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Testimony: 

Before the Committee on Veterans' Affairs, U.S. Senate: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected at 9:30 a.m. EDT:
Tuesday, July 14, 2009: 

VA Health Care: 

Preliminary Findings on VA's Provision of Health Care Services to Women 
Veterans: 

Statement of Randall B. Williamson:
Director, Health Care: 

GAO-09-884T: 

GAO Highlights: 

Highlights of GAO-09-884T, a testimony before the Committee on 
Veterans’ Affairs, U.S. Senate. 

Why GAO Did This Study: 

Historically, the vast majority of VA patients have been men, but that 
is changing. VA provided health care to over 281,000 women veterans in 
2008—an increase of about 12 percent since 2006—and the number of women 
veterans in the United States is projected to increase by 17 percent 
between 2008 and 2033. Women veterans seeking care at VA medical 
facilities need access to a full range of health care services, 
including basic gender-specific services—such as cervical cancer 
screening—and specialized gender-specific services—such as treatment of 
reproductive cancers. 

This testimony, based on ongoing work, discusses GAO’s preliminary 
findings on (1) the on-site availability of health care services for 
women veterans at VA facilities, (2) the extent to which VA facilities 
are following VA policies that apply to the delivery of health care 
services for women veterans, and (3) key challenges that VA facilities 
are experiencing in providing health care services for women veterans. 
GAO reviewed applicable VA policies, interviewed officials, and visited 
19 medical facilities—9 VA medical centers (VAMC) and 10 community-
based outpatient clinics (CBOC)—and 8 Vet Centers. These facilities 
were chosen based in part on the number of women using services and 
whether facilities offered specific programs for women. The results 
from these site visits cannot be generalized to all VA facilities. GAO 
shared this statement with VA officials, and they generally agreed with 
the information presented. 

What GAO Found: 

The VA facilities GAO visited provided basic gender-specific and 
outpatient mental health services to women veterans on site, and some 
facilities also provided specialized gender-specific or mental health 
services specifically designed for women on site. Basic gender-specific 
services, including pelvic examinations, were available on site at all 
nine VAMCs and 8 of the 10 CBOCs GAO visited. Almost all of the medical 
facilities GAO visited offered women veterans access to one or more 
female providers for their gender-specific care. The availability of 
specialized gender-specific services for women, including treatments 
after abnormal cervical cancer screenings and breast cancer, varied by 
service and facility. All VA medical facilities refer female patients 
to non-VA providers for obstetric care. Some of the VAMCs GAO visited 
offered a broad array of other specialized gender-specific services on 
site, but all contracted or fee-based at least some services. Among 
CBOCs, the two largest facilities GAO visited offered an array of 
specialized gender-specific care on site; the other eight referred 
women to other VA or non-VA facilities for most of these services. 
Outpatient mental health services for women were widely available at 
the VAMCs and most Vet Centers GAO visited, but were more limited at 
some CBOCs. While the two larger CBOCs offered group counseling for 
women and services specifically for women who have experienced sexual 
trauma in the military, the smaller CBOCs tended to rely on VAMC staff, 
often through videoconferencing, to provide mental health services. 

The extent to which the VA medical facilities GAO visited were 
following VA policies that apply to the delivery of health care 
services for women veterans varied, but none of the facilities had 
fully implemented these policies. None of the VAMCs and CBOCs GAO 
visited were fully compliant with VA policy requirements related to 
privacy for women veterans in all clinical settings where those 
requirements applied. For example, many of the medical facilities GAO 
visited did not have adequate visual and auditory privacy in their 
check-in areas. Further, the facilities GAO visited were in various 
stages of implementing VA’s new initiative to provide comprehensive 
primary care for women veterans, but officials at some VAMCs and CBOCs 
reported that they were unclear about the specific steps they would 
need to take to meet the goals of the new policy. 

Officials at facilities that GAO visited identified a number of 
challenges they face in providing health care services to the 
increasing numbers of women veterans seeking VA health care. One 
challenge was that space constraints have raised issues affecting the 
provision of health care services. For example, the number, size, or 
configuration of exam rooms or bathrooms sometimes made it difficult 
for facilities to comply with VA requirements related to privacy for 
women veterans. Officials also reported challenges hiring providers 
with specific training and experience in women’s health care and in 
mental health care, such as treatment for women veterans with post-
traumatic stress disorder or who had experienced military sexual 
trauma. 

View [hyperlink, http://www.gao.gov/products/GAO-09-884T] or key 
components. For more information, contact Randall B. Williamson at 
(202) 512-7114 or williamsonr@gao.gov. 

[End of section] 

Mr. Chairman and Members of the Committee: 

I am pleased to be here today as the Committee considers issues related 
to the Department of Veterans Affairs' (VA) delivery of health care 
services to women veterans. Historically, the vast majority of VA 
patients have been men, but that is changing. As of October 2008, there 
were more than 1.8 million women veterans in the United States 
(representing approximately 7.7 percent of the total veteran 
population), and more than 102,000 of these women were veterans of the 
military operations in Afghanistan and Iraq, known as Operation 
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). According to 
VA data, in fiscal year 2008, over 281,000 women veterans received 
health care services from VA--an increase of about 12 percent since 
2006. Looking ahead, VA estimates that while the total number of 
veterans will decline by 37 percent between 2008 and 2033, the number 
of women veterans will increase by more than 17 percent over the same 
period. 

The health care services needed by women veterans are significantly 
different from those required by their male counterparts. Women 
veterans are younger, in the aggregate, than their male counterparts. 
Based on an analysis conducted by the VA in 2007, the estimated median 
age of women veterans was 47, whereas the estimated median age of male 
veterans was 61. Women veterans seeking care at VA medical facilities 
need access to a full range of physical health care services, including 
basic gender-specific services--such as breast examinations, cervical 
cancer screening, and menopause management--and specialized gender- 
specific services such as obstetric care (which includes prenatal, 
labor and delivery, and postpartum care) and treatment of reproductive 
cancers. Women veterans also need access to a range of mental health 
care services, such as care for depression. 

In addition, women veterans of OEF/OIF present new challenges for VA's 
health care system. Almost all of these women are under the age of 40--
58 percent are between the ages of 20 and 29. VA data show that almost 
20 percent of women veterans of OEF/OIF have been diagnosed with post- 
traumatic stress disorder (PTSD).[Footnote 1] Additionally, an alarming 
number of them have experienced sexual trauma while in the military. 
[Footnote 2] As a result, many women veterans of OEF/OIF have complex 
physical and mental health care needs. 

Congress and others have raised concerns about how well VA is prepared 
to meet the physical and mental health care needs of the growing number 
of women veterans, particularly veterans of OEF/OIF. Traditionally, 
women veterans have utilized VA's health care services less frequently 
than their male counterparts. In fiscal year 2007, 15 percent of women 
veterans used VA's health care services, compared to 22 percent of male 
veterans. VA believes that part of this difference may be attributable 
to barriers that the current care models at many VA medical facilities 
present to women veterans. For example, women veterans have often been 
required to make multiple visits to a VA facility in order to receive 
the full spectrum of primary care services, which includes such basic 
gender-specific care as cervical cancer screenings and breast 
examinations. Because many of these women work or have child care 
responsibilities, multiple visits can be problematic, especially when 
services are not available in the evenings or on weekends. 

VA has taken some steps to improve the availability of services for 
women veterans, including requiring that all VA medical facilities make 
the Women Veterans Program Manager (WVPM)--an advocate for the needs of 
women veterans--a full-time position and providing funding for 
equipment to help VA medical facilities improve health care services 
for women veterans. Additionally, in November 2008, VA began a 
systemwide initiative to make comprehensive primary care for women 
veterans available at every VA medical facility--VA medical centers 
(VAMC) and community-based outpatient clinics (CBOC). In announcing 
this initiative, VA established a policy defining comprehensive primary 
care for women veterans as the availability of complete primary care-- 
including routine detection and management of acute and chronic 
illness, preventive care, gender-specific care, and mental health care--
from one primary care provider at one site. 

You asked us to examine VA's health care services for women veterans. 
In my testimony today, I will discuss our preliminary findings, based 
on visits to selected VA facilities, regarding (1) the on-site 
availability of health care services at VA facilities for women 
veterans, (2) the extent to which VA facilities are following VA 
policies that apply to the delivery of health care services for women 
veterans, and (3) some key challenges that VA facilities are 
experiencing in providing health care services for women veterans. 

