NINETEEN

Compensation, Pension, and Other Benefits for Women Veterans with Disabilities

JACQUELINE GARRICK

American women have stood alongside the nation’s men from the moment the first woman stepped ashore at Plymouth. As a union was formed and defended, they have endured the same hardships and deprivations as their male countrymen. Women were equally patriotic and courageous—willing to risk life and limb for the creation and preservation of the United States. Women sometimes disguised themselves as men to join the Army since females were prohibited from military service until the Spanish-American War in 1901. However, there are a multitude of examples of women’s service that pre-date their entitlement to actual military service. The work these women performed was at times recognized at the state and federal level with various approaches to benefits and compensation based on the cultural and political will conforming to the era. Compensation and benefits were provided in various forms that included subsidence, sustenance, formal appointment, and pension. These benefits were outgrowths of the attitudes that informed remuneration policies as women went from patriotic volunteerism, religious charity, and civilian employment to actual military service.

The procession of patriotic women in service to this nation has been a constant; the recognition of a grateful nation however has undergone a sea change from generation to generation. The way in which we value this service has directly impacted the way in which we compensate women for their disabilities. Women to this day do not always recognize themselves as veterans, so they do not apply for the same benefits at the same rate as men. Furthermore, the clinicians that evaluate and treat them do not always understand or appreciate the circumstances of military women.

Although not in uniform, 20,000 female patriots during the Revolutionary War (1775–1783) provided their state’s militia and the Continental Army with support that they could not have done without. As the period of Enlightenment spread across Europe, the philosophies of medicine experienced progress in the 18th century, which also informed medical care during the Revolutionary War. As medicine moved away from a soul-saving engagement to addressing sanitary conditions, prevention, and mental health, armies and navies were a primary focus for reducing the spread of diseases, such as scurvy and typhus (Ackerknecht, 1982). As the importance of personal hygine and sanitation became better understood, the role of women in facilitating and performing these functions grew with public health acceptance. Performing activities that were considered appropriate for housewives, Revolutionary War women delivered food and supplies, cooked meals, spun and sewed clothes and blankets, washed laundry, spied on the enemy, couriered messages, and nursed the injured and the ill without compensation. Males who performed similar roles were considered professional merchants and service providers, and therefore were compensated until General Washington directed that the Continental Army Medical Corps establish a system for nursing in 1777 that had one matron supervising 10 nurses. The matrons were paid 50 cents a day plus a food ration and the nurses were paid 25 cents a day plus a food ration (Brooks, 2013).

Historian John Resch documents the trials and tribulations of the Revolutionary War minutemen and Continental Army soldiers. He describes battlefield deaths, wounds and infections, along with putrid sanitary conditions within the camps and improper clothing for harsh winters and long marches, which caused illnesses, such as dysentery and typhoid, to run rampant. He goes on to describe veterans with troubled minds, physical disabilities, and pauperism (Resch, 1999). Thirty-five years after the Continental Army’s disband and amid much controversy, Congress passed the 1818 Revolutionary War Pension Act, which finally recognized the reduced quality of life for those veterans who were suffering from injuries and illness that had resulted from their military service. Initially, the law required a means test so that only destitute Revolutionary War Veterans were eligible, but two years later that provision was repealed (Resch, 1999). Means testing is in effect today when determining eligibility for Department of Veterans Affairs (VA) healthcare eligibility for non-service connected¹ medical conditions.

Although Resch documents well the service and conditions of the men, he rarely notes the impact that the Revolutionary War had on its daughters. However, it would stand to reason that if wives, sisters, daughters, and other women were following the troops, then these women also got hurt, sick, and died without recognition or compensation, since the 1818 pension only applied to the men who actually wore a uniform. Even under circumstances when women impersonated men and fought valiantly, they were not afforded the same level of benefits or recognition as men.

Such was the case of Deborah Sampson, who joined the 4th Massachusetts Regiment as Robert Shurtliff and was wounded by a musket ball to her thigh and a deep cut to her forehead in 1782. Treatment at that time did not expose her gender, but she became ill a year later and was discovered, thus prompting her immediate discharge from the Army. She was awarded a veteran’s pension many years later, but only after a long bureaucratic battle. Sally St. Clair also dressed in men’s clothing. Her gender was discovered only when she was killed in 1779 at the Battle of Savannah (Blankenship, 2008).

Although the federal government did not recognize these women, there were occasions when the states stepped up to support their heroines. In the legendary accounting of “Molly Pitcher” (a nickname given to many women carrying water to thirsty soldiers), the actual Mary Ludwig Hays McCauley followed her husband, William, into the Battle of Manmouth with the First Pennsylvania Artillery, along with 400 other women (Blankenship, 2008). As was customary, they carried pitchers of water onto the battlefield to cool the cannons and the ramrods and hydrate the men, which in the summer of 1778 was essential since temperatures were very high. When William collapsed from heat stroke, Mary took his place at the cannon and fought on until the battle ended. Impressed with her valor and fortitude, General George Washington granted her noncommissioned officer (NCO) status in the Continental Army. From then on, she was known as Sergeant Molly. Although she was not eligible under the 1789² or the 1818 pension provisions authorized by the Continental Congress, in 1822 the Pennsylvania legislature awarded her an annual pension of $40, which she collected until her death 10 years later (Flanagan, 1996). She was buried with military honors.

