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Good Morning Mr. Chairman, I am Dr. Linda Spoonster Schwartz, Associate Research Scientist at Yale University School of Nursing. I also have the honor of serving as Chairman of the VA Advisory Committee on Women Veterans during the period of the 1998 Report. I would like to thank you for holding these hearings and for your support of women veterans. I would especially like to thank Congressman Lane Evans for his continued leadership in introducing legislation, which has improved VA services and programs and significantly enhanced the quality of life for America’s 1.2 million women veterans. It is my understanding that the focus of today’s hearing is the 1998 VA Advisory Committee on Women Veterans Report. It is indeed a pleasure to be able to address the specific recommendations made by the members of the Committee and VA’s responses to those proposals.

As you know, the Advisory Committee was authorized by Congress in 1983 to assess the needs of women veterans with respect to compensation, health care, rehabilitation, outreach and other benefits and health care programs administered by the Department of Veterans Affairs. Additionally, the Committee was empowered to make recommendations for change and entrusted with the responsibility to evaluate these activities and report progress to the Congress in a biennial report. From that time to this, Committee members and advisors from all walks of life and all parts of this Nation have collaborated to improve the status of services and programs and assure that women veterans receive quality and gender specific care in a safe and secure environment.

It has been more than 15 years since I first came to this Hearing Room to voice the concerns of women veteran to this Committee. In that time we have seen great change. We have graduated from a time we did not know the exact numbers of women veterans in America to a time when women constitute the fastest growing population of VA eligible veterans. An increase which is also reflected in the increased numbers of women, who are using the VA today.

No doubt you have noticed that a common theme that runs through a majority of the recommendations in the Report has to do with the continued need for outreach and educating women about their eligibility for VA services and programs available to them as veterans. While many good efforts have been made on the local and national level to identify women veterans, the truth is that after 15 years outreach remains the number one priority for our Committee. We feel that new approaches need to be instituted to assure that women veterans are not lost in the system and that they receive the benefits that Congress, in the name of the American people, has authorized for them.

We have suggested that an orientation to VA programs and services be incorporated in basic military training. As a disabled veteran with 16 years Active Duty and Reserve military service, I can tell you I had no idea what the VA could do for me. At the time of my injuries, I was so impaired, I could neither think nor act on my own behalf. Everyone told me the "Air Force takes care of its’ own "but no one told me what happens when you have to leave the service for medical reasons. We believe that it is important for all military members, from day one of their service, to know and understand how to access their VA benefits.

Additionally, we have suggested that it is important that DOD Healthcare Providers be oriented to the VA Compensation and Pension Programs. We believe that instructing DOD Healthcare Professionals about the criteria for care and process of compensating military veterans will lay a foundation for a better understanding of the continuum of care for disabled veterans. We see that this will ultimately improve the quality of the documentation of injuries and illness incurred while on Active Duty and assist VA in making accurate and valid compensation decisions.

Additionally, we recommended that VA use the medium of professional medical nursing, social work and psychiatric journals to inform healthcare providers in the public sector about the availability of VA benefits and programs. This is especially important for women veterans, who still are unaware that their military service qualifies them for VA health care. With the increasing numbers of women entering the military, the restructuring of America’s welfare system and VA eligibility criteria than can change from one year to the next, it makes sense to educate health care professionals in private practice about the array of services and benefits available to veterans and the criteria for eligibility for these programs. As VA looks for more local venues to provide health care to veterans, it is important that non-VA professionals understand the unique needs and experiences of the men and women who have served in the military. The articles we suggested would be informational and will also assist health care professionals in the public sector to identify veterans and make appropriate referrals to VA.

In that same vein, the Committee has suggested that asking questions about veteran status on intake forms for federally funded social service programs and research projects would help identify veterans and their utilization of public support systems. This very procedure has been suggested by providers of services to homeless veterans to assist with outreach, allocation of resources and the development of community based programs. Instituting this process in a wider spectrum will not only facilitate needs assessments and delivery of services; the information can be used by VA for strategic and health care planning and policy.

