Force. We also reviewed relevant guidelines, such as those issued by 
the American College of Obstetricians and Gynecologists,[Footnote 3] 
and prior related GAO reports.[Footnote 4] We also obtained 
information on reported patient encounters for deployed servicemembers 
for fiscal year 2012. To assess the reliability of these data, we 
contacted cognizant DOD officials in order to understand the processes 
used to collect these data and any known limitations of the data. We 
determined that these data were sufficiently reliable for the purposes 
of our report--that is, to provide context for the approximate number 
of reported patient encounters for servicewomen during fiscal year 
2012 and the frequency with which such encounters specifically 
concerned women's health by summarizing the top 25 diagnoses.[Footnote 
5] In addition, we visited seven military installations in Afghanistan 
and eight Navy vessels at their home ports in the United States. The 
locations we visited in Afghanistan included forward operating bases 
and military installations with more robust infrastructures, and were 
selected because they allowed us to visit each of the levels of health 
service support in Afghanistan. The Navy vessels we visited were 
selected because they allowed us to visit different types of vessels 
within both the U.S. Atlantic and U.S. Pacific Fleets where women are 
an integrated part of the crew. During our site visits we met with 
health care providers, military commanders, and a total of 92 female 
servicemembers from various pay grades and from all services. Although 
the results of our discussions with servicewomen cannot be generalized 
across DOD, a service, or any single location we visited, the results 
do provide insight into the perspectives of servicewomen regarding 
DOD's efforts to address the health care needs of deployed 
servicewomen. 

To determine the extent to which female-specific health care services 
are available to deployed servicewomen, we reviewed DOD and service-
specific requirements and obtained information from health care 
providers during our site visits regarding the availability of select 
female-specific health care services at each location. Specifically, 
these female-specific health care services included clinical breast 
examination; screening mammography; diagnostic mammography; pelvic 
examination; PAP smear; treatment of patients with abnormal PAP smear; 
treatment for disorders of the female genitals; treatment for 
disorders of menstruation; pregnancy test; and contraceptives, or 
contraceptive counseling.[Footnote 6] We also focused on female-
specific behavioral health care services, to include mental health and 
substance abuse counseling. If female-specific health care services 
were not available, we sought to understand how situations requiring 
the need for such services would be handled during deployments. 

To determine the extent to which medical and mental health care are 
available to servicewomen who are victims of sexual assault, we 
obtained and analyzed various documents, including legislative 
requirements and DOD's policies and guidance for the prevention of and 
response to sexual assault, and interviewed knowledgeable officials 
from DOD's Sexual Assault Prevention and Response office. We also 
reviewed DOD's Annual Report on Sexual Assault in the Military 
Services to identify the department's efforts to provide medical and 
mental health services to the 2,420 females who in fiscal year 2011 
reported to DOD that they had been victims of sexual assault. We 
conducted site visits to three military installations in the United 
States in addition to the seven military installations in Afghanistan 
and eight Navy vessels we visited for our larger review, in order to 
assess the availability of medical and mental health care services for 
victims of sexual assault in the military. The three locations we 
visited in the United States were selected because they enabled us to 
meet with military personnel who have served as Sexual Assault 
Response Coordinators both while deployed and while at a military 
installation in the United States. During our site visits we met with 
Sexual Assault Response Coordinators, Victim Advocates, and health 
care providers. 

We conducted this performance audit from April 2012 through January 
2013 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. Further 
details about our scope and methodology can be found in appendix I. 

Background: 

DOD's Military Health System: 

DOD's health care system, known as the Military Health System, is one 
of the largest and most complex health care systems in the nation. 
Operationally, DOD's Military Health System has two missions: 
supporting wartime and other deployments, known as the readiness 
mission, and providing peacetime care, known as the benefits mission. 
The readiness mission provides medical services and support to the 
armed forces during military operations and deployments, including 
deploying medical personnel and equipment throughout the world, and 
ensures the medical readiness of personnel prior to deployment. Within 
DOD's Office of the Under Secretary of Defense for Personnel and 
Readiness, the Office of the Assistant Secretary of Defense for Health 
Affairs oversees the Military Health System and also issues guidance 
to DOD components on medical matters. The Departments of the Army and 
the Navy each have a medical command, headed by a Surgeon General, who 
manages each department's respective military treatment facilities and 
medical personnel. The Navy's Bureau of Medicine and Surgery supports 
both the Navy and the Marine Corps. The Air Force Surgeon General, 
through the role of medical advisor to the Air Force Chief of Staff, 
exercises similar authority to that of the other Surgeons General. 

DOD's Sexual Assault Prevention and Response Program: 

The Under Secretary of Defense for Personnel and Readiness also has 
the responsibility for developing the overall policy and guidance for 
the department's sexual assault prevention and response program except 
for criminal investigative policy matters assigned to the DOD 
Inspector General and legal processes in the Uniform Code of Military 
Justice. DOD Directive 6495.01 defines sexual assault as "intentional 
sexual contact characterized by use of force, threats, intimidation, 
or abuse of authority, or when the victim does not or cannot consent. 
Sexual assault includes rape, forcible sodomy (oral or anal sex), and 
other unwanted sexual contact that is aggravated, abusive, or wrongful 
(including unwanted and inappropriate sexual contact), or attempts to 
commit these acts."[Footnote 7] 

DOD's directive provides active duty servicemembers with two options 
for reporting a sexual assault: (1) restricted and (2) unrestricted. 
DOD's restricted reporting option allows sexual assault victims to 
confidentially disclose an alleged sexual assault to select 
individuals, including health care personnel, and receive medical 
treatment without initiating an official investigation. In cases where 
a victim elects restricted reporting, first responders--including 
health care providers--may not disclose confidential communications or 
information on the forensic examination to law enforcement or command 
authorities unless certain exceptions apply, and improper disclosure 
of confidential communications and medical information may result in 
discipline pursuant to the Uniform Code of Military Justice or other 
adverse personnel or administrative actions. In contrast, DOD's 
unrestricted reporting option allows sexual assault victims to receive 
medical treatment and request an official investigation of the 
allegation using existing reporting channels, such as their chain of 
command or law enforcement. 

DOD's directive also identifies the various types of support, to 
include the coordination of medical and mental health care services, 
that shall be provided to victims of sexual assault. Specifically, the 
directive specifies that sexual assault victims shall receive timely 
access to comprehensive medical treatment, including emergency care 
that shall consist of emergency medical care and the offer of a sexual 
assault forensic examination consistent with Department of Justice 
protocols.[Footnote 8] Further, sexual assault victims shall be 
advised that even if a forensic examination is declined, the victim is 
encouraged (but not required) to receive medical care, psychological 
care, and victim advocacy. 

Since 2008 we have issued a series of reports examining DOD's 
implementation of its Sexual Assault Prevention and Response Program 
and made a total of 25 recommendations with which DOD has generally 
concurred and taken actions to implement to varying degrees. These 
reports include reviews of DOD's sexual assault prevention and 
response programs for the military academies; programs for the active 
components of DOD, including during deployments; and processes for 
investigating and adjudicating allegations of sexual assault. For 
further information on these reports as well as our prior 
recommendations, see the summary we issued in March 2012.[Footnote 9] 

DOD Is Taking Steps to Help Address the Health Care Needs of Deployed 
Servicewomen: 

DOD has developed policies and guidance that include female-specific 
aspects to help address the health care needs of female servicemembers 
during deployment. Prior to deploying, servicewomen are screened for 
potentially deployment-limiting conditions. According to DOD officials 
and health care providers with whom we met, such pre-screening helps 
ensure that many female-specific health care needs are addressed prior 
to deployment. Further, DOD components have conducted reviews of the 
health care needs of servicewomen during deployments. DOD also 
collects health care data on the medical services provided to deployed 
servicewomen in Afghanistan and aboard Navy vessels.[Footnote 10] 

DOD Policies Addressing the Health Care Needs of Deployed 
Servicemembers Include Female-specific Aspects: 