To examine the availability of health care services at VA facilities 
for women veterans and to determine the extent to which VA facilities 
are following VA policies that apply to the delivery of health care 
services for women veterans, we reviewed applicable VA policies 
[Footnote 3] and available VA data, and interviewed officials from VA 
headquarters, Veterans Integrated Service Networks (VISN),[Footnote 4] 
and VA facilities. In addition, we conducted site visits to a 
judgmental sample of nine VAMCs located in Atlanta and Dublin, Georgia; 
San Diego and Long Beach, California; Minneapolis and St. Cloud, 
Minnesota; Sioux Falls, South Dakota; and Temple and Waco, Texas. We 
also visited 10 VA CBOCs affiliated with these nine VAMCs, and eight 
Vet Centers, which are counseling centers that help combat veterans 
readjust from wartime military service to civilian life. We used VA 
data to select these sites based on several factors, including the 
number of women veterans using health care services at each VAMC and 
whether facilities offered specific programs for women veterans, such 
as outpatient or residential treatment programs for women who have PTSD 
or have experienced military sexual trauma (MST). See appendix I for 
additional details on the selection criteria we used and information on 
the number of women veterans using health care services at each VAMC 
and CBOC we visited. To further examine the availability of services 
for women veterans, we obtained information from each VAMC and CBOC 
regarding the organization and availability of primary care services, 
basic gender-specific services, specialized gender-specific services, 
and mental health services in outpatient, residential, and inpatient 
settings; and the availability of specific clinical services such as 
prenatal care, osteoporosis treatment, mammography, and counseling for 
MST. When services were not available on site, we determined whether 
they were available through fee-for-service arrangements (fee basis), 
contracts, or sharing agreements with non-VA facilities. During our 
site visits we also toured each facility and documented observations of 
the physical space in each care setting. We examined how facilities 
were implementing VA policies pertaining to ensuring the privacy of 
women veterans in outpatient, residential, and inpatient care settings; 
and VA's model of comprehensive primary care for women veterans. 
Finally, to identify key challenges that VA facilities are experiencing 
in providing health care services for women veterans, we reviewed 
relevant literature; interviewed VA officials in headquarters, medical 
facilities, and Vet Centers; interviewed VA experts in the area of 
women veterans' health; and documented challenges observed during our 
site visits. The findings of our site visits to VA facilities cannot be 
generalized to other VA facilities. We shared the information contained 
in this statement with VA officials, and they generally agreed with the 
information we presented. 

We conducted our performance audit from July 2008 through July 2009 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: 

VA Health Care System: 

VA's integrated health care delivery system is one of the largest in 
the United States and provides enrolled veterans, including women 
veterans, with a range of services including primary and preventive 
health care services, mental health services, inpatient hospital 
services, long-term care, and prescription drugs.[Footnote 5] VA's 
health care system is organized into 21 VISNs that include VAMCs and 
CBOCs. VAMCs offer outpatient, residential, and inpatient services. 
These services range from primary care to complex specialty care, such 
as cardiac and spinal cord injury care. VAMCs also offer a range of 
mental health services, including outpatient counseling services, 
residential programs--which provide intensive treatment and 
rehabilitation services, with supported housing, for treatment, for 
example, of PTSD, MST, or substance use disorders--and inpatient 
psychiatric treatment. CBOCs are an extension of VAMCs and provide 
outpatient primary care and general mental health services on site. VA 
also operates 232 Vet Centers, which offer readjustment and family 
counseling, employment services, bereavement counseling, and a range of 
social services to assist combat veterans in readjusting from wartime 
military service to civilian life.[Footnote 6] 

When VA facilities are unable to efficiently provide certain health 
care services on site, they are authorized to enter into agreements 
with non-VA providers to ensure veterans have access to medically 
necessary services.[Footnote 7] Specifically, VA facilities can make 
services available through: 

* referral of patients to other VA facilities or use of telehealth 
services,[Footnote 8] 

* sharing agreements with university affiliates or Department of 
Defense medical facilities, 

* contracts with providers in the local community, or: 

* allowing veterans to receive care from providers in the community who 
will accept VA payment (commonly referred to as fee-basis care). 

VA Policies Pertaining to Women's Health: 

Federal law authorizes VA to provide medically necessary health care 
services to eligible veterans, including women veterans.[Footnote 9] 
Federal law also specifically requires VA to provide mental health 
screening, counseling, and treatment for eligible veterans who have 
experienced MST.[Footnote 10] Although the MST law applies to all 
veterans, it is of particular relevance to women veterans because among 
women veterans screened by VA for MST, 21 percent screened positive for 
experiencing MST. VA provides health care services to veterans through 
its medical benefits package--health care services required to be 
provided are broadly stated in a regulation and further specified in VA 
policies. Through policies, VA requires its health care facilities to 
make certain services, including gender-specific services and primary 
care services, available to eligible women veterans.[Footnote 11] 
Gender-specific services that are included in the VA medical benefits 
package[Footnote 12] include, for example, cervical cancer screening, 
breast examination, management of menopause, mammography, obstetric 
care, and infertility evaluation. See table 1 for a list of selected 
basic and specialized gender-specific services that VA is required to 
make available and others that VA may make available to women veterans. 

Table 1: Selected Clinical Services That VA Is Required to Make 
Available and Others That VA May Make Available to Women Veterans, by 
Category: 

Services that VA medical facilities may make available to women 
veterans: 

Primary care/basic gender-specific services[A]: 
* Intake and initial assessment, including screening for military 
sexual trauma (MST)[B]; 
* Routine physical exams; 
* Intimate partner violence screening; 
* Smoking cessation counseling; 
* Smoking cessation treatment; 
* Nutrition counseling; 
* Weight management and fitness; 
* Urgent/emergent gender-related care--normal hours; 
* Urgent/emergent gender-related care--evenings, weekends, and 
holidays; 
* Pelvic examination[B]; 
* Clinical breast examination[B]; 
* Education on performing breast self-examination[B]; 
* Cervical cancer screening[B]; 
* Menopause management[B]; 
* Uncomplicated vulvovaginitis treatment[B]; 
* Osteoporosis screening[B]; 
* Osteoporosis treatment[B]; 
* Hormone replacement therapy[B]; 
* Prescription of oral contraceptives[B]. 

Specialized gender-specific services[A]: 
* Treatment after abnormal cervical cancer screening[B]; 
* Surgical sterilization--evaluation[B]; 
* Surgical sterilization; 
* Sexually transmitted disease (STD) screening; 
* STD counseling; 
* STD treatment; 
* Intrauterine device (IUD) placement; 
* Pregnancy test--urine; 
* Pregnancy test--serum; 
* Prenatal care; 
* Labor and delivery; 
* Postpartum care; 
* Infertility evaluation[B]; 
* Endometriosis treatment; 
* Evaluation of polycystic ovarian syndrome[B]; 
* Treatment of polycystic ovarian syndrome[B].
* Screening mammography[B]; 
* Diagnostic mammography; 
* Surgical treatment of breast cancer[B]; 
* Surgical treatment of reproductive cancer[B]; 
* Medical treatment of breast cancer[B]; 
* Medical treatment of reproductive cancer[B]. 

Source: GAO review of VA data. 

Notes: The data are from a review of VHA Handbook 1330.1 and VA's 
annual Plan of Care and Clinical Inventory Survey. 

[A] The distinction between "basic" and "specialized" gender-specific 
services is based on the definitions included in VHA Handbook 1330.1 
and the 2003 article by Yano and Washington. Elizabeth Yano and Donna 
Washington, "Availability of Comprehensive Women's Health Care Through 
Department of Veterans Affairs Medical Center." Published by Donna 
Washington, et al., in Women's Health Issues, v. 13 (2003). 

[B] Denotes a service that VA medical facilities are required to make 
available to women veterans, based on VHA Handbook 1330.1. 

[End of table] 

In November 2008, VA established a policy that requires all VAMCs and 
CBOCs to move toward making comprehensive primary care available for 
women veterans. VA defines comprehensive primary care for women 
veterans as the availability of complete primary care--including 
routine detection and management of acute and chronic illness, 
preventive care, basic gender-specific care, and basic mental health 
care--from one primary care provider at one site. VA did not establish 
a deadline by which VAMCs and CBOCs must meet this requirement. 

VA policies also outline a number of requirements specific to ensuring 
the privacy of women veterans in all settings of care at VAMCs and 
CBOCs.[Footnote 13] These include requirements related to ensuring 
auditory and visual privacy at check-in and in interview areas; the 
location of exam rooms, presence of privacy curtains, and the 
orientation of exam tables; access to private restrooms in outpatient, 
inpatient, and residential settings of care; and the availability of 
sanitary products in public restrooms at VA facilities. 