Members of the Selected Reserve and National Guard

Today, members of the Armed Forces Selected Reserve and National Guard are an integral part of the defense of this nation. The demand on Reserve and National Guard units is great and not likely to decline in the near future. The issues, needs and concerns encountered by these "Citizen Soldiers" after incurring an injury or illness in the line of duty or while mobilized and/or deployed are difficult to address because of the precarious status of these individuals in relation to the military and VA eligibility.

The Committee put forth several recommendations regarding the benefits and informational needs of members of the Selected Reserves and National Guard. It is important that Congress assess the utilization of these troops in the defense of our nation and initiate measures which will protect these individuals when they are deployed, when they are injured in the line of duty and when they are injured while on in active duty for military training. We are very much aware of VA’s position that veteran status depends on the number of continuous Active Duty days.

As a Retired Air Force Nurse and Reservist, I can tell you that I had to meet the same training requirements as my Active Duty counterparts. There was no compromise of mission readiness in my unit because we were not on Active Duty. I can tell you something else, Reservists on inactive duty training are injured, they bleed and they have to deal with returning to a civilian job that often has no sympathy. I can tell you that Insurance Companies will not take care of them because their injury was sustained under provisions, which consider all military service to be "an act of war".

In my travels as Chair of the VA Advisory Committee on Women Veterans, I have listened to Reservists pose these very same concerns in several meetings. For them the issue of health care while they are in uniform and for their families when they are deployed is a major concern. Military Training is an integral part of the defense of this nation. It can be as dangerous as a combat mission. That is why it is imperative that the men and women serving in the Reserve and National Guard and their Commanders need to be educated about the process required to establish VA eligibility and access to care for disabilities sustained in the line of duty.

This issue of VA eligibility emerged as our Committee reviewed the eligibility for Reserve and members of the National Guard who are victims of sexual assault while on In-Active Duty status. As we learned more about the problem, we realized that this state of affairs is not only a women veteran issue nor is it solely a veteran issue. We believe that adequate health care for members of the Reserve and Guard components of America’s Armed Forces injured while on military duty is an issue of national security of sufficient importance to warrant the attention of Congress.

Since the problem of sexual assault and trauma in the military was first identified, VA has made a sterling effort to implement quality treatment programs through the Readjustment Counseling Service (RCS) and Veterans Healthcare Administration (VHA). Year after year, VA, Veteran Service Organizations, and veterans have returned to Congress to request a continuance for the present program. Surely by now, this Committee is aware that the need for this treatment program will persist as long as incidents of sexual assault and trauma continue to occur in the ranks of our military. For all practical purposes, this problem is not going away.

Indeed, there is no question that there is sufficient utilization of VA resources committed to treat veterans who were victimized while in the service of their country. Women of all ages and periods of service continue to seek assistance from VA for the physical and emotional aftermath of these traumatic events. The burning question to this Committee is why hasn’t this become a permanent program of the VA? As more is learned about the dynamics of sexual assault and trauma in a military setting, it is unquestionably a moral and ethical responsibility of the Congress to eliminate all restrictions and time limits on the VA’s authority to provide care to those who are victimized while in military service.

As noted earlier, under the current provisions of Title 38, VA is prohibited from providing sexual trauma counseling to Reserve and Guard personnel, who experience a sexual assault or trauma while on inactive duty training days because this does not satisfy the legal definition of Active Duty. It is important to note that incidents of sexual misconduct and victimization are not limited to Active Duty Personnel. The very sensitive nature of these incidents often delay victims from coming forward which complicates documentation, adequate reporting and therapeutic interventions. This is especially true for Reservists and National Guard personnel who may experience one of these assaults during a weekend drill. We understand that a legislative remedy is required to effect these changes. We encourage this Committee to consider this situation and devise a just and fair means of providing access to VA care to Reserve and National Guard personnel injured or assaulted on non Active Duty training days.

