[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]




 
    CULTURAL BARRIERS IMPACTING WOMEN VETERANS' ACCESS TO HEALTHCARE

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         THURSDAY, MAY 2, 2019

                               __________

                           Serial No. 116-10

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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             U.S. GOVERNMENT PUBLISHING OFFICE 
39-914               WASHINGTON : 2021         
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

                         SUBCOMMITTEE ON HEALTH

                 JULIA BROWNLEY, California, Chairwoman

CONOR LAMB, Pennsylvania             NEAL P. DUNN, Florida, Ranking 
MIKE LEVIN, California                   Member
ANTHONY BRINDISI, New York           AUMUA AMATA COLEMAN RADEWAGEN, 
MAX ROSE, New York                       American Samoa
GILBERT RAY CISNEROS, Jr.            ANDY BARR, Kentucky
    California                       DANIEL MEUSER, Pennsylvania
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                              ----------                              

                         Thursday, May 2, 2019

                                                                   Page

Cultural Barriers Impacting Women Veterans' Access To Healthcare.     1

                           OPENING STATEMENTS

Honorable Julia Brownley, Chairwoman.............................     1
Honorable Neal P. Dunn, Ranking Member...........................     2

                               WITNESSES

Ms. Joy Ilem, National Legislative Director, Disabled American 
  Veterans.......................................................     3
    Prepared Statement...........................................    31
Ms. Lindsay Church, M.A., Minority Veterans of America...........     5
    Prepared Statement...........................................    37
Ms. Ginger Miller, Women Veterans Interactive....................     7
    Prepared Statement...........................................    40
Ms. BriGette McCoy, Women Veteran Social Justice Network.........     8
    Prepared Statement...........................................    42
CAPT (Ret.) Lory Manning, Service Women's Action Network.........    10
    Prepared Statement...........................................    46
Dr. Patricia M. Hayes, PhD, Veterans Health Administration.......    19
    Prepared Statement...........................................    47

                       STATEMENTS FOR THE RECORD

Women Who Serve..................................................    53
Iraq and Afghanistan Veterans of America (IAVA)..................    56
Paralyzed Veterans of America (PVA)..............................    59
Vietnam Veterans of America (VVA)................................    61
Veterans of Foreign Wars (VFW)...................................    63


    CULTURAL BARRIERS IMPACTING WOMEN VETERANS' ACCESS TO HEALTHCARE

                              ----------                              


                         Thursday, May 2, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:04 a.m., in 
Room 1300, Longworth House Office Building, Hon. Julia Brownley 
[Chairwoman of the Subcommittee] presiding.
    Present: Representatives Brownley, Lamb, Levin, Brindisi, 
Rose, Cisneros, Peterson, Dunn, Coleman, Barr, and Meuser.
    Also Present: Representatives Houlahan and Radewagen.

        OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN

    Ms. Brownley. Good morning, everyone, thank you for being 
here, and I am calling this oversight hearing to order. And, 
before we get started, I would like to ask for unanimous 
consent that Ms. Houlahan join us today on the dais.
    Without objection, so moved.
    I want to welcome everybody to the Subcommittee on Health's 
second hearing of the 116th Congress. Today is a historic day 
in this Committee, as it marks the first time in recent memory 
that this Committee has held a hearing singularly focused on 
serving our Nation's 2 million living women veterans.
    Women have served in every American conflict since the 
Revolutionary War. Deborah Sampson and Margaret Corbin, the 
first American women known to have served in combat earned 
pensions for their service during the Revolutionary War. Today, 
2 million women veterans live in the United States and are the 
fastest-growing demographic in both the military and veteran 
population. Currently, women comprise nearly 20 percent of 
military personnel and 10 percent of the veteran population, 
and 35 percent of whom are women of color.
    Even though women have served in every American conflict, 
the Department of Veterans Affairs is a system created to serve 
men and did not serve women veterans until the 1980s. While the 
Department of Veterans Affairs has indeed evolved and some say 
that the organization is not your grandfather's VA, but there 
is still a long way to go. That is why the Women Veterans Task 
Force has been created to ensure there is equitable access to 
all VA services for our Nation's women veterans. And I will add 
that I am encouraged that the VA and the Secretary himself has 
committed to working with us to that end.
    However, despite centuries of honorable service, the women 
who serve our country are still treated as second class 
servicemembers and veterans. A visible minority in the 
military, women experience everyday indignities that make them 
feel like they do not belong. The probable root causes range 
from the impacts of the long-standing prohibition on women in 
combat jobs, to going into combat-wearing protective equipment 
that was made for men.
    Most troubling is the widespread incidence of sexual 
violence in the ranks, an epidemic that disproportionately 
affects women. At least one in four servicewomen experience 
military sexual trauma by the very teammates who are supposed 
to have their backs. More than half of servicemembers who 
report their assaults also report that their commands 
retaliated against them.
    Therefore, it should not be surprising then when women 
leave the military, they are reluctant to enter veteran-serving 
spaces. When they do, they often find the same lack of respect 
that they endured on active duty. Recent research found that at 
least 25 percent of women veterans experience sexual harassment 
or questioning of service status by male veterans while at the 
VA.
    Even the organizations meant to serve veterans are often 
hostile to women veterans. In her statement for the record, 
Army veteran Melissa Bryant, Chief Policy Officer of Iraq and 
Afghanistan Veterans of America explained, ``Now, as a 
veterans' advocate, I still hear the misogyny in our community 
from the time I am asked who is your sponsor at VA medical 
centers to when I am referred to as young lady by my own 
veteran colleagues.''
    VA's system itself remains rife with barriers to care. 
Twenty four percent of women veterans using VA health care 
still do not have a specially trained woman's health primary 
care provider. Women veterans are 46 percent more likely to use 
community care than male veterans, largely to receive basic 
preventive services such as Pap smears and mammograms. This has 
resulted in billing problems, which again disproportionately 
affect women. In addition, women veterans face longer wait 
times, staffing shortages, and facilities that fail to meet 
basic environment-of-care standards. Even here in Washington, 
DC, the Women's Health Center has more limited hours available 
for primary care appointments than are available for men.
    Women veterans are remarkable Americans and deserve 
equitable access to the benefits and resources that they have 
earned. Women represent resilient leadership in their 
communities and classrooms and their careers, and right here in 
Congress.
    In short, our goal is to make the invisible woman veteran 
visible. So, as chair of this Subcommittee and the Women 
Veterans Task Force, I am well aware of the work we need to do 
and today is our first step in doing it.
    So, with that, I would like to recognize Ranking Member 
Dunn for 5 minutes for opening remarks he may wish to make.

         OPENING STATEMENT NEAL P. DUNN, RANKING MEMBER

    Mr. Dunn. Thank you very much, Chairwoman Brownley, and 
thank you for having this hearing.
    Today's hearing is just the start of an ongoing 
conversation I expect this Subcommittee to have throughout the 
116th Congress. So, in the interest of time and given the 
constraints we are under this morning, I will keep my comments 
brief and to the point.
    I appreciate the opportunity to be here to discuss how to 
break down the barriers for women veterans in the Department of 
Veterans Affairs system, systemwide.
    Women are a sizable and growing segment of the VA's 
population, as you noted, with the number of women who use the 
VA health care system tripling in just the last 18 years. VA 
has made a number of strides to address the unique and often 
complex needs of women veterans; however, far too many 
disparities continue to exist in care, benefits, services, and 
treatment.
    I am particularly distressed to have learned that, 
according to a recent study, one in four women veterans report 
being subjected to inappropriate, unwanted comments from male 
veterans in the VA system; that is unacceptable. I look forward 
to this morning what steps we are going to be taking to 
eradicate this type of harassment in the VA enterprise-wide and 
to ensure the equitable treatment of women veterans within the 
VA's environment.
    So, thank you again for calling this important hearing and 
I yield back to you, Chairwoman Brownley.
    Ms. Brownley. Thank you, Dr. Dunn. And thank you to our 
witnesses for being here today. We have two extraordinary 
panels joining us today.
    For the first panel, we have a formation of all women 
veterans. First we have Ms. Joy Ilem, National Legislative 
Director of Disabled American Veterans; next we have Ms. 
Lindsay Church, Chief Executive Officer of Minority Veterans of 
America; next we have Ms. Ginger Miller, Chief Executive 
Officer of Women Veterans Interactive; next we have Ms. 
BriGette McCoy, Chief Executive Officer of Women Veteran Social 
Justice Network; and, finally, we have Captain Lory Manning, 
Director of Government Relations for Service Women's Action 
Network.
    With that, I now recognize Ms. Ilem for 5 minutes. Welcome.

                     STATEMENT OF JOY ILEM

    Ms. Ilem. Chairwoman Brownley, Ranking Member Dunn, and 
members of the Subcommittee, thank you for inviting DAV to 
testify today.
    As a service-disabled veteran who has gotten my care at VA 
for more than two decades, I appreciate the opportunity to 
discuss cultural barriers impacting women veterans' access to 
health care. There is no bigger barrier to care than a culture 
that does not embrace women veterans or, at best, makes them 
feel marginalized. Ensuring that women veterans are treated 
with dignity and respect, have equal access to high-quality 
comprehensive care, and readjustment services from VA is a top 
legislative priority for DAV.
    The number of women coming to VA for care has tripled, as 
you have all noted, since 2000, and many have wartime service, 
and more than half of the women using the VA health care system 
have a service-related injury and will need a lifetime of care. 
While VA has made progress and illustrated a commitment to 
improving services for women veterans, several long-standing 
challenges still remain.
    DAV's most recent report issued in 2018, ``Women Veterans: 
The Journey Ahead,'' highlighted the need for culture change in 
VA. We found that women veterans perceived their military 
service was not understood or appreciated like their male 
peers. Women veterans told us they want to be treated with 
dignity, respect, have equal access to earned benefits, and, 
most importantly, they want to be recognized as veterans and 
appreciated for their contributions in military service.
    Another notable barrier to care is that many women veterans 
do not feel welcome or safe at VA facilities. As confirmed by 
the recent study just mentioned, that one in four women 
reported being harassed by male veteran patients. 
Unfortunately, women who experience this harassment were 
significantly more likely to report either delaying or missing 
care.
    We applaud VA's new anti-harassment campaign and training 
of employees that is underway to intervene when they see 
harassment occurring, and encouraging veterans to immediately 
report such conduct.
    To meet the goal of a zero tolerance policy for harassment, 
we challenge all veterans and Veterans Service Organizations to 
do their part as well.
    Women veterans who have their military service questioned, 
who are routinely disrespected, and will not stay to find out 
that VA offers exceptional, evidence-based, and culturally 
competent clinical care and integrated services, and women 
veterans need that expertise, and they deserve to have a system 
that full embraces and supports them.
    VA researchers have been specifically looking at barriers 
to care for this population, as well as health impacts of 
wartime service and the unique transition issues women face 
when they return home. These concerns are heightened for women, 
who make greater use of community care than their male peers, 
and who have experienced a variety of problems under the Choice 
program. As VA transitions to its new community care network, 
it will be essentially that community providers are properly 
trained about women veteran culture, common military exposures 
and health conditions for women, and receive training and 
evidence-based practices for treating them.
    VA health care is the best system of care for women 
veterans with complex health care needs. VA's veteran-focused 
research, comprehensive health and mental health services, and 
specialized programs for trauma make it uniquely suited to care 
for this population, but longstanding issues that persist act 
as barriers to that care for some women. VA still struggles at 
certain locations to ensure privacy, safety, a welcoming 
environment--all noted--and sufficient members of staff with 
expertise in women's health; and specialty care coordinators, 
women peer specialists, and dedicated women's clinics.
    To address these persistent challenges, it will require the 
Secretary to commit to cultural transformation at all levels of 
the organization and to dedicate the necessary resources to 
achieve that change. This means keeping the needs of women 
veterans central to planning and decision-making in all program 
offices.
    In closing, we are pleased with the progress VA has made, 
but there is so much more to do. We do, however, want to 
recognize the exceptional work of the Women's Health Services 
Office, the Center for Women Veterans, and the Veterans' 
Experience Office, which we are pleased to learn are listening 
and collaborating with women veterans to build trust and 
improve their health care experience, so they can count on VA 
for providing access to quality, timely care at all sites.
    Again, Madam Chairwoman, we thank you and the Subcommittee 
for your continued interest in improving the health services 
for our Nation's women veterans, and I look forward to 
responding to any questions you may have.
    Thank you.

    [The prepared statement of Joy Ilem appears in the 
Appendix]

    Ms. Brownley. Thank you, Ms. Ilem.
    And I now call on Ms. Church for 5 minutes.

                  STATEMENT OF LINDSAY CHURCH

    Ms. Church. Chairwoman Brownley, Ranking Member Dunn, and 
distinguished members of the Committee, thank you for the 
opportunity to testify today about the cultural barriers 
impacting women veterans' access to health care.
    I would like to begin by acknowledging that the land on 
which we gather is the unceded territory of the Piscataway and 
Nacotchtank people.
    My name is Lindsay Church and I am the CEO and cofounder of 
the Minority Veterans of America. I served in the United States 
Navy from 2008 to 2012 as a Persian/Farsi linguist. I am a 
queer, gender-nonconforming women veteran that served all but 3 
months under ``Don't ask, don't tell.'' I was medically retired 
after three surgeries to my sternum and rib cage left me 
permanently disabled, and I personally receive my care at the 
VA.
    As the CEO of MVA, I represent veterans across 46 states, 
two territories, and three countries; 47 percent of them are 
women and several of whom are in the audience today. Together, 
our members account for over 6,000 years of service, some 
dating back to conflicts and eras that predate when they were 
legally recognized as veterans, my mom being one of them.
    In today's military, the role of women is quickly expanding 
and, though more jobs and occupations are opening up to women 
every day, the culture and institutions meant to support women 
veterans after service has not kept up with the rapid growth.
    Similar to our male counterparts, we as women veterans are 
immensely proud of our service and what we have done, the 
service and support we have offered to our nation; however, 
many of us experienced instances of harassment, degradation, 
and discrimination based on our gender identities and/or sexual 
orientations. We withstood and persevered those experiences, 
and we did so honorably.
    The harassment that happens to women in the service is 
magnified by the weight of the entire United States military 
that renders each of us powerless until the day that separate. 
Even if we want to leave out of fear for our own safety, we are 
beholden to a system that demands compliance no matter the 
circumstances. Upon discharge, we must decide, based on the 
severity of our experiences and the intensity of our needs, 
whether or not we will return to a setting where military 
affiliation is the common thread among the community. This is 
the dilemma that each of us faces when we are deciding whether 
or not to enroll in the VA.
    For many women, voluntarily reentering military culture to 
use our VA benefits is an insurmountable barrier. Moreover, the 
VA has a poor reputation among our community. We know them for 
perpetuating a toxic culture for women and minorities, 
providing sub-par care that lacks a nuanced understanding of 
who we are, and seemingly every day there is a new story of a 
veteran dying by suicide in the VA parking lots and waiting 
rooms.
    For those of us that finally overcome these barriers, we 
enter VA facilities across the Nation only to be met with 
plaques inscribed with the words, ``To care for him who shall 
have borne the battle, and for his widow and his orphan.'' 
Lincoln's words, which are the motto and mission of the 
Department of Veterans Affairs, serve as physical 
representations of the deep and lasting history of invisibility 
for women in the military and veteran community.
    Changing the motto won't by itself address the deep 
cultural divide that exists between women and the veteran 
community, but it is a step in the direction toward inclusion. 
Continuing to maintain and uphold the motto, despite that women 
veterans have called for change, signals a willful desire to 
exclude us.
    Chairwoman Brownley, Ranking Member Dunn, and members of 
the Committee, if we are to change the outcomes that women 
veterans are experiencing today and increase their access to 
health care, we must look to the roots of the problems and not 
just triage the results.
    First and foremost, this starts by opening a dialogue about 
the inclusion of all servicemembers in the VA's motto.
    Second, accessing the VA needs to be easier. We want an 
opt-out rather than opt-in process, not just for women, for all 
veterans. If we believe that veterans have earned their 
benefits, servicemembers should automatically be enrolled in VA 
benefits and rated for their service-connected disabilities 
before they are charged without relying on outside agencies to 
file their claims. Additionally, women veterans should be 
assigned a primary care doctor in the nearest women's clinic.
    Third, women veterans need to have greater access to 
positions of leadership at the VA. Representation matters and 
if we are not represented in the places where decisions are 
being made about our health care and our benefits, how can we 
ensure that we are heard, considered fully, and that our ideas 
are acted upon in the same way as our male counterparts.
    Lastly, all VA facilities should have community standards 
and expectations of staff and patients. Stories of women 
veterans being sexually assaulted, harassed, discriminated at 
VA facilities should be anomalies and not commonplace.
    Thank you for your time and consideration on this matter. I 
look forward to your questions.

    [The prepared statement of Lindsay Church appears in the 
Appendix]

    Ms. Brownley. Thank you, Ms. Church.
    And I now recognize Ms. Miller for 5 minutes.

                   STATEMENT OF GINGER MILLER

    Ms. Miller. Chairman Brownley and members of the 
Subcommittee, as the President of and CEO of the national 
nonprofit organization Women Veterans Interactive, I am 
grateful to present my testimony regarding the cultural 
barriers impacting women veterans' access to health care.
    To understand the cultural barriers impacting women 
veterans' access to health care, one must first understand the 
climate in which we exist: the women veterans' climate, a 
hostile takeover.
    Women veterans are trying to stay afloat in a culture that 
has been male-dominated for centuries and now we are competing 
to stay relevant in a culture that insists we downgrade our 
service to run parallel with that of a commitment by a military 
spouse or a husband. Women veterans are uniquely different from 
military spouses and it is time that this country stops lumping 
us together, not to mention being overshadowed by the 
caregivers.
    Women veterans are existing in a climate where we have 
become good for business, but not good enough to do business 
with. And, even more unfortunate, women veterans are living in 
a culture where our voices are only heard in a celebratory 
fashion when we achieve something great or when we hit rock 
bottom and become good for press.
    I am here to testify this morning in an effort to change 
the climate and culture that has become the norm for women 
veterans. Our noble service to this country is worth more than 
a story. Our sacrifices as women veterans are worth more than a 
tick mark on an outdated, one-sided survey conducted by male-
dominated VSOs who may happen to have a few women veterans on 
staff.
    Women veterans are more than objects and we don't need 
another survey, we need action; we don't need another national 
portrait campaign, we need a national outreach and engagement 
campaign. Women veterans don't need another male-dominated VSO 
to represent us at the table, we need to have a seat at the 
table, and, if we can't have a seat at the table, we will 
continue to build our own.
    For women veterans, the environment in which we are 
expected to thrive in after serving in the military has become 
hostile and at times volatile, to say the least, because our 
voices are not being heard appropriately and we do not have 
adequate representation at every level of government. Women 
veteran nonprofit organizations are grossly overlooked and 
underfunded, if funded at all. Our volunteers are overworked 
and for some the outlook is bleak, and yet we continue to hold 
on and hope against hope, hope for inclusion to have a seat at 
the table where our voices will be heard and hope for much-
needed funding to deliver the proper services to the population 
we serve.
    Women Veterans Interactive is a solutions-driven nonprofit 
organization focused on outreach and engagement. WVI delivers 
impact in the lives of women veterans through a holistic, 
proactive approach that is grassroots in nature.
    The mission of Women Veterans Interactive is to meet women 
veterans at their points of need through advocacy, empowerment 
into action, outreach and unification, all to break down 
barriers that lead to homelessness. WVI addresses the unique 
needs and unrecognized challenges faced by our Nation's 2 
million women veterans. Since inception, Women Veterans 
Interactive has supported over 3500 women veterans and our 
network has grown past 50,000.
    Women Veterans Interactive and the Department of Veterans 
Affairs have an intimate understanding of the importance of 
women veterans becoming connected to health care. Since 2012, 
WVI has invited the Department of Veterans Affairs into our 
fold to collaborate with us on all of our outreach efforts.
    Most recently, WVI's 2018 and 2017 Annual Women Veterans 
Leadership and Diversity Conference, we had a benefits claims 
clinic in collaboration with the Department of Veterans 
Affairs, in which each clinic had approximately 150 veterans to 
attend. The feedback from the benefits claims clinic have been 
remarkable, with some women veterans stating that it is the 
first time the VA has treated them like their service matters, 
and other women veterans said they have a brighter outlook on 
going to the VA medical center to receive health care.
    Additionally, in 2017, WVI partnered with the Center for 
Minority Veterans to conduct a virtual town hall with over 300 
attendees. In 2016, we created the State of Women Veterans 
social media campaign with a goal to reach 500,000 veterans, 
and we surpassed that goal.
    Every Women Veterans Interactive and Department of Veterans 
Affairs collaboration is positive. So, I pose the question, why 
is more not being done by the Department of Veterans Affairs to 
collaborate with women veteran nonprofit organizations like 
Women Veterans Interactive? And why are more women veterans' 
organizations not invited to the Veterans Affairs meetings, 
especially when it comes to discussing issues and solutions 
around women veterans?
    If we are going to change the culture and we are going to 
have women veterans to have more access to health care, then, 
Madam Chairwoman, we need to be at the table. I am recommending 
that we work together to find solutions and have something 
where we can allocate funding for collaborative women veterans 
direct outreach and engagement with the Department of Veterans 
Affairs, and require the Department of Veterans Affairs to 
focus on consistent outreach with women veterans, and meet with 
the Secretary of the Department of Veterans Affairs on a 
biannual basis.
    Thank you, Madam Chairwoman.

    [The prepared statement of Ginger Miller appears in the 
Appendix]

    Ms. Brownley. Thank you, Ms. Miller, for your testimony, 
and I now recognize Ms. McCoy for 5 minutes.

                  STATEMENT OF BRIGETTE MCCOY

    Ms. McCoy. Thank you to the House Committee and Committee 
chair, thank you for inviting my organization and inclusion of 
my testimony on issues concerning women veterans, specifically 
the cultural issues impacting women veterans. You will see in 
the notes, I have sent a document that has all of the 
information related to the organization that I founded 10 years 
ago, Women Veteran Social Justice Network, as a homeless 
veteran in HUD-VASH housing during my process, disability 
process in the VA.
    So, I am an ally. I am a military sexual trauma MST 
survivor and advocate. My service and contributions are as 
important as my male veteran counterparts.
    Women veterans serve, yet our visibility and opportunities 
have unseen barriers to accessing many of the programs that the 
civilian sector believes are available to all who served. It is 
vitally important to hold in high regard and utilize the 
narratives of veteran women like me of all eras and all service 
periods and all service backgrounds as primary sources to 
inform research, curriculum, and policies concerning women 
veterans.
    The cultural issues impacting women veterans are vast; 
there are too many to fully note in this setting to give the 
full historical context, legislative background, and full 
unintended consequences and implications of each.
    I do believe that the historical context of women not being 
formally included in the military structure until the 1940s is 
a topic for inclusion in this hearing. Women veterans were not 
legislated to use the VA for gender-specific medical care until 
the early 1990s. Only in recent years have women's specific 
health care spaces been constructed in VA's facilities.
    In my work over the past 10 years and my personal 
experience interacting with the government and the community 
for support, a major factor that repeatedly and consistently 
challenged me has been the language which is used to describe 
and talk about me as a woman veteran. Within the context of 
being a woman veteran I have heard terms like low-hanging 
fruit, female, victim, and references by men about how easy it 
is for a woman to get disability benefits, and I assure you 
that that is categorically untrue.
    These othering terms have an unintended consequence for our 
country and the communities that serve women veterans. How we 
speak about women veterans can be a part of a deeper problem of 
what we believe and have been socialized to believe about women 
in general. This is a root-cause factor that drives the 
cultural divisions and creates a barrier for meaningful, well-
funded support for women.
    The language used to speak about research, legislative, 
create, and institute programs for our women veteran community 
continues to be a major limiting factor toward addressing 
issues and needs. Why are organizational leaders calling us 
female after the military service? There are no female veteran 
organizations. Where is the national female veteran of America 
organization? Even in 1948 when President Truman signed the 
Armed Services Integration Act, ``female'' was not used in the 
title, but the word ``women.''
    I know that there will be some that say that doesn't 
matter, but I will argue that using biological terms to 
dehumanize what you name or call something or the language you 
use to speak about a person does have impact, positively or 
negatively. We can trace the language in policies and 
legislation and funding, and see that funding drives services 
and programs.
    Second, women veterans currently have narrowly-defined, 
language-specific access to some of the most well-funded and 
highly-engaged programs. Most are intentionally excluding a 
huge proportion of women, and the funding legislated for their 
programs is language-specific to eras, combat, and gender. It 
is emotionally draining as an advocate to continually send 
women to organizations that have veteran programs to have them 
told that they don't meet the guidelines.
    Further, the brochures are male-centered and the veteran 
service community organizations and their organizing documents 
do not include women who have served, or they are told to go to 
auxiliary membership, are put together with spouses, which is a 
completely different population.
    Third, VA medical treatment visits pose issues when 
organizing documents and place cards have male-centered quotes 
and presentations. The space was not created with women in 
mind.
    There have been upgrades and changes in support of women in 
the facilities, but we are still being catcalled and harassed 
going into the mental health and medical appointments, when we 
can get them. It is never clear what the outcome will be for 
women who reports harassment, or for the patient or employee 
that harasses. My personal experiences of being harassed within 
the VA and the discussions with other women about the need to 
change their appearance, come at certain times of day, switch 
to other hospitals, or stop going to the VA at all is another 
area of discussion.
    We are not always treated with the same professional 
respect as our male counterparts. Many times our rank and era 
in service are used to limit access to programs for 
professional advancement.
    I have more, but I know that my time is winding down, and 
so I want to hand over the time to my colleague here.
    Thank you.

    [The prepared statement of BriGette McCoy appears in the 
Appendix]

    Ms. Brownley. Thank you, Ms. McCoy, and I now recognize 
Captain Manning.

