This is the accessible text file for GAO report number GAO-13-205 entitled 'DOD Health Care: Domestic Health Care for Female Servicemembers' 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: DOD Health Care: Domestic Health Care for Female Servicemembers: GAO-13-205: GAO Highlights: Highlights of GAO-13-205, a report to congressional addressees. Why GAO Did This Study: Female servicemembers are serving in more complex occupational specialties and are being deployed to combat operations, potentially leading to increased health risks. Similar to their male counterparts, female servicemembers must maintain their medical readiness; however, they have unique health care needs that require access to gender- specific services. The National Defense Authorization Act for Fiscal Year 2012 directed GAO to review a variety of issues related to health care for female servicemembers. This report describes (1) the extent that DOD’s policies for assessing individual medical readiness include unique health care issues of female servicemembers; (2) the availability of health care services to meet the unique needs of female servicemembers at domestic Army installations; and (3) the extent that DOD’s research organizations have identified a need for research on the specific health care needs of female servicemembers who have served in combat. GAO reviewed DOD and military-service policies on individual medical readiness and surveyed senior health care officials about the availability of specific health services at the 27 domestic Army installations with MTFs that report directly to the domestic regional medical commands. GAO focused on the Army because it has more female servicemembers than the other military services. GAO also visited six Army installations—-two from each of the Army’s three domestic regional medical commands-—and interviewed DOD officials who conduct research on health issues for servicemembers. What GAO Found: The Department of Defense’s (DOD) policy for assessing the individual medical readiness of a servicemember to deploy establishes six elements to review, most of which are gender-neutral. Four of the six elements—-immunization status, medical readiness laboratory tests, individual medical equipment, and dental readiness-—apply equally to female and male servicemembers. The remaining elements of individual medical readiness-—deployment-limiting conditions and periodic health assessments-—include aspects that are specific to female servicemembers. For example, the Army, Navy, Air Force, and Marine Corps have policies that define pregnancy as a deployment-limiting condition. Officials surveyed by GAO reported that female-specific health care services and behavioral health services were generally available through domestic Army installations. Specifically, according to GAO’s survey results: * Most routine female-specific health care services—-pelvic examinations, clinical breast examinations, pap smears, prescription of contraceptives, and pregnancy tests—-were available at the 27 surveyed domestic Army installations. * The availability of specialized health care services—-treatment of abnormal pap smears, prenatal care, labor and delivery, benign gynecological disorders, postpartum care, and surgical, medical, and radiation treatment of breast, ovarian, cervical, and uterine cancers—- at the 27 surveyed domestic Army installations varied. However, when these services were not available at the installation, they could be obtained through either another military treatment facility (MTF) or from a civilian network provider. * The availability of behavioral health services, such as psychotherapy or substance abuse treatment, which were not gender- specific, varied across the 27 domestic Army installations; however, similar to specialty care, these services could be obtained from other MTFs or civilian network providers. In addition, 18 of the 27 surveyed Army installations reported offering female-specific programs or activities, such as a post-deployment group for female servicemembers or a postpartum group. One DOD organization, the Women’s Health Research Interest Group, is currently in the process of identifying research gaps on health issues affecting female servicemembers. Interest group officials said that the goal is to develop a repository for peer-reviewed research articles related to health issues for female servicemembers, including those who served in combat, and to use this repository to identify research that could enhance the health care of female servicemembers, including those who have served in a combat zone. To ensure that researchers will have access to the results of their work, officials have plans to distribute their results in presentations at local and national conferences. In addition, officials told GAO that they will disseminate their findings through peer-reviewed publications and post this information on the Internet to make it available to the public. GAO provided a draft of this report to DOD for comment. DOD responded that it did not have any comments on the draft report. View [hyperlink, http://www.gao.gov/products/GAO-13-205]. For more information, contact Randall B. Williamson, 202-512-7114, williamsonr@gao.gov. [End of section] Contents: Letter: Background: DOD's Policies for Assessing Individual Medical Readiness Are Mainly Gender-Neutral but Include Some Aspects That Are Female-Specific: Health Care and Behavioral Health Services Were Generally Available to Female Servicemembers through Domestic Army Installations: One DOD Organization Is in the Process of Identifying Research Gaps on Health Care Needs for Female Servicemembers: Agency Comments: Appendix I: List of Domestic Army Installations with a Primary Military Treatment Facility: Appendix II: Scope and Methodology for the Survey Sent to Domestic Army Military Treatment Facilities: Appendix III: GAO Survey Sent to Domestic Army Military Treatment Facilities: Appendix IV: GAO Contact and Staff Acknowledgments: Tables: Table 1: Availability of Female-Specific Specialized Health Care Services at the 27 Domestic Army Installations, by Primary Military Treatment Facility Type: Table 2: Number of Domestic Army Installations with a Primary Military Treatment Facility That Offered Behavioral Health Services, by Type and Source of Service: Table 3: Number of Domestic Army Installations with a Primary Military Treatment Facility That Offered Behavioral Health Services for Substance Abuse, by Type and Source of Service: Figures: Figure 1: Number of Active-Duty Female Servicemembers, by Military Service, Fiscal Year 2007 through 2012: Figure 2: Active-Duty Army Female Servicemembers by Age Group: Abbreviations: DOD: Department of Defense: IMR: individual medical readiness: MEDCOM: Army Medical Command: MEDPROS: Medical Protection System: MTF: military treatment facility: NIH: National Institutes of Health: PHA: periodic health assessment: PTSD: post-traumatic stress disorder: [End of section] United States Government Accountability Office: Washington, DC 20548: January 29, 2013: Congressional Addressees: The role of women in the military is changing. Over the last four decades, the percentage of female servicemembers among enlisted ranks has increased seven-fold (from 2 to 14 percent) and the percentage of female servicemembers among commissioned officers has increased four- fold (from 4 to 16 percent). Currently, the largest total number of female servicemembers resides in the Army. Female servicemembers also are serving in more complex occupational specialties and are being deployed to combat operations, potentially leading to increased health risks. Similar to their male counterparts, female servicemembers must maintain their medical readiness by ensuring that they are free of health-related conditions that would limit their ability to actively fulfill an assigned mission. Female servicemembers also have unique health care needs that require access to gender-specific services, including routine gynecological care, such as breast and cervical examinations, as well as specialized services, such as obstetric care (which includes prenatal, labor and delivery, and postpartum care) and the treatment of reproductive cancers. Additionally, while all servicemembers need access to a range of behavioral health services, such as individual or group therapy sessions, men and women may be affected by behavioral health conditions differently.[Footnote 1] Servicemembers receive health care services through the Department of Defense's (DOD) Military Health System, which has a dual health care mission of supporting wartime and other deployments, known as the readiness mission, and providing peacetime care, known as the benefits mission. The National Defense Authorization Act for Fiscal Year 2012 directed us to review a variety of issues related to health care for female servicemembers, including the availability of female-specific health care and behavioral health services, as well as the need for further clinical research on the health care needs of female servicemembers who have served in a combat zone, among other issues.[Footnote 2] In this report, we describe (1) the extent that DOD's policies for assessing individual medical readiness (IMR) include unique health care issues of female servicemembers; (2) the availability of health care services to meet the unique needs of female servicemembers at domestic Army installations; and (3) the extent that DOD's research organizations have identified a need for research on the specific health care needs of female servicemembers who have served in combat. While this report focuses on domestic installations, a separate report will provide information on the availability of health care for female servicemembers in deployed environments and for servicemembers who are victims of sexual assault.