SEVEN

Women, Ships, Submarines, and the US Navy

HEATHER D. HELLWIG AND PAULETTE T. CAZARES

For centuries, and as long as men have been sailing them, seagoing vessels have been referred to as women. The sea itself has been called a woman.

The United States, like many strong nations, has a long naval history. Americans chose early on to establish a navy, and actually completed its formation nine months before declaring independence. Historically and currently, a strong navy has represented strength, national unity, and a strong commitment to national defense (http://www.history.navy.mil/history/history1.htm). Yet for many, many years, women were not permitted to serve as part of a ship’s company, or to serve on submarines. In fact, in the Navy’s early years, they were not even physically on board.

This chapter will first cover a brief history of women and the Navy. Then it will discuss modern developments for women in the fleet, including their addition to the crews of submarines. Women’s healthcare follows and, finally, a female Navy physician will offer a first-person account of her experiences as a ship’s doctor and will provide some clinical pearls.

In the early years of the United States’ growth, the prohibition of women on ships was canonized. An early regulation from 1802 read: “He (Captain or commander) is not to carry any women to sea without orders from the navy office, or the commander of the squadron.”

Throughout the 1800s, regulations were periodically reviewed without much interval change. By 1841 the wording was changed to require even higher, and more detailed, chain of command authority for women to embark, stating, “Women are not to be taken to sea from the United States in any vessel of the Navy without permission from the Secretary of the Navy: nor when on foreign service, without the express permission of the Commander-in-Chief of the fleet or squadron, or of the senior Officer present and then only to make a passage from one port to another.”

The Naval History and Heritage Command reports that regulations of 1881 were, again, similar, stating, “Officers commanding fleets, squadrons, divisions, or ships, shall not permit women to reside on board of, or take passage in, any ship of the Navy in commission, except by special permission of the Secretary of the Navy” (http://www.history.navy.mil/faqs/faq48-3a.htm). In a century of our nation’s development, not much had changed.

Despite these segregating policies, women managed to slowly advance in the workplace. In military circles, their presence especially grew in medical fields, where they were contracted for work. This was, in fact, the only capacity in which they could serve until officially serving the Armed Forces through the creation of the Nurse Corps in 1908.

In 1913, as part of the war effort in support of World War I, Navy nurses served aboard the transports USS Mayflower and USS Dolphin (http://www.navygirl.org/navywomen/navy_women_history_page.htm). After both world wars, women were relegated back to support roles, which grew over the years, but remained restricted to the shore.

The irony in the restrictions for women off ships at this time is that during World War I, as well as World War II, women were called to fill industrial roles traditionally filled by men, which had been left vacant due to military service. Not only did women fill those positions, but they did so successfully. So, while women obviously were able to fill jobs they were not previously allowed to fill in the civilian sector, this was not occurring in the military environment. Rosie the Riveter would not only have to remain marginalized to civilian industry, she would largely go home after the war was complete.

It was not until the 1970s that naval roles grew substantially, with women serving in the Chaplain corps, the Reserve Officer training corps, aviation training, and finally, in 1978, as part of ship commands (http://www.history.navy.mil/special%20highlights/women/navywomen.pdf). Jimmy Carter was president, and the US Navy had just approved their 1979 budget; it included women on non-combat ships (http://www.history.navy.mil/faqs/faq48-3g.htm). Interestingly, while there were many strong leaders who worked to make this happen, there remained questions as to possible strong secondary motives for the military in including women as part of the seagoing force, as this also coincided with the end of the draft. Additionally, by that time, women had already entered the US Naval Academy, beginning in the year of the nation’s bicentennial; the first female graduates would need additional roles in which to practice the skills that their degrees conferred (US Naval Academy, 2012).

Years continued to go by, however, before the Navy realized the need to fully open the ranks to women. This awareness followed the loss of highly trained Officers and enlisted to attrition, at least in part ascribed to a lack of advancement opportunities. It turns out, equality is more than the simple presence of women in a physical space.

In 1984, combat logistics support ships were opened to women. These are known as supply ships, re-fuelers, and those that support the fighting Navy. It did expose and create opportunities, allowing Lieutenant Commander Darlene Iskra, in 1993, to be named the first woman to command a ship, fittingly named the USS Opportune (ARS-41) (US Naval Academy, 2012).

