http://www.goodhousekeeping.com/health/womens/va-healthcare-falls-short
Female vets find the VA health-care system lacks the resources and
initiative to care for women returning from duty
By Jan Goodwin
"I could spend all day browsing in bookstores," says the former Army
Reserve specialist. "It's my favorite thing to do." But it has been
four years since the Minnesota native has been in a bookstore or
any kind of shop. Since she returned from Iraq in 2005, her panic
attacks have been so severe, she can no longer leave her house
outside Minneapolis. The attacks started when she rode city buses
"they sounded like a Humvee," explains the woman, who asked that her
name not be used for privacy reasons. That rumbling set off hideous
flashbacks to her time in Iraq, where she crisscrossed the country in
canvas-sided Humvees doing convoys as a turret gunner. "It was one of
the most dangerous things you can do," she says. Although she had no
emotional trouble while carrying out her unit's missions, eight
months after she returned home, the panic attacks started; then she
became haunted by nightmares of her wounded buddies and of injured
Iraqi civilians and fell into a despair she still cannot escape. "I
feel worthless," says the vet, who has been diagnosed with severe
depression as well as post-traumatic stress disorder (PTSD), a
condition triggered by a terrifying experience and characterized by
anxiety, disturbed sleep, and feelings of disconnection.
Currently, she receives 100 percent disability from the Army. But
what this woman soldier hasn't received is the medical care that will
help her get well.
Talk to her, and you will hear details of a Veterans Affairs
health-care system astonishingly out of touch with the grim
experiences many of today's troops face and then have to deal with
at home. She describes the perky little pamphlet she received from a
VA therapist with the advice to "Get a butterfly tattoo!" and "Drive
with the windows open!" as ways to lift her spirits while she
struggled with emotional trauma. As for her therapy, "I've been in
all-male groups with vets who were shoplifters, sexual assaulters,
wife-beaters," she says. When she requested a group with other women
vets, she was reassigned, but "none of them had been in combat, and
they asked that I not tell my stories. They were too disturbing."
Today, over 10 percent of our troops are female (it's been as high as
15 percent); they are maimed, mentally scarred, and killed protecting
U.S. interests. Yet when it comes to the care they receive once they
come home, it can seem, as one former Air Force sergeant says, "as if
we are Martians, abnormalities, descending on the VA health system."
Patients may be met by indifferent, overworked clerks who don't know
what services are available. Doctors can be insensitive, surprised to
be caring for young women and uncomfortable with it. Some facilities
have no women's restrooms next to exam rooms, so women clad in skimpy
gowns may have to walk through public hallways if, for example, they
need to leave a urine sample in the restroom. Exam rooms may lack
privacy curtains. "It was the single most depressing place I've
seen," says former Marine Corps captain Anuradha Bhagwati, describing
her first visit to a VA hospital. "You've got the walking dead
surrounding you, unstable male veterans, loose cannons, screaming."
Beyond the disturbing atmosphere, women vets can have trouble getting
the actual care they need. Of the country's 153 VA medical centers
often large, multi-specialty hospitals about half do not have a
gynecologist on staff (though, VA officials point out, women can find
the care elsewhere, through contracted services). Women who have been
sexually assaulted while serving and, shockingly, one-third have
experienced rape or attempted rape, a major study found have had to
endure uncomfortable flirting from security guards and other vets as
they wait for treatment. And while women seeking counseling for
sexual assault or harassment (formally dubbed "military sexual
trauma," or MST) can choose to see a female therapist, that's not
necessarily the case for women vets with other emotional problems.
While the government has long been aware of these problems, efforts
to legally change the system have been mired in politics. One
holdout: Senator (and physician) Tom Coburn (R-OK), who had for many
months blocked legislation designed to combat the problem. "The VA
cannot handle its current responsibility...so it is unwise to add
more to their load," he said through a spokesperson. (Ironically, it
was Senator Coburn who tried to help his philandering colleague,
Senator John Ensign [R-NV], saying, "When someone is sick, do you not
try to help them get well? Or do you say, 'Oh, you're sick
goodbye'?" Apparently this same logic doesn't apply to our vets and
their families.)
