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Female veterans face barriers to health care
Critics say VA not responsive to women’s needs
By Tara Bannow, The Bulletin, @tarabannow
Rhonda Gleason thought the Veterans Affairs doctor wasn’t listening. Turns out, she was right.
She’d driven more than three hours from her centeral Oregon home to the VA medical center in Portland, where most veterans are sent for cancer treatment. At 45 years old, she had been diagnosed with breast cancer for the second time in six years.
Since her last visit, she’d paid out of pocket to get a second opinion from a cancer doctor in Bend, who agreed she didn’t need chemotherapy, a crippling treatment she desperately wanted to avoid.
Her cancer is hormone dependent, so the only way to kill it is to deplete her body of estrogen.
“No. 1, she wouldn’t have needed chemotherapy and No. 2, it wouldn’t have worked anyway,” said Dr. Robert Boone, Gleason’s oncologist at the St. Charles Cancer Center.
Gleason relayed all this to the doctor in front of her. As if not hearing her, he grabbed the phone next to him and called a nurse. He asked when a room would be available for chemotherapy that afternoon.
“I go, ‘I’m not taking a port from you,’” Gleason said, referring to the devices used to infuse chemotherapy.
“He schedules the appointment, completely ignoring me. He goes, ‘I think you need to go walk around, really consider and come back. I’m sure you’ll come to your senses on this decision and get chemotherapy.’”
The VA declined to allow interviews with Gleason’s physician.
Female veterans for decades have faced significant barriers to accessing health care and mental health services through the Department of Veterans Affairs, which provides discounted health care to men and women who served in the military and were discharged under conditions other than dishonorable.
Advocates charge it’s a system still largely devoted to men — a population that comprises roughly 90 percent of veterans — and its providers don’t always understand female-specific services and needs.
Not only do veterans clinics not offer the physical services women need in some cases, but many women say its providers aren’t well educated on women-specific services.
Women are far more likely to be sexually assaulted during military service than their male counterparts, creating a unique set of needs and challenges, including post-traumatic stress disorder, which compound the difficulty of obtaining health care services. Many say they’ve had to jump through several hoops before being able to access sexual assault counseling.
Gleason thinks the doctor she saw at the VA treats far more cancer-stricken males than he does females with breast cancer — likely why he ordered for her the same generic treatment he might give to all breast cancer patients, rather than designing one that made sense for her case.
“He’s still in the old days,” she said, “because he serves men, not women.”
A growing role
Elizabeth Estabrooks in January became Oregon’s first women veterans coordinator, a new position within the Oregon Department of Veterans Affairs (ODVA) mandated by a 2015 state law.
The Army veteran spends most of her time traveling around the state hearing from female veterans who say they don’t get appropriate treatment through the VA.
“The VA was formed by men, for men, about men and still continues to be that every day,” she said.
A section of the VA’s motto reads, “To care for him who shall have borne the battle and for his widow, and his orphan.”
Estabrooks despises that motto. “But what about us?” she asks.
Women participated in U.S. war efforts long before Congress passed the 1901 law that formally carved out a role for them as nurses. Early on, however, the idea of women serving in non-nursing roles was controversial.
The need for women to serve in the military finally outweighed that controversy in 1942 when, about five months after the Japanese military attacked the U.S. at Pearl Harbor, Congress allowed women to enlist in noncombat roles. More than 400,000 women served in World War II, according to the National Women’s History Museum. Of those, 432 died.
Six years later, another law granted women access to veterans benefits.
Women are among the fastest growing subgroups of veterans. VA forecasting shows the number of male veterans will decline from about 18 million in 2020 to about 12.7 million in 2040. Meanwhile, the number of female veterans will increase from 2.1 million to about 2.4 million.
Between 2002 and 2012 alone, VA data show the number of female veterans using VA health care services had nearly doubled.
Of the roughly 321,000 veterans in Oregon today, just under 29,000 are women, according to the ODVA.
There are lots of differences between male and female veterans — some obvious, some not so obvious. Female veterans, for example, have higher rates of unemployment than their male counterparts: 5.4 percent in 2015 compared with 4.5 percent among males, according to the Bureau of Labor Statistics. That trend is reversed among nonveterans.
Women veterans kill themselves at nearly six times the rate of nonveteran women, according to a 2015 VA study that tracked about 174,000 suicides between 2000 and 2010. Among male veterans, the suicide rate was one and a half times that of nonveteran men.