While this was a great victory, with the promise of career advancement for women in the Navy, the sprint of women ahead was paralleled by the widening awareness of unacceptable sexual harassment and assault, a problem that persists today. So, in 1992, under Chief of Naval Operations Admiral Kelso, the Navy’s first fleet-wide training on sexual assault was established. This came at a complex time of public discussions about moving women onto combatant ships and accusations of continuing sexual assault.

Seemingly unjust and abusive incidents had been happening for years during the integration of women into the fleet. In public interviews, Navy leadership appeared puzzled by their inability to make headway into this dangerous situation. Even today—in the midst of intensified focus, study, and scrutiny—some of this “confusion” lives on in the Navy and in the military as a whole. This is the case, despite leadership now having more clearly stated, rehearsed, and impactful statements on the matter.

While roles were opening, criticisms of the plan to fully integrate women into a ship’s crew ran the spectrum from well-intended concerns about women’s health, to tangential beliefs that large numbers of women would intentionally get pregnant to avoid ship service and deployments. A 1991 a New York Times article highlighted this sentiment with the headline “36 Women Pregnant Aboard a Navy Ship That Served in Gulf.”

Nevertheless, in 1994, after testimony from the Chief of Naval Personnel, Admiral Ronald Zlatoper, surface combat ships finally opened to women. He stated in his May 1993 testimony to Congress that it is “a logical progression after 50 years of service by Navy women… including 20 years in naval aviation and 15 years at sea” (http://nation.time.com/2012/10/03/more-navy-women-joining-the-silent-service).

While Congress did move forward and enable women to serve on all ships, two significant equally limiting pieces of restrictions and legislation were enacted. First, women were specifically prohibited from serving in ground combat roles. This controversial rule, known as the Combat Exclusion Law, remained in place until January 2013, when it was finally repealed in full (http://www.defense.gov/Releases/Release.aspx?ReleaseID=15784).

Second, accommodations were not made for women to join submarine crews, reportedly due to the expected cost of modifying these vessels. In 2000, official guidance from the Defense Advisory Committee on Women in the Services (DACOWITS) recommended that (1) for long-term integration, the Secretary of the Navy direct redesign of the Virginia class (“fast-attack”) submarines to accommodate mixed-gender crews, and (2) for short-term integration, the Secretary of the Navy and Chief of Naval Operations commence with assigning women to SSBNs (“boomers”) fleet ballistic missile submarines. The Committee further recommended Congressional approval of a Department of the Navy policy change.

Five years after the Navy opened the path for women to serve on combatant ships, Captain Michelle Howard became the first woman to rise to the esteemed position of Commanding Officer (CO) of a combatant vessel, the USS Rushmore (LSD-37) (http://www.history.navy.mil/special%20highlights/women/navywomen.pdf). The next followed one year later: Captain Kathleen McGrath, CO of the frigate USS Jarrett. Captain Howard ultimately retired as a two-star admiral, and Captain McGrath guided her ship to the northern reaches of the Persian Gulf, where the crew hunted boats suspected of smuggling Iraqi oil in violation of United Nations sanctions (http://www.arlingtoncemetery.net/kmcgrath.htm).

When it came to the submarine fleet, however, it was not until 2011 that women first began working aboard ballistic missiles subs and guided missile subs. Recently, the Navy announced that the USS Virginia and the USS Minnesota would be the first two gender-integrated fast-attack submarines by January 2015. As of this writing, 43 female Officers have been integrated into the sub force; a plan for enlisted integration is scheduled for May 2015 (Navy News Service, 2013).

In the midst of the political background debating allowances for women to cross the brow, there was an appropriate concern about the medical requirements necessary to provide for the safe care and medical success of providers and Sailors alike. It has been difficult to independently verify the original discussions around these concerns, but some of the public data are documented here.

As would be expected, concerns for women’s health would range from complex to routine, including pregnancy, annual exams (including Pap smears), medical staffing, supplies, and pharmacy requirements, as adjustments to the ship-based formulary would be debated with cost and efficacy in mind.

Since women have been working on submarines for such a short time, data regarding women’s health concerns are currently lacking. In 2001, a Naval Submarine Medical Research Laboratory (NSMRL) technical report described the potential “Medical Implications of Women on Submarines.” The conclusions of the report were divided into three categories: (1) implications affecting the submarine; (2) implications affecting women’s health, and (3) research requirement recommendations.