The Pennsylvania legislature previously had granted pension to another female heroine whose story is similar to Mary’s. In 1776, during a battle against the Hessians at Fort Washington, John Corbin was killed in action, at which time his wife, Margaret, assumed his position at the cannon until she was badly wounded in the arm. In 1779, Margaret was the first woman in the United States to be awarded a military pension. Pennsylvania granted her a stipend of $30 and Congress later granted her a pension that was half that of the monthly allotment paid to soldiers plus a one time clothing allowance³ (US Army Women’s Museum—Ft. Lee, VA).

The War of 1812 again saw wives following their husbands to military camps. Perhaps to avoid the masses of women and children who were at camp during the Revolutionary War, some Army regiments instituted a lottery for enlisted soldiers’ wives so that only six could be in camp per 100 soldiers. These women took care of their own families and an entire unit (Ferguson, 2013). As the only benefit afforded these women, they were able to stay up to six months after their husbands died to give them time to grieve and make arrangements to return home. If she wanted to remain with the Army camp, she had to marry another soldier, which sometimes happened multiple times. Although war widows were already afforded pensions based on previous legislation from the Revolutionary Era, women opted to do this to ensure their protection and financial security (Women During the War, 2013).

Women during the Civil War served in many of the same capacities as in previous generations of war, providing laundry, cooking, and nursing support. These domestic activities were seen as being in the purview of women and a necessary support function to conserve the strengh of the fighting forces. By 1863, the Union was more organized in its approach to recruiting and retaining women into voluntary and professional positions. Servitude varied between Northern and Southern women, as well as the inclusion of free women of color and former female slaves. Although women were motivated by various factors ranging from patriotic beliefs, religious callings, widowhood, or indigence, remuneration for appointments played a key role in filling these crucial support positions. So, although women were not recruited to join the military, they were given appointments as civilian military personnel. Amid much confusion, spreading disease, and a paucity of male medical personnel, organizations formed, such as the US Sanitary Commission, Sisters of Charity, US Christian Commission, and Womens Central Relief Association, that unified the local aid societies, which assisted in the recruitment and placement of women in military hospitals and camps to care for and feed the troops (Straubing, 1993).

Well known for her reformation work with prisons and asylums, Dorothea Dix was appointed as superintendent in 1861 by the Army Surgeon General to establish the Office of Army Nurses and to create guidelines for selecting, appointing, and compensating Union Army nurses (Schultz, 2004). She established a pay scale based on the nature of the work and experience of the worker. Women of distinction and affluence often chose to support the wounded and ill through charity work and volunteered their nursing skills, whereas widows and poorer white and black women sought compensation for their work. Nuns were also recruited to care for the worst of the wounded and ill, especially those with highly contagious diseases. There were serious divisions of class labor between nursing, cooking, and laundering, which was the most physically taxing job, but the least paid, so often performed by the lowest class of white women or former slaves.

Nurses often experienced combat on the battlefield, as they lived in tents among the troops, ate with them, suffered the same hardships, and treated them on the battlefield. They dragged wounded soldiers back to their amulances, which they were deputized to drive (Schultz, 2004). Many of these nurses where shot or hit by shrapenel. Juliet Hopkins⁴ (shot twice in the leg), Annie Etheridge⁵ (shot in the hand), and Elmina Spencer (shot in thelower back) are examples of wounded nurses who, once recovered, returned to duty.

Women who worked around and aboard ships also suffered injuries or drowned by falling through hatches or between ships. Diseases, such as smallpox, measles, pneumonia, erysipelas, flu, diarrhea, consumption, and typhoid were still the most common causes of disability and death for these women, as they was for the men, but women were not compensated for these injuries or illnesses. Some of the nurses benefited from the Consolidation Act of 1873, which, along with revising pension to be based on disability rather than rank, created the aid and attendance program that authorized eligible disabled veterans to pay a nurse or maid (Department of Veterans Affairs, 2006). Former military nurses and other service providers were then able to continue using their skills in paid employment, serving disabled veterans.

In 1890, the US Record and Pension Division estimated that 21,208 women (10% were black) were paid as Union nurses throughout the Civil War. White Union nurses were paid 40 cents per day and a ration, which amounted to about $12 per month. Black nurses made about $2 less a month. Cooks and laundressesses were paid $6–$10 per month. The Sanitary and Christian Commission paid their workers slightly more than the Army. Unpaid workers—usually from religious orders or a higher socioeconomic class—refused pay and often cited their convictions as reward enough. They also used their social status to argue with surgeons and hospital administrators for better conditions and treatment of the wounded and ill soldiers and the staff that cared for them. However, nurses’ pay was often delayed or never received since the paymaster had difficulties keeping track of all of the pay tables and allowances for the women. There was also a system that paid contracted hospital workers in places, such as in New Orleans, where Southern women were hired to nurse Union troops. Superindenant Dix often heard protests from women about their wages and appeals that tied competency to compensation. Nurses and surgeons often had to advocate for pay and benefits for workers—giving rise to an appreciation for nursing as a profession and the women who performed the work, which had not previously been recognized or documented (Schultz, 2004). This public voice contributed to overcoming the stigma (and questioning of their virtue) that many women felt when first offering to join the war effort and paved the way for women to travel alone and work alongside men who were not their relatives. Nurses as veterans would again become activists as they fought for pension and other social reforms in the years following the war. Since so many former Union officers went to Congress, the women found among them those who would listen to their cause, understood what they had endured, and found ways to officially recognize and validate their role in military service.