1n 1991, VA established the position of Women Veteran Coordinator--now 
the WVPM--to ensure that each VAMC had an individual responsible for 
assessing the needs of women veterans and assisting in the planning and 
delivery of services and programs to meet those needs. Begun as a part- 
time collateral position, the WVPM is now a full-time position at all 
VAMCs. In July 2008, VA required VAMCs to establish the WVPM as a full- 
time position (no longer a collateral duty) no later than December 1, 
2008. Clinicians in the role of WVPM would be allowed to perform 
clinical duties to maintain their professional certification, 
licensure, or privileges, but must limit the time to the minimum 
required, typically no more than 5 hours per week. 

VA Mental Health Services: 

In September 2008, VA issued the Uniform Mental Health Services in VA 
Medical Centers and Clinics,[Footnote 14] a policy that specifies the 
mental health services that must be provided at each VAMC and CBOC. 
[Footnote 15] The purpose of this policy is to ensure that all 
veterans, wherever they obtain care in VA's health care system, have 
access to needed mental health services. The policy lists the mental 
health care services that must be delivered on site or made available 
by each facility. To help ensure that mental health staff can provide 
these services, VA has developed and rolled out evidence-based[Footnote 
16] psychotherapy training programs for VA staff that treat patients 
with PTSD, depression, and serious mental illness. VA's training 
programs cover five evidence-based psychotherapies: Cognitive 
Processing Therapy (CPT) and Prolonged Exposure (PE), which are 
recommended for PTSD; Cognitive Behavioral Therapy (CBT) and Acceptance 
and Commitment Therapy (ACT), which are recommended for depression; and 
Social Skills Training (SST), which is recommended for serious mental 
illness. The training programs involve two components: (1) attendance 
at an in-person, experientially-based, workshop (usually 3-4 days 
long), and (2) ongoing telephone-based small-group consultation on 
actual therapy cases with a consultant who is an expert in the 
psychotherapy. 

VA Facilities Provided Basic and Specialized Gender-Specific Services 
and Mental Health Services to Women Veterans, though Not All Services 
Were Provided On Site at Each VA Facility: 

The VA facilities we visited provided basic gender-specific and 
outpatient mental health services to women veterans on site, and some 
facilities also provided specialized gender-specific or mental health 
services specifically designed for women on site. All of the VAMCs we 
visited offered at least some specialized gender-specific services on 
site, and six offered a broad array of these services. Among CBOCs, 
other than the two largest facilities we visited, most offered limited 
specialized gender-specific care on site. Women needing obstetric care 
were always referred to non-VA providers. Regarding mental health care, 
we found that outpatient services for women were widely available at 
the VAMCs and most Vet Centers we visited, but were more limited at 
some CBOCs. Eight of the VAMCs we visited offered mixed-gender 
inpatient or residential mental health services, and two VAMCs offered 
residential treatment programs specifically designed for women 
veterans. 

Basic Gender-Specific Care Services Were Generally Available On site at 
VA Medical Facilities: 

Basic gender-specific care services were available on site at all nine 
of the VAMCs and 8 of the 10 CBOCs that we visited. (See table 2.) 
These facilities offered a full array of basic gender-specific services 
for women--such as pelvic examinations, and osteoporosis treatment--on 
site. One of the CBOCs we visited did not offer any basic gender- 
specific services on site and another offered a limited selection of 
these services. These CBOCs that provided limited basic gender-specific 
services referred patients to other VA facilities for this care, but 
had plans underway to offer these services on site once providers 
received needed training. In general, women veterans had access to 
female providers for their gender-specific care: of the 19 medical 
facilities we visited, all but 4 had one or more female providers 
available to deliver basic gender-specific care. 

Table 2: On-site Availability of Selected Basic Gender-Specific 
Services for Women Veterans at Selected VA Facilities: 

Service: Pelvic exam and cervical cancer screening; 
VAMC, by number: 1: Service available on site; 
VAMC, by number: 2: Service available on site; 
VAMC, by number: 3: Service available on site; 
VAMC, by number: 4: Service available on site; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Service available on site; 
VAMC, by number: 7: Service available on site; 
VAMC, by number: 8: Service available on site; 
VAMC, by number: 9: Service available on site; 
CBOC, by number: 1: Service available on site; 
CBOC, by number: 2: Service available on site; 
CBOC, by number: 3: Service available on site; 
CBOC, by number: 4: Service available on site; 
CBOC, by number: 5: Service available on site; 
CBOC, by number: 6: Refer to another VA facility; 
CBOC, by number: 7: Refer to another VA facility[A]; 
CBOC, by number: 8: Service available on site; 
CBOC, by number: 9: Service available on site; 
CBOC, by number: 10: Service available on site. 

Service: Prescription of oral contraceptives; 
VAMC, by number: 1: Service available on site; 
VAMC, by number: 2: Service available on site; 
VAMC, by number: 3: Service available on site; 
VAMC, by number: 4: Service available on site; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Service available on site; 
VAMC, by number: 7: Service available on site; 
VAMC, by number: 8: Service available on site; 
VAMC, by number: 9: Service available on site; 
CBOC, by number: 1: Service available on site; 
CBOC, by number: 2: Service available on site; 
CBOC, by number: 3: Service available on site; 
CBOC, by number: 4: Service available on site; 
CBOC, by number: 5: Service available on site; 
CBOC, by number: 6: Service available on site; 
CBOC, by number: 7: Refer to another VA facility[A]; 
CBOC, by number: 8: Service available on site; 
CBOC, by number: 9: Service available on site; 
CBOC, by number: 10: Service available on site. 

Service: Osteoporosis treatment; 
VAMC, by number: 1: Service available on site; 
VAMC, by number: 2: Service available on site; 
VAMC, by number: 3: Service available on site; 
VAMC, by number: 4: Service available on site; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Service available on site; 
VAMC, by number: 7: Service available on site; 
VAMC, by number: 8: Service available on site; 
VAMC, by number: 9: Service available on site; 
CBOC, by number: 1: Service available on site; 
CBOC, by number: 2: Service available on site; 
CBOC, by number: 3: Service available on site; 
CBOC, by number: 4: Service available on site; 
CBOC, by number: 5: Service available on site; 
CBOC, by number: 6: Service available on site; 
CBOC, by number: 7: Refer to another VA facility[A]; 
CBOC, by number: 8: Service available on site; 
CBOC, by number: 9: Service available on site; 
CBOC, by number: 10: Service available on site. 

Service: Menopause management; 
VAMC, by number: 1: Service available on site; 
VAMC, by number: 2: Service available on site; 
VAMC, by number: 3: Service available on site; 
VAMC, by number: 4: Service available on site; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Service available on site; 
VAMC, by number: 7: Service available on site; 
VAMC, by number: 8: Service available on site; 
VAMC, by number: 9: Service available on site; 
CBOC, by number: 1: Service available on site; 
CBOC, by number: 2: Service available on site; 
CBOC, by number: 3: Service available on site; 
CBOC, by number: 4: Service available on site; 
CBOC, by number: 5: Service available on site; 
CBOC, by number: 6: Service available on site; 
CBOC, by number: 7: Refer to another VA facility[A]; 
CBOC, by number: 8: Service available on site; 
CBOC, by number: 9: Service available on site; 
CBOC, by number: 10: Service available on site. 

Source: GAO. 

Note: We collected this information using a data collection instrument 
during site visits to VA medical facilities from October 2008 through 
April 2009. Some VA facilities reported that serious or complicated 
cases may be referred to other VA medical facilities. 

[A] This facility may also fee-base this service to an outside provider 
on a case-by-case basis. 

[End of table] 

The facilities we visited delivered basic gender-specific services in a 
variety of ways. Seven of the nine VAMCs and the two large CBOCs we 
visited had women's clinics. The physical setup of these clinics ranged 
from a physically separate dedicated clinical space (at five 
facilities) to one or more designated women's health providers with 
designated exam rooms within a mixed-gender primary care clinic. 
Generally, when women's clinics were available, most female patients 
received their basic gender-specific care in those clinics. When 
women's clinics were not available, female patients either received 
their gender-specific care through their primary care provider or were 
referred to another VA or non-VA facility for these services. 

Basic gender-specific services were typically available between 8:00 
a.m. and 4:30 p.m. on weekdays. At one CBOC and one VAMC, however, 
basic gender-specific care was only available during limited time 
frames. At the CBOC, a provider from the affiliated VAMC traveled to 
the CBOC 2 days each month to perform cervical cancer screenings and 
pelvic examinations for the clinic's female patients. In general, 
medical facilities did not offer evening or weekend hours for basic 
gender-specific services. 