Primarily, the report concluded that since women use healthcare more than men and have a higher incidence of certain disease states (including migraine headaches and asthma), the demand for medical services while underway, as well as initial waiver requests, would increase. Another concern was the potential loss of manpower due to pregnancy. In addition, the authors recommended modifying the submarine psychiatric screen due to the differences between men and women in the types of psychiatric diseases and disorders from which they suffer. Finally, adjustment of the Authorized Medical Allowance Lists and the addition of gynecological management algorithms were deemed necessary modifications to the current medical processes.

Women’s health issues brought up by the authors included osteoporosis risk due to lack of sunlight, inactivity, and increased levels of carbon dioxide; ectopic pregnancy and spontaneous abortion; and risks to the developing fetus. Other than recommending rigorous pre-deployment screening due to the difficulties in the submarine MEDEVAC process, the authors were unable to draw conclusions about these potential women’s health issues due to a lack of existing data.

The report concluded with several recommendations regarding further research. These recommendations included bone health studies; modeling studies to determine the impact of increased healthcare utilization; risk of ectopic pregnancy, spontaneous abortion, and pregnancy on the submarine service; and assessment of additional medical staffing, fixtures, supplies, and equipment needed to ensure adequate medical care. As independent duty corpsmen (IDCs, the Navy’s equivalent of a physician’s assistant) are the primary medical providers for submarines and serve as the only medical provider available while a submarine is deployed, the authors recommended review of the year-long IDC training curriculum to ensure that these practitioners are adequately prepared for providing healthcare to both men and women.

Other than osteoporosis risk due to the lack of sunlight, concerns for the care of women on a ship are similar to those of care for men. Again, most small ships (frigates, destroyers, cruisers) do not have a physician aboard, and the medical staff is generally led by an IDC. Without a family practitioner or obstetric doctor onboard, pregnant women would need to be evacuated from ship duty, and the line was drawn at 20 weeks. This meant that a woman could be retained on the ship to carry out her duties until she was 20 weeks pregnant. However, in practice, most women are removed from shipboard duty once a positive pregnancy test is confirmed, as there are multiple safety hazards onboard. Additionally, concerns for preterm labor, hemorrhage, and miscarriage were appropriate, as they could put patient and medical staff at risk, as well as potentially compromise the ship’s mission, especially during periods in which the ship is underway or deployed. Most Commanding Officers (COs) recognize this (or are encouraged by their Medical Officers to appreciate the implications), and women are typically quickly reassigned to a shore-based command at the time a pregnancy is discovered. (Of note, this is a time when a Medical Officer [doctor] can, and really must, break confidentiality to ensure that the CO is aware of the Sailor’s health status.)

Once the pregnancy concludes, the Sailor can rejoin a ship-based crew after a period of convalescence. Of course, not all pregnancies occur before deployment, and for those whose tests turn positive while the ship is deployed, the Sailor is medically evacuated back to the ship’s home port.

For routine health concerns on ships, policies were instituted to ensure that Pap smears occurred annually (the requirement at the time) and that they were done prior to deployment, as lab facilities on board are neither equipped nor staffed to process those samples. Additionally, even if samples could be processed (on board or at bases overseas), little could be done to manage abnormal results at that point, necessitating pre-deployment “rushes” to get these exams completed for the crew.

Pharmacy requirements and formularies were another issue. Ship-based formularies are known as the Authorized Medical Allowance List, or AMAL, and requirements for such were and are determined by history, experience, and the shore-based medical chain of command. The AMAL includes all medications and treatment equipment (bandages, tubing, ACLS supplies) required by each class of ship. As such, ships were absolutely mandated to ensure that the pharmacy was stocked prior to a deployment according to the details of the AMAL. The AMAL was changed to include various forms of oral contraceptives and treatment for gynecologic infections. Additional meds could be purchased at the request of a ship’s medical department and approved by the Supply Officer and Commanding Officer. This often led to some variation in pharmacy supplies from one ship to another, and, in my experience, these were significant when it came to the issue of emergency contraception (EC).

