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t m c ยป p u l s e | n o v e m b e r 2 0 1 7 36 36 According to the American Psychological Association, female veterans who were sexually assaulted are more prone to develop PTSD than other women who experienced combat and are much less likely than other PTSD sufferers to seek help. Military sexual trauma, as defined by the federal government, is "psychological trauma resulting from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the veteran was serving on active duty, active duty for training, or inactive duty training." With this in mind, the Women's Health Center offers its own entrance at the VA, so every female patient who visits walks into an environment that offers privacy and security. "Having a place with a private entrance makes these women feel important and reduces their stress," El-Serag said. In the waiting room, decorated in soothing blues and beiges, photos of daisies and branches in bloom hang on the walls. A check-in kiosk helps the flow of patients; individuals can sign in and look at their lab results or refill their prescriptions. At one end of the waiting room, the Kids Zone offers activities for chil- dren who tag along with their mothers. "I've been here 14 years," El-Serag said. "Women with PTSD exhibit avoidance behaviors. They're no-shows to appointments. They only walk in when they need to. Continuity is important. These women need support and reassurance. They don't trust that easily." Among the most prevalent primary service- connected disabilities for women veterans are PTSD, major depressive disorder, migraines, cervical strain, bronchial asthma and degenerative arthritis of the spine, according to the National Center for Veterans Analysis and Statistics. The Women's Center treats a lot of medical conditions clustered around PTSD, including chronic migraines, irritable bowel syndrome, fibromyalgia, mood swings, excessive anger and acting out. Every veteran must deal with the trauma of active duty, El-Serag said. Ignoring it simply doesn't work. "I tell new patients: It will come back to get you, and when it does, it will come back with a vengeance," she said. The Women's Health Center employs a staff of about 30, including doctors, nurses, radiologists, mammography techs and administrators. Different teams work with specific groups of patients, including the transgender and LGBTQ communities. The big challenge is to encourage women veterans to make use of the center's services, and to keep them coming back for follow-up visits and routine care. Marlene Cano, RN-BC, breast care coordinator at the center and acting Women Veteran's Program Manager, explained that the VA leads the nation in breast cancer screening rates. She oversees that out- reach in Houston, making sure patients are notified of routine screenings and additional services. The average age of a woman veteran in Houston is 40, El-Serag added, while the average age for a male veteran in Houston falls closer to retirement age, between 60 and 65. Serving a younger female population means addressing specific health and lifestyle issues. "We see a whole lot of women in their twenties and thirties," El-Serag said, "and they don't want to spend all day at the VA." So the center aims to streamline patient care, Women make up about 10% of the veteran population in the United States. As of Sept. 30, 2016, the total U.S. veteran population was 21,368,156, and women accounted for 2,051,484 of that total. Texas has the highest number of women veterans in the country, with 183,597. In 2015, 35.9% of women veterans were enrolled in the Veterans Health Administration health care system. Not all women who enroll ultimately become health care users. From 2005 to 2015, the number of women veterans enrolled in VA health care increased 83.9 %, from 397,024 to 729,989. From 2005 to 2015, the number of women veterans using VA health care increased 46.4%, from 237,952 to 455,875. To put this in perspective, about 13.1 percent of all women veterans in 2005 used VA health care, compared with 22.4 percent of all women veterans in 2015. HEALTH CARE AND WOMEN VETERANS Breast radiologist Mahdieh Parizi, M.D., at work at the Women's Health Center. Sources: Department of Veterans Affairs, National Center for Veteran Analysis and Statistics