In November, Coburn finally dropped his opposition. The Senate and
the House have passed similar versions of the Women Veterans Health
Care Improvement Act and, as GH went to press, President Obama was
expected to sign the bill. That's progress. But even if it becomes
law, it will take more than an act of Congress to fundamentally
change the way the system responds to women. "We know the VA has not
been women-friendly," says Patricia Hayes, Ph.D., chief consultant of
the VA's Women Veterans Health Strategic Health Care Group.
Real change has to come from the inside, and it starts with being
honest about what women face day after day, night after night in
today's wars.
Memo to the Military: Girls Do Fight
In 2004, Cara Hammer, now 32, was an Army sergeant driving with three
others from Kuwait to Tikrit, Iraq, when their Humvee was stopped
because of an IED (improvised explosive device) threat. As they were
getting back into the vehicle, "there was a huge blast," says Hammer,
who was "pushed back by massive sound waves, knocked out." She
suffered permanent hearing loss in her left ear, and soon after
realized her short-term memory had been affected, too. "I have to
carry a notebook around and write down everything," says Hammer. "My
boyfriend will say something; I'll say 'yes,' and two minutes later,
completely forget what he said."
Those physical injuries were only part of the challenge Hammer
confronted. In 2005, after completing her tour, she returned to
Germany, where she had been stationed, and began to suffer from
flashbacks, anxiety, insomnia, and, when she could sleep, terrible
nightmares all classic signs of post-traumatic stress disorder.
Trying to escape her demons, Hammer became obsessive, running 10 to
15 miles a day. She lost 35 pounds in eight weeks.
Her problems continued when she got home to Phoenix a few months
later. "I felt so disconnected from everyone I love, and everything
that I was looking forward to getting back to," she says.
So she decided to seek care at a VA hospital, but it was a totally
humiliating experience. "The male vets whistled, made catcalls. I
felt like a candy striper, not a colleague." And, to her
astonishment, the doctor refused to connect her symptoms to combat,
instead declaring that Hammer had attention deficit disorder. "It was
like a slap in the face," she says. "I was 29 years old. Until that
explosion, I'd functioned very well, with zero symptoms of ADD."
Doctors, whether military or civilian, can make the wrong call. But
Hammer's case, like that of many female vets, reflects a persistent
problem: Historically, post-traumatic stress disorder has been
diagnosed in service members who've been in combat or who have been
prisoners of war. And since the Department of Defense bars women from
serving in units that primarily engage in direct combat on the
ground, it can be mission nearly impossible for women vets to prove
their war experiences qualify.
That mindset linking PTSD to "direct combat" is totally at odds
with today's warfare. In Iraq and Afghanistan, the battlefront is
everywhere; the moment a soldier leaves her base, and sometimes even
when she doesn't, war is all around her. Shells, grenades, land
mines, and IEDs don't distinguish between male and female troops;
neither do snipers and suicide bombers. Women carry weapons, like
M14s or M16s. They are gunners on vehicles, fly combat aircraft, take
part in armed patrols on dangerous streets, dispose of explosives.
And, like their male colleagues, they are wounded and killed.
They also suffer psychological fallout. In the military, PTSD affects
one out of every five service members, male and female, returning
from Iraq or Afghanistan, reports the RAND Corporation, a nonprofit
research organization. But women are more than twice as likely as men
to suffer PTSD, which may be related in part to basic hormonal
makeup. "After an unpleasant incident, estrogen activates a very
large field of neurons in a woman's brain, which records greatly
detailed memories of the incident. It also prompts the release of the
stress hormone cortisol, which persists, causing anxiety and
depression. As a result, PTSD can occur more frequently in women and
cause more intense symptoms," explains Marianne Legato, M.D.,
director of the Partnership for Gender-Specific Medicine at Columbia
University, who has reviewed studies on the health effects on women in war.
Yet since the thinking has been that women haven't been in direct
combat, female vets with mental injuries have faced an entirely
different battlefield at home, trying to get help. Some prevail, but
it can require enormous persistence to fulfill bureaucratic requests
for documentation and explanations that can be extremely hard to come by.