[Footnote 3] To describe the extent to which DOD's policies for assessing IMR include unique health care issues of female servicemembers, we reviewed IMR policies for DOD and each of the military services--Army, Navy, Air Force, and Marine Corps--to determine whether these assessments include female-specific information and to identify any potential variations among the military services.[Footnote 4] We also interviewed DOD and military service officials about the IMR assessments that are conducted prior to deployment to identify any specific health care issues related to female servicemembers. To describe the availability of health care services to meet the unique needs of female servicemembers at domestic Army installations [Footnote 5]--the military service with the largest number of female servicemembers--we surveyed senior health care officials at the 27 domestic Army installations[Footnote 6] that had a primary military treatment facility (MTF).[Footnote 7] (To see a list of the 27 domestic Army installations with a primary MTF, see app. I.) Through this survey, we obtained information about the availability of routine, specialized, and behavioral health services for female servicemembers from all MTFs at these installations, including the primary MTFs and other, smaller MTFs, such as clinics.[Footnote 8] (For more details about the survey methodology and a copy of the survey, see appendix II and III.) Additionally, we asked the officials to report on services available for these female servicemembers from other sources, including MTFs outside the installation and civilian network providers, and challenges associated with ensuring physical privacy. Through this survey, health care officials at the 27 domestic Army installations reported on the availability of health care services at these installations, to which more than two-thirds of the Army's female servicemembers were attached as of August 1, 2012. [Footnote 9] To supplement information collected in the survey, we also conducted site visits to six domestic Army installations--two installations in each of the medical regions and two of each type of MTF that serves as the primary MTF[Footnote 10]--to interview officials in charge of routine, specialized, and behavioral health services. We also spoke with officials about policies related to physical privacy and observed the physical space used for health care delivery for female servicemembers. We visited MTFs at Fort Benning, Georgia; Fort Gordon, Georgia; Fort Huachuca, Arizona; Fort Lee, Virginia; Fort Lewis, Washington; and Fort Meade, Maryland. Additionally, during our site visits, we conducted individual interviews with 39 female servicemembers about available health care services, including questions about physical privacy. Specifically, we interviewed six to eight women at each location who: * were either an enlisted servicemember or an officer; * did not work at any of the MTFs on the installation; and: * had previously deployed. The views expressed by these servicemembers cannot be generalized to all female Army servicemembers. To describe the extent to which DOD's research organizations identified a need for research on the specific health care needs of female servicemembers who have served in combat, we interviewed officials from specific DOD research organizations that fund or conduct research involving individuals who have served in a combat zone. This includes the Defense Health Program from the Office of the Assistant Secretary of Defense for Health Affairs, as well as organizations for the three military departments, such as the U.S. Army Medical Research and Materiel Command. Additionally, we interviewed officials from other DOD research organizations, including the TriService Nursing Research Program and its Women's Health Research Interest Group. We also reviewed documentation about research currently underway and descriptions on how these organizations determine what research to fund or conduct. We conducted this performance audit from April 2012 through January 2013 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Background: From fiscal year 2007 through 2012, the total number of female servicemembers has grown from 200,941 to 208,905, with female servicemembers comprising about 14 percent of the total active duty force. During this time, the largest number of active-duty female servicemembers resided in the Army.[Footnote 11] (See figure 1.) Figure 1: Number of Active-Duty Female Servicemembers, by Military Service, Fiscal Year 2007 through 2012: [Refer to PDF for image: multiple line graph] Fiscal year: 2007; Army: 71,100; Navy: 48,755; Marine Corps: 11,706; Air Force: 64,430. Fiscal year: 2008; Army: 73,272; Navy: 48,930; Marine Corps: 12,290; Air Force: 63,273. Fiscal year: 2009; Army: 73,771; Navy: 50,090; Marine Corps: 12,964; Air Force: 64,063. Fiscal year: 2010; Army: 75,507; Navy: 51,385; Marine Corps: 13,493; Air Force: 63,310. Fiscal year: 2011; Army: 76,015; Navy: 52,416; Marine Corps: 13,691; Air Force: 62,592. Fiscal year: 2012; Army: 73,495; Navy: 53,151; Marine Corps: 13,991; Air Force: 62,239. Source: Defense Manpower Data Center. Note: The Coast Guard is not included in this figure. Data are as of September 30, 2012. [End of figure] In fiscal year 2012, more than three-quarters of the Army's female servicemember population was age 35 and under, with the largest group being between 18 and 24 years old. Recommendations for female-specific preventative health screenings are based on age, such as cervical cancer screening, which would be applicable for female servicemembers from an early age, while others, such as mammograms, are currently not recommended until age 50, absent any personal history of health problems of this nature.[Footnote 12] (See figure 2.) Figure 2: Active-Duty Army Female Servicemembers by Age Group: [Refer to PDF for image: pie-chart] Over age 45: 4%; Age 41-45: 7%; Age 36-40: 10%; Age 30-35: 19%; Age 25-29: 26%; Age 18-24: 34%; Under age 18: 0.09%. Source: Defense Manpower Data Center. Note: Due to rounding, the percentages do not add up to 100. Data are as of September 30, 2012. [End of figure] The Military Health System: DOD operates its own large, complex health system--the Military Health System--that provides health care to approximately 9.7 million beneficiaries across a range of venues, from MTFs located on military installations to the battlefield.[Footnote 13] These beneficiaries include active-duty servicemembers and their dependents, eligible National Guard and Reserve servicemembers and their dependents, and retirees and their dependents or survivors. The Military Health System has a dual health care mission: supporting wartime and other deployments, known as the readiness mission, and providing peacetime care, known as the benefits mission. The readiness mission provides medical services and support to the armed forces during military operations and involves deploying medical personnel and equipment, as needed, around the world to support military forces. The benefits mission provides medical services and support to members of the armed forces, their family members, and others eligible for DOD health care. The care of the eligible beneficiary population is spread across the military departments--Army, Navy, and Air Force. Each military department delivers care directly through its own MTFs, which are managed by their medical departments, including: * the Army's Medical Command (MEDCOM); * the Navy's Bureau of Medicine and Surgery, which is also responsible for providing health care to members of the Marine Corps and their beneficiaries; and: * the Air Force Medical Service. Servicemembers obtain health care through the military services' system of MTFs, which is supplemented by participating civilian health care providers, institutions, and pharmacies to facilitate access to health care services when necessary. Active-duty servicemembers receive most of their care from MTFs, where they receive priority access over other beneficiaries. Army MTFs: Within the continental United States, the Army is organized into three medical regions--Northern, Southern, and Western--each headed by a subordinate regional medical command, which exercises authority over the MTFs in its region. Across the three regions, there are 27 domestic Army installations with a primary MTF, which report directly to the regional medical commands and are responsible for reporting information for other associated MTFs, which may include smaller MTFs, such as clinics, on the same installation, as well as MTFs on different Army installations or at installations operated by other military services. For example, at Fort Benning, there are multiple facilities located on the installation, including Martin Army Community Hospital--the primary MTF--as well as several clinics. In addition to reporting for all of those facilities, Martin Army Community Hospital also reports to the regional medical command for other Army facilities located off the installation, including an Army clinic at Eglin Air Force Base in Florida. All Army MTFs, both primary and associated, can be classified under one of three categories on the basis of their size: * Army Health Centers/Clinics are generally the smallest facilities only offering outpatient primary care.