I would like to thank Congressman Lane Evans and Congresswoman Shelley

Berkley for taking the initiative to introduce this legislation, to amend Title 38 of the US Code Section (USC) 114 (k) and 38 Code of Federal Regulations (CFR) Section 3.350 (a) to include a Special Monthly Compensation K-award for veterans who have survived radical or modified radical mastectomy of one or more breast. The Committee felt this recommendation was in keeping with the spirit and intent of the existing law, which also authorizes an additional compensation for, the loss of both buttocks, loss of sense of smell as well as the loss of or loss of use of one or more extremities. The tenor of the present language to the law is one of compassion and concern for a veteran who has sustained an anatomical loss or loss of one of the vital senses..

In this case, the Veterans Benefits Administration of the VA did not concur with the recommendation on mastectomies. This is not the first nor will it be the last time advocates for women veterans will encounter policies, regulations, or legal barriers, which constrain VA ability to respond to women veterans. We appreciate that some of the laws and regulations for compensation were codified long before women were an integral part of our Armed Forces.

It is the Committee’s belief that radical and modified radical mastectomies involve a loss comparable to those presently covered by Title 38 and should qualify for the "Special Monthly Compensation K Award". For women, the outcome of these procedures frequently results in sever physical disfigurement which necessitates major reconstructive surgery and/or the use of prosthetics. In addition to the loss of physical integrity, the loss of a breast to a woman is the loss of an identifying feature, a secondary sex characteristic and a part of her persona as a female.

Mastectomy and the post-operative treatment for cancer can also precipitate premature menopause and infertility. Especially striking is the American Cancer Society report that one out of 3,000 American women who are pregnant report a diagnosis of breast cancer. VA Reports note that there is an increased number of eligible women veterans of childbearing age using health care services. Thus, we see that these dynamics pose real questions about the loss of a breast in the reproductive/creative process.

In addition to the question of breast-feeding and the ability to nurture a newborn, several factors may place a woman at higher risk for sexual problems following a mastectomy. There is the question of the loss of body image that comes with the loss of a breast and how that affects the ways in which a woman views herself and her body- her self-esteem, her hopes and fears and her place in society. There is the question of sexuality and how she will relate to her partner and express love physically and emotionally.

Psychological responses to the losses that mastectomies pose for women may persist long after the surgical procedure and physiologic recovery. Presently VA does have provisions for the care and treatment of psychological problems following mastectomy. However there is no additional increase in percent of disability of compensation. There is a need for VBA to review the present Schedule, which grants the same compensation for mastectomy to a man and a woman. The degree of loss is not equal. This is another challenge for the VA system to begin to officially acknowledge that the physiology of a woman does differ from that of a man and needs to be considered from a holistic perspective.

The recently completed and published VA study on the Reproductive Outcomes and Birth Defects of Children born to women veterans who served in Vietnam has evoked great interest in the Congress. We again thank Mr. Evans for his leadership on introducing legislation to compensate and care for children severely impaired by birth defects. We welcome these legislative initiatives and look forward to the day this program will begin to help the innocent casualties of the Vietnam War. However, I would be remiss if I did not say that in all fairness, our attention must now turn to investigating the problems of children with birth defects that were fathered by male Vietnam veterans. It is abundantly clear that the often cited Air Force Health Study, better known as the Ranch Hand Study, is should only be used to gauge the health of that particular group of Vietnam veterans. It is not an accurate reflection of the health status of the health and reproductive outcomes experienced by the majority of the men who served in Vietnam. For all practical purposes, there is no study of birth defects in children born to the men who served in Vietnam. In view of the pending legislation regarding women who served in Vietnam, this Committee must consider a comparable study of the birth outcomes of children of the men who served there.

One cost effective option that should be considered in revisiting the National Vietnam Veterans Readjustment Study (NVVRS). The strength of the study was the three comparison groups: Vietnam veterans with Era veterans and civilians. Congress used this study to estimate the needs of Vietnam veterans 11 years ago. We have suggested that returning to the NVVRS study subjects now would be extremely informative and valuable as a longitudinal look at how this generation of veterans has experienced the 25 years since the end of the war.

Women veterans who are homeless also have needs and problems that vary from those of male veterans who are homeless. These challenges range from privacy and childcare to treatment for physical and sexual abuse and prenatal care. It was with great enthusiasm that we welcomed the news that Congressional funding had specifically been set aside for programs for women veterans who are homeless. As we eagerly awaited the initiation of the process that would bring these vital programs on line, we witnessed yet another cruel reality of the "One VA".

