Despite strides by the Veterans Health Administration to accommodate 400,000 women, the fastest growing population using VA hospitals and clinics, legislators and patient advocates say there are still big gaps in care.

The VA Palo Alto Health Care System has been a model of gender-specific primary care and mental health services for women. But in many other areas of the state and nation women VA patients, 25 percent of whom have been diagnosed with Post Traumatic Stress Disorder (PTSD) related to Military Sexual Trauma (MST), are receiving fragmented care in facilities that are often not welcoming to women.

Roughly one third of VA medical centers don’t have a full-time gynecologist on staff. Seventy-five percent of patient mammograms are done in the private sector, making results and reminders difficult to track. And many VA centers don’t provide facilities in which women feel comfortable getting care.

In March 11 members of the House Committee on Veteran Affairs sent a letter to the VA Inspector General’s office requesting an inspection of the VA’s policies for meeting the needs of women, specifically regarding privacy concerns and basic and complex gynecological services.

Congresswoman Julia Brownley (D-Westlake Village) was one of them. In an e-mail response to questions she wrote that “The Oxnard CBOC (Community-Based Outpatient Clinic) and West Los Angeles VA Medical Center certainly need to improve services for women veterans.”

Kara Mahoney, a staff attorney representing women vets for the nonprofit Inner City Law Center in Los Angeles, has a client who said it’s very painful to get treatment at the West L.A. VA because of the cat-calling from male veterans.

“Often women don’t associate as being a veteran because they’re still so marginalized in the community,” Mahoney said.

The same is true at the San Francisco VA, said Army veteran Victoria Sanders, who was raped in the military. She said at VA facilities she gets called “sir” by people who don’t bother to look at her first name on paperwork. And getting to the women’s clinic through hallways and elevators filled with men is “like running the gauntlet,” she said.

To address these kinds of issues five years ago, the Palo Alto VA created a Women’s Health Center with interdisciplinary teams. A women being treated for breast cancer can see a surgeon, an oncologist and a physical therapist in one visit, said Center Director Samina Iqbal, who is also an internist. And mental health services are embedded in primary care with a psychologist available right down the hall if during a visit a patient needs to be seen for anxiety, depression or MST issues.

Sanders said she got excellent one-on-one treatment at the Palo Alto VA for her PTSD related to her military sexual trauma. But when she moved to Novato, she said care at the San Francisco VA was awful. She never got any therapy and she had trouble getting appointments for primary care visits. Now she drives two hours to the Palo Alto VA for medications, dental and eye appointments. But she also has Medicare and private insurance as well and now gets most of her care outside the VA, she said.

Saunders is not alone. One third of all women VA patients get some health care outside the VA, reported the Department of Veteran Affairs in its 2014 publication Sourcebook Vol 3.

Patricia Hayes, Chief Consultant for Women’s Health Services for the VHA, said that tracking the results of mammograms done in the private sector has been challenging in her April 21 testimony to a Senate Committee addressing access and quality of care for women at the VA.

But she said a new information technology system, which should be completed by the end of the year, would improve their ability to track such data.

In its struggle to incorporate the unique needs of women into a system built on serving men for the last 200 years, the VA has trained more than 2,000 women health providers and has established a designated woman’s health provider at all of its medical centers and 90 percent of its Community-Based Outpatient Clinics, Hayes told the Senate Committee.

Joy Ilem, deputy national legislative director for the nonprofit advocacy group Disabled American Veterans, applauds the VA’s significant progress since it launched its five-year plan in 2008 to redesign its delivery system for women’s health care. But there’s still a long way to go, she said.

She maintains there is enough volume of women patients at VA medical centers now to warrant gynecologists at all centers. Her organization released a report last year, Women Veterans: The Long Journey Home, which states that one third of VA medical centers don’t have a gynecologist.

“They should be your team leader if you have a difficult case or concern,” she said.

Senators Dean Heller (R-Nevada) and Patty Murray (D-Washington) introduced S. 471, the Women Veterans Access to Quality Care Act, in February. The Act would require every medical center to have a full-time obstetrician and/or gynecologist.

Like Sanders, Lurae Horse has also experienced vastly differing care at VA facilities. At 17 she became a B52 mechanic for the Air Force during the Grenada Conflict. She was raped four times on the job over three years. Her first attacker threatened her with a dishonorable discharge if she reported it. So rather than lose her financial stability, a job she loved and her health benefits, she kept quiet.

Those attacks left her with with PTSD and she now takes medications to keep her from dreaming at night, as well as for pain and vertigo.

But she has had trouble getting some medications and therapy from the Long Beach VA. Over the years at the VA back home in Hot Springs, South Dakota, and in Wichita, Kansas and Fort Collins, Colorado she received her medications with no trouble as well as PTSD sessions with Ph.D. therapists. In Long Beach her therapist retired and they offered her 12 weeks of therapy, which she declined, saying she needs it long term.

“It makes no sense when you’ve got 22 vets a day committing suicide,” she said.

The Palo Alto VA has an in-patient Women’s Trauma Recovery Program in Menlo Park for patients suffering from PTSD. They can live there for up to three months. But there are only seven such programs nationally.

“Palo Alto is excellent …and has everything you would want to see for women vets,” Ilem said. There just aren’t enough VA facilities like that, she said. She applauds the VHA’s efforts so far and the work done by Hayes’ Women’s Health Services program office.

“But customer service for women vets needs to be equal to men,” she said. “They need to dedicate resources through interagency strategic plans, not through one small program office. It’s everyone’s responsibility to care for our women vets.”