Female service during the Civil War changed many of the other social conventions by which nineteenth-century women lived, but the greatest recognition for the equal role of women to soldiers came with the passage of the Army Nurses Pension Act of 1892, which provided a $12 a month pension to nurses who could prove service and need. At the time, the Union Forces were receving pension under a General Law system. Compensation was based on rank and degree of disability; thus compensation ranged from $8 a month to $30 (The President’s Commission on Veteran’s Pension, 1956). Thirty years after the war, payroll, marriage certificates,⁶ and testimonials from fellow hospital staff workers, administratiors, surgeons, and patients became significant for women in their ability to prove service to the Pension Bureau, which processed 2,448 women’s claims for almost the next half century (Schultz, 2004). However, those who had volunteered, women of color, and those unable to secure witnesses had a great deal of difficulty proving their claims to the Pension Bureau. A witness statement is still considered evidence by today’s VA standards, and veterans are encouraged to find former battle buddies or family members who can attest to their injuries and manifestation of symptoms when filing a claim for benefits.

Altough the Confederacy did establish a hospital system and women were employed, there is less accurate accounting of Confederate women and the work that they did, since their work was often conducted in their homes or churches and they were less likely to be compensated for their services. However, those who were compensated were done so at a highter rate than Union workers. Confederate wages for women ranged from $25 to $40 a month (Schultz, 2004).

As daring as the female nurses and other caregivers were, another group of women exemplified even greater bravery by secretly enlisting as men during the Civil War. For the same reasons they became nurses, they became soldiers: patriotism, closeness to male relatives, and poverty. There are approximately 250 known women who disguised themselves to enlist under an assumed male name, wore bulky military uniforms, and engaged in unlady-like behavior—smoking, drinking, and swearing (Krowl, 2006). The lackluster enlistment physical allowed these women to join, and the poor quality of medical care often allowed them to continue serving, even after being wounded, without being discovered. Pregnancy was often the game changer. Those who died in battle or from disease were buried under their assumed identities. However, if discovered, they were thrown out of the Army.

During the period after the Civil War, with so many Union veterans in Congress, veteran’s benefits for Union servicemembers were lucrative. Yet, as veterans, these undercover female soldiers were not given the same recognition as the men, with a few exceptions. For example, Jeannie Hodgers as Albert Cashier served honorably until discharge and received a veteran’s pension. She remained undiscovered as Cashier until aged and hospitalized in a veteran’s hospital, when she was discovered by the medical staff after a fall in 1911. Although the issue was controversial, she was allowed to keep her benefits. In another case, Sarah Edmonds, who served as Franklin Thompson, deserted. The charges were later overturned and she was able to secure a veteran’s pension with the support of her male compatriots.

The Spanish-American War saw little movement in the expansion of veterans’ benefits. In fact, the only changes came in 1918, which allowed for non-service connected pension for those destitute. In 1920, there was an expansion of disability pension. In 1922, pension was authorized for surviving dependents, and then pension for Spanish-American War veterans themselves was enacted in 1938 (The President’s Commission on Veteran’s Pension, 1956). However, in 1901, during the Spanish-American War, with an epidemic of typhoid spreading through the forces, Congress created the Army Nurse Corps (ANC), but did not authorize women to carry rank—they were given the title “nurse,” (Department of Veterans Affairs, 2011). Furthermore, they were not compensated at nearly the same rates as male soldiers. The Navy followed suit in 1908 with the Navy Nurse Corps. About 1,500 women served, and more than 20 became casualties from the exposures they encountered while performing their duties.

The fight that Civil War nurses had faced for recognition and the long delays of their benefits did not keep another generation of women from answering the call of duty when the United States entered into World War I. With a stringent physical examination required for entrance into the military, women no longer could disguise themselves as men to join. So, more than 3,500 women joined the ANC and another 18,000 joined the Reserves. In 1917, the Navy and Marine Corps opened recruitment for women to join its Reserves. They filled additional administrative and logistics roles and served in the United States (mostly in the Washington, DC, area) and abroad. In all, 34,000 women served during World War I. While serving overseas, 101 nurses died from exposure to combat and mustard gas, three were wounded, and 134 nurses, along with 51 female Navy yeomen, died at home from illnesses incurred while serving. An additional 300 women were sworn into the Army as volunteers to man switchboards in France. Many of these female Army contractors, like their sisters in previous wars, did so without any benefits, had to obtain their own food and shelter, and were not entitled to the same legal or medical care as the military (Bellafair, 2009). The uniformed women were not authorized the same benefits as those afforded to men, whether on active duty or as veterans. However, in 1923, Congress did extend veterans’ hospitalization benefits and long-term care in veterans’ homes to the Army and Navy women Service members, but did not include the voluntary telephone operators until 1979 (Blankenship, 2008).

The lessons learned by Congress after the political patronage and the institutional disorganization associated with compensating Civil War disability benefits (for Union troops only) and in anticipation of war in Europe culminated in the passage of an amendment to the War Risk Insurance Act of 1914. This added responsibility for adjudicating benefits for Service members (along with ships and cargo) to the responsibilities of the Bureau of War Risk Insurance (Ridgeway, 2013). Congress knew it needed a better way to remunerate returning disabled veterans, so the first compensatory rating schedule, established for measuring the degree of loss or loss of use of a body part, was introduced in 1921, based on requirements outlined in the War Risk Insurance Act of 1917. Already used in some European countries and Canada, the rating schedule was based on a workmen’s compensation model since it tied level of disability to loss of earnings capacity in a civilian occupation (Veterans Disability Benefits Commission, 2007). Only male veterans were eligible.