Hammer, who now works as a veteran support associate for the Iraq and
Afghanistan Veterans of America in New York City, feels the VA wrote
her off. Too many of the clinicians making assessments, she and other
female vets assert, have never been in a war and have no
understanding of what troops go through. "It's easy for the VA to
twist a diagnosis to avoid having to pay. It's like an HMO," she
says. She's debating whether to return to the VA to make the case
that her injuries are connected to her service. That way, she could
continue to receive treatment at no cost. Sighing, she says, "I'm
just not sure I want to get into that again. Dealing with the VA is
such a belittling process."
It also can be a fruitless one. Currently, there's a backlog of
951,000 claims, many of which have been pending for years and are
part of a class action lawsuit that's been winding its way through
the courts since 2007. It can take an astounding 15 years for a claim
to be decided. (Private insurers process 30 billion claims annually,
in an average of 89 days per claim, according to the suit.)
Not surprisingly, many wounded veterans, particularly those with
mental illness, give up in frustration or die while their claims
are pending. The problem is especially acute for vets waiting for
mental-health services which could be one reason for a troublingly
high suicide rate. Although actual numbers are hard to come by, an
analysis of 2005 data found those who'd served in the armed forces
were more than twice as likely as nonvets to kill themselves.
Sexual Assault, Then VA Assault
Tia Christopher can still see the face "it was hard, cold," she
says of the sailor who raped her in her barracks just two months
after she began training at the Defense Language Institute in
Monterey, CA, in 2001. Christopher was studying to be a naval
cryptologist, specializing in creating and translating Arab-language
codes. She'd had two dates with the man; on one, they'd attended a
Bible study class together, "which was why I trusted him," she says.
And while they had kissed, they'd never had sex; indeed, Christopher
was a virgin and, at 19, "pretty naive," she says.
After an evening of watching movies with friends, Christopher had
returned to her room and was nearly asleep when her assaulter barged
in, climbed into her bed, and, despite her crying and pleading for
him to stop, raped her. "My head kept banging into the concrete
wall," says Christopher, who after the man finally left
frantically washed her sheets and then curled up on the shower floor,
letting the water run over her.
While the rape was horrific, what followed may be worse. Fearing
reprisal, Christopher didn't report the attack. She had been sharing
drinks with her friends and knew she could be severely punished, even
demoted, for underage drinking. Two weeks later, however, she heard
about another woman who had been assaulted by the same man. She
herself was unraveling at that point, and "I knew I had to say
something," says Christopher. But the military policewoman who took
her story wouldn't allow Christopher to write her own statement, only
to give it to her verbally. Her report stated that Christopher had
had consensual sex and that, because of a lovers' quarrel, she had
changed her mind afterward and claimed it was rape. Christopher was
furious, but she knew there was nothing she could do. This was the
military you had to go along with the command. Then she was brought
to speak with her commanding officer, who said that she was the third
woman in the unit to report rape by a service member that week. "Do
you females think it's a game?" he asked.
Christopher contacted first a military, then a civilian, lawyer; both
told her that because there was no physical evidence, there was
nothing they could do for her. Her rapist, who knew she had reported
him, began stalking her, trying to intimidate her. Although he spoke
to her only once, "he was everywhere," says Christopher. Her life
became so miserable other men were harassing her as well that she
left the Navy and retreated to her grandmother's house in Washington
State. "For a month, I lay on her couch, curled up in a fetal ball," she says.
Several months later, Christopher sought help at a VA medical center
in Seattle. She had no papers with her, and at first, no one believed
she was even a veteran. "They assumed I was someone's granddaughter
or wife," Christopher says. Then a clerk told her she wasn't eligible
for benefits because she had served only one year. "It's a good thing
my grandmother read the newspaper," says Christopher, "because she'd
seen an article about a woman who, in a case of military sexual
trauma, got benefits after one year" something no one seemed to
have told the clerk. "I had to yell a lot, but finally, someone from
the psychology department came down."
Many of the therapists working at VA hospitals are social work or
psychology students doing rotations through the VA as part of their
graduate programs. "Counselors may have no connection to the
military," Christopher says, "no understanding of what's different
for females in the VA." That's how Christopher felt about her first
therapist, a civilian woman.