[Footnote 14] * Army Community Hospitals are larger than clinics and offer primary and secondary care, such as inpatient care and surgery under anesthesia. * Army Medical Centers are generally the largest facilities offering primary and secondary care as well as other care, such as cancer treatments, neonatal care, and specialty diagnostics. Individual Medical Readiness: Each of the military services is responsible for maintaining the medical readiness of its active-duty force. DOD's IMR policy establishes six elements for the military services to assess in order to determine a servicemember's medical readiness to deploy: 1. dental readiness, 2. deployment-limiting conditions, 3. immunization status, 4. individual medical equipment,[Footnote 15] 5. medical readiness laboratory tests, and: 6. periodic health assessments (PHA). DOD's policy establishes a baseline of standards for continuously assessing each of the IMR elements. In addition to this, each of the military services establishes its own policy that may include more specific criteria. Each military service is responsible for assessing and categorizing a servicemember's IMR as follows: * Fully medically ready, current in all categories. * Partially medically ready, lacking one or more immunizations, readiness laboratory tests, or medical equipment. * Not medically ready, existence of a chronic or prolonged deployment- limiting condition, including servicemembers who are hospitalized or convalescing from serious illness or injury, or individuals who require urgent dental care. * Medical readiness indeterminate, inability to determine the servicemember's current health status because of missing health information such as a lost medical record, an overdue PHA, or an overdue dental exam. All of the military services use different systems to collect information about IMR status.[Footnote 16] In addition, DOD requires that each of the services provide quarterly reports about the IMR status of their servicemembers. Research Organizations: DOD and the military services have a number of organizations that fund or conduct research, including research on health care issues that affect those who have served in a combat zone. The Defense Health Program within DOD's Office of the Assistant Secretary of Defense for Health Affairs receives significant funding for this research through its annual appropriation.[Footnote 17] Through an interagency agreement, the Army Medical Research and Materiel Command manages the day-to-day execution of this funding through joint program committees. There are several joint program committees that focus on specific research areas, including clinical and rehabilitative medicine and military operational medicine.[Footnote 18] Officials from the other military services participate in these committees. Research organizations from the military services, such as the Naval Medical Research Center, the Office of Naval Research, and the Air Force Medical Support Agency, also manage funds from the Defense Health Program for research. In addition to the military services, other organizations within DOD also fund or conduct research, including the TriService Nursing Research Program, which funds and supports research on military nursing. DOD's Policies for Assessing Individual Medical Readiness Are Mainly Gender-Neutral but Include Some Aspects That Are Female-Specific: DOD's policy establishes six elements for assessing the IMR of a servicemember to deploy, most of which are gender-neutral. Four of the six elements--immunization status, medical readiness laboratory tests, individual medical equipment, and dental readiness--are gender- neutral; they apply equally to female and male servicemembers. In order to pass these elements of the IMR assessment, servicemembers must be current for each element, by having: * immunizations, including MMR (measles, mumps, and rubella); * medical readiness laboratory tests, such as a human immunodeficiency virus test and results current within the past 24 months; * individual medical equipment, such as gas mask inserts for all personnel needing visual correction; and: * an annual dental exam.[Footnote 19] The remaining elements of IMR--deployment-limiting conditions and PHAs--include some aspects that are specific to female servicemembers. The Army, Navy, Air Force, and Marine Corps have policies that define pregnancy as a deployment-limiting condition. In addition, they also have policies that establish a postpartum deferment period--generally 6 months after delivery[Footnote 20]--when a female servicemember is not required to deploy. The deferment period was established in order to provide for medical recovery from childbirth and to allow additional time to prepare family care plans and child care. However, each of the military services has a policy that allows the servicemember to voluntarily deploy before the period has expired. In addition, cancer that requires continuing treatment and specialty evaluations can also be a deployment-limiting condition. Although cancer treatment could affect both male and female servicemembers, there are some cancers that would be specific to female servicemembers, such as ovarian cancer, while other cancers are specific to male servicemembers, such as prostate cancer. The PHA includes a review of information about preventative screenings and counseling for each servicemember. Some of the preventative screenings that are reviewed as part of the PHA are female-specific, such as mammograms and pap smears. To satisfy this element of IMR, a servicemember's PHA must be current--the assessment of any changes in health status must have occurred within the past year--for both female and male servicemembers.[Footnote 21] The results of these preventative screenings do not negatively affect this element of a servicemember's readiness assessment even when follow-on studies, labs, referrals or additional visits may be pending or planned. [Footnote 22] Nonetheless, these screenings could identify a health issue that would be considered a deployment-limiting condition--a separate element of IMR--and could therefore limit readiness. For example, the results of a mammogram may identify cancer that requires treatment or specialized medical evaluations that could be determined to be a deployment-limiting condition. Health Care and Behavioral Health Services Were Generally Available to Female Servicemembers through Domestic Army Installations: Routine and Specialized Female-Specific Health Care Services Were Generally Available at the Domestic Army Installations We Reviewed or from Other Sources: On the basis of our survey, we found that most routine female-specific health care services--including pelvic examinations, clinical breast examinations, pap smears, screening mammographies, prescription of contraceptives, and pregnancy tests--were available through the MTFs at the 27 domestic Army installations with a primary MTF.[Footnote 23] Screening mammography services were not available at two of these installations; however, in those instances, this service was available from a civilian network provider. Senior health care officials at all of the 27 domestic installations we surveyed reported that both male and female providers were available to perform routine services for female servicemembers with the exception of mammography, which varied; however, all of the installations that made this service available (25 of 27) had female technicians.[Footnote 24] At the 6 installations that we visited, 21 of the 39 female servicemembers we interviewed told us that they did not have a gender preference for their providers, while 14 said that they did have a preference that was accommodated. The remaining 4 female servicemembers we interviewed stated that they had asked for a female provider, but the request could not be immediately accommodated. One female servicemember was told that she would have to wait 3 months to see a female provider, so she opted to see a male provider. On the basis of our survey, the availability of specialized health care services varied by the type of primary MTF on the domestic Army installation; however, when services were not available at the installation, they were available through other MTFs or from a civilian network provider.