DOD components have put in place policies and guidance that include 
female-specific aspects to help address the health care needs of 
servicewomen during deployment. DOD and service officials told us that 
while the department's policies are generally gender-neutral and focus 
on addressing the health care needs of all servicemembers, some of the 
policies and guidance include female-specific aspects such as 
pregnancy, pelvic examinations, and screening mammography. In certain 
instances, the services' policies reflect clinical practice guidelines 
that come from outside the department, such as those from the American 
College of Obstetricians and Gynecologists. For example, we found that 
the Army changed its pre-deployment screening requirements due to a 
change in American College of Obstetricians and Gynecologists 
guidelines for cervical cytology screening. Additionally, we found 
that Navy guidelines require the provision of standbys--individuals 
who could be present during sensitive or potentially compromising 
physical examinations--during medical examinations when female 
genitalia or breasts are exposed or examined by a medical provider, in 
accordance with Joint Commission guidelines.[Footnote 11] 

According to DOD and service officials, although there may be some 
gender differences for particular diagnoses, behavioral health care 
services--that is, mental health care and substance abuse counseling--
are not gender-specific. The treatment of servicemembers' behavioral 
health care needs and the availability of services to treat those 
needs, therefore, do not vary based on gender. 

Pre-deployment Screening Processes Help Ensure That Many Female-
specific Needs Are Addressed Prior to Deploying: 

DOD has established a medical tracking system for assessing the 
medical condition of servicemembers to help ensure that only those who 
are medically and mentally fit are deployed outside of the United 
States. According to service officials and health care providers with 
whom we met, pre-deployment screenings help ensure that many women's 
health care needs are addressed prior to deployment. As part of DOD's 
pre-deployment screening process, servicemembers of both sexes are 
screened for potentially deployment-limiting medical conditions that 
would render them unsuitable to perform their duties during 
deployment. Servicemembers of both sexes are also required to complete 
a pre-deployment health assessment questionnaire. DOD requires that 
servicemembers' questionnaires be reviewed by a health care provider 
to determine whether the servicemember is fit to deploy. Service 
officials we spoke with told us that this screening also provides 
servicemembers an opportunity to discuss and address with a health 
care provider any health concerns they may have prior to deploying. 
The officials said they rely on the questionnaires, reviews of 
servicemembers' medical records, and physical examinations to identify 
an individual's health care needs prior to deployments. 

Some deployment-limiting conditions are female-specific: for example, 
each of the military services defines pregnancy as a deployment-
limiting condition. Each of the services has also established a 
postpartum deferment period--6 months for the Army, the Air Force, and 
the Marine Corps, and 12 months for the Navy. During this period, 
servicewomen are not required to deploy or redeploy, so as to enable 
mothers to recover from childbirth and to bond with their children. 
However, each of the military services has a policy that allows 
servicewomen to voluntarily deploy before the period has expired. 
Typically, during deployment servicewomen who are confirmed to be 
pregnant may not remain deployed. For example, servicewomen who are 
confirmed to be pregnant in Afghanistan may not remain in theater and 
must notify their military chain of command or supervisor immediately. 
They are required to be redeployed within 14 days of receipt of 
notification. Navy guidance prohibits a pregnant servicewoman from 
remaining aboard a vessel if the time required to transport her to 
emergency obstetric and gynecological care exceeds 6 hours. 
Servicewomen who are confirmed to be pregnant at sea are to be sent at 
the earliest opportunity to the closest shore-based U.S. military 
facility that can provide obstetric and gynecological care. Navy 
medical providers we met with during our site visits stated that 
pregnant servicewomen are typically transferred off the vessel within 
days of confirmation of their pregnancy. Further, we found that female-
specific deployment-limiting conditions sometimes depend on the 
deployed environment: for example, women with conditions such as 
recurrent pelvic pain or abnormal vaginal bleeding are disqualified 
from submarine service. 

DOD Has Also Conducted Some Reviews of the Health Care Needs of 
Servicewomen during Deployments: 

DOD components have conducted reviews of the health care needs of 
servicewomen while they are deployed. For example: 

* As part of a review the Army Surgeon General's office initiated in 
2011, the Army issued a white paper entitled "The Concerns of Women 
Currently Serving in the Afghanistan Theater of Operations." This 
white paper outlined a number of concerns over such things as lack of 
education about birth control, menstrual cycle control, and feminine 
hygiene during deployment. The paper included a total of 23 
recommendations to the Army Surgeon General aimed at improving women's 
health during deployments. Subsequently, in December 2011 the Army 
Surgeon General established a women's health task force to evaluate 
issues faced by servicewomen both in theater and in the continental 
United States. According to Army task force officials, the Army's 
white paper served as the starting point for their initial efforts, 
and the task force is taking steps to address each of the 23 
recommendations made in the paper. For example, the Army Surgeon 
General's office is working to develop a kit to address a 
recommendation that female soldiers be provided training and tools to 
promote self-diagnosis and care of common urinary tract and vaginal 
infections. Task force officials told us that the kits should be 
available by the end of 2013. 

* For 2012 the Defense Advisory Committee on Women in the Services 
[Footnote 12] (DACOWITS) has focused on the health care needs of 
deployed servicewomen. As reported in the quarterly meeting minutes of 
its March 2012 proceedings, "DACOWITS is interested in health concerns 
of deployed women, particularly since women are increasingly deployed 
in operational field environments, taking on ground combat roles." 
DACOWITS last reported on deployed women's health issues in its 2007 
annual report. DACOWITS expects to issue its 2012 annual report to the 
Secretary of Defense in early 2013. 

* The TriService Nursing Research Program[Footnote 13] is currently 
funding a Women's Health Research Interest Group that is reviewing the 
available literature to identify research gaps on health issues 
affecting servicewomen. Officials from the Women's Health Research 
Interest Group told us that once they complete their review they plan 
to develop a Web-based community repository of research in the area of 
military women's health. The program is also funding research efforts 
focused on deployed women's health issues, including the use of female 
urinary diversion devices and a review of the health education 
provided to servicewomen before they deploy. 

DOD Is Capturing Data on the Medical Services Provided to Deployed 
Servicewomen: 

DOD is collecting health care data on the medical services provided to 
deployed servicewomen, as well as servicemen, in Afghanistan and 
aboard Navy vessels. According to service officials, data that health 
care personnel enter into electronic systems on servicemen and women's 
encounters with providers are accessible by commanders in order to 
allow them to track the medical status of units and 
individuals.[Footnote 14] According to information provided by service 
officials in Afghanistan, the total number of reported patient 
encounters in U.S. Central Command's area of operations[Footnote 15] 
during fiscal year 2012 was around 460,000. Of these, servicewomen 
accounted for about 62,000 patient encounters. For U.S. Central 
Command's area of operations, DOD's fiscal year 2012 data show that 
the most frequent diagnosis for servicemembers, based on International 
Classification of Diseases codes,[Footnote 16] was lumbago, or, lower 
back pain. Of the top 25 diagnoses, none were related specifically to 
women's health issues. According to information provided by the Office 
of the Navy Surgeon General, the total number of reported patient 
encounters aboard Navy vessels during fiscal year 2012 was 
approximately 69,000, of which servicewomen accounted for about 
21,000. For Navy vessels, based on International Classification of 
Diseases codes the Navy's data show that the most frequent diagnosis 
during fiscal year 2012 for servicemembers was lumbago. Of the top 25 
diagnoses, only one¯urinary tract infection¯was commonly associated 
with women's health. 