The announcement that VA will be able to fund 11 projects for women veterans this year is a hollow victory. I say hollow because there is only one year of funding guaranteed for these programs. There is no question that VA’s Mental Health Strategic Health Care Group and the Homeless Provider Grant and Per Diem Program have achieved significant progress in meeting the needs of veterans who are homeless. However like several other "Special Programs" authorized and funded by Congress, the importance placed on these initiatives is lost in the maze

of funding mechanisms that characterizes the bureaucracy of the "One VA".

When VA’s Internal Policy Board ruled that money authorized for the Homeless Grant and Per Diem Program had to be spent in FY 2000 or it would revert back to the General Fund, the legislation passed by Congress to assist women veterans who are homeless was vetoed de facto. As a part of the RFP, VISN Directors were required to make a statement that if funded, they would commit, despite the availability of one year of funding, to keeping the program operational for 3 years. It is not difficult to see why some would be reluctant to make that guarantee. It has come to our attention that although sites for the funding are identified, VISN Directors are hedging their bet by using the money for temporary positions with no guarantees of employment for more than 12months. Mr. Chairman, this is not the program we envisioned. I don’t think it was the program Congress intended. However this is the program as it stands now.

In the past, money for special programs were "fenced" to assure that programs authorized and funded by Congress would be used for that purpose only. Funding streams at VA have been reduced to the level of a "shell game". Now you see it, now you don’t. Where did it go? Is it in the new furniture for the Directors office? Is it in a slush fund for discretionary project? Did it pay for someone to go to a Conference? We ask this Committee to take measures to protect this funding, preserve these valuable programs and in essence protect veterans with special needs.

Invisible Veterans

I remember my first Hearing on the VA in this room. The major topic that day was cosmetics in the VA Canteens. Now we have progressed to inquiry into the compensation for women veterans who are homeless and mastectomies. It has taken a great deal of effort on the part of Congress, Veteran Service Organizations and VA to increase the quality of benefit and health care delivery to women veterans. While it is important to note the many improvements that have occurred in the last 20 years, there is also evidence that there is still much work to do.

I was particularly disappointed as I read VA’s responses to the recommendations made by the Women Veteran Advisory Committee. For example the response to our recommendation that " all studies and surveys funded or conducted by VA must include gender specific information" was answered with a statement that "women can be expected to benefit from a much wider range of VA research studies. This seems to be a reasonable assumption given that many biological processes are common to both men and women" seems quite enlightened given the state of science in the 21^st Century. That VA would state for the record that " In the 1997 Women Patient Privacy Survey…. two thirds of the VA medical Centers responded as either having or in the process of developing programs/policies addressing patient privacy issues" is also disappointing given the fact that for the past 20 years protecting patient privacy has been the main thrust of our efforts and concern for women veterans in VA health care settings.

These responses coupled with observations made by the Committee on our site visits to specific facilities and VISIN’s, indicated that services and programs for women veterans are eroding. There is no doubt that there is a pervasive and disingenuous attitude that programs for women veterans are "window dressing" trivial or optional. We have encountered these sentiments at every echelon of the Department of Veteran Affairs. It is amazing how much the decision by a Chief of Staff, not to fill the position of a Gynecologist in a facility that served over 3,000 women veterans a year, can effect the overall functioning and efficacy of a successful program. We have also noted the funding of two Residencies in Women’s’ Health in a facility that does not even have a Woman’s Clinic. These are decisions that are not always made at the "Top". However they do illustrate that many only pay lip service to providing quality care for the women who have served in the Armed Forces of this Nation.

I know that this Committee has already acted to assure that the biannual reports

of the VA Advisory Committee on Women Veterans will continue to be forwarded by the Secretary of Veterans Affairs to the Congress. I believe that the stewardship of the responsibilities charged to the members of the Advisory Committee have been well served in the years since it was authorized. I also hope that the proceedings of today’s Hearing are not only informative but also provocative enough to warrant your attention and action.

Mr. Chairman, this concludes my testimony. I will be happy to answer any of the Committee’s questions.

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