In 1925, the rating schedule was modified to accommodate the notion that a disability should be rated based on the individual’s similar occupation at the time of enlistment (Veterans Disability Benefits Commission, 2007). This meant that each veteran would be judged in accordance to the skills and abilities that he had when he joined the military and the rating schedule recognized the unique needs of individual veterans based on their previous occupation. So, for example, a carpenter who lost an arm would not be rated in the same light as a lawyer with the same level of impairment since the impact to their careers would be different. Since the work that women performed for the military was considered on par with housework, it was not valued in the same way as the occupations of men outside the home.

With the backdrop of the Great Depression, the Economy Act, Bonus Army marches, a tuberculosis epidemic, and the drum beats of war sounding again in Europe, the Veterans’ Bureau was instituted and 54 regional offices⁷ opened, while the veteran’s hospital system expanded to 91 facilities⁸ (Veterans Disability Benefits Commission, 2007). In order to manage the influx of claims and systematically provide assistance, the 73rd Congress published the United States Veterans’ Administration Schedule for Rating Disabilities (VASRD) on March 20, 1933. This rating schedule would see two additional revisions; five levels of disability impairment were added, and the average man concept of the 1921 rating schedule was restored, since rating cases on such a subjective level as the 1925 schedule required was too challenging for adjudicators at the Veterans’ Bureau.

The 1933 rating schedule for the first time included codes for gynecological conditions as women were becoming integrated into the military rolls. Among these were ratings for uterus displacement, in degrees of mild, moderate, severe, complete prolapsed through vulva, and loss of; panhysterectomy; loss of both ovaries; mammary loss of unilateral, bilateral, and unilateral with extensive muscle loss, and bilateral with extensive muscle loss (Veterans Administration, March 20, 1933). This revision of benefits for military women fueled their interests to serve in expanding military capacities beyond nursing.

As early as 1940, Congress was already preparing for the next war and created new insurance programs for Service members and veterans, while it also instituted the first peacetime draft (Department of Veterans Affairs, 2006). At about the same time, the notion of the Women’s Army Auxiliary Corps (WAAC) was being hatched by Congresswoman Edith Nourse Rogers to support the Army with a non-combant workforce, similar to the jobs women were holding in the civilain business world. By 1942, the Navy had created the Women Accepted for Volunteer Emergency Service (WAVES) and the Marine Corps Women’s Reserve, the Coast Guard Women’s Reserve, and the Women Air Force Service Pilots (WASP⁹). In total, over 350,000 women served in the military during World War II (Klein, 2005).

According to a historical account of the WAACs by the US Army Center of Military History, Congresswoman Rogers advocated for women to have equal pay, pension, and disability benefits, which had been denied to World War I women. The Army finally agreed to provide 150,000 WAACs with “food, uniforms, living quarter, pay, and medical care” (Bellafair, 2009). The first WAAC director, Oveta Culp Hobby, served in the rank of major with first, second, and third officers (equal to lieutenants and captains), while all of the enlisted were auxiliaries. Although these were great concessions at the time, there were still many inequities. Women could not command men and were not equally compensated, nor were they eligible for wartime legal protections, overseas pay, life insurance, or veterans’ benefits or treatment. If they became pregnant, they were discharged (Bellafair, 2009). But women (including many black women) flocked in droves to become WAACs—for many of the same patriotic and familial reasons as had motivated previous generations. It was not long before they were assigned to missions overseas and were exposed to the same hardships, accidents, and war as other soldiers—along with the same questioning of their virtue that Civil War nurses had endured.

The prejudices and stigma against them among civilian men and women on the home front fed a political debate over the role of women in the military. Yet, the Army needed them, and by mid-1943, the Women’s Army Corps (WAC) was authorized by Congress so that women serving with the Army could now serve in the Army and were afforded rank, benefits, and the same wartime protections as the regular forces. As the roles and assignements of the women increased worldwide, new health challenges emerged related to psychological issues as a result of the tedious work and social isolation instilled to protect their virtue. Illnesses, such as respitory diseases, malaria, and skin conditions, occurred because of improper uniforms that did not protect against environmental conditions, exhaustion from the hours worked, and malnutrition since supplies were inadequte. WACs were medically evacuated 267 per 100,000—significantly higher than the rate for men, who were better supplied and clothed. WACs sustained injuries from bombings and 16 of them recieved the Purple Heart for combat-related injuries (Bellafair, 2009). Eleven of the Navy nurses were captured in the Phillipines and held as prisoners of war (POWs) (National Center for Veterans Analysis and Statistics, 2011). There were 68 Army POW nurses as well. Over 540 women died during World War II; 16 were killed by enemy fire (Blankenship, 2008).

In 1945, with World War II ending and veterans returning stateside in droves, the Veterans Administration (VA) amended the 1933 VASRD to primarily account for the organ system injuries and illness suffered by over 670,000 wounded Service members (Veterans Disability Benefits Commission, 2007). The 1945 edition provided extensive guidance on rating gynecological conditions. It did not allow for conditions related to menopause, amenorrhea, pregnancy, or complicated childbirth, except for some surgical complications or other treatment resulting in disability or otherwise attributable to the unusual circumstances of service. Congenital malformations and conditions resultant from misconduct (equally for both genders), such as syphilis or gonorrhea, were not ratable. The excision of the uterus, ovaries, and related body systems prior to natural menopause were considered disabling conditions. Gynecological conditions considered ratable were vulvovaginitis, vaginitis, cervicitis, metritis, salpingitis, and oophoritis. These conditions were rated as severe (30%), moderate (10%), or mild (0%). Complete removal of the uterus and both ovaries was rated at 100% for the first six months and 50% thereafter. Uterus removal, including corpus, was rated 100% for three months and 30% thereafter. Complete removal of both ovaries and artificial menopause was rated 100% for six months and 30% thereafter. Removal of one ovary with or without partial removal of the other was rated at 10%. Complete atrophy of both ovaries was rated at 20%. A complete prolapsed uterus was rated at 50%, or 30% if incomplete. Severe uterus displacement was rated at 30%, moderate at 10%, and mild at 0%. Surgical complications from a pregnancy were rated as severe with rectocele or cystocele at 50%, at moderate with relaxation of the perineum at 10%, or mild at 0%.