[Footnote 25] Specifically, more types of specialized health care services were available on installations with a larger Army Medical Center as the primary MTF than at installations with a smaller Army Health Center/Clinic. For example, none of the installations where the primary MTF was an Army Health Center/Clinic offered surgical, medical, or radiation treatments for breast, ovarian, cervical, and uterine cancers, whereas some installations where the primary MTFs were Army Community Hospitals and Army Medical Centers did make these treatments available. (See table 1.) Additionally, both male and female providers were available to provide specialized female-specific services--such as treatment of abnormal pap smear, prenatal care, labor and delivery, benign gynecological disorders, and postpartum care--that were offered at the 27 domestic Army installations. Table 1: Availability of Female-Specific Specialized Health Care Services at the 27 Domestic Army Installations, by Primary Military Treatment Facility Type: Specialized health care service: Treatment of abnormal pap smear; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 5 (71%); Army Community Hospital (n=14): 14 (100%); Army Medical Center (n=6): 6 (100%). Specialized health care service: Prenatal care; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 1 (14%); Army Community Hospital (n=14): 13 (93%); Army Medical Center (n=6): 6 (100%). Specialized health care service: Labor and delivery; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 1 (14%); Army Community Hospital (n=14): 12 (86%); Army Medical Center (n=6): 5 (83%). Specialized health care service: Benign gynecological disorders; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 7 (100%); Army Community Hospital (n=14): 14 (100%); Army Medical Center (n=6): 6 (100%). Specialized health care service: Postpartum care; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 5 (71%); Army Community Hospital (n=14): 13 (93%); Army Medical Center (n=6): 6 (100%). Specialized health care service: Diagnostic mammography; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 2 (29%); Army Community Hospital (n=14): 14 (100%); Army Medical Center (n=6): 6 (100%). Specialized health care service: Surgical treatment of breast cancer; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 0 (0); Army Community Hospital (n=14): 11 (79%); Army Medical Center (n=6): 6 (100%). Specialized health care service: Medical treatment of breast cancer; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 0 (0); Army Community Hospital (n=14): 3 (21%); Army Medical Center (n=6): 5 (83%). Specialized health care service: Radiation treatment of breast cancer; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 0 (0); Army Community Hospital (n=14): 0 (0); Army Medical Center (n=6): 2 (33%). Specialized health care service: Surgical treatment of ovarian, cervical, uterine cancer; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 0 (0); Army Community Hospital (n=14): 7 (50%); Army Medical Center (n=6): 3 (50%). Specialized health care service: Medical treatment of ovarian, cervical, uterine cancer; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 0 (0); Army Community Hospital (n=14): 2 (14%); Army Medical Center (n=6): 4 (67%). Specialized health care service: Radiation treatment of ovarian, cervical, uterine cancer; Type of primary military treatment facility on the installation: Army Health Center/Clinic (n=7): 0 (0); Army Community Hospital (n=14): 0 (0); Army Medical Center (n=6): 3 (50%). Source: GAO. Note: Data are from GAO's survey of the 27 domestic Army installations with a primary military treatment facility. [End of table] In addition, when asked about the availability of other programs, officials from 25 of the 27 domestic Army installations we surveyed reported offering female-specific health care programs or activities, including female-specific groups for breast cancer, pregnancy education, pregnancy physical training, postpartum care, women's clinics, and health care fairs. Five of the six installations that we visited reported having female-specific programs, such as breast cancer awareness activities, lactation consultants, a women's clinic or health care team, annual women's health care fair, and a pregnancy physical training program. With respect to privacy for individuals, including female servicemembers, who seek care at domestic Army MTFs, Army MEDCOM officials noted that reasonable safeguards should be in place to limit incidental, and avoid prohibited, uses and disclosures of information. [Footnote 26] For example, cubicles, dividers, shields, curtains, or similar barriers should be utilized in an area where multiple patient- staff communications routinely occur. DOD provides space-planning criteria for health facilities that assert that private space be made available to counsel patients, including facilities for outpatient women's health services. When asked to report on the challenges MTFs face in ensuring the physical privacy of female servicemembers, senior health care officials at most domestic Army installations (18 of 27) we surveyed did not report examples of any challenges. However, officials from the remaining nine installations cited two privacy-related challenges-- physical layout of the exam rooms and auditory issues. For example, officials from three installations reported that some exam rooms were configured such that some examination tables face the door. Officials from two of these installations reported the use of a privacy curtain to overcome this room limitation. Nonetheless, all of the female servicemembers that we interviewed at the six sites that we visited felt that adequate steps were taken to ensure their physical privacy during health care visits. Officials from another installation reported on the survey that the layout of a waiting room may allow for conversations at the reception desk to be overheard, which may compromise patient privacy. Additionally, 3 of the 39 female servicemembers that we interviewed stated that they had concerns regarding auditory privacy in the waiting or exam rooms. At three of the six installations that we visited, we observed clinics that had waiting areas with separate check-in bays, such as those for walk-in appointments, pharmacy, and laboratory tests. The separation of these check-in areas spread people out and provided more distance between those checking in and those sitting in the waiting rooms. While Not Inherently Gender-Specific, Availability of Behavioral Health Services at Domestic Army Installations Varied but Was Offered from Other Sources: Behavioral health illnesses affect both men and women, and with the exception of postpartum depression, are not easily distinguished by gender. Consequently, behavioral health services are not inherently gender-specific. Behavioral health services were provided in a variety of settings, such as through outpatient, inpatient, residential, and telebehavioral settings. We found in our survey that the availability of behavioral health services at domestic Army installations varied; however, when these services were not available at the installation, they were available from other sources, including from other MTFs or from civilian network providers. (See table 2.) All of the 27 domestic Army installations we surveyed offered individual and group outpatient treatments, and most (23 of 27) offered family outpatient treatment. If treatments were not available at the installation, they were offered from another MTF or a civilian network provider. About one- third (10 of 27) of domestic Army installations offered inpatient treatment, and fewer offered residential treatment (5 of 27). Table 2: Number of Domestic Army Installations with a Primary Military Treatment Facility That Offered Behavioral Health Services, by Type and Source of Service: Behavioral health service: Individual outpatient treatment; Available at the installation: 27; Available from another military treatment facility (off the installation): 18; Available from a civilian network provider: 25. Behavioral health service: Family outpatient treatment; Available at the installation: 23; Available from another military treatment facility (off the installation): 12; Available from a civilian network provider: 25. Behavioral health service: Group outpatient treatment; Available at the installation: 27; Available from another military treatment facility (off the installation): 16; Available from a civilian network provider: 24. Behavioral health service: Inpatient treatment; Available at the installation: 10; Available from another military treatment facility (off the installation): 15; Available from a civilian network provider: 25. Behavioral health service: Residential treatment; Available at the installation: 5; Available from another military treatment facility (off the installation): 14; Available from a civilian network provider: 24. Source: GAO. Note: Data are from GAO's survey of the 27 Army domestic installations with a primary military treatment facility, 2012. Survey respondents were asked to report on the availability of a behavioral health service from each of these sources for female servicemembers at their installation. Services may be available from more than one source, so the totals are not mutually exclusive. [End of table] In addition to general behavioral health services, all of the domestic Army installations included in our survey offered some type of behavioral health services for substance abuse. (See table 3.) With regard to the availability of substance abuse treatment options, all 27 domestic Army installations we surveyed offered individual outpatient treatment. All but one domestic Army installation offered group outpatient treatment and more than a third (11 of 27) offered family outpatient treatment. Few domestic Army installations offered inpatient treatment (5 of 27) or residential treatment (4 of 27) for substance abuse. If these treatments were not available on the installations, they were available from another MTF, a civilian network provider, or both. Table 3: Number of Domestic Army Installations with a Primary Military Treatment Facility That Offered Behavioral Health Services for Substance Abuse, by Type and Source of Service: Behavioral health service for substance abuse: Individual outpatient treatment for substance abuse; Available at the installation: 27; Available from another military treatment facility (off the installation): 18; Available from a civilian network provider: 23. Behavioral health service for substance abuse: Family outpatient treatment for substance abuse; Available at the installation: 11; Available from another military treatment facility (off the installation): 12; Available from a civilian network provider: 24. Behavioral health service for substance abuse: Group outpatient treatment for substance abuse; Available at the installation: 26; Available from another military treatment facility (off the