VVA Testimony VVA Testimony
VVA Testimony

Statement for the Record

Submitted by

Marsha (Tansey) Four, RN

Chair, VVA Woman Veterans Committee

Before the
Senate Veterans Affairs Committee

S.252, The Veterans Health Care Authorization Act of 2009, Section 111, Woman Veterans Health

July 14, 2009


Good morning Mr. Chairman, Ranking Member Burr, and distinguished members of the Senate Veterans Affairs Committee.  Thank you for giving Vietnam Veterans of America (VVA) the opportunity to submit our statement for the record regarding VA Health Care Services for Woman Veterans.  VVA supports swift passage of S.252, “The Veterans Health Care Authorization Act of 2009”; however, we would like for additional language to be included in Section III, regarding woman veterans health care which was missing from H.R. 1211,  the Women Veterans Health Care Improvement Act that was passed by the House.

It is indisputable that the number of women in the military has risen consistently since the two percent cap on their enlistment in the Armed Forces was removed in the early 1970s.  This has resulted in an increased number of women we can now call “veterans”, and most assuredly, will have a direct bearing on the number of women who will be knocking on the door of the VA in the very near future.  A focus on the capacity and capability of the VA to equitably and effectively provide care and services must be a priority today.  Planning and readiness is essential for the future.  These responsibilities also require oversight and accountability in order to meet VA and veteran goals, objectives, requirements, standards, and satisfaction, along with agency advancement.

While much has been done over the past few years to advance and ensure greater equity, safety, and provision of services for the growing number of women veterans in the VA system, these changes and improvements have not been completely implemented throughout the entire VA system.  In some locations, women veterans still experience significant barriers to adequate health care. Thus, VVA asks Secretary Shinseki to ensure senior leadership at all VA facilities and in each VISN to be held accountable for ensuring that women veterans receive appropriate care in an appropriate environment by appropriate staff.

There is much to learn about women veterans as a separate patient cohort within the VA.  Women’s Health is now studied as a specialty in every medical school in the country.  It has moved far beyond that of obstetrics and gynecology.  Gender has an impact on nearly every system of the body and mind.  This has great significance in the ability of any health care system to provide the most appropriate, comprehensive, and evidence-based

scientific treatment and care.  This also has a direct effect on the delivery system along with staff requirements to meet the needs of women now utilizing the VA health care system, as well as for those new women veterans who will soon be accessing the system in the days and years to come.

The VA has already identified that our country’s new women veterans are younger and that they expect to use the system more consistently.  For example, in December 2008, the VA reported that of the total 102,126 female OIF-OEF veterans, 42.2 percent of them have already enrolled in the VA system, with 43.8 percent using the system for 2 – 10 visits.  Among these returning veterans, 85.9 percent are below the age of 40 and 58.9 percent are between 20 and 29.  In fact, the average age of female veterans using the VA system is 48 compared with 61 for men.  The needs of women veterans have yet to be fully identified or recognized…these needs are growing and already taxing the VA system, which historically has focused on an older male population.

As time, social environments, and veterans’ population demographics change, there are also cultural expectations based on scientific advancements in healthcare that elicit a re-definition of women veterans’ needs in the VA system.  Knowing the needs is vital to understanding and meeting them.  The VA has recognized many of the needs of women veterans by actually creating interest groups comprised of not only VA staff, but veterans as well.  For example, there is recognition that younger women veterans are also working women who need flexible clinic and appointment hours in order to also meet their employment and child-care obligations.  They also need to have sexual health and family planning issues addressed, along with the needs of infertility and pre-natal maternity. And there are unanswered questions and concerns about the role of exposures to toxic substances and women’s reproductive health.

VVA requests that this committee continue to focus on treating women veterans who are homeless with children, victims of sexual trauma, and provide funding for additional caseworkers and mental health counselors, a women's mental health treatment program, and a comprehensive mental health study of returning female soldiers.

Studies and Assessments of Department of Veterans Affairs Health Services for Women Veterans  

VVA believes that this study is vital to understanding today’s women veterans and that building on the “National Survey of Women Veterans in Fiscal Year 2007-2008” is a referenced starting point and this study should be included as language in the bill as similar to H.R 1211 to expand a survey of sufficient size and diversity to be statistically significant for women of all ethnic groups and service periods.
VVA believes that this study should identify the “best practices” that facilities utilize to overcome identified barriers.