In personal experience, the years that I (CDR Cazares) was a GMO¹ (2005–2007), most Medical Officers used combinations of existing OCPs when women presented to medical requesting EC. However, once Plan B² became more widely available, it could be purchased like any other medication for the ship’s supply. An appeal was made at the time to install Plan B as part of the AMAL, but soon after, it was approved as an over-the-counter medication, and the discussion became generally moot.

All of this practical experience mirrors a 2007 DACOWITS report, in which it was noted that ensuring women’s health while underway on a submarine (or, by extension, a ship) is likely largely tied to ensuring ongoing health while ashore. The report used focus groups and surveys to describe the healthcare experiences of female Service members prior to, during, and after deployment. The report also summarized participant recommendations to improve their experiences and outcomes. In order to improve the Pre-Deployment Health Assessment (PDHA) Form and review process, participants recommended adding more female-specific questions, conducting more thorough health assessments (e.g., asking about recurring medical issues such as urinary tract infections), and providing more privacy during the PDHA process.

The report also recommended providing briefings on female-specific issues, improving healthcare accessibility, requiring well-woman exams, conducting mental health screenings, and improving Service members’ ability to acquire prescription medications prior to deployment. Although submariners deploy on a recurring basis for shorter periods of time than those included in these focus groups and may not utilize the PDHA Forms, these recommendations may be useful to incorporate in the screening and education provided before selection for submarine (or ship) duty, before an initial deployment, and then periodically while assigned to a deploying unit.

I had little to no idea of this history when I took my oath of office in May 2000, and matriculated as a first-year medical student at the Uniformed Services University. By the time I graduated in 2004 as a Navy lieutenant, I had spent some time learning about the history of women in medicine, but was still rather oblivious to the history of women in the Navy.

I completed a year of internship in San Diego and, at that time, chose not to continue to residency, but instead to “go to the Fleet.” (I actually had completed my online application for a psychiatry residency, but at the last moment, withdrew it.) Being a General Medical Officer (GMO) was something I heard and learned about through my four years of medical school, and I didn’t want to pass up the opportunity to live and work in the “real” Navy, as hospital work is not considered by most to be representative of traditional life as a Sailor. I was encouraged by many on both sides: “go to the Fleet, you’ll love it!” and “just finish residency, then your training will be done.” At that point in my life, I was able to choose adventure freely, and I did.

Interestingly, with the start of the war in Iraq, male GMOs were being funneled to work with the Marine Forces, as women were not yet allowed to serve in combat those roles (even though many women subsequently did effectively fill and excel in these roles during actual combat operations). As a result, all the billets for GMOs on ships were going to women. The GMO class of 2005 was one of the largest percentage of female shipboard GMOs ever; it was something unique.

My ship actually left for deployment a month before I was able to be freed from the hospital and meet it. I flew to Darwin, Australia, and completed turnover with my predecessor, a particularly unemotional appearing but very nice and organized guy. (He later became an internist.) Turnover was made to seem straightforward, but I found it nothing short of overwhelming. This was a new language, a new environment, and I was surely aware of my minority status on the ship as a woman, notably so among the Officers. I worked hard through four months of an intensely steep learning curve, and succeeded in large part due to wonderful mentorship from other medical staff. The initial difficulty is not what women in the 1980s experienced onboard, nor surely what women before them faced. When I joined the crew, women had been in roles on combat ships, in one way or another, for 20 years. What I faced and felt was different. I was offered a wonderful opportunity to serve, but there was isolation. There were five female Officers in total on the ship. As the senior woman, I socialized with two younger female Officers whom I befriended, but had to be cautious not to cross the line and be “too social.” The Navy puts high value on perception, and as the ship’s doctor, I took this to heart—at least through my first of two years. (I thankfully relaxed during the second half of my duty.) I felt tremendous pressure to live beyond reproach, and over time, I have learned that this is an incredibly intense, stressful, and ultimately unsustainable and inhumane way to live. Come the second year and second deployment, I was able to dance in bars at ports of call and enjoy a cigar with the CO and know I was on stable footing. I completed two deployments in two years, made wonderful friends, and saw the world.

I never felt harassed on the ship or in the wardroom, and I thankfully never experienced anything remotely resembling an assault. However, as those who have served on ships know, the entire tone, feel, and tempo of the ship is established and maintained by the Commanding Officer. If he (it’s still rare to find a female shipboard CO) is an ethical, hardworking, progressive, fun person, so goes the ship.

