The current Global War on Terrorism, which is entering its 10th year, exemplifies the need to provide improved services for women veterans. Never before have women service members been engaged in unremitting combative environs. Women serving in Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) have adapted and magnified their military missions and roles from the norm of combat support and combat service support to leading patrols, conducting civil affairs engagements, flying attack aviation and lift aircraft, executing military policing duties, serving as combat medics, and many other military occupational specialties that put them “in the action” every day – safeguarding their own survival as well as the survival of their units.

 

Women Veterans’ Developments

This is not your father’s military. Today’s counterinsurgency battlefield is no longer linear, and long gone are rear echelon units. Women are no longer “in the rear with the gear.” Men and women serve together in close combat, patrol together “outside the wire” regularly, protect the population, and conduct humanitarian assistance missions in hostile neighborhoods – where the enemy wears no distinctive uniform. Enemy tactics and their choice of weapons are non-gender specific, are equal opportunity killers, and produce the lethality to maim all. Roadside bombs, indirect fire attacks, lethal ambushes, and precision sniper fire are all on the enemies’ attack menu. The biggest killer on today’s battlefield in both Iraq and Afghanistan is the improvised explosive device (IED), and it does not differentiate between males and females, hostiles or “friendlies.“ The IED is a

nasty weapon that if not instantly lethal, can cause numerous types of serious bodily injury, including concussions, traumatic amputations, loss of eyesight, and non-physical scars such as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). America’s female warriors today are enduring the same types of injuries that their male peers endure throughout the depth of the battlefield environment every day. Clearly, you don’t have to be “outside the wire” to feel the wrath of an enemy attack.

Women represent a large and growing segment of America’s veterans population:

• Women make up approximately 1.8 million of the nation’s 23 million veterans.
• Women comprise 7.8 percent of the total veteran population and nearly 5.5 percent of all veterans who use Department of Veterans Affairs (VA) health care services.
• The VA estimates women veterans will constitute 10.5 percent of the veteran population by 2020 and 9.5 percent of all VA patients.
• Women veterans are one of the fastest growing sectors of the veteran population.
• The largest groups of women Veterans today are ones who have served in the OIF/OEF operations since 9/11.
• Women make up 11.3 percent of OIF/OEF veterans.
• 49.7 percent of female OIF/OEF veterans have enrolled for VA health care. Of this group, 47.8 percent have used VA health care 11 or more times.
• 47.3 percent of female OEF/OIF veterans who used VA care during FY 2002-2009 were under age 30, compared to 43.1 percent of male OIF/OEF veterans.
• Through late 2009, the number of female veterans diagnosed with post-traumatic stress disorder nationwide reached 11,713, according to the Department of Veterans Affairs.
• The number of women in the military has doubled in the past 30 years, and they now comprise 14 percent of the active-duty force, 17.5 percent of the Reserves, and 20 percent of new recruits, according to an August 2009 report by the California Research Bureau.

These numbers are expected to double in the next decade, according to VA estimates. With the current battlefield geometry and active role of women in combat, there has been steady increase, growth, and progress made in the area of women veterans’ health care and service needs. There is more awareness of the importance of mental health and sexual trauma counseling and clinics run by women, for women. Congress acknowledges the changing dynamics of today’s fighting force and has been aggressive in seeking legislation to care for its wounded warriors. A recent milestone bill – S.1963: The Caregivers and Veterans Omnibus Health Services Act of 2010 – addressed the changing environment, and is a significant step forward to improving health care systems and capabilities to meet changing battlefield injuries as well as recognizing the needs of the women serving in today’s military.