VVA believes that with the fragmentation of women’s health care services there needs to be consideration for driving time/transportation to medical facilities that offer specialty care as well as primary care.

While VVA holds great respect for and recognizes the important work of both the Office of the Center for Women Veterans and that of the Advisory Committee on Women Veterans, this section as written would limit the initial review, creating unnecessary delays.  Rather, VVA believes that this study should also go immediately to these two entities, plus the VA Undersecretary for Health, the Deputy Undersecretary for Quality and Performance, the Deputy Undersecretary for Operations, the Office of Patient Care Services, and the Chief Consultant for the Women Veterans Health Program for review and recommendations, which in turn are then forwarded to the Deputy Undersecretary for action to remove or ameliorate the identified barriers.

VVA recognizes that this requires 30 months after the VA publishes the 2007-08 National Survey of Women Veterans that the VA Secretary in turn is required to report to Congress on the barriers study and what actions the VA is planning.  However, in reality, this means that the information/directions contained in the ’07-08 report is/are put “on hold” for two and a half years.  Therefore VVA believes that the Secretary’s report to


Congress should also include what actions – if any -- have transpired both during the survey and the 30 month hiatus.

Independent Study on Health Consequences of Women Veterans of Military Service in Operation Iraqi Freedom and Operation Enduring Freedom

VVA believes this section should include appropriate language directing the study format to include the use of evidence-based “best practices in care delivery”.

During the 110th Congress, VVA was heartened to see that the S.2799 legislation included a “Long Term Study of Health of Women Veterans of the Armed Forces Serving Operation Iraq Freedom and Operation Enduring Freedom”.  However, VVA is extremely disappointed to see that while calling for “a study on health consequences for women veterans of service on active duty in the Armed Forces in deployment in Operation Iraqi Freedom and Operation Enduring Freedom”; it eliminates the longitudinal aspect contained in S2799 of the 110th Congress.   

As you know, the second round of the National Vietnam Veterans Readjustment Study was never completed by the VA, even though it was mandated by Congress to do so.  VVA urges you not to let this opportunity be lost again on a statistically significant and diverse population of veterans.  It is an important element to a study that will bring long term identification and understanding and of the long term implication of military service during this period of history when the role and duties of women veterans has far expanding the service of women in the past. 

Report on Full-Time Program Managers for Women Veterans Programs at Medical Centers  

VVA applauds the VA for recognizing the need and importance of the requirement for a full time Woman Veteran Program Manager at all VA medical center.  However, VVA feels this action falls short of providing these managers with the reporting process that is commensurate with their

full duties and responsibilities.  Consistency is vital in recognizing the true tracking of the work they perform and in evaluating the issues of their mission.  VVA believes this position is most significant and demands that this position’s reporting line should also be significant and not determined by individual medical centers.  It is known that reporting lines are varied from medical center to medical center.  In some instances the reporting of identified items of the Woman Veteran Program Manager is moved forward through the medical center hierarchy based, not on the desire of the Woman Veteran Program Manager, but of other staff who are selective on what is actually “moved up the chain of command” at the medical centers. VVA calls for the Undersecretary of Health to define the reporting line for the Woman Veteran Program Managers as that of the Chief of Staff at each medical center. This action backs up the initial significance that the VA recognized when elevating the position to full time.  It brings significant investment in the importance of meting the needs of women veterans in its vast health system.  If not, a true reporting of the work of the Woman Veteran Program Managers and the issues of women veterans could fall into the vast dark pit of the unknown.  The work of the Woman Veteran Program Managers is vital to recognizing not only the needs but also providing clear information for program and process formation but also on establishing even possible research opportunities.        

Improvement of Health Care Programs of the Department of Veterans Affairs for Women Veterans

VVA asks that particular reflective consideration be given to the following -- VVA seeks a change in this section of the proposed legislation that would increase the time for the provision of neonatal care from 14 to 30 days, as needed for the newborn children of women veterans receiving maternity/delivery care through the VA.  Certainly, only newborns with extreme medical conditions would require this time extension.  VVA believes that there may be extraordinary circumstances wherein it would be detrimental to the proper care and treatment of the newborn if this provision of service was limited to solely 14 days.  If the infant must have extended hospitalization, it would allow time for the case manager to make the necessary arrangements to arrange necessary medical and social services assistance for the women veteran and her child.  This has important

implications for our rural woman veterans in particular.  And this is not to mention cases where there needs to be consideration of a woman veteran’s service-connected disabilities, including toxic exposures and mental health issues, especially during the pre-natal period.