                   STATEMENT OF LORY MANNING

    Captain Manning. Chairman Brownley, Ranking Member Dunn, 
distinguished members of the Subcommittee, on behalf of the 
Women's Service Action Network, I thank you for the opportunity 
to share our views and recommendations regarding the cultural 
barriers to women veterans' access to health care at the 
Department of Veterans Affairs.
    In the past years, VA has made hard-won improvements to the 
quality and comprehensiveness of women's care, but all that 
improvement is for naught if women encounter barriers when 
trying to use that care. I will discuss two of these barriers 
today: sexual harassment and the invisibility of women 
veterans.
    Over the years, we at SWAN have heard many complaints about 
groups of male veterans getting together to harass women 
veterans on VA grounds, including at the Washington, DC VA 
Hospital.
    An academic study and a newspaper article both published 
this year elucidate the problem. The study appears in the 
Women's Health Issues published by the Jacobs Institute of 
Women's Health; the article by reporter Jennifer Steinhauer was 
in the March 12th edition of the New York Times and headlined, 
quote, ``Treated Like a Piece of Meat: Female Veterans Endure 
Harassment at the VA.''
    The study sampled women veterans who use 12 different VA 
hospitals and found one in four of those sampled reported 
receiving catcalls, derogatory comments, propositions, and 
denigrations of the women's status as veterans from male 
veterans on the grounds.
    The New York Times article recounts how, quote, ``An 
entrenched sexist culture at many veterans' hospitals is 
driving away female veterans,'' unquote. SWAN believes that 
what women veterans want, and warrant is for VA leaders at all 
levels, with oversight from Congress, to stop that harassment 
now and to create a VA culture in which women veterans are 
treated with the same respect, appreciation, and dignity as 
male veterans.
    Women veterans also report to SWAN that they feel invisible 
in the office staffs of VA facilities and to the American 
public in general, and they are. It begins with the VA motto: 
``To care for him who has borne the battle, his widow and his 
orphan.'' SWAN, while appreciating Lincoln's historic words, is 
among the veteran's organizations which support changing that 
motto.
    According to the Department of Veterans Affairs February 
2017 report, ``The Past, Present, and Future of Woman 
Veterans,'' only 22.4 percent of all women veterans use VA 
health care, making them a mere 7.5 percent of total VA health 
care users.
    Women veterans are irked when they are asked for their 
husband's Social Security numbers at check-in desks or are 
refused free coffee provided at some VA facilities with the 
admonition that the coffee is only for veterans. These slights 
seem minor, but they accrete over time, leaving women veterans 
frustrated and disheartened.
    The invisibility becomes more damaging when the gender-
specific needs of women veterans are ignored as happens, for 
example, when they are sometimes issued prosthetic devices 
designed for men. This should never happen. And major damage 
can be done if women veterans are invisible to those at any 
level making tough decisions on health care resources if those 
decision-makers either don't understand the need for women's 
programs or conclude that reallocation from these programs 
helps many while hurting only a few. SWAN believes leadership 
at all levels must take great care when initially allocating or 
later reprogramming resources to or from women's health care 
programs that they have a clear understanding of the effects 
their actions can have.
    SWAN additionally entreats Congress to exercise its 
oversight responsibilities to ensure the needs of women 
veterans and other special-focus populations are not unduly 
sacrificed when such actions are necessary at the national 
level.
    Madam Chairman, let me say how deeply I appreciate the 
opportunity to offer SWAN's views on these critically important 
matters. Thank you for your time and attention.

    [The prepared statement of Lory Manning appears in the 
Appendix]

    Ms. Brownley. And I thank you for your testimony, and I 
thank all of the witnesses here today for their testimony. To 
me, it sounds like we are having a veteran women me-too moment 
that I think all of us collectively have to make into a 
movement, so I think we are in the beginning steps of that.
    So we will now begin the question portion of the hearing 
and I will recognize myself for 5 minutes.
    And the first question I wanted to Ms. Ilem from DAV is, 
you talked about in your testimony with regards to solutions to 
some of the issues is to make women's health a stand-alone 
program with its own leadership structure at the central 
office, et cetera. I know in talking to some of the medical 
center directors who get allocated, you know, a large chunk of 
money and it is their responsibility then to allocate it as 
they see fit in terms of what their needs are, and I believe 
that in some situations women's needs are being overlooked 
across the country. But if you could just speak a little bit to 
how you think things should be restructured?
    Ms. Ilem. Well, I think that a task force would help in 
terms of internally within VA. I mean, we are hoping that the 
Secretary will really take this to heart. I mean, he has 
indicated that he wants to ensure women veterans receive the 
care and benefits they deserve through VA.
    These programs, I think you are exactly right, have been 
ignored because of the funding structure. They are often lumped 
in, their VERA allocation with, you know, primary care. We have 
seen report after report from the IG or GAO about these same 
problems. I mean, I could look back at testimony or those 
reports over the years and we see the continued same problems; 
they don't get resolved.
    So I think it is going to take a different tack and I hope 
that VA, the Secretary, from the leadership down, will 
determine what would be, you know--convene a task force, 
determine from the leadership, at the VISN level, at the local 
level, how can they best serve to make sure they really get at 
these problems.
    Ms. Brownley. Thank you.
    And, Ms. Church, I thank you for your testimony and I think 
you were very clear in saying that women veterans are more 
likely to be a member of an ethnic or racial minority, the 
LGBTQ community or the like, than are male veterans. I think 
the data shows that if you are a minority, if you are a part of 
the LGBT community, that actually the services rendered are 
even less than women overall.
    You also talked about using the traditional VSO for 
accessing compensation and benefits, and you described them as 
insurmountable barriers for women veterans. You know, what 
needs to be done there?
    Ms. Church. Honestly, in order to be able to access your 
benefits, you should be able to do it automatically through the 
VA or through the Department of Defense. We have gone to a 
place where we use a third party to file our benefits and our 
claims; however, it should be automatic, it should be something 
that happens right when you get out of the service.
    As a medical retiree, I was part of a pilot program in 2012 
of the--I was one of the first to get DOD disability rating, as 
well as a VA rating, as soon as I got out. So, as soon as I got 
out, I knew exactly what my benefits were going to be, I 
already had my service-connected disabilities, and I was able 
to carry on with my life. I didn't have to use a traditional 
VSO and I didn't have to be re-traumatized, because some of 
these places can be the biggest perpetrators of toxic culture. 
It has happened for years and years, but at the end of the day 
we shouldn't have to go to a third party in order to get access 
to our benefits through the government that we work for. So the 
recommendation is remove the third party.
    Ms. Brownley. Great. And when you exited the military, was 
it clear what you needed to do to receive your services?
    Ms. Church. Absolutely. I was actually--you are actually 
able to, if your unit allows you to, apply for VA benefits 6 
months before you are out; however, it is not a mandate. It 
should be a mandate that you go 6 months before you are out, 
that you go and get your disability rating.
    Ms. Brownley. Thank you.
    Ms. Miller and Ms. McCoy, you both have served our country 
honorably and in both of your testimonies you have talked about 
your homelessness and certainly I think all of us here on the 
dais believe that no one who wore the cloth of our Nation 
should be without a home, and women veterans are the fastest-
growing homeless population in our country.
    So if you could just describe a little bit about what the 
economic--how the economic stability is a factor in enabling 
women veterans to access their own health care?
    Ms. Miller. Thank you for that question.
    From where I sit, the economic status has something to do 
with it, but it is really the outreach to women veterans when 
they get out of the military, because they are disconnecting 
from service and they are disconnecting from their peers. As 
for me, when I became homeless in the early '90s, my husband 
was suffering from post-traumatic stress disorder, I got a 
medical discharge, we stayed with family for X amount of time, 
then when his post-traumatic stress disorder kicked into high 
gear, we had to find someplace to go. I was unskilled, my son 
was about two years old at the time, I didn't have a college 
degree.
    So I think for women veterans to get connected and stay 
connected to the source, then that will also help to prevent 
the homelessness. The economic status has a little bit to do 
with it.
    One of the things we do at Women Veterans Interactive, if a 
woman veteran is homeless or on the brinks of being homeless 
and she has a claim in with the Department of Veterans Affairs, 
we can get that claim expedited. You know, we stopped at least 
two to three evictions in 2018. If a woman veteran was getting 
evicted, we would call the Department of Veterans Affairs, they 
would expedite the claim.
    So I think there is just like a major disconnect when it 
comes to the economic status of homeless women veterans.
    Ms. Brownley. Thank you.
    Ms. McCoy, briefly, because I am way over my time, which 
the chair is not supposed to do.
    Ms. McCoy. So, yes, it is economic. In my case, I came out 
of the military, I didn't understand that the benefits--that I 
needed to keep fighting for my benefits. I was considered 
service-connected right out of the military at zero percent. I 
was a single mom with a very disabled daughter, and I had 
medical conditions that were already there and went untreated. 
And so in that process, you know, I had had some education 
after I got out, I did all of the things I thought were the 
right things, and still ended up homeless.
    And so it is an economic issue, in my case it was an 
economic issue, but it also has to do with what Ms. Ginger 
said, you know, it is the disconnect. So, in my case, that is 
why I created the WVSJ. We started online as a community peer-
supported network, supporting one another online just with 
information resources and through that process grew to over 
12,000 followers on Facebook with over 50 networks worldwide.
    So it is very important to get information and resources 
out to women veterans, but also the challenge with homelessness 
is that it keeps changing. Every year, what is homelessness 
keeps changing. So when I was experiencing homelessness, couch 
surfing was considered, and now it is not. So we have to--you 
know, again, language is a big part of it.
    Ms. Brownley. My time is up, but thank you, thank you very 
much.
    I now call on Dr. Dunn for 5 minutes.
    Mr. Dunn. Thank you very much, Chairwoman Brownley. And 
thank all the members of the panel for your compelling 
testimony, I appreciate that.
    This is a question, let me just start on the right end of 
the panel and sort of work over. Given some of the barriers to 
care within the VA health care system and the other portions of 
the VA system, which all of you have referenced, and the fact 
that it can take a long time to change a culture like the 
culture in the VA, would you support granting women veterans 
greater authority to use VA health care benefits in the 
community to ensure they have access to care?
    And I will start with Ms. Ilem, if you will start--Ilem, 
I'm sorry.
    Ms. Ilem. Thank you for the question.
    In my testimony, one of the things that I point out is that 
women veterans do use higher rates of community care in VA, 
through VA being referred to the community, because of their 
lack of ability to provide maternity care and some other 
specialty services that they don't always have a provider 
available for.
    Mr. Dunn. So for specialty services clearly, but I was 
thinking more of the routine.
    Ms. Ilem. Right. So the issue that I bring up in our 
testimony is that VA has done so much research on women 
veterans and they are--the women veterans who are coming to VA 
are very clinically complex and users of a high number of 
services across the board in both primary care, specialty care, 
and mental health, and we are just concerned that fragmentation 
of care can relate to gaps in care for them and we want to make 
sure that providers in the community have the expertise to 
treat them.
    While we want women to get the care they need and what is 
best for them, and that may be the situation they prefer or 
want or need, but we need to make sure that the women 
providers--or the providers that they are going to, that they 
are going to get quality care with expertise in the conditions 
and having an understanding of what exposures women have, you 
know, experienced and what are the most conditions that they 
are being treated for.
    Mr. Dunn. And maybe quickly down, the same question about 
access to care in the community. I mean, we assume in the 
community they have--presumably, they have solved these issues, 
or they would be out of business. Go ahead.
    Ms. Church. So, I hear your question and I would like to 
actually say that I prefer that the VA step up first. I believe 
that we have a lot of work to do and that there are a lot of 
actionable items for us to continue to build the outreach and 
build the reputation up of the VA first. I do believe that we 
are going to see--women will experience barriers whether it be 
civilian care or VA. In the civilian, they will lack 
understanding of what it means to be a servicemember, in the VA 
they will lack understanding what it means to be a woman; 
however, breaking apart the VA doesn't necessarily accomplish 
that.
    Mr. Dunn. As a veteran, I certainly agree with you on that.
    And just we are working our way across. So, access to care 
in the community as a potential stopgap maneuver.
    Ms. Miller. Well, I think that would be an awesome option, 
because the VA has been researching women veterans for years; 
we are not aliens, we are women. There are plenty of doctors 
out in the private sector that support and service women every 
day. So, you know, while you are trying to figure this thing 
out, I would like to have an option to go get my Pap smear and 
to get my mammogram with a provider that I am used to when I 
had my private care. I mean, why should we have to suffer and 
walk through the halls and be catcalled and all these things 
while you figure it out. I would love to get a voucher to go 
out to a private sector, to a private doctor to get my health 
care, especially my women health care, because I know that, if 
one thing or another, at least they are certified, they are 
real doctors.
    Mr. Dunn. Thank you. And--
    Ms. McCoy. So in my case, I spend tens of thousands of 
dollars outside of the VA on my own care, because there are so 
many different areas of gaps in services.
    I agree with Ms. Lindsay and Ms. Ginger, because I think 
both parts are equally as strong. We don't need to just let the 
VA just walk away and say they don't have to do anything, they 
need to hold up their part of the bargain, but I also feel 
like, while we are waiting on that process, we do need services 
in place. I would love to have a voucher to pay for my 
chiropractic, I would love to have a voucher to pay for my 
acupuncture, because these are things that are coming out of my 
pocket. So it is very important to have these types of services 
and resources.
    Mr. Dunn. Thank you.
    Captain?
    Captain Manning. I would like to signal a little bit 
different notice. I mean, I live in the Washington, DC area and 
get most of my health care on the outside, because I am 
military retiree and I have no service connection. It is not 
that easy to get appointments on the outside, particularly for 
some of the specialty things. Do you want to see a 
dermatologist? Call me in 3 months.
    I also think that it is necessary as a stopgap sometimes, 
but I worry about, particularly if you address women as a group 
and send them outside, that VA will at some point down the road 
think that we don't have to be responsible for them anymore, it 
is just the guys we are really taking care of now.
    Mr. Dunn. I appreciate your insights on that.
    As you can tell, the way everybody evacuated, the votes 
have been called across the street. So--
    Ms. Brownley. So are you taking over the meeting?
    Mr. Dunn. We will be back; we can come back--
    Ms. Brownley. I am just teasing you.
    I wanted everybody to know that members are getting up 
because we need to go and vote on the floor. So we will pause 
momentarily. I anticipate it will probably be at least a half 
an hour, it could be a little bit longer than that. And--what?
    [Pause.]
    Ms. Brownley. Excuse me, the terminology is we will recess.
    [Laughter.]
    Ms. Brownley. But we will reconvene. Is that the 
appropriate word? Excellent.
    So thank you very much for being here and we will join you 
shortly.
    Mr. Dunn. Thank you.

    [Whereupon, at 10:51 a.m., the Subcommittee recessed, to 
reconvene at 12:24 p.m., the same day.]

    Ms. Brownley. Thank you, everyone, for waiting. We had 
quite a few votes on the floor. So I deeply apologize, and I am 
afraid that some members who are needing to get back to their 
districts, because we are not going to be voting again today, 
might not be returning to the Committee. We will see how it 
goes, but we are reconvening, and I am gaveling back in.
    And, Mr. Meuser, you have 5 minutes, and thank you for 
sitting in as the ranking member.
    Mr. Meuser. Well, thank you, Chairwoman, very much. It is 
my honor to be here with you all. And thank you all for waiting 
as well.
    I am in Pennsylvania's 9th Congressional, we have a 
Veterans Administration and a VA in Lebanon, which tends to be 
ranked very well and we are pretty proud of it actually, always 
room for improvements. We also have a VA in Wilkes-Barre that 
many of my constituents attend. And we are a very military-
focused or very military-heavy district at Fort Indian Town 
Gap, so we have over 50,000 veterans within my district.
    Also on my district team I have three veterans, Navy and 
Army, and two of which are women. So I find that to be a great 
benefit to the type of constituent services that we provide, as 
well as the work that we do for veterans, men and women.
    Your testimonies earlier were very compelling, very 
compelling. This is a very important hearing. This information 
is essential for us to be aware of, know better, and to respond 
to. That is the whole idea. It certainly sounds as if the HR 
departments within the VA facilities and perhaps on a more 
macro level need to not just be aware of this information, but 
take this in and create new procedures and plans around it. I 
think that goes without saying and I think that is a 
responsibility of this Committee to assure that does in fact 
occur.
    You mentioned that there wasn't much collaboration with 
your organizations, so we need to be inclusionary by all means, 
the Veterans Administration as a whole right up to the 
Secretary. The Secretary does need to engage; I am sure he has, 
but more so. And you mentioned other things, from homelessness 
to various other issues.
    So do know that your words are very, very important and are 
resonating.
    So the question I want to ask is, what is your 
recommendation as far as some of the things I just mentioned, 
what you talked earlier, what can we do within the human 
resources department to recognize these issues, work on them on 
a daily basis, on a larger scale, and right down into the VA 
facilities themselves?
    So I think I will start with Ms. McCoy, if you could 
answer?
    Ms. McCoy. So I think that the big thing is going to again 
go back to language, crafting the appropriate language to make 
the changes, the appropriate changes, so that the policies, the 
legislation, the funding, all of those are aligned in a way 
that they are allied--that you are an ally and not that the 
agencies are hostile. They are presenting as supportive, but in 
their writing, in their funding, and all of these other things, 
they are presenting as hostile.
    So I think that that is going to--that is where we have to 
like start, but in order to do that you have to bring subject 
matter experts, women veterans, to the table, not to just talk 
at us, but to actually have the input from us to give the 
insight, so that the legislation and the policies are 
appropriately placed and the verbiage is correct, so that it 
doesn't exclude people like our Reservists and our National 
Guard members.
    Mr. Meuser. I agree. Excellent.
    Ms. Ilem, could you respond as well.
    Ms. Ilem. Sure. I would agree that we need to make sure at 
the local facility level that facility director is engaged with 
their people, making sure they are out there watching that the 
training has occurred, making sure that, you know, harassment 
is not occurring, that they have a way to deal with it, that 
they are working with employees, and that there is a way for--
if it is reported, how they are going to resolve that and what 
they are going to do. I mean, it has got to be at the facility 
level; while you want to have a national program and you want 
them to push that all the way down, I mean, it is at the 
facility where you really need to make sure wherever a veteran 
might go, you don't want to see that happen.
    So it can't just be one program office or, you know, 
information coming from just one direction, it has to be across 
the system.
    Mr. Meuser. Thank you. And we look forward to working with 
you and for you.
    Madam Chairwoman, I yield back.
    Ms. Brownley. Thank you, Mr. Meuser.
    Mr. Cisneros, 5 minutes.
    Mr. Cisneros. Thank you, Madam Chair.
    Thank you to all our witnesses who are here today. I really 
do appreciate you coming and speaking on this matter.
    Care for our women veterans and the specific obstacles they 
face that may impact their pathways and willingness to seek out 
VA treatment is of utmost importance to me, being a veteran 
myself, especially as it relates to intimate partner violence.
    Director Ilem, in your testimony you mentioned some 
research, that the VA researchers are becoming increasingly 
aware of the rise of woman veteran patients who are survivors 
of intimate partner violence, and in fact emerging research has 
proved that women veterans are at a greater risk for intimate 
partner violence than non-veteran women. Could you elaborate on 
this specific research, the data that was found, and why you 
think they found that data?
    Ms. Ilem. Well, I think one thing that VA research has 
really shown--I mean, they have done more research over a short 
period of time, like almost in a 7-or-8-year period than they 
had done in 25 years, so they are really learning a lot about 
this population--and VA has always been forward-thinking in 
terms of asking questions when veterans come in, they are 
looking to make sure that they have the services available if 
someone is homeless, if someone has experienced trauma of some 
sort, and their findings are really I think showing that we 
need to, you know, pay attention, be looking for these types of 
things. What are the specifics within this population that seem 
to be--put veterans more at risk, that can help for prevention 
and can help moving forward in terms of addressing the issue?
    So I think researchers are on the forefront and part of 
that whole aspect that really make VA unique and special, and 
they need to make sure that they continue that line to really 
be working with veterans.
    Mr. Cisneros. And do you have any recommendations? And, you 
know, it is good that you say the VA is good out there in 
asking the questions, but what could they do and what also 
could Congress do to kind of help along with that process to 
make it better?
    Ms. Ilem. Well, I think they need to make sure that those--
once they have asked the question, what are the programs and 
services that these women veterans need to address that issue, 
to make sure that they have the mental health services, to make 
sure they have the support services around that. So turning 
that into action is the most critical thing once they have 
asked the question, what can we do to make sure we support this 
veteran.
    Mr. Cisneros. So you raise another issue actually that I 
was going to bring up as well. You know, it is also troubling 
that women veterans who have experienced intimate partner 
violence place them at risk for developing certain mental 
health conditions and substance use disorder, increasing the 
risk of suicide.
    What would you recommend are appropriate outreach programs 
and efforts to support women veterans that are impacted by 
intimate partner violence?
    Ms. Ilem. Well, I think some of the organizations here at 
the table really also have some great--an opportunity and for a 
really important role to play, I think like BriGette McCoy and 
others, who have a support system and have an outreach that is 
beyond the VA arm.
    I mean, this is one thing that we know is often women 
veterans don't have the--they are not connected with the VA or 
they are not connected with the VSO community, where they might 
not readily know about the resources that are available. So it 
is important to engage the organizations that are here. This is 
everyone's issue and I think that that will be a critical piece 
in moving forward.
    Mr. Cisneros. Does any other members have any comments on 
this and how we can address this issue?
    Ms. McCoy. So I think one of the bigger problems related to 
this topic is that there will be a large group of women who 
will not perceive themselves as being victims of domestic 
violence. Having clear presentation of the awareness, being 
able to describe what domestic violence includes, because it is 
to me similar to military sexual trauma, there are a lot of 
people who say they didn't experience it until you start 
describing what it is and what it includes. And so that is one 
big part of the outreach.
    The other part, because WVSJ has been instrumental in 
connecting groups of women within certain demographics, social 
media, although some people think it is the devil, actually we 
have been able to, you know, extract people from situations 
where it was unsafe, because we had an integrated network of 
peer support online, crowd-sourced, to intervene on behalf of 
woman veteran. So there are ways to implement those things and 
keep the person safe, and protect their identity as well.
    Mr. Cisneros. All right. Well, thank you for your answers. 
My time has expired.
    Ms. Brownley. Thank you, Mr. Cisneros, for being here after 
a long day on the floor.
    I thank the panel again for being here. I think today's 
meeting is just a terrific start for all of the issues that we 
need to continue to drill down on until we really do determine 
solutions, and keep working and making that cultural change and 
shift that is so very, very necessary. And as I said earlier in 
my comments, I think this is, you know, a veteran women's me-
too moment and I think we have to really make it into a 
movement, and I think that movement will help to shift a lot of 
the cultural issues that you all are all facing as women 
veterans.
    So, thank you very much, and we are going to go to our 
second panel. And for our second panel we have Dr. Patricia 
Hayes. Dr. Hayes is the Chief Consultant for Women's Health 
Services at the Veterans Health Administration.
    Thank you, Dr. Hayes, again, for having to wait for a long 
period of time. We appreciate you being here. And as you take 
your chair and get comfortable, I will recognize you for 5 
minutes.

                 STATEMENT OF PATRICIA M. HAYES

    Dr. Hayes. Thank you very much. Good afternoon, Chairwoman 
Brownley and Congressman Meuser, and distinguished members of 
the Subcommittee.
    I am going to start my statement, but I have to just 
acknowledge the tremendous sense of being moved by the members 
of these--of these veterans themselves coming here today and 
taking time from their lives to let us know their concerns 
about the VA, it is very, very important.
    I wanted to talk about the number of women veterans 
enrolling in VA health care is increasing, which places new 
demands on the VA health care system. More women are choosing 
VA for their health care than ever before, with women 
accounting for over 30 percent of the increase in veterans over 
the last 5 years. To address this influx, VA is strategically 
enhancing service and access for women veterans.
    Every VHA health care system has a full-time women veterans 
program manager who advocates for the needs of women veterans 
using that facility. VA has enhanced provision of care to women 
veterans by focusing on the goal of developing women's health 
primary care providers at every site of VA care. VA now has at 
least two women's health providers at all of VA's health care 
systems, and at least one at 90 percent of the community-based 
outpatient clinics.
    VA has implemented models of care that ensure women 
veterans receive equitable, timely, high-quality primary health 
care from a single primary care provider and team, thereby 
decreasing fragmentation and improving quality of care for 
women veterans. And we have worked to implement a mobile 
training to specifically meet the needs of rural primary care 
providers and nurses at 40 CBOCs per year.
    VA provides a wide scope of services to women veterans, 
including comprehensive primary care, gynecology care, 
maternity care, and fertility services other than in vitro 
fertilization, specialty care, and mental health services. 
Additionally, recent legislation authorizes IVF for married 
veterans with service-connected disabilities that result in 
infertility.
    VA has witnessed 154-percent increase over the past decade 
in the number of women veterans accessing VA mental health 
care. Over 40 percent of women veterans who use VA have been 
diagnosed with at least one mental health condition, and many 
also struggle with multiple medical and psycho-social 
challenges, including trauma-related difficulties, and 
increased risk for suicide is of great concern.
    To ensure that VA mental health providers have the skills 
and expertise to meet women veterans' unique treatment needs, 
VA developed innovative clinical training such as the women's 
mental health mini-residency. Unfortunately, some women 
veterans experience sexual assault or harassment during their 
military service and may struggle even years later with its 
aftereffects. VA provides free care, including outpatient, 
residential and in-patient care for any mental or physical 
health condition related to military sexual trauma, and 
eligibility is expansive. Veterans do not need to have reported 
their experiences at the time or have any documentation that 
they occurred, and may be able to receive free military sexual 
trauma-related care even if they are not eligible for other VA 
care.
    VA is proud of high-quality health care for women veterans. 
Ongoing quality measures show that women veterans are more 
likely to receive breast cancer and cervical cancer screening 
than women in private sector health care. Unlike other health 
care systems, VA analyzes quality performance measures by 
gender. This has been key in the reduction and elimination of 
gender disparities in important aspects of health screenings 
and chronic disease management.
    Since 2014, VA has tracked access by gender and identified 
small, but persistent disparities in access for women veterans, 
who overall are waiting longer for appointments than male 
veterans. To mitigate this disparity, VA has identified sites 
with longest wait times for women veterans and is working with 
those sites directly on initiatives to improve access, 
including designating more women's health providers through 
hiring or training, and improved team efficiency.
    VA continues to make significant strides in enhancing the 
language, practice, and culture of the Department to be more 
inclusive of women veterans. My office sponsored the recently 
published research by Drs. Klap and Yano that found that one in 
four women veterans reported experiencing harassment by other 
veterans when they visited VA health care facilities. VA is 
focused on ensuring all veterans are treated with dignity and 
respect, and women who served in our country's military deserve 
to be treated with honor, just as their male counterparts are.
    With input from male and female veterans, VA launched an 
End Harassment Program in every VA medical center in the summer 
of 2017 and has continued to implement this program nationally. 
Through increased awareness, education, reporting, and 
accountability, VA is working to address this issue. We have 
launched messaging, including, ``It's not a compliment, it's 
harassment,'' directed primarily at educating male veterans 
that certain conduct is unacceptable.
    Employees have been trained on culture-change efforts, 
including an awareness of the experience of women veterans, and 
ways to intervene and respond. We will be persistent in our 
culture-change efforts.
    Gains for women veterans would not have been possible 
without consistent congressional commitment in the form of both 
attention and financial resources. It is critical we continue 
to move forward with the current momentum and preserve the 
gains made thus far. Your continued support is essential to 
providing high-quality care for our veterans and their 
families.
    Madam Chairwoman, this concludes my testimony. I am 
prepared to answer any questions.