While All VAMCs Offered at Least Some Specialized Gender-Specific 
Services On site, CBOCs Typically Referred Patients Needing These 
Services to Other VA or Non-VA Medical Facilities: 

The provision of specialized gender-specific services for women, 
including treatment after abnormal cervical cancer screenings and 
breast cancer treatment, varied by service and by facility. (See table 
3.) All VA medical facilities referred female patients to outside 
providers for obstetric care. Some of the VAMCs we visited offered a 
broad array of other specialized gender-specific services on site, but 
all contracted or fee-based at least some services. In particular, most 
VAMCs provided screening and diagnostic mammography through contracts 
with local providers or fee-based these services. In addition, less 
than half of the VAMCs provided reconstructive surgery after mastectomy 
on site, although six of the nine VAMCs we visited provided medical 
treatment for breast cancers and reproductive cancers on site. In 
general, the CBOCs we visited offered more limited specialized gender- 
specific services on site. For example, while most CBOCs offered 
pregnancy testing and sexually transmitted disease (STD) screening, 
counseling, and treatment, only the largest CBOCs offered IUD placement 
on site. Most CBOCs referred patients to VA medical facilities-- 
sometimes as far as 130 miles away--for some specialized gender- 
specific services. Because the travel distance can be a barrier to 
treatment for some veterans, officials at some CBOCs said that they 
will fee-base services to local providers on a case-by-case basis. At 
both VAMCs and CBOCs, specialized gender-specific services were usually 
offered on site only during certain hours: for example, four medical 
facilities only offered these services 2 days per week or less. 

Table 3: On-site Availability of Selected Specialized Gender-Specific 
Services for Women Veterans at Selected VA Facilities: 

Service: Treatment of sexually transmitted diseases (STD); 
VAMC, by number: 1: Service available on site; 
VAMC, by number: 2: Service available on site; 
VAMC, by number: 3: Service available on site; 
VAMC, by number: 4: Service available on site; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Service available on site; 
VAMC, by number: 7: Service available on site; 
VAMC, by number: 8: Service available on site; 
VAMC, by number: 9: Service available on site; 
CBOC, by number: 1: Service available on site; 
CBOC, by number: 2: Service available on site; 
CBOC, by number: 3: Service available on site; 
CBOC, by number: 4: Service available on site; 
CBOC, by number: 5: Service available on site; 
CBOC, by number: 6: Service available on site[A]; 
CBOC, by number: 7: Refer to another VA facility; 
CBOC, by number: 8: Service available on site; 
CBOC, by number: 9: Service available on site; 
CBOC, by number: 10: Service available on site. 

Service: Treatment after abnormal cervical cancer screening; 
VAMC, by number: 1: Service available on site; 
VAMC, by number: 2: Service available on site; 
VAMC, by number: 3: Refer to another VA facility[B]; 
VAMC, by number: 4: Service available on site; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Service available on site[C]; 
VAMC, by number: 7: Service available on site[A]; 
VAMC, by number: 8: Service available on site[A,C]; 
VAMC, by number: 9: Service available on site[A]; 
CBOC, by number: 1: Service available on site; 
CBOC, by number: 2: Service available on site; 
CBOC, by number: 3: Refer to another VA facility; 
CBOC, by number: 4: Refer to another VA facility; 
CBOC, by number: 5: Refer to another VA facility[C]; 
CBOC, by number: 6: Refer to another VA facility; 
CBOC, by number: 7: Refer to another VA facility[C]; 
CBOC, by number: 8: Refer to another VA facility; 
CBOC, by number: 9: Refer to another VA facility; 
CBOC, by number: 10: Refer to another VA facility. 

Service: Intrauterine device (IUD) placement; 
VAMC, by number: 1: Service available on site; 
VAMC, by number: 2: Service available on site; 
VAMC, by number: 3: Refer to another VA facility[B]; 
VAMC, by number: 4: Service available on site; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Service available on site; 
VAMC, by number: 7: Service available on site[A]; 
VAMC, by number: 8: Service available on site; 
VAMC, by number: 9: Service available on site; 
CBOC, by number: 1: Service available on site; 
CBOC, by number: 2: Service available on site; 
CBOC, by number: 3: Refer to another VA facility; 
CBOC, by number: 4: Refer to another VA facility; 
CBOC, by number: 5: Refer to another VA facility[C]; 
CBOC, by number: 6: Refer to another VA facility; 
CBOC, by number: 7: Refer to another VA facility[C]; 
CBOC, by number: 8: Refer to another VA facility; 
CBOC, by number: 9: Refer to another VA facility; 
CBOC, by number: 10: Refer to another VA facility. 

Service: Screening mammography; 
VAMC, by number: 1: Service available on site; 
VAMC, by number: 2: Refer to a contract provider[D]; 
VAMC, by number: 3: Service available on site; 
VAMC, by number: 4: Refer to a contract provider; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Refer to a fee-basis provider; 
VAMC, by number: 7: Refer to another VA facility; 
VAMC, by number: 8: Refer to a contract provider; 
VAMC, by number: 9: Refer to a contract provider[D]; 
CBOC, by number: 1: Refer to another VA facility; 
CBOC, by number: 2: Refer to a fee-basis provider; 
CBOC, by number: 3: Refer to a contract provider; 
CBOC, by number: 4: Refer to another VA facility; 
CBOC, by number: 5: Refer to a contract provider; 
CBOC, by number: 6: Refer to another VA facility; 
CBOC, by number: 7: Refer to another VA facility[C]; 
CBOC, by number: 8: Refer to a contract provider; 
CBOC, by number: 9: Refer to a contract provider; 
CBOC, by number: 10: Refer to a contract provider. 

Service: Obstetric care; 
VAMC, by number: 1: Refer to a fee-basis provider; 
VAMC, by number: 2: Refer to a fee-basis provider; 
VAMC, by number: 3: Refer to a fee-basis provider; 
VAMC, by number: 4: Refer to a fee-basis provider; 
VAMC, by number: 5: Refer to a fee-basis provider; 
VAMC, by number: 6: Refer to a fee-basis provider; 
VAMC, by number: 7: Refer to a fee-basis provider; 
VAMC, by number: 8: Refer to a fee-basis provider; 
VAMC, by number: 9: Refer to a fee-basis provider; 
CBOC, by number: 1: Refer to a fee-basis provider; 
CBOC, by number: 2: Refer to a fee-basis provider; 
CBOC, by number: 3: Refer to a fee-basis provider; 
CBOC, by number: 4: Refer to a fee-basis provider; 
CBOC, by number: 5: Refer to a fee-basis provider; 
CBOC, by number: 6: Refer to a fee-basis provider; 
CBOC, by number: 7: Refer to a fee-basis provider; 
CBOC, by number: 8: Refer to a fee-basis provider; 
CBOC, by number: 9: Refer to a fee-basis provider; 
CBOC, by number: 10: Refer to a fee-basis provider. 

Service: Medical treatment of breast and reproductive cancers; 
VAMC, by number: 1: Service available on site[C]; 
VAMC, by number: 2: Service available on site[C,E]; 
VAMC, by number: 3: Service available on site[C]; 
VAMC, by number: 4: Service available on site[C]; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Refer to another VA facility[C]; 
VAMC, by number: 7: Refer to another VA facility; 
VAMC, by number: 8: Service available on site[E]; 
VAMC, by number: 9: Refer to another VA facility; 
CBOC, by number: [Data about the availability of this service were not 
collected at CBOCs]. 

Service: Reconstructive surgery after mastectomy; 
VAMC, by number: 1: Refer to a fee-basis provider; 
VAMC, by number: 2: Service available on site; 
VAMC, by number: 3: Service available on site[C]; 
VAMC, by number: 4: Service available on site; 
VAMC, by number: 5: Service available on site; 
VAMC, by number: 6: Refer to a fee-basis provider; 
VAMC, by number: 7: Refer to a fee-basis provider; 
VAMC, by number: 8: Refer to a contract provider; 
VAMC, by number: 9: Refer to another VA facility; 
CBOC, by number: [Data about the availability of this service were not 
collected at CBOCs]. 

Source: GAO. 

Notes: We collected this information using data collection instruments 
during site visits to VA medical facilities from October 2008 through 
April 2009. 

[A] This facility may refer this service to another VAMC. 

[B] This facility refers this service to a large CBOC located 
approximately 13 miles from this facility. 

[C] This facility may also fee-base this service to a non-VA provider 
on a case-by-case basis. 

[D] This facility provided screening mammography services through a 
contract provider. That contract provider has a mobile unit that offers 
screening mammography services on site at the VAMC a few days a month. 

[E] This facility contracts for associated stereotactic biopsies. 