What's more, the atmosphere at the mental-health center was hardly
therapeutic. "You have to walk past ogling male vets, sit in waiting
rooms with men who have mental problems," she says. Indeed,
Christopher became so fed up that, although she was still having
problems, she left therapy in 2005 and didn't return until 2008, when
she was overcome by panic attacks and insomnia. "I have no option. If
you're a woman vet with military sexual trauma, your only hope of
finding someone who understands your experience is at the VA," says
Christopher, who now serves as the women veterans coordinator for
Swords to Plowshares, a San Francisco-based group that advocates for veterans.
The Military Fires Back
The Department of Defense is not unaware of these problems; if
nothing else, it's bad PR. In 2005, the agency formed the Sexual
Assault Prevention and Response Office (SAPRO) in hopes of making it
easier for women to come forward. The government's statistics suggest
that the number of women who experience rape or attempted rape in the
military is roughly double the civilian rate.
These attacks are not carried out by the enemy, but by fellow service
members. However, by the Pentagon's own estimate, fewer than 10
percent of sexual attacks in the military are reported each year. In
part, this is because many are perpetrated by peers or higher-ranked
service members against lower-ranked ones. Women are often too
intimidated to name a superior, and may also worry about seeming
disloyal. "The military is a culture where it is deemed dishonorable
and conduct unbecoming to inflict reputational damage," explains
Elizabeth Hillman, Ph.D., J.D., professor of law at the University of
California Hastings College of the Law in San Francisco.
"Many...think it is more important to protect the reputation of the
force, and of the soldier concerned, than it is to prosecute rape."
There's another reason, too, that women keep quiet: fear of
retaliation. When Keri Christensen, 36, a National Guard sergeant
stationed in Kuwait (and a wife and mom with two little girls back in
Wisconsin), reported that her superior had made sexual advances, she
was court-martialed for drinking alcohol on duty. "I thought I was
going crazy," says Christensen, who, despite having had a negative
Breathalyzer test, was ultimately demoted two ranks. She was also
reassigned to duty at the Kuwait airport, near the theater mortuary
where coffins of killed soldiers were loaded onto planes heading
home. "My commanding officer said that this wasn't because I'd
complained about harassment, but everyone around me knew it was,"
notes Christensen.
Because it can be so harrowing to report a sexual attack, women
contacting SAPRO can make restricted and confidential reports, which
means that, while they can get treatment, their assault won't be
investigated and the attacker will likely never be brought to
justice. "We felt it was most important to help victims come forward
to get the help they need," explains SAPRO's director, Kaye Whitley,
Ed.D., who observes that more than 2,600 service members have
reported sexual attacks without naming names since they've been able
to do so victims who otherwise would likely have kept silent.
As for the help they get, treatment for military sexual trauma at VA
hospitals remains uncertain at best. Part of the problem may be the
shortage of mental-health professionals generally. Often, too, vets
confront a staff that seems stuck in the era of Vietnam
uncomfortable dealing with women, much less victims of sexual assault.
The insensitivity of some VA staffers is staggering. In testimony
before the House Committee on Veterans' Affairs last July, Bhagwati,
executive director of Service Women's Action Network, told the story
of a woman who, while having her annual checkup and Pap smear at the
local VA hospital, asked to have a female present in the exam room
(as VA policy requires) and explained to the male gynecologist that
she suffered from military sexual trauma. Leaving the room, the
doctor barked down the hall, "We've got another one!"
And there are more basic problems as well. By directive, VA staff are
encouraged to give vets being treated for post-traumatic stress
disorder and military sexual trauma the option of a same-sex
counselor when clinically indicated. But it's not required, so such a
request can be ignored. What's more, there simply may not be enough
female therapists. One survey found that some VA centers have few or
none at all, so only 6.7 percent of women can be assured a same-sex
counselor, another 8.2 percent will almost certainly be assigned to a
male, and for the remainder it varies widely.
Nor can women always get into an all-female therapy group. Like the
former Army reservist from Minnesota, Aston Tedford, 27, who served
in Afghanistan from November 2002 to August 2003, found herself the
sole female in a PTSD group in Ohio. "When I tried to talk, I was
always being shut down by the male vets."