    [The prepared statement of Patricia M. Hayes appears in the 
Appendix]

    Ms. Brownley. Thank you, Dr. Hayes, and I appreciate your 
testimony, and I will now recognize myself for 5 minutes for 
questioning.
    The first question that I have--and I think anybody who is 
in the audience--I am not sure that you can answer questions 
beyond the medical arena around women's health in issues like 
homelessness and other kinds of things, so we are not going to 
get into those questions, but I had recently had the 
opportunity to visit the VA medical center which has really a 
very beautiful women's health center. I did mention earlier 
that they didn't have extended hours, but the center is 
absolutely beautiful, you feel like you are walking into a spa-
like atmosphere. And women there can receive all of their 
gender-specific care, including mammograms, they don't have to 
leave the clinic to make that happen. But according to a 2017 
VA report--I call this the gold standard in some sense and the 
standard that we all want to achieve--only 7 percent of the VA 
facilities met this standard.
    So I am wondering if you could speak to what VA's plans are 
in terms of replicating the gold standard across the country.
    Dr. Hayes. Certainly. Thank you for the question.
    We have been working for a number of years to make sure 
that women veterans have the right kind of care wherever they 
go for care. So we actually shifted away from building women's 
clinics for a number of years, because we wanted to make sure 
that women out in the more rural areas, in the distant areas 
geographically had access. That is our primary care provider, 
we are saying that--we are still concerned that 90 percent of 
our CBOCs have it, but 10 percent don't. So we have been 
focused very much on making sure that, wherever you come for 
care, you have a women's health provider.
    In the meantime, as the population has grown exponentially, 
many sites have moved towards developing a women's clinic, we 
call it a Model 3 Women's Clinic comprehensive care with GYN on 
site. We are now at 75 women's clinics.
    So we didn't say you have to do it. In fact, what we really 
said is that you must talk to the women veterans in your 
community; you must hold a town hall, you must have input from 
the women as to what do the women at that site want, and add in 
the issues about what is the best way to deliver care. And we 
have some sites that the women said we do not want a stand-
alone women's clinic. We are women, we are soldiers where a 
soldier is a soldier, and we don't want that.
    Most sites there is some combination of women's clinics, 
comprehensive women's clinics, and integrated primary care for 
women.
    Ms. Brownley. So women veterans disproportionately use 
community care compared to male veterans and we know the 
reasons why, but how will the women veterans be uniquely 
impacted by the MISSION Act and how is the VA going to ensure 
equitable, integrated care for women?
    Dr. Hayes. The MISSION Act, of course, does allow for 
different kind of choice going out, but for women veterans 
about 30 percent of the care every year must be in the 
community, and that is because of maternity care, some of the 
infertility care, in some places mammograms, and also a lot of 
it is actually in-home care. As women age and live longer than 
men, they have more of the community care dollar.
    I think that what is most critical about community care is 
care coordination and care navigation, and we have invested in 
mammogram coordinators, maternity care coordinators, and really 
our issue is going to be that we have right-sized our resources 
to have enough community care navigation and coordination and 
that is our challenge right now.
    Ms. Brownley. Thank you. And there are only 65 mammogram 
sites in the country and that really doesn't necessarily 
correspond to where there are large concentrations of women 
veterans. For example, Puget Sound VA system in Washington 
State is used by thousands of women veterans and there is no 
on-site mammogram capability.
    So what are the standards that the VA is using to determine 
where mammograms should be placed?
    Dr. Hayes. We have recently developed a tool to continue to 
look at the key issues on where mammograms are and you are 
absolutely correct, most places we do not have a significant 
population to be able to have the highest quality of mammogram. 
That is critical to me, that we make sure that women are not 
seen by someone who hasn't seen enough mammograms.
    In places like Puget Sound, the other--one of the other big 
issues is space and it takes considerable space and lead-lined 
walls. And so we are continuing to work with sites like that 
about how they can prioritize adding radiology space and 
mammogram space. So it is about a population issue and it is 
about making sure that we have the highest-quality care.
    And the third part is navigation and if we don't have 
someone who is tracking to make sure that that mammogram result 
gets noted by the primary care provider, gets to the breast 
cancer surgeons or whoever they need, we are in trouble. So we 
need to make sure that, number one, we are tracking mammograms, 
and that is the biggest part of what we are doing.
    Ms. Brownley. Thank you very much. My time is up, so I 
yield to Mr. Meuser for 5 minutes.
    Mr. Meuser. Thank you, Madam Chairwoman.
    Dr. Hayes, I thank you for being with us here this 
afternoon. I do understand that you do some really positive 
work for the Veterans Administration and for women veterans, so 
thank you.
    Dr. Hayes. Thank you, sir.
    Mr. Meuser. I also understand that you were here during the 
testimony of the previous panel. Do you have any comments or 
response to some of the testimony given?
    Dr. Hayes. Certainly, thank you.
    I think that the issue of culture change, we really can't 
say enough about how that is a problem that we are focused on. 
We knew it was happening, we got the data to show that it was 
happening, we continued to throughout the country do more work 
on a wider spread of research on the topic, but it has been a 
challenge. Other systems don't actually have to manage this 
challenge of military culture bleeding over into veteran 
culture and how to deal with training our employees and our 
veterans to end harassment. So we do, we have worked a lot with 
research, but it is not good enough to say that women can just 
have a separate space or that they should go out to the 
community; we have to step up. I really like that comment about 
VA, it not only is stepping up, we have to step up. We have to 
end the harassment, not just of women, end harassment for race 
and ethnicity issues, for LGBT issues, we have got to change 
this culture.
    And a lot of it is engaging Veterans Service Organization 
folks here, because part of VA is what I call right-thinking 
men who are appalled by this behavior, and empowering them as 
well as they come to VA to say something to the other folks 
that are conducting themselves this way. So, VA has this as a 
high agenda.
    I think the other thing that was really striking in hearing 
the panel is kind of the disconnection, whether it is a little 
bit of disconnection between them, but also the ongoing issue 
of us making sure that we are working with these partners, 
these women veteran expert partners in everything that we can 
do. And the challenge from the level of the Center for Women 
Veterans and the level of every VA to make sure that we are 
involving these groups of women veterans and the other groups, 
i.e. MVA and others that have provided information, to make 
sure that we are hearing them and incorporating the veteran's 
word in what it is that we offer to veterans, and I heard that 
loud and clear from them today.
    Mr. Meuser. Certainly. All right, thanks.
    What steps as of late has the VA taken to combat harassment 
when it is detected or seen at the VA facilities?
    Dr. Hayes. The End Harassment Program--and you notice I 
call it End Harassment, because we are not anti-harassment, we 
are not against harassment, we want it to stop, we want it to 
end--and we have done a number of things. We developed an 
education program for veterans, which it talks about this is 
not a compliment, this is harassment. We have worked with male 
veterans to have them tell us, you know, what were some of 
these things, because this behavior disrupts care. It is a 
terrible experience for veterans who experience harassment and 
it just disrupts the whole system.
    So we have to educate male veterans, we do it in some of 
the new employee orientation. We are in the process, a 
widespread process of educating the employees to understand 
these experiences, and also what is widely known in research as 
a bystander intervention, teaching them through a role-playing 
system how to actually intervene. And if they don't feel 
comfortable intervening, they can call their supervisor, they 
can call the police, there are a number of options. So we 
educate.
    The next step is reporting. We have set up reporting 
systems locally. Veterans can report, staff can report; you can 
report to the police, you can report to the patient advocate, 
and you can report to the Women Veterans Program manager. There 
will be people that are evidenced as, you know, putting out 
there as you can call me, their name is on a poster.
    And then there is accountability and we believe very 
strongly the accountability has to be at the local level. The 
local leadership has to be out and engaged in this, they have 
to know what the reports are and they have to be actively 
working to change this culture, to engage the employees, to 
engage the veterans, to walk around and themselves say this has 
to stop, we have to change this.
    Mr. Meuser. All right, very good.
    The panel also brought up the idea of an outside agency to 
conduct a cultural assessment of the VA or specific VAs; what 
are your thoughts on that?
    Dr. Hayes. I honestly don't know of groups that could do 
this for us. I mean, we work closely with some of the other 
major think tanks, Mitre and Rand and folks like that, and they 
have been involved in some of the research. I actually think 
that the best assessment is listening to the veterans 
themselves. We have what we call a card study, we have just 
done another round that we will be publishing about what do 
veterans think about this effort, do they notice that we are 
changing the efforts.
    So I would be very interested in hearing more specifically 
about what someone might think we could get, what would be the 
utility of that, but listening to the veterans is the number 
one strong message that we have. I encourage facility directors 
to call in veterans and ask them specifically about this, what 
have you experienced at this VA and where are the hot spots, 
where are the trouble spots.
    Mr. Meuser. Thank you.
    Thank you, Madam Chair. I yield.
    Ms. Brownley. Thank you. And, Mr. Cisneros, you have 5 
minutes.
    Mr. Cisneros. Thank you, Madam Chairwoman.
    Thank you, Dr. Hayes for being here today. I want to ask 
you about a specific pilot program that is being run between 
the Air Force Women's Health Initiative team and the VHA's 
Office of Women's Health Services, the program is a Women's 
Health Transition Assistance Training Pilot Program. As one of 
the previous witnesses testified, veterans aren't always aware 
of their services or the benefits that they have, and I will 
even kind of testify that was true in my own case when I was 
getting out of the military. Some of the data that was 
collected in this for those that have gone through the program 
indicate 99 percent of the participants surveyed responded they 
would recommend this course to others; 80 percent of 
participants have agreed to post-course follow-up.
    Could you elaborate on some of the data findings and why is 
this program being so successful, and why these women have said 
they want to continue with this?
    Dr. Hayes. Absolutely. As you well know, VBA and the 
Department of Defense and the Department of Labor run a TAP 
program for servicemembers as they exit the military. We knew 
for a long time that women veterans have been telling us that 
they didn't know about their benefits. And the other thing that 
was brought to our attention is that the time--the year after 
transition, that whole transition year, is at higher risk for 
suicide. We are very concerned about the high suicide rate and 
the rising suicide rate among women veterans.
    And so we worked with the great partners in the Department 
of Defense to design a TAP program for women, which is in 
addition to the regular TAP program. It does walk them through 
their benefits. It is a time when women are with women, so they 
can talk about issues, about things like reproductive health 
issues, gender-specific health issues, and I think that is part 
of why they find it a comfortable place, but it also gives them 
a lot more technical information about what is VA health care 
and how can they access it.
    They also--for most sites we get them to a VA hospital, so 
that they can kind of blow away the myths about what is a VA 
hospital like and see some of these gold standard clinics that 
are there, and realize that they may want to enroll and use 
that care.
    This project is a proof-of-concept project. We are in pilot 
phase and we are happy to announce that Navy just this week has 
very much agreed to come on board and help with Navy and Marine 
sites. So now we have participation in Air Force, Army, Navy, 
and we think that we are going to get a wider ability to have 
people come into it and have the various services, be able to 
speak to what they think what benefit it is for them.
    So we are going to continue to collect the data, we are 
going to go back to the Joint Executive Committee of DOD and VA 
and report our findings. And so far, people actually think it 
is wonderful; we are not surprised, we think it is a very 
important part of what we are doing. We are also going to 
compare it to an online version, so we can see whether is it 
really--what is the importance of having it in person, what can 
you get from an online version for those that want to take it 
virtually.
    Mr. Cisneros. All right. So just to be clear, it sounded 
like you said Army, Navy, and the Air Force are now going to 
implement this program?
    Dr. Hayes. Yes, sir.
    Mr. Cisneros. Oh, wow, that is wonderful.
    Dr. Hayes. It is wonderful, yes.
    Mr. Cisneros. So how do we get it out of the pilot program 
phase and to really make sure that we implement this through 
the entire Department of Defense or all three military 
branches, maybe even the Coast Guard at some point there too, 
to make sure that we are taking care of our women veterans?
    Dr. Hayes. Well, we are going to fund up the next part of 
the pilot, carrying us through the end of '19 now and into 
2020. We need the data. It really is important, I think, when 
you look at something that is going to be costly in some ways 
to make sure that it really is a proof of concept that this is 
an important addition to the TAP program.
    So, as I said, the next thing would be a decision. There is 
a well-oiled machine that works between the TAP oversight, as I 
said, with the Department of Labor, VBA, and DOD, and it will 
go back to that group, in their wisdom, to consider it.
    Mr. Cisneros. All right. Well, thank you very much, and I 
yield back my time.
    Ms. Brownley. Thank you, Mr. Cisneros.
    Mrs. Radewagen, you have 5 minutes. Thank you for joining 
us.
    Mrs. Radewagen. Thank you, Madam Chairman.
    Dr. Hayes, according to DAV's written testimony, VA reports 
that only 70 percent of women veterans are assigned a 
designated women's health primary care provider. That is 
concerning considering the improved satisfaction and quality 
that data indicates are correlated with such an assignment. 
What steps are you taking to ensure that every woman enrolled 
in the VA health care system is assigned to a designated 
women's health primary care provider?
    Dr. Hayes. Thank you for that question. We, as you have 
heard, are really committed to having designated women's health 
primary care providers. There is a national shortage of primary 
care providers, so we have worked a lot on training up our own 
providers who may have been rusty about women's health, 5800 of 
them have been provided, but we found that we are still having 
difficulty recruiting in the remote and rural areas. And so we 
have established a training program that takes the training to 
that remote site.
    Our community-based outpatient clinics frequently have very 
few staff and can't send their staff away for a week to 
training. So in the last year and a half we have actually 
trained up over 70 providers.
    And you may be relieved to hear that the first week of May 
and the last week in April we trained in Hawaii, and we had 
several folks from the islands come, so they can now be 
designated women's health providers. We wanted to make sure 
that we reached groups that have had great difficulty in 
accessing this training, and you may want to interview them. I 
think that they were very excited to be included and we were 
very happy to be able to make sure that they could get their--
lots of travel, as you well know, and it is a group that we 
wanted to make sure.
    And I am glad you asked the question, because it happened 
to be that we reached--as I said, we are looking at those sites 
that are geographically dispersed that can't easily access, 
can't hire up. There may not be a primary care provider in that 
area, and we can't steal them from another--you know, we can't 
steal them from Indian Health Service or another federally-
qualified health center. We have to make sure that we are 
working in partnership with all of those groups and provide the 
best training that we can for our women's health providers.
    So we still have a long way to go. We actually have such a 
wave of women coming in that even with all of the training we 
are doing, this year we are going to hit over 700 trained and 
we are still going to probably have a gap of five to 700 
providers. So I am continuing to look. Workforce management is 
working with me in terms of enhancing the recruitment under the 
Secretary's recruitment provisions and our goals for 
recruitment, but we have an uphill battle here.
    Mrs. Radewagen. Also, you note that provider turnout is an 
issue with respect to the initiatives VA is pursuing to improve 
training on women's health across the VA health care system. 
What, if any, incentives exist to encourage providers to seek 
out those training opportunities? And, if none exist, what 
incentives do you think would be helpful?
    Dr. Hayes. There are not specific incentives to be a 
women's health provider and that is problematic. If anything, 
there is a bit of disincentive, because we are getting so busy 
that they frequently get over-paneled quickly, they have 
difficulty kind of keeping everything going. We do have 
retention--we have a turnover in retention in this group that 
is higher than the other primary care groups. And it is really 
a technical issue about there is not a separate medical 
certification for this group of providers, so we are not able 
within the laws and rules about provider groups. We would need 
to have some specific way to identify the work they are doing 
and to be able to provide additional financial incentives in 
this group.
    Mrs. Radewagen. I see. So what outcome improvements do you 
see for women veterans following the mini-residencies in 
women's health that your statement references?
    Dr. Hayes. The training itself, I think that there are both 
kind of subtle and really obvious things. The obvious things 
are resolved when you can have someone not have to go somewhere 
else for Pap smear, because someone has been trained up on live 
models and feels comfortable handling a Pap smear, handling a 
vaginal infection.
    The more subtle things or not so direct things are about 
understanding the experience of veterans in the military, 
trying on, you know, what we call the battle rattle, and then 
going back and realizing that this complaint about 
musculoskeletal pain, about a headache or a neck problem, or a 
joint problem, is because of what that woman had to do with her 
heavy equipment on. And then we also have them trained up a lot 
on military sexual trauma, interpersonal violence, depression, 
management of basic mental health conditions in the primary 
care setting. So we have taken someone who is a good VA 
provider and helped them expand their role to really, truly be 
a good provider for women veterans.
    Mrs. Radewagen. Thank you, Madam Chair. I yield back.
    Ms. Brownley. Thank you, Mrs. Radewagen.
    I thank you, Dr. Hayes, for being here. And I had--before 
we conclude, I just had one very quick follow-up question on 
the End Harassment Program you were speaking of.
    So the last thing you said about the program is 
accountability and I just--I was curious to know when you are 
teaching employees around harassment, is that a required 
program that each and every employee must undergo, like we do 
here in Congress, and, you know, they must go through this 
training and must go through it on an annual basis?
    Dr. Hayes. Every employee must go through the employee OPM 
harassment program. What we are doing in VA is we are adding to 
that program and to several other training programs that 
employees are taking. There is a new program the Secretary has 
been rolling out called Own the Moment, and it is about 
customer service, it is about direct interaction with veterans, 
and we are enhancing that program to add this together.
    So, to answer your question directly, that is not a 
mandatory program. We are still in development of how to roll 
this out additionally. In fact, I have a meeting with the 
Secretary in about a week with various groups within the VA. So 
it is a little bit preliminary to say how much more we are 
going to be making sure happens, but we can get back to you on 
what the plans are. And not just for VHA where we have the 
medical centers and the accountability, but we also want to 
extend the program across all of VA, the cemeteries and the 
benefits agencies, in terms of being able to address the 
culture everywhere.
    Ms. Brownley. So it is very possible that we have employees 
across the VA who have been untouched by any of these programs?
    Dr. Hayes. Quite--yes, sir--yes, ma'am. I believe that 
right now there are employees who have been untouched by the 
program.
    Ms. Brownley. And then you talked about the reporting 
system. So, once an incident reported, is every incident then 
investigated and pursued?
    Dr. Hayes. The reporting is done locally, and it is done to 
the patient advocate and/or what is called the Disruptive 
Behavior Committee for mental health disruption; it is 
accounted to the local director, and they are tracking and 
accounting for what is done.
    So because this range of behaviors can be everything from 
catcalling, where there might be something like looking at the 
design and trying to make sure that you can't congregate there 
and have women walk the gauntlet, that might be the action. 
There are many other much--I don't want to sort of qualify 
them, but egregious things that absolutely have to have police 
intervention, maybe the veteran has to be accompanied every 
time he comes into the setting. So there are various ranges of 
action that are possible.
    Ms. Brownley. But a supervisor or a medical director or a 
VISN director or anybody at central office may not hear about 
any of these instances?
    Dr. Hayes. We actually decided not to roll them up to the 
central office level.
    Ms. Brownley. So medical director level, VISN level--
    Dr. Hayes. Yes. I want the action to be accountable 
locally.
    Ms. Brownley. I agree, I agree, but sometimes one has to 
make sure that it is happening locally.
    Dr. Hayes. I defer to your judgment. And in this area, you 
know, we have been going back and forth on it. I just didn't 
want us to create a meaningless report that people were just 
sending up somewhere.
    Ms. Brownley. Understood, yeah.
    Dr. Hayes. That was the issue for me is that what is the 
utility in a report that just has a lot of numbers, which 
hopefully will go up initially, you know. We see this challenge 
with these kind of reports.
    Ms. Brownley. Yeah. I just feel like this is really, you 
know, we are sort of--in terms of culture, it is sort of in a 
crisis situation. I think everybody, including yourself and 
others in the VA, acknowledge that, but it just seems to me 
that we need to have more tools that replicate that urgency, 
and so that is why I am sort of following up on those 
questions.
    But I think our time has come to a close and I really 
appreciate you being here. And I think just before we close the 
hearing, I just would like to say, I think what we have learned 
today has been extensive, and I think the conclusion is that 
women continue to face sexism and discrimination and inequities 
in the system, in a system that was originally built for men. 
And I think everyone on the Committee believes that no woman 
should endure sexual harassment of any kind when she is seeking 
her health care and no veteran should ever have her service 
considered less valuable because of her gender or minority 
status.
    So I think we have got a lot of work and the work is cut 
out for us, and I intend on following up and having more 
hearings like this one, so that we can drill down further.
    So I appreciate everybody's participation, and, with that, 
I will ask Mr. Meuser if he has any closing comments.
    Mr. Meuser. Thank you, Madam Chairwoman. No, I do not. I do 
too thank you very much, Dr. Hayes, and our previous panelists 
and their testimony. So, thank you very much.
    Ms. Brownley. So, thank you again.
    And, with that, all members will have 5 legislative days to 
revise and extend their remarks, and include extraneous 
material.
    So, without objection, the Subcommittee stands adjourned. 
Thank you.

    [Whereupon, at 1:08 p.m., the Subcommittee was adjourned.]




                            A P P E N D I X

                              ----------                              

                   Prepared Statement of Joy J. Ilem
    Chairwoman Brownley, Ranking Member Dunn and Members of the 
Subcommittee:
    Thank you for inviting DAV (Disabled American Veterans) to testify 
today at this oversight hearing on Cultural Barriers Impacting Women 
Veterans' Access to Health Care. DAV is a non-profit veterans service 
organization comprised of more than one million wartime service-
disabled veterans that is dedicated to a single purpose: empowering 
veterans to lead high-quality lives with respect and dignity. Ensuring 
that women veterans are treated with respect and dignity and have equal 
access to high quality comprehensive primary care, gender-specific 
health care services, disability benefits and the broad range of 
specialized care and readjustment services from the Department of 
Veterans Affairs (VA) is a top legislative priority for DAV.
    Women are serving in the military in record numbers and represent 
10 percent of the veteran population. There are more than two million 
women veterans in the U.S. today and according to VA it expects women 
will make up 18 percent of the veteran population by 2040. \1\ Women 
are also turning to VA for care in record numbers and more than half of 
the women using VA services have a service-connected condition and are 
eligible for VA benefits and a lifetime of care. \2\
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs. Women Veterans' Health Care. 
Women Veterans Today.
    \2\ Women's Health Services. Office of Patient Care Services. 
Veterans Health Administration. Department of Veterans Affairs. 
Sourcebook: Women Veterans in the Veterans Health Administration Vol. 
4: Longitudinal Trends in Sociodemographics, Utilization, Health 
Profile, and Geographic Distribution. February 2018. P. 3
---------------------------------------------------------------------------
    These sociodemographic changes led DAV to release two special 
reports on women veterans. Women Veterans: The Long Journey Home was 
released in 2014, with a follow-on report in 2018, Women Veterans: The 
Journey Ahead. These reports highlight the changes in this population 
over time, critical policy implications for VA, what was needed to 
ensure women veterans have access to high quality health services in 
all VA sites of care, and most importantly how we could better serve 
this population of veterans. Our 2014 report looked at barriers women 
veterans returning from recent deployments faced in readjusting to 
civilian life after military service. Our new study looks at progress 
made and more generally, at the needs of a diverse women veterans' 
population using VA health care today. We very much appreciate this 
opportunity to discuss the recommendations in our most recent report in 
relation to the barriers identified in women veterans' pursuit of 
veteran-centric health care.
    The unprecedented growth in the number of younger women veterans 
coming to VA for care over the past two decades has placed specific 
demands on the system and relates to a number of policy changes that 
have taken place related to delivery of care for this population. 
Specifically, a national focus on oversight, starting in 2008, by the 
Women's Health Services Program Office and the advent of training and 
deployment of designated women's health primary care providers (WH-
PCPs) and the provision of comprehensive primary care, including 
gender-specific services for women patients.
    Understanding VA's specific challenges requires a look back at the 
changing dynamic of women veterans seeking VA health care services. The 
number of women seeking VA care has tripled since 2000, growing from 
about 160,000 to 500,000 today. \3\ VA has had to ensure younger women 
in their childbearing years have access to reproductive health services 
and that older women veterans, another growing population in VA, have 
access to age appropriate services for chronic health conditions and 
sex-specific care. Additionally, the increasing proportion of women 
veterans with a service-connected condition who use VA care (48 percent 
in fiscal year (FY) 2000 compared to 63 percent in FY 2015) \4\ also 
required program adjustments and policy changes to ensure quality of 
care and effectiveness of services for this group. Higher utilization 
of outpatient services among women veterans, as well as increased rates 
of purchased care and specialized services all resulted in the need for 
increased capacity, research, resources and oversight of the Women's 
Health Program.
---------------------------------------------------------------------------
    \3\ Department of Veterans Affairs. News Release. New Text Feature 
Available Through VA's Women Veterans Call Center. April 23, 2019.
    \4\ Sourcebook, p. 3
---------------------------------------------------------------------------
    Women's care needs and preferences for health care in VA are often 
quite different than those of the male veterans the VA health care 
system was originally created to serve and long-standing cultural 
barriers that have impacted women veterans' access to VA care are often 
a result of failing to understand the different needs, preferences, and 
perspectives of women veteran patients.
    While there has been significant progress in many aspects of VA 
health care for women, there are some longstanding issues that still 
exist. VA's environment of care surveys, which identify deficiencies in 
privacy, safety and dignity in patient care settings seem to routinely 
get shortchanged or ignored. In recent reports the GAO (Government 
Accounting Office) has highlighted these deficiencies and made 
recommendations about how to correct them. \5\ However, little has 
changed in the way VA collects or submits these surveys or holds its 
leadership accountable for implementing necessary changes. While Women 
Veterans Program Managers (WVPMs) are responsible for managing 
environment of care surveys, they have no authority to hold facility 
leadership accountable for accuracy and completion of responses to 
surveys or to ensure changes are made to correct identified 
deficiencies.
---------------------------------------------------------------------------
    \5\ Government Accountability Office. VA MEDICAL CENTERS: VA Should 
Establish Goals and Measures to Enable Improved Oversight of 
Facilities' Conditions. GAO-19-21: Published: Nov 13, 2018. Publicly 
Released: Nov 13, 2018.
---------------------------------------------------------------------------
    Women have been found to value privacy, safety and appearance of 
patient care environments. In the VA, where women are still a minority 
of the patient population, these aspects of health care may be even 
more important to ensure women are made to feel welcome and comfortable 
in seeking care. DAV feels strongly that women veterans should be able 
to take advantage of VA's comprehensive system of care and specialized 
programs and services. Women should be able to rely upon a system that-
at its best-understands the unique needs of this population through its 
dedicated Women's Health Research program and commitment to evidence-
based care.
    We are pleased to learn that VA researchers are looking at how gaps 
in the delivery of gender-sensitive comprehensive care can result in 
disparities in quality and patient experience among women veterans 
using VA health care and more importantly that VA's Women's Health 
Program, in collaboration with researchers, has adopted VA's model of 
using evidence-based quality improvement-or EBQI to see if it can be 
used to help facilities with gaps in delivering comprehensive services 
to women. These sorts of initiatives are essential for breaking down 
barriers to care and achieving delivery of comprehensive care in gender 
sensitive care environments throughout the system that ensure safety, 
dignity and privacy for women patients.
    Research has also shown that women veterans prefer women clinical 
providers, particularly when it comes to ``sensitive'' sex-specific 
care such as gynecology \6\ and express a preference for women's 
comprehensive health clinics. Veterans who use these clinics express 
high satisfaction with communication and care coordination. \7\ Yet 
despite the efforts of many policy leaders within VA, there are still 
many women who lack access to women's clinics and ensuring adequate 
staffing for such clinics has remained an organizational challenge.
---------------------------------------------------------------------------
    \6\ J Obstetrics Gynecology Apr 2005, Vol 105, #4, p 747-750.
    \7\ Brunner, J. et al, Women Veterans: Patient-Rated Access to 
Needed Care: Patient-Centered Medical Home Principles Intertwined. 
Women's Health Issues 28-2 (2018) 165-171.
---------------------------------------------------------------------------
    VA reports that a majority of women veterans (approximately 70 
percent) are assigned to a designated women's health primary care 
provider. Only a small percentage receive care in designated women's 
health clinics-in FY 2005 and FY 2010, VA reported that only 12 percent 
of women used women's health clinics and 22 percent used both women's 
health clinics and general primary care clinics (34 percent of the 
total population). In FY 2015, 16 percent used women's health clinics 
and 17 percent used both women's health clinics and general primary 
care clinics (32 percent of the total population). \8\ Women's health 
clinics must be staffed with specialized primary care providers in 
addition to adequate clinical and non-clinical support staff. Ideally 
these clinics should also have integrated mental health care services 
available. Because these clinics require appropriate staffing levels 
and space, VA medical center directors must support their growth and 
maintenance as a high priority.
---------------------------------------------------------------------------
    \8\ Sourcebook. P. 58
---------------------------------------------------------------------------
    With these longstanding issues still not fully addressed it may be 
time for Congress and VA to consider a new hierarchy for women's 
health, specifically making it a program with its own leadership 
structure at the Veterans Health Administration (VHA), VISN and 
facility level. In this type of hierarchy, leadership within the 
program would be able to control resources within the program's budget 
and hold staff accountable for adhering to policies that affect women 
patients. Elevating the Women's Health Program in this manner would 
also send the message from the top down that women veterans are 
important to VA, perhaps leading to the important cultural change 
embracing women veterans as an important part of the community-a change 
that women veterans and their advocates have long sought.