The department also uses the data to develop reports that address 
broader health issues. For example, the Armed Forces Health 
Surveillance Center[Footnote 17] has issued reports that provide, by 
service, data on deployment-related conditions of special interest, 
such as traumatic brain injury, amputations, and severe acute 
pneumonia, among other data. While these reports generally do not 
separate data by gender, the Armed Forces Health Surveillance Center 
has issued two reports since December 2011 focusing on women's health 
issues. For example, a July 2012 report presented data on the 
incidence of acute pelvic inflammatory disease, ectopic pregnancies, 
and iron deficiency among active duty women, as well as data on 
selected conditions among women after initial and repeated deployments 
to Afghanistan and Iraq. According to these reports, from January 2003 
through December 2011, based on International Classification of 
Diseases codes, 50,634 servicemembers--comprising 6,376 females and 
44,258 males--were evacuated from Iraq and Afghanistan for medical 
reasons. The most frequent causes of medical evacuations for females 
were mental disorders, musculoskeletal disorders, "signs, symptoms, 
and ill-defined conditions," and non-battle-injuries, whereas the most 
frequent causes of such evacuations for males were battle injuries, 
musculoskeletal disorders, non-battle injuries, and mental disorders. 

Servicewomen's Perceptions Suggest that Health Care Services Available 
to Deployed Servicewomen Generally Meet Needs: 

A Variety of Health Care Services Are Available to Servicemembers 
Deployed to Afghanistan and at Sea: 

The health care services, and in turn the female-specific health care 
services available to deployed servicewomen, vary depending on the 
deployed environment. DOD provides three levels of health service 
support to servicemembers deployed to Afghanistan. The most basic 
level of care is provided at "Role 1" facilities, which include 
primary care facilities and outpatient clinics. "Role 2" facilities 
provide advanced trauma management and emergency medical treatment. 
The highest level of care that DOD provides in Afghanistan is at "Role 
3" facilities. These facilities are equivalent to full-spectrum 
hospitals and are staffed and equipped to provide resuscitation, 
initial wound surgery, and post-operative treatment. As of November 
2012, there were 143 facilities in Afghanistan providing Role-1 level 
care, 24 facilities providing Role-2 level care, and 5 facilities 
providing Role-3 level care.[Footnote 18] According to senior medical 
officials with U.S. Forces Afghanistan and the International Security 
Assistance Force Joint Command, most gynecological care is provided at 
Role 1 facilities, and infantry battalions and most forward operating 
bases and combat outposts in Afghanistan can at a minimum provide Role 
1-level care. 

We found that servicewomen while deployed at sea have access to 
providers of primary care, although the health care services that are 
available aboard Navy vessels largely depend on the type and class of 
vessel. Larger vessels generally offer a wider range of services--
including specialized services--than do smaller vessels, due largely 
to their more robust crew levels and capabilities. The medical 
department of an aircraft carrier, for example, typically consists of 
more than 40 billets, including a family practitioner, a physician's 
assistant, and a clinical psychologist. Similarly, the medical 
department of a WASP-class amphibious assault ship consists of more 
than 20 billets, including a medical officer. For cruisers, 
destroyers, and frigates, the medical department typically consists of 
only a handful of billets, including an Independent Duty Hospital 
Corpsman,[Footnote 19] but no medical officer. For Ohio-class 
submarines, the sole source of medical care aboard is an Independent 
Duty Hospital Corpsman. Each of these classes of vessels is capable of 
providing health care services to servicemembers of both sexes. 

Health Care Providers and Servicewomen Said DOD Generally Meets 
Women's Health Care Needs during Deployments: 

At the 15 selected locations we visited in Afghanistan and Navy 
vessels, health care providers and servicewomen told us that the 
health care services available to deployed servicemembers generally 
meet the needs of servicewomen. Health care providers we spoke with in 
Afghanistan and aboard Navy vessels told us they were capable of 
providing a wide range of female-specific health care services--
including treating certain gynecological conditions such as urinary 
tract infections and conducting clinical breast examinations--that 
women might seek while deployed.[Footnote 20] They also told us that 
servicemembers had access at least to basic mental health care 
services. Some female-specific services--such as treatment for an 
abnormal PAP smear result, or mammography services--were not always 
available, but providers told us that conditions resulting in the need 
for more specialized services were routinely addressed prior to 
deployment. For example, providers with an expeditionary medical group 
we met in Afghanistan told us that in their experience PAP smears are 
rarely performed in theater except for women who had received abnormal 
PAP smear results prior to deploying and needed follow-up checks after 
6 months. Those providers also told us that screening mammography is 
not provided in theater because screening mammography is generally 
preventative care, which is conducted as part of a woman's annual exam 
prior to deployment. Health care providers from multiple Navy vessels 
we visited also told us that a number of female-specific health care 
services--from performing PAP smears to treating patients with 
abnormal PAP smear results to mammography services--were not needed 
during deployments at sea because such services were provided prior to 
deploying. 

According to health care officials and providers with whom we met, 
women who developed acutely urgent conditions during deployments, to 
include female-specific conditions, would typically be transferred to 
a locale offering access to more specialized services. Health care 
providers with whom we met were able to identify their available 
options for referring individuals with acutely urgent conditions for 
specialized care elsewhere if necessary--in Afghanistan, typically, to 
a higher level of care; during deployments at sea, to another vessel 
or a shore-based facility. Providers also noted that in some cases 
they could consult with other health care providers if necessary, 
including providers specializing in women's health care. For example, 
at one Role 1 facility we visited in Afghanistan, health care 
providers noted that their Deputy Command Surgeon specialized in 
obstetrics and gynecology and was available to consult on cases if 
they needed assistance. As another example, Navy Independent Duty 
Hospital Corpsmen told us that they could consult with their physician 
supervisor if necessary during deployments at sea. 

At each of the locations we visited we found that a variety of steps 
were being taken to help ensure that servicewomen had a reasonable 
amount of privacy during examinations as well. For example, each of 
the locations we visited offered at a minimum a medical examination 
room with privacy curtains that could be drawn. In most instances, 
doors with locks were available as well. We also observed that signs 
could be posted indicating that an examination was in process. 
Further, health care providers told us that a standby--individuals who 
could be present during sensitive or potentially compromising physical 
examinations--was available at each location we visited. Figures 1 
through 3 show photographs of the medical examination rooms at 
selected locations we visited. 

Figure 1: Medical Examination Rooms at Selected Facilities A and B in 
Afghanistan: 

[Refer to PDF for image: 2 photographs] 

Source: GAO. 

[End of figure] 

Figure 2: Medical Examination Rooms at Selected Facilities C and D in 
Afghanistan: 

[Refer to PDF for image: 2 photographs] 

Source: GAO. 

[End of figure] 

Figure 3: Medical Examination Rooms Aboard Selected Navy Vessels A and 
B: 

[Refer to PDF for image: 2 photographs] 

Source: GAO. 

[End of figure] 

Based on information provided by the 92 servicewomen we interviewed at 
selected locations in Afghanistan and aboard Navy vessels, the 
responses from 60 indicated that they felt the medical and mental 
health needs of women were generally being met during deployments, 
whereas the responses from 8 indicated they did not feel the medical 
and mental health needs of women were generally being met during 
deployments. The responses from an additional 8 servicewomen suggested 
that they had a mixed opinion as to whether the medical and mental 
health needs of women were being met during deployments, and 16 told 
us they did not know or did not have an opinion. Servicewomen who 
indicated during our interviews that the medical and mental health 
needs of women were generally being met during deployments offered a 
variety of reasons for their responses. At one location we visited in 
Afghanistan, a female Airman told us that if she had a health problem, 
the medical facility at her location could treat her or send her 
elsewhere if needed. She further noted that if the problem were 
serious enough she could be evacuated. Similarly, a female Army 
soldier we met at another location told us she felt some of the best 
care that she has received in her life has been military health care. 
At another location, a female Marine told us that the care provided to 
her was as good as she could imagine, given the operating environment. 
Aboard one Navy vessel we visited, a female sailor told us that even 
though mental health care was not available aboard her ship, it was 
available ashore, and the ship could handle emergencies at sea. 

Servicewomen we interviewed who indicated that they felt the medical 
and mental health needs of women were generally not being met during 
deployments offered a variety of reasons for their responses as well. 
At one location we visited in Afghanistan, a female airman told us 
that she believed the military was trying to meet the health needs of 
women, but still had work to do--noting, for example, that a 
medication she was prescribed had given her yeast infections. At 
another, a female Army soldier told us that she had experienced 
difficulty obtaining sleep medication. In the case of deployments at 
sea, one female sailor expressed concern that a mental health provider 
was not aboard. Of servicewomen who offered a mixed opinion, one 
female sailor told us that she felt junior health care providers were 
limited in the types of procedures they could perform and lacked 
practical experience. 