Even inpatient facilities for mental-health care often overlook
women's needs. In her testimony for the House, Bhagwati cited the
case of a troubled Iraq war veteran who checked herself into a
California VA psychiatric unit and was forced to share a bathroom
with male veterans, including a Peeping Tom. When the Minneapolis
vet, hospitalized during a particularly rough time, reported that
she'd been threatened by one of the male patients on the ward, a
doctor replied, "Sorry, we don't have programs for women."
The Government Accountability Office (GAO), the investigative arm of
Congress, examined 19 VA medical facilities in 2008 and 2009. In
testimony released last July, it found that 88 percent of the
facilities served women in mixed-gender inpatient psychiatric units,
mixed-gender residential treatment programs, or both. Women vets
weren't even guaranteed private bathing facilities. Some bathrooms
lacked locks, making it possible for male patients to intrude while a
woman showered or used the restroom. The GAO's conclusion: Not one of
the hospitals or outpatient clinics it visited was complying fully
with federal privacy requirements.
Routine Care: Also MIA
Last July, while driving home from a family visit, former Air Force
staff sergeant Dawn Whitt-Chenelly began to suffer severe pain in her
lower abdomen and rushed to the large VA hospital in Bath, NY.
Contrary to VA policy, there were no stirrups on the exam table (a
metal bedpan was placed under her hips) and no privacy curtains
around the table, and the hospital had no sonogram machine. Most
disconcerting: The physician told her it had been years since he'd
done a pelvic exam.
Whitt-Chenelly's husband, Joe Chenelly, and three of the couple's
children (young sons then aged 2, 1, and 4 weeks) didn't fare much
better in the waiting room. Several patients clearly had
mental-health issues. When one became agitated and potentially
violent, a staff member suggested Joe and the children wait in a
storage closet the only safe place.
Over and over, women complain of poor even incompetent care at VA
health centers. Brandy Wight, 24, a former medic who served in
Afghanistan, went to a VA clinic in Louisville, KY, for a Pap smear.
She had to return three times "before they managed to get a proper
sample," Wight reports. "If they can't get something that simple
right, how could I trust them for more serious medical care?"
Lack of appropriate treatment is a serious problem at VA centers.
"Too many VA providers either have not treated women or are not
up-to-date on women's health issues and procedures," says Joy Ilem, a
former Army medic who is national appeals officer for Disabled
American Veterans. At facilities that lack women's-health
specialists, care is contracted out, making it piecemeal at best.
There is no formal program, for example, for tracking mammography
results and following up on abnormal screens to make sure women
receive timely care, says Delilah Washburn, 57, president of the
National Association of State Women Veterans Coordinators and a
former Air Force first sergeant who served for more than 20 years.
"We suspect Congress would be appalled by the differences in
timeliness-to-treatment data for abnormal mammograms at VAMCs [VA
medical centers] across the nation," she testified before the House
Committee on Veterans' Affairs last summer.
Women veterans die because of this neglect. Sadly, Washburn knows
better than most how important prompt follow-up can be. In 2004, her
mammogram films at the VA clinic in Wichita Falls, TX, were read by
another hospital under VA contract. The report she was given,
Washburn says, concluded that because there was no breast cancer in
her family and her breast tissue was dense, the doctors didn't see
anything abnormal, so they would call it normal. Every mammogram she
had in the following three years was also reported as "normal." Then,
in 2007, she was diagnosed with Stage III ductal carcinoma. Her tumor
was nearly an inch in diameter, and the cancer had spread to her
lymph nodes. "I know now they should have sent me for an ultrasound,
which could have revealed the tumor when it was much smaller," says
Washburn. "But it was never mentioned."
Many experts do advise that women with dense breast tissue who face
a greater risk of breast cancer and whose mammograms are harder to
read have an ultrasound screening.
Case Study: Captain Dawn Halfaker
The mission: While on night patrol in 2004 in Iraq's dangerous Sunni
Triangle, Halfaker was struck by a rocket-propelled grenade. It tore
off her right arm, shattered her shoulder, smashed her ribs, burned
her face, bruised her lungs, and peppered her body with shrapnel.