[End of table] 

Outpatient Mental Health Services Were Widely Available at Most VAMCs 
and Vet Centers, but More Limited at Smaller CBOCs: 

A range of outpatient mental health services was readily available at 
the VAMCs we visited. The types of outpatient mental health services 
available at most VAMCs included, for example, diagnosis and treatment 
of depression, substance use disorders, PTSD, and serious mental 
illness. All of the VAMCs we visited had one or more providers with 
training in evidence-based therapies for the treatment of PTSD and 
depression. All but one of the VAMCs we visited offered at least one 
women-only counseling group. Two VAMCs offered outpatient treatment 
programs specifically for women who have experienced MST or other 
traumas. In addition, several VAMCs offered services during evening 
hours at least 1 day a week. While most outpatient mental health 
services were available on site, facilities typically fee-based 
treatment for a veteran with an active eating disorder to non-VA 
providers. 

Similarly, the eight Vet Centers we visited offered a variety of 
outpatient mental health services, including counseling services for 
PTSD and depression, as well as individual or group counseling for 
victims of sexual trauma. Five of the eight Vet Centers we visited 
offered women-only groups, and six had counselors with training or 
experience in treating patients who have suffered sexual trauma. Vet 
Centers generally offered some counseling services in the evenings. 

The outpatient mental health services available in CBOCs were, in some 
cases, more limited. The two larger CBOCs offered women-only group 
counseling as well as intensive treatment programs specifically for 
women who had experienced MST or other traumas, and two other CBOCs 
offered women-only group counseling. The smaller CBOCs, however, tended 
to rely on staff from the affiliated VAMC, often through telehealth, to 
provide mental health services. Five CBOCs provided some mental health 
services through telehealth or using mental health providers from the 
VAMC that traveled to the CBOCs on specific days. 

While Most VAMCs Offer Mixed-Gender Residential or Inpatient Mental 
Health Services, Few Have Specialized Programs for Women Veterans: 

While most VAMCs offer mixed-gender residential mental health treatment 
programs or inpatient psychiatric services, few have specialized 
programs for women veterans. Eight of the nine VAMCs we visited served 
women veterans in mixed-gender inpatient psychiatric units, mixed- 
gender residential treatment programs, or both. Two VAMCs had 
residential treatment programs specifically for women who have 
experienced MST and other traumas. (VA has ten of these programs 
nationally.) None of the VAMCs had dedicated inpatient psychiatric 
units for women. VA providers at some facilities expressed concerns 
about the privacy and safety of women veterans in mixed-gender 
inpatient and residential environments. For example, in the residential 
treatment programs, beds for women veterans were separated from other 
areas of the building by keyless entry systems. However, female 
residents in some of these programs shared common areas, such as the 
dinning room, with male residents, and providers expressed concerns 
that women who were victims of sexual trauma might not feel comfortable 
in such an environment. 

Medical Facilities Had Not Fully Implemented VA Policies Pertaining to 
the Delivery of Health Care Services for Women Veterans: 

The extent to which VA medical facilities we visited were following VA 
policies that apply to the delivery of health care services for women 
veterans varied, but none of the facilities had fully implemented VA 
policies pertaining to women veterans' health care. In particular, none 
of the VAMCs or CBOCs we visited were fully compliant with VA policy 
requirements related to privacy for women veterans. In addition, the 
facilities we visited were in various stages of implementing VA's new 
initiative on comprehensive primary care: most medical facilities had 
at least one provider that could deliver comprehensive primary care 
services to women veterans, although not all of these facilities were 
routinely assigning women veterans to these providers. Officials at 
some VA facilities reported that they were unclear about the specific 
steps they would need to take to meet VA's definition of comprehensive 
primary care for women veterans. 

None of the Facilities Were Fully Compliant with VA Policies Related to 
Ensuring the Privacy of Women Veterans: 

None of the VAMCs and CBOCs we visited were fully compliant with VA 
policy requirements related to privacy for women veterans in all 
clinical settings where those requirements applied. Table 4 summarizes 
the extent to which the facilities we visited complied with VA policy 
requirements related to privacy for women veterans. 

Table 4: VA Facilities' Compliance with VA Privacy Requirements: 

Privacy requirement: Adequate visual and auditory privacy at check-in; 
Compliance with requirement: VAMC, by number: 1: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 2: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 7: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 8: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 9: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 1: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 2: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 3: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 4: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 5: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 6: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 7: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 8: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 9: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 10: Facility was not 
compliant with requirement in any clinical settings. 

Privacy requirement: Adequate visual and auditory privacy in the 
interview area; 
Compliance with requirement: VAMC, by number: 1: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 2: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 7: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 8: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 9: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 1: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 3: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 4: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 6: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 7: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 8: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 9: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 10: Facility was 
compliant with requirement in all clinical settings. 

Privacy requirement: Exam rooms located so they do not open into a 
public waiting room or a high-traffic public corridor; 
Compliance with requirement: VAMC, by number: 1: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 7: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 8: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 9: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 1: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 3: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 4: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 6: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 7: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 8: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 9: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 10: Facility was 
compliant with requirement in all clinical settings. 

Privacy requirement: Privacy curtains present in exam rooms; 
Compliance with requirement: VAMC, by number: 1: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 7: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 8: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 9: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 1: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 3: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 4: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 6: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 7: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 8: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 9: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 10: Facility was 
compliant with requirement in all clinical settings. 

Privacy requirement: Exam tables placed with the foot facing away from 
the door (if not possible, placed so they are fully shielded by privacy 
curtains)[A]; 
Compliance with requirement: VAMC, by number: 1: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 2: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 7: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 8: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 9: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 1: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 3: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 4: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 5: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 6: N/A; 
Compliance with requirement: CBOC, by number: 7: N/A; 
Compliance with requirement: CBOC, by number: 8: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 9: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 10: Facility was not 
compliant with requirement in any clinical settings. 

Privacy requirement: Changing area provided behind privacy curtain; 
Compliance with requirement: VAMC, by number: 1: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 7: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 8: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 9: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 1: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 3: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 4: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 6: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 7: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 8: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 9: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 10: Facility was 
compliant with requirement in all clinical settings. 

Privacy requirement: Toilet facilities immediately adjacent to 
examination rooms where gynecological exams and procedures are 
performed; 
Compliance with requirement: VAMC, by number: 1: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 7: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 8: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 9: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: CBOC, by number: 1: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 2: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 3: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 4: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC, by number: 6: N/A; 
Compliance with requirement: CBOC, by number: 7: N/A; 
Compliance with requirement: CBOC, by number: 8: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 9: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 10: Facility was not 
compliant with requirement in any clinical settings. 

Privacy requirement: Sanitary napkin and/or tampon dispensers and 
disposal bins in at least one women's public restroom; 
Compliance with requirement: VAMC, by number: 1: Facility was compliant 
with requirement in all clinical settings[B]; 
Compliance with requirement: VAMC, by number: 2: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 7: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: VAMC, by number: 8: v
Compliance with requirement: VAMC, by number: 9: Facility was compliant 
with requirement in all clinical settings[B]; 
Compliance with requirement: CBOC, by number: 1: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 2: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 3: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 4: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 5: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 6: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 7: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 8: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 9: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC, by number: 10: Facility was not 
compliant with requirement in any clinical settings. 

Privacy requirement: Privacy curtains in inpatient rooms (exception: 
psychiatry and mental health units); 
Compliance with requirement: VAMC, by number: 1: 
Compliance with requirement: VAMC, by number: 2: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 7: N/A; 
Compliance with requirement: VAMC, by number: 8: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 9: Facility was not 
compliant with requirement in any clinical settings; 
Compliance with requirement: CBOC: [This requirement does not apply to 
CBOCs]. 

Privacy requirement: Access to a private bathroom facility (with toilet 
and shower) in close proximity to the patient's room (inpatient and 
residential units); 
Compliance with requirement: VAMC, by number: 1: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 2: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 3: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 4: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 5: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: VAMC, by number: 6: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 7: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 8: Facility was compliant 
with requirement in at least one--but not all--clinical settings; 
Compliance with requirement: VAMC, by number: 9: Facility was compliant 
with requirement in all clinical settings; 
Compliance with requirement: CBOC: [This requirement does not apply to 
CBOCs]. 

Source: GAO. 

N/A: We did not tour any clinical settings at this facility where this 
requirement must be applied; 

Notes: We collected this information using data collection instruments 
during site visits to VA medical facilities from October 2008 through 
April 2009. 

[A] We did not observe any clinical settings where it was not possible 
to orient exam tables with the foot facing away from the doorway. 

[B] At this facility, sanitary napkins, tampons, or both were available 
free of charge in baskets that had been placed in public restrooms. 