Although service-connected and disability benefits were being extended to World War II women veterans, they were still not fully equal under the law. For example, the 80th Congress did not allow women to claim a husband as a dependent for the purposes of applying for additional compensation under the otherwise allowable provision for wives within Public Law 877 dated December 19, 1945 (Claims, 1949).

To reintegrate Service members into civilian life, Congress passed the Servicemen’s Readjustment Act of 1944, which included women. This vast benefit covered everything from mustering-out pay, home and business loans, education, and VA medical coverage. Four out of five veterans used their GI Bill, and within 10 years, they were socially and economically better off than their non-veteran counterparts (Veterans Disability Benefits Commission, 2007). Among these successful veterans were 64,728 female veterans, who used their GI Bill to attend college at a greater rate than the men. Women veterans enrolled in college at a rate of 19.5%, while male enrollment was 15% of those eligible (Bellafaire, 2006). It could be argued that the aptitude for these women was greater since they had served in military positions, such as administration, communication, logistics, and medical fields that gave them the skills necessary for college. In addition, with colleges under pressure to register veterans, women veterans were more likely to be accepted into college programs than their non-veteran female counterparts—making advanced degrees more limited and competitive among American women in general.

At the end of World War II, 12 million Service members were discharged from active duty—and among them were 280,000 women. The US Armed Forces needed to downsize over the next few years, but the need to keep a vital force was obvious to President Truman. So, he signed the Women Armed Services Integration Act of 1948, capping at 2% the number of women who could permanently be in the military (National Center for Veterans Analysis and Statistics, 2011). However, just two years after the integration of women into the military, there were only 22,000 women left on active duty (a third were medical professionals) as the Korean Conflict escalated in 1950. But, they were among the first group of American troops to deploy.

By the war’s end, almost 120,000 women would serve, including the newly formed Air Force Nurse Corps, which would medically evacuate 350,000 wounded,¹⁰ ill, or injured patients (National Center for Veterans Analysis and Statistics, 2011). To focus more on the recruitment and retention of women, the Department of Defense (DoD) created the Department Advisory Committee on Women in the Services (DACOWITS)¹¹ in 1951, which makes recommendations to improve the benefits and services available to women in the US Armed Forces to this day.

In the years following the Korean War, the focus on veterans’ benefits and the success of the VA were documented by Omar Bradley, the Chairman of the President’s Commission on Veterans’ Pension. Overall, the Commission found that “[e]‌xisting veterans’ benefit programs on the whole are working well and are being soundly administered. Veterans as a group are better off economically than nonveterans. . . . The present practice of assisting the veteran in his immediate readjustment to civilian life is much more effective” (The President’s Commission on Veteran’s Pension, 1956). However, the Commission found that there were inconsistencies with the VASRD and made recommendations to align the progression of ratings from degrees of disability to more accurately reflect loss of earnings capacity and mortality, especially for the more totally disabled. The Commission further advocated for a system that was much more holistic in its approach (The President’s Commission on Veteran’s Pension, 1956).

The Bradley Commission report, although very comprehensive and respected in its time, did not provide discussion on the present or future issues of female veterans. Categories of veterans were examined by period of service, disability, age, and family status, but not gender. The one notation in the Bradley Commission report that related to women was that of the 2,076,026 veterans receiving service-connected disability compensation as of June 30, 1955, 1,631 or .1% of the total were doing so for gynecological conditions¹² (The President’s Commission on Veteran’s Pension, 1956). So, as DoD began to change its focus on including women in the military under programs such as DACOWITS, the VA was still not providing them the same level of recognition and services.

Throughout the Vietnam War, the military would continue to expand the roles for women and the level of compensation that they were entitled to, making them equal to those of male Service members, including the opening of flag officer rank—Ana Mae Hays became the first woman brigadier general in 1970. Congress also lifted the 2% cap in 1967, so that more women could join. Although still with limitations, women voluntarily served during the Vietnam War since they were not conscripted. During the war, approximately 250,000 women served, 7,500 in theater, with the majority of these (6,200) as nurses treating the wounded (Blankenship, 2008).

To assist disabled Vietnam veterans, Congress expanded the GI Bill programs in 1966 and increased life insurance coverage. It expanded eligibility for Reservists and National Guard members and academy students. Women veterans also benefited from these expansions, and more VA benefits were made available to them.

Mostly because of the Bradley Commission’s earlier recommendations, by 1961, the VA updated the VASRD, primarily to modernize the terminology being applied to psychiatric conditions in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM). By 1971, the VA would make 15 revisions to the VASRD. But, in the late 1960s, Congress asked the VA to ensure that the VASRD was meeting the needs of disabled veterans, since a great deal of criticism was focused on its outdated loss of earnings approach (based on a physical labor construct) and advances in medicine that it did not account for. The 1971 VA study, entitled “Economic Validation of the Rating Schedule” (ECVARS), incorporated several recommendations based on organizational reviews and interviews with 485,000 veterans, none of whom were women (Veterans Administration, 1971). ECVARS made recommendations to change ratings and rates of compensation within the VASRD. The VA made the proposed changes, but after much political controversy among Congress and the Veteran Service Organizations, the 1973 VASRD was not adopted, and the 1945 edition of the VA Rating Schedule remained (Veterans Disability Benefits Commission, 2007). This is the same VASRD construct in effect in 2014, with regulatory changes having been made on an intermittent basis.

