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How we’re failing our female veterans

From ill-fitting equipment to an ill-equipped VA medical system, we must do better.

Greta Rybus

Navy veteran Ruth Moore at her Maine home, holding a portrait of herself in uniform.

ON A RECENT MONDAY MORNING, Ruth Moore and her family stopped for a late breakfast at the Denny’s in Ellsworth, Maine. Their coffee had not yet arrived when an elderly man approached their table. Moore had never seen him before, but it took her only a moment to find signs he might be in trouble: the stains on his “World’s Greatest Husband” sweat shirt, the overgrown fingernails, the meekly held cap proclaiming him a veteran of three wars.

Moore wore amber-tinted glasses and a tight ponytail pulled high off her neck. She had a kind of beatitude about her, endowed by her time spent in seminary, perhaps, or her multiple black belts in martial arts. Or maybe it was because she’d spent so many years making peace with her role in a seemingly unwinnable fight.

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The reasons behind Moore’s demeanor didn’t matter to the veteran. Nor did the fact that she was accompanied by her husband, their adolescent daughter, and me — a reporter following them around. Something about Moore made the man want to talk only to her. He told her about where he had been stationed, about his wife who had died a few years back, about how he’d been taught never to shake a woman’s hand unless she offered it first.

Moore thanked him for his service and offered to connect him with the local VFW. She wrote down his name and phone number so she could check in on him. She told him again how much she appreciated his time in the military. And then she took his hand.

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“Thank you, sir,” she said. “I understand what your service means. I’m a veteran, too. US Navy.”

The man didn’t thank Moore for her service in return — if he cared that she was a fellow veteran at all, he didn’t show it. Instead, he joked about not wanting to flirt in front of her husband and then meandered away.

When asked, Moore says the man’s lack of recognition doesn’t come as a surprise. And she frankly prefers his response to some of the others she has received. She’s come out of stores to find that her truck, which has disabled veteran license plates, has been spat on. More than once, men have yelled at her for parking in a handicapped space, apparently assuming she’s taking advantage of a husband’s or father’s plates. They’ve told her she should be ashamed of herself.

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She’s heard that line a lot. She’s done believing it.

Moore, who is 46, grew up in Maine’s Washington County at a time when the median household income was around $10,000. Even by those standards, her family was poor. She enlisted in the Navy at 17. After finishing boot camp, she was sent to a duty station in the Azores. She’d barely been there three months when she was raped by her supervisor outside the station club. After she reported the incident to her chaplain, her supervisor raped her again — this time for snitching.

A few weeks later, Moore was diagnosed with chlamydia. She tried to kill herself and was medevaced to a military hospital in the States. She reported the rapes to her psychiatrist there. He misdiagnosed Moore with a borderline personality disorder, which resulted in her discharge from the military in 1987.

Back home, Moore’s parents didn’t believe her story. Her sister stopped speaking to her. Her first marriage crumbled. She spent a while living in a van, picking blueberries for a couple bucks a box. Meanwhile, symptoms of post-traumatic stress disorder began to emerge: debilitating headaches, insomnia, anxiety. She enrolled in college but found it hard to make sense of the textbooks. Still, she struggled through a master’s degree program in behaviorism and psychology. She became a special education teacher in Maine, then in Vermont, but panic attacks kept her from doing her job well, and she was eventually forced to leave her post. She applied for disability coverage through the Department of Veterans Affairs but was denied — eight times in all. Each one felt like a blow.

“I’ve gone through times that are really dark,” Moore says. “I’ve spent a lot of time hiding myself.”

Moore fought for 23 years before she received full recognition from the VA — not only that she had been raped but that it also had left her permanently damaged. Her brain scans resemble those of people with high-functioning autism. She still has unrelenting migraines. Anxiety attacks force her to pick outings carefully, and she never wants to be far from her vehicle when one strikes (hence the handicap plate). The tinted glasses help her process visual stimuli. “I might look fully functional, but I have a profound disability,” Moore explains. “These problems can’t be fixed or healed through therapy.”