Women Veterans under the New Veterans Community Care Program (VCCP)


    Congress enacted major reforms in Public Law 115-182, the VA 
MISSION Act of 2018, which will soon affect health care for all 
veterans. While DAV supported the enactment of this bill and believes 
it has the potential to better serve veterans using VA services through 
an integrated care network of well trained and knowledgeable VHA and 
private-sector providers that will provide improved access to services 
veterans need-our confidence has waned given VA's proposed rule on 
access standards which is likely to cause more disruption and confusion 
among veterans. We sent comments reflecting our concerns about using 
the new ``drive time'' standard for primary care; about the VA's lack 
of requirements for comparable quality and access data for network 
providers; and about the dangers of using access measures for VA's 
specialized care models (for polytrauma care, blindness, spinal cord 
injury or dysfunction or homelessness among others) as inclusionary 
criteria for contract care. We believe implementing the access 
standards as proposed may have the effect of fragmenting care and 
unraveling some of the best systems of care available for veterans with 
complex care needs such as our women veterans.
    The transition to the Veterans Choice Program (VCP) under Veterans 
Access, Choice and Accountability Act of 2014 (VACAA, P.L. 113-146) 
proved difficult for VA, its contractors, and most of all, veterans. 
Women veterans use more contract care then male counterparts because 
frequently, the sex-specific care they require such as mammography, 
maternity care, and gynecological care is not available at VA (in FY 
2015, 37 percent of women veterans compared to 23 percent of male 
veterans used community care.) \9\ Contracting, once seen as the answer 
to veterans' wait times and access, was not proven to be the panacea 
some policy makers had hoped. A recent study found that women veterans 
experienced confusion about eligibility, frustration when scheduling 
appointments, difficulty obtaining lab and test results from contract 
providers and problems with being held personally liable for VA's late 
payments for contract care. \10\ Notably, a GAO study also showed that 
appointment waiting times for VCP providers were, on average, 
significantly longer than 30 days as required under VACAA. \11\
---------------------------------------------------------------------------
    \9\ Women's Health Services. Office of Patient Care Services. 
Veterans Health Administration. Department of Veterans Affairs. 
Sourcebook: Women Veterans in the Veterans Health Administration Vol. 
4: Longitudinal Trends in Sociodemographics, Utilization, Health 
Profile, and Geographic Distribution. February 2018. P. 49.
    \10\ Mattocks, KM, et al. Examining Women Veteran's Experiences, 
Perceptions, and Challenges With the Veterans Choice Program, Med Care 
2018;56: 557-560.
    \11\ Veterans Choice Program: Improvements Needed to Address 
Access-Related Challenges as VA Plans Consolidation of its Community 
Care Programs GAO-18-281: Published: Jun 4, 2018. Publicly Released: 
Jun 4, 2018.
---------------------------------------------------------------------------
    During the implementation phase of the MISSION Act, DAV believes 
veteran populations who often have complex health histories and require 
specialized care with supportive wraparound services, such as our women 
veterans, should receive special attention to ensure their needs are 
served. Women veterans' health care must be a highly reliable service 
with knowledgeable women's health care providers whether at VA sites of 
care or in the community.
    For example, VA knows that many women have experienced sexual and 
physical trauma that puts them at risk for a number of adverse life 
outcomes and health consequences. An integrated system of care allows 
VA to closely follow these veterans and coordinate their care and 
provide access to necessary supportive services-which is particularly 
important to women veterans dealing with intimate partner violence, 
homelessness or child care issues. Without special coordinated 
wraparound systems of care, these women could easily fall between the 
cracks (as was demonstrated in their experiences with VCP). In our 2014 
report, Women Veterans: The Long Journey Home, DAV discovered this was 
the case with too many women returning from deployments to Iraq, 
Afghanistan and other combat zones. The Department of Defense and VA 
missed critical opportunities for communication and warm handoffs 
during transitions between systems. While many federal programs and 
services exist to serve women veterans' readjustment needs, without 
appropriate support and coordination too many women have been unaware 
of them or unsure how to access them, as evidenced by lower market 
penetration rates between male and female veterans-according to VA, 
only 22 percent of female veterans used VA in fiscal year 2015 compared 
to 28 percent of male veterans. \12\
---------------------------------------------------------------------------
    \12\ Sourcebook. Vol. 4. P. 18.
---------------------------------------------------------------------------
    Access to community health care services has been necessary and 
will continue to be so in a system that caters to a small, dispersed 
population of women. For these reasons VA must ensure the preparedness 
of network participants within its community care program. According to 
a RAND study only about two percent of New York providers surveyed were 
adequately prepared to address veterans' health care needs. \13\ For 
these reasons VA must also ensure that contractors are properly trained 
about military and veterans' culture, special conditions within the 
veterans' population and evidenced-based treatments for service-related 
mental health conditions. VA must provide community partners guidance 
on how to properly screen and treat certain conditions for which it has 
expertise such as PTSD and ensure referrals are made back to VA for 
specialized services when necessary.
---------------------------------------------------------------------------
    \13\ Tanielian, Terri, Carrie M. Farmer, Rachel M. Burns, Erin L. 
Duffy, and Claude Messan Setodji, Ready or Not? Assessing the Capacity 
of New York State Health Care Providers to Meet the Needs of Veterans. 
Santa Monica, CA: RAND Corporation, 2018. https://www.rand.org/pubs/
research--reports/RR2298.html.
---------------------------------------------------------------------------
    To ensure quality of care integrity VA has created robust systems 
to coordinate the care veterans receive in the private sector. However, 
more contracting will require more VA coordination and case management 
for veterans with complex medical conditions. If their coordinator 
roles are collateral with other assignments, VA must ensure that each 
coordinator has sufficient time allotted to fulfill all their 
responsibilities.

Deficiencies in VA Programs and Staffing to Meet the Needs of Women 
    Veterans

    In an effort to ensure all sites of care are capable of providing 
high quality gender-specific care, VA has developed a program to train 
women's health primary care providers (WH-PCPs) yet VA's IG found that 
many of these designated providers do not meet VA's own proficiency 
standards and have too few women assigned to their panels to gain or 
maintain proficiency. Training and support for VHA staff and its 
contract providers is essential to ensure that women using VHA have 
knowledgeable providers wherever they seek care. DAV is pleased with 
VA's women's health mini-residency program which provides specialized, 
hands-on training to many providers, yet it appears that VA lacks the 
resources needed to be able to train a sufficient number of providers 
to meet steadily growing demands for care and replacements for staff 
attrition. Retention can also be difficult if providers do not believe 
they have adequate clinical and administrative support. Hiring and 
contracting knowledgeable providers is essential for filling these 
gaps-therefore, for FY 2020, the Independent Budget coauthors 
recommended adding additional funding for VA to hire 1000 new staff to 
include women's health providers, specialty care coordinators, peer 
counselors and administrative support staff to address increased demand 
for care.
    DAV also believes Congress must make women veterans' maternity care 
a more robust benefit. Because women veterans have several conditions 
(often service-connected) including combat injuries and mental health 
conditions that put them at risk for adverse birth outcomes, VA should 
be authorized to provide at least 14 days of post-maternity care to the 
woman veteran and her newborn infant. Congress must also authorize 
emergency transportation for the newborn (without the mother) if needed 
care is unavailable at the facility in which the mother is receiving 
care.
    Continued leadership at the local and national level is important 
to ensuring that women's programs remain a priority. Making women's 
health a distinct program may also ensure programs have the funding and 
authority necessary to implement important changes. Having a designated 
funding stream better ensures that women's issues remain at the 
forefront of VA's agenda. Strategic plans must also specifically 
address VA's programs for women.

Culture Changes Needed-VA's End Harassment Campaign

    As VA transforms its health care system, it must ensure that its 
facilities offer the safety and privacy in welcoming therapeutic 
environments that all veterans deserve. Unfortunately, recent research 
indicates that women veterans still do not always feel safe or welcome 
at VA health facilities. While this may partially relate to a negative 
experience with VA staff or the less than optimal aspects of facility 
design at some facilities or lack of gender-specific supplies for women 
patients at certain locations, a recent study found that it often stems 
from male veteran patients who make inappropriate or unwanted comments 
or sexually suggestive remarks to women veterans or question their 
right to use VA care. Unfortunately, the percentage of women veterans 
who claim to have been subjected to sexual harassment in the military 
approximately 25 percent or 1 in 4, \14\ is similar to the proportion 
of women who report harassment (1 in 4) from other veterans while 
seeking care at VHA. \15\ More importantly, the study found that those 
that reported harassment were significantly more likely to report 
either delaying or missing care.
---------------------------------------------------------------------------
    \14\ https://www.mentalhealth.va.gov/msthome/saam.asp accessed 4/
29/19.
    \15\ Women's Health Issues 29-2 (2019) 107-115.
---------------------------------------------------------------------------
    This type of harassment is most likely to impact younger women 
veterans who have a history of trauma exposure, or screen positive for 
anxiety or depression. \16\ We are pleased to see that VA is working to 
address this issue, to make needed cultural changes and to eliminate 
harassment or disrespectful behavior from fellow patients, visitors or 
staff. The Veterans Experience Office reported it convened women 
veterans panels who recommended that management reward and hold staff 
accountable for creating an empathetic and responsive culture using the 
VA as a way of implementing the End Harassment Campaign. \17\
---------------------------------------------------------------------------
    \16\ Women's Health Issues 29-2 (2019) 107-115.
    \17\ https://www.va.gov/ve/docs/storybookWomenVeterans.pdf
---------------------------------------------------------------------------
    According to VA, its End Harassment Campaign trains employees 
through simulations aimed at identifying and intervening in situations 
where women are being harassed. It creates messaging for potential 
harassers and urges women to report harassing incidents to VA security. 
We concur that it is every VA employee's responsibility to ensure that 
all veterans feel safe when seeking care at VA. We suggest that the 
facility director has the ultimate responsibility for oversight and 
should be accountable for ensuring that any type of harassment at the 
facility is immediately addressed and resolved. VA may consider 
offering new women patient's volunteer escorts from the main entrance 
to their appointments for those that want them, or any other veterans 
as requested. This could also serve as an opportunity to provide women 
veterans with a welcome package including a facility map and contact 
information for the women's clinic, the women veterans' program 
manager, military sexual trauma coordinator and the patient advocate. 
Escorts would perhaps allow women to feel both welcome and safe as they 
become oriented to the facility and access care.
    VA's programs rely upon research and data to ensure effective 
programming. Women's research in VA has accelerated significantly over 
the last several years with the creation of the Women's Health Research 
Network and other collaborative efforts. Over a five-year period 2011-
2015, VA published more studies on women veterans' health than in the 
previous 25 years combined. \18\ This research directly benefits 
veterans at the bedside and is part of what makes VA, in our opinion, 
the best place for women veterans to seek care. For example, in recent 
years VA clinician/researchers became aware that many of their women 
veteran patients were survivors of intimate partner violence (IPV). 
Emerging research proved that women veterans are at greater risk for 
IPV than non-veteran women.
---------------------------------------------------------------------------
    \18\ Yano, E.M. Advances in VA Women Veterans' Research. Center for 
the Study of Healthcare Innovation, Implementation and Policy. Briefing 
to the Advisory Committee on Women Veterans. VA Central Office. May 9, 
2018.
---------------------------------------------------------------------------
    This prompted VA to hire coordinators at each medical center to 
serve women veterans reporting IPV. We commend VA appropriators for 
understanding this need and providing the funding to assure all VA 
medical centers had these coordinators. Another issue identified within 
the women veterans' population is a heavy reliance on VA mental health 
services.

Mental Health Care

    Women veterans often have a variety of exposures including combat, 
military sexual trauma (MST), childhood trauma, and intimate partner 
violence that place them at risk for developing certain mental health 
conditions. Eating disorders are also common among survivors of MST. 
\19\ While rates of suicide for women veterans are lower than their 
male peers, women veterans are twice as likely to commit suicide as 
women who have no military service. The rate of suicide among women 
veterans is also accelerating much more quickly than that of male 
peers. More must be done to understand risk and protective factors for 
women veterans and to assure there are more gender tailored 
interventions to prevent suicides among this subpopulation. 
Specifically, VA health care facilities must ensure that women's mental 
health champions and MST coordinators, whose positions are collateral 
duties, have the ability to independently dedicate at least 30 percent 
of their time to carry out required administrative responsibilities 
associated with these positions. Suicide prevention remains a top 
clinical priority for VHA and the Department has developed a number of 
innovative practices to assure veterans are able to have the level and 
type of support and services they need to recover from mental health 
conditions common among veterans.
---------------------------------------------------------------------------
    \19\ DAV Women Veterans Report. 2018 p. 32.
---------------------------------------------------------------------------
    Substance use disorder (SUD), is also common among women veterans 
who use VHA, and often co-occurs with other mental health conditions 
complicating diagnosis and treatment. SUD increases the risk of 
suicides and can make women vulnerable to intimate partner violence. 
SUD puts veterans at risk for a spiral of decline: job loss, adverse 
health effects, homelessness, criminal activity, and family 
dissolution. To prevent a downward trajectory, VA must ensure women 
veterans have timely access to services offered by VHA including the 
full spectrum of mental health and substance abuse treatment services 
from detoxification to rehabilitation. The underlying causes of women's 
SUDs are often different than men's, and, accordingly, VA should make 
women-only programs and/or topic-specific programming (based primarily 
on women's interests such as parenting and safe relationships) more 
widely available.
    VA is one of the largest employers of peer specialists using them 
in mental health care and primary care settings. Peer counselors are 
generally in recovery from a mental health condition including 
substance use, an eating disorder, or PTSD from combat or military 
sexual trauma. Because they've ``been there,'' peer specialists often 
serve as role models for veterans offering encouragement, helping to 
answer questions about options for care, supporting goals for recovery, 
and help veterans remain engaged in their care plan. VHA has hired a 
disproportionately high number of women peer specialists (relative to 
women's use of VA) but we understand they are not equitably distributed 
throughout the system. DAV urges Congress to provide dedicated 
resources to hire and train women peer counselors for placement within 
patient aligned care teams with a focus on supporting care for women 
veterans with mental health conditions, particularly for women dealing 
with MST-related health issues and those at higher risk for suicide.VA 
should also be provided dedicated resources to increase the number of 
full-time clinical staff focused on providing mental health counseling 
to women patients dealing with reproductive mental health issues, such 
as postpartum depression, perinatal loss, and menopausal transition.
    Unfortunately, even with commitment from DoD leadership, improved 
preventive and survivor assistance programs, rates of military sexual 
assault continue to soar. A 2016 report indicated that officer 
candidates in service academies were often unaware of which behaviors 
might constitute sexual harassment or assault. \20\ As the military 
continues to rely upon women service members to carry out its mission 
and women are integrated into all military occupations, DoD must 
redouble its efforts and focus on training troops about what 
constitutes inappropriate behavior and to ensure, at all levels of the 
command structure, there is zero tolerance for sexual harassment or 
assault and adherence to ethical and professional conduct toward women 
service members as colleagues.
---------------------------------------------------------------------------
    \20\ Davis, L. et al., eds. (2017) Office of People Analytics. 
Defense Research, Survey, and Statistics Center. 2016 Workplace and 
Gender Relations Survey of Active Duty Members. XVI.
---------------------------------------------------------------------------
    Many veterans turn to VA for specialized MST-related treatment and 
value Vet Centers which strive to staff according to the demographics 
and needs of veterans they serve in the communities in which they are 
located. These centers offer programs for combat and military sexual 
trauma and other highly sought mental health services that at times 
involve family members in a veteran's care. Because of the knowledge of 
local veterans' needs and the market they are serving, local Vet Center 
leadership must be included in any local planning to establish 
community care networks. Vet Centers also offer women-only retreats for 
post-deployment readjustment and more than 300 women have participated 
in these retreats which have produced consistent and positive results. 
VA should conduct research to confirm long-term effectiveness of these 
programs and Congress should consider expansion and permanent 
reauthorization of retreats if warranted.
    Madam Chairwoman, in closing, I want to thank you and the 
Subcommittee for your continued interest in improving health care 
programs and services for our nation's women veterans. With major 
reforms underway at VA, now is the time to address longstanding 
cultural barriers impacting women veterans' access to the high quality 
comprehensive gender-sensitive health care they need and deserve. As an 
organization, DAV also wants to ensure that the role of women in the 
military and the sacrifices they have made are understood, acknowledged 
and fully appreciated. Please know that DAV is ready to assist you in 
your efforts. This completes my statement. I will be happy to respond 
to any questions you may have.

                                 
                  Prepared Statement of Lindsay Church
    Chairwoman Brownley, Ranking Member Dunn, and members of the 
Subcommittee, on behalf of the Minority Veterans of America (MVA), 
thank you for the opportunity to testify about the cultural barriers 
impacting women veterans' access to healthcare.
    My name is Lindsay Church and I am the Chief Executive Officer and 
Co-Founder of MVA. I served in the United States Navy from 2008-2012 as 
a Persian linguist, all but three months of which were under Don't Ask, 
Don't Tell. I am a medical retiree and I, personally, receive my care 
through the VA.
    Since starting MVA in 2017, we have grown to over 800 veterans 
across 46 states, 2 territories, and 3 countries, 47% of them are 
women. Together, our members account for 6,000 years of service, some, 
dating back to conflicts and eras that pre-dated when they were legally 
recognized as women veterans.
    I am here today to testify from both my own personal experience and 
on behalf of the countless women veterans who will never have the 
opportunity to be heard or accounted for.
    In the military and veteran community, the role of women is quickly 
expanding and their stake of the community is constantly growing. With 
more ranks and rates opening to women all the time, the portion of the 
community that women make up is only anticipated to continue to grow. 
This rapid growth has left a lag in the the culture meant to support 
women after service.The culture that we have created, or neglected to 
advance, in our military and veteran communities has left many women 
veterans without a community to call home.
    The cultural barriers that women veterans face are complex in 
nature and require a unique understanding of the lived experiences of 
women in the military community. At the heart of the cultural barriers 
that we face are two primary areas of concern: 1) The toxic culture for 
women and minorities in the military and veteran community that have 
caused a loss of faith in services designed to support them; and 2) The 
perpetuation of systems that render our service and voices, as women 
veterans of all kinds, invisible.

Toxic Culture for Women and Minorities:

    The military and veteran community have histories of harassment 
culture that have long been acceptable when directed at women and 
minorities. There have been instances of institutionalized 
discrimination that have been held in place for years, sometimes even 
decades, before being struck down through acts of Congress or decisions 
made at the highest levels. These policies create a space where 
harassment and discrimination of the individuals who are impacted by 
them is seen as acceptable and tolerated. The harassment that we face 
as a result of the culture that is created inflicts lasting damage on 
those of us who endure the behavior without an ability to change our 
circumstances.
    The discrimination that happens in the military to women-identified 
individuals is compounded by the force of the entire United States 
military that renders each service member powerless until their date of 
discharge. Even if you want to leave the military because you are being 
harassed, assaulted, or fear for your safety in any way, you are 
beholden to a system that demands compliance no matter the 
circumstances.
    Women identified individuals experience instances of gender-related 
discrimination, sexual harassment, and assault at rates that are 
exponentially higher than that of our male peers. \1\ In many cases the 
offending individual is a supervisor or unit leader who committed the 
violation(s), leading to a mistrust for those in positions of 
authority.
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    \1\ Complete Results from Major Survey of U.S. Military Sexual 
Assault, Harassment Released, RAND Corporation. May 1, 2015. https://
www.rand.org/news/press/2015/05/01.html.
---------------------------------------------------------------------------
    In addition to harassment and discrimination based on our gender, 
we are often made to feel as though reporting our wounds and injuries 
will make us seem inferior to our male counter parts. We unnecessarily 
push ourselves beyond human physical capacity and often to the point of 
injury or permanent disability. The military perpetuates a 'culture of 
fitness' that unduly impacts women who serve. Compared to our civilian 
counterparts, women veterans experience higher rates of arthritis, 
cancer, cardiovascular disease, and functional impairment. \2\
---------------------------------------------------------------------------
    \2\ Data from the Centers for Disease Control and Prevention's 
Behavioral Risk Factor Surveillance System (BRFSS), and the Substance 
Abuse and Mental Health Services Administration's National Survey on 
Drug Use and Health (NSDUH).
---------------------------------------------------------------------------
    Anecdotal evidence of this can be found in cases such as that in 
Naval Training Station Great Lakes where the second woman in eight 
weeks died after a physical fitness test in basic training on Saturday, 
April 27, 2019. \3\ I can personally attest to this culture of fitness 
and pushing beyond my personal limits as I treated my body as though I 
was invincible during service and now I live with the permanent 
disabilities as a result.
---------------------------------------------------------------------------
    \3\ ``Navy recruit is second woman to die at Illinois boot camp in 
2 months''. CBS News, Apr. 27, 2019. https://www.cbsnews.com/news/
kelsey-nobles-navy-recruit-alabama-collapses-dies-boot-camp-navy-recr 
uit-training-center-great-lakes-illinois/
---------------------------------------------------------------------------
    We carry these memories from our time in service of when we were 
harassed or made to feel less than worthy forward with us like battle 
scars into our civilian lives. When we separate from the military, we 
must decide, based on the severity of our treatment and the intensity 
of our needs after service, whether or not we will return, in any 
capacity , to a setting where affiliation with the military is the 
common thread among the community.
    Like our male counterparts, we are proud of our service and what we 
have accomplished and, our stories are complicated. For many women, 
overcoming this barrier of re-entering military culture voluntarily in 
their life after service to use their VA care is too great, so they 
choose not to engage their care or benefits.
    Despite the barriers, some women decide to engage and attempt to 
join the veteran community, either to find others with similar lived 
experiences or to gain access to their benefits through a Veteran 
Service Officer only to find themselves further harassed and 
discriminated against by other veterans . Traditional Veteran Service 
Organizations, those that were long seen as the leading experts on 
veteran advocacy, have held together some of the most toxic culture for 
women.
    The Minority Veterans of America itself is an organizations whose 
roots are in the harassment I experienced at the American Legion. \4\ 
When I first shared my story publicly of the discrimination I endured 
and witnessed while serving as a Post Commander was met with hundreds 
of others who had similar stories to my own from their times trying to 
be a part of the American Legion of VFW. These spaces are often the 
places that veterans are expected to go to gain access to their 
compensation and benefits. This in itself can be an insurmountable 
barrier.
---------------------------------------------------------------------------
    \4\ Commander quits Seattle veterans group over harassment, racism. 
NPR. Mar. 9, 2018.
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    In addition to the hurdle of being forced to re-enter military 
culture in order to use the VA, the organization itself has a 
reputation in the community for being sub-par care that lacks a nuanced 
understanding of who we are. Whether that is true or not, perception to 
the user is reality if they have yet to walk through the door. If re-
entering military culture alone does not prove to be a stopping point, 
the larger emergent narrative is that the VA does not care as it should 
for veterans. The stories that shake the public to the core of veterans 
who die by suicide in the parking lots and waiting rooms are too common 
for us to be assured that we will be treated with care.
    Of the MVA members who are women identified individuals, 54% 
disclosed a story of harassment, discrimination, or feeling outside the 
military or veteran community on their application for membership. 14% 
indicated that they had been raped or sexually assaulted while serving 
in the military. These numbers may seem small in comparison to 
expectation but, these responses came solely from the prompt, ``Tell us 
your story.''