So, while I always felt safe carrying out my work, I was aware that I was definitely in the minority. Men cringed when they needed separation physicals that required a genitourinary exam. Many had never been touched by a female doctor in their lives, let alone in their careers. Telling a chief, a senior enlisted member of the crew, that he was due for a prostate exam would almost certainly bring blank stares, and in many cases, dropped jaws and speechless moments (from the patient).

Additional constraints of the shipboard environment that extend to the full crew include the technical limitations of the practice of medicine. For example, our ship was deployed during the Thanksgiving holiday in 2005. That morning, I walked down to Medical feeling excited, and anticipating a “happy” day of Nat King Cole and clinic holiday decorating. My mother had sent six boxes of decorations, and after staring at gray walls already for months by that time, I had a need to decorate.

I opened the main treatment door that morning, expecting to see my staff’s smiling faces, but I was stopped, literally, by the vision of a sick patient. There was one of our enlisted, hunched over a garbage pail on the floor. It took only a preliminary abdominal and pelvic exam to know that she needed to leave the ship with a presumptive diagnosis of appendicitis. This is pure clinical medicine—no surgery consult, no ultrasound, no CT scanner. It could’ve been her ovary, or it could’ve been her appendix—but there was no way for me to know definitively. What was known was that she needed to leave the ship that day—Thanksgiving day—when most other ships were in port (even in the deployed setting).

“Ok, let’s get things up and moving, I’ll talk to the Captain and let him know we’ll need a helo.”

As is typical with military chains of command, or corporate environments, they all handle crisis differently. The responses are all unique, as ships and capabilities are, and that’s exactly what is the same about them. But one thing is true, and that is that when a medical emergency is at play, they’ll move mountains to get their Sailors the help they need. Before I knew it, the ship was literally full-steam ahead in the direction of an incoming helicopter. The helo ETA was to be 3 hours. I thought, “Ok, this is alright. I have morphine, I have Phenergan for nausea and if she gets bad, I have lots of fluid and plenty of antibiotics.”

She understood the plan, and before long, her young-adult orange Adidas bag was packed, and her friends were hanging around Medical, chit-chatting and laughing. She was occasionally smiling, but something wasn’t smelling right to me, and as I continued to watch her, I noticed she was going from pale to paler to paler. There were two of those wirey steel wool Department of Defense issue blankets on her and she was still telling my corpsmen she was cold. We were closely monitoring her vitals, and over the last hour, I noticed her temp was slowly climbing, the blood pressure slowly sinking, and her pulse slowly increasing. For anyone who works in medicine, this is bad.

I knew it was time to speed up the process. Orders were written for Tylenol, antibiotics, a second IV with fluids as fast as they could go, and, “Me? I’m running to CIC to get a move on this helo.”

CIC is military lingo for the Combat Information Center. If you want to see bells and whistles on a naval warship, that’s where they live—hanging digital screens, communications in encrypted and secret forms. From Combat, it’s possible to log on to a kind of Internet chat with folks in military officialdom and “make things happen.” I excused some young Petty Officer from the main communications screen and sat down at the keyboard, typing as quickly as I could.

Yes sir. It’s the Doc. Sir, let me repeat… I have an urgent medevac, with worsening vitals; I need you to expedite the process now. Explain? Sir, all due respect, I have confirmed this case with 2 other staff physicians. I need a helo here now, or this Sailor will die today.

Silence is a unique state, especially in the midst of an emergency.

After what seemed longer than the 30 seconds it likely was, I had my response, and I was informed the pilot would be there sooner than we had originally expected.

At the beginning of that deployment, I would’ve never known or had the courage to waltz into Combat, sit down, turn off the big screen for privacy, and demand that a helo move faster—forget about demanding it from the Admiral’s representative—but a few months at sea made this girl a little saltier than she was when she left San Diego.

At 1625 that day, my team was loading her onto a stretcher to carry her out to the flight deck. She was able to cautiously and painfully slowly walk outside, and that was enough for me; stretcher the rest of the way. I was standing on the steps above her, reviewing the mental checklist with my radiology tech, whose turn it was to travel with our medevac. As her medical escort, she would carry out all basic care from our ship to the nearest overseas hospital.