installation): 19; Available from a civilian network provider: 23. Behavioral health service for substance abuse: Inpatient treatment for substance abuse; Available at the installation: 5; Available from another military treatment facility (off the installation): 15; Available from a civilian network provider: 26. Behavioral health service for substance abuse: Residential treatment for substance abuse; Available at the installation: 4; Available from another military treatment facility (off the installation): 15; Available from a civilian network provider: 25. Source: GAO. Note: Data are from GAO's survey of the 27 Army domestic installations with a primary military treatment facility, 2012. Survey respondents were asked to report on the availability of a behavioral health service for substance abuse from each of these sources for female servicemembers at their installation. Services may be available from more than one source, so the totals are not mutually exclusive. [End of table] As a way to increase access to behavioral health services, telebehavioral health services--medically supervised behavioral health treatment using secured two-way telecommunications technology to link patients from an originating site for treatment with providers who are at another site--can be used to connect servicemembers and behavioral health providers. This service was available at 22 of the 27 domestic installations we surveyed. Telebehavioral health services can be used to provide treatment to servicemembers in remote locations, where providers may not be readily available, and to ensure continuity of care for servicemembers who change duty stations. While behavioral health services are not inherently gender-specific, a number of Army installations we surveyed reported offering programs or activities that were specific to women. Officials from 18 of 27 domestic Army installations provided examples of female-specific behavioral health programs or activities, including a post-deployment group for female servicemembers, postpartum groups, and specific therapy groups for female servicemembers. Four of the six installations we visited reported having female-specific behavioral health programs or activities, such as postpartum, post-deployment, and general women's support groups. The importance of female-specific groups was echoed by most (34 of 39) of the female servicemembers that we interviewed. These female servicemembers told us that there was a need for female-specific groups for certain topics, such as post- traumatic stress disorder (PTSD), postpartum depression, parenting, and general female servicemember issues. With respect to privacy when providing behavioral health services, officials from 17 of the 27 domestic Army installations that we surveyed did not report any challenges to ensuring physical privacy when providing behavioral health services to female servicemembers when asked to report on the challenges MTFs face in ensuring the physical privacy of female servicemembers. Officials from the other 10 installations reported two main challenges to ensuring physical privacy--having mixed gender waiting rooms and concerns regarding auditory privacy in the waiting or exam rooms. Three of the 27 installations reported using white noise machines in an effort to help mask noise and address any potential auditory concerns. All of the female servicemembers we interviewed at the six installations that we visited felt that adequate steps were taken to ensure their physical privacy during behavioral health visits. One DOD Organization Is in the Process of Identifying Research Gaps on Health Care Needs for Female Servicemembers: The Women's Health Research Interest Group, which is supported by the TriService Nursing Research Program, is currently in the process of identifying research gaps on health issues affecting female servicemembers. As part of this effort, they are comparing a compiled list of existing research with data on health care issues for female servicemembers to determine if there are any existing gaps in research. Interest group officials said that the goal is to develop a repository for peer-reviewed research articles related to health issues for female servicemembers, including those who served in combat, and to use this repository to identify research that could enhance the health care of female servicemembers, including those who have served in a combat zone. To ensure that researchers will have access to the results of their work, officials have plans to distribute their results in presentations at local and national conferences. In addition, officials told us that they will disseminate their findings through peer-reviewed publications and post this information on the TriService Nursing Research Program website, which is available to the public. However at the time of our review, only one DOD research organization that we spoke with was aware of their work. Specifically, an official from the Air Force Medical Support Agency told us that it was aware of the efforts by the Women's Health Research Interest Group. In addition, other DOD research organizations told us that they would be interested in the results of this work even though they were not aware of it at the time of our discussion. While none of the other DOD research organizations that we spoke with are trying to identify gaps in research on female servicemembers, officials from each organization told us that they conduct research based on needs and capabilities. For example, one organization said that it reviews health care issues experienced during deployments and speaks with health care providers to determine what research is needed to better restore a servicemember's ability to function. DOD research organizations said that while they focus their research on needs or capabilities, they consider gender in their research efforts. For example, officials from one division of the Army Medical Research and Materiel Command told us that when developing a research announcement based on genitourinary injuries sustained during deployments, they contacted the services to determine the type and extent of injuries encountered. At the time of the inquiry, only one female was reported by the services as having a significant genitourinary injury and this led to the development of an announcement that did not specifically mention females or males. While this announcement was not gender- specific, officials said that research proposals could include female servicemembers. In addition, officials from another division of the Army Medical Research and Materiel Command told us that when discussing proposed research to examine blood markers for PTSD, the original proposal did not include female servicemembers because researchers believed that female hormones would make detecting blood biomarkers for PTSD more difficult. Officials from Army Medical Research and Materiel Command found this justification for leaving out female servicemembers unsatisfactory so they required researchers to include both genders in this study.[Footnote 27] Agency Comments: We provided a draft of this report to DOD for comment. DOD responded that it did not have any comments on the draft report. We are sending copies of this report to the Secretary of Defense, appropriate congressional committees, and other interested parties. In addition, the report will be available at no charge on GAO's website at [hyperlink, http://www.gao.gov]. If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or at williamsonr@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix IV. Signed by: Randall B. Williamson: Director, Health Care: 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: List of Domestic Army Installations with a Primary Military Treatment Facility: Facility type: Army Health Center/Clinic; Installation: Fort Drum, NY; Primary military treatment facility: Guthrie Army Health Center; Army Regional Medical Command: Northern. Installation: Fort Eustis, VA; Primary military treatment facility: McDonald Army Health Center; Army Regional Medical Command: Northern. Installation: Fort Huachuca, AZ*; Primary military treatment facility: Bliss Army Health Center; Army Regional Medical Command: Western. Installation: Fort Leavenworth, KS; Primary military treatment facility: Munson Army Health Center; Army Regional Medical Command: Western. Installation: Fort Lee, VA*; Primary military treatment facility: Kenner Army Health Clinic; Army Regional Medical Command: Northern. Installation: Fort Rucker, AL; Primary military treatment facility: Lyster Army Health Clinic; Army Regional Medical Command: Southern. Installation: Redstone Arsenal, AL; Primary military treatment facility: Fox Army Health Center; Army Regional Medical Command: Southern. Facility type: Army Community Hospital; Installation: Fort Benning, GA*; Primary military treatment facility: Martin Army Community Hospital; Army Regional Medical Command: Southern. Installation: Fort Campbell, KY; Primary military treatment facility: Blanchfield Army Community Hospital; Army Regional Medical Command: Southern. Installation: Fort Carson, CO; Primary military treatment facility: Evans Army Community Hospital; Army Regional Medical Command: Western. Installation: Fort Irwin, CA; Primary military treatment facility: Weed Army Community Hospital; Army Regional Medical Command: Western. Installation: Fort Jackson, SC; Primary military treatment facility: Moncrief Army Community Hospital; Army Regional Medical Command: Southern. Installation: Fort Knox, KY; Primary military treatment facility: Ireland Army Community Hospital; Army