On May 5, 2010, the Caregivers and Veterans Omnibus Health Services Act of 2010 was signed by President Barack Obama. During the signing, Obama said, “We’re forever mindful that our obligations to our troops doesn’t end on the battlefield. Just as we have a responsibility to train and equip them when we send them into harm’s way, we have a responsibility to take care of them when they come home.” This bill, that took two years to write and is the first of its kind, is finally bringing equality to both men and women veterans across the entire VA system. Part of the bill calls for expanding VA services for over 1.8 million women veterans currently receiving VA care or expected to enroll in the system. For example, VA for the first time will cover up to seven days of newborn care for enrolled female veterans. Other initiatives will force changes to the VA health care system to make it respectful of privacy and other needs of female veterans. The bill’s caregiver support provisions:

• fulfill VA’s obligation to care for the nation’s wounded veterans by providing their caregivers with training, counseling, supportive services, and a living stipend;
• provide health care to the family caregivers of injured veterans under CHAMPVA (the Civilian Health and Medical Program of the Department of Veterans Affairs); and
• require independent oversight of the caregiver program.

The bill also provides numerous other improvements for veterans, by:

•  expanding health care services for women veterans;
• • reaching out to veterans living in rural areas;
• • improving mental health care;
• • removing barriers to care for catastrophically disabled veterans;
• • enhancing VA medical services;
• • strengthening VA’s workforce; and
• • improving and increasing services to homeless veterans.

S.1963 also provides numerous other improvements for female veterans, including something called The Veteran Affairs Study on Women – Vietnam Veteran’s Era. After one of the fiercest conflicts in the history of war, disparaged by flag burners and rejected by many citizens of the United States, the participating service members in the Vietnam War are only recently getting the attention, recognition, and treatment they so rightly

deserve. Recently the women who so diligently served in all branches of service as professional nurses, physical therapists, occupational therapists, air traffic controllers, aerial reconnaissance photographers, intelligence and language specialists, legal officers, and in clerical positions are getting formal recognition and equal treatment. An enormous part of that recognition came when the VA announced a first of its kind study on women’s health issues from the Vietnam War era.

No study has ever been directed by Congress on the long-term health effects of military service on women. The Department of Veterans Affairs is beginning a complete study of women veterans who served in the military during the Vietnam War to examine the effects of their military service upon their mental and physical health. It will not only be beneficial to Vietnam-era women but also to the present and upcoming generations of women veterans. The purpose of the study will bring an understanding for forecasting and providing proper services for all women veterans. The outcome of the study is to improve assessment instruments and services for all. The study, which begins in November 2010, will last more than four years and will connect with approximately 10,000 women through mailed surveys, telephone interviews, and reviews of their medical records.

Approximately 250,000 women served in the U.S. military during the Vietnam War. Today, women Vietnam veterans are approaching their mid-60s, and it is vital to understand the impacts of the war as they relate to women’s health care issues. The study will explore and measure the relationship between PTSD and other mental and physical health conditions for women Vietnam veterans. It will also study participants who served in facilities in and around Vietnam, such as Thailand, the Philippines, and Guam. Women served alongside men throughout the Vietnam War in non-combat situations, and have earned the right to bring insight to others in terms of their experiences so the world can better understand the magnitude of their support.

 

Medical Facilities to Suit the Needs of Women

The VA’s Women Veterans Health (WVH) Strategic Health Care Group provides programmatic and tactical support to implement positive changes in the delivery of care for all women veterans. Services offered to the female veteran through the VA are ample. Women can receive the full spectrum of health care, including health promotion and disease prevention, primary care, women’s gender-specific health care, hormone replacement therapy, breast and gynecological care, maternity and limited infertility (excluding in-vitro fertilization), acute medical/surgical care, emergency and substance abuse treatment, mental health, homebound, rehabilitation, and long-term care.

Female veterans who have served their country in Iraq and Afghanistan are coming home, many in need of mental and physical care specific to women’s needs. The obligation to provide women’s health care on such a scale is new within the VA, and there are centers that are not prepared to treat female veterans. However, the VA has now required facilities to expand services for female veterans in their construction plans. In 2007, the change began when the Women Veterans’ Health program was elevated to a Strategic Health Care Group within the Office of Public Health and Environment Hazards. The following year, facilities across the country began receiving their portions of a $32.5 million investment in women’s health equipment, training, and supplies. In addition, the VA’s 2011 budget includes $217.6 million in funding for the gender-specific-needs of women veterans, an increase of $18.6 million over the 2010 level. The VA’s ultimate goal is to include gender-specific care at every VA site. With these changes, the VA has made it mandatory that each facility hire a full-time Women Veterans program manager to facilitate the changes.