“Continuous vitals, 2 IVs are in place, you have morphine and Phenergan in your bag and an ambulance will be waiting on the other end. Be sure to get all records and if you need a translator, demand one. Ok, that should cover it, you’ll be alright.” And she nodded the entire time, humoring me in my nervousness and my maternal physician-ness.

There were rough seas that day and the sun was beginning to set, so other than my elevated blood pressure and that small headache above my right eye, I thought it looked, relatively speaking, beautiful outside. They carried the stretcher away and I watched her get loaded on the helicopter. As I stood there, my pharmacy tech appeared with a dish of the garlic-mashed potatoes he had been intermittently cooking throughout the day for the crew. I realized at that point I had no memory of when I had last eaten. We exchanged “Happy Thanksgivings” and I dug into those potatoes—and let me tell you, they were good.

And that was Thanksgiving. I was wound up until finally, at 0040, my inbox rang with a message from my trusted radiology tech. They had arrived safely, the ambulance was at the ready, ultrasound in the ER confirmed appendicitis, and she went directly to the OR. The surgeon informed her that only a few more hours and it would have ruptured. The surgery went well and she was resting comfortably.

I breathed, deeply, and yes, I cried. It was just a few tears, but I needed to cry. Out to sea, there’s a difference. On the ship, here, they’re not strangers; they’re one of your own and the whole experience changed me. Care in that close environment is different from the hospital, it’s different from reading academic case files, and it was different from life before deployment.

• • •

I remained the senior woman on the ship for some time, until finally another female lieutenant transferred aboard. By the time we left on our second deployment in two years, I felt confident professionally. I had earned a pin that qualified me as an honorary-pseudo-Surface Warfare Officer (SWO), which basically means I was a Medical Officer who had learned enough about the ship to pass an oral board with the real SWOs. The technical knowledge helped, but gaining the confidence to speak up in a busy, male-dominated wardroom or mission-focused meeting was the most difficult. Despite my experience, I often second-guessed myself.

We deployed to South America on what is often called a “cocktail cruise,” a round-the-continent tour including visits with all America-friendly Navies, this time with two smaller ships (without doctors). South America offers wonderful, culturally rich port calls, and I served as the Medical Officer for all three ships for the four months of that tour, seeing clinic and taking calls for the smaller ships when we were in port, and managing medical evacuations when necessary. (I did also get to enjoy my share of many sites.) It was a thrilling experience that taught me how much medicine can actually be practiced without fancy technology, without specialists, and without the cutting-edge practices of an academic hospital. That being said, it could be very lonely at times. The military restricts socialization in the ranks, and that left few women to befriend. I did make friends, great ones, but I found not having colleagues to discuss cases with frustrating, not for need of specialty care (I could get that if needed), but even if just to help manage the stress, intensity, and passion of it all. Further, as physicians, we are a group that self-selects to engage in lifelong learning. By the end of my two-year tour, I missed Grand Rounds, I was all too happy to get my hands on a current medical journal, and I was ready to advance my academic career.

Clinical Pearls (CDR Cazares)

After having navigated my tour, and subsequently trained psychiatry residents preparing for deployments, I have gathered a few pearls for the white coat pocket. By no means is this an exhaustive list, but they serve to protect and promote a doc’s good health and performance on board a naval ship.

1. Understand the CO’s philosophy and intent, and the deployment plan for the next one to two years. This will help profoundly in planning for spikes in needed exams (well-woman) as well as creating storage for deployment meds. When a Sailor is prescribed a routine medication, either by the ship’s physician or a specialist, each one of them requires a 6+ month supply prior to deployment. For safety, most medical departments store the majority of meds in the medical spaces, and during deployment, will administer them at manageable intervals.

2. Inspect the pharmacy, lab, and condition of medical records yourself. As a new leader on the ship, it is incumbent on the physician to be confident that inspection reports match supplies, reported cleanliness, and functionality. “Trust, but verify.”

3. Sit in on interactions between junior staff and patients. This opens tremendous opportunities to understand a staff’s skill level, as well as to identify areas ripe for teaching, or for immediate correction. Properly teaching a junior staff, who almost universally want to learn, frees the physician to engage in higher level planning, thinking, supervising, and mentoring.