Homelessness appears to be growing at a faster rate among female veterans compared with male veterans. The estimated number of homeless women veterans grew by more than 140 percent between 2006 and 2010, from 1,380 to 3,328, according to a Government Accountability Office report.
The report conceded that its data on the subject was limited, and likely did not encompass the entire homeless female veteran population.
During the same time period, the estimated number of homeless male veterans increased 45 percent, from 34,137 to 49,373.
Having experienced military sexual trauma greatly increases one’s risk of becoming homeless upon discharge. Military sexual trauma, or MST, is the term the VA uses to refer to sexual assault or harassment that happened while the veteran was in the military. It includes any sexual activity in which someone was involved against his or her will.
While MST strikes both men and women, VA data show 1 in 5 women seen at VA facilities experienced MST compared with one in 100 men.
In Oregon, 59 percent of female veterans reported experiencing sexual assault or harassment in the military, according to an ODVA survey published in October of about 600 female veterans.
Estabrooks was among the second wave of women to serve in the fully integrated Army in 1978, the year after a women-only branch of the Army disbanded and females began to serve side-by-side with males, except for in combat.
When she and her comrades got off the bus to begin basic training, five drill sergeants told them there was no place in the Army for women and the sergeants would do their best to make sure the women failed.
At that time, she said sexual harassment was “unrelenting and incessant.”
“They would literally hang out the windows and yell at me,” Estabrooks said. “They would form gauntlets when we had to walk past them to go to work and they would grab themselves, make obscene comments. If we were walking down the street, they would say something. We had no place to go.”
In recent years, women veterans and their advocates have helped turn the tide on women veterans’ treatment in the VA and their access to health care services.
One of the first big victories came in 1994, when Congress passed a law requiring the VA to create a Center for Women Veterans, whose role was to monitor and coordinate health care services for women veterans nationwide.
The Portland VA Health Care System, which serves Central Oregon, established its own Center for Women Veterans Health in 2010. The Center includes a women-only health care clinic in Portland, a feature many female veterans say is the only way they’ll access care.
Christine Krugh, a licensed independent social worker who took over as the Center’s manager in June, said VA providers tend to grow accustomed to caring for male patients. Her job is to make sure female veterans aren’t lost in the system.
“They have to stop and say, ‘Oh, women have different needs,’” she said. “It’s not like a provider in the community who has 50 percent men and 50 percent women, and they’re dealing with both populations on an equal basis every day.”
But the Center lacks a full-time gynecologist on staff. Instead, two gynecologists from Oregon Health & Science University spend one and a half days a week at the clinic, which had a wait time of about 12 days in October.
Portland is not alone in that respect. An Associated Press investigation in 2014 found nearly 1 in 4 VA hospitals did not have a full-time gynecologist on staff. The investigation also found about 140 of the 920 community-based VA clinics in rural areas did not have designated women’s health providers, despite the VA’s goal that every clinic would have one.
In Oregon, female veterans can choose to receive care at the women’s clinic in Portland or at their local outpatient clinic. Both clinics have what’s called “women proficient providers,” meaning they receive training specific to providing care to female patients, Krugh said. The training includes education on services such as contraceptives, menopause, breast and pelvic examinations, bone-density testing and infertility.
Krugh said access is limited by the fact that few primary care providers have the training — only 22 in the Portland VA system, which covers Oregon and southwest Washington — have such training. Four of those are male.
Female patients who wish to see providers with female-specific training at outpatient VA clinics in Oregon, Washington state and Alaska wait about eight days on average, according to data provided by the VA.
To improve the situation, the system has hired an additional recruiter and set up a team that will study provider access issues, Krugh said. Provider salaries have also been increased to become more competitive.
President Barack Obama in 2010 signed a law calling on the VA to conduct an independent study into nine barriers female veterans said prevent them from receiving health care through the VA. The barriers were identified through about 8,400 interviews. Some apply to men as well.
The barriers include:
•The availability of child care while using VA services.
•The acceptability of integrated primary care, women’s health clinics or both.
•The gender sensitivity of health care providers and staff to issues that particularly affect women.
•The perception of personal safety and comfort in inpatient, outpatient and behavioral health facilities.
•The effectiveness of outreach for health care services to women veterans.
•The location and operating hours of health care facilities that provides services to women veterans.