Several Factors Affect the Availability of Medical and Mental Health 
Care to Sexual Assault Victims: 

DOD has taken steps to address the provision of medical and mental 
health care for servicemembers who are sexually assaulted, but several 
factors affect the extent to which this care is available. 
Specifically, the branch of military service and the operational 
uncertainties of a deployed environment can affect the ready 
availability of medical and mental health care services for victims of 
sexual assault. Additionally, care is in some cases affected because 
military health care providers do not have a consistent understanding 
of their responsibilities in caring for sexual assault victims who 
make restricted reports of sexual assault. Further, first responders 
such as Sexual Assault Response Coordinators and Victim Advocates are 
not always aware of the specific health care services available to 
sexual assault victims at their respective locations.[Footnote 21] 

Availability of Medical and Mental Health Care for Sexual Assault 
Victims Can Vary by Service and Operational Uncertainties: 

Each military service offers medical and mental health care resources 
to servicemembers who have been sexually assaulted, including those 
serving in a deployed environment. However, as we have noted in our 
prior work, the availability of such resources for victims can vary 
based on a number of factors, including branch of military service and 
the operational uncertainties associated with serving in a deployed 
environment.[Footnote 22] For example, the availability of deployed 
medical providers who are trained to conduct a sexual assault forensic 
examination varies across the military services because each service 
has a different process for deploying personnel. Specifically, we 
spoke with Army officials who told us that the Army requires each 
brigade to deploy with a health care provider who is trained to 
conduct a forensic examination, whereas the Air Force deploys trained 
health care providers based on the medical needs at specific 
locations. Navy medical providers we spoke with told us that the Navy 
does not require that its vessels deploy with a provider trained to 
conduct a forensic examination, and will instead transfer a victim to 
the nearest trained provider, whether at sea or ashore. Navy medical 
providers also told us that if a transfer is not possible they would 
do their best to conduct the forensic examination using the 
instructions provided with examination kits. 

Additionally, operational factors that are inherent to the deployed 
environment can have an impact on the provision of medical and mental 
health services to victims of sexual assault. Specifically, DOD 
reported in its fiscal year 2011 Annual Report on Sexual Assault in 
the Military that transportation and communication challenges, as well 
as the propensity of military personnel to form close communities, 
made the provision of forensic examinations and the maintenance of 
restricted reporting confidentiality more difficult during deployment. 
[Footnote 23] DOD added, however, that it was taking steps, such as 
establishing memoranda of understanding between the military services 
in joint environments, to resolve these issues. Similarly, we reviewed 
sexual assault standardized operating procedures for an Army Treatment 
Medical Clinic in Afghanistan that identified factors such as weather 
and other unforeseen conditions that can limit the ability to fly a 
victim off of a base for treatment. To mitigate these limitations, the 
Army included a primary and alternate evacuation protocol in its 
standardized operating procedures, to help ensure that servicemembers 
who are sexually assaulted during deployment have access to care. 

Guidance Has Not Been Developed for the Provision of Specialized 
Medical and Mental Health Care for Sexual Assault Victims: 

DOD has established policies and procedures for its sexual assault 
prevention and response program that address, among other things, the 
provision of medical and mental health care for servicemembers who are 
sexually assaulted. Specifically, in October 2005 DOD published a 
directive that contains its comprehensive policy for the prevention of 
and response to sexual assault.[Footnote 24] While generally 
applicable to all servicemembers and locations, DOD's directive calls 
for the sexual assault prevention and response program to be gender-
responsive, culturally competent, and recovery-oriented; and for an 
immediate, trained sexual assault response capability to be available 
in deployed locations. For example, DOD requires care for sexual 
assault victims to be linguistically appropriate; sensitive to gender-
specific issues such as pregnancy; and supportive of a victim's 
ability to be fully mission-capable and engaged. 

In June 2006, DOD's Office of the Under Secretary of Defense for 
Personnel and Readiness issued an instruction that provides guidance 
for implementing its policy and specifies roles, responsibilities, and 
required training for program personnel such as health care providers 
who may be involved in responding to victims of sexual assault. 
[Footnote 25] For example, DOD's instruction identifies various types 
of health care providers who, depending on their training, may be 
eligible to conduct sexual assault forensic examinations; and directs 
the military services to establish a multi-disciplinary case 
management group and include provisions for continuity of victim care 
when a victim has a temporary or permanent change of station, or is 
deployed. Additionally, DOD's instruction identifies required 
categories of training for program personnel on topics that include 
victim advocacy and medical treatment resources, sexual assault 
response policies, and the sexual assault examination process. 

Although DOD issued this overarching instruction that provides 
guidance for implementing its sexual assault prevention and response 
policies to personnel such as health care providers, we found that the 
Office of the Assistant Secretary of Defense for Health Affairs--the 
organization responsible for ensuring the effective execution of the 
department's medical mission--has not, in turn, developed more 
specified guidance to address the military services' responsibility to 
provide specialized medical and mental health care to victims of 
sexual assault. According to DOD Directive 5136.01, the Assistant 
Secretary of Defense for Health Affairs is required to, among other 
things, exercise authority, direction, and control over DOD medical 
policy, and to establish policies, procedures, and standards that 
govern the management of DOD health and medical programs.[Footnote 26] 
The Office of the Assistant Secretary of Defense for Health Affairs 
has performed these responsibilities for some medical issues in DOD, 
but it has not established guidance for the treatment of injuries 
stemming from sexual assault--a crime that requires a specialized 
level of care to help ensure that forensic evidence is properly 
collected, medical care is provided in a way that minimizes the risk 
of revictimization, and a victim retains the right to disclose the 
assault with confidentiality. 

Absent department-level guidance from DOD's Office of the Assistant 
Secretary of Defense for Health Affairs, the services have, to varying 
degrees, revised their respective medical guidance to address care for 
victims of sexual assault. For example, at one location we visited we 
reviewed a command's medical policy and found that while the policy 
addressed some responsibilities of health care providers in responding 
to sexual assault incidents, it had not been updated to identify how 
care should be modified for restricted reports of sexual assault. For 
example, the policy addressed topics such as when and where forensic 
examinations should be conducted, and health care provider 
responsibilities for transferring evidence to law enforcement. 
However, it did not mention DOD's policy on restricted reporting or 
provide guidance, for example, on the use of non-identifying 
information to label and store evidence collected from restricted 
reports of sexual assault. At another location, we found that a 
command's medical policy contained requirements for health care 
personnel that conflicted with their responsibilities under restricted 
reporting. The policy required the command's medical department 
representatives to document all injuries and referrals of personnel 
for care, and to keep the commanding officer and chain of command 
informed of medical conditions that affect the health, safety, and 
readiness of all command personnel. However, the policy was silent on 
the issue of sexual assault and did not identify exceptions to these 
requirements or offer health care providers alternative procedures for 
documenting and reporting medical issues associated with restricted 
reports of sexual assault. Accordingly, we found that military health 
care providers do not have a consistent understanding of their 
responsibilities in caring for sexual assault victims. We met with 
senior medical personnel from the command who confirmed that 
provisions in their medical policy conflicted with other command 
policy and had created confusion for health care providers regarding 
the extent of their responsibility to maintain the confidentiality of 
victims who choose to make a restricted report of sexual assault. 
These inconsistencies can put DOD's restricted reporting option at 
risk, undermine DOD's efforts to address sexual assault issues, and 
erode servicemembers' confidence. As a consequence, sexual assault 
victims who want to keep their case confidential may be reluctant to 
seek medical care. 