With the addition of posttraumatic stress disorder (PTSD) to the DSM in 1980, VA began to refocus its efforts on “Vietnam syndrome” and “war neurosis” disabilities. In 1984, Congress required the VA under Public Law 98-160 to engage in an independent study of PTSD and other readjustment problems among the Vietnam veteran community—the National Vietnam Veterans Readjustment Study (NVVRS) was created. Vietnam veterans were provided a five-hour survey that included an oversampling of disabled, black, Hispanic, and female veterans (with civilian control groups). The NVVRS found that 15.2% of males and 8.5% of females who served in Vietnam had PTSD, with a lifetime prevalence of PTSD being 30.9% for males and 26.9% for females. Comparisons of current and lifetime rates found that 49.2% of the males and 31.6% of the females who ever had PTSD still had it (Veterans Administration, 1984). The rates of PTSD among female Vietnam veterans created new awareness of the challenges facing them that differed from their male counterparts. Further analysis showed that these women veterans were more likely to be older and better educated than their male counterparts (given that most of the women were nurses or other professionals during service), and that the onset of their PTSD resulted more from the medical traumas they witnessed and the sexual assaults that they suffered. However, in the early 1980s, the Government Accountability Office (GAO) issued reports that documented the lack of VA data on women veterans, as well as the concern that those who identified as veterans (since many did not) and used the VA did not feel safe at medical facilities (nor did women feel that the facilities did a good job at accommodating their needs). There was also a lack of information regarding the benefits and services available to women veterans. The NVVRS began to inform the VA regarding the types of programs that it needed specifically to compensate and treat women from their disability perspective. The VA developed its “Women Are Veterans Too” campaign to help increase awareness of available benefits and services and increase women’s utilization of VA resources. Nevertheless, problems persist today with women not identifying themselves as veterans and not thinking that they are entitled to the same benefits as male veterans.

By the 1990s women were averaging over 10% of the force, and when the Gulf War struck, 400,000 women deployed. In 1992, the National Defense Authorization Act repealed the exclusion that kept women from flying combat missions, and in 1994 the combat exclusion that kept women off warships was also lifted (National Center for Veterans Analysis and Statistics, 2011). With the additional roles and responsibilities came additional risks, and more and more women have been involved in training accidents, have been exposed to safety hazards, have experienced unwanted sexual contact, and have endured dangerous deployments, which have led to increases in disabilities among women veterans.

In 1992,¹³ Congress expanded counseling and treatment services for military sexual trauma (MST¹⁴) within the VA healthcare system to all active duty or National Guard or Reserves who were active duty for training, regardless of eligibility for VA healthcare. The law requires the VA to provide medical care and psychological counseling to overcome trauma resulting from “a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment,” further defined as “repeated, unsolicited, verbal or physical contact of a sexual nature, which is threatening in character” (38 U.S. Code Section 1720D). The VA will also provide compensation for a PTSD diagnosis resulting from MST. The Veterans Benefits Administration (VBA) requires evidence from DoD documentation, law enforcement, medical personnel, family, friends, peers, or a chaplain related to any witnessing or performance issues related to the trauma (Department of Veterans Affairs, 2012). MST compensation is applied for in the same way as benefits for any other disability. However, the challenge in obtaining these benefits results from the level of dificulty veterans have in producing the required evidence that the VA needs to rate a claim. Since most victims do not report the crime while on active duty because of the stigma and negative career impacts (real or precieved) (Frayne, 1999), it is usually many years later that they will seek compensation, and the ability to produce evidence is lost (a situation similiar to that of the Civil War nurses who needed to find witnesses willing to file affidavits testifying to their experience and resulting symptoms). Since it is often difficult to produce this level of evidence, clinicians conducting disability exams need to be aware and sensitive to the nature of MST when narrating those cases and to record as much of an oral history as possible.

The 2001 National Survey of Veterans found female veterans to be younger than their male counterparts, more likely to have college degrees, and a higher percentage classified themselves as Black. Women surveyed were also more likely to seek care for chronic pain issues and arthritis than men, who sought care more often for high blood pressure. However, men and women were equally as likely to seek care for eye or vision problems (Department of Veterans Affairs, 2001). Women veterans are more likely to seek healthcare at younger ages. The top three diagnostic categories for which the VA treated female veterans in 2004 were hypertension, depression, and hyperlipidemia.

In a special report on the work of the Congressional Black Caucus, Veterans’ Brain Trust, Estella Norwood Evans reported that African American women represent the largest group of minority women serving in the military at 30.8% (while only 12% of the US population), which means that they serve in a greater percentage than their African American male counterparts. However, these women were more likely to come from and endure poverty, even while on active duty. Additionally, they were more likely to suffer unwanted sexual contact and hazing, but had less access to adequate VA services, which also resulted in the misdiagnosis of physical or psychiatric disorders (Evans, 2004). A diagnosis by a VA or other medical doctor is required as evidence for a service-connected disability, which further impacts these women’s ability to receive VA compensation or access to other programs.