Halfaker's injuries were so severe she was medevaced to Germany, then
the U.S., where she was kept in a medical coma for 10 days.
A dream lost: When she woke up at Walter Reed Army Medical Center
in Washington, DC her parents told her she had lost her right arm
and shoulder. Halfaker, who was right-handed, had been a basketball
player at West Point and had considered trying out for the Women's
National Basketball Association. Instead, "I saw that bandage where
my arm used to be. I didn't want to believe it," she says.
Adding insult to injury: After nearly a year, Halfaker left Walter
Reed, which is not part of the VA and where her treatment had been
excellent. She then entered the regular system at a VA medical center
in Washington, DC. The first doctor she saw there assumed she
couldn't have been in direct combat and expressed surprise that she'd
lost an arm in Iraq. "Even though women are flooding the system,
they're still unaccustomed to dealing with us," says Halfaker. Her
care was disorganized; she had to return multiple times to get basic
treatment for her shrapnel injuries. "The VA acted like they'd never
seen shrapnel wounds before," she says. "They didn't even know that
these are skin wounds and that I needed to see a dermatologist, not
an orthopedist."
A warrior again: Today, Halfaker runs her own successful
national-security consulting company and serves on the board of the
Wounded Warrior Project, a group that offers support and training
programs to severely injured service members. And she's a passionate
advocate for women in the military: There has to be "an aggressive
approach," she told Congress last spring, "to eliminating the
barriers" that keep women vets from getting help.
Case Study: Sergeant Carolyn Schapper
Perilous patrols: In 2005 and 2006, Schapper, 37, went out on some
200 combat patrols in a hostile region near Tikrit, Iraq. "There was
a hole under the driver's pedals of our Humvee. You could see sand,"
says Schapper, who worked in military intelligence attached to the
Georgia National Guard. "The unit before us had been hit by an IED
and it wasn't repaired, so it wasn't properly armored. We called it
our IED magnet."
The message in the field: Schapper was the only female in her unit on
her base, and had to share bathrooms and sleeping areas with her male
colleagues. "The team leader would say, 'No one's a man or woman.
Everyone's a soldier,'" she recalls.
The message at home: At a VA hospital in Washington, DC, however,
where Schapper went for a neck and shoulder injury, support was not
quite so forthcoming. She was in agony from compressed discs pressing
on nerves, a condition aggravated by firing a weapon while lying flat
on her stomach and carrying 50 pounds of equipment every day while on
patrol. But when Schapper needed to renew the prescription for her
pain meds, a VA doctor told her there was no budget for the drugs. Go
buy some Advil, he advised. If Advil worked, Schapper fired back, she
wouldn't be there. "It seemed as if the staff just didn't give a
damn," she says.
VA Health System: How It Works
How Many VA Hospitals Are There?
153 medical centers throughout the U.S. provide both inpatient and
outpatient services. But not all are full-service: A 2007 survey of
133 of these hospitals found that only 54 percent had a women's health center.
Who Is Eligible for Care?
Anyone who suffered a service-related injury, finished a tour with
honorable discharge, or, generally, served a minimum of two years.
But for ongoing care, there's a complicated "prioritization" system
that weighs extent of disability and income. As a result, many
patients fall out: A Harvard Medical School study recently calculated
that 2,300 vets died in 2008 because they were uninsured, often
because they no longer qualified for VA services, and didn't have
coverage through work or adequate income to buy private insurance.
Does the VA Offer All Services?
Women are supposed to receive "gender-specific comprehensive care,"
just as men are. But only 50 percent of the medical centers have an
ob-gyn on staff and, amazingly, only 56 percent of those with a
women's health center have one.
How You Can Help
Finally, Congress has passed the Women Veterans Health Care
Improvement Act. Now, legislators must appropriate funds to carry out
the law. Let your senators and representative know you want them to
make funds available to fulfill the promises of this act quickly.
For a sample letter, go to goodhousekeeping.com/womenvets. You can
e-mail your legislators directly from this page. Or you can find
contact info for your senators at senate.gov; representatives are
listed at house.gov.
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