First Responders Are Not Always Aware of the Health Care Services 
Available to Sexual Assault Victims: 

DOD requires that personnel designated as first responders[Footnote 
27] to sexual assault incidents, whether in the United States or in 
deployed environments, receive initial and annual refresher training 
on topics that include available medical and mental health treatment 
options. Although DOD provides this required training, we found that 
first responders we met with were still unsure of the health care 
services available to sexual assault victims at their respective 
locations. This was particularly the case among first responders we 
met with during visits to selected locations in the United States, in 
part because of the increased medical and mental health care options 
that were available to them. For example, we regularly found that 
Sexual Assault Response Coordinators, Victim Advocates, and health 
care personnel differed in their understanding as to where to take a 
sexual assault victim for a forensic examination--a potentially 
problematic issue, given that the quality of forensic evidence 
diminishes the later it is collected following a sexual assault. The 
Department of Justice's National Protocol for Sexual Assault Medical 
Forensic Examinations identifies 72 hours after an assault occurs as 
the standard cutoff time in many jurisdictions for collecting evidence 
(except for blood alcohol determinations, which should be done within 
24 hours of ingestion of alcohol), but notes that evidence collection 
beyond that point is conceivable. Additionally, we found that not all 
first responders fulfill the requirement to annually complete 
refresher training on tasks DOD deems essential to their role in 
responding to incidents of sexual assault. According to DOD's 
instruction, first responders are required to complete periodic 
refresher training on a variety of topics that include management of 
restricted and unrestricted reports of sexual assault and local 
protocols and procedures. DOD reported in its fiscal year 2011 Annual 
Report on Sexual Assault in the Military that while each of the 
military services continued to implement sexual assault prevention and 
response training for first responders, not all first responders had 
completed the required training. For example, DOD reported that for 
fiscal year 2011, the Army trained only about 6,000 of the more than 
17,000 personnel who served as Sexual Assault Response Coordinators or 
Victim Advocates. Further, DOD's report noted that only 69 percent of 
Department of Navy Victim Advocates--which include Navy and Marine 
Corps personnel--completed the required training, and the report also 
noted that some of the training for Air Force first responders was 
overdue.[Footnote 28] 

Conclusions: 

As women continue to assume an expanding and evolving role in the 
military it is important that DOD be well positioned to meet the 
health care needs of deployed servicewomen and ensure their readiness. 
To the department's credit, DOD components have taken positive steps 
toward addressing the female-specific health care needs of deployed 
servicewomen, and we note that at the selected locations we visited 
during the course of our review the responses from most servicewomen 
we spoke with indicated that they felt the medical and mental health 
needs of women were generally being met during deployments. DOD also 
has taken positive steps in making medical and mental health care 
services available to sexual assault victims of both sexes. However, 
DOD's limited health care guidance on the restricted sexual assault 
reporting option and first responders' inconsistent knowledge about 
available resources are factors that affect the quality and 
availability of that care. Left unaddressed, such factors can 
undermine DOD's efforts to address the problem of sexual assault in 
the military by eroding servicemembers' confidence in the department's 
programs and decreasing the likelihood that victims of sexual assault 
will turn to the programs or seek care and treatment when needed. 

Recommendations for Executive Action: 

To help ensure that sexual assault victims have consistent access to 
health care services and the reporting options specified in DOD's 
sexual assault prevention and response policies, we recommend that the 
Secretary of Defense direct the Under Secretary of Defense for 
Personnel and Readiness to direct the Assistant Secretary of Defense 
for Health Affairs to develop and implement department-level guidance 
on the provision of medical and mental health care to victims of 
sexual assault that specifies health care providers' responsibilities 
to respond to and care for sexual assault victims, whether in the 
United States or in deployed environments. 

To help ensure that Sexual Assault Response Coordinators, Victim 
Advocates, and health care personnel have a consistent understanding 
of the medical and mental health resources available at their 
respective locations for sexual assault victims, we recommend that the 
Secretary of Defense direct the Under Secretary of Defense for 
Personnel and Readiness, in collaboration with the military 
departments, to take steps to improve compliance regarding the 
completion of annual refresher training on sexual assault prevention 
and response. 

Agency Comments and Our Evaluation: 

In written comments on a draft of this report, DOD stated in its cover 
letter that, overall, the department did not concur with the report's 
findings and conclusions. However, DOD's cover letter did not provide 
an explanation for this comment. In an enclosure to its letter, DOD 
stated that it did not concur with our first recommendation that the 
Assistant Secretary of Defense for Health Affairs develop and 
implement department-level guidance on the provision of medical and 
mental health care to victims of sexual assault that would specify 
health care providers' responsibilities to respond to and care for 
sexual assault victims, whether in the United States or in deployed 
environments. DOD's justification of its assessment, however, did not 
make clear why the department did not concur. Instead, DOD provided 
examples of steps it has been taking that may help to address the 
findings in this report. Specifically, DOD stated that, while the 
second version of DOD Instruction 6495.02, entitled "Sexual Assault 
Prevention and Response (SAPR) Program Procedures" has been in 
coordination for nearly 2 years and is not yet published, the revised 
instruction will be comprehensive and will contain two medical 
enclosures. According to DOD, the first medical enclosure will address 
health care provider procedures and direct the Surgeons General of the 
military services to carry out responsibilities related to the 
coordination, evaluation, and implementation of care, while the second 
medical enclosure will address health care providers' responsibilities 
related to Sexual Assault Forensic Examination kits. During the course 
of this review, we met with DOD officials who had knowledge of and 
were involved in the instruction's revision, but these officials did 
not discuss or share their draft revisions with us when we presented 
our findings to them. We cannot verify, therefore, whether the 
enclosures referenced in DOD's comments will address our 
recommendation. However, we plan to review the instruction when DOD 
finalizes it to determine whether it meets the intent of our 
recommendation. Finally, DOD stated that the department meets its 
oversight responsibilities with regard to sexual assault response 
through training in graduate medical education and through monitoring 
and oversight of the process that governs credentialing and 
privileging of providers. However, it is not clear why this statement 
is applicable to our recommendation. We did not address these points 
in the finding that led to this recommendation, and our recommendation 
is focused on the need for additional guidance. 

DOD concurred, without comment, on our second recommendation that the 
Under Secretary of Defense for Personnel and Readiness, in 
collaboration with the military departments, take steps to improve 
compliance with completing annual refresher training on sexual assault 
prevention and response. DOD's comments are reprinted in appendix II. 

We are sending copies of this report to the Secretary of Defense, the 
Under Secretary of Defense for Personnel and Readiness, the Assistant 
Secretary of Defense for Health Affairs, and appropriate congressional 
committees. In addition, this report will also be available at no 
charge on the GAO Web site at [hyperlink, http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-3604 or farrellb@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major 
contributions to this report are listed in appendix III. 

Signed by: 

Brenda S. Farrell: 
Director: 
Defense Capabilities and Management: 

List of Addressees: 

The Honorable Carl Levin: 
Chairman: 
The Honorable James Inhofe: 
Ranking Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Chairman: 
The Honorable Thad Cochran: 
Ranking Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
United States Senate: 

The Honorable Howard P. "Buck" McKeon: 
Chairman: 
The Honorable Adam Smith: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

The Honorable C.W. Bill Young: 
Chairman: 
The Honorable Pete Visclosky: 
Ranking Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
House of Representatives: 

[End of section] 

Appendix I: Scope and Methodology: 

Determining the Extent to Which the Health Care Needs of Deployed 
Servicewomen Are Being Addressed and Female-specific Health Care 
Services Are Available: 

In our review of female-specific health care services provided by DOD 
to deployed servicewomen, our scope included each of the military 
services. We focused our work in conducting this review on the health 
care services available to servicewomen deployed to Afghanistan or 
aboard Navy vessels at sea. 