It’s a story that has become common among women in the military. And Ruth Moore is dedicated to changing that. After receiving a $405,000 settlement for back benefits from the VA last year, she founded a nonprofit organization. She gave her name to a bill that would make it easier for survivors of military sexual assault to seek aid from the VA. And that, she says, is just the beginning.

“This is about getting dignity and respect for all veterans.”

AUGUSTA, MAINE- MAY 6: (Photo by Greta Rybus for the Boston Globe). AUGUSTA, MAINE- MAY 6: Veteran Holly Fleming, a former Air Force medic, gets her vitals checked by Health Tech Samantha Hinkley. (Photo by Greta Rybus for the Boston Globe).

Greta Rybus

The women’s clinic at Togus VA hospital in Maine, which opened in June 2014, offers veterans a full array of health services.

THE VA’S VETERANS HEALTH ADMINISTRATION is the nation’s largest integrated care system. Despite its more than 1,500 hospitals, clinics, and other facilities, the VHA is struggling to keep up with the influx of female patients. That number almost doubled between 2003 and 2012, from 200,631 to 362,014. It’s expected to double again by 2020.

Such escalation poses challenges to a system that once relied upon barracks-like facilities for patients, including open exam rooms and shared bathrooms. But far more important than infrastructure is the ability to provide the specialized care women need, says Patty Hayes, the VA’s chief consultant for Women’s Health Services.

“We’ve known for quite some time that women vets’ health is different than men’s health,” she says. “Historically, women have been an extreme minority at the VA, and many have felt invisible in our system. Now the challenge is figuring out how to ramp up fast enough for the women on our doorstep.”

Some aspects of VHA care are regulated by federal statute. Other aspects, like how dollars are allocated, are decided at the state level. Veterans Affairs has mandated that every medical center employ a program manager to coordinate care for female veterans. The VA also offers online courses and three-day “mini-residencies” to train doctors and nurses caring for female veterans. But VHA staff members, together with advocates and veterans, say these steps aren’t enough to meet the rapidly expanding number of women who need care.

Female veterans who use the VHA tend to be younger and more ethnically diverse than their male counterparts. Nearly 20 percent were on active duty in the Middle East (a percentage twice as high as male vets). They require specialized medical services, including mammograms and pap smears, along with labor and delivery and neonatal expertise. As they age, they will also require hormonal therapies, cardiac care, and hospice services in increasing numbers.

In the meantime, they report significantly higher rates of unintended pregnancy, rape, and domestic violence than civilian women. They are more likely to be homeless or unemployed than either civilian women or male veterans. They are also more likely than male vets to return home with PTSD and musculoskeletal damage, particularly in their backs, hips, and feet.

According to an Army task force created in October 2012, some injuries sustained by women on active duty are caused by ill-fitting gear. That doesn’t surprise Jennifer Hogg, a cofounder of the Service Women’s Action Network, an advocacy group seeking to end discrimination in the military. When she was a mechanic for the National Guard, Hogg was told her unit didn’t have steel-toed boots small enough for her size 5 feet. Instead, they found a pair of lesser-quality boots that lacked the arch support and what she calls “the bells and whistles” seen in the standard-issue models worn by men. “Those boots caused me a ton of pain,” Hogg says. “I don’t think it was a coincidence I was eventually discharged for foot problems.”

Just how big a problem ill-fitting gear is for female soldiers is difficult to determine. The VA does not keep statistics on the issue, and recent reports of retaliation against whistleblowers in the VA have made other care providers reluctant to speak on the record.

When I asked a VHA care provider about gear-related injuries, she told me about female patients with back problems. “They were given boots several sizes too big and told to stuff extra socks in the toe.” She began to say more but was silenced by her public affairs representative. “We can’t say anything critical of the Department of Defense,” he said.