Systems that Perpetuate Invisib ilit y and a Toxic Culture:

    In addition to the issues of toxic culture, from the highest levels 
of the Department of Veterans Affairs, systems have been built that 
hold together and perpetuate the problem. In some cases, these systems 
are constructed through mere happenstance. In others these are 
constructed through willfully declination to change or adapt to the 
changing needs and demographics of the community.
    On plaques at VA facilities across the country are the words of 
Abraham Lincoln, ``To care for him who shall have borne the battle and 
for his widow, and his orphan. ``These words serve as the motto and 
mission of the organization. At the time that President Lincoln 
delivered this address, women were serving as nurses, spies, and some, 
even, as soldiers in the field . When these words were adopted as the 
VA's motto, in 1959, thousands of women were on their way to Vietnam as 
part of the Army's Nurse Corps.
    Despite the fact that they would not be given legal recognition as 
veterans until 1980, women have always been among the ranks of those 
who have served . The plaques inscribed with Lincoln's words are 
physical representations of the deep and lasting history of 
invisibility for women in the military and veteran community.
    This invisibility is interwoven into the memories of our service 
and becomes the narrative of our experiences as veterans. Where our 
male counterparts are thanked for their service, women have to fight 
for adequate representation, especially for those of us with multiple 
minority identities. Women have to fight to be seen. Women have to 
fight against the conflicting and confusing memories we have of their 
service.
    The outcomes that women veterans are experiencing today - rise in 
suicide rates and mental health crises, homelessness, health 
disparities - are challenges that show the results of our inequitable 
access to care. To change these outcomes, we must look to the root of 
the problem and not just triage the results. The roots in this instance 
are the systems that exist that continue to render our service and 
voices, as women veterans of all types, invisible.
    Looking at one of these systems as an example is the advisory 
committees to the Department of Veterans Affairs. Of the 26 Advisory 
Committees to the VA \5\ with committee chair information available 
online, only six were chaired exclusively by women identified 
individuals . Of those six, only three had served in the U.S. military. 
Of those three women, one was a Woman of Color, and none were gender-
diverse.
---------------------------------------------------------------------------
    \5\ There are currently 27 standing advisory committees to the 
Department of Veterans Affairs. 26 had current information about their 
members available online.
---------------------------------------------------------------------------
    The lack of ability for women veterans to form any type of majority 
without the assistance of our male counterparts, reinforces the belief 
and understanding that we do not have the opportunity to make decisions 
about our own healthcare.
    No matter the composition of these advisory committees, the power 
structures in place still ensure that an overwhelming majority of the 
decision-makers and advisors to those who lead the Department itself, 
are men.
    When structures are built in a way that men must give us the 
ability to self-govern our own health outcomes, the power dynamic 
begins with an imbalance.
    Without the voices of women veterans in these positions of 
authority, there is no assurance that that we are heard, considered 
fully, and that our ideas are acted upon in the same ways as our male 
counterparts. Instead, this structure assures women veterans are 
beholden to a system that lacks the insight of our lived experiences as 
those that are currently being underserved.
    Chairwoman Brownley, Ranking Member Dunn, distinguish ed members of 
the Committee, as a representative of Minority Veterans of America, I 
provide the following recommendations to address the growing and 
complex needs of the woman veteran community:

    1.Contract with an ou tside ag ency with experience working with 
and including women veterans to conduct a cultural assessment of the 
Department of Veterans Affairs and its facilities as it relates to 
gender identity.

      Assess internal staff culture, core values of the 
organization, strategic plan and initiatives, and leadership st 
ructures.
      Assess external culture and what the experience of women 
veterans is while navigating the VA system. Examine behaviors and 
mannerisms that are considered acceptable within the VA for patrons and 
staff.

    2.Create community standards for conduct at Department of Veterans 
Affairs' facilities for patrons and staff.

      Eliminate harassment culture and implement and publicize 
department-wide anti -harassm ent campaign.
      Make reporting easier and accountability more transparent 
in instances where harassment has occured.

    3.Create a streamlined process between the Department of Defense 
and Department of Veterans Affairs so that VA coverage is op t-out 
rather than opt-in.

      Assign each woman veteran a primary care doctor in their 
nearest Women's Clinic.
      Invest furthe r in the tele-mental health system and 
prioritize finding providers who specialize in women military and 
veteran communities.
      This increases access for fill yeterans to ensure they do 
not feel bad for seeking care and treatment.
      The time a veteran is likely to use their VA healthcare 
is a point of crisis. That's too late if the veteran is going to 
navigate getting benefits.

    4.Invest in expanded research around intersectionality as it 
pertains to women veterans and systemic barriers impacting minority 
women veterans from accessing healthcare.

      Minority women such as women veterans of color, lesbian 
and bisexual women (especially those that served during and prior to 
Don't Ask, Don't Tell), transgender women veterans, and (non)religious 
minority women veterans.

    5.Open the VA's motto to public comment to consider change.

      Either maintain gender neutrality or revisit the motto 
and mission with representation from all communities to ensure input.

    Chairwoman Brownley, Ranking Member Dunn, and distinguished members 
of the Committee, thank you for the opportunity to testify today on 
behalf of Minority Veterans of America about the cultural barriers 
impacting women veterans' access to healthcare. For additional 
information regarding this testimony, please contact Lindsay Church, 
Chief Executive O fficer of Minority Veterans of America at 
[email protected].

                                 
                  Prepared Statement of Ginger Miller
    Chairwoman Brownley and members of the Subcommittee, as the 
President and CEO of the national nonprofit organization, Women 
Veterans Interactive, I am grateful to present my testimony regarding 
the Culture Barriers Impacting Women Veterans Access to Healthcare.
    To understand the cultural barriers impacting women veterans' 
access to healthcare, one must first understand the climate in which we 
exist.
        THE WOMAN VETERAN COMMUNITY CLIMATE (A HOSTILE TAKEOVER)
    Women veterans are trying to stay afloat in a culture that has been 
male-dominated for centuries, and now we are competing to stay relevant 
in a culture that insists we downgrade our service to run parallel with 
that of a commitment made by a military spouse to her husband. Women 
veterans are uniquely different from military spouses, and it's time 
that this country stops lumping us together, not to mention being 
overshadowed by the caregivers.
    Women veterans are existing in a climate where we have become good 
for business but not good enough to do business with and even more 
unfortunate, women veterans are living in a culture where our voices 
are only heard in a celebratory fashion when we achieve something great 
or when we hit rock bottom and become good for press.
    I'm here to testify this morning in an effort to change to the 
climate and culture that has become the norm for women veterans. Our 
noble service to this country is worth more than a story, our sacrifice 
as women veterans are worth much more than a tick mark on outdated, 
one-sided surveys conducted by male-dominated VSO's who may happen to 
have a few women veterans on staff.
    Women veterans are more than objects, and we don't need another 
survey; we need action. We don't need another national portrait 
campaign; we need a national outreach and engagement. Women veterans 
don't need another male-dominated VSO to represent us at the table, we 
need to have a seat at the table, and if we can't have a seat at the 
table, we will continue to build our own.
    For women veterans, the environment in which we are expected to 
thrive in after serving in the military has become hostile and at times 
volatile to say the least because our voices are not being 
appropriately heard and we do not have accurate representation at every 
level of government.
    Women veteran nonprofit organizations are grossly overlooked and 
underfunded if funded at all, our volunteers are overworked, and for 
some, the outlook is bleak, and yet we continue to hold out and hope 
against hope. Hope for inclusion to have a seat at the table where our 
voices will be heard and hope for much-needed funding to deliver proper 
services to the population we serve.
                 WHY WOMEN VETERANS INTERACTIVE EXISTS
    I started Women Veterans Interactive because I became homeless 
after faithfully serving in the United States Navy. During my time as a 
homeless woman veteran in the early '90s, I was also the caregiver to 
my husband who suffered from severe Post Traumatic Stress Disorder and 
mother to our son who was a toddler at the time. Instead of being a 
victim, I became a victor by working three jobs and going to school 
full time to pull my family and me out of the deadly jaws of 
homelessness.
    After that horrific experience, I dedicated my life worked to 
support veterans, and in 2009 I formed the nonprofit organization John 
14:2, Inc. In 2011, I formed Women Veterans Interactive as a division 
of John 14:2, Inc. Due to the growth of WVI, in 2018 we applied to IRS 
to become a standalone 501 c3 nonprofit organization and was approved 
in 15 days.
    Women Veterans Interactive (WVI) is a solutions-driven nonprofit 
organization focused on outreach and engagement. WVI delivers a 
positive impact in the lives of women veterans through a holistic, 
proactive approach that is grassroots in nature.

Mission Statement

    The mission of WVI is to meet women veterans at their points of 
need through Advocacy, Empowerment, Interaction, Outreach, and 
Unification to break down the barriers that lead to homelessness. WVI 
addresses the unique, and often unrecognized, challenges facing our 
nation's 2.3 million women veterans as they return to civilian life. 
With members nationwide, WVI provides outreach & support services to 
thousands of women veterans through the three pillars of transition, 
empowerment, leadership, and diversity. WVI offers tailored programs, 
training and resources to equip women veterans at all stages of their 
military transition
    Since its inception, WVI has supported over 3,500 women veterans 
through strategic outreach, signature events, and programs. The WVI 
network has grown to more than 50,000 women veterans and continues to 
grow every day.
    The growth of Women Veterans Interactive is directly related to the 
need of women veterans to be connected to and supported by an 
organization that is ``For Women Veterans by Women Veterans.'' We do 
not have a magic solution, a secret sauce, or a long drawn out 
dissertation but we do have a proven method that is directly related to 
our grassroots effort approach in engaging and empowering women 
veterans.
 WOMEN VETERANS INTERACTIVE AND THE U.S. DEPARTMENT OF VETERANS AFFAIRS
    Having an intermate understanding of the importance of women 
veterans being connecting to healthcare, since 2012, WVI has invited 
the U.S. Department of Veterans Affairs Center into our fold to 
collaborate with us on all our outreach efforts.
    The Department of Veterans Affairs has attended and participated in 
every Women Veterans Interactive annual conference since 2012. 
Participation included keynote speeches, leadership panels and 
facilitation of workshops.
    Most recently during WVI's 2018 and 2017 annual Women Veterans 
Leadership and Diversity Conference both of which had over 200 
attendees, we held a veteran's benefits claims clinics in collaboration 
with the Veterans Benefits Administration (VBA). Each year 
approximately 125 to 150 veterans were able to receive onsite benefits 
claims assistance.
    The feedback from the benefits claims clinics have been remarkable 
with some women veterans stating that this is the first time the VA has 
treated them like their service matters and other women veterans said 
they have a brighter outlook on going to the VA Medical Center to 
receiving health care from the VA Medical Center.
    Additionally, in 2017, WVI partnered with the Center for Minority 
Veterans to conduct a virtual town hall that had 300 veteran attendees.
    In 2106, WVI created the State of Women Veterans Campaign social 
media campaign and reached out to the Department of Veterans Affairs 
and formed a collaboration that to reach over 500,000 veterans. The 
goal of the campaign was to raise awareness of women Veterans' military 
and societal contributions and provide an avenue for informing women 
Veterans about the VA benefits they have earned. The campaign was 
successful and surpassed the goal of reaching 500,000 veterans.
    Every Women Veterans Interactive, Department of Veterans Affairs 
collaboration a woman veteran encounters help to change the image of 
the VA in a positive matter.
    So, I pose the questions, why is more not being done by the 
Department of Veterans to collaborate with women veteran nonprofit 
organizations like Women Veterans Interactive and why are women 
veteran's organization not invited to Department of Veterans Affairs 
VSO meetings, especially when it comes to discussing issues and 
solutions surrounding women veterans.
                CHANGE THE CLIMATE TO CHANGE THE ACCESS
    A significant barrier impacting women veterans' access to health 
care lies within a system at the Department of Veterans Affairs 
dominated by a climate that is neither inviting nor inclusive for women 
veterans. It's time to build a culture that is inclusive for women 
veterans rather than a culture that treats women veterans as an object 
of affection because it's the right thing to do.
    One cannot expect a population to engage in healthcare services 
they are not aware of, cannot access due to personal hardships, or do 
not feel safe accessing because most of the services are located within 
a male-dominated environment.
    I humbly ask this Subcommittee to work with Women Veterans 
Interactive to change the climate that has been set before the women 
who have so bravely served and sacrificed for our country.

    We can change the climate by establishing legislation that will

      Allocate funding for collaborative women veteran direct 
outreach and engagement
      Require the Department of Veterans Affairs to focus on 
consistent strategic outreach and engagement strategies in 
collaboration with qualified women veteran nonprofit organizations
      Require the Secretary of Veterans Affairs to have semi-
annual meetings with women veteran nonprofit organization.

    On behalf of Women Veterans Interactive, our members and the 
population we serve, I am appreciative for the opportunity to share our 
views on the Culture Barriers Impacting Women Veterans Access to Health 
Care.

                                 
                  Prepared Statement of BriGette McCoy
                            The Organization
    Thank you for inviting our voices and insight For over a decade, 
Women Veteran Social Justice network (WVSJ), has been heralded as a 
safe space to land for women seeking information resources and wanting 
to stay informed about military sexual trauma, PTSD, domestic violence, 
suicide prevention, housing, peer support and events in their local and 
national neighborhood. We also have become known for training other non 
profit leaders, supporting the launch of critical programs and services 
and bringing communities of women veteran and military women of diverse 
backgrounds together online and in person through our integrated 
network.
    WVSJ Network's digital media component manages an interconnected 
network of over 12,500 community connections online with a 
collaborative network of 50 other networks of support for the veteran 
population at large. Since 2008, WVSJ has been a primary source and 
stakeholder to national women military and veteran; outreach, research, 
educational and institutional programs, political policy and community-
based program support. This work includes partnering with educational 
institutions to bring veteran and civilian communities to network, 
published articles within the clinical professional community, national 
non-profits for Art and Music organizations, been a stakeholder in Emmy 
Award-winning documentaries and non-profit narrative digital 
storytelling to bring the military and war times experiences to the 
public.
    WVSJ advocates collection of the first person narrative for 
military service members working with the organizations Unsung Heroes, 
Warrior Songs and the National Association of Black Military Women to 
collect the narratives. WVSJ is instrumental in leading discussions in 
the community to allow a holistic compassionate and honorable way for 
the service members to tell their story.
    Our collaborations with other community organizations allow 
instructional and creative work to include musical and digital art to 
help strengthen veteran community connections.
    WVSJ community participated in musical and creative art events; 
2010- 2012 Creative art in Kentucky, 2014-2015- JDTR Conference Plenary 
Workshop Presentations on women veteran and military sexual trauma 
research and government policies, Bowling Green University Fall 2013 
Bowling Green, facilitate the collection of the narrative of members to 
educate community leaders on nuance of best practices to support. WVSJ 
Ambassadors have participated in the education journal writing and 
publishing articles in Combat Stress E-magazine in Spring 2014, Fall 
2018 and Warrior Songs award-winning songwriting and music CD 
production of the narratives of women of all eras who have served.
    For the past three years, WVSJ has participated in the Women 
Veterans Health Fair at Emory University, allowing the first person 
narratives to bring awareness and sensitivity to the medical and mental 
health needs of women veteran to future clinical staff.
    Our founder has consulted with and been in support of graduate and 
doctoral student researchers across the country by insight and 
expertise contributions to advancing peer-reviewed research since 2012. 
Through our programs, national partnerships and collaborative projects, 
we have reached tens of thousands of women veterans, their family 
members and community leaders.
                              The Founder
    BriGette McCoy is a nationally recognized keynote speaker, veteran 
advocate, conference facilitator, and veteran community leader. Her 
veteran experience has been requested by multiple media networks 
including CNN, MSNBC, NPR and the Today Show.
    In 2011 Ms. McCoy and five other women veterans, were interviewed 
for the Emmy Award Winning Documentary Service: When Women Come 
Marching Home, about women veterans and their civilian transition. 
Disabled Veterans of America supported the National Distribution.
    In 2013, McCoy provided Congressional testimony on her personal and 
professional experiences with military sexual assault, and on suicide 
prevention and awareness as a member of the on the Surgeon General's 
2012 Suicide Prevention Taskforce.
    A Gulf War era veteran who served in the US Army from 1987-1991, 
McCoy held a Top Secret Clearance as a data telecommunications computer 
operator. She is service-connected and compensated for Post-Traumatic 
Stress Disorder (PTSD) from Military Sexual Trauma (MST) and 
Neurological injuries. McCoy is one of many women veterans who have 
experienced difficulties reintegrating to civilian infrastructures, to 
include chronic homelessness with dependent children, challenges 
maintaining a career with multiple disabilities, and the impact of 
multiple sexual traumas in the military. Despite these barriers, she 
leads and volunteers in multiple areas collaborating with various 
community organizations who are engaged with veteran outreach.
    Ms. McCoy embraces building community relationships inter-
generationally amongst veterans while encouraging participation in 
quality life activities, some of which include: retreats for art and 
recreation within local and national communities, seeking medical care 
utilizing the VA as part of holistic modality for medical and 
psychological care, and training or education to increase availability 
for socioeconomic growth and development.
    McCoy's educational background includes a Bachelors of Science in 
Psychology, Masters of Theology and course completion in Education 
Technology and Media Design.
    Her work is about connecting of communities, organizations and 
multidisciplinary fields of study and resources influencing 
technological changes of resource delivery to veterans.
                           Personal Testimony
    To the House Committee and Committee Chair: thank you for inviting 
my organization and the inclusion of my testimony on issues concerning 
women veterans, specifically the cultural issues impacting women 
veterans.
    I am an ally, a Military Sexual Trauma (MST) survivor and advocate. 
My service and contributions are as important as my male veteran 
counterparts. Women Veteran serve, yet our visibility and opportunities 
have unseen barriers to accessing many of the programs that the 
civilian sector believes are available to all who have served.
    It is vitally important to hold in high regard and utilize the 
narratives of veteran women like me, of all eras, service periods and 
service backgrounds as primary sources to inform research, curriculum 
and policies concerning women veterans. The cultural issues impacting 
women veterans are vast. There are too many to note fully in this 
setting and give the full historical context, legislative background 
and the full unintended consequences and implications of each. I do 
believe that the historical context of women not being formally 
included in the military structure until the 1940's is a topic for 
inclusion in this hearing.
    Women veterans were not legislated to use the VA for gender 
specific medical care until the early 1990's. Only in recent years have 
Women specific health care spaces been constructed in VA facilities.
    In my work over the past 10 years and my personal experience 
interacting within the government and community for support a major 
factor that repeatedly and consistently challenged me, has been the 
language which is used to describe and talk about me as a woman 
veteran.
    Within the context of being a woman veteran, I have heard terms 
like, ``low hanging fruit'', ``female'', ``victim'', and references by 
men about how easy it is for women to get disability benefits. I assure 
you - THAT is categorically untrue. These ``othering'' terms have an 
unintended consequence for our country and the communities that serve 
women veterans.
    How we speak about women veterans can be part of a deeper problem 
of what we believe and have been socialized to believe about women in 
general. This is a root cause factor that drives the cultural divisions 
and creates a barrier for meaningful, well funded support for the women 
veteran community at large.
    The language used to speak about, research, legislate, create and 
institute programs for our women veteran community, continues to be a 
major limiting factor toward addressing issues and needs.
    Why are organizational leaders calling us female after military 
service? There are no Female veteran organizations. Where is the 
national female veterans of america organization? Even in 1948 when 
then President Truman signed the Armed Services Integration Act, Female 
was not used in the title, but the word Women. I know there will be 
some that say that doesn't matter.
    I will argue that using biological terms is dehumanizing; that what 
you name or call something, or the language you use to speak about a 
person does have impact positively or negatively. We can trace the 
language in the policies and legislation and funding and see that 
funding drives programs and service. Second, women veterans currently 
have very narrowly defined, language specific access to some of the 
most well funded and highly engaged programs. Most are intentionally 
excluding a huge proportion of women, and the funding legislated for 
their programs is language specific to eras, combat and to gender. It 
is emotionally draining as an advocate to send women to organizations 
that have veteran programs to have them told they don't meet the 
guidelines for the program. Further, the brochures are male centered 
and the veteran service and community organizations and their 
organizing documents do not include women who have served or they are 
told to go to auxiliary membership or put together with spouses, which 
is a completely different population.
    Third, VA medical treatment visits poses issues when the organizing 
documents and placards have male centered quotes and presentations. The 
space was not created with women in mind.
    There have been upgrades and changes in support of women using the 
facilities yet women are still being catcalled and harrassed going to a 
mental health or medical appointments - and when they can get them.(see 
the illustration below re:harassment).
    It is never clear what the outcome will be for a woman who reports 
harassment, or for the patient or employee that harasses. My personal 
experiences of being harassed within the VA and the discussions with 
other women about the need to change their appearance, come at certain 
times of day, switch to other hospitals (where the harassment is less 
pronounced) or stop going to the VA at all is another area for 
discussion.
    Next, women veteran professionals are not always treated with the 
same professional respect as our male counterparts. Many times rank, 
era and service time are used to limit access to programs for 
professional advancement. When Program managers ask me to send them 
people to fill their programs but won't make exception for a woman 
veteran of any era because their funding stipulates a specific era.
    I recognize brands and businesses have certain markets. However, if 
your market is veterans - that is who I am. We are the only segment 
that is singled out.
    Women Veterans are being leveraged and discarded based on the 
visibility and funding gained by our presence. There are quite a few 
veteran women who have needed to remove themselves from the non profit 
community because the environment is extremely toxic and their self 
care became more important than the presented image of working for the 
organization.
    Last, we are veterans first and foremost. When we served the only 
time we were called ``female'' was when we were being seperated from 
our teams by our gender. Needless to say, it was not in many cases, a 
positive reason it was being used.
    I also wish to focus on our women Reservists, and National Guard 
members.
    The language of their service has been a factor that excludes them 
from much needed programs and services. With the most recent changes to 
service availability for these uniformed personnel it is vitally 
important that language includes our women serving in these capacities. 
I have many other areas of concern but time is a limiting factor so I 
chose to highlight these areas specifically.
    Recommendations for us to move forward toward positive changes are 
as follows:
                           My recommendations
      Create equity with women veteran subject matter experts 
as the co-leads and leads in future events including queries, 
discussions, panels part of best practices policy and procedures.
      Create space where veteran women thought leaders and 
innovators have a primary voice in their care and treatment.
      Research of impact of including narrative works, and 
veteran and survivor subject matter experts in the planning of programs 
and services for veteran women and survivors.
      Increase access to funding for women veteran led programs 
with cultural competence and history of serving women veterans with 3 
or more years.
      Include leaders and organizations with proven results and 
outcomes directly benefiting women veterans of all eras and service 
times for legislative and policy input.
      Create Veteran Affairs medical and claims spaces no 
tolerance no access for veteran who harass other veterans during times 
veterans who are seeking medical treatment or utilizing the VA any VA 
programs
      Use Ally centered* language, program descriptions, and 
educate leaders to present and legislate from that position. *This 
includes disability, gender identification, race etc.

    (photos upon request)

    J.Payton, B.McCoy 2018 ``Current Challenges and Future Directions 
Supporting Veteran After Military Sexual Trauma.''

    Ambassador Contributions

    (Board Member Sr Ambassador Connie Baptiste)

National Guard And Reserve

      Women Veterans Access to VA facilities - National Guard 
and Reserve Units in rural areas have to travel sometime over an hour 
to access a VA
      Women Veterans are younger they are only doing one term 
and getting out with disabilities.
      Child care and access to it during appointments
      Mental health support in rural areas
      VA education being provided to the location
      State vs VA health care for veterans who don't meet the 
VA's definition to receive support.
      Spousal programs of support for the caregivers
      Access to care and support for children born to women 
veterans with disabilities
      The new policy, Deploy or Get out, military members non-
deployable for more than 12 months will be administratively discharged, 
more disabled veterans
      Statistics show that veterans move back to their home 
area, many from rural areas
      Underemployment/unemployment high for deployed Guard and 
Reservist.

Current Guard Posture Statement

    Army 343,000 Soldiers,
    8 division headquarters,
    27 brigade comba teams,
    96 multifunctional brigades, 8 combat aviation brigades and 2 
Special Forces groups Provides the Army 39% of its operational forces 
Operates and manages nearly 42% of the Army's manned and unmanned 
aircraft. Air Guard 105,700 Airmen, 90 wings,
    1,111 aircraft Flies 44% of Air Force's KC-135 air refueling 
missions Flies nearly 30% of the Air Force's strategic and tactical 
airlift (C-130s / C-17s) missions Flies 30%of the fighter / attack (A-
10s, F-15s, F-16s, F-22s) missions Provides 42% of the Air Force's 
Prime BEEF and 53% of the deployable RED HORSE civil engineer units.

Deployments

    Since 9/11, the National Guard has supported more than 850,000 
overseas deployments.
    More than 2,800 Guard Airmen from 48 units served in nine different 
locations while filling 46% of the total force's civil engineer needs 
overseas last year.
    The Air Guard is providing 23% of the total force's Remotely 
Piloted Aircraft capability and 25% of the total force's Distributed 
Common Ground System (a system that produces military intelligence for 
multiple military branches) capacity in direct support of combatant 
commanders' intelligence, surveillance and reconnaissance requirements.
    Guard Soldiers and Airmen have served on every continent and in 
every Combatant Command in more than 70 countries around the world

Army Reserves

    Since Sept. 11, 2001, more than 300,000 Army Reserve soldiers have 
mobilized, some serving multiple tours, seamlessly integrating into the 
active Army and the Joint Force.

