Moving Women Veterans’ Health Research Forward: a Special Supplement

VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, University of California (UC) Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA; Division of General Internal Medicine, UC San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Departments of Medicine and Clinical and Translational Research, University of Pittsburgh, Pittsburgh, USA; VA HSR&D Center of Innovation to Accelerate Discovery and Practice Transformation, DurhamVAHealth Care System, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA.

W omen's increased rate of participation in the US military is reshaping the Veteran population. With the growing number of women Veterans, it is imperative to understand the unique facets of military women's and women Veterans' health and health care experiences to ensure that they receive the highest-quality patient-centered care throughout the life course. This special issue of the Journal of General Internal Medicine (JGIM), sponsored by VA Health Services Research & Development (HSR&D) Service and the VA Women's Health Research Network, highlights innovations and new findings related to women Veterans' health and health care, including the diverse needs and experiences of women Veterans and active-duty and Reserve/National Guard servicewomen. We received an extraordinary number of submissions, reflecting the richness and depth of the field. After careful review and reflection, we accepted papers clustered around the five themes described below.

SEXUAL AND REPRODUCTIVE HEALTH
The scientific literature about sexual and reproductive health among women Veterans is a relatively new field, which has largely been descriptive to date. This supplement includes nine papers that move this field forward, adding nuance and actionable findings. Additional papers help us understand in more detail women Veterans' family planning needs. Gawron et al. describe the low frequency of emergency contraception provision among women Veterans, while Callegari et al. report that women Veterans' perceptions of contraception counseling vary by clinical setting in which the counseling was received. Judge-Golden et al. describe Veterans' experiences with abortion and associations with mental health diagnoses, while Grindlay et al. contribute findings indicating that while unintended pregnancy rates are higher among active-duty US Navy members than among civilians, abortion rates appear to be lower.

SEXUAL VIOLENCE
While the prevalence and burden of sexual trauma are welldescribed among women Veterans, this special issue includes three papers that set a foundation for future work in this area.

WOMEN VETERANS' HEALTH NEEDS
As our understanding of women Veterans' health conditions and needs evolves, we must grow our knowledge of how to structure the health care workforce and what areas of clinical care must be improved to address ongoing disparities in quality of care. To this end, we include four studies that elucidate the complex health issues faced by women Veterans and the areas needing improvement among those caring for this prioritized population. Lehavot et al. identified the unique health care needs of women Veterans with lower-extremity amputation, and Dhruva et al. identify persistent gender-based disparities in guideline-directed medical therapy among younger women Veterans. Sheehan et al. describe the significant multimorbid physical conditions, mental health diagnoses, and trauma histories of women Veterans using VA primary care, while Farkas et al. explore how VA women's health primary care providers can prepare for and sustain their work in caring for the medical complexity of women Veterans by receiving training at women's health mini-residencies.

INNOVATIONS IN CLINICAL PRACTICE
Finally, we included three papers that round out the supplement by describing efforts to improve the way that care is delivered to women Veterans. Galovski et al. describe Wo-VeN, a unique national social network of women Veterans that trains peer leaders in facilitating group sessions with w o m e n V e t e r a n s . M i l l e r e t a l . d e s c r i b e t h e innovative national reproductive mental health consultation program and evaluation. Spinella et al. describe an integrated multidisciplinary women Veteran substance use disorder primary care clinic.
Collectively, this outstanding set of papers builds on the research agenda laid out over a decade ago by Yano and colleagues 1 ; that agenda remains relevant today and reflects the ongoing health concerns of many women Veterans. 1 The work included in this supplement advances the field by offering a deeper understanding of women Veterans' and activeduty military women's health and health care needs. In a 2017 evidence map of the women Veterans' health research literature, 2 the majority of the papers in the field were observational studies, suggesting an opportunity for more interventional and implementation science. 1 This supplement provides examples of how VA women's health research continues to develop with thoughtful nurturing and support, both to expand the types of study designs employed and to include a focus on the range of health needs of this population (see Yano and Tomoyasu editorial, this issue).
We acknowledge the limitations of language focused on "women's health," recognizing the gender diversity of Veterans and that "cisgender women are not the only ones who need 'women's health' care and research." 3 We agree with Boerner and colleagues, who suggest that researchers should be "conceptualizing gender as a more fluid construct that can shift with changes in hormones, abilities, roles, and socially imposed expectations…" 4 As our understanding of VA users begins to better reflect the reality of the diversity of Veteran gender identity, it will be critical not only to conceptualize and address gender more inclusively, but also other intersecting identities. 5 We continue to need to identify when gendertailoring of care is or is not necessary, and how to effectively intervene upon persistent disparities (e.g., in cardiovascular disease 6 ) and how to prevent new disparities from developing. We must learn from our experience during a world-changing, multi-year health crisis, and pursue research that addresses the "external context," or the forces and influences surrounding women's lives and health care (e.g., environmental exposures, restricted access to critical reproductive health care, climate change 7 ) that will affect their social roles, personal well-being, and family structure. Finally, we will be interested to see how VA women's health care evolves in response to recent congressional mandates for increased access to and satisfaction with VA care, for example, via efforts to provide child care and to eliminate harassment on VA grounds. 8 This collection of cutting-edge research in women's health will be of interest both within and beyond the VA health care system. This work is relevant not only to Veterans and VA employees, but also to women's health clinicians outside of the VA as many health conditions (e.g., PTSD secondary to sexual trauma, complex co-morbid diagnoses) and health care challenges (e.g., barriers to reproductive health care, disparities in guideline-concordant cardiovascular disease care) that are prevalent among our Veterans are common among civilian women populations as well. We appreciate VA Health Services Research & Development for providing this opportunity to disseminate exemplary women's health research, and the Journal of General Internal Medicine for supporting this special issue and providing a vibrant home for VA health services research.