To determine the extent to which DOD is addressing the health care 
needs of deployed servicewomen, we reviewed legislative requirements 
and pertinent DOD and service-specific policies and guidance. We also 
interviewed responsible officials within the Office of the Assistant 
Secretary of Defense for Health Affairs, each of the services' medical 
commands, and the TriService Nursing Research Program and its Women's 
Health Research Interest Group. We reviewed guidelines specifically 
applicable to women, such as guidelines issued by the American College 
of Obstetricians and Gynecologists, and prior GAO reports. We also 
obtained information on reported patient encounters for deployed 
servicemembers for fiscal year 2012 collected by U.S. Central Command 
and the Navy's Office of the Surgeon General. To assess the 
reliability of these data, we contacted cognizant DOD officials in 
order to understand the processes used to collect these data and any 
known limitations of the data. We found that while the data likely 
underreported the total number of patient encounters, these data were 
sufficiently reliable for the purposes of our report--that is, to 
provide context for the approximate number of reported patient 
encounters for servicewomen during fiscal year 2012 and the frequency 
with which such encounters specifically concerned women's health by 
summarizing the top 25 diagnoses.[Footnote 29] In addition, we 
conducted a total of 15 site visits where we met with health care 
providers, military commanders, and female servicemembers to obtain 
their perspectives on DOD's efforts to address the health care needs 
of deployed servicewomen. In Afghanistan we visited 7 military 
installations, selected so as to enable us to visit each of the three 
levels of health service support across Afghanistan. Figure 4 shows 
the locations in Afghanistan we visited during the course of our 
review, which included Bagram Air Field, Camp Eggers, Camp 
Leatherneck/Bastion, Camp Phoenix, Camp Stone, Forward Operating Base 
Fenty, and Forward Operating Base Gardez. 

Figure 4: Locations in Afghanistan Visited during GAO's Review: 

[Refer to PDF for image: illustrated map of Afghanistan] 

Locations depicted: 

Bagram Air Field; 
Camp Eggers; 
Camp Leatherneck/Bastion; 
Camp Phoenix; 
Camp Stone; 
Forward Operating Base Fenty; 
Forward Operating Base Gardez. 

Sources: GAO; Map Resources (map). 

[End of figure] 

We also visited 8 Navy vessels at their home ports in the United 
States, selected so as to enable us to visit different types of 
vessels on which women are an integrated part of the crew, for both 
the U.S. Atlantic and U.S. Pacific Fleets. The Navy vessels we visited 
included the USS George H.W. Bush (CVN 77), USS Boxer (LHD 4), USS 
Carl Vinson (CVN 70), USS Chancellorsville (CG 62), USS Georgia (SSGN 
729), USS McClusky (FFG 41), USS Mesa Verde (LPD 19), and USS Truxtun 
(DDG 103). Table 1 provides information on the composition of the crew 
for each of the Navy vessels we visited. 

Table 1: Crew Composition for Navy Vessels Visited: 

Vessel (hull number): USS George H.W. Bush (CVN 77); 
Type: Nimitz-class Aircraft Carrier; 
Home port: Norfolk, Virginia; 
Number of personnel assigned[A]: 
Women: 464; 
Men: 1,670; 
Total: 2,134. 

Vessel (hull number): USS Boxer (LHD 4); 
Type: WASP-class Amphibious Assault Ship; 
Home port: San Diego, California; 
Number of personnel assigned[A]: 
Women: 187; 
Men: 827; 
Total: 1,014. 

Vessel (hull number): USS Carl Vinson (CVN 70); 
Type: Nimitz-class Aircraft Carrier; 
Home port: San Diego, California; 
Number of personnel assigned[A]: 
Women: 448; 
Men: 2,350; 
Total: 2,798. 

Vessel (hull number): USS Chancellorsville (CG 62); 
Type: Ticonderoga-class Guided Missile Cruiser; 
Home port: San Diego, California; 
Number of personnel assigned[A]: 
Women: 43; 
Men: 258; 
Total: 301. 

Vessel (hull number): USS Georgia (SSGN 729); 
Type: Ohio-class Guided Missile Submarine; 
Home port: Kings Bay, Georgia; 
Number of personnel assigned[A]: 
Women: 4; 
Men: 151; 
Total: 155. 

Vessel (hull number): USS Mesa Verde (LPD 19); 
Type: San Antonio-class Amphibious Transport Dock Ship; 
Home port: Norfolk, Virginia; 
Number of personnel assigned[A]: 
Women: 88; 
Men: 282; 
Total: 370. 

Vessel (hull number): USS McClusky (FFG 41); 
Type: Oliver Hazard Perry-class Frigate; 
Home port: San Diego, California; 
Number of personnel assigned[A]: 
Women: 4; 
Men: 199; 
Total: 203. 

Vessel (hull number): USS Truxtun (DDG 103); 
Type: Arleigh Burke-class Destroyer; 
Home port: Norfolk, Virginia; 
Number of personnel assigned[A]: 
Women: 55; 
Men: 218; 
Total: 273. 

Source: GAO and DOD. 

[A] Number of personnel assigned is as of the time of GAO's visit. 

[End of table] 

To determine the extent to which female-specific health care services 
are available to deployed servicewomen, we focused on the following 
female-specific health care services: clinical breast examination; 
screening mammography; diagnostic mammography; pelvic examination; PAP 
smear; treatment of patients having abnormal PAP smear results; 
treatment for disorders of the female genitals; treatment for 
disorders of menstruation; pregnancy test; and contraceptives, or 
contraceptive counseling. We also focused on female-specific 
behavioral health care services, to include mental health and 
substance abuse counseling.[Footnote 30] To determine availability of 
the services, we obtained information from health care providers 
during our site visits regarding the availability of these services at 
that location. If female-specific health care services were not 
available, we sought to understand how situations requiring the need 
for such services would be handled during deployments. In the case of 
the Navy, we also obtained information from senior officials from the 
Navy Type Commands responsible for overseeing health care units 
supporting air craft carriers, surface ships, and submarines. 

To obtain female servicemembers' perspectives on women's health and 
wellness issues, we conducted 92 one-on-one structured interviews with 
servicewomen from various pay grades and from all services during our 
site visits to 7 military installations in Afghanistan and 8 Navy 
vessels. Our objective in using this approach was to obtain female 
servicemembers' perspective on a range of women's health and wellness 
issues, such as specific health issues and challenges women might face 
in seeking medical care while deployed. Although the results of our 
discussions are not generalizable and therefore cannot be projected 
across DOD, a service, or any single location we visited, the results 
of our discussions provide insight into the perspectives of 
servicewomen regarding DOD's efforts to address the health care needs 
of deployed servicewomen. Because of the sensitivity of some of the 
information we were seeking, we took steps to assure a confidential 
environment and encourage an open discussion during these interviews. 
Only female GAO analysts conducted these interviews. 

Determining the Availability of Medical and Mental Health Care to 
Servicewomen Who Are Victims of Sexual Assault: 

To determine the extent to which medical and mental health care are 
available to servicewomen who are victims of sexual assault, we 
obtained and reviewed various documents, including legislative 
requirements and DOD's and the military services' policies and 
guidance establishing requirements for the prevention of and response 
to sexual assault. We also interviewed knowledgeable officials, 
including officials from DOD's Sexual Assault Prevention and Response 
office. We also reviewed DOD's Annual Report on Sexual Assault in the 
Military Services to identify the department's efforts to provide 
medical and mental health services to the 2,420 females who in fiscal 
year 2011 reported to DOD that they had been victims of sexual 
assault. We conducted site visits to 3 other military installations in 
the United States in addition to the 7 military installations in 
Afghanistan and the 8 Navy vessels we visited for our review, in order 
to assess the availability of medical and mental health care services 
for servicewomen who are victims of sexual assault in the military. To 
select the additional locations, we requested the military services' 
respective Sexual Assault Prevention and Response offices to identify 
locations that met select criteria. The locations we visited included 
Camp Pendleton, California; Davis-Monthan Air Force Base, Arizona; and 
Joint Base San Antonio, Texas. These locations were selected because 
they enabled us to meet with military personnel who have served as 
Sexual Assault Response Coordinators both while deployed and while at 
a military installation in the United States. During our site visits 
we met with Sexual Assault Response Coordinators, Victim Advocates, 
and health care providers. 