Suicide Rate among Guard and Reserve

    In 2013, the suicide rate among reservists was 23.4 per 100,000, In 
2013, the suicide rate among National Guardsmen, 28.9 per 100,000.

History Makers

    The New Hampshire Army Guard's 2nd Lt. Katrina Simpson made history 
when she became the first woman officer in the National Guard to 
graduate from the U.S. Army infantry officer basic course. (The Army 
National Guard Warrior)
    https://www.nationalguard.mil/Portals/31/Documents/
PostureStatements/2018-National-Guard-Bureau-Posture-Statement.pdf
    https://giveanhour.org/wp-content/uploads/RCP-Fact-Sheet-March-201 
7.pdf
    https://www.militarytimes.com/news/your-military/2018/02/14/dod-
releases-new-deploy-or-get-o ut-policy/

                                 
                   Prepared Statement of Lory Manning
    Chairwoman Brownley, Ranking Member Dunn and Distinguished Members 
of the Subcommittee:
    On behalf of the Servicewomen's Action Network (SWAN), I thank you 
for the opportunity to share our views and recommendations regarding 
the cultural barriers to women veterans' access to healthcare at the 
Department of Veterans Affairs.
    In the past years, VA has made hard-won improvements in the quality 
and comprehensiveness of women's care, but all that improvement is for 
naught if women encounter barriers when trying to use this healthcare. 
I'll discuss two of these barriers today: 1.) sexual harassment and 2.) 
the invisibility of women veterans.
    Sexual Harassment at VA Facilities. Over the years, we at SWAN have 
heard many complaints about groups of male veterans getting together to 
harass women veterans on VA grounds including at the Washington, DC VA 
hospital. An academic study and a newspaper article both published this 
year elucidate the problem. The first, done by Ruth Klap, Ph.D. and 
others, called ``Prevalence of Stranger Harassment of Women Veterans at 
Veterans Affairs Medical Centers and Impacts of Delayed and Missed 
Care,'' appears in Women's Health Issues, published by the Jacobs 
Institute of Women's Health. (http://whijournal.com/article/S1049-
3867(18)30194-4/fulltext.) The second, by reporter Jennifer Steinhauer, 
was in the March 12th edition of the New York Times and headlined 
``Treated Like a `Piece of Meat': Female Veterans Endure Harassment at 
the VA''.
    The Klap study sampled women veterans who used 12 different VA 
hospitals and found one in four of those sampled reported receiving 
catcalls, derogatory comments, propositions, and denigrations of the 
women's veteran status from male veterans on the hospital grounds. The 
New York Times article recounts how an ``entrenched, sexist culture at 
many veterans' hospitals is driving away female veterans.''
    SWAN believes that what women veterans want, and warrant, is for VA 
leaders at all levels, with oversight from Congress, to stop the 
harassment now and to foster a VA culture in which women veterans are 
treated with the same respect, appreciation and dignity as male 
veterans.
    Invisibility: Women veterans report to SWAN that they feel 
invisible to the office staffs of VA facilities and to the American 
public. And they are; it begins with the VA motto ``To care for him who 
has borne the battle, his widow and his orphan''. SWAN, while 
appreciating Lincoln's historic words, is among those veterans' 
organizations which support changing that motto.
    According to DVA's February 2017 Report ``The Past, Present and 
Future of Women Veterans,'' only 22.4% of all women veterans use VA 
healthcare making them a mere 7.5% of total VA healthcare users. Women 
veterans are irked when they are asked for their husbands' social 
security numbers at the check-in desk or are refused free coffee 
provided at some VA facilities with the admonition that the coffee is 
only for veterans. These slights seem minor, but they can accrete over 
time leaving women veterans frustrated and disheartened.
    Their invisibility becomes more damaging when the gender-specific 
needs of women veterans are ignored, as happens, for example, when they 
are sometimes issued prosthetic devices designed for men; this should 
never happen.
    And major damage can be done, if women veterans are invisible to 
those, at any level, making tough decisions on healthcare resources if 
the decision makers either don't understand the need for women's 
programs or conclude that reallocation from these programs helps many 
while hurting only a few.
    SWAN believes leadership at all levels must take great care when 
initially allocating-or later reprogramming-resources to or from 
women's healthcare programs that they have a clear understanding of the 
effects their actions can have on these programs. SWAN, additionally, 
entreats Congress to exercise its oversight responsibilities to ensure 
the needs of women veterans and other special focus populations are not 
unduly sacrificed when such actions are necessary at the national 
level.
    Madam Chairwoman let me say how deeply I appreciate the opportunity 
to offer SWAN's views on these critically important matters. Thank you 
for your time and attention.

                                 
                Prepared Statement of Dr. Patricia Hayes
    Good Morning Madam Chair, Ranking Member Dunn, and distinguished 
Members of the Committee. I appreciate the opportunity to discuss the 
high-quality care and support VA is providing to our women Veterans and 
the cultural barriers impacting women Veterans' access to VA health 
care.

Overview

    The number of women Veterans enrolling in VA health care is 
increasing, placing new demands on VA's health care system. Women make 
up 16.2 percent of today's Active Duty military forces and 19 percent 
of National Guard and Reserves. Based on the upward trend of women in 
all service branches, the expected number of women Veterans using VA 
health care will rise rapidly, and the complexity of injuries of 
returning troops is also likely to increase. More women are choosing VA 
for their health care than ever before, with women accounting for over 
30 percent of the increase in Veterans served over the past 5 years. 
The number of women Veterans using VHA services has tripled since 2001, 
growing from 159,810 to 500,000 today. To address the growing number of 
women Veterans who are eligible for health care, VA is strategically 
enhancing services and access for women Veterans.

Access to Care

    Every VHA health care system across the United States now has a 
full-time Women Veteran's Program Manager tasked with advocating for 
the health care needs of women Veterans using that facility. Mini-
residencies in women's health with didactic and practicum components 
have been disseminated system-wide to enhance clinician proficiency; 
since 2008, over 5,800 health care providers have been trained in this 
national program. Under a new collaboration with the Office of Rural 
Health, a pathway for accelerating access to women's health training 
for rural primary care providers has been established. Meanwhile, VHA 
is actively recruiting additional providers with experience in women's 
health care. Numerous initiatives have been launched to improve access 
to state-of-the-art reproductive health services, mental health 
services, and emergency services for women Veterans, and others have 
focused on enhancing care coordination through technological 
innovations such as registries and mobile applications.
    VA has enhanced the provision of care to women Veterans by focusing 
on the goal of developing Women's Health Primary Care Providers (WH-
PCP) at every site of VA care. VA has at least two WH-PCP's at each VA 
Medical Center and 90 percent of community-based outpatient clinics 
(CBOC) have a WH-PCP in place. We are in the process of training 
additional providers to ensure that every woman Veteran has an 
opportunity to receive her primary care from a WH-PCP. VA has 
implemented women's health care delivery models of care that ensure 
women receive equitable, timely, high-quality primary health care from 
a single primary care provider and team, thereby decreasing 
fragmentation and improving quality of care for women Veterans.
    VA is proud of high-quality health care for women Veterans. We are 
on the forefront of information technology (IT) for women's health. 
Because quality measures show that women Veterans using VA health care 
are more likely to receive breast cancer and cervical cancer screening 
than women in private sector health care, VA is redesigning the 
electronic medical record to track breast and reproductive health care. 
Unlike other health care \1\systems \2\, VA analyzes quality 
performance measures by gender. This has been key in the reduction and 
elimination of gender disparities in important aspects of health 
screening, prevention, and chronic disease management. \3\
---------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention (CDC). 2018. 
``Breast Cancer Statistics.'' http://www.cdc.gov/cancer/breast/
statistics/index.htm
    \2\ 2017 VHA Support Service Center National Performance Measure 
Report
    \3\ https://www.womenshealth.va.gov/WOMENSHEALTH/docs/WVHC--
GenderDisparities--Rpt--061212--FINAL.pdf#

---------------------------------------------------------------------------
Scope of Services

    VA provides full services to women Veterans, including 
comprehensive primary care, gynecology care, maternity care, specialty 
care, and mental health services.

Comprehensive Primary Care

    To provide the highest quality of care to women Veterans, VA offers 
women Veterans assignments to trained and experienced designated WH-
PCPs. The providers can furnish general primary care and gender-
specific primary care in the context of a longitudinal patient/provider 
relationship. National VA satisfaction and quality data indicate that 
women who are assigned to WH-PCPs have higher satisfaction and higher 
quality of gender-specific care than those assigned to other providers. 
Importantly, we also find that women assigned to WH-PCP's are twice as 
likely to choose to stay in VA care over time. \4\
---------------------------------------------------------------------------
    \4\ Bastian L, Trentalange M, Murphy TE, et al. Association between 
women Veterans' experiences with VA outpatient health care and 
designation as a women's health provider in primary care clinics. 
Womens Health Issues. 2014;24:605-612.

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Gynecology Care

    VA offers many gynecologic services, including complex gynecology 
care such as gynecologic surgery and treatment of gynecologic cancers. 
Women Veterans have access to gynecology care as a basic component of 
high-quality care. One hundred and thirty-three sites have a 
gynecologist on site. For those facilities where VA does not have a 
gynecologist on site, Veterans receive services through care in the 
community. VA is unable to recruit gynecologists at some sites because 
there is no Surgery Service at those facilities and gynecology is a 
surgical specialty. In 2017, VA held its first-ever national VA 
gynecology conference: VA Gynecology Health System - Optimizing Access 
and Facilitating Best Practices Training. The mission of this 
conference was to optimize access to gynecologic services for women 
Veterans. A second gynecology conference is planned for June 2019, 
focusing on specific gynecologic surgery skills.

Maternity Care

    Maternity benefits for enrolled women have been included in the VA 
medical benefits package since 1996. In general, these benefits begin 
with the confirmation of pregnancy. VA medical facilities do not 
provide on-site obstetric care to pregnant Veterans. However, female 
Veterans receiving their care through VA have their pregnancies 
confirmed at a VA medical facility and receive further maternity care 
through community (non-VA) health care providers. Some Veterans will 
continue to receive other health care services, such as mental health 
services, during their pregnancies through the VA health care system.
    Once a pregnancy is confirmed, the VA Maternity Care Coordinator 
(MCC) educates the Veteran on maternity benefits and the process for 
maternity care throughout the pregnancy. MCCs help Veterans navigate 
and coordinate care between VA and maternity care providers in the 
community and are available to answer questions and remain in 
communication throughout the pregnancy. Because of high rates of mental 
health conditions in women Veterans using VA health care \5\, it is 
essential that they are supported by MCCs during pregnancy, and women 
Veterans are encouraged to return to VA primary care women's health 
after their delivery.
---------------------------------------------------------------------------
    \5\ Katon JG, Zephyrin L, Meoli A, Hulugalle A, Bosch J, Callegari 
L, Galvan IV, Gray KE, Haeger KO, Hoffmire C, Levis S, Ma EW, Mccabe 
JE, Nillni YI, Pineles SL, Reddy SM, Savitz DA, Shaw JG, Patton EW. 
Reproductive Health of Women Veterans: Systematic Review of the 
Literature from 2008 to 2017. Semin Reprod Med. 2018 Nov;36(6):315-322. 
doi: 10.1055/s-0039-1678750. Epub 2019 Apr 19.
---------------------------------------------------------------------------
    VA offers newborn care for up to 7 days after the birth of a child. 
Newborn care includes, but is not limited to, inpatient care, 
outpatient care, medications, immunizations, circumcision, well-baby 
office visits, neonatal intensive care, and other appropriate post-
delivery services.

Infertility and Adoption Reimbursement Services

    VA provides infertility services, other than in vitro fertilization 
(IVF), to all enrolled Veterans. Veterans receiving care through VA are 
offered infertility evaluation and treatment, regardless of service 
connection, sexual orientation, gender identity, gender expression, or 
relationship or marital status. This includes diagnostic testing and 
many infertility treatments, with the exception of IVF.
    Congress has authorized VA to furnish fertility counseling and 
treatment, including IVF, for married Veterans with a service-connected 
disability that results in infertility and their spouses. The Veteran 
must be legally married and meet the eligibility requirements of a 
service-connected condition that results in infertility. Eligible 
Veteran couples can receive a total of three IVF cycles and 
cryopreservation storage of their own gametes and embryos without time 
limits. Donor eggs, sperm, embryos and surrogacy are not covered 
benefits. Treatment with IVF is provided by specialists in the 
community, with care coordinated among relevant VA providers and the VA 
facility's Women Veterans' Program Manager.
    VA has implemented regulations to provide reimbursement of 
qualifying adoption expenses incurred by Veterans with a service-
connected disability that results in the inability to procreate without 
the use of fertility treatment. Covered Veterans may request this 
$2,000 reimbursement for qualifying adoption expenses incurred for 
adoptions finalized after September 29, 2016.

Mental Health Services

    VA has witnessed a 154 percent increase over the past decade in the 
number of women Veterans accessing VA mental health care. Over 40 
percent of women Veterans who use VA have been diagnosed with at least 
one mental illness, and many struggle with multiple, clinically complex 
conditions, such as trauma, mood, and eating disorders \6\. VA's mental 
health programming for women Veterans is guided by the principles of 
gender-sensitive care and recognizes the importance of offering choice, 
flexibility, and options for care. To ensure that VA mental health 
providers have the skills and expertise to meet women Veterans' unique 
and diverse treatment needs and preferences, VA's Office of Mental 
Health and Suicide Prevention (OMHSP) has developed innovative clinical 
trainings and initiatives to strengthen mental health services for the 
growing population of women Veterans. These initiatives expand the 
portfolio of treatment options available to women Veterans and 
complement the strong cadre of evidence-based practices available to 
all Veterans.
---------------------------------------------------------------------------
    \6\ Greenberg, Greg; and Hoff, Rani. FY2018 Mental Health Data 
Sheet: National, VISN, and VAMC Tables - All Veterans. West Haven, CT: 
Northeast Program Evaluation Center. Annual (2010-Present).

---------------------------------------------------------------------------
    Here are some examples:

      In 2016, OMHSP conducted the first VA Women's Mental 
Health Mini-Residency. During this intensive 3-day training, national 
experts led sessions on gender-tailored psychotherapies and psychiatric 
medication management, with a focus on the influence of hormonal 
changes and the reproductive cycle. Participants serve as local Women's 
Mental Health Champions and, as part of the training, developed Action 
Plans to disseminate women's mental health practices at their 
facilities. The facility Women's Mental Health Champions are now an 
important component of the Women's Mental Health infrastructure. In 
2018, VA partnered with the Department of Defense (DoD) to conduct a 
joint Women's Mental Health Mini-Residency. VA now conducts a yearly 
Women's Mental Health Mini-Residency and partners with DoD every even 
year.
      OMHSP developed clinical training programs in STAIR 
(Skills Training in Affective and Interpersonal Regulation) and 
Parenting STAIR. STAIR and Parenting STAIR are cognitive-behavioral 
trauma treatments that focus on strengthening emotional regulation and 
building healthy relationships, including parenting relationships. 
These are important areas of functioning that can be highly disrupted 
in women with histories of serious interpersonal traumas, such as 
sexual assault. Research suggests that emotion dysregulation is 
associated with suicidal ideation. Parenting STAIR training teaches 
therapists to deliver a component of the STAIR treatment that is 
designed to help Veterans who have persistent trauma-related reactions 
that negatively impact their parenting and parent-child relationships.
      To address an identified need for eating disorder 
treatment options, OMHSP partnered with Women's Health Services (WHS) 
to develop a cutting-edge multidisciplinary eating disorder treatment 
team training, aligned with the Joint Commission's rigorous standards 
for outpatient eating disorder care. Coordinated, specialized clinical 
care is needed to effectively treat serious eating disorders, which are 
associated with increased risk for suicide attempts and death by 
suicide.
      OMHSP developed a monthly training series to enhance 
knowledge of gender-tailored prescribing practices. Effective treatment 
of reproductive-linked mental health conditions (e.g., premenstrual 
dysphoric disorder [PMDD], perinatal depression and anxiety disorders, 
and perimenopausal depression) could reduce suicide risk for affected 
women Veterans. Treatment of mental health conditions during specific 
reproductive cycle stages differs in some respects from treating those 
conditions during non-reproductive parts of the life-cycle. For 
example, some, but not all antidepressants have efficacy for PMDD. 
Taking antidepressants during only the luteal phase of the menstrual 
cycle can be effective for PMDD.

Military Sexual Trauma

    Unfortunately, some women experience sexual assault or harassment 
during their military service and may struggle even years later with 
its after-effects. VA's services for military sexual trauma (MST) can 
be critical resources to help them in their recovery journey. Services 
for any mental and physical health conditions related to MST are 
available for free at every VA medical center (VAMC) and eligibility is 
expansive: Veterans do not need to have reported their experiences at 
the time or have any documentation that they occurred and may be able 
to receive free MST-related care even if they are not eligible for 
other VA care. VHA has a number of initiatives to help ensure that 
targeted, specialized services are available, and that Veterans are 
aware of these services. Since Fiscal Year (FY) 2007, these efforts 
have resulted in a 297 percent increase in the number of women Veterans 
receiving MST-related outpatient care, indicating the positive impact 
of these efforts. Some key initiatives include maintaining a full 
continuum of outpatient, inpatient, and residential mental health 
services.
    As part of the universal screening program, all Veterans seen for 
VA health care are asked whether they experienced MST, so that they can 
be connected with MST-related services as appropriate, and every VA 
health care system has a designated MST Coordinator who can help 
Veterans access MST-related services and programs.
    VHA also has a range of initiatives to promote continued expansion 
of its MST-related programming and promote provider expertise. These 
include bimonthly training calls for staff, an annual conference on 
treatment program development, online courses, a community of practice 
Intranet Web site, and a national MST Consultation Program available to 
any VA staff member with a question related to assisting Veterans who 
experienced MST. These are important efforts; however, outreach and 
engagement efforts must remain an ongoing area of emphasis to ensure 
Veterans have access to the care they need.

Child Care

    VA is aware of the challenges faced by Veterans with children in 
terms of accessing medical appointments and other medical care, 
counseling, and caregiving services. Women Veterans currently are and 
will continue to be an important part of the Veteran community and an 
important part of VA. The total number of women Veteran patients age 
18-44 increased from 81,832 in FY 2000 to 187,137 in FY 2015, a 2.3-
fold increase. From the 2015 Study of Barriers to Care for Women 
Veterans, when queried about the possibility of on-site child care, 
three out of five women (62 percent overall) indicated that they would 
find on-site child care very helpful, but in general this was not a 
significant factor in whether they choose to use VA care.
    Section 205 of Public Law 111-163, Caregivers and Veterans Omnibus 
Health Services Act of 2010, as amended (38 United States Code Sec.  
1710 note), authorizes VA to provide child-care services through a 
pilot program. VA is authorized to continue this pilot program through 
FY 2020. Since 2011, VA has been providing child care services through 
the pilot program offered at Buffalo, New York, Veterans Integrated 
Service Network (VISN) 2; Northport, New York, VISN 3; American Lake-
Puget Sound (American Lake), Washington, VISN 20; and Dallas, Texas, 
VISN 17.
    While mothers were the largest users of drop-in child care services 
at 47 percent; fathers used the service nearly as much at 44 percent; 
and grandparents used the service at 9 percent. Utilization and costs 
vary at each of the sites, but Veteran satisfaction with the service 
remains consistent at all locations. VA has sought permanent but 
discretionary authority to provide child care assistance for the 
children of eligible Veterans while those Veterans are accessing health 
care services at facilities.

Women Veterans Call Center

    In 2014, VA established a hotline specific for women Veterans. The 
Women Veterans Call Center (WVCC) makes outgoing calls to women 
Veterans to provide information about VA services and resources and 
responds to incoming calls from women Veterans, their families, and 
caregivers. WVCC implemented a chat feature in May 2016, to increase 
access for women Veterans and has responded to 1,979 chats. As of 
January 31, 2019, the WVCC has received 83,984 calls and has made 
1,328,256 outgoing calls, with 672,815 of these calls being successful 
(spoke with the Veteran or left a voice message). We are very excited 
to announce that VA instituted text interaction for WVCC (1-855-829-
6636) on April 23, 2019.

Expanding Mammograms

    Mammograms for women Veterans are available on-site at 64 VHA 
health care sites where digital mammography is available. Because we 
want to ensure that Veterans are receiving the highest quality 
mammograms, when there are insufficient numbers of women to support 
such a program in-house, VA uses its community care authorities to 
provide mammograms in the community. VHA has also convened a task force 
of subject matter experts from women's health, oncology, radiology, 
surgery, and radiation oncology to develop guidance to standardize and 
enhance breast cancer care in VA facilities nationally. Despite these 
accomplishments, VHA agrees with a recent VA Office of Inspector 
General report that tracking the results of mammograms performed 
outside VA has been a challenge. In response, VA has established 
national guidelines for mammography and cervical cancer tracking. VA is 
funding positions for cervical cancer and breast cancer screening 
coordinators at 27 rural sites and has established education materials, 
toolkits, and a national community of practice for Mammogram 
Coordinators.
    VA has been working to ensure that test results from studies done 
outside of VA are documented in the Computerized Patient Record System 
and that patients are notified of normal and abnormal mammography 
results within an appropriate timeframe. VA completed two IT projects 
that will revolutionize tracking and results reporting for breast 
cancer screening and follow-up care: The Breast Care Registry and the 
System for Mammography Results Reporting. These systems are designed to 
work together to identify, document, and track all breast cancer 
screening and diagnostic imaging (normal or abnormal), order results, 
notify patients, and follow-up to ensure that all women Veterans 
receive high-quality, timely breast care, whether treatment is provided 
within or outside of VA.

Quality Care

    VA is proud of its high-quality health care for women Veterans. 
Beginning in FY 2008, VHA launched a concerted Women's Health 
improvement effort focusing providers' attention on gender-disparity 
data. From 2008 to 2011, VA saw a significant reduction in gender 
disparity for many measures, including hypertension, diabetes, 
pneumococcal vaccine, and influenza prevention \7\. Improvements were 
also made in screening measures for colorectal cancer, depression, 
posttraumatic stress disorder, and alcohol misuse. In FY 2011, VA 
included Gender Disparity Improvement as a performance measure in the 
VISN Director Performance Plans, which concentrated management 
attention on systems to continuously reduce gender disparity. WHS has 
continued to publish reports on these efforts; the FY 2017 report \8\ 
illustrates that VA has made continued progress in closing the gap in 
gender disparities. At the close of FY 2017, small gender gaps existed 
in only a few measures including cholesterol management in high-risk 
patients, diabetes care, and rates of influenza vaccination.
---------------------------------------------------------------------------
    \7\ https://www.womenshealth.va.gov/WOMENSHEALTH/docs/WVHC--
GenderDisparities--Rpt--061212--FINAL.pdf#
    \8\ Improving trends in gender disparities in the Department of 
Veterans Affairs: 2008-2013. Whitehead AM, Czarnogorski M, Wright SM, 
Hayes PM, Haskell SG. Am J Public Health. 2014 Sep;104 Suppl 4:S529-31. 
doi: 10.2105/AJPH.2014.302141.
---------------------------------------------------------------------------
    Since 2014, VA has tracked access by gender and identified small 
but persistent disparities in access for women Veterans, who overall 
are waiting longer for appointments than male Veterans. To mitigate 
this disparity VA has identified sites with the longest wait times for 
women Veterans and is working with those sites directly on initiatives 
to improve access, including designating more women's health providers 
through hiring or training and improved provider and team efficiency.
    VA has conducted site visits at all health care systems to assess 
the quality of the women's health program. After completing a national 
review in 2017, VA developed an Evidence-Based Quality Improvement 
(EBQI) Process to assist sites with women's health quality improvement 
projects. VA has completed EBQI initiatives at 14 sites and will 
complete 7 additional site projects in 2019.

Barriers to Care

    Although VA continues to successfully expand its female-centric 
health care coverage, it has encountered several challenges in meeting 
the demand of the increasing women Veteran population. Although VA has 
made it a priority to provide top-notch training to providers and other 
clinical staff, VA is unable to keep up with the demand to have trained 
providers to care for women Veterans. Provider turnover continues to be 
an issue, and a national shortage of primary care providers results in 
recruitment challenges.
    In 2018, VHA Leadership directed that Privacy and Dignity Standards 
for Women Veterans be extended to all Veterans. A Workgroup on Privacy 
and Environment of Care worked to define all terms and standards for 
privacy and environment of care. The definitions were incorporated in 
the Appendix C (Veterans Health Environmental Privacy and Security) of 
VHA Directive 1330.01(2), Health Care Services for Women Veterans, and 
was published on July 24, 2018. In addition, VA's Office of 
Construction and Facility Management (CFM) identified appropriate 
updates for Design Standards and released a Design Alert to the field 
in October 2018, which effectively updated the 2010 CFM design 
standards to extend to all Veterans.

New Initiatives/Outreach

Office of Rural Health (ORH) Training Initiative

    WHS has partnered with ORH to develop and implement a training 
program to specifically meet the needs of rural primary care providers 
and nurses at rural CBOCs and VAMCs. This mini-residency for rural 
providers and nurses launched in June 2018 and is on track to visit up 
to 35 rural clinical sites during its first program year and up to 40 
sites per year thereafter, supporting the highest level of care for 
women Veterans in rural areas.

Telehealth Services for Women

    WHS understands it may be difficult to always make an appointment 
in person and is collaborating with the Office of Connected Care and 
ORH to ensure that primary and specialty care is delivered via 
telehealth to women Veterans both in rural areas of the country and in 
other geographical areas where there is a shortage of providers. The 
nationwide initiative, Virtual Integrated Multisite Patient Aligned 
Care Team (V-IMPACT), implements virtual women's health PACT teams in 
their primary care hub sites for the provision of gap coverage in VA 
facilities with a shortage of women's health providers. In addition, 
WHS has worked with ORH to ensure the inclusion of Women's Health 
Clinical Pharmacy Specialists (CPS) in their recent initiative to 
expand the availability of CPS via telehealth to rural VA facilities. 
Finally, WHS is actively working to promote the use of VA Video Connect 
among women's health providers to improve access to primary care.