Women veterans who are looking to seek care through the VA should contact the nearest VA Medical Center and ask for the Women Veterans program manager. Women can find a facility near them by going to the VA Web site.

 

The Lioness Film

When some people think of women in combat, they may think of someone like Joan of Arc, who successfully led French troops into battle against the English. But this is not the case in today’s counterinsurgency environment. Women’s mission profiles are just now coming into their own, and Operation Desert Shield/Desert Storm was an enormous turning point in their development. It displayed that the modern battlefield geometry between combat and combat support/combat service support were becoming more distorted. Allowing both men and women to strive for all military occupational specialties is not an equal rights issue, but one

of military efficiency. The military needs to have the best person in each job or situation, regardless of their gender. Operations Enduring Freedom and Iraqi Freedom have provided the venues for women to move into roles traditionally thought unsuitable for females, a trend which is likely to continue in the future.

Various media are gradually bringing to light the story of women in combat today. One example is the documentary Lioness, produced for Showtime. The film shows the role women are playing on the front lines in the war in Iraq. Team Lioness was developed to defuse tensions with the local national women and children on the objective during kill or capture raid operations. The film focuses on five of the earliest “Lionesses” and portrays their lack of training for these specific missions, their experiences in battle, and what it was like to return home to a domestic population that didn’t understand a woman’s role in the war.

The women in the documentary are women who did not have the same training as their male counterparts, yet ended up in fierce battles during full-spectrum combat operations. The documentary exposes the unexpected costs caused by using these female service members to neutralize tensions with local civilians (mothers and children) but resulted in their fighting alongside Marine combat units in the streets of Ramadi. When the turning point had been reached, the rise of the insurgency had eliminated the concept of a front line, and the support units in which women served were increasingly in the line of fire. The war was changing the face of America’s combat warrior; it was no longer exclusively male. The team that made the documentary said of their film, “It is our hope that Lioness can contribute to a national discussion of these issues and help us all to remember those who have served and who continue to serve in Iraq and Afghanistan.”

Military, political, religious, and world leaders will forever debate the causes and reasons for the United States and its allies engaging in Operations Iraqi Freedom and Enduring Freedom. But one thing will forever remain constant: that the costs of war are high, with the bill paid in the nation’s most precious treasure – its sons and daughters. Politics aside, OIF and OEF have delivered numerous lessons learned at the tactical, operational, and strategic levels, but more importantly, have caused our medical care and VA systems to re-evaluate how we care for our wounded, past and present, which now total more than 32,000 (OIF – 30,490, OEF – 2,309). It has also made us examine the differences in medical care for active duty wounded (26,056/79.4 percent) and National Guard and Reserve wounded (6,743/20.5 percent), where there should be no difference in care. And more importantly, it has determined that the wounds sustained on today’s battlefield may be different (or not) than those wounds suffered in previous conflicts. Today’s battlefield wounded should have specialized care to treat specialized needs. Female wounded warriors have specialized needs that should be addressed, and serious steps are being taken by the administration, our Congress, military leaders, and the medical community, including outreach to the civilian medical sector and schools, to bring the best care in the United States to those who have served their country on the front lines of today’s military conflicts.

This past year has truly been a milestone in women veterans’ health issues. The Caregivers and Veterans Omnibus Health Services Act of 2010 bill was passed and signed by Obama, taking great strides in bringing much needed health care to all veterans, including women veterans. The results of the Vietnam Veteran’s study can only help us better understand the scope and breadth of all wounded veterans, and improve the medical care for all veterans. Women are now engaging in ground combat and are victims of its devastation. The past decade has changed the face of the battlefield and the composition of U.S. forces fighting on it; the face of medical care for the women returning from those battlefields is finally changing to better support them when they come home.

This article was first published in The Year in Veterans Affairs and Military Medicine: 2010-2011 Edition.