According to the VA as of 2013, there were almost 22 million American veterans, dating back to the early part of the twentieth century. Among that population were 1,692,398 female veterans. They represent about 8% of the total veteran population. But in the current US Armed Forces, women have grown to be 15% of active duty forces, which means that there are 121,700 serving female soldiers, sailors, airman, and Marines. Among that population in 2013, there were 7,200 females on deployment overseas. Therefore, the female segment of the veteran population will grow to about 15% as well by 2035, while the overall veteran population will decrease with the passing of World War II and Korean War veterans.

Since September 11, 2001, women have engaged in more combat support roles, which will increase following the 2013 rescinding of the ban on women serving in combat units and occupations. The numbers of female troops being exposed to the hardships of military life, combat, and disease will increase. More than 220,000 women have served in Operation New Dawn (OND), Operating Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF). As of January 14, 2014, the DoD casualty report notes that there were 51,802 wounded, ill, and injured (WII) Service members and 6,791 deaths (Department of Defense, 2014) with 1,715 combat zone amputees (Fischer, 2013). A 2010 study notes that of the deployed female Service member population, there were over 120 deaths, 620 injuries, and over 20 amputations. Although these women faced the same challenges of adjusting to an amputation as would others, these women noted that a positive recovery could be attributed to their military attitude and training, social support, and finding a sense of purpose and meaning as a result of their service (Carter, 2011).

In general, when rating disabilities, the VBA today follows the statutes outlined in Title 38 of the United States Code and the 38 Code of Federal Regulations, which delineates procedures for rating conditions and adjudicating claims made by veterans and their families. In 2007, the Veterans Disability Benefits Commission (VDBC) observed that the VASRD outlines 14 body systems that encapsulate 700 diagnostic codes. The overarching body systems include the musculoskeletal, visual, auditory, respiratory, cardiovascular, digestive, genitourinary, hemic and lymphatic, skin, endocrine, neurological and convulsive, dental and oral disorders, mental disorders, and gynecological and breast disorders. The VASRD rates disabilities on a zero to 100% scale in 10-degree declinations, and computes additive disabilities with a combined rating formula based on the remaining level of function.

In order for a claim to be adjudicated in favor of the veteran, there must be three crucial pieces of evidence: (1) proof that the condition was incurred or aggravated by military service, (2) a current diagnosis, and (3) a nexus between the two. Clinicians are crucial to the evidence-building process. Treatment notes and exams need to identify the military circumstances that led to a diagnosis and the continuous impact that the condition is having on the veteran’s quality of life. This sensitivity is particularly important in the clinical environment with female veterans as patients since they have a harder time identifying their military service as even eligible for VA benefits, and then have an even greater challenge producing evidence of events, such as MST or combat-related PTSD. Over the years, female veterans have testified at several Congressional hearings on not understanding the VA system and its applicability to them or not being believed when they reported their traumas or injuries to clinicians who were uneducated on the roles that women play in the military. According to Delilah Washburn, “Because females are officially excluded from ‘combat roles’ in the military,¹⁵ women veterans have a greater burden of proof in establishing the link between PTSD and combat. . . . Because there is no clear front line on the ground in Iraq and Afghanistan, female service members are exposed to direct fire, Improvised Explosive Devices (IEDs), and constant threats from insurgents without the benefit of the awards and decorations to prove it” (Washburn, 2009).

In 2011, there were 3,354,741 veterans receiving a service-connected disability from the VA (US Department of Veterans Affairs, Veterans Benefits Administration, 2011). Gulf War era veterans were over 1.2 million of that population, in which the female demographic continues to grow. In 2011, 217,038 veterans began receiving disability compensation; women were 16,546 of that population. A 10% disability rating was the most common for both genders. While 305,510 males were awarded 100%, only 17,860 women saw that level of an award by the VA (US Department of Veterans Affairs, Veterans Benefits Administration, 2011). The top 10 most common disabilities for all veterans were (in descending order) tinnitus, hearing loss, PTSD, scars, diabetes, back strain, knee range of motion limitations, hypertension, traumatic arthritis, and knee impairment. Within the gynecological body system, uterus removal was the most common disability with 14,779 cases, followed by removal of uterus and both ovaries with 13,296 cases, and then benign growths within the reproductive system or mammary glands in 7,683 cases. Women are most likely to be service connected today for PTSD, lower back pain, and migraines (US Department of Veterans Affairs, Veterans Benefits Administration, 2011). If eligible for VA medical care, then they are entitled to all primary and specialty care services, residential treatment, and gynecological and reproductive health services, which include contraception, menopause management, and cancer screenings through Pap smears and mammography. Civilian-provided maternity care and a week of newborn care are covered by the VA, along with limited infertility evaluation and treatment (Department of Veterans Affairs, 2013).

Women veterans are likely to partake in Vocational Rehabilitation and Employment (VR&E), which assists disabled veterans in obtaining an education and entering the workforce and assists those who cannot work with independent living skills. VR&E is available for 10 years post military discharge, and most veterans are eligible with a 10% disability rating. Women comprised 20% of the participation rate within the VR&E program. Additionally, over 80% of women use their GI Bill benefits, and 12% continue on to advanced degrees (Department of Veterans Affairs, 2011).

In studies conducted for the VDBC, the CNA Corporation found that “as the degree of disability increased, generally overall health declined,” with mental disabilities impacting physical health more than the converse. Furthermore, when comparing disabled male veterans to their non-disabled counterparts, there was a slight loss in earning capacity¹⁶ below parity, but for female veterans it was slightly above parity (Eric Christensen, 2007). Disabled women veterans were less likely than their non-disabled veteran counterparts to be employed across their life span and across levels of disability (10%–100%). They were also less likely to be employed in comparision to the general population group. Therefore, without VA compensation, disabled female veterans would fare worse than other non-disabled comparison groups (Eric Christensen, 2007). Women in general earned less than men across all spectrums. Ultimately, the CNA found that the greater impacts of disability were associated with younger age at onset and mental versus physical disabilities, not necessarily gender.