Transition Assistance Pilot Program

    The Women's Health Transition Assistance Training Pilot Program (WH 
TAP Pilot) is a collaboration between the Air Force Women's Health 
Initiative Team (AFWHIT) and the VHA's Office of Women's Health 
Services conducted under the auspices of the VA/DoD Health Executive 
Committee, Clinical Care and Operations Business Line, Women's Health 
Workgroup (HEC CCO BL WHWG). The aim of this initiative is to increase 
transitioning Servicewomen's knowledge about the VHA health care 
system, the VHA enrollment process, and eligibility and specific 
services and resources available for separating Servicewomen. The 
ultimate goal of the WH TAP Pilot Program is to increase timely 
enrollment and utilization of VA health care services among eligible 
women after they separate from the military, and to ``provide a female 
perspective'' and connect Servicewomen to relevant care services 
available through VHA.

Musculoskeletal Training

    VA tracks the prevalence of medical conditions among women Veterans 
and has noted that musculoskeletal conditions such as back pain and 
joint pain are the most common conditions in women Veterans, often 
resulting in poor quality-of-life and chronic pain. To address this 
problem, VA has developed a Musculoskeletal Training Program to train 
providers in the physical examination and diagnosis of musculoskeletal 
conditions common in women Veterans. This training has been conducted 
at seven VA sites and will be conducted at the national simulation 
center in 2019. An additional collaborative provider musculoskeletal 
training with DoD was piloted in 2018 and will be repeated in Dayton, 
Ohio in 2019.

Conclusion

    VA continues to make significant strides in enhancing the language, 
practice, and culture of the Department to be more inclusive of women 
Veterans. These gains would not have been possible without consistent 
Congressional commitment in the form of both attention and financial 
resources. It is critical that we continue to move forward with the 
current momentum and preserve the gains made thus far. Your continued 
support is essential to providing high-quality care for our Veterans 
and their families. Madam Chair, this concludes my testimony. My 
colleague and I are prepared to respond to any questions you may have.

                                 
                       STATEMENTS FOR THE RECORD

                            Women Who Serve
Diana D. Danis, Lead Administrator Service

    Bio: Diana D. Danis is a lifelong advocate and activist on behalf 
of women and veterans. Her world-view focuses on changing cultural 
paradigms that relegate women to a second-class status and affect their 
full and equal participation in society.
    She deeply understands that use of language, definitions, access, 
communication and inclusion in research determines how effectively 
women receive treatment in health care systems. Danis currently serves 
as a Senior Advisor to Women Veterans Social Justice and is a lead 
administrator for the social media platform of Service: Women Who Serve 
as well as the women Military and Veteran advisor to People Demanding 
Action and ERA Action.
    For 16 years, she and her husband were Caregivers for six family 
members, gaining unique insight into insurance, medication, hospital, 
rehabilitation, nursing home and hospice systems. Her body of work 
includes contributions to the first comprehensive women veterans' 
health programs legislation for the Department of Veterans Affairs 
while Executive Director of the National Women Veterans Conference 
(NWVC), the first social justice women veteran organization in the 
country. She contributed to development of the first McKinney-Vinto 
Homeless Veterans Act as well as the Reasonable Accommodations in the 
workforce section of the Americans with Disabilities Act (ADA).
    Danis was the first military woman radio network news broadcaster 
on the American Forces Network (AFNE) while serving in the Army. During 
her service in Europe, she was one of a handful of women in the 
International Women's Coalition for Change that created the first Women 
and Families Support Centers for the US Army in Europe to address 
domestic violence.
    She formerly served on the President's Committee for Employment of 
People with Disabilities, was a member of the Colorado Coalition for 
the Homeless Board of Directors and the Veterans Program Director for 
the International Association for Personnel in Employment Security 
while serving as a training development instructor and Course Manager 
at the National Veterans Training Institute (NVTI). Danis developed and 
presented the first Diversity Training Certificate Course at the 
University of Colorado at Denver and is a co-developing specialized 
segments of Crisis Intervention Training (CIT) emphasizing Unique 
Populations.
    Danis serves on the Advisory Committee for the Military Women's 
Coalition founded in 2018 and consulted to Diloitte on the anticipated 
needs and issues of women who serve for the next decade.
    She regularly speaks on grassroots organizing for individuals and 
small organizations, addressing sexual assault in the military and VA, 
disability concerns, women's status in society and diversity issues.
    Thank you Chairwoman Brownley and Ranking member Dunn a for the 
opportunity to submit this statement to the House committee on Veterans 
Affairs regarding Cultural Issues Confronting Women Veterans.
    In the 1980's when I first came to the House and Senate Veterans 
Affairs Committees about the status of women veterans, I truly believed 
Congress was going to do what was necessary to right a plethora of 
wrongs.
    Senator Inoye launched a GAO inquiry in 1981 to find out what is 
was going to take to insure women veterans had equal access to medical 
care and benefits. An earnest effort ensued, 13 facilities visited, 
calls to 32 others, interviews with VA Central Office and Veteran 
Service organizations. They decided the VA had made progress but 
because we were only 2.5% (742,000) they really hadn't focused on our 
needs. Mind you that's half of the number we are today, but the vet 
population was massive back then and even though Congress was packed 
with veterans, there were no women veterans and we were not even an 
afterthought.
    Here's what they decided:

    - we should have access to treatment programs and facilities.
    - we should be able to get complete physical exams
    - that gyn and other gender specific care should be provided
    - that plans should be made for inevitable increases in our 
population
    - And that every effort should be made to identify us and inform us 
of our benefits.

    That 29 page report came out in 1982.

    I went to the Denver VA ER in 1985 and was told they didn't treat 
women. After that I met a bunch of people in Congress and spent years 
working on changing the system, working on legislation, creating a 
national organization - trying to make all those changes happen.
    In 1991, another GAO report requested to see what had happened 
since 1982 because now there were women and men in Congress asking a 
lot of questions and furiously working on legislation and of course the 
testimony around Tailhook was hammering Armed Services and Veterans 
Affairs in both the House and Senate and none of it was pleasant.
    The gist of the 1992 publication was as expected:

    - The VA had made significant progress toward providing health care 
to women vets. They said equal to men. I was there, not so much, though 
better - at least they were treating us.
    - The VA Advisory Committee on Women Veterans was created and Women 
Veteran Coordinators were assigned in each medical center. It was an 
additional duty, not a regular job, but it was progress.
    - They found out that doing in house Mammography required following 
American College of Radiology Standards and they weren't doing enough 
of them to be on target or proficient. Sometimes wanting a a service 
in-house has good intentions that aren't viable and still aren't in 
most locations today.
    - Privacy issues continued to be a huge problem and weren't being 
corrected with renovations to add things like women's bathrooms - true 
story, few VA's had women bathrooms other than for staff and outside 
the cafeteria.
    - And finally, the report said they couldn't find any programs that 
were unable to accommodate female patients. Had they talked to any of 
us using VA services, they just would have heard peals of laughter 
waving across the country.
    - They would have heard the laughter immediately turn to anger as 
they revealed sexual harassment and sexual assault IN VA facilities.
    - They would have heard about safety and security and the need to 
never go to appointments unaccompanied
    - They would have heard about providers ignoring health complaints 
and being shined on as malingerers
    - They would have heard about not knowing about programs being 
offered in the VA medical centers that women could also participate in
    After years of work, the Women Veterans Health Programs Act of 1992 
first authorized the VA to provide gender specific care to women 
veterans and established mental health care, regardless of disability 
status for those traumatized by sexual harassment, sexual assault and 
rape in the military. That public law 102-585 has been amended a lot in 
the last two and a half decades.
    I testified next to the bill's sponsor Congresswoman Patricia 
Schroeder, (D) (CO) and have a signed copy of the bill in a box 
somewhere.
    So here we are, 26 years later, walking the same path.
       What are the Cultural Barriers Confronting Women Veterans?
    Natural progression should have brought us further than continued 
sexual harassment in the VA and discomfort attending appointments for 
many, many women veterans along with being referred to as men - when 
being called back to see a provider. At this point it is not just 
education but an ingrained sense of disdain for those women who serve. 
That requires a big rethink in how the VA educates and punishes 
personnel.
    -I recommend legislation to deal with harassment and assault on VA 
campuses. Clearly expecting people to be respectful and not assault 
others is too big of an ask, so more severe implications are in order.
    For example, a staff member calls a woman veteran back who has 
close-cropped hair and is dressed in sweats. The individual refers to 
her as ``Mister'' or makes some other snarky remark. It is 
unprofessional, unnecessary and harmful.
    There continue to be deep concerns about the treatment of older 
women veterans and the in patient status of women veterans, especially 
those with mental health issues and dementia problems is growing.
    My husband has been going with me to VA appointments for 23 years. 
He has been regularly asked which doctor he is waiting for, if he would 
like some coffee and thanked for his service hundreds of times. He is a 
civilian. They don't ask me.
    We have seen the Women Veteran Coordinator positions morph into 
Women Veteran Program manager capacities in recent years. 
Unfortunately, in spite of many highly qualified women veterans 
applying for these positions, they tend to be used as internal 
promotional opportunities for civilian nursing staff rather than for 
external hiring of competent, highly trained women veterans seeking 
positions where they can best used their skill, knowledge and abilities 
to serve their sister veterans.
    The Center for Women Veterans should be a fertile information, 
training and education ground for feeding the best and brightest 
nationally to the VA facilities across the country. A full scale Train 
the Trainer staff preparing Women Veteran Coordinators to review 
problematic Claims issues - like Sexual assault claims, development of 
complicated records construction for those who served in Iraq and 
Afghanistan whose field records are lost or incomplete, aiding in the 
training of Women Veteran Program Managers to do the best possible 
outreach and assistance for women veterans, especially for those in 
rural areas would bridge many of the the gaps we continue to see in 
addressing the needs of women veterans.
    Cultural issues in this day and age include ethnic, religious and 
regional differences. The rules and regulations that come with 
implementation of the Mission Act June 6th are going to have an instant 
impact on those already jaundiced by years of constant upheaval 
experienced by those impacted by Choice. Rumors are already flying and 
the stress level of the third of veterans who reside in rural America - 
many of them women - are already over the top. Rural veterans tend to 
be isolated and deeply suspicious of the ``next great idea'' being 
sprung on them by government.
    Many have had a lot of issues with getting providers paid that they 
were referred to by Choice - either TriWest or HealthNet. Now, they are 
going to have four new entities to deal with and the rumblings, 
especially for women who have to get their mammograms and a lot of 
specialty gender specific care in the community, are growing.
    Every day those of us who deal with women veterans in crisis are 
faced with those afraid to go to an exam alone. Many do not have anyone 
to take them to appointments or go with them and be there to help them 
just be calm. Some are unsafe driving by themselves because they are 
stressed beyond measure by an upcoming Compensation & Pension exam (C & 
P).
    A couple of examples of how outlandish some of these contracted 
situations have become:
    One of our women vets was instructed to have her C & P for Military 
Sexual Trauma (MST) in a Chiropractic Office, another in a Nail Salon. 
I repeat, A NAIL SALON!
    Service: Women Who Serve, the MST Committee of the Military Women's 
Coalition (MWC), the 2019 VA Trailblazers, and Women Veteran Social 
Justice (WVSJ) are all recommending hands-on peer support and 
assistance for women veterans who are attending VA appointments or C & 
P exams by themselves and would like someone to attend with them 
through the process.
    Another issue is the manner in which women veteran claims for PTSD 
or other mental health issues derived from sexual assaults are 
adjudicated in favor of women veterans far less often than PTSD for 
combat veterans. Following GAO reports highlighting additional 
discrepancies due to poor Claims Adjudicator training, those denied 
were suppose to be informed and their claims revisited. To our 
knowledge, that has yet to occur.
    At this point I am not even going to go into legal issues, veterans 
family court, transportation, bad VSOs, homelessness, childcare or 
decent paying jobs for women who already get paid far less than their 
male counterparts - especially women of color. I do thank your 
contemporaries in the House Judiciary Committee for the hearing 
yesterday on extending the deadline for the Equal Rights Amendment - We 
would appreciate Constitutional equality.
    The big last issue I will address is women veteran suicide. When 
you look at the myriad of barriers women veterans face and how 
overwhelming these issues can become, it is no wonder that the thing 
someone may see as not so big a deal, is the deal breaker for 
continuing to ride this rock around the sun. Over the years, I have 
brought only the most serious cases of bad treatment at the hands of 
the VA to members of this committee and the members have always come 
through and made a difference. Please know that in doing so, you save 
lives.
    As disabled veteran I have used VA services for many years. The 
majority of the time accessing benefits is reasonable and getting 
health care is as well. I've had some poor treatment upon occasion, and 
make sure the appropriate parties are informed. As an advocate, it's 
easier for me, I know the system. We need to make access, continuity 
and consistency of care reality for ALL veterans. Thank you for your 
time.

                                 
            Iraq and Afghanistan Veterans of America (IAVA)
Statement of Melissa Bryant
Chief Policy Officer
    Chairwoman Brownley, Ranking Member Dunn, and Members of the 
Subcommittee, on behalf of Iraq and Afghanistan Veterans of America 
(IAVA) and our more than 425,000 members worldwide, thank you for the 
opportunity to share our views, data, and experiences on the matter of 
cultural barriers impacting women veterans' access to health care.
    Support and Recognition of Women Veterans is an incredibly 
important part of our work; it is why it is included in our Big Six 
Priorities for 2019 which are the Campaign to Combat Suicide, Defend 
Veterans Education Benefits, Support and Recognition of Women Veterans, 
Advocate for Government Reform, Support for Injuries from Burn Pits and 
Toxic Exposures, and Support for Veteran Medicinal Cannabis Use.
    I am here today not only as IAVA's Chief Policy Officer, but also 
as a former Army Captain and a combat veteran of Operation Iraqi 
Freedom. I was a military intelligence officer who led women and men in 
combat; but some my most salient memories are from my times leading 
troops in garrison, when far too often the true colors of soldiers you 
would normally trust in battle would surface. As one of the few, if not 
only, women (and especially women of color) officers in my units, I can 
point to many an occasion where I helped women soldiers who came to me 
for advice and counsel in dealing with harassment in the ranks.
    Sadly, I can also point to my own dealings with harassment from my 
peers, superior officers, and even soldiers. It was a double burden I 
faced when the intersectionality of being a black woman officer would 
creep into misogynistic and prejudiced comments made toward me--perhaps 
simply because I was a confident leader with a no-nonsense approach to 
my work. Now as a veterans advocate, I still hear the misogyny in our 
community, from the time I'm asked, ``who is your sponsor?'' at 
Department of Veterans Affairs (VA) medical centers to when I'm 
referred to as, ``young lady'' by my own veteran colleagues. At best, 
it's a casual dismissal of my credentials and expertise to have earned 
a seat at the table; at worst, it means just what it sounds like--
flagrant disregard for my service and ultimately an emotional barrier 
to care at VA.
    Over the past few years, there has been a groundswell of support 
for women veterans' issues. From health care access to reproductive 
health services to a seismic culture change within the veteran 
community, women veterans have rightly been focused on and elevated on 
Capitol Hill, inside VA, and nationally. In 2017, IAVA launched our 
groundbreaking campaign, #SheWhoBorneTheBattle, focused on recognizing 
the service of women veterans, closing gaps in care provided to us by 
VA, and finally changing the outdated VA motto to represent ALL 
veterans.
    IAVA made the bold choice to lead on an issue that was important to 
not just the 20% of our members who are women, but to our entire 
membership, the future of America's health care and national security. 
We continue to fight hard for top-down culture change in VA for the 
more than 345,000 women who have fought in our current wars.
    The number of women in both the military and veteran communities 
has been growing steadily since the 1970s. While more women are joining 
the military and are finally given unprecedented roles in combat and 
greater responsibilities in leadership, veteran services and benefits 
often lag behind. Since 2001, the number of women veterans seeking care 
at VA has tripled, but women veterans are also more likely to fall out 
of VA health care due to longer wait times and opportunity costs, a 
sign that a lack of gender specific services and ease of access is 
impacting care for women veterans at the VA.
    Despite the ever-growing contribution of women to our national 
defense, the American public still does not understand the extent of 
our involvement and sacrifice. This lack of understanding not only 
impacts our reception when seeking health care from the VA, as I 
outlined in my own experience, but throughout our transition home. 
Often having faced an unwelcoming culture in the military, the VA can 
seem like an equally unwelcoming place to women who are transitioning. 
The VA motto does not help. It explicitly excludes women and our 
survivors from its mandate, and it reads as outdated: ``To care for him 
who shall have borne the battle and for his widow, and his orphan.''
    Women veterans are becoming more prominent in American culture 
overall, and are stepping up and leading: From the growing number of 
women veterans serving in Congress, to the highest leadership positions 
among the service branches, veteran and military service organizations, 
and other leading groups. Also, as more women veterans step into the 
public sphere, our contributions and sacrifices are becoming known and 
recognized.
    However, every day women veterans enter into VAs nationwide and are 
not recognized for our service. Every day, women veterans are looked 
past in favor of the familiar image of a man serving in uniform. Until 
women veterans are as known and understood as our male counterparts, 
IAVA's work will not be done.
    For women veterans who choose to seek care at the VA, finding 
quality providers who understand the needs of women veterans can be 
difficult. While VA has made progress improving women-specific care for 
women veterans, including expanding the services and care available 
within the VA, there is still much progress needed. Women veterans are 
more likely than our male counterparts to seek care in the community, 
meaning we are often seen by private care providers that may or may not 
understand military service and its health impacts. IAVA's recent 
member survey underscores this, as we found that while 70% of 
respondents felt that VA clinicians understand the medical needs of 
veterans, only 44% felt that non-VA clinicians understood them.
    Among IAVA's women veterans, those that self-reported their health 
as terrible were more likely to report negative VA experiences and 
those with self-reported excellent health were more likely to report 
positive experiences with VA health care. These results indicate that 
women with more health concerns have worse experiences at the VA, even 
though logically they would have larger health concerns than those who 
feel their health is excellent. Furthermore, IAVA women veterans aged 
31 to 45 were less likely to report a positive experience with the VA 
than older women veterans aged 46 to 65. This indicates that the 
younger veterans of the post-9/11 generation are the ones struggling 
with VA care most - an ominous sign for the future of women's health 
care at the VA.
    Additionally, women who do seek care at the VA report the quality 
and standard of care are not at all uniform. According to the most 
recent GAO report on the standards of care of VA medical centers, VA 
``does not have accurate and complete data on the extent to which its 
medical centers comply with environment of care standards for women 
veterans.'' The same report noted a deficiency of 675 women's health 
primary care providers as of 2016. This means that these facilities may 
not meet basic privacy standards like locked doors, privacy curtains, 
and other adjustments to make them feel welcome.
    Changing this will require establishing clear standards, training 
VA staff to meet these standards, and investing in appropriate 
facilities, including women practitioners and doctors who specialize in 
women's health. Facilities and providers must regularly be evaluated to 
ensure they meet the standards our veterans deserve. The VA, with its 
partners, must do a better job of reaching out to women and telling 
them about the resources VA has to offer.
    This is why in 2017, IAVA worked with Congressional allies on both 
sides of the aisle and in both chambers to introduce the Deborah 
Sampson Act. This bill called on the VA to modernize facilities to fit 
the needs of a changing veteran population, increasing newborn care, 
establishing new legal services for women veterans, and eliminating 
barriers faced by women who seek care at VA. This bill would also 
increase data tracking and reporting to ensure that women veterans are 
getting care on par with their male counterparts.
    Although the Deborah Sampson Act, the centerpiece of IAVA's She Who 
Borne The Battle campaign, was not passed in the 115th Congress, IAVA 
is pleased with progress made overall, with key provisions of the 
legislation passed or funded in the last two years. These hard-fought 
victories included funding to improve services for women veterans, such 
research on and acquisition of prosthetics for female veterans, 
increased funds for gender-specific health care, women veterans' 
expanded access and use of VA benefits and services, improved access 
for mental health services, and for supportive services for low income 
veterans and families to address homelessness.
    Similar to another Deborah Sampson Act provision, the MISSION Act 
created a peer counseling program that provided for at least two peer 
specialists in patient aligned care teams at VA medical centers to 
promote the use and integration of services for mental health, 
substance use disorder, and behavioral health in a primary care 
setting. The law mandated that the needs of female veterans are 
specifically considered and addressed; and that female peer specialists 
are made available to female veterans who are treated at each location. 
Further, we are pleased that the SUPPORT for Patients and Communities 
Act included language that encouraged the hiring of female peer support 
counselors, directed VA to facilitate peer counseling for women 
veterans and to conduct outreach to inform female veterans about the 
program. We urge your Committee to ensure these provisions are carried 
out appropriately.
    IAVA is also pleased that the Administration recently implemented 
another Deborah Sampson Act provision to expand the capabilities of the 
VA Women Veterans Call Center to include a text messaging capability. 
VA provided testimony in support of this provision during a 2017 
hearing on the bill before the Senate Committee on Veterans Affairs, 
and we are encouraged that the Department heard our calls for reform. 
Women veterans can now text 855-829-6636 to receive answers and 
guidance about VA services.
    Finally, IAVA is also particularly interested in seeing the results 
of the report sought under the FY 2019 Energy and Water, Legislative 
Branch, and Military Construction and Veterans Affairs Appropriations 
Act that requires the VA to submit a report to Congress on retrofitting 
its facilities to eliminate barriers to care for women veterans. That 
report was due in March 2019.
    While we have seen greater awareness of and progress toward 
improving services for women veterans, there is much more we can do. 
Toward this goal, IAVA strongly supports passage of the updated Deborah 
Sampson Act (S. 514) recently reintroduced by Sens. Jon Tester and John 
Boozman. Provisions of the new bill include expanded peer to peer 
services, such as the ability for women to receive reintegration 
counseling services with family members in group retreat settings, 
increased newborn care services, and an increase in spending in order 
to retrofit VA facilities to enhance the privacy and environment women 
are being treated in, such as privacy curtains and door locks. It also 
provides for legal and support services to focus on unmet needs among 
women veterans, like prevention of eviction and foreclosure and child 
support issues. This must be the year that Congress passes the Deborah 
Sampson Act into law.
    Beyond care, ensuring women veterans have proper access at the VA 
requires addressing the culture problem and harassment at its 
facilities. While not only impacting women veterans, harassment at the 
VA is a systemic issue that oftentimes happens between patients, in 
waiting rooms, and while veterans are checking in or leaving care--just 
as it remains a systemic problem in the military, as I have detailed in 
my own experiences. It is hard to quantify just how many women veterans 
face harassment in or around VA facilities, but according to the VA's 
most recent reporting, 25 percent of women veterans faced harassment 
from strangers in a VA facility such as lewd comments or catcalling. 
And for those women that do experience harassment at VA facilities, 
these women are more likely to delay or miss their health care 
appointments. Harassment has a very real effect on the physical and 
mental health of women veterans and VA must do more to address it.
    The VA has implemented some programs to combat sexual harassment in 
its facilities but ensuring patients are aware of these programs before 
entering the Department's doors and empowering VA staff to intervene in 
harassment situations and understand reporting requirements must be a 
top priority. This can begin by ensuring that the VA's End Harassment 
Campaign is fully implemented and understood across every VA facility 
nationwide, a move that will set the overall tone for VA culture. This 
public outreach campaign is a starting point for what must be a 
continued and robust conversation around harassment at VA facilities.
    Thank you for allowing IAVA to share our views. I look forward to 
working with the House Veterans' Affairs Subcommittee on Health and its 
dedicated Women's Task Force to better remedy the problems discussed in 
this testimony.

Biography of Melissa Bryant:

    Melissa Bryant is the Chief Policy Officer for IAVA. She leads 
IAVA's policy division, overseeing the legislative, research, and 
intergovernmental affairs departments. Melissa spearheads the 
development of our annual policy agenda and advocacy campaigns in 
collaboration with IAVA leadership, and leads IAVA's engagement with 
the White House, government departments and agencies, particularly the 
Departments of Defense and Veterans Affairs, Veteran and Military 
Service Organizations, and advocacy organizations.
    A former Army Captain and Operation Iraqi Freedom combat veteran, 
Melissa has an extensive record of public service, having served on 
both active duty and in the civil service as an intelligence officer 
prior to joining IAVA. A plans, policy, and operations expert with 15 
combined years of experience in the federal government, she has served 
in key leadership positions with the Defense Intelligence Agency, the 
Joint Staff, the United States Military Academy, and Army Intelligence. 
She was successful in building ``coalitions of the willing'' to advance 
operational and strategic objectives while developing and implementing 
plans and policy for the defense and intelligence communities.
    Melissa is an ROTC Distinguished Military Graduate and holds a 
Bachelor of Arts degree in Political Science cum laude from Hampton 
University, is an alumna of Howard University School of Law, and also 
holds a Master of Arts in Policy Management from Georgetown University.
    Melissa is a spokesperson for IAVA, and has been featured several 
times on MSNBC with Andrea Mitchell, Katy Tur and others, HLN, in The 
Washington DC 100, and more.

                                 
                  PARALYZED VETERANS OF AMERICA (PVA)
    Chairwoman Brownley, Ranking Member Dunn, and members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for this opportunity to draw attention to barriers women veterans, 
particularly those with catastrophic disabilities, encounter in 
accessing health care. VA has made tremendous progress in improving 
health care programs and services for all women veterans. But there is 
still work to be done, and VA must continue to evolve its facilities, 
programs, and services to ensure they can meet the health care needs of 
women veterans and keep up with the increasing demand for women 
veterans' health care services.

Ingress/Egress

    It may come as a surprise to some, but the first hurdle that women 
veterans with catastrophic disabilities may encounter could be the 
entrance to the VA women's health clinic. Because many of these 
locations were established in haste, they did not receive the careful 
level of planning necessary to ensure wheelchair users could enter the 
facility. For example, the outside entrance to a women's health care 
clinic our staff recently visited did not have an automatic door for 
patients to use. To complicate matters further, the entrance was not 
visible to VA staff so they could not see if a patient outside needed 
assistance, nor was there an external bell for the patient to alert 
them if they needed assistance. Thus, any patient needing help entering 
the clinic would be exposed to the elements until someone came along to 
help her. VA must ensure that all women's health clinics are easily 
accessible for disabled women veterans.