A spokeswoman at the Defense Department did not respond to questions about the extent of gear-related injuries in female soldiers, instead redirecting questions to the four military branches. “You’ve asked questions about uniform and equipment decisions that are made by the military services, so the answers would rest with them,” she wrote in an e-mail. “You should reach out to them for comment.”

Greta Rybus

Katelyn Labbe gets her vitals checked at Togus.

Navy spokesmen did not return phone calls regarding the matter. An Air Force representative said women in that branch have access to female-specific boots but not body armor. The Army has just 2,963 female-specific body armor vests in circulation for its more than 74,000 female soldiers. A spokeswoman for the Marines said that branch is “monitoring” the Army’s development of gender-specific body armor but doesn’t issue any of its own. She said the Marines used to offer a female-specific boot but stopped “after data showed a lack of use and a preference for the male-sized boot.”

Concerns over women-specific gear and medical attention don’t end with service. Women who have returned from the Middle East missing limbs, for instance, demonstrate higher rates of prosthetic limb rejection and chronic pain than male patients. Last year, officials complained of reports that VHA providers were forced to fit female amputees with sanded-down prosthetics originally designed for men.

IN MANY WAYS, New England is leading the fight to improve health care for female veterans. US Representative Niki Tsongas, a Lowell Democrat, has championed legislation to provide more female-specific gear in the military, some of which is being manufactured at the state’s Natick Soldier Systems Center.

“We must ensure that servicewomen receive the same quality resources and protections as servicemen,” Tsongas says. “Continued scrutiny, including continued congressional oversight, can ensure that the development and implementation of modernized and gender-specific body armor makes its way to the troops it is intended to protect.”

Tsongas is one of 12 women serving on the House Armed Services Committee. Seven women (including both New Hampshire senators) also serve on the Senate committee — the most in congressional history. Senator Jeanne Shaheen credits that record number with positive legislative changes, but the Granite State Democrat says Congress still needs to do more.

In 2013, she sponsored an amendment that allowed female servicewomen to seek an abortion in the case of rape or incest (all other abortions, along with abortion counseling and in-vitro fertilization, were banned at the VHA in 1999). This session, Shaheen also proposed legislation that would make birth control more widely available to women using the VHA.

“I don’t think it’s right that women who are putting their lives on the line for our safety don’t have access to the same care as civilian women,” Shaheen says.

US Senator Susan Collins, a Maine Republican, agrees. Earlier this year, she and Senator Angus King, also of Maine, again cosponsored the Ruth Moore Act, which would make it easier for survivors of military sexual trauma to receive benefits and treatment for conditions resulting from their assaults. The bill was passed in the House last year, but it never made it out of the Senate.

“Even in a time of severe budget constraints such as we are living in now, we cannot shortchange our veterans,” Collins says. “It is simply not fair to ignore, limit, or discourage legitimate claims.”

Both male and female veterans are victims of military sexual trauma. However, women are disproportionately affected. The VA’s Women’s Health Sciences Division, which is located in Boston, has spearheaded much of the research concerning female veterans and military sexual trauma. They contend that nearly 1 in 4 female VHA patients has been sexually assaulted or repeatedly sexually harassed while on duty. A study released by the Rand Corporation in December estimates that about 19,000 active-duty servicewomen endured unwanted sexual contact last year. Advocacy groups contend both statistics are actually much higher, but victims tend not to report their attacks for fear of retaliation — and theirs is a very real fear. According to that same Rand report, 62 percent of women who reported unwanted sexual contact experienced at least one form of retaliation.

Greta Rybus

“In so many ways, we weren’t ready to meet the needs of our returning soldiers,” said LaRhonda Harris, women veterans program manager for Maine.

For LaRhonda Harris, the Maine VA’s women veterans program manager, caring for female veterans who have survived military sexual trauma has become disturbingly commonplace. Many suffer from severe PTSD and associated conditions. “In so many ways, we weren’t ready to meet the needs of our returning soldiers,” she says. “That’s particularly true for our female veterans.”