[End of table] 

All facilities were fully compliant with at least some of VA's privacy 
requirements; however, we documented observations in many clinical 
settings where facilities were not following one or more requirements. 
Some common areas of noncompliance included the following: 

* Visual and auditory privacy at check-in. None of the VAMCs or CBOCs 
we visited ensured adequate visual and auditory privacy at check-in in 
all clinical settings that are accessed by women veterans. In most 
clinical settings, check-in desks or windows were located in a mixed- 
gender waiting room or on a high-traffic public corridor. In some 
locations, the check-in area was located far enough away from the 
waiting room chairs that patients checking in for appointments could 
not easily be overheard. In a total of 12 outpatient clinical settings 
at six VAMCs and five CBOCs, however, check-in desks were located in 
close proximity to chairs where other patients waited for their 
appointments. At one CBOC, we observed a line forming at the check-in 
window, with several people waiting directly behind the patient 
checking in, demonstrating how privacy can be easily violated at check- 
in. 

* Orientation of exam tables. In exam rooms where gynecological exams 
are conducted, only one of the nine VAMCs and two of the eight 
CBOCs[Footnote 17] we visited were fully compliant with VA's policy 
requiring exam tables to face away from the door.[Footnote 18] In many 
clinical settings that were not fully compliant at the remaining 
facilities, we observed that exam tables were oriented with the foot of 
the table facing the door, and in two CBOCs where exam tables were not 
properly oriented, there was no privacy curtain to help assure visual 
privacy during women veterans' exams. At one of these CBOCs, a 
noncompliant exam room was also located within view of a mixed-gender 
waiting room. Figure 1 shows the correct and incorrect orientation of 
exam tables in two gynecological exam rooms at two VA medical 
facilities. 

Figure 1: Correct and Incorrect Placement of Exam Tables in 
Gynecological Exam Rooms at VA Medical Facilities: 

[Refer to PDF for image: two photographs] 

Correct placement of the exam table; 
Incorrect placement of the exam table. 

Source: GAO. 

[End of figure] 

* Restrooms adjacent to exam rooms. Only two of the nine VAMCs and one 
of the eight CBOCs we visited were fully compliant with VA's 
requirement that exam rooms where gynecological exams are conducted 
have immediately adjacent restrooms.[Footnote 19] In most of the 
outpatient clinics we toured, a woman veteran would have to walk down 
the hall to access a restroom, in some cases passing through a high- 
traffic public corridor or a mixed-gender waiting room. 

* Access to private restrooms in inpatient and residential units. At 
four of the nine VAMCs we visited, proximity of private restrooms to 
women's rooms on inpatient or residential units was a concern. In one 
mixed-gender inpatient medical/surgical unit, two mixed-gender 
residential units, and one all-female residential unit, women veterans 
were not guaranteed access to a private bathing facility and may have 
had to use a shared or congregate facility. In two of these four 
settings, access to the shared restroom was not restricted by a lock or 
a keycard system, raising concerns about the possibility of intrusion 
by male patients or staff while a woman veteran is showering or using 
the restroom. 

* Availability of sanitary products in public restrooms. At seven of 
the nine VAMCs and all 10 of the CBOCs we visited, we did not find 
sanitary napkins or tampons available in dispensers in any of the 
public restrooms. 

Medical Facilities Were in Various Stages of Implementing VA's 
Initiative on Comprehensive Primary Care for Women Veterans, but 
Officials at Some Facilities Were Unclear about the Steps Needed to 
Implement VA's New Initiative: 

VA has not set a deadline by which all VAMCs and CBOCs are required to 
implement VA's new comprehensive primary care initiative for women 
veterans, which would allow women veterans to obtain both primary care 
and basic gender-specific services from one provider at one site. 
Officials at the VA medical facilities we visited since the 
comprehensive primary care for women veterans initiative was introduced 
reported that they were at various stages of implementing the new 
initiative. Officials at 6 of the 7 VAMCs and 6 of the 8 CBOCs we 
visited since November 2008--when VA adopted this initiative--reported 
that they had at least one provider who could deliver comprehensive 
primary care services to women veterans. However, some of the medical 
facilities we visited reported that they were not routinely assigning 
women veterans to comprehensive primary care providers. 

Officials at some medical facilities we visited were unclear about the 
steps needed to implement VA's new policy on comprehensive primary care 
for women veterans. For example, at one VAMC, primary care was offered 
in a mixed-gender primary care clinic and basic gender-specific 
services were offered by a separate appointment in the gynecology 
clinic, sometimes on the same day. The new comprehensive primary care 
initiative would require both primary care and basic gender specific 
services to be available on the same day, during the same appointment. 
Officials at this facility said that they were in the process of 
determining whether they can adapt their current model to meet VA's 
comprehensive primary care standard by placing additional primary care 
providers in the gynecology clinic so that both primary care services 
and basic gender-specific services could be offered during the same 
appointment, in one location. Facility officials were uncertain about 
whether it would meet VA's comprehensive primary care standard if 
primary care and basic gender-specific services were still delivered by 
two different providers. However, VA's comprehensive primary care 
policy is clear that the care is to be delivered by the same provider. 
Another area of uncertainty is the breadth of experience a provider 
would need to meet VA's comprehensive primary care standard. Officials 
from VA headquarters have made it clear that it is their expectation 
that comprehensive primary care providers have a broad understanding of 
basic women's health issues--including initial evaluation and treatment 
of pelvic and abdominal pain, menopause management, and the risks 
associated with prescribing certain drugs to pregnant or lactating 
women. However, in one location, we found that the only provider who 
was available to deliver comprehensive primary care may not have had 
the proficiency to deliver the broad array of services that are 
included in VA's definition, because the facility serves a very low 
volume of women veterans and opportunities to practice delivering some 
basic gender-specific services are limited. 

VA Officials Identified Key Challenges Related to Space, Hiring Staff 
with Specific Experience and Training, and Establishing the WVPM as a 
Full-time Position: 

VA officials at medical facilities we visited identified a number of 
key challenges in providing health care services to women veterans. 
These challenges include physical space constraints that affect the 
provision of care, including problems complying with patient privacy 
requirements, and difficulties hiring providers that have specific 
experience and training in women's health, as well as hiring mental 
health providers with expertise in treating veterans with PTSD and who 
have experienced MST. Officials at some VA medical facilities also 
reported implementation issues in establishing the WVPM as a full-time 
position. 

VA Facility Officials Identified Space Constraints as a Challenge 
Affecting the Provision of Health Care Services to Women Veterans: 

Officials at VA medical facilities we visited reported that space 
constraints have raised issues affecting the provision of health care 
services to women veterans. In particular, officials at 7 of 9 VAMCs 
and 5 of 10 CBOCs we visited said that space issues, such as the 
number, size, or configuration of exam rooms or bathrooms at their 
facilities sometimes made it difficult for them to comply with some VA 
requirements related to privacy for women veterans. At some of the 
medical facilities we visited, officials raised concerns about busy 
waiting rooms and the limited space available to provide separate 
waiting rooms for patients who may not feel comfortable in a mixed- 
gender waiting room, particularly women veterans who have experienced 
MST. Officials at one CBOC said they received complaints from women 
veterans who preferred a separate waiting room. At this facility, space 
challenges that affected privacy were among the factors that led to the 
relocation of mental health services to a separate off-site clinic. VA 
facility officials told us that some of the patient bedrooms at two 
VAMC mixed-gender inpatient psychiatric units that were usually 
designated for female patients were located in space that could not be 
adequately monitored from the nursing station. VA policy requires that 
all inpatient care facilities provide separate and secured sleeping 
accommodations for women and that mixed-gender units must ensure safe 
and secure sleeping arrangements, including, but not limited to, the 
ability to monitor the patient bedrooms from the nursing station. 

VA facility officials also told us they have struggled with space 
constraints as they work to comply with VA's new policy on 
comprehensive primary care for women and the requirements in the 
September 2008 Uniform Mental Health Services in VA Medical Centers and 
Clinics, as well as the increasing numbers of women veterans requesting 
these services. For example, officials at a VAMC said that limitations 
in the number of primary care exam rooms at their facilities made it 
difficult for providers to deliver comprehensive primary care services 
in an efficient and timely manner. Providers explained that having only 
one exam room per primary care provider prevents them from 
"multitasking," or moving back and forth between exam rooms while 
patients are changing or completing intake interviews with nursing 
staff. Similarly, mental health providers at a medical facility said 
that they often shared offices, which limits the number of counseling 
appointments they could schedule, and primary care providers sometimes 
have two patients in a room at the same time separated by a curtain 
during the intake or screening process. In addition, at one VAMC, 
officials reported that the facility needed to be two to three times 
its current size to accommodate increasing patient demand. 