Training and Certification for Mental Health Care Providers on Care for Veterans Suffering from Sexual Trauma

VVA has concerns about the VA establishing a “certification” program.  In order to be valid, VVA believes that such a certification program be based upon and modeled after those already utilized by many professional organizations.  Such a certification program would lend itself well to oversight and accountability. Too many VA certification programs now consist of only a one-hour training class or reading materials.

Although this section calls for reporting the number of women veterans who have received counseling, care and services under subsection (a) from “professionals and providers who received training under subsection (4)”, VVA asks “Who in the VA is already trained and holds professional qualifications under these subsections”?

Care for Newborn Children of Women Veterans Receiving Maternity Care

VVA asks that particular reflective consideration be given to the following -- VVA seeks a change in this section of the proposed legislation that would increase the time for the provision of neonatal care to 30 days, as needed for the newborn children of women veterans receiving maternity/delivery care through the VA.  Certainly, only newborns with extreme medical conditions would require this time extension.  VVA believes that there may be extraordinary circumstances wherein it would be detrimental to the proper care and treatment of the newborn if this provision of service was limited to less than 30 days.  The decision for extended would require professional justification. If the infant must have extended hospitalization, it would allow time for the case manager to make the necessary arrangements to arrange necessary medical and social services assistance for the women veteran and her child.  This has important implications for our rural woman veterans in

particular.  And this is not to mention cases where there needs to be consideration of a woman veteran’s service-connected disabilities, including toxic exposures and mental health issues, especially during the pre-natal period, multiple births and pre-mature births.  Prenatal and neonatal birthrate demographics (including miscarriage and stillborn data) would seem to be an important element herein.

Delivery of Services

Considering the ever increasing percentage of women veterans in the homeless veteran population and the extraordinary occurrence of this in the OEF/OIF homeless veteran population, one can see that their presence in the VA system will affect all levels of service, delivery, treatment, and care.  Advocacy for them within the VA will be paramount.    

Vietnam Veterans of America believes women’s health care is not evenly distributed or available throughout the VA system.  Although women veterans are the fastest growing population within the VA, there seems to remain a need for increased focus on women health and its delivery. It seems clear that although VACO may interpret women’s health as preventative, primary and gender specific care, this comprehensive concept remains ambiguous and splintered in its delivery throughout all the VA medical centers. Many view women’s health as only a GYN clinic. As you are aware, throughout medical schools across the country and in the current health care environment, women’s health is viewed as a specialty onto itself and involves more that gender specific GYN care. 

The new woman veterans also need increased mental health services related to re-adjustment, depression, and re-integration, along with recognition of differences among active duty, Guard, and reserve women.  The VA already acknowledges the issue of fragmented primary care, noting that in 67 percent of VA sites, primary care is delivered separately from gender specific health care – in other words, two different services at two different times, and in some cases, two different services, two different times, and two different delivery sites.  The VA also notes that there are too few primary care physicians trained in women’s health, and at a time when medicine recognizes the link between mental and medical health, most mental health is separate from primary care.  VVA seeks to ensure that every woman

veteran has access to a primary care provider who meets all her primary care needs, including gender specific and mental health care in the context of an on-going patient-clinician relationship; and that general mental health providers are located within the women’s and primary care clinics in order to facilitate the delivery of mental health services.
Providing care and treatment to women veterans by professional staff that have a proven level of expertise is vital in delivering appropriate and competent gender-specific care.  It is not sufficient to simply have training in internal medicine.  Women’s health care is a specialty recognized by medical schools throughout the country. Providers who have both a knowledge base and training in women’s health are able to keep current on health care and its delivery as it relates to gender.  In order to maintain proficiency in delivering care and performing procedures, these providers must meet experience standards and maintain an appropriate panel size. This cannot occur if women veterans are lost in the general primary care setting.  It is critical that women receive care from a professional who is experienced in women’s health.  If attention is not given to defining qualified providers, it will be a detriment to the quality of care provided to women veterans.
VVA does, however, feel comprehensive women’s health care clinics are most desirable where the medical center populations indicate because comprehensive consolidated delivery systems present increased advantage to the patients they serve. 

Vietnam Veterans of America applauds the VA for elevating its Office of Women’s Health to the Strategic Health Care Group level.  With this action, the VA has “pumped up” the volume on the attention and direction of the VA regarding woman veterans.  But there remains much to be learned about women veterans as a health care cohort.  Data collection and analytical studies will provide increased opportunities for research and health care advancement in the field of women’s health, as well as offer evidence-based “best practices” models and innovative treatments.  