One of Harris’s clients was severely injured by an improvised explosive device while serving in the Middle East. The woman said she has healed from that trauma, but recovering from the rape perpetrated by one of her fellow soldiers is taking a lot more time.

The fear of such trauma has also compelled women on active duty to make choices that compromise their health. Many women returning from active duty in the Middle East arrive with vaginal or urinary tract infections or both. “They’re dehydrating themselves and avoiding latrines at night because they don’t want to be raped,” Harris says. They know they’re far more likely to be raped by a fellow soldier than killed by an enemy combatant.

The stress related from that concern can be significant, says Harris. She and the military sexual trauma coordinator at Togus, Maine’s VA hospital, have also seen patients suffering anxiety and what psychologists call “betrayal trauma,” which occurs when an individual has been misused or violated by an institution expected to support or protect that person.

THE FEAR OF MISTREATMENT can cause female veterans to avoid the VA altogether. That’s one factor that helps explain why even though some 360,000 women now use VHA for their health care, nearly 2 million women who are eligible don’t. And many don’t even know they qualify for care at the VHA, despite having served in the military for years.

That was true for Judy Atwood Bell, a 20-year Army and Army Reserve veteran from New Hampshire. Atwood Bell worked in military intelligence for 10 years before earning her nursing credentials and moving on to stints in the ICU of an Army hospital and a VHA nursing home. She suffers from depression, PTSD, high blood pressure, and arthritis in her neck, she says, all the result of being raped by a fellow soldier when she was a 19-year-old private at Fort Devens in Massachusetts.

Atwood Bell didn’t seek care initially — she was afraid that she might lose her security clearance. When the concomitant depression began to interfere with her ability to work as a nurse at a VA facility, a colleague suggested she go to the VA for her own treatment. Atwood Bell says that idea had never even occurred to her.

“I was like ‘Really?’ Here I was, having served in the military for 19 years at that point, and I still didn’t consider myself a veteran.”

Educating female veterans about the care available to them at the VA has become a major project for people like LaRhonda Harris, especially after a recent report published by the American Legion indicated that women’s failure to identify as veterans was one of the primary barriers to their care (that same report also identified a need for more specialized providers, particularly in the areas of gynecology and therapists for military sexual trauma). Other studies, including some authored by the US Government Accountability Office, cite the backlog of unresolved claims at the VA’s benefits division as a significant issue.

Atwood Bell knows more about these issues than she would like. Like Moore, she had her claim for disability denied for years (it was eventually resolved in 2014, more than 15 years after she first applied). In the meantime, she joined a group therapy program offered through the VHA. It helped. But her visits to VHA medical centers are not without their own trauma. She used to go to a clinic in Massachusetts, but she was often the only woman in the waiting room. She says that, while there, she was harassed by both staff members and male patients.

“Walking into that place with all those men staring and jeering at me brought back lots of flashbacks. It’s too much. Why does a woman need that? I joined the military in 1978. I volunteered. I didn’t have to go, but I was proud to serve my country. I deserve to feel safe now.”

According to Patty Hayes, the VA consultant, experiences like Atwood Bell’s are all too common. “We’ve recognized that one of the main barriers to women is the culture of the VA. Women veterans feel like they’re walking the gantlet when they arrive for appointments. They’re being catcalled — and even worse — by male vets. They’re asked if they’re lost or waiting for their husbands. They don’t get recognition that they are soldiers.”

Greta Rybus

The women’s clinic at Togus includes a female-only waiting area and a private lactation room (pictured).

The VA has introduced an educational campaign aimed at promoting respect at its facilities. They’ve hung posters as reminders that women have served, too. “But we recognize that we haven’t done enough,” says Hayes. She thinks training will need to go beyond care providers to include every level of staff at clinics, including security guards and janitors. It will also require a major dispositional shift in male veterans, particularly those of older generations who may not have served side by side with women.