Accessible Exam Rooms

    Accessibility to doctors' offices is essential in providing medical 
care to people with severe or catastrophic disabilities, but this is 
often the next hurdle a woman veteran may encounter at VA. Some of VA's 
exam rooms are too small to accommodate a woman veteran in a wheelchair 
and a portable lift. Other rooms may not be big enough for a larger 
wheelchair to enter at all. A portable lift would be unnecessary if the 
examination rooms had built-in ceiling lifts to hoist a woman veteran 
from her wheelchair to the examination table, but many women's health 
clinics do not have an installed ceiling lift.
    Barriers like these tend to make individuals with severe 
disabilities less likely to get their routine preventative medical 
care. It's a major concern because wheelchair users face the insidious 
health threat of remaining seated at all times. Loss of muscle tone and 
diminished circulation cause pressure sores to develop and it is very 
important that seemingly minor problems like these be detected and 
treated early before turning into major and possibly life-threatening 
problems. However, if the patient cannot enter the exam room or be 
placed upon the exam table, the physician may be forced to examine the 
patient in her wheelchair leaving her at risk of further injury and 
diminishing the quality of the exam and any care provided.

Mammography Exams

    Some VA medical centers do not have diagnostic equipment to provide 
mammograms. For the facilities that do, wait times are excessively long 
(two months or longer), or the equipment is inaccessible for women 
veterans in wheelchairs, particularly quadriplegics. While there are 
mammography machines that allow women with physical disabilities to lay 
on an exam table, not every VA health care facility has this type of 
equipment. We urge VA to ensure that women veterans have timely access 
to mammograms regardless of their disabilities.

Internal Communication Barriers

    Some women PVA members have expressed the need for better lines of 
communication between their main VA health care providers and those 
from other service lines. For example, certain oral contraceptives can 
be dangerous to women with spinal cord injuries or disorders (SCI/D) 
because they can cause deep vein thrombosis (blood clots) in the legs. 
Without specialized training, the prescribing doctor may not understand 
that this side-effect poses a significantly greater risk to women with 
impaired mobility. Therefore, PVA recommends VA establish clinical 
guidelines for the treating physician to follow when prescribing 
contraceptives for women with limited mobility issues.

In Vitro Fertilization (IVF)

    Last year, Congress passed legislation extending for two more years 
VA's ability to offer IVF services to veterans with service-connected 
disabilities that result in infertility. Although VA covers certain 
therapies for those with service-connected disabilities that result in 
infertility, there are gaps in this care that primarily affect female 
veterans. For instance, VA does not cover surrogacy or outside donors 
for IVF and offers virtually nothing for women who cannot conceive or 
carry a child due to their service. Likewise, there has been little 
research and attention given to female infertility and the impact of 
service on reproductive health from other military-related sources like 
toxic exposures from chemicals and burn pits. Permanently providing 
procreative services through VA would help ensure that greater numbers 
of women veterans are able to have a full quality of life that would 
otherwise be denied to them as a result of their military service. We 
strongly support H.R. 915, which would make IVF services a permanent 
part of the medical benefits package at VA and help female veterans 
with SCI/D overcome some of the unique challenges they face in 
establishing or growing their families.

Importance of Prosthetics for Women Veterans

    Despite the increase in the number of women veterans, the 
availability of prosthetic devices that meet their needs versus those 
of their male counterparts has been lagging far behind. VA must ensure 
that prosthetists and administrators at every level understand women's 
prosthetic needs. This understanding is necessary to ensure the 
outcomes and satisfaction of women veterans is equal to men in using 
their prosthetic aids.
    All VA facility leaders must be accountable for meeting women 
veterans' standard of care for quality, privacy, safety, and dignity. 
To advance the understanding and application of prostheses for women, 
VA must include academic affiliates, other federal agencies, and for-
profit industry in their research. Meeting the prosthetic needs of 
women veterans can be an opportunity for VA to excel.

Peer-to-Peer Counselors for Women Veterans

    PVA supported legislation in the 115th Congress directing the VA 
Secretary to employ a sufficient number of peer counselors to meet the 
needs of women veterans, particularly to address military sexual 
trauma, post-traumatic stress, and those at risk of homelessness. Women 
veterans who have been able to access peer-to-peer counseling or 
retreats provided through VA reported having a better understanding of 
how to develop support systems and access VA and community resources. 
Peer counseling programs have been a marked success for participants 
who show consistent reductions in stress symptoms and increased coping 
skills. Congress should actively work to promote peer-to-peer programs 
which time and time again have demonstrable success in helping veterans 
during their time of need.
    PVA will be hosting a new peer-to-peer event this fall that 
celebrates the service of women veterans. Our ``WE Served'' event will 
be an all-expenses-paid retreat focusing on the holistic wellbeing of 
women veterans with disabilities. This immersive and outcomes-driven 
experience will empower 50 disabled women veterans to navigate the 
unique challenges of their daily lives and help them flourish. 
Attendees will receive education and advice from a host of experts on 
whole health practices, independent living, financial security, 
nutrition, finding meaningful employment, accessing veterans benefits, 
and women's health issues. We hope that this event will be the first of 
many similar outreach efforts.
    PVA appreciates this opportunity to express our views on the 
barriers our women veterans face in accessing health care. It is 
important to note that many of the barriers that catastrophically 
disabled women veterans face in the VA health care system are just a 
prevalent if not worse in the community. Thus, we look forward to 
working with the Subcommittee to eliminate these barriers and ensure 
full access to VA health care and services for all women veterans.

                                 
          VETERANS OF FOREIGN WARS OF THE UNITED STATES (VFW)
KRISTINA KEENAN, PAST-COMMANDER
POST 605 BENJAMIN FRANKLIN POST

    Chairwoman Brownley, Ranking Member Dunn, and members of the 
Subcommittee, on behalf of the men and women of the Veterans of Foreign 
Wars of the United States (VFW) and its Auxiliary, thank you for the 
opportunity to provide recommendations on how to improve Department of 
Veterans Affairs (VA) health care services for women veterans.
    VA reports that nearly 492,000 women veterans used the VA health 
care system in fiscal year 2017, which was a nearly 150 percent 
increase since fiscal year 2003, and these numbers will continue to 
increase in years to come. VA has worked to improve the gender-specific 
care for this population of veterans, but more work needs to be done. 
Women veterans using VA often have complex health care needs that 
require specialty care for service-connected conditions such as post-
deployment readjustment challenges, post-traumatic stress disorder due 
to war-related trauma and sexual trauma, mental health care, and 
substance use disorders - services which, on average, they use at 
higher rates and more often than male veterans. The VFW is disappointed 
not a single piece of legislation became law in the 115th Congress to 
address the needs of women veterans. This must change in the 116th 
Congress.
    Peer-to-peer support has proven time and again to be invaluable to 
veterans and VA. This is why the VFW advocates so strongly for the 
constant expansion of peer-to-peer support programs. The VFW urges 
Congress to pass legislation to expand these programs for women 
veterans, providing them more peer and gender-based one-on-one 
assistance from those to whom they can relate and connect. This is 
extremely crucial in instances when a woman suffers from a mental 
health condition, but especially in instances when she is on the verge 
of homelessness. In a VFW survey of women veterans, 38 percent of women 
who reported experiencing homelessness also have children. These women 
face unique barriers to overcoming homelessness, and frequently 
commented on the lack of support from anyone who could understand those 
barriers. By providing peer-to-peer support for women with those who 
have gone through the same hardships, VA would provide a level of 
understanding and trust they desperately need. This is why the VFW 
urges Congress to pass H.R. 840, the Veterans Access to Child Care Act, 
which would provide access to child care for veterans seeking 
employment training who have an income at or below their states' 
poverty lines. This would serve as a way to reduce homelessness among 
women veterans.
    According to VA, the majority of women veterans are assigned to 
Designated Women's Health Primary Care Providers (DWHP). VA and its 
Center for Women Veterans have worked to increase those numbers, and 
the VFW asks Congress to provide VA with the resources they need to 
continue expanding outreach for knowledge of and access to providers 
with necessary gender-specific specializations. Surveys conducted by 
the VFW have found women veterans overwhelmingly prefer to receive 
their health care from female primary care providers, and are more 
likely to be satisfied with their VA health care experience when they 
receive care from these providers. That is why the VFW has urged VA to 
allow women veterans to choose the gender of their providers when 
enrolling in health care.
    While the DWHP program continues expanding and providing above-
satisfactory care to patients, the VFW understands there is still a 
need for trained gynecologists within VA. Gynecology is a specialty 
that has traditionally been understaffed at VA medical facilities 
across the country. While some providers are able to perform certain 
gynecological procedures, it is important to increase the number of 
doctors trained in the specialization of gynecology.
    For women veterans who rely on VA for postnatal care, the VFW urges 
Congress to extend the number of days newborn care is covered by VA. 
Currently, VA only covers newborn care for seven days. One week is not 
enough to provide coverage for critical care that may be necessary in 
the first weeks of a child's life--especially in the relatively common 
instance of false-positive newborn disease testing--nor is it enough to 
ease the new mother of unnecessary stress.
    The VFW urges Congress to pass S. 514, the Deborah Sampson Act, 
which would expand newborn coverage for veterans who use VA while 
receiving maternity care. In addition to expanding this care, the 
legislation would provide many other improvements to women veterans' 
needs within VA. Some of these improvements include analysis of 
staffing needs, the establishment of a women veteran training module 
for non-VA health care providers, expansion of legal services for women 
veterans, and information to be added to the VA website relating to 
women veteran programs.
    The VFW applauds VA and Congress for their work to provide more 
access to gender-specific health care providers for women veterans. 
While overall progress has been made, gender-specific mental health 
care is still lacking. In VFW surveys, women veterans have voiced 
concerns over what they view as a lack of gender-specific training for 
mental health care providers. Congress and VA must work to ensure every 
VA medical center has mental health care providers who are well trained 
in conditions such as postpartum depression and conditions that stem 
from menopause or sexual trauma.
    Women service members and veterans have also been found to have an 
increased risk for eating disorders, which have serious consequences 
for both physical and psychological health as well as high mortality 
rates. Some of the risk factors which contribute to women veterans 
struggling with eating disorders include military sexual trauma and 
combat exposure. As VA continues to meet the needs of women veterans, 
it is important that VA establishes a comprehensive program for the 
treatment of eating disorders.
    The VFW has noticed a much lower utilization and awareness of 
benefits among older women veterans compared to their younger 
counterparts. In one of the VFW's surveys, we found older women 
veterans were less likely to report receiving disability compensation, 
but equally as likely to have been injured or made ill as a result of 
their military service. Similarly, older veterans were less likely to 
report that they use VA health care, but equally as likely to report 
being eligible for VA health care. We are also concerned that several 
respondents who reported being 55 years old or older believed that they 
did not rate the same benefits as their male counterparts, which is an 
egregious misperception that must be addressed.
    No veteran should be left to wonder what, if any, benefits she is 
eligible to receive. Furthermore, it must be clear that women veterans 
have earned the exact same benefits as their male counterparts. That is 
why the VFW urges Congress and VA to continue improving outreach to 
women veterans and conduct targeted outreach to older women veterans to 
ensure they are aware of all the benefits and services VA provides.
    The VA formulary currently carries all categories of 
pharmaceuticals deemed preventive by the U.S. Preventive Services Task 
Force. However, VA is not required to comply with the Affordable Care 
Act requirement for all private sector insurance providers to cover 
preventive care and services without cost-shares.
    Cost is a significant barrier for lower income veterans who use VA 
health care. There are currently 11 categories of preventive 
medications found to be effective by the U.S. Preventive Services Task 
Force, such as prescribing aspirin to lower the risk of cardiovascular 
disease. Cardiovascular disease is the number one cause of death in the 
United States and is highly prevalent among the veteran population. 
Additionally, folic acid is recommended for pregnant women to prevent 
neural tube defects. It is unjust to require women veterans to pay for 
preventive medication to prevent such birth defects. Vitamin D is 
another preventive medicine which is often prescribed to prevent bone 
fractures, which benefits traumatic brain injury patients with 
hindbrain injuries. There is also breast cancer prevention medication 
which is useful not just for individuals with a family medical history 
of breast cancer, but for Camp Lejeune toxic water survivors who have 
been found to suffer from increased rates of breast cancer.
    These pharmaceuticals have been found to prevent possible disease 
and have shown to be cost-saving. The VFW calls on Congress to swiftly 
pass legislation which would eliminate this inequity and ensure 
veterans have access to lifesaving preventive medicine.

                                 
                   VIETNAM VETERANS OF AMERICA (VVA)
Kate O'Hare Palmer
Chair, Women Veterans Committee
    Good morning, Madam Chairwoman Brownley, Ranking Member Dunn and 
distinguished members of the Subcommittee on Health. Thank you for 
giving Vietnam Veterans of America (VVA) the opportunity to submit our 
statement for the record regarding ``Cultural Barriers Impacting Women 
Veterans' Access to Healthcare.''
    ``By March 1973 and the withdrawal of US troops and the remaining 
WACs, an estimated four million people had died in the Vietnam War. For 
most returning veterans there was no welcome home. Being heckled and 
spat on at the airport was the beginning of their private aftermath. 
Women, especially, learned to keep silent about being in 'Nam. Many 
just tried to get on with life, careers and families, burying their 
inward and outwards scars, shame or pride, horror or honor, all mixed 
up with memories of friendships forged and loves found. Many have died 
without daring to reveal they served in Vietnam. All believe it changed 
their lives, for better or worse, but certainly forever.''--The Women 
Who Served in Vietnam BBC 2016
    Since 1982, Vietnam Veterans of America has been a leader in 
advocacy and championing appropriate and quality health care for all 
women veterans. The Department of Veterans Affairs (VA) has made many 
innovations, improvements and advancements over the past thirty years. 
However, some concerns remain respective of its policies, care, 
treatment, delivery mode, and monitoring of services to women veterans.

MEDICAL TREATMENT OF WOMEN VETERANS

    VA-eligible women veterans are entitled to complete health care 
including care for gender-specific illnesses, injuries and diseases. 
The VA has become increasingly more sensitive and responsive to the 
needs of women veterans and many improvements have been made. 
Unfortunately, these changes and improvements have not been completely 
implemented throughout the entire system. In some locations, women 
veterans experience barriers to adequate health care, and oversight 
with accountability is lacking. Primary care is fragmented. What would 
be routine primary care in the community is referred out to specialty 
clinics in the VA. Over the last five years the percent of women 
veterans using the VA has grown from 11% to 17%, with 56% of OEF/OIF 
women Veterans having enrolled in the VA. Their average age of women 
veterans using the VA is 48; the age of a Vietnam woman veteran is 72.
    VVA will continue its advocacy to secure appropriate facilities and 
resources for the diagnosis, care and treatment of women veterans at 
all VA hospitals, clinics, and Vet Centers. We ask the VA Secretary 
ensure senior leadership at all facilities and all regional directors 
be held accountable for ensuring women veterans receive appropriate 
care in an appropriate environment. Further, we seek that the Secretary 
ensure:

      The competency of staff who work with women in providing 
gender-specific health care;
      That VA provides reproductive health care;
      That appropriate training regarding issues pertinent to 
women veterans is provided;
      That an environment is created in which staff are 
sensitive to the needs of women veterans; that this environment meets 
the women`s needs for privacy, safety, and emotional and physical 
comfort in all venues;
      Those privacy policy standards are met for all patients 
at all VHA locations and the security of all veterans is ensured;
      That the anticipated growth of the number of women 
veterans should be considered in all strategic plans, facility 
construction/utilization and human capital needs;
      That patient satisfaction assessments and all clinical 
performance measures and monitors that are not gender-specific be 
examined and reported by gender to detect differences in the quality of 
care;
      That general mental health care providers are located 
within the women`s and primary care clinics to facilitate the delivery 
of mental health services;
      Ensure that sexual trauma care is readily available to 
all veterans;
      Provide support services for women veterans seeking legal 
assistance;
      Require VA to report on availability of prosthetics for 
women;
      That an evaluation of all gender-specific sexual trauma 
intensive treatment residential programs be made to determine if this 
level is adequate as related to level of need for each gender;
      That a plan is developed for the identification, 
development and dissemination of evidence-based treatments for PTSD and 
other co- occurring conditions attributed to combat exposure or sexual 
trauma;
      That women veterans, upon their request, have access to 
female mental health professionals, and if necessary, use VA outsource 
to meet their needs;
      That all Community-Based Outpatient Clinics (CBOCs) which 
do not provide gender-specific care arrange for such care through VA 
outsourcing or contract in compliance with established access 
standards;
      That evidence-based holistic programs for women's health, 
mental health, and rehabilitation are available to ensure the full 
continuum of care;
      That the Women's Health Service aggressively seek to 
determine root causes for any differences in quality measures and 
report these to the Under Secretary for Health, Assistant Secretary for 
Operations and Management, the VISN directors, regional directors, 
facility directors, and providers;
      That legislation be enacted to ensure neonatal care is 
provided for up to 30 days as needed for the newborns of women veterans 
receiving maternity/delivery care through the VA;
      That H.R. 840, the Veterans Access to Child Care Act, 
introduced by Congresswoman Brownley, is enacted into law.

HOMELESS WOMEN VETERANS

    Over the past several decades, we have become increasingly more 
vested in the recognition of the situation of homelessness among 
veterans. VVA well remembers the time when the VA acknowledged that as 
many as 275,000 veterans were homeless on any given night. Currently 
the VA cites that the number of homeless veterans has been reduced to 
37,878 as reported by the most recent Point in Time count. VVA 
recognizes this as a useful tool but doubts that this number is 
necessarily a solid number. It is a snapshot: it is impossible to have 
on record all veterans who are homeless. Nonetheless, it is a true 
indicator that all the energy surrounding the above-mentioned programs 
has made a difference. It is undeniable that the number of homeless 
women veterans has been climbing; however, collection data on homeless 
women veterans is not reliable as indicated in the Government 
Accountability Office's (GAO) 2011 report, ``Homeless Women Veterans: 
Actions Needed to Ensure Safe and Appropriate Housing.'' The report 
also cited some significant barriers to access of housing for homeless 
women vets:

      They are not aware of the opportunities available to 
them;
      They don't know how or where to obtain housing services;
      They are not easily found/identified in the community;
      They often ``couch surf'';
      They have children and avoid shelters because of the 
safety factor;
      They avoid social service agencies for fear of losing 
their children to the system;
      Some 24 percent of VA Medical Center homeless 
coordinators indicated they have no referral plans or processes in 
place for temporarily housing homeless women while they await placement 
in HUD-VASH and GPD programs;
      Nearly two-thirds of VA HGPD programs are not capable of 
housing women with children;
      The expense of housing women with children is a 
disincentive for providers.
    VVA believes that the VA's ``plan'' to end homelessness among 
veterans is quite ambiguous, and that it needs to address several key 
questions: Are women veterans and their needs truly being met by the 
programs that exist for them today? What will be done to reach them, to 
know them, to meet their needs and provide them a safe environment in 
which to address these needs? VVA believes that a coordinated plan 
needs to be developed at the local level by the leadership of the 
respective VA medical center within its homeless veterans program. The 
influx of women in the military - one of every ten soldiers serving in 
Iraq is a woman - the female homeless population will only grow, making 
the need for additional facilities dedicated to women.

WOMEN VETERANS RESEARCH

    Because women veterans have historically been a small percentage of 
the veteran population, many issues specific to them have not been 
researched. General studies of veterans often had insufficient numbers 
of women veterans to detect differences between male and female 
veterans and/or results were not reported by gender. Today, however, 
women are projected to be more than 12% of the veteran population by 
2020 and 15% by 2025.
    Vietnam Veterans of America asks the Secretary to conduct several 
studies specific to women and that Congress pass legislation to mandate 
such studies if the Secretary does not act:

      A comprehensive assessment of the barriers to and root 
causes of disparities in the provision of comprehensive medical and 
mental health care by VA for women;
      A comprehensive assessment of the capacity and ability of 
women veterans' health programs in VA, including Compensation and 
Pension examinations, to meet the needs of women;
      A comprehensive study of the relationship of toxic 
exposures during military training and service, and the infertility 
rates of veterans;
      A comprehensive evaluation of suicide among women 
veterans, including rates of both attempted and completed suicides, and 
risk factors, including co-morbid diagnoses, history of sexual trauma, 
unemployment, deployments, and homelessness;
      VA evaluation of the integration of services to support 
veterans.

CARE FOR NEWBORN CHILDREN OF WOMEN VETERANS

    VVA requests that any proposed legislation should include language 
to increase the time for 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. If the infant must have 
extended hospitalization, it would allow time for the case manager to 
make the necessary arrangements for necessary medical and social 
services assistance for the woman and her child. This has important 
implications for our rural women in particular. And there needs to be 
consideration given for a veteran's service-connected disabilities, 
including toxic exposures and mental health issues, especially during 
the pre-natal period, or in cases of multiple births or pre-mature 
births. Prenatal and neonatal birthrate demographics (including 
miscarriage and stillborn data) would seem to be an important element 
herein.

WOMEN VETERANS AND VETERANS BENEFITS

    The Veterans Benefits Administration (VBA), and to a lesser extent, 
the National Cemetery Administration (NCA), have been less proactive 
than the Veterans Health Administration in targeting outreach to women 
veterans and in ensuring competency in managing claims filed by women 
veterans.

    VVA asks the Secretary to ensure:

      That leadership in all VA Regional Offices is cognizant 
of and kept current on women veterans' issues; that they provide and 
conduct aggressive and pro-active outreach activities to women vets; 
and that VBA leadership ensures oversight of these activities;
      That a national structure be developed within VBA for the 
Women Veteran Coordinator (WVC) positions at each VARO;
      That VBA establish consistent standards for the time 
allocated to the position of WVC based on the number of women veterans 
in the VARO's catchment area;
      That VBA develop a clear definition to the job 
description of the WVC and implement it as a full-time position with 
defined performance measures;
      That VBA identify a subject matter expert on gender-
specific claims as a resource person in each regional office location;
      That the WVC is utilized to identify training needs and 
coordinate workshops;
      That the WVC have a presence in the local VHA system;
      That VBA ensure that all Regional Offices display 
information on the services and assistance provided by the Women 
Veteran Coordinator with clear designation of her contact information 
and office location;
      That VBA establish a method to identify and track 
outcomes for all claims involving personal assault trauma, regardless 
of the resulting disability, such as PTSD, depression, or anxiety 
disorder;
      That VBA perform an analysis and publish the data on 
Military Sexual Trauma (MST) claims volume, the disparity in the claim 
ratings by gender, assess the consistency of how these claims are 
adjudicated, and determine if increased training and testing are 
needed;
      That all claims adjudicators who process claims for 
gender-specific conditions and claims involving personal assault trauma 
receive mandatory initial and regular on-going training necessary to be 
competent to evaluate such claims;
      That the VARO create an environment in which staff are 
sensitive to the needs of women veterans, and the environment meets 
women`s needs for privacy, safety, and emotional and physical comfort;
      That the National Cemetery Administration enhances its 
targeted outreach efforts in those areas where burial benefits usage by 
women veterans does not reflect the women veterans' population. This 
may include collaboration with VBA and VHA in seeking means to 
proactively provide burial benefits information to women veterans, 
their spouses and children, and to funeral directors.

WOMEN VETERAN PROGRAM MANAGERS

    Women Veteran advocates call for congressional oversight and 
accountability during this Congress. We are weary of hearing that the 
position of facility Women Veteran Program Managers would be full-time 
positions, while in reality, after all this time, this isn't 
necessarily true. As a system-wide directive, the VA 2017 Handbook 
1330.01, Health Care Services for Women Veterans, defines the 
responsibilities of both the VISN and VAMC directors. Additionally, 
both WVPM positions are further defined in the VA 2018, Handbook 
1330.02 Women Veteran Program Managers.

MILITARY SEXUAL TRAUMA (MST)

    Currently, instances of sexual assault in the military must be 
reported through the chain of command. The creation of a separate and 
independent office to address such crimes would remove barriers to 
reporting and provide additional protection and safety for victims.
    According to the DoD Sexual Assault Prevention and Response Office 
(SAPRO), 71% of survivors of MST are under 24 years old and of lower 
rank; whereas just under 60% of assailants are between 20 and 34 years 
old and of a higher rank. Military groups are extremely small 
communities and when reports of assault must proceed through the chain 
of command, it is impossible to guarantee that confidential information 
will stay with those who have a `need-to-know'. Additionally, survivors 
may fear that their own actions may be cause for punishment. The threat 
of retaliation or fear of being reprimanded is enough to silence many 
survivors or have them recant their stories. A defined system of checks 
and balances is needed to level the playing field.
    VVA is aware that this issue is outside the purview of the House 
Veterans' Affairs Committee. However, VVA would urge members who sit on 
the House Armed Services Committee to join your colleagues in pursing 
legislation that reassigns MST complaints by service members and all 
alleged perpetrators outside of their immediate chain of command.

Suicide Risk

    Suicide has become a major issue for the military over the last 
decade. Most research by the Pentagon and the Veterans Affairs 
Department has focused on men, who number more than 90% of the nation's 
22 million former troops. Little has been known about female veteran 
suicide until recently. According to an LA Times article in July 2016, 
the suicide rates are highest among young female veterans--for women 
ages 18 to 29, veterans kill themselves at nearly 12 times the rate of 
non-veteran women. And, according to the Times, among the cohort of 
nearly 174,000 veteran suicides in 21 states between 2000 and 2010, the 
suicide rate of female vets closely approximates that of their male 
counterparts--women vets 28.7 per 100,000 vs 32.1 per 100, 000 male 
vets.
    VVA would like to thank Congresswoman Brownley for her hard work 
and dedication to women veterans, and we thank this Subcommittee for 
the opportunity to submit our views for the record.

IN CLOSING

    More than 250,000 women served during the Vietnam era worldwide; 
eight women are listed on the Vietnam Veterans Memorial here in our 
nation's Capitol. The Angels on the Wall listed below served with honor 
and made the ultimate sacrifice. Please remember them and all the women 
who served during the Vietnam War.

      1st Lt. Sharon Ann Lane
      2nd Lt. Pamela Dorothy Donovan
      Col. Annie Ruth Graham
      Mary Therese Klinker
      2nd Lt. Carol Ann Elizabeth Drazba
      2nd Lt. Elizabeth Ann Jones
      Eleanor Grace Alexander
      1st Lt. Hedwig Diane Orlowski