As discussed by Phyllis Greenberger, President and CEO of the Society for Women’s Health Research, at a recent Roundtable on Women Veterans before the House Committee on Veterans Affairs, Ms. Greenberger stated that the focus of The Society clearly demonstrated that sex and gender differences exist throughout all conditions that affect women differently, disproportionately or exclusively and research needs to be done to identify those differences and understand their implications for diagnosis and treatment.   She discussed the unknown in regard to the influence of hormones on not only the bodily process of the women’s medical and mental care but also its influence on the regime of medication prescribed by the care providers and utilized by women veterans.  This is especially true with medications in the mental health arena.

It is well recognized that biological differences related to hormones affect mental health risks, rates of disorders and course of those disorders.  Research had indicated that estrogen and progesterone influence brain function and stress response. Some women experience increased vulnerability to depression droning times of reproductive endocrine changes such as premenstrual, postpartum and perimenopausal periods. VVA believes more funding needs to be available for research into sex differences and better coordination is needed among VA centers throughout the country to increase the number of women in clinical trials to understand the differences and their implication for treatment.

Suicide Risk

Lastly, but just as important, VVA is deeply concerned about the high suicide risk among women veterans as reported at the American Psychiatric Association’s May 2009 meetings in San Francisco.  A 2007 longitudinal study of women veterans, which followed individuals for a period of 12 years, suggests that women who have been in the military have a 3-fold increased risk for suicide compared with nonmilitary women.  Furthermore, female veterans are more likely to be young and use firearms to commit suicide compared with their civilian counterparts, who tend to choose other methods — commonly drug overdose.  Data for this study came from the National Health Interview Study and was then linked with data from the National Death Index.  It is important to note that this study was population-

based and therefore, the findings are applicable to all military personnel and not just those in the Veterans Affairs (VA) health system.
 The VA is a massive health care system that possesses challenges for woman veterans, who are encouraged to seek treatment at VA facilities; but not many do. Treatment of women veterans at various facilities throughout the country are not "women" friendly.   We are hopeful that any shortfalls can be turned into positive action for our so woman veterans who deserve the same care and treatment because of their service and sacrifice to this country.

In closing, VVA would like to personally thank Senator Patty Murray, for her hard work and dedication to our woman veterans, for without Senator Murray, VVA believes that this hearing today would not be possible. We thank this committee for the opportunity to submit testimony for the record.  

Marsha (Tansey) Four, RN

Ms. Four is a Vietnam in-country veteran who served on active duty with the Army Nurse Corps from 1967 to 1970. A life member of the Vietnam Veterans of America, she serves on its National Board of Directors and is Chair of the Women Veterans Committee.

Currently, she is the Director of Homeless Veterans Services for the Philadelphia Veterans Multi-Service and Education Center. As such, she is responsible for a 95-bed homeless veteran transitional residence, a 30-bed homeless women veterans’ transitional residence, and a day service program for the homeless veterans on the streets and in the shelters of Philadelphia.

Ms. Four has been actively involved in veterans’ issues on a local, regional and national level for many years. She initiated and was the Executive Director of the Philadelphia Stand Down from 1993 to 1998, and currently serves as the Ex-Officio Director of this volunteer project. She is also a member of VA VISN 4 Veterans Assistance Council and VISN 4 Homeless Working Group.

Ms. Four has served as a consultant to the Department of Veterans Affairs Advisory Committee on Homeless Veterans. She was appointed by Secretary Principi to the Advisory Committee on Women Veterans in March 2001, serving as its Chair for two years. In 2004, she was re-appointed as Chair.


Funding Statement
July 14, 2009

The national organization Vietnam Veterans of America (VVA) is a non-profit veterans' membership organization registered as a 501(c) (19) with the Internal Revenue Service.  VVA is also appropriately registered with the Secretary of the Senate and the Clerk of the House of Representatives in compliance with the Lobbying Disclosure Act of 1995.

VVA is not currently in receipt of any federal grant or contract, other than the routine allocation of office space and associated resources in VA Regional Offices for outreach and direct services through its Veterans Benefits Program (Service Representatives).  This is also true of the previous two fiscal years.

For Further Information, Contact:

Executive Director of Policy and Government Affairs

Vietnam Veterans of America.
(301) 585-4000, extension 127

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