Atwood Bell isn’t content to wait for that to happen. She points to VHA facilities like the one at Vermont’s White River Junction, which has a private entrance for women. She’d like to see those kinds of accommodations across the country. “It is imperative that our needs are met now,” she says.

At Togus, in Maine, female veterans can choose to be seen at the main clinic or at a separate women’s clinic housed in a different building. There, an enclosed waiting room includes a play area and toys for kids. Private exam rooms are painted a muted green. Glass etchings of trees obscure windows, and separate consultation offices allow women to meet with care providers before exams.

While on a recent tour of the clinic, which opened about a year ago, I am taken by Harris to a small, warmly lit room furnished with a large, comfortable chair. “This is our lactation room,” she says. “Who would have ever thought we’d see the day when the VA has one of these?”

Harris would like to see every VHA facility in the country offer a clinic exclusively for women. “They at least deserve a choice,” she says, “even if they decide they’d rather not be segregated.”

In the meantime, she and her staff are working on logistics, such as where to locate the office of the military sexual trauma coordinator. Traditionally it’s been housed in the women’s clinic, but male survivors of sexual assault felt feminized there, Harris says. She kept the office where it was, but arranged for a separate waiting room. She spends a lot of her day ironing out problems like that, and they all take money to solve.

Earlier this year, President Obama proposed an 8.3 percent increase in funding specifically for women’s programs at the VA. Harris knows it will take more than that. For her part, Atwood Bell is hopeful more funds will be spent on outreach as well. “There are so many women veterans my age or older that have remained silent and alone or have committed suicide because they’ve given up.” It’s because of them, she says, that she can’t give up.

Greta Rybus

In her mobile office, Ruth Moore will travel to VHA facilities around the country to educate veterans about military sexual trauma.

Neither can Ruth Moore. Earlier this spring, she used some of her settlement money to buy a camper, converting it to a mobile office that can be towed behind the family truck. She’s started an organization called Internity to provide advocacy and assistance for survivors of military sexual trauma, and has been invited to run educational programs at VHA facilities across the country. She’s planning on logging thousands of miles over the next couple of years as she seeks to train a new generation of caregivers.

Atwood Bell has joined the board of directors for Moore’s Internity. So, too, has Stephanie Grant, an Iraq war veteran who was diagnosed with PTSD and traumatic brain injury after she was attacked by other members of her National Guard unit. Grant, who lives in Farmingdale, Maine, credits people like Moore and Atwood Bell with her recovery.

“We are people who have pulled ourselves up out of a dark hole,” she says. “I’ve gone from wondering how I’m going to get through life to flourishing and really loving that life.”

Grant is in the process of completing a bachelor’s degree in psychology. When she’s done, she hopes to get a job or volunteer at a group home specializing in veteran care.

“I’d like to become a counselor for veterans like me,” Grant says. “I want to help build them back up.”

Kathryn Miles, a writer based in Portland, Maine, is the author of “Superstorm: Nine Days Inside Hurricane Sandy” and other books. Send comments to magazine@globe.com.

By The Numbers

1865 — The year President Lincoln created the National Asylum for Disabled Volunteer Soldiers, a precursor to the Veterans Health Administration

1866 — The year the first veteran was admitted to Maine’s Togus, the national program’s first home

1928 — The first year women were admitted to the homes

1980 — The first year the US Census asked women if they were veterans; 1.2 million said yes

1988 — The year the Women Veterans Health Program was established

2.2 million — Estimated number of female veterans of the US Armed Forces

280,000+ — Number of female veterans who served in Iraq and Afghanistan

362,014 — Number of female veterans who use VA medical services

950 — Approximate number of VHA hospitals and clinics

77 — Number of clinics classified as comprehensive women’s centers, with separate space wholly dedicated to female veterans

Related coverage:

- Haverhill residents mourn troubled Vietnam veteran

- New veterans’ services director has ambitious agenda

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