We visited or contacted the following organizations during our review: 

Department of Defense: 

* Defense Advisory on Women in the Services, Washington, D.C. 

* Office of the Under Secretary of Defense for Personnel and Readiness: 
- Office of the Assistant Secretary of Defense for Health Affairs, 
Arlington, Virginia: 

* Sexual Assault Prevention and Response Office, Arlington, Virginia: 

Department of the Army: 

* Office of the Army Surgeon General, Falls Church, Virginia: 
- Army Medical Command, Fort Sam Houston, Texas: 
- Army Medical Research and Materiel Command, Fort Detrick, Maryland: 

Department of the Air Force: 

* Office of the Secretary of the Air Force: 
- Office of the Assistant Secretary of the Air Force for Manpower and 
Reserve Affairs, Washington, D.C. 

* Office of the Air Force Surgeon General: 
- Air Force Medical Support Agency, Falls Church, Virginia: 

Department of the Navy: 

* Office of the Surgeon General, Washington, D.C.
- Bureau of Medicine and Surgery, Office of Women's Health, 
Washington, D.C. 

* Bureau of Naval Personnel: 
- Office of Women's Policy, Washington, D.C. 

* Commander Naval Air Force, U.S. Atlantic Fleet, Norfolk, Virginia: 

* Commander Naval Air Force, U.S. Pacific Fleet, San Diego, California: 

* Commander Naval Surface Force, U.S. Atlantic Fleet, Norfolk, 
Virginia: 

* Commander Naval Surface Force, U.S. Pacific Fleet, San Diego, 
California: 

* Commander Submarine Force, U.S. Atlantic Fleet, Norfolk, Virginia: 

* Commander Submarine Force, U.S. Pacific Fleet, Pearl Harbor, Hawaii: 

* Navy and Marine Corps Public Health Center, Portsmouth, Virginia: 

* Sexual Assault Prevention and Response Office, Washington, D.C. 

United States Marine Corps: 

* Headquarters, U.S. Marine Corps (Health Services), Arlington, 
Virginia: 

* U.S. Marine Corps Sexual Assault Prevention and Response Office, 
Quantico, Virginia: 

In Afghanistan, we visited or contacted the following organizations: 

* International Security Assistance Force Joint Command, Afghanistan: 

* Task Force Medical-Afghanistan, Afghanistan: 

* U.S. Forces Afghanistan, Afghanistan: 

We conducted this performance audit from April 2012 through January 
2013 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: Comments from the Department of Defense: 

The Assistant Secretary of Defense: 
Health Affairs: 
1200 Defense Pentagon: 
Washington, DC 20301-1200: 

January 17, 2013: 

Ms. Brenda S. Farrell: 
Director, Defense Capabilities and Management: 
U.S. Government Accountability Office: 
441 G. Street N.W. 
Washington, DC 20548: 

Dear Ms. Farrell: 

This is the Department of Defense (DoD) response to the GAO Draft 
Report, GAO-13-182, `Military Personnel: DoD Has Taken Steps to Meet 
the Health Care Needs of Deployed Servicewomen, but Actions Needed to 
Enhance Care for Sexual Assault Victims,' dated December 14, 2012 (GAO 
Code 351718)." 

Thank you for the opportunity to review and comment on the draft 
report. Overall, the department does not concur with the findings and 
conclusions of the draft report. The department's response to the 
recommendations contained in the draft report is enclosed. 

My points of contact on this issue are CAPT Michael Colston 
(functional) at (703) 6813611 and Mr. Gunther Zimmerman (audit 
liaison) at (703) 681-4360. 

Sincerely, 

Signed by: 

Jonathan Woodson, M.D. 

Enclosures: As stated. 

GAO Draft Report Dated December 14, 2012: 
GAO-13-182 (GAO Code 351718): 

"Military Personnel: DOD Has Taken Steps To Meet The Health Needs Of 
Deployed Servicewomen, But Actions Needed To Enhance Care For Sexual 
Assault Victims" 

Department Of Defense Comments To The GAO Recommendation: 

Recommendation 1: The GAO recommends that the Secretary of Defense 
direct the Under Secretary of Defense for Personnel and Readiness, to 
direct the Assistant Secretary of Defense for Health Affairs, to 
develop and implement department-level guidance on the provision of 
medical and mental health care to victims of sexual assault which 
specifies health care providers' responsibilities to respond to and 
care for sexual assault victims, whether in the United States or in 
deployed environments. 

DoD Response: DoD does not concur with this recommendation that the 
Assistant Secretary of Defense for Health Affairs (ASD-HA) develop and 
implement department-level guidance as specified in the finding. 
Coordination of the second version of DoD Instruction 6495.02 "Sexual 
Assault Prevention and Response (SAPR) Program Procedures" has been 
ongoing for nearly two years. This comprehensive instruction contains 
two medical enclosures. Enclosure 7, "Healthcare Provider Procedures," 
directs the Surgeons General of the Services "to coordinate timely 
access to emergency, follow-up, and specialty care" and "evaluate and 
implement, to the extent feasible, processes linking the medical 
management of the sexually assaulted patient to the Primary Care 
Manager." Enclosure 8 addresses healthcare providers' responsibilities 
with regard to Sexual Assault Forensic Examination (SAFE) kits. 
Healthcare addenda were vigorously studied and reviewed by medical 
specialists, administrators, and legal counsel throughout DoD and the 
Services. The instruction will be published as an Interim Federal 
Rule, and will soon be added to the CFR. Finally, ASD-HA meets its 
oversight responsibilities in regard to sexual assault response 
through training in graduate medical education and through monitoring 
and oversight of the process that governs credentialing and 
privileging of providers. 

Recommendation 2: The GAO recommends that the Secretary of Defense 
direct the Under Secretary of Defense for Personnel and Readiness, in 
collaboration with the military departments, to take steps to improve 
compliance with completing annual refresher training on sexual assault 
prevention and response. 

DoD Response: DoD concurs with Recommendation 2. 

[End of section] 

Appendix III: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Brenda S. Farrell, (202) 512-3604 or farrellb@gao.gov: 

Acknowledgments: 

In addition to the contact named above, key contributors to this 
report include David E. Moser (Assistant Director), Wesley A. Johnson, 
Ronald La Due Lake, Kim Mayo, Amanda Miller, Sharon Reid, Cheryl A. 
Weissman, and K. Nicole Willems. In addition, Carole F. Coffey, Kasea 
Hamar, David W. Hancock, and Tamiya R. Lunsford provided assistance 
during site visits. 

[End of section] 

Footnotes: 

[1] Pub. L. No. 112-81, § 725 (2011). 

[2] DOD Health Care: Domestic Health Care for Female Servicemembers, 
[hyperlink, http://www.gao.gov/products/GAO-13-205] (Washington, D.C.: 
Jan. 29, 2013). 

[3] The American College of Obstetricians and Gynecologists is a 
national organization that develops guidelines for clinical practice 
for women's health care services. 

[4] See, for example, VA Health Care: VA Has Taken Steps to Make 
Services Available to Women Veterans, but Needs to Revise Key Policies 
and Improve Oversight Processes, [hyperlink, 
http://www.gao.gov/products/GAO-10-287] (Washington, D.C.: Mar. 31, 
2010); Defense Health Care: Health Care Benefit for Women Comparable 
to Other Plans, [hyperlink, http://www.gao.gov/products/GAO-02-602] 
(Washington, D.C.: May 1, 2002); and Gender Issues: Medical Support 
for Female Soldiers Deployed to Bosnia, [hyperlink, 
http://www.gao.gov/products/GAO/NSIAD-99-58] (Washington, D.C.: Mar. 
10, 1999). 

[5] During these assessments we learned that not all medical encounter 
data are documented electronically during deployments to Afghanistan 
and aboard Navy vessels, and therefore may be underreported. DOD 
officials noted this, and an official from the Office of the Navy 
Surgeon General identified steps the Navy is taking to increase 
electronic documentation of data on servicemembers' medical encounters 
aboard Navy vessels. 