In addition to all of the benefits and services available through the VA, the Department of Defense offers programs to facilitate maintaining those on active duty and in the National Guard and Reserves through its Medical Treatment Facilities and its Tricare network. The Transition Assistance Programs (TAP) helps Service members access the VA and prepare for civilian life. A joint VA/DoD Disability Evaluation System (DES) has been designed to expedite the process between medically discharging from the Services and filing a VA disability claim. For those not being medically discharged from the Services, they can still file a VA claim through a Benefits Delivery at Discharge (BDD) process. Benefits information is available through an eBenefits portal; if, after separation, a veteran still wants to file a claim, it can be done online through the www.va.gov website. The DoD Computer/Electronic Accommodations Program (CAP) provides assistive technologies to individuals with disabilities who want to continue in government employment. Additional info can be found at www.cap.mil to assist those with impaired vision or hearing, dexterity loss, cognitive impairments, and other communication deficits.

Besides the government programs, there are a multitude of community service programs and resources dedicated to assisting veterans in overcoming the adversity that disability brings. There are over 15,000 sources listed on the National Resource Directory (www.nrd.org) dedicated to connecting wounded warriors and their families with federal, state, local government, and nonprofit organizations. The Veteran Service Organizations (i.e., the American Legion, Disabled American Veterans, Veterans of Foreign Wars, Iraq and Afghanistan Veterans of America, etc.) assist veterans with filing VA disability compensation claims and offer other social support. There are specialized programs that assist women veterans, such as the Service Women’s Action Network (SWAN), which provides legal support for VA claims and appeals. The Wounded Warrior Project has also instituted summits for women designed to build their resilience while recovering from disabling injuries and illnesses.

In general, recognition and compensation for military service have been a point of great debate from generation to generation. Societal beliefs that military service was a duty of every American and did not warrant compensation changed as early as post–Revolutionary War, as veterans aged and suffered more deficits than their non-veteran peers. Military service has always had a physical, psychological, economic, or social impact on those who served and their families. For some, it was to their betterment. They learned resilience and how to overcome adversity with a positive attitude and the continued use of military skills; however, as studies have demonstrated over time, even limited disability will have an effect on one’s quality of life. For the subset of women who served this nation, that service has been the subject of much debate as well. The value that society places on the roles and functions that military women can undertake remains controversial. The way in which women were awarded or compensated for their service was very much based on the values of their era. Clinicians today need to assess their own beliefs about the military and women in uniform before evaluating or treating this population. Military cultural competency training is recommended, such as that offered by the Center for Deployment Psychology.¹⁷

Each time a generation of women stepped up to serve, they added to the national understanding of the capabilities that women had, and benefits and services to support Service women were added to the federal benefits package. It was not until after the Vietnam era that women were given full and equal benefits to their male counterparts, but it took an array of advisory committees, Congressional hearings, and government reports to document their needs and the inadequacies of the support available to them to make it happen. Often the benefits available to military widows precipitated the debate on benefits offered to military Service women. Over the ages, women veterans were their own best advocates as they took leadership positions and made the political changes necessary. From Molly Pitcher to Dorothea Dix and her nurses to Congresswoman Tammy Duckworth,¹⁸ the first disabled female veteran to serve in the US House of Representatives, women have not let adversity, disability, or political opinion stand in the way of their service. Remuneration, compensation, and other benefits came later.

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¹ Service connection is the process by which a veteran applies for and is granted a disability compensation award from the Department of Veterans Affairs.

² With the passage of the US Constitution.

³ A clothing allowance is still afforded to some service connected veterans whose disability causes wear and tear on clothes, such as with prosthetic devices or skin creams from the Department of Veterans Affairs and is paid annually.

⁴ Hopkins, who had used her fortune to establish confederate hospitals, died in poverty.

⁵ Etheridge was the only woman who served in the field for four years with the 2nd Michigan Infantry, but never received pay. She was awarded the Kearney Cross for bravery and later worked for the US Patent Office at the Department of Treasury.

⁶ Widows were also given a pension, so nurses were not allowed to “double dip,” and thus had to apply for one or the other pension. When rates changed for one and not the other, women would opt for the higher paying pension and re-file claims.

⁷ As of 2014, VA has 57 Veterans Benefits Administration Regional Offices.

⁸ As of 2014, VA has 153 VA Medical Centers, about 800 Community Based Outpatient Clinics (CBOC), and over 300 Vet Centers.

⁹ WASPs were given veteran status in 1977.

¹⁰ According to the Veterans Disability Benefits Commission, there were 103,284 wounded warriors during the Korean Conflict.

¹¹ DACOWITS continues to make policy and program recommendations to the DoD in 2014.

¹² Since the report did not break out disabilities by gender, it is unknown how many of those receiving service-connected disability for other conditions, such as medical or psychiatric, were women.

¹³ Public Law 102-585.

¹⁴ MST is a term used by the VA to describe a set of experiences. It is not a diagnosis contained in the DSM, nor is it a criminal code under the justice system.

¹⁵ The removal of this ban should change the ability of women to prove combat experiences.

¹⁶ Earning capacity was calculated by taking the ratio of earned income and adding VA Service Connection Compensation.

¹⁷ See www.deploymentpsych.org/military-culture.

¹⁸ A former Army helicopter pilot who lost both legs in Iraq in 2004.