Regional Medical Command: Northern. Installation: Fort Leonard Wood, MO; Primary military treatment facility: General Leonard Wood Army Community Hospital; Army Regional Medical Command: Western. Installation: Fort Meade, MD*; Primary military treatment facility: Kimbrough Ambulatory Care Center; Army Regional Medical Command: Northern. Installation: Fort Polk, LA; Primary military treatment facility: Bayne Jones Army Community Hospital; Army Regional Medical Command: Southern. Installation: Fort Riley, KS; Primary military treatment facility: Irwin Army Community Hospital; Army Regional Medical Command: Western. Installation: Fort Sill, OK; Primary military treatment facility: Reynolds Army Community Hospital; Army Regional Medical Command: Southern. Installation: Fort Stewart, GA; Primary military treatment facility: Winn Army Community Hospital; Army Regional Medical Command: Southern. Installation: Fort Wainwright, AK; Primary military treatment facility: Bassett Army Community Hospital; Army Regional Medical Command: Western. Installation: West Point, NY; Primary military treatment facility: Keller Army Community Hospital; Army Regional Medical Command: Northern. Facility type: Army Medical Center; Installation: Fort Bliss, TX; Primary military treatment facility: William Beaumont Army Medical Center; Army Regional Medical Command: Western. Installation: Fort Bragg, NC; Primary military treatment facility: Womack Army Medical Center; Army Regional Medical Command: Northern. Installation: Fort Gordon, GA*; Primary military treatment facility: Dwight D. Eisenhower AMC; Army Regional Medical Command: Southern. Installation: Fort Hood, TX; Primary military treatment facility: Carl R. Darnall Army Medical Center; Army Regional Medical Command: Southern. Installation: Fort Lewis, WA*; Primary military treatment facility: Madigan Army Medical Center; Army Regional Medical Command: Western. Installation: Fort Sam Houston, TX; Primary military treatment facility: Brooke Army Medical Center; Army Regional Medical Command: Southern. Source: Department of the Army. Note: An asterisk (*) Indicates that the installation was selected for a site visit. [End of table] [End of section] Appendix II: Scope and Methodology for the Survey Sent to Domestic Army Military Treatment Facilities: To describe the availability of routine, specialized, and behavioral health care services to female servicemembers at domestic Army installations[Footnote 28] and from other sources, we surveyed senior health care officials at the 27 domestic Army installations that had a primary military treatment facility (MTF).[Footnote 29] Through this survey, we collected information on the availability of these services to female servicemembers at installations to which more than two- thirds of the Army's female servicemembers were attached as of August 1, 2012. In developing the survey, we conducted pre-tests to refine and validate the specific health care services as those services available to female servicemembers in the Army and checked that (1) the terminology was used correctly; (2) the questionnaire did not place undue burden on agency officials; (3) the information could be feasibly obtained; and (4) the survey was complete and unbiased. We chose the four pretest sites to include at least one installation with a primary MTF that was a medical center, a community hospital, and a health center/clinic. We conducted one of the pretests where all GAO participants were present and three pretests with some GAO participants in person and others participated by telephone. We made changes to the content and format of the survey on the basis of the feedback we received during the pretests. On August 20, 2012, Army Medical Command (MEDCOM) officials sent the survey to senior health care officials at the 27 domestic Army installations as a Word document by email that the respondents were requested to return after marking checkboxes or entering responses to open-answer boxes. All surveys were returned by September 26, 2012, for a 100 percent response rate. We conducted follow-up with senior health care officials about missing or inconsistent responses, through Army MEDCOM officials, between September 2012 and December 2012. The survey is presented in appendix III. [End of section] Appendix III: GAO Survey Sent to Domestic Army Military Treatment Facilities: United States Government Accountability Office: Survey of Care Provided for Female Servicemembers At Domestic Military Treatment Facilities: Introduction: The U.S. Government Accountability Office (GAO) is conducting work for Congress on healthcare services provided to female servicemembers by DOD. This survey is being disseminated to selected military treatment facilities to help GAO understand the unique physical and behavioral healthcare services available to female servicemembers from your facility and other medical facilities at your installation. This form should be completed by the Senior Clinicians at your site who are most responsible for and/or knowledgeable about the delivery of physical and behavioral healthcare services for female servicemembers. Please ensure that the answers to the questions on this form focus on the delivery of services for female servicemembers at the locations noted in each question. Please be aware that this form is broken down into three parts, and should be completed by the person most knowledgeable in these areas: * Section I: Contact and Administrative Information; * Section II: Physical Healthcare for Female Servicemembers; * Section III: Behavioral Health care for Female Servicemembers. Instructions: * Save this file to your computer's hard drive. * Fill out this questionnaire in Microsoft Word by clicking checkboxes or typing in answer spaces, which will expand to fit your answer. * Save your work frequently. * Attach your completed questionnaire to an email to Laurie Thurber at ThurberL@gao.gov by August 31. 2012. If you have any questions about anything in this survey, please contact Laurie Thurber at 202-512-6472 or Natalie Herzog at 404-679- 1889. Thank you for your participation. Section Contact and Administrative Information: Section I should be completed by the senior officials or administrators at your site with knowledge of the medical treatment facilities and female servicemember enrollment. Name of Facility and DMIS #: Facility: DMIS #: Address of Facility: Street: City: State: Zip: Point of Contact for Physical Healthcare Services: Names: Email: Title: Phone: Point of Contact for Behavioral Healthcare Services: Names: Email: Title: Phone: Other medical facilities or clinics at this installation: If your facility reports information for any clinics or other medical facilities at this installation, please provide the following information: DMIS ID#: DMIS ID Name: Does this facility or clinic treat female servicemembers who are not enrolled, such as officer or enlisted trainees? Yes: No: Other medical facilities or clinics outside of this installation: If your facility reports information for any clinics or other medical facilities outside of this installation, please provide the following information: DMIS ID#: DMIS ID Name: Location: City: State: Does this facility or clinic treat female servicemembers who are not enrolled, such as officer or enlisted trainees? Yes: No: Section II: Physical Healthcare: Section II should be completed by the senior clinicians at your site who are most responsible for and/or knowledgeable about the delivery of physical healthcare services for female servicemembers. We understand that your facility may provide services to many people, but for the purposes of this survey, we are only interested in active duty female servicemembers. 1. As of August 1, 2012, were female servicemembers able to access the following types of routine physical healthcare services at this installation, from another MTF outside of this installation, and from a civilian network provider? (Check all that apply on each row.) Please note the following definitions for the purposes of this survey: Military treatment facility (MTF) - a hospital or clinic, typically located on an installation, which provides medical or dental services to eligible beneficiaries. Physical healthcare services - all healthcare services, including routine and specialized care, with the exception of behavioral healthcare services. Routine physical healthcare service: Pelvic examination; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Routine physical healthcare service: Clinical breast examination; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Routine physical healthcare service: Pap smear; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Routine physical healthcare service: Screening mammography Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Routine physical healthcare service: Prescription of contraceptives/contraceptive counseling; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Routine physical healthcare service: Pregnancy test; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: 2. For any types of routine healthcare services listed in Question 1 that female servicemembers were not able to access at this installation as of August 1, 2012, why were these services not available at that time? 3. As of August 1, 2012, were female servicemembers able to access the following types of specialized physical healthcare services at this installation, from another MIT outside of this installation, and from a civilian network provider? (Check all that apply an each row.) Specialized physical healthcare service: Treatment of