•The comprehension of eligibility requirements for, and the scope of services available under, hospital care and medical services.
•The perceived stigma associated with seeking mental health care services.
•The effect of driving distance or availability of other forms of transportation to the nearest medical facility on access to care.
Lack of expertise
A common complaint among female veterans is that the VA’s physicians are so accustomed to treating male patients, they don’t have as much expertise when it comes to female-specific issues, such as fertility or menopause.
Female veterans can receive services like Pap smears, a procedure that screens for cervical cancer, and primary care through the VA. The VA does not offer obstetrics services or mammography, and instead pays for its female patients to receive those services from private providers. That’s not uncommon for civilian women, however, most of whom receive mammography screenings in separate clinics from where they receive primary care.
Some female veterans who have experienced military sexual trauma report feeling uncomfortable in typical VA clinic waiting rooms. Several women interviewed for this article said being surrounded by men who remind them of their assailants can trigger flashbacks, especially if the other patients try to talk to them or sit by them.
VA clinics aren’t necessarily safe spaces for women, Estabrooks said. She’s personally been to five VA hospitals, and Portland was the only one in which she wasn’t verbally harassed by other patients.
Being a female veteran going into a VA clinic, you try to make yourself invisible, she said.
“You have your earbuds, you have your reading material,” Estabrooks said. “You sit away from them. You don’t make eye contact with anybody.”
Military sexual trauma
One thing Estabrooks sees as a pivotal part of her role is removing some of the unnecessary red tape around seeking the VA’s assistance for military sexual trauma, thereby avoiding the chance that the veteran will have to go through the excruciating task of retelling the story to several different providers.
“Women don’t want to have to tell their story,” she said. “They don’t want to tell those gruesome details, but they feel like they have to.”
At one VA clinic, for example, the system was set up so that patients first had to make appointments with their primary care providers in order to be referred to a military sexual trauma coordinator, who would then refer them for counseling.
“So not only did she have to tell her story to each of those contact points, then she had to wait three to four weeks for an appointment with a primary care provider then wait again for an appointment with a military sexual trauma specialist,” she said.
Today, any veteran, even if that person does not have a claim for service-connected disability, can get counseling for military sexual trauma without having to first get approval from a doctor.
Every VA clinic is required to have an MST coordinator to answer questions about the issue and the services available through the VA, including counseling and support groups.
There are several ways to arrange an appointment to arrange counseling for MST, Krugh said. A veteran could either call their system’s MST coordinator, call the mental health clinic directly or call their primary care provider and tell them what type of referral is needed. Veterans can also call a crisis line to be connected with counseling, she said.
“There are a lot of doors to get to the services you want,” Krugh said. “We want to make things easy.”
Military sexual trauma is very different from sexual assaults that happen outside the military, Estabrooks said. Some people say it’s almost more like incest, because from day one, you’re told your comrades are your siblings, she said. Your superiors are your parents.
“When you’re raped or assaulted or sexually harassed, oftentimes it’s by the people you have been told are your family members that you’re safe being with, or it’s by somebody who is considered your mommy or daddy or next up the line,” she said. “When you try to get help, there is no help there.”
‘There are female vets’
Whenever Gleason shows up at a VA clinic, she said the person behind the front desk assumes she’s there for her husband. One time, she went to the VA medical center in Portland to pick up medical records. She provided her name and the last four digits of her social security number, and then was told to wait.
“He calls me back up and said, ‘Do you have authorization to pick this up? I understand you’re his wife, but you have to have actual written authorization from him,’” Gleason said. “I’m like, ‘For who? Let me educate you. There are female vets.’”
Gleason showed him her veteran ID card. She didn’t get an apology.
Shortly after her second breast cancer diagnosis, she had her ovaries removed, per her doctor’s recommendation. She has completed radiation treatments, but is still taking a medication to block estrogen production – which happens in the body’s adrenal glands in addition to the ovaries — and another that makes it more difficult for her cells to respond to the hormone.
Boone, her oncologist at St. Charles, said she’ll likely be cured. He praised Gleason for sticking to her guns and refusing chemotherapy.
“I think if Rhonda was less of an aggressive woman, she might have just said, ‘Well, the doctor said I need chemo, I’m just going to go ahead and have it,’” he said. “When that happens, the doctor is being what we call paternalistic. Like, ‘You don’t know what you’re doing. I’m the boss. This is what we’re going to do.’”