STATEMENT OF
MARGARET SEAVER, M.D.
MEDICAL DIRECTOR, WOMEN VETERANS HEALTH CENTER
VA BOSTON HEALTH CARE SYSTEM
BEFORE THE
HOUSE VETERANS AFFAIRS COMMITTEE
SUBCOMMITTEE ON HEALTH

October 2, 2002

My name is Margaret Seaver; I am an internist and primary care physician. I have been Medical Director in the Women Veterans Health Center at VA Boston Healthcare System for three years. This past year we were recognized as a VA Clinical Program of Excellence. Our program was among the original eight comprehensive women's health centers funded by the VA in the early 90's. We provide a broad spectrum of women's health services both within our facility and on contract and fee basis. Medical and mental health services are highly integrated in our program. At our facility, we have the Women's Stress Disorders Treatment Team, which is part of the National Center for PTSD, we have one of the few women-only psychiatric inpatient wards in the country, the first transitional residence for women veterans, and the Women's Homelessness Program. Although primary care is at the core of our program, to adequately serve our patients, our women's health program must be much more.

You have heard about the great improvements that the VA has made in caring for women. The Women Veterans Coordinators provide essential services acting as advocates, case managers, and resources for patients. The mandate for all VA facilities to have a Women Veterans Coordinator has made the difference for many women as they enter the VA system and continue as our patients. The implementation of women's clinics and centers has contributed to a research-based body of knowledge about women veterans health and mental health, expert treatment of military sexual trauma, coordinated care for complex medical and mental health problems, improved quality of life for patients struggling with PTSD and its co morbidities, and excellent compliance with preventive health measures such as pap smears and mammograms. However, this is only part of the story. Fragmentation of care is still a major problem. A recent national survey in VA shows that many gender specific services are contracted out to community medical providers, or affiliates. Contract and fee basis arrangements for maternity, infertility, and sub specialty women's health services result in a layer of complexity that disrupts continuity of care. In order to overcome this issue, women's health programs need to have adequate staffing for case coordination. We also need support from administration to continue to provide this labor intensive care.

VA women's clinics were established because, unlike the private sector, where women make up 50 percent to 60 percent of a primary care practitioner's clientele, women veterans comprise less than five percent of VA's total patient population. As a result, VA clinicians are generally less familiar with women's health issues, less skilled in routine gender-specific care, and often hesitant to perform exams essential to assessing a woman's complete health status. Women veterans are different from male veterans, not simply because of their anatomy, but because they have different demographics, and their medical and mental health needs are different. For example, women respond to trauma differently from men, and women experience higher rates of sexual trauma and military sexual trauma than their male counterparts. The VA Women's Health Project found that 23 percent of women veterans report being sexually assaulted in the military and 55 percent report they were sexually harassed.

Women who report rape as their most traumatic experience have significantly higher rates of PTSD than men reporting combat as their most stressful experience. And women with PTSD have higher rates of substance abuse. There is a strong association between sexual assault and physical symptoms. Chronic conditions including diabetes, arthritis, and asthma are seen with increased frequency in women reporting sexual assault. Other physical consequences of sexual violence include pelvic pain, irritable bowel syndrome, back pain, headache, eating disorders, poor reproductive outcomes, digestive problems, and hypertension.

Research has found that women with a sexual trauma history have long-term high rates of healthcare utilization subsequent to the experience of assault. Research also suggests that women with sexual trauma histories present in medical settings with significant mental health needs and that performing invasive gynecological exams and other medical procedures on these patients may require particular sensitivity on the part of providers. Our center offers these services in a safe, private setting that women with a history of military sexual trauma not only prefer, but also need. These women would not come for care if they had to sit in a room full of men. Thus, our patients' care can be resource intensive. In order to minimize this fact, and to utilize our clinic space fully, we have developed a multidisciplinary clinic with specialists and primary care providers.

The story of Women's Health in the VA is one of success, of building an outstanding program in a few years. It was built on the foundation of the comprehensive women's health centers, and these centers still provide the highest quality care to women as evidenced by the fact that five of the original eight have been recognized as VA Clinical Programs of Excellence. We still have a great deal of work to do to train more staff to care for women, to combat the discrimination that still exists in the VA, and to contribute to the growing field of women's health through our research. I have personally cared for patients who could only have received the care that they did from the VA, because their issues were ones that the VA specializes in, such as military and sexual trauma and the PTSD that often results from these experiences. I am extremely proud of our women's health program, inspired on a daily basis by the dedication and commitment of my colleagues, and most of all honored to care for our nation's veterans. I hope I have been clear that many of the problems we face in caring for women stem from the fact that women in the VA are an extreme numerical minority. We need to continue to have separate women's health clinics in order to provide the services women veterans need and are eligible for, as well as the resources to provide primary and gender specific care in a safe and private environment. We need to have access to specialists, and case managers who have the time to spend coordinating the care of each women veteran. Thank you for listening to my testimony.