abnormal pap smear; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Prenatal care; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Labor and delivery; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Benign gynecological disorders; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Postpartum care; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Diagnostic mammography; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Surgical treatment of breast cancer; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Medical treatment of breast cancer (could define if needed); Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Radiation treatment of breast cancer; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Surgical treatment or ovarian, cervical, uterine cancer; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Medical treatment of ovarian, cervical, uterine cancer; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Specialized physical healthcare service: Radiation treatment of ovarian, cervical, uterine cancer; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: 4. For any types of specialized healthcare services listed in Question 3 that female servicemembers were not able to access at this installation as of August 1, 2012, why were these services not available at that time? 5. As of August 1, 2012, were male or female providers available to provide the following physical healthcare services to female servicemembers at this installation? (Check all that apply on each row.) Routine Care at this Installation: Physical healthcare services at this installation: Pelvic examination; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: Physical healthcare services at this installation: Clinical breast examination; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: Physical healthcare services at this installation: Pap smear; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: Physical healthcare services at this installation: Mammography (technician); Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: Physical healthcare services at this installation: Prescription of contraceptives/contraceptive counseling; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: Specialized Care at this Installation: Physical healthcare services at this installation: Treatment of abnormal pap smear; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: Physical healthcare services at this installation: Prenatal care; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: Physical healthcare services at this installation: Labor and delivery; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: Physical healthcare services at this installation: Postpartum care; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: Physical healthcare services at this installation: Benign gynecological disorders; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this installation: 6. What, if any, existing or planned healthcare activities or programs at this installations are focused on females (e.g., women's health fair or women's clinic)? 7. What, if any, challenges does your MTF face in ensuring the physical privacy of female servicemembers while providing medical services (e.g., orientation of exam table towards doors and windows or waiting rooms and exam rooms may not prevent conversations from being overhead)? Section III: Behavioral Healthcare: Section III should be completed by the senior clinicians at your site who are most responsible for and/or knowledgeable about the delivery of behavioral healthcare services for female servicemembers. 1. As of August 1, 2012, were female servicemembers able to access the following behavioral healthcare treatments at this installation, from another MTF outside of this installation, and from a civilian network provider? (Check all that apply on each row.) Please note the following definitions for the purposes of this survey: Outpatient treatment — healthcare services for individuals at risk of, or suffering from mental and behavioral disorders (excluding addictive/substance abuse disorders) that does not require an overnight stay. Inpatient treatment — treatment provided due to medical necessity for physical, behavioral or substance abuse related diagnosis during an admission to a hospital or other authorized institution that requires at least one overnight stay. Residential treatment — intensive treatment for physical, behavioral, or substance abuse provided during an extended stay at a live in healthcare facility. Behavioral healthcare treatments: Individual outpatient treatment (excluding addictive/substance abuse disorders); Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Behavioral healthcare treatments: Family outpatient treatment (excluding addictive/substance abuse disorders); Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Behavioral healthcare treatments: Group outpatient treatment (excluding addictive/substance abuse disorders); Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Behavioral healthcare treatments: Inpatient treatment; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Behavioral healthcare treatments: Residential treatment; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: 2. For any types of behavioral healthcare treatments listed in Question 1 that were not available to female servicemembers at this installation as of August 1, 2012, why were these services not available at that time? 3. As of August 1, 2012, were female servicemembers able to access the following substance abuse healthcare treatments at this installation, from another MTF outside of this installation, and from a civilian network provider? (Check all that apply on each row.) Please note the following definitions for the purposes of this survey: Substance abuse and treatment - healthcare services for individuals at risk of, or suffering from addictive/substance abuse disorders (excluding all other mental and behavioral disorders). Behavioral healthcare treatments for substance abuse: Individual outpatient treatment for substance abuse; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Behavioral healthcare treatments for substance abuse: Family outpatient treatment for substance abuse; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Behavioral healthcare treatments for substance abuse: Group outpatient treatment for substance abuse; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Behavioral healthcare treatments for substance abuse: Inpatient treatment; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: Behavioral healthcare treatments for substance abuse: Residential treatment; Services at this installation: Yes: No: Not sure: Services outside of this installation: From another MTF: Yes: No: Not applicable: From a civilian network provider: Yes: No: Not applicable: 4. For any types of substance abuse healthcare treatments listed in Question 3 that female servicemembers were not able to access at this installation as of August 1, 2012, why were these services not available at that time? 5. As of August 1, 2012, did female service members at your installation have access to telebehavioral healthcare treatments from providers at other installations? Please note the following definitions for the purposes of this survey: Telebehavioral treatment — medically supervised behavioral health treatment using secured two way telecommunications technology to link patients from an originating site for face-to-face treatment with providers who are offsite. Yes: Go to question 6; No: Skip to question 7; Don't know: Skip to question 8. 6. If yes, what telebehavioral treatments are provided to female servicemembers at this installation? When Complete, Skip To Question 8. 7. If no, why were telebehavioral treatment services not available at that time? 8. Do providers at your installation provide telebehavioral healthcare treatment services to female servicemembers at other installations or locations? Yes: Go to question 9; No: Skip to question 10; Don't know: Skip to question 10. 9. If yes, what telebehavioral treatments are provided to female servicemembers at other installations or locations? 10. As of August 1, 2012, were male or female providers available to provide the following behavioral healthcare services to female servicemembers at this installation? (Check all that apply.) Behavioral healthcare service at this installation: Individual outpatient treatment; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this Installation: Behavioral healthcare service at this installation: Family outpatient treatment; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this Installation: Behavioral healthcare service at this installation: Group outpatient treatment; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this Installation: Behavioral healthcare service at this installation: Inpatient treatment; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this Installation: Behavioral healthcare service at this installation: Residential treatment; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this Installation: Behavioral healthcare service at this installation: Telebehavioral health treatment; Male providers available: Yes: No: Not sure: Female providers available: Yes: No: Not sure: Service not available at this Installation: 11. As of August 1, 2012, what, if any, outpatient behavioral healthcare programs, groups, or treatments were available or planned for females at this installation, such as separate therapy sessions for male and female servicemembers? 