4. Do not engage in VIP medicine. The rank structure in the military lends itself to the idea that senior ranking members deserve or should receive care that is qualitatively different from care provided to junior ranking members. This is absolutely untrue, and in fact opens the provider to mistakes they would usually never make, and exposes the patient to substandard care. This can be secondary to nervousness on the part of the physician, or institutional structures that demand it (e.g., executive medicine wards), or the misinformed idea that Officers are less sick, engage in less risky behaviors, and drink less than enlisted Sailors. As a combination of all of these, I have witnessed good providers make unusual mistakes that are solely due to a divergence from their practiced and standardized history, physical, and laboratory examination. For example, when addressing a complaint of headaches, commanders need to be questioned about alcohol use just as much as a junior Sailor.

I would argue that this can be especially poignant in the case of a female physician caring for senior enlisted and senior Officers who are men. There is an added reluctance on the part of patient and provider to engage in questions about a sexual history, alcohol use, and other behavioral patterns, even when clinically indicated. There is anxiety around urologic, rectal, or even abdominal exams. It is critical to do the same basic thing at all times. Making exams convenient (e.g., drawing blood in the CO’s stateroom versus medical) is one thing; not doing the exam is another.

Finally, when treating a patient of higher rank, there is often significant intrusion from the chain of command regarding the patient’s diagnosis, prognosis, and so on. This is understandable, but it is more than prudent for the provider assigned to the patient to politely (or directly) excuse the interested parties from e-mails, meetings, and conversations. The only people who need to know are the same who need to know about a junior Sailor’s health. The doctor-patient relationship is critical, and should be protected at all costs.

The history of women’s integration into regular shipboard life, and specifically into medical care, has covered a tremendous distance, including the recent integration of women onto submarines. There are known and unknown figures who have moved us in this direction, and we are clearly indebted to all of them. We hope to continue to learn more as experiences and data grow.

We close with a remark made by a Navy woman nearly 20 years ago to The Navy Times:

I did not join the Navy to advance a social program, file subjective harassment suits, get pregnant, and accidentally carry out my assigned military mission in the process. I joined to serve my country. (http://nation.time.com/2012/10/03/more-navy-women-joining-the-silent-service/)

We love being in the presence of women who work without question, and we serve proudly with them, onboard or ashore.

36 women pregnant aboard a Navy ship that served in Gulf. (1991, Apr 29). The New York Times.

2012. Celebrating women’s history month at the U.S. Naval Academy, women’s education—women’s empowerment. Retrieved from the US Naval Academy site. http://www.usna.edu/PAO/newsarticles/images/2012.03.29-01/Womens_History_Poster.pdf.

Armed Forces Surveillance Center, Medical Surveillance Monthly Report. (2013). Medical evacuations from Afghanistan during Operation Enduring Freedom, Active and Reserve Components, U.S. Armed Forces, 7 October 2001–31 December 2012 (Vol. 20, No. 6). Retrieved from http://www.afhsc.mil/viewMSMR?file=2013/v20_n06.pdf.

Commander, Submarine Forces Public Affairs. (2010, April 29). Navy policy will allow women to serve aboard submarines. Navy News Service. NNS100428-31.

DACOWITS Defense Department Advisory Committee on Women in the Services. (2000). Fall Conference 2000. Retrieved from the DACOWITS website. http://dacowits.defense.gov/ReportsMeetings/2000Fall.aspx.

DACOWITS Defense Department Advisory Committee on Women in the Services. (2007). 2007 Report. Retrieved from the DACOWITS website. http://dacowits.defense.gov/Portals/48/Documents/Reports/2007/Annual%20Report/dacowits2007report.pdf.

DACOWITS Defense Department Advisory Committee on Women in the Services. (2012). 2012 Report. Retrieved from the DACOWITS website. http://dacowits.defense.gov/Portals/48/Documents/Reports/2012/Annual%20Report/dacowits2012report.pdf.

Kane, J. L., & Horn, W. G. (2001). The medical implications of women on submarines (NSMRL Technical Report #1219). Groton, CT: Naval Submarine Medical Research Laboratory.

¹ A GMO is a general Medical Officer, serving in a primary care capacity for the ship’s crew.

² Plan B is a one tablet oral form of emergency contraception, intended to prevent unwanted pregnancy by preventing ovulation, fertilization, and implantation. It was prescription only until August 2006, at which time it was approved by the FDA to be sold over the counter for women over age 18. In June 2013, it was approved for sale over the counter to women 15 and older.