Women have served in every U.S. military conflict since the American Revolution, but it wasn’t until 1923 that Congress directed the Veterans Health Administration (VHA) to provide hospitalization and medical services to women veterans. At the time, women comprised a very small minority within the VHA, in a system designed, understandably, to serve the needs of men. The proportion of women service members began to increase slightly after 1973, when Congress lifted a legislative limit on women’s military participation, but women were still, by the end of the 20th century, a fractional subset of the overall veteran population.

That minority has been growing rapidly since the 2001 onset of the wars in Iraq and Afghanistan. Today more than 2.2 million women account for about 8 percent of the total veteran population, and the Department of Veteran Affairs (VA) estimates that 10 percent of veterans will be women by 2018. These women veterans are increasingly seeking access to VHA’s services; from 2001 to 2010, the number of women veterans using VHA nearly doubled. More than 360,000 women veterans currently use the system.

Today more than 2.2 million women account for about 8 percent of the total veteran population, and the Department of Veteran Affairs (VA) estimates that 10 percent of veterans will be women by 2018. These women veterans are increasingly seeking access to VHA’s services; from 2001 to 2010, the number of women veterans using VHA nearly doubled. More than 360,000 women veterans currently use the system.

While the health and care of women veterans has always been important to VA, their limited and dispersed numbers created many challenges for the VA healthcare system in meeting their special needs, as well as in conducting research to better understand how VA could best improve their health and healthcare.

In 2004, the VA convened a conference to formulate a comprehensive research agenda to bring focus to the unique healthcare needs of the growing number of women veterans, and the challenges in improving access to comprehensive quality healthcare in a healthcare system still largely unaccustomed to caring for women. This agenda-setting effort also laid the groundwork for development and assessment of new VHA program and service innovations aimed at meeting all of the healthcare needs of women veterans.

Since the first agenda-setting conference in 2004, research on women veterans has expanded exponentially: In the 1990s, there were 15 researchers addressing the health of women veterans; today there are more than 200. Between 2004 and 2008, more research was published on the health of women veterans than in the previous 25 years combined. This dramatic and critical expansion of knowledge about the health and healthcare needs of women veterans continues. Several special journal issues in the last several years, such as Women’s Health Issues July/August 2011, and the Journal of General Internal Medicine (July 2013) have been devoted to research on women veterans and women in the military. This growing evidence not only informs VHA programs and services, other researchers, and women veterans, but has put VA at the “forefront of women’s health research and quality improvement” and identified it as a model for those “interested in promoting healthcare for women,” wrote Carolyn Clancy, former AHRQ director, in the aforementioned edition of Journal of General Internal Medicine issue.

Linda Lipson, who manages the VHA’s scientific research portfolio focused on improving the health and care of women veterans, said that these research projects are not only more numerous, but they also, with the guidance of continual VHA researcher and program input as well as important research conferences (the second and most recent was held in 2010), converge on issues most important to the needs of today’s women veterans.

“That first agenda-setting conference helped establish initial research priorities we wanted to look at – the gaps in what we knew about women veterans, their health and their healthcare,” said Lipson. “More recently, we’ve identified new and expanding research priorities, including a focus on finding ways to translate our research findings into practice sooner and more effectively, and to begin implementing innovations in care that will make a real difference to women veterans.” Much of this research is funded by VA’s Health Services Research and Development Service (HSR&D).

 

Gender-Specific Issues for Patient-centered Care

HSR&D investigators conduct long- and short-term research projects on a variety of topics, including studies designed to determine gender differences in veteran health, special health considerations for women, and also what are termed gender-specific healthcare needs, for example those related to gynecological and reproductive care. Many of these studies are related to the health effects of military service, and deployment in particular. While recent VA studies have revealed that women veterans are as resilient as men in terms of mental health, for example, they are also far more likely to suffer sexual trauma while deployed. This sexual trauma has been associated with a number of adverse outcomes, including posttraumatic stress disorder (PTSD) and homelessness.

In February 2013, a team of researchers from the VA in Los Angeles published results from a national survey of women veterans establishing the prevalence of PTSD among them. The study was the first to quantify the rate of PTSD among the entire women veterans population, as opposed to smaller subsets such as women who use VHA care or who served during a specific war era. Among a sample of more than 3,600 women of all ages from across the United States, more than one in eight – 13 percent – screened positive for PTSD.

VA research has shown that women veterans generally have a higher mental health burden than men. They are more likely to experience comorbidity – the presence of mental health symptoms along with other physical or physiological symptoms. Women veterans have also proven far more likely than men to use mental health services; these facts have led researchers – and also the VHA – to focus on how to provide more integrated mental health and physical health care in VA and meet women’s complex healthcare needs.

The current generation of women veterans has done much to heighten the VA’s awareness of gender-specific issues, and also has highlighted that women veterans have different needs and challenges in getting care based on other factors, with one important one being age.

“It used to be that you were seeing mostly middle-aged or older women [at VA facilities],” said Lipson. “And now there is also a large number of younger women as a result of the latest wars. Research really has to span that range of ages and also the diverse health needs of these different groups of women veterans. That’s why we’re doing more research now in the fields of contraceptive care and reproductive health care and post-deployment family functioning. But that doesn’t mean we don’t need to look at cardiovascular risk – that’s certainly an area that is getting more attention – and also long-term care issues.”

As the current generation of women veterans ages, VA hopes to be ready for its needs, and some studies have already been designed to look at the issues confronted by older women veterans – many of whom have served in theater during wartime and may have had direct exposure to traumatic events. In 2010, VA developed a cooperative study known as Health ViEWS (the Health of Vietnam-Era Veteran Women’s Study), which involved medical record reviews and telephone and mail surveys of close to 5,000 women who served during the conflict.

“These are primarily women in their 60s and 70s,” Lipson said. “The goal was to document aspects of military service, their experiences, what their health has been like since that time, and what it is now. We want to understand their needs but also learn something about the impacts of military service – even though obviously for women, it’s different now in the current conflicts than it was then, because women have been much closer to being in combat during this war even before they were technically allowed to be.”

The data from Health ViEWS is currently being analyzed, and Lipson – who expects it to become a milestone in women veterans’ health research – anticipates its results will be released soon: “It’s a really important study that will give us a lot of really good information in terms of looking at long-term effects of military service in women,” she said. “This, in combination with a number of studies we’ve already launched looking at the current generation and trying to follow them over time, will help us understand both the immediate and longer-term health consequences of military service and war.”

Reproductive and mental health are only two of the many healthcare and more gender-focused issues of women veterans being investigated by VA researchers; other studies are aimed at the cellular processes involved in breast and cervical cancers, intimate partner violence, the role of hormones in aging and stroke, homelessness among women veterans, barriers to care, effective treatment for PTSD in women, prosthetics designed for women, and chronic diseases or conditions.

These studies reveal the VHA’s patient-centered focus: In delivering healthcare, it seeks to meet the needs of veterans in a way that aligns with their own preferences and requirements. The patient-centered philosophy is further evidenced by studies that seek to address subsets of the women veteran population. “One of the populations that’s been of growing interest to VA in terms of meeting their needs is the lesbian, gay, bisexual, and transgender [LGBT] population. A new Office of Health Equity was established within VA in the last year to further advance health equity in VA, and improving access and services to the LGBT population is one of their priorities as well. We have other research that is focused on other groups of women, including racial and ethnic minorities and rural women – who may need some special services and have different issues of access to care.”