12. As of August 1, 2012, what, if any, inpatient or residential behavioral healthcare programs, groups, or treatments were available or planned specifically for females at this installation, such as separate wings of buildings or location of rooms? 13. What, if any, challenges does your MTF or other providers face in ensuring the physical privacy of female servicemembers while providing behavioral healthcare services (e.g., waiting rooms and exam rooms may not prevent conversations from being overhead)? [End of section] Appendix IV: GAO Contact and Staff Acknowledgments: GAO Contact: Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov: Staff Acknowledgments: In addition to the contact named above, Bonnie Anderson, Assistant Director; Jennie Apter; Danielle Bernstein; Natalie Herzog; Ron La Due Lake; Amanda K. Miller; Lisa Motley; Mario Ramsey; and Laurie F. Thurber made key contributions to this report. [End of section] Footnotes: [1] Behavioral health care includes services such as psychotherapy or treatment for substance abuse disorders. [2] Pub. L. No. 112-81, § 725 (2011). [3] For information on the availability of health care for female servicemembers in deployed environments and for servicemembers who are victims of sexual assault, see GAO, Military Personnel: DOD Has Taken Actions to Meet the Needs of Deployed Servicewomen, but Actions Are Needed to Enhance Care for Sexual Assault Victims, [hyperlink, http://www.gao.gov/products/GAO-13-182] (Washington, D.C.: Jan. 29, 2013). [4] The Navy is responsible for providing health care to members of the Marine Corps and their beneficiaries. The Marine Corps follows the Navy's health care-related policies. However, in some cases, the Marine Corps has its own health care policies. [5] Section 2687 of Title 10 of the United States Code defines a military installation, for the purpose of certain base realignments and closures, as a base, camp, post, station, yard, center, homeport facility for any ship, or other activity under the jurisdiction of DOD, including any leased facility, located within a state, the District of Columbia, the Commonwealth of Puerto Rico, American Samoa, the Virgin Islands, the Commonwealth of the Northern Mariana Islands, or Guam. This term does not include any facility used primarily for civil works, rivers and harbors projects, or flood control. [6] The 27 domestic Army installations that had a primary MTF are located in the continental United States. [7] An MTF is a hospital or clinic owned and operated by DOD that provides medical or dental care or both to eligible individuals. For the Army, a primary MTF is a facility that reports directly to the regional medical command and is responsible for reporting information for other associated MTFs, which may include smaller MTFs, such as clinics, on the same installation, as well as MTFs on different Army installations or at installations operated by other military services. All domestic Army MTFs report to the Army Medical Command through the 27 primary MTFs that we surveyed. Our survey focused only on the services available for female servicemembers located at one of the installations with a primary MTF. [8] We developed lists of female-specific routine and specialized health care services, as well as a list of behavioral health services. We then refined and validated these lists of services as those services that should be available to female servicemembers through discussions with Army health care providers. [9] For example, the survey would not account for services available to female servicemembers who may be attached to 1 of the 27 domestic installations but are temporarily located at another location, such as those who are off the installation for training. [10] Within the continental United States, the Army is organized into three medical regions--Northern, Southern, and Western. Additionally, all primary Army MTFs are classified as an Army Health Center/Clinic, Army Community Hospital, or an Army Medical Center. [11] This information does not include the Coast Guard. [12] The Guide to Clinical Preventive Services 2012, Recommendations of the U.S. Preventive Services Task Force. [13] In addition to approximately 9.7 million beneficiaries, DOD also provides care and, in some cases, rehabilitation for veterans as part of its coordination with the Department of Veterans Affairs on health care services. [14] Primary care is basic or general health care traditionally provided by doctors trained in family practice, pediatrics, and internal medicine. It may also include care provided by doctors trained in gynecology. [15] The core requirement for individual medical equipment is one pair of gas mask inserts for all personnel needing visual correction. Service-specific policies, such as those for the Navy, may identify additional items of medical equipment, such as two pair of prescription spectacles and hearing aid batteries. [16] For example, for the Army, the Medical Protection System (MEDPROS) was developed to track all immunization, medical readiness, and deployability data for all active and reserve components of the Army as well as civilians, contractors, and others. It is a tool allowing the chain of command to determine the medical and dental readiness of individuals, units, and task forces. Commanders and medical leaders at various echelons are responsible for the use and implementation of MEDPROS to measure their unit/individual medical readiness status. [17] The Department of Defense Appropriations Act, 2012, provided $1,267,306,000 for research, development, testing, and evaluation for the Defense Health Program for fiscal year 2012. Pub. L. No. 112-74, div. A, tit. VI, 125 Stat. 786, 802 (2011). [18] Military operational medicine includes research on psychological health. [19] The results of the dental exam must fall into class 1 or 2 in order to pass this element. Class 1 results do not require dental treatment or reevaluation. For class 2, the results require nonurgent dental treatment or reevaluation of conditions that are unlikely to result in dental emergencies within the next 12 months. [20] The Navy has a 12-month postpartum deferment period. [21] DOD's instruction allows for a 90-day grace period to conduct this assessment. [22] The frequency of these screenings is based on national standards, such as recommendations by the U.S. Preventive Services Task Force and may not be conducted annually. [23] We surveyed senior health care officials at the 27 domestic Army installations with a primary MTF to obtain information about the availability of routine, specialized, and behavioral health services for female servicemembers. A copy of the survey and the specific types of health care services are included in app. III. [24] We did not survey about the availability of male and female providers to provide pregnancy tests as senior health care officials stated that this health care service is not one that is necessarily administered by health care providers. [25] Other MTFs could include Army MTFs located on a different installation or an MTF operated by another military service. [26] The Health Insurance Portability and Accountability Act Privacy Rule requires covered entities to have in place appropriate administrative, technical, and physical safeguards to protect the privacy of protected health information and to make reasonable efforts to prevent uses and disclosures not permitted by the rule. See 45 C.F.R. § 164.530(c). The Department of Health and Human Services does not consider restructuring of hospitals and doctors' offices, such as providing private rooms and soundproof walls, to be a requirement under this standard. [27] DOD's approach to considering gender when conducting research is similar to that of the National Institutes of Health (NIH), another federal agency that conducts research. NIH notes that women, as well as others, must be considered in all NIH-funded research, but may be excluded from the research with a clear and compelling rationale. See NIH Policy and Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research, accessed October 24, 2012, [hyperlink, http://grants.nih.gov/grants/funding/women_min/guidelines_amended_10_200 1.htm]. [28] For purposes of our report, the 27 domestic Army installations that had a primary military treatment facility (MTF) are those located in the continental United States. Section 2687 of Title 10 of the United States Code defines a military installation, for the purpose of certain base realignments and closures, as a base, camp, post, station, yard, center, homeport facility for any ship, or other activity under the jurisdiction of the Department of Defense (DOD), including any leased facility, located within a state, the District of Columbia, the Commonwealth of Puerto Rico, American Samoa, the Virgin Islands, the Commonwealth of the Northern Mariana Islands, or Guam. This term does not include any facility used primarily for civil works, rivers and harbors projects, or flood control. [29] An MTF is a hospital or clinic owned and operated by DOD that provides medical or dental care or both to eligible individuals. For the Army, a primary MTF is a facility that reports directly to the regional medical command and is responsible for reporting information for other associated MTFs, which may include smaller MTFs, such as clinics, on the same installation, as well as MTFs on different Army installations or at installations operated by other military services. All domestic Army MTFs report to the Army Medical Command through the 27 primary MTFs that we surveyed. [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. 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