[6] We did not focus on abortion services because, by law, funds 
available to DOD may not be used to perform abortions except where the 
life of the mother would be endangered if the fetus were carried to 
term or in a case in which the pregnancy is the result of an act of 
rape or incest. Additionally, by law, no DOD facility may be used to 
perform an abortion except where the life of the mother would be 
endangered if the fetus were carried to term or in a case in which the 
pregnancy is the result of an act of rape or incest. See 10 U.S.C. 
§1093. 

[7] Department of Defense Directive 6495.01, Sexual Assault Prevention 
and Response (SAPR) Program (Jan. 23, 2012). According to DOD's Sexual 
Assault Prevention and Response office, the department has proposed a 
revision to the definition of sexual assault in the directive to align 
it with the changes made to the Uniform Code of Military Justice by 
section 541 of the National Defense Authorization Act for fiscal year 
2012. 

[8] U.S. Department of Justice, Office on Violence Against Women, A 
National Protocol for Sexual Assault Medical Forensic Examinations, 
Adults/Adolescents (September 2004). 

[9] Military Personnel: Prior GAO Work on DOD's Actions to Prevent and 
Respond to Sexual Assault in the Military, [hyperlink, 
http://www.gao.gov/products/GAO-12-571R] (Washington, D.C.: Mar. 30, 
2012). 

[10] DOD also conducts medical screening and collects health care data 
on the medical services provided to deployed servicemen. The focus of 
this report, however, is on the health care services provided to 
deployed servicewomen. 

[11] The Joint Commission is an independent, not-for-profit 
organization that accredits and certifies health care organizations 
and programs in the United States. 

[12] The Defense Advisory Committee on Women in the Services was 
established in 1951 and is composed of civilian women and men who are 
appointed by the Secretary of Defense to provide advice and 
recommendations on matters and policies relating to the recruitment 
and retention, treatment, employment, integration, and well-being of 
highly qualified professional women in the Armed Forces. 

[13] The TriService Nursing Research Program funds and supports 
scientific research in the field of military nursing in order to 
advance military nursing science and optimize the health of military 
members and their families. 

[14] The service components utilize a variety of systems to capture 
information from medical encounters during deployments. However, not 
all information from medical encounters is documented electronically, 
and some information is accessible only by reviewing an individual's 
paper medical record. 

[15] U.S. Central Command's area of operations include Afghanistan, 
Bahrain, Egypt, Iran, Iraq, Jordan, Kazakhstan, Kuwait, Kyrgyzstan, 
Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, Tajikistan, 
Turkmenistan, United Arab Emirates, Uzbekistan, and Yemen. 

[16] The International Classification of Diseases codes are designed 
to promote comparability in the collection, processing, and 
classification of diseases and are used in assigning coded diagnoses 
associated with inpatient, outpatient, and physician office 
utilization. 

[17] The Armed Forces Health Surveillance Center was established in 
February 2008 by the Deputy Secretary of Defense to be the central 
epidemiological health resource for the U.S. Military. 

[18] The Role-3 facilities include one facility run by the Air Force, 
one by the United Kingdom, and three under the auspices of the North 
Atlantic Treaty Organization. 

[19] Independent Duty Hospital Corpsmen are enlisted personnel who, 
when certified, serve as health care providers under the indirect 
supervision of a physician. 

[20] Specifically, during our site visits we asked health care 
officials about the availability of the following female-specific 
health care services: clinical breast examination; screening 
mammography; diagnostic mammography; pelvic examination; PAP smear; 
treatment of patients having abnormal PAP smear results; treatment for 
disorders of the female genitals; treatment for disorders of 
menstruation; pregnancy test; and contraceptives, or contraceptive 
counseling. 

[21] According to DOD Directive 6495.01, Sexual Assault Response 
Coordinators are the single point of contact at an installation or 
within a geographic area who oversees sexual assault awareness, 
prevention, and response training; coordinates medical treatment, 
including emergency care, for victims of sexual assault; and tracks 
the services provided to a victim of sexual assault from the initial 
report through final disposition and resolution. Victim Advocates are 
personnel who shall provide non-clinical crisis intervention, 
referral, and ongoing non-clinical support to adult sexual assault 
victims, including providing information on available options and 
resources to victims. 

[22] GAO, Military Justice: Oversight and Better Collaboration Needed 
for Sexual Assault Investigations and Adjudications, [hyperlink, 
http://www.gao.gov/products/GAO-11-579] (Washington, D.C.: June 22, 
2011). 

[23] Department of Defense, Fiscal Year 2011 Annual Report on Sexual 
Assault in the Military (April 2012). 

[24] Department of Defense Directive 6495.01, Sexual Assault 
Prevention and Response (SAPR) Program (Oct. 6, 2005). DOD released 
revisions to its Directive in January 2012. 

[25] Department of Defense Instruction 6495.02, Sexual Assault 
Prevention and Response Program Procedures (June 23, 2006). 

[26] Department of Defense Directive 5136.01, Assistant Secretary of 
Defense for Health Affairs (ASD(HA)) (June 4, 2008). 

[27] DOD identifies first responders as personnel in the following 
disciplines or positions: Sexual Assault Response Coordinators, Victim 
Advocates, health care personnel, law enforcement personnel, judge 
advocates, and chaplains. 

[28] Department of Defense, Fiscal Year 2011 Annual Report on Sexual 
Assault in the Military (April 2012). 

[29] During our assessments we learned that not all medical encounter 
data are documented electronically during deployments to Afghanistan 
and aboard Navy vessels, and therefore may be underreported. DOD 
officials noted this, and an official from the Office of the Navy 
Surgeon General identified steps the Navy is taking to increase 
electronic documentation of data on servicemembers' medical encounters 
aboard Navy vessels. 

[30] We did not focus on abortion services because, by law, funds 
available to DOD may not be used to perform abortions except where the 
life of the mother would be endangered if the fetus were carried to 
term or in a case in which the pregnancy is the result of an act of 
rape or incest. Additionally, by law, no DOD facility may be used to 
perform an abortion except where the life of the mother would be 
endangered if the fetus were carried to term or in a case in which the 
pregnancy is the result of an act of rape or incest. See 10 U.S.C. 
§1093. 

[End of section] 

GAO’s Mission: 

The Government Accountability Office, the audit, evaluation, and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the 
performance and accountability of the federal government for the 
American people. GAO examines the use of public funds; evaluates 
federal programs and policies; and provides analyses, recommendations, 
and other assistance to help Congress make informed oversight, policy, 
and funding decisions. GAO’s commitment to good government is 
reflected in its core values of accountability, integrity, and 
reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO’s website [hyperlink, http://www.gao.gov]. Each 
weekday afternoon, GAO posts on its website newly released reports, 
testimony, and correspondence. To have GAO e-mail you a list of newly 
posted products, go to [hyperlink, http://www.gao.gov] and select 
“E-mail Updates.” 

Order by Phone: 

The price of each GAO publication reflects GAO’s actual cost of 
production and distribution and depends on the number of pages in the 
publication and whether the publication is printed in color or black 
and white. Pricing and ordering information is posted on GAO’s 
website, [hyperlink, http://www.gao.gov/ordering.htm]. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 
TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card, 
MasterCard, Visa, check, or money order. Call for additional 
information. 

Connect with GAO: 

Connect with GAO on facebook, flickr, twitter, and YouTube.
Subscribe to our RSS Feeds or E mail Updates. Listen to our Podcasts.
Visit GAO on the web at [hyperlink, http://www.gao.gov]. 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 
Website: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]; 
E-mail: fraudnet@gao.gov; 
Automated answering system: (800) 424-5454 or (202) 512-7470. 

Congressional Relations: 

Katherine Siggerud, Managing Director, siggerudk@gao.gov: 
(202) 512-4400: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7125: 
Washington, DC 20548. 

Public Affairs: 
Chuck Young, Managing Director, youngc1@gao.gov: 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, DC 20548. 

[End of document]