VA officials are aware of these challenges and VA is taking steps to 
address them, such as funding construction projects, moving to larger 
buildings, and opening additional CBOCs. However, some of these 
projects will not be finished for a few years. In the interim, 
officials said, some facilities are leasing additional space or 
contracting some services to community providers. 

VA Facility Officials Identified Difficulties Hiring Primary Care 
Providers with the Specific Training and Experience Needed to Provide 
Services to Women Veterans: 

VA facility officials reported difficulties hiring primary care 
providers with specific training and experience in women's health. VA's 
comprehensive primary care initiative requires that women veterans have 
access to a designated women's health primary care provider that is 
"proficient, interested, and engaged" in delivering services to women 
veterans. The new policy requires that this primary care provider 
fulfill a broad array of health care services including, but not 
limited to: 

* detection and management of acute and chronic illness, such as 
osteoporosis, thyroid disease, and cancer of the breast, cervix, and 
lung; 

* gender-specific primary care such as sexuality, pharmacologic issues 
related to pregnancy and lactation, and vaginal infections; 

* preventive care, such as cancer screening and weight management; 

* mental health services such as screening and referrals for MST, as 
well as evaluation and treatment of uncomplicated mental health 
disorders and substance use disorders; and: 

* coordination of specialty care. 

Officials at some facilities we visited told us that they would like to 
hire more providers with the required knowledge and experience in 
women's health, but struggle to do so. For example, at one VAMC, 
officials reported that they had difficulty filling three vacancies for 
primary care providers, which they needed to meet the increasing demand 
for services and to replace staff who had retired. They said it took 
them a long time to find providers with the skills required to serve 
the needs of women veterans. Similarly, at one CBOC, officials reported 
that it takes them about 8 to 9 months to hire interested primary care 
physicians. Further, officials at some facilities we visited said that 
they rely on just one or two providers to deliver comprehensive primary 
care to women veterans. This is a concern to the officials because, 
should the provider retire or leave VA, the facility might not be able 
to replace them relatively quickly in order to continue to provide 
comprehensive primary care services to women veterans on site. 

VA officials have acknowledged some of the challenges involved in 
training additional primary care providers to meet their vision of 
delivering comprehensive primary care to women veterans. A November 
2008 report on the provision of primary care to women veterans cites 
insufficient numbers of clinicians with specific training and 
experience in women's health issues among the challenges VA faces in 
implementing comprehensive primary care.[Footnote 20] To help address 
the knowledge gap, VA is using "mini-residency" training sessions on 
women's health. These training sessions--which VA designed to enhance 
the knowledge and skills of primary care providers--consist of two and 
one-half days of case-based learning and hands-on training in gender- 
specific health care for women. During the mini-residency, providers 
receive specific training in performing pelvic examinations, cervical 
cancer screenings, clinical breast examinations, and other relevant 
skills. 

VA Medical Facility and Vet Center Officials Identified Challenges 
Hiring Mental Health Providers with Training and Experience in Treating 
PTSD and MST: 

VA medical facility and Vet Center officials reported challenges hiring 
psychiatrists, psychologists, and other mental health staff with 
specialized training or experience in treating PTSD and MST. Medical 
facility officials often noted that there is a limited pool of 
qualified psychiatrists and psychologists, and a high demand for these 
professionals both in the private sector and within VA. In addition, 
two officials reported that because it is difficult to attract and hire 
mental health professionals with experience in treating the veteran 
population, some medical facilities have hired younger, less 
experienced providers. These officials noted that while younger 
providers may have the appropriate education and training in some 
evidence-based psychotherapy treatment methods that are recommended for 
treating PTSD and MST, they often lack practical experience treating a 
challenging patient population. 

Some officials reported that staffing and training challenges limit the 
types of group or individual mental health treatment services that VA 
medical facilities and Vet Centers can offer. For example, officials at 
one VAMC said that they had problems attracting qualified mental health 
providers to work at its affiliated CBOCs. The facility posted 
announcements for psychiatrist and psychologist positions, but 
sometimes received no applications. Because the facility has not been 
able to recruit mental health providers, it relies on contract 
providers and fee-basing to deliver mental health services to veterans 
in its service area. At one Vet Center, officials told us that because 
none of their counselors have been trained to counsel veterans who have 
experienced MST, patients seeking counseling for MST are usually 
referred to the nearby CBOC or VAMC. At one CBOC, a licensed social 
worker reported that he provides individual counseling for about seven 
women who have experienced MST, even though he has limited training in 
this area. He said that this situation was not ideal, but said that he 
consults with mental health providers at the associated VAMC on some of 
these cases, and that without his services some of these women might 
not receive any counseling. 

VA officials told us that they are aware of the challenges involved in 
finding clinical staff with specialized training and experience in 
working with veterans who have PTSD or have experienced MST. A VA 
official told us that as part of a national effort to enhance mental 
health providers' knowledge of clinically effective treatment methods 
and make these methods available to veterans, VA has developed 
evidenced-based psychotherapy training for VA mental health staff. In 
particular, CPT, PE, and ACT are evidence-based treatment therapies for 
PTSD and also commonly used by providers who work with patients who 
have experienced MST.[Footnote 21] A VA headquarters official who is 
responsible for these training programs told us that as of May 4, 2009, 
1,670 VA clinicians had completed VA-provided training in evidence- 
based therapies. Although VA is providing training in these evidence- 
based therapies, VA officials stated that this training is not 
mandatory for VA mental health providers who work with patients who 
have PTSD or have experienced MST. 

Some VAMC Officials Reported That Establishing the WVPM as a Full-time 
Position Has Raised Implementation Issues: 

Some VA officials expressed concerns that certain aspects of the new 
policy making the WVPM a full-time position may have the unintended 
consequence of discouraging clinicians from applying for or staying in 
the position, potentially leading to the loss of experienced WVPMs. One 
concern that some WVPMs raised during our interviews was that they were 
interested in performing clinical duties beyond the minimum required to 
maintain their professional certification, but would not be able to do 
so under the new policy. The new policy limits a WVPM's clinical duties 
to the minimum required to maintain professional certification, 
licensure, or privileges, typically no more than 5 hours per week. 
Another concern was that the change to full-time status could result in 
a reduction in salary for some clinicians because the position could be 
classified as an administrative position, depending on how the policy 
is implemented at the VAMC. At two VAMCs we visited, such concerns had 
discouraged the incumbent WVPM from accepting the full-time position. 

VA headquarters officials told us that they are aware of and have 
expressed their concerns to VA senior headquarters officials about 
unintended consequences of the new policy. VA headquarters officials 
provided VISN and VAMC leadership with some options that they could use 
to help avoid or minimize the potential loss of experienced WVPMs. For 
example, one option that could be approved on a case-by-case basis is 
to use a job-sharing arrangement that would allow the incumbent WVPM 
and another person to each dedicate 50 percent of their time to the 
WVPM position, performing clinical duties the other 50 percent, in 
order to transition staff into the full-time position or as a 
succession planning effort. VA headquarters officials said that action 
on this issue was important because VA does not have the time or 
resources to train new staff to replace experienced WVPMs who may leave 
their positions. 

Mr. Chairman, this completes my prepared remarks. I would be happy to 
respond to any questions you or other Members of the committee have at 
this time. 

For further information about this testimony, please contact Randall 
Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this statement. GAO staff who made major 
contributions to this testimony are listed in appendix II. 

[End of section] 

Appendix I: Information on the Selection of VA Facilities Examined in 
This Report: 

We selected locations for our site visits using VA data on each VA 
medical center (VAMC) in the United States. Our goal was to identify a 
geographically diverse mix of facilities, including some facilities 
that provide services to a high volume of women veterans, particularly 
women veterans of Operation Enduring Freedom (OEF) and Operation Iraqi 
Freedom (OIF); some facilities that serve a high proportion of National 
Guard or Reserve veterans; and some facilities that serve rural 
veterans. We also considered whether VAMCs had programs specifically 
for women veterans, particularly treatment programs for post-traumatic 
stress disorder (PTSD) and for women who have experienced military 
sexual trauma (MST). For each of the factors listed below, we examined 
available facility-or market-level data to identify facilities of 
interest: 

* total number of unique women veteran patients using the VAMC; 

* total number of unique OEF/OIF women veteran patients using the VAMC; 

* proportion of unique women veterans using the VAMC who are OEF/OIF 
veterans; 

* proportion of unique OEF/OIF women veterans using the VAMC who were 
discharged from the National Guard or Reserves; 

* within the VA-defined market area for the VAMC, the proportion of 
women veterans who use VA health care and live in rural or highly rural 
areas; and: 

* availability of on-site programs specific to women veterans, such as 
inpatient or residential treatment programs that offer specialized 
treatment for women veterans with PTSD or who have experienced MST, 
including programs that are for women only or have an admission cycle 
that includes only women; and outpatient treatment teams with a 
specialized focus on MST. 

We selected a judgmental sample of the VAMCs that fell into the top 25 
facilities for at least two of these factors. Once we had selected 
these VAMCs, we also selected at least one community-based outpatient 
clinic (CBOC) affiliated with each of the VAMCs and one nearby Vet 
Center, which we also visited during our site visits. In selecting 
these CBOCs and Vet Centers, we focused on selecting facilities that 
represented a range of sizes, in terms of the number of women veterans 
they served. 

Tables 5 and 6 provide information on the unique number of women 
veterans served by each of the VAMCs and CBOCs we selected for site 
visits. 

Table 5: Women Veterans' Health Care Utilization at Selected VA Medical 
Centers (VAMC): 

VAMC, by number: VAMC 1; 
Number of unique women veterans served in fiscal year 2008: 6,464; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of women veterans served: 19.5; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the total number of veterans served (both men and women): 8.5. 

VAMC, by number: VAMC 2; 
Number of unique women veterans served in fiscal year 2008: 6,360; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of women veterans served: 22.4; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the total number of veterans served (both men and women): 12.8. 

VAMC, by number: VAMC 3; 
Number of unique women veterans served in fiscal year 2008: 4,497; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of women veterans served: 8.2; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the total number of veterans served (both men and women): 7.3. 

VAMC, by number: VAMC 4; 
Number of unique women veterans served in fiscal year 2008: 3,588; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of women veterans served: 19.4; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the total number of veterans served (both men and women): 10.2. 

VAMC, by number: VAMC 5; 
Number of unique women veterans served in fiscal year 2008: 2,324; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of women veterans served: 11.7; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the total number of veterans served (both men and women): 4.8. 

VAMC, by number: VAMC 6; 
Number of unique women veterans served in fiscal year 2008: 1,846; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of women veterans served: 20.2; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the total number of veterans served (both men and women): 3.9. 

VAMC, by number: VAMC 7; 
Number of unique women veterans served in fiscal year 2008: 1,841[A]; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of women veterans served: 19.8; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the total number of veterans served (both men and women): 5.1[A]. 

VAMC, by number: VAMC 8; 
Number of unique women veterans served in fiscal year 2008: 999; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of women veterans served: 12.5; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the total number of veterans served (both men and women): 1.0. 

VAMC, by number: VAMC 9; 
Number of unique women veterans served in fiscal year 2008: 995; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of women veterans served: 22.5; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the total number of veterans served (both men and women): 6.9. 

Source: VA data and GAO analysis. 

[A] This VAMC is part of the same health care system as VAMC 1. Some of 
these veterans may also have received services at VAMC 1. 

[End of table] 

Table 6: Women Veterans' Health Care Utilization at Selected Community- 
Based Outpatient Clinics (CBOC): 

CBOC, by number: CBOC 1; 
Number of unique women veterans served in fiscal year 2008: 2,926; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: 12.5. 

CBOC, by number: CBOC 2; 
Number of unique women veterans served in fiscal year 2008: 1,750; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: 27.0. 

CBOC, by number: CBOC 3; 
Number of unique women veterans served in fiscal year 2008: 599; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: 90.2. 

CBOC, by number: CBOC 4; 
Number of unique women veterans served in fiscal year 2008: 554; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: 51.0. 

CBOC, by number: CBOC 5; 
Number of unique women veterans served in fiscal year 2008: 224; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: 13.1. 

CBOC, by number: CBOC 6; 
Number of unique women veterans served in fiscal year 2008: 115; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: 8.5. 

CBOC, by number: CBOC 7; 
Number of unique women veterans served in fiscal year 2008: 103; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: 21.2. 

CBOC, by number: CBOC 8; 
Number of unique women veterans served in fiscal year 2008: 88; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: 54.4. 

CBOC, by number: CBOC 9; 
Number of unique women veterans served in fiscal year 2008: 48; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: 9.1. 

CBOC, by number: CBOC 10[A]; 
Number of unique women veterans served in fiscal year 2008: 42; 
Percentage increase between fiscal year 2006 and fiscal year 2008 in 
the number of unique women veterans served: not applicable[A]. 

Source: VA data and GAO analysis. 

[A] This facility opened in 2007, so percentage increase since fiscal 
year 2006 does not apply. 

[End of table] 

[End of section] 

Appendix II: 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, Marcia A. Mann, Assistant 
Director; Susannah Bloch; Chad Davenport; Alexis MacDonald; and Carmen 
Rivera-Lowitt made key contributions to this testimony. 

[End of section] 

Footnotes: 

[1] PTSD may develop following exposure to combat, natural disasters, 
terrorist incidents, serious accidents, or violent personal assaults 
like rape. People who experience stressful events often relive the 
experience through nightmares and flashbacks, have difficulty sleeping, 
and feel detached or estranged. These symptoms can occur within the 
first few days after exposure to the stressful event but may also be 
delayed for months or years. If symptoms continue for more than 30 days 
and significantly disrupt an individual's daily activities, a diagnosis 
of PTSD is made. 

[2] VA defines military sexual trauma (MST) as "psychological trauma, 
which in the judgment of a VA mental health professional resulted from 
a physical assault of a sexual nature, battery of a sexual nature, or 
sexual harassment which occurred while the veteran was serving on 
active duty or active duty for training." VA reported that in fiscal 
year 2008, 21 percent of women screened for MST, screened positive for 
having experienced MST. 

[3] The scope of services VA requires to be provided to women veterans, 
including requirements for ensuring the privacy of women veterans, are 
outlined in Veterans Health Administration (VHA) Handbook 1330.1, and 
the requirements for WVPM are outlined in VHA Handbook 1330.02 and in a 
July 2008 VA directive titled "Women Veteran Program Managers Full-Time 
FTEE Positions." 

[4] The management of VAMCs and CBOCs is decentralized to 21 regional 
networks referred to as VISNs. 

[5] See 38 U.S.C. § 1710(a), 38 C.F.R. § 17.38 (2008). Any veteran who 
has served in a combat theater after November 11, 1998, including OEF/ 
OIF veterans, and who was discharged or released from active service on 
or after January 28, 2003, has up to 5 years from the date of the 
veteran's most recent discharge or release from active duty service to 
enroll in VA's health care system and receive VA health care services. 
See 38 U.S.C. § 1710(e)(1)(D), (e)(3)(C). Veterans who were discharged 
or released before January 28, 2003, and who did not enroll in VA's 
health care system are eligible for these VA health care services for 3 
years after January 28, 2008. 

[6] All veterans who have served in a combat theater, including OEF/OIF 
veterans, are eligible for Vet Center services. See 38 U.S.C. § 
1712A(a). 

[7] See 38 U.S.C. § 1703. 

[8] Telehealth is the provision of health services from a distance 
using telecommunications technologies, such as videoconferencing. 

[9] 38 U.S.C. § 1710. 

[10] 38 U.S.C. § 1720D. 

[11] These services are defined in VHA Handbook 1330.1, VHA Services 
for Women Veterans (revised July 16, 2004) and VHA Handbook 1160.01, 
Uniform Mental Health Services in VA Medical Centers and Clinics (Sept. 
11, 2008). 

[12] See 38 C.F.R. § 17.38 (2008). 

[13] VHA Handbook 1160.01 and VHA Handbook 1330.1. 

[14] VHA Handbook 1160.01. 

[15] The mental health services that must be provided in CBOCs differ 
according to the size of the clinics. 

[16] Psychotherapies that have consistently been shown in controlled 
research to be effective for a particular condition or conditions are 
referred to as "evidence-based." 

[17] We visited 10 CBOCs, but 2 of the CBOCs we visited did not offer 
gynecological exams. 

[18] According to VA policy, if it is not possible for exam tables to 
be placed with the foot facing away from the door, they may be placed 
so that they are fully shielded by privacy curtains. However, we did 
not observe any clinical settings where it was not possible to orient 
exam tables with the foot facing away from the door. 

[19] We visited 10 CBOCs, but 2 of the CBOCs we visited did not offer 
gynecological exams, so this requirement was not applicable at those 2 
CBOCs. 

[20] Department of Veterans Affairs, Report of the Under Secretary for 
Health Workgroup, Provision of Primary Care to Women Veterans, Office 
of Public Health and Environmental Hazards, Women Veterans Health 
Strategic Health Care Group (Washington, D.C.: November 2008). 

[21] According to VA officials, these therapies address the PTSD 
diagnosis commonly associated with sexual trauma. Other diagnoses 
commonly associated with MST are depression